Neuroscience and Biobehavioral Reviews 37 (2013) 1172–1177

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Neuroscience and Biobehavioral Reviews

journal homepage: www.elsevier.com/locate/neubiorev

Review

Behavioural treatment of tics: Habit reversal and exposure with

response prevention
J.M.T.M. van de Griendt a,∗ , C.W.J. Verdellen a,1 , M.K. van Dijk b,2 , M.J.P.M. Verbraak b,2
a
HSK Group BV, Hambakenwetering 5b, 5233 DD ‘s-Hertogenbosch, The Netherlands
b
HSK Group BV, Oude Oeverstraat 120, 6811 JZ Arnhem, The Netherlands

a r t i c l e i n f o a b s t r a c t

Article history: Behaviour therapy has been shown to be an effective strategy in treating tics; both habit reversal (HR) and
Received 31 May 2012 exposure and response prevention (ER) are recommended as first-line interventions. This review pro-
Received in revised form 4 October 2012 vides an overview of the history, theoretical concepts and evidence at present for HR and ER. In addition,
Accepted 11 October 2012
treatment manuals for HR and ER are described. Despite the evidence and availability of treatment manu-
als, many patients do not receive a first-line psychological intervention for tics. Barriers to the acceptance
Keywords:
and dissemination of behaviour therapy are discussed as are ways to overcome these barriers, such as
Tourette
the use of E-health and E-learning.
Tic disorder
Behaviour therapy © 2012 Elsevier Ltd. All rights reserved.
Habit reversal
Exposure and response prevention

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1172
2. Habit reversal (HR) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1173
2.1. History and theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1173
2.2. Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1173
2.3. HR Treatment manual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1174
3. Exposure and response prevention (ER) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1174
3.1. History and theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1174
3.2. Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1175
3.3. ER treatment manual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1175
4. When to apply HR or ER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1175
5. Conclusion and future directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1176
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1176

1. Introduction an A-level of evidence (Roessner et al., 2011). Although rather

effective in reducing tics, risperidone and other antipsychotics are
In the treatment of tic disorders, pharmacotherapy is the com- associated with a wide range of adverse effects including seda-
monly used strategy. Patients are mostly referred to medical tion, weight gain, orthostatic hypotension and extrapyramidal side
specialists (e.g. neurologists, psychiatrists and pediatricians) and effects. Many patients are reluctant to take antipsychotics and up
often receive antipsychotics to reduce tics. In Europe, risperidone to 70 percent of patients discontinue medication regimes within
has shown to be the most applied agent in tic disorders, with the first year (Shapiro and Shapiro, 1993).
Behaviour therapy has shown to be an effective strategy in
treating tics as well (Cook and Blacher, 2007). Recently published
∗ Corresponding author. Tel.: +31 736410111; fax: +31 736410022. European clinical guidelines for Tourette syndrome (TS) and other
E-mail addresses: j.vandegriendt@hsk.nl (J.M.T.M. van de Griendt), tic disorders offer a review of different behavioural and psychoso-
c.verdellen@hsk.nl (C.W.J. Verdellen), m.vandijk@hsk.nl (M.K. van Dijk),
m.verbraak@hsk.nl (M.J.P.M. Verbraak).
cial interventions (Verdellen et al., 2011a). Both habit reversal (HR)
1
Tel.: +31 736410111; fax: +31 736410022. and exposure and response prevention (ER) are recommended as
2
Tel.: +31 263687700; fax: +31 263687701. first-line interventions for tics. To date, studies comparing the

0149-7634/$ – see front matter © 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.neubiorev.2012.10.007
 J.M.T.M. van de Griendt et al. / Neuroscience and Biobehavioral Reviews 37 (2013) 1172–1177
effectiveness of pharmacotherapy and behaviour therapy in tic
disorders are absent. Despite this lack in research, the European
guidelines recommend to start treatment with psychoeducation
and behaviour therapy (HR or ER) because of the better long term
effects beyond the duration of treatment and assumed fewer side
effects. If these interventions are insufficient or not available, then
pharmacotherapy is recommended (Roessner et al., 2011).
The present article presents an outline of the history and theory
of HR and ER, the available evidence and treatment manuals for
HR and ER. However, despite growing evidence and availability of
treatment manuals, many patients do not receive a first-line psy-
chological intervention for tics (Verdellen and van de Griendt, 2012;
Woods et al., 2007). Barriers to the dissemination and implemen-
tation of behaviour therapy are discussed, as are ways to overcome
these barriers.
2. Habit reversal (HR)
2.1. History and theory
Habit reversal is one of the oldest and most researched inter-
ventions for tics. Azrin and Nunn presented the technique in 1973
as a method for eliminating nervous habits and tics. They viewed
tics as learned responses or, more specifically, adapted startle
reflexes. An injury or traumatic event was thought to evoke a
reflex which developed into a tic. The tic persisted because of
response chaining, limited awareness, excessive practice, social
reinforcement and tolerance of the tic. Azrin and Nunn introduced
HR as a multi-component treatment package consisting of tic
recording, awareness training, competing response training, moti-
vation enhancement, and generalization training (Azrin and Nunn,
1973). Since their original paper, HR has been applied in different,
more or less extended forms. Attempts have been made to iden-
tify the active components of the HR package that are necessary
and sufficient for tic reduction, indicating that awareness training
and competing response training are central to HR effectiveness
(Miltenberger et al., 1985; Peterson and Azrin, 1992).
