Dr. B. Duncan McKinlay, Psychologist, Clinic Lead, Brake Shop. 600 Sanatorium Road London, ON, N6J 2Y3 (519) ext. 2344

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2 SONG BY BIFF NAKED

3 Dr. B. Duncan McKinlay, Psychologist, Clinic Lead, Brake Shop Crombie 1-40, 1 CPRI, 600 Sanatorium Road London, ON, N6J 2Y3 (519) ext. 2344

4 Habit Reversal Training (HRT): A Non- Pharmaceutical 'Brake Job' for Treating Tics Presented by The Brake Shop service for Tourette Syndrome & Associated Disorders (CPRI) Ministry of Children and Youth Services

5 Leaky Brakes...over movements and sounds Ministry of Children and Youth Services

6 Gilles de la Tourette Syndrome Phenomenology: You say itch, I say twitch Premonitory urge: 80-92% of cases more often precede complex tics (Woods, 2006 symposium)? itch/pressure/heat/tickle elimination of this urge by scratching the itch (ticcing) negatively reinforces tics (Himle( et al., 2007)

7 Gilles de la Tourette Syndrome Phenomenology: You say itch, I say twitch The longer you suppress, the worse it gets: real cost involved: permanent poison ivy = irritation exhaustion sacrifice attention sacrifice social interactions ( Little Stone Statues )

8 Gilles de la Tourette Syndrome Phenomenology: You say itch, I say twitch the more you think about it, the worse it gets: distraction helps the ahh ahh feeling of satiation: self-injurious behaviours (15-20%) satiation is fleeting

9 Behavioural Treatments & TS Our track record hasn t been great Massed Negative Practice: = deliberate, quick, effortful repetitions of tic movement = the WORST thing you could do from an Incidental Associations perspective actually increases rather than decreases tics replicated in numerous studies (e.g. Turpin & Powell, 1984)

10 Behavioural Treatments & TS Our track record hasn t been great Operant techniques: if they were just motivated to stop?? punishing tics, rewarding tic-free periods

11 Behavioural Treatments & TS But Then We Got On Track: Relaxation Techniques: e.g. Peterson & Azrin (1992) alone = short-lived; doesn t generalize a component of HRT Awareness Training: alone = promise (Raz( & Norman, 2004) also a component of HRT

12 Behavioural Treatments & TS But Then We Got On Track: Exposure & Response Prevention (ERP): Wetterneck & Woods, 2006; Verdellen et al., 2004 a sister treatment to HRT exposing oneself to the premonitory urge, then preventing the tic response

13 Habit Reversal Training Very Strong Data (but small n s n s): up to 90% (home), 80% (clinic) effectiveness (Piacentini & Chang, 2001; 2005) 64-99% (home), 95% (clinic); Azrin & Peterson, 1988) 93% (home), 93.5% (clinic); Azrin & Peterson, % (Young & Montano, 1988) 85% (Finney et al., 1983) etc

14 Habit Reversal Training A Compelling Logic To The Approach: The Incidental Associations Theory of Tic Formation (McKinlay, 2001).pdf file of paper available at A Compelling Paper Written Comparing Pharmaceutical Approaches to HRT: Peterson & Azrin (1993) yet nothing

15 So Why Are We Still Debating This HRT Stuff??? Psychological Treatment Studies meets established criteria as empirically supported treatment IIII, IIII, IIII, Medical Treatment Studies IIII, IIII, IIII, IIII, IIII, IIII, IIII, IIII, IIII, IIII, IIII, IIII, IIII, IIII, IIII, IIII, IIII, IIII, A matter of college size, funding, politics That s s now changing, thanks to ERP, thanks to the TSA

16 Newsweek Magazine (September 3, 2007) and thanks to these guys!

17 Habit Reversal Training Comprehensive Behavioural Intervention for Tics (CBIT): The Six-Million Dollar Study NIMH N = 240 (120 adults, 120 children) multi-site Looking at all potential reinforcement (external or internal) Principal investigators = John Piacentini, Doug Woods, Michael Himle results due soon!

