Assessment and Treatment of Habit Disorders PDF

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North Dakota State University and University of Wisconsin-Milwaukee

Raymond G. Miltenberger and Douglas W. Woods

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habit disorders behavioral treatments assessment methods

Summary

This document discusses assessment and treatment of habit disorders, including tics, trichotillomania, thumb sucking, and nail biting. It examines definitions, descriptions, prevalence, development, and etiological theories. It also explores various treatment approaches.

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# Chapter 6: Assessment and Treatment of Habit Disorders ## Habit Disorders Habit behaviors are repetitive or stereotypical responses that serve no apparent social function but are maintained by operant contingencies. Examples include: - Physical damage - Poor social acceptability Habit disord...

# Chapter 6: Assessment and Treatment of Habit Disorders ## Habit Disorders Habit behaviors are repetitive or stereotypical responses that serve no apparent social function but are maintained by operant contingencies. Examples include: - Physical damage - Poor social acceptability Habit disorders can be maintained by automatic reinforcement in the form of self-stimulation or arousal reduction. This chapter reviews the four most frequent habit disorders: - Tic disorders - Trichotillomania - Thumb sucking - Nail biting ## Tic Disorders ### Definition, Description, & Prevalence There are three types of tic behavior patterns: - **Motor tics:** Rapid, repetitive, and often jerking muscle movements that are not caused by spasms, chorea, or tremors. Examples include excessive or forceful eye-blinking, facial grimacing, and arm or neck jerking. - **Vocal tics**: "sudden, rapid, recurrent, nonrhythmic vocalizations." Examples include barking sounds, coughing and throat clearing (unrelated to illness), snorting, and coprolalia (i.e., swearing). - **Tourette's syndrome**: A condition that combines motor and vocal tics. Prevalence rates: - **Motor tics:** Approximately 1% of the population. - **Vocal tics:** Unclear prevalence, but 6.5% of college students engage in throat clearing at least 5 times per day. - **Tourette's syndrome:** Approximately .04-.05% and is more common in males. Individuals with tic disorders (especially Tourette's syndrome) sometimes have concurrent problems such as: - Obsessive-compulsive behaviors - Attention deficit/hyperactive behavior - Aggression management problems - Sleep problems Tics may also cause physical damage such as cuts, burns, and bruises. ### Development and Current Etiological Theories of Habit Disorders Tic disorders are believed to have occurred for a number of centuries, but Tourette's syndrome was not classified until 1885. **Biological perspective**: - Genetic research has shown a 77% concordance rate among monozygotic twins. - An excess of the neurotransmitter dopamine may be responsible for tics. **Behavioral perspective**: - Individuals experience heightened tension in specific muscle groups and tics may be maintained by tension reduction in those muscles; muscles are tense prior to the occurrence of the tic and this tension is temporarily reduced following a tic. - Tics are also thought to be increased by positive and negative reinforcement, and the presence of an anxiety-provoking person. ## Trichotillomania - Trichotillomania refers to chronic hair pulling which results in noticeable hair loss. - Individuals exhibiting the behavior often experience a feeling of tension/anxiety that is relieved after pulling the hair. - **Prevalence:** Approximately 1-4% of the population; adult females are 3 times more likely to receive the diagnosis than males. - **Consequences :** Chronic hair pulling can result in hair-follicle damage or severe gastrointestinal difficulties when the hair is ingested. ### Development and Current Etiological Theories of Habit Disorders - Etiological explanations of the behavior began to be presented in the 1940s. - Biological theories have not established a causal link between neurological activity and trichotillomania. - Some studies suggest that trichotillomania may be related to a seratonin deficiency. - Hair pulling may be maintained through social consequences. **Behavioral theory** suggests that hair pulling produces automatic reinforcing consequences such as: - Tactile stimulation resulting from stroking or manipulating the hair - Tension/anxiety reduction. ## Thumb Sucking - Thumb sucking occurs in up to 46% of children under the age of 4 and continues in 19% of children over the age of 5. - Thumb or finger mouthing occurs in approximately 2.8% of college-age adults. - Females are more likely to engage in thumb sucking. **Consequences:** Chronic thumb sucking can cause physical damage such as: - Dental malocclusion - Atypical root resorption - Increased risk of accidental poisoning. **Behavioral theory** suggests that the behavior is learned early in infancy to modulate arousal (i.e., comforts the anxious child or arouses the bored child) In cases where thumb sucking continues, the behavior is maintained by an arousal modulation function. ## Nail Biting - Nail biting includes placing any digit into the mouth and biting either the nails or the skin around the nails. **Consequences:** Chronic nail biting can result in: - Damage or inflammation of the tissue around the nail - Possible infection - Shortening of the roots of the teeth. ### Development and Current Etiological Theories of Habit Disorders - Nail biting may be maintained by biological processes affected by clomipramine. - Nail biting is thought to be maintained by tension/anxiety or increase arousal in under-stimulating situations (Woods & Miltenberger, 1996b). ## Assessment of Habit Behaviors - In assessing longer duration behaviors (such as thumb sucking, nail biting, and hair pulling), it may be best to use a duration measure. - Physical trace measures might not always correspond highly with the occurrence of the behavior (e.g., a small amount of the behavior might produce a substantial amount of damage). ### Measuring Habit Behaviors - **Direct Observation:** Regardless of the habit behavior being measured, it is preferable to have direct (live or videotaped) observations of the habit behavior. - **Indirect Observation procedures:** Nail biting may be measured using physical trace procedures, most often by measuring the length of the fingernails (from cuticle to tip) on each digit. - **Self-report, self-monitoring, and parental report procedures:** Have been criticized for methodological problems such as proneness to bias and distortion, lack of specificity, and relatively poor correspondence with more objective assessment strategies. ### Assessing the Social Validity of Habit Disorder Treatments and Outcome - The assessment of treatment acceptability using standardized measures has only been conducted extensively in evaluating the habit reversal procedure. ### A Functional Approach to the Assessment of Habit Disorders - Functional assessment may provide two key pieces of information: - Data needed to modify etiological theories of the various habit disorders. - Information to alter treatment plans in an effort to maximize their effectiveness. - Functional analysis attempts to identify the function(s) that maintain the behavior: - Antecedent manipulations - Consequence manipulations ## Treatment of Habit Disorders ### Tic Disorders #### Medical Treatments - The three most common medications used to treat tic disorders are haloperidol, clonidine, and pimozide. - Drugs used to treat tics may have side effects such as dry mouth, constipation, sedation, and possible risk of developing permanent movement disorders such as tardive dyskinesia. #### Behavioral Treatments - **Massed (negative) practice (MP)**: The participant intentionally engages in the target behavior rapidly and with great effort for a specified frequency or length of time. - **Habit reversal (HR)**: A multi-component procedure originally developed to treat nervous habit and motor tics. - **Awareness training:** Uses four techniques to increase awareness of the habit behavior: - Response description - Response detection - Early warning - Situation awareness training - **Competing response (CR) training:** The client engages in a behavior (for approximately 1-3 minutes) that is incompatible with the target habit behavior. - Behaviors chosen for CRs typically involve isometric tensing of muscles that oppose the habit behavior. - **Motivation training:** After the CR is established, three techniques are used to increase motivation: - Habit inconvenience review - Public display - Social support procedure - Symbolic rehearsal - **Relaxation training:** Has been shown to be effective as a solely treatment for tics, as it may function as a dissimilar CR. ### Trichotillomania #### Medical Treatments - Medications have varied widely with respect to medication type and effectiveness. - Medications used to treat trichotillomania include fluoxetine, clomipramine, imipramine, haloperidol, and lithium. #### Behavioral Treatments - **Habit reversal** is the most extensively evaluated and is effective in 60% of the cases when presented in a group format. - **Simplified HR package:** Consists of awareness training and CR training with parental social support. - **Self-monitoring** has also produced effective results. - **Other treatments:** - Aversive condition - Eliminating a covarying habit behavior such as thumb sucking - Various reinforcement and punishment procedures ### Thumb Sucking #### Medical Treatments - No medications have been used to treat chronic thumb sucking. #### Behavioral Treatments - **Bitter substance application** is one of the most popular and effective treatments. - **Habit reversal** is another popular and effective treatment. ### Nail Biting #### Medical Treatments - One medical intervention has been attempted with nail biting: clomiprimine. #### Behavioral Treatments - **Self-monitoring** has been demonstrated to be effective. - **Habit reversal** has also been evaluated in several studies. - **Other treatments:** - Electric shock - A portable self-administered shock device - Bitter substances - Contingency contracting - Covert sensitization ### Conclusions - Habit disorders are a complex set of behaviors that need to be approached from a functional assessment standpoint. - It is important to consider the social validity of treatment procedures and results. - HR is the most effective behavioral treatment for habit disorders. - Future research should focus on comparing the effectiveness of medical treatments to behavioral treatments for various habit disorders.

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