New Thoughts on the Behavioral Treatment of Tourette Syndrome

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New Thoughts on the Behavioral Treatment
ofTourette Syndrome
Advances in Tourette Syndrome Felsenstein Medical
Research Center Schneider Childrens Medical
Center of Israel Tel Aviv, Israel - February
26, 2006

• John Piacentini, Ph.D., ABPP
• Child OCD, Anxiety, and Tic Disorders Program
• Semel Institute for Neuroscience and Human
  Behavior
• UCLA School of Medicine

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Acknowledgements
Some of the work described in this presentation
was supported by grants from the TOURETTE
SYNDROME ASSOCIATION NATIONAL INSTITUTE OF
HEALTH NIMH / NINDS KAREN MAYES GAMORAN
FAMILY FOUNDATION The Dr. David Feinberg
Fellowship of the Semel Institute - UCLA and
Schneider's Children's Medical Center Israel
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TSA Behavioral Sciences Consortium
Susanna Chang, PhD. UCLA Neuropsychiatric
Institute Thilo Deckersbach, PhD. Mass General
Hospital/Harvard Golda Ginsberg, PhD. Johns
Hopkins University Alan Peterson, PhD. Wilford
Hall Medical Center John Piacentini, PhD. UCLA
Neuropsychiatric Institute Lawrence Scahill, MSN,
PhD. Yale Child Study Center John Walkup,
MD. Johns Hopkins University Sabine Wilhelm,
PhD. Mass General Hospital/Harvard Douglas Woods,
PhD. University of Wisconsin-Milwaukee
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How can Behavioral Psychology inform us about TS
The central tenet of Behavioral Psychology is
that behavior is determined by a combination of
forces comprised of biological - including
genetic - and environmental factors.
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Behavioral Psychology and TS
Behavioral Psychology primarily concerned with
this relationship
Tics
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Biological Factors

• Genetics
• Twin Studies
• MZ concordance 86 DZ concordance 20
• Family Studies
• Risk of TS in relatives 10-15
• Perinatal/Postnatal Insults
• LBW, maternal stress, chemical exposure,
  placental insufficiency, gestational diabetes,
  PANDAS
• Neurobiology
• Cortico-striato-thalamo-cortical (CSTC) circuits

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Role of the Environment
Underlying biological abnormalities may explain
broad consistency of symptom presentations seen
in TS Different experiences involving
interactions with the environment may explain
presentation differences. Environmental
Factors Environmental antecedents and
consequences Environmental determinants of tic
suppression Role of Premonitory Urge An
individualized approach to understanding
environment/behavior interaction is key
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Environmental Factors
ANTECEDENTS Being upset or anxious (Silva et
al., 1995) Watching TV (Silva et al., 1995)
Being Alone or with Others (Silva et al., 1995)
Stressful Life Events (Surwillo et al., 1978)
Hearing Others Tic or Talking about Tics
(Commander et al., 1991 Woods et al.,
2000) CONSEQUENCES Being teased TIC SUPRESSION
Ticcers can control tics under certain conditions
Woods, 2004 and others
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• A Neurobehavioral Model
• of Tourette Syndrome
• Behavioral Sciences Consortium
• of the Tourette Syndrome Association

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Neurobehavioral Model of TS

• Speculative at this point
• Some data supporting certain aspects of the
  model
• Other aspects are consistent with clinical
  observation
• Useful as an aid to treatment development and
  planning
• Identify specific individual and environmental
  targets for intervention
• Identify specific techniques to use
• Spur additional research to better understand
  TS
• Environmental impacts on TS expression,
  suppression, etc.
• Development of Premonitory Urge

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Premonitory Urge

• Internal event
• Sensation that precedes tics
• Unpleasant itch, tension, tingle, pressure
• Sometimes localized, sometimes general
• Awareness begins around age 9-10
• Very common up to 90 of TS individuals
  describe urges
• Urges more likely to precede complex tics than
  simple tics
• Consequences
• Urge is relieved or reduced contingent on tic

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Premonitory Urge

• Premonitory urge emerges over time (Leckman et
  al., 1993)
• Descriptions of the urge become more internally
  consistent over time (Woods, Piacentini et al.,
  2005)

