Evaluation of a cognitive-behavioural program for the management of chronic tic and habit disorders

A Hierarchical Personality Approach Toward a Fuller Understanding of Onychophagia and Compulsive Buying

PURPOSE

Employing a hierarchical model of personality, prior research suggests that cardinal traits such as conscientiousness and agreeability predict central traits such as materialism and need for arousal that in turn impact surface traits such as onychophagia and compulsive buying. More research is needed to explore additional central traits and their effect on onychophagia and compulsive buying. Thus, the goal of the current research is to examine how another central trait-negative perfectionism-impacts onychophagia and compulsive buying.

DESIGN/METHODOLOGY/APPROACH

A survey was administered both online and face-to-face resulting in a sample of 634 subjects of which 391 were individuals with onychophagia. Through a multi-group analysis, a causal model was tested to identify personality traits and their relationship with compulsive buying.

RESULTS

Results showed that onychophagia was affected by other obsessive-compulsive disorders-particularly trichotillomania, and excoriation disorder, which significantly increased the likelihood that the participant was a compulsive buyer.

Tourette Syndrome Treatment Updates: a Review and Discussion of the Current and Upcoming Literature

PURPOSE OF REVIEW

This study aims to examine the treatments currently available for Tourette syndrome (TS) and to discuss evolving therapies, spanning behavioral, pharmacologic, complementary and alternative medicine, and neuromodulation approaches.

RECENT FINDINGS

Behavioral therapies have undergone several modifications to improve accessibility, including transitioning to a virtual format which is particularly important in the current pandemic. There are several recent or ongoing pharmacologic studies that have shown promise including the selective D1 receptor antagonist ecopipam and various cannabinoid compounds. Adaptive DBS may enable the physiologic markers of tics to determine stimulation parameters and improve tic outcomes related to neuromodulation. In recent years, there has been a wealth of research across multiple treatment domains in the TS field. This review highlights exciting and new potential options for the future treatment of patients with TS.

A Review of Cognitive and Behavioral Interventions for Tic Disorder

OBJECTIVES

Tic disorder is a neurodevelopmental disorder characterized by multiple involuntary movements of muscles or vocalization. Although tic symptoms subside as the patient ages, some patients suffer from significant functional impairments related to severe tic symptoms. This manuscript aimed to review the latest scientific evidences for the effect of cognitive-behavioral interventions on tic disorder.

METHODS

The relevant studies were identified by searching medical research databases. We focused our search on studies published between 2000 and 2020 in order to reflect the latest scientific evidence. A total of 821 articles were identified in the initial database search and 27 articles were finally included for the review after the exclusion of duplicated and irrelevant articles.

RESULTS

Behavioral therapies including habit reversal training, Comprehensive Behavioral Intervention for Tics, and exposure and response prevention were the most widely studied interventions for tic disorder and are recommended as first-line treatments for tic disorders with high confidence. Cognitive psychophysiologic approaches were also reported to be effective.

CONCLUSION

Further studies are needed to support the future treatment of tics with low-cost and more widely available treatments, in order to ensure better treatment outcomes.

The Role of Self-Criticism and Shame in Body-Focused Repetitive Behaviour Symptoms

Body-focused repetitive behaviours (BFRBs), such as hair-pulling, skin-picking, and nail-biting, are non-functional habits associated with difficulties in emotion regulation. Although several models have been developed to explain the difficulties experienced by people suffering from BFRBs, a number of cognitive and emotional processes have yet to be explored. This study sought to investigate the psychological characteristics involved in the development and maintenance of BFRB symptoms. In particular, we aimed to evaluate the relationship of self-criticism, shame, and maladaptive cognitive emotion strategies with symptoms and examine if the relationship between perfectionism and symptoms was mediated by self-criticism and shame. Seventy-six participants from a community sample completed a number of self-report measures. Findings from our multivariate linear regression model supported that shame and maladaptive cognitive emotion regulation strategies significantly predicted BFRB symptoms. Results of our mediational analyses revealed that shame significantly mediated the relationship between perfectionism and BFRB symptoms. Interventions that target shame may be beneficial for treating these conditions. Future studies should replicate these findings with clinical populations and other BFRB subtypes.

Targeting Cognitions, Emotions, and Behaviors in a Complex Case of Tourette Syndrome: Illustration of a Psychophysiological Perspective

Recent research stresses that cognitive and affective processes are implicated in Tourette Syndrome (TS) and might influence treatment. The cognitive-behavioral and psychophysiological (CoPs) approach posits that negative appraisals and maladaptive action-planning elicit negative emotions and behaviors that increase muscular tension and thus the urge to tic in TS. Hence, the CoPs targets cognitive-behavioral and affective processes increasing tension prior to tic onset. This article provides clinically novel information in the implementation and utility of the CoPs approach in a severe case of a young man with TS and a range of comorbidities marked by negative cognitions and emotions as well as planning deficits with a long-term follow-up. He received 14 sessions of CoPs therapy. Tic severity significantly decreased post-treatment with maintenance up to 36-months. The process measure of action-planning improved significantly from pre-treatment to 12-months follow-up. Results support the feasibility and acceptability of the CoPs in treating complex TS cases.

