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This chapter talks about the tenth and final session of the Acceptance and Commitment Therapy (ACT) Enhanced Behavior Therapy for Trichotillomania (AEBT-T) treatment package. The therapist should urge the client to continue using the skills learned in therapy. Common pitfalls and methods for addressing them are covered. The first pitfall involves becoming less reliable in using habit reversal training and trigger reduction strategies. The second pitfall involves more time fighting with urges, increased pulling, and less time pursuing the meaningful parts of life. Clients may once again react to pulling-related thoughts, urges, or emotions as if they were real events with physical characteristics. In the final session the therapist should review with the client the progress made in therapy and should congratulate the client on their progress.

BackgroundTrichotillomania (TTM) and skin picking disorder (SPD) are common and often debilitating mental health conditions, grouped under the umbrella term of body-focused repetitive behaviors (BFRBs). Recent clinical subtyping found that there were three distinct subtypes of TTM and two of SPD. Whether these clinical subtypes map on to any unique neurobiological underpinnings, however, remains unknown.MethodsTwo hundred and fifty one adults [193 with a BFRB (85.5% [n = 165] female) and 58 healthy controls (77.6% [n = 45] female)] were recruited from the community for a multicenter between-group comparison using structural neuroimaging. Differences in whole brain structure were compared across the subtypes of BFRBs, controlling for age, sex, scanning site, and intracranial volume.ResultsWhen the subtypes of TTM were compared, low awareness hair pullers demonstrated increased cortical volume in the lateral occipital lobe relative to controls and sensory sensitive pullers. In addition, impulsive/perfectionist hair pullers showed relative decreased volume near the lingual gyrus of the inferior occipital–parietal lobe compared with controls.ConclusionsThese data indicate that the anatomical substrates of particular forms of BFRBs are dissociable, which may have implications for understanding clinical presentations and treatment response.

Trichotillomania (hair pulling disorder) and skin picking disorder are common and often debilitating mental health conditions, grouped under the umbrella term of body focused repetitive behaviors (BFRBs). Although the pathophysiology of BFRBs is incompletely understood, reward processing dysfunction has been implicated in the etiology and sustention of these disorders. The purpose of this study was to probe reward processing in BFRBs. 159 adults (125 with a BFRB [83.2% (n = 104) female] and 34 healthy controls [73.5% (n = 25) female]) were recruited from the community for a multi-center between-group comparison using a functional imaging (fMRI) monetary reward task. Differences in brain activation during reward anticipation and punishment anticipation were compared between BFRB patients and controls, with stringent correction for multiple comparisons. All group level analyses controlled for age, sex and scanning site. Compared to controls, BFRB participants showed marked hyperactivation of the bilateral inferior frontal gyrus (pars opercularis and pars triangularis) compared to controls. In addition, BFRB participants exhibited increased activation in multiple areas during the anticipation of loss (right fusiform gyrus, parahippocampal gyrus, cerebellum, right inferior parietal lobule; left inferior frontal gyrus). There were no significant differences in the win-lose contrast between the two groups. These data indicate the existence of dysregulated reward circuitry in BFRBs. The identified pathophysiology of reward dysfunction may be useful to tailor future treatments.

Consistent with international reports,1 this group of Tourette syndrome (TS) experts has noticed a recent increase in adolescents presenting with tic-like symptoms that show a markedly atypical onset and course. These sudden-onset motor movements and vocalizations are often associated with significant impairment and disability, resulting in emergency department visits and hospitalizations for some affected youths.

The use of an oral orthotic, called an occlusal splint, has gained recognition for the potential to reduce the frequency of tics for individuals with Persistent Tic Disorders. The purpose of this study was to assess the feasibility of a fully blinded, randomized controlled trial (RCT) to assess the safety, tolerability and initial efficacy of the oral orthotic in youth with chronic tics. Thirteen youth were randomly assigned to wear an active or sham orthotic in a two week double-blind RCT, with a 4–6 week unblinded follow up period. A statistically significant difference was found for change in tic severity between participants wearing the active and sham orthotic. However, this difference was not replicated during the follow up period. The oral orthotic is a promising intervention for the reduction of tics in youth with Tourette’s Syndrome and is worthy of continued study to establish intervention efficacy and mechanism of action.

Excoriation (Skin-Picking) Disorder (SPD) is characterized by repetitive skin picking resulting in tissue damage. This study examined associations between the tendency to experience a sense of incompleteness (henceforth trait incompleteness) and pathological skin picking across two studies. In study 1, undergraduate students (n = 481) completed self-report measures of skin picking severity, trait incompleteness, perfectionism, obsessive-compulsive symptoms, and negative affect (i.e., depression, anxiety). In study 2, undergraduate students with a diagnosis of SPD (n = 61) and a control group without SPD (n = 63) rated skin picking severity, trait incompleteness, obsessive-compulsive symptoms, and negative affect (i.e., depression, anxiety, and stress). In study 1, linear regression showed that trait incompleteness significantly predicted skin picking severity, after controlling for other variables. In study 2, logistic regression showed trait incompleteness significantly predicted SPD diagnosis, after controlling for other variables. There was no significant correlation between incompleteness and symptom severity within the SPD group. The results indicate a robust association between SPD and trait incompleteness. More research is needed to establish whether trait incompleteness may represent a vulnerability factor underlying SPD, or if skin picking leads to susceptibility to trait incompleteness.

This study describes impairment in academic, interpersonal, recreational, and family financial or occupational domains across children in three mutually exclusive diagnostic groups: ever diagnosed with Tourette syndrome (TS), attention-deficit/hyperactivity disorder (ADHD), and both disorders. In 2014, parents reported on impairment and diagnostic status of children aged 4-17years (n = 3014). Weighted analysis and pairwise t-tests showed more children with ADHD (with or without TS) experienced impairment in overall school performance, writing, and mathematics, relative to children with TS but not ADHD. More children with TS and ADHD had problematic handwriting relative to children with ADHD but not TS. More children with TS and ADHD had problematic interpersonal relationships relative to those with ADHD but not TS. Children with TS and ADHD had higher mean impairment across domains than children with either TS or ADHD. Findings suggest assessing disorder-specific contributions to impairment could inform targeted interventions for TS and ADHD.

