The UpTic

Transforming Tourette's Treatment: Dr. Lichtman's Perspective on CBIT

November 20, 2023 New Jersey Center for Tourette Syndrome and Associated Disorders Season 1 Episode 3
Transforming Tourette's Treatment: Dr. Lichtman's Perspective on CBIT
The UpTic
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The UpTic
Transforming Tourette's Treatment: Dr. Lichtman's Perspective on CBIT
Nov 20, 2023 Season 1 Episode 3
New Jersey Center for Tourette Syndrome and Associated Disorders

Today we dig into the world of Tourette Syndrome (TS) and its management through Comprehensive Behavioral Intervention for Tics (CBIT). Our guest, Dr. Jeremy Lichtman, a licensed psychologist specializing in Tourette patients, sheds light on the myths and truths surrounding TS. We explore the intricacies of CBIT, debunking common misconceptions, and understanding its role as a transformative tool rather than a cure. Whether you're directly affected by TS, a caregiver, or just curious, this episode offers valuable insights and hope for managing Tourette Syndrome.

Key Moments:

- [00:00] Dr. Lichtman discusses the common misconception of CBIT as a cure for TS.
- [01:17] Dr. Lichtman simplifies CBIT as a 'tool, not cure' for TS.
- [04:48] Deep dive into CBIT: the principles, components, and how it functions.
- [10:38] Real-life examples and success stories in managing TS with CBIT.
- [17:02] Understanding the unique challenges of vocal tics and adult patients in CBIT.
- [24:06] The journey of a patient mastering CBIT and its long-term impact.
- [30:14] Addressing misconceptions about CBIT and identifying ideal candidates.
- [35:20] Differentiating between TS and its comorbidities for effective treatment.
- [42:28] Dr. Lichtman reflects on the power of conversation and education in TS management.

Links & Resources
- New Jersey Center for Tourette Syndrome and Associated Disorders: 
- Dr. Jeremy Lichtman's Practice Information: [Website Link]
- Comprehensive Overview of CBIT: [Resource Link]

Thank you for tuning into The UpTic. If you found this episode insightful, please consider rating, following, and sharing our podcast. Your support helps us reach and empower more individuals. Remember, you're not alone in your journey with TS. Let's continue to stretch the boundaries and live our best lives!

Send us a Text Message.

Support the Show.

Show Notes Transcript

Today we dig into the world of Tourette Syndrome (TS) and its management through Comprehensive Behavioral Intervention for Tics (CBIT). Our guest, Dr. Jeremy Lichtman, a licensed psychologist specializing in Tourette patients, sheds light on the myths and truths surrounding TS. We explore the intricacies of CBIT, debunking common misconceptions, and understanding its role as a transformative tool rather than a cure. Whether you're directly affected by TS, a caregiver, or just curious, this episode offers valuable insights and hope for managing Tourette Syndrome.

Key Moments:

- [00:00] Dr. Lichtman discusses the common misconception of CBIT as a cure for TS.
- [01:17] Dr. Lichtman simplifies CBIT as a 'tool, not cure' for TS.
- [04:48] Deep dive into CBIT: the principles, components, and how it functions.
- [10:38] Real-life examples and success stories in managing TS with CBIT.
- [17:02] Understanding the unique challenges of vocal tics and adult patients in CBIT.
- [24:06] The journey of a patient mastering CBIT and its long-term impact.
- [30:14] Addressing misconceptions about CBIT and identifying ideal candidates.
- [35:20] Differentiating between TS and its comorbidities for effective treatment.
- [42:28] Dr. Lichtman reflects on the power of conversation and education in TS management.

Links & Resources
- New Jersey Center for Tourette Syndrome and Associated Disorders: 
- Dr. Jeremy Lichtman's Practice Information: [Website Link]
- Comprehensive Overview of CBIT: [Resource Link]

Thank you for tuning into The UpTic. If you found this episode insightful, please consider rating, following, and sharing our podcast. Your support helps us reach and empower more individuals. Remember, you're not alone in your journey with TS. Let's continue to stretch the boundaries and live our best lives!

Send us a Text Message.

Support the Show.

Jeremy Lichtman, PsyD  00:00
One thing that I think people sometimes look at is like it's going to be this cure. And it's not. And that's another major misconception. It is not a cure. It is a set of tool that individuals with Tourette syndrome in their families can use to minimize the intensity and frequency of their tics if and when they choose to. But it's not a cure, it's not going to make the text go away.

Michael Leopold  00:21
Welcome to The UpTic, brought to you by The New Jersey Center for Tourette syndrome and associated disorders, empowering children and adults through education, advocacy and research by sharing the stories and experiences relevant to the TS community. Thank you for joining us on this episode of our podcast. I am here today with Jeremy Lichtman, who's a licensed psychologist offering cognitive behavioral therapy in central New Jersey. And he specializes in Tourette patients. Jeremy, how's your day going? Hi,

Jeremy Lichtman, PsyD  00:55
Mike it's going Excellent. Thank you. How are the Earth? Very good, very

Michael Leopold  00:59
good, busy day but doing doing well. Good start to the week here. So I know you are a specialist in CBIT and we'll talk in a second about what that is. I would love to know just off the bat. If you could describe CBIT and one or two words, how would you describe it?