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Premonitory UrgeDevelopmental Factors

• Premonitory Urge for Tics Scale (PUTS)
• 9-item child self-report measure of premonitory
  urge severity
• Tested in 42 TS/CTD youngsters aged 8-16
• Total score did not differ between younger (8-10)
  and older (11-16) group

Woods, Piacentini, Himle, Chang, 2005
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Premonitory UrgeDevelopmental Factors

• Premonitory Urge for Tics Scale (PUTS)
• PUTS score only correlated with tic severity in
  older group
• Sensations are present in younger children but
  perhaps in more diffuse form or association with
  tics not as easily recognized

Woods, Piacentini, Himle, Chang, 2005
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Neurobehavioral Model of Tics
Environment builds on this biologically derived
sequence.
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Behavioral Model of Tics
Although the Biological Basis for the Premonitory
Urge may be present, the urge itself may not
exist at the very beginning of the disorder.
The underlying sensation may not be experienced
as related to the tic.
Expression of tic leads to both internal and
external consequences.
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Situational Antecedents
As child starts to experience negative
consequences of ticcing, he/she will begin to
associate these negative consequences with the
situations in which the tics occurred.
Biological Basis for Premonitory Urge
Expression of TIC
Over time, these situational antecedents become
more salient and increasingly aversive to the
child (e.g., classical conditioning).
Consequences
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Biological Antecedents
Situational Antecedents
Negative Consequences
Biological Basis for Premonitory Urge
and Situational Antecedents also impact
internal cues, e.g., underlying sensations such
that these sensations take on aversive qualities
as well.
Expression of TIC
The more salient the sensations become to the
child, the more strongly he/she associates them
with his/her tics.
Consequences
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Premonitory Urge

• Premonitory urge severity becomes more related to
  behavior patterns suggestive of avoidance and
  social withdrawal as children get older (Woods,
  Piacentini et al., 2005)
• Connection between premonitory urge and tics may
  be shaped by negative social response to tics

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Development of Premonitory Urges
Situational Antecedents
As the child becomes more aware of these
underlying sensations and they begin to predict
specific consequences (e.g., tics), they begin to
be experienced as premonitory urges. Premonitor
y urges become aversive to the extent they
predict aversive consequences.
PREMONITORY URGE(unpleasant)
Biological Basis for Premonitory Urge
Expression of TIC
Consequences
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Negative Reinforcement of Tics
Relief from unpleasant premonitory urge serves to
negatively reinforce tic expression. Negative
Reinforcement any action reducing or
eliminating an aversive stimulus will be more
likely to occur upon subsequent presentation of
that aversive stimulus. If my child stops
misbehaving when I shout at him, Im more likely
to use shouting as a disciplinary procedure in
the future.
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Positive Reinforcement of Tics
Positive Consequences also serve to reinforce
tics and increase their frequency
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Support for the Neurobehavioral Model

• Data examining impact of environmental factors on
  tic expression are very preliminary
• Consequences of Tic expression
• Antecedents of Tic expression
• However, these data provide at least indirect
  support for Neurobehavioral Model

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Antecedent Events that Impact Tics

• Being upset or anxious (Silva et al., 1995)
• Watching TV (Silva et al., 1995)
• Being Alone (Silva et al., 1995)
• Social Gatherings (Silva et al., 1995)
• Stressful Life Events (Surwillo et al., 1978)
• Hearing Others Cough (Commander et al., 1991)
• Talking about tics (Woods et al., 2001)

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Consequences Impacting Tic Occurrence

• Evidence for external consequences increasing
  tics
• Social reactions can result in a worsening of
  tics (e.g., Watson Sterling, 1998)
• Child may get out of a task because of his or her
  tics (e.g., getting out of math homework).
• Evidence for external consequences decreasing
  tics
• Real life negative consequences for tics (i.e.,
  teasing, failure to participate in social
  activities, etc.)
• Some children avoid these consequences through
  suppressing their tics

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Environmental Control of Tic ExpressionWoods
Himle, Univ Wisconsin-Milwaukee

