1990 Treatment of Tourette Syndrome by Habit Reversal a Waiting-list Control Group Comparison

8/9/2019 1990 Treatment of Tourette Syndrome by Habit Reversal a Waiting-list Control Group Comparison

1/14


2/14

306

AZlUN AND PETERSON

Three studies (Ross

M o l d ~ f ~ k y 1978;

Shapiro, &

S h ~ p i r o 1984; S h a p ~ r o

• e t . a 1 : ~

r989) ~ t a ~ d

oq.t. - ~ ~ thC·IJlbSt

< { e , n i t i v e t ~ ~ ~ i l l ~ o l o g k ~ l . · t r e . l t f i - ~ ~ t ~ ...

;,.

·

outcome stud1es

of

TS

conducted to date. All three studtes used double-blind ·

designs and utilized frequency counts of tics to evaluate treatment effective-

ness. The results

of

these studies showed that total tics were reduced by 38-StOJ o

with haloperidol and by 34-S20J o with pimozide. These studies and others

(Borison et al., 1982; Bruun,

1982;

Cohen, Detlor, Young,

&

Shaywitz, 1980:

Moldofsky Brown,

1982; Nee.

Caine, Polinsky, Eldridge, Ebert ,

1980:

Shapiro, Shapiro, Eisen kraft ,

1983)

found

that

the reduction of tics varied

greatly on an individual basis from almost complete remission of tics in some

individuals to no noticeable decrease

or

even

an

increase in symptoms in other

individuals. Consequently, single case study reports are to be interpreted with

caution.

A major limitation of drug treatments of TS has been the unwanted side

effects of these medications. In an epidemiological study of

75

TS patients

(Jagger et al. 1982) one

or

more unwanted side effects was noted by 800Jo

or

the patients receiving haloperidol. Lethargy, impaired functioning, and depres

sion accounted for the majority

of

the complaints.

Habit reversal is a behavioral treatment approach which has recently showed

promise as an effective treatment for TS (Azrin Peterson,

1988a;

Finney,

Rapoff, Hall,

&

Christopherson,

1983;

Franco,

1981;

Zikis, 1983). The method

was developed initially to treat behavioral stereotypy

of

retarded and autistic

persons (Azrin, Kaplan Foxx, 1973; Foxx Azrin, 1973) and then extended

to tics and nervous habits of normals (Azrin

&

Nunn 1973; Azrin, Nunn

&

Frantz, 1980).

The

rationale for the method, as stated in Azrin Nunn (1973)

is that

a tic or habit may originally start in early childhood or as a reaction

to a trauma or stress. Normally, the

tic/habit

would decrease with maturity

because

of

the negative social reaction to its peculiarity.

The

movement may,

however, have escaped personal awareness and adverse social reaction and

blended into other movements as a part

of

a response chain that assumes a

compulsive character.

The

habit reversal procedure was designed to counteract

these influences primarily by use of a compet ing response to prevent the tic,

relaxation to reduce contributory stress, awareness t raining to permit preven

tion or interruption and reinforcement contingencies for motivation.

In

a re

cent pilot study with this method (Azrin Peterson, 1988a), the frequency

of

tics was reduced by

93

to

9SOJ o

in the clinic and by 64 to

950J o

at home after ..

6-8

months

of

treatment. This study

was

limited, ttowever, in that it included

only three subjects in a within-subjects- experimental

i ~ i g n .

·

Several other case studies ofTS subjects havebeen conducted using massed

negative practice, contingency management, relaxation training, or self

monitoring (see reviews by Azrin Peterson, 1988b; Thrpin, 1983). All

of

these

studies have been controlled case studies of

one

or two TS subjects using within

subject designs and have yielded results

of

similar

or

lesser magnitude as the

habit reversal method (Azrin & Peterson, 1988b). The absence

of

any pub

lished behavioral treatment studies

of

TS with more

than

three subjects may

be influenced by the relatively low incidence of

the

disorder and the results

of initial uncontrolled studies (e.g., Shapiro et al., 1978)

that

found substan-


3/14


4/14

308

A

ZlliH

AND

PET

Ell SO

N

·

-

. .

