This post is part of a series of guest posts on GPS by the graduate students in my Psychopathology course. As part of their work for the course, each student had to demonstrate mastery of the skill of “Educating the Public about Mental Health.” To that end, each student has to prepare three 1,000ish word posts on a particular class of mental disorders, with one of those focusing on changes made from the DSM-IV to the DSM-5.
Deep Brain Stimulation for Tic Disorders: Fad Therapy or Good Medicine? by Tyler Whitehead
For someone with a disorder that has outwardly noticeable and unpredictable symptoms, like the tic disorders, life can be difficult, to say the least. It can present problems in their home, academic, career, and social spheres, such that those who do not know about the disorder or understand it may think that the individual is acting out on purpose. This is not, however, the case. A tic is an involuntary, spontaneous, and repetitive motor movement or vocal expression. The individual may experience premonitory urges, which are a feeling or sensation that the tic is about to occur. While some people can use these urges to their advantage and suppress the behavior, they cannot do this long term. If the tics occur to the wrong person at an inopportune moment, this could be cause for serious social, physical, familial, and sometimes, even legal implications. Severe tics can also cause the individual to harm themselves if the disorder persists into adulthood. This can lead the individual or those close to him or her to seek help from a variety of sources. Some of these options are not always the safest, depending on the individual’s age and severity of the tics. The below documentary does a great job of illustrating various types of tics that one may have.
In the past, few treatment options were available to those with a Tic Disorder, particularly Tourette’s Syndrome, as it is the most severe and encompasses both motor and vocal tics. Individuals with this condition had to rely on either medications or habit reversal training (HRT) and it’s newest incarnation, Comprehensive Behavioral Interventions for Tics (CBIT). Within the past 10 years, deep brain stimulation (DBS) has been proposed as another option for the treatment of tics. Although medications are a frequently employed therapy for tics, as it is typically more available than a psychologist trained in HRT or CBIT, medications which help alleviate Tourette’s are generally antipsychotics, which leave the individual rather incapacitated for quite some time (think “doped up”). These types of medications also have some rather nasty side effects as well. Considering that this is typically a disorder that afflicts the young, usually onsetting around age four to six and worsening between ten and twelve years old this, is not an option for an abundance of people with the Tourette’s. The disorder does not usually persist past adolescence and rarely stays as problematic once someone moves into adulthood. But for the rare cases in which it does, many people do not consider this a viable option, when weighing the potential negative side effects versus a potential of improving one’s quality of life.
In an effort to quickly have results, another option exists for the treatment of severe tics: DBS. DBS has been around for approximately 20 years and has been used in the treatment of Parkinson’s Disease, Tremor Disorders, Major Depressive Disorder (MDD), Epilepsy, cluster headaches, and Fibromyalgia. It has been proposed as a treatment for Tourette’s Disorder as well, with the first reports of DBS being used as early as 1999. DBS essentially involves the placement of electrodes in certain areas of the brain to produce electrical impulses that regulate the functioning of that area. For someone with Tourette’s, this impulse would occur before the tic would happen, in order to prevent the individual from having motor or vocal tics. Obviously, this is an invasive procedure and requires surgery under a skilled neurosurgeon. As such, it is reserved for only the most severe of cases for a number of reasons. Beyond the invasiveness of the procedure, there are many potential risks and side effects to this treatment, including: brain hemorrhaging, infection, seizures, headaches, insomnia, memory problems, speech problems, balance problems, and mood changes, to name a few.
So why do it then? Typically, it is because someone is non-responder to typical treatments, meaning that medication and behavioral therapy are either not an option or haven’t worked. Plus, there is research to confirm that this is an appropriate possibility for severe, intractable cases. However, such research is limited to case studies. Further, this treatment may not be fully effective for all the tics occurring. The individual may need additional procedures and it may not be effective for the comorbid symptoms accompanying it. There have even been some dismal reports concerning the efficacy and success of the procedure. With this type of surgery being so new to the field and the lack of more than just case study evidence, one would have to ask themselves, is it really worth it?
Comparatively, CBIT has been shown to be an effective treatment of choice for any of the Tic Disorders, including Tourette’s Disorder. CBIT incorporates behavioral techniques to diminish the amount of tics that occur. The individual with the Tic Disorder is first be educated about their disorder, given relaxation training (since the tics become worse when the person is in an anxiety-provoking environment or situation), learns how to participate in self-monitoring, and then undergoes habit reversal training (HRT). The person can also engage in function-based interventions, in which their situation can be modified to reduce stress or triggers, thereby causing a reduction in tics. HRT has been one of the most efficacious methods of tic treatment, particularly in combination with the full implementation of CBIT. HRT occurs when the individual learns to perform a behavior that runs counter to the tic, which should reduce the tics from occurring. So how is this different from simply stifling the urge to perform the tic? Stifling the tic would be the equivalent of stifling a sneeze. You still need to sneeze and you are probably still going to sneeze later on. However, if you blow your nose, you will reduce your need to sneeze. It should make the urge to sneeze go away. This is why HRT is so effective – it retrains the body to not need to tic when those urges are felt. CBIT, unlike the other treatments, doesn’t have potentially nasty side effects; it promotes coping mechanisms and helps the individual learn to rely on themselves. It is empowering, but for some people may not be enough (it doesn’t seem to be as effective for vocal as for motor tics, for example) or may not be available. Nevertheless, parents and persons with tics should certainly investigate it as an option before jumping into medication or surgery.