Search

Background: The major treatments reported to be effective in the treatment of trichotillomania are cognitive-behavioral therapy (CBT) with habit reversal and serotonin-norepinephrine reuptake inhibitors such as clomipramine. However, the 2 treatments have not been previously compared with each other. This study examines the efficacy of CBT and clomipramine compared with placebo in the trcatment of trichotillomania. Method: Twenty-three patients with trichotillomania as determined by the Structured Clinical Interview for DSM-III-R entered and 16 completed a 9-week, placebo-controlled, randomized. parallel-treatment study of CBT and clomipramine. Efficacy was evaluated by the Trichotillomania Severity Scale, the Trichotillomania Impairment Scale, and the Clinical Global Impressions-Improvement scale, which were conducted by an independent assessor blinded to the treatment condition. Results: CBT had a dramatic effect in reducing symptoms of trichotillomania and was significantly more effective than clomipramine (p = .016) or placebo (p = .026). Clomipramine resultcd in symptom reduction greatcr than that with placebo, but the difference fell short of statistical significance. Placebo response was minimal. Conclusion: Clinicians should be aware of the potential treatments available for trichotillomania. A larger and more definitive study comparing CBT and a serotonin-norepinephrine reuptake inhibitor is indicated.

Azrin & Nunn (1973) entwickelten das Habit Reversal Training (HRT), um damit eine Vielzahl nervoser Verhaltensgewohnheiten und Tics zu behandeln. Ausgangspunkt ihrer Uberlegungen war die Annahme, das derartige Verhaltensweisen dann zu andauernden Problemen werden, wenn sie Teil einer Verhaltenskette sind, die durch standige Wiederholung aufrechterhalten wird, teilweise unbewust ablauft und sozial toleriert wird. Zentrale Elemente des Trainings sind daher das Lernen adaquater Selbstwahrnehmung und die systematische Unterbrechung des Verhaltens durch konkurrierende Reaktionen.

Tics are sudden, rapid and repetitive stereotyped movements or vocalizations. Once thought to be a rare disorder, many children and adults are now known to suffer from tic disorders, including Tourette syndrome. Pharmacological treatments have been the most commonly used treatment modality for tic disorders. More to the point behavioral psychotherapies have been shown to be effective. The present article aims to introduce one of the behavioral techniques, namely Habit Reversal Training (HRT) for the treatment of tic disorders including Tourette syndrome and evaluate the results of randomized-controlled studies. Results of the studies with large groups of children and adults demonstrated that HRT are effective compared to the control groups. Future studies are needed to develop new behavioral treatments for those patients who do not respond to HRT and also to examine the effects of combining behavioral treatments for tics with pharmacotherapy.

Little attention has been directed at interventions that directly teach facial pain patients to detect, interrupt, and reverse the maladaptive oral habits and cognitions thought to be associated with muscle hyper-reactivity and pain. The present study tested a seven-session structured-group habit reversal treatment intervention for facial pain patients. Nine facial pain subjects participated in treatment groups and seven qualified subjects who did not participate in treatment served as a comparison group. Pre, post, and follow-up assessments included measures of pain and psychological functioning. Subjects in the treatment group improved on all measures of pain relative to those in the comparison group. These improvements were maintained or augmented at four month follow-up assessments suggesting that habit reversal training, particularly in a group format, may provide a cost-effective intervention for facial pain patients.

In this study, we sequentially administered up to four components of the habit-reversal treatment to 4 children with motor tics within a multiple baseline design. The habit-reversal components included (a) awareness training; (b) awareness training and self-monitoring; (c) awareness training, self-monitoring, and social support; and (d) awareness training, social support, and the use of a competing response. Results demonstrated that the combined use of awareness training, social support, and competing response training was effective in eliminating motor tics in 2 of 4 children, that awareness training alone was effective for 1 child, and that a combination of awareness training and self-monitoring was effective for the 4th child. The treatment and ensuing improvement were found to be socially valid. We discuss possible explanations for these results and recommend directions for future research.

We developed the MGH Hairpulling Scale to provide a brief, self-report instrument for assessing repetitive hairpulling. Seven individual items, rated for severity from 0 to 4, assess urges to pull, actual pulling, perceived control, and associated distress. We administered the scale to 119 consecutive patients with chronic hairpulling. Statistical analyses indicate that the seven items form a homogenous scale for the measurement of severity in this disorder.

