2008 - Managing Tourette Syndrome - Adult Workbook PDF

Managing Tourette Syndrome
EDITOR-IN-CHIEF
David H. Barlow, Ph.D.
SCIENTIFIC
ADVISORY BOARD
Anne Marie Albano, Ph.D.
Gillian Butler, Ph.D.
David M. Clark, Ph.D.
Edna B. Foa, Ph.D.
Paul J. Frick, Ph.D.
Jack M. Gorman, M.D.
Kirk Heilbrun, Ph.D.
Robert J. McMahon, Ph.D.
Peter E. Nathan, Ph.D.
Christine Maguth Nezu, Ph.D.
Matthew K. Nock, Ph.D.
Paul Salkovskis, Ph.D.
Bonnie Spring, Ph.D.
Gail Steketee, Ph.D.
John R. Weisz, Ph.D.
G. Terence Wilson, Ph.D.

Managing Tourette
Syndrome
A BEHAVIORAL INTERVENTION
A d u l t Wo r k b o o k
Douglas W. Woods • John C. Piacentini

Susanna W. Chang • Thilo Deckersbach
Golda S. Ginsburg • Alan L. Peterson
Lawrence D. Scahill • John T. Walkup
Sabine Wilhelm
1
2008
1
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About TreatmentsThatWorkTM
One of the most difficult problems confronting patients with various disorders
and diseases is finding the best help available. Everyone is aware of friends or
family who have sought treatment from a seemingly reputable practitioner, only
to find out later from another doctor that the original diagnosis was wrong or
the treatments recommended were inappropriate or perhaps even harmful. Most
patients, or family members, address this problem by reading everything they can
about their symptoms, seeking out information on the Internet, or aggressively
“asking around” to tap knowledge from friends and acquaintances. Governments
and healthcare policymakers are also aware that people in need do not always
get the best treatments—something they refer to as “variability in healthcare
practices.”
Now healthcare systems around the world are attempting to correct this vari-
ability by introducing “evidence-based practice.” This simply means that it is in
everyone’s interest that patients get the most up-to-date and effective care for a
particular problem. Healthcare policymakers have also recognized that it is very
useful to give consumers of healthcare as much information as possible, so that
they can make intelligent decisions in a collaborative effort to improve physical
and mental health. This series, TreatmentsThatWorkTM , is designed to accom-
plish just that. Only the latest and most effective interventions for particular
problems are described in user-friendly language. To be included in this series,
each treatment program must pass the highest standards of evidence available, as
determined by a scientific advisory board. Thus, when individuals suffering from
these problems or their family members seek out an expert clinician who is famil-
iar with these interventions and decides that they are appropriate, they will have
confidence that they are receiving the best care available. Of course, only your
healthcare professional can decide on the right mix of treatments for you.
This workbook describes a comprehensive behavioral approach for treating

Tourette syndrome (TS). If you suffer from a tic disorder, this program will teach
you ways of managing and decreasing your tics. Over the course of 11 sessions with
a qualified mental health professional, you will learn to become aware of your tics,
how to substitute other behaviors for your tics, and how to avoid factors that may
v
make your tics worse. You will also practice relaxation techniques to reduce stress,
which can exacerbate tic symptoms. Relapse prevention strategies will help you
keep up your progress after treatment has ended. User-friendly forms for tracking
symptoms and monitoring tic severity are provided in this workbook, along with
an appendix of resources that you can access in order to obtain more information
on tic disorders.
David H. Barlow, Editor-in-Chief,
TreatmentsThatWorkTM
Boston, MA
vi
Contents
Chapter 1 Overview 1
Chapter 2 Session 1 9
Chapter 3 Session 2 17
Chapter 4 Remaining Sessions 31
Chapter 5 Relaxation Training 37
Chapter 6 Relapse Prevention 43

Appendix of Forms 47
Appendix of Resources 71
vii
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Chapter 1 Overview
Introduction to the Program
Welcome to the program! You are taking an important first step in learning to
effectively manage your tic disorder. Working closely with your therapist, you will
learn how to manage your tics. This program involves becoming aware of your
tics and the situations that make them worse. You will learn to restructure your
environment to make your tics less frequent, and you will learn specific exercises
to help you tic less. You will also practice relaxation techniques to reduce stress.
Relapse prevention strategies will help you keep up your progress after treatment
has ended.
Use of This Workbook
This workbook is designed to help you follow along with your treatment. Chap-
ter 2 guides you through the activities for the first session. Likewise, Chapter
3 guides you through the activities for the second session. The basic structure
of the remaining sessions (3–8) is then outlined in Chapter 4. Chapter 5 gives
instructions for the breathing and progressive muscle relaxation exercises that
you will learn in therapy. Relapse prevention, including how to address new tics, is
addressed in Chapter 6. This workbook also includes a list of additional resources
that you might find helpful.
In sessions, you and your therapist will work together as a team to address your
tics. You will also be assigned homework to put your new skills into effect. The
workbook chapters include instructions for homework and the forms to be used.
An appendix includes extra copies of blank forms; you may photocopy these
forms as needed. Be sure to bring your workbook and completed homework
forms to every session.
1
About Tic Disorders
Some information about tic disorders is included here for your reference. You and
your therapist may review this information together during the first session.
DSM Criteria for Tic Disorders
There are three types of tic disorders: Tourette syndrome (TS), chronic tic dis-
order (CTD), and transient tic disorder (TTD). Mental health professionals
use criteria listed in the Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition, Text Revision (DSM-IV-TR) to diagnose these disorders. See
Tables 1.1–1.3 for the DSM-IV-TR criteria for each disorder.
Note that motor and vocal tics are the main symptoms of each disorder and that
the only differences among the disorders are the types of tics and how long they
have been present. There are several types of tics including simple tics and com-
plex tics (see Table 1.4). Simple tics are very quick movements that may involve
Table 1.1 Diagnostic Criteria for Transient Tic Disorder
1. Single or multiple motor and/or vocal tics.

