Behaviour therapy has shown to be an effective strategy in treating tics; both habit reversal (HR) and exposure and response prevention (ER) are recommended as first-line interventions for children and adults according to the Canadian and European Guidelines (Steeves et al., 2012; Verdellen et al., 2011).


It is advised to start with behaviour therapy instead of medication, because of the side effects that are associated with medication and the better long term effects of behaviour therapy following treatment. Only if a behavioural intervention is insufficient or not available, pharmacotherapy is recommended (Roessner et al., 2011).


Both HR and ER are described in the manual “Tics” (available in our bookstore). 


Habit Reversal

HR is one of the oldest and most researched beavioural interventions for tics. Azrin & Nunn presented the technique in 1973, as a method for eliminating nervous habits and tics (Azrin and Nunn, 1973). The main components of HR are “awareness training” and “competing response training”.


Awareness training consists of tic description, tic detection, an early warning procedure, and situation awareness training. The patient learns to become aware of the presence of the tic and of the warning signs (i.e., premonitory sensation or urge ) that the tic is about to occur. The tic is analyzed closely, starting with the premonitory urge  and followed by detection and description of the different muscle groups involved in the tic. In addition, the patient learns to become aware of the situations in which the tic occurs. 


With competing response training the patient learns to initiate a response contingent upon the urge to perform a tic or the actual occurrence of the tic. For example, instead of blinking the eyes, a patient could learn to stare at a fixed point, or with head shaking, he learns to tense the neck muscles. The competing response should be applied for at least a minute or until the urge to tic fades away.


Exposure and response prevention

The application of exposure and response prevention to reduce tics is based on the association of unpleasant premonitory urges and sensations followed by a motor or vocal tic that relieves the sensation (Bliss, 1980; Leckman et al., 1993). The relief in the sensation after completion of the tic reinforces repetition of the tics (negative reinforcement).  The main goal of ER is to interrupt this association, thus preventing the tics to occur (Verdellen et al., 2004). Whereas in HR each tic is treated separately, ER targets all tics at once.


Treatment starts with a training phase, during which the patient is trained to systematically suppress all tics. Subsequently, the patient is asked to focus on the premonitory sensations and urges (exposure) for a prolonged period of time while resisting every tic (response prevention). Exposure can be optimized by asking the patient to focus the attention to that part of the body where the unpleasant urge at that moment is.  Furthermore, the patient is asked to describe situations or activities in which tics often occur. These situations or activities are imagined and, if possible, practiced in session.


Support was found for the theory  that confronting the patient with premonitory sensations while resisting all tics leads to habituation of these upleasant sensatons (Hoogduin et al, 1997). Reductions in premonitory sensations were found both within and between 10 two-hour ER sessions (Verdellen et al., 2008), with no indications for rebound effects (Verdellen et al., 2007).



Several randomized controlled trials (RCTs) into HR  showed significant tic reduction in the HR condition, when compared to waiting list (Azrin & Peterson, 1990) and supportive psychotherapy (Deckersbach et al., 2006; Piacentini et al., 2010; Wilhelm et al., 2003, 2012). Effect sizes between 0.68 and 1.50 were reported, indicating large treatment effects. Results remained stable at 2 to 10 month follow-up. One RCT compared HR to ER in 43 Tourette syndrome patients aged 7-55 years  (Verdellen et al., 2004). Significant tic reductions were found in both conditions as measured by the Yale Global Tic Severity Scale (YGTSS, Leckman et al., 1989) and tic frequency counts both at the institute and at home. No significant differences were found between HR and ER, although there were indications that ER is more effective when there are multiple tics. Effect sizes on the different outcome measures ranged from 0.47 to 1.06 for HR and from 0.88 to 1.42 for ER. The charts shown below show the reductions that were found in tic severity for both methods (Verdellen  et al., 2004). 


































  • Azrin, N.H., Nunn, R.G., 1973. Habit reversal: A method of eliminating nervous habits and tics. Behaviour Research and Therapy 11, 619-628.

  • Azrin, N.H., Peterson, A.L., 1990. Treatment of Tourette Syndrome by habit reversal: A waiting-list control group comparison. Behavior Therapy 21, 305-318.

