Abstract
Available treatment for chronic tic disorders (CTD) focuses on the reduction of tics but often does not directly address the psychosocial impairment associated with tics. There is empirical support for a new psychosocial intervention to reduce tics and their related impairment, but this treatment has not yet been applied to adults with CTD. With this in mind, the authors report on the case of “Jim,” a 22-year-old male with significantly impairing tic symptoms. Following 10 sessions of weekly cognitive-behaviorally oriented therapy combining habit reversal training, distress tolerance, cognitive restructuring, and problem solving, Jim exhibited marked improvement in tic severity as illustrated by a decrease in his score on the total tic score of the Yale Global Tic Severity Scale from 16 at baseline to 8 at posttreatment. Therapeutic gains were maintained at 4-month follow-up. This case study provides preliminary support for the use of a psychosocial intervention for addressing coping with CTD in young adults.
1 Theoretical and Research Basis for Treatment
Tourette disorder and chronic tic disorders (CTD) require the presence of tics for at least 12 months. In particular, for a diagnosis of CTD, multiple motor tics and one or more vocal tics must be present, with no complete remission of tics for a period longer than 3 months (American Psychiatric Association, 2000). Onset must occur prior to age 18 years and cannot be attributable to either the direct physiological effects of a substance or a general medical condition (American Psychiatric Association, 2000). Tics are can be either simple (involving one muscle group or sound) or complex (involving multiple muscle groups and appearing more purposeful or coordinated; Zinner & Coffey, 2009). The estimated international prevalence of CTD is about 1% (Robertson, 2008; Robertson, Eapen, & Cavanna, 2009). Several studies have evaluated the time course of CTD across development, noting that the mean age for tic onset is age 7 years, with tic severity peaking between the ages of 7 and 10 years (Scahill, Bitsko, Visser, & Blumberg, 2009). Most individuals with a history of CTD in childhood or adolescence report a decrease in tic frequency and severity into adulthood (Bloch et al., 2006; Bloch & Leckman, 2009; Burd et al., 2001; Leckman et al., 1998; Peterson, Pine, Cohen, & Brook, 2001).
Because the typical natural course of CTD is for symptoms to subside or completely remit by adulthood, less information is available on the phenomenology and consequences of CTD among adults with CTD than there is for children and adolescents. Studies with children and adolescents found that having CTD is related to poorer quality of life and more functional impairments in a number of domains, including school, home, and social relationships (Storch, Lack, et al., 2007; Storch, Merlo, et al., 2007). Available research in adults has shown that tics are more common in men than women but that the ratio of male to female actually decreases somewhat from childhood to adulthood (Freeman et al., 2000). Despite the lower prevalence of tics in females, they appear to have poorer psychosocial outcomes when they have a CTD relative to males (Lewin et al., in press). Tourette’s disorder is related to several other comorbid illnesses even into adulthood (Burd et al., 2001). The most commonly reported comorbid psychological problems include attention-deficit hyperactivity disorder (Peterson et al., 2001), obsessive-compulsive disorder (Bloch et al., 2006; Elstner, Selai, Trimble, & Robertson, 2001; Peterson et al., 2001), other anxiety disorders (Elstner et al., 2001; Lewin et al., 2011), mood disorders (Elstner et al., 2001; Lewin et al., 2011; Robertson, 2006), and substance use disorders (Zinner & Coffey, 2009). Even if no other psychological problems are present, tic severity in adults is related to poorer quality of life across several studies, including poorer health-related quality of life and social functioning (Altman, Staley, & Wener, 2009; Coffey et al., 2004; Elstner et al., 2001).