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. The tic is
analysed closely, starting with the premonitory urge preceding the
tic (Bliss, 1980; Leckman et al., 1993), and followed by the different
muscle groups involved in the tic. Mirrors or camera’s can be used
to facilitate awareness. 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. Azrin and Nunn stated that the competing
response should be opposite to the tic behaviour, and strengthen
the antagonistic muscles that are incompatible with the tic (Azrin
and Nunn, 1973). Furthermore, the response should be maintained
for several minutes, be socially inconspicuous and easily fit into
daily life. Later studies demonstrated that the response does not
necessarily need to be isometrically opposite to the tic in order to be
effective (Evers and van de Wetering, 1994; Piacentini and Chang,
2001; Sharenow et al., 1989). Evers and van de Wetering (1994)
for example, showed that any response that is able to decrease the
tension that arises from the premonitory sensation as do the tics,
is to be considered an effective response. The competing response
should be applied for at least a minute or until the urge to tic fades
away (Piacentini et al., 2010; Woods et al., 2008).
The mechanisms underlying HR are currently insufficiently
understood. It is stated that the competing response acts as a puni-
tive measure for tic behaviour and that HR enhances self-control
and active coping skills (Miltenberger et al., 1985). Moreover, the
1173
effect of HR is attributed to the interruption of stimulus-response
associations. By having the patient initiate the competing response
at the first symptom signalling the emerging tic, the tic is prevented
from manifesting itself, thus facilitating habituation to the sen-
sory experiences (Himle et al., 2007; Hoogduin et al., 1996; Turpin,
1983).
2.2. Evidence
HR is researched in both controlled and uncontrolled stud-
ies. Dozens of case studies (1973–2011) showed tic reductions of
30–100% (for a review, Carr and Chong, 2005; Cook and Blacher,
2007). Furthermore, several randomized controlled trials (RCTs)
were performed. One of the oldest RCTs compared HR to massed
practice in 22 patients, both children and adults (age 11–62 years;
mean age 30.5 years) (Azrin et al., 1980). Massed practice consists
of repeated, rapid, voluntary performance of tics for a specified
period of time, interspersed with brief periods of rest. In one or
two 2.5 h sessions, 92% self-reported tic reduction was found for
HR as compared to 33% tic reduction for massed practice. In a study
of Azrin and Peterson (1990), HR was compared to waiting list in 10
patients aged 6–36 years (mean age 18.1 years). In the HR condition,
93% tic decrease was found compared to no significant decrease in
the waiting list condition (Azrin and Peterson, 1990), as measured
by home-reported tic counts by a spouse/parent and independent
video rating. In this study, between 13 and 30 sessions were per-
formed (mean 20 sessions). O’Connor et al. (2001) also compared
HR to waiting list in 47 adults (age 18–60 years; mean age 39.1
years) with either tics or habit disorders like hair pulling. After 12
weekly sessions, 65% of completers reported between 75 and 100%
control over the tic/habit, while waiting list showed no significant
decrease (O’Connor et al., 2001).
Furthermore, four studies compared HR to supportive psy-
chotherapy. Three studies included adults (Deckersbach et al.,
2006; Wilhelm et al., 2003, 2012), and one included children
(Piacentini et al., 2010). The two largest studies to date included
126 children (age 9–17; mean age 11.7 years, Piacentini et al., 2010)
and 122 adults (age 16–69; mean age 31.6 years, Wilhelm et al.,
2012). All studies showed a significant decrease in the HR condi-
tion on the Yale Global Tic Severity Scale (YGTSS;Leckman et al.,
1989), following 8–14 sessions. The YGTSS is a well-known and
reliable instrument to measure tic severity. Effect sizes between
0.57 and 1.50 were reported. Comprehensive behavioural inter-
vention for tics (CBIT) was applied, consisting of habit reversal (i.e.,
awareness training, competing response training and social sup-
port), relaxation training and function-based interventions. In a
function-based treatment, individually unique factors that exacer-
bate or decrease tics are identified and then altered. CBIT, compared
with supportive psychotherapy and education, resulted in greater
improvement in tic severity.
HR was also compared to cognitive behavioural treatment in one
RCT with 14 adults (age 23–49 years, O’Connor et al., 1997). The cog-
nitive behavioural treatment contained HR besides a more general
cognitive and behavioural restructuring of the person’s approach
to high risk tic situations. In this cognitive restructuring, anticipa-
tions and appraisals concerning the appearance of the tics were
the central theme. However, no additive effect of these cognitive
interventions was found based on a self-reported tic frequency and
degree of control. Recently, HR was compared to a combination
of HR and mindfulness in 13 children (age 14–18 years; mean age
15.4 years), without finding an additive effect on the YGTSS as well
(Franklin et al., 2011). Finally, one RCT compared HR with expo-
sure and response prevention (ER; Verdellen et al., 2004a) in 43
patients aged 7–55 years (mean age 20.6 years). The technique of
ER will be explained later in this article. HR was equally effective
as ER on three outcome measures: the YGTSS, home tic frequency
1174 J.M.T.M. van de Griendt et al. / Neuroscience and Biobehavioral Reviews 37 (2013) 1172–1177
(as counted by a parent/spouse using a mechanical counter) and
frequency at the institute (as counted on video by an independent
assessor using a mechanical counter).
