Treatment of Nervous Tics in Girona: An Evidence-Based Behavioral Perspective

To begin with and very importantly: we need to Understanding the Tic Cycle

Effective management of tic disorders requires a rigorous approach, grounded in behavioral science. Although tic expression has a neurobiological origin, it is profoundly modulated by psychological and environmental factors. This is the key that opens the door to psychological intervention.

The Negative Reinforcement Cycle

The neurobehavioral model that underpins the most effective interventions postulates that tics are maintained through negative reinforcement. The tic acts as a motor or vocal response that temporarily relieves the aversive premonitory urge, an internal sensation of discomfort or tension that precedes the movement. This temporary relief reinforces the tic behavior, perpetuating the cycle.

Premonitory urges are interoceptive sensations fundamental to understanding treatment. Leckman et al. (1993) documented that between 80-90% of patients with tic disorders experience these sensations before tics, describing them as “itching,” “tension,” or “pressure” that only resolves with tic execution.

Cognitive-Behavioral Therapy Comes into Play:

Cognitive-behavioral therapy, whose founding father is Aaron T. Beck, is a revolutionary therapeutic approach validated by more than 2,000 clinical studies for a wide range of psychiatric disorders. Within the spectrum of tics, the specific behavioral intervention known as comprehensive behavioral intervention for tics is the first-line non-pharmacological therapy recommended by international clinical guidelines.

Undeniable Evidence: Data from Randomized Controlled Trials

The results from multicenter studies are compelling and irrefutable:

In pediatric population (Piacentini et al., 2010, JAMA):

• 52.5% of patients who received comprehensive behavioral intervention for tics were classified as treatment responders
• Only 18.5% of the control group with supportive therapy and psychoeducation responded
• The difference is statistically significant and clinically relevant

In adult population (Wilhelm et al., 2012, Archives of General Psychiatry):

• 38% of patients who received comprehensive behavioral intervention for tics were responders
• Only 6% in the supportive therapy and psychoeducation group showed improvement
• These results demonstrate that behavioral therapy is also effective in adults, a historically underserved population

Effect Size: A recent meta-analysis (McGuire et al., 2014) identified a moderate to large effect size (d = 0.78) for habit reversal therapy in tic reduction. This efficacy is considered comparable to that of antipsychotic medications, but with a much more favorable adverse effect profile.

Components of Comprehensive Behavioral Intervention for Tics

The therapy, as manualized by Woods, Piacentini, and Walkup (2008), consists of eight essential components distributed across 8-10 weekly one-hour sessions:

1. Psychoeducation about tics: Understanding the neurobehavioral model and the negative reinforcement cycle
2. Increased awareness: Training to identify premonitory urges before the tic appears
3. Competing response development: Creating an alternative physical response incompatible with the tic
4. Motivation training: Reinforcing therapeutic adherence and effort
5. Relaxation techniques: Diaphragmatic breathing and progressive muscle relaxation to reduce tension
6. Function-based behavioral assessment: Identifying environmental antecedents (stress, fatigue, anxiety) that exacerbate tics
7. Relapse prevention: Strategies to maintain therapeutic gains
8. Generalization: Application of skills to multiple contexts

The effectiveness of comprehensive behavioral intervention for tics is significantly greater in tics preceded by a premonitory urge, which confirms the role of premonitory urge as a central therapeutic target.

Evidence-Based Protocols: Our Stepped Approach in Girona

At Centro de Psicología Jaume Primer – Psicólogos Girona, we apply a rigorous protocol that prioritizes interventions with the highest level of evidence, following the recommendations of Canadian guidelines (Steeves et al., 2012) and the practice parameters of the American Academy of Child and Adolescent Psychiatry.

Guiding Principles of the Protocol

• Priority to psychosocial burden: The main source of disability and loss of quality of life in nervous tic disorder is often neuropsychiatric comorbidity (obsessive-compulsive disorder, attention deficit hyperactivity disorder, anxiety, depression) and not just tic severity. Treatment must focus first on the most disturbing condition.
• Activation of agency and awareness: We leverage the unique characteristic of tics: their temporary suppressibility. Comprehensive behavioral intervention for tics capitalizes on awareness of the premonitory urge, which is fundamentally an interoceptive sensation, to allow conscious intervention.

