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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-
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308
A
ZlliH
AND
PET
Ell SO
N
·
-
. .
, T.A
BLf,
1 •
i
Nf
.
•
\
~ - _ I
.
•
· Su
mEtT
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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.
8/9/2019 1990 Treatment of Tourette Syndrome by Habit Reversal a Waiting-list Control Group Comparison
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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
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D
W
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T
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IS
T
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R
OU
P
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M
o
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s
'i
o
C h
a
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e
2
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s
6
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p
re
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m
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&
ro
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S
l
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II
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