• TIC DETECTOR
• Remote controlled operant token dispenser
• Inactive computer camera mounted on top of box
• Tokens delivered by experimenter who observes
  from behind an observation mirror
• Tokens delivered for every 10 sec. tic-free
  intervals
• Interval resets if a tic occurs
• Tokens later exchanged for small amount of money

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Environmentally Mediated Tic Reduction Woods
Himle (2004)

• Compared tic reduction with and without support
  of environmental consequences in 4 children with
  TS
• Verbal Instructions to suppress produced a 10.3
  reduction in tic occurrence from BL
• Reinforcement-enhanced procedures produced a 76
  decrease in tics
• Results suggest that consequences to tics can
  impact tic frequency

BL (Baseline) VI (Verbal Instructions) DRO
(Reinforcement for No Tics)

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Environmental Influences can be long lasting
Woods, Himle, Miltenberger, Carr, ongoing

• Nine children with TS exposed to Rewards of 3
  different durations (5 min, 25 min, 40 min)
  presented in a random order
• Rewards interspersed with 5 min rebound
  evaluation phase
• Rewards led to statistically significant tic
  reduction
• No statistically significant rebound effects for
  any of the different durations

Funded by the Tourette Syndrome Association
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Implications of Model for Treatment

• Behavioral Intervention should address
• Antecedents and Consequences of Tics
• Negative Reinforcement

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Function-BasedInterventionsIdentify
function of enviromental factors on tic
expression
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Impact of Environment on Tics
Environmental Consequences catch kids COMING or
GOING
Positive consequences can increase ticcing
Tic
Positive Consequence
More Tics
Negative consequences can increase ticcing
Negative response
Distress
Tic
More Tics
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Functional Analysis

• Response to environment is typically not a
  conscious or voluntary process
• Child/family/school often unaware this is
  happening
• Environmental influence does not imply that tics
  are behaviorally caused or that child is
  manipulating the system

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Functional Analysis

• Common Antecedents
• - What happens before the tic
• Demand placed on child
• Teasing
• Anxiety
• Stress

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Functional Analysis

• Common Consequences
• - What happens after the tic
• Comforting - extra attention
• Stop ticcing
• Teasing
• Leave table, classroom, or other situation
• Dont finish meal, homework, or chores

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Function-based Interventions

• Does not imply that tics are behaviorally caused.
  
• Despite the tics, the child is still expected to
  be treated as normally as possible
• both positive and negative consequences
• Tics should not dictate what the child does or
  does not do, and the child does not receive any
  special treatment for his or her tics.
• ENVIRONMENT SHOULD BE TIC NEUTRAL
• Over 20 published studies of contingency
  management

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Neutral Environment
Situational Antecedents
PREMONITORY URGE(unpleasant)
Expression of TIC
Positive and Negative Consequences
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Neutral Environment
Situational Antecedents
PREMONITORY URGE(unpleasant)
Expression of TIC
Consequences
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Neutral Environment
Situational Antecedents
PREMONITORY URGE(unpleasant)
Expression of TIC
Consequences
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Function-based Interventions What to do?

• ADDRESS ANTECEDENTS
• Provide child with 15 minutes warning and
  free time to calm
• down prior to making specific requests
  (homework, chores)
• ADDRESS SOCIAL CONSEQUENCES
• Dont respond to tics in the moment teasing,
  telling to stop,
• comforting, etc.
• This means parents, sibs, teachers, everyone

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Function-based Interventions What to do?

• ADDRESS ESCAPE CONSEQUENCES
• (Negative Reinforcement)
• If tics interfere, leave situation for 15 minutes
  then return - BUT no escape from
  responsibilities
• If leaves dinner table, must come back and finish
  meal
• Needs to begin homework at set time regardless of
  tics can take brief breaks according to
  set schedule
• If tics still bothersome, encourage child to use
  HRT or other techniques to address them

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Habit Reversal Training (HRT)
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Habit Reversal Training

• Multicomponent Behavioral Treatment Package
• developed by Azrin Nunn (1973)
• Targeted tics and other habit disorders,
  including
• trich, nailbiting, thumbsucking, skin picking
• Originally consisted of 14 techniques aimed at
• increasing tic (habit) awareness
• developing competing responses to tics (habits)
• building and sustaining motivation and compliance