Table 1: Evidence-Based Stepped Protocol

Third-Generation Cognitive-Behavioral Therapy: Acceptance and Commitment Therapy

Acceptance and commitment therapy is proposed as an ideal framework for integrating habit reversal therapy. Acceptance and commitment therapy goes beyond mere tic suppression and focuses on the patient’s self, helping them live a meaningful life centered on their values, without tics or associated negative emotions acting as a barrier.

This approach is crucial for managing frustration, perceived self-control, and suffering associated with catastrophic thoughts (“I’ll lose control,” “they’ll reject me”) that can exacerbate tics. Acceptance and commitment therapy works with six fundamental processes: acceptance, cognitive defusion, contact with the present moment, self as context, values, and committed action.

The Evidence on Supplementation:

In marked contrast to the robust evidence for comprehensive behavioral intervention for tics, the scientific rationale for nutritional supplementation as a direct treatment for tics is limited, incipient, and lacks large randomized controlled trials.

L-theanine and Vitamin B6: The Most Promising Potential

Neurophysiological mechanism of action: Supplements such as L-theanine and vitamin B6 have been explored for their potential to modulate neuronal overexcitation in cortico-striato-thalamo-cortical circuits. L-theanine can increase GABA (inhibitory neurotransmitter) and modulate glutamate (excitatory), promoting calm. Vitamin B6 is crucial, as pyridoxal phosphate, a derivative of B6, is a necessary cofactor for the enzyme glutamic acid decarboxylase, which synthesizes GABA.

Conditional results: A pilot study in children with Tourette syndrome and comorbid anxiety (Rizzo et al., 2022) reported that the combination of L-theanine and B6 showed statistically significant improvements in tics and anxiety, being well tolerated. However, this is phase IV evidence (pilot studies) that requires validation in large-scale placebo-controlled studies, not reaching the threshold for first-line recommendation.

A 2024 systematic review also observed a decrease in tic severity with L-theanine, although in an open study without a control group.

Table 2: Level of Evidence for Nutritional Supplementation

Scientific Detail on Taurine: An Inhibitory Neuromodulator

From a neurobehavioral perspective, the theoretical potential of Taurine as an adjuvant for TS lies in its capacity to modulate neuronal excitation, which is considered dysregulated in tic-genic circuits (cortico-striatal circuits).

GABAergic agonist: Taurine is a sulfo-amino acid structurally similar to GABA and functions as a partial agonist of receptors. Activation of these receptors increases inhibitory tone in the CNS, which could counteract the overexcitation observed in tic disorder. This action is supported by in vitro experiments where Taurine promotes neuronal differentiation of progenitor cells, an effect comparable to GABA and regulated by receptor interaction.

Osmolytic function and neuronal release: Taurine has a fundamental role as an osmolyte, helping regulate cell volume in nervous tissue. It is noteworthy that in isolated nerve terminals (synaptosomes), Taurine is released mainly through a diffusional pathway (55% of its release), while GABA is released through a combination of exocytotic (30%) and diffusional (18%) pathways, and Glutamate mainly by exocytotic pathway (44%). This differentiates its function, as Taurine acts primarily as an osmolyte, a role that could be regulatory of general synaptic function.

Lack of clinical evidence: Despite these plausible mechanisms, the clinical utility of Taurine for tics has not been established. This absence of evidence requires classifying it as “Recommendation U” (Non-Classifiable/Insufficient) for tic treatment, requiring rigorous clinical research (RCTs) to define its potential role, possibly as an adjuvant agent for anxiety or neuroregulation.

Our Professional Position

As a responsible evidence-based psychologist, my recommendation is clear: supplementation with L-theanine and vitamin B6 can be considered only as adjuvant support for modulating anxiety, insomnia, and neuronal overexcitation in patients with anxious comorbidity. Never as first-line treatment nor as a substitute for behavioral therapy.

The Critical Importance of Comorbidities

One of the most important aspects I want to highlight, and which is often overlooked, is that the main source of disability and loss of quality of life in nervous tic disorder is not tic severity, but associated neuropsychiatric comorbidity.

Epidemiological Data on Comorbidity

• Obsessive-compulsive disorder: Present in a significant percentage of patients with tic disorders
• Attention deficit hyperactivity disorder: 50-60% in pediatric population
• Anxiety disorders: 30-40%
• Depression: 20-30% in adults

Lewin et al. (2011) demonstrated that anxiety and depression are the main mediators between tic severity and functional disability. That is, it is not tic severity itself that predicts quality of life, but associated anxiety and depression.

