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Over the past decade, behavioral interventions have become increasingly recognized and recommended as effective first-line therapies for treating individuals with tic disorders. In this article, we describe a basic theoretical and conceptual framework through which the reader can understand the application of these interventions for treating tics. The three primary behavioral interventions for tics with the strongest empirical support (habit reversal, Comprehensive Behavioral Intervention for Tics, and exposure and response prevention) are described. Research on the efficacy and effectiveness of these treatments is summarized along with a discussion of the research evaluating the delivery of these treatments in different formats and modalities. The article closes with a review of the possible mechanisms of change underlying behavioral interventions for tics and areas for future research.

Tics peak in late childhood and decline during adolescence. Yet, for some with Tourette's disorder, tics persist into adulthood. We evaluated childhood predictors of adult tic severity and tic impairment, and change over time. Eighty adolescents/adults were evaluated 11 years following a randomized-controlled trial of behavior therapy. An independent evaluator rated tic severity and tic impairment at baseline, posttreatment, and long-term follow-up. At baseline, parents completed demographics/medical history, and youth tic, internalizing, and externalizing symptom ratings. Youth rated premonitory urge severity and family functioning. After controlling for prior tic treatment effects, female sex and higher tic severity predicted higher tic severity in adulthood; and female sex, no stimulant medication use, higher tic severity, and poorer family functioning predicted higher tic impairment. Higher tic severity and premonitory urge severity predicted smaller reductions in tic severity, whereas higher externalizing symptoms predicted greater reduction in tic severity. Female sex predicted smaller reduction in tic impairment, and externalizing symptoms predicted greater reduction in tic impairment. Female sex and childhood tic severity are important predictors of tic severity and tic impairment in adulthood. Family functioning, premonitory urge severity, and tic severity are important modifiable targets for early or targeted intervention to improve long-term outcomes.

Trichotillomania is characterized by recurrent pulling out of one's hair, leading to significant hair loss and accompanied by clinically significant distress and/or functional impairment. The current study used data from a randomized controlled trial comparing the effectiveness of acceptance-enhanced behavior therapy (AEBT) to psychoeducation plus supportive therapy (PST; active control) for trichotillomania in an adult sample. The objectives were to examine the moderating and mediating influence of trichotillomania-specific psychological flexibility in treatment for trichotillomania. Participants with lower baseline flexibility performed better in AEBT than PST in terms of greater symptom reduction and quality of life. Lower baseline flexibility also predicted higher likelihood of disorder recovery in AEBT relative to PST. In addition, relative to PST, symptom reduction in AEBT was mediated by psychological flexibility, controlling for anxiety and depression. These findings suggest that psychological flexibility is a relevant process of change in the treatment of trichotillomania. Clinical implications and directions for future research are discussed.

BackgroundBehaviors typical of body-focused repetitive behavior disorders such as trichotillomania (TTM) and skin-picking disorder (SPD) are often associated with pleasure or relief, and with little or no physical pain, suggesting aberrant pain perception. Conclusive evidence about pain perception and correlates in these conditions is, however, lacking.MethodsA multisite international study examined pain perception and its physiological correlates in adults with TTM (n = 31), SPD (n = 24), and healthy controls (HCs; n = 26). The cold pressor test was administered, and measurements of pain perception and cardiovascular parameters were taken every 15 seconds. Pain perception, latency to pain tolerance, cardiovascular parameters and associations with illness severity, and comorbid depression, as well as interaction effects (group × time interval), were investigated across groups.ResultsThere were no group differences in pain ratings over time (P = .8) or latency to pain tolerance (P = .8). Illness severity was not associated with pain ratings (all P > .05). In terms of diastolic blood pressure (DBP), the main effect of group was statistically significant (P = .01), with post hoc analyses indicating higher mean DBP in TTM (95% confidence intervals [CI], 84.0-93.5) compared to SPD (95% CI, 73.5-84.2; P = .01), and HCs (95% CI, 75.6-86.0; P = .03). Pain perception did not differ between those with and those without depression (TTM: P = .2, SPD: P = .4).ConclusionThe study findings were mostly negative suggesting that general pain perception aberration is not involved in TTM and SPD. Other underlying drivers of hair-pulling and skin-picking behavior (eg, abnormal reward processing) should be investigated.

This chapter details the third session of the Acceptance and Commitment Therapy (ACT) Enhanced Behavior Therapy for Trichotillomania (AEBT-T) treatment package. The therapist explains how clients often value things, such as being a good caregiver, spouse, or friend; being a great employee; being there for others; or being a good listener. However, the immediate rewards produced by pulling often outweigh the delayed rewards that come from behaving in a way that is more consistent with the aspects of life the client most values. The therapist helps the client see why time is spent talking about defining and following values, noting how this differs from following emotions. Thinking about values as things people do, rather than things people think and feel, can help the client conceptualize their own values.