Objective Tourette syndrome (TS) is a chronic neuropsychiatric movement disorder characterised by multiple motor and one or more phonic tics, plus associated behavioural problems. Specific behavioural interventions, either alone or as an adjunct to pharmacological treatment, have been shown to effectively decrease tic severity and improve health-related quality of life. Habit reversal training (HRT) is increasingly recognised as an effective behavioural intervention in the treatment of TS. However, little is known about the characteristics of patients who attend and adhere to HRT sessions, which results in inappropriate use of resources and therapist appointment times. The present study is aimed to determine the demographic (gender, age) and clinical (disease duration, tic severity, family history of tics, co-morbid behavioural problems, pharmacotherapy) characteristics of adult patients with TS who attend HRT sessions following initial referral, in order to develop recommendations for treating clinicians on the development of appropriate care pathways. Method Data regarding the demographic/clinical characteristics of a cohort of 57 patients with TS consecutively referred to HRT intervention were retrospectively reviewed. Correlation and regression analyses were used to examine associations between patients9 characteristics and their attendance at HRT sessions. Results Out of the initial sample, 12/57 patients were excluded from the analysis because of inappropriate referral and/or insufficient data. About one in three patients (15/45) failed to attend HRT following referral by the treating consultant. There were no significant differences in the demographic/clinical characteristics between patients who attended HRT sessions and patients who did not. However, a trend towards statistical significance (p=0.08) was found for decreased tic severity as a predictor of poor attendance. Conclusion Our findings suggest that initial treatment retention to HRT in TS can be suboptimal. The trend towards statistical significance of tic severity as a predictor of poor attendance is of potential clinical relevance and needs further investigation in larger samples.

Context Tics in Tourette syndrome begin in childhood, peak in early adolescence, and often decrease by early adulthood. However, some adult patients continue to have impairing tics. Medications for tics are often effective but can cause adverse effects. Behavior therapy may offer an alternative but has not been examined in a large-scale controlled trial in adults. Objective To test the efficacy of a comprehensive behavioral intervention for tics in adults with Tourette syndrome of at least moderate severity. Design A randomized controlled trial with posttreatment evaluations at 3 and 6 months for positive responders. Setting Three outpatient research clinics. Patients Patients (N = 122; 78 males; age range, 16-69 years) with Tourette syndrome or chronic tic disorder were recruited between December 27, 2005, and May 21, 2009. Interventions Patients received 8 sessions of comprehensive behavioral intervention for tics or 8 sessions of supportive treatment for 10 weeks. Patients with a positive response were given 3 monthly booster sessions. Main Outcome Measures Total tic score on the Yale Global Tic Severity Scale and the Clinical Global Impression–Improvement scale rated by a clinician masked to treatment assignment. Results Behavior therapy was associated with a significantly greater mean (SD) decrease on the Yale Global Tic Severity Scale (24.0 [6.47] to 17.8 [7.32]) from baseline to end point compared with the control treatment (21.8 [6.59] to 19.3 [7.40]) (P Conclusion Comprehensive behavior therapy is a safe and effective intervention for adults with Tourette syndrome. Trial Registration clinicaltrials.gov Identifier: NCT00231985

Trichotillomania is characterized by the repeated urge to pull out hair, leading to noticeable hair loss, distress, and social or functional impairment. Most of the cases present initially to dermatologists with complaints of loss of hair and is often confused with other dermatological conditions like alopecia areata, tinea capitis, traction alopecia, and loose anagen syndrome. It is a chronic condition and difficult to treat. No formal treatment algorithm is present for trichotillomania and no drug has been found to be universally effective. We present a case report of a 22-year-old single female diagnosed with trichotillomania, with complaints of recurrent hair pulling resulting in noticeable hair loss since the age of 8 years. She was treated with Habit Reversal Training with Stimulus Control over a period of 12 weeks and attained complete remission. The effectiveness of HRT plus for the treatment of Trichotillomania is ascertained.

