When someone has bedwetting, it’s embarrassing, and often humiliating, but no one goes to school, raises their hand, and says, “Hey! I’m still wetting the bed. Does anybody else still have this problem?”
Or when someone misses school or work because of a migraine headache, people will tell them, “Oh, we are so glad you’re feeling better and are back today!”
But tics can be physically exhausting, mentally exhausting, emotionally exhausting, and often they are humiliating to patients, causing them to be teased and ridiculed by others.
So, when I get to treat patients with tics, it is the most rewarding part of my practice because it is absolutely life-changing for them.
Prior to the COVID pandemic, I would average one patient flying in from out of town every month, to spend a week with me. I would meet with the patient on Monday, Tuesday, Wednesday, Thursday, and Friday, and then they would fly back home. These included people from across the United States, as well as from other countries, too.
Because I screen my patients so carefully, they typically do well.
Tics are sudden or brief movements (motor tics) or sounds (vocal tics, also known as vocalizations or phonic tics). They are often repetitive.
Motor tics can be simple, involving a single muscle group, or complex, involving sustained and/or coordinated movements. Vocal tics, also called phonic tics, are characterized by any noise, including throat-clearing, grunting, coughing, sniffing, snorting, etc.
Tics are ALWAYS absent during sleep.
Many children experience tics that last for a few weeks or a few months and often go away on their own. These patients do not have Tourette syndrome, which is characterized by multiple motor tics and vocalizations that last more than one year.
I prefer to refer to tics as “habits” and use these terms interchangeably. I believe that when patients think of them as “habits,” they seem more manageable. This is similar to why I prefer to refer to pain as “discomfort,” or, even better, “sensations,” as those terms make the problem more manageable.
Cough tic, also called habit cough, is a common vocal tic in children. It is usually dry and non-productive.
The cough tic is commonly developed as an extension of some sort of respiratory infection and remains as a comforting behavior once the infection is gone.
15-year old Matt suffered from a recurrent coughing tic.
After many unsuccessful medications and other treatments, Matt learned self-hypnosis from Dr. Jeffrey E. Lazarus, MD, in Menlo Park, CA.
The video will show part of Matt’s first session with Dr. Lazarus, a follow up to how he uses self-hypnosis in his 4th session and a message from his mother.
Often, the patient develops the throat-clearing behavior as a result of post-nasal drip or cough associated with a respiratory condition due to a common cold or allergies. Because the throat-clearing is comforting, the patient continues the behavior after the cold is gone.
The patient frequently has a dry (non-productive) cough during the day, but the cough is absent while the individual is asleep. Some parents report that the cough keeps the patient up at night, but on closer questioning, they realize that the cough is gone while the patient is actually asleep.
Many of the patients have tried medications that have not helped the condition. They have often undergone tests such as a chest x-ray and a sinus CT scan.
They have seen sub-specialists including ear, nose and throat (ENT) doctors, allergists, and pulmonary (lung) specialists, and have been told that there is nothing wrong. In most cases it leaves the patient and their family feeling hopeless and discouraged, and often in a worse state emotionally than before they began the medication and all of the testing.
Tourette syndrome (TS) is a complex neurobehavioral disorder characterized by multiple motor tics, as well as vocalizations, which wax and wane.
The motor tics involve specific muscle groups and can change from one part of the body to another. The vocalizations, or phonic tics, may involve grunting, sniffing, coughing, snorting, throat-clearing or other sounds.
The tics occur many times a day, nearly every day, or intermittently for more than a year. Many people believe that these tics and vocalizations are involuntary. However, many patients are able to suppress their tics, especially when they are concentrating intently on something.
Patients with Tourette syndrome may have other associated conditions, including anxiety, obsessive compulsive behavior, learning problems, ADD, and ADHD.
It is important to realize that although hypnosis can be quite helpful in controlling the tics, these other conditions need to be addressed separately.
When Dr. Lazarus sees patients with tics, with or without Tourette syndrome, as long as there is no significant anxiety, depression, or obsessive compulsive behavior, there is usually significant improvement after only 1-3 visits
As it happens, hypnosis and habit reversal are more alike than different.
Both are behavioral approaches. Both involve having patients be able to identify the premonitory urge before a tic occurs. And, although in habit reversal the goal is to perform the “competing response,” in hypnosis, patients learn how to control and prevent the tic from happening.
With hypnosis, patients are taught how to actually get rid of the tics.
Dr. Lazarus usually teaches his patients medical hypnosis to control the tics at their first visit. This is because he has found this approach to be much faster than habit reversal. At a subsequent visit, he then may teach habit reversal.
One of the main differences between using medical hypnosis compared to comprehensive behavioral intervention for tics (CBIT) with habit reversal, is a difference in style. CBIT with habit reversal includes using a “support person” to help the child patient. Typically, this is the parent.
Also, CBIT practitioners believe in rewarding patients with tangible or monetary rewards to try and reinforce the program.
Although the rewards are given for compliance with the program, Dr. Lazarus believes that tic control should be its own reward. And, Dr. Lazarus is concerned that if the main reason the patient is doing the exercises is to get a present, the patient is not truly motivated to gain control over their tics in the first place.
Dr. Lazarus is trained in both medical hypnosis as well as CBIT. And, habit reversal is often included as one of the hypnotic techniques he teaches. His goal is to give patients several tools and then have them choose the ones that work best for them.
