Behavioral interventions for tic disorders

The therapeutic effect of habit reversal training for Tourette syndrome: a meta-analysis of randomized control trials

OBJECTIVES

Comprehensive behavioral intervention for tics (CBIT) and habit reversal training (HRT) are forms of cognitive behavioral therapy that can effectively reduce tic symptoms in patients with tic disorders, but their efficacies and potential moderators were needed to be clarified.

METHODS

In the present study, a meta-analysis was performed to identify the efficacy of HRT and CBIT for individuals with tic disorders. The standard mean difference (SMD) was calculated to assess the effect size of the efficacy of HRT. Subgroup analysis and meta-regression analysis were performed to identify the potential heterogeneity of the SMD of HRT.

RESULTS

A total of 10 randomized controlled trials (RCTs) including 586 patients with tic disorders were identified. The pooled SMD was -0.43 (95% CI: -0.71, -0.16). The effect size of HRT was moderated by different 'Comparison Conditions' (it means the different behavioral therapies in the control group).

CONCLUSION

Overall, the authors found a small to medium effect size for the efficacy of HRT. As the most promising behavioral therapy, they conclude that HRT is effective for the treatment of patients with tic disorders. Further high-quality RCTs are needed to determine the efficacy of HRT compared with that of medications.

Review of habit reversal training for tic disorders

Tic disorders (TD) is a neurodevelopmental disorder that is often first recognized in children and adolescents and is characterized mainly by motor and phonic tics. Drug treatment of TD has been criticized because of serious side effects, and TD treatment emphasizes behavioral psychotherapy. This study reviewed the most common behavioral psychotherapy for TD: habit reversal training (HRT). We examined the contents, variation, curative effects, and premonitory urge control of HRT and other behavioral psychotherapies. The findings suggest that current understanding of HRT is insufficient and further studies are needed. First, studies of online guidance training are needed to implement technology that can help more patients. Second, the future integration of HRT and other technologies is important. Third, imaging techniques could be used to further explore the brain mechanisms underlying HRT. Research on HRT for TD in China is insufficient. We call on more Chinese researchers to study, investigate, and develop technology to promote the development of behavioral psychotherapy for TD in China.

[A review on the management of tic disorders in children: psychoeducation and behavioral intervention]

Tic disorders (TD) are a group of neurodevelopmental disorders that are characterized by motor and/or vocal tics in children and adolescents. The etiology and pathogenesis of TD remain unclear, and it is believed to be caused by a combination of genetic, biological, psychological, and environmental factors. The major treatment for TD includes psychoeducation, behavioral intervention, and drug treatment. To further explore the management of TD, this article reviews the research advances in psychoeducation and behavioral intervention for patients with TD.

Systematic review of interventions for treating or preventing antipsychotic-induced tardive dyskinesia

BACKGROUND

Antipsychotic medication can cause tardive dyskinesia (TD) - late-onset, involuntary, repetitive movements, often involving the face and tongue. TD occurs in > 20% of adults taking antipsychotic medication (first-generation antipsychotics for > 3 months), with this proportion increasing by 5% per year among those who continue to use these drugs. The incidence of TD among those taking newer antipsychotics is not different from the rate in people who have used older-generation drugs in moderate doses. Studies of TD have previously been found to be limited, with no treatment approach shown to be effective.

OBJECTIVES

To summarise the clinical effectiveness and safety of treatments for TD by updating past Cochrane reviews with new evidence and improved methods; to undertake public consultation to gauge the importance of the topic for people living with TD/the risk of TD; and to make available all data from relevant trials.

DATA SOURCES

All relevant randomised controlled trials (RCTs) and observational studies.

REVIEW METHODS

Cochrane review methods, network meta-analysis (NMA).

DESIGN

Systematic reviews, patient and public involvement consultation and NMA.

SETTING

Any setting, inpatient or outpatient.

PARTICIPANTS

For systematic reviews, adults with TD who have been taking a stable antipsychotic drug dose for > 3 months.

INTERVENTIONS

Any, with emphasis on those relevant to UK NHS practice.

