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What Is Comprehensive Behavioural Intervention For Tics (CBIT)?

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  • What Is Comprehensive Behavioural Intervention For Tics (CBIT)?

    Comprehensive Behavioral Intervention for Tics (CBIT)
    Anxiety and OCD Behavioral Health Center
    posted August 8, 2013

    What Is Comprehensive Behavioral Intervention For Tics (CBIT)?

    Comprehensive Behavioral Intervention for Tics (CBIT) is an evidence-based behavioral therapy for managing Tourette's Disorder and chronic tic disorders that provides additional benefit to pharmacotherapy.

    What Is Involved In CBIT?
    CBIT consists of:
    • Psychoeducation about tic disorders
    • Training the patient to be more aware of tics
    • Habit reversal training (HRT): training patients to do a competing behavior when they feel the urge to tic (e.g., put hands on knees when an urge to perform the tic happens)
    • Making changes to day-to-day activities in ways that can be helpful in reducing tics (e.g., if a child with TS often has a certain tic during math class, the math teacher can be educated about TS, and perhaps the child’s seat can be changed so that the tics are not as visible).

    Continued in post #2
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  • #2
    Re: What Is Comprehensive Behavioural Intervention For Tics (CBIT)?

    Nix the tics
    New research debunks Tourette's syndrome myths and lays the groundwork for a behavioral intervention.

    By Sadie F. Dingfelder
    Monitor Staff
    American Psychological Association
    December 2006, Vol 37, No. 11

    Most researchers agree that the roots of Tourette's syndrome are largely biological. The disorder's characteristic tics--head jerks, eye blinks and grunts, to name a few--seem to stem from abnormalities in the basal ganglia or with dopamine function. What's more, people with the disorder generally experience tics as involuntary, which would seem to make Tourette's a poor candidate for behavior therapy, notes psychologist John Piacentini, PhD, director of the Child OCD, Anxiety and Tic Disorders program at the University of California, Los Angeles.

    "For the last 50 years, Tourette's has been considered a neurological disorder with very little role for behavioral interventions," Piacentini says.
    However, attitudes are changing, he says. Though previously people believed that the tics of Tourette's could only be stopped by medication, new research indicates that environmental contingencies play a role in tic expression. For instance, people suppress tics if they are rewarded for doing so, according to several recent studies.

    This finding is promising, but a barrier remains: Many medical professionals still falsely believe that holding in tics leads to an explosion of tics later, notes Michael Himle, a fifth-year graduate student and Tourette's syndrome researcher at the University of Wisconsin-Milwaukee.
    "There is a lot of belief out there that when a child suppresses their tics, what you get is a rebound effect," Himle says. "Some professionals have used this to caution against the use of behavior therapy."

    Research by Himle and others is countering that belief, and, as a result, funding agencies are now taking a serious look at nonpharmacological treatments for Tourette's. In fact Piacentini and his colleagues recently received about $6 million in grants from the National Institute of Mental Health to try out a new behavioral technique for treating Tourette's. The treatment, known as the Comprehensive Behavioral Intervention for Tics, (CBIT) combines behavior therapy with an attempt to root out anything that might be inadvertently rewarding tic attacks.

    "This is a really exciting time," Piacentini notes. "We are...developing behavioral interventions for what at root cause is a neurological disorder."

    Debunking myths
    Fifty-five percent of medical professionals believe that Tourette's tics can't be controlled and 77 percent believe that if tics are suppressed, they will be even worse later, according to a 2004 survey published in Cognitive and Behavioral Practice (Vol. 11, No. 1, pages 298-305). The survey of 78 neurologists, family practitioners, psychiatrists and clinical psychologists showed that many members of the medical community held beliefs about Tourette's syndrome that were false or untested, says study author Douglas Woods, PhD, a University of Wisconsin-Milwaukee psychology professor.
    "It's almost Freudian, this idea that you can try to repress an unwanted urge, and the more you suppress it the more it will bubble up somewhere else," Woods notes.

    Woods and his student Himle set out to test those assumptions. In a study published in a 2005 issue of Behaviour Research and Therapy (Vol. 43, No. 1, pages 1443-1451), they rewarded seven children, ages 8 to 11, for suppressing their tics. They told the children a "tic detector" would reward them with a token for every 10 seconds they did not tic. They also said the tokens were worth a few cents each, but regardless of their performance, all the participants received $2 at the end of the study.

    While the children believed the tic detector worked automatically, a behind-the-scenes experimenter actually controlled the dispensing of the tokens. The tics exhibited by the participants in the study--which included throat clearing, nose scrunching and grunting--were too complex and subtle to be detected by a machine, Woods notes.

    Before introducing the tic detector, the researchers recorded the frequency of the children's tics. Afterward, they also "turned off" the machine for five minutes and instructed the participants to tic freely, to measure any rebound effect.

