Investigating Habituation to Premonitory Urges in Behavior Therapy for Tic Disorders

Abstract

Behavior therapy is effective for Persistent Tic Disorders (PTDs), but behavioral processes facilitating tic reduction are not well understood. One process, habituation, is thought to create tic reduction through decreases in premonitory urge severity. The current study tested whether premonitory urges decreased in youth with PTDs (N = 126) and adults with PTDs (N = 122) who participated in parallel randomized clinical trials comparing behavior therapy to psychoeducation and supportive therapy (PST). Trends in premonitory urges, tic severity, and treatment outcome were analyzed according to the predictions of a habituation model, whereby urge severity would be expected to decrease in those who responded to behavior therapy. Although adults who responded to behavior therapy showed a significant trend of declining premonitory urge severity across treatment, results failed to demonstrate that behavior therapy specifically caused changes in premonitory urge severity. In addition, reductions in premonitory urge severity in those who responded to behavior therapy were significant greater than those who did not respond to behavior therapy but no different than those who responded or did not respond to PST. Children with PTDs failed to show any significant changes in premonitory urges. Reductions in premonitory urge severity did not mediate the relationship between treatment and outcome in either adults or children. These results cast doubt on the notion that habituation is the therapeutic process underlying the effectiveness of behavior therapy, which has immediate implications for the psychoeducation and therapeutic rationale presented in clinical practice. Moreover, there may be important developmental changes in premonitory urges in PTDs, and alternative models of therapeutic change warrant investigation.

Patterns and Predictors of Tic Suppressibility in Youth With Tic Disorders

“…Behavioral models have conceptualized premonitory urges as a facilitator of tic suppression, as they provide salient cues to initiate tic inhibition ( 6 ). In recent years, findings, including those in the current study, call this idea into question ( 13 , 23 , 24 , 46 ), instead suggesting that the urge-tic relationship is heterogeneous across individuals and more nuanced than once thought [( 5 , 17 , 22 )]. For example, in the CBIT trials ( 41 ), individuals with higher PUTS scores demonstrated blunted treatment response, raising the possibility that higher urges are associated with a more treatment-refractory form of TD.…”

Combined habit reversal training and exposure response prevention in a group setting compared to individual training: a randomized controlled clinical trial

“…Correspondingly, Ganos et al found no correlation between scores of premonitory urges and the ability to suppress tics [13]. Furthermore, the premonitory urge has been shown to remain unchanged during tic suppression [12, 41]. Thus, some patients may not experience a habituation to the premonitory urge, but rather have to learn to accept and endure the urge feeling.…”

Sensory aspects of Tourette syndrome

“…A recent study has specifically investigated the effect of CBIT on premonitory urges (Houghton et al, 2017). The authors hypothesised that urge severity would be decreased in patients who responded to treatment, suggesting a habituation effect.…”