MAIN OUTCOME MEASURES

Any measure of TD, global assessments and adverse effects/events.

RESULTS

We included 112 studies (nine Cochrane reviews). Overall, risk of bias showed little sign of improvement over two decades. Taking the outcome of 'TD symptoms improved to a clinically important extent', we identified two trials investigating reduction of antipsychotic dose [n = 17, risk ratio (RR) 0.42, 95% confidence interval (CI) 0.17 to 1.04; very low quality]. Switching was investigated twice in trials that could not be combined (switching to risperidone vs. antipsychotic withdrawal: one RCT, n = 42, RR 0.45, 95% CI 0.23 to 0.89; low quality; switching to quetiapine vs. haloperidol: one RCT, n = 45, RR 0.80, 95% CI 0.52 to 1.22; low quality). In addition to RCTs, six observational studies compared antipsychotic discontinuation with decreased or increased dosage, and there was no clear evidence that any of these strategies had a beneficial effect on TD symptoms (very low-quality evidence). We evaluated the addition to standard antipsychotic care of several treatments, but not anticholinergic treatments, for which we identified no trials. We found no clear effect of the addition of either benzodiazepines (two RCTs, n = 32, RR 1.12, 95% CI 0.6 to 2.09; very low quality) or vitamin E (six RCTs, n = 264, RR 0.95, 95% CI 0.89 to 1.01; low quality). Buspirone as an adjunctive treatment did have some effect in one small study (n = 42, RR 0.53, 95% CI 0.33 to 0.84; low quality), as did hypnosis and relaxation (one RCT, n = 15, RR 0.45, 95% CI 0.21 to 0.94; very low quality). We identified no studies focusing on TD in people with dementia. The NMA model found indirect estimates to be imprecise and failed to produce useful summaries on relative effects of interventions or interpretable results for decision-making. Consultation with people with/at risk of TD highlighted that management of TD remains a concern, and found that people are deeply disappointed at the length of time it has taken researchers to address the issue.

LIMITATIONS

Most studies remain small and poorly reported.

CONCLUSIONS

Clinicians, policy-makers and people with/at risk of TD are little better informed than they were decades ago. Underpowered trials of limited quality repeatedly fail to provide answers.

FUTURE WORK

TD reviews have data from current trials extracted, tabulated and traceable to source. The NMA highlights one context in which support for this technique is ill advised. All relevant trials, even if not primarily addressing the issue of TD, should report appropriate binary outcomes on groups of people with this problem. Randomised trials of treatments for people with established TD are indicated. These should be large (> 800 participants), necessitating accrual through accurate local/national registers, including an intervention with acceptable treatments and recording outcomes used in clinical practice.

STUDY REGISTRATION

This study is registered as PROSPERO CRD4201502045.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Los tics y su relación con las dificultades de aprendizaje: estudio longitudinal de la prevalencia de los tics primarios y comorbilidad asociada en población escolar

Con el objetivo de estudiar la prevalencia de los trastornos con tics y la asociación con las dificultades de aprendizaje, se realizó un estudio epidemiológico en una muestra de 1.139 escolares. Los resultados señalaron una prevalencia del 16,86% (IC 95% del 14,10 – 19,63). Además se encontraron dificultades académicas en el 11,9% de los escolares, y la presencia de tics en el 8,6%. La presencia de trastornos de tics no se asoció con el bajo rendimiento académico en la cohorte. Los resultados obtenidos fueron contradictorios con relación a otros estudios publicados anteriormente. Como consecuencia de la divergencia en los resultados, se diseña un segundo estudio, que toma como punto de partida el seguimiento longitudinal de la cohorte de los escolares estudiados. En el análisis de regresión de Cox, durante el periodo de seguimiento de 4 años, la repetición de curso se asoció con una menor frecuencia de apoyo psicológico en el centro escolar (HR = 17,5; IC del 95% 5,7 a 53,9) y menor practica de deporte (HR = 4,02, 95% CI 01/03 a 11/08). No se encontró una asociación entre los tics y mayor riesgo de repetir curso.