OBJECTIVE: Treatment guidelines for Tourette’s Disorder (TD) are based on patients’ degree of tic severity and impairment. However, clear benchmarks for determining tic severity and impairment have not been established. This study examined benchmarks of tic severity and tic impairment using the Yale Global Tic Severity Scale (YGTSS) and the Clinical Global Impression of Severity (CGI-S). METHOD: Individuals with TD or another Tic Disorder (N = 519) recruited across nine sites were administered a diagnostic interview, the YGTSS, and the CGI-S. Correlations and trend analyses contrasted YGTSS scores across CGI-S ratings. A logistic regression model examined predictive benchmarks for tic severity, tic impairment, and global severity. Model classifications were compared against CGI-S ratings, and agreement was examined using kappa. RESULTS: Spearman correlations between the CGI-S and YGTSS scores ranged from 0.54 to 0.63 (p < 0.001). Greater CGI-S ratings were associated with a linear stepwise increase in YGTSS Total Tic scores, Impairment scores, and Global Severity scores. Despite moderate-to-strong associations (ρ = 0.45–0.56, p < 0.001) between the CGI-S and predictive logistical regression models, only fair agreement was achieved when applying classification benchmarks (κ = 0.21–0.32, p < 0.001). CONCLUSIONS: CGI-S ratings are useful to characterize benchmarks for tic severity, tic impairment, and global severity on the YGTSS. Logistic regression model benchmarks had only fair agreement with the CGI-S and underscore the heterogeneity of TD symptoms. Collectively, findings offer guidance on the delineation of tic severity categorizations to apply evidence-based treatment recommendations.

The Comprehensive Behavioral Intervention for Tic Disorders (CBIT) has demonstrated efficacy in large randomized controlled trials for children (≥9 yrs), adolescents and adults with Tourette Syndrome and Chronic Tic Disorders. Given the early age of onset for tic disorders, a large portion of affected individuals with chronic tic disorders are less than 9 years of age and appropriate developmental adaptations of behavioral treatment have not yet been tested. The goal of this study was to adapt and evaluate the acceptability and utility of a family-based adaptation of CBIT for children under 9 years of age. Children 5–8 years of age (N = 15) with chronic tics were recruited from three study sites. CBIT was adapted for use with young children and included habit reversal strategies introduced in a developmentally appropriate game format and function-based interventions to reduce family accommodation of and attention to tic symptoms. Children and parents described high level of treatment satisfaction and study retention rate was 100%. Treatment response rate was 54% (CGI-I = 1 or 2) with a significant decrease in the YGTSS total score (Cohen’s d = 0.73) that was largely maintained at 3-month and 1-year follow-up assessments. Treatment was associated with reduction of some symptoms of tic-related comorbid syndromes and with changes in parental accommodation and attention to tics. Future research should determine if parental attention to tics and symptom accommodation are important mediators of treatment outcome, or if participating in this intervention at a younger age may prevent the chronic course of tic symptoms.

It is not clear whether the development of tics can be prevented. Contextual variables can impact tic expression; therefore, shifting attention to behaviors that reduce tics is an important part of decreasing tic severity. Several medications are effective in reducing tic severity, but side effects restrict their use. Behavioral treatment is the gold standard psychotherapy intervention for tic disorders, with Comprehensive Behavioral Intervention for Tics being the most well-supported nonpharmacological treatment. Although children may be unable to prevent the development of tics, they can still use several strategies to reduce tic severity and impairment.

Premonitory urges (PUs) are sensory phenomena that immediately precede tics. The Premonitory Urge for Tics Scale (PUTS) is widely used to assess the severity of PUs, but the psychometric properties of PUTS and clinical features of PU in Chinese patients with tic disorders are still unclear. In this study, we examined the psychometric properties of the Chinese version of the PUTS in a large sample (including 367 Chinese pediatric patients with tic disorders). We found no difference in PU in different age groups. The exploratory factor analysis (EFA) of PUTS showed the emergence of four primary factors. The results of reliability and validity analyses indicated that the Chinese version showed good psychometric properties. It seemed that PU was associated with the severity of obsession symptoms in patients with tic disorders. Network analysis showed that Item 7 is a critical node for the PU, in addition to Items 1 and 4. Overall, the Chinese version of PUTS can be used in Chinese child and adolescent patients with tic disorders, particularly for patients with Tourette syndrome.

This chapter explores the treatment of trichotillomania (TTM; also referred to as hair pulling disorder) and Tourette disorder (TD). TTM and TD exist in separate diagnostic categories but exhibit functional similarities and respond to similar treatments. The chapter reviews the characteristics of each disorder. It then describes habit reversal training (HRT) and function-based interventions, which serve as core therapeutic elements in the treatment of both TTM and TD. The chapter also discusses additional treatment strategies that occur as part of standard protocols for both disorders, before looking at the treatment efficacy research. It considers the key features of the manual-based treatments (behavior therapy protocols), as well as ways these protocols can be flexibly implemented for those with TTM and TD. Finally, consistent with the call for “flexibility within fidelity,” the chapter provides an example of a flexible implementation of these treatments.

Objective Describe the diagnostic process for Tourette syndrome (TS) based on parent report, as well as TS severity and associated impairment; the influence of common daily activities on tics; and the presence of co-occurring mental, behavioral, and developmental disorders among children in the United States. Methods Parent-report data from the 2014 National Survey of the Diagnosis and Treatment of ADHD and Tourette Syndrome on 115 children ever diagnosed with TS were analyzed. Descriptive, unweighted analyses included frequencies and percentages, and means and standard deviations. Fisher's exact test and t-tests were calculated to determine statistically significant differences. Results The mean age that tics were first noticed was 6.3 years, and, on average, TS was diagnosed at 7.7 years. The time from initially noticing tics to TS diagnosis averaged 1.7 years. The mean age when TS symptoms were most severe was 9.3 years. Tic severity was associated with impaired child functioning but not tic noticeability. Almost 70% of parents reported that fatigue and major transitions made their child's tics worse. Children with ever-diagnosed TS had a mean of 3.2 ever-diagnosed co-occurring mental, behavioral, or developmental disorders; a quarter (26.9%) had 5 or more co-occurring disorders. Discussion In this sample of children with TS, the time to diagnosis averaged less than 2 years from when tics were initially noticed. More severe TS was associated with greater functional impairment, and co-occurring disorders were common among children with TS. This study provides insight into the current experiences of children with TS in the United States and their families.