Some RCTs describe follow-up data for HR (Azrin et al., 1980;
Deckersbach et al., 2006; Piacentini et al., 2010; Verdellen et al.,
2004a; Wilhelm et al., 2003), showing that the improvements
achieved in treatment are maintained after end of treatment. Azrin
et al. (1980) used telephone calls to measure durability of treatment
gains after 18 months and found still 97% tic decrease. O’Connor
et al. (2001) found stable treatment results after 2 months, based
on a self-reported tic frequency and experienced degree of con-
trol. A telephonic follow-up after 2 years showed that 52% of the
patients still experienced 75–100% control over their tics. Wil-
helm et al. used the Clinical Global Impression-Improvement (CGI
(Guy and Bonato, 1970)) in available patients that showed positive
response earlier. They found continued benefit in 86% of available
patients at 3 months follow up, and in 80% at 6 months follow up
(Wilhelm et al., 2012). Other studies used the YGTSS, finding that
stable results after 3 months (Piacentini et al., 2010; Verdellen et al.,
2004a), 6 months (Deckersbach et al., 2006; Piacentini et al., 2010)
and 10 months (Wilhelm et al., 2003). Woods et al. (2011) showed
in the same children that Piacentini et al. (2010) researched that
HR is effective in reducing long term secondary psychiatric symp-
toms as well, such as anxiety, disruptive behaviour, family strain
and improved social functioning.
In reviewing the literature, Cook and Blacher (2007) concluded
that HR is ‘a well established treatment’ according to the American
Psychological Association’s Division 12 Task Force criteria: sev-
eral RCTs into HR have been performed using adequate outcome
measures, results are replicated by different researchers and man-
ualized treatment protocols for HR are available (Cook and Blacher,
2007).
2.3. HR Treatment manual
Several treatment manuals of HR are available, describing
exactly what the therapist needs to do each session (Verdellen
et al., 2004b, 2011b; Woods et al., 2008). These manuals integrate
psychoeducation on tic disorders with different HR components.
Verdellen et al. developed a manual for adults (Verdellen et al.,
2004b), available in Dutch, and a manual suitable for children ages
7–13 (Verdellen et al., 2011b), also available in English. Both manu-
als contain 10 HR sessions; sessions take place on a weekly basis. In
HR, each tic is tackled separately. The treatment manuals consist of
a therapist manual and a workbook for the patient. The manual for
children also includes a (digitally available) workbook for parents
(Verdellen et al., 2011c). The manual for children is most compre-
hensive and will be discussed here. It starts with psychoeducation
and a tic registration assignment for parents. HR consists of training
awareness and learning to apply competing responses. Attention is
paid to motivation enhancement, a reward system and general-
ization. Function-based interventions and relaxation training are
added as optional, add-on interventions following HR and/or ER
in case there are remaining tics in specific situations. The manual
ends with relapse prevention. Homework assignments are pro-
vided each session, and at the end of treatment the child receives a
tic diploma for good practice (Verdellen et al., 2011b).
Woods et al. developed a manual for children and adults (ages
9 and up), which integrates psychoeducation, awareness training,
competing response training, social support training, contingency
management, relaxation training and function-based interventions
(comprehensive behavioural intervention for tics; CBIT (Woods
et al., 2008). The manual consists of a therapist guide, a workbook
for adults and a workbook for parents. Treatment consists of 11
sessions (6 weekly, 2 every 2 weeks and 3 booster sessions once
a month). Homework assignments are provided per session. The
manual starts with psychoeducation and creating a tic hierarchy. In
addition, a rationale for the treatment is provided and a behavioural
reward program to enhance motivation is introduced. Furthermore,
in the first session function-based interventions are introduced. In
the second session, a tic inconvenience review is conducted. In the
tic inconvenience review, a list is made of things the patient dislikes
about his tics (e.g., embarrassing, disturbs relaxation etc.). The list
is reviewed at each session and functions as a motivator to help the
patient do the treatment. Furthermore, in the second session HR
and function-based interventions for the first tic in the tic hierar-
chy are applied. In the following sessions, more tics are treated the
same way, adding relaxed breathing in session 4, and progressive
muscle relaxation in session 5. From session 7 onward, relapse pre-
vention strategies are added. Although the manual is designed to
address one tic per session over six sessions (i.e., sessions 2–7), the
manual advises to be flexible in the implementation of treatment,
and if necessary spend additional sessions (Woods et al., 2008).
All the available manuals (Verdellen et al., 2004b, 2011b; Woods
et al., 2008) include awareness training and competing response
training as core HR elements. A main difference between the man-
uals is the sequence in which the interventions are offered. Whereas
the manual of Woods et al. (2008) integrates function-based inter-
ventions and relaxation in HR treatment, Verdellen et al. (2011b)
present these interventions as additional interventions. The latter
is in line with the European guidelines, which consider function-
based interventions and relaxation as second-line interventions
(Verdellen et al., 2011a). However, to date adequate research is
lacking into the additional value of these interventions and whether
these are to be provided in a blended or sequential fashion.