“Dr. Lazarus met with us about childhood tics that our daughter is experiencing. We went into depth about history and possible treatment. It is clear to me that Dr. Lazarus is incredibly knowledgeable in the area of tics/Tourette’s/anxiety. My husband and I found the consultation to be useful and informative.
After the 2.5 hour consultation, Dr. Lazarus suggested that it wasn’t the right time to bring in our daughter for a variety of factors (age, the fact that she is not bothered by the tics herself, etc) and that we would call back when these factors change. Dr. Lazarus did not try to sell us anything when it could have been easy for him to do so.
As parents, we are always desperate to help our children and I believe many professionals out there take advantage of this and prescribe treatments that may or may not be necessary or helpful.
When he suggested a home plan for my husband to try, we were thankful and surprised at the same time.
As parents, we look to professionals to help us help our children, so it was refreshing to have a professional make this recommendation. It built trust between us and Dr. Lazarus and we will definitely come back when the tics start to bother our daughter.”
“Dr. Lazarus is someone I will remember forever. Thank you Dr. Lazarus for all that you did for me!!!”
Celeste is a 9 year old patient from out of state who was able to experience a breakthrough with her tics.
Cleveland WKYC-TV, NBC, Channel 3
Cleveland WKYC-TV, NBC, Channel 3’s Health News with Monica Robbins, aired a story about one of Dr. Lazarus’ patients, a boy with Tourette Syndrome who had been asked to leave school for a week because his cough tic was so disruptive to the class.
As Monica Robins, the health news anchor, reports, the child was able to control the cough tic after meeting two or three times with Dr. Lazarus.
Five years later, he is still doing well. When a tic occurs, he is able to control it using the techniques that he learned from Dr. Lazarus.
Cleveland WJW, Fox, Channel 8
That’s Life with Robin Swoboda,
WJW/Fox8 News in Cleveland, Ohio, features an interview with Jeffrey Lazarus, MD on February 21, 2007.
The medications that are commonly used for tics often don’t work and can have tremendous negative side effects.
These side effects include:
In addition, there is an insufficient number of randomized, double-blind trials comparing medication with a placebo. And, there have been no studies comparing behavioral and pharmacological approaches.1
Below is the approach I use for patients with tics, with and without Tourette syndrome.
As you probably know, most therapists meet with patients for 50 minutes once a week for weeks, months, or years.
That is not my approach.
I find that meeting once a week for short periods of time like that is half the time you’re doing catch-up and the other half of the time you’re doing crisis intervention.
For example, “My brother said this, my teacher did that, my friend said this, my boss said this, or my partner said that.”
Although these are important, they take away from the task at hand.
I treat children, adolescents, and adults of all ages. My youngest patient with tics was five years old, and my oldest was 95 years old!
When a potential patient or parent of a patient reaches out to me, I schedule a 20-minute free screening phone call.
If it is the right fit, and it is a child, I meet with the parents alone for 2 1/2 to 3 hours. Yes, 2 1/2 to 3 hours!.
I provide a very detailed intake in order to hear not only about the problem, but also about school/work, sports, hobbies, family, friends, etc. And then I describe my approach: what I do, how I do it, why I do it, and when I do it, because we are on “Team Jane” or “Team John,” as I like to call us. Describing my approach takes about 45 minutes to an hour!
And I want the parents to understand every step of the process.
Then I schedule long visits.
The first patient visit is usually around 2 1/2 to 3 hours. I have found that we will be able to accomplish a lot more in one visit of 150 or 200 minutes than we could ever hope to accomplish in three, four, or even five visits of 50 minutes each. If a patient has more than one tic, I have them choose the one that’s bothering them the most. And that is what we focus on.
At the end of that visit, the patient, parents, and I meet together to discuss how best to move forward.
At the patient’s second visit, I do something that no one else in the world is doing. I show them video clips of previous patients of mine. It shows them before, during, and after treatment.
I believe this is a key component to the treatment as it allows patients to realize that they are not the only ones in the world with this problem.
Furthermore, it gives them the hope and motivation that if these other individuals can gain control over their bodies and life challenges, then they can too!
The third and fourth visits are usually shorter: about an hour to an hour and a half each.
Typically, there is significant improvement in that one tic after only 1 to 3 visits.
The same approach outlined above is also used for adults, except, of course, there is no additional parent visit!
Again, my patients typically experience significant improvement after only 1 to 3 visits.
And, what is exciting to me, is that rather than simply taking a temporary pill, patients will learn lifetime skills!
And, they will be able to use these skills in the future, in ways that they’re not even aware of, yet!
What an opportunity parents will be providing for their children, and adults will be providing for themselves!
I look forward to talking with you soon.
References
1. Scahill, L. et al. April 2006. “Contemporary assessment and pharmacotherapy of Tourette syndrome.”. NeuroRx : the Journal of the American Society for Experimental NeuroTherapeutics 3 (2): 192–206.
2. Roessner, V, et al. “European clinical guidelines for Tourette Syndrome and other tic disorders.” Eur Child Adolesc Psychiatry. 2011 April; 20(4): 153–154.
3. Lazarus, J.E. & Klein, S. (2010). Non-pharmacological treatment of tics in Tourette Syndrome with videotape training in self-hypnosis. Journal of Developmental & Behavioral Pediatrics, 31:6, 498-504.