Clinical Correlates and Predictors of Caregiver Strain in Children with Chronic Tic Disorders

Although tics are the defining feature of chronic tic disorders (CTD), many children experience comorbid internalizing and externalizing problems that contribute to impairment across several domains, including family functioning. The current study examined clinical correlates and predictors of caregiver strain in parents of children with CTD. Participants were 123 children and adolescents diagnosed with a CTD who participated in a randomized-controlled trial of behavior therapy for reducing tics. Results showed that a combination of disruptive behavior, inattention/hyperactivity, and tic intensity best explained objective strain and a combination of inattention/hyperactivity and tic intensity were the best predictors of subjective caregiver strain. Implications of these findings for care providers are discussed.

Tic disorders

PURPOSE OF REVIEW

Primary tic disorders are complex, multifactorial disorders in which tics are accompanied by other sensory features and an array of comorbid behavioral disorders. Secondary tics are proportionally much less frequent, but their etiology is diverse. This review aims to guide clinicians in the recognition of the phenomenology, pathophysiology, and treatment of these disorders.

RECENT FINDINGS

Advances include greater phenomenologic insights, particularly of nonmotor (sensory) features; increased knowledge of disease mechanisms, particularly coming from neuropsychological, functional imaging, pathologic, and animal model studies; growing evidence on the efficacy of alpha-2 agonists and the newer generation of dopamine-modulating agents; and recent strides in the evaluation of cognitive-behavioral therapy and deep brain stimulation surgery.

SUMMARY

The correct diagnostic approach to tic disorders requires accurate historical gathering, a thorough neurologic examination, and detailed definition of the patient's psychopathologic profile. Treatment should always begin with individualized psychoeducational strategies. Although pharmacologic treatments remain beneficial for most patients, cognitive-behavioral treatments have thus far shown promising efficacy. Deep brain stimulation surgery should still be limited to adult patients refractory to pharmacotherapy and cognitive-behavioral therapy.

Type IIB thyroplasty for phonic tics in a pediatric patient with autism spectrum disorder: a case report

OBJECTIVES/HYPOTHESIS

Autism spectrum disorders (ASDs) are commonly associated with Tourette syndrome (TS). TS is classically associated with tic production. A tic is defined as sudden, brief, involuntary production of movement (motor tics) or sound (phonic tics).

STUDY DESIGN

Case report.

METHODS

We present a case report of a 14-year-old boy with ASD and vocal tics. Vocal tic frequency was nearly 2000 per day and 90 dB in volume. He presented to our laryngology clinic after multiple failed attempts of pharmacologic management of vocal fold botulinum toxin injection. After evaluation in our clinic, we recommended a lateralization (type IIB) thyroplasty. An autologous cartilage graft from the superior thyroid ala was used and held in place with a bioresorbable mesh. Using 4-0 prolene sutures, the mesh was secured in place. The operation was well tolerated with minimal signs of aspiration, and he was discharged to his home within 48 hours.

RESULTS

Six months postoperatively, there was 90% reduction in tic frequency and 50% reduction in intensity. Additionally, he has shown improved ability to converse with his peers, participate in school activities, and even has improved nutritional status.

CONCLUSIONS

Alteration of laryngeal geometry could serve as an effective site of intervention for intractable phonic tics. Reduction of phonic tic frequency and intensity may also stimulate language development in patients ASD. We also demonstrate additional use of bioresorbable plates in pediatric laryngeal framework surgery. Additional neurophysiologic studies are needed to explore the mechanism by which midline lateralization thyroplasty influences phonic tic generation.

Bridging neuroscience and clinical psychology: cognitive behavioral and psychophysiological models in the evaluation and treatment of Gilles de la Tourette syndrome

Cognitive neuroscience and clinical psychology have long been considered to be separate disciplines. However, the phenomenon of brain plasticity in the context of a psychological intervention highlights the mechanisms of brain compensation and requires linking both clinical cognition and cognitive psychophysiology. A quantifiable normalization of brain activity seems to be correlated with an improvement of the tic symptoms after cognitive behavioral therapy in patients with Gilles de la Tourette syndrome (GTS). This article presents broad outlines of the state of the current literature in the field of GTS. We present our clinical research model and methodology for the integration of cognitive neuroscience in the psychological evaluation and treatment of GTS to manage chronic tic symptoms.