3. Exposure and response prevention (ER)
3.1. History and theory
The application of ER 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 reduction 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., 2004a).
Bullen and Hemsley were the first to report a case study using ER
for tics. They found an improvement in voluntary tic control dur-
ing a 15-min response prevention exercise and a temporary relief
from a premonitory itch (Bullen and Hemsley, 1983). More than
a decade later, Hoogduin et al. reported success using prolonged
(i.e., 2 h) ER sessions (Hoogduin et al., 1997). The application of 2-h
sessions was based on the long session durations used in earlier
studies into anxiety disorders (Chaplin and Levine, 1980; Rabavilas
et al., 1976; Stern and Marks, 1973). Treatment started with a train-
ing phase consisting of 2 sessions, during which the patient was
trained to systematically suppress all tics. Then 10 sessions were
applied consisting of exposure to the premonitory sensations and
urges while resisting every tic. Support was found for the theory
of habituation; confronting the patient with premonitory sensa-
tions (exposure) for a prolonged period of time while resisting all
tics (response prevention), leads to habituation to these unpleasant
sensations (Hoogduin et al., 1997).
The treatment of ER in tics is derived from the application
of ER in obsessive compulsive disorder (OCD). In OCD, ER is the
behavioural treatment of choice; this treatment has shown posi-
tive effect in several RCTs (for a review, Abramowitz et al., 2005).
In OCD, response prevention of the compulsion leads to exposure
to objects or situations that trigger (anxiety inducing) obsessions.
Over time, exposure to obsessional cues results in a reduction of
 J.M.T.M. van de Griendt et al. / Neuroscience and Biobehavioral Reviews 37 (2013) 1172–1177
anxiety. Although tics in TS are phenomenologically different from
compulsions seen in OCD (Cath, 2000), tics bear similarities with
compulsions with regard to their reinforcing character (Bliss, 1980).
Verdellen et al. (2008b) tested the habituation hypothesis as a pos-
sible working mechanism of ER in 20 TS patients. Reductions in
premonitory sensations were found both within and between 10
two-hour sessions.
Furthermore, in line with modern learning theory, it is suggested
that the reduction of the premonitory urge found in ER is the result
of falsification of the (classically conditioned) expectation that the
premonitory sensation provokes an unbearable urge that is only to
be reduced by tics. In this case, extinction rather than habituation
may be a mechanism underlying ER effectiveness (Verdellen et al.,
2007).
3.2. Evidence
In an uncontrolled study of four cases (ages 12–30 years), tic
frequency reductions (as counted by family members) of 68–83%
were reported after 12 ER sessions (Hoogduin et al., 1997). To date,
there is only one RCT on ER, comparing it to the well established
method of HR (Verdellen et al., 2004a). In this RCT, 43 patients
aged 7–55 years (average 20.6 years) were randomly assigned to
either 12 two-hour ER sessions or 10 one-hour HR sessions. Both
treatments resulted in significant tic reductions, both as measured
at the institute and at home. The severity of tics as measured by
the YGTSS improved significantly in both conditions; 58% of the
ER patients showed at least 30% reduction in severity as com-
pared to 28% of HR patients. Larger effect sizes were found on the
YGTSS for ER (1.42) than for HR (1.06). Furthermore, 74% of the
ER patients showed at least 30% reduction in tic frequency at the
institute (as counted on video by an independent assessor using a
mechanical counter) versus 53% of the HR patients. At home, 89% of
the ER patients showed at least 30% tic frequency reduction, com-
pared to 72% of HR patients (as counted by a parent/spouse using
a mechanical counter). The reported differences between ER and
HR were not significant, but showed a trend in favour of ER. How-
ever, these differences may possibly be related to the difference in
the number and duration of treatment sessions (Verdellen et al.,
2004a). Follow-up results after 3 months remained stable as mea-
sured by the YGTSS. However, these follow-up data are confounded
by a cross-over design as 68% of all patients received additional
treatment.
In their review of the literature, Cook and Blacher concluded that
ER satisfies the requirements for a ‘probably efficacious treatment’
according to the American Psychological Association’s Division
12 Task Force criteria: ER produced comparable results to the
well established treatment of HR in a RCT, the treatment pro-
tocol was sufficiently described to be replicated by others, and
the patients included were described well (Cook and Blacher,
2007).
3.3. ER treatment manual
Verdellen et al. developed a manual for adults (Verdellen et al.,
2004b) and a manual for children ages 7–13 (Verdellen et al.,
2011b), containing both HR and ER. Furthermore, the manual for
children includes psychoeducation, relapse prevention and addi-
tional interventions (function-based interventions and relaxation),
the latter in case HR and ER do not result in sufficient tic reduction
(Verdellen et al., 2011b). The manual describes 12 ER sessions that
take place on a weekly basis. In the first two sessions, response pre-
vention is practiced. Whereas in HR each tic is tackled separately,
ER targets all tics at once. Patients are asked to suppress all tics for
as long as possible. The duration of this suppression is timed. Once a
tic comes through, the time is stopped, and the tic is written down.
