Matthew R. Capriotti

Negative Reinforcement and Premonitory Urges in Youth With Tourette Syndrome An Experimental Evaluation

Tourette syndrome (TS) is marked by the chronic presence of motor and vocal tics that are usually accompanied by aversive sensory experiences called “premonitory urges.” Phenomenological accounts suggest that these urges occur before tics and diminish following their occurrence. This has led some to suggest that tics are negatively reinforced by removal of premonitory urges. This hypothesis has proven difficult to test experimentally, however, due in part to challenges in measuring premonitory urge strength. We tested predictions of the negative reinforcement conceptualization of premonitory urges using novel experimental tactics within the context of the “tic detector” paradigm. We compared tic rates and ratings of premonitory urge strength exhibited by youth with TS or chronic tic disorder under free-to-tic baseline (BL), reinforced tic suppression (RTS), and reinforced tic suppression with escape (RTS + E) conditions. Results were consistent with previous research and hypotheses of the present study. Participants rated the strength of their premonitory urges as higher during RTS conditions than during BL conditions. Within RTS + E conditions, tic rates were higher during escape portions when the contingency supporting tic suppression was inactive than during components where the contingency was active, and ratings of urge strength were higher at the onset of break periods than at the offset. All participants engaged in some level of escape from reinforced suppression during the course of the experiment. Results of this study support the notion that tics may be negatively reinforced by removal of aversive premonitory urges. Future directions for basic and clinical research are discussed.

Variables Associated With Tic Exacerbation in Children With Chronic Tic Disorders

Research has shown that motor and vocal tics fluctuate in frequency, intensity, and form in response to environmental and contextual cues. Behavioral models have proposed that some of the variation in tics may reflect context-dependent interactive learning processes such that once tics are performed, they are influenced by environmental contingencies. The current study describes the results of a function-based assessment of tics (FBAT) from a recently completed study comparing Comprehensive Behavioral Intervention for Tics (CBIT) with supportive psychotherapy. The current study describes the frequency with which antecedent and consequence variables were reported to exacerbate tics and the relationships between these functional variables and sample baseline characteristics, comorbidities, and measures of tic severity. Results showed that tic-exacerbating antecedents and consequences were nearly ubiquitous in a sample of children with chronic tic disorder. In addition, functional variables were related to baseline measures of comorbid internalizing symptoms and specific measures of tic severity.

COMPARING THE EFFECTS OF DIFFERENTIAL REINFORCEMENT OF OTHER BEHAVIOR AND RESPONSE-COST CONTINGENCIES ON TICS IN YOUTH WITH TOURETTE SYNDROME

Tics are rapid, repetitive, stereotyped movements or vocalizations that arise from neurobiological dysfunction and are influenced by environmental factors. Although persons with tic disorders often experience aversive social reactions in response to tics, little is known about the behavioral effects of such consequences. Along several dimensions, the present study compared the effects of two treatments on tics: response cost (RC) and differential reinforcement of other behavior (DRO). Four children with Tourette syndrome were exposed to free-to-tic baseline, DRO, RC, and quasibaseline rebound evaluation conditions using an alternating treatments design. Both DRO and RC produced substantial decreases in tics from baseline levels. No differential effects of DRO and RC contingencies were seen on self-reported stress or in the strength of the reflexive motivating operation (i.e., premonitory urge) believed to trigger tics, and neither condition produced tic-rebound effects. Implications of these findings and directions for future research are discussed.

Measuring the role of psychological inflexibility in Trichotillomania

Psychological Inflexibility (PI) is a construct that has gained recent attention as a critical theoretical component of Acceptance and Commitment Therapy (ACT). PI is typically measured by the Acceptance and Action Questionnaire-II (AAQ-II). However, the AAQ-II has shown questionable reliability in clinical populations with specific diagnoses, leading to the creation of content-specific versions of the AAQ-II that show stronger psychometric properties in their target populations. A growing body of the literature suggests that PI processes may contribute to hair pulling, and the current study sought to examine the psychometric properties and utility of a Trichotillomania-specific version of the AAQ-II, the AAQ-TTM. A referred sample of 90 individuals completed a battery of assessments as part of a randomized clinical trial of Acceptance-Enhanced Behavior Therapy for Trichotillomania. Results showed that the AAQ-TTM has two intercorrelated factors, adequate reliability, concurrent validity, and incremental validity over the AAQ-II. Furthermore, mediational analysis between emotional variables and hair pulling outcomes provides support for using the AAQ-TTM to measure the therapeutic process. Implications for the use of this measure will be discussed, including the need to further investigate the role of PI processes in Trichotillomania.

A Randomized Waitlist-controlled Pilot Trial of Voice Over Internet Protocol-delivered Behavior Therapy for Youth with Chronic Tic Disorders

