Oh What A Tangled (Neural) Web We Weave: A first-person account of Tourette Syndrome (part 5, behavioral treatment)

EDITOR’S NOTE: This multipart series first appeared in the March 2010 edition of the Journal of Clinical Psychology Practice and also can be found on Life’s A Twitch, a website run by Canadian psychologist Dr. B. Duncan McKinlay.

This model predicts a behavioural treatment like Habit Reversal Training (HRT) would be highly effective in managing tics — as indeed it has been found to be. By “blocking” a tic’s expression via a competing response whenever the urge arises I am weakening the incidental association between whatever behaviour, action or sound just occurred and the tic itself.

Over multiple trials this should extinguish the tic as well as the “marker” for the now-defunct association (the premonitory urge). This is indeed what I and others have found. Finally, since number of trials to completely eliminate a tic would be a function of how much “unlearning” there is to do, it’s of little surprise to me that “younger” tics tend to respond more quickly and fully to HRT than do “older” tics. It is to my experience with behavioural treatment that I turn next.

My decision to treat certain tics did not stem from social pressure or poor self-image. Anytime I’ve mistakenly equated “treatment of tics” with “being acceptable or likeable” I’ve been disappointed. All life’s woes do not stem from TS, and its absence would not be a panacea.

Even an abrupt magical cessation of tics would not fix issues that are indirect products of 30 years living with them. Such an approach actually reinforces a negative self-image (i.e. I’m only “OK” if I’m “better”), and hangs too much expectation on tic elimination. Instead, the decisions I’ve made have been pragmatic ones:

  • Addressing rapidly senescing joints (jaw movements)
  • Rapidly thinning tooth enamel (teeth clacking)
  • Rapidly growing astigmatism (eye-gouging)
  • Injury (clenching objects with my right hand)

The initial effort required to engage in a competing response (in general, isometric muscle contractions each time premonitory urges arise) cannot be understated. Subjectively, the face validity is naught: in the beginning HRT is an extremely consuming, irritating and exhausting ordeal with no apparent purpose or progress whatsoever. In fact on the surface things may even seem worse. Had I not learned of “extinction bursts” as part of my behavioural training I would not have continued.

Instead I envisioned the neuronal web which entangled me — isolated filaments I was now pruning away one by one. And, like a steadily weakening web supporting a thrashing weight, when the sudden release came it was as startling as it was fulfilling. I came to learn that the subtleties of this web work bidirectionally — acquisition of learning occurs as incrementally as does extinction and can surprise you with its (re)emergence.

Seduced into idleness by my initial success, I was swiftly again entwined. I had allowed the web, broken but still easily mended, to reweave its filaments around me. Vigilance is the key in the early stages of behavioural treatment. Multiple instances of “spontaneous recovery,” successively diminishing in length and strength, occurred. The more I practiced the greater the results, the longer they lasted, and the more of a buffer I appeared to accumulate for “slip-ups.”

Targeted symptoms eventually vanished completely; the first tic I exposed to HRT (a snort) has been extricated from my repertoire for 15 years now – despite continual references (and even demonstrations) within my clinical work and presentations. Each successive use of HRT appears to come easier, too, as if some generalization of the learned discipline is occurring.

Focussing on one symptom at a time may be necessary. The effort required has costs and the mental exertion required has limits. Attempts to simultaneously initiate HRT with all (or even multiple) tics are reminiscent of vain struggles to “hold in” one’s tics; however, traditional suppression is devoid of tools, support, a plan, or the right mind frame. One mustn’t be greedy, and must also learn the art of patience.

I find symptoms more difficult to combat when stakes are high (e.g. “my livelihood as a presenter and singer rides on the eradication of this throatclearing tic!”) or when my physical damage (perhaps as sequelae to the tic itself) significantly heightens one’s preoccupation with this area of the body (therefore compounding urges to tic in that area as well).

Despite its initial vex, behavioural treatment holds high personal appeal for me and many of my patients. I can selectively target symptoms to suit my needs. This ability to tailor (and deliver) the treatment myself is also very empowering, and has allowed me to expand my limits beyond where I had grudgingly (and erroneously) accepted them to be.

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