Dr. Piacentini describes habit reversal training (HRT) as a two-part approach that has shown considerable promise:
Awareness training — This teaches Tourette patients how to become more aware of their tics. “Some of the kids and adults describe a premonitory urge or feeling before the tic begins,” says Piacentini. “We try and teach them how to become more aware of that.”
Competing response substitution —”We teach a specific behavior to do that is typically unrelated to the tic but has the same muscle involvement,” says Piacentini. “For vocal tics the competing response is typically breathing through the nose. If they have an arm tic where they shoot their arm out, when they feel an urge they might pull the arm into their side.”
Awareness training is used to bring greater attention to tics and other behaviors so that the affected person can gain better self-control. Awareness training is usually carried out in a number of smaller steps:
Step 1: The person describes in detail each time they carry out the behavior (e.g., eye-rubbing, hair-pulling, skin-picking) while looking into a mirror.
Step 2: The therapist will tell the person whenever he or she carries out the tic or impulse. This is done repeatedly until the person notices every time they do their tic.
Step 3: The person learns to identify the earliest warning that a tic or impulsive behavior is about to take place. These warning signs can be urges, sensations or thoughts.
Step 4: The person identifies all the situations in which the tic or impulsive behavior occurs.
Development of a Competing Response
Once the patient has developed good awareness of their tic or impulsive behavior the next step is to develop a competing response that replaces the old tic or impulsive behavior. Usually the competing response is opposite to that of the tic or impulsive behavior and is something that can be carried out for longer than just a couple of minutes. As well, it is usually helpful to choose a response that will be more or less unnoticeable by others.
To keep the tics and impulsive behaviors from coming back, the patient is encouraged to make a list of all of the problems that were caused by their behavior. Parents and friends are also asked to praise the person for their accomplishments thus far. In addition, it can often be helpful for patients to demonstrate their ability to suppress tics or impulsive behaviors to others.
Generalization of New Skills
In this phase of treatment, patients are encouraged to practice their new skills in a range of different contexts, not just those that they have mastered to date. For example, while it might be easy to learn to suppress a tic or impulsive behavior in the relative safety of the doctor’s office this also needs to be practiced at home, at work, at school and other environments.
Habit reversal therapy (HRT) for Tourette syndrome
Compiled by Kevin J. Black, M.D. (June, 1999; updated August, 2001, and August, 2003)
- a behavior therapy treatment for tics
- substantial reduction in tics often seen after first session
- careful observation shows no evidence of substitution of one tic for another, and treatment effects are observed both at home and in the clinic
- 4 main components as originally described
- more recent research suggests that the only essential components are Awareness Training and Competing Response Training (see below) (Woods et al 1996)
- about 20 sessions per year in one study
- Evidence for efficacy
- one study randomly assigned 10 subjects with DSM-IV Tourette syndrome to active treatment or a wait list; the immediate treatment group had significantly better response at the end of the wait period (Mann-Whitney U test, 1-tailed p<0.025), which persisted (~90% reduction in tics after 12 months); the group that started after 3 months of wait list remained stable until treatment began, then improved rapidly to similar levels (Azrin & Peterson 1990)
- a pre-DSM-IV study randomly assigned 22 subjects with neurologist-diagnosed tics to habit reversal or massed practice; the treatments differed significantly (p < 0.001 by ANOVA); the HRT group had 97% reduction in tics at 18-month follow-up with 80% of patients tic free (Azrin et al 1980)
- The largest study yet reported randomly assigned 47 patients with chronic tic disorders to active treatment with HRT and 22 to a wait list control group; a treatment manual was used; wait-list and active treatment groups differed significantly in mean self-reported tic scores at the end of the wait list period (p < 0.001) and after 4 months (wait list, 21 + 31; active treatment, 7 + 16). At 2-year follow-up, 52% rated tics as “75-100% controlled”; ratings of patient videos and ratings by a friend or family member gave similar results (O’Connor et al 2001; O’Connor 2001, 2003)
- In 2003, Wilhelm and colleagues reported a randomized controlled study of habit reversal therapy (HRT) versus supportive psychotherapy (intended to serve as a control) in 32 patients with DSM-IV Tourette’s disorder. Mean tic severity scores from the Yale Global Tic Severity Scale after 14 sessions of treatment were significantly better in the HRT group (19.8 + 7.6) than in the control group (26.9 + 9.2, p < 0.05 by t test; p < 0.01 after controlling for baseline tic severity by ANCOVA). In addition, functional impairment ratings improved significantly, and significantly more, in the HRT group (p < 0.01 for each comparison). Patients rated themselves as significantly more improved with HRT (CGI score, mean 2.13 vs 3.55 in the supportive therapy group; p < 0.01). Unfortunately, these ratings were not done blind to treatment status.
