Tourette's Syndrome – Duke University Behavioral Therapy


The announcement by the Duke University Medical Center Clinic that therapists there have had significant success treating a nine-year old boy with a severe case of Tourette's Syndrome, using behavioral therapy aimed at habit reversal, has generated reactions among some involved with TS ranging from skepticism to sarcasm and derision.

Rick Shocket has suffered so grievously with TS symptoms that his case might be referred to as debilitating. Among a host of other TS tics, the boy felt compelled to do deep knee bends between almost every walking step. The impetus of the therapy he was treated with at Duke was to have him become aware of the warning signs that precede his tics and then resist the urge to perform them.

Here is a quote from an Associated Press article:

"It's a controversial development. For decades, Tourette's patients have been told that tics are involuntary and that they should do their best to ignore them. Habit-reversal training, the type of behavioral therapy Rick does, preaches the exact opposite. to be hyper-aware of tics so they can learn to anticipate and suppress them.

"Duke has been a leader in establishing behavioral therapy as a treatment for children who have neurocognitive conditions such as obsessive-compulsive disorder."

Patients with TS like this youngster are taught to "surf the urge," which sounds much like the advice my older character in my story gives to the boy with a mild case of TS. He advises him to learn to "float" through repetitive thought patterns that precede the onset of his tics.

This development at Duke is of great interest to me. I have never understood why Tourette's Syndrome was ever reclassified from a mental health issue to a "neurological disorder," which seems to give the distinct impression that TS has some physical cause. If there was ever an affliction less likely to be attributed to some physical abnormality, I would think it would be TS; which, in my opinion, is nothing other than a variation of obsessive-compulsive disorder.

Although I might be able to be made to understand how some errant neuronal impulses within my brain were responsible for the head twitches and facial grimaces I had been afflicted with as a boy, for the life of me I do not see how anyone could attribute any physical cause to verbal tics (shouting inappropriate words at aberrant times) and tics along the lines that have afflicted this boy, such as his feeling compelled to perform deep knee bends for no discernable reason.

My concern is that If TS is thought of as a physical condition, those who suffer with the affliction are left feeling as though their tics are inevitable and are left waiting for some magic bullet of a cure, such as a medication or an operation. I believe this behavioral approach is the most exciting new development within TS therapy in some time, even if apparently the staff at Duke seems unwilling to drop the "inherited neurological condition" description of TS, which their own treatment and results seem to undermine (if that implies that TS is a physical

The only tenable way I can see to label TS a physical condition is to accept as valid the equation that "brain = mind," in the longstanding brain / mind duality debate. If brain is identical to mind, then no one has any control over any action, from behavioral patterns as extreme as criminality, to feeling the compulsion, for example, to constantly wash one's hands or to pick up pieces of glass outside. By accepting this equation, it would seem to me that psychiatrists would be basically putting themselves out of jobs, except as diagnosticians and prescribers of medication, unless they wish to begin practicing neurosurgery.

I do not accept the equation that brain = mind, and I prefer to use a computer analogy to explain what I do believe. The brain is analogous to hardware, while mind is the software it generates. What unique "software" outcomes can be generated by the brain in regard to each individual is determined by the brain's composition, which is determined by genetic inheritance. It is this individualized software of the mind that mental health therapists attempt to understand and hopefully help correct for the patient when it functions in a manner deleterious to the patient's welfare.

Inherent within one's mind are self-analytic abilities, which a mental health practitioner strives to connect with so that a patient might gain insights concerning the functioning of his or her mind, and hopefully learn to take whatever corrective actions that are possible to eliminate, or at least mitigate, the symptoms of obsessive-compulsive disorders.

To call TS an "inherited" condition is certainly not controversial. Our entire bodies are inherited from our parents and their myriad progenitors. Everything from our hair and eye colors to our various aptitudes and weaknesses can be laid on the doorstep of genetic inheritance. Eventually, scientists might well find the individual genes that account for every aspect of our physical and mental compositions. Therefore, the fact that researchers are currently working on identifying the gene ("hardware") which renders one susceptible to becoming afflicted with TS seems meaningless, as there is a cause for every effect.

But the brain that generates the software of the mind is capable of producing myriad manifestations within the limitations of its inherited genetic composition. The same mind that induces a TS sufferer to tic, might quite possibly be able to produce an adaptation within the mind towards self-correction, the habit-reversal methodology of the Duke approach.

