Suppressing Tics and Environmental Cuing of Tics—Why tics happen in one location/situation, but not another
Many individuals with TS give reports that tics are different in different settings: certain tics happen only in certain settings (e.g., at home, but not at school); certain tics are much more intense in certain settings (e.g., a hardly audible squeaking vocal tic that becomes a piercing shout in the privacy of one’s bedroom); and certain tics occur at a different rates depending on the setting (e.g., an infrequent eyeblinking tic that happens every couple of seconds in the car). What causes the variance in tics depending on location/situation? A possible explanation is tic suppression: holding back tics in places where ticking could lead to a negative outcome (e.g. ridicule, embarrassment). Unfortunately, suppressing tics can be a distraction that can interfere with other tasks (e.g. schoolwork, socializing, etc). If tic suppression explains low tics in certain settings, performance may be suffering in those settings.
Indeed, distraction is a common consequence of tics. Tics can cause distractions in school or work settings, such as distraction from suppressing tics, distraction from tic-related task interference (e.g. losing one's place while reading due to eye movement tics; speaking difficulties from sniffing tics, etc.), distractions from anxiety about tics, and distractions from negative social attention following hard-to-disguise tics (e.g. a grunting tic in a quiet classroom or work setting). Any of these distractions can disrupt performance. Having a plan for the management of TS can be important to help minimize the impact of distractions (see section on Learning to Live With TS).
Of the many distractions from tics, distraction from tic suppression may be less of a concern. Why is this? Over time, tic urges tend to decrease within any environment/situation where suppressing occurs. Conversely, tics urges tend to increase within any environment/situation where tics are not suppressed (see section on Premonitory Urges for further explanation of tic urges). When a new tic emerges, the inconsistent responding to an urge to tic in different settings (along with an varied presence of an urge in different settings) may predict where a tic will be frequent versus infrequent. For example, a child might have an urge to perform a grunting tic. At school, they worry about what their peers might think and suppress the tic. At home, they feel comfortable – there are not any peers around – so they perform the tic. Over time, the urge to tic becomes strong at home and weak at school. Therefore, the tic happens more frequently at home than at school with no change in distractibility. When the child enters the high-urge environment of the home, the urges to tic may come on strong, leading to a flurry of tics. This is not because the child has been suppressing his or her tics all day, but because home is an urge-cuing environment.
Knowing that tics can occur at different rates and intensities in different environments is important when thinking about tics. First, it explains why parents often feel that they see tics that no one else sees; they are probably seeing tics that are not present in other environments. Second, it can allay a concern that suppressed tics are leading to distractions in any environment where the tic is not present (or present at a lower frequency). The distraction from suppressing is likely to dissipate as the urge to tic decreases within the environment of suppression. Third, knowing that tics occur at different rates in different environments can be useful for behavioral therapy for tics, Habit Reversal Therapy (HRT/CBIT). I will often target environments of high-tic frequency as good places to practice HRT strategies for a specific tic.