Introduction Comprehensive Behavioral Intervention for Tics (CBIT) has been shown to be efficacious for chronic tic disorders (CTDs), but utilization is limited by a lack of treatment providers and perceived financial and time burden of commuting to treatment. A promising alternative to in-person delivery is voice over Internet protocol (VoIP), allowing for remote, real-time treatment delivery to patients’ homes. However, little is known about the effectiveness of VoIP for CTDs. Therefore, the present study examined the preliminary efficacy, feasibility, and acceptability of VoIP-delivered CBIT (CBIT-VoIP). Methods Twenty youth (8–16 years) with CTDs participated in a randomized, waitlist-controlled pilot trial of CBIT-VoIP. The main outcome was pre- to post-treatment change in clinician-rated tic severity (Yale Global Tic Severity Scale). The secondary outcome was clinical responder rate (Clinical Global Impressions – Improvement Scale), assessed using ratings of ‘very much improved’ or ‘much improved’ indicating positive treatment response. Results Intention-to-treat analyses with the last observation carried forward were performed. At post-treatment (10-weeks), significantly greater reductions in clinician-rated, (F(1,18) = 3.05, p < 0.05, partial η2 = 0.15), and parent-reported tic severity, (F(1,18) = 6.37, p < 0.05, partial η2 = 0.26) were found in CBIT-VoIP relative to waitlist. One-third (n = 4) of those in CBIT-VoIP were considered treatment responders. Treatment satisfaction and therapeutic alliance were high. Discussion CBIT can be delivered via VoIP with high patient satisfaction, using accessible, low-cost equipment. CBIT-VoIP was generally feasible to implement, with some audio and visual challenges. Modifications to enhance treatment delivery are suggested.

Behavioral treatments for Tourette syndrome

Tourette syndrome (TS) is a neuropsychiatric condition associated with substantial distress and functional impairment. Pharmacotherapy has traditionally been considered the first-line intervention for this condition, but there is strong evidence that behavior therapy is a comparably effective treatment option. Here we review empirically supported behavior therapy protocols for treating TS and the evidence associated with each. Potential mechanisms through which behavior therapy operates and concerns surrounding the utilization of behavioral interventions are also discussed.

Sensory Phenomena in Tourette Syndrome: Their Role in Symptom Formation and Treatment

The primary symptoms of Tourette Syndrome (TS) are motor and vocal tics, but increasingly, researchers have examined the role of sensory phenomena in biobehavioral models of the disorder. These sensory phenomena involve tic-related premonitory urge sensations as well as potential abnormalities in the perceptual and behavioral experiences associated with external sensory input. As such, dysfunctional sensorimotor integration might represent a key facet of TS pathology. The current paper reviews the literature on sensory phenomena in tic disorders and highlights possible connections to TS symptoms and directions for future research.

Patterned changes in urge ratings with tic suppression in youth with chronic tic disorders

BACKGROUND Premonitory urges are central to emerging behavioral models of chronic tic disorders (CTD). Urge reduction has been proposed as a behavioral explanation for tic maintenance and exacerbation as well as the efficacy of behavioral treatments. Prior investigations have produced inconsistent findings despite common methodologies. The current study evaluated the possibility that data aggregation obscures distinct and meaningful patterns of change in urge ratings when tics are freely expressed versus suppressed. METHOD Participants (n = 12) included children with moderate-to-marked tic severity and noticeable premonitory urges. Tic frequencies and urge ratings were obtained at 15 s and 10-s intervals, respectively, across an alternating sequence of 10-min tic freely and 40-min tic suppression conditions. Patterns were established using a two step approach. RESULTS Five distinct patterns of urge rating change emerged, suggesting data aggregation may obscure meaningful patterns in the urge-tic relationship when tics are completed versus suppressed. LIMITATIONS Eligibility criteria may have unintentionally excluded younger affected children and included older participants with more severe tic disorders than commonly seen. Additional research with less stringent eligibility criteria and a larger sample size will help validate the results. CONCLUSIONS The relationship between urges and tics is much more complex than previously theorized. Investigations that rely on global assessments of urge and tic severity and/or assume uniformity when aggregating participant data may obscure meaningful differences in the urge-tic relationship. Future investigations should examine the possibility that individual differences and/or developmental considerations modulate the functional urge-tic relationship.

The Role of Parental Perceptions of Tic Frequency and Intensity in Predicting Tic-Related Functional Impairment in Youth with Chronic Tic Disorders

Tic severity is composed of several dimensions. Tic frequency and intensity are two such dimensions, but little empirical data exist regarding their relative contributions to functional impairment in those with chronic tic disorders (CTD). The present study examined the relative contributions of these dimensions in predicting tic-related impairment across several psychosocial domains. Using data collected from parents of youth with CTD, multivariate regression analyses revealed that both tic frequency and intensity predicted tic-related impairment in several areas; including family and peer relationships, school interference, and social endeavors, even when controlling for the presence of comorbid anxiety symptoms and Attention Deficit Hyperactivity Disorder diagnostic status. Results showed that tic intensity predicted more variance across more domains than tic frequency.

Defining treatment response in trichotillomania: a signal detection analysis.

The Massachusetts General Hospital Hairpulling Scale (MGH-HPS) and the NIMH Trichotillomania Severity Scale (NIMH-TSS) are two widely used measures of trichotillomania severity. Despite their popular use, currently no empirically-supported guidelines exist to determine the degrees of change on these scales that best indicate treatment response. Determination of such criteria could aid in clinical decision-making by defining clinically significant treatment response/recovery and producing accurate power analyses for use in clinical trials research. Adults with trichotillomania (N=69) participated in a randomized controlled trial of psychotherapy and were assessed before and after treatment. Response status was measured via the Clinical Global Impressions-Improvement Scale, and remission status was measured via the Clinical Global Impressions-Severity Scale. For treatment response, a 45% reduction or 7-point raw score change on the MGH-HPS was the best indicator of clinically significant treatment response, and on the NIMH-TSS, a 30-40% reduction or 6-point raw score difference was most effective cutoff. For disorder remission, a 55-60% reduction or 7-point raw score change on the MGH-HPS was the best predictor, and on the NIMH-TSS, a 65% reduction or 6-point raw score change was the best indicator of disorder remission. Implications of these findings are discussed.