Speaking of Psychology - Understanding Tourette disorder and other tic disorders, with John Piacentini, PhD

Episode Date: March 18, 2026

Tourette disorder and other tic disorders affect millions of people yet remain widely misunderstood. John Piacentini, PhD, director of the UCLA Child OCD, Anxiety, and Tic Disorders Clinic, explains the brain basis of Tourette disorder; talks about why tics are very common in young children; debunks common myths—such as the idea that Tourette disorder mainly involves uncontrollable swearing—and discusses how recent behavioral therapies are helping many patients manage tics. Learn more about your ad choices. Visit megaphone.fm/adchoices

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GoogleFi Wireless is not subject to data traffic deprioritization during times of high network usage. Tourette disorder and other tick disorders affect up to one in 50 school-age children in the U.S. according to estimates from the Centers for Disease Control and Prevention. Yet, the disorders are often widely misunderstood. Many people associate Tourette's with uncontrollable swearing, but that symptom is actually relatively rare among the constellation of motor and vocal ticks that make up Tourette's. Meanwhile, for many years, medications were thought, to be the only effective treatment for tick disorders. But in recent decades, researchers have developed effective behavioral treatments that are now a frontline option. Today we're going to talk to a psychologist

who's been one of the leaders in developing those treatments. We'll ask him, what is the state of science around Tourette's and other tick disorders? What causes these disorders? How common are they, and at what age do they usually begin? What treatments are available, and when are they necessary? and where can patients and families go to learn more. Welcome to Speaking of Psychology, the flagship podcast of the American Psychological Association that examines the links between psychological science and everyday life. I'm Kim Mills. My guest today is Dr. John Piacentini, a professor in the UCLA Department of Psychiatry and Biobehavioral Sciences,

at a board-certified clinical psychologist. He directs the UCLA Child OCD, Anxiety, and Tick Disorder, clinic, which provides diagnostic and treatment services for those disorders. Dr. Piacentini's research has focused on developing and testing effective treatments for youth OCD, anxiety, and ticks. He's published more than 300 scientific papers and chapters, as well as nine books. He also co-chairs the Scientific Advisory Board for the Tourette Association of America. Dr. Piacentini, thank you for joining us.

It's my pleasure. Thank you for inviting me. inviting me. Could you start by giving us an overview of what Tourette's and other tick disorders encompass? And how is Tourette's diagnosed? How does it differ from other tick disorders? Well, Tourette's disorder and other tick disorders are characterized by obviously the presence of ticks. And we think of two types or general categories of ticks. The first is motor ticks. And these would be like eye blinking, head shaking, maybe arm movements, leg kicking, even stomach tensing or abdominal tensing. So those are motor tics. And vocal tics is the other category, or phonic tics. And these are making noises like maybe whistling or grunting or throat clearing.

And then the coprolalia, which I think you had referenced, which is, would be using vulgar or profane words. And that's, those are, those are less rare. Tarrette syndrome or Tourette disorder basically means that you have motor ticks and phonic or vocal tics. You'd make noises and you do movements. The other types of diagnoses would be a motor tick disorder, and that is the motor tics without the vocal tics, and then vocal tick disorder, which would be vocalizations without the vocal tic disorder. motor behaviors. Now, vocal ticks in the absence of motor ticks are extremely rare. Now, I want to ask about the recent controversy at the British Academy Film Awards when Tourette's advocate John Davidson shouted a racial slur during the ceremony. And we talked about

this being called coprolalia. I understand it's less common than people think. Why does coprolalia occur and how common is it in actuality? In actuality, it's. In actuality, it's It's about maybe 10% of people with Tourette's disorder, maybe up to 15%. So it's not that common. And the problem with my coprolalia occurs because, you know, people would say, how could somebody do that? How could somebody say a word like that? Especially in the settings in which these types of behaviors or sounds are made.