, T.A

BLf,

1 •

i

Nf

.

•

\

~ - _ I

.

•

· Su

mEtT


5/14


6/14


7/14


8/14

3

12

AZ I

UN

ND P

ETER

SON

T

he two

ra t

ers t

hen

revie

wed

a br

ief p

o rt

ion

th

e vi

deot

ape.

disc

uqe

d di

ffer

en

ces-

in

a

ndug

re.:d

-.up

on>a

: . $ q

f t t ~

iie

ria •

fo

r eac

h ty

pe

of ti

c. A

ll fo

ur of

th

e vid

eot

apes

fo r

eac

h o

th e

.two

s ub

ject

s

we

re re

scor

ed, a

nd

the i

ntero

bse

rver

agre

em e

nt

was

g

reat

er th

an t

he m

inim

um

.8

0 lev

el;

the i

nter

obse

rver

ag r

ee m

ent

was

m ai

ntain

ed

abov

e th

e .8

0 lev

el fo

r

t

he tw

o s

ubje

cts

o

n

th

e s u

bs e

quen

t 25

of th

e ta

pes

that

were

sco

red

by t

he

ad

ditio

nal

rate

r.

A

t

h

om e

. an

int

erob

serv

er re

liab

ility

m e

asur

e

was

po

ssib

le a

nd t

aken

fo

r

fi

ve o

f the

subj

ects

by

havi

ng a

noth

er f

amil

y m

em b

er

(e .

g.

o

th e

r pa

rent)

als

o

observe the subject during th e sam e reco rding period. These measures were

t

aken

ab

out o

nce

eve

ry tw

o w

eeks

an

d th e

inte

ro b

serv

er ag

re e

men

t

was 82CP

fo

Fi

gure

1 sh

ow s

the

aver

age

tic f

requ

ency

at

hom

e (le

ft p

ortio

n o

f he

figu

re)

an

d in t

he c

linic

(r i

ght

port

ion

of th

e fi

gure

) fo

r th

e Im

m ed

iate

T re

at m

ent

sub

ject

s (up

per

pan

of

the f

igure

) a

nd th

e W

aitin

g- L

ist s

ubje

cts (

lowe

r fig

ure)

for

each

of

the

12.m

on t

hs i

n wh

ich

the

stud

y

was c

ondu

cte

d. A

ll da

ta w

ere

pro

rate

d to

tics

p er

hou

r. M

onth

ly

dat

a poin

ts fo

r th

e ho

m e

reco

rdin

gs re

pre

se

n t t

he a

vera

ge to

tal

tics

per

hour

fo r

ea c

h su

bjec

t ba

sed

on t

he n

um b

er

of

d

ays

in w

hich

rec

ordin

gs

we

re take

n. M

on

thly

dat

a po

ints

for

clini

c s e

ssio

ns

are

from

th e

vid

eota

pes.

A m

inim

um

of

one

a

nd a m

axim

um

o

f four

vid

eo

ta

pes

were

ta k

en e

ac h

m o

nth.

I

MME

DIAT

E

TREA

TME

NT GR

OUP

(N

=

5}

.

-

....

-

-

.

II

:

:;

0

:z::

a:

to

a

.

ll

u

•

=

0

a:

II

·

~

-

...

...

..

..

..

..

...

·

··

··

WAIT

ING

USTC

ONTR

OL

; · s ;

I •

I

I

I

;

z

_

z

:

.

_

-

- -

-

-

-

.

-

•

I

\

_

_

_

••

•

••

•r

•

••

'

'

t

ll

t

r

t

n

•

-

-

ta

1

.

Mo

nthly

aver

age o

fTou

rctte

Syn d

rom e

tics

p

er

h

our m

casu

rm in

the

clinic

and

hom e

settln

ss ro

r su

b jccu

in t

he Im

me d

iate t

reatm

ent

and w

aitin

g-lis

t co n

trol g

roup

s.


