Introduction

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...