is a clinical psychologist and founder of the Cognitive Behavioral Therapy Institute of Southern California. He is the author of multiple books on tic disorders and contributes to a wide range of publications, including HuffPost, The Hill and Reader’s Digest.
is a clinical psychologist and founder of the Cognitive Behavioral Therapy Institute of Southern California. He is the author of multiple books on tic disorders and contributes to a wide range of publications, including HuffPost, The Hill and Reader’s Digest.
If you’re one of the many millions of people around the world living with chronic tics, then as you begin to read this article, you may feel like you’re constantly juggling between your mind and body, with your tics taking centre stage. To avoid the stares or the frustration of not being in full control, perhaps you’ve spent much effort in life (as I have) on trying to manage your tics – the darting of your eyes, twisting of your neck, eye-blinking bursts, or even grunting sounds. Or maybe you know someone dealing with tics. In either case, I want you to realise that there is more than hope: there is an answer. Scientific research has uncovered practical strategies and insights that can help you to manage your tics more effectively. In this Guide, I will share how you can start dialling down the intensity of your tics, or even eliminate them altogether.
Tics and Tourette Syndrome
Tics come in the form of involuntary movements, from face twitching to leg jerking, and involuntary vocalisations – these can be non-speech sounds, such as whistling or coughing, or words, such as repeating the same utterance over and over. Unfortunately, you may face stigma from peers and society, with people assuming you are ‘weird’ or ‘mental’. Gaining more control of your tics will grow your confidence and can also serve as a metaphor for overcoming life’s obstacles in general.
Not everyone who has tics has Tourette Syndrome (TS), which is a specific neurological condition characterised by the presence of both vocal and motor tics that persist for more than a year. I’m going to focus on strategies that can help you manage any form of chronic tics, whether you have a diagnosis of TS or not.
Thank goodness the treatment of tics has improved since the neurologist Georges Gilles de la Tourette first identified TS in 1885. Originally, it was thought to be a ‘mental’ condition. Freudian therapy was used to treat TS and other tic problems, and it centred around blaming the patient’s parents and resolving their childhood conflicts. You might not be surprised that there is no convincing evidence that addressing perceived Oedipal conflicts or penis envy reduces tics in any meaningful way.
Today, TS is recognised as having a complex mix of causes. It is highly heritable, and environmental factors, such as birth complications, can also play a role. Chronic tics, whether part of TS or not, are thought to arise from specific neurological differences. The corticostriatal (CSTC) circuits in your brain play an important role in motor control. Tics are seen as a misfire within these circuits, resulting in motor tics and/or vocalisations that are difficult to suppress. The more you tic, the deeper the neural pathways underlying your tics become, resulting in stronger urges to tic. Still, just as the CSTC circuits fire out these tic blasts, with the right treatment, you can definitely learn to fire back.
Seek professional support prior to self-help
Before focusing on specific strategies for managing your tics, it’s important to zoom out. The right treatment starts with the right diagnosis. If you are experiencing chronic tics and haven’t done so already, it is a good idea to get assessed by a healthcare professional so they can evaluate your medical history and conduct a physical and neurological examination. This will help to rule out other possible causes for the tics, such as other movement disorders, psychiatric conditions or medication side effects. Your healthcare provider can determine whether you have a specific tic disorder like TS or another form of chronic tic disorder. Difficulties with tics can also co-occur with problems such as anxiety or ADHD, and a professional will be able to provide you an overall support package.
However, regardless of your specific diagnosis, the self-help strategies and approaches discussed in this Guide will be applicable to helping you manage your tics and improve your quality of life.
The most evidenced-based behavioural approach for eliminating or managing tics is comprehensive behavioural intervention for tics (CBIT). If your tics are moderate or severe, your healthcare provider may consider prescribing medication in conjunction with CBIT – this is something to discuss carefully with them.
CBIT was developed in the early 2000s and, surprisingly, remains relatively unknown. The approach was designed by the clinical psychologist Douglas Woods and his colleagues and is adaptable to different ages. It combines elements of cognitive behavioural therapy (CBT) with habit reversal training (HRT) to reduce tic severity and improve overall functioning.
If you are unable to access a trained CBIT therapist, or perhaps you don’t feel ready to work with a therapist, you can follow the self-help approach to CBIT detailed in this Guide. It has four main steps, and I will walk you through them.
Key points
Know the basic facts about tics and Tourette Syndrome. Not everyone who has tics has Tourette Syndrome (TS), which is a specific neurological condition. However, the same self-help approach for tics can work in all cases.