Therapeutic Implications

Elevated anxiety magnifies interoceptive signals (premonitory urges), fueling more severe tics. Additionally, cognitive hypervigilance toward one’s own tics creates a vicious circle of attention-exacerbation. Therefore, at Centro de Psicología Jaume Primer – Psicólogos Girona:

• We exhaustively evaluate all comorbidities using validated instruments (Yale Global Tic Severity Scale, anxiety inventories, obsessive-compulsive disorder scales)
• We prioritize treatment of the most disturbing condition, which is often anxiety or obsessive-compulsive disorder
• We apply specific protocols: Exposure therapy with response prevention for obsessive-compulsive disorder, cognitive-behavioral therapy for anxiety, coordination with psychiatry for attention deficit hyperactivity disorder

Research Leaders: Who Has Transformed the Field

Table 3: Most Influential North American Researchers in Tic Disorders

Other Fundamental Researchers

• Nathan Azrin and R. Gregory Nunn: Original developers of habit reversal therapy (1973), the foundation upon which comprehensive behavioral intervention for tics is built
• James Leckman: Key researcher in characterizing premonitory urges (1993)
• Kieron O’Connor: Expert in cognition and metacognition in the onset and management of tic disorders

Our Commitment to Scientific Excellence

At Centro de Psicología Jaume Primer – Psicólogos Girona, our commitment is to apply only interventions with rigorous empirical support. This means:

✓ Continuous training: Constant updating in manualized protocols of comprehensive behavioral intervention for tics and habit reversal therapy

✓ Systematic evaluation: Use of validated instruments at each treatment phase

✓ Transparency about evidence: Honestly informing about what works and what doesn’t

✓ Integrative approach: Combination of behavioral therapy, third-generation techniques, and, when indicated, adjuvant support

✓ Interdisciplinary coordination: Joint work with neurology and psychiatry when pharmacotherapy is needed

Conclusions: Hope Grounded in Science

After reviewing more than 50 randomized controlled trials and hundreds of studies, the conclusion is unequivocal: nervous tic disorders have effective and scientifically validated treatment. Comprehensive behavioral intervention for tics and habit reversal therapy are not experimental therapies, but the gold standard with Class I evidence.

The Data Are Clear:

• More than 50% of children respond favorably to behavioral treatment
• Effect size (d = 0.78) is comparable to antipsychotics, but without adverse effects
• Treatment of comorbidities is as important as treatment of tics
• Supplementation can be a useful adjuvant, but never a substitute for behavioral therapy

As a profession, we have the responsibility to base our interventions on the strongest available evidence. Patients with tic disorders and their families deserve access to treatments that have demonstrated their efficacy under rigorous scientific conditions.

If you (or a family member) experience nervous tics in Girona that affect quality of life, I encourage you to seek specialized professional help in cognitive-behavioral therapy. In cases of severe or complex symptoms, evaluation in specialized multidisciplinary units is recommended.

For more information or to schedule a specialized consultation on tic disorders, you can contact our center. We work with evidence, scientific rigor, and, above all, with the goal of improving your quality of life.

Bibliography:

Behavioral Interventions and Empirical Evidence

– Azrin, N. H., & Nunn, R. G. (1973). Habit-reversal: A method of eliminating nervous habits and tics. Behaviour Research and Therapy, 11(4), 619–628.

– Garcia-Lopez, R., Perea-Milla, E., Ruiz Garcia, C., Rivas-Ruiz, F., Romero-Gonzalez, J., Moreno, J. L., … & Ramos Diaz, J. C. (2009). New therapeutic approach to Tourette Syndrome in children based on a randomized placebo-controlled double-blind phase IV study of the effectiveness and safety of magnesium and vitamin B6. Trials, 10(16).

– McGuire, J. F., Piacentini, J., Brennan, E. A., Lewin, A. B., Murphy, T. K., Small, B. J., & Storch, E. A. (2014). A meta-analysis of behavior therapy for Tourette syndrome. Journal of Psychiatric Research, 50, 106–112.

– Ochoa-de la Paz, L., Zenteno, E., Gulias-Cañizo, R., & Quiroz-Mercado, H. (2019). Taurine and GABA neurotransmitter receptors, a relationship with therapeutic potential? Expert Review of Neurotherapeutics, 19(4), 289–291

– 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 controlled trial. Journal of the American Medical Association, 303(19), 1929–1937.