This chapter covers the fifth session of the Acceptance and Commitment Therapy (ACT) Enhanced Behavior Therapy for Trichotillomania (AEBT-T) treatment package. It discusses how to work with a client on an alternative way of responding to hair-pulling urges, pulling-related cognitions, cravings for specific sensory experiences, and emotions that have commonly led to pulling. It also describes the “paper in shoe” exercise; the therapist can equate the tactile sensations generated by the paper in the shoe to the private event the client uses pulling to control. The chapter reviews activities that present acceptance or willingness to have pulling-related inner experiences and highlights how attempting to control those inner experiences works. It mentions behavioral commitment to reduce hair pulling. The basis for using acceptance in AEBT-T is that urges and other inner experiences ultimately cannot be controlled and attempts at controlling them can be harmful.

This chapter describes the sixth and seventh sessions of the Acceptance and Commitment Therapy (ACT) Enhanced Behavior Therapy for Trichotillomania (AEBT-T) treatment package. Defusion is described as a therapeutic context that challenges the literality of language. The purpose of defusion exercises is not to change the client’s thinking from something that is illogical to something that is logical; rather, it is to change the context of language from something that supports inner experiences as literal events to something that looks at inner experiences as something to simply be experienced. One part of defusion is the ability to see that a person has thoughts that are separate from themselves and that thoughts and feelings affect the way the world is experienced. The chapter shows the therapist how to help a client see that their mind does not stop, that it always has something to say.

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.

This chapter introduces trichotillomania, which is chronic hair pulling resulting in noticeable hair loss. Scalp hair, eyebrows, and beards are some of the common hair-pulling areas. People diagnosed with trichotillomania experience substantial distress or impairment in important areas of their life. They tend to feel an increasing sense of tension immediately before pulling out the hair and when trying to resist pulling and feel a sense of gratification when pulling hair. Some people tend to use automatic hair pulling, which occurs when hairs are pulled outside of the person’s awareness, while others use focused hair pulling to control private experiences like urges, sensations, thoughts, or emotions. The chapter discusses how trichotillomania can be treated through habit reversal training and trigger reduction procedures and offers ways of self-monitoring trichotillomania.

This chapter describes the ninth session of the Acceptance and Commitment Therapy (ACT) Enhanced Behavior Therapy for Trichotillomania (AEBT-T) treatment package. It includes exercises to help clients create a new relationship with pulling-related inner experiences. It also illustrates how to move from a situation where pulling-related inner experiences are events that push the client to engage in actions that regulate experiences, to a situation where these inner experiences are just inner experiences the client notices and does not interact with. In one exercise, the client practices having the particular inner experience with which they most commonly struggle. It determines which processes of change the client should focus on while engaged in a behavioral exercise.

This chapter explores the strategies patients can use to control pulling urges while also regulating their internal experiences. It highlights the importance of values, which help provide motivation for the work the patient is putting into improving their life. The therapist encourages the patient to talk about the strategies they use to try to control urges to pull or other unpleasant internal experiences such as thoughts, emotions, or cravings for sensory experiences. The goal is for the patient to learn whether these controlling procedures truly work in the long run to regulate those internal experiences. The patient is asked to make a behavioral commitment to reducing hair pulling using Acceptance and Commitment Therapy, which involves reducing the habit while experiencing the urges to pull. The chapter compares urges to pull to a playground bully, who is better off ignored despite the difficulty of doing so.

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.

Although pharmacological interventions are efficacious for reducing tic severity, they yield suboptimal symptom relief for most patients and are often associated with side effects that limit long-term tolerability. Behavioral and cognitive–behavioral therapies have demonstrated efficacy for reducing tic severity and tic-related impairment in patients with Tourette disorder. This has led numerous professional organizations to recommend behavioral therapies such as habit reversal training and the Comprehensive Behavioral Intervention for Tics as first-line treatments for Tourette disorder. This chapter provides an overview of different behavioral and cognitive–behavioral therapies for Tourette disorder and reviews the extant evidence for each therapeutic approach. The chapter highlights challenges confronting behavioral and cognitive–behavioral therapies, discusses treatment mechanisms, and identifies steps to overcome these treatment challenges.

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.

Given the limited treatment options for trichotillomania (TTM), or Hair Pulling Disorder, this large randomized clinical trial evaluated the efficacy of acceptance-enhanced behavior therapy for TTM (AEBT-TTM) in reducing TTM severity relative to psychoeducation and supportive therapy (PST). Eighty-five adults (78 women) with TTM received 10 sessions (over 12 weeks) of either AEBT-TTM or PST. Independent evaluators masked to treatment assignment assessed participants at baseline (week 0), midpoint (week 6), and endpoint (week 12). Consistent with a priori hypotheses, 64% of the adults treated with AEBT-TTM were classified as clinical responders at post-treatment relative to 38% treated with PST. Clinical responders were identified by a score of 1 or 2 on the Clinical Global Impressions-Improvement (CGI-I) scale. Relative to the PST group, the AEBT-TTM group demonstrated significantly greater pre-to post-treatment reductions on the self-report Massachusetts General Hospital-Hairpulling Scale (MGH-HS) and the evaluator-rated National Institute of Mental Health Trichotillomania Severity Scale (NIMH-TSS). There were no significant post-treatment group differences on the Clinical Global Impressions-Severity (CGI-S) scale, or rate of TTM diagnoses. Results suggest AEBT-TTM provides greater treatment benefit than PST. Future research should continue to investigate AEBT-TTM along with mediators and moderators of its efficacy.

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.

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.

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