The comprehensive behavioral intervention for tics (CBIT) represents a safe, effective non-pharmacological treatment for Tourette's disorder that remains underutilized as a treatment option. Contributing factors include the perceived negative consequences of tic suppression and the lack of a means through which suppression results in symptom improvement. Participants (n = 12) included youth ages 10–17 years with moderate-to-marked tic severity and noticeable premonitory urges who met Tourette's or chronic tic disorder criteria. Tic frequency and urge rating data were collected during an alternating sequence of tic freely or reinforced tic suppression periods. Even without specific instructions regarding how to suppress tics, youth experienced a significant, robust (72%), stable reduction in tic frequency under extended periods (40 min) of contingently reinforced tic suppression in contrast to periods of time when tics were ignored. Following periods of prolonged suppression, tic frequency returned to pre-suppression levels. Urge ratings did not show the expected increase during the initial periods of tic suppression, nor a subsequent decline in urge ratings during prolonged, effective tic suppression. Results suggest that environments conducive to tic suppression result in reduced tic frequency without adverse consequences. Additionally, premonitory urges, underrepresented in the literature, may represent an important enduring etiological consideration in the development and maintenance of tic disorders.
Recently, a multi-site, randomized controlled trial found a specific cognitive-behavioral therapy, the comprehensive behavioral intervention for tics (CBIT), to be more effective than psychoeducation and supportive therapy in the treatment of children with tic disorders (Piacentini et al., 2010). Despite its efficacy, CBIT and its predecessor, habit reversal training, remains underutilized (Marcks, Woods, Teng, & Twohig, 2004). The present study focuses on addressing specific barriers to underutilization.
Barriers to widespread acceptance of CBIT as a front-line intervention include clinician, patient, and family fears regarding the perceived negative consequences of tic suppression. Many physicians (55%) believe that tics are not suppressible and a preponderance of health care providers (77%) believe that tic suppression will subsequently result in an increase or ‘rebound’ in tic frequency (Burd & Kerbeshian, 1987; Marcks et al., 2004; Woods, Conelea, & Himle, 2010). There has also been concern that suppressing a particular tic may worsen other non-targeted tics.
Reduction in total tic severity in the CBIT for children with tic disorders study (Piacentini et al., 2010) suggests that tic suppression, as part of a comprehensive treatment approach, is effective in reducing total tic severity and improving symptoms. An independent line of research has begun to address fears regarding the perceived negative consequences of tic suppression (Himle & Woods, 2005; Meidinger et al., 2005). Single-case behavioral analytic studies suggest that children are capable of suppressing tic symptoms for prolonged periods of time (40 min) when contingently reinforced for effective suppression, even without being provided robust suppression strategies (Woods & Himle, 2004; Woods et al., 2008). Also, there does not appear to be a subsequent increase (rebound) in tic symptoms during post-suppression “tic freely” periods (Himle & Woods, 2005; Meidinger et al., 2005). Lingering concerns regarding the negative effects of tic suppression hinge on the shortcomings associated with single-case studies (i.e., lack of statistical analysis and limited generalizability).
In addition to concerns about the negative effects of tic suppression, there is a significant question regarding how behavioral treatments produce durable decreases in symptom severity ( Woods et al., 2011). Genetic and biological contributions and the efficacy of biological interventions are undisputed. However, preliminary evidence suggests that the maintenance and exacerbation of tics as well as tic reduction following non-pharmacological treatment can, in part, be explained via operant conditioning principles. The negative reinforcement hypothesis of tic maintenance suggests that tics persist, in part, because tic completion results in a temporary reduction in the unpleasant “premonitory urge” (i.e., unpleasant feeling or sensation). A single-case study appears to confirm this notion in that premonitory urge ratings were higher during periods of tic suppression and lower during periods of tic completion ( Himle, Woods, Conelea, Bauer, & Rice, 2007). The “urge habituation” hypothesis predicts that while tic suppression may initially result in an increase in premonitory urge severity, continued tic suppression (a component of CBT for tics) results in an eventual reduction of premonitory urge ratings, thereby breaking the negative reinforcement cycle and resulting in symptom improvement. Indeed, a recent study found that average urge ratings decreased significantly within and between exposure and response prevention treatment sessions for tics ( Verdellen et al., 2008).
This current study builds on prior single-case studies by using improved methods, which allow for statistical analysis, and was designed to a) replicate previous findings regarding the ability to suppress tics, b) replicate the absence of a subsequent ‘rebound’ in tics following prolonged suppression, c) replicate prior findings regarding the negative reinforcement hypothesis with respect to tic maintenance and, d) examine the urge habituation hypothesis in treatment-naive youth with tic disorders. Specific hypotheses were that a) tic frequency would be significantly lower during periods of tic suppression, compared to periods of tic completion, b) there would be no statistical difference in frequency before and after periods of prolonged tic suppression, c) average urge severity ratings would be statistically higher during initial tic suppression than during periods of tic completion, and d) urge severity would return to a statistically non-significant level in comparison to tic completion levels by the end of 40 min of tic suppression.