Background Cognitive control processes are implicated in the behavioral treatment of Tourette's disorder (TD). However, the influence of these processes on treatment outcomes has received minimal attention. This study examined whether cognitive control processes and/or tic suppression predicted reductions in tic severity and treatment response to behavior therapy. Method Fifty-three youth with TD or a pervasive tic disorder participated in a randomized wait list-controlled trial of behavior therapy. Following a baseline assessment to evaluate psychiatric diagnoses, tic severity, and cognitive control processes (e.g., response selection, inhibition, and suppression), youth were randomly assigned to receive eight sessions of behavior therapy (n = 23) or a wait list of equal duration (n = 28). Youth receiving immediate treatment completed a post-treatment assessment to determine improvement in tic severity. Meanwhile, youth in the wait list condition completed another assessment to re-evaluate tic severity and cognitive control processes, and subsequently received 8 sessions of behavior therapy followed by a post-treatment assessment to determine improvement. Results A multiple linear regression model found that pretreatment inhibition/switching on the Delis-Kaplan Executive Function System Color-Word Interference Test predicted reductions in tic severity after behavior therapy (β = -.36, t = -2.35, p = .025, ƞ2 = .15). However, other cognitive control processes and tic suppression did not predict treatment response and/or reductions in tic severity. Small nonsignificant effects were observed in cognitive control processes after behavior therapy. Conclusion Cognitive control processes may influence tic severity reductions in behavior therapy. Notably, even when other cognitive control processes are impaired and youth are initially unable to voluntarily suppress their tics, youth with TD can still benefit from behavior therapy. Findings offer implications for clinical practice and research for TD.

Behavior therapy is a first-line intervention for Tourette's Disorder (TD), and a key component is the practice of therapeutic skills between treatment visits (i.e., homework). This study examined the relationship between homework adherence during behavior therapy for TD and therapeutic outcomes, and explored baseline predictors of homework adherence during treatment. Participants included 119 individuals with TD (70 youth, 49 adults) who received behavior therapy in a clinical trial. After a baseline assessment of tic severity and clinical characteristics, participants received 8 sessions of behavior therapy. Therapists recorded homework adherence at each therapy session. After treatment, tic severity was re-assessed by independent evaluators masked to treatment condition. Greater overall homework adherence predicted tic severity reductions and treatment response across participants. Early homework adherence predicted therapeutic improvement in youth, whereas late adherence predicted improvement in adults. Baseline predictors of greater homework adherence in youth included lower hyperactivity/impulsivity and caregiver strain. Meanwhile in adults, baseline predictors of increased homework adherence included younger age, lower hyperactivity/impulsivity, obsessive-compulsive severity, anger, and greater work-related disability. Homework adherence is an integral component of behavior therapy and linked to therapeutic improvement. Strategies that improve homework adherence may optimize the efficacy of behavioral treatments and improve treatment outcomes.

Objective To determine the long-term durability of behavior therapy for tics among youth with Tourette disorder and persistent (chronic) motor or vocal tic disorders. Method Of the 126 youth who participated in a randomized controlled trial of behavior therapy 11 years prior, 80 were recruited for this longitudinal follow-up. Consenting participants were interviewed in person or remotely (Web-based video) by trained evaluators to determine the course of tics, current tic severity, and tic-related impairment. Recruitment and data collection occurred between 2014 and 2019, with an average follow-up duration of 11.2 years. Results Treatment responders to both conditions in the original trial achieved partial, but not full, tic remission. Tic severity also decreased significantly across the sample, with 40% reporting partial remission. Behavior therapy responders (n = 21) in the original trial were more likely (67%) to achieve remission at follow-up (Total Tic Score = 12.52, SD = 10.75) compared to psychoeducation/supportive therapy responders (n = 6, 0%) at follow-up (Total Tic Score = 20.67, SD = 6.92) on the Yale Global Tic Severity Scale. Tic-related impairment decreased across the sample, with no significant differences between treatment groups or responders. Conclusion Despite limitations of unmeasured variables and veracity of self-report at follow-up, this study supports guidelines recommending behavior therapy as the first-line intervention for tics. Further investigation of behavior therapy as an early preventive intervention also merits attention.

In 2013, the American Psychiatric Association (APA) published the 5th edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5). In 2019, the World Health Assembly approved the 11th revision of the International Classification of Diseases (ICD-11). It has often been suggested that the field would benefit from a single, unified classification of mental disorders, although the priorities and constituencies of the two sponsoring organizations are quite different. During the development of the ICD-11 and DSM-5, the World Health Organization (WHO) and the APA made efforts toward harmonizing the two systems, including the appointment of an ICD-DSM Harmonization Group. This paper evaluates the success of these harmonization efforts and provides a guide for practitioners, researchers and policy makers describing the differences between the two systems at both the organizational and the disorder level. The organization of the two classifications of mental disorders is substantially similar. There are nineteen ICD-11 disorder categories that do not appear in DSM-5, and seven DSM-5 disorder categories that do not appear in the ICD-11. We compared the Essential Features section of the ICD-11 Clinical Descriptions and Diagnostic Guidelines (CDDG) with the DSM-5 criteria sets for 103 diagnostic entities that appear in both systems. We rated 20 disorders (19.4%) as having major differences, 42 disorders (40.8%) as having minor definitional differences, 10 disorders (9.7%) as having minor differences due to greater degree of specification in DSM-5, and 31 disorders (30.1%) as essentially identical. Detailed descriptions of the major differences and some of the most important minor differences, with their rationale and related evidence, are provided. The ICD and DSM are now closer than at any time since the ICD-8 and DSM-II. Differences are largely based on the differing priorities and uses of the two diagnostic systems and on differing interpretations of the evidence. Substantively divergent approaches allow for empirical comparisons of validity and utility and can contribute to advances in the field.

Body-focused repetitive behavior disorders (BFRBs) include Trichotillomania (TTM; Hair pulling disorder) and Excoriation (Skin Picking) Disorder (SPD). These conditions are prevalent, highly heterogeneous, under-researched, and under-treated. In order for progress to be made in optimally classifying and treating these conditions, it is necessary to identify meaningful subtypes. 279 adults (100 with TTM, 81 with SPD, 40 with both TTM and SPD, and 58 controls) were recruited for an international, multi-center between-group comparison using mixture modeling, with stringent correction for multiple comparisons. The main outcome measure was to examine distinct subtypes (aka latent classes) across all study participants using item-level data from gold-standard instruments assessing detailed clinical measures. Mixture models identified 3 subtypes of TTM (entropy 0.98) and 2 subtypes of SPD (entropy 0.99) independent of the control group. Significant differences between these classes were identified on measures of disability, automatic and focused symptoms, perfectionism, trait impulsiveness, and inattention and hyperactivity. These data indicate the existence of three separate subtypes of TTM, and two separate subtypes of SPD, which are distinct from controls. The identified clinical differences between these latent classes may be useful to tailor future treatments by focusing on particular traits. Future work should examine whether these latent subtypes relate to treatment outcomes, or particular psychobiological findings using neuroimaging techniques.

