At first blush, tics, stims, and compulsions can look pretty similar to the untrained eye. All three are repetitive behaviors that are seemingly involuntary. They all have a coping or self-regulatory function and can show up in a wide variety of ways.
They’re also all associated with distinct underlying conditions. It’s these distinct root causes that tell mental health care providers how to treat them or whether to treat them at all. Yet another thing stims, tics, and compulsions share is that two or even all three can show up in the same person simultaneously.
In this article, we’ll get a handle on what stims, tics, and compulsions are, how to tell them apart, the underlying disorders that they’re associated with, which of them can be effectively treated in a mere matter of weeks, and which of them is a perfectly good coping mechanism that shouldn’t be interfered with.
What are stims?
Let’s begin here by acknowledging that stims or “self-stimulatory behaviors” are a behavior that virtually everybody engages in. Neurotypical people can often be seen drumming their fingers on a desktop when they’re feeling impatient or twirling their hair when they’re bored, for example. Some do it to counteract an overwhelming sensory input, or conversely, do it when we’re understimulated. Others do it to reduce feelings of anxiety. We can think of stims as something we do when we’re trying to “keep it together” and regulate our sensory systems.
Neurodivergent people, particularly autistic people, may also stim to cope with whatever’s going on around them. One difference between ordinary stimming and stimming in neurodivergent people is that the stimming behaviors are often more conspicuous and can include:
- Rocking back and forth
- Hand flapping
- Repeating words or phrases
- Humming
- Hard blinking, among others
Another difference between neurotypical and neurodivergent stimming is that when a neurotypical person realizes that their behavior has attracted other people’s attention, they tend to stop. Autistic people, on the other hand, may perceive social cues differently and not pick up as consistently on other people’s reactions, or simply may not feel that these reactions demand that they stop doing what makes them most comfortable.
“People with autism often have difficulty processing their senses,” explains April Kilduff, MA, LCPC, LMHC. Kilfuff is a clinical trainer at NOCD and also autistic herself. “This means that they may over or under-respond to things like sounds, light, textures, and smells. They may stim to block out too much sensory information if they are hypersensitive, provide more sensory information if they are hyposensitive, help manage emotions that feel overwhelming, help distract themselves from physical discomfort, or just express excited, positive emotions in a physical way, such as with hand flapping.”
It’s important to note that many autistic people stim when pleasantly stimulated and happy, not just to defuse feelings of being overstimulated or distressed.
Another group of people who stim are those with attention deficit hyperactivity disorder (ADHD). As with autistic people, people with ADHD stim for several reasons, including being under-stimulated, over-stimulated, or simply happy. Regardless of its underlying cause, people often perceive their stimming as pleasurable and engage in it for that reason alone and without an obvious trigger.
In some cases, stimming behaviors can be disruptive—e.g., clapping in a classroom setting—or cause injury—e.g., from repeated scratching or hair pulling—and steps may be taken to reduce their frequency or intensity. These may include changing the environment, using stress management tools, or in some cases, using medications like Risperdal (risperidone) and Abilify (aripiprazole). But otherwise, stimming is entirely healthy, and stopping people from stimming altogether is generally considered unnecessary and harmful.
“In the past, applied behavior analysis (ABA) was used to try to extinguish stims,” explains Kilduff. “But all that did was just take away a perfectly good tool that autistic people can use.”
Exploring tics
A tic is an involuntary movement or vocalization associated with several conditions, including Tourette Syndrome (TS). Tics that involve movement are called motor tics and can include a wide range of behaviors, from minor nose twitches to full-body movements and repetitive, ritualistic actions such as hair pulling or skin picking. Vocal tics, on the other hand, can range from subtle throat clearing to complete sentences with linguistic meaning, though it is important to note that the words spoken do not reflect the person’s intentions or opinions.
One notable aspect of tics, which differentiates them from stims and compulsions, is the presence of a “premonitory urge”: an intense, distressing sensation before the tic occurs. This premonitory urge can show up differently for each person, with sensations such as an itch, tension, pressure, or “itchy blood.” It may feel like something is stuck on the skin, in the throat or chest, or as a surge of electricity shooting up the spine or limbs. Different tics may be associated with distinct sensations, and the urge may be felt in another body part from where the tic physically occurs.
Another characteristic of tics is their transient nature. They can change over time and be replaced by different tics within hours, days, weeks, or years. The development of a new tic can cause anxiety, as its duration may be uncertain. However, tics generally wax and wane in frequency, duration, and intensity, with triggers such as sensory overload, stress, excitement, and even certain foods potentially exacerbating their occurrence.
Motor and vocal tics can have various adverse effects on people, varying in severity depending on their frequency, intensity, and duration. Common challenges associated with these tics include social difficulties, impaired concentration, physical discomfort, limitations in certain occupations, emotional distress, disruptions to daily activities, and impacts on mental health.
“Tics can also attract attention, leading to embarrassment and social stigma,” says Kilduff, adding that they can also interfere with concentration and performance in academic or work settings. Over time, living with tics can lead to emotional distress, disrupt daily activities, and contribute to mental health issues like anxiety and depression.