1175
Patients are motivated to start again, and beat their earlier times. If
the same tic is performed three times in a row, the patient is asked
to concentrate on that specific tic only, and practice this until the
patient is capable of suppressing this tic for 5 consecutive minutes.
From session three on, the patient is asked to focus attention on
the premonitory urges, and to continue resisting all tics. The patient
is asked to strive for complete response prevention. Exposure can
be optimized by talking about tics and bringing 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 activ-
ities in which tics are abundant. These situations or activities are
imagined or, if possible, practiced in session. Urge-eliciting objects
(for example (computer) games) can be brought to the session. To
monitor the occurrence of habituation, at fixed time points during
the session, the severity of the premonitory sensations is rated on a
five point Subjective Unit of Distress Scale (SUD scale). Tics that are
not suppressed are noted. The role of the therapist in this treatment
is like a coach, motivating and encouraging the patient to suppress
all tics and to keep the patient focusing on the urges.
4. When to apply HR or ER
The only research that compared HR and ER (Verdellen et al.,
2004a) found no significant differences between the two treatment
methods. However, a trend was found in favour of ER on all out-
come measures. Specifically, an advantage for ER was found on the
YGTSS dimension “number of tics”, suggesting ER is more effective
when many different tics are present. This may be the result of ER
intervening with all tics at once, thus providing more opportunity
to treat more different tics, whereas HR reduces one tic at a time
(Verdellen et al., 2004a). Taking this into account, ER would be the
treatment of choice when many different tics are present, while
HR would be the first choice when the patient reports only a few
different tics. In addition, from a clinical perspective, it’s easier to
apply HR than ER when there are no tics present during sessions,
since in ER the patient learns to directly inhibit the tic, which is
more difficult to train and practice when there are no tics during
the session. The absence of tics during sessions is less a problem in
HR since the techniques can be discussed during the session and
then trained at home. Furthermore, based on clinical practice it is
suggested to apply ER when premonitory urges are obvious, since
ER directly focuses on habituation to these urges. On the other hand,
when no premonitory urges or sensations are reported at the start
of treatment, response prevention can increase awareness of these
sensations (Verdellen et al., 2008b).
Comorbidity can play a role too in choosing for a specific treat-
ment method. First of all, one must choose whether the tics are
to be treated first or the comorbid disorder. ADHD for example, a
common comorbid disorder, is often treated before tics are treated
(Döpfner and Rothenberger, 2007), since attentional problems may
disturb behavioral treatment of tics. In addition, attentional prob-
lems may predict poor treatment outcome (Himle and Woods,
2005). It may prove beneficial to implement interventions aimed
at increasing attentional facilities and do the (ER or HR) sessions in
an environment, free of distractions and external stimuli. For ER,
where patients have to concentrate for a sustained period on the
premonitory urges, good results have been reported changing the
therapist halfway the session (Verdellen et al., 2008a). In comorbid
OCD, ER is often applied since this is an effective strategy for OCD
as well (Abramowitz et al., 2005). While practising response pre-
vention of the tics and/or compulsions, either a premonitory urge
will rise (treatment is aimed at the tic disorder), or an anxiety pro-
voking obsession (when treating the OCD). In either case, exposure
to the urge or obsession can lead to a reduction of the compulsive
behaviour.
1176 J.M.T.M. van de Griendt et al. / Neuroscience and Biobehavioral Reviews 37 (2013) 1172–1177
5. Conclusion and future directions
The literature provides evidence for HR and ER as first-line inter-
ventions for tics. HR has a broader evidence base and is usually
offered. Results indicate that ER may be more effective than HR at
the severe end of TS, i.e., when many tics are involved (Verdellen
et al., 2011a). One of the questions that remain to be answered is
whether HR and ER share a common underlying working mecha-
nism. It can be questioned whether both methods differ that much,
since in both treatments the premonitory urges are endured, pro-
viding an opportunity to habituate. In HR this is achieved by training
the patient to apply a competing response to inhibit the tic and in
ER by having the patient resist tics directly. In each case, the patient
does not give in to the urge or premonitory sensation. This can be
seen as response prevention in both treatments, sharing habitua-
tion as a possible working mechanism. Further research is needed
to find out the exact working mechanism of both treatments, tak-
ing into account biological substrates of TS and modern insights in
learning theory. Also, more research into comorbidity and treat-
ment of choice should be done, since to date choices for HR or ER
are mainly clinical based.
The available treatment manuals for HR differ in number, fre-
quency and duration of sessions, duration of treatment, ingredients
and order in which they are applied. Research is needed to draw
conclusions on the optimal amount, frequency and length of ses-
sions, and on the value of booster sessions and function-based
interventions. Flancbaum et al. for example, describe a case of a
high density treatment of HR, in which seven 60–75 min sessions
were performed in 2 weeks. The treatment had comparable results
to regular HR treatment (Flancbaum et al., 2010). An advantage
of HR as compared to ER is the reported length of the session,
since HR sessions usually take 1 h whereas ER sessions take 2 h.
Recently however, research showed that shorter exposure sessions
lead to comparable results (van de Griendt et al., in preparation-a;
van Minnen and Foa, 2006). Research is also needed into possible
predictors of success. Deckersbach et al. for example found that
impaired inhibition, as measured by the visuospatial priming task
(VSP) predicted less treatment response to HR (Deckersbach et al.,
2006). To our knowledge, inhibition has not been tested in ER, a
treatment that primarily aims at inhibiting tics. Furthermore, to
date there are no studies that tested inhibition and brain function-
ing following a behavioural treatment for tics.
