New Thoughts on the New Thoughts on the Behavioral Treatment of Behavioral Treatment of Tourette Syndrome Tourette Syndrome John Piacentini, Ph.D., ABPP John Piacentini, Ph.D., ABPP Child OCD, Anxiety, and Tic Disorders Program Child OCD, Anxiety, and Tic Disorders Program Semel Institute for Neuroscience and Human Semel Institute for Neuroscience and Human Behavior Behavior UCLA School of Medicine UCLA School of Medicine Advances in Tourette Syndrome Felsenstein Medical Research Center Schneider Children’s Medical Center of Israel Tel Aviv, Israel - February 26, 2006
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New Thoughts on the Behavioral Treatment of Tourette Syndrome John Piacentini, Ph.D., ABPP Child OCD, Anxiety, and Tic Disorders Program Semel Institute.
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New Thoughts on the New Thoughts on the Behavioral Treatment ofBehavioral Treatment of
Tourette Syndrome Tourette Syndrome
New Thoughts on the New Thoughts on the Behavioral Treatment ofBehavioral Treatment of
Tourette Syndrome Tourette Syndrome
John Piacentini, Ph.D., ABPPJohn Piacentini, Ph.D., ABPP
Child OCD, Anxiety, and Tic Disorders ProgramChild OCD, Anxiety, and Tic Disorders Program
Semel Institute for Neuroscience and Human BehaviorSemel Institute for Neuroscience and Human Behavior
UCLA School of MedicineUCLA School of Medicine
Advances in Tourette SyndromeFelsenstein Medical Research Center
Schneider Children’s Medical Center of IsraelTel Aviv, Israel - February 26, 2006
AcknowledgementsAcknowledgements
Some of the work described in this presentation was supported by grants from the:
TOURETTE SYNDROME ASSOCIATION
NATIONAL INSTITUTE OF HEALTH
NIMH / NINDS
KAREN MAYES GAMORAN FAMILY FOUNDATION
The Dr. David Feinberg Fellowship of the Semel Institute - UCLA and Schneider's Children's Medical Center – Israel
Susanna Chang, PhD.Susanna Chang, PhD. UCLA Neuropsychiatric InstituteUCLA Neuropsychiatric Institute
Thilo Deckersbach, PhD.Thilo Deckersbach, PhD. Mass General Hospital/HarvardMass General Hospital/Harvard
Golda Ginsberg, PhD.Golda Ginsberg, PhD. Johns Hopkins UniversityJohns Hopkins University
Alan Peterson, PhD.Alan Peterson, PhD. Wilford Hall Medical CenterWilford Hall Medical Center
John Piacentini, PhD.John Piacentini, PhD. UCLA Neuropsychiatric InstituteUCLA Neuropsychiatric Institute
Lawrence Scahill, MSN, PhD.Lawrence Scahill, MSN, PhD. Yale Child Study CenterYale Child Study Center
John Walkup, MD.John Walkup, MD. Johns Hopkins UniversityJohns Hopkins University
Sabine Wilhelm, PhD.Sabine Wilhelm, PhD. Mass General Hospital/HarvardMass General Hospital/Harvard
Douglas Woods, PhD.Douglas Woods, PhD. University of Wisconsin-MilwaukeeUniversity of Wisconsin-Milwaukee
How can Behavioral Psychology How can Behavioral Psychology inform us about TSinform us about TS
The central tenet of Behavioral Psychology is that behavior is determined by a combination of forces comprised of biological - including genetic - and environmental factors.
Biology/GeneticsBiology/Genetics
Behavioral Psychology and TSBehavioral Psychology and TS
EnvironmentEnvironment
TicsTics
Behavioral Psychology primarily concerned with this relationship
Biological FactorsBiological Factors
GeneticsGenetics Twin StudiesTwin Studies
• MZ concordance 86%; DZ concordance 20% Family StudiesFamily Studies
• PUTS score only correlated with tic severity in older group
• Sensations are present in younger children but perhaps in more diffuse form or association with tics not as easily recognized
Woods, Piacentini, Himle, & Chang, 2005
Neurobehavioral Model of TicsNeurobehavioral Model of Tics
Contemporary Behavioral Psychology assumes an underlying neurological deficiency/deficit for TS.
