Treatment of Habit and Tic Disorders

Rachel Valleley, Ph.D.Munroe-Meyer Institute

Overview

Habits vs. Tics DSM Criteria Assessment Treatment options:

Medication Habit Reversal

Case Example

Habits

“frequent, repetitive behaviors that cannot be explained by physiological causes and appear to serve no identifiable physiological function”

Examples: nail biting, nail picking, trichotillomania, thumb sucking, hair twirling

Tics

“sudden, brief, involuntary, rapid, nonrhythmic, repetitive movements or utterances that are purposeless and stereotypic”

Examples: eye blinking, facial grimacing, shoulder shrugging, throat clearing, coughing, growling, sniffing

DSM Diagnoses

Habits: Stereotypic Movement Disorder Trichotillomania

Tics: Transient tic disorder Chronic motor or vocal tic disorder Tourette’s disorder

Habits

Stereotypic Movement Disorder Trichotillomania

Stereotypic Movement Disorder

Repetitive, seemingly driven, & nonfunctional motor behavior

Interferes with normal activities or results in self-inflicted bodily injury

Not accounted for by other disorders (e.g., OCD, tics, trichotillomania)

Not due to substance or general medical condition

Lasts longer than 4 weeks

Trichotillomania

Recurrent pulling out of one’s hair, resulting in noticeable hair loss

Sense of tension immediately before pulling out the hair or resisting the behavior

Pleasure, gratification, or relief when pulling out hair

Not better accounted for by other disorder or medical condition

Causes clinically significant distress or impairment

Demographics of Trichotillomania

Prevalence: 0.6% Non-clinical hair pulling (10-13%)

Age of Onset: 13.1 yrs More frequent in females Onset if often precipitated by

stressful life event (e.g., divorce, loss, academic pressures)

Scalp (80.6%)

Brow (43.5%)

Lash (47.3%)

Hair Pulling Episodes

Touching, manipulating region before pull Can range from brief sessions with only a

few hairs lost to sessions lasting several hours with hundreds of hairs pulled

Occurs in solitude but children do in front of family

Increased pulling during periods of stress, relaxation, or distraction

May be unaware they are pulling their hair and thus do not experience tension or relief

More often use dominant hand for pulling

Consequences of Hair Pulling

Post pull: play with hair Result in total absence of hair, bald

spots, or thinning of hair Most serious consequence occurs

when patients eat the hair and form hairballs in the stomach. Results in all kinds of complications like anemia, loss of appetite, nausea, vomiting

Comorbid Conditions

Most Common Anxiety Mood disorders

OCD: Some speculation that it is related to OCD

Tic Disorders

Transient tic disorder Chronic motor or vocal tic disorder Tourette’s disorder

Transient tic disorder

Single or multiple motor &/or vocal tics Occur many times a day, nearly every day

for at least 4 weeks but not longer than 12 consecutive months

Causes marked distress or impairment Onset prior to 18 Not due to substance/medical condition Do not meet criteria for other tic disorder

Chronic motor or vocal tic disorder

Single or multiple motor OR vocal tics but not both

Occur many times a day, nearly every day or intermittently for over 1 year, no more than 3 consecutive months tic free

Causes marked distress or impairment Onset prior to 18 Not due to substance or medical condition Do not meet criteria for Tourette’s

Tourette’s disorder

Both multiple motor & one or more vocal tics have been present but do not have to be at same time

Occur many times a day (usually in bouts), nearly every day or intermittently for over 1 year, no more than 3 consecutive months tic free

Causes marked distress or impairment Onset prior to 18 Not due to substance or medical condition

Impairment from Habit or Tic

Common impairments/distress Physical Social

What causes or maintains habits/tics?

Physical Trauma Automatic reinforcement

Positive Negative

Social reinforcement Very limited data on functional

analysis of habits and tics

Mechanisms involved in Trichotillomania

Negative reinforcement Tension Arousal reduction Negative affective states

Automatic reinforcement Sedentary (watching TV, getting ready

for bed) Contemplative (homework, reading)

Assessment Considerations

Rule out medical problem Comorbid condition or habit? Distress or impairment? Observation Self-monitoring Permanent products High probability situations Ratings scales available

Empirically Supported Treatments

Medication Haldol Pimozide Clonidine Anafranil & Prozac for Trichotillomania

Behavioral Procedures Habit Reversal

Medication

Haldol: Tourette’s Relieves symptoms up to 70-80% of

patients. Short term side effects Long Term side effects

Pimozide Clonidine

Behavioral Procedures

Massed negative practice Punishment Reinforcement Relaxation Training Function-Based Treatments Habit Reversal

Massed negative practice

Requires the individual to perform each tic accurately & effortfully for a specified amount of time

Punishment

Time out Trichotillomania

Topical creams Sensory Extinction: e.g., gloves Increasing effort: e.g., wrist weights

Reinforcement

Differential reinforcement of other behaviors or differential reinforcement of alternative behaviors

Relaxation Training

Reducing tension before the occurrence of tics

No data to support as sole treatment for tics

Function-Based Treatments

Determining the function of the tic to tailor treatment. Is the tic occurring to escape something

aversive or due to social attention provided, or is it occurring due to the sensory

stimulation provided?