2. The tics occur many times a day, nearly every day for at least 4 weeks, but for no longer than 12 consecutive
months.
3. The onset is before age 18 years.
4. The disturbance is not due to the direct physiological effects of a substance (e.g., stimulants) or a general
medical condition (e.g., Huntington’s disease or postviral encephalitis).
5. Criteria have never been met for Tourette’s disorder or chronic motor or vocal tic disorder
Table 1.2 Diagnostic Criteria for Chronic Tic Disorder
1. Single or multiple motor or vocal tics.

2. The tics occur many times a day, nearly every day or intermittently throughout a period of more than 1 year,
and during this period, there was never a tic-free period of more than 3 consecutive months.
5. Criteria have never been met for Tourette’s disorder.
2
Table 1.3 Diagnostic Criteria for Tourette Syndrome
1. Both multiple motor and one or more vocal tics have been present at some time during the illness, although
not necessarily concurrently.
2. The tics occur many times a day (usually in bouts) nearly every day or intermittently throughout a period of
more than 1 year, and during this period, there was never a tic-free period of more than 3 consecutive months.
Table 1.4 List of Simple and Complex Tics

Simple motor tics Complex motor tics
Eye blinking Eye movements

Eye movements Mouth movements
Nose movements Facial movements or expressions
Mouth movements Head gestures or movements
Facial grimace Shoulder movements
Head jerks or movements Arm movements
Shoulder shrugs Hand movements
Arm movements Writing tics
Hand movements Dystonic or abnormal postures
Abdominal tensing Bending or gyrating
Leg, foot, or toe movements Rotating
Leg, foot, or toe movements
Blocking
Tic-related compulsive behaviors (touching,
tapping, grooming, evening-up)
(obscene gestures)
Self-abusive behavior
Groups of simple tics
Simple vocal tics Complex phonic symptoms
Sounds, noises (coughing, throat clearing, Syllables

sniffing, or animal or bird noises) Words
Coprolalia (obscene words)
Echolalia (repeating others’ words)
Palilalia (repeating your own words)
Blocking
Disinhibited speech
3
only a specific muscle group or sound. Complex tics are more obvious and usually
involve multiple muscle groups or sounds. One type of complex vocal tic that
many people associate with tic disorders is coprolalia, or swearing tics. Although
the popular media make this seem like a common symptom, it actually does not
happen for most people with tic disorders. As you probably noticed, tics do not
occur in a steady way. Rather, they wax (get worse) and wane (get better) over the
course of time.
Premonitory Urges
People with tic disorders not only have the tics themselves, but they often have
what are called “premonitory urges.” These urges usually occur right before the
tic. They feel similar to an urge to sneeze or scratch an itch. They are some-
times described as an “inner tension.” Urges usually go away or get less intense
for a little while right after a tic. Not all tics have urges associated with them,
and younger patients are less likely to have them than older patients. Table 1.5
summarizes where urges most commonly occur in the body.
People with tic disorders are also sometimes very sensitive to things going on
around them. They may be bothered by particular sensory stimuli such as tags
Table 1.5 Common Areas for Premonitory Urges

Left palm
Right shoulder blade
Right palm
Left shoulder
Left shoulder blade
Midline abdomen
Throat
Right shoulder
Back of right hand
Front of right thigh
Front of right foot
Back of left hand
Inside of right upper arm
Front of left thigh
Left eye
Right eye
Note. Adapted from Leckman, Walker, and Cohen (1993).
4
in clothing or textures of fabrics. Also, certain words or sounds may trigger tics.
Some have urges to do dangerous or forbidden acts such as shouting in church or
opening the door of a moving car. Others have to do something in a certain way
until it is arranged properly or “evened up,” or until it feels “just right.” Some-
times these latter behaviors are mistaken for symptoms of obsessive-compulsive
disorder (OCD). Your therapist can discuss with you the distinction between tic
symptoms and OCD symptoms.
Natural History of Tics
Tics usually start around the age of 5–7 and usually increase in frequency and
intensity up to around the age of 10–11 (refer to Tables 1.6 and 1.7). Tic disorders
are more common in boys, and the severity of symptoms tends to decrease in
adulthood.
Introduction to Causes
Just like asthma or diabetes, tics are a medical illness with a genetic basis and are
greatly affected by your lifestyle and what happens in your life.
Table 1.6 Age-of-Onset Distribution for Tics

Age Number of cases out of 221
1 4
2 7
3 22
4 22
5 32
6 28
7 24
8 21
9 22
10 15
11 7
12 6
13 4
14 2
15 3
16 2
Note. Adapted from Leckman, King, and Cohen (1999).
5
Table 1.7 Percentage of Clients Stating the
Age of Worst Ever Tic Severity
Age % of clients
1 0
2 0
3 0
4 0
5 0
6 5
7 7
8 7
9 18
10 16
11 11
12 18
13 14
14 5
15 0
16 2
17 0
18 0
Note. Adapted from Bloch et al. (2006).
Genetics
We know there is an inherited component to tic disorders, but it is unlikely that
only one gene is responsible. It appears that a certain genetic makeup involving
many genes puts individuals at a greater risk of developing tic disorders.
Neurological basis
Evidence suggests that specific circuits in the brain are responsible for many
symptoms of tic disorders. These circuits are known as the cortico-striatal-
thalamo-cortical (CSTC) circuits. In this area, signals from the cortex, or the
part of the brain that plans movements, get sent to the part of the brain that con-
trols movements and then loop back into the front part of the brain. In patients
with TS, the parts of the brain that initiate and inhibit movement do not work
properly.
In addition to these brain structures, we know that the chemical systems within
these structures play a role in tic expression. For example, high levels of dopamine
6
activity have been implicated in tics. Other neurotransmitters believed to be
involved in tics include glutamate, GABA, serotonin, and norepinephrine. Medi-
cations used to treat tics may alter these chemical systems. Although we do not yet
have direct evidence that the procedure described in this manual actually affects
brain chemistry, we do know that learning can produce changes in the way the
brain works.
Other risk or protective factors
Other events have also been found to worsen tics or put someone at greater risk of
developing a tic disorder. For example, factors that influence the development and
function of certain brain circuits include premature birth, maternal stress during
pregnancy, prolonged labor, fetal distress, and use of forceps. It may also be the
case that some individuals develop tics in reaction to recurrent strep infections.
It is important to note that although these factors may be related to tics, they do
not necessarily cause tics.
Prevalence
The best available evidence from the most recent studies indicates that 3–8
school-age children per 1,000 have TS. The prevalence of CTDs or TTDs is
less certain—but altogether, the prevalence of tic disorders may be as high as 4%
in children. From these numbers, you can tell that tic disorders are not “rare” in
school-age children. Given what we know about the natural history of TS, the
prevalence of TS and tic disorders is likely to be lower in adulthood.
For more information on tic disorders, see the list of resources provided in the
appendix at the end of this workbook.
7
Chapter 2 Session 1
Goals
■ To review your history of tic disorder and related problems
■ To understand the rationale for treatment
■ To review information about tic disorders

