AN EVALUATION OF THE EFFECTIVENESS OFEXPOSURE AND RESPONSE PREVENTION ONREPETITIVE BEHAVIORS ASSOCIATED WITH

TOURETTE’S SYNDROME

CHAD T. WETTERNECK AND DOUGLAS W. WOODS

UNIVERSITY OF WISCONSIN–MILWAUKEE

Exposure and response prevention (ERP) was evaluated as treatment for three repetitive behaviorsin an 11-year-old boy using a multiple baseline across behaviors design. The repetitive behaviorsand associated self-reported distress were eliminated. At 3-month follow-up, the frequency for twoof the three behaviors returned to baseline levels. This study demonstrates that ERP may be a usefultreatment for repetitive behaviors, although booster sessions may be needed to maintain thetreatment effects.

DESCRIPTORS: Tourette’s syndrome, tics, behavior therapy, exposure and responseprevention

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Tourette’s syndrome involves motor andvocal tics that occur for at least 12 months(American Psychiatric Association, 2000). Ob-sessive compulsive features, often characterizedas complex tics, have been found in up to 80%of individuals with the disorder (Leckman,King, & Cohen, 1999). Private antecedents tosuch behaviors often include aversive sensoryphenomena and urges or feelings of tension thatdissipate after engaging in the behavior. Onemethod that has been used to reduce suchrepetitive behavior in other clinical populations(obsessive compulsive disorder) is exposure andresponse prevention (ERP). ERP consists ofrepeated, prolonged exposures to stimuli thatelicit discomfort and instructions to refrainfrom any behavior that serves to reducediscomfort. However, only one uncontrolledcase study has examined the specific treatmentof repetitive behaviors using ERP (Woods,Hook, Spellman, & Friman, 2000) in a patientwith Tourette’s syndrome. The present studydisplays the first controlled evaluation of thetreatment of complex tics using ERP.

METHOD

Participant

Brett was an 11-year-old Caucasian boy ofnormal intelligence who had been exhibitingsymptoms of Tourette’s syndrome since the ageof 8. According to a structured clinical interview(Schaffer, Fisher, Lucas, Dulcan, & Schwab-Stone, 2000), Brett met the diagnosis forTourette’s syndrome only, and obsessive com-pulsive disorder was ruled out. Throughout thestudy, Brett was taking Luvox.

Three of Brett’s repetitive behaviors withidentifiable antecedents were investigated fortreatment: evening up, arranging, and symmetry.The antecedents were reported to be varyinglevels of physical anxiety in which he felt warmthroughout his body. Evening up was defined asmoving similar objects to match (e.g., theorientation, function, or location) others aroundthem. Arranging was defined as placing a groupof mixed objects (e.g., silverware) into separatematching groups. Symmetry was defined asmoving similar classes of objects (e.g., books,models, etc.) in a manner so that the objects werearranged in ascending or descending orderaccording to a physical dimension such as widthor height. Brett reported that none of thesebehaviors were performed in response to anobsession or with the intent to prevent or

Address correspondence to Douglas W. Woods, Uni-versity of Wisconsin–Milwaukee, Box 413, Milwaukee,Wisconsin 53201 (e-mail: dwoods@uwm.edu).

doi: 10.1901/jaba.2006.149-03

JOURNAL OF APPLIED BEHAVIOR ANALYSIS 2006, 39, 441–444 NUMBER 4 (WINTER 2006)

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discontinue a feared event (as seen in individualswith obsessive compulsive disorder). A hierarchyof situations that were most likely to elicit eachbehavior was constructed. For example, situa-tions that evoked evening up included seeingitems that hang off the edge of a shelf or hangover the edge of table (e.g., paper or a televisionremote control) or being presented with a stackof papers in which the edges of some papers stickout at various lengths.

Procedure

Behavioral exposure tests. Behavioral exposuretests for the three behaviors were composed ofthe situation in each hierarchy most likely toelicit the behavior. Each test was separatelyadministered for 5 min, two to three times perweek in Brett’s home. Before treatment began,the tests were recorded by a videocamera withinBrett’s view and were administered by anindependent evaluator. Each minute, the par-ticipant was asked for his rating on a subjectiveunits of discomfort scale (0 to 10, with thehigher score indicating greater distress), and thefrequency of the completion of a target behavior(i.e., placing all objects into matching groups)was noted. After a target behavior wasperformed, the situation was immediatelyrecreated by the evaluator, and the testcontinued until the 5-min assessment wascompleted. Treatment began for the firstbehavior that did not demonstrate a downwardtrend based on self-reported discomfort ratings.Behavioral exposure tests were then adminis-tered once or twice per week after treatment wasinitiated and at a 3-month follow up. All teststook place in Brett’s home.

Treatment. Treatment involved ERP ina clinic setting, approximately two to threetimes per week. Up to four of the situationsmost likely to elicit the target behavior werepresented to Brett, who was given instructionsto resist performing the behavior in thatsituation. Brett was given verbal reminders toresist the behavior if he made attempts tocontact the objects in the eliciting situation.