[Tourette syndrome: Research challenges to improve clinical practice]

Tourette syndrome is a neurodevelopmental disorder which is characterized by the presence of motor and phonic tics. These tics are generally more prevalent in childhood. Tics typically reach their maximum severity before puberty, around age 10 to 12. In most patients, tic severity usually decreases during late adolescence and adulthood. However, this is not true for all individuals. To date, the developmental trajectory leading to the persistence of tics into adulthood is still poorly understood. There are very few markers that can predict the evolution of tic symptoms from childhood to adulthood. Yet, while we cannot cure Tourette syndrome, it is possible to reduce tic severity with various treatments. The most common treatments are pharmacotherapy and behavioral and cognitive-behavioral therapy. However, there appears to be a limit to the proportion of tics that can be treated, since most treatments offer an average reduction in tics of no more than 50%. Thus, at first, this article reviews recent advances in treatment and symptom progression. Next, we propose some lines of research to improve the management and treatment of people with Tourette syndrome.

Evidence-based treatment of Tourette's disorder and chronic tic disorders

Introduction: Chronic Tic Disorders and Tourette's Disorder (collectively referred to as TD) are characterized by sudden, rapid, and repetitive motor movements or vocalizations called tics. Children, adolescents, and adults with TD often experience co-occurring psychiatric symptoms and impairments in multiple domains. As a result of tics and other symptoms, patients with TD can develop negative self-views, require considerable accommodations, and experience a poor quality of life. Therefore, the efficient and effective management of TD bears considerable importance. Areas covered: This expert review evaluated the empirical support for behavioral and pharmacological interventions based on the results of randomized controlled trials (RCTs). Behavioral interventions evaluated include habit reversal training (HRT), comprehensive behavioral intervention for tics (CBIT), and exposure response prevention (ERP). Reviewed pharmacological interventions included alpha-2 agonists, antipsychotics, and anticonvulsants. Expert opinion: This review identified several efficacious behavioral and pharmacological interventions for TD. However, several gaps in the management of TD include: (1) the access/availability of behavioral interventions, (2) novel and more efficacious treatment approaches, and (3) the development of more comprehensive interventions to manage TD. In order to advance the treatment of TD, additional research is necessary to efficiently, effectively, and comprehensively develop and evaluate new treatments for patients with TD.

[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.

The psychology of Tourette disorder: Revisiting the past and moving toward a cognitively-oriented future

Tourette syndrome is a neurodevelopmental disorder characterized by chronic tics (i.e., repetitive and stereotyped movements and vocalizations) and premonitory urges (i.e., aversive sensations preceding tics that are alleviated once a tic is performed). Research supports that dysfunctional neurobiological and psychological processes interact and contribute to the development and maintenance of tics. However, psychological theories of Tourette syndrome and accompanying research have mainly focused on the emotional states (e.g., anxiety and frustration) and behavioural principles (i.e., operant conditioning) that play a role in tic exacerbation. This selective review summarizes key discoveries pertaining to the emotional and behavioural aspects of Tourette syndrome but also proposes a more comprehensive, cognitively-oriented conceptualization of the disorder. Specifically, it is proposed that maladaptive beliefs about discomfort and about one's ability to cope with discomfort underlie negative appraisals of unpleasant sensory experiences in individuals with Tourette syndrome. It is further suggested that these beliefs lead individuals to perceive premonitory urges in a catastrophic manner and thereby enhance tic frequency. Concrete research avenues to empirically examine these hypotheses are outlined and clinical implications for the field of cognitive-behaviour therapy are discussed.

Self-esteem in adults with Tourette syndrome and chronic tic disorders: The roles of tic severity, treatment, and comorbidity

BACKGROUND

Tourette syndrome (TS) and chronic tic disorders (CTD) are stigmatizing disorders that may significantly impact self-esteem. Alternatively, comorbid psychiatric illnesses may affect self-esteem more than tics themselves. Extant research on self-esteem in TS/CTD is limited, has inconsistently examined the effect of comorbidities on self-esteem, and yields mixed findings.

METHOD

This study aimed to clarify the roles of tics versus comorbid diagnoses on self-esteem in a large, carefully diagnosed sample of adults with TS/CTD (N = 122) receiving 10 weeks of Comprehensive Behavioral Intervention for Tics (CBIT) or Psychoeducation and Supportive Therapy (PST).

RESULTS

Baseline self-esteem did not differ between adults with TS/CTD only and normative means, whereas self-esteem was significantly lower among adults with TS/CTD with a comorbid psychiatric illness. In a multiple regression testing the baseline association between tic severity, presence of comorbid psychiatric illness, and depression severity with self-esteem, comorbidity and depression severity were significantly associated with self-esteem, whereas tic severity was not. Finally, using a generalized linear model, we tested the effects of treatment assignment, comorbidity, and their interaction on changes in self-esteem across treatment, controlling for baseline depression severity. Results showed that for those with a comorbid illness, self-esteem improved significantly more with CBIT than with PST.

