Therapy: Tourette's, OCD & Behavioural Theory

• Therapy for Tourette's Syndrome (TS) and Obsessive-Compulsive Disorder (OCD) primarily focuses on individual therapy for young people, differing from many therapies that heavily involve family.
• Direct therapy places significant demands on young individuals, requiring careful consideration of their motivation and engagement.
• Depression, anxiety, and OCD are other examples of disorders effectively treated with evidence-based individual treatment protocols.

Behavioural Theory

• Pavlov (1901) introduced classical conditioning.
• Watson (1934) emphasized the control and prediction of behaviour.
• Skinner (1971) developed operant conditioning/reinforcement concepts.
• Bandura (1963) highlighted social learning through observation and models.
• Operant conditioning suggests behaviour is influenced by environmental experiences.

Theoretical Principles

• Positive reinforcement increases the frequency or intensity of a behaviour.
• Withdrawing positive reinforcement reduces behaviour.
• Undesirable behaviour can be extinguished through negative consequences.
• Exposure and response prevention are effective therapeutic techniques.

Perceptions of Tourette’s

• Tourette's syndrome is characterized by verbal or physical tics.
• Anxiety and emotional states like boredom or excitement can exacerbate tics.
• Swearing or inappropriate language is present in a small percentage of cases.
• Tics can manifest as back rolling, noises, coughing, eyebrow movements, shoulder rolls, grimacing, cheek movements, sniffing, and eye rolling.
• Tics can be disruptive, tiring, and persistent.

Tourette’s Syndrome

• Diagnosis involves multiple motor tics and at least one phonic tic, persisting for a minimum of 12 months.
• The quality and severity of tics change over time, exhibiting a waxing and waning pattern.
• Tic disorders are milder and more transient, lasting less than 12 months.
• Tourette's syndrome was identified by Giles de la Tourette (1885).
• The male to female ratio is 3-4:1.
• 1 in 100 people have TS and 1 in 20 have a tic disorder.
• TS has a genetic basis with complex inheritance patterns.
• Identical twins show a 90% concordance for TS, highlighting the role of environmental factors.
• Candidate genes are located on chromosomes 2 and 13.
• Neurobiological substrates include the basal ganglia, thalamus, and cortex
• Excess dopamine or sensitive dopamine receptors in the brain are implicated.
• Dopamine antagonists like haloperidol and risperidone can be effective. GABA is also implicated.
• Medications can be effective, but are indicated in a minority of cases.
• Tics are experienced as involuntary, pointless, but recognizable actions.
• Tics provide a release of tension or a sense of satisfaction.
• Tics can be suppressed for short periods of time.
• Tics are suggestable, as seen in group settings where people may copy each other’s tics.

Simple vs Compound Tics

• Simple tics are fast, small movements like eye blinks or grimaces, or sounds like grunts or sniffs.
• Complex tics are slower, more noticeable movements like kissing or curtsying, or the use of words, including taboo language. 10-17% of young people have coprolalia (swearing).

Premonitory Urge

• A premonitory urge, similar to the feeling before a sneeze, precedes tics.
• Awareness of this urge varies widely.
• The urge is experienced as aversive, such as an itch, tension, or tingle.
• Tics reduce tension and relieve discomfort, making the act of performing a tic highly reinforcing.

History of Tourette's Syndrome

• Onset typically occurs around age 6, starting with simple tics around the head and neck, progressing to more complex tics over time.
• Tics often resolve to some degree in early adolescence, with symptoms worsening around ages 9-10.
• Both puberty and starting school are not direct risk factors, but should be considered in context.
• A "pure" TS diagnosis with younger onset and less severity indicates a more positive outcome.
• By adulthood, 30% of individuals either still have tics or do not notice them.