■ To create tic hierarchy
■ To learn about function-based interventions
■ To begin monitoring tics
History of Tic Disorder
An assessment will be conducted before beginning the treatment. At the begin-

ning of the first session, your therapist will review the assessment results with
you. You will discuss your history and the impact of tic disorder on your past and
current functioning.
Rationale for Comprehensive Behavioral Intervention for Tics
This therapy program has two parts. First, you and your therapist will figure out
when things happen in your life that make your tics worse. You will then see
whether you can keep these things from happening or at least make them have
less of an impact on your tics. Second, your therapist will teach you how to man-
age your tics better, so that they do not bother you as much. Let’s say you have a
tic that makes you shake your head. This can be embarrassing or annoying and
maybe even a bother to other people who are around you. So, instead of shaking
your head, you could tense your neck muscles slightly. If you can learn to do things
that are less noticeable than your tics, this may make things a lot easier for you.
9
Review of Tic Disorders
Your therapist may provide information on tic disorders at the beginning of treat-
ment. You may want to review the “About Tic Disorders” section in Chapter
1 of this workbook. An appendix at the end of this workbook lists additional
resources.
Creating a Tic Hierarchy
Your therapist will work with you to develop a comprehensive list of your current
tics. This list should be recorded on the Tic Symptom Hierarchy Tracker form
provided in this chapter.
Once your current tics have been identified, you and your therapist will create
definitions for each tic. For example, if you have a neck shaking tic, you may
agree on the following definition, “A neck shaking tic is when your head departs
from midline, moves left, and then returns to midline.”
After your tics have been identified and operationally defined, you will rate how
bothersome each tic is on a scale of 0–10. A rating of 0 indicates that a tic either
is not occurring or produces absolutely no distress or discomfort. A score of 10
indicates that the tic is creating significant amounts of distress or discomfort. The
Subjective Units of Discomfort Scale (SUDS) rating should be recorded on the
Tic Symptom Hierarchy Tracker. See Figure 2.1 for a completed example of a Tic
Symptom Hierarchy Tracker. Your treatment will be based on the tics identified
in this hierarchy. Generally, an easier-to-treat tic is addressed first.
Symptom SUDS Rating
Session #: 1 2 3 4
Date: 12/1 12/8 12/15 12/22
1. arm jerking: pull arm back when it’s bent at elbow 2 3 2 3
2. head shaking: moving head rapidly to the right 7 6 5 5
3. coughing: short hard cough 8 9 9 3
4. leg/head tic: rapidly bring legs together and then stretch neck 9 10 6 5
5. blink 2 3 2 2
Figure 2.1
Example of a Completed Tic Symptom Hierarchy Tracker
10
Tic Symptom Hierarchy Tracker
Instructions: Provide a SUDS rating for each symptom listed on the Tic Symptom Hierarchy Tracker at the begin-
ning of each treatment session. New symptoms can be added to the bottom of the list. Do not drop any previously
reported symptoms. Symptoms reported as no longer present or not currently distressing are to be rated as “0.”
Symptom SUDS Rating
Session #:
Date:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
11
Function-Based Intervention
Events that happen before or after tics can make them more likely to happen.
Two methods will be used for determining what events affect your tics. First, in
each session, your therapist will conduct what is called a “functional assessment
interview” for the tic being addressed in that particular session. It will be impor-
tant for you to provide your therapist with as much detail as possible about the tic
and the situations in which it occurs. This process is described in more detail in
Chapter 3. Second, you will be given homework assignments (starting today) to
observe the tics at home, note when they seem to be worse, and to describe the sit-
uations in which they were worse. Such information will be helpful in developing
treatments specifically for you.
For homework, you will be completing a Functional Assessment Self-Report
Form. In the next week, you should pay very close attention to all of your tics and
the situations in which they are most likely to happen. Notice when tics happen,
where they happen, who they happen around, and how you were feeling at the
time. Also notice what happens right after you tic. Do people say things, laugh,
or tell you to stop? Do they ask you to go somewhere else by yourself? Record all
of this information on the form and be sure to bring it to your next session. A
blank copy is provided at the end of the chapter.
Self-Monitoring Training
Over the next week, you will monitor the first tic, chosen in this session, a mini-
mum of 3–4 times. Using the My Tic Sheet, record each occurrence of the first tic
during a set time interval (15–30 min). Choose a time period when tic occurrence
is likely. In addition to these structured monitoring times, try to self-monitor the
first tic on the hierarchy whenever you can (e.g., when alone, at work, and around
bedtime). When noting the tic, do something unnoticeable to others like saying
“T” under your breath.
A blank copy of the monitoring sheet is provided at the end of the chapter. You
will use this form multiple times throughout the course of the program. Each
chapter contains a copy of the form, and additional copies are included in an
appendix at the end of the book.
12
Homework
✎ Monitor the first tic on the hierarchy using the My Tic Sheet.
✎ Complete the Functional Assessment Self-Report Form.
13
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My Tic Sheet
Day/Time What’s the Activity (e.g., watching TV) What’s the Tic Tic Count
Monday/3:00 At work on computer Coughing ////