Tourette's syndrome traditionally has been viewed as a hyperkinetic movement disorder characterized by involuntary motor and phonic tics. Many patients, however, describe their tics as a voluntary response to premonitory urges. This cross-sectional study evaluated premonitory urges and related phenomena in subjects with tic disorders.A total of 135 subjects with tic disorders, aged 8 to 71 years, completed a questionnaire concerning their current and past tic symptoms. Subjects were asked to describe and, if possible, localize their premonitory urges. The Yale Global Tic Severity Scale was used to assess current tic severity. The method of case finding does not provide prevalence data for premonitory urges.Ninety-three percent of the subjects reported premonitory urges. Anatomical regions with the greatest density of urges were the palms, shoulders, midline abdomen, and throat. Eighty-four percent of the subjects reported that tics were associated with a feeling of relief. A substantial majority (92%) also indicated that their tics were either fully or partially a voluntary response to the premonitory urges.While epidemiological studies of tic disorders have yet to incorporate questions concerning premonitory urges, these results suggest that such urges may be commonplace in adolescent and adult subjects with tic disorders. These results challenge the conventional wisdom that tic behaviors are wholly involuntary in character. They also implicate brain regions involved in the processing of sensorimotor information in the pathobiology of tic disorders.

The present study evaluated the effectiveness of self-monitoring, relaxation training and habit reversal in the treatment of 6 Tourette Syndrome (TS) subjects with multiple motor and vocal tics. A counterbalanced design was employed and tic frequencies were measured in the clinic setting using videotapes taken through a one-way mirror. Tics were reduced by an average of 55% with habit reversal, 44% with self-monitoring, and 32% with relaxation training and each behavioral procedure was the most effective treatment for at least one subject. All three treatment approaches may have some utility in the behavioral treatment of TS.

About 40% of young children suck their thumbs, an action which is associated with dental problems and for which intra-oral devices have been the most effective treatment. The present study of 30 thumbsucking children evaluated the habit reversal treatment which included competing response training, parental support, and stimulus identification during a single session plus follow-up maintenance by the parent. Habit reversal training reduced thumbsucking by 92% in the first week, 95% in the fourth month, and 89% at the 20-month follow-up. A comparison treatment by a bitter tasting substance produced a reduction of about 35%.

Habit reversal, a multicomponent treatment package, was compared with a simplified package consisting of just two components, awareness and competing response training, in the treatment of muscle tics. Nine subjects with various muscle tics were divided into two treatment groups. Awareness and competing response training was introduced for five subjects in a multiple baseline across subjects design. Using a similar design, four subjects were exposed to the entire habit reversal package. Objective measures of tics were attained by videotaping subjects under clinic conditions designed to evoke their respective tic. The results indicated that the awareness and competing response training was as effective in decreasing tic frequency as the whole habit reversal program. One subject with severe torticollis failed to benefit from the habit reversal. All other subjects in both groups showed marked improvement which was maintained at brief follow-up.

Trichotillomania, an irresistible impulse to pull out one's own hair, is a chronic psychiatric illness that causes severe discomfort, interferes with daily activities, and leads to social isolation. Treatment is usually unsatisfactory. Thirteen women with severe trichotillomania completed a 10-week double-blind, crossover trial of clomipramine, a new tricyclic antidepressant agent with selective antiobsessional effects, and desipramine, a standard tricyclic antidepressant. Treatment with clomipramine resulted in significantly greater improvement in symptoms than desipramine, as indicated by physicians' ratings of the women's clinical progress on a scale in which lower scores indicate improvement (mean [+/- SD] scores: at base line, 10.0; after desipramine treatment, 8.7 +/- 2.4; after clomipramine treatment, 4.7 +/- 3.1; P = 0.006) and by scores on a trichotillomania-impairment scale, in which higher scores indicate greater impairment (at base line, 6.8 +/- 1.7; after desipramine treatment, 6.2 +/- 1.7; after clomipramine treatment, 4.2 +/- 2.7; P = 0.03). The severity of symptoms (mean base-line score, 15.9 +/- 3.8) was reduced more by clomipramine (10.6 +/- 6.4) than by desipramine (14.4 +/- 3.9). The patients reported that the compulsion decreased in intensity and that they were more able to resist the urge to pull out their hair during treatment with clomipramine. We conclude that clomipramine appears to be effective in the short-term treatment of trichotillomania.

Despite the overt nature of most motor and phonic tic phenomena, the development of valid and reliable scales to rate tic severity has been an elusive goal. The Yale Global Tic Severity Scale (YGTSS) is a new clinical rating instrument that was designed for use in studies of Tourette's syndrome and other tic disorders. The YGTSS provides an evaluation of the number, frequency, intensity, complexity, and interference of motor and phonic symptoms. Data from 105 subjects, aged 5 to 51 years, support the construct, convergent, and discriminant validity of the instrument. These results indicate that the YGTSS is a promising instrument for the assessment of tic severity in children, adolescents and adults.