Co-morbidity

• OCD is present in 30-50% of TS cases.
• ADHD is present in 50-60% of TS cases.
• Rage episodes and behavioral problems are seen in 80% of TS cases.
• TS, ADHD, and OCD share a genetic component.
• 5-15% of individuals with TS also have ASD.
• Learning disabilities are more common in individuals with TS than in the general population.
• 30% experience mood or anxiety disorders.
• Only 15% of cases are "pure" TS.
• It's important to inform families about developmental patterns, delivering data with careful support.

Functional Tics

• Functional tics involve a sudden and later onset, often not responding to common medications.
• Functional tics often remit suddenly and are linked to increased stress or recent events.
• Functional tics tend to run in families.

Classic Tics

• Classic tics have a gradual onset around age 5-6 and respond to medication.
• Classic tics rarely remit suddenly and exhibit waxing and waning patterns.
• Classic tics tend to run in families.

Treatment

• Stage 1: ALWAYS offer psychoeducation.
• Stage 2: Behavioral treatment and/or medication.
• Most children only require psychoeducation as the primary intervention.
• Additional therapies include behavioural therapies (ERP and HRT) and medication.
• Treatment decisions should be carefully considered, as most individuals do not need extensive interventions.
• European guidelines published in July 2021 recommend psychoeducation for all.
• Behaviour therapy (CBIT, HRT, ERP) is generally the first-line treatment due to fewer adverse effects compared to medication.
• Medication is also an evidence-based treatment option.

Behavioural Treatments

• Comprehensive behavioural intervention for tics includes psychoeducation and functional assessment.

Psychoeducation

• Defining tics and disorders in the DSM.
• Natural history, comorbidities and causes of TS (brain and genetics.)
• Describing premonitory urge and suppression.
• Behaviour therapies and drug options, common moderators, myth busting, and support groups (Tourette Action.)

Functional Assessment

• Identification of moderators, tic hierarchy, and family experiences. ABC.

Habit Reversal Training

• Involves awareness training, competing response training, and praise/reinforcement.
  • Awareness training includes recording and acknowledging tics, including the premonitory urge, identifying the core of the tic, and considering the first tic in a complex chain.
  • Competing response training involves behaviours that are physically incompatible with the tic. For example, deep breathing for grunting or pressing the back against a wall for a body jerk. The competing response should be used for at least 1 minute.
  • Praise and reinforcement from a parent should be contingent on carrying out the competing response.
• Exposure response prevention (ERP).
• Other aspects of TS work include family work, narrative therapy, and education intervention.

Case Study – Josh

• Josh was a 14-year-old, the youngest of 3 siblings, with an absent father who had a significant mental health history.
• He presented a complex picture of TS, OCD, ADHD, school refusal, and social isolation.
• Vocal tics included screeching, coughing, corprolalia and echolalia.
• Motor tics included gagging, chest punching, and back stretching.
• His YGTSS score was 85 (high).
• Josh experienced positive reinforcement from parents, siblings, and peers who laughed with him.
• The taboo nature of his tics fascinated 14-year-old boys.
• The school response involved removing him from class and showing YouTube videos.
• Positive reinforcement of tics increases their frequency/intensity.
• CBIT was used due to his ADHD and the tic hierarchy revealed coprolalia as the greatest concern.
• Functional analysis showed high levels of positive reinforcement at home and school after tic episodes.
• HRT was utilized with a breathing technique as a competing response.
• His mother, siblings, and TA were tic supporters, requiring them to extinguish their responses to the tics.
• After treatment, Josh could go 1.5 hours without any tics.
• His YGTSS score dropped from 88 to 65, a meaningful change.
• His CGAS score improved from severe to moderate impairment.
• Josh was able to go out in public and attend school 5 days a week.

Evidence

• Objective pre and post measures are key to successful treatment, aiming for a 25% tic reduction.
• Post treatment tic levels may still be high.
• HRT (CBIT) has established efficacy.
• 9 RCTs indicate HRT is more effective than waitlist/supportive therapy/’massed practice’.
• HRT can reduce tics between 20-100% and can have a medium effect size.