CONCLUSIONS

Comorbid illnesses appear to affect self-esteem more so than tics among adults with TS/CTD. Therapeutic attention should be paid to treating comorbid diagnoses alongside tics when treating TS/CTD.

A Randomized Controlled Trial Comparing Behavioral, Educational, and Pharmacological Treatments in Youths With Chronic Tic Disorder or Tourette Syndrome

CONTEXT

The existing literature on the treatment of pediatric chronic tic disorder (CTD) and Tourette syndrome (TS) indicates that both behavioral therapy (BT) and pharmacotherapy (PT) are effective for reducing symptoms.

OBJECTIVE

To evaluate the efficacy of BT compared to psychoeducation (PE) or PT for reducing tics and co-occurring symptoms and for improving quality of life (QoL) in a sample of youths with CTD and TS.

DESIGN

A 10 weeks, 2 sites (Catania, Rome) randomized controlled trial. Participants were randomized to receive one of the following treatments: BT, PE, or PT.

PARTICIPANTS

110 outpatients aged between 8 and 17 years affected by CTD or TS.

RESULTS

Patients in the BT and PT groups showed a significant reduction in the severity of tic symptoms, while the PE group did not show any improvement. PT was more effective for reducing obsessive compulsive symptoms than BT, while PE group did not show any improvement. Both BT and PT groups showed an improvement in most QoL domains, whereas no differences were found in the PE group.

CONCLUSIONS

BT is as effective as pharmacological therapy in the treatment of tic disorders in children and adolescents, thus offering an alternative to medications for CTD and TS.

P300 Source Localization Contrasts in Body-Focused Repetitive Behaviors and Tic Disorders

Tic disorders (TD) and body-focused repetitive behaviors (BFRB) have similar phenotypes that can be challenging to distinguish in clinical settings. Both disorders show high rates of comorbid psychiatric conditions, dysfunctional basal ganglia activity, atypical cortical functioning in the prefrontal and motor cortical regions, and cognitive deficits. Clinicians frequently confound the two disorders and it is important to find reliable objective methods to discriminate TD and BFRB. Neuropsychological tests and event-related potential (ERP) studies have yielded inconsistent results regarding a possible context updating deficit in TD and BFRB patients. However, most previous studies did not control for the presence of comorbid psychiatric condition and medication status, which might have confounded the findings reported to date. Hence, we aimed to investigate the psychophysiology of working memory using ERP in carefully screened TD and BFRB patients excluding those with psychiatric comorbidity and those taking psychoactive medication. The current study compared 12 TD patients, 12 BRFB patients, and 15 healthy control participants using a motor oddball task (button press). The P300 component was analyzed as an index of working memory functioning. Results showed that BFRB patients had decreased P300 oddball effect amplitudes over the right hemisphere compared to the TD and control groups. Clinical groups presented different scalp distributions compared to controls, which could represent a potential endophenotype candidate of BFRB and TD.

Behavioral therapy for Tourette syndrome and chronic tic disorders

Purpose of review

To summarize behavioral interventions for the treatment of primary tic disorders.

Recent findings

Although tics were attributed to a disordered weak volition, the shift towards neurobiological models of tic disorders also transformed nonpharmacologic treatment practices. Current international guidelines recommend habit reversal training, comprehensive behavioral intervention, and exposure and response prevention as first-line therapies for tics. Appropriate patient selection, including age and presence of comorbidities, are salient clinical features that merit consideration. Evidence for further behavioral interventions is also presented.

Summary

Currently recommended behavioral interventions view tics as habitual responses that may be further strengthened through negative reinforcement. Although availability and costs related to these interventions may limit their effect, Internet-based and telehealth approaches may facilitate wide accessibility. Novel nonpharmacologic treatments that take different approaches, such as autonomic modulation or attention-based interventions, may also hold therapeutic promise.

Cognitive-Behavioral Treatment of Trichotillomania, Targeting Perfectionism

Trichotillomania or hair pulling has been considered mainly as a tensionreducing habit. However, other cognitive, emotional, and situational factors have been identified as important in the development andmaintenance of this disorder. The present case study applied habit reversal techniques, with the addition of a cognitive modification of perfectionist beliefs and style of action, in the treatment of a 23-year-old woman. During an 18-week period, her hair-pulling behavior decreased from a mean of 24 hairs pulled each day to 1 hair pulled overall in a week. A 1.5-year follow-up showed that the client suffered a small relapse during a period of 2 weeks. A self-imposed return to cognitive and behavioral techniques eliminated further pulling. This single case report raises the possibility that perfectionismmay be an important target for cognitive-behavioral treatment intervention in habit disorders such as trichotillomania.

