Objective
In this pilot study we sought to develop and test a modified form of mindfulness-based stress reduction (MBSR-tics) for the treatment of Tourette Syndrome (TS) and Chronic Tic Disorder (CTD). Our specific aims were: 1) To determine the feasibility and acceptability of an 8-week trial of MBSR-tics in individuals 16 and older with TS or CTD and 2) To determine the efficacy of an 8-week trial of MBSR-tics in individuals 16 and older with TS or CTD.
Methods
Eighteen individuals age 16–67 completed an uncontrolled open trial of MBSR-tics. The intervention consisted of 8 weekly 2-hour classes and one 4 hour retreat in the fifth or sixth week of the program. Symptomatic assessments were performed at baseline, post-treatment, and one-month follow-up.
Results
MBSR-tics proved to be a feasible and acceptable intervention. It resulted in significant improvement in tic severity and tic-related impairment. 58.8% of subjects were deemed treatment responders. Therapeutic gains were maintained at 1-month follow-up. Improvements in tic severity were correlated with increases in self-reported levels of mindfulness.
Conclusions
This small open pilot study provides preliminary support for the feasibility, acceptability, and efficacy of MBSR-tics for individuals 16 or older with TS or CTD. A larger randomized controlled trial with blind assessment is necessary to confirm these initial, promising findings.
Trial Registration Partners Clinical Trials Registry Number 2011P000606 (clinicaltrials.partners.org).
Despite recent advances in the treatment of individuals with Tourette syndrome (TS) and chronic tic disorder (CTD), there remains room for improvement. Pharmacological treatments, although effective, carry a substantial risk of unpleasant side effects [1]. Psychosocial interventions, such as Comprehensive Behavioral Intervention for Tics (CBIT; [2]) offer meaningful symptomatic relief without burdensome side effects but also fail to help a significant number of individuals (e.g., [3], [4] and [5]. Thus, it is essential that we continue to develop and test alternative treatments. In this pilot study we sought to develop and test a modified form of mindfulness-based stress reduction (MBSR) for the treatment of TS and CTD.
MBSR was originally developed in 1979 by Jon Kabat-Zinn at the University of Massachusetts [6]. Through direct practice in meditation, MBSR promotes the development of nonjudgmental moment-to-moment awareness of one's perceptions, bodily sensations, thoughts, and emotions. Participation is highly experiential and centers around four primary meditative practices: sitting meditation, the body scan, yoga, and walking meditation. In each of these exercises participants gain experience in directing their attention to the content of their moment-to-moment experience while refraining from any efforts to change their experience. Participants are encouraged to adopt a curious, patient, accepting, non-striving, and non-judgmental attitude toward themselves and their inner experience. MBSR has garnered empirical support as a treatment for a range of medical and psychological conditions including chronic pain, fibromyalgia, anxiety, binge eating disorder, and recurrent major depression (for review [7] and [8]). Of particular relevance to TS and CTD, mindfulness-based interventions have recently shown promise in the treatment of two commonly comorbid disorders: obsessive-compulsive disorder (OCD; [9] and [10]) and attention deficit hyperactivity disorder (ADHD; [11] and [12]).
The behavioral model of tic maintenance [2], [13] and [14] posits that while tics are of neurobiological origin, there are important internal and environmental factors that make them more likely to occur. The most central assumption in the model is that tics are negatively reinforced every time that they relieve the individual from the discomfort associated with the premonitory urge to tic. Indeed, many individuals report that their tics are voluntary automatic reactions to the premonitory urge to tic [15]. Additional internal factors (e.g., stress or anxiety) and external factors (e.g., social attention, certain activities, caffeine) have also been associated with tic worsening [16]. Consistent with this model, we hypothesized that a modified version of MBSR for individuals with TS or CTD (MBSR-tics) might benefit individuals with TS and CTD in three possible ways. First, meditation has been shown to improve attentional control (for review [17]). Thus, we hypothesized that improved attentional control might increase participants' awareness of when their tics are about to occur, are occurring, and the factors that make them better or worse. This awareness is essential in enabling the individual to respond differently to the urges to tic. Second, meditative practice in observing and allowing one's internal experiences to transpire without trying to change them may help individuals sit with the discomfort of the premonitory urge and allow it to subside on its own without engaging in the tic, thereby breaking the cycle of negative reinforcement. Functionally, this aspect of the intervention was similar to the core intervention found in CBIT, competing response training, although the means of adopting this approach to the tics and the urges to tic were quite different. And third, MBSR has also been shown to decrease physiological arousal and emotional reactivity (for review [18]). Thus, we hypothesized that the intervention may reduce the stress, anxiety, and frustration that are commonly associated with tic exacerbation.
Our specific aims were: 1) To determine the feasibility and acceptability of an 8-week trial of MBSR-tics in individuals 16 and older with TS or CTD and 2) To determine the efficacy of an 8-week trial of MBSR-tics in individuals 16 and older with TS or CTD. We hypothesized that MBSR-tics would be feasible and acceptable to individuals with TS or CTD, as measured by dropout rate, patient satisfaction, patient feedback, and adverse events. We also hypothesized that MBSR-tics would result in a significant reduction in the severity of tics and the degree of tic-related impairment from pre- to post-treatment, as measured by the Yale Global Tic Severity Scale (YGTSS).