Jeremy Lichtman, PsyD  01:17
Oh, that is a good question. Just jumping off real quick. You got it right? You're in the club? Because it's sivut, not CBIT. So the secret handshake of the CBIT club is which which one do you call it? So you got it? So one or two words is tool not cure?

Michael Leopold  01:34
That's good. It's one tool in the toolbox for managing tics. So talk to me a little bit about your background and how you got started as a psychologist but also what made you want to specialize in Tourette patients?

Jeremy Lichtman, PsyD  01:46
Sure, way back when we in Vietnam I'm getting. But basically I'm not completely kidding when I say that both my parents are psychologists, the end as a child, I have Tourette Syndrome diagnosis myself, I ADHD, you know, learning challenges, you know, the the range, and I was really lucky, I had parents who got it in a way that you know, very often you're working with parents and families of children with Tourette Syndrome, you know, like, like, they're scrambling for answers. And my parents had a little bit of that background knowledge to begin with. And they really created an environment that was set up for me to be successful for me to create the kind of life that I would want to live with no particular limitations, especially no limitations, per se, given my diagnosis. And so kind of growing up experiencing that, and seeing the work that my parents did with other people and helping other people, my father's run nonprofit organizations, whole life, helping people with special needs, and just kind of watching the impact that they've had their work definitely led me in this direction plus, just a fascination with human psychology in general and, and kind of wanting to understand how people work. And as I've learned more, I really learned that we have no idea. But that aside, now, it's just a mystery that intrigues me. So really kind of, you know, their experiences, my experiences growing up. And so by high school, I kind of had the idea of going to become a psychologist that was important to me. And then college and grad school. When I was in graduate school. One of the the graduate schools I applied to was Rutgers, in part because they had a traction drum program, which I was really interested in less in some ways because I have tried to injure myself without obviously that's a piece of it. But largely because there was supposed to be really excellent training in cognitive behavioral therapy for Tourette Syndrome, but the CO occurring, you know, commonly co occurring comorbidity, right OCD, anxiety, depression, these other areas, I had a lot of interest in and really, really wanted to become an expert in cognitive behavioral therapy. And so that's what led me to Rucker than the TF program. And by definition being in the TF program I was working with, you know, patients or clients with Tourette Syndrome, but really something I kind of knew from my own life and tangentially. But what really came home to me was how heterogeneity, right? How differently TS can be experienced by different people and how so it's like, you know, rule number one, the treatment of Tourette syndrome is assessed for everything, because very often there's more going on. And the other things are more challenging than the tics themselves very often. Yeah, really, that really came home to me there. And so when I think about working with individuals or families with Tourette Syndrome, I really I really think more broadly about using cognitive behavioral therapy to help individuals who are struggling, because as I said before, it's even it's a tool. It's not a cure. And cognitive behavioral therapy is not about curing the symptoms that people experience, not about curing people. It's about empowering people, to have the tools to manage the symptoms that they're experiencing in the life not to necessarily make them go away. But to be able to achieve a life worth living knowing that they have the tools to do that. I love that.

Michael Leopold  04:48
Do you want to talk to me a little bit about what CBIT is, what it stands for, and how the process works