The Impact of a Cognitive-Behavioral Therapy on Event-Related Potentials in Patients with Tic Disorders or Body-Focused Repetitive Behaviors

CONTEXT

Tic disorders (TD) are characterized by the presence of non-voluntary contractions of functionally related groups of skeletal muscles in one or multiple body parts. Patients with body-focused repetitive behaviors (BFRB) present frequent and repetitive behaviors, such as nail biting or hair pulling. TD and BFRB can be treated with a cognitive-behavioral therapy (CBT) that regulates the excessive amount of sensorimotor activation and muscular tension. Our CBT, which is called the cognitive-psychophysiological (CoPs) model, targets motor execution and inhibition, and it was reported to modify brain activity in TD. However, psychophysiological effects of therapy are still poorly understood in TD and BFRB patients. Our goals were to compare the event-related potentials (ERP) of TD and BFRB patients to control participants and to investigate the effects of the CoPs therapy on the P200, N200, and P300 components during a motor and a non-motor oddball task.

METHOD

Event-related potential components were compared in 26 TD patients, 27 BFRB patients, and 27 control participants. ERP were obtained from 63 EEG electrodes during two oddball tasks. In the non-motor task, participants had to count rare stimuli. In the motor task, participants had to respond with a left and right button press for rare and frequent stimuli, respectively. ERP measures were recorded before and after therapy in both patient groups.

RESULTS

CoPs therapy improved symptoms similarly in both clinical groups. Before therapy, TD and BFRB patients had reduced P300 oddball effect during the non-motor task, in comparison with controls participants. An increase in the P300 oddball effect was observed posttherapy. This increase was distributed over the whole cortex in BFRB patients, but localized in the parietal area in TD patients.

DISCUSSION

These results suggest a modification of neural processes following CoPs therapy in TD and BFRB patients. CoPs therapy seems to impact patients' attentional processes and context updating capacities in working memory (i.e., P300 component). Our results are consistent with a possible role of the prefrontal cortex and corpus callosum in mediating interhemispheric interference in TD.

The Effect of a New Therapy for Children with Tics Targeting Underlying Cognitive, Behavioral, and Physiological Processes

Tourette disorder (TD) is characterized by motor and vocal tics, and children with TD tend to present a lower quality of life than neurotypical children. This study applied a manualized treatment for childhood tics disorder, Facotik, to a consecutive case series of children aged 8-12 years. The Facotik therapy was adapted from the adult cognitive and psychophysiological program validated on a range of subtypes of tics. This approach aims to modify the cognitive-behavioral and physiological processes against which the tic occurs, rather than only addressing the tic behavior. The Facotik therapy lasted 12-14 weeks. Each week 90-min session contained 20 min of parental training. The therapy for children followed 10 stages including: awareness training; improving motor control; modifying style of planning; cognitive and behavioral restructuring; and relapse prevention. Thirteen children were recruited as consecutive referrals from the general population, and seven cases completed therapy and posttreatment measures. Overall results showed a significant decrease in symptom severity as measured by the YGTSS and the TSGS. However, there was a discrepancy between parent and child rating, with some children perceiving an increase in tics, possibly due to improvement of awareness along therapy. They were also individual changes on adaptive aspects of behavior as measured with the BASC-2, and there was variability among children. All children maintained or improved self-esteem posttreatment. The results confirm the conclusion of a previous pilot study, which contributed to the adaptation of the adult therapy. In summary, the Facotik therapy reduced tics in children. These results underline that addressing processes underlying tics may complement approaches that target tics specifically.

Behavior Therapy for Tic Disorders: An Evidenced-based Review and New Directions for Treatment Research

Behavior therapy is an evidenced-based intervention with moderate-to-large treatment effects in reducing tic symptom severity among individuals with Persistent Tic Disorders (PTDs) and Tourette's Disorder (TD). This review describes the behavioral treatment model for tics, delineates components of evidence-based behavior therapy for tics, and reviews the empirical support among randomized controlled trials for individuals with PTDs or TD. Additionally, this review discusses several challenges confronting the behavioral management of tics, highlights emerging solutions for these challenges, and outlines new directions for treatment research.

The Role of Cognitions and Beliefs in Trichotillomania: A Qualitative Study Using Interpretative Phenomenological Analysis

Trichotillomania (TTM) is characterised by the removal of one's hair, causing hair loss. Phenomenological research on TTM has investigated its associated behavioural and affective factors. Few studies have investigated the possible role of cognitions and beliefs, despite emerging support for cognitive therapies in treating this disorder. This study aimed to explore and describe the cognitions and beliefs that contribute to the onset and maintenance of hairpulling in TTM. Eight women with TTM participated in semi-structured, in-depth interviews to explore their experience of cognitions and beliefs before, during and after typical hairpulling episodes. Interviews were analysed using the qualitative method of Interpretative Phenomenological Analysis. Six superordinate themes of beliefs were identified as important: negative self-beliefs, control beliefs, beliefs about coping, beliefs about negative emotions, permission-giving beliefs, and perfectionism. These preliminary findings suggest that cognitions may play an important role in TTM phenomenology. Future quantitative research on the role of cognitions and beliefs in TTM in larger samples has the potential to advance cognitive-behavioural models and treatments of this poorly understood disorder.

Psychological treatments for trichotillomania: update and future directions

OBJECTIVE

This paper aims to provide an overview of evidence-based psychological treatments for trichotillomania.