This deficit may reflect brain deficit in ability to inhibit competing motor patterns.
Initiation of Biological Process
EXPRESSION OF TIC
Termination of Biological Process
Biological Basis for Premonitory Urge
Biological basis for premonitory urge may or may not be present for different types of tics. Simple tics may not contain the biological basis for the premonitory urge.
Environment builds on this biologically derived sequence.
Behavioral Model of TicsBehavioral Model of Tics
Expression of TIC
Although the Biological Basis for the Premonitory Urge may be present, the “urge” itself may not exist at the very beginning of the disorder.
The underlying sensation may not be experienced as related to the tic.
Biological Basis for Premonitory Urge
Internal External
Consequences
Expression of tic leads to both internal and external consequences.
Discomfort
Teasing
?
Situational AntecedentsSituational Antecedents
As child starts to experience negative consequences of ticcing, he/she will begin to associate these negative consequences with the situationssituations in which the tics occurred.
Discomfort
Expression of TIC
Teasing
Consequences
Situational Antecedents School, Home, Social
Biological Basis for Premonitory Urge
Over time, these situational antecedentssituational antecedents become more salient and increasingly aversive to the child (e.g., classical conditioning).
Biological AntecedentsBiological Antecedents
Negative ConsequencesNegative Consequences
Discomfort
Expression of TIC
Teasing
Consequences
Situational Antecedents
Biological Basis for Premonitory Urge
The more salient the sensations become to the child, the more strongly he/she associates them with his/her tics.
and Situational AntecedentsSituational Antecedents
also impact internal cues, e.g., underlying sensations such that these sensations take on aversiveaversive qualities as well.
Premonitory UrgePremonitory Urge
Premonitory urge severity becomes more related to behavior patterns suggestive of avoidance and social withdrawal as children get older (Woods, Piacentini et al., 2005)
Connection between premonitory urge and tics may be shaped by negative social response to tics
Development of Premonitory UrgesDevelopment of Premonitory Urges
As the child becomes more aware of these underlying sensations and they begin to predict specific consequences (e.g., tics), they begin to be experienced as “premonitory urges”.“premonitory urges”.
Premonitory urges become aversive to the extent they predict aversive consequences.
Biological Basis for Premonitory Urge
Negative Reinforcement of TicsNegative Reinforcement of Tics
PREMONITORY URGE(unpleasant)
Expression of TIC
Termination of URGE
Situational Antecedents
++
Relief from unpleasant premonitory urge serves to negatively reinforcenegatively reinforce tic expression.
Negative ReinforcementNegative Reinforcement = any action reducing or eliminating an aversive stimulus will be more likely to occur upon subsequent presentation of that aversive stimulus.
If my child stops misbehaving when I shout at him, I’m more likely to use shouting as a disciplinary procedure in the future.
