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Mechanisms Underlying Behavior Therapy for Tourette’s Disorder

  • Tourette’s Syndrome (M Yadegar and E Ricketts, Section Editors)
  • Published:
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Abstract

Purpose of Review

Behavior therapy is the recommended first-line treatment for Tourette’s disorder and other tic disorders (TD). Despite its therapeutic benefit, not all patients exhibit a positive treatment response. Understanding the mechanisms underlying behavior therapy for TD (i.e., how behavior therapy reduces symptoms) can help identify strategies to optimize treatment outcomes. This review examines evidence for three proposed mechanisms—habituation, associative learning, and cognitive control—across laboratory studies and clinical trials.

Recent Findings

Evidence shows that mechanisms likely differ in youth and adults. The most promising evidence points to interactions between associative learning and cognitive control as mechanisms, with nuanced differences between youth and adults with TD. Habituation may also be a mechanism for adults with TD, but not for youth with TD.

Summary

As multiple mechanisms are implicated and several promising ones remain unexamined, future mechanistic research is essential to identify approaches that could optimize behavior therapy outcomes.

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Notes

  1. A note on the usage of “inhibition” and “suppression.” In this paper, when we refer to HRT/CBIT, we use the term “inhibition,” whereby patients inhibit the expression of tics using a competing response. Meanwhile when we refer to ERP, we use the term “suppression” because patients are asked to suppress tics for successively increasing timed durations, with no inclusion of competing response. Similarly, we use the term “suppression” to describe tic suppression studies and tasks, which also do not incorporate a competing response. However, we use the combined term “inhibition/suppression” when we refer to behavior therapy for tics in general (HRT/CBIT/ERP) and the cognitive control processes.

  2. Negative reinforcement is distinct from punishment. Negative reinforcement results in an increase of the targeted behavior by means of removing a stimulus—often undesirable or aversive. Punishment results in a decrease of the targeted behavior by introducing a stimulus—usually undesirable.

  3. As many individuals with TD experience co-occurring ADHD, it may be of interest to explain why attention-related cognitive control processes are not discussed here. While attention-related cognitive control is necessary for general therapeutic interactions, they are only peripherally recruited for awareness training and not actively recruited in the tic-inhibition components of treatment.

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Funding

This work was supported in part by grants from the Tourette Association of American (Dr. McGuire, Dr. Essoe), American Academy of Neurology (Dr. McGuire), and the American Psychological Foundation (Dr. McGuire).

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Authors and Affiliations

  1. Division of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 1800 Orleans St, Baltimore, MD, 21287, USA

    Joey Ka-Yee Essoe, Kesley A. Ramsey, Marco Grados & Joseph F. McGuire

  2. Department of Pediatric Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Harvey S. Singer

  3. Kennedy Krieger Institute, Baltimore, MD, USA

    Harvey S. Singer

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  1. Joey Ka-Yee Essoe
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Correspondence to Joseph F. McGuire.

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Essoe, J.KY., Ramsey, K.A., Singer, H.S. et al. Mechanisms Underlying Behavior Therapy for Tourette’s Disorder. Curr Dev Disord Rep 8, 161–174 (2021). https://doi.org/10.1007/s40474-021-00225-1

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