Functional Assessment Self-Report Form
Instructions: At the end of each day during the next week, please think about the situations where your tics were occurring a lot. Please write down what was
happening in those situations, including where you were, what you were doing, who was around, and what you were feeling. Also write down what happened
after the tics occurred in these situations.
Day Where were you? What were you doing? Who was there? Feelings? Reactions to the tics?
Monday Lunchroom at Eating lunch 4 co-workers Nervous and embarrassed My co-workers kept
work looking at me
15
Chapter 3 Session 2
Goals
■ To review events of the past week and update your tic hierarchy
■ To create a list of why you dislike your tics
■ To develop function-based interventions for the first tic

■ To do HRT for the first tic
Weekly Review
At the beginning of the second session, your therapist will review with you the
events of the past week, including:
■ Any significant events in your life
■ Tic symptoms and impact on work, social, and family functioning
■ At least one positive event or thing that occurred since last session
You will then review the Tic Symptom Hierarchy Tracker (see Session 1) and pro-
vide SUDS ratings for the past week. Together with your therapist you will revise
the list as needed, considering that old tics may resolve and new ones may appear.
Inconvenience Review
In this session, you will create a list of things that you dislike about your tics.
For example, you may find your tic disorder embarrassing or dislike explaining
it to new people you meet. You may also find that it gets in the way of doing
certain activities (writing, playing sports, working, etc.). Your list of reasons why
your tics are inconvenient, embarrassing, distressing, and/or annoying should be
recorded on the Tic Hassles Form. You can keep this list in mind to help motivate
you during the treatment. As your tics improve and are no longer relevant, you
can cross items off the list.
17
Tic Hassles Form
Instructions: List reasons why your tics are inconvenient, embarrassing, distressing, and/or annoying. Provide a
0–10 rating for each item listed below by the end of each treatment session (0 = no distress; 10 = great distress). New
items can be added to the bottom of the list. Items that are no longer present or not currently distressing can be
crossed off.
Tic Hassles SUDS Rating (From 0 to 10)

0—No distress
10—Maximum distress
Session #:
Date:
1. I hate explaining it to new people I meet. 6 5 3
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
18
Function-Based Assessment and Interventions for First Tic
During the session, your therapist will ask you questions to assess the factors that
make your tics worse. Some of these questions will help identify what internal or
external events occur before tics. These events are called “antecedents.” Examples
of internal antecedent events include anxiety, anticipation, excitement, anger, etc.
Examples of external antecedent events include particular settings or the pres-
ence of particular people. Other questions will help determine those events that
occur in reaction to tics, or the “consequences.” Consequences include other peo-
ple’s reactions to your tic and anything else that happens as a result of the tic
occurrence.
Specific Interventions
Your therapist will also review your Functional Assessment Self-Report Form
of the past week. All of these data will be used to develop function-based
interventions using the following five principles.
Five Principles of Developing a Function-Based Intervention
1. When possible, situations or settings that make the tic more likely to happen
should be either minimized or eliminated.
2. In situations where tics are more likely to happen, events that occur soon
after a tic happens should be eliminated.
3. When entering those situations where tics are more likely to happen, use the
HRT strategies taught for that particular tic. HRT will be introduced later in
the session.
4. When entering situations that are not easily modifiable, use strategies to
minimize your own reactions that may contribute to tics.
5. The final rule when developing function-based interventions is to minimize

the impact of tics on your life.
Intervention Planning
After the function-based intervention for a particular tic has been developed,
you will record it on the Function-Based Interventions Form. For example, if a
19
family member’s reaction to a tic is a problem, you may talk to him or her about
how to react appropriately. Or, if anxiety makes your tics worse, you may learn
ways to modify your own anxious response to the situation. Your therapist will
work with you to come up with a concrete plan for how to implement these
interventions.
20
Function-Based Interventions Form
Date Developed: Date Implemented:
Target Tic:
List specific plausible strategies that can prevent the antecedent situations from occurring or prevent you from
encountering them.
1.
2.
3.
4.
List specific strategies that could make a situation less likely to worsen tics if the situation cannot be prevented.
1.
2.
3.
4.
List ways in which consequences for this tic can be avoided or changed.
1.
2.
3.
4.
21
Habit Reversal Training for First Tic
During the session, you will be given HRT. The purpose of HRT is to
■ make you aware of when the tic is happening or is about to happen
(awareness training)
■ teach you to engage in a behavior that is physically incompatible with

