2 He has had several psychiatric consultations in his local area of residence and had received mainly drug treatment. Information from R’s parents and available clinical doc- umentation on previous treatments indicated that R. had been on large doses of medication for many months. These treatments had been initiated with low doses but had been gradually increased due to poor response. Parents reported good compliance with taking medication and close supervi- sion by them. Maximum doses reached were a combination of risperidone 6 mg/day and haloperidol 15 mg/day. These doses provided temporary relief initially but soon ceased to be eﬀective even though they were continued without interruption. R. had missed much of schooling in the previous 3 years because of the vocal utterances, which disturbed everyone around him. The school supported by making special arrangements for lessons but this too could not be sustained. At the time of his presentation to our service (at the age of 12 years and 9 months), R. had not attended school continuously for 3 months, was almost housebound, and avoided social contacts. At the time, R. had taken haloperidol 15 mg/day and risperidone 6 mg/day continuously for over 6 months. 2.2. Assessment. R. was reassessed following admission for inpatient care and the diagnosis of TS was conﬁrmed. In addition to TS, multiple other problems were elicited on clinical and psychometric assessments: (i) prominent symp- toms diagnostic of attention deﬁcit hyperactivity disorder (ADHD) combined type, based on DSM IV-TR [1] criteria and SNAP IV scores, (ii) obsessions and compulsions mainly related to cleanliness, method and order, (iii) below average for age in reading, spelling, and verbal expressive language skills (based on standards for Sri Lankan children set by the Institute of Education), and (iv) tendency to overeat with a weight for age was at 85th centile. Obsessions and compulsions did not amount to a diagnosis of obsessive compulsive disorders (OCD). There was no self-injurious behavior and no report of recurrent throat infections. R. has never suﬀered from any seizure disorders or any other common and recurrent childhood illnesses. Except for a mild delay in beginning to use language, his development has not been of concern to his parents. Because of a positive family history of tics in a second degree male relative on his father’s side, R was examined and investigated but considered to be negative for Wilson’s disease. A CT brain scan and an EEG did not show any abnormalities. Metabolic screening and liver function tests also were within normal limits. 2.3. Pharmacological Therapy. Due to unacceptably high doses of haloperidol taken for many months, the dose was reduced to 6 mg/day. Risperidone was discontinued due to persistence of overeating and to prevent further weight gain. Clonidine 25 µgm/day was added to the drug regime, increased to 50 µgm/day one week later. As the symptoms of ADHD appeared to have a strong negative impact on R’s learning, behavior, and the ability to cooperate with planned behaviour therapy, methylphenidate 20 mg/day in 2-divided doses was also added. This had the desired eﬀect Case Reports in Psychiatry of bringing about a noticeable reduction in inattention and impulsiveness. 2.4. Behaviour Therapy. Under inpatient care, therapy was initiated by encouraging R. to identify a premonitory symptom for the vocal tic, which was the most disabling and distressing. Premonitory symptoms are unpleasant sensations of somatosensory nature that prompt a tic. This results in a momentary relief of the sensation. In the ﬁrst 3 therapy sessions once a day and lasting 30 minutes each, R. was able to identify the premonitory urge as a pricking sensation arising in his epigastric area and reaching up to his throat. R was guided to focus on this premonitory symptom and resist it progressing to a vocal tic by voluntarily suppression. R. adopted a swallowing action at the beginning to help himself to suppress the urge. Starting from an initial 15 minute of suppression of symptom on his own within 5 to 6 days, R. was able go through one full hour without vocalizations by the end of 2 weeks. To keep R. motivated, a reward system contingent on compliance was added. At the time of discharge from hospital after a 4-week stay, R had successfully habituated to the premonitory urge. He had an immediate recurrence of vocal tics in the same intensity as before on attempting to reintegrate back to school. This was overcomed by a one-week break from school, continued practice at home and returning a week later. At one- and 3- month followup, he was having less than 10 vocal tics a day, but low in intensity and not much noticeable in public. At 6 month followup, this too had largely disappeared. R. had by then returned to school full time, was receiving individual support for learning, but was still struggling to cope with academic diﬃculties, and missed school work. He showed some deﬁant behaviour with parents at home but not in school. 3. Discussion ERP rather than habit reversal was chosen as method of behavioural intervention for several reasons. Firstly, vocal tics were the most prominent and disabling symptom. Secondly, although tics are recognized as involuntary due to its neurodevelopmental basis, they are also described as volitional responses to irresistible and involuntary impulses (premonitory symptoms) [6, 7]. Thirdly, ERP is a useful behavioural technique, known to be as eﬀective as habit reversal in tic disorders, with no rebound phenomena on termination of treatment [8, 9]. Fourthly, R. responded well to this intervention and the improvement was sustained. Failure to respond to haloperidol and risperidone in this patient cannot be explained from the available data. Use of clonidine was justiﬁed on the basis of the presence of multiple comorbidities and poor response to commonly used drugs. Clonidine improves attention, compulsive behavior, and aggression and is said to beneﬁt 70% of patients with tics [3]. Contrary to previous beliefs, exacerbation of tics with psychostimulants is not an inevitable outcome. Hence, aggressive treatment of comorbid ADHD in TS is recommended [10]. In R., addition of MPH had the desired