Introduction

Tic disorders, including Tourette disorder and chronic tic disorder, are classified as neurodevelopmental conditions characterized by involuntary, repetitive motor, or vocal outbursts. Contemporary understanding of these conditions has shifted toward a neurobehavioral perspective that integrates innate biological vulnerabilities with learned behavioral patterns [1]. Although genetic and neurophysiological factors serve as the foundation for tic development, their expression is significantly influenced by situational influences and individual learning histories. A prominent feature of Tourette disorder is the experience of premonitory urges and unpleasant bodily sensations that typically precede a tic and are temporarily alleviated following its execution. Research has indicated that this sensation-relief cycle reinforces tics through negative reinforcement [2,3]. Premonitory urges are reported by approximately 92% of adults with Tourette disorder and 79% of children with Tourette disorder, highlighting their prevalence across different age groups [4]. Moreover, environmental triggers such as heightened stress or engagement in unpleasant tasks can exacerbate tic severity. When individuals avoid or prematurely terminate stress-inducing situations, tics may be unintentionally reinforced by avoidance learning [5]. Among the available non-pharmacological options, behavioral treatments have consistently demonstrated robust efficacy. Behavioral interventions may operate through both cognitive-behavioral and neurophysiological mechanisms, including modulation of cortico-striato-thalamo-cortical circuits, habituation to premonitory urges, and reduction in limbic hyperactivity. In particular, habit reversal training (HRT), comprehensive behavioral intervention for tics (CBIT), and exposure with response prevention (ERP) have accumulated strong empirical support. These interventions specifically aimed to disrupt the reinforcement cycles associated with tic expressions, especially the momentary relief of premonitory urges. This review offers an integrated examination of their clinical effectiveness, encompassing both short- and long-term outcomes as well as evidence from controlled trials.

Data collection

This review selected randomized controlled trials (RCTs) and systematic reviews published in English, focusing on the clinical efficacy of HRT, CBIT, and ERP. Literature research was conducted in PubMed, PsycINFO, and Embase using keywords such as “tic disorders,” “HRT,” “CBIT,” “ERP,” and “behavioral therapy.” Studies involving both children and adults were included. Network meta-analyses were excluded due to inconsistencies in intervention components across studies and concerns about comparability, which could limit interpretability.

1. Habit reversal training

Originally developed by Azrin and Nunn [6], HRT comprises several core components, including self-monitoring, awareness training, competing response training, motivational enhancement strategies, and generalization techniques. Later dismantling studies identified three elements—awareness training, competing response practice, and social reinforcement—as most critical in reducing tic severity [7,8]. Awareness training in HRT aims to help individuals recognize tics and the internal or external cues that precede them. This process involves identifying the occurrence of a tic (response detection), its physical characteristics (response description), and the early signals or premonitory urges that typically occur immediately before the tic (early detection). Once early signs are detected, the individual learns a competing response, which is an intentional behavior that physically prevents or interferes with the tic. This competing action should be socially acceptable, incompatible with the tic, and sustainable for at least 1 minute. Following detection, the patient implemented a competing response in real time to block the tics. Social support was integrated to reinforce the application of these skills. A designated support person, often a caregiver or partner, is trained to recognize the appropriate use of awareness and competing responses outside the therapy sessions, offering praise or encouragement to maintain adherence. This support system enhances the generalization of therapeutic behaviors beyond clinical settings. Through consistent application, individuals with tic disorders can become increasingly proficient in identifying tics early and interrupting the tic–urge cycle. The therapeutic rationale behind HRT is that by repeatedly inhibiting the tic in response to the premonitory urge, the link between the urge and tic is weakened, ultimately reducing tic frequency and severity [7,8].

The effectiveness of HRT

HRT has been the focus of numerous clinical studies and RCTs over the past several decades, consistently demonstrating its efficacy in reducing tic symptoms in Tourette disorder and chronic tic disorder. One of the earliest RCTs by Azrin and Peterson [9] compared HRT to waitlist controls and found significantly greater improvements in tic severity among those receiving HRT. This study, involving 14 participants, demonstrated that individuals receiving HRT showed significantly greater reductions in clinician-rated tic severity than those in the waitlist group. These findings highlight the potential of HRT as an active therapeutic intervention, in contrast to passive observation. An earlier study by Azrin et al. [10] compared HRT with a behavioral strategy called "negative practice" and reported superior outcomes for the HRT group, with effects sustained for up to 18 months. In the early 2000s, Wilhelm et al. [11] conducted an RCT comparing HRT with psychoeducation and supportive therapy (PST). Participants receiving HRT showed significantly greater improvements on the Yale Global Tic Severity Scale (YGTSS), with benefits lasting throughout the 10-month follow-up period. Similarly, Deckersbach et al. [12] reported better outcomes for HRT than for supportive therapy, with more than half of the participants classified as treatment responders after 6 months. Verdellen et al. [13] conducted a head-to-head trial comparing HRT and ERP and found comparable efficacy between the two in reducing tic severity, suggesting that both are viable behavioral options. More recently, Yates et al. [14] compared HRT with psychoeducation in a sample of 30 participants and found that while both groups improved, no significant difference was observed, raising questions about whether the benefits of HRT exceeded those of general therapeutic engagement in certain contexts. Overall, the evidence supports HRT as a robust behavioral intervention for tic disorders. It has outperformed passive controls and nonspecific therapies in multiple studies, and its benefits often persist. Although ERP and psychoeducation also show utility, HRT remains the cornerstone of behavioral treatment for tic-related conditions due to its structured approach and efficacy.