the tic (competing response (CR) training)
■ find someone who can reinforce you for using the CR correctly and
prompt you to use the CR when you do not recognize that a tic has
occurred
Awareness Training
In session, you will practice becoming aware of when you do the tic. This is very
important, because you first have to know when the tic is happening before you
can learn how to manage it.
Defining the Tic
First you and your therapist need to be on the same page about what you are
dealing with. You will work together to define your tic, using as much detail
as you can. You might consider: What does it sound like? Look like? Is it fast
or slow? Is it noticeable or not? Are there different parts to it, or is it just one
movement?
Describing Antecedent Sensations and Behaviors
The first part of being aware is being able to define the problem. The second
part is actually being able to say when it happens or is about to happen. In the
case of tics, your body is probably giving you signals that let you know tics are
about to happen. These “warning signs” or “tic signals” can either be things you
do or things you feel. You may have private experiences such as an uncomfort-
able, vague itching sensation, tightness, tension, or even something as general
as “it just feels like I need to do it.” Or you may have behaviors that precede
the tic. For example, if a person has an arm-extending tic, he may raise his
22
arms from the side before the tic. In this case, the warning sign (raising arms)
is public.
You and your therapist will work together to establish all your tic signals. These
should be written down on the Tics, Tic Signals, and Competing Responses form
under the column “Tic Signals” (see first row for an example).
23
24
Tics, Tic Signals, and Competing Responses
# Name of Tic Definition Tic Signals Competing Response
1 Leg/head tic Calves tighten, heels come up, knees come —General tense Place heels flat on the ground, hold
together forcefully making a cracking noise. feelings in the legs and knees together and tighten thighs
As the knees come together, the chin goes neck while tensing neck muscles gently
down toward the chest and then goes up —Calves tighten
toward the sky as the top of the head goes —Heels go up
back.
Acknowledging Your Tics
Next you will practice noticing your tic. As you talk with your therapist, you will
acknowledge your tic as soon as it happens by giving your therapist a signal (e.g.,
by raising your index figure).
Once you are aware of the tic, you will then practice being aware of your tic
signals, instead of the tic itself. Just as you did for the tic, you will give your
therapist an acknowledgement of your tic signal as soon as you notice it.
Note that making yourself more aware of your tics may make them seem worse
at first. This is because you are noticing tics that used to occur without your
awareness. It may be upsetting at first to become aware of how much you tic. It is
important to hang in there, because over time, awareness will help you to tic less.
Competing Response Training
The core of HRT is CR training. A CR is a behavior you can do when the urge
to tic appears or soon after the tic has started. After you do this exercise long
enough, your brain may learn that the tic does not need to occur, and the tic gets
very weak or even goes away completely. Anytime the competing response is done,
it should be held for at least 1 min or until the urge to tic fades away—whichever is
longer.
Selecting the Competing Response
Your therapist will work with you to select a behavior to be used as a CR to a

particular tic. The following criteria should be used to develop a CR.
1. The behavior should either be physically incompatible with the target tic or
be a relaxed, more natural, graceful variation of the original tic. A variation
of the original tic may include trying to make adjustments to the tic, so that
only part of the tic movement is expressed. Although both options may be
effective, it is preferable to start with a physically incompatible behavior. A
more subtle variation of a tic should be used only if the physically
incompatible option has failed.
2. The CR should optimally be able to be maintained for at least 1 min or until

the urge(s) to tic goes away or is (are) significantly reduced.
25
3. The CR should be socially inconspicuous (or at least, less noticeable than
the tic) and easily compatible with normal ongoing activities.
4. Various CRs may exist for a particular tic. Select the CR that works the best
for you.
Although there is no “correct” CR, Table 3.1 lists common CRs for use with
different motor tics.
For vocal tics, a “controlled” breathing CR should be implemented. Controlled
breathing involves inhaling through the nose or mouth and exhaling through
the nose or mouth. On the inhale, your abdomen should expand, while your
shoulders remain stationary. On the exhale, your abdomen should contract, while
your shoulders again remain stationary.
Table 3.1 List of Possible Competing Responses for Different Motor Tics
Tic Competing response
Body jerk Tighten stomach and buttocks muscles

Body twist Stand or sit up straight while tensing back
and keep hands to side (or in pockets,
under legs)
Evening out Hold arms at side
Eye blinking Controlled, voluntary eye blinking
Stare ahead, focus on object
Eyebrow movements (i.e., raise Slow, controlled eye blink
eyebrows or frowning) Stare at one point, end with one controlled
eye blink
Eye close and hold Controlled eye blink
Eye darting Stay focused on one spot in the room and
engage in smooth, controlled blinking
Eye widening Tense eyebrows and use controlled
breathing
Facial grimacing Purse lips together gently
Nose scrunching Pull nose down slightly, keep lips pressured
shut, deep breathing
Finger movements (i.e., hair twirl, Place hands on knees, squeezing if needed
head rubbing) Cross arms
Flicking toes, curling toes Press all toes flat on ground
continued
26
Tic Competing response
Head nodding, head jerking Tense neck muscles gently, fixate eyes
Straighten and tense neck while lowering
and tensing shoulders
Jaw clicking or thrusting Let jaw hang loosely while doing relaxed
breathing, holding breath for 2–3 s before
exhale
Close mouth and tense jaw
Knuckle cracking Cross arms
Fold hands
Leg lift or ankle twist Push heels into floor
Hold knees together tightly
Leg tensing Tense buttocks
Licking lips Clench jaw softly, pressure lips together
Mouth opening Purse lips, push teeth together, and push
tongue up to roof of mouth
Neck roll Tense neck muscles with chin down slightly
Nose twitching Breathe in and out through mouth while
tensing nose and eyebrows
Purse lips and tense nose
Nostril flaring Clench jaw and pressure lips together
Picking lips Place hands on leg, squeezing if needed
Shaking head side-to-side Tense neck in place, push chin toward
chest and deep breathe
Shaking head up and down Hold chin down to chest and deep breathe
Tense neck muscles
Shoulder popping or shrugging Push hand down on thigh and push elbow
toward hip
Tense shoulders in downward position,
keep arms at sides
Spitting Purse lips and use diaphragmatic breathing
Tensing arm or flailing arm Interlock fingers, push shoulders down and
push arms into side
If standing up, push arms into side and
push shoulders down
Tongue clicking Push tongue to roof of mouth, close mouth
and breathe
Wrist twisting Hand on leg, squeeze leg if needed
27
Be sure to record the agreed-upon CR in the appropriate column on the Tics, Tic
Signals, and Competing Responses form.
Learning the Competing Response
Your therapist will show you what your CR exercise should look like and then
will have you practice. As soon as you do the tic or notice one of your tic signals,
you will do the exercise for 1 min or until the urge goes away. At the end of 1 min,
you should ask yourself whether the urge is still present. If so, the CR should
be continued. It is important to remember that your life and social interactions
should not stop entirely when doing a CR; you should try to continue doing
other things as you do the exercises.
After you have learned the CR in the session, your therapist will ask you to do the
exercise every time you tic or every time you have a warning sign from this point
forward. You should do the exercise as needed at all times and in all situations. It
may be very difficult to catch each and every tic at first, but do the best you can.
If you miss a tic, that’s okay—just try to catch the next one.
Social Support
After you have learned to do the exercises, you may select a support person to
help you. This person will be taught to assist you in doing the CR. The support
person or “helper” has two main jobs. One is to let you know when you have
done a good job with the exercises, and the other is to remind you to do the
exercises when you forget.
If possible, the support person should attend the session so that your therapist
can teach him or her how to provide support in an appropriate manner.
Homework
✎ Use the CR developed for Tic 1 and recorded on the Tics, Tic Signals,
and Competing Responses form during both planned and unplanned
times.
28
✎ Do planned CR practice at least 3–4 times this week, for at least 30 min
each time. During the planned exercises, monitor the tic using the My
Tic Sheet.
✎ Implement the interventions described on the Function-Based
Interventions Form.
29
30
My Tic Sheet
Day/Time What’s the Activity(e.g., watching TV) What’s the Tic Tic Count
Chapter 4 Remaining Sessions
Goals
■ To review events of the past week and update tic hierarchy
■ To review Tic Hassles Form
■ To review treatment procedures for previous tic

