Behavior Therapy for Adults with Tourette Syndrome

描述（由申请人提供）：抽动秽语综合征（TS）是一种以持续运动和声音抽搐为特征的神经系统疾病。抽搐可以是面部、肩部和四肢的短暂、快速和飞奔的运动，也可以是更复杂和有目的的外观。声音抽搐可以是简单的声音，如嗅闻或咕噜声，也可以是更复杂的声音，包括重复的单词和短语。抽搐随着时间的推移逐渐减弱，严重程度在10到12岁之间达到顶峰。然而，有些人在成年后会有更持久的抽搐过程。当出现在成年人身上时，TS的抽搐可能与相当大的痛苦、社会和职业障碍以及歧视有关。大量证据表明，涉及丘脑、基底神经节和额叶皮质的皮质-皮质下通路功能障碍。虽然以神经学为基础，行为和环境因素也可能在抽动维持中发挥作用。目前，抽动抑制的标准治疗方法是药物治疗，特别是中枢作用的多巴胺阻断药物。然而，这些药物与一系列不良反应相关，可能导致依从性差或过早终止治疗。此外，目前可用的药物很少能消除所有抽搐。因此，在控制他们的慢性疾病时，成年人经常面临对药物的部分反应，或者由于不可接受的副作用，他们选择避免所有药物。本应用程序上列出的调查人员的初步研究表明，一种称为习惯逆转训练（HRT）的行为治疗是一种有希望的抽搐干预方法。HRT是一种多成分的治疗方法，包括意识训练、自我监控、应急管理、不便回顾、放松训练和竞争反应。激素替代疗法被设计为单一疗法和/或药物治疗的强化疗法。尽管评估HRT在TS中的疗效的初步研究令人鼓舞，但迄今为止的调查都是案例研究或小型随机试验，HRT从未作为药物治疗的补充进行过系统的研究。

DESCRIPTION (provided by applicant): Tourette Syndrome (TS) is a neurological disorder characterized by persistent motor and vocal tics. Tics can be brief, rapid and darting movements of the face, shoulders, and extremities or more complex and purposeful in appearance. Vocal tics can be simple sounds such as sniffing or grunting or more complex sounds including repeated words and phrases. Tics wax and wane over time with peak severity between ages 10 and 12 years. However, some individuals have a more enduring course of tics into adulthood. When present in adults, the tics of TS can be associated with considerable distress, social and occupational impairment, and discrimination. A substantial body of evidence implicates dysfunction of cortical-subcortical pathways involving the thalamus, basal ganglia and the frontal cortex. Although neurologically-based, behavioral and environmental factors may also play a role in tic maintenance. Currently, the standard treatment for tic suppression is medication, particularly centrally acting dopamine-blocking drugs. However, these medications are associated with a range of adverse effects that can result in poor compliance or in premature termination of treatment. Moreover, currently available medications rarely eliminate all tics. Thus, when managing their chronic condition, adults are often faced with a partial response to medication, or they opt to avoid all medications due to unacceptable side effects. Preliminary research by the investigators listed on this application suggests that a behavioral treatment called habit reversal training (HRT) is a promising intervention for tics. HRT is a multi-component treatment approach that includes awareness training, selfmonitoring, contingency management, inconvenience review, relaxation training and competing responses. HRT is designed as a monotherapy and/or as an augmentation to pharmacotherapy. Although the initial studies evaluating the efficacy of HRT in TS have been encouraging, to date the investigations have been case studies or small randomized trials, and HRT has never been systematically investigated as an augmentation to pharmacotherapy. In response to Program Announcement PA 01-123, this application describes a multisite investigation to evaluate the efficacy of a structured HRT program for tic reduction in adults with TS. To conduct this study, the Tourette Syndrome Association (TSA) assembled the Behavioral Sciences Consortium (BSC). The BSC is a multidisciplinary group of investigators representing some of the leading TS research programs in the country including Yale, Massachusetts General Hospital (MGH)/Harvard Medical School, University of California at Los Angeles (UCLA), and Johns Hopkins. Two additional centers, Wilford Hall Medical Center/University of Texas Health Sciences Center at San Antonio (WHMC/UTHSCSA), and the University of Wisconsin-Milwaukee (UWM), have investigators with specific expertise in HRT. The mission of the BSC is to develop, test, and disseminate behavioral interventions for patients with TS. In this proposed study, 120 eligible participants will be randomly assigned to receive either HRT or Enhanced- Supportive Psychotherapy. Both treatments will consist of 10 sessions over 12 weeks followed by 2 booster sessions and 3- and 6-months follow up assessments. The primary outcome of interest will be change in tic severity assessed by an independent evaluator blind to treatment assignment. The effect of HRT as a monotherapy for tics and as augmentation to ongoing, stable tic-suppressing medication will also be evaluated. The three study recruitment sites are MGH/Harvard, WHMC/UTHSCSA, and Yale University. Investigators from UCLA and the UWM will provide specific quality assurance and assessment services via separate subcontracts, and a Data Safety and Monitoring Board (DSMB) will be assembled for data and safety monitoring purposes. The Informatics group at Yale University will provide data management services.