Key randomized trials demonstrating HRT efficacy are summarized in Table 1. HRT has demonstrated superior efficacy compared to various control conditions such as waitlist, supportive therapy, and negative practice across multiple RCTs.

2. Exposure with response prevention

ERP is another form of behavioral intervention tailored to tic disorders, building upon principles originally developed for obsessive-compulsive disorders. In its adapted format for tics, the ERP emphasizes sustained exposure to premonitory urges while intentionally inhibiting the associated tic response. This approach is grounded in the hypothesis that, through repeated non-reinforced exposure, individuals undergo habituation to aversive sensory phenomena, thereby reducing their urgency to tic over time [15]. Treatment typically begins with a training phase during which patients are guided to practice comprehensive tic suppression. As therapy progresses, patients shift their focus to internal sensations that signal the onset of tics and inhibit the motor response. Over time, the complexity of the sessions increases, incorporating focused attention on specific body regions where urges are felt as well as exposure—real or imagined—to environments that commonly trigger tics. Throughout this process, patients actively suppress their tics to weaken the link between the urge and the response [16]. Unlike HRT or CBIT, which typically target individual tics sequentially, ERP trains patients to suppress all tics simultaneously, to gradually lengthen the periods of complete suppression. This global suppression approach aims to disrupt the reinforcement loop by breaking the cycle of urge relief through tic execution [17].

The effectiveness of ERP

ERP represents a distinct behavioral treatment approach for tic disorders, grounded in principles that differ from those used in competing response-based interventions. The core mechanism of ERP involves systematically confronting the premonitory urges that precede tics while consciously inhibiting the tic behavior itself. Through repeated non-reinforced exposure, patients gradually become habituated to these sensory urges, leading to a decline in tic frequency and severity. Although ERP originated as a treatment modality for obsessive-compulsive disorder, it has been adapted to disrupt the reinforcement patterns observed in tic-related conditions. In a landmark RCT, Verdellen et al. [13] directly compared ERP with HRT in 43 participants. Both interventions led to meaningful reductions in tic symptoms, as assessed using the YGTSS, and no significant differences emerged between the two groups. These results validate ERP as an effective behavioral alternative to the HRT, particularly in individuals who experience intense sensory urges before the onset of tics. Rizzo et al. [18] investigated ERP using a three-group randomized design that included psychoeducational support and pharmacological treatment. Their findings indicated that ERP achieved therapeutic outcomes comparable to those of the other two interventions, highlighting their potential role in multidimensional treatment strategies for tic disorders. Despite these encouraging outcomes, ERP has not yet been studied as extensively as CBIT, and evidence of its effectiveness across various populations remains relatively limited. In addition, the extended duration of ERP sessions, often lasting between 90 and 120 minutes, can pose logistical challenges for routine implementation in outpatient settings. Nonetheless, ERP may be particularly well suited for patients whose tics are closely associated with sensory phenomena, or for those who show a limited response to other behavioral interventions, such as competing response training [18].

3. Comprehensive behavioral intervention for tics

CBIT can be viewed as an expanded and refined form of HRT, building upon its foundational strategies while integrating additional components to enhance therapeutic effectiveness [19]. Like HRT, CBIT retains essential behavioral elements, such as psychoeducation regarding tic disorders, awareness training, development and application of competing responses, structured social support, and the use of positive reinforcement to encourage skill acquisition and maintenance. What distinguishes the CBIT is its incorporation of relaxation training and function-based assessment/intervention, which are designed to target a broader range of internal and external factors that contribute to tic expression [16]. The relaxation techniques employed in the CBIT, including diaphragmatic breathing and progressive muscle relaxation, are based on the observation that increased anxiety and muscle tension frequently exacerbate tics [20]. Although these methods have not demonstrated robust long-term effects as stand-alone treatments, short-term reductions in tic severity have been observed [21]. Function-based assessment/intervention aims to systematically identify antecedents and consequences, both cognitive-emotional and environmental, that influence tic severity. Specific exacerbating variables were identified using structured interviews and self-monitoring. Once these variables are known, individualized strategies are implemented to mitigate them. These may include modifying environmental triggers (e.g., reducing discussions about tics and eliminating stressful activities) and reducing reinforcement patterns such as attention or task avoidance that follow tic occurrence. Additionally, patients are guided to manage internal contributors such as negative emotional responses or maladaptive beliefs related to tics [19]. Similar to HRT, the overarching goal of CBIT is to weaken the reinforcement mechanisms that maintain tic behavior. However, CBIT offers a more comprehensive approach by targeting both internal cues (e.g., premonitory urges, anxiety, and stress) and external situational factors. By addressing these multiple domains, the CBIT reduces the frequency and intensity of tic expressions, ultimately weakening the association between urges and tic performance [16].