Tsetsos, Fotis et al., Tourette syndrome (TS) is a neuropsychiatric disorder of complex genetic architecture involving multiple interacting genes. Here, we sought to elucidate the pathways that underlie the neurobiology of the disorder through genome-wide analysis. We analyzed genome-wide genotypic data of 3581 individuals with TS and 7682 ancestry-matched controls and investigated associations of TS with sets of genes that are expressed in particular cell types and operate in specific neuronal and glial functions. We employed a self-contained, set-based association method (SBA) as well as a competitive gene set method (MAGMA) using individual-level genotype data to perform a comprehensive investigation of the biological background of TS. Our SBA analysis identified three significant gene sets after Bonferroni correction, implicating ligand-gated ion channel signaling, lymphocytic, and cell adhesion and transsynaptic signaling processes. MAGMA analysis further supported the involvement of the cell adhesion and trans-synaptic signaling gene set. The lymphocytic gene set was driven by variants in FLT3, raising an intriguing hypothesis for the involvement of a neuroinflammatory element in TS pathogenesis. The indications of involvement of ligand-gated ion channel signaling reinforce the role of GABA in TS, while the association of cell adhesion and trans-synaptic signaling gene set provides additional support for the role of adhesion molecules in neuropsychiatric disorders. This study reinforces previous findings but also provides new insights into the neurobiology of TS., This research is co-financed by Greece and the European Union (European Social Fund—ESF) through the Operational Programme «Human Resources Development, Education and Lifelong Learning» in the context of the project “Reinforcement of Postdoctoral Researchers - 2nd Cycle” (MIS-5033021), implemented by the State Scholarships Foundation (IKY). L.K.D. was supported by grants from the National Institutes of Health including U54MD010722-04, R01NS102371, R01MH113362, U01HG009086, R01MH118223, DP2HD98859, R01DC16977, R01NS105746, R56MH120736, R21HG010652, and RM1HG009034.

The present study used parent-report data to explore crosscultural similarities and differences in tic severity and reactions to tics across 223 children with Tourette’s disorder (TD) from the United States, United Kingdom, and Netherlands/Norway. Psychometric properties of the TARS-PR and PTQ were also examined and results indicated that both measures may be suitable for assessing tic severity and the consequences of tics in these countries. No differences in parent-reported tic severity were found. However, parents of children with TD from the United Kingdom reported significantly more reactions to their child’s tics than parents from the United States and Netherlands/Norway.Citation - Jordan T. Stiede, Douglas W. Woods, Seonaid Anderson, Valsamma Eapen, Ella Gev, Robyn Latimer & Aud M. Bredesen (2021) Cultural Differences in Reactions to Tics and Tic Severity, Child & Family Behavior Therapy, 43:3, 161-180, DOI: 10.1080/07317107.2021.1940586

The present study investigated inhibitory control deficits in Tourette's Disorder (TD)-only, Attention Deficit/Hyperactivity Disorder (ADHD)-only, and TD+ADHD and explored the degree to which measures of inhibitory control, and tic and ADHD severity predicted objective tic suppressibility. Participants were youth ages 9 to 14 (M=11.15) with TD-only (n=24), TD+ADHD (n=19), ADHD-only (n=139), and typically-developing controls (n=59) drawn from a larger study. Groups were compared on computer-based and paper and pencil neurocognitive inhibitory control tasks. Among youth with TD, neurocognitive measures of inhibitory control, subjective tic-suppressibility (Premonitory Urge for Tics Scale, item 10), and ADHD symptom severity were evaluated as predictors of objective tic suppressibility (i.e., laboratory-based tic suppression task), controlling for total tic severity. There were significant group differences on Color-Word inhibition/switching performance, though post-hoc comparisons yielded no significant pairwise group contrasts. Subjective tic suppressibility was the only significant predictor of objective tic suppressibility. The evident intact neurocognitive inhibitory control among youth with TD suggests that individuals with TD may use compensatory neural mechanisms to support typical speed and accuracy of response. The role of cognitive flexibility in mechanisms of tic suppression should also be further explored.

Habit reversal training (HRT) has been a mainstay of behavior analysts' repertoire for nearly the last 50 years. HRT has been effective in treating a host of repetitive behavior problems. In the face of the current coronavirus pandemic, HRT has practical public health importance as a possible intervention for reducing hand-to-head behaviors that increase the risk of viral infection. The current paper provides a brief review of HRT for hand-to-head habits that is designed for a broad audience and concludes with practical suggestions, based on HRT, for reducing face-touching behaviors.

In this study, 285 adults who met criteria for trichotillomania (TTM) via self-report completed an online, cross-sectional survey examining antecedent phenomenological experiences pertaining to hair pulling along with measures of TTM severity and experiential avoidance (i.e., avoidance of or escape from unwanted thoughts or feelings). Results showed a heterogeneous depiction of antecedent experiences. Subsequent analyses revealed that certain antecedents were not significantly related to TTM severity but were significantly correlated with higher levels of experiential avoidance. In particular, four of five classes of antecedents (i.e., bodily sensations, physical symptoms, mental anxiety, and general uncomfortableness) were significantly related to greater experiential avoidance. The authors conclude that treatments may need to be designed to address specific private antecedents, and that this may be done through targeting experiential avoidance.

Children with persistent (chronic) tic disorders (PTDs) experience impairment across multiple domains of functioning, but given high rates of other non-tic-related conditions, it is often difficult to differentiate the extent to which such impairment is related to tics or to other problems. The current study used the Child Tourette's Syndrome Impairment Scale - Parent Report (CTIM-P) to examine parents' attributions of their child's impairment in home, school, and social domains in a sample of 58 children with PTD. Each domain was rated on the extent to which the parents perceived that impairment was related to tics versus non-tic-related concerns. In addition, the Yale Global Tic Severity Scale (YGTSS) was used to explore the relationship between tic-related impairment and tic severity. Results showed impairment in school and social activities was not differentially attributed to tics versus non-tic-related impairment, but impairment in home activities was attributed more to non-tic-related concerns than tics themselves. Moreover, tic severity was significantly correlated with tic-related impairment in home, school, and social activities, and when the dimensions of tic severity were explored, impairment correlated most strongly with motor tic complexity. Results suggest that differentiating tic-related from non-tic-related impairment may be clinically beneficial and could lead to treatments that more effectively target problems experienced by children with PTDs. Keywords: Impairment, Tourette's disorder, Tic severity, Children