And it goes back to the way we think about ticks and the way that ticks work. So if I can go into a little bit just about maybe the basic neurology of ticks and then come back because I think it will make it more helpful to understand. So ticks arise in the brain. They're little bits of what we call chunks of behavior. So for example, if you reach for a coffee cup, you just reach for the cup. You don't think about it. Your arm goes smoothly. You grab the handle.

You bring it to your mouth. You drink the coffee. You put it back down. There's no thought involved. But that action may involve hundreds, even more, of very minute motor movements. You need to know where you are in space. Your hand needs to move. You need to pick it up without spilling any of the coffee.

It's all unconscious. And that's because our brain anticipates what we want to do or behavior. Our brain is really, like, loaded and ready to go, and it anticipates. So if I'm thinking maybe about coffee, my brain is already assembling all the little muscle movements, instructions for the muscle movements, and sending them down through my brain, through the basal ganglia, up to my muscles so I can grab the coffee. If I decide that I don't want the coffee, all those little behaviors just evaporate. They go away.

There's a filter in our brain that only lets through the behaviors that are going to be useful to us. Now, in Tourette's, the Tourette's brain is overactive in terms of creating these little bits of behavior. It runs a little hotter. So all these behaviors are just waiting to go down and be released and turn on muscles. The problem is the filter that keeps our brains from engaging in all these behaviors is a little leaky in people with Tourette's.

So a lot of these behaviors get through. So if you see somebody with Tourette's, you see ticks are just things that we would do anyway. Moving my hand, smiling, shouting, making a noise, kicking my legs, tensing my stomach. these are just typical behaviors. They're coming out at the wrong time. So we have an overactive brain and less inhibition or leaky or filters to let the behaviors through. So if you're in a situation where all these behaviors are floating around in your brain and

you're starting to think, I don't want to do these, it's really embarrassing. And of course, your brain is going to focus on the stuff that's most embarrassing or most hurtful or worst. And that's where coprolalia comes from. If I'm in a situation and I see something and I say, I can't do the wrong thing, somebody with coprolalia, that behavior is going to trigger. Don't say this word. Don't make that movement. That word and that movement, that little piece of behavior is going to be released. And that leaky filter is going to let it through. So we think about coprolalia as behaviors or sounds or noises that almost always occur at the worst possible place at the worst possible time. Because the more I'm thinking not to do something in Tourette's,

it's going to happen, you know, at least some time. It's like the old saw about, don't think about a blue elephant. And now, of course, everybody will think of a blue elephant. That's exactly right. Well, what do we know about the causes of Tourette's and other tick disorders? Are they genetic? Do they run in families? Yeah, Tourette's is genetic. There's a genetic component to it.

Tourette's do run in families. You know, so we see that quite a bit. It really is brain-based. There are some neurotransmitters that are involved in regulating some of these areas. of the brain, like I was talking about the basal ganglia. And these are kind of a transmission, you know, of our brain that converts intention to action in other areas of the brain related to the ability to inhibit unwanted behaviors, to express behaviors and also to inhibit behaviors. And these areas, neurotransmitters tend to not work as well. So we used to think of the brain

is really overactivity. It was too active. And that is still part of the reasoning. But it really also is that it's also a lack of inhibition, as I said earlier. People with Tourette's have a harder time stopping these behaviors. It's like they're more impulsive in certain ways. When in development do tick disorders typically manifest? And if they show up in kids, do children sometimes just outgrow these things? So we can see ticks very young in life. The typical onset age, though, is around four, five, six or so, maybe seven, about up to 20 percent of young children in that age, kindergarten first grade, exhibit ticks. So they've done surveys in classrooms encountered ticks. So ticks are quite normal. And it's kind of a growing pain kind of a thing,