Because of the complex psychological sequelae of tic disorders, it is important in treatment to target all of the associated features of the disorder. The most commonly used treatments for CTD across the life span are medications including alpha-adrenergic agonists, typical and atypical neuroleptics, and benzodiazepines (De Nadai, Storch, McGuire, Lewin, & Murphy, 2011; Woods, Conelea, & Himle, 2010; Zinner & Coffey, 2009). However, efficacious psychotherapy interventions are available without the adverse side effects associated with medications. Habit reversal training (HRT, also referred to as Comprehensive Behavioral Intervention for Tics; CBIT), first developed by Azrin and Nunn (1973), has demonstrated strong efficacy in reducing tic severity and frequency with lasting effects in a number of studies (Deckerbach, Rauch, Buhlmann, & Wilhelm, 2006; Piacentini & Chang, 2001; Piacentini et al., 2010; Wilhelm et al., 2003). Basic HRT consists of awareness training, self-monitoring, and competing response training, but can also be easily adapted to include relaxation training using progressive muscle relaxation and diaphragmatic breathing to help target the anxiety and tension associated with purposely suppressing tics (Bryson, Edwards, Sommer, & Scorr, 2010; Deckerbach et al., 2006; Flancbaum, Rockmore, & Franklin, 2011; Piacentini et al., 2010). Although the typical course of HRT can last approximately 10 to 14 weeks, others have demonstrated that condensed HRT can be used to effectively reduce tic severity and interference in case studies of adults (Bryson et al., 2010; Flancbaum et al., 2011).
Despite the promising results of available interventions for CTD (e.g., Murphy et al., 2009; Piacentini et al., 2010), few have incorporated standardized treatment for the co-occurring quality of life issues that may even be more detrimental and impairing than the tics themselves (Erenberg, Cruse, & Rothner, 1987). Furthermore, even in the best available treatments, a large portion of patients may not achieve a clinically significant response and tics may remain despite a positive treatment outcome (Piacentini et al., 2010; Scahill et al., 2006). However, neither pharmacotherapy nor standard psychotherapy offers a means for coping with the lingering tics or their effects on daily functioning.
Our research group has developed a promising treatment in youth with tics, termed Living With Tics, that provides a standardized treatment that incorporates features of HRT, as well as coping skills strategies aimed to improving quality of life, reducing distress, and improving overall functioning in those with CTD (Storch et al., 2012). Preliminary data have shown the efficacy of this intervention with youth with CTD. Although the CBIT (Piacentini & Chang, 2005) includes psychosocial modules on coping with tics, the main focus of treatment is to reduce and manage tics (Piacentini et al., 2010) rather than having an overarching goal of managing distress, anxiety, and impairment related to tics. The present case study reports on the application of an adapted version of the Living with Tics protocol with an adult with Tourette syndrome to improve quality of life and psychosocial functioning, with secondary goals of improving the management of tics.
2 Case Introduction
Jim (fictional name), a 22-year-old White male, presented to a university medical clinic that specializes in tic disorders and related conditions for a diagnostic evaluation and treatment of vocal and motor tics. Jim presented as a polite and respectful young man, who reported moderate distress over his lifelong inability to control his vocal and motor tics (e.g., throat clearing, sniffing/nasal clearing, swishing saliva between his teeth, and rubbing his toes together). Furthermore, he noted that he was interested in reducing the negative interactions between himself and his parents regarding his tics. Following a thorough clinical evaluation by the attending clinical psychologist, Jim initiated psychosocial treatment.
3 Presenting Complaints
Jim reported a history of simple vocal and motor tics dating back to his childhood. At the time of evaluation, he noted two persistent vocal tics involving throat and nasal clearing or sniffing and two simple motor tics including rubbing his big toe and his second toe together to the point of forming a callous and occasionally broken skin between his toes, and finally, swishing saliva back and forth between his teeth. He reported that the first simple motor tic occurred around age 8 years (toe rubbing) and that his vocal tics appeared at approximately age 12 years. The most recent simple motor tic had an onset at age 21 years and was reported to be the least intrusive and distressing. Jim noted that the greatest impairment was from his vocal tics because they are the most observable to others. He reported a history of being teased in his early adolescence for his vocal tics but denied any current interpersonal problems related to his tics beyond the familial distress.
Despite the long history, Jim had never received formal evaluation or treatment for his tics until now at the urging of his parents. However, he did note that in the past, his mother had attempted to teach him to use different strategies to control his tics including breathing exercises with limited success. Jim reported that he did not use these strategies often and typically ignored his tics due to their generally limited intrusiveness. He denied current social or academic distress related to his tics.