Jeremy Lichtman, PsyD  04:53
through CBIT or comprehensive behavioral intervention for tics is a form of cognitive behavior. therapy, right? So cognitive behavior therapy, or CBIT is kind of this umbrella, right. And there's a CBIT, for depression, for anxiety for self harm for OCD, right? You know, lots of different forms of cognitive behavioral therapy. But the core principles within cognitive behavioral therapy more broadly is one. So these cognitive and the behavioral principles, right behaviors are causal, and they don't exist in a vacuum, things going on around us affect us. And if we can shape, shape our behavior, change our behaviors, we can change the way we interact with the world around us and the emotions that we experience. But also thoughts. cognitions are really, really key part, right? The idea that the way we think about situations can also affect how we feel and how we respond to situations and the idea that let's teach people to recognize how their thoughts and their behavior than the environment are impacting how they're feeling and what they're doing. And give them the tools to shift or change some of those where it makes sense to. And so that's kind of cognitive behavior therapy broadly. So then we narrow in into CBIT. CBIT is really a package of treatments that's composed of, I think of it at least four main components. The first is education, psycho education, the idea that, you know, there's so much misconception around Tourette Syndrome, myths versus facts. And the key piece in the education piece is to really help the individual you're working within the families you're working with have a clear sense of what is a tick, what is not a tick, what is what are the comorbidities? How do we talk about ticks? How do we think about it, what's, you know, I wouldn't say what causes them because we don't really know, but kind of all of that educational component, and also what this treatment is going to look like. And then the treatment itself has three main components. So this is a package again, that was put together by Doug woods and have collaborators. And it's also a treatment that has meat, so the EPA division 12, gold standard for being an effective treatment, right. So we know it works, doesn't mean it works 100% for everyone, but it's a treatment that works, right, the research shows in double blind, randomized controlled trials that it works. And so after education, there are the three other components. One major piece is relaxation strategies. The idea that we know heightened emotional states anything is the classical ones, like being sad, being angry, being frustrated, being angry, but also being excited, being overwhelmed being really, really happy. These all can affect how intense and how frequent one to take Sar. And so if we can find ways to sort of relax, our tics might not be as bad. And so really, the two main strategies here in the CBIT manual are diaphragmatic, or deep breathing, right kind of slowing down the breath as a way to trigger the parasympathetic nervous system slow down, that's in fact, nervous system reaction. And then also progressive muscle relaxation, right tightening and loosening the muscles to sort of create that feeling of relaxation and looseness throughout the body. The key here is that this is not a strategy that's meant to respond directly to the tics, it's a strategy that's meant to help us respond to stressful environmental situations, thereby one decreasing, hopefully, the intensity and frequency of tics in and of itself, but also allowing us to more effectively use the other core pieces of this treatment. So that's a kind of that first piece is a relaxation. The second piece is what's called a functional assessment and the functional intervention, a core principle in behavioral treatment CBIT comprehensive behavioral intervention for tics, right? Cognitive behavioral therapy, a core principle in behavioral therapy is that the Environment Matters things that you when we look at the behavior in isolation, that's a challenge or causing a problem or something that we want to change, we have to look at what's called the antecedents what's coming before that might be increasing the likelihood of that behavior occurring, and also what's happening after right? What's the consequence that might be reinforcing that behavior? So an example outside of tics might be, you know, a child who is pushing another kid, and they push another kid or throwing property or tantruming. But we always want to look at what's going on right before? Well, the kid just pushed a kid out of nothing, probably not. Maybe the other kid pushed that first kid that the kid we're looking at first. Maybe they said something really upsetting to that kid, maybe this is a kid who's not getting a lot of attention. It was waiting to see other people look at him or her before they push together, what's going on right beforehand, right? And then what's going on after afterwards is a bunch of people cheer the kid on, that's probably going to increase the likelihood that he's going to or she's going to push a child again in the future, because that's reinforcing they got something good out of pushing the child. So with ticks, we believe the Environment Matters. What this means that what are the things that are kind of going on before that might be increasing the likelihood of increasing the intensity or frequency of the text? So like common examples that we might be looking for our things are stressful, taking tests, homework, being in public places, all these things that might for some kids, and not all kids or individuals or not just kids may increase the likelihood of their texts becoming more frequent and more intense. And we have a whole way of kind of assessing for that. And then we also want to look at the consequences. What's happening afterwards? Is the child or the individual? Are they being comforted? Right? Are they able to escape an aversive situation? Are they being laughed at? What are the things are happening afterwards, because if we could understand the antecedents and the consequences, we can find ways to shift the environment. So the example I like to think of in family workers were, you know, this child would come home from school and their tics would get really bad whenever they had to do homework homework when the stressful situation for them, and which is you know, stress homework stressful for a lot of people definitely was always rough. Yeah. Oh, my wife, she liked homework. But for me, it was,

Michael Leopold  10:38
it's hard when you have ADHD, exactly. Homework was a challenge for me.

Jeremy Lichtman, PsyD  10:42
Same. So you know, child comes home, and you have the expectation when they do their homework right away, right. So they come home, they knew within five minutes, you know, mom or dad would kind of sit down with them various time to start your homework, right? They start to homework and their tics we get really, really bad. They do a lot of movement, tics, you know, a lot of sound tics, they would get really uncomfortable for the child. And for everyone around them who you know, the expectation was that he was going to be doing his homework. That's the antecedent doing homework, okay. And then the consequence of that was, almost inevitably, most nights, mom or dad would either finish the homework for him, after about, you know, 1015 20 minutes of having after having stares at homework, or, you know, they wouldn't email the teacher with something saying, you know, he couldn't do the homework that night. And what would happen is that once he got out of doing homework, the ticks full, they would get much better. Still going on, but they will get much better. And so this cycle was created where homework became TIG time, and then he got out of it got out of this aversive situation, and the tics will get better.

