What is the role of habit reversal therapy in the treatment of Tourette syndrome (TS) and other tic disorders?

Updated: May 30, 2019
  • Author: William C Robertson, Jr, MD; Chief Editor: Stephen L Nelson, Jr, MD, PhD, FAACPDM, FAAN, FAAP  more...
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Five RCTs have demonstrated the efficacy of a specific form of behavior therapy for tics. [168, 169, 83, 170, 171, 172] The originally tested treatment consisted of a package of interventions called habit reversal therapy, [173] which comprises monitoring, relaxation, and other nonspecific elements of behavior therapy. The most important element is application of a competing response whenever the patient notices either a tic or the urge to tic.

Initially, heavy effort on the part of the patient may be needed. However, in all 4 reported studies, at long-term follow-up at least one half of treated patients had greater than 75% reduction in overall tic severity, whether based on self-report of home tic counts or on blind review of a videotape filmed in the clinic.

The effort expended by patients decreased dramatically as tic frequency declined, usually within the first few weeks of treatment. No substitution of other tics was noted, which commonly occurs when patients substitute a volitional action on a haphazard basis (see image below).

Tourette syndrome and other tic disorders. In a ra Tourette syndrome and other tic disorders. In a randomized controlled trial of habit reversal therapy (HRT), results differed significantly from those of a control therapy (massed practice; P < .001, analysis of variance). The HRT group had a 97% reduction in tics at 18-month follow-up, with 80% of patients tic-free.

Anecdotally, others have not found such impressive results, which may relate to patient selection or therapeutic technique. Further replication studies are being supported by the TSA.

Interestingly, several elements of this treatment are reminiscent of treatments used by Brissaud in 1902 (though with a radically different theoretical background). [8] Some data now explain why his treatments may not have been as effective. If the competing response is not paired with tic urges or tics, no benefit is observed. [174] Similarly, other behavior therapies used in the last several decades (eg, massed practice) are relatively ineffective.

Since the realization of the failures of psychoanalysis in treating tic disorders in the 1970s, patients and physicians have looked askance at psychological treatment, including behavior therapy. The available data no longer justify this view.

In fact, the plausibility of behavior therapy makes some sense on an intuitive level. Since tics respond briefly even to random environmental influences, it is not surprising that a well-designed behavioral intervention may produce more satisfactory results. Note that this is very different from simply telling the patient not to tic, or from "trying harder," neither of which tends to be effective over the long run.

A parallel is present with obsessions and compulsions, which share many phenomenologic characteristics with tics. Obsessive-compulsive disorder (OCD) symptoms do not respond well to psychodynamic treatment but are effectively treated with behavior therapy. Such treatment has biologic effects, such as normalization of abnormally high baseline metabolism in the orbitofrontal cortex. Case series have shown a reduction in tics by using the same behavior therapy method proven to benefit patients with OCD. [175, 176]

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