  • Bliss, J., 1980. Sensory experiences of Gilles de la Tourette syndrome. Archives of General Psychiatry 37, 1343-1347.

  • Deckersbach, T., Rauch, S., Buhlmann, U., Wilhelm, S., 2006. Habit reversal versus supportive psychotherapy in Tourette's disorder: a randomized controlled trial and predictors of treatment response. Behaviour Research and Therapy 44, 1079-1090.

  • Hoogduin, K., Verdellen, C., Cath, D., 1997. Exposure and Response prevention in the treatment of gilles de la tourette's syndrome: Four case studies. Clinical Psychology and Psychotherapy  4, 125-135.

  • Leckman, J.F., Riddle, M.A., Hardin, M.T., Ort, S.I., Swartz, K.L., Stevenson, J., Cohen, D.J., 1989. The Yale Global Tic Severity Scale - initial testing of a clinician-rated scale of tic severity. Journal of the American Academy of Child & Adolescent Psychiatry 28, 566-573.

  • Leckman, J.F., Walker, D.E., Cohen, D.J., 1993. Premonitory urges in Tourette's syndrome. American Journal of Psychiatry 150, 98-102.

  • Piacentini, J., Woods, D.W., Scahill, L., Wilhelm, S., Peterson, A.L., Chang, S., Ginsburg, G.S., Deckersbach, T., Dziura, J., Levi-Pearl, S., Walkup, J.T., 2010. Behavior therapy for children with Tourette disorder: A randomized controlled trial. JAMA 303, 1929-1937.

  • Roessner, V., Plessen, K.J., Rothenberger, A., Ludolph, A.G., Rizzo, R., Skov, L., Strand, G., Stern, J.S., Termine, C., Hoekstra, P.J., 2011. European clinical guidelines for Tourette syndrome and other tic disorders. Part II: pharmacological treatment. European Child and Adolescent Psychiatry 20, 173-196.

  • Steeves, T., McKinlay, B.D., Gorman, D., Billinghurst, L., Day, L., Carroll, A., Dion, Y., Doja, A., Luscombe, S., Sandor, P., Pringsheim, T., 2012. Canadian guidelines for the evidence-based treatment of tic diorders: Behavioural therapy, deep brain stimulation, and transcranial magnetic stimulation. Canadian Journal of Psychiatry 57, 144-151.

  • Verdellen, C., van de Griendt, J., Hartmann, A., Murphy, T., 2011. European clinical guidelines for Tourette syndrome and other tic disorders. Part III: behavioural and psychosocial interventions. European Child & Adolescent Psychiatry 20, 197-207.

  • Verdellen, C.W., Hoogduin, C.A., Kato, B.S., Keijsers, G.P., Cath, D.C., Hoijtink, H.B., 2008. Habituation of premonitory sensations during exposure and response prevention treatment in Tourette's syndrome. Behavior Modification 32, 215-227.

  • Verdellen, C.W., Hoogduin, C.A., Keijsers, G.P., 2007. Tic suppression in the treatment of Tourette's syndrome with exposure therapy: The rebound phenomenon reconsidered. Movement disorders 22, 1601-1606.

  • Verdellen, C.W., Keijsers, G.P., Cath, D.C., Hoogduin, C.A., 2004. Exposure with response prevention versus habit reversal in Tourettes's syndrome: A controlled study. Behaviour Research and Therapy 42, 501-511.

  • Wilhelm, S., Deckersbach, T., Coffey, B.J., Bohne, A., Peterson, A.L., Baer, L., 2003. Habit reversal versus supportive psychotherapy for Tourette's disorder: a randomized controlled trial. Am Journal of Psychiatry 160, 1175-1177.

  • Wilhelm, S., Peterson, A., Piacentini, J., Woods, D., Deckersbach, T., Sukhodolsky, D., Chang, S., Liu, H., Dziura, J., Walkup, J., Scahill, L., 2012. Randomized trial of behavior therapy for adults with tourette syndrome. Achives of General Psychiatry 69, 795-803.


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