No, no, not surprised to hear that. Yeah, exactly. It

Jeremy Lichtman, PsyD  11:45
makes total sense. Although, again, not always, because if we think of tics as something that's divorced from the environment, this shouldn't be happening, but relationship with tics and how much people tick in the environment. And so the intervention, right, knowing this, helping them see this pattern was the first part. But the second part was creating intervention. And so putting aside my feelings on homework for a second, which are really I don't know, that kid should be doing it at all is there needs to be homework, but working on something that like this kid needed to do his homework in the School of expecting a defender, etc, we decided to come up with a plan, that would shift a little bit of these antecedents what happened before and the consequences to decrease the likelihood that his picture gets so much worse when doing homework. And so the choosing that we did well, one, we create a plan where he actually would have about 1520 minutes before needing start homework to just relax, chill out, eat a snack, watching TV. So he didn't have to jump straight from seven hours in school into doing his homework. And then the other piece we added was instead of he just got out of doing his homework, when the tics would get bad, we implemented set breaks. So he would do his homework, however long you have a huge amount of homework, and I'd say about 30 to 4560 minutes worth of homework, but every 10 to 15 minutes, you'd have a break, regardless of how bad his tics were. The idea was that by creating the breaks, he would have a chance to let loose some of that steam that was building up from just like the aggravation that's come from from homework, exhaustion, all of that stuff, he'd get the brakes, but it wasn't done immediately in response to his tics, which were then reinforced. Like, my tics get really bad when they have to do my homework. Right? Right. It was done at set intervals every about 15 to 1015 minutes, right, he get a few minutes. And what we saw is over time, well, one homework became less of an issue overall with the family. But to the tics actually weren't quite as bad during homework than they used to be, where they're still worse during homework than other times homework is still stressful, but it wasn't as bad. So that's the functional assessment and intervention piece. And then the third piece of the bed. And this is really the core of it. There have been studies on CBIT as a package, but there's been a number of studies on the HRT component itself, which is Habit Reversal training, bad name, it was Habit Reversal therapy was something that was existing in around like the 70s, for things that weren't tick related for habits, and it was kind of been co opted and used for tests, but ticks on that habit. But here is where individuals with tics are basically learned to become really aware of their tics and use what's called a competing response. So before I get into I'm gonna have to take a step backwards and provide some background here because it gets a little technical. So basically, the way to think about it is the behavioral model of Tourette's Syndrome. people with Tourette's is something genetic. It's something neurological, there's something going on in the brain, we really don't quite know what it is something related to the basal ganglia. What seems to be the case for about 70% of people with Tourette syndrome is that they experienced what's called a pre monetary urge before they so this uncomfortable feeling, you know, phenomenological feeling localized in the area with a ticker curve. So, if it's, you know, a shoulder twitching tech, right, there's probably a feeling somewhere around the shoulder can be described as a pressure or tickle or an itch and What happens is the individual with tics does the kick as a way of relieving that feeling in that part of their body, getting rid of that uncomfortable feeling. And what we have here is what's called a negative reinforcement cycle. What that means is, we have urge, discomfort, pick, really relief. Relief is it's called a negative reinforcement cycle, because you take away the discomfort. And what happens is that there's this sort of implicit or unconscious learning going on of, you know, relief, oh, next time I have a tick, I'm going to I have this urge, I'm going to do the tick that makes this feeling go, right. Okay. And the more it happens, they get at least is that that gets reinforced. And basically, you learn, the only way to get rid of this bad feeling is I need to do this tech right now, or else this bad feeling will never go away. Right, right. And so what he does, is it says, Hold on, hold on, hold on. There's very little in our experience as behavioral psychologists, that actually just goes on forever. And I wonder if we there might be another way of stopping that negative reinforcement cycle, right, right. Now we have kick equals relief, I wonder if there's another way to get relief, okay. And what what we what we do is we teach our clients to become really, really aware of that urge, because you need to know when that urge is happening in order to do the second this next piece. And instead of doing the tick, they engage in what's called a competing response. So competing responses and behavior that has three rules is incompatible with the tech. So if the ticket some sort of shoulder up and down movement on the podcast, I can show you. It's something where you might kind of hold your shoulder down, okay, incompatible, you can't have your shoulder going up and hold it down at the same time. Right, right. Rule number two, that can be done anytime, anywhere. So you can stick your hand in great. So when I teach kids this, I, you know, they're inevitably say something, stick your hand in your pocket, and I'll say, Well, do you wear pockets into the shower?

Michael Leopold  16:59
Oh, probably not. Oh, so you can't do it everywhere? Yeah,

Jeremy Lichtman, PsyD  17:02
exactly, exactly. Right now, every pair of pants has pockets, girl pants tends to be much less likely to have pockets or take your hands and stuff. So it needs to be something that can be done anytime, anywhere. And then the third rule is it's less noticeable than the tip. If you just held your hand straight up, you know, while you had the urge to do the tick, it might be incompatible with the up and down movement. But it's gonna look a little strange probably to walk around with your head

Michael Leopold  17:28
robot, you know, the teacher will think you have a question all the time. Exactly.

Jeremy Lichtman, PsyD  17:32
It's like, no, no, it's just my competing response.

Just ignore it. Yeah,

Jeremy Lichtman, PsyD  17:36
the idea is that if you engage with the competing response, instead of the tick, eventually, the urge is going to go up and up. But eventually, it actually hits a natural ceiling. And when it hits that ceiling, that urge is actually going to go down on its own. And so what you're learning is, hey, I don't need to tick in order to get relief, that relief will actually come on its own. Wow, the way the way I talk about it is you know, I talk with kids and I'll be like, you know, have you ever gone swimming in a cold pool? And kids like yeah, of course I've gone swimming. What can stupid person you see? Me Right? What

can I do? Right? Exactly? Of

Jeremy Lichtman, PsyD  18:18
course I go swimming. So let's say Have you ever jumped into a cold pool? Of course they have. Why all the dumb question about that. Right. So how does it feel when you jump into a cold pool?

Michael Leopold  18:28
You notice it? It's cool. That hurts? For the first part? Yeah.

Jeremy Lichtman, PsyD  18:32
Ah, your uh, your your your, your I know the answer, right? It's cold at first. But what happened when you stay in the pool for a little while

Michael Leopold  18:40
you get used to it, you don't notice the cold anymore?

Jeremy Lichtman, PsyD  18:43
Exactly. You don't notice a cold anymore? Your body adjusts the temperature of the water objectively change? No, not unless you're peeing in my

story, then yeah,

Jeremy Lichtman, PsyD  18:55
the temperature doesn't change, right? Not really, what changes your relationship with that feeling right with that temperature. And that's the idea that by engaging with a competing response for long enough, right, and the idea that you hold the competing response for at least a full minute, or until the urge to tick goes away, whichever one is longer. Your relationship with the need to tick changes your relationship with the urge started with the pre monetary urge changes. It goes from this thing that oh my god, I can't handle this. I need to get rid of this right now. To this thing of, hey, I'm okay, I can handle this. It actually goes away on its own. And at least theoretically, ostensibly over time, the more you do this, the shorter and shorter that time period between urgent tech and an urge going away by holding competing response that should be getting shorter over time.

