Exposure and response prevention
in the treatment of tics in Tourette's syndrome
I came to be aware of the faint signals that preceded a movement. I described them as vague, ‘unfulfilled’ feelings. Later, they became more recognizable as discrete sensations… The Tourette’s syndrome movement is not the whole message. Each movement is the result of a voluntary capitulation to a demanding and relentless urge accompanied by an extraordinarily subtle sensation that provokes and fuels the urge… There is really no adequate description of the sensations that signal the onset of the actions. The first one seems irresistible, calling for an almost inevitable response. Joseph Bliss, 1980
This thesis (Boom Publishers, 2007) examines the potential value of exposure and response prevention (ER) as a new behavioral treatment for tics in TS. ER consists of prolonged exposure to unpleasant premonitory sensations and response prevention of the tics. Behavioral treatments are derived from learning theory principles. Chapter 2 provides an overview of the behavioral treatments that have been developed over time to reduce tics, and the possible learning processes underlying these treatments. To date, most studies are peformed into the effectiveness of habit reversal (HR). In chapter 3, the manualized treatments of ER and HR are introduced and illustrated with therapist-patient interactions. Chapter 4 presents the results of a pilot study into the effectiveness of ER in the treatment of tics in TS. This pilot study explored the value of ER in reducing tic frequency and in obtaining habituation of premonitory sensations in 4 TS patients. Chapter 5 presents the results of a controlled outcome study in 43 TS patients comparing ER with HR, including 3-month follow-up results. Outcome measures were the YGTSS and tic frequency counts. In chapter 6, the results are presented of a study into habituation of premonitory sensations as a possible mechanism of change in ER. The aim of this study was to investigate whether TS patients can get used to these sensations when they are exposed to them during 2-hour ER sessions. In chapter 7 the results are presented of a study into the rebound effect following ER tic suppression. Chapter 8, finally, contains a general discussion and the conclusions of the findings. In addition, recommendations for future research are offered.