    They found that the children were able to suppress their tics--they expressed a tic during 16 percent of the 10-second intervals when they were being rewarded, as opposed to 50 percent of the intervals at the beginning of the experiment. Though the children returned to a high rate of tics once they thought the machine was off, they flinched and grunted less after the suppression period than they did at the beginning of the experiment.

    That same year, another study--published in Behavior Modification (Vol. 29, No. 5, pages 716-745)--showed no rebound effect for tic suppression in five people with Tourette's syndrome, ranging in age from 7 to 20. In that study, psychology professor Raymond Miltenberger, PhD, and his North Dakota State University asked the participants to consciously suppress their tics for 30 minutes while watching television or while holding a conversation with an experimenter. In both cases the participants were only modestly able to control themselves--though some were much better than others. And, during a 30-minute period afterward they did not tic more than they had at the beginning of the experiment.

    "There is really no support for a rebound effect, based on that study," says Miltenberger. "And what we found is that kids have variable ability to control their tics to begin with."

    In addition to debunking the rebound myth, the studies demonstrate that environmental factors can influence the expression of Tourette's syndrome, says Woods.

    The findings also show that people can control their tics--especially if rewards are involved, Woods adds. That is an important foundation for therapy; however, chasing after clients with a coin-dispensing "tic suppressor" would not be a good way to help them control their behavior, he notes.

    Tools for tic suppression
    Most people with Tourette's are treated with drugs, says Roger Kurlan, MD, a psychiatry professor and Tourette's syndrome researcher at the University of Rochester.

    "Behavioral interventions for tics...have never been shown to have more than modest potential benefit," he notes. For that reason, people with Tourette's are generally prescribed medications like risperidone, an antipsychotic, or clonidine, a blood pressure medication. The drugs do reduce tics, but the side effects are often worse than the symptoms they treat, says Woods.

    "The antipsychotics have a 70 to 80 percent tic reduction, but the side effects are abysmal," he notes. "They experience weight gain and fatigue, have dry mouths--and a lot of parents just don't want to put their kids on medication."

    The time is ripe for an alternative treatment, says Piacentini. So he is leading a consortium of scientists who are using the basic science foundation to develop a new behavioral treatment for the disorder. Currently, they are testing CBIT with 120 adults and 120 children in a randomized controlled trial funded by the National Institute of Mental Health, with administrative support from the Tourette Syndrome Association.

    The intervention hinges on findings that show Tourette's tics can be affected by environmental and internal reinforcement. While a tic attack in the lab might be discouraged by a token reward system, in school it might be discouraged by the likelihood of teasing. Or, alternately, a child who gets out of doing household chores due to a tic attack might tic more when it's time to wash dishes, notes Joyce Chang Lee, PhD, a clinical psychologist who is applying the CBIT treatment as part of her postdoctoral fellowship at the University of California, Los Angeles.

    "We try to change those things and stress that the child be treated as normally as possible," Lee says. For instance, parents might let children take a break if they have a tic attack during chore time, but should send them back to finish afterward, she says.

    In addition to removing external rewards, Lee and her colleagues teach children to break the internal reward system for doing tics. Many people with Tourette's syndrome report a premonitory urge or sensation right before they flinch or flail, notes Lee. So, over the course of eight one-hour sessions, she teaches them to be aware of that feeling and then perform a quick countermeasure to quash the tic.

    For instance, one child she worked with would feel tension build up in his arm right before he flung it outward. Lee taught him to hold his arms tightly by his side whenever he started to feel that tension build.

    The training tends to weaken tics over time, Lee says.

    "Usually what happens is, once they use the competing response, the premonitory urge fades away," she notes.

    The treatment addresses the symptoms of Tourette's, not its root causes. But it can make a big difference in the lives of people with the disorder, Woods says. In fact, pilot data show that people who undergo the treatment have a 30 to 60 percent reduction in their tics--an improvement that is comparable to many medications, he says.

    And giving children tools to control their tics can reduce embarrassment and social stigma, Lee says.

    "My first time working with children with Tourette's was a difficult experience because they have behaviors that are so distressing for them; it was really hard to watch," says Lee. "But it has been so rewarding to see the changes that have been made and the improvements in their lives."
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    • #3
      Re: What Is Comprehensive Behavioural Intervention For Tics (CBIT)?

      Source: Tourettes Action U.K.
      Behaviour Therapies and Tourette Syndrome
      August 9, 2013

      Originally posted by Steve
      This excellent article is quoted from Tourettes Action U.K.

      Behavioural therapies and Tourette Syndrome
      Behaviour therapy is a way of doing something to control your tics rather than taking medication, and it is possible to use behavioural therapy alongside other medical treatments.

      Behavioural therapy can be useful for most people with tic disorders, although most evidence suggests that it is effective for children older than eight years of age and adults. Behavioural therapy is not a cure but can be very effective in helping people to gain control over their tics in situations where they would like to do so.

