Habit reversal therapy (HRT) for Tourette syndrome
Compiled by Kevin J. Black, M.D. (June,
1999; updated August, 2001, and August, 2003)
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Overview
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a behavior therapy treatment for tics
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substantial reduction in tics often seen after first session
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careful observation shows no evidence of substitution of one tic for another,
and treatment effects are observed both at home and in the clinic
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4 main components as originally described
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more recent research suggests that the only essential components are Awareness
Training and Competing Response Training (see below) (Woods et al 1996)
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about 20 sessions per year in one study
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Evidence for efficacy
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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)
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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)
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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)
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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.
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several other less rigorous studies and detailed case reports
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a review concludes that overall efficacy of HRT for tics is ~90% at home,
~80% in clinic
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no evidence of symptom substitution from videotape review or self-report
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improvement seems to be independent of medication status or age, and generalizes
over different settings
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Evidence regarding side effects:
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little data
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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)
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Method:
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Awareness Training
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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
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Reponse Description Procedure: describe the detail of each tic to therapist,
using mirror and/or videotape
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Response Detection Procedure: therapist alerts subject each time a tic
is observed, with progressively less intrusive warnings
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Early Warning Procedure: subjects practice self-detection of earliest signs
or sensory cues before a tic
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Situation Awareness Training: subjects identify situations, persons or
places in which symptoms were better or worse
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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
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Competing Response Training (contingent)
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"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)
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example: for head jerking back: contraction of the neck flexors with chin
slightly down and in
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example: for vocal tic: slow rhythmic deep breathing through the nose with
the mouth closed
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The competing response is to be done for 3 minutes after each tic and after
each sensation that a tic is about to occur.
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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.
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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.
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"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)
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Contingency Management
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family instructed to comment favorably on signs of
improvement (and in 1973 paper, remind them to "do exercises" if they forgot)
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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
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frequent praise from therapist (in 1973 paper, daily
phone calls!)
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participate in enjoyable activities that may have
been avoided in the past
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go into situations in which tic likely to occur and
tell or show friends & family about the improved ability to control
tics
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Generalization Training: practice on how to control
tics in everyday situations
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practice procedures in session until done correctly
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symbolic rehearsal: imagine common and tic-eliciting situations and then
perform the exercise
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practice the procedure for the rest of the session; therapist prompts subject
if s/he forgets (see 1973, p. 625)
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Self-monitoring alone (e.g. keep count with a hand counter) has (possibly
transient) but significant benefit
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O'Connor adds cognitive therapeutic goals and strategies
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References:
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Azrin NH, Nunn RG: Habit-reversal: A method of eliminating nervous habits
and tics. Behav Res Ther 11:619-628, 1973.
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Azrin NH, Nunn RG, Frantz SE: Habit reversal vs. negative practice treatment
of nervous tics. Behav Ther 11:169-178, 1980.
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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.
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Azrin NH, Peterson AL: Habit reversal for the treatment of Tourette Syndrome.
Behav Res Ther 26:347-351, 1988.
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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.
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Azrin NH, Peterson AL: Treatment of Tourette Syndrome by habit reversal:
A waiting-list control group comparison. Behav Ther 21:301-318, 1990.
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Peterson AL, Azrin NH: An evaluation of behavioral treatments for Tourette
Syndrome. Behav Res Ther 30:167-174, 1992.
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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.
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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.
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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.
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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.
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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.
(current
MEDLINE list) This
link also includes other behavior therapy techniques.
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