- several other less rigorous studies and detailed case reports
- a review concludes that overall efficacy of HRT for tics is ~90% at home, ~80% in clinic
- no evidence of symptom substitution from videotape review or self-report
- improvement seems to be independent of medication status or age, and generalizes over different settings
- Evidence regarding side effects:
- little data
- note that detailed questioning and blinded videotape review were performed in some studies and suggests that patients generally end up using the behavior therapy techniques rarely, because tic frequency declines (i.e. patients don’t just incorporate the behavior therapy technique as a new tic)
- Awareness Training
- first visit: subject & (spouse) to record frequency of each tic for a specified duration each day (10min or all day depending on frequency of tic); videotape subject at beginning of each session
- Reponse Description Procedure: describe the detail of each tic to therapist, using mirror and/or videotape
- Response Detection Procedure: therapist alerts subject each time a tic is observed, with progressively less intrusive warnings
- Early Warning Procedure: subjects practice self-detection of earliest signs or sensory cues before a tic
- Situation Awareness Training: subjects identify situations, persons or places in which symptoms were better or worse
- Relaxation Training: progressive muscular relaxation, deep breathing, visual imagery, self-statements of relaxation; taught during first visit and instructed to practice at least daily for 10-15 minutes as well as for 1-2 minutes whenever anxious or whenever they have a tic
- Competing Response Training (contingent)
- “taught a specific response pattern that would be incompatible with the [tic]. . . . In addition, . . . (1) . . . opposite to the nervous movement, (2) capable of being maintained for several minutes, (3) . . . isometric tensing of the muscles involved in the movement, (4) . . . socially inconspicuous and easily compatible with normal ongoing activities . . . (5) strengthening the muscle antagonistic to the tic.” (1973 p.623)
- example: for head jerking back: contraction of the neck flexors with chin slightly down and in
- example: for vocal tic: slow rhythmic deep breathing through the nose with the mouth closed
- The competing response is to be done for 3 minutes after each tic and after each sensation that a tic is about to occur.
- Research suggests that only contingent use of the competing response is helpful (i.e. every time a tic or sensory tic happens), while non-contingent (e.g. random or scheduled) use of the competing response is not.
- Also, a study showed that the competing response (CR) need not be truly competing; e.g. for a head-turning tic, a CR of pressing the foot into the floor works just as well as a head-turning CR.
- “The tic that was the most frequent or most disruptive was treated first after the relaxation training. At least one session was devoted to training the individual to employ the Competing Response Procedure both during the session and during the following week in the subject’s natural home setting. In subsequent sessions, each additional tic was treated one at a time until a specific competing response had been established for each tic.” (1988 p.349)
- Contingency Management
- family instructed to comment favorably on signs of improvement (and in 1973 paper, remind them to “do exercises” if they forgot)
- Habit Inconvenience Review: therapist and subject reviewed inconveniences, embarrassment and suffering from tics plus positive aspects of eliminating tics; write notes on a card carried & reviewed frequently by subject
- frequent praise from therapist (in 1973 paper, daily phone calls!)
- participate in enjoyable activities that may have been avoided in the past
- go into situations in which tic likely to occur and tell or show friends & family about the improved ability to control tics
- Generalization Training: practice on how to control tics in everyday situations
- practice procedures in session until done correctly
- symbolic rehearsal: imagine common and tic-eliciting situations and then perform the exercise
- practice the procedure for the rest of the session; therapist prompts subject if s/he forgets (see 1973, p. 625)
- Self-monitoring alone (e.g. keep count with a hand counter) has (possibly transient) but significant benefit
- O’Connor adds cognitive therapeutic goals and strategies
- Azrin NH, Nunn RG: Habit-reversal: A method of eliminating nervous habits and tics. Behav Res Ther 11:619-628, 1973.
- Azrin NH, Nunn RG, Frantz SE: Habit reversal vs. negative practice treatment of nervous tics. Behav Ther 11:169-178, 1980.
- Miltenberger RG, Fuqua RW: A comparison of contingent vs non-contingent competing response practice in the treatment of nervous habits. J Behav Ther Exp Psychiatr 16:195-200, 1985.
- Azrin NH, Peterson AL: Habit reversal for the treatment of Tourette Syndrome. Behav Res Ther 26:347-351, 1988.
- Azrin NH, Peterson AL: Behavior therapy for Tourette’s syndrome and tic disorders. Ch. 16 (pp. 237-255) in Cohen DJ, Bruun, RD, Leckman JF, eds., Tourette’s syndrome and tic disorders: clinical understanding and treatment. New York, John Wiley & Sons, 1988.
- Azrin NH, Peterson AL: Treatment of Tourette Syndrome by habit reversal: A waiting-list control group comparison. Behav Ther 21:301-318, 1990.
- Peterson AL, Azrin NH: An evaluation of behavioral treatments for Tourette Syndrome. Behav Res Ther 30:167-174, 1992.
- Peterson AL, Campise RL, Azrin NH: Behavioral and pharmacological treatments for tic and habit disorders: A review. J Dev Behav Pediatr 15:430-441, 1994.
- Woods DW, Miltenberger RG, Lumley VA: Sequential application of major habit-reversal components to treat motor tics in children. J Appl Behav Anal 29:483-493, 1996.
- Miltenberger RG, Fuqua RW, Woods DW: Applying behavior analysis to clinical problems: Review and analysis of habit reversal. J Appl Behav Anal 31:447-469, 1998.
- O’Connor KP, Brault M, Robillard S, Loiselle J, Borgeat F, Stip E: Evaluation of a cognitive-behavioural program for the management of chronic tic and habit disorders. Behav Res Ther 39:667-681, 2001.
- O’Connor KP: Personal communication to Kevin Black, 2001 and 2003.
- Wilhelm S, Deckersbach T, Coffey BJ, Bohne A Peterson AL, Baer L: Habit reversal versus supportive psychotherapy for Tourette’s disorder: A randomized controlled trial. Am J Psychiatry 160:1175-1177, 2003.