In my essay on TS and ADHD, I put forth my theory that the root cause of all mental afflictions once labeled as "neurotic" is acute self-awareness and the chronic (and sometimes acute) anxiety that often results from it. But what exactly do I mean by "acute self-awareness," and what is responsible for it?

Those who suffer from acute self-awareness might be compared to automobiles that have their engines' idles set too high. In every living animal, there is an instinct to survive and a corresponding inherent fear of pain and death (the latter at least in the case of humans). The sympathetic nervous system (responsible for the "fight-or-flight response" in moments of danger or perceived threats) of those with acute self-awareness is genetically hyper-sensitized, so that the person is acutely aware of internal sensations and perceived environmental threats, as interpreted internally, over and above a normal threshold. Thus, the person's attention becomes inordinately directed inwards.

Behaviorism is an utilitarian school of psychology. It stresses self-knowledge, understanding and behavior modification as a means to address and redress many afflictions of the mind.

Dr. Claire Weekes was a truly remarkable woman whom I had the privilege once to speak with on the telephone. She was the first female physician in Australia and was a pioneer in the area of ​​nervous illnesses, having treated shell-shocked World War I veterans. She advocated a behavioral approach within the field which stresses that the patient gain knowledge of the causes of his or her affliction with nervous illness and to use that knowledge to learn to address the symptoms.

She wrote in one of her books that if she had to pinpoint the exact point at which a person suffers a nervous breakdown it would be the point at which the person becomes aware of his or her symptoms. A nervous breakdown begins when the person is no longer merely afraid of the initial conditions which precipitated the stress causing his or her nervous anxiety, but when the person also becomes afraid of the stress symptoms themselves.

For example, a person becomes afraid that he or she is about to suffer a heart attack as a result of his or her heart pounding after the initial cause of the stress. The advent of this secondary fear is when a nervous breakdown can be said to occur. This causes a vicious cycle of fear feeding fear.

Dr. Weekes' approach was to reassure the sufferer that the heart is a wonderfully thick muscle that can sustain a very rapid heartbeat for an extended period of time without deleterious effects. The comfort of this knowledge (and similar such advice) serves to lessen the secondary fear and allows the patient to regain confidence in his or her personal survival and ability to address the conditions that initially caused the acute response.

As such, she seemed to anticipate President Franklin Roosevelt's admonition that: "We have nothing to fear but fear itself!" She taught her patients and readers to learn to "float" through anxiety attacks and not be concerned with the symptoms themselves or try to fight them (adding yet more adrenaline), using the knowledge and techniques they had learned under her guidance.

Just as in the case of those who have lost control of their nervous systems by feeding fear with more fear, I believe those with both OCD and TS can learn to recognize that as much as it might seem otherwise, their compulsions or tics are not truly involuntary. Rather, they have become virtually involuntary from learned behavior by repetition and reinforcement as attempted defense and concentration mechanisms resulting from the underlying condition of acute self-awareness.

I think the Duke University's clinical staff's therapy is one that merits close scrutiny, and if their approach continues to yield significant results using their behavior-modification method of learning, then perhaps it is time to rethink prevailing attitudes towards TS and perhaps even OCD.

Albert Einstein once observed: "All it would take to disprove my theory [of special relativity] is one observation to the contrary." If Duke's approach has worked to even significantly mitigate the symptoms of young Rick Shocket, then if such a result proves capable of being replicated in others afflicted with Tourette's Syndrome, it would seem as if it is time to once again reevaluate TS and approaches to its treatment. No degree of talk therapy, self-insight or willpower could ever, for example, restore sight to a person with a destroyed optic nerve, a strictly physical condition.

This is not to assert that other approaches, such as medications, must be discarded, but only to assert that it must be recognized that the only goal of any value for those concerned about people with Tourette's Syndrome should be embracing whatever avenues of approach work to eliminate, or to mitigate to the fullest extent possible, the problems and pain associated with this affliction.


Note: I am not in the medical or mental health fields and my views are based upon my own experiences. Those who disagree with the views expressed in this essay have every right to do so, and it is always advisable to fully research any topic before forming any definite conclusions.

Source by Donald Schneider