Michael A. Tompkins, Ph.D.
Co-Director of the San Francisco Bay Area Center for Cognitive Therapy
Tourette disorder is a chronic neurological condition characterized by brief, rapid movements (motor tics) such as blinking, sniffing, or tongue thrusting) or sounds (vocal tics) such as throat clearing, grunting, humming. However, both motor and vocal tics can be quite complex, such as a girl who repeatedly and violently thrusts her index finger up a nostril or a boy who repeats phrases or songs he hears. Tics begin in childhood with severity peaking in adolescence, and often declining in young adulthood. One to ten in 1000 school-aged youth have Tourette disorder although many other youth have relatively mild motor and vocal tics that they typically outgrow. Males are about three to four times more likely than females to develop Tourette disorder. Youth cannot control the tics, although with great effort they can temporarily suppress tics until they find a place where it is less disruptive to express them. Premonitory urges or sensations commonly precede tics and youth often describe these urges or sensations as a tingling, itchy, or tension or a vague discomfort. Tourette disorder can cause considerable social distress. Other youth can tease, bully, or ridicule youth with Tourette disorder. Youth with Tourette disorder may fall behind academically when tics make it difficult for the child to stay in the classroom, engage effectively with the curriculum, or complete homework. Although there is no cure for Tourette disorder, we now have effective behavioral treatment for the condition that can live full and successful lives.
Antipsychotic medications have been the primary treatment for Tourette disorder, such as haloperidol, pimozide, and resperidone. However, unless the frequency and intensity of the tics is quite severe, clinicians are understandably reluctant to prescribe these powerful medications. Often youth experience unacceptable side effects to these medications, such as sedation, weight gain, and cognitive dulling. Prolonged use of these antipsychotic medications can result in tardive dyskinesia, a serious movement disorder characterized by involuntary movements of the tongue, lips, face and limbs. Furthermore, it is unclear how effective these medications really are for Tourette disorder due to the limited number of well-controlled studies in youth. The shortcomings of medication treatments have encouraged researchers to develop and test psychological or behavioral treatments for the condition.
The most promising psychological treatment for Tourette disorder is the Comprehensive Behavioral Intervention for Tics (CBIT). The primary component of CBIT is habit reversal training that includes awareness training and competing-response training.
Tic awareness training. Awareness training is a critical intervention in the treatment of tics. All future interventions depend on the youth recognizing both premonitory urges prior to a tic as well as when he is exhibiting motor and vocal tics in the moment. Awareness training includes a careful description of the features of the motor chain, and includes all sensations and motor behaviors that result in the expression of a particular motor or vocal tic. Once the youth learns the early motor signs that a tic is coming or happening, he then learns to recognize the premonitory urge that signals that the tic (or motor cascade for complex tics) is about to occur.
Competing-response training. The goal of competing-response training is for the youth to learn to break the conditioned link between the discomfort associated with the premonitory urge and the relief the youth experiences upon expression of the tic. Through competing-response training, the youth engages in a voluntary behavior that is physically incompatible with the tic and contingent on the premonitory urge or other signs that the tic is about to occur. The competing response is not simply suppressing the tic but instead creating a new response to the premonitory urge that is less disruptive (functionally and socially) for the youth.
Tic hierarchy. The clinician and youth rank order tics from most to least distressing and begin with the more distressing tics early in treatment to capitalize on the youth’s willingness to work on those tics that he perceives as the most troublesome. With the hierarchy in place, the youth practices the competing response in session. For example, the clinician can teach a youth with a neck-jerking tic to look forward with his chin slightly down while he gently tenses his neck muscles for 1 minute or until the urge goes away. The youth engages in the competing response when he notices the tic is about to occur, during a tic, or after a tic occurs. Effective competing responses are incompatible with the expression of the tic, and at the same time compatible with activities in and out of the classroom. In addition, effective competing responses are transparent to others.
Relaxation training. The clinician teaches relaxation strategies that the youth practices daily to lessen the physiological arousal that builds over the course of the day and that can increase the intensity of premonitory urges.
Functional interventions. Other factors can influence the expression of tics (or what appear to be tics), such as the youth who exhibits tics to escape difficult or aversive tasks. The clinician carefully identifies situational antecedents and consequences that influence tic frequency and severity and then devises behavioral interventions to target these factors. For example, parents of a 12-year old boy were reluctant to encourage their son to continue his homework in the middle of a tic episode or to complete routine tasks at home, such as washing dishes. The clinician asked the parents whether their son exhibited tics when he played his favorite video game. They told the clinician that he did and that he refused to stop playing the game even when in the middle of a severe tic episode. The clinician then worked with the parents to hold a similar expectation (e.g., continue the task even when you have tics) for homework and other tasks at home. Similarly, the clinician taught the parents to praise and reward their son when he practiced the behavioral interventions he learned.
National Tourette Syndrome Association (www.tsa-usa.org)
Woods, D. W., et al. (2008). Mangaing Tourette Syndrome: A behavioral intervention. New York: Oxford University Press.
Woods, D. W., Piacentini, J. C., & Walkup, J. T. (Eds.) (2007). Treating Tourette Syndrome and tic disorders: A guide for practitioners. New York: Guilford Press.