Michael Leopold  19:46
I see. I see. This is so fascinating. It sounds like in the early stages, we would tell people to hold on to that competing response for a minute and then after that, if they needed to, I guess they take or or if they have the ability to keep hold Holding it,

Jeremy Lichtman, PsyD  20:00
but actually we tell them from the beginning, you want to hold the competing response for as long as really yes to hold it until the urge goes away. Okay, work under the with the confidence with the the knowledge, the belief that the urge will go away. And when I've done this with clients, right, sometimes it can be done within less than a minute sometimes. Sometimes I've had clients hold a computer response, especially that first time 1520 minutes. So yeah, but I have I've yet to be in a situation with a client where the urge hasn't at some point dissipated. And that's the best thing, the look on the child's face movie. I work with children when they do it for that first time. And it's like, yeah, it actually went to No, turn them like, like, before they did this make sense? Do you think we're working? And then afterwards when actually works? So did you actually think that was gonna work? Like I did. That was so cool. Wow,

Michael Leopold  20:51
it's got to be eye opening. I mean, I personally, I've had to read since I was a kid, I did a little bit of CBIT in eighth grade, but with a therapist that was actually trying to learn as we went, he bought when I bought the book is he had never, never done even CBIT, you did CBIT, but not CBIT and not specifically for Tourette's, I ended up not going through the full course of it. I know, it can take three months or so. And it takes a lot of stress and time. So even just hearing you say that, that like if I were to just keep holding the competing response, eventually the urge to take that pre monetary urge would go away. That's amazing. That's like mind blowing for me, I would just I just imagined myself, you know, my energy, the tension, stress just boils and boils and boils. And then I I explode or something. But like, I don't know, I've never tried to hold it that long. But yeah, that's so promising to hear that this is you know, that you've seen this with everyone you've worked with. And then over time, it just takes less and less. And I guess eventually, is it fair to say that eventually, the competing response will satisfy that pre monetary urge in the same way that the tech would.

Jeremy Lichtman, PsyD  21:53
So it's interesting, right? So the way I like to the metaphor I like to use is, if someone's like training for some sort of like triathlon or something where like, for some reason you will be swimming, like, it's really cold water, right? I don't know, that's, that's my understanding of the things. And so, to train, you decide to start winning every day, you know, 5am, you jump into a cold pool, you swim, you know, for an hour, however long and they don't want, it's going to be cold that first day number two is going to be cold at first week. Number three, it still may be cold. But by month number six, it might not be as cold anymore. Over time, again, your relationship with the urge to tick changes. This is one of the things with Tourette Syndrome, especially with younger kids is that the tics change a lot. And so, you know, you might need different competing responses for different texts, in fact, usually do. One thing I do with all my clients is we track over time, right in the frequency of their tics and how much their tics are bothering them for every tick that they have. We add new ones every week if new tics come. And you're one of the ways we track success is hey, the tics we're working on, have those been getting better, right has a frequency decrease and has the discomfort the what's called subjective units of discomfort, such scores have those gone down. Almost always, that's what we see. But sometimes we see that photo ticks that we haven't even started working on, because that's the nature of ticks. That's not because of the treatment. It's because right ticks just sort of shift over time, right. And so we do know this works, because when we do the research on when the studies have been done on people in the weightless conditions versus treatment conditions, or the alternative treatment conditions, the tics for the people in the HRT or the CBIT treatment condition, their tics do get better over time. But the idea is that, again, it's not a cure, it's a tool, right? It's Oh, I know how to learn to be really all become really aware of this urge to tick and I know how to come up with a competing response. And I can use it, if and when I want. And that's really key, right? Because a lot of times ticking is actually easier and less distracting than using a competing response might be, you really have to be focused on it. And I do believe it gets easier and easier over time. But I don't use it for all of my tics. Because at this stage in my life, very often my tics are pretty minor. And it's just easier to do a tickle into you the competing response,

Michael Leopold  24:06
you know, for the self injuring texts, or the very embarrassing noticeable texts, I can see those being big candidates for it. So like let's say, let's say I have 12 tics roughly. And you know, maybe four of those I would rank is like pretty bad like or, you know, problematic. They're the ones I'm concerned about. Maybe they're embarrassing, or they're painful to do a lot. Would you start on all four of them at once? Or do you try to develop a competing response kind of one tick at a time? Because obviously there's a certain level of like, we couldn't wait to prioritize the work we're doing? Or is this such a thing where you you actually can focus on multiple ticks at the same time.

