Tics, Tourette Syndrome & Habit Disorders
Most of the children and adults I see for tics arrive having been told some version of the same thing: just stop, don’t think about it, you’re doing it for attention. None of that is true. Tics are not a choice, not a habit you can simply break, and not a sign of weak willpower. They are involuntary movements or sounds that come with their own internal pressure: a building urge, a brief release, and the quiet exhaustion of trying to hold them in.
The same is true for hair-pulling, skin-picking, and the other body-focused repetitive behaviours that often get treated as bad habits. They aren’t habits in the everyday sense. They follow a predictable pattern of urge, action, and short-lived relief, and most people who do them have already tried, more times than they can count, to stop.
What I see in the room
The presentations I work with most often:
- Tic disorders and Tourette syndrome. Repetitive motor tics (blinking, head jerks, shoulder shrugs, complex sequences) and vocal tics (throat-clearing, sniffing, words). Tourette syndrome is the diagnosis when both motor and vocal tics persist for more than a year. Tics wax and wane, often worsen with stress or fatigue, and can cause real social distress at school, at home, or in front of colleagues.
- Trichotillomania. Recurrent pulling of hair from the scalp, eyebrows, eyelashes, beard, or body, leading to noticeable hair loss. Often a private struggle for years before anyone names it.
- Excoriation (skin-picking) disorder. Recurrent picking at skin, leading to lesions, scarring, and shame about being seen.
- Other body-focused repetitive behaviours. Nail biting, cheek biting, lip chewing, and similar patterns when they cause physical damage or real distress.
Tic disorders and BFRBs commonly co-travel with OCD, anxiety, and ADHD. That overlap is part of why I see them in this practice. Neurodiversity and the OC-spectrum share a clinical lineage, and most people who walk in with tics or hair-pulling have at least one of those other pieces in the picture too. A careful first session sorts out what’s driving what before treatment begins.
CBIT and HRT — what the evidence-based work actually looks like
For tics and Tourette syndrome, the first-line behavioural treatment is Comprehensive Behavioral Intervention for Tics (CBIT). For trichotillomania, skin-picking, and other BFRBs, the core protocol is Habit Reversal Training (HRT), which is also the central component inside CBIT. Both are recommended as first-line by the American Academy of Neurology’s 2019 practice guideline, with effect sizes comparable to medication and durable beyond the end of treatment.
What the work involves, in plain language:
- Awareness training. Most people with tics or BFRBs are surprisingly unaware of the urge that precedes the movement. The first piece of the work is learning to feel that urge clearly. It sounds small. It is the lever everything else turns on.
- Competing response. A specific physical response, incompatible with the tic or pull, that is held until the urge fades. It is not suppression. It is using a different muscle group while the urge passes through.
- Functional intervention. Identifying the situations and internal states that reliably make tics worse (sleep debt, stress at school or work, certain settings) and changing what we can.
- Family and environment work, for children. Parents and sometimes siblings learn the protocol so the child is not the only one carrying it. Schools are looped in when that helps. The child is never the one held responsible for tics.
CBIT and HRT are not about willing tics away. They give you a working relationship with the urge, so the urge stops running the show.
When tics travel with OCD, anxiety, or ADHD
This page sits inside the same clinical neighbourhood as my anxiety and OCD work, and that is not an accident. Tic disorders and OCD share substantial genetic, neural, and treatment lineage. Exposure-based CBT for OCD and HRT for tics are sibling protocols. ADHD turns up in a substantial proportion of children with Tourette syndrome and changes how treatment lands.
Practically, that means the first consultation does more than treat the tics. I look at the OCD piece if it is there. I screen for ADHD when the picture suggests it. The work gets sequenced thoughtfully. Sometimes the tics aren’t the most distressing thing, and treating the anxiety or the ADHD first changes everything.
What this looks like in practice
First consultation. Up to two hours, at SGD 600. We map the tic history, what they look like now, what makes them better and worse, what’s already been tried, and what else is in the picture. My aim is that you leave the session having learned something real about what’s going on, even if we decide together that another clinician is a better fit for the ongoing work.
Treatment. Sessions are sixty to ninety minutes, variable but structured, depending on what the work needs that day. CBIT and HRT are typically delivered over 8 to 14 sessions, weekly at first, spacing out as the protocol takes hold. Some families do well with a shorter course. Others need longer when there’s significant comorbidity.
Children and teens. Parents are in the work, not just informed about it. For school-age children especially, the family carries the protocol between sessions, and that’s how change consolidates. School coordination is part of the package when it helps.
Adults. Many of the adults I see with tics or BFRBs were never offered the behavioural treatment as children, or were told they would grow out of it. Starting in adulthood works. The protocol is the same. The language is calibrated to the life you’re actually living.
Who this is for, and who it isn’t
This page is the right starting point for children, adolescents, and adults whose primary presentation is tics, Tourette syndrome, trichotillomania, skin-picking, or another body-focused repetitive behaviour, with or without co-occurring OCD, anxiety, or ADHD.
This is not the right starting point if the primary need is medication management for severe Tourette syndrome. That work belongs with a paediatric neurologist or psychiatrist, and I am happy to coordinate care alongside the prescribing clinician. If the picture suggests a different primary concern, I’ll say so on the first call and point you to someone who fits better. /clinical-fit/ walks through how I think about fit.
Sessions, fees, and scheduling
Sessions are sixty to ninety minutes, pro-rated at SGD 300 per hour. The first consultation is usually up to two hours at SGD 600. After-hours sessions (weekday evenings, Saturdays, Sundays and public holidays) carry a published rate. Full structure on the fees page. Payment is due before each session.
If you are not yet sure whether to book, the free 15-minute Meet & Greet (Zoom or phone) is a low-friction first step.