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Hypnosis and Biofeedback in the Treatment of Tics And SPECIAL TOPICS Hypnosis and Biofeedback in the Treatment of Tics and Tourette Syndrome Kevin Harrington, PhD, and Timothy P. Culbert, MD Integrative Medicine Program, Children’s Hospitals and Clinics, Minneapolis, MN Keywords: Tourette syndrome, tics, pediatrics, hypnosis, biofeedback Tics (vocal and motor) and Tourette syndrome are neu- curiosity to facilitate tic regulation. By using biofeed- robiologic disorders that commonly present in child- back or hypnosis, children engage more actively in their hood. Although the mainstay of treatment has been the own treatment process. use of psychotropic medications, evidence and clinical experience support the use of self-regulation strategies Mechanisms of Action for Self- including hypnosis and biofeedback as effective adjuncts Regulation Approaches or, in some cases, first-line treatments. This article Although Kohen (1995) described the successful use of reviews the rationale for using these treatment self-hypnosis for TTS, little is known about the mecha- approaches, gives a case study example, outlines specific nism of therapeutic change on a psychophysiological biofeedback modalities that are useful, and describes level. In the case of biofeedback-based relaxation train- appropriate hypnotic language and technique as applied ing, one possible explanation for benefit has to do with to the treatment of Tourette syndrome. autonomic nervous system (ANS) balance. Children with TTS frequently experience increased frequency and Introduction: Self-Regulation Strategies severity of tics with heightened levels of emotions (pos- for Tic Disorders itive or negative) and also when experiencing stress Motor and vocal tics and Tourette syndrome (TTS) are (with resultant increases in sympathetic nervous system neurobiologic disorders of variable intensity that are activity). Clinical experience has strongly suggested that common in childhood (see the Table). Although psy- training children in emotional regulation and strategies chopharmacologic management is often considered the that create lowered levels of sympathetic nervous sys- treatment approach of choice, many children with TTS tem arousal is an effective way to assist them in devel- benefit from learning self-management strategies such oping better voluntary control of TTS symptoms in key as self-hypnosis and biofeedback and can realize mean- situations. ingful symptom control with these techniques. In gener- One goal of this kind of training is to help children al, we have found these techniques to be more effective with TTS selectively determine when, where, and how in the control of mild to moderate tics than of severe tic much they will tic. This can be very adaptive and does behaviors. These self-regulation strategies can be used not mean they will not or should not tic at all, but rather successfully in conjunction with pharmacologic inter- allows them the control to tic “selectively” in a way that vention. is less functionally impairing. Morbidity from tics can be TTS can have a significant impact on a child’s func- experienced in several ways. One of the most common tioning at home, school, and with peer relationships. One challenges for kids with TTS is that tics can be socially aspect of TTS that can be very difficult for a child is that problematic and result in teasing, reprimands, and other “my body is doing something that I don’t want it to do.” unkind behaviors from peers and adults. Other compli- The need for self-control and self-management repre- cations of TTS, such as coprolalia, can create additional sents a strong developmental drive for all children. social problems. Children with frequent and intense tics Biofeedback Techniques such as biofeedback and hypnosis can assist can also experience muscle pain or other bodily injury children by harnessing this innate developmental drive from recurrent, strong motor or phonic tics. In the aca- for mastery and autonomy and applying it for therapeu- demic setting, children with frequents tics may find it ⎪ tic benefit in the control of their TTS symptoms. Self- difficult to focus and sustain attention while reading and Summer 2005 hypnosis also utilizes a child’s strong imagination and writing and also may be disruptive to others. It is impor- 69 Hypnosis and Biofeedback in Tourette Treatment tant to note that obsessive-compulsive disorder and of your body, adjust the lever so that your [designated attention deficit/hyperactivity disorder (ADHD) can co- body part] does exactly what you want since you are in occur with TTS, further complicating the picture and charge.” The child is guided through different parts of increasing the child’s distress and dysfunction. his or her body, including the parts that are affected by tics. Affirmation and ego strengthening are used to rein- Clinical Approaches in Children force success. The child is guided to leave the control with TTS room and return to the fun activity he or she utilized Providing information is always a key element in during the induction. Posthypnotic