CONCLUSIONS

Advances in the understanding of the phenomenology of trichotillomania has led to the augmentation of behavioural treatments with dialectical behaviour therapy and acceptance and commitment therapy. Further studies of treatment component efficacy and cognitive behavioural models are required.

Cognitive Behavioral Therapy in Movement Disorders: A Review

In addition to motor symptoms, patients with movement disorders often complain of psychiatric disturbances, including mood, anxiety, and impulse-control disorders and psychosis. These abnormalities are often misdiagnosed and left untreated, thus resulting in a worse prognosis and lower quality of life. Besides the use of standard pharmacological treatments, psychiatric abnormalities can be treated by means of nonpharmacological approaches. These approaches include various types of psychological therapies, the most widely used being cognitive behavioral therapy (CBT). We reviewed all articles, conducted until 2014, that contained primary data derived from clinical trials and case reports on the effect of CBT in the most common movement disorders. One randomized, controlled study and several uncontrolled studies on the efficacy of CBT in Parkinson's disease (PD) have shown a short-term benefit of depression and anxiety. In Tourette's syndrome (TS), CBT has been assessed in a number of large controlled clinical trials that have demonstrated an improvement in psychiatric disturbances and tics. There are no controlled studies on the efficacy of CBT in other types of movement disorders, such as dystonia, Huntington's disease, and essential tremor. Only a limited number of studies have evaluated the efficacy of CBT in the management of psychiatric disorders in movement disorders. The evidence available suggests that CBT is useful in TS and probably useful in PD. We recommend the planning of randomized, controlled clinical trials to investigate the effects of CBT and group CBT in the treatment of psychiatric disturbances in movement disorders.

The impact of emotions on body-Focused repetitive behaviors: evidence from a non-treatment-seeking sample

Body-focused repetitive behaviors (BFRBs) are repetitive, injurious, and non-functional habits that cause significant distress or impairment, including hair-pulling, skin-picking, and nail-biting. The emotion regulation (ER) model suggests that BFRBs are triggered by negative emotions and reinforced by alleviation of unpleasant affect. The frustrated action (FA) model suggests that BFRBs are triggered by and alleviate impatience, boredom, frustration, and dissatisfaction. Individuals with BFRBs are hypothesized to be particularly susceptible to these emotions because they demonstrate maladaptive planning styles characterized by high standards and unwillingness to relax.

OBJECTIVES

The objective of this study was to test these two models.

METHODS

This study compared urge to engage in BFRBs in a BFRB group (n = 24) and a control group (n = 23) in experimental conditions designed to elicit boredom/frustration, stress, and relaxation, respectively.

RESULTS

The BFRB group reported a significantly greater urge to engage in BFRBs than did the control group across conditions. Participants in the BFRB group reported a stronger urge to engage in BFRBs in the boredom/frustration condition than in the relaxation condition but not in the stress condition. Finally, the BFRB group presented significantly higher scores on maladaptive planning style, and maladaptive planning style was significantly correlated with difficulties with ER.

LIMITATIONS

Future studies may wish to exclusively use validated mood induction techniques and more stringent inclusion criteria.

CONCLUSIONS

The results highlight the role of boredom, frustration, and impatience in triggering BFRBs, and support the FA model.

Cognitive behavior therapy for obsessive-compulsive and related disorders

Cognitive behavior therapy (CBT) is considered a first-line intervention for obsessive-compulsive disorder (OCD) across the lifespan. Efficacy studies of CBT with exposure and response prevention suggest robust symptom reduction, often with sustained remission. Acceptability of CBT is high, and the treatment is devoid of adverse side effects. The primary mechanism of CBT is based on operant principles, specifically extinction learning. The efficacy of extinction-based treatments such as CBT is being shown for other obsessive-compulsive spectrum disorders. This article reviews the theoretic basis, clinical application, and relevant treatment outcome research for CBT and related therapies for several obsessive-compulsive spectrum disorders.

A meta-analysis of behavior therapy for Tourette Syndrome

Individual randomized controlled trials (RCTs) of habit reversal training and a Comprehensive Behavioral Intervention for Tics (collectively referred to as behavior therapy, BT) have demonstrated efficacy in reducing tic severity for individuals with Tourette Syndrome and Chronic Tic Disorders (collectively referred to as TS), with no examination of treatment moderators. The present meta-analysis synthesized the treatment effect sizes (ES) of BT relative to comparison conditions, and examined moderators of treatment. A comprehensive literature search identified eight RCTs that met inclusion criteria, and produced a total sample of 438 participants. A random effects meta-analysis found a medium to large ES for BT relative to comparison conditions. Participant mean age, average number of therapy sessions, and the percentage of participants with co-occurring attention deficit hyperactivity disorder (ADHD) were found to moderate treatment effects. Participants receiving BT were more likely to exhibit a treatment response compared to control interventions, and identified a number needed to treat (NNT) of three. Sensitivity analyses failed to identify publication bias. Overall, BT trials yield medium to large effects for TS that are comparable to treatment effects identified by meta-analyses of antipsychotic medication RCTs. Larger treatment effects may be observed among BT trials with older participants, more therapeutic contact, and less co-occurring ADHD.

