Using Habit Reversal Training to Reduce Physical and Verbal Tics

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Habit reversal training is a therapy that can be effective in treating troublesome behaviors caused by a number of conditions. One of these is Tourette's syndrome, which is characterized by physical or verbal tics, such as blinking, throat clearing, repeating obscenities.

People dealing with symptoms of impulse control disorders, such as trichotillomania (hair-pulling) and pathological skin picking, also may benefit from habit reversal training, which is composed of these four main elements.

What Is Awareness Training?

Awareness training is used to bring greater attention to tics and other behaviors so that the affected person can gain better self-control. Awareness training is usually carried out in a number of smaller steps:

  1. While watching himself in a mirror, the person describes in detail each time he carries out behavior that's associated with his condition—pulling his hair, for instance, or rubbing his eyes.
  2. The therapist will point out to the person whenever he carries out the tic or impulse repeatedly until the person is able to notice the behavior for himself.
  3. The person learns to identify the earliest warning that a tic or impulsive behavior is about to take place. These warning signs can be urges, sensations, or thoughts.
  4. The person identifies all the situations during which the tic or impulsive behavior occurs.

Development of a Competing Response

Once the patient has developed a good awareness of his tic or impulsive behavior the next step is to develop a competing response—an action meant to replace the old tic or impulsive behavior. Usually, the competing response is opposite that of the tic or impulsive behavior and is something that can be carried out for longer than just a couple of minutes.

For example, a competing response to hair-pulling might be to ball the hands into a fist and hold them rigidly alongside the body. Someone who repeatedly sticks out his tongue might purse his lips instead. Another goal of a competing response is that it is an action other people aren't likely to notice.

Building Motivation

To prevent tics and impulsive behaviors from coming back, people undergoing habit reversal training are encouraged to make a list of problems caused by their behavior. Parents and friends are also asked to praise the person for their accomplishments thus far.

In addition, it can often be helpful for people to demonstrate their ability to suppress tics or impulsive behaviors to others.

Generalization of New Skills

In this phase of treatment, people are encouraged to practice their new skills in a variety of different contexts, not just those that they have mastered to date. Learning to turn off a tic in the relative safety of the doctor's office is one thing.

More challenging is reaching a point at which it becomes easy to control impulsive behaviors where it really counts—in the real world: at home, work, school, and in other public places.

3 Sources
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  1. Mcguire JF, Ung D, Selles RR, et al. Treating trichotillomania: a meta-analysis of treatment effects and moderators for behavior therapy and serotonin reuptake inhibitors. J Psychiatr Res. 2014;58:76-83. doi:10.1016/j.jpsychires.2014.07.015

  2. Pile V, Lau JYF, Topor M, Hedderly T, Robinson S. Interoceptive accuracy in youth with tic disorders: Exploring links with premonitory urge, anxiety and quality of life. J Autism Dev Disord. 2018;48(10):3474-3482. doi:10.1007/s10803-018-3608-8

  3. Nissen JB, Kaergaard M, Laursen L, Parner E, Thomsen PH. Combined habit reversal training and exposure response prevention in a group setting compared to individual training: a randomized controlled clinical trial. Eur Child Adolesc Psychiatry. 2019;28(1):57-68. doi:10.1007/s00787-018-1187-z

By Owen Kelly, PhD
Owen Kelly, PhD, is a clinical psychologist, professor, and author in Ontario, ON, who specializes in anxiety and mood disorders.