Hairpulling is an uncommon behavior which has received little study and for which effective treatment has not been established. The present study evaluated the habit reversal and the negative practice method of treatment with 34 subjects randomly assigned to the two treatments. Habit reversal was about twice as effective as the negative practice with respect to the average percentage reduction in hairpulling episodes, the number of subjects who stopped hairpulling entirely, and those who stopped almost entirely. Follow-up phone calls or a single booster session were often effective in preventing or correcting the relapses. It appears that hairpulling can be successfully treated by brief habit reversal training with substantial and enduring benefits.

Gilles de la Tourette syndrome (GTS) is characterised by multiple motor and one or more vocal/phonic tics. GTS was once thought to be rare, but many relatively recent studies suggest that the prevalence is about 1% of the worldwide community, apart from in Sub-Saharan Black Africa. Comorbidity and coexistent psychopathology are common, occurring in about 90% of clinical cohorts and individuals in the community. The most common comorbidities are attention deficit hyperactivity disorder, obsessive-compulsive behaviours, and disorder, and autistic spectrum disorders, while the most common coexisting psychopathologies are depression, anxiety and behavioural disorders such as oppositional defiant and conduct disorder. There has been an increasing amount of evidence to show that the quality of life in young people is reduced when compared with normative data or healthy control populations. It is widely accepted that most cases of GTS are inherited, but the genetic mechanisms appear much more complex than previously understood, as evidenced by many recent studies; indeed, there have been suggestions of 'general neurodevelopmental genes' which affect the brain development after which the 'specific GTS gene(s)' may further affect the phenotype. Other aetiopathogenetic suggestions have included environmental factors such as neuro-immunological factors, infections, prenatal and peri-natal difficulties and androgen influences. Few studies have addressed aetiology and phenotype, but initial results are exciting. The search for endophenotypes has followed subsequently. Intriguing neuroanatomical and brain circuitry abnormalities have now been suggested in GTS; the most evidence is for cortical thinning and a reduction in the size of the caudate nucleus. Thorough assessment is imperative and multidisciplinary management is the ideal. Treatment should be 'symptom targeted', and in mild cases, psycho-education and reassurance for the patient and the family may be sufficient. Behavioural treatments such as Comprehensive Behavioural Intervention for Tics including Habit Reversal Training have been shown to be significantly better than other behavioural/psychological treatments and 'placebo'. Medication is often necessary for moderately affected individuals. In more severe cases, medical treatment is not simple and referral to an expert may be advisable. In general, neuroleptics and clonidine or guanfacine are the medications of choice for the tics. Other treatments which may be needed for loud and severe phonic tics include botulinum toxin. In severe adult GTS patients who are refractory to medication and other therapies, deep brain stimulation looks promising.

In uncontrolled studies, several behavioural methods, including habit reversal, were said to be useful in writer's cramp. In this controlled study, 23 subjects with writer's cramp recruited from a neurology clinic were randomly allocated to five sessions over four weeks of either habit reversal training or a control treatment of relaxation training. Three subjects dropped out. Twenty patients (9 habit reversers, 11 controls) completed the trial up to three months follow-up. Outcome measures included observation of writing within the session, assessment of writing tasks completed at home, and blind ratings by an independent assessor. The results showed that habit reversal was no better than relaxation. Taking both treatments together, patients improved to three months follow-up on seven of nine measures, but remained substantially handicapped.

A meta-analysis based on 575 participants in 18 studies found Habit Reversal Therapy (HRT) to be an efficacious intervention for a wide variety of maladaptive repetitive behaviors, including stuttering, tics, nail biting, temporomandibular disorder, thumb sucking, and mixed repetitive oral-digital habits. Compared to control conditions, HRT showed a large effect size pre-treatment to final post-treatment assessment, d=0.80. Moderator analyses revealed significant treatment effects for HRT for most moderator levels, indicating that HRT is efficacious in a number of variations for a variety of types of maladaptive behaviors, across a wide range of sample characteristics. The findings provide substantial support for the efficacy of HRT for disorders it is commonly used to treat. The findings are consistent with recent arguments for the classification of HRT as a well-established treatment for tic and habit disorders.