Dr Robert London

The Challenge of Treating Facial Tics

Clinical Psychiatry News - Volume 36, Issue 7, Page 48 (July 2008)

Facial tics and tic-like movement that spreads to the shoulders, parts of  the torso, or other parts of  the body are difficult to treat. The patients I've treated with tic disorders had one thing in common: They knew that the tics worsened when they were under stress.

None had Tourette's syndrome. They all had tried medications that either were ineffective or had side effects that proved troubling. Because of these problems, the patients had stopped medicinal treatments.

We know that tics many times start in childhood. Sometimes they are transient, but they also can persist for a lifetime.

I'd like to discuss two instances in which I treated simple tics.

One man had been told that his tics started after an infection. There might have been something to that idea. In one theory of tic origin, for example, they might begin after a streptococcal infection.

Both of my patients had been told that the simple tics disappeared during sleep. That information suggested that a relaxation approach might work best.

One patient sought my assistance based on the recommendation of a colleague who I had successfully treated for smoking cessation using hypnosis as an adjunct. The patient with the tics, an attorney who worked as a litigator, had tried multiple medications. None had helped, and he found the side effects troubling.

He said that the facial tics had started around age 9 or 10 years after he had been sick with a bad sore throat. The pediatrician had assured the family that tics could happen after an infection and was optimistic that they would go away, but no treatment was sought until the patient himself, as an adult, sought it out.

The other patient had no idea why the tics had occurred, but said that they had been present since he was about 10 years old. He was a successful businessman who felt that the tics became worse when he was under stress, particularly when he was trying to close in on a project. Interestingly, the first patient also reported that the tic phenomenon got worse under stress.

I decided to use the same strategy for both patients involving relaxation and projection coupled with reciprocal inhibition. I taught a simple relaxation/hypnotic technique, therefore reducing anxiety and reducing tics.

Each patient was taught to sit quietly in an easy chair, take three or four deep breaths, and allow himself to float into a relaxed state.

I suggested that the patient try to imagine that his facial and neck muscles were becoming more and more relaxed, focusing more and more on the muscle groups where the tics occurred.

At this point, I would have the patient come out of this relaxed state and then go back into it at least six to eight times during our first visit. The point was to help the patient know and understand the relaxation strategy without my help. I noticed that the tics disappeared as the patient relaxed these muscle groups.

The point of the repetition was for the patient to become as good as I am in inducing relaxation states and to empower him to gain control of the tic movement. In addition, I always teach a very quick method of reaching a relaxed state (5–10 seconds) in which the patient can enter this state when necessary to decrease or avoid the tic phenomenon.

For the second visit, I offered each patient two separate strategies: one in projection and the other as a behavioral/habit control technique.

In the projection technique, I had the patient see himself on a big movie screen experiencing the tics. As the visualization got projected on the screen, it left the patient. It's an interesting approach to project a physical experience onto a screen—not unlike what a patient would do when trying to deal with chronic pain patterns. They, of course, need the practice effect so it can be done very quickly when stress is coming on or has arrived.

The other strategy is one I have used successfully for nail biting. This approach is used when the patient is feeling under stress, as the businessman felt when he was at the close of a project. The attorney found that his stress tended to come during legal presentations.

The strategy is quite simple. When the patient senses that the tic is becoming overwhelming, he tries to soothe himself by touching the facial area or neck area and repeating to himself: “Relax, relax, relax.” The patient also can give himself reassurances such as “You need not be nervous.” In a matter of seconds, for these two patients, the tics became less prevalent.

It is interesting to see how self-awareness about a particular problem and a focus on addressing the problem can be therapeutic. In this strategy, the patient reinforces self-care and even self-love. And both patients took their assignments seriously.

There are many ways to help control simple tics. A dance/art therapist I know, Mara Rivera, told me that she has worked with people who have movement disorders, including simple tics. Ms. Rivera says it appears that the flow of movement leads to a reduction of simple tics, and she has seen the tics stop when people learn how to enter into this flow. She hypothesizes that such reductions can be lasting, because they become part of body memory.

An interesting and valuable bit of information comes from a recent study (Clin. Psychol. Sci. Prac. 2007;14:252–267). Researchers at the University of California, Riverside, found that habit reversal training (HRT) and exposure and response prevention (ERP) were two psychosocial treatments that meet evidence-based standards for the control of tic disorders. I believe that I was doing this work before HRT and ERP were deemed helpful. Still, it's great to see behavioral therapies making such fine advances.

Certainly, more psychiatrists and psychologists might want to explore the treatment of tic disorders by looking at my work, by exploring the observations of people doing dance therapy such as Ms. Rivera, or by using HRT and ERP methods.

Let me know your thoughts on psychosocial treatments for tic disorders, and I will try to pass them along to my readers.

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