9/14

T

O

U

R

E

TT

E

S

Y

t-

ID

R

O

M

E

3

13

I

t.

c

a

n

. b

e

se

e

n

t

h

a

i th

e

m

e

a

n

t i

c

f

r

c

q

u

e

n

s;

y

r

em

a

iJ

le

g

fo

r

t

h

e

h

o

m

e

r

ec

o

r

d

in

g

s

a

n

d

i

n

cr

e

a

se

d

t

h

e

~

c

o

i

£

l

m

~

~

~

g

4

-

m

o

nt

h

w

a

i

t-

li

st

p

e

r

io

d

.

F

o

r

b

o

th

g

r

o

u

p

s,

th

e

m

e

an

t i

c

f

re

q

u

e

n

c

y

d

e

cr

e

a

se

d

s

u

b

s

ta

n

ti

a

ll

y

d

u

r

in

g

t

h

e

i

n

i

ti

a

l2

m

o

n

th

s

o

f

r

e

a

tm

e

n

t

a

n

d

m

o

r

e

sl

ig

h

t

ly

d

u

ri

n

g

t

h

e

l

a t

e

r

m

o

n

t

h

s .

D

u

ri

n

g

t

h

e

fi

rs

t

m

o

n

t

h

o

f t

r

e

at

m

e

n

t

o

f

t

h

e

Im

m

e

d

ia

t

e

T

r

ea

t

m

e

nt

s

u

b

je

c

t

s,

t

ic

s

w

er

e

r

e

d

u

ce

d

b

y

5

2

0J

o

in

t

h

e

c

li

n i

c

a

n

d

32

0

Jo

a

t

h

o

m

e

an

d

f

o

r

th

e

p

r

e

v

io

u

s

ly

w

a

it

-l

is

te

d

su

b

j

e

ct

s

b

y

6

7

0J

o

i

n

t

h

e

c

li

n

ic

a

n

d

7

90

J

o

a

t h

o

m

e.

T

h

e

p

e

r

c

en

t

o

f

c

h

a

n

g

e

w

a

s

c

al

cu

l

a

te

d

b

y c

o

m

p

a

ri

n

g

e

a

c

h

s

u

b

je

c

t

s

t

ic

fr

e

quency during each treatment mont

h

to

t

h

e

f

r

eq

u

e

n

c

y

d

u

ri

n

g

t

h

e

-

m

o

n

t

h

(

i

m

m

e

d

i

at

e

t

re

a

tm

e

n

t)

o

r

4

-

m

on

t

h

{

w

a

it

in

g

-

li

st

)

b

a

se

l

in

e

p

e

r

io

d

s

.

U

s

in

g

a

per

c

e

n

t

o

f

c

h

a

n

ge

s

co

r

e

h

e

lp

e

d

co

n

t

r

o

l f

o

r

c

o

nf

o

u

n

d

s

t

h

a

t m

ay

o

c

c

ur

w

h

e

n

a

v

e

ra

g

e

f r

e

q

ue

n

c

i

es

ar

e

c

al

cu

l

a

te

d

fo

r

g

ro

u

p

s

w

i t

h

i

n

d

iv

i

d

u

al

s

w

i

t

h

v

e

ry

h

ig

h

T

A

B

L

E

2

N U

M

B

E

R

O

F

TI

C

S P

E

R

H

o

U

R

F

OR

EA

C

H

S

U

BJ

E

C

T

E

A

C

H

I

N

Ti

lE

H

O

M

E

A

N

D

C

L

IN

I

C

SE

T

lW

CS

F

OR

T

il

E I

M

M

E

DI

A

TE

A

N

D

W

At

T

•L

IS

T

G

R

OU

P

S

M

o

n

th

s

'i

o

C h

a

ng

e

2

3

4

s

6

1

8

9

1

0

1

2

p

re

-p

o

st

I

m

m

ed

ia

te

t

re

a t

m

e

n t

&

ro

u

p

T

r

ea

tm

e

n

t

S

l

H

o

m

e 22

II

6

.5

4.

