The Thinking Person's Guide to Easing Tourette's

Add Tourette syndrome to the list of psychiatric and neurological disorders that you may be able to think your way out of.

That is only a slight exaggeration, but then emphasis is on “slight.” The recognition that mental illnesses are biological diseases of the brain is a welcome change from the medieval notion that they are evidence of witchcraft, demonic possession, “refrigerator mothers,” and the like, but the conclusion that scientists leapt to—that the only effective treatments for biological diseases are drugs—is both illogical and unfortunate. Hard on the heels of research showing that changing the way a patient thinks and behaves can be as effective in treating depression and obsessive-compulsive disorder (to name just two) comes evidence that changing behavior can also alleviate Tourette syndrome.

Tourette’s, which strikes an estimated 6 in 1,000 school-age children, is characterized by verbal and behavioral tics such as repetitive and uncontrolled blinking, head jerking, facial grimacing, throat clearing, grunting, and—most famously but least commonly—spouting obscenities. The tics appear in childhood and tend to be worst in early adolescence (exactly when odd behavior is guaranteed to make your school life a living hell), often (in half to one third of cases) fading away in young adulthood. The most common treatment, in our pill-obsessed society, is an antipsychotic medication such haloperidol, pimozide, and risperidone. But the drugs rarely vanquish the tics completely, and often have side effects, causing sleepiness, weight gain, and even cognitive impairment, notes a paper in today’s issue of the Journal of the American Medical Association.
 
Psychiatry professor John Piacentini of UCLA thought there could be an alternative to the drugs. He started from the fact that before someone with Tourette’s displays a tic, he usually has a few seconds warning: he feels uncomfortable urges or sensations, much like an incipient itch, that can be relieved only through grunting or blinking or twitching—whatever form that patient’s illness takes. That seemed like a window of opportunity, Piacentini reasoned: get to the patient when he knows the tic is coming and try to intervene. “The idea is to bring the urge to tic into consciousness, and break the link between the urge and the tic,” he told me.

As Piacentini and colleagues describe in their JAMA paper, that intervention was to teach the children—there were 126 in their study, ages 9 to 17—a specialized form of behavior therapy called comprehensive behavioral intervention for tics. First, the children learned to recognize when the urge to tic arose. But rather than just telling them “don’t!”, as some parents (unhelpfully) do, the behavioral intervention taught the kids to perform a movement incompatible with the tic. For instance, children whose tic was to jerk their neck were taught to look forward with the chin slightly down while gently tensing neck muscles for a minute, or until the urge to tic went away. Children with vocal tics learned to start slow, rhythmic breathing from the diaphragm when they felt the urge to grunt or cry out.

After only eight sessions of 60 to 90 minutes over 10 weeks, 53 percent of the children receiving the behavior therapy had significantly fewer tics, compared with 19 percent in the control group (who received simply supportive psychotherapy and information about tic disorders). The improvement was comparable to that found with antipsychotics (but without the side effects, of course). Six months later, 87 percent of the kids were still better—reinforcing the finding that when patients with a psychiatric illness learn to think and behave differently, it stays with them. In contrast, the effect of drugs disappears when the patient stops taking them.

“This is a real paradigm shifter from passively waiting for a pill to kick in,” Piacentini says. “We're teaching kids to monitor and confront their tics consciously.” He and his colleagues are now starting workshops to train clinicians in the therapy.

One of the most fascinating findings in studies of cognitive or behavioral therapy for mental illness is that these treatments can alter the aberrant patterns of brain activity that underlie the disease, just as drugs do. For instance, Jeff Schwartz of UCLA and colleagues showed that a form of mindfulness—essentially, thinking about your thoughts differently—alters the pathological brain activity of OCD just as drugs do, they reported in a 1996 paper. Scientists got similar results with mindfulness and depression, as John Teasdale of Cambridge reported here and here, while scientists in Canada found that cognitive therapy was just as effective in alleviating symptoms of depression, and in altering the underlying brain pathology, as drugs, as they reported in 2004. Now Tourette’s joins the lengthening list of mental illnesses in which the mind can change the brain.
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