Tourette’s Disorder is diagnosed when an individual has more than one motor tic and at least one vocal tic which occur multiple times a day for over a year. Tourette’s is usually diagnosed in childhood and is a lifelong condition. Treatment of Tourette’s Disorder can include medication or behavioral therapy or both.
One of the first steps in behavior modification is identifying both the stimulus and the response. In the case of Tourette’s, we consider the stimulus to be an urge (which may or may not be noticed) and the paired response to be the tic. Our goal is not to try to control the urge; this is not possible. Our goal is to use response prevention in order to disconnect the association between the urge and the tic. In this way, we aren’t trying to make the feeling go away, we are waiting for it to go away by not reinforcing it with the response (tic).
Before we can teach and practice response prevention we must first have a good description of the tic. Having the person with Tourette’s describe in detail what the tic looks like is crucial. Having them include information about the small motor and gross motor movement as well as what other parts of the body are doing is important.
One way to get specific information about the precise sequence of movements is to have the person with Tourette’s replicate the tic as slowly as possible while they notice and describe what they are doing. By having them slow the tic down they can also pay attention to any cues their body may be giving them about the tic that is about to occur. In this way they are increasing their awareness of these early warning signals and the urge to tic.
Many people erroneously think that identification of the early warning signals and urge should help the person with Tourette’s stop the tic before it happens. As stated earlier, attempts to control the urge are not helpful nor successful. We must remember that one of the basic truths about behavior change is that it is easier and more successful to have a person start doing something rather than having them stop.
The term for the action we have the person with Tourette’s do instead of the tic is known as the competing response; the process of doing this action repeatedly is known as habit reversal. In order for some action to be a viable competing response it must be completely prohibitive – it must be something that makes it physically impossible to do the tic. In addition, the competing response should not be noticeable to observers and the competing response must be accessible in any situation or circumstance.
In order to break the connection between the urge and the tic, the person with Tourette’s must use the competing response in every and all situations: every time they notice the early warning signs; when they start the tic; or even after they do the tic. Even correcting the tic (by performing the competing response after the tic has occurred) helps the brain associate the urge with the competing response. This in turn disrupts the prior brain connection between the urge and tic. When the person with Tourette’s starts the competing response before or right when the tic starts, they should keep performing the competing response until the urge to tic lessens significantly.
Like any attempt at behavioral change, the progress we see in habit reversal training is not linear. Those who begin this process will likely notice an initial increase in urge strength and/or frequency. However, if they remain persistent in their practice of habit reversal via response prevention, they will begin to notice a gradual decrease in their tics over time.