While tics are commonly associated with TS, it is essential to recognize that they can also occur in other conditions like anxiety disorders, ADHD, and others.
Understanding compulsions
A compulsion is a repetitive and ritualistic behavior that can be either physical or mental. Compulsions are most often associated with Obsessive Compulsive Disorder (OCD)—a mental disorder characterized by obsessive thoughts (obsessions) and compulsive physical and/or mental behaviors (compulsions) intended to reduce the distress caused by those thoughts.
An example of an obsessive thought might be a random, unwanted intrusive thought about pushing a stranger off the platform and into the path of an oncoming train. To reduce that anxiety that this thought brings, a person with OCD might repeatedly whisper “I’m a good person” under their breath, frequently ruminate about their behavior and values for clues about their capacity for murder, continuously glance around themselves to check that they are more than an arm’s length away from others, count on their fingers to distract themselves from their fears, or take pains to avoid taking the train altogether.
As you can imagine, some of these behaviors are very similar, on the surface, to the physical appearance of stims or tics. But in this instance, OCD is causing them to doubt their core values, and the reassurance, review, checking, and avoidance behaviors are all compulsions intended to reduce that uncertainty. While the compulsions may temporarily alleviate this untenable distress, they have the unintended effect of strengthening the OCD cycle.
Being caught in this never-ending sequence of obsessions, anxiety, compulsions, and temporary relief can take up a lot of time, cause distress, and negatively affect a person’s relationships, social life, and job performance. If not treated, OCD symptoms worsen over time and can be debilitating. Left untreated, people with OCD can end up housebound and at greater risk of major depression and suicide.
Evidenced-based approaches to treating stims, tics, and compulsions
Despite their superficial similarities, stims, tics, and compulsions are linked to various underlying causes, and must be approached differently.
As discussed, stims typically don’t need to be treated as they’re a way for people to regulate their senses and emotions, though sometimes steps may be taken to modify these behaviors should they cause injury or be disruptive in specific settings.
Tics, in contrast, can have a host of negative impacts that can and do interfere with day-to-day life. Habit reversal training (HRT) is an effective behavioral therapy approach that helps people with tics and Tourette syndrome (TS) manage their symptoms.
HRT involves several key components. First, people with tics are educated about their condition, learn about the nature of tics, their triggers, and the cycle of premonitory sensations that precede them. Next, people learn to identify and track their tics using self-monitoring techniques. This helps increase self-awareness and provides valuable information for developing specific strategies.
The core technique in HRT is the introduction of a competing response. This involves identifying physically incompatible behavior with the tic and practicing it whenever the urge to tic arises. For example, if a person has a neck-jerking tic, they may be instructed to flex the muscles in their neck and hold the tension for a few seconds instead of performing the tic. The goal is to replace the tic with the competing response, disrupting the habitual pattern.
HRT is typically conducted with the guidance of a trained therapist and implemented over several sessions, gradually increasing the complexity and difficulty of the competing responses.
By increasing awareness, developing alternative responses, and promoting self-control, HRT empowers people with tics and TS to actively manage and reduce the impact of their symptoms, improving their overall quality of life.
OCD, as we’ve seen, can have highly damaging effects on the lives of OCD sufferers, their friends, and their families. The gold standard treatment for OCD is called exposure and response prevention therapy (ERP). ERP aims to break the cycle of anxiety and compulsive behaviors by purposely exposing people to situations or triggers that provoke obsessions while guiding them to resist engaging in their typical compulsive responses.
ERP gradually exposes people to their feared obsessions or situations through a hierarchy of triggers. The exposure can be real-life or imagined, depending on the specific obsession. For example, someone with contamination obsessions may touch a doorknob without washing their hands immediately afterward. The exposure is conducted in a controlled and supportive environment with the guidance of a therapist.
During the exposure, people are encouraged to refrain from engaging in their compulsive behaviors or rituals. This prevention of the usual response is what differentiates ERP from other therapies. People learn that their anxiety naturally decreases over time without performing the compulsive action by resisting the compulsion. This process is known as habituation. It helps people realize that they are able to tolerate their discomfort without resorting to compulsions that only make it worse over time.
As we mentioned earlier, stims, tics, and OCD-related compulsions can occur in the same person, requiring a trained therapist to help determine what’s what.
“I specialize in treating autistic adults with OCD,” says Kilduff. “We are often both trying to figure out what is a compulsion and what’s just a stim because, as we said, we want to eliminate compulsions but leave the stims alone. It’s the same with the co-occurrence of tics and compulsions or stims and tics. So we have to pull it apart a little to ensure we’re addressing each issue properly.”
Getting help
If you or someone you know is struggling with tics compulsions, I encourage you to learn about NOCD’s accessible, evidence-based approach to treatment with the NOCD Care Team to learn more about how a licensed therapist can help.
While all NOCD therapists specialize in OCD and receive ERP-specific training, many also specialize in treating tics and Tourette syndrome with HRT and have experience treating people with a co-occurrence of both, and many more have additional experience treating autistic people with either condition.