Although many questions remain to be answered, a growing
body of research supports the efficacy of both HR and ER as first-line
interventions for tics. To date, studies comparing the effective-
ness of behaviour therapy with pharmacotherapy in tic disorders
are absent. Currently, a multicentre RCT is conducted comparing
ER with risperidone (van de Griendt et al., in preparation-b). The
results of this study will provide insight into the differential effect
between these treatments. The European guidelines for tic disor-
ders recommend to start a treatment for tics with psychoeducation
and HR or ER. Only if these interventions are insufficient or not
available, it is recommended to apply pharmacotherapy (Roessner
et al., 2011).
However, despite all the available evidence for a behavioural
treatment for tics, clinicians are often not aware of HR or ER as
first-line interventions for tics. A study into the knowledge of pro-
fessionals (Marcks et al., 2004) showed that only 14% of physicians
and 31% of psychologists had heard of HR, and even fewer knew
how to implement it. This means patients often do not receive a
psychological evidence based intervention for tics, just because of
a lack of knowledge of the professional.
When awareness of behavioural interventions is available,
the information professionals have is not always correct. Woods
et al. (2007) and Marcks et al. (2004) provide examples of mis-
conceptions about behavioural treatments for tics that can be
disconfirmed by scientific data. For example, the concern that sup-
pression causes a rebound of tics is not confirmed in research
(Himle and Woods, 2005; Verdellen et al., 2007). Also, no evidence
could be found for symptom substitution after behaviour therapy
(Peterson, 2007). Additional education in tic disorders seems nec-
essary. Research showed that almost half (45.7%) of all interviewed
physicians and more than half (62.5%) of all interviewed psychol-
ogists were interested in learning more about HR (Marcks et al.,
2004).
Another barrier to the dissemination of behaviour therapy for
tics is the sparse availability of the treatment, both reported in
Europe (Verdellen and van de Griendt, 2012) and the USA (Himle
et al., 2010). E-health may help to overcome this barrier in sev-
eral ways. Himle et al. (2010) tested video/web based treatment
in three children; HR was performed in front of a camera in a
treatment room, while the therapist was miles away giving instruc-
tions through the camera. All three children showed tic reduction
and were satisfied by the videobased treatment. Recently, Himle
et al. replicated this finding in a randomized pilot trial; in 18 chil-
dren aged 8–17, they found a significant decrease on the YGTSS
both in the face-to-face CBIT as in the videoconference CBIT (Himle
et al., 2012). This way, more patients can be treated in areas where
there are few specialists. Other ways to increase the availability of
behaviour therapy for tics is to translate treatment manuals into
different languages and to train more therapists in the methods
of HR and ER. This can be done by actual workshops, but also by
using video- or web based materials. So-called ‘telepsychology’ or
E-learning was found to be an effective teaching method to reach
professionals in nonmetropolitan areas (Nelson et al., 2011; Rees
and Gillam, 2001; Rees and Haythornthwaite, 2004). In this way, the
scarce awareness, knowledge and availability of trained therapists
can be enlarged, enabling more patients to benefit from first-line
interventions.
References
Abramowitz, J.S., Whiteside, S.P., Deacon, B.J., 2005. The effectiveness of treatment
for pediatric obsessive-compulsive disorder: a meta-analysis. Behavior Therapy
36, 55–63.
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.
Azrin, N.H., Nunn, R.G., Frantz, S.E., 1980. Habit reversal vs negative practice treat-
ment of nervous tics. Behavior Therapy 11, 169–178.
Bliss, J., 1980. Sensory experiences of Gilles de la Tourette syndrome. Archives of
general psychiatry 37, 1343–1347.
Bullen, J.G., Hemsley, D.R., 1983. Sensory experience as a trigger in Gilles de la
Tourette’s syndrome. Journal of Behavior Therapy and Experimental Psychiatry
14, 197–201.
Carr, J.E., Chong, I.M., 2005. Habit reversal treatment of tic disorders: a methodo-
logical critique of the literature. Behavior Modification 29, 858–875.
Cath, D.C., 2000. Comparative Studies in Gilles de la Tourette Syndrome and
Obsessive-Compulsive Disorder. University of Leiden, The Netherlands.
Chaplin, E.W., Levine, B.A., 1980. The effects of total exposure duration and inter-
rupted versus continuous exposure in flooding. Behavior Therapy 12, 360–368.
Cook, C.R., Blacher, J., 2007. Evidence-based psychosocial treatments for tic disor-
ders. Clinical Psychology: Science and Practice 14, 252–267.
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.
Döpfner, M., Rothenberger, A., 2007. Behavior therapy in tic-disorders with co-
existing ADHD. European Child and Adolescent Psychiatry 16 (Suppl. 1), 89–99.
Evers, R.A.F., van de Wetering, B.J.M., 1994. A treatment model for motor tics based
on a specific tension reduction technique. Journal of Behavior Therapy and
Experimental Psychiatry 25, 255–260.