S

3

.7

3

.8

4

2

4

9

- S

9.

1 l

o

Cl

in

ic

9

6

3

0

9

I

S

6

1

6

66

S

4

2

4

-7

S

.

l'

1t

5 2

H

o

m

e

47

4

3

2

4

4

2

3

21

1

6

13

18

4 ,

S

6

. 3

2S

4.

8

-9

8

.9

'7

•

C l

in

ic

17

4

l

iS

3 4

0

IS

O

2

12

l

2

I l

l

S

l

4

6

s

s

13

2

8

4

-

8

9

.

1

T

o

S

l

H

om

e

:

I

Sl

8

2

3

4

1

1

3

.4

u

0

l

.S

I

0

0

-

IO

O

.

O

'it

C

li

n i

c

93

1

08

12

1

2

2

0

0

0

0

0

0

0

- I

OO

O

Of

o

S4

H

o

m

e:

1

14

l

l4

7

4

4

8

1

34

7

l

s

s

4

4

4

8 27

6

-

9

6.

6'

1t

C

li

n i

c

1

6

3

6

12

4

1

2

1

0

0

18

6

4.

S

4 .S

-

96

.1

1

•

s

s

H

o

m

e

7

4

6

2

2

7

1

8

9

6.

S

6.

7

2.

8

l

u

I.

S

9

-

87

.8

'1

o

C

lin

ic

:

1

94

7 l

1

6 6

6

28

0 3

0

0

0

0

-

IO

O

.O

'l

o

W

:a

it·

li s

te

d

uc

::a

tm

c

:n

t cr

ou

p

T

re

a

tm

e

n t

S

6

H

om

e

4

0

0

4

02

44

6

4S

7 77

3.3 I .S

. l

0 2

9

9.S

1o

C

l

in

ic

1

79

0

N

A

N

A

3

31

8

:

9

6

2

21

·.

3

6

'

11

0

•

8

S

I

.H

1

2

0

9

0

-

96

.S

'i

o

S7

H

om

e

:

1

0

9

4

62

6

0

6

3

70

11

2

0

7

4

32

0

0

0

0

-1

0

0.

0'7

•

C

li

n i

c

6

27

N

A

N

A

Sl

l

6

2

0

3

0

3

0

0

8

7

16

0

.

-

IO

O

.O

lo

s

Ho

m

e

:

2

8

2

4

17

7

0

6

4

9

2

2

7

14

IS

7

4

0

-I

O

O

.O

'

lt

C

l

in

ic:

9 3

N

A

N

A

6

4

8

1

3

2

4

19

3

4

27

9

S

8

.6

'1

o

S

9

H

om

e

:

17

1 l

l l

27

0

30

1

3

7

3S

1

6

12

2

.4

3

5

31

2

6

-

89

.3

'1

o

C

lin

ic

&I

N

A

N

A

66

2

.5

1

.5

9

9

9

1

.5

-S

9.

&

'1'

o

S

IO

llo

r

nc

43

2

2

6

0

l

S

I

3

2

7

4

4

8

1

2

8

4

4

4

9

.1

1

o

<

.1i

ni

c

l

iS

N

A

N

A

3

6

6

0

6

3

0

0

0

-I

O

O

.O

lo

A

ve

ra

g

e

o

f

al

l

su

b

je

c

ts

N

.

.

10

)

:

H

o

m

e

3

.0

'lo

C

l

in

ic

-

9

3

.S

'l

o

.


10/14


11/14


12/14


13/14


14/14

1990 Treatment of Tourette Syndrome by Habit Reversal a Waiting-list Control Group Comparison

Documents

Transcript of 1990 Treatment of Tourette Syndrome by Habit Reversal a Waiting-list Control Group Comparison