Although Jim’s tics were not uniformly impairing, he reported a principal concern regarding how they affected his relationship with his parents, as he reported ongoing distress due to disagreements with them about how to best deal with his tics. In particular, he stated that he found their comments to be critical, unhelpful, and frequent, and he noted that his tics generally increased when he was around his parents. He currently viewed his tics as minimally impairing, although he was somewhat distressed about whether his tics would affect his ability to find suitable employment following college. Jim reported that he typically did not discuss his tics with others and was not comfortable revealing to most people that he had tics. He reported being unsure of how to discuss his tics with others, preferring instead to avoid the topic altogether unless with family or close friends.
4 History
At the intake assessment, Jim was living with his mother and father while attending college as a full-time student in a small, urban city in the southeastern United States. He was in excellent academic standing and was working part-time. He reported being in a long-term romantic relationship with a supportive partner with whom he felt comfortable discussing his tics. He denied past or present concerns about his mood or substance use and denied any history of psychosis, mania, or suicidal ideation. He did note some limited symptoms of anxiety that he mostly attributed to academic stress, which he reported that he typically managed well on his own. His family history was positive for anxiety. Jim’s medical history was notable for chronic, intermittent sinus infections, with episodes occurring throughout the year.
5 Assessment
Prior to treatment, Jim completed a comprehensive assessment. Semistructured clinical interviews were administered to determine the presence of comorbid disorders, and the nature and severity of his presenting symptoms and associated impairments. Jim also completed a battery of self-report forms to assess depressive and anxiety symptoms, quality of life, physical health, and self-esteem.
The Mini International Neuropsychiatric Interview (MINI; Sheehan et al., 1998) and the Yale Global Tic Severity Scale (YGTSS; Leckman et al., 1989) were used to assess Jim’s presenting problems. The MINI is a semistructured diagnostic interview that is used for differential diagnosis and to assess for the presence of Axis I disorders. The measure has demonstrated good reliability and validity (Lecrubier et al., 1997). The YGTSS is a semistructured clinical interview that assesses tic severity and corresponding impairment. Scores on the YGTSS range from 0 to 25 for tic severity and from 0 to 50 for impairment (with higher scores indicating greater tic severity and impairment). The YGTSS has demonstrated sound psychometric properties in a number of studies (Leckman et al., 1989; Storch et al., 2005).
Jim also completed a series of self-report measures. (a) The State-Trait Anxiety Inventory (STAI; Spielberger, Gorsuch, & Lushene, 1970) is a 40-item measure of state and trait anxiety with good internal consistency, internal stability, and construct validity (Oei, Evans, & Crook, 1990; Spielberger, et al., 1970; Stanley, Beck, & Zebb, 1996). (b) Beck Depression Inventory–Second Edition (BDI-II; Beck, Steer & Brown, 1996) is a 21-item rating scale that assesses the presence of depressive symptoms within the past 2 weeks. Responses range from 0 (not present) to 3 (severe). The BDI-II has demonstrated excellent psychometric properties (Beck et al., 1996; Storch, Roberti, & Roth, 2004). (c) Medical Outcome Study (MOS) 36-Item Short Form Health Survey (SF-36; Ware & Sherbourne, 1992) is a commonly used measure of quality of life associated with physical health. Eight domains (overall health, physically functioning, limitations to physical health, emotional well-being associated with physical health, social activity, bodily pain, work, and energy) are assessed, and each domain provides a score that ranges from 0 to 100 (0 being the worst, 100 being the best quality of life).
Assessment results
Information derived from the MINI indicated that Jim currently did not suffer from any comorbid Axis I disorders. Table 1 presents the assessment results. According to the YGTSS, Jim had both simple motor (toe movements, swishing saliva in his mouth) and vocal (sniffing and throat clearing) tics. Jim received a YGTSS total tic score of 16 and a tic impairment score of 20.
Treatment Outcomes
Note: YGTSS = Yale Global Tic Severity Scale; STAI = State-Trait Anxiety Inventory; BDI-II = Beck Depression Inventory–Second Edition; SF-36 = MOS 36-Item Short Form Health Survey.
On the STAI, Jim received raw state and trait score of 21 (T-score = 35) and 25 (T-score = 39), respectively, indicating low state and trait anxiety. Jim’s BDI score (raw score = 4) was within the minimal range and showed no indication of depressive symptoms. His SF-36 responses suggested that Jim viewed his overall quality of life and quality of life associated with his health to be very high.