Randomized trial of behavior therapy for adults with Tourette syndrome

CONTEXT

Tics in Tourette syndrome begin in childhood, peak in early adolescence, and often decrease by early adulthood. However, some adult patients continue to have impairing tics. Medications for tics are often effective but can cause adverse effects. Behavior therapy may offer an alternative but has not been examined in a large-scale controlled trial in adults.

OBJECTIVE

To test the efficacy of a comprehensive behavioral intervention for tics in adults with Tourette syndrome of at least moderate severity.

DESIGN

A randomized controlled trial with posttreatment evaluations at 3 and 6 months for positive responders.

SETTING

Three outpatient research clinics.

PATIENTS

Patients (N = 122; 78 males; age range, 16-69 years) with Tourette syndrome or chronic tic disorder were recruited between December 27, 2005, and May 21, 2009.

INTERVENTIONS

Patients received 8 sessions of comprehensive behavioral intervention for tics or 8 sessions of supportive treatment for 10 weeks. Patients with a positive response were given 3 monthly booster sessions.

MAIN OUTCOME MEASURES

Total tic score on the Yale Global Tic Severity Scale and the Clinical Global Impression-Improvement scale rated by a clinician masked to treatment assignment.

RESULTS

Behavior therapy was associated with a significantly greater mean (SD) decrease on the Yale Global Tic Severity Scale (24.0 [6.47] to 17.8 [7.32]) from baseline to end point compared with the control treatment (21.8 [6.59] to 19.3 [7.40]) (P < .001; effect size = 0.57). Twenty-four of 63 patients (38.1%) were rated as much improved or very much improved on the Clinical Global Impression-Improvement scale compared with 4 of 63 (6.4%) in the control group (P < .001). Attrition was 13.9%, with no difference across groups. Patients receiving behavior therapy who were available for assessment at 6 months after treatment showed continued benefit.

CONCLUSION

Comprehensive behavior therapy is a safe and effective intervention for adults with Tourette syndrome.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00231985.

Randomized trial of behavior therapy for adults with Tourette syndrome

CONTEXT

Tics in Tourette syndrome begin in childhood, peak in early adolescence, and often decrease by early adulthood. However, some adult patients continue to have impairing tics. Medications for tics are often effective but can cause adverse effects. Behavior therapy may offer an alternative but has not been examined in a large-scale controlled trial in adults.

OBJECTIVE

To test the efficacy of a comprehensive behavioral intervention for tics in adults with Tourette syndrome of at least moderate severity.

DESIGN

A randomized controlled trial with posttreatment evaluations at 3 and 6 months for positive responders.

SETTING

Three outpatient research clinics.

PATIENTS

Patients (N = 122; 78 males; age range, 16-69 years) with Tourette syndrome or chronic tic disorder were recruited between December 27, 2005, and May 21, 2009.

INTERVENTIONS

Patients received 8 sessions of comprehensive behavioral intervention for tics or 8 sessions of supportive treatment for 10 weeks. Patients with a positive response were given 3 monthly booster sessions.

MAIN OUTCOME MEASURES

Total tic score on the Yale Global Tic Severity Scale and the Clinical Global Impression-Improvement scale rated by a clinician masked to treatment assignment.

RESULTS

Behavior therapy was associated with a significantly greater mean (SD) decrease on the Yale Global Tic Severity Scale (24.0 [6.47] to 17.8 [7.32]) from baseline to end point compared with the control treatment (21.8 [6.59] to 19.3 [7.40]) (P < .001; effect size = 0.57). Twenty-four of 63 patients (38.1%) were rated as much improved or very much improved on the Clinical Global Impression-Improvement scale compared with 4 of 63 (6.4%) in the control group (P < .001). Attrition was 13.9%, with no difference across groups. Patients receiving behavior therapy who were available for assessment at 6 months after treatment showed continued benefit.

