Habit Reversal Therapy (HRT) is relatively well established in the treatment of Tic Disorders, with large effect size versus control conditions. HRT is first-line treatment focusing on: awareness training (encouraging awareness of situations that can precede tics and awareness of the nature of the tics); relaxation training (since anxiety and stress can trigger tics); competing response training (encouraging unwanted tics to be replaced with a less conspicuous action—e.g., tensing muscles antagonistic to the tic action); motivation procedures (designed to improve how acceptable HRT is to patients and their families); and generalization training (rehearsing trigger situations and the sequence of starting the tic, stopping it, and undertaking a competing response). There is evidence that a short course of HRT is as effective as more protracted number of sessions; and that benefits extend beyond the end of the treatment.

Exposure and Response Prevention (ERP) also shows efficacy in the treatment of Tic Disorders, and involves exposure to sensations and urges preceding tics, and response prevention of the tics. In a head-to-head comparison, ERP and HRT were similarly effective for tic symptoms, but it should be noted that ERP is typically more involving in terms of therapist/patient time.

treatment Choice and Sequencing of treatment

Psychological therapy (HRT or ERP) should be implemented as a first-line treatment for Tic Disorders where treatment is indicated.

For those with severely functionally impairing tics, and for those who cannot engage with psychological therapy, antipsychotic medication can be considered. Likewise, tics that persist and impair life despite a course of talk therapy can be treated with antipsychotic medication. For patients with Tic Disorder plus ADHD, an alpha-2 receptor agonist (clonidine or guanfacine) should be started as the first-line treatment in conjunction with psychotherapy: this is important since these two conditions likely have synergistic negative effects on long-term functional outcomes if not robustly treated.

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