Jeremy Lichtman, PsyD  24:43
I typically focus on one tick at a time. So we create you know, with all the individual I work with, we create our tick hierarchy, which is a list of tasks that we review every week at the start of the session. We'll pick our first tick to work on and we'll start with this awareness trading. Actually before we get to wherever the are Would you start with just making sure they're aware of the ticket itself, you get a description of it. And then you say, or every time you do the tech, you know, I just want you to raise your hand to show me that you know that you're doing the tech, you know, I make it a game, usually with kids. And then you know, they'll get good at that. And then we'll say, Okay, let's now work on catching the urge. So every time you feel the urge to take, raise your hand before, and then you can do the 10. And early on this awareness piece alone might take a good portion of the session, usually, the very first thing I'll work on with a client, we usually don't get past this awareness training piece, I send them home over the week to practice just that awareness training with a parent or a support person. And then you know, next week, they'll come back, you know, and assuming that they still have that good awareness, we then develop our convenient response, I have a whole system for going through it, and we'll do one together time. And I'm very big on I know, different clinicians are different on this, some clinicians just kind of give their clients tick, sorry, competing responses. I don't like to do that. My goal is to make sure my clients know how to do this themselves. I have a repository of I don't know hundreds of competing responses at this point. But it's because actually, I've learned a lot from the clients I've worked with, where I have them, we come we go through, you know, we create a list together, and then we pick which ones meet the three criteria, and you know, they think would work best, and then we practice it. So would you want to get the time, right? And so it might take two, three weeks to go through tip number one. But by the time we're up to tip number three or four, it might be awareness training, competing response development, competing response practice, all in one session, 145 minute session. We're also working on all the ticks previously, you know, by the time we get to tip number three or four, we're still working on all the other competing responses when those ticks occur. I

Michael Leopold  26:37
see and I imagined no two clients are the same. That's the nature of the idiosyncrasy of Tourette. If you had to say a typical or average duration for someone to really master see bid master the art of developing competing responses. You know, I remember years ago, I heard three months get cited as like an approximate, you know, kind of ballpark, is that still what we say? Or what's your thoughts on that

Jeremy Lichtman, PsyD  27:01
these numbers, right. And this is true of really all treatment, research based treatment, and the numbers are based off of their clinical research trials, which has sort of cut off points, you know, they only go on for so long. So the treatment, you know, so typically, no TS treatments have been about, you know, the research has been about, you know, three months, the way I like to put it with a family that I work with is that by, you know, after our intake sessions and feedback by six to eight sessions, and if we're not seeing any difference, and doing something wrong, or this might not be the right time for treatment, or any number of other things, I'd say by six to eight weeks, we should start seeing a difference. The way I like to structure graduation from treatment is all I can have children that I work with, run through an entire CBIT session with their parents in the room. They're running it though, right, though, kind of like I'm not running it, I'm just there in the background. Right, this is to show that they've learned that mastery, I would say three months is a is a is a fair timeframe for most individuals that I've worked with at least to really get that beginning stage mastery. But you know, I have found that my clients with tics that listen to the kids and the families, they tend not to want to leave me. You know, we kind of have like a weekly sessions, I would say three months is a good rough marker, you know, we usually move on to every other week and then to monthly check ins. And then like sometimes I've had clients who have, you know, maybe haven't seen for a year or more, come back in for a month or two for booster sessions, just as like life stages to see.

Michael Leopold  28:27
Have you noticed any differences in CBIT for adults versus for children?

Jeremy Lichtman, PsyD  28:33
Yes. So I think that there are sort of two main differences with ly found with children versus adults. The first is, in some ways, it's harder working with adults, I think that relationship between sort of the urge and the tick has just become so reinforced, so automatic for us, right? Where it's actually can be a lot harder to really use a competing with a you're saying how like you try to imagine using a competing response, it just feels like it's never gonna end. And I think that's actually more common in some ways with adults and with children. Right, with children, it's like the tics are changing a lot more. Right? So they might have a tick for a week. And then that's it's gone forever, right? by adults tend to have the same tics I've kind of stuck around for a more extend mine are pretty stable. Yeah, exactly. And so I think the relationship between the urge and the ticking is so quick, that it can be much harder, even though typically awareness of the urges better, be able to sort of jump in there and use a competing response can be harder, and use it until the urge goes away. So that's usually where things are harder with adults, where things are easier. It after adult is bringing themselves to treatment for feedback. They tend to be pretty motivated. And they tend to have the know that more fully functioning kind of frontal lobe thing going on but basically like they're able to, you know, they don't need to be enticed or rewarded and they tend to be more aware of the urge actually, once they start paying attention to it, like training for awareness of the urge tends to be easier. And so that's what I found is the major difference is that like, it's usually the better recognizing the urge other adults. But it can be harder to fully implement the competing response until the urge goes away. Kids, I find this a little bit the opposite. I say that's interesting.

Michael Leopold  30:14
One of the things I've heard is that CBIT can be very helpful with motor tics and the movement tics with vocal tics I've heard, it can be a bit of a challenge, just because a lot of it comes down to breathing exercises, and the relaxation piece becomes a lot more more important. That's a bigger piece of you know, of reducing the urge. What are your thoughts on that? Do you find some tics are more conducive to this kind of therapy than others?

Jeremy Lichtman, PsyD  30:39
So I hear I think motor tics are easier for two reasons. Typically, as far as I know, at least the research actually doesn't show that it's easier for motor with vocal tics. I might be missing something there. But as far as I know that,

Michael Leopold  30:52
oh, this is just what I heard anecdotally. So that's great to hear that the research is not I don't