Posttreatment assessment results
At termination, Jim received a total tic score of 8 on the YGTSS, a 50% reduction from his baseline score. His impairment score posttreatment was 0, indicating that Jim experienced no difficulties within his life due to his tics. Although Jim’s STAI scores were low at baseline, his anxiety symptoms improved at posttreatment, with a raw score of 20 (T = 34) for both state and trait anxiety. For example, at baseline, he reported “often” to the item “I take disappointments so keenly that I can’t put them out of my mind”; at posttreatment, he reported “almost never” for the same item. Depressive symptoms decreased slightly from a total raw score of 4 at baseline to 0 at posttreatment. According to the SF-36, Jim’s self-reported physical and mental health improved slightly from baseline.
6 Case Conceptualization
Overall, Jim presented as a well-rounded adult, with few clinically significant problems other than his moderate tics. However, he reported some distress related to the persistence of his tics and ongoing interference from tics with regards to his interactions with his parents. Although his Tourette disorder did not produce gross functional impairment, the effect of his tics on his interactions with close family members was distressing enough to warrant intervention. In particular, there was a clear connection between stress resulting from his parents criticizing his tics, an increase in stress, and finally a resulting increase in his tic frequency shortly after these interactions. The result was often a frustrating reinforcement of tic severity whenever his tics were discussed at home. When discussing his parents’ reactions to his tics, Jim was visibly annoyed and reported that he often responded in anger to their comments about his tics.
In terms of the characteristics of his tics, Jim reported a limited premonitory urge. Instead, he noted that his tics often occurred in groups of two or three and that he was only able to recognize that another tic might occur and attempt to suppress it after at least one or two had occurred. Jim noted that his tics often increased during states of arousal (including excitement and stress) and would also increase when he was actively engaged in tasks that required concentration and sustained attention. As a student and employee, he was often engaged in cognitively demanding activities and was concerned that attempting to control tics during these tasks would reduce his ability to stay focused and so he rarely made active attempts to limit his tics at these times, which is a common misperception about tics (Woods et al., 2010). Furthermore, although he did not meet criteria for an anxiety disorder, he did report a demanding and stressful academic schedule, which appeared to trigger episodes of tics when he was under stress. He denied academic impairment from his tics, but did note that he could benefit from stress management techniques to control the stress that often triggered a worsening of his Tourette syndrome symptoms.
Based on his report of poorly controlled tics, tic-related distress in his interpersonal relationships, heightened anger in response to tics, and limited strategies for coping with daily stressors, a comprehensive treatment for tics that focused on his overall psychosocial functioning was selected. This intervention provides abbreviated HRT to teach basic tic management skills but primarily focuses on broad stress management techniques, cognitive restructuring, and problem solving to improve overall coping skills. Basic habit reversal techniques were used to teach Jim ways to independently manage his tics and were adapted to limit the input of his parents in his tic management. Stress management techniques including increasing pleasurable and relaxing activities were included to reduce the stressful states that often intensified his tic severity. Research has shown evidence for a link between arousal states and tic severity (Nagai, Cavanna, & Critchley, 2009). Cognitive restructuring was incorporated to teach more adaptive cognitive strategies for handling negative emotions such as stress and anger. Finally, problem-solving techniques were included to teach an effective, step-by-step approach to handling problems that may arise because of tics, such as familial discord or explaining tics to a potential employer.
7 Course of Treatment and Assessment of Progress
Jim was seen in 10 weekly, 50-min sessions during a 3-month time period. Treatment was provided by two master’s level therapists (H.L.M. & A.S.D.) receiving weekly supervision by a licensed clinical psychologist (E.A.S.). The first session focused on rapport building, psychoeducation about tics, treatment rationale, and obtaining a baseline of symptoms (10- to 15-min self-reported observations at different times and variable settings, conducted throughout the week). The active treatment phase was conducted across all 10 sessions (see Table 2 for the treatment outline). Treatment comprised the following components: abbreviated HRT, stress management strategies, cognitive restructuring, and problem solving.