      The most commonly validated behavioural therapy is called Habit Reversal Therapy (HRT), which has been researched since the 1970s. More recently, HRT has been shown to be effective as part of a package alongside other elements of therapy, known as Comprehensive Behavioural Intervention for Tics (CBiT).

      Comprehensive Behavioural Intervention for Tics

      CBiT is a combination of the following elements:

      Learning about Tic Disorders and Tourette syndrome. The sorts of information that is typically included in psychoeducation is: understanding the causes (as much as they are known), appreciating that it is a brain-related condition, the usual course of tics and the sorts of co-occurring conditions that often occur in individuals with Tourette syndrome. This is only the beginning and there is much more to learn and understand, which can really help cope with having a tic disorder. Feeling comfortable and confident in what you know about having a tic disorder is very important and remembering that having tics is only a very small part of any person.

      Functional Intervention
      Functional analysis is used to identify environmental events that be make tics worse or maintain tics for an individual. A therapist will help a person with tics to understand what tends to happen before and after a bout of tics. This may include reactions to situation, thoughts or feelings that a person has in a particular place and the way in which other people respond to that person when they tic. The therapist will then work with the person to reduce or get rid of tic increasing situations. Relaxation or the ability to look at the situation in another way may help.

      Habit Reversal Therapy
      The first stage of HRT is tic description and awareness. This involves the person identifying all of their tics in detail. Understanding where they occur in the body and which muscles are involved. Then the person is asked to choose the tic which bothers them most from the list of current tics. The therapist will then help the individual become aware of when that tic is about to occur. Increasing the persons’ sense of when a tic is about to happen , called a premonitory urge (i.e. ‘feeling that a tic is about to emerge’), will help them to control it.

      The next stage is finding a competing response. This trains the person to perform an intentional movement, which means that the tic cannot happen. It should not look more unusual that the tic and does not interfere with the persons activities. For example, if somebody has a motor tic which involves flinging their arm out, they can be taught to channel the premonitory urge into something more favourable such as placing their hand on their leg and pushing gently. This approach is then applied to the list of tics. People can get really good as creating their own competing responses once they understand the principle of how to do it.

      Social Support and Reward System
      Having support from another person is very helpful with getting to know how to do the Competing response and for motivation to continue doing it over time. This is usually a parent or carer for children and a close friend or partner for adults. It can be helpful to set up a reward system in which the child receives praise or points which can be exchanged for prizes when they put great effort into getting to know how to control their tics.

      Relaxation Training
      Relaxation is used to reduce the stress that a person with tic disorders experiences. This is included in therapy because of the idea that having stress makes a person less well able to control their tics. The most common relaxation training involves deep breathing combined with progressively tensing and relaxing the muscle groups in your body.

      CBiT is usually offered in 6-10 weekly or fortnightly sessions but this can depend on the person with tics and the therapist. There is evidence to show that following the CBiTs protocol completely using telemedicine (similar to voice over internet / Skype) can be just as effective, so this is an approach we are hopeful will be more widely available in the future.

      If somebody is already seeing a behavioural therapist or clinical psychologist, they could recommend a therapist’s workbook on HRT to their clinician: Managing Tourette Syndrome: A Behavioral Intervention for Children and Adults Therapist Guide (Treatments That Work)’ by Douglas W. Woods, John Piacentini, Susanna Chang, Thilo Deckersbach, Golda Ginsburg, Alan Peterson, Lawrence D Scahill.

      Other major therapies for Tourette Syndrome and associated conditions

      Exposure and Response Prevention (ERP)
      ERP is another type of therapy that focuses on getting used to the premonitory urge. Although the full programme available for work with children (Tics - Therapist Manual & Workbook for Children Cara Verdellen, Jolande van de Griendt, Sanne Kriens, Ilse van Oostrum)is similar to CBiTS in many ways, in that it involves relaxation, functional analysis and social support, the key ingredient is about suppressing tics. During therapy, the therapist will use strategies to make the premonitory urge as strong as possible and encourage the child or adult to get used to the feeling without doing the tic. There is evidence to suggest that this approach is as effective as CBiTS. Exposure and Response Prevention may be best suited to people who have a range of very annoying tics or are younger.

      Cognitive Behavioural Therapy (CBT)
      CBT is a type of therapy that focuses on helping people to change both their thinking (cognition) and how they act on it (the behaviour). The technique focuses on current problems and aims to give practical results. For example, it helps to challenge any negative behaviour and thoughts, and builds on the notion that changing our behaviour can help to make us feel better. CBT is based on scientific methods and the efficacy has been proven in research trials. CBT is increasingly more accessible in the NHS, and it’s often a choice for treating problems such as depression, anxiety and Obsessive Compulsive Disorder (OCD).

      Read the attached factsheet produced by Tourettes Action U.K. for a brief overview of behavioural therapy and Tourette.
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