Positive Reinforcement of TicsPositive Reinforcement of Tics
Expression of TIC
Internal External
Consequences
Positive Consequences also serve to reinforce tics and increase their frequency
Relief Avoidance
++
Support for the Neurobehavioral Support for the Neurobehavioral ModelModel
Data examining impact of environmental factors on tic expression are very preliminary
• Consequences of Tic expression
• Antecedents of Tic expression
However, these data provide at least indirect support for Neurobehavioral Model
Antecedent Events that Impact TicsAntecedent Events that Impact Tics
Environmental Influences can be long lastingEnvironmental Influences can be long lasting Woods, Himle, Miltenberger, & Carr, ongoingWoods, Himle, Miltenberger, & Carr, ongoing
• Nine children with TS exposed to Rewards of 3 different durations (5 min, 25 min, 40 min) presented in a random order
• Rewards interspersed with 5 min “rebound evaluation” phase
• Rewards led to statistically significant tic reduction
• No statistically significant rebound effects for any of the different durations
0
2
4
6
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12
Tic
s P
er M
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te
Ba
se
line
5 m
in R
+
Re
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d
25
min
R+
Re
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d
40
min
R+
Re
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un
dFunded by the Tourette Syndrome Association
Behavioral Intervention should address:
• Antecedents and Consequences of Tics
• Negative Reinforcement
Implications of Model for Implications of Model for TreatmentTreatment
Function-BasedFunction-Based
InterventionsInterventionsIdentify “function” of enviromental factors on tic Identify “function” of enviromental factors on tic
expressionexpression
Impact of Environment on TicsImpact of Environment on Tics
Environmental Consequences catch kids COMING or GOING
Tic
Positive consequences can increase ticcing
Tic Positive Consequence More Tics
Negative consequences can increase ticcing
Negative response Distress More Tics
Response to environment is typically not a conscious or voluntary process
• Child/family/school often unaware this is happening
• Environmental influence does not imply that tics are behaviorally caused or that child is manipulating the system
• If tics interfere, leave situation for 15 minutes then return - BUT no escape from responsibilities
• If leaves dinner table, must come back and finish meal
• Needs to begin homework at set time regardless of tics – can take brief breaks according to set schedule
• If tics still bothersome, encourage child to use HRT or other techniques to address them
Function-based InterventionsFunction-based Interventions What to do?What to do?
Habit ReversalHabit Reversal TrainingTraining
(HRT)(HRT)
Habit Reversal TrainingHabit Reversal Training
Multicomponent Behavioral Treatment Package
developed by Azrin & Nunn (1973)
Targeted tics and other habit disorders, including
trich, nailbiting, thumbsucking, skin picking
Originally consisted of 14 techniques aimed at:• increasing tic (habit) awareness• developing competing responses to tics (habits)• building and sustaining motivation and compliance
TWO PRIMARY COMPONENTS
Awareness Training
Competing Response
TWO PRIMARY COMPONENTS
Awareness Training
Competing Response
Habit Reversal TrainingHabit Reversal Training
ANCILLARY COMPONENTS - Addressing tic antecedents
Psychoeducation• Reduce family anxiety/stress and negative reactions
Barbara Coffey, MD.Barbara Coffey, MD.Antje Bohne, MS.Antje Bohne, MS.
Alan Peterson, Ph.D.Alan Peterson, Ph.D.Lee Baer, PhD.Lee Baer, PhD.
Massachusetts General HospitalMassachusetts General Hospital
Harvard Medical SchoolHarvard Medical School
Suppported by a grant from the TSA Permanent Research FundSuppported by a grant from the TSA Permanent Research FundSuppported by a grant from the TSA Permanent Research FundSuppported by a grant from the TSA Permanent Research Fund
HRT for Adults - SymptomsHRT for Adults - Symptoms
35% decrease 35% decrease in tic severityin tic severity
Wilhelm et al. (2003)Wilhelm et al. (2003)
0
5
10
15
20
25
30
0 4 8 10 12 14 10mFU
SESSION
YG
TS
S I
nte
rfer
ence
Sco
re
HRT
Supp Tx**
HRT for Adults - InterferenceHRT for Adults - Interference
**
55% decrease 55% decrease in tic interferencein tic interference
Wilhelm et al. (2003)Wilhelm et al. (2003)
Comparison of HRT and Awareness Comparison of HRT and Awareness Training for Children with TSTraining for Children with TS
Suppported by a grant from the Suppported by a grant from the TSA Permanent Research FundTSA Permanent Research FundSuppported by a grant from the Suppported by a grant from the TSA Permanent Research FundTSA Permanent Research Fund
John Piacentini, Ph.D.John Piacentini, Ph.D.Susanna Chang, Ph.D.Susanna Chang, Ph.D.