Course of Treatment
Habit reversal training
An abbreviated version of HRT was the main focus of four sessions with review of these skills throughout the remaining sessions. Awareness training was completed in the first session, and competing response training was conducted at the second session. Awareness training initiated with the identification of Jim’s tics, implementation of operational definitions for each to facilitate communication, and identification of each tic during behavioral observations. A tic hierarchy was created by rank ordering each tic in terms of its severity and functional impairment, with the most bothersome tics becoming the main focus of therapy. Jim identified his two vocal tics as the primary targets for therapy, noting that they were the most readily observable tics to others and were the most difficult for him to control on his own. He provided a detailed behavioral description for each to distinguish the throat clearing and sniffing tics from other similar behaviors. Jim noted few sensations that signaled the onset of his vocal tics, noting that both the throat clearing and sniffing tics were typically preceded by a sensation in the back of his throat. He also noted that this was true when he made similar movements that were not tics; however, he did identify key differences in his tics in that they were typically repetitive in nature and in excess of what was required to soothe the sensation in his throat and nasal passage. Once the tics and premonitory urges were clearly defined, Jim was instructed to inform the therapist whenever he experienced a premonitory urge in session. Jim initially had some difficulty noting the premonitory urges but was quick to note each tic as it occurred. Awareness training continued with Jim successfully identifying the clinician’s simulated tics in session. Jim was instructed to track his tics and urges to tic at home in varying time intervals and settings, including during rest, work, and class because Jim reported that the frequency of his tics varied with different types of activities.
Competing response training entailed teaching Jim to engage in a behavior that was physically incompatible with his tics. Upon anticipation or occurrence of a tic, Jim was instructed to perform the competing response for one full minute or until the urge to perform the tic subsided. Each competing response was modeled by the therapist and then performed by Jim, with the therapist timing a full minute for each behavior. Because both of Jim’s vocal tics involved clearing of his airway, slow, deep breathing was selected as the competing response. He was instructed to count to three silently each time he inhaled and to slowly and methodically exhale. For Jim’s toe motion tic, he was instructed to keep his entire foot still or spread his toes so that they were no longer touching as a competing response. Jim continued monitoring his tics during short intervals throughout the week and also monitored his ability to engage in his competing responses. He also noted difficulty in correctly identifying tics when he had a sinus infection and hence, an increase in throat and nasal clearing. Additional time in session was dedicated to elaborating how his tics differed from other nonvoluntary behaviors. Jim also noted that his competing response for his vocal tics was difficult when his breathing was obstructed due to physical illness. Because Jim reported that he often experienced these types of sinus infections throughout the year, an alternative competing response was tried involving controlled, slow breathing through the mouth. With additional in-session practice throughout the remaining therapy sessions and weekly home practice, he developed greater proficiency at identifying both his tics and premonitory urges and noted improvement in his ability to enlist competing responses at the anticipation of his tics.
Distress tolerance
Because Jim noted considerable anxiety and stress related to schoolwork and deadlines and an exacerbation of his tics with increasing stress, the next two therapy sessions incorporated stress management techniques and distress tolerance. He noted anger and frustration whenever his parents would note that he was experiencing tics, which would typically result in an increase in his tic frequency. He also reported a demanding and hectic schedule that would often increase his overall level of stress and ability to effectively cope with negative emotions. Distress tolerance techniques were introduced as temporary solutions to coping with negative emotions such as stress, anger, and frustration in a manner that would help reduce arousal and associated tics.