Jeremy Lichtman, PsyD  30:56
think it seems to show that. That being said, I think major difference is that for motor tics, typically, there could be a number of different competing responses and might work. Again, like I have this repository, and they have like hundreds of points, probably competing responses throughout the body with vocal tics are tend to be fewer competing responses that you can really come up with. So typically, for any number of our movements, right, there might be different arm potential arm tics, there might be 12, potential competing responses for those eight different types. For vocal tics, it tends to be breathing. So slow, controlled breathing tends to be really one of the only ones now it's not quite true. Again, you want to know where the urge located. So hypothetically, for a tick, that's saying something, just holding your mouth closed, might be a good competing response, right breathing or not? Typically, that's why I think, you know, the anecdotally that people say vocal tics are harder. And that's also why like, we do know that they can be a little bit harder at first. And so I typically will, when I work with a client Pixal is like the larger muscle motor tech, you know, I've usually an easier place to start. But I'll tell you things, the hardest tics are usually AI related tech, so probably harder than any vocal tics I've worked with. And that's typically the case. But yeah, I think there's just a variety of different competing responses you can come up with are more varied and vast for motor tics. And so that's why they can be a little harder for vocal take some time to do that. Like there's just fewer options to try to engage with that competing response and to have the urge path.

Michael Leopold  32:32
Right, that makes sense. Who would be a can't a not so great candidate for see, but

Jeremy Lichtman, PsyD  32:39
that's a really good question. And so typically, there are, I would say, two mean, only disqualifying or three kinds of, quote unquote disqualifying factors for for CVID. One might be age, right? How old is the kid? Younger kids tend to have a harder time with this like, and by young, I mean, like, for the six for the seven? I've actually so there's actually CBIT Jr, which is a treatment for younger kids. Where, yeah, and it focuses a lot more on the functional assessment and intervention piece, the assumptions that younger kids aren't going to have that same ability to recognize notice the urge to use a compete come up with and use a competing response. Right, right, right. So age might be one factor. Another and this is kind of a funny one considering the the overlap. But ADHD, like there's a 40 to 60% comorbidity rate of ADHD with trend syndrome, but it seems to be ADHD is another one because it's just one the awareness is harder to build when you have less ability to focus when focusing is harder. And then also the impulsivity can make it harder to not engage with a tick while holding a competing response. I've not found this a huge actually, personally, anecdotally, I've not found most of my clients with stretching from OSA V EG and I've not found it a huge disqualifying factor. But the research seems to indicate that ADHD is a factor that makes us treatment less effective. And then the third, I would say is, are there other things that are going on that are more challenging or problematic? So just do the EEG again, as an example, right? You see a lot with kids, I found where you know, the EDG is what's causing more of the academic impact, social impact all this stuff. But the tics are more obviously noticeable. Right, right. And so the tics become the target, you know, of like, oh my god is it tics that are the problem, but really the text might not be and the research seems to indicate actually that individuals with more clinical peer TF tend to have many fewer academic and social challenges than kids with ADHD in Tourette syndrome. And kids with ADHD and Tourette Syndrome, their social academic, the impact, their social and academic profile tends to be a lot more similar to kids with ADHD alone than kids with Tourette Syndrome alone. And so that's another disqualifying factors in my mind is are there other things that are actually more challenging or problematic than The ticks even if the ticks are the most obvious, OCD might be another example 2014 and comorbidity right, but the ticks might be more obvious a lot of the people with OCD are very good at hiding their OCD or the OCD is pretty subtle. But it might be the OCD. So that's kind of a third is I want to look at the other things and potentially treat those if there's actually going to be causing more of a challenge or a problem.

Michael Leopold  35:20
I think that makes a lot of sense. As part of that, taking a holistic look at their care and making sure that you know, we're prioritizing the issue that we need to what would you say is a major misconception about C bet.

Jeremy Lichtman, PsyD  35:34
So a major misconception is, that doesn't work. I've heard a lot of people say like, Oh, it doesn't work, or it didn't work for me. And like it just doesn't work. And I think that there are two pieces that kind of fit into that usually are a few one two that I think people sometimes look at is like it's going to be this cure, and it's not. And that's another major misconception. It is not a cure. It is a set of tool that individuals with Tourette syndrome in their families can use to minimize the intensity and frequency of their tics if and when they choose to. But it's not a cure, it's not going to make the tics go away. So the idea that doesn't work is like I think it's because people often look at it as if it's supposed to cure the kicks cure them rather than just the tool. And I mean, who can use right? And again, it doesn't work for everyone. The research shows that works. But it works for about 50% of people who try it. I mean that there's 50% Oh, well, it's worked for right. We don't know, 100% know why? I think there could be a lot of different factors. But again, it's not a cure. Two of the major misconception that I hear is one is that it will make my tics worse if I don't do my tech, right. And there's this idea of the rebound effect. So for awhile, there was what we now know that myth they give like, if you holding your tics are just going to come back and forth. And just came to light, it seemed to be like from kids who would come home from school or ostensibly are holding in their tics trying to suppress their tics. And then they get really bad. They have

Michael Leopold  36:57
gotten old school now they're home and all the tics come out and yeah,

Jeremy Lichtman, PsyD  37:01
right. But when we've done careful studies on rebound effects, it doesn't exist and what seems to be happening maybe in the school situations, it's like, well, these are kids who are also they spent entire day in school, they're exhausted, right? They take the course when you're tired, they're more comfortable at home,

Michael Leopold  37:16
you got to do homework when you get home, like all the stressors.

