An Empirical Examination of Symptom Substitution Associated With Behavior Therapy for Tourette's Disorder

Abstract

Over the past 6 decades, behavior therapy has been a major contributor to the development of evidence-based psychotherapy treatments. However, a longstanding concern with behavior therapy among many nonbehavioral clinicians has been the potential risk for symptom substitution. Few studies have been conducted to evaluate symptom substitution in response to behavioral treatments, largely due to measurement and definitional challenges associated with treated psychiatric symptoms. Given the overt motor and vocal tics associated with Tourette’s disorder, it presents an excellent opportunity to empirically evaluate the potential risk for symptom substitution associated with behavior therapy. The present study examined the possible presence of symptom substitution using 4 methods: (1) the onset of new tic symptoms; (2) the occurrence of adverse events; (3) change in tic medications; and (4) worsening of co-occurring psychiatric symptoms. Two hundred twenty-eight participants with Tourette’s disorder or persistent motor or vocal tic disorders were randomly assigned to receive behavioral therapy or supportive therapy for tics. Both therapies consisted of 8 sessions over 10 weeks. Results indicated that participants treated with behavior therapy were not more likely to have an onset of new tic symptoms, experience adverse events, increase tic medications, or have an exacerbation in co-occurring psychiatric symptoms relative to participants treated with supportive therapy. Further analysis suggested that the emergence of new tics was attributed with the normal waxing and waning nature of Tourette’s disorder. Findings provide empirical support to counter the longstanding concern of symptom substitution in response to behavior therapy for individuals with Tourette's Disorder.

Neurocognitive correlates of treatment response in children with Tourette's Disorder

“…While neurocognitive predictors of response to behavior therapy were not identified, youth receiving Comprehensive Behavior Intervention for Tics exhibited significantly reduced tic severity without any diminished cognitive functioning (Piacentini et al, 2010). This is important because some parents and clinicians express concern that implementing behavioral strategies for tics are likely to yield adverse effects on tics and increase the demand on children’s cognitive resources (Burd and Kerbeshian, 1987; Woods et al, 2010; Peterson et al 2016). Thus, these findings provide evidence that behavior therapy does not negatively impact neurocognitive functioning, relative to a non-tic specific treatment.…”

“…Traditionally, pharmacotherapy has been used to manage tic severity with antipsychotic and alpha-2 agonist medications yielding moderate reductions in tic severity (Weisman et al, 2012), although these medications are typically accompanied by adverse side effects and only partial response (Scahill et al, 2006). Meanwhile, behavioral interventions such as habit reversal training (HRT) and the Comprehensive Behavioral Intervention for Tics (CBIT) (Woods et al, 2008) have demonstrated moderate-to-large reductions in tic severity with no significant adverse effects or concerns of symptom substitution (Piacentini et al, 2010; McGuire et al, 2014; Peterson et al, 2016). Despite the proven efficacy of behavior treatments for tics, the neural mechanisms underlying their response remain largely unexamined and the limited neurocognitive research to date has produced mixed findings among youth with Tourette’s Disorder.…”

Behavior Therapy for Tic Disorders: an Evidenced-Based Review and New Directions for Treatment Research

“…For example, if an arm tic was treated with behavior therapy, the concern may be that the patient may develop a new tic (e.g., leg kick) in response to suppressing their original tic and/or experience a worsening in severity of non-targeted tics. Despite possible evidence in among case reports [59, 60], systematic empirical evaluations have found no evidence of symptom substitution in response to behavior therapy for tics for individuals with PTD [62]. …”

Tourette syndrome research highlights from 2016

“…Still, some practitioners retain misconceptions about its safety. A report on 228 participants in randomized controlled trials (RCTs) of Comprehensive Behavioral Intervention for Tics (CBIT) helps to confute those concerns 62 . Specifically, CBIT participants were no more likely to have new tics, have adverse events, increase tic medications or have an exacerbation in psychiatric symptoms relative to patients who received supportive therapy.…”