Three techniques were described including distraction, self-soothing, and increasing pleasant activities. Simple distraction techniques comprised activities that served to focus attention onto neutral stimuli such as counting to a certain number or counting colors in a room. Other strategies involved the following: engaging in physical activities; taking a break from whatever problem created the negative emotions; creating opposite emotions by reading, looking through photos, listening to music, or watching movies or TV; or creating other strong sensations by holding ice, squeezing a rubber ball very hard, standing under a very hot or very cold shower, or listening to very loud music. Self-soothing techniques were aimed specifically at reducing negative emotions by increasing calming sensations. Jim was encouraged to find ways to create a sense of calm by engaging each of the five senses in a calming sensation such as finding pleasurable sights (e.g., improving the appearance of immediate environment or by looking at pleasant pictures), sounds (e.g., music or natural soothing sounds), smells (e.g., scented candles or perfumes), tastes (e.g., favorite foods, chew gum or suck on a piece of candy), and physical sensations (e.g., soak in a bath, pet an animal, apply a cold washcloth to the forehead). Finally, Jim was encouraged to increase his experience of positive emotions by increasing his involvement in pleasant, enjoyable activities. He noted that there were several short intervals throughout his day, even during periods of time in which he was under pressure because of a deadline. The clinician helped brainstorm some pleasurable activities that would be brief and relaxing without increasing his distress about completing projects on time. He was provided with handouts to help remind him which techniques to try at home and was encouraged to come up with his own types of activities that could be used to help reduce his distress. Also, Jim planned brief, pleasurable breaks throughout more stressful activities such as studying for exams and working on challenging projects. He noted an overall reduction in his stress levels, without any interference with his ability to accomplish tasks, perform academically, or meet deadlines.
Cognitive restructuring
Two sessions incorporated abbreviated cognitive restructuring, providing Jim with yet another skill to help him cope with his emotional reactions that both lead to tics and that result from tics. First, psychoeducation was provided concerning how distress can be related to tics. Jim was instructed how to identify emotions that were related to his own tics, with high arousal states such as feeling stressed, anxious, angry, or even excited noted as key emotional triggers for his tics, and with frustration and anger reported as common negative emotions in response to his tics. He was able to identify the internal cues of different emotional states and taught how to rate the intensity of different emotions based on a 0 to 10 scale with higher numbers representing more intense emotional states. In addition, the relationship between thoughts and feelings was discussed, focusing on how various emotions can arise from the same situation based on how a person thinks about and interprets the situation. Finally, common cognitive distortions that are known to increase the intensity of negative emotions were discussed.
In the first session related to cognitive restructuring, Jim was able to complete the first few steps of a thought record, including identifying the situation, the emotion with intensity rating, and the thought that triggered the emotions. For between-session homework, he noted any intense emotions throughout the week, especially those related to his tics, and identified any cognitive distortions present. At the second session, he noted several instances of black-and-white thinking, imperatives, and jumping to conclusions in the past week during times he was feeling stressed and frustrated. With guidance from the clinician, Jim was able to identify both evidence for and against his initial thoughts and to formulate a more balanced, undistorted thought. After working through the cognitive restructuring exercises, Jim was able to identify his key thought distortions and restructure them into more balanced thoughts with less intense emotions attached to them. He noted that the techniques helped to reduce the intensity of his triggering emotions and were helpful in reducing his negative emotional reactions to other’s comments about his tics.
Problem solving
After working on cognitive restructuring, we then turned our attention to problem-solving skills for three sessions, with a particular focus on the role of tics in overall functioning. The main foci of this portion of the treatment protocol was to foster a sense of efficacy in addressing tic-related psychosocial problems, provide a framework for addressing such problems, and then apply this framework to specific tic-related stressors. Jim identified one major consequence of his tics was discord when addressing them with his parents, as he found them to be critical about his symptoms. We then considered this as the operational problem to be solved and took several steps in addressing it. We first overviewed varying strategies people use to solve problems, which include being impulsive, engaging in avoidance of the issue, and to approach the problem with a logical plan. Jim mentioned in many instances he was able to approach problems with a reasoned approach, but when dealing with his parents regarding his tics, he could be somewhat impulsive and then subsequently avoidant. To identify techniques that had worked well in the past and develop self-efficacy, we discussed some previous school-related problems and how he was very logical in solving those. Jim was able to identify that he was capable of using this reasoned strategy with success but had more difficulty using it with family members. We then carefully outlined this problem, with an attempt to focus on facts instead of assumptions and emotions. The problem was specifically characterized by parental criticism when he would experience tics, with some perceived impatience about him eliminating his tics.
