Advances in the behavior analytic treatment of trichotillomania and Tourette's Syndrome.

Abstract

Tourette's Syndrome (TS) and Trichotillomania (TTM) are both subsumed under a larger category of repetitive behavior disorders. The purpose of this paper is to provide an overview of the most recent behavioral research on TS and TTM. A description of both disorders is provided along with the most recent research on their etiology and maintenance. Behavioral treatments are then discussed with an emphasis on habit reversal--a multi-component procedure shown to be effective for treating repetitive behavior disorders. In addition, research analyzing the relative efficacy and importance of each habit reversal component is discussed. The review then concludes with treatment considerations ADVANCES IN THE BEHAVIOR ANALYTIC TREATMENT OF TRICHOTILLOMANIA AND TOURETTE'S SYNDROME Over the past 30 years, behavior analysts have been at the forefront in developing nonpharmacological treatment options for persons with repetitive behavior problems such as tic disorders, chronic hair pulling, and chronic skin picking. The current paper briefly describes these repetitive behavior disorders, presents recent behavioral research on their etiology and maintenance, and describes habit reversal--an effective behavioral treatment for these problems. After this review, the most recent research on the efficacy of habit reversal and its components is discussed. Describing Tourette's Syndrome and Trichotillomania All tic disorders involve the presence of one or more motor and/or vocal tics (i.e., sudden, rapid, recurrent, nonrhythmic motor movements or sounds). Perhaps the most representative of the tic disorders is Tourette's Syndrome (TS) which is characterized by multiple motor tics and one or more vocal tic(s) that have been present for at least one year. Other tic disorder diagnoses include chronic tic disorder and transient tic disorder (American Psychiatric Association, 1994). Tics can vary in location, topography and frequency (i.e., waxing and waning) and can be either simple or complex. Examples of simple tics include facial grimacing, head and shoulder jerking, arm and hand movements, leg kicking, stomach tensing, noises, grunting, coughing, and throat clearing. Examples of complex tics include touching objects or other people, difficulty starting actions, hurting oneself, hopping, picking at objects (e.g., clothing), tapping or straightening objects, obscene gestures (copropraxia), spontaneously saying words or parts of words, echolalia and palalalia, and shouting insults or obscenities. According to the American Psychiatric Association (APA, 1994), TS is diagnosed in four to five of every 10,000 individuals. Other reports have found TS to be as prevalent as 3% in certain populations. TS has been reported across a variety of cultures and ethnicities and is more common in males than females (APA, 1994; Kadesjo & Gillberg, 2000). The average age of onset of TS is approximately 7 years and it has been reported in children as young as two years of age (APA, 1994). Trichotillomania (TTM) is listed as an impulse control disorder in the Diagnostic and Statistic Manual of Mental Disorders (DSM-IV). The essential feature of TTM is the recurrent pulling of one's hair resulting in noticeable hair loss. To receive a diagnosis of TTM, the individual must report an increased sense of tension prior to pulling out his/her hair and pleasure/gratification after pulling. Common sites of pulling include the scalp, eyebrows, eyelashes, and pubic regions, but hair may be pulled from other locations as well (Christenson, Mackenzie, & Mitchell, 1991). A related behavior problem, chronic skin picking, has a substantially smaller body of research than TTM, but is generally considered a similar problem (Woods, 2002). Prevalence estimates of TTM in adults range from 3.2% to 22.4% (Hansen, Tishelman, Hawkins, & Doepke, 1990; Woods, Miltenberger, & Flach, 1996a), however most prevalence studies have not strictly adhered to DSM-IV diagnostic criteria (e. …