is, you know, bodies and brains mature. But only about 2%, 2 to 3% of these kids will the ticks stay on last longer than a few weeks or a few months. So we see them quite commonly, and there's a diagnosis for children with ticks that have had ticks for less than one year. We call them provisional tick disorder, because there's a likelihood that many of these kids will outgrow their ticks over time. We don't really know why 20% of first graders have ticks and only 2% of fifth graders. It's probably related to brain maturation of some kind. Now, I know that Tourette's often co-occur with obsessive compulsive disorder and ADHD. Why are these overlaps so common? And are there even other mental health conditions that co-occur with Touretz? We know that there are much higher

rates of OCD, much higher rates of ADHD. We see high rates of anxiety in children with Tourette's. And we also see pretty frequent ticks in youth with autism and related disorders. And it's not clear why there's probably some overlapping mechanisms in the brain that might lead to this overlap. Again, some of these are disorders of disinhibition. Certainly ADHD is characterized by impulsivity, you know, difficulty in controlling some behaviors similar to Tourette's. We see with OCD, OCD is also characterized by unwanted behaviors. I have a bad thought or a feeling and I need to engage in a behavior. I may do things that potentially even could be harmful, if not embarrassing.

So there's some overlap as well with OCD. We also consider all of these disorders as disorders of negative reinforcement. So there are also environmental, non-biological aspects that we feel relate to these behaviors. And what a disorder of negative reinforcement is, well, first let's talk about positive reinforcement. If I do something good and I get a reward, I'm going to do it again. That's positive reinforcement. That's we get paid to go to work. We get good grades in our job, you know, whatever that might be.

Negative reinforcement is if I make something bad go away, that's also going to be reinforced because I don't like feeling bad things. So with the OCD, I have a lot of anxiety. I feel my hands are dirty. I feel I'm going to get sick. So I wash my hands and the threat disappears and that feels very good. That reinforces my hand washing. I'm making something bad go away.

Same thing with ticks. So ticks are often triggered by something called the promontory urge. A tightness, an uncomfortable feeling, an urge. sometimes it's even kind of just a sensory feeling that I need to make this movement. I'm really uncomfortable right now. And when I do the tick, that bad feeling goes away and that reinforces the tick. So in some ways, ticks can actually be helpful by making these bad feelings go away. So all of these disorders kind of have similar relationships in that area.

During the COVID-19 pandemic a few years ago, you published a study that found a rise in tick disorders among young people that was tied to social media use. Can seeing ticks on social media really cause people to develop ticks? Yes and no. We think of the, you know, the psychiatric psychological diagnosis of Tourette's syndrome, of persistent tick disorders, which were the ticks lasting longer than a year of either motor or vocal, of provisional ticks, which are the ticks that were not sure if, they're going to last longer than a year. But their ticks occur in a lot of other places and people

in a lot of other times. So people with individuals with ticks, if they see somebody else ticking, that's likely to start them ticking. They can be contagious. And we see people that are doing ticks that don't have a formal diagnosis of tick disorder. They may be non-biologically related ticks. And that's what we are seeing over COVID. And these ticks, have a number of names, but most commonly they're called functional ticks, functional neurologic disorder or functional tick-like behaviors. And that means that there's no known ideology or known biological ideology for these ticks. They're just kind of happening out of the blue to some extent. Your summer starts now with Memorial Day deals at the Home Depot. It's time to fire up summer

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When we return, we'll talk about treatments for Tourette's and other tick. disorders, including behavioral therapies. Well, let's shift gears and talk about treatments. I know historically medications have been the main treatments for tick disorders, but in recent years, the behavioral treatments that you and others have developed have become very common options. To tell us about the history and where we are right now and what are these behavioral treatments. Yeah, and I think the history of treatment is really fascinating for a number of reasons. So, Childe La Tourette, who was the person that published one of the first case series of these behaviors

and the disorder ended up being named after him, was in the early 1900s. He was a French neurologist, and he worked with another neurologist, Charkot, who was a contemporary of Sigmund Freud. Student or contemporary, I can't remember exactly. So when these ticks were first you know, started being described and people started diagnosing them, they were considered symptoms of, you know, psychoanalytic trauma because that was a zeitgeist at the time, right? So psychoanalysis was the treatment of choice and it didn't work because it was a neurologic disorder. And actually, I'm a behaviorist, you know, I have respect for all treatments, you know, including psychoanalysis, although I tend to be more evidence-based, and psychoanalysis is isn't