We then brainstormed potential solutions, with a focus on generating as many solutions as possible without judging any of them as good or bad. Some potential solutions generated included ignoring the problem, working to completely eliminate his tics, to fight back with his parents, have an assertive conversation about his desired response from them, and thanking them when they were supportive. We then discussed the benefits and downfalls of each of these strategies. For instance, although reducing his tics was his central treatment goal, it was unrealistic at present to assume that they would become completely nonexistent, and thus, his parents would still notice them at some point. Jim decided that he wanted to have a conversation with each of his parents where he would make an assertive, respectful request for them to provide a supportive, noncritical tone when addressing his tics. Barriers to enacting this plan were then discussed, which included the possibility of Jim inadvertently creating a hostile tone in the conversation himself and also finding a proper time and place to have this conversation.
To address this first concern, Jim practiced in session what he would say. After practicing several times, he refined his statement to one with a sentiment where he recognized that his parents meant well and wanted to help him but that their chosen method actually contributed to increasing his tics and made him feel worse instead of better. He would then discuss with them the nature of his tics, and that what would be more helpful in the long run would be to provide supportive feedback if he is experiencing tics, and that he appreciated their support. In this way, he designed the conversation to allow his recognition of parental support while letting them know the behaviors that would be most beneficial to him. Subsequent plans included thanking his parents every time they addressed him in this encouraging manner, and if they were to harshly criticize his tics that he could mention that while he appreciates their concern, he would be appreciative if they could portray their comments in the supportive style they had discussed.
Regarding the time and place to have this conversation, Jim identified that he often rode in the car with his father on various errands and this would be an opportune time to talk to him, while at home he had much flexibility during the day to pick a time to talk to his mother. In this way, Jim worked to make the conversation a constructive one by avoiding a scenario where he would express his sentiment in the middle of an argument about his tics. We also prepared for the likelihood that there might not be an overnight change in behavior but by continually showing his appreciation for his desired behavior that matters could improve over time. Jim decided to measure his outcome by how much confrontation subsequently occurred after implementing his plan as compared to before, where it occurred several times per week. He reported that his talks with each of his parents went well and that they reported understanding him and his concern. Although there remained small flare-ups, he reported that things went much better regarding this goal after implementing his plan.
Throughout later sessions, earlier parts of the protocol were returned to as necessary, where at least 5 min per session was spent reviewing the efficacy of HRT and any barriers experienced. At the end of treatment, the clinician reviewed the entire protocol, discussed what had went well in treatment, as well as how Jim would apply these techniques to novel situations in the future such as a job interview or a stressful work environment, and how he could self-monitor his progress so as to make adjustments should he revert to old tendencies. The premise here was to make Jim an expert in the cognitive and behavioral principles underlying the protocol, so that he could apply them to himself when necessary in the future. Jim expressed appreciation for his progress both with regard to his tic frequency and addressing tic-related psychosocial problems through the treatment protocol.
8 Complicating Factors
Certain aspects of treatment were complicated by Jim’s comorbid medical problems, including sinus infections and a postnasal drip that occurred during the course of treatment, making it difficult to distinguish his tics from the symptoms of sinus problems. Because Jim’s most common tics were nearly identical to the sniffing and throat clearing associated with sinus infections, additional time was spent in session to differentiate the tics from nontic vocalizations. It was noted that Jim’s tics could be distinguished based on the fact that his tics were often rapidly repeated two or more times, while sniffing or throat clearing related to physical illness occurred more infrequently. After noting this key distinction, Jim was able to better determine when his vocalizations represented tics and would then begin his competing responses. He found that sinus infections would sometimes trigger his tics to increase and so awareness of this trigger became an important aspect of his awareness training.
In addition, Jim approached treatment with negative impressions of the effect of discussing tics and deliberately trying to suppress them. He noted that whenever his tics were pointed out by his parents, they typically increased in frequency, and so he had learned to not discuss tics to reduce their occurrence. Despite his previous experiences with family members, his tics typically were not exacerbated in session, even when they were explicitly pointed out and discussed at length. He also reported concerns about diverting attentional resources to tracking his tics, noting that this initially interfered with his ability to concentrate on other tasks and felt somewhat “draining” at times. Over a short period of time, however, he became more adept at noting his tics, even during cognitively demanding tasks, and was able to more efficiently apply his competing responses without interrupting his concentration on other tasks.
