CBIT: An Alternative to Medication for Tics
Although new treatments often bring great excitement and hope, some in the TS community are concerned that promoting behavioral approaches for treating tics may have negative consequences. There is concern that families, co-workers, and teachers will read about CBIT and conclude that tics are willful and easily controlled. We have known for years that this conclusion is incorrect and harmful to people with tics. Expecting people to “stop ticcing” or treating them as if tics are done “on purpose” increases distress and triggers efforts to voluntarily suppress tics, which is ineffective and leads to greater impairment. While there are likely to be people who misunderstand or misuse a powerful tool such as CBIT, we still need to let patients and families of those with TS know about CBIT so that they have choices. It’s important to understand what CBIT is and isn’t, what it can and can’t do and how behavioral interventions are helpful in reducing tic severity.
It is important to note that many of these strategies are already commonly used in the management of TS symptoms. Upon hearing a description of CBIT, many adults with TS report that they have come up with similar strategies to manage their tics. CBIT takes the best of these ideas and blends them with strategies that allow people to quickly learn the techniques.
CBIT is a non-drug treatment consisting of three important components:
- Training the patient to be more aware of tics
- Training patients to do competing behavior when they feel the urge to tic
- Making changes to day to day activities in ways that can be helpful in reducing tics.
CBIT is a highly structured therapy that typically takes place in a therapist’s office on a weekly basis. The standard treatment is 8 sessions over 10 weeks, but can be longer or shorter depending on the needs of the patient and his or her family. The first step in CBIT is to teach the patient to become more aware of his or her tics and the urge to tic. Next, the patient is taught to perform a specific behavior that makes the tic more difficult to do, as soon as the tic or urge appears. This “competing response” helps to reduce, and in some cases, even eliminate the tic. For example, a youngster with a frequent throat clearing tic would be taught to engage in slow rhythmic breathing whenever he felt the urge to clear his throat. A competing response chosen for a head-shaking tic might be gently tensing the head or neck muscles. Consistent and repeated practice of a carefully chosen competing response done at the appropriate time is necessary for the treatment to be effective.
The final step of CBIT, the functional intervention (FI), is based on the fact that certain situations or reactions to tics can make them worse than they might otherwise be. The goal of FI is to identify these situations and have the patient and family attempt to change them so the tics aren’t made worse unnecessarily. For example, someone whose tics get worse when doing homework or before a presentation at work would be taught to manage their stress before and during these situations.
CBIT is a highly structured therapy that typically takes place in a therapist’s office on a weekly basis. The standard treatment is 8 sessions over 10 weeks, but can be longer or shorter depending on the needs of the patient and his or her family.
While we know that tics are neurological in nature, they are often also extremely sensitive to the environment in which they occur. Every person with TS knows that a stressful or hostile environment can make tics worse. CBIT is designed to help children and adults figure out those factors in their environment that make their tics worse; teach these individuals how to create environments that are more stable, predictable and easily manageable; and learn skills to cope with environments that are stressful and tic-challenging.
Because a person can voluntarily suppress tics for a short period of time, some incorrectly assume that a person with tics should be able to control them all the time. This is not the case. Voluntary tic suppression can be done short term, but is not a very effective strategy for regular use. Voluntary suppression is stressful and people who do it become tired, frustrated and irritable. It is important to realize that CBIT is not the same as voluntary tic suppression. Instead, CBIT teaches people with TS a set of specific skills they can use to manage their tic urges or behaviors, without having to use voluntary suppression.
When a person applies the right competing response in a calm focused manner, the tic gets better, and they feel better and more in control, not frustrated and irritable. Initially, this requires some effort and concentration, but with practice, both adults and children can learn to do their competing responses and easily participate in routine activities. In this regard, CBIT is like other learned skills which often take effort in the beginning but quickly become second nature.
Since not everyone will necessarily benefit from CBIT, we recommend that patients get a complete evaluation and address any symptoms that might make it harder for them to learn and practice CBIT. A person can learn CBIT without treating co-occurring problems, but it might be harder for them and they may not be as successful.
A 2010 study found that children and adolescents who completed a 10-week course of CBIT showed a decrease in tic severity that was only slightly less than that associated with antipsychotics. Nearly 90 percent of the children who responded to the CBIT sessions were still exhibiting reduced symptoms six months after the therapy ended, as compared to the resumption of symptoms when children go off their medication. Likewise, if children stop practicing competing responses, their symptoms will likely re-emerge.
Unlike medication, the behavioral intervention had no adverse side effects. In fact, in many cases, CBIT can have positive effects, such as boosting self-esteem. Still, no treatment is 100 percent effective.
When a person applies the right competing response in a calm focused manner, the tic gets better, and they feel better and more in control, not frustrated and irritable
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