The Modulating Role of Stress in the Onset and Course of Tourette's Syndrome: A Review

Accumulating data indicate a common occurrence of tic exacerbations and periods of psychosocial stress. Patients with Tourette's syndrome (TS) also exhibit aberrant markers of hypothalamic-pituitary-adrenal (HPA) axis activation. Based on these findings, a functional relationship between stress and tic disorders has been suggested, but the underlying mechanism of how stress may affect tic pathology remains to be elucidated. We suggest that dopaminergic and noradrenergic neurotransmission as well as immunology play a crucial role in mediating this relationship. Two possibilities of causal direction might be assumed: (a) psychosocial stress might lead to an exacerbation of tics via activation of HPA axis and subsequent changes in neurotransmission or immunology and (b) TS-related abnormalities in neurotransmission or immunology result in a higher vulnerability of affected patients to respond to psychosocial stress with a strong activation of the HPA axis. It may also be the case that both assumptions hold true and interact with each other.

Cognitive aspects of hyperactivity and overactivity in preadolescents with tourette syndrome

Attention deficit disorder with hyperactivity (ADHD) is a common comorbidity in children with Tourette syndrome (TS). However, motor restlessness and high levels of sensorimotor activation or “overactivity” may be a feature of TS rather than a distinct ADHD comorbidity. The link between overactivity and ADHD in TS has yet to be established and in particular between adult and preadolescent manifestations. The current study furthers this understanding of ADHD features in TS by investigating the relationship between cognitive and behavioral aspects of ADHD and TS. The style of planning (STOP) overactivity scale was compared in preadolescent (n = 17) and adult (n = 17) samples. The STOP overactivity scale measures the characteristic overactive style of planning in everyday life. The aims of the study were twofold as follows: (1) to see if an overactive style was present in adolescents as well as in adults, and (2) to see if this overactive style correlated with hyperactivity, impulsivity, or perfectionism. Results suggest that overactivity may be a better description of the hyperactivity manifestations in TS. Behavioral components of overactivity were present in preadolescents while the cognitive components were more frequent in adults. Overactivity relates at the same time to perfectionism and impulsivity.

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.

Middle ear myoclonus associated with forced eyelid closure in children: diagnosis and treatment outcome

OBJECTIVES/HYPOTHESIS

Forceful eyelid closure syndrome (FECS) was first reported at the Proceedings of the Second International Tinnitus Seminar in 1983. The main symptom of this syndrome is a spontaneous muscular tinnitus related only to forced eye closure, specifically the voluntary contraction of the periorbital muscles. Although investigation of the syndrome was initiated >100 years ago, only four cases have been published in the past 20 years. We report six cases of middle ear myoclonus tinnitus diagnosed as FECS in children and discuss issues surrounding the diagnosis and treatment of this syndrome.

STUDY DESIGN

Retrospective case series.

METHODS

From 2009 to 2011, six children complaining of clicking or crackling sounds in their ears presented at Seoul St. Mary's Hospital. Endoscopic examination and recording of the tympanic membrane were performed while the patients were asked to close their eyes forcefully. Audiologic studies including acoustic reflex decay and static compliance were performed for documentation of the movement of the tympanic membrane. Triggering factors of FECS in the children were carefully evaluated.

RESULTS

Synchronous movement of the tympanic membrane in response to forced eye closure on endoscopic examination was the most reliable finding to diagnose FECS. Acoustic reflex decay and other impedance audiogram findings showed irregular perturbations during forced eye closure, which led to diagnosis of the tinnitus as middle ear myoclonus. Most of the patients had triggering factors for FECS. Reassurance and removal of the triggering or causal factors with or without medication improved clicking sounds coming from middle ear myoclonus.

CONCLUSIONS

FECS is a rare clinical entity and can be easily missed in routine clinical examination. We suggest that patients, especially children, with clicking or crackling tinnitus should be evaluated for FECS using proper diagnostic tools. A possible mechanism of FECS in children postulated from our case review is suggested.

Therapie der Tic-Störungen

Seit dem Erscheinen unserer letzten Übersichtsarbeit zur «Therapie der Tic-Störungen» in der Zeitschrift für Kinder- und Jugendpsychiatrie wurden große Fortschritte auf diesem Gebiet erzielt. So wurden einzelne Bausteine auf dem Weg zur optimalen Behandlung konkretisiert, z. B. Veröffentlichung einheitlicher Kriterien zur Behandlungsindikation oder Entwicklung und Evaluierung eines detaillierten verhaltenstherapeutischen Manuals zum Habit-Reversal-Training. Daneben sind neue Therapiemöglichkeiten, wie das Medikament Aripiprazol oder die Tiefenhirnstimulation, erfolgreich implementiert worden. Auch wurde das Augenmerk viel stärker auf begleitende Störungen, wie ADHS und Zwangsstörungen, gerichtet, da diese in der Regel eine besonders starke Beeinträchtigung für die weitere Entwicklung des Kindes oder Jugendlichen darstellen. Dennoch bestehen weiterhin große Wissenslücken über die Effektivität der einzelnen Behandlungsmethoden, möglicher Kombinationsbehandlungen sowie deren direkter Vergleich untereinander. Daneben erschwert das Fehlen jeglicher Parameter zur Vorhersage der individuell sehr unterschiedlichen Entwicklung der Tics über die nächsten Monate und Jahre eine evidenzbasierte Therapieempfehlung und damit das Erlernen der Feinheiten bei der Behandlung von Tic-Störungen. Zusammengefasst ist noch immer eine große klinische Erfahrung für die Therapieentscheidungen beim einzelnen Patienten von großem Vorteil angesichts der enormen Bandbreite an individueller Tic-Symptomatik und Komorbidität gepaart mit den unvorhersehbaren Schwankungen im zeitlichen Verlauf.