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Habit Reversal Training

• TWO PRIMARY COMPONENTS
• Awareness Training
• Competing Response

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Habit Reversal Training

• ANCILLARY COMPONENTS
• - Addressing tic antecedents
• Psychoeducation
• Reduce family anxiety/stress and negative
  reactions to childs tics
• Relaxation Training
• Reduce child anxiety/stress

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Habit Reversal Training

• ANCILLARY COMPONENTS
• - Addressing motivation/compliance
• Social Support
• Enhance use of HRT
• Behavioral Reward System
• Enhance treatment motivation and compliance
• Inconvenience Review
• Identify functional impairments and enhance
  motivation

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Habit Reversal TrainingAwareness Training

• Response Description and Detection
• Describe details of tic and re-enact under
  therapist supervision
• Early Warning Procedure
• Practice detecting earliest sign of movement or
  tic urge
• Situation Awareness Training
• Recall high-risk situations and describe tic in
  these settings
• Ancillary Procedures
• Use videotape or enlist support persons

Necessary level of awareness is unclear
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Premonitory Urge

• Relationship of HRT to Premonitory Urge
• Simple tics
• Less likely to experience premonitory urge
• HRT focused on other early warning signs or
  initial aspects of tic expression
• Complex tics
• Typically preceded by premonitory urge
• HRT focused on detecting and intervening at
  premonitory urge stage

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Habit Reversal TrainingCompeting Response

• Incompatible physical behavior performed in
  response to
• Urge to tic
• Initial expression of tic itself
• CR Should be
• Opposite to the tic behavior
• Capable of being maintained for at least one
  minute
• Socially inconspicuous - compatible with normal
  activity

Necessary level of compliance is unclear
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Habit Reversal Training
Treatment Tips

• Start with a relatively big and noticeable tic
  first
• Simple eyeblinks often not targeted by HRT
• Shaping procedure often used for motor tics
• Slow, rhythymic breathing used as CR for vocal
  tics
• Developmentally sensitive implementation
  (tic-buster)

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Habit Reversal TrainingSocial Support/Reward
System

• Goal is to reinforce and prompt use of competing
  response
• Significant others prompt use of CR
• Significant others praise correct use of CR
• Necessity of social support is unclear, but
  probably required for most children
• Rewards offered for compliance with treatment
  assignments (effort not outcome)

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Impact of TS on Family

• Family confusion, upset, blame
• Due to inaccurate, inconsistent information
  about TS
• Due to improper and/or failed treatment
  attempts
• Due to reaction of others in the environment
• Disruption caused by excessive attention, energy
  focused on the problem
• Other family needs remain unaddressed
• Other family members (sibs) may become jealous
• Relaxation of regular family rules or roles

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Family Involvement in Treatment

• Family plays crucial role in treatment and
  recovery
• Provide support and encouragement to child
• Exact role depends on age/developmental level of
  child
• For younger children
• Parents may need to be directly involved in
  implementation of treatment techniques
• For older children and adolescents
• Parent typically needs to accept a less direct
  role
• Primary task is to provide support

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Empirical Support for HRT
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Empirical Support for HRT

• Over 25 published studies of HRT for TS or
  Chronic Tic Disorder
• Most single case or small case series reports
• At least 6 published randomized, between group
  studies of HRT for TS/CTD
• Only two included children (most subjects were
  adults)
• One unpublished trial solely of children

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Empirical Support for HRT

• Azrin Nunn (1973) 12 individuals with habits
  or tics
• 90 symptom reduction after 1 session
• 99 symptom reduction at 3 month follow-up
• Tourettes Syndrome
• More effective than relaxation training or
  self-monitoring (Peterson Azrin, 1992)
• More effective than wait-list control (Azrin
  Peterson, 1990)

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Habit Reversal for Adult TS

• Sabine Wilhelm, PhD.
• Thilo Deckersbach, PhD.
• Barbara Coffey, MD.
• Antje Bohne, MS.
• Alan Peterson, Ph.D.
• Lee Baer, PhD.
• Massachusetts General Hospital
• Harvard Medical School

Suppported by a grant from the TSA Permanent
Research Fund
Am J Psychiatry, 160, 1175-1177 (2003)
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HRT for Adults - Symptoms

