Managing Tic and Habit Disorders

A Cognitive Psychophysiological Treatment Approach with Acceptance Strategies
Wiley-Blackwell (Verlag)
  • erschienen am 10. August 2017
  • |
  • 200 Seiten
E-Book | ePUB mit Adobe-DRM | Systemvoraussetzungen
978-1-119-16728-0 (ISBN)
A pioneering guide for the management of tics and habit disorders
Managing Tic and Habit Disorders: A Cognitive Psychophysiological Approach with Acceptance Strategies is a complete client and therapist program for dealing with tics and habit disorders. Groundbreaking and evidence-based, it considers tics and habit disorders as part of the same spectrum and focuses on the personal processes that are activated prior to a tic and habit rather than the tic or habit itself. By drawing on acceptance and mindfulness strategies to achieve mental and physical flexibility in preparing action, individuals can release unnecessary tension, expend less effort and ultimately establish control over their tic or habit.
The authors explain how to identify the contexts of thoughts, feelings and activities that precede tic or habit onset, understand how self-talk and language can trigger tic onset, and move beyond unhelpful ways of dealing with emotions - particularly in taking thoughts about emotions literally. They also explore how individuals can plan action more smoothly by drawing on existing skills and strengths, and overcome shame by becoming less self-critical and more self-compassionate. They conclude with material on maintaining gains, developing new goals, and creating a more confident and controlled lifestyle.
Managing Tic and Habit Disorders is a thoughtful and timely guide for those suffering from this sometimes all-consuming disorder, and the professionals who set out to help them.
weitere Ausgaben werden ermittelt
Kieron O'Connor, PhD, is currently director of the OCD Spectrum Study Centre at the University Institute of Mental Health at Montreal, and Centre Integré Universitaire de Santé et de Service Sociaux de L'Est de l'Ile de Montreal. He is also Full Professor at the Psychiatry Department of the University of Montreal and affiliated professor at the University of Quebec.
Marc E. Lavoie, PhD, is a professor of psychiatry and neuroscience at the University of Montréal and is currently head of the Cognitive and Social Psychophysiology laboratory at the research center of the Institut Universitaire en Santé Mentale de Montréal.
Benjamin Schoendorff, MA, MSc, is a clinical psychologist and director of the Contextual Psychology Institute in Montreal, Canada.
List of Tables and Figures ix
List of Contributors xiii
Acknowledgments xv
About the Companion Web Site xvii
Introduction 1
1 The Nature of Tics and Habits 9
Overview of the Nature of Tics and Habits 9
Idea of a Tourette or Tic and Habit Spectrum 10
Current Diagnostic Criteria of Tics and Habits 10
Current Multidimensional Etiology of Tics and Habits 13
Social Impact and Consequences 17
Current Treatment Options 18
2 Evaluation and Assessment 21
Evaluation and Assessment: What are Tics and Habits? 21
Evaluating the Severity of Tics and Habits and Their Impact on the Client's Life 22
Assessing Style of Planning and Thinking and Beliefs about Tics
or Habits 32
3 Motivation and Preparation for Change 43
Motivation: Ready to Change the Habit 43
The Pros and Cons of Tics and Habits; and Setting Goals and How to Attain Them 50
Client's Perception of the Tic or Habit 52
Dealing with Stigma and Self-stigma 53
Control: Micro- and Macro-control 55
The Contextual Nature of Tic or Habit Onset 57
4 Developing Awareness 61
Choosing and Describing the Tic or Habit 61
Awareness of the Tic or Habit 63
Discovery of Seeing the Habit Differently 63
Discovery Exercises 64
Making a Video: Replaying and Watching the Video 64
Premonitory Signs 67
Daily Diary 68
Tic or Habit Variations 73
Tics or Habits in Context 74
5 Identifying At-Risk Contexts 77
Identifying Variations in the Context of the Tics or Habits 77
Discovering High and Low Risk Situations or Activities 78
Evaluating the Situation or Activity 79
Linking High Risk Activities and Evaluations to Feelings and Thoughts and Assumptions 83
6 Reducing Tension 87
Tension Before Ticking: How to Use Your Muscles 87
Conflicting Preparation Versus Coherent Preparation 92
Unhelpful Attempts at Self-management of Tics or Habits 95
Mindful Engagement 96
Mindfulness Exercises 97
7 Increasing Flexibility 101
Discriminating Muscle Contractions 101
Rationale and Procedure for Discrimination Exercises 102
Whole Body Muscle Control 105
Muscle Relaxation 105
Check the Breathing, Posture, and Flow During Movement 106
Breathe Better 106
Relaxation Exercises 107
Refocusing Sensations 111
8 Addressing Styles of Planning Action 115
Style of Planning: Pulling Together Sensory, Emotional, and Motor Aspects of Ticking 115
Styles of Action 116
Behavioral Cost 118
Thoughts associated with Styles of Action: Perfectionism in Personal Standards and Personal Organization 120
9 Experiential Avoidance, Cognitive Fusion, and the Matrix 127
Experiential Avoidance and Cognitive Fusion 127
Improving Flow and Goal Directed Action Using the ACT Matrix 131
Discriminating Thoughts, Actions, and Experiences 134
Using the ACT Matrix to Work with Styles of Action 137
10 Emotional Regulation and Overcoming the Habit-Shame Loop 141
The Habit-Shame Loop 145
Adaptive and Maladaptive Coping 146
Validating Emotion 147
Working with Self-talk 148
Relational Frame Theory 149
An RFT-inspired Link between Dysfunctional Thoughts and Tension 152
11 Achieving Goals and Maintaining Gains 155
Maintaining the New Behavior 155
New Situations 158
Reward and Self-compassion 159
Relapse Prevention 160
Achieving Non-tic Goals 160
Finally 161
References 163
Index 171