18 Habit Reversal Training Psychological Treatment: Four main components: 1. self-awareness (= ) describe tic: be sure it s a tic (compulsions have a related but different treatment) describe warning signs : awareness of PREMONITORY URGE ( itch ) component crucial

19 Tic List Tic Annoyance Level (1-10) 2005, CPRI Brake Shop

20 Warning Signs Things you feel Things you do 2005, CPRI Brake Shop

21 Habit Reversal Training Psychological Treatment: Four main components: 1. self-awareness (= ) detect tic e.g. raise hand when tic is demonstrated/occurs in client 2. relaxation training e.g. deep breathing, progressive muscle relaxation, stretching

22 Breathing Triangle In for 5 (relax) Out for 5 Rest for , CPRI Brake Shop

23 Habit Reversal Training Treatment Psychological: Four Main Components: 3. development of a competing response: incompatible: motor = isometric muscle contraction phonic = breathing in/out through nose more benign capable of performing for long periods

24 Habit Reversal Training Treatment Psychological: Four Main Components: 3. engage in competing response for 1 minute: when feel premonitory urge: habituate to premonitory urge after performing tic to disrupt possible bout in tic-eliciting situation

25 Competing Responses: Common Examples (Carr, 1995)

26 Competing Responses: Common Examples In all or nothing tic combinations or paroxysms, target the trigger tic Azrin, Nathan & Nunn, 1977

27 Competing Responses: Common Examples Azrin, Nathan & Nunn, 1977

28 That Tic Ain t the Boss of Me!!! Use your exercises: each time you do the tic!!! each time you notice a warning sign: you feel it coming!!! you are in a place where that tic comes out a lot!!! 2005, CPRI Brake Shop

29 Habit Reversal Training Treatment Psychological: Four Main Components: 4. social support: be a cheerleader. Not a nag. praise for correct/independent/ sustained use of competing response provide prompts/reminders if miss using competing response = motivation to USE TREATMENT, not to JUST STOP

30 Tic Tracking Week 2 Week 3 Week , CPRI Brake Shop

31 Habit Reversal Training T(r)IC(k)S from the Trenches: Watch those stimulant levels Start On A Long Weekend or Holiday: pick or create a time period (few days to a week) with relatively few demands and stress Start As Soon As You Wake Up: with leaky brakes, it s always easier to REFRAIN than to RESTRAIN

32 Only One Tic At A Time!!! don t shake your head! don t blink! stop humming! quit clearing your throat! Limited Reservoir of Energy! So choose your battles wisely choose your battles wisely

33 Give Yourself Some Credit! Tolerance for and Negotiations with some tics earns credit. CREDIT: which can later be cashed in on tics you wish to change! DEBIT: hopping blinking humming ok ok ok throat-clearing head-shaking snorting no no no

34 No Immediate Payoff training complex skills True Change Takes Time and Consistent Practice. My goal is to be as good as I can be. Not to be good in a hurry -Tiger Woods

35 effort The Path to Extinction (or: how to boss back a tic!!!!!! ) picture the most entrenched tic to take 3 months to reach complete extinction Expect this first victory to take 4 days to a week this is called spontaneous recovery. It s a normal and expected part of HRT time

36 HRT: Myths & Misunderstandings Some great ideas, but also some unfortunate language popular understanding of some jargon in this field can have some very negative (even visceral) connotations? very understandably has polarized some adults who have fought most of their lives to not be perceived as being able to stop themselves

37 HRT: Myths & Misunderstandings Woods, Conelea & Walther, 2007: HRT doesn t lead to tic rebounds Non-targeted tics don t get worse HRT doesn t replace an old tic with a new one Focussing attention on tics in the context of treatment doesn t make them worse: only a problem outside of a therapeutic context