Background: Tourette syndrome (TS) and chronic tic disorders (CTD) are stigmatizing disorders that may significantly impact self-esteem. Alternatively, comorbid psychiatric illnesses may affect self-esteem more than tics themselves. Extant research on self-esteem in TS/CTD is limited, has inconsistently examined the effect of comorbidities on self-esteem, and yields mixed findings. Method: This study aimed to clarify the roles of tics versus comorbid diagnoses on self-esteem in a large, carefully diagnosed sample of adults with TS/CTD (N = 122) receiving 10 weeks of Comprehensive Behavioral Intervention for Tics (CBIT) or Psychoeducation and Supportive Therapy (PST). Results: Baseline self-esteem did not differ between adults with TS/CTD only and normative means, whereas self-esteem was significantly lower among adults with TS/CTD with a comorbid psychiatric illness. In a multiple regression testing the baseline association between tic severity, presence of comorbid psychiatric illness, and depression severity with self-esteem, comorbidity and depression severity were significantly associated with self-esteem, whereas tic severity was not. Finally, using a generalized linear model, we tested the effects of treatment assignment, comorbidity, and their interaction on changes in self-esteem across treatment, controlling for baseline depression severity. Results showed that for those with a comorbid illness, self-esteem improved significantly more with CBIT than with PST. Conclusions: Comorbid illnesses appear to affect self-esteem more so than tics among adults with TS/CTD. Therapeutic attention should be paid to treating comorbid diagnoses alongside tics when treating TS/CTD. Keywords: Self-esteem, Tourette syndrome, Chronic tic disorder, Comorbidity, Comprehensive Behavioral Intervention for Tics

This paper examined neurocognitive functioning and its relationship to behavior treatment response among youth with Tourette’s Disorder (TD) in a large randomized controlled trial. Participants diagnosed with TD completed a brief neurocognitive battery assessing inhibitory functions, working memory, and habit learning pre- and post-treatment with behavior therapy (CBIT, Comprehensive Behavioral Intervention for Tics) or psychoeducation plus supportive therapy (PST). At baseline, youth with tics and Attention Deficit Hyperactivity Disorder (ADHD) exhibited some evidence of impaired working memory and simple motor inhibition relative to youth with tics without ADHD. Additionally, a small negative association was found between antipsychotic medications and youth’s performance speed. Across treatment groups, greater baseline working memory and aspects of inhibitory functioning were associated with a positive treatment response; no between-group differences in neurocognitive functioning at post-treatment were identified. Within the behavior therapy group, pre-treatment neurocognitive status did not predict outcome, nor was behavior therapy associated significant change in neurocognitive functioning post-treatment. Findings suggest that co-occurring ADHD is associated with some impairments in neurocognitive functioning in youth with Tourette’s Disorder. While neurocognitive predictors of behavior therapy were not found, participants who received behavior therapy exhibited significantly reduced tic severity without diminished cognitive functioning.

Trichotillomania (TTM) and eating disorders (ED) share many phenomenological similarities, including ritualized compulsive behaviors. Given this, and that comorbid EDs may represent additional functional burden to hair pullers, we sought to identify factors that predict diagnosis of an ED in a TTM population. Subjects included 555 adult females (age range 18–65) with DSM-IV-TR TTM or chronic hair pullers recruited from multiple sites. 7.2% (N = 40) of our TTM subjects met criteria for an ED in their lifetime. In univariable regression analysis, obsessive-compulsive disorder (OCD), Yale-Brown Obsessive Compulsive Scale (Y-BOCS) worst-ever compulsion and total scores, certain obsessive-compulsive spectrum disorders, anxiety disorder, attention-deficit/hyperactivity disorder (ADHD), and substance disorder all met the pre-specified criteria for inclusion in the multivariable analysis. In the final multivariable model, diagnosis of OCD (OR: 5.68, 95% CI: 2.2–15.0) and diagnosis of an additional body-focused repetitive behavior disorder (BFRB) (OR: 2.69, 95% CI: 1.1–6.8) were both associated with increased risk of ED in TTM. Overall, our results provide further support of the relatedness between ED and TTM. This finding highlights the importance of assessing for comorbid OCD and additional BFRBs in those with TTM. Future research is needed to identify additional predictors of comorbid disorders and to better understand the complex relationships between BFRBs, OCD and EDs.

Although research has consistently linked unidimensional anxiety with Trichotillomania (TTM) severity, the relationships between TTM severity and anxiety dimensions (i.e., cognitive and somatic anxiety) are unknown. This knowledge gap limits current TTM conceptualization and treatment. The current study examined these relationships with data collected from ninety-one adults who participated in a randomized clinical trial for TTM treatment. To examine whether the Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steer, 1988) could be used to measure multidimensional anxiety in TTM samples, we conducted a factor analysis. Results showed four emergent factors, including a cognitive factor and three somatic factors (neurophysiological, autonomic, and panic). Based on prior research, it was hypothesized that TTM severity would be related to the cognitive anxiety dimension and that psychological inflexibility would mediate the association. Hypotheses were not made regarding the relationship between TTM severity and somatic anxiety. Regression analyses indicated that only cognitive dimensions of anxiety predicted TTM severity and that psychological inflexibility mediated this relationship. Implications for the conceptualization and treatment of TTM are discussed.

Purpose of review:To summarize behavioral interventions for the treatment of primary tic disorders.Recent findings:Although tics were attributed to a disordered weak volition, the shift towards neurobiological models of tic disorders also transformed nonpharmacologic treatment practices. Current international guidelines recommend habit reversal training, comprehensive behavioral intervention, and exposure and response prevention as first-line therapies for tics. Appropriate patient selection, including age and presence of comorbidities, are salient clinical features that merit consideration. Evidence for further behavioral interventions is also presented.Summary:Currently recommended behavioral interventions view tics as habitual responses that may be further strengthened through negative reinforcement. Although availability and costs related to these interventions may limit their effect, Internet-based and telehealth approaches may facilitate wide accessibility. Novel nonpharmacologic treatments that take different approaches, such as autonomic modulation or attention-based interventions, may also hold therapeutic promise.