Seek professional support prior to self-help. Before using a self-help approach based on the comprehensive behavioural intervention for tics (CBIT), it is important to get assessed by a health professional.
Perform a functional analysis. The first step of CBIT is to focus on the tic that hassles you the most and write down everything you can about when it occurs, what you’re doing at the time, where you are, and who you are with.
Complete awareness training. Next, break down your tic into all its component parts, paying special attention to the ‘premonitory urge’ that signals the tic is beginning. Practise catching the tic before it unfolds.
Undertake competing response training. Once you’ve achieved an 80 per cent success rate at catching your tic, practise performing a ‘battle line’ – an intentional behaviour that is less obvious than your tic and prevents it from breaking through.
Generalise to everyday life. Finally, it’s time to apply your training in everyday life and use your increased awareness and battle lines to take control of your tics.
Don’t forget to reward yourself. Maintaining motivation is critical in CBIT. From the start, plan small rewards for yourself for practising these steps.
Perform a functional analysis
It is good to start with the one tic that hassles you the most. We want to get a snapshot of this tic. How many times are you ticking in a given 15-minute period? (This will help you track whether your tic work is working.) During high-tic times, ask yourself:
Who is present?
What are you doing?
Where are you?
When is this happening?
How are people responding?
Write all this down. It will help you learn what dials up and down the tic, and give insight into how you can make environmental adjustments to dial down the tic. This helps weaken the tic bursts before you attack them head on.
Here’s an example from my clinic. Jayden, aged 15, had a frequent throat-clearing tic that he found embarrassing, especially when in a quiet environment, such as at the library or during class.
As the first part of CBIT, Jayden decided to track the throat-clearing tic during his study session. He wrote down:
Who is present?I am alone.
What are you doing?Reading textbooks or solving problems.
Where are you?In a quiet study space.
When is this happening?In the late afternoon, between 3 and 4 pm.
How are people responding?No one is around to comment, but I feel frustrated with myself when I clear my throat.
Reviewing his notes, Jayden realised that the throat-clearing tic increased when he tried to concentrate and when he put pressure on himself. Creating a more relaxing study environment and being around people actually helped Jayden. Identifying that he could talk more supportively to himself about his tics and learning tools to manage school pressure helped dial them down as well.
Complete awareness training
As tics can be involuntary or semi-voluntary, increasing your awareness of how they occur is crucial for managing them. After all, if you want to stop your enemy, it is important to study and know them well. There are two parts to this second step of CBIT.
Breaking down the tic. It may seem like your tic is one step: a head jerk, a grunt, etc. But, there are actually many steps involved in doing it. At the start, there is a clue that the tic is about to happen. There is an urge, a tingle or pressure that comes quickly before you do the tic, which is known as a ‘premonitory urge’. It is important to break down all the steps of the tic, including this initial urge. This will prepare you for the second stage of awareness training which is about catching tics before they fully unfold.
Consider the case of Amira, aged 32, who was dealing with a persistent neck jerk that she found especially bothersome at work during meetings. She decided to tackle this tic by breaking it down into its constituent steps:
A tingle on the right side of her neck.
Lifting her chin slightly upward.
A subtle pull towards the left side of her neck.
A sharp jerk to the right to relieve the pressure.
Repeat this until it ‘feels right’.
Amira wrote down these steps to better understand how her body moved when the tic happened. In particular, Amirapaid attention to the premonitory urge before the tic happened, which for her took the form of a slight tension building on the right side of her neck. This prepared her well for the next stage of awareness training.
Catching it coming. If you want to beat a tic, then you have to get good at catching it. Grab a supportive person to play the ‘catch it coming’ game. Engage in a conversation with them and raise your hand when you feel the urge to do the tic. The supportive person will say ‘Good job!’ when you catch it, and ‘Whoops, you missed it’ when you don’t catch it. We want you to reach an 80 per cent catch rate before you progress to the next step of CBIT self-help. Practise this for 15 minutes daily until you achieve your 80 per cent. If you are struggling to reach 80 per cent, try your best to eliminate distractions when practising and focus on fine-tuning where the urge surfaces.
Amirapractised awareness with the help of her partner, Sarah. After work, they would have a casual conversation, and whenever Amirafelt the telltale tingle in her neck (the premonitory urge she had identified in her earlier breakdown of her tic), she raised her hand to signal to Sarah. The goal was to catch the tic before it happened. After seven days of 15 minutes of practice, Amirawas able to catch the urge with an 80 per cent success rate. This prepared Amirato succeed in the third step of CBIT self-help.