Kieron P. O'Connor, Marc E. Lavoie, and Benjamin Schoendorff

Cognitive-behavioral management complements the neurodevelopmental aspects of tic and habit disorders. In the chapters that follow, we describe a new and improved therapist and accompanying client manual of our tic and habit management program: the cognitive psychophysiological approach (CoPs) (O'Connor, 2005). The program has widened to include psychosocial, metacognitive, and other behavioral aspects, which we combine with acceptance strategies. We have now carried out over 20 years of clinical research dealing with tics or habits, during which time we have conducted a number of clinical trials and neuropsychological work. Our research has informed our opinion that tics or habits are really the tip of the iceberg; that there are background behavioral aspects influencing tics or habits; that tics or habits are embedded in personal activity; that surrounding psychosocial and thought processes define tics or habits; and that tics or habits interact with how we perceive others and our own activities. So, although tics or habits may well serve a short-term function in reducing stress, so producing reinforcing consequences that immediately maintain them, they are also products of a context of cognitive-behavioral psychophysiological activity occurring prior to and during their occurrence (see Figure 0.1).

Figure 0.1 Local immediate triggers and reinforcing tic or habit cycle

The program has been validated for both tic and habit disorders (the user friendly term we use for bodily focused repetitive behaviors, BFRBs) so the manual addresses both disorders, which, despite some differences, we consider to be part of the same spectrum of disorders. Tic or habit onset may be an inevitable endpoint of tension built up as a result of the way action is planned and executed. So the tic or habit, often arising locally, is not the focus here-in fact we recommend accepting the tic or habit when it occurs, rather than fighting the tic or habit or holding it in, contracting or disguising it: all self-sabotaging strategies that tend to exacerbate the underlying tension. Rather, we encourage developing a flow of action and moving past the tic or habit toward goals, and heading smoothly and effortlessly toward goal-directed planning activity.

The CoPs model is a comprehensive model taking into account, as the name implies, cognitive, physiological, and emotional dimensions, and treating the client holistically. It is predicated on two sound assertions:

  1. That thinking and physiology are interlinked. This is not obvious since clients have often considered the tic or habit problem as purely neurological. But tics or habits are best viewed as psychophysiological, which is to say that the physiological elements of ticking are often modulated by psychological factors, which include: behavior, mood, social setting, and perceived external triggers. The effects are two-way, and change in behavior can influence change in physiology. In particular, thought processes involved in anticipation and preparation can be triggers for ticking and are a key connection between thoughts and physiology.
  2. There is an important distinction between controlling the tic or habit and achieving a sense of mastery from being able to prevent the tic or habit through mastery over the processes that build up to it. We make the distinction between positive acceptance and mastery, and a negative fighting and containing type of control over the tic or habit.