Background This study sought to investigate the effectiveness of group treatment for trichotillomania (TTM) in ordinary clinical settings. Treatment consisted of a combination of habit reversal training (HRT) and acceptance and commitment treatment (ACT). Both short- and long-term effects were explored, as well as individual change trajectories. Methods The sample consist of fifty-three patients with TTM. Treatment outcomes were evaluated at post-treatment and at one-year follow-up using self-report questionnaires (Massachusetts General Hospital Hair Pulling Scale, MGH-HS), structured clinical interviews (National Institute of Mental Health Trichotillomania Severity Scale, NIMH-TSS), and the Clinical Global Impression scale for TTM (CGI-TTM). Results Analyses by mixed models for repeated measurements yielded a statistically significant effect of time (p Conclusions ACT-enhanced behavior therapy in a group format seems efficient for reducing symptoms of trichotillomania.

Trichotillomania (hair pulling disorder, HPD) and pathological skin picking (PSP) are associated with significant rates of psychosocial impairment and distress. Little research has addressed the physical consequences and associated impairment in youth (e.g., poor body-esteem). The present study explores the relationship between body-esteem, skin picking (SP), and pulling-related impairment in a sample of adolescents with primary HPD. Ninety four adolescents who pull their hair, 40 of whom also pick their skin, were recruited via internet-sampling as part of the Child and Adolescent Trichotillomania Impact Study (CA-TIP). All youth and a parent completed anonymous questionnaires online assessing psychiatric symptoms, repetitive behaviors, and psychosocial impairment, among other variables. Appearance-based body-esteem was not found to be predictive of more severe psychosocial impairment in these youth. However, SP, in combination with HPD, contributed to worse appearance-based body-esteem above and beyond symptoms of HPD alone. The current study suggests that psychosocial functioning in youth with HPD is less impacted by body-esteem or pulling than other factors (e.g., depression and anxiety), and that SP contributes to lowered body-esteem. These findings suggest the importance of addressing body-esteem in case conceptualization for youth with both HPD and SP. Further research is required to confirm these suggestions.

Trichotillomania (hair pulling disorder) (TTM) and excoriation (skin picking) disorder (SPD) are characterised by repetitive hair pulling and skin picking, which respectively cause hair loss and sk...

Background A promising approach to reducing the phenotypic heterogeneity of psychiatric disorders involves the identification of homogeneous subtypes. Careful study of comorbidity in obsessive‐compulsive disorder (OCD) contributed to the identification of the DSM‐5 subtype of OCD with tics. Here we investigated one of the largest available cohorts of clinically diagnosed trichotillomania (TTM) to determine whether subtyping TTM based on comorbidity would help delineate clinically meaningful subgroups. Methods As part of an ongoing international collaboration, lifetime comorbidity data were collated from 304 adults with pathological hair‐pulling who fulfilled criteria for DSM‐IV‐TR or DSM‐5 TTM. Cluster analysis (Ward's method) based on comorbidities was undertaken. Results Three clusters were identified, namely Cluster 1: cases without any comorbidities (n = 63, 20.7%) labeled “simple TTM,” Cluster 2: cases with comorbid major depressive disorder only (N = 49, 16.12%) labeled “depressive TTM,” and Cluster 3: cases presenting with combinations of the investigated comorbidities (N = 192, 63.16%) labeled “complex TTM.” The clusters differed in terms of hair‐pulling severity (F = 3.75, p = .02; Kruskal–Wallis [KW] p, Findings from analysis of data from one of the largest clinically diagnosed cohorts of trichotillomania (TTM) to date emphasize the prominence of depression in this condition, as well as an association between increased comorbidity and severity of hair‐pulling and depressive symptomatology. In the clinic, there should be cognizance of the potential presence of comorbidity and of depression in particular, that could impact on treatment choice, response, and outcome. In the presence of comorbidity, treatment for TTM may need to be modified.

Body-focused repetitive behaviors (BFRBs) and non-suicidal self-injury (NSSI) are recognized as distinct categories in the DSM-5. However, definitions and assessment of NSSI sometimes encompasses behaviors similar to BFRBs, and little data exist about their clinical differences. The current study examined clinical characteristics and symptom features associated with NSSI vs. BFRBs. The current sample included 1523 individuals who endorsed moderate to severe NSSI (n = 165) or BFRBs: hair pulling group (n = 102), skin picking group (n = 216), nail picking group (n = 253), nail biting group (n = 487), and cheek biting group (n = 300). Responders were asked to complete questionnaires on clinical features relevant for BFRBs and NSSI. NSSI and BFRBs had significant differences on several clinical features. Individuals in the NSSI group were more likely than individuals with BFRBs to report engaging in the behavior for social-affective reasons (i.e., to get out of doing something, or receive attention from others). Individuals in the NSSI group were also more likely to engage in the behavior to regulate tension and feelings of emptiness, and to experience relief during the act. In contrast, individuals in the BFRB groups were more likely to engage in the behavior automatically without reflective awareness, to reduce boredom, or to fix appearance. The NSSI group obtained significantly higher scores on questionnaires assessing stress, anxiety, depression, and harm avoidance. Overall, the results showed several notable differences between NSSI and BFRBs that are consistent with clinical literature and definitions of these problems in the DSM-5.

BackgroundAlthough behavior therapy reduces tic severity, it is unknown whether it improves co-occurring psychiatric symptoms and functional outcomes for adults with Tourette's disorder (TD). This information is essential for effective treatment planning. This study examined the effects of behavior therapy on psychiatric symptoms and functional outcomes in older adolescents and adults with TD.MethodA total of 122 individuals with TD or a chronic tic disorder participated in a clinical trial comparing behavior therapy to psychoeducation and supportive therapy. At baseline, posttreatment, and follow-up visits, participants completed assessments of tic severity, co-occurring symptoms (inattention, impulsiveness, hyperactivity, anger, anxiety, depression, obsessions, and compulsions), and psychosocial functioning. We compared changes in tic severity, psychiatric symptoms, and functional outcomes using repeated measure and one-way analysis of variance.ResultsAt posttreatment, participants receiving behavior therapy reported greater reductions in obsessions compared to participants in supportive therapy ($\eta _p^2 $ = 0.04, p = 0.04). Across treatments, a positive treatment response on the Clinical Global Impression of Improvement scale was associated with a reduced disruption in family life ($\eta _p^2 $ = 0.05, p = 0.02) and improved functioning in a parental role ($\eta _p^2 $ = 0.37, p = 0.02). Participants who responded positively to eight sessions of behavior therapy had an improvement in tic severity ($\eta _p^2 $ = 0.75, p < 0.001), inattention ($\eta _p^2 $ = 0.48, p < 0.02), and functioning ($\eta _p^2 $ = 0.39–0.42, p < 0.03–0.04) at the 6-month follow-up.ConclusionBehavior therapy has a therapeutic benefit for co-occurring obsessive symptoms in the short-term, and reduces tic severity and disability in adults with TD over time. Additional treatments may be necessary to address co-occurring symptoms and improve functional outcomes.