European clinical guidelines for Tourette syndrome and other tic disorders. Part III: behavioural and psychosocial interventions

This clinical guideline provides recommendations for the behavioural and psychosocial interventions (BPI) of children and adolescents with tic disorders prepared by a working group of the European Society for the Study of Tourette Syndrome (ESSTS). A systematic literature search was conducted to obtain an update on the efficacy of BPI for tics. Relevant studies were identified using computerised searches of the Medline and PsycINFO databases and the Cochrane Library for the years 1950-2010. The search identified no meta-analyses, yet twelve (systematic) reviews and eight randomised controlled trials provided evidence for the current review. Most evidence was found for habit reversal training (HRT) and the available but smaller evidence also supports the efficacy of exposure with response prevention (ERP). Both interventions are considered first line behavioural treatments for tics for both children and adults and should be offered to a patient, taking into account his preference. Treatments that are considered second line or add-on behavioural treatments are contingency management, function based interventions and relaxation training. Neurofeedback is still experimental. Almost no research was identified that examined the efficacy of psychosocial interventions, e.g., psychoeducation and group work. Based on clinical practice, this guideline recommends behavioural treatment as first line offer to patients in most cases. It should be embedded within a psychoeducational and supportive context and can be combined with drug treatment.

Cognitive-behavioral therapy for childhood repetitive behavior disorders: tic disorders and trichotillomania

This article provides an overview of cognitive-behavioral therapy (CBT) for repetitive behavior disorders. Because tic disorders and trichotillomania are the most often studied and most debilitating of these conditions, this article focuses on the efficacy of CBT for these 2 conditions. An overview of CBT for children presenting with these concerns is provided. This review focuses particularly on habit reversal training, which is at the core of most CBT-based interventions. Two recent empirical studies on the immense potential of CBT in treating childhood repetitive behavior disorders and future areas of research are also discussed.

Application of Habit Reversal Training for the Treatment of Tics in Early Childhood

Habit-reversal training (HRT) has demonstrated efficacy in adults and in children above 9 years of age with tic disorders. However, less is known about the utility of this treatment with children younger than 9 years of age.This is alarming given that most children with tic disorders experience symptom onset before 9 years and that existing pharmacological treatments show modest efficacy, may have side effects, and may not be an acceptable intervention to parents. With this in mind, this case report documents the use of HRT with a 6-year-old female with pronounced and impairing motor tics. Throughout the course of the treatment (eight sessions) “Megan” showed improvement in her ability to control her symptoms. Furthermore, treatment gains and improved quality of life were maintained at follow-up. This case report suggests the utility of HRT for the treatment of tics in early childhood, with developmental considerations and the integration of family-based skills training.

Cognitive behavioral management of Tourette's syndrome and chronic tic disorder in medicated and unmedicated samples

OBJECTIVE

Cognitive behavior therapy (CBT) and medication can be administered in combination in treating tic disorders but there are no studies evaluating the effectiveness of CBT with and without medication. The current study compares the efficacy of CBT in combination with medication and without medication.

METHOD

CBT was administered in a consecutively referred sample of 76 people diagnosed either with Gilles de la Tourette Syndrome or chronic tic disorder. The sample was divided into a medicated and a non-medicated group. Twenty three were stabilized on medication and 53 were not receiving medication. Measures administered pre- and post-CBT in both groups included: main outcome measure of Tourette Syndrome Global Scale and measures of mood.

RESULTS

Repeated measures analysis of variance on the initial sample revealed no difference between medicated and non-medicated groups in outcome. A further analysis comparing the 23 receiving medication with 23 not receiving medication matched on baseline clinical variables also yielded no significant group differences, either in treatment outcome on main tic outcome measures or on other clinically relevant questionnaires.

DISCUSSION

CBT for tic disorders is an effective treatment administered either in combination with medication or alone.

Habit Reversal Treatment of Repetitive Hand Writing in a 7-Year-Old Child with a Learning Disability

Habit reversal (HR) is a cognitive—behavioral treatment for tic disorders, Tourette syndrome, stereotypic movements, and habit disorders. This case study utilizes aspects of habit reversal, including awareness training, self-monitoring, and competing response training, as an intervention for obsessive—compulsive repetitive air handwriting in a 7-year-old girl with a significant learning disability. Therapy is provided on an outpatient basis in a private practice setting. Analysis of in-home, at-school, and in-session data collected by the parents, teacher, and therapist show decreased frequency in repetitive handwriting. Supplemental and cojoint administration of antianxiety medication extinguishes all obsessive handwriting within a 6-month period. These results support previous research demonstrating the efficacy of cojoint cognitive—behavioral and medication treatment of acute obsessive—compulsive symptomatology in children.