Undertake competing response training
Once you can reliably identify the premonitory urge prior to your tic, the next step is to develop a ‘competing response’. CBIT therapists call this your ‘battle line’: an intentional behaviour you do that is physically incompatible with the tic. This is where the breakdown of your tic that you prepared earlier can be useful. (You may be tempted to jump to this section without completing the first two steps of CBIT, but for competing responses to work effectively, I strongly recommend completing those earlier steps first). Look at the steps of the tic for ideas for a good battle line. It should be a behaviour that the tic can’t break through; is less obvious than your tic; and you can hold for at least a minute and until the urge is gone. Your brain needs at least a minute to process not sending that tic signal out anymore.
Let’s return to Jayden’s story. Jayden chose controlled breathing through his nose as his battle line. When the urge to clear his throat hit, he practised breathing slowly and deeply through his nose instead (3 seconds breathing in, holding for 1 second, 6 seconds breathing out). He held this breathing pattern for at least a minute each time and until that urge was gone, allowing the urge to fade.
Initially, the tic may try to increase as you are focusing on it. However, within a week of using your battle line, you are likely to experience fewer tics spaced further apart. If you cannot find a battle line, focus on the opposite action of the muscles used to make the tic. Here are some examples of common battle lines used by my clients (their tics appear in bold, followed by the battle line):
Head jerking: tuck chin and elongate back of neck.
Shoulder shrugging: hold shoulders down as if holding weights.
Hand grabbing or flapping: push hands on lap.
Throat clearing: slow controlled breathing through nose.
Sniffing: slow controlled breathing through mouth.
Generalise to everyday life
Finally, it is important for you to generalise your battle line to everyday life. That means, no matter what, whenever you feel the urge to do that tic, you must do your competing response – not just when practising but in everyday situations too. Challenges with generalisation include:
Catching the tic coming: noticing the urge before the tic unfolds.
Feeling it: getting your muscles engaged to combat the tic with your battle line.
Holding it: completing your battle line for at least a minute and until that urge is gone.
So, these are the aspects to rehearse as much as possible.
Follow the four-step process described in this Guide for all of the tics that hassle you. When you are getting more confident with one, move on to another. As a bonus, try to see where you can come up with battle lines that cover more than one tic. Don’t worry, your battle lines are not your ‘new normal’. They are a temporary defence to break the brain’s habit of firing out these tics. If done consistently, you will use a battle line only if the tic tries to sneak back. Sometimes, a ‘tic whack-a-mole’ can make one tic increase while another comes down. This is manageable. Considering battle lines that can cover more than one tic is possible and helpful when this occurs. This will teach the tics that you are the boss.
Don’t forget to reward yourself
Maintaining motivation is critical in CBIT. From the start, plan small rewards for yourself for practising these steps. Try to make working on CBIT as pleasurable as possible. Start getting back what you enjoyed doing prior to these tics. For example, let’s say you are a video gamer and you’ve reduced your time playing because you’d noticed you tend to tic frequently while gaming. As you practise your battle line and make progress, allow yourself to increase your game time as a reward. Also, think about people you admire who are strong and resilient, and imagine yourself emulating them as you hold your battle lines. For example, Jayden played Fortnite and admired the character Midas for his gold touch, sharp style, power and enigmatic presence. During his battle line, Jayden imagined Midas’s posture and confidence as he engaged in controlled breathing.
Final notes
CBIT has been shown to reduce tics and improve quality of life for many individuals. Positive results can be seen in as little as a week, and many people show very good progress in five to 10 weeks (dramatically decreasing or eliminating their tics). Though self-help is a viable option, if your tics continue to impair your life and your happiness, I recommend seeking a professional therapist for support (if you have the resources and accessibility to do so). A professional eye can catch errors in your work that you may not see and help hold you accountable. They can also help to tailor your treatment plan to your own circumstances.
Self-help is a great way to begin managing your tics or to support your progress alongside professional treatment. Of course, everyone’s situation is different and, longer term, addressing all of your tic challenges may require a multidisciplinary approach, incorporating medical professionals, mental health specialists, educators and family support. But remember, you can learn to manage your tics. I did, and I have seen people from the ages of five to 80 do it as well. If you need more specific information or resources on any aspect, feel free to leave comments on this Guide or speak to your healthcare providers. Learning to manage your tics can be very empowering and resilience-building, and is definitely possible!