as evidence-based. But again, with the zeitgeist of the times when the patients weren't getting better, they were blamed for their lack of improvement because in psychoanalysis, the patient needs to work to undercover these hidden traumas that are triggering the ticks. And there was no underlying hidden trauma. It was a biological disorder. So there was a lot of backlash against therapy of any kind, psychiatry or psychology. And as soon as medications in the 1950s, by accident, some medications were found to help ticks, it immediately, the understanding of the disorder immediately swung from more of a psychological to a biological understanding. And it a biological disorder. But as we will continue to talk, when I get to the behavioral treatments,

psychological factors are very important. So it was all medication all the time. And this went through about the 1960s, 1970s, when a couple of people started looking at behavioral treatments. Now, there had been some treatments in the 50s that were a little wacky behavioral that didn't really work. But a brilliant psychologist, and some of the listeners may know who, who this is, Nathan Azrid, who was a brilliant behaviorist. He and his colleagues, Asron and Nunn, published a paper looking at something called Haber Reversal Training, where it's basically, don't do your tick, was kind of the way that it worked. And it actually worked kind of well, but not as well as maybe people thought at the time.

The research methodology wasn't very strong. But medication still remained the same. and the kind of the old psychoanalytic beliefs that if you try not to do your tick, if you try to hold your tick in, your brain might blow up. I mean, it really, you know, you can't, it's not a good thing to do. Yeah. So the more work was developing on this. And in the late 90s, myself and some of my now colleagues at different places,

including Harvard, started working on treatments and refining these behavioral treatments. and the primary treatment was, again, called habit reversal training, and this is what Azarin had developed, where you try to identify your ticks, keep track at your ticks, recognize the warning sign. Again, ticks are triggered by, in many cases, by a promontory urge or a sensation. I feel like I need to do my tick. I do my tick. The bad feeling goes away. So from behavioral principles, behavioral psychology, we know that if you have this urge and you don't do the tick, the urge is going to get stronger. It's going to be really uncomfortable. But at some point, your body will habituate and the urge will go away without doing your tick.

So the key was to teach patients how to recognize the urge, engage in a behavior incompatible with the tick so that they wouldn't do the tick and wade it out. And lo and behold, it actually worked pretty well. And the way that the patients were able to not do their tick was to do an incompatible response. So do the opposite of the tick. So if I had a head shaking tick, the idea would be to kind of tense your neck muscles gently just enough to hold your head in place and not do the tick. Or if I had an arm tick to hold your arm into your body so it wouldn't move. For vocal ticks, the competing response is breathing in an opposite pattern.

So if I have a yelling tick, if I breathe in through my mouth and out through my nose in very controlled fashion, I can't make any noises. If I have a sniffing tick, I breathe in through my mouth and exhale through my nose so I can't do the sniffing. Snippin. And that worked pretty well, but it wasn't getting a lot of traction. You know, cycle farm was still the big treatment. And cycle farm works quite well. We use a lot of cycle farm in our clinic. I'm not saying it's not an effective treatment. But a lot of children, you know, ticks are most common in children. and families were worried about using some of these medications, which were pretty strong in children with ticks.

So the Tourette Association of America, which is the international leading organization to support Tourette's research and families, commissioned a work group, the Behavioral Sciences Consortium, and I was asked to lead that group. And we had all the people that did behavioral treatments, including physicians, get together and try to come up with a new treatment that we could use. And we knew that habit reversal training would be the most important part of this. And we added a family behavioral component as well. And the reason we added this is, I think I'd said earlier, that the environment can reinforce ticks.

