Optimizing behavior therapy for youth with Tourette’s disorder


Tourette’s Disorder (TD) is characterized by tics that cause distress and impairment. While treatment guidelines recommend behavior therapy as a first-line intervention, patients with TD may exhibit limited therapeutic response. Given the need to improve treatment outcomes, this study examined the efficacy of augmenting behavior therapy with d-cycloserine (DCS) to reduce tic severity in a placebo-controlled quick-win/fast-fail trial. Twenty youth with TD completed a baseline assessment to characterize tic severity, premonitory urges, medical history, and psychiatric comorbidity. Youth were randomly assigned to receive a single session of habit reversal training (HRT) augmented by either 50 mg of DCS or placebo. Two bothersome tics on the Hopkins Motor/Vocal Tic Scale (HM/VTS) were targeted for treatment during HRT. One week after the HRT session, youth completed a posttreatment assessment to evaluate change in the severity of bothersome tics. All assessments were completed by independent evaluators masked to treatment group. There was a Treatment Group by Time Interaction in favor of DCS-augmented HRT (p < 0.01), controlling for baseline tic severity, tic medication, and attention deficit hyperactivity disorder. Follow-up comparisons revealed small group differences at the treatment visit (d = 0.27), with the DCS group exhibiting slightly greater severity for targeted tics. There was a large group difference at posttreatment, in which the DCS group exhibited lower severity for targeted tics (d = 1.30, p < 0.001) relative to the placebo group. Findings demonstrate the preliminary enhancement of tic severity reductions by augmenting HRT with DCS compared with placebo augmentation.

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Fig. 1: CONSORT diagram of participant flow through the trial.
Fig. 2: Treatment by Time Interaction for Tics Targeted in Habit Reversal Training on the Hopkins Motor/Vocal Tic Scale, controlling for baseline tic severity on the HM/VTS, co-occurring ADHD and tic medication status.


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This work was supported in part by grants from the Tourette Association of American (JFMG, JKYE), American Academy of Neurology (JFMG), American Psychological Foundation (JFMG), and NIMH T32MH073517 (JTMC and JP). The views expressed within this article represent those of the authors, were not influenced by the funding sources, and are not intended to represent the position of the NIMH.

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JFMG, JTMC, and JP contributed to the design of the study. JFMG, NG, KR, JKYE, EJR, JTMC, and JP contributed to the acquisition, analysis, and/or interpretation of the data for the work. JFMG, JTMC, and JP composed the initial draft of the work, and NG, KR, JKYE, and EJR contributed revisions and important intellectual content to the work. All authors approved the version of the paper, and agree to be accountable for all aspects of the work to ensure that any questions related to the accuracy or integrity are appropriately investigated and resolved.

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Correspondence to Joseph F. McGuire.

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McGuire, J.F., Ginder, N., Ramsey, K. et al. Optimizing behavior therapy for youth with Tourette’s disorder. Neuropsychopharmacol. (2020). https://doi.org/10.1038/s41386-020-0762-4

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