Yale, Harvard and others to collaborate on study of behavior therapy for adults with Tourette syndrome
New Haven, CT — November 1, 2005
The National Institutes of Health has awarded a multisite grant to Yale, Harvard and Wilford Hall Medical Center in San Antonio to evaluate a Comprehensive Behavioral Intervention for Tics in Adults with Tourette syndrome. Yale researchers, led by Principal Investigator Lawrence Scahill, MSN, PhD, launched the four year study on October 1, 2005.
One hundred twenty adults with Tourette syndrome will be randomly assigned to Comprehensive Behavioral Intervention for Tics (CBIT) or a structured supportive psychotherapy program. Both treatments consist of 10 sessions over 12 weeks followed by 2 booster sessions and follow up assessments at 3- and 6-month intervals. The primary outcome measure is the change in tic severity assessed by an independent evaluator blind to treatment assignment.
This $ 3 million grant will complement an identical study funded last year by NIH to evaluate the same behavioral intervention in children. The study in children with TS is being conducted by other collaborating sites including Johns Hopkins, UCLA and University of Wisconsin at Milwaukee. Together, the funding for the two studies amounts to $6 million. Data management for both studies is being done by the Informatics group at Yale.
"This study is particularly exciting because it is the first time in psychiatry that the same behavioral intervention is being applied in a single disorder across the lifespan," notes Dr. Scahill, who holds a joint appointment at the Yale Child Study Center and the Yale School of Nursing, where he is Acting Associate Dean for Scholarly Affairs.
Tourette Syndrome (TS) is a neurological disorder characterized by enduring motor and vocal tics. Motor tics are usually rapid and darting movements of the face, head, neck and shoulders. However, the tics in TS may also involve the extremities and more complex movements that are purposeful in appearance. Vocal tics are usually simple sounds such as throat clearing, snorting or grunting or more complex sounds including the repetition of words or short phrases. The tics of TS fluctuate over time with a peak severity between the ages 10 and 12 years in most cases. For some patients, however, the tics persist into adulthood and may be associated with considerable distress, social and occupational impairment. (See HBO Special Report on November12, 2005)
Currently, the standard treatment for tic suppression is medication, particularly drugs that block dopamine in the brain. However, these medications are often associated with a range of dose-related adverse effects that may threaten compliance and result in premature termination of treatment. Moreover, currently available medications rarely eliminate all tics. Given these limitations, adults with TS are often faced with a partial response to medication. Others choose not to use medication due to unacceptable side effects. The need for non-pharmacological interventions is clear.
CBIT is based on a promising behavioral treatment called habit reversal training (HRT). HRT uses awareness training and voluntary competing response to reduce tics. Many individuals with TS report an odd warning or sensation prior to the occurrence of some or all of their tics. However, the warning happens so close in time to the execution of the tic - that the person can not stop the tic from occurring. Following the performance of the tic there is a brief sense of relief. This sensory cue and momentary relief may be similar to the tickle in the throat that many people experience prior to cough. Indeed, some individuals with TS declare that the purpose of the tic is to quell the premonitory sensation - albeit briefly. This momentary relief may act to reinforce the performance of the tic.
Through awareness training, the patient may be able to identify the sensory warning sooner and mount a voluntary competing response rather than perform the tic. In addition to habit reversal training, the behavioral intervention also includes sessions on relaxation training, stress management and problem solving. These therapeutic elements have been added because of the well-documented data showing that stress and anxiety increase tics.
The control treatment employs these same interventions - but does not involve habit reversal. To ensure that the study will provide useful results to clinicians and patients with TS, the study includes subjects on stable medication or subjects who are not taking medication.
"The success of these two grants is undoubtedly due to the extensive collaborative effort prior to the grant proposal ...," noted Dr. Scahill. These efforts were undertaken in close collaboration with the Tourette Syndrome Association (TSA), a consumer group dedicated to the advocacy of children and adults with TS. The TSA assembled a multidisciplinary team of investigators representing some of the leading TS research programs in the country and asked for advice on non-pharmacological interventions for individuals with TS across the life span. This outreach by the TSA led to the establishment of the Behavioral Sciences Consortium (BSC), whose mission to develop, test, and disseminate behavioral interventions for TS. According to Scahill: "...this partnership between the TSA and investigators in the BSC is a model of collaboration for academic research centers and a consumer organization."