9 Access and Barriers to Care
Common barriers to effective treatment of CTD are lack of available clinicians with specialized training (Woods et al., 2010). Despite worse tic severity in his early adolescence, Jim reported that he had never sought formal treatment for this very reason. By the time he was referred to our specialty clinic by a family member, his tics had only partially subsided and were severe enough to warrant treatment as an adult. He still needed to travel approximately 45 to 60 min for his sessions, which required considerable time and effort, especially given his schedule as a full-time student. Such barriers are not uncommon for other adults seeking efficacious, nonpharmacological treatment for tics. Despite these barriers to treatment, Jim was committed to attending his weekly sessions and was able to effectively balance therapy homework with his already demanding academic and work schedules, demonstrating that this type of intervention is feasible with adult clients.
Another challenge when working with adults is finding appropriate social support to assist in HRT. In most cases with children and adolescents, the parents typically serve this role. However, in this case, Jim noted that his parents’ comments about his tics were often stressful and contributed to temporary increases in his tic frequency and so he preferred if his parents were not involved in his individual therapy. Other appropriate social support was found in his romantic partner, with whom he felt comfortable discussing his tics and treatment. Hence, careful adaptations must be made when working with young adult clients in an individual therapy setting.
10 Follow-Up
At 4-month follow-up, Jim had maintained his gains. He received a total tic score of 8 on the YGTSS, and his impairment score remained at 0 from posttreatment.
11 Treatment Implications of the Case
This case study offers preliminary evidence for the use of a multicomponent intervention for Tourette syndrome to target effective coping strategies in addition to training in tic management. Jim’s lack of psychological comorbidities, high motivation to reduce tics and develop coping skills, intelligence, and insight contributed significantly to his treatment success. In addition, this case highlights the benefits that can be achieved when combining effective coping skill training strategies with HRT, offering patients an opportunity to reduce the stress that may contribute to and result from tics as well as problem solve the challenges that may arise as tics naturally wax and wane.
Although multiple strategies were used throughout the course of treatment, earlier strategies were reviewed in subsequent sessions, with HRT skills reiterated throughout therapy. Each subsequent skill was presented as a part of a tool kit that Jim could use both with regard to tics and broader sources of distress. In this particular case, Jim experienced interference from his tics within his familial relationship but not within other interpersonal areas. Hence, intervention was not required in several life domains, which contributed to the short duration of treatment. In addition, Jim was not experiencing clinically significant depressive or anxiety symptoms and was not experiencing extreme levels of distress. Cases which demonstrate psychological comorbidities or more maladaptive coping skills may require modifications to the treatment plan to build up the necessary coping skills to benefit from this type of therapy. Although this case describes a relatively well-adjusted adult’s outcomes, the treatment protocol presented is adaptable for cases in which more severe psychosocial problems related to tics are observed. For instance, additional time may be spent emphasizing various coping skills depending on the needs of the case. It is yet to be determined whether cases with more severe distress would require additional sessions to adequately cover the skills presented in this treatment (Storch et al., 2012).
12 Recommendations to Clinicians and Students
Tourette disorder in adulthood may present with a reduced severity since adolescence, but the functional impairment of tics may linger. Established therapies for tics do not directly address problems in psychosocial functioning that often accompany chronic tics (De Nadai et al., 2011). The promising results of our pilot work in youth with CTD (Storch et al., 2012) suggests that overall quality of life can be improved along with improvements in tic frequency and severity in youth. Our case study furthers these findings and elaborates how this protocol can be adapted and applied to an adult case with positive results. The Living with Tics protocol provides a structured guide for how abbreviated HRT can be combined with effective coping strategy training to provide a comprehensive approach to treating CTD and their psychosocial consequences without the additional burden of increasing the number of treatment visits.
Clinicians interested in providing combined psychosocial skills training and HRT should carefully assess the degree to which tics interfere with the quality of life of their patients. For some patients, the intrapersonal, social, academic, and professional consequences of tics may be more diverse than those observed in the present case. It may be necessary to first address other treatment goals before focusing on tics and their impairment for cases with other comorbid psychological illnesses in addition to CTD (e.g., obsessive-compulsive disorder). The therapy protocol presented allows for comprehensive treatment of these concerns and can be easily adapted to provide additional focus on those areas of most concern for that particular case.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.