Trichotillomania (TTM) involves the chronic pulling out of hair to the point of hair loss or thinning, which continues despite repeated attempts to stop. Behavior therapy is a promising treatment for the condition, but studies have been limited by the lack of a credible control condition, small sample sizes, follow-up periods of short duration, and low participation by underrepresented populations. In the current article, the authors describe the theoretical rationale for an acceptance-enhanced form of behavior therapy for TTM in adults and describe the methodology used to test the efficacy of this intervention against a psychoeducation and supportive control condition. In addition, the authors discuss the importance of and difficulties encountered with enrolling minority participants into TTM research, as well as strategies used to enhance minority recruitment. Finally, the authors discuss the instruments, procedures, and related outcomes of the fidelity measures used in the randomized controlled trial.

Comprehensive Behavioral Intervention for Tics (CBIT) is an efficacious treatment for children with Chronic Tic Disorders (CTDs). Nevertheless, many families of children with CTDs are unable to access CBIT due to a lack of adequately trained treatment providers, time commitment, and travel distance. This study established the interrater reliability between in-person and VoIP administrations of the Yale Global Tic Severity Scale (YGTSS), and examined the preliminary efficacy, feasibility, and acceptability of Voice over Internet Protocol (VoIP)-delivered CBIT for reducing tics in children with CTDs in an open case series. Across in-person and VoIP administrations of the YGTSS, results showed mean agreement of 91%, 96%, and 95% for motor, phonic, and total tic severity subscales. In the pilot feasibility study, four children received 8-weekly sessions of CBIT via VoIP and were assessed at pre- and post-treatment by an independent evaluator. Results showed a 29.44% decrease in clinician-rated tic severity from pre to post-assessment on the YGTSS. Two of the four patients were considered treatment responders at post treatment, using Clinical Global Impressions-Improvement ratings. Therapeutic alliance, parent and child treatment satisfaction and videoconferencing satisfaction ratings were high. CBIT was considered feasible to implement via VoIP, although further testing is recommended.

ObjectiveTo make recommendations on the assessment and management of tics in people with Tourette syndrome and chronic tic disorders.MethodsA multidisciplinary panel consisting of 9 physicians, 2 psychologists, and 2 patient representatives developed practice recommendations, integrating findings from a systematic review and following an Institute of Medicine–compliant process to ensure transparency and patient engagement. Recommendations were supported by structured rationales, integrating evidence from the systematic review, related evidence, principles of care, and inferences from evidence.ResultsForty-six recommendations were made regarding the assessment and management of tics in individuals with Tourette syndrome and chronic tic disorders. These include counseling recommendations on the natural history of tic disorders, psychoeducation for teachers and peers, assessment for comorbid disorders, and periodic reassessment of the need for ongoing therapy. Treatment options should be individualized, and the choice should be the result of a collaborative decision among patient, caregiver, and clinician, during which the benefits and harms of individual treatments as well as the presence of comorbid disorders are considered. Treatment options include watchful waiting, the Comprehensive Behavioral Intervention for Tics, and medication; recommendations are provided on how to offer and monitor these therapies. Recommendations on the assessment for and use of deep brain stimulation in adults with severe, treatment-refractory tics are provided as well as suggestions for future research.

ObjectiveTo systematically evaluate the efficacy of treatments for tics and the risks associated with their use.MethodsThis project followed the methodologies outlined in the 2011 edition of the American Academy of Neurology's guideline development process manual. We included systematic reviews and randomized controlled trials on the treatment of tics that included at least 20 participants (10 participants if a crossover trial), except for neurostimulation trials, for which no minimum sample size was required. To obtain additional information on drug safety, we included cohort studies or case series that specifically evaluated adverse drug effects in individuals with tics.ResultsThere was high confidence that the Comprehensive Behavioral Intervention for Tics was more likely than psychoeducation and supportive therapy to reduce tics. There was moderate confidence that haloperidol, risperidone, aripiprazole, tiapride, clonidine, onabotulinumtoxinA injections, 5-ling granule, Ningdong granule, and deep brain stimulation of the globus pallidus were probably more likely than placebo to reduce tics. There was low confidence that pimozide, ziprasidone, metoclopramide, guanfacine, topiramate, and tetrahydrocannabinol were possibly more likely than placebo to reduce tics. Evidence of harm associated with various treatments was also demonstrated, including weight gain, drug-induced movement disorders, elevated prolactin levels, sedation, and effects on heart rate, blood pressure, and ECGs.ConclusionsThere is evidence to support the efficacy of various medical, behavioral, and neurostimulation interventions for the treatment of tics. Both the efficacy and harms associated with interventions must be considered in making treatment recommendations.

Chronic tic disorders (CTDs) involve motor and/or vocal tics that often cause substantial distress and impairment. Differential reinforcement of other behavior (DRO) schedules of reinforcement produce robust, but incomplete, reductions in tic frequency in youth with CTDs; however, a more robust reduction may be needed to affect durable clinical change. Standard, fixed-amount DRO schedules have not commonly yielded such reductions, so we evaluated a novel, progressive-amount DRO schedule, based on its ability to facilitate sustained abstinence from functionally similar behaviors. Five youth with CTDs were exposed to periods of baseline, fixed-amount DRO (DRO-F), and progressive-amount DRO (DRO-P). Both DRO schedules produced decreases in tic rate and increases in intertic interval duration, but no systematic differences were seen between the two schedules on any dimension of tic occurrence. The DRO-F schedule was generally preferred to the DRO-P schedule. Possible procedural improvements and other future directions are discussed.

Although cognitive behavioral treatments (CBTs) have been recommended as first-line interventions for trichotillomania (hair-pulling disorder [HPD]), research on CBT for young children with HPD is limited. We illustrate the use of family-based CBT for HPD in an 8-year-old boy. The client had a 5-year history of chronic HPD and several large bald spots on the crown of his head. Treatment primarily comprised habit reversal training (HRT) and function-based interventions. The child showed significant improvement in HPD severity and impairment after 8 weekly sessions, although complete abstinence was not achieved. The findings underscore the importance of parental involvement in the treatment and show that children as young as 8 years of age can successfully use strategies taught in HRT.

