title: An Empirical Examination of Symptom Substitution Associated With Behavior Therapy for Tourette's Disorder.
abstract: 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.
authors.affiliation: University of Texas Health Science Center at San Antonio, South Texas Veterans Health Care System, and University of Texas at San Antonio. Electronic address: petersona3@uthscsa.edu.
authors.forename: Alan L
authors.initials: AL
authors.lastname: Peterson
authors.affiliation: University of California, Los Angeles Semel Institute for Neuroscience.
authors.forename: Joseph F
authors.initials: JF
authors.lastname: McGuire
authors.affiliation: Massachusetts General Hospital and Harvard Medical School.
authors.forename: Sabine
authors.initials: S
authors.lastname: Wilhelm
authors.affiliation: University of California, Los Angeles Semel Institute for Neuroscience.
authors.forename: John
authors.initials: J
authors.lastname: Piacentini
authors.affiliation: Texas A&M University.
authors.forename: Douglas W
authors.initials: DW
authors.lastname: Woods
authors.affiliation: Weill Cornell Medical College.
authors.forename: John T
authors.initials: JT
authors.lastname: Walkup
authors.affiliation: University of Texas Health Science Center at San Antonio.
authors.forename: John P
authors.initials: JP
authors.lastname: Hatch
authors.affiliation: University of Texas Health Science Center at San Antonio.
authors.forename: Robert
authors.initials: R
authors.lastname: Villarreal
authors.affiliation: Emory University School of Medicine.
authors.forename: Lawrence
authors.initials: L
authors.lastname: Scahill
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001521:Behavior Therapy / Q000379:methods*; D002648:Child; D036262:Empirical Research; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D013981:Tic Disorders / Q000175:diagnosis / Q000523:psychology / Q000628:therapy; D005879:Tourette Syndrome / Q000175:diagnosis / Q000523:psychology* / Q000628:therapy*; D055815:Young Adult
keywords: Tourette’s disorder; behavior therapy; chronic tic disorder; comprehensive behavioral intervention for tics; symptom substitution