CONCLUSION

Comprehensive behavior therapy is a safe and effective intervention for adults with Tourette syndrome.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00231985.

Sensory sensitivity to external stimuli in Tourette syndrome patients

Patients with Tourette Syndrome often state that their sensitivity to sensations is equally or more disruptive than are motor tics. However, their sensory sensitivity is not addressed by standard clinical assessments nor is it a focus of research. This lapse likely results from our limited awareness and understanding of the symptom. In this study (1) we defined the patients' experience of sensitivity to external stimuli in detail, and (2) we tested 2 hypotheses regarding its origin. First, we interviewed in depth and administered a lengthy questionnaire to adult Tourette patients (n = 19) and age-matched healthy volunteers (n = 19). Eighty percent of patients described heightened sensitivity to external stimuli, with examples among all 5 sensory modalities. Bothersome stimuli were characterized as faint, repetitive or constant, and nonsalient, whereas intense stimuli were well tolerated. We then determined whether the sensitivity could be the result of an increased ability to detect faint stimuli. After measuring the threshold of detection for olfactory and tactile stimuli among the patients and healthy volunteers, we found no significant differences between them for either sensory modality. These results indicate that patients' perceived sensitivity derives from altered central processing rather than enhanced peripheral detection. Last, we assessed one aspect of processing: the perception of intensity. When subjects rated the intensity of near-threshold tactile and olfactory stimuli, there was a surprising difference: Tourette patients more frequently used the lowest range of the scale than did healthy volunteers. Future research is necessary to define the anatomical and physiological basis of the patients' experience of heightened sensitivity. © 2011 Movement Disorder Society.

Motor tic disorder and traumatic cervical myelopathy: a case report

The association between motor tics and cervical myelopathy is rare and not well understood. Only a few papers in the literature reported this disorder until the present date. This is a case report of a cervical myelopathy case secondary to a motor tic disorder. A 23-year-old male with a 10-year history of motor tic disorder, involving sudden forced extension of the head and cervical spine. Disturbed tactile sensation and kinetic posturing that progressed to the Lhermitte sign every time he made the movement were detected over the last six months. Magnetic resonance imaging (MRI) showed hyperintense intramedullary lesion at C2-C3, degeneration at C3-C4, and no signs of spinal cord compression. On sagittal view, functional MRI with head extension showed anterior compression with protrusion of the intervertebral disc and posterior compression of the yellow ligaments causing spinal cord stenosis. Anterior discectomy and fixation of C3-C4 were performed. There were no complications. The patient showed improvement and the motor tics were controlled by haloperidol. The patient remains symptom-free after 2 years of follow-up. Uncontrolled motor tics can compromise spinal cord function. Functional MRI can reproduce the abnormal movements and clarify the physiopathology.

Emerging drugs in Tourette syndrome

Proper education of the patient is the first step in the treatment of Tourette syndrome (TS). Before deciding how to treat the patient, it is important to decide whether to treat the TS-related symptoms. Counselling and behavioural modification may be sufficient for those with mild symptoms. Medications, however, may be considered when symptoms begin to interfere with peer relationships, social interactions, academic or job performance, or with activities of daily living. Therapy must be individualised and the most troublesome symptoms should be targeted first. Antidopaminergic agents are clearly the most effective drugs in the treatment of tics. Although haloperidol and pimozide are the only drugs currently approved by the FDA for the treatment of TS, other dopamine receptor-blocking drugs and tetrabenazine, a dopamine depleting drug, as well as botulinum toxin injections, have been used to treat tics associated with TS. Carefully designed, comparative, longitudinal trials assessing the efficacy and adverse-effect profiles of these drugs, including tardive dyskinesia, are lacking. Selective serotonin reuptake inhibitors are recommended for the treatment of obsessive-compulsive behaviour: a common comorbidity. Psychostimulants, such as methylphenidate, are the treatment of choice for attention deficit hyperactivity disorder. Even though these drugs may transiently increase tics, this does not necessarily constitute a definite contraindication to the use of these drugs in patients with TS. Here, existing and emerging medical treatments in patients with tics and comorbid behavioural disorders associated with TS are reviewed.