Some have argued that hair pulling in trichotillomania (TTM) is triggered by traumatic events, but reliable evidence linking trauma to TTM is limited. However, research has shown that hair pulling is associated with emotion regulation, suggesting a connection between negative affect and TTM. We investigated the associations between trauma, negative affect, and hair pulling in a cross-sectional sample of treatment seeking adults with TTM (N=85). In the current study, participants’ self-reported traumatic experiences were assessed during a structured clinical interview, and participants completed several measures of hair pulling severity, global TTM severity, depression, anxiety, experiential avoidance, and quality of life. Those who experienced trauma had more depressive symptoms, increased experiential avoidance, and greater global TTM severity. Although the presence of a trauma history was not related to the severity of hair pulling symptoms in the past week, depressive symptoms mediated the relationship between traumatic experiences and global TTM severity. These findings cast doubt on the notion that TTM is directly linked to trauma, but suggest that trauma leads to negative affect that individuals cope with through hair pulling. Implications for the conceptualization and treatment of TTM are discussed.

The objective of this study was to examine the influence of environmental challenges on tic expression by subjective and objective measures. The study group consisted of 41 children aged 6-18 years (M=10.15, SD=2.73) with a primary diagnosis of Tourette syndrome. Subjective measures included the Functional Assessment Interview developed for this study and three standard validated instruments. The objective measure was a video-recording of the patients in five daily-life situations: watching television, doing homework, being alone, receiving attention when ticcing, and talking to a stranger. In addition, the effect of premonitory urges on assessment of tic expression was evaluated. The associations between the subjective and objective measures of tic expression were moderate to low. A significantly higher number of tics were observed in the television situation, and a significantly lower number in the alone situation, compared to the other situations. Higher levels of premonitory urge were associated with greater awareness of objectively measured tic expression. In conclusion, tic expression is significantly influenced by the environment. Subjective measures of tic expression may be misleading. These results have implications for refining the clinical assessment of tics, improving research methodology, and developing new therapeutic strategies.

Premonitory urges (PU) often precede motor and vocal tic expression, are relieved by completion of the tic and may be more bothersome than tics. Most treatments focus more on tics than on PU. The present study examines the effect of an acceptance-based approach on PU. Forty five participants, aged 8–17, with Tourette syndrome (TS) were assessed. The procedure included three conditions, of 2 min’ duration: free-to-tic (baseline), tic suppression and urge acceptance. For each condition, participant’s monitored PU frequency and intensity, and discomfort level and tic frequency were measured. There was a significant decrease in frequency and intensity of urges during acceptance based approach. The same significant decrease was seen for discomfort level and tic frequency. These results may lead to new insights regarding therapy.

Trichotillomania (TTM) is associated with significant embarrassment and is viewed negatively by others. A potentially important outcome variable that is often overlooked in treatment for TTM is appearance and social perception.The present study tested whether participants in a randomized controlled trial (RCT) of psychotherapy for TTM are viewed more positively by others. All participants in the trial were photographed at baseline and posttreatment. Three treatment responders and three treatment nonresponders were selected randomly for the present study. Several healthy controls were also photographed in a similar manner. Undergraduate college students (N = 245) assessed whether they would reject the person socially, whether the individual has a psychological or medical problem, and attractiveness.Individuals with TTM were viewed more negatively than healthy controls at baseline, but treatment responders showed positive improvements on all perceptions relative to nonresponders. While treatment responders were still perceived more poorly than controls on social rejection and perceptions of problems at posttreatment, responders where rated no differently than controls on attractiveness at posttreatment.The results suggest that persons with TTM who respond to treatment are rated by others as significantly improved in appearance, but they might be still stigmatized or socially rejected.

Although photographic assessment has been found to be reliable in assessing hair loss in Trichotillomania, the validity of this method is unclear, particularly for gauging progress in treatment. The current study evaluated the psychometric properties of photographic assessment of change in Trichotillomania. Photographs showing hair loss of adults with Trichotillomania were taken before and after participating in a clinical trial for the condition. Undergraduate college students (N = 211) rated treatment response according to the photos, and additional archival data on hair pulling severity and psychosocial health were retrieved from the clinical trial. Photographic assessment of change was found to possess fair reliability (ICC = 0.53), acceptable criterion validity (r = 0.51), good concurrent validity (r = 0.30–0.36), and excellent incremental validity (ΔR 2 = 8.67, p

Despite its prevalence and a growing body of research, significant gaps remain in the knowledge of trichotillomania (TTM). The current study sought to address this issue by examining personality characteristics, impulsivity, and experiential avoidance of those with TTM compared to an age and gender matched sample. 56 Female participants (28 with TTM and 28 non-clinical age-matched controls) completed the Personality Assessment Inventory (PAI), Barratt's Impulsivity Scale (BIS), and the Acceptance and Action Questionnaire (AAQ). Paired-sample t -tests compared each of the 28 individuals who met criteria for TTM to an age and gender matched individual who did not meet criteria for TTM or any Axis I condition. Significant differences were found between many of the PAI scales and subscales, impulsivity, and experiential avoidance. The TTM group displayed higher levels of pathology than the control group. The findings provide evidence that individuals with TTM demonstrate differing levels of personality characteristics compared to individuals without TTM and that treatment may benefit from acknowledging and targeting these areas.

Over the past six decades, behavior therapy has been a major contributor to the development of evidence-based psychotherapy treatments. However, a long-standing concern with behavior therapy among many nonbehavioral clinicians has been the potential risk for symptom substitution. Few studies have been conducted to evaluate symptom substitution in response to behavioral treatments, largely due to measurement and definitional challenges associated with treated psychiatric symptoms. Given the overt motor and vocal tics associated with Tourette's disorder, it presents an excellent opportunity to empirically evaluate the potential risk for symptom substitution associated with behavior therapy. The present study examined the possible presence of symptom substitution using four methods: (a) the onset of new tic symptoms, (b) the occurrence of adverse events, (c) change in tic medications, and (d) worsening of co-occurring psychiatric symptoms. Two hundred twenty-eight participants with Tourette's disorder or persistent motor or vocal tic disorders were randomly assigned to receive behavioral therapy or supportive therapy for tics. Both therapies consisted of eight sessions over 10 weeks. Results indicated that participants treated with behavior therapy were not more likely to have an onset of new tic symptoms, experience adverse events, increase tic medications, or have an exacerbation in co-occurring psychiatric symptoms relative to participants treated with supportive therapy. Further analysis suggested that the emergence of new tics was attributed with the normal waxing and waning nature of Tourette's disorder. Findings provide empirical support to counter the long-standing concern of symptom substitution in response to behavior therapy for individuals with Tourette's disorder.