■ To develop function-based interventions for next tic
■ To do habit reversal training for next tic
Weekly Review
At the beginning of each of the remaining sessions, your therapist will review
with you the events of the past week, including:
■ Any significant events in your life

■ Tic symptoms and impact on work, social, and family functioning
■ At least one positive event or thing that occurred since last session
■ Any situations in which tics were increased, and factors that may have
contributed to the exacerbation
You will then review the Tic Symptom Hierarchy Tracker (see Session 1) and
provide SUDS ratings for the past week. Together with your therapist you will
revise the list as needed, considering that old tics may resolve and new ones may
appear.
Inconvenience Review
You and your therapist will review the Tic Hassles Form completed in Session 2.
You may use this list for motivation to work on tics.
31
Review of Function-Based Intervention and Competing Response for Previous Tic
If you had any difficulties with function-based interventions for the previous tic,
you will discuss these with your therapist. Your therapist will help you problem-
solve these in session and modify function-based intervention as needed.
You will review the competing response (CR) for the previous tic and again prac-
tice your exercises. If you had any difficulties with CR implementation, you will
discuss these with your therapist. Your therapist will help you problem-solve these
in session and modify the CR as needed.
Function-Based Assessment and Interventions for Second Tic
As in Session 2, your therapist will ask you questions to assess factors that make
tics worse. This time the focus will be on the next tic from your hierarchy. The
assessment will identify the “antecedents” (what internal or external events occur
before tics) and “consequences” (those events that occur in reaction to tics). This
information and the data from your Functional Assessment Self-Report Form
from the first week will be used to develop function-based interventions. Recall
the five principles of function-based intervention (see Session 2).
The agreed-upon interventions for the next tic should be written down on the
Function-Based Interventions Form. Your therapist will work with you to come
up with a concrete plan for how to implement these interventions.
32
Target Tic:
encountering them.
1.
2.
3.
4.
1.
2.
3.
4.
1.
2.
3.
4.
33
Habit Reversal Training for Next Tic
As in Session 2, you will do HRT with your therapist. The same procedure will
be used for the next tic.
Awareness Training
■ Define the tic
■ Describe antecedent sensations and behaviors
■ Acknowledge tics and tic signals
Competing Response Training
■ Select the CR
■ Learn the CR
■ Teach the support person
Homework
Additional copies of homework forms can be found in an appendix at the

end of the book. You may photocopy these as needed.
✎ Use the CRs for tics during both planned and unplanned times. Refer to
the Tics, Tic Signals, and Competing Responses form in Chapter 3.
✎ Do planned CR practice at least 3–4 times for all tics worked on in

treatment, for at least 30 min each time. During the planned exercises,
monitor the tics using the My Tic Sheet (refer to Session 1 for
monitoring procedures).
✎ Implement the interventions described on the Function-Based

Interventions Form.
34
My Tic Sheet
35
Chapter 5 Relaxation Training
Goals
■ To learn about relaxation training
■ To practice relaxed or deep breathing exercise
■ To practice progressive muscle relaxation (PMR)
Introduction of Relaxation Techniques
In Sessions 4 and 5, your therapist will introduce relaxation training. It is impor-

tant to learn how to relax because tics can make your muscles tense and leave
your whole body tight and tense. This may sometimes make you feel upset or
tired. For some people, tics get worse when they have stress, when they are upset,
or when they are physically tired. Learning to relax will reduce stress and might
help your tics get better.
Relaxed or Deep Breathing Exercise
During Session 4, you will work on doing a type of relaxation called relaxed or
deep breathing. Deep breathing is a technique used to slow down your breathing.
When you slow down your breathing, you also slow down your heart rate and
decrease most of the body symptoms of stress.
During the exercise, you should breathe in through your nose and breathe out
through your mouth. When you breathe in, your stomach should go out, and
when you breathe out, it should go back in.
Your therapist will discuss with you possible targeted times in which relaxed
breathing may be useful in reducing stress. Together you will identify two situa-
tions in the next week in which you can practice using relaxed breathing. Record
these situations on the Breathing Exercise Sheet.
37
Breathing Exercise Sheet
1. Pretend you are a balloon that gets big when it fills up with air and shrinks when air goes out.
2. Put one hand on your stomach and one hand on your chest.
3. Breathe in through your nose, blowing up like a balloon, hold it for 3 seconds, and let the air out—pushing
out all the anxious feelings in your body. Tell yourself “relax.”
4. Repeat one time.
5. As you feel relaxed, imagine yourself in your favorite place—a place where you feel comfortable and relaxed.
Remember: Just as you can make your body tense, you can make it relax by practicing this exercise.
Where will you practice?
———————————————————————————————————————————
———————————————————————————————————————————
When will you practice?
———————————————————————————————————————————
———————————————————————————————————————————
38
Introduction of Progressive Muscle Relaxation
In Session 5, you will learn another relaxation technique—PMR. This exercise