Cognitive-behaviour therapy and skilled motor performance in adults with chronic tic disorder

The first aim of the present study was to compare performance of people with tic disorders (TD) and controls on executive function and a range of skilled motor tests requiring complex performance, guided movements, hand co-ordination, and fine control of steadiness. The second aim was to investigate the effect of cognitive behaviour therapy (CBT) on motor performance. A total of 55 patients with TD were recruited at baseline from participants in a behavioural management programme. A comparison group of 55 patients suffering from a variety of habit disorders (HD) involving complex manual movements, were matched on age and level of education to 34 non-psychiatric controls. Participants were evaluated pre- and post-treatment and post-waitlist with a neuropsychological evaluation focusing on executive function (Wisconsin Card Sorting Test, WCST) and skilled motor performance (Purdue Pegboard, Hole Steadiness Test, and the Groove Test). Results revealed WCST scores in the normal range, while motor performance differed significantly on the Purdue Pegboard Tests in both TD and HD as compared to the control group. Cognitive-behavioural treatment selectively improved motor performance in both clinical groups compared to waitlist control, and this improvement related to clinical outcome measures.

Behavior therapy in tic-disorders with co-existing ADHD

OBJECTIVES

To give an overview concerning the behavioral treatment approaches for Chronic Tic Disorder (CTD) and Attention-Deficit/Hyperactivity Disorder (ADHD) and to provide some suggestions for the behavioral treatment of children and adolescents with a combination of both disorders.

RESULTS

Pharmacotherapy plays an important role in the treatment of both ADHD and CTD. However, behavior therapy has also been proven to ameliorate the core symptoms of both disorders. The most prominent behavioral technique to reduce tics is habit reversal training. In ADHD behavioral interventions, especially parent training and behavioral interventions in preschool/school, are effective in reducing ADHD core symptoms and comorbid problems. In children and adolescents with ADHD plus CTD both ADHD and tic symptoms can be treated by behavioral interventions alone or in combination with pharmacotherapy. However, most of the published studies on behavioral interventions in children with ADHD or CTD do not give detailed information on comorbidity and many studies excluded patients with comorbid problems.

CONCLUSIONS

Clinical experience suggests that in CTD+ADHD success may be easier to achieve using behavioral treatment of ADHD first. Adherence to the habit reversal procedure to reduce tics in daily living is the most important problem in the behavioral treatment of tics especially in children with comorbid ADHD. Practical suggestions to overcome these difficulties are presented.

Tic- und Zwangsstörungen

Zusammenfassung. In diesem Übersichtsartikel werden die Gemeinsamkeiten und Unterschiede von Tic- und Zwangsstörungen auf verschiedenen Ebenen dargestellt. In der Psychopathologie unterscheiden sich beide Phänomene zunächst deutlich - Tics sind plötzlich auftretende, unwillkürliche, motorische Bewegungen oder Vokalisationen. Zwänge sind wiederholte, zweckmäßige und beabsichtigte Verhaltensweisen. Es gibt jedoch fließende Übergänge, die sich vor allem bei den Just-Right-Zwängen manifestieren, die bei Tourette-Störungen gehäuft auftreten. Die diagnostischen Strategien und die dabei hilfreichen Instrumente werden vorgestellt. In der Therapie haben sich bei beiden Störungen sowohl verhaltenstherapeutische als auch pharmakotherapeutische Verfahren bewährt. Es wird eine Übersicht über den Stand der empirischen Evidenz gegeben. Die Behandlung von kombinierten Tic- und Zwangsstörungen wird speziell erörtert.

Habit reversal versus supportive psychotherapy in Tourette's disorder: A randomized controlled trial and predictors of treatment response

Tourette syndrome (TS) is characterized by chronic motor and vocal tics. Habit reversal therapy (HR) is a behavioral treatment for tics which has received recent empirical support. The present study compared the efficacy of HRT in reducing tics, improving life-satisfaction and psychosocial functioning in comparison with supportive psychotherapy (SP) in outpatients with TS. In addition, we investigated whether impairments in response inhibition in patients with TS predict response to HR treatment which specifically aims to inhibit tics. Thirty adult outpatients with DSM-IV TS were randomized to 14 individual sessions of HR (n = 15); or SP (n = 15). HR but not SP reduced tic severity over the course of the treatment. Both groups improved in life-satisfaction and psychosocial functioning during active treatment. Reductions in tic severity (HR) and improvements in life-satisfaction and psychosocial functioning (HR and SP) remained stable at the 6-month follow-up. The extent of pre-treatment response inhibition impairment in the HR group predicted reductions in tic-severity from pre- to post-treatment. Our results suggest that HR has specific tic-reducing effects although SP is effective in improving life-satisfaction and psychosocial functioning. Assessments of response inhibition may be of value for predicting treatment response to HR.