Behavioural Therapy for Tics

A brief overview of behaviour intervention for Tourette's Syndrome

Behavioural therapy is used to teach people with Tourette's ways to manage their tics. However, it is important to remember that it is not a cure for tics, that said it has been proven to help reduce the number, severity, and impact of tics.
" It is important to understand that even though behavioural therapies may help reduce the severity of tics, this does not mean that tics are just psychological or that anyone with tics should be able to control them" (Tourette's Action)

There are three main behaviour interventions currently available, some have been utilised longer than others however the newest treatment available, has seen tremendous results.
Premonitory Urge
Tic
Relief 

Firstly, what is CBiT? CBiT stands for Comprehensive Behaviour Intervention for Tics.
CBiT is a treatment for tics only and not for the co-occurring conditions that may be associated with Tourette’s.
CBiT is behavioural therapy, it is used to support people with Tourette’s to manage their tics. Behaviour therapy is not a cure for Tourette’s but aids in the reduction of tic severity and frequency.
CBiT is made up of 6 therapeutic components and is a clinically proven therapy in tic reduction.
These six components consist of:
 
PSYCHOEDUCATION
Includes looking into when tics are better vs worse and then working out strategies to spend more time in positive situations and making difficult situations easier.

SELF-AWARENESS
Includes teaching how to recognise and identify premonitory urges and when tics are coming.

RELAXATION
Includes teaching strategies such as deep breathing to help reduce stress and anxiety which can exacerbate tics.
   
TIC ANALYSIS
Includes teaching tic hierarchy, focusing on the most problematic for the client (not others), and learning the premonitory urge and what muscles are used for these tics.

COMPETING RESPONSE
Includes the therapist analysing and evaluating the tic analysis, then deciding on which competing response (CR) should be used. The CR is designed to make the tic not happen.

SOCIAL SUPPORT
It is paramount that the child has a supportive family, social and educational network for them to be able to be successful. Parents will need to advocate to the child’s school to ensure they're on board.

Habit Reversal Therapy
At the heart of CBiT is an intervention called Habit Reversal Therapy (HRT). HRT is the most researched validated behavioural therapy for Tourette's to date, with research that stems back to the 1970s. HRT treats tics individually, you work on tics by implementing a competing response/ Tic Blocker. HRT has two main parts to it as highlighted above.

HOW DOES CBiT WORK?
CBiT’s success is down to the comprehensive components used within the therapy. The success has been proven in much research and has shown that it is thought to work by strengthening the neural pathways between two areas of the brain, the pre-frontal cortex, and the basal ganglia.
The basal ganglia are where it is thought the issues around Tourette Syndrome occur. The basal ganglia are also responsible for the unwanted muscle movements associated with Tourettes. The pre-frontal cortex is where control over our actions happens.

CBiT uses methods that break the tic pathways

  

It is important to remember that although behaviour intervention is being used to aid tic management, this does not mean that tics are done deliberately or for attention.
After a few months of learning these techniques, most individuals will have the ability to manage their tics.
Learning the skills via CBiT gives the individual the tools to manage their tics in the future. With the combination of continued relaxation methods, along with the awareness skills of tic triggers and alerts and then being able to develop their own competing response, most individuals can manage their tics independently moving forward.
It is important to be aware that CBiT should be carried out by a trained therapist, others trying to implement these treatments may cause more harm than good resulting in exacerbating symptoms.

Comprehensive Behavioural intervention for Tics (CBiT)

Habit Reversal Therapy (HRT) Overview

Habit Reversal Therapy is the most researched validated behavioural therapy for Tourette's to date, the research stems back to the 1970s. HRT treats tics individually unlike other behavioural therapies used to treat tics. You will work on becoming more aware of how a certain tic is expressed, then you learn a competing response. You do this by contracting a group of muscles that make it impossible to do the tic at the same time, as soon as you feel the urge coming on, you need to do the competing response and keep doing it even after the urge passes. Eventually, you learn to take control of the tic.
This can be hard work, and an uncomfortable sensation to begin with but with lots of practice, it gets easier.
To learn how to do this, strategies are used to increase the need for you to tic, making the urge as strong as possible, and then you will work at implementing a competing response to make it hard for your tic to breakthrough.
HRT is hard work and takes time and practice however HRT has been proven to reduce tics by up to 40%
There are 5 rules when considering competing responses. The competing response must be able to be done anywhere, without props, can be actioned for more than 1 minute, must be incompatible with the tic, and should be more socially acceptable.

Exposure Response Prevention (ERP)
Overview

Exposure Response Prevention is also known as tic suppression. The main aim of ERP is for you to learn to tolerate the urge that comes before a tic, by learning to tolerate the urge you are learning to suppress the tic.​ This can be hard work, and an uncomfortable sensation to begin with but with practice, it gets easier. By exposing your tics, you practice resisting the urge for longer periods, until you can stop it in most situations for a period of time. Evidence suggests that ERP is as effective as Habit Reversal Therapy. ERP is best suited to individuals who have a range of troublesome tics or are young. Tic reduction is the result.

Behavioural therapy  - What to expect 

In the sessions, strategies will be used to increase the need for you to tic, making the urge that often comes before tics as strong as possible, and then together we will work on using methods to help you take control of your tics. ​Sometimes in these sessions, we will work on all tics at the same time, but sometimes we will concentrate on the more problematic tics as and when they arise. ​You will need to practice these strategies both in the sessions and at home, both you and your parents will have some homework but nothing too much so don't worry!
 

Behavioural therapy - Sessions

The initial assessment last's approximately one hour, then subsequent sessions are run every week, and usually last between 30/45 minutes.
Sessions are charged at an hourly rate and are to be paid for in advance via the website at the time of booking.
Clients will be assigned homework to practice which will be taught in the sessions, parents are required to help with some of the homework tasks.

Behavioural therapy - The Result

There is not a cure for tic disorders and even after treatment, tics can still increase due to the natural course Tourette's takes by waxing and waning. However, after behaviour intervention, you will have the tools to be able to take some control of your tics.
A plan is also put in place at the end of the treatment to assist in trying to prevent tics from increasing and what to do if this happens.