Subject:
Tourette's Syndrome

Short Description:
Habit Reversal Training Effective Treatment for Tourette’s Syndrome

Background:
The first line treatment for patients with Tourette’s syndrome is low-dose, high potency antipsychotic medications. Ziprasidone (Geodon) and risperidone (Risperdal) have been proven to be effective in reducing the severity of tics in children, although not for eliminating them (Salee FR et al., J Am Acad Child Adolesc Psych 2000;39(3):292– 299; Scahill et al., Neurology 2003;60(7): 1130–1135). For many families, the risk of using antipsychotics long term is daunting, and if a different treatment were to prove as effective, it would be welcome. Recently, a group of researchers examined the efficacy of comprehensive behavioral intervention therapy (CBIT) for the treatment of Tourette’s syndrome. One hundred and twenty-six children, ranging in age from nine to 17 years (mean age 11.7) with Tourette’s syndrome were randomly assigned to one of two conditions: a special type of behavioral therapy called comprehensive behavioral intervention therapy (CBIT) (61 patients), or a control that consisted of supportive therapy and education, the usual adjuncts to medication (65 patients). Each group had eight sessions of their assigned therapy over a course of 10 weeks. Responders received three monthly “booster treatments” and were evaluated at three and six months post-treatment. Participants were aware of their assigned condition, but evaluators were not. Thirty eight percent of children entering the study continued taking their tic-suppressing or other psychiatric medication throughout the study, as long as they had been on a stable dose for six weeks and made no changes throughout the course of the research. These children were randomly assigned to each group, and there were no significant between group differences in regard to medication. The CBIT focused mainly on habit reversal training. This practice teaches children to recognize when a tic is about to occur and engage in a voluntary behavior that is incompatible with the tic until the urge passes. For example, for children with a neck-jerking tic, this might mean looking down and tensing the neck until the urge goes away. According to researchers, this teaches children to establish behavior that counters the urge to perform the tic, rather than just suppresses the tic. CBIT resulted in significantly greater reduction in tic severity, based on the Yale Global Tic Severity Scale (from 24.7 to 17.1), than the control treatment (24.6 to 21.1). Significantly more CBIT participants were rated “very much improved” or “much improved” on the CGI-I scale compared to control participants (52.5% vs. 18.5%). Six months after treatment, 87% of available CBIT participants were continuing to benefit from the treatment (Piacentini J et al., JAMA 2010;303(19):1929–1937).

TCPR's Take:
This research is good news for our patients with Tourette’s syndrome. The 31% decrease in scores on the Yale Global Tic Severity Scale is very close to the decreases seen with antipsychotics (35% for Geodon and 36% for Risperdal). A low drop-out rate may indicate that children and families are willing to give this intervention a try. In addition, there were no cases of tic worsening during the therapy, so there is no reason to discourage CBIT. The researchers point out that they lacked data on the severity of tics before starting medication for the participants who were on tic-suppressing medication at the start of the study. This leaves a question as to whether these kids were improving already as a result of their meds. However, the risks of habit reversal training are low, and the gains may be substantial.