During behavioral therapy, people with Tourette syndrome learn to perform competing movements to counteract their tics, or they learn to suppress their tics for increasingly longer periods. This latter form of treatment is called Exposure and Response Prevention (ERP).
Behavioral therapy
In ERP, patients practice suppressing their tics for as long as possible. Many patients feel a strong urge to perform a tic and initially delay it for only a few seconds. Over time, they progress to a minute, and after a few sessions, perhaps even fifteen minutes. “In treatment, we focus on that feeling,” says Van de Griendt. “We make it harder by, for example, talking about the tic—then that tic really wants to come out.”
Van de Griendt observed that, for most people, the urge to perform a tic grew stronger during the first fifteen minutes of the treatment session and then stabilized rather than subsided. “The trick is to delay the tics for longer and longer periods when that urge is strongest,” she explains. “That way, you get used to the feeling, just like when you jump into cold water. At first it’s unpleasant, but your body gradually learns to tolerate the cold. Once you’re used to it, you can still swim just fine. In the same way, you can learn to tolerate the urge, and by practicing every day, the tics often become less frequent.”
No pills
The psychologist compared the effectiveness of this type of behavioral therapy with that of medication (antipsychotics, which were previously the standard first-line treatment). The effects turned out to be more or less the same.
“I was slightly disappointed,” says Van de Griendt, who has run her own practice specializing in behavioral therapy for tics and Tourette syndrome since 2016. “I actually expected behavioral therapy to be more effective than medication, but that wasn’t the case.”
It did, however, prove difficult to recruit enough participants because of the mandatory random assignment. Many people preferred behavioral therapy and did not want to risk being assigned to the medication group. “Medication isn’t very popular among patients anymore,” Van de Griendt says. “Especially for children, side effects such as fatigue and weight gain can be quite severe. On the other hand, behavioral therapy naturally requires more effort from the patient. That’s why it’s important that people can choose for themselves.”
She also concluded that patients benefited just as much from one-hour behavioral therapy sessions as they did from two-hour sessions. “That’s less tiring for the patient, and if we shorten those long sessions by an hour, we could treat twice as many people,” says the Ph.D. candidate. “That’s important because specialized treatment for tic disorders isn’t available everywhere.”
Treatment Is Not Always Necessary
Tourette syndrome is the best-known tic disorder, in which people experience involuntary movements and vocalizations for more than a year. It usually begins between the ages of six and eight, with symptoms peaking between the ages of ten and twelve. After puberty, one in three children outgrows the condition.
Tourette syndrome affects about one in every hundred people, but not everyone experiences symptoms that require treatment. For example, some people may have a mild cough, frequently shake their head, or blink excessively without finding these behaviors bothersome. Temporary tics are even more common, occurring in one in every five to ten children. In most cases, these resolve on their own.
“Sometimes parents come to my practice because they want their child’s tics treated, even though the child isn’t bothered by them,” Van de Griendt continues. “That’s a shame. Tics shouldn’t be something to be ashamed of. But some people experience muscle pain because of their tics or become very tired as a result. In those cases, treatment is appropriate.”