So if, and this is also some work done by Azrin and others. If children are ticking and somebody yells at them to stop ticking, that's going to make them more anxious and probably tick more. And that's negative reinforcement. If children are ticking and mom and God love moms, you know, say, oh, Billy, you're ticking, you don't need to do your homework, here's some cookies. That's going to be great for Billy, but that's reinforcing ticks, right? We all know about positive reinforcement, right?

Pavlov and his dogs, et cetera. So we created another component designed to create a, tick neutral environment, the child should not be punished nor rewarded for ticks in order to support reduction in the ticks. And we put those together and that was called the comprehensive behavioral intervention for ticks or cbit because it's comprehensive because it has the direct habit reversal to directly affect children, teach them how to manage the tick and resist the tick. And the other piece would be, we call it the func shell or the environmental piece by creating a neutral environment that doesn't reinforce ticks or create negative energies or anxiety that might also

increase ticks. And we were lucky to get funded and do two large studies and show that it worked. What are the drugs you were alluding to that may help people with tick disorders? The most common, well, originally these were neuroleptic medications. So the same kinds of medications that would be used for psychosis. like Haldol, there was another one, ORAP, that were pretty powerful drugs. More recently, now there are some new classes of medication, so probably the most common medications.

We still use some of the neuroleptic medications, but newer versions. And then there's medications called Alpha II antagonists, which are Guantucine and Clonidine. And these are a little bit milder, but the medications are still have a lot of side effects. So we use them when we need to. We use them in combination with CBIT. But if we can, we're going to want to do a behavioral treatment, a non-medication treatment first, if it all possible. Sure. Is treatment always necessary? I mean, how can patients and families know when they really need to learn CBIT, for example? The most common treatment throughout history for Tourette's, especially in children, has been watch and wait, or psychoeducation and support.

and we would recommend that as well because we know a lot of kids, very young kids, there is a chance that their ticks might resolve on their own. And with medication, especially the medications, you know, did have side effects. You know, it really was, let's just see what happens. Let's support the child. Let's watch. And hopefully the child will grow out of the ticks. So even in our clinic, if a child is very young or the ticks are very mild,

we probably would say let's watch and wait. we are always, always going to teach the families that environmental intervention. Ignore the ticks. The child should gain nothing or lose anything because of the ticks. The child should still go to school, should still have friends, should go to birthday parties, whatever it is with the ticks. We don't want the child to be treated any differently than a child without ticks because that, again, will help build some resilience and we want,

and then we'll see what happens. Most kids do end up, you know, if kids are having ticks that are seven, eight years old, and even if they're going to be potentially temporary, we may try CBIT with them because it's a pretty simple treatment. And it's not that hard to do. So if we can shorten the duration of the ticks or potentially prevent worsening ticks with the behavioral intervention, we can do that. But children that are a bit younger than that, the treatment may be more difficult.

There we would watch and wait. What got you interested in this line of research? I actually was an OCD researcher. And I moved to UCLA from Columbia University in 1995 to start an OCD program, a treatment program, again, using behavior therapy. And we started seeing a lot of kids with comorbid ticks. So my boss said, you need to learn about ticks. And he sent me to a support meeting. a Tourette's, a parent's support group for kids with Tourette's.

And I went to this meeting and they said, oh, we're so glad you're here. We have all these questions. And I said, no, I don't know anything about Ticks. I'm here to learn from you. And they all looked at me, you know, with this surprise. And then they realized what a great opportunity. So that was my start. And so I take it there are support groups around the country for people who are listening

if they're interested in joining one. How do they find one? Yeah, if I can, the Tourette Association of America. I think it's Tourette.org or TAA.org is an amazing resource. They have lists of support groups. They have tons of material. I work quite closely with them, and they can provide support. Or, you know, you can go online or, you know, just look for Tourette support group in your area.

Seabit is becoming much more common. And again, going back to the Tourette Association, they were our partners on this grant. It was the CBIT treatment studies were supported by the National Institute of Mental Health with the TRED Association as a partner. And once we completed the study and showed that the treatment was very safe and effective, they created a program to disseminate these details. So they sent us all over the country to give talks and do workshops and support the dissemination of this treatment. So it's actually pretty well available in a number of places now as a result of that.