suggestions of suc- increasing a child’s sense of control. In the first session cess, ego strengthening, and practice are given. After the after a complete history is taken, the child is provided child is fully alert, the experience is processed, paying information on how the mind and body work together to attention to the imagery the child used and reinforcing bring about a desired change (i.e., fewer tics). A child can the child’s feeling of success. The child is asked to prac- learn fairly quickly that a change in thoughts and feel- tice the self-hypnosis exercise outside of the session and ings can bring about a physiologic change. Information to continue to monitor his or her stress level. is then given regarding how stress can affect the fre- The parents are brought in at the end of the session quency, intensity, and duration of tics. The child is given and the child explains the mind-body connection, soft a calendar and asked to monitor his or her stress level belly breathing, hypnosis, and the practice schedule. In with the stress ruler between appointments. The stress the child’s presence, parents should be informed that ruler is a visual analogue scale that rates stress from 0 to therapy practice assignments are the child’s plan, and 10. The low end of the ruler means “no stress,” the high therefore parents do not need to remind the child to end of the ruler means “most stress,” and the practice. This supports empowerment and decreases the children/teens rate themselves anywhere in between. chance of a power struggle between the parent and the The stress ruler provides a helpful tool to track daily child. When the child returns for the next appointment, progress and identify stressful situations. the child’s stress level, practice schedule, and level of tics This self-monitoring establishes the expectation that are reviewed. the child is an active participant in the treatment and helps the child develop self-awareness. The following Case Study: Hypnosis and TTS session focuses on reviewing the calendar while Tom is a 16-year-old boy who was diagnosed with TTS strengthening the child’s understanding about the mind- at age 12. He also had a diagnosis of ADHD, inattentive body connection. Soft belly breathing is taught and prac- type. Tom also had some obsessive/compulsive charac- ticed. Children are instructed to place one hand on the teristics. He had tried a variety of medications that were belly or abdomen and feel their own breathing. Then not effective with tic regulation. The stimulant was they are guided to take long, slow, and full breaths and reported to have increased the frequency of tics. Tom’s to notice the changes in their bodies and minds. tics included frequent vocalizations, swearing, severe After the child practices the breathing, a question shoulder rolling, and cracking his neck. School provided similar to the following is asked: “Would you like to the option of going to the counselor’s office if he needed learn something else fun so that you can have fewer a break from the classroom. At the time of the referral, tics?” The purpose of this question is to elicit a sense of Tom was out of the classroom 75% of the school day. curiosity, tap into fantasy and imagination, and promote This was an increase from the previous year, when he a sense of empowerment. After the child agrees to “learn would go several times a week for 30 minutes. Tom had something fun,” the therapist then teaches the child a few close supportive friends and interacted little with hypnotic induction. The child is asked to “Picture your- other classmates. Tom reported that his mother was very self doing something fun, something you are really good supportive; however, he reported that his father “yells at at.” After strengthening the image, the child is instruct- me if I tic in front of him.” ed further: “Go to another part of your brain to a control Tom was already aware that his tics were exacerbated room with a big comfortable chair that is in front of a by stress. In applying his “stress rule calendar,” Tom board with a lot of knobs and levers. Each knob and lever recorded that his stress spiked in the afternoon at school Biofeedback ⎪ controls a different part of your body. Find one that con- and after dinner at home. Tom was able to identify the trols your [designated body part]. Since you are the boss specific stressors at school as two classes in which the Summer 2005 70 Harrington, Culbert Table. Definitions Tics (may be transient or chronic) Vocal or phonic tics involve movement of air, noises, breathing, and words including sniffing, snorting, blurting out words, and coughing Motor-involved muscle movements may be simple or complex Tics of all kinds are commonly associated with a prodromal sensory “urge” to perform the tic and then a sense of “release of tension” afterward Tourette syndrome The combination of both vocal (also called phonic) and motor tics for a period of at least 1 year in a manner that results in significant functional impairment kids and teacher did not know about his TTS.
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