38 HRT: Myths & Misunderstandings In essence, supporters of HRT are saying, if you tell yourself not to tic then you won t or just don t do it : no one said tics were purposeful no one said they weren t motivated to stop no one said stopping is a skill they already have and no one said it would be easy! this is remediation of a skill deficit: it takes time and patience

39 HRT: Myths & Misunderstandings but it IS possible though: learning more and more about the ability of the brain to compensate and adapt. called neuroplasticity e.g. The Brain That Changes Itself (Dr. Nathan Doidge) analogy of a lazy eye: can be fixed, but nothing will change without active intervention think of it as taking your frontal lobe to the gym! Or getting a "Brake Job

40 HRT: Myths & Misunderstandings Supporters of HRT are portraying TS as a mental disorder and not a neurological disorder : it s both psychology is neurology, and neurology is psychology: simply about level of explanation e.g. describing grains of sand vs. a beach Nature and Nurture exist in a bidirectional relationship e.g. therapy for OCD caused same neurological changes as medication did neurological changes as medication did

41 Different Routes To The Same Destination pharmaceutical therapeutic X YES! It s a neurological condition!!! NO! NO! A neurological condition doesn t presume a pharmaceutical treatment

42 When HRT May Be Appropriate Desire selective control over treatment effects: the power of choice over which symptoms will be removed from repertoire a scalpel versus shotgun approach Resistant/intolerant to medications could be treatment-resistant resistant could be philosophically opposed (e.g. not wanting to lose the positives of leaky brakes )

43 When HRT May Be Appropriate Require/desire a treatment that will increase rather than decrease a sense of personal empowerment: with medical treatment, the implication is that you yourself can t help it : breeds a victim mentality, powerlessness, and depression with HRT, you are bettering yourself; it s not a pill fixing you or making you better, and you can do something about your symptoms. Breeds a victor victor mentality

44 When HRT May Not Be Appropriate Cognitively limited: require mental age of 9 best if IQ within broad range of Average A quick response is needed: symptoms present immediate jeopardy to health/safety (e.g. painful, self-injurious tics) More pressing areas of dysfunction: energies better directed in bigger battles energies better directed in bigger battles

45 When HRT May Not Be Appropriate Too leaky for strategies: combining medications with HRT can be complementary; greater than sum of parts modest doses of medication could stabilize create optimal arousal levels provide scaffolding for learning to begin

46 When HRT May Not Be Appropriate Presenting problem(s) ) have to do with people s REACTIONS or ATTITUDES towards the tic, rather than the actual tic itself cultivating understanding/acceptance is a different treatment altogether other referrals are more appropriate (e.g. peer assembly, directing to local support group, family therapy, etc.)

47 When HRT May Not Be Appropriate Untreated ADHD-PHI poor impulse control will interfere with use of competing response a little OCD in the mix can help The person bothered by the tic(s) ) is NOT the person WITH the tics: HRT requires high degree of motivation without significant distress or impairment, is that individual with tics disordered? No! Good for him/her. We ll treat you instead

48 Final Verdict??! Yes it works. Quite well. Comes down to individual choice and circumstances: the only wrong answer is denying an option: when categorically dismiss HRT, allowing preconceptions to blind you no different than dismissing tics as bad behaviour! ultimate goal = happiness and being free of impairment client must be involved and considered in decision

49 A Message to Psychologists and Psychological Associates: AnTIC TICipate the future!!! new manual coming for now, use Habit Reversal Treatment Manual for Tic Disorders : Woods, DW & Miltenberger,, RG (Eds.), Tic disorders, trichotillomania, and other repetitive behavior disorders: Behavioral approaches to analysis and treatment.. Boston, MA: Kluwer (chapter 6).

50 Source: The Far Side Gallery 2001 Off-The-Wall Calendar. Copyright FarWorks, Inc.; Far Side Cartoons

51 BEFORE neatness was emphasized

52 and AFTER.