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Behavioural therapies and Tourette Syndrome

Behavioural interventions provide tools for helping a person learn ways to change certain behaviours. Cognitive therapies can help a person to change the way they think about tics in addition to taking certain action. Often the two forms of intervention are combined to help a person make changes to what they do and think to improve their lives.

Behavioural therapies and Tourette Syndrome

Behavioural therapies can be useful for most people with tic disorders, although evidence suggests that it is effective for children as young as five years of age and adults.  Treatment is hard work so it is key that the individual with tics is highly motivated to work on their tics.

The best scientifically validated behavioural treatment is called Habit Reversal Therapy (HRT), which has been researched since the 1970s. More recently, HRT has been shown to be effective as part of a package alongside other elements of therapy, known as Comprehensive Behavioural Intervention for Tics (CBiT; Treatment that works; Woods et al, 2008). Another behavioural intervention which has emerging evidence is called Exposure and Response Prevention (ERP). Both therapies focus on getting used to the tense or uncomfortable feeling which precedes a tic (called premonitory urge) and tolerating the urge by resisting it or using an action until the urge to tic fades and the individual resists the tic.

There are limitations to the number of clinicians who deliver behavioural therapy for tics across the world. Therefore, most research in the past 10 years has focused on helpful strategies to deliver effective behavioural treatment other ways than merely face to face.  Research has demonstrated successful treatment with behavioural therapy delivered by telemedicine (such as Skype), group interventions; and there are currently exciting projects for children and adults with tics using online treatments both with and without therapist support.

Habit Reversal Therapy

The first stage of HRT is tic description and awareness. This involves the person identifying all of their annoying tics in detail. The individual then chooses one particular tic to work on, most likely the tic which bothers them most. The person must understand where the tic occurs in their body and which muscles are involved. The therapist will then help the individual become aware of when that tic is about to occur. Increasing the persons’ sense of when a tic is about to happen, (i.e. the premonitory urge), will help them to control it.

The next stage is finding a competing response. This trains the person to perform an intentional movement, which means that the tic cannot happen. It should not look more unusual that the tic and does not interfere with the person’s activities. The person should be able to hold the competing response for as long as is needed for the urge to reduce. For example, if somebody has a motor tic which involves flinging their arm out, they can be taught to channel the premonitory urge into something more favourable such as placing their hand on their leg and pushing gently. This approach is then applied to each tic in turn. People can get really good at creating their own competing responses once they understand the principles of how to do it, which could be helpful in the future when new tics emerge at a point when therapy may have finished.

Exposure and Response Prevention

The key ingredient in ERP is tolerating the urge while the individual suppresses their tics. In the beginning, the person with tics may believe that this will be uncomfortable but with practice it becomes easier. It can be tiring. During therapy, the therapist will use strategies to make the premonitory urge as strong as possible and encourage the child or adult to get used to the feeling without doing the tic. In ERP, the individual with tics works on all of their tics at the same time.

There is a treatment manual and workbook for children available currently (Tics - Therapist Manual & Workbook for Children Cara Verdellen, Jolande van de Griendt, Sanne Kriens, Ilse van Oostrum, 2011) and hopefully the adult version will be available soon.

Both treatments require practice of the strategy outside of the clinical appointment in order to ensure that the techniques become more natural and less effortful for the individual. Studies show that most individuals who have a successful response to behavioural treatment typically experience a 30-40% reduction in tics.

Both of these interventions have been combined with other tic management tools which are described below:

Psychoeducation

Learning about Tic Disorders and Tourette syndrome is essential. The sorts of information that is typically included in psychoeducation is: understanding the causes (as much as they are known), appreciating that it is a brain-related condition, the usual course of tics (that tics usually occur most frequently between 10-12 years and then reduce in early adulthood) and the sorts of co-occurring conditions that often occur in individuals with Tourette syndrome. This is only the beginning and there is much more to learn and understand which can help someone cope with having a tic disorder. Feeling comfortable and confident in what you know about having a tic disorder is very important and remembering that having tics is only a very small part of any person. There are a great many books and videos on Tourette syndrome which can be found here

Functional Intervention

Functional analysis is used to identify environmental events that can make tics worse or maintain the occurrence of tics for an individual. A therapist will help a person with tics to understand what tends to happen before and after a bout of tics. This may include reactions to a situation, thoughts or feelings that a person has in a particular place and the way in which other people respond to that person when they tic. The therapist will then work with the person to reduce or get rid of tic increasing situations. Relaxation or the ability to look at the situation in another way may help.

Social Support and Reward System

Having support from another person is very helpful with getting to know how to do the Competing response and for motivation to continue doing it over time. This is usually a parent or carer for children and a close friend or partner for adults. It can be helpful to set up a reward system in which the child receives praise or points which can be exchanged for prizes when they put great effort into getting to know how to control their tics.

Relaxation Training

Relaxation is used to reduce the stress that a person with tic disorders experiences. This is included in therapy because of the idea that having stress makes a person less able to control their tics. The most common relaxation training involves deep breathing combined with progressively tensing and relaxing the muscle groups in your body.

Access to behavioural therapy

CBiT is usually offered in 8-12 weekly or fortnightly sessions (although fewer might be suitable for milder tics) but this can depend on the person with tics and the therapist. Our list of Behavioural therapists features clinicians who deliver CBiT using telemedicine.  You can read more information about telemedicine on our web page

Behavioural therapy is practiced by psychologists, occupational therapists, specially trained nurses and other professionals who have undergone specific training in behavioural therapy for tics. NHS referral to a clinical psychologist is mainly from professional sources including hospital consultants, psychiatrists, occupational therapists, nurses, physiotherapists and sometimes GPs. Tourettes Action’s list of behavioural therapists includes clinicians working in both the NHS and privately.

If you wish to access a clinical psychologist privately then it is advised that you request a referral from a qualified health professional or make contact with a clinician using a website which lists only qualified members such as www.achippp.org.uk, who may have a specialist interest in working with people with tics.

This information was produced by Tara Murphy, Honorary Consultant Clinical Psychologist, in August 2017.

Information from Tourettes Action

Tourettes Action holds a list of Behavioural therapists which can be given out on request. Please email our Helpdesk for a copy.

If you are a therapist and would like to be added to the list please contact us with your details.

"As a child everything had to be in its exact place and things had to be equal/even and I still often need things to be 'just right'"

 
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