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.

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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) 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 and often worsen with stress or fatigue.
Trichotillomania	Recurrent pulling of hair from the scalp, brows, lashes, beard, or body, enough to cause noticeable hair loss. Often a private struggle for years before anyone names it.
Excoriation (skin-picking)	Recurrent picking at skin, leading to lesions, scarring, and shame about being seen.
Other body-focused 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 treatment is Comprehensive Behavioral Intervention for Tics (CBIT). It is what the American Academy of Neurology’s 2019 practice guideline places ahead of every other behavioural therapy, and it works without the side-effect load that medication can carry.

In the landmark trial behind that recommendation, just over half of the children who did CBIT were rated much or very much improved, against fewer than one in five given supportive therapy alone, and most who responded still held those gains six months later (Piacentini and colleagues, JAMA, 2010; American Academy of Neurology, Neurology, 2019).

For trichotillomania, skin-picking, and the other body-focused repetitive behaviours, the core treatment is Habit Reversal Training (HRT), the same engine that sits inside CBIT. Behavioural therapy built around HRT is the first-line psychological treatment for these conditions, with randomised trials showing real, lasting reductions in pulling and picking. Medication has a much thinner evidence base here, which is part of why the behavioural work carries so much of the weight.

What the work involves, in plain language:

Awareness training	Learning to feel the premonitory urge clearly, the uncomfortable build-up before the movement. It is the lever everything else turns on.
Competing response	A specific physical response, incompatible with the tic or pull, held until the urge fades. Not suppression, just a different muscle group while the urge passes through.
Functional intervention	Identifying the situations and states that reliably make things worse (sleep debt, stress at school or work) and changing what we can.
Family and environment, for children	Parents and sometimes siblings learn the protocol so the child is not the only one carrying it. The child is never held responsible for tics.

For hair-pulling (trichotillomania) and skin-picking (sometimes called dermatillomania), I usually work inside a fuller framework called ComB, short for Comprehensive Behavioral. No two people pull or pick for quite the same reason, so before we try to change anything, we map what your particular habit is actually doing for you: a sensory craving, a way of discharging tension or boredom, a thought that quietly gives it permission, a motor pattern your hands fall into while your mind is elsewhere.

The plan is then built around those specific functions, rather than one technique applied to everyone. There’s a randomised trial behind this approach for hair-pulling (Carlson and colleagues, Behavior Therapy, 2021), and in practice it’s where I see the work genuinely move.

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.

Because tics so often travel with OCD, I stay connected to that field as a Professional Member of the International OCD Foundation (IOCDF), a community of clinicians and researchers working on OCD and related disorders.

What this looks like in practice

First consultation	Up to two hours, typically SGD 700. We map the history, what the tics look like now, what makes them better or worse, what has been tried, and what else is in the picture. You leave having learned something real, even if we decide another clinician is the better fit.
Treatment	Sessions are 60 to 90 minutes. CBIT and HRT typically run over 8 to 14 sessions, weekly at first, spacing out as the protocol takes hold.
Children and teens	Parents are in the work, not just informed about it. The family carries the protocol between sessions. School coordination is part of the package when it helps.
Adults	Many adults were never offered the behavioural treatment as children. Starting in adulthood works. The protocol is the same, calibrated to the life you are 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. My clinical-fit page walks through how I think about fit.

Sessions, fees, and scheduling

Sessions are sixty to ninety minutes, pro-rated at SGD 350 per hour. The first consultation is usually up to two hours, typically SGD 700. Sessions on Saturdays, Sundays and public holidays carry published weekend and holiday rates; weekday evenings after 5pm run slightly higher than daytime. 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.