– Steeves, T., McKinlay, B. D., Gorman, D., Billinghurst, L., Day, L., Carroll, A., Dion, Y., Doja, A., Luscombe, S., Sandor, P., & Pringsheim, T. (2012). Canadian guidelines for the evidence-based treatment of tic disorders: Behavioural therapy, deep brain stimulation, and transcranial magnetic stimulation. The Canadian Journal of Psychiatry, 57(3), 144–151.

– Verdellen, C. W. J., Keijsers, G. P. J., Cath, D. C., & Hoogduin, C. A. L. (2004). Exposure with response prevention versus habit reversal in Tourette’s syndrome: A controlled study. Behaviour Research and Therapy, 42(5), 501–511.

– Wilhelm, S., Peterson, A. L., Piacentini, J., Woods, D. W., Deckersbach, T., Sukhodolsky, 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(8), 795–803.

– Woods, D. W., Piacentini, J. C., Chang, S. W., Deckersbach, T., Ginsburg, G. S., Peterson, A. L., Scahill, L., Walkup, J. T., & Wilhelm, S. (2008). Managing Tourette syndrome: A behavioral intervention for children and adults (Therapist Guide). Oxford University Press.

– Woods, D. W., Piacentini J. C., & Walkup, J. T. (Eds.). (2007). Treating Tourette syndrome and tic disorders: a guide for practitioners. Guilford Press.

Premonitory Urges and Comorbidity

– Leckman, J. F., Walker, D. E., & Cohen, D. J. (1993). Premonitory urges in Tourette’s syndrome. American Journal of Psychiatry, 150(1), 98–102.

– Lewin, A. B., Storch, E. A., Conelea, C. A., Woods, D. W., Zinner, S. H., Budman, C. L., Scahill, L., & Walkup, J. T. (2011). The roles of anxiety and depression in connecting tic severity and functional impairment. Journal of Anxiety Disorders, 25(2), 164–168.

– Worbe, Y., Mallet, L., Golmard, J.-L., Tézenas du Montcel, S., Durif, F., Moro, E., Krystkowiak, P., Pollak, P., Lhommée, E., Bourdain, F., Welter, M.-L., Yelnik, J., & Hartmann, A. (2010). Repetitive behaviours in patients with Gilles de la Tourette syndrome: Tics, compulsions, or both? PLoS ONE, 5(12), e12959.

Nutritional Supplementation

– Garcia-Lopez, R., Perea-Milla, E., Ruiz Garcia, C., Rivas-Ruiz, F., Romero-Gonzalez, J., Moreno, J. L., … & Ramos Diaz, J. C. (2009). New therapeutic approach to Tourette Syndrome in children based on a randomized placebo-controlled double-blind phase IV study of the effectiveness and safety of magnesium and vitamin B6. Trials, 10(16).

– Rizzo, R., Prato, A., Scerbo, M., Saia, F., Barone, R., & Curatolo, P. (2022). Use of nutritional supplements based on L-theanine and vitamin B6 in children with Tourette syndrome, with anxiety disorders: A pilot study. Nutrients, 14(4), 852.

– Sánchez-Olea, M. D., & Pasantes-Morales, H. (1995). La taurina. En: Funciones fisiológicas de la taurina. (pp. 147–160). UNAM.

– Vidal Alarcón, A. J., & Andrade Urrejola, J. A. (2023). Efecto de los ácidos grasos omega 3 en el tratamiento de pacientes con trastorno por déficit de atención hiperactivo: una revisión bibliográfica. Universidad del Desarrollo.

Cognitive-Behavioral Foundations

– Beck, A. T. (2020). Aaron T. Beck: Padre de la terapia cognitiva. iNeurociencias.

– Murphy, T. K., Lewin, A. B., Storch, E. A., & Stock, S. (2013). Practice parameter for the assessment and treatment of children and adolescents with tic disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 52(12), 1341–1359.

– O’Connor, K., Leclerc, J., Lavoie, M., Valois, P., Gauthier, B., & Bonenfant-Menard, L. (2019). Cognition and meta-cognition in onset and management of tic disorders. Proceedings of the 9th World Congress of Behavioural & Cognitive Therapies Berlin.