Specialist Behavioural Interventions for Tic Disorders

Twelve Neuroscience provides specialist assessment and behavioural interventions for adults with Tic Disorders and Tourette Syndrome. Interventions are individually formulated and can include Habit Reversal Training (HRT) and Exposure and Response Prevention (ERP).

London · Online

Understanding Tic Disorders

Tics are repeated movements or sounds that can feel difficult to control. They can include simple behaviours, such as blinking, facial movements, head or shoulder movements and throat clearing, as well as more complex sequences of movements or vocalisations.

Many people describe an uncomfortable sensation before a tic, known as a premonitory urge. This may feel like pressure, tension, itching, an internal build-up, or a sense that something is “not quite right”. Performing the tic can temporarily reduce or change this sensation.

However, not everyone experiences tics in this way. Some people find it difficult to recognise an urge at all. Others experience a sensation that seems to be present almost continuously, or feel that a movement needs to be repeated until it feels complete or “just right”.

Understanding what happens before, during and after the tic is therefore an important part of assessment and helps determine which behavioural strategies are most appropriate.

Behavioural Interventions for Tics

Behavioural interventions aim to increase awareness of the processes surrounding a tic and develop greater flexibility in how a person responds to urges and sensations.

Rather than simply trying to suppress tics, we examine the relationship between sensations, urges, attention, movements and relief, and identify where that sequence can be changed.

Two established approaches are particularly relevant: Habit Reversal Training (HRT) and Exposure and Response Prevention (ERP).

Habit Reversal Training

Habit Reversal Training (HRT) helps an individual become more aware of the earliest signs associated with a tic and learn an alternative response. A central component is the competing response – a behaviour that is physically incompatible with, or makes it more difficult to perform, the tic. The competing response is selected according to the individual tic rather than using the same strategy for everyone. Intervention can also involve identifying situations, sensations and other factors that influence tic frequency or intensity.

Exposure and Response Prevention

Exposure and Response Prevention (ERP) takes a different approach. The individual practises experiencing the premonitory urge or associated sensations without immediately responding by performing the tic. This provides an opportunity to learn that an urge can be experienced without automatically acting upon it and to develop greater flexibility over the relationship between urge and response. ERP may be particularly useful when there are multiple tics or when working with individual competing responses for every tic would be impractical.

Which Intervention Is Right for Me?

Tic Disorders can look similar from the outside while being experienced very differently by the individual having them. For this reason, intervention begins by understanding how your particular tics work, rather than automatically applying the same technique to every tic. Factors that may influence the approach include:

• whether there is a recognisable premonitory urge
• whether the sensation is brief or continuously present
• whether performing the tic produces relief, completion or a “just-right” feeling
• whether the earliest part of the tic can be recognised
• whether the tic can be delayed or changed

This helps determine whether HRT, ERP, or a combination of behavioural strategies is likely to be most appropriate.

Complex Tic Presentations

Some tic presentations do not fit neatly into a simple urge → tic → relief pattern.

For some people, the sensation associated with a tic may be continuously present. Others describe a part of the body feeling tense, uncomfortable, misaligned or “not right”, followed by repeated movements intended to correct or change the sensation. Tics may also occur rapidly or in complex sequences, making it difficult to recognise what happens before the movement.

In these situations, intervention may initially focus on slowing the sequence down, developing awareness of subtle sensory or movement-related signals, and identifying points where the usual pattern can be interrupted or changed.

When Tic Disorders and OCD Overlap

Tic disorders and obsessive-compulsive disorder (OCD) can occur together, and sometimes the distinction between a tic and a compulsion is not immediately clear.

Some repetitive behaviours are preceded primarily by a physical or sensory urge. Others are driven by an intrusive thought, feared consequence or need to prevent something from happening. Some behaviours are repeated because something feels incomplete, uneven or “not quite right”.

Understanding what drives the behaviour is important because behaviours that look similar may require different approaches. Where tic and obsessive-compulsive processes overlap, intervention may incorporate both tic-focused behavioural strategies and ERP for OCD.

Assessment

The first stage is a detailed behavioural assessment. The aim is not simply to identify or count tics, but to understand how they operate for you.

Assessment explores what happens before, during and after a tic, including sensations or urges, where they are experienced in the body, the movement or vocalisation itself, and what happens when the tic is performed, delayed or resisted.

This information is brought together into an individual behavioural formulation, which helps determine what to target and whether HRT, ERP, or a combination of behavioural strategies is most appropriate.

About Dr. Patel

Dr. Dipesh Patel is an HCPC-registered Practitioner Psychologist with specialist clinical and research interests in tic disorders, Tourette Syndrome, obsessive-compulsive (OCD), and obsessive-compulsive symptoms.

He currently works within the Tourette Syndrome service at the National Hospital for Neurology and Neurosurgery (NHNN) and is undertaking PhD research at the UCL Queen Square Institute of Neurology investigating behavioural interventions for individuals with co-occurring tic disorders and obsessive-compulsive symptoms.

His clinical and research work focuses on understanding the relationship between tics, premonitory urges, compulsions and repetitive behaviours, and on developing individually formulated behavioural interventions using approaches including Habit Reversal Training (HRT) and Exposure and Response Prevention (ERP).

Frequently Asked Questions

1. Do I need a referral?

No. You can contact Twelve Neuroscience directly to discuss whether an assessment may be appropriate.

2. Are appointments available in person or online?

Yes. Appointments are available in person in London or online. Where possible, the initial assessment is preferably conducted in person, as this provides an opportunity to directly observe the tics, associated movements and other aspects of the presentation that can help inform the behavioural assessment. Subsequent appointments can be conducted either in person or online, depending on individual circumstances and preferences.

3. What happens during the first appointment?

The first appointment focuses on understanding your tics, urges and any related repetitive behaviours. This helps develop an individual behavioural formulation and determine which intervention may be most appropriate.

4. Can you help if I have both tics and OCD symptoms?

Yes. Where tic and obsessive-compulsive processes overlap, assessment considers what is driving each behaviour so that tic-focused strategies and ERP for OCD can be incorporated where appropriate.

Appointments

Appointments are available in person in London and online for adults with Tic disorders, Tourette Syndrome, OCD, and related obsessive-compulsive symptoms. If you would like to discuss whether an assessment may be appropriate, please get in touch.