35 decrease in tic severity
Wilhelm et al. (2003)
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HRT for Adults - Interference


55 decrease in tic interference
Wilhelm et al. (2003)
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Comparison of HRT and Awareness Training for
Children with TS
John Piacentini, Ph.D. Susanna Chang, Ph.D. Velma
Barrios James McCracken, M.D. UCLA -
Neuropsychiatric Institute
Suppported by a grant from the TSA Permanent
Research Fund
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Treatment Response Rates
INTENT TO TREAT ANALYSES Condition
Responder Rate HRT 6/13
46 AT 3/12 25 TREATMENT COMPLETERS
Condition Responder
Rate HRT 6/11 55 AT 3/9 33
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Habit Reversal Efficacy
HRT 30 decrease in tic severity 55
decrease in tic-related impairment
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Durability of HRT (3 Month FU)
HRT 80 response rate at 3 mos
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Exposure plus Response Prevention

• Some evidence that ERP effective for tic
  reduction
• Verdellen et al., 2004 Woods et al., 2000
• Consistent with neurobehavioral model
• - negative reinforcement of tics by urge
  reduction

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CBITS Studies
Comprehensive Behavioral Intervention for Tics
Studies
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TSA Behavioral Sciences Consortium
Susanna Chang, PhD. UCLA Neuropsychiatric
Institute Thilo Deckersbach, PhD. Mass General
Hospital/Harvard Golda Ginsberg, PhD. Johns
Hopkins University Alan Peterson, PhD. Wilford
Hall Medical Center John Piacentini, PhD. UCLA
Neuropsychiatric Institute Lawrence Scahill, MSN,
PhD. Yale Child Study Center John Walkup,
MD. Johns Hopkins University Sabine Wilhelm,
PhD. Mass General Hospital/Harvard Douglas Woods,
PhD. University of Wisconsin-Milwaukee
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Child Behavioral Intervention for Tics Study
(CBITS-C)

• 120 children (aged 9-17) with TS/CTD (40 at each
  of 3 sites)
• UCLA
• Johns Hopkins University
• University of Wisconsin - Milwaukee
• Three supporting sites
• Mass General Hospital/Harvard
• Yale Child Study Center
• Wilford Hall Medical Center (Texas)
• Comparison of two psychosocial treatments
• Comprehensive Behavioral Intervention for TS
  (CBIT)
• - HRT Function-based Intervention
• Psychoeducation/Supportive Therapy (PST)
• Funded by NIMH (R01 70802) through the Tourette
  Syndrome Association

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CBITS Treatments

• CBIT
• Components
• Psychoeducation
• Habit Reversal Therapy
• Functional Intervention
• Reward System
• Relaxation Training

• Psychoed/Support
• Components
• Phenomenology of TS
• Prevalence of TS
• Natural History of TS
• Common Comorbidities
• Causes of TS
• Psychosocial Impairments
• Nonspecific Support

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Adult Behavioral Intervention for Tics Study
(CBITS-A)

• 120 adults (aged 16-60) with TS/CTD (40 at each
  of 3 sites)
• Mass General Hospital/Harvard
• Yale Child Study Center
• Wilford Hall Medical Center (Texas)
• Three supporting sites
• UCLA
• Johns Hopkins University
• University of Wisconsin- Milwaukee
• Comparison of two psychosocial treatments
• Comprehensive Behavioral Intervention for TS
  (CBIT)
• - HRT Function-based Intervention
• Psychoeducation/Supportive Therapy (PST)
• Funded by NIMH through Collaborative R01s to MGH,
  Yale, and WHMC

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Behavioral Interventions for Tics

• SUMMARY
• Although tics are biologically-based,
  environmental factors can be important
  determinants of tic expression and maintenance
• Integrative neurobehavioral models provide
  theoretical basis for psychosocial treatment of
  TS
• Best approach may be combination of
  Function-based and Tic-specific intervention
• Good supportive data from numerous small open and
  pilot controlled trials
• CBITS ABITS Multisite Trials will provide
  large-scale efficacy data
• Future trials need to examine comparative
  efficacy of HRT and medication and mechanisms of
  action