The effectiveness of CBIT

CBIT is a structured, multicomponent therapy that evolved from the foundational elements of HRT. It integrates key behavioral strategies such as competing response training, psychoeducation, relaxation techniques, and function-based interventions aimed at identifying and modifying environmental factors that precipitate or reinforce tic behaviors. Over the past 20 years, CBIT has emerged as a first-line behavioral treatment for Tourette disorder and persistent tic disorder, supported by robust evidence from multiple large-scale RCTs. A pivotal study by Piacentini et al. [22] evaluated the efficacy of CBIT in a multi-site RCT involving 126 children diagnosed with Tourette disorder. Compared with those receiving PST, participants in the CBIT group demonstrated significantly greater improvements in tic severity, as measured using the YGTSS and associated functional outcomes. Notably, 52.5% of children who received CBIT were classified as treatment responders, in contrast to only 18.5% in the PST group. These results establish CBIT as an empirically supported treatment and contribute to its inclusion in the national clinical guidelines for pediatric Tourette disorder. The generalizability of the CBIT to adults was confirmed in a subsequent trial by Wilhelm et al. [23], which enrolled 122 adult participants. These findings mirrored those in the pediatric population, with 38% of adults treated with CBIT meeting the responder criteria and benefits persisting through a 6-month follow-up. This was particularly significant given the scarcity of effective behavioral interventions historically available for adults with Tourette disorder. In a randomized waitlist-controlled pilot trial, Ricketts et al. [24] demonstrated that CBIT delivered via Voice over Internet Protocol significantly reduced clinician- and parent-rated tic severity in youth with chronic tic disorders, with high treatment satisfaction and feasibility despite minor technological challenges. Rowe et al. [25] demonstrated that CBIT significantly reduced tic severity, distress levels, and improved children's self-perceived occupational competence and the value they placed on daily activities. Similarly, Nonaka et al. [26] evaluate a culturally adapted CBIT program in Japan and confirm its feasibility and effectiveness in a non-Western context. Recently, Chen et al. [27] provided preliminary evidence supporting the utility of abbreviated CBIT protocols integrated with treatment-as-usual in standard outpatient practice. Collectively, these studies reinforce the efficacy, adaptability, and scalability of CBIT. This treatment has demonstrated sustained benefits across developmental stages and clinical contexts, supporting its role as a broadly applicable intervention for individuals with tic disorders. A summary of the studies that evaluated the CBIT and ERP is presented in Table 2. CBIT is currently a widely supported behavioral intervention for tic disorders, with strong evidence of both short- and long-term efficacy across diverse settings.

ERP is a promising alternative, particularly for individuals with strong premonitory urges, but more longitudinal studies are needed to establish its durability. Table 3 summarizes the key features and differences among HRT, CBIT, and ERP.

Conclusions

Behavioral therapies grounded in learning theory have demonstrated strong efficacy in managing tic disorders. HRT focuses on disrupting the reinforcement cycle associated with premonitory urges, whereas CBIT builds upon this approach by addressing contextual and emotional contributors to tic expression. By contrast, ERP emphasizes repeated suppression in response to premonitory urges to promote habituation. Collectively, these interventions represent the leading non-pharmacological treatment options. Among these, HRT and CBIT have been the most extensively studied, with consistent evidence supporting their effectiveness in terms of both short- and long-term outcomes. In particular, the CBIT offers enhanced clinical flexibility by incorporating function-based and motivational strategies. ERP is a promising alternative, especially for individuals whose symptoms are closely tied to sensory phenomena. In Korea, a shortage of trained behavioral therapists and limited insurance coverage make it challenging to implement full CBIT protocols in clinical practice. Therefore, simplified HRT modules or parent-based online education programs could serve as realistic alternatives. Moreover, ERP techniques may be more feasibly adopted by clinicians with prior cognitive-behavioral therapy experience if adequate training systems are developed. The limited number of ERP studies likely reflects a lack of trials rather than inefficacy, and future work should emphasize methodological rigor, including randomized assignment and blinded outcome assessors. Given the practical constraints of long-term studies in behavioral treatment research, meta-analyses and network meta-analyses using existing data may provide viable alternatives for comparative efficacy assessments and cross-population applicability. To advance the field, future studies should employ more rigorous methodologies, such as blinded outcome assessments, inclusion of larger and more diverse populations, and multicenter designs to enhance the generalizability of the findings and support wider implementation in routine clinical practice.

Article information

Conflicts of interest

No potential conflict of interest relevant to this article was reported.

Funding

This study was supported by a 2025 research grant from Pusan National University Yangsan Hospital.

Author contributions

All the work was done by Bum-Sung Choi.

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Figure & Data

References

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