Jeremy Lichtman, PsyD  37:20
zactly. So the idea that it will make your tics worse, there's a definite misconception that there's zero research, as far as I know, showing that it makes it worse. And another misconception is, oh, if I do this competing response that can become a tick. And I will not say that has never happened. But it is rarely rarely in the not 100. Yeah, but maybe even 100 Plus kids I've worked with with Tourette syndrome at this point, I've rarely ever seen a competing response become a tick, but the competing response, right, they've done what's called exposure and response prevention, which is a treatment for anxiety and OCD and PTSD. And they've done that with Tourette syndrome, which is basically eat your tea without the competing response. And the small scale studies, it works seemingly just as well as the competing response as H or T. The competing response is a tool to help us not engage with the tick, right and get that what's called habituation, right, that urge goes away. So that's another misconception is that like the competing response to become a tech, it doesn't seem to happen. And he's just a part of the tool.

Michael Leopold  38:22
That makes sense. Well, thank you so much, Dr. Littman, for all of your wonderful insight and input on this topic. Anything else that comes to mind that you want people to know about seebut or Tourette.

Jeremy Lichtman, PsyD  38:36
I think something that's really, really important is when we think about Tourette syndrome in general and CBIT more specifically, is to keep things in the boxes. That makes sense. And so what I mean by that is with Tourette Syndrome, there tend to be a lot of comorbidity, EDG, OCD, anxiety, learning disabilities, all of this stuff, right? It really comes a load, I think what's really, really important is that when we think of Tourette Syndrome, we are able to distinguish what is a tick or what is Tourette's? And what is these other things? Because I think what happens is when we talk about my kids, you know, and really, you know, we're talking about the the HD or the OCD will then end up happening is that they say and then CBIT didn't work for me. It's like, well, CBIT isn't meant for OCD. CBIT wasn't meant to help ADHD, and to just sort of homogenized and highlight all of the diagnoses, all the different challenges I don't want to be putting into just having just a text, I think really can can make it a lot more difficult to think about treatment and what treatment is going to be effective for what. And so I think that's a really important piece, right again, CBIT is not a cure, it's a tool. And it's a tool for kicks. It's not a tool for OCD. It's not a tool for ADHD. And you can have Tourette syndrome and ADHD and OCD and these can be different things that again, they do have all mixed together. It's not always clean cut, but I think it's an important distinction so that when we talk about our challenges, right, and I think about this in my own life between like, where he had been the challenge for me where my tics have been a challenge for me, and so it'd be recognize that they're not the same thing, always all the time.

Michael Leopold  40:12
No, that's a really important distinction to make to between the different comorbidities, especially with people were who'd have been looking specifically at OCD and the overlap with that people will talk about Tourette ik OCD and like that kind of unique mix. I mean, I remember as a kid, I, if I read a paragraph in a textbook, and I didn't understand it, the OCD part of my brain would tell me, okay, read it seven more times. And I would just reread the whole thing again, again, again, again, but I can tell you that that urge in my head to reread it again and again, again, was it felt like the urge to tick it was that it was a kind of premonitory urge, right? But you know, in this case, what you may be saying is, that wouldn't really be a candidate for a C bet. That is more of the OCD kind of speaking louder.

Jeremy Lichtman, PsyD  40:53
I would say that I mean, based on what you just described, that actually made me more of a tech, right, it's there with OCD of just getting it gets a little messy there. Right. And I don't want to deny that. But with OCD, what we're looking for is specifically obsessive content, right was there a, if I don't do this, something bad is going to happen, or whether the thought really like, I need to do this, or else this bad feeling would never go away, or the more just to see the illogical experience, right, maybe somewhere in your eye or head that made you have to reread and reread, right. So if it's more of the kind of like the content of like, if I don't reread the paragraph seven times, something bad is going to happen to me or my family, something I care about, the exposure I would do would be a little different than the than the feedback than the competing response behavior that I might do for it would be a little different.

Michael Leopold  41:41
My fear would always be that this is going to be on the test somewhere, I need to know it. So let me make sure I understand it. And then some and I would just keep reading it. And so that's

Jeremy Lichtman, PsyD  41:50
more of an OCD thing where I would actually there, right, like, if that was a tick, I would just have you read it once and then just has a page in front of you and not rereading it. You know, maybe closing your eyes, maybe putting the book down putting the book behind you. Maybe but for the OCD, what I do is for an exposure, I would probably have you, you read it once turned it over and then tell yourself because I'm not rereading this I am I am gonna fail, you know, and right.

Michael Leopold  42:14
Right, and work through that that thought process, you know, go down that rabbit hole of in your brain. Make sense? Well, Dr. Littman, thank you so much for your time. I really appreciate this. This was a great discussion. And so glad we get to have you on

Jeremy Lichtman, PsyD  42:28
I liked it, I can talk to a wall. So what's better than talking to a wall talking to a screen?

Michael Leopold  42:34
You got a bunch of listeners that will be eager to hear it. So now you have an audience for sure. Well enjoy the rest of your day and hope you have a wonderful week ahead as well. Thank you

Jeremy Lichtman, PsyD  42:43
so much for this opportunity. That was really

Michael Leopold  42:45
lovely. Likewise, take care. Thank you for listening to the uptick, brought to you by The New Jersey Center for Tourette syndrome and Associated Disorders empowering you to stretch the boundaries to live your best life. The NJ center for Tourette syndrome and Associated Disorders NJ CTS, its directors and employees assume no responsibility for the accuracy, completeness, objectivity, or usefulness of the information presented on this podcast. We do not endorse any recommendation or opinion made by any guest nor do we advocate any treatment