Flancbaum, M., Rockmore, L., Franklin, M.E., 2010. Intensive behavior therapy for
tics: implications for clinical practice and overcoming barriers to treatment.
Journal of Developmental and Physical Disabilities 23, 61–69.
Franklin, M.E., Best, S.H., Wilson, M.A., Loew, B., Compton, S.N., 2011. Habit reversal
training and acceptance and commitment therapy for Tourette Syndrome: a
pilot project. Journal of Developmental and Physical Disabilities 23, 49–60.
Guy, W., Bonato, R., 1970. CGI: Clinical Global Impressions. National Institute of
Mental Health. Chevy Chase, MD.
 J.M.T.M. van de Griendt et al. / Neuroscience and Biobehavioral Reviews 37 (2013) 1172–1177
Himle, M.B., Woods, D.W., 2005. An experimental evaluation of tic suppres-
sion and the tic rebound effect. Behaviour Research and Therapy 43,
1443–1451.
Himle, M.B., Woods, D.W., Conelea, C.A., Bauer, C.C., Rice, K.A., 2007. Investigat-
ing the effects of tic suppression on premonitory urge ratings in children and
adolescents with Tourette’s syndrome. Behaviour Research and Therapy 45,
2964–2976.
Himle, M.B.O., Himle, E., Tucker, J., Woods, B.T.P.D.W., 2010. Behavior therapy for
tics via videoconference delivery: an initial pilot test in children. Cognitive and
Behavioral Practice 17, 329–337.
Himle, M.B., Freitag, M., Walther, M., Franklin, S.A., Ely, L., Woods, D.W., 2012. A
randomized pilot trial comparing videoconference versus face-to-face delivery
of behavior therapy for childhood tic disorders. Behaviour Research and Therapy
50, 565–570.
Hoogduin, C.A.L, de Haan, E., Cath, D.C., van de Wetering, B. M.J., 1996. Gedragsther-
apie. In: Buitelaar, J.K., van de Wetering, B.M.J. (Eds.), Syndroom van Gilles de la
Tourette: Een Leidraad Voor Diagnostiek En Behandeling. Van Gorcum & Comp,
B.V., Assen, pp. 61–68.
Hoogduin, K., Verdellen, C., Cath, D., 1997. Exposure and response prevention in
the treatment of Gilles de la Tourette’s syndrome – 4 case studies. Practitioner
Report 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 and Adolescent
Psychiatry 28, 566–573.
Leckman, J.F., Walker, D.E., Cohen, D.J., 1993. Premonitory urges in Tourette’s syn-
drome. American Journal of Psychiatry 150, 98–102.
Marcks, B.A., Woods, D.W., Teng, E.J., Twohig, M.P., 2004. What do those who know
know – investigating providers’ knowledge about Tourette’s syndrome and its
treatment. Cognitive and Behavioral Practice 11, 298–305.
Miltenberger, R.G., Fuqua, R.W., McKinley, T., 1985. Habit reversal with muscle tics:
replication and component analysis. Behavior Therapy 16, 39–50.
Nelson, E.L., Bui, T.N., Velasquez, S.E., 2011. Telepsychology: research and practice
overview. Child and Adolescent Psychiatric Clinics of North America 20,
67–79.
O’Connor, K., Gareau, D., Borgeat, F., 1997. A comparison of a behavioural and a
cognitive-behavioural approach to the management of chronic tic disorders.
Clinical Psychology and Psychotherapy 4, 105–117.
O’Connor, K.P., Brault, M., Robillard, S., Loiselle, J., Borgeat, F., Stip, E., 2001. Evaluation
of a cognitive-behavioural program for the management of chronic tic and habit
disorders. Behaviour Research and Therapy 39, 667–681.
Peterson, A.L., 2007. Psychosocial management of tics and intentional repetitive
behaviors associated with Tourette syndrome. In: Woods, D.W., Piacentini, J.C.,
Walkup, J.T. (Eds.), Treating Tourette syndrome and Tic Disorders: A Guide for
Practitioners. Guilford Press, New York, pp. 154–184.
Peterson, A.L., Azrin, N.H., 1992. An evaluation of behavioral treatments for Tourette
syndrome. Behaviour Research and Therapy 30, 167–174.
Piacentini, J., Chang, S., 2001. Behavioral treatments for Tourette syndrome and tic
disorders: state of the art. Advances in Neurology 85, 319–331.
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 con-
trolled trial. JAMA: The Journal of the American Medical Association 303,
1929–1937.
Rabavilas, A.D., Boulougouris, J.C., Stefanis, C., 1976. Duration of flooding sessions in
the treatment of obsessive-compulsive patients. Behaviour Research and Ther-
apy 14, 349–355.
Rees, C.S., Gillam, D., 2001. Training in cognitive-behavioural therapy for mental
health professionals: a pilot study of videoconferencing. Journal of Telemedicine
and Telecare 7, 300–303.
Rees, C.S., Haythornthwaite, S., 2004. Telepsychology and videoconferencing: issues,
opportunities and guidelines for psychologists. Australian Psychologist 39,
212–219.
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.
1177
Shapiro, A.K., Shapiro, E., 1993. Neuroleptic drugs in Tourette’s syndrome. In: Kurlan,
R. (Ed.), Handbook of Tourette’s Syndrome and Related Behavioral Disorders.
Marcel Dekker, New York, pp. 347–358.