involves tightening and then relaxing groups of muscles. See the PMR Exercise
Form for instructions. During the exercise, you will tense for 5–7 seconds and
then relax for 20 seconds each muscle group twice in a row. Throughout the
exercise, you should use relaxed breathing. As you relax each muscle group, you
will be focusing on the sensations of relaxation.
After the PMR exercise, your therapist will discuss with you possible targeted
times in which the relaxed breathing and PMR may be useful in reducing stress
that contributes to tics. Together you will identify two situations in the next week
in which you can practice using relaxation techniques. Record these situations on
the PMR Exercise Sheet.
39
PMR Exercise Sheet
1. Get comfortable!! Either sit or lie down. Remember to use relaxed breathing.
2. Tense each muscle group, hold it for 5–7 seconds, and then relax. Do this twice in a row.
You may want to use the following instructions for tensing each muscle group:
Arms & Hands—make a fist with both hands and hold your elbows in really tight to your side like you are
trying to squeeze yourself
Legs, Buttocks, & Feet—stick your legs out straight, lift them off the chair a little bit and try to point your
toes at your face.
Chest & Stomach—make your stomach hard by imagining that you are lying on the ground and a giant
purple elephant is going to step on your stomach and you need to make your stomach hard until the
elephant goes by.
Face, Neck & Shoulders—bring your shoulders up toward your ears, put your chin down and make it try to
touch your chest. While you are doing this, clench your teeth a little bit, pull back your mouth like you are
screaming, and open your eyes wide.
3. Make sure to notice the difference between tension and relaxation.
Where will you practice?
———————————————————————————————————————————
———————————————————————————————————————————
When will you practice?
———————————————————————————————————————————
———————————————————————————————————————————
40
Homework
Along with the regular session homework (see end of Chapter 4), do the
following relaxation homework as assigned:
✎ Practice relaxed breathing 5 min per day, 3–4 times per week and try
using the breathing exercise in the identified tic-stressing situations.
✎ Practice PMR 3 times this week, particularly before, during, or after the
two stressful situations identified in session.
41
Chapter 6 Relapse Prevention
Goals
■ To learn strategies for relapse prevention

■ To develop competing responses (CRs) for new tics
Relapse Prevention I
By definition, your condition is chronic. Symptoms may return or become exac-

erbated during times of greater stress. Specific tics will also wax and wane over
time. The following strategies will help you monitor your condition and prevent
or minimize relapse.
1. Be vigilant for tics that reappear or worsen during stressful periods (but there
is no need to overprotect yourself from stress).
2. Engage in stress management techniques that you find personally effective.
3. Be aware of triggers (situational, emotional, and physical) that could lead to

an increase in symptoms.
Relapse Prevention II
It is important to remember that despite your best efforts, you will not always
be able to completely prevent relapse. If tic symptoms reappear or worsen, you
should:
1. Initially monitor symptoms at planned times and unplanned times.
2. Develop CRs to perform in response to tics (refer to the List of Possible

Competing Responses in Chapter 2).
43
3. Seek family support and reinforcement for implementing CRs to tics.
4. Consider referral for a return to treatment for assistance with more

complicated symptoms.
Developing CRs to New Tics
After treatment, new tics may appear. If this happens, you will develop CRs to the
new tics just as you and your therapist did in session. Review the characteristics
of a good CR:
1. The behavior should either be physically incompatible with the target tic or
should be a relaxed, more natural, graceful variation of the original tic. A
varation of the original tic may include trying to make adjustments to the
tic so that only part of the tic movement is expressed. Although both
options may be effective, it is preferable to start with a physically
incompatible behavior. A more subtle variation of a tic should be used only
if the physically incompatible option has failed.
2. The CR should optimally be able to be maintained for at least 1 min or

until the urge(s) to tic goes away or is (are) significantly reduced.
3. The CR should be socially inconspicuous (or at least, less noticeable than

the tic) and easily compatible with normal ongoing activities.
4. Various CRs may exist for a particular tic. Select the CR that works the best
for you.
See Session 2 for further review of HRT. If you have trouble developing a CR for
a particular tic on your own, you may want to schedule a booster session with
your therapist.
Remember that you should initiate the CR as soon as you get the urge to tic.
You may even perform the CR during or after tic occurrence. Anytime the CR
is done, it should be held for at least 1 min or until the urge to tic fades away—
whichever is longer. Try to do planned CR practice at least 3–4 times this week,
for at least 30 min each time. During the planned exercises, monitor the tic using
the My Tic Sheet.
You may also want to do a self-functional assessment for the new tic and imple-
ment function-based interventions. See Session 2 for a review of the five principles
of developing a function-based intervention.
44
Therapy Termination
Congratulations on completing the treatment! This marks the end of therapy,

but not the end of your progress. You will continue to use the techniques and
strategies you have learned to better manage your disorder. For best results, it is
important that you keep monitoring your tics and developing CRs.
45
Appendix of Forms
47
Symptom SUDS Rating
Session #:
Date:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
48
Symptom SUDS Rating
Session #:
Date:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
49
50
My Tic Sheet
My Tic Sheet
51
52
My Tic Sheet
My Tic Sheet
53
54
My Tic Sheet
My Tic Sheet
55
56
My Tic Sheet
My Tic Sheet
57
Tic Hassles Form
0–10 rating for each item listed below by the end of each treatment session (0 = no distress; 10 = great distress).
New items can be added to the bottom of the list. Items that are no longer present or not currently distressing can
be crossed off.