The cognitive element is also essential to the program in the sense that we encourage exercises to enhance awareness or, as we choose to call it, discovery. In fact awareness is about discovery and bringing new elements into consciousness, but discovery is also actively exploring and integrating new knowledge about the nature of the client's tic or habit, like exploring a new land, sailing down the stream along a new river-a metaphor that fits well within the steps of the program (see client manual).

This manual addresses both tics and what we call habit disorders (the technical name is bodyfocused repetitive behaviors), including hair pulling, nail biting, skin picking, and skin scratching. These problems are distinct and vary on several dimensions, but they seem to respond to the same treatment, namely CoPs, and share features in common. Although BFRBs or habits may require additional strategies, particularly regarding emotional regulation, we decided to deal with tics and habits together since they fall under the same tic or habit-like spectrum, despite differences in awareness and action motivating people, and clinicians often ask: is the problem a tic or a habit disorder?

We provide guidelines to distinguish tics and habits and other movement disorders. But we do suggest that the client consult a medical professional such as a neurologist to receive a diagnosis.

A Cognitive-Behavioral Psychophysiological Model of Tension Buildup

So what are the ingredients of the CoPs model of tic or habit onset and maintenance? The CoPs model integrates physiological and behavioral aspects as well as cognitive and emotional experiences. It paints a comprehensive picture of the interactions between the physiological dimensions of muscle tension, ticking, and behavior, and cognitive and emotional patterns that may feed tics and habit disorders. The key theme of the program is developing flexibility in muscles, planning, thinking, emotional coping, self-talk, and self-judgment. On the psychophysiological side, heightened sensory awareness, an overactive behavioral style, and impulsive tendencies contribute to the onset and maintenance of tics or habits, while, on the cognitive side, perfectionism regarding self-image, personal standards, and a dysfunctional way of approaching planning of action are implicated. People with tics or habits often display somewhat perfectionist beliefs about the importance of being efficient, doing as much as possible, and not wasting time or appearing to do so. On the action side, they attempt too much at once, have trouble pacing action, invest more effort than necessary in a given task, and abandon tasks prematurely. They are also unwilling to relax, have trouble being present in the here and now, and tend to overinvest in trying to foresee the unforeseeable. Finally, rather than using visual feedback of a particular action, people with tics or habits may pay more heed to more general proprioceptive information, leading them to tense until they attain a sense of "feeling just right," or have felt they put the right amount of effort into a task. In fact, tics and habits may be providing just such a muscle focused feedback by occupying the client in a proprioceptive loop, which gives the impression of "doing something" in situations where normal goal directed activity is frustrated. Also people with habit disorders in particular, but also some people with tics or habits, experience a lot of self-criticism and shame about themselves, and generally find it difficult to cope with negative emotions, which can trigger the habit (see Figures 0.2 and 0.3). So we suggest that more compassionate ways of viewing the self and accepting self and emotions may help with control.

Figure 0.2 Why tics happen

Figure 0.3 Why habits happen

Structure of the Program

In line with our model, the first part of the program describes the history of Tourette's, tic disorders, and habit disorders, current thinking on etiology, and the growing recognition of the utility of behavioral interventions. The second part considers all aspects, both psychosocial and clinical, needed for a comprehensive diagnostic and psychological assessment. The formal semi-structured interviews are cited but not explored; rather, focus is on evaluations essential to the program. Included in evaluation is a look at how the client and other people judge the problem, and the problem of stigma and living with and communicating about the problem. The third section involves steps of the program, beginning with motivation and education about the close link between thoughts and actions and the way that sometimes how we react to our tics and habits leads to self-sabotaging strategies. We discuss discovery and awareness exercises to help the client learn about the nature and form of their tic or habit. The role of tension in triggering the tic or habit in action is illustrated, along with exercises to improve muscle flexibility, discrimination between muscles, and relaxation. High and low risk activities/situations for tic onset are evaluated, and how these reveal existing strengths and control and also give us an insight into how evaluations can influence tensions. The importance of obtaining cognitive and physical flexibility is highlighted, with exercises to improve flexibility and efficient muscle use, and showing how to focus on acceptance of the tic or habit whilst avoiding strategies that lead the client away from goals. Rethinking the client's entire style of planning in order to prevent tic or habit onset by using existing strengths in the client's repertoire and planning less effortful action is encouraged, as well as improving emotional regulation and self-perception, particularly in body focused disorders or habit disorders. We also cover the important role of the B.e.s.t. Buddy and social support, and inform on...

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