Although Brett did not require more thanverbal reminders to resist the behavior, thetherapist could have used physical prompts (i.e.,gently guiding Brett’s hands away from thestimulus in question) to direct him away fromthe target behavior. Each situation was admin-istered for a maximum of 20 min per sessionand was considered completed after Brett’sdiscomfort rating was 2 or less for 5 consecutiveminutes starting within the first 3 min of theexposure exercise for two straight sessions. Atthe end of each session, Brett was instructed topractice ERP for 15 to 20 min per day at homeand to refrain from participating in the behaviorcurrently being treated. After all situationsrelevant to a specific target behavior had beentreated, the next behavior that did not displaya downward trend began treatment. Onetreatment session occurred before the fourthtest, and two sessions occurred before the fifthtest to treat symmetry. After treatment forsymmetry had been completed, two sessionsoccurred before the sixth test, and finally a singlesession before the seventh test was conducted totreat evening up. However, because arrangingbehaviors and associated discomfort scoresdecreased to zero at this point, no sessions wereconducted to specifically target arranging. Amultiple baseline across behaviors was used toevaluate the intervention.

Interobserver agreement. The frequency of therepetitive behaviors during behavioral exposuretests were coded by the first author. Interob-server agreement was calculated by having anindependent observer score 25% of the tests anddividing the smaller frequency total by thehigher frequency total. Agreement was 100%for evening up, 100% for arranging, and 92%for symmetry (range, 83% to 100%). Agree-ment was calculated for the verbal discomfortreports by having an independent observerlisten to 25% of the videotaped recordings oftests and dividing the total number of agree-ments on a discomfort response by the totalnumber of responses. Agreement was 100%.

442 CHAD T. WETTERNECK and DOUGLAS W. WOODS

RESULTS AND DISCUSSION

The results are presented in Figure 1. Brettdisplayed a mean of three symmetry behaviorsduring baseline behavioral exposure tests; thesebehaviors decreased to zero after three treatmentsessions. The session average discomfort ratingsfor the symmetry condition went from a baselinemean of 1.33 to zero after three treatmentsessions. Brett displayed a mean of 11 evening-upbehaviors during baseline tests; this numberdropped to zero after two treatment sessions. Thesession average discomfort ratings went froma mean of 3.65 for the baseline period of eveningup to zero after two treatment sessions. Brettdisplayed a mean of 6.3 arranging behaviorsacross the first five tests; this number decreased tozero after two treatment sessions. The sessionaverage discomfort ratings went from a mean of1.44 during the first five tests to zero after twotreatment sessions. At the 3-month follow-up,Brett’s discomfort rating remained at zero,although his evening-up and arranging behaviorsreturned to baseline levels.

The treatment successfully reduced Brett’sdiscomfort ratings and actual behavior for all

the repetitive behaviors in question. Althoughwe cannot rule out the possibility of anextraneous variable accounting for the remissionof the self-reported antecedent distress andbehaviors in the arranging condition, we believethe most parsimonious accounts for this effectto be either the generalization of the treatmentor perhaps that arranging and evening-upbehaviors were part of the same functional class.

In summary, this study was conducted as aninitial controlled exploration into the efficacy ofERP for treating repetitive behaviors in anindividual with Tourette’s syndrome. The studyextends the effectiveness of ERP on complex ticsthat resemble those of obsessive compulsivedisorder. Despite the success of the study, severallimitations should be noted. First, the effects oftreatment were not maintained at a 3-monthfollow-up. Future studies should evaluate boostersessions to maintain the treatment effects, assuggested by Riggs and Foa (1993). Second,although Brett and his father reported that Brettwas no longer performing these behaviors outsidethe tests, there was no direct observation toconfirm these statements. Finally, Brett reportedlow levels of discomfort while performing the

Figure 1. Discomfort ratings and frequency of behaviors during home behavioral exposure tests.

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task, which may indicate a low level of severity inthe presentation of his disorder.

Despite these limitations, the study suggestssome promise for ERP in treating repetitivebehaviors of Tourette’s syndrome and alsosuggests other areas for future research. A numberof variables could be addressed to determine thegeneralizability of the treatment to other areas,such as the severity of Tourette’s syndrome, theamount of impairment caused by the repetitivebehaviors, and the ability to identify an anteced-ent to elicit the repetitive behavior. Finally, thegeneralizability of this procedure in more severecases of repetitive behaviors associated withTourette’s syndrome may be pursued.

REFERENCES

American Psychiatric Association. (2000). Diagnostic andstatistical manual of mental disorders (4th ed., textrev.). Washington, DC: Author.

Leckman, J. F., King, R. A., & Cohen, D. J. (1999). Ticsand tic disorders. In J. F. Leckman & D. J. Cohen(Eds.), Tourette’s syndrome—tics, obsessions, compul-sions: Developmental psychopathology and clinical care(pp. 23–42). New York: Wiley.

Riggs, D. S., & Foa, E. B. (1993). Obsessive-compulsivedisorder. In D. H. Barlow (Ed.), Clinical handbook ofpsychological disorders (pp. 189–239). New York:Guilford.

Schaffer, D., Fisher, P., Lucas, C., Dulcan, M., &Schwab-Stone, M. (2000). NIMH Diagnostic In-terview Schedule for Children Version IV (NIMHDISC-IV): Description, differences from previousversions, and reliability of some common diagnoses.Journal of the American Academy of Child andAdolescent Psychiatry, 39, 28–38.

Woods, D. W., Hook, S. T., Spellman, D., & Friman, P.(2000). Case study: Exposure and response pre-vention for an adolescent with Tourette’s syndromeand OCD. Journal of American and Child AdolescentPsychiatry, 39, 904–907.

Received October 3, 2003Final acceptance December 22, 2004Action Editor, Iser DeLeon

444 CHAD T. WETTERNECK and DOUGLAS W. WOODS