Behavioral Treatments for TS: Habit Reversal Therapy
by Michael Goldberg, Ph.D.
Child and Family Psychological Services, Inc. Norwood, MA
www.cfpsych.org

(A version of this article originally appeared in the Newsletter of the Massachusetts Chapter of the Tourette Syndrome Association)

A major limitation of medical treatment for TS has been the unwanted side effects. Until medical science finds more specific and effective treatments for this disorder, people with TS and parents of children with TS continue searching for alternative treatments. Unfortunately, many people falsely conclude that "non-medical" implies treatments that are not based on scientific study or have not been subjected to scientific investigation.

Psychologists have studied the use of various behavioral techniques for treating tics for more than 35 years. In the early 1970's, clinical researchers applied techniques originally developed to treat stereotyped behavior related to other disorders, to tic symptoms. The goal of the treatment, called Habit Reversal Therapy, is to increasing the person's ability to decrease the frequency and severity of tics.

There are 5 basic components of the treatment, each of which may vary depending on the age of the person and nature of the tics. Initially, the therapist addresses the person's motivation by reviewing with them their responses to a questionnaire assessing the impact of the symptoms on their life. During the awareness training component, the person and therapist work together to increase the person's awareness of (a) the frequency and severity of tics, (b) the situations that influence the tics, and (c) the specific movements, muscle contractions, and sensations associated with the tics. Next, the therapist teaches the individual how to create and use competing responses for each tic. This is the most distinctive feature of the treatment. A competing response is something that is incompatible with the tic, socially inconspicuous, and easily compatible with one's activities. Competing responses are usually isometric muscle tensing exercises such as contraction of the neck flexors to inhibit a head jerk. Breathing techniques and eye exercises may be used with vocal tics and eye blinking tics.

The fourth aspect of HRT is usually relaxation training. The person is trained in using relaxation strategies such as progressive muscle relaxation, deep breathing exercises, visual imagery, and self-statements. The effectiveness of relaxation in inhibiting tics seems to be related to helping the person learn to use it on a "cue-controlled" basis. That is relaxing their body in situations in which that are likely to experience a lot of tics or in response to tics. Lastly, the therapist employs techniques with the goal of helping the person employ the techniques in new situations and in the future should new tics appears.

Several studies have directly studied the effectiveness of HRT (Azrin & Peterson, 1988; Azrin & Peterson, 1990; Deckersbach, Coffey, Peterson & Baer, 2003). These studies found that the frequency of reductions of in the frequency of tic symptoms over a 6-8 month period by 64-99% in the clinic and at home with a decrease in the severity of tics. Reductions in tic symptoms were found for vocal tics and motor tics, for children and adults, and for those receiving medication and those who were not. The most recent of these three studies found that patients who had HRT improved significantly more than those receiving supportive psychotherapy. These individuals remained significantly better than pre-treatment when evaluated 10 months later. An evidence based analysis of psychosocial treatments to ameliorate tics (Cook & Blacher, 2007) concluded that habit reversal training "met criteria necessary for classification as a probably efficacious treatment" based on the rigorous evidence-based criteria established by an American Psychological Association's Division 12 Task Force.

A small study of people with Obsessive Compulsive Disorder (OCD) conducted at UCLA found that a small group of people treated effectively with behavior therapy alone had the same changes in their neurochemical functioning as those who demonstrated positive response to Prozac. We must use caution in interpreting this one small study. However, the implication of this finding is that behavior therapy, at least for OCD, causes changes in the neurochemistry. Given the data that supports a genetic relationship between OCD and TS it is possible that the one day researchers will find a similar result for people with TS who complete successful behavior therapy.

My intention in writing this article is not to give false hope. HRT is by no means a cure or panacea for TS. More research is greatly needed. However, it is one non-medical intervention without demonstrable side effects that may help people decrease the frequency and. severity of tics when they choose to do so. The treatment offers particular hope to people with gross motor tics that have secondary effects such as muscle pain. For example, one young man with whom I have worked has developed complete control of his head jerk tics, which caused him great neck pain and headaches.