Are there any other myths or misconceptions about Tourette syndrome that we haven't covered? That's a good question. You know, individuals with Tourette's are just like anybody else. They're just as smart. They're just as funny. They're just as athletic. I think that's been something of trying to kind of destigmatize or demystify Tourette's. Going back to kind of before the behavioral treatments, when we're really, we're really,

really no good treatments. There was medication. The idea was that these kids needed to be sheltered because we knew that stress increased ticks, and these kids were patientized. They were treated almost as invalids and just keep quiet, let's not stress. You really shouldn't go out. You shouldn't do other things, you know, because you don't have that capacity. Because people learn very early on that stress, anxiety, attention would worsen ticks. Again, like I was saying before, if a child is in a situation where they're afraid to tick, they're likely going to tick. And what we learned through our treatment, the behavioral treatment is, you know, don't hide, but, you know, seek out and believe in yourself and push yourself and go into these situations.

We want you to lead a normal life. We want you to push and be out there and be active and have and have faith and confidence that you're going to be able to do these treatments. And in fact, that was a big turning point. And I think the way we understood Tix is a result of some of these behavioral work that we and many others have done is you need to get out in society and live your life and face the challenges and be accepted. The other issue is that people don't really understand Tourette's in the community, and especially with coprolalia.

People think that coprolalia is purposeful during COVID when you're in a situation and you're around and you have a coughing tick. What's going to happen? Don't cough, don't cough, and these kids were coughing like crazy. And it was a tick. They weren't sick and they were getting kicked out of school. We had a number of kids with coprolalia, maybe shouting out sexual words again during a lot of the societal, social changes that were going on. And the number of individual threats got arrested for shouting profanity or shouting, you know, sexually, you know, unwanted words, or either maybe reaching out and trying to touch somebody. You know, the tick, there can be like a touching tick.

And it was really, really, really a dark time. So society hopefully is coming around, but we still need to spread the word that these folks are like anyone else. It's uncontrolled. They don't want to do these things. They're not shouting out profanity because they believe. believe in it, they're shouting it out because they're trying not to, because they don't believe in it. So just to wrap up, what are you researching now?

What are the big questions that still need to be answered? In Tourette's, well, I work one of my close colleagues at UCLA, Dr. Sandra Lou is looking at EEG, and we're looking at some other trying to better understand the biology of Tourette's and the underlying neurology. some work going on with transcranial magnetic stimulation as a, not for kids yet, but, and don't go rushing out because it hasn't been really, it's just only starting to be studied. So looking at different kinds of more sophisticated biological interventions, but the real important thing is trying to identify, create awareness, greater awareness in the

community, because if everybody was able just to see somebody with Tourette's and ignore their ticks, I have no doubt that the level of ticking would go down pretty dramatically because the reason people, the ticks are get worse is because the more you try not to tick, the more you're saying, I can't do this, the stronger and stronger it's going to get in the louder and the bigger and the more intrusive the tick will be. So it really is a matter of educating the community. And I think the BAFTA event is difficult as it was, you know, for the presenters who were the targets, as well as John Davidson, you know, it was really, really an unfortunate situation

all the way around. But something like that, if it is able to raise awareness significantly and lead to better lives for these folks, then, you know, that may be a good thing. Yeah. Well, Dr. Pia Chintini, I want to thank you for joining me today.

I think this has been interesting and enlightening. Great. Thank you very much. You can find previous episodes of Speaking of Psychology on our website at speakingof psychology.org or on Apple, Spotify, YouTube, or wherever you get podcasts. And if you like what you've heard, please subscribe, leave a review. If you have comments or ideas for future episodes, you can email us at speaking of psychology at APA.org. Speaking of psychology is produced by Lee Weinerman. Thank you for listening for the American Psychological Association. I'm Kim Mills.