0—No distress
Session #:
Date:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
58
Tic Hassles Form
0–10 rating for each item listed below by the end of each treatment session (0 = no distress; 10 = great distress).
New items can be added to the bottom of the list. Items that are no longer present or not currently distressing can
be crossed off.

0—No distress
Session #:
Date:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
59
Target Tic:
encountering them.
1.
2.
3.
4.
1.
2.
3.
4.
1.
2.
3.
4.
60
Target Tic:
encountering them.
1.
2.
3.
4.
1.
2.
3.
4.
1.
2.
3.
4.
61
Target Tic:
encountering them.
1.
2.
3.
4.
1.
2.
3.
4.
1.
2.
3.
4.
62
Target Tic:
encountering them.
1.
2.
3.
4.
1.
2.
3.
4.
1.
2.
3.
4.
63
Target Tic:
encountering them.
1.
2.
3.
4.
1.
2.
3.
4.
1.
2.
3.
4.
64
Target Tic:
encountering them.
1.
2.
3.
4.
1.
2.
3.
4.
1.
2.
3.
4.
65
Target Tic:
encountering them.
1.
2.
3.
4.
1.
2.
3.
4.
1.
2.
3.
4.
66
Target Tic:
encountering them.
1.
2.
3.
4.
1.
2.
3.
4.
1.
2.
3.
4.
67
68

69
Appendix of Resources
Books
Handler, L. (1998). Twitch and shout: A Touretter’s tale. New York: Dutton.
Kushner, H. I. (1999). A cursing brain?: The histories of Tourette syndrome.

Cambridge, MA: Harvard University Press.
Marsh, T. L. (2007). Children with Tourette syndrome: A parents guide. Bethesda,
MD: Woodbine House.
Shimberg, E. F. (1995). Living with Tourette syndrome. New York: Fireside.
Websites
National Tourette Syndrome Association

www.tsa-usa.org
Tourette Syndrome Plus
www.tourettesyndrome.net
Videos (all videos listed and more are available on the TSA website)
After the Diagnosis . . . The Next Steps For those with a new diagnosis of TS,
clarifies what TS is, offers encouragement, and dispels misperceptions. Excerpts
from the “Family Life With TS” video, experiences with TS, comments from
medical experts, 35 min.
Family Life With Tourette Syndrome . . . Personal Stories . . . A Six-Part

Series Adults, teenagers, children and their families . . . all affected by Tourette
syndrome describe lives filled with triumphs and setbacks . . . struggle and growth.
Informative and inspirational. Each vignette also available separately—AV11a–
AV11f, 58 min.
71
Using Behavior Therapy to Manage Tic Disorders in Children A presentation
by Dr. Doug Woods about using behavior therapy to manage tics in children,
CD-ROM format.
Diagnosing and Treating Tourette Syndrome A series of medical education

programs for physicians and allied health care professionals along with a series of
important medical articles, 2-Disc Set.
72

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Managing Tourette Syndrome

David H. Barlow, Ph.D.

Anne Marie Albano, Ph.D.

Gillian Butler, Ph.D.

David M. Clark, Ph.D.

Edna B. Foa, Ph.D.

Paul J. Frick, Ph.D.

Jack M. Gorman, M.D.

Kirk Heilbrun, Ph.D.

Robert J. McMahon, Ph.D.

Peter E. Nathan, Ph.D.

Christine Maguth Nezu, Ph.D.

Matthew K. Nock, Ph.D.

Paul Salkovskis, Ph.D.

Bonnie Spring, Ph.D.

Gail Steketee, Ph.D.

John R. Weisz, Ph.D.

G. Terence Wilson, Ph.D.

Douglas W. Woods • John C. Piacentini

Oxford New York

Published by Oxford University Press, Inc.

Oxford is a registered trademark of Oxford University Press

All rights reserved. No part of this publication may be reproduced,

Printed in the United States of America

This workbook describes a comprehensive behavioral approach for treating

Chapter 4 Remaining Sessions 31

Chapter 5 Relaxation Training 37

Chapter 6 Relapse Prevention 43

Introduction to the Program

Use of This Workbook

DSM Criteria for Tic Disorders

Table 1.1 Diagnostic Criteria for Transient Tic Disorder

1. Single or multiple motor and/or vocal tics.

Table 1.2 Diagnostic Criteria for Chronic Tic Disorder

1. Single or multiple motor or vocal tics.

Table 1.4 List of Simple and Complex Tics

Eye blinking Eye movements

Simple vocal tics Complex phonic symptoms

Sounds, noises (coughing, throat clearing, Syllables

Table 1.5 Common Areas for Premonitory Urges

Note. Adapted from Leckman, Walker, and Cohen (1993).

Natural History of Tics

Table 1.6 Age-of-Onset Distribution for Tics

Note. Adapted from Leckman, King, and Cohen (1999).

Note. Adapted from Bloch et al. (2006).

Other risk or protective factors

■ To review your history of tic disorder and related problems

■ To understand the rationale for treatment

■ To review information about tic disorders

■ To learn about function-based interventions

■ To begin monitoring tics

History of Tic Disorder

An assessment will be conducted before beginning the treatment. At the begin-

Rationale for Comprehensive Behavioral Intervention for Tics

Creating a Tic Hierarchy

Symptom SUDS Rating

Symptom SUDS Rating

Monday/3:00 At work on computer Coughing ////

■ To create a list of why you dislike your tics

■ To develop function-based interventions for the ﬁrst tic

■ Tic symptoms and impact on work, social, and family functioning

Tic Hassles SUDS Rating (From 0 to 10)

1. I hate explaining it to new people I meet. 6 5 3