Tourette’s Disorder and the Mind-Body Divide
How tics can be controlled—with the right therapy
Clinical Expert: Alan Apter, MD
Tourette’s Disorder is especially interesting for the reason that it is a syndrome in which the boundaries between mind and body are blurred.
What is the difference between a tic and a muscle spasm? A muscle spasm is just a local contraction of a muscle. But a tic, although it may originate in the muscle, goes through the cerebral cortex, through the emotional parts of the brain, the thalamus, and finally goes back to the muscle and makes it move.
This results in two very interesting things. First, that a tic is controllable. But, second, it’s only controllable at a price—the effort it takes to suppress it actively. If I asked you not to blink, you could probably not blink for 5 seconds, or 10 seconds, or 15 seconds—eventually you would have to blink. The same thing is true of the child with Tourette’s. He is continually under siege to do movements that he doesn’t want to do. He doesn’t feel that he is controlling his life. One famous psychiatrist described Tourette’s Syndrome as a siege against the self. How much do you control what you do and how much do you not?
Interestingly enough, this is not just in motor tics. Many children with Tourette’s also have obsessional thoughts. It’s as if somebody else in your brain is controlling what you think and how you move. You can fight it, but fighting it all the time means never being able to relax. And especially in embarrassing situations, it can really challenge a person’s sense of identity and sense of self.
And there are, of course, vocal tics, which usually get the most attention when one is talking about Tourette’s. Basically a vocal tic is merely a contraction of the vocal cords, which are, after all, just a muscle, like any other muscle. When they contract, the child will either blurt out a sound or, in some cases, because of the emotional baggage that is attached to the circuit as it goes through the cortex and thalamus, it could be something related to the situation.
Imagine if I were thinking right now, “All right, let’s finish this already; I want to go home.” If I had Tourette’s I would have difficulty, much more difficulty, controlling this thought than I do now. Since I don’t have Tourette’s, I don’t feel anxious that I will blurt out something that you don’t want to hear. And that is what makes Tourette’s an interesting condition, vocal tics included.
What does this imply about the treatments for Tourette’s?
Tics are very difficult to treat with medication. The reason is that tics come in bouts, come in attacks, and each bout has little bouts in between it, and each little bout has little bouts in between it, so you really don’t know when the attack of tics is going to go finish by itself. Often when the tics are at their worst, this is a sign that you’ve reached the top of the hill and you are now going to go down. Also, many cases of tics and Tourette’s tend to improve dramatically after the age of about 11 or 12—not all—and then gradually disappear. So the problem with treating it with medication is that you might be giving it for no real reason.
But there are some very interesting psychological treatments that have recently been developed. Perhaps the most important one is a therapy called “habit reversal treatment,” or “habit reversal therapy.”
Tics have a side phenomenon that just before you tic there is a warning. It’s like sneezing—I feel a little bit of an itch and then I sneeze. A child with a tic can say, essentially, well, I’m going to blurt out this curse, it’s going to happen, okay, it happened. Now if you can teach a child to recognize that pre-warning, what we call in technical jargon the “premonitory urge,” and then do some other movement or other action, that can very often block the expression of the tic.
This is a major change in our thinking about the psychology of tics. Whereas once we told kids, don’t try to control the tic, because in the end it will just burst out, we’ve now changed our recommendations and we try to teach children to control their tics. The old myth was that if you suppressed your tics eventually there would be what they called a “rebound.” So if you didn’t tic for 5 minutes, then you would go crazy. But that’s not true. If you stop the tics, and you manage to control them, they gradually disperse.
So there’s been this major change in the management of tics—less medication and more psychological therapies. Psychological therapies based on trying to control the tics—and you can do it.
This brings us back to what’s interesting about Tourette’s—this difference between body and mind. We know tics are biological, so it’s particularly interesting that a psychological treatment can change the biology, with the potential to cure the tics.