Sharenow, E.L., Fuqua, R.W., Miltenberger, R.G., 1989. The treatment of muscle tics
with dissimilar competing response practice. Journal of Applied Behavior Anal-
ysis 22, 35–42.
Stern, R.S., Marks, I.M., 1973. Brief and prolonged flooding: a comparison in agora-
phobic patients. Archives of General Psychiatry 28, 270–276.
Turpin, G., 1983. The behavioral management of tic disorders: a critical review.
Advances in Behavior and Research Therapy 5, 203–245.
van de Griendt, J.M.T.M., van Dijk, M.K., Verdellen, C.W.J., Verbraak, M.P.J.M., in
preparation-a. The effect of prolonged versus shorter exposure on treatment
outcome in Tourette’s syndrome and tic disorders.
van de Griendt, J.M.T.M., Wertenbroek, A.A.A.C.M., Verdellen, C.W.J., Cath, D., de
Bruijn, S.F.T.M., Verbraak, M., in preparation-b. Pharmacotherapy versus Behav-
ior Therapy in tic disorders, a randomised controlled trial.
van Minnen, A., Foa, E.B., 2006. The effect of imaginal exposure length on outcome
of treatment for PTSD. Journal of Traumatic Stress 19, 427–438.
Verdellen, C., van de Griendt, J., 2012. Awareness and application of behaviour ther-
apy for tics in Europe, data presentation of a survey among ESSTS members.
Catania.
Verdellen, C.W., Keijsers, G.P., Cath, D.C., Hoogduin, C.A., 2004a. Exposure with
response prevention versus habit reversal in Tourettes’s syndrome: a controlled
study. Behaviour Research and Therapy 42, 501–511.
Verdellen, C.W.J., Hoogduin, C.A.L., van de Griendt, J.M.T.M., Kriens, S., 2004b.
Behandelprotocol bij Ticstoornissen Therapeutenboek en Werkboek (Treatment
Protocol for Tic Disorders, Therapist Manual and Patient Workbook). Cure and
Care Publishers, Nijmegen.
Verdellen, C.W., Hoogduin, C.A., Keijsers, G.P., 2007. Tic suppression in the treat-
ment of Tourette’s syndrome with exposure therapy: the rebound phenomenon
reconsidered. Movement Disorders: Official Journal of the Movement Disorder
Society 22, 1601–1606.
Verdellen, C., van de Griendt, J., Kriens, S., Hoogduin, C., 2008a. Protocollaire behan-
deling van tics bij kinderen en adolescenten. In: Braet, C., Bögels, S. (Eds.),
Protocollaire Behandelingen Voor Kinderen Met Psychische Klachten. Boom,
Amsterdam, pp. 285–305.
Verdellen, C.W., Hoogduin, C.A., Kato, B.S., Keijsers, G.P., Cath, D.C., Hoijtink,
H.B., 2008b. Habituation of premonitory sensations during exposure and
response prevention treatment in Tourette’s syndrome. Behavior Modification
32, 215–227.
Verdellen, C., van de Griendt, J., Hartmann, A., Murphy, T., 2011a. European clinical
guidelines for Tourette syndrome and other tic disorders. Part III: behavioural
and psychosocial interventions. European Child and adolescent Psychiatry 20,
197–207.
Verdellen, C.W.J., van de Griendt, J.M.T.M., Kriens, S., van Oostrum, I., 2011b. Tics –
Therapist Manual and Workbook for Children. Boom Cure & Care, Amsterdam.
Verdellen, C., van de Griendt, J., Kriens S., van Oostrum F I., http://
www.uitgeverijboom.nl/upload/Tics Workbook for parents EN.pdf, Retrieved
October 4.
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. American Journal of Psychiatry 160, 1175–1177.
Wilhelm, S., Peterson, A.L., Piacentini, J., Woods, D.W., Deckersbach, T., Sukhodol-
sky, D.G., Chang, S., Liu, H., Dziura, J., Walkup, J.T., Scahill, L., 2012. Randomized
trial of behavior therapy for adults with Tourette syndrome. Archives of General
Psychiatry 69, 795–803.
Woods, D.W., Conelea, C.A., Walther, M.R., 2007. Barriers to dissemination: explor-
ing the criticisms of behavior therapy for tics. Clinical Psychology: Science and
Practice 14, 279–282.
Woods, D.W., Piacentini, J.C., Chang, S.W., Deckersbach, T., Ginsburg, G.S., Peterson,
A.L., Scahill, L.D., Walkup, J.T., Wilhelm, S., 2008. Managing Tourette Syndrome:
A Behavioral Intervention for Children and Adults. University Press, Oxford.
Woods, D.W., Piacentini, J.C., Scahill, L., Peterson, A.L., Wilhelm, S., Chang, S., Deck-
ersbach, T., McGuire, J., Specht, M., Conelea, C.A., Rozenman, M., Dzuria, J., Liu, H.,
Levi-Pearl, S., Walkup, J.T., 2011. Behavior therapy for tics in children: acute and
long-term effects on psychiatric and psychosocial functioning. Journal of Child
Neurology 26, 858–865.