“Complete Habit Reversal”

Originally developed by Arin & Nunn (1973)

Consisted of 10-13 steps components Simplified Habit Reversal: only 4

components necessary 90-100% reduction of tics that

maintained over 12 months Has been found effective for many types

of habits and tics

Simplified Habit Reversal

Awareness Training Competing Response Training Relaxation Training (optional) Social Support

Awareness Training

Increase awareness of when habit is occurring by:

Practice habit/tic in front of mirror Focus on how muscles/body feels while

engaging in habit Have child identify times when habit

occurs Prompt child when habit occurred Keep data on habit occurrence

Competing Response Training

Teach an incompatible behavior for when habit occurs

Select competing response Practice competing response in front of

mirror Use competing response when urge for

habit occurs Use competing response in situations

when habit is likely to occur After habit occurs, practice competing

response for one minute

Relaxation Training (optional)

Reduce stress or anxiety if related to habit

Practice daily Options

Progressive muscle relaxation Visual imagery Breathing exercises

Social support

Parents provide feedback and encourage child to use habit reversal procedure

Provide feedback to child to become aware of habit occurrence

Encourage competing response Add reinforcement procedure if

necessary

Reinforcement

Parents could reinforce: Awareness training practices Use of the competing response Habit free periods of time

Case Example

11 year-old, 5th grade Caucasian male Tourette’s Disorder Special Education for LD in Written

Expression Motor Habit: Tensing face, pulling

arms up, anticipation antecedent Vocal Habit: ‘ah’ added between

words, occurred both in conversation & oral reading

Assessment of Motor Tic

Interview of parent and child Description of tic, duration, frequency Situations more likely to do it in Awareness? Parent response

Parent, Teacher Observation Videotape at home

Treatment of Motor Tic

Habit Reversal Awareness

Watching videotape of self in session Incompatible behavior Social Support

Reinforcement for practices

Assessment of Vocal Habit

Assessment involved: Determining instructional reading level

(5th grade, 91-106 WPM & 95% Comprehension)

Determining base rate of vocal habit while reading (28-29 VHM)

Sampling conversation (13 VHM) Conducting a Brief Reading

Experimental Analysis

Brief Experimental Reading Analysis

Baseline conditions alternated with treatment conditions Repeated Reading Listening Passage Previewing Word Error Correction Reinforcement Phrase Error Correction

Brief Experimental Reading Analysis

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Intervention

Phrase error correction chosen as intervention

Mother trained Home reading practices (10-20 minutes of

preferred reading & one minute generalization probe) conducted over 2 months

Reading sessions recorded for reliability & treatment integrity

Tokens earned for participation

Results: Pre Integrity Feedback

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Integrity Data: Pre-Feedback

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Results

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Home Reading Sessions

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Home Reading Generalization Probes: Pre Integrity Check

Home Reading Generalization Probes After In Session Integrity Check

Results: Integrity data

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June 19th June 27th June 28th July 23rd July 24th July 26th July 29th July 30th

Integrity session checks

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Pre feedback Post feedback

signif icantly few er habits in session (5)

Results

Decreased rate of oral habit from 28 per minute to 0-1 per minute while reading

Did not impact reading fluency (109 WPM at two month follow up)

Generalized to conversation speech (13 to 1 per minute)

Discussion

Vocal habit conceptualized as dysfluency PEC intervention resembles awareness

training and practice of competing response

Important to collect treatment integrity data

Parents can be trained to conduct these types of interventions & collect data for reliability & treatment integrity

References

Christopherson, E. R., & Mortweet, S. L. (2001). Treatments that work with children: Empirically supported strategies for managing childhood problems. Washington, DC: American Psychological Association

Glaros, A. G., & Epkins, C. C. (1995). Habit Disorders: Bruxism, Trichotillomania, and Tics. In M.C Roberts (Ed.), Handbook of Pediatric Psychology (2nd ed., pp.558-574). New York: The Guilford Press.

Miltenberger, R. G., Fuqua, R. W., & Woods, D. W. (1998). Applying behavior analysis to clinical problems: Review and analysis of habit reversal. JABA, 31, 447-469.

References

Valleley, R. J., Shriver, M. D., & Rozema, S. (2005). Using brief experimental assessment of reading interventions for identification and treatment of a vocal habit. Journal of Applied Behavior Analysis, 38, 129-133

Woods D. W., Miltenberger, R. G. (2001). Tic Disorders, Trichotillomania, and othr repetitive behavior disorders. Norwell, MA: Kluwer Academic Publishers