Behavioral activity and tic disorder.

Previous approaches to functional assessment of tic and habit disorders have centred largely around environmental contingencies or interceptive sensory processes as positive reinforcers. The current article argues rather that ongoing telic behavioral activity is functionally linked to tic onset and so type of behavioral activity and overall action plan at the time of ticcing should also be assessed. Evidence is presented from past studies in support of a link between tic location and type of activity and the way this activity is appraised. It is further proposed that intervention strategies for reversing tic habits should include a more holistic behavioral restructuring of muscle use rather than just an exclusive focus on developing antagonistic muscle actions as competing responses. Keywords: tic disorder, habit disorders, habit reversal, holistic behavioural restructuring, antagonistic muscle actions ********** BEHAVIORAL TREATMENTS FOR TIC DISORDERS Recent studies have shown that behavior therapy (BT) can be successfully applied to the management of Tourette's syndrome (TS), tic and habit disorders (O'Connor, 2005). The results rival those achieved with medication and given the problems of compliance with medication and the perils of neuroleptic use with children (Peterson & Azrin, 1993), behavioural programs could in theory become the treatment of choice for these disorders. But despite small scale studies showing successful outcome in a range of tic subtypes (Peterson & Azrin, 1992), behavioural treatments are far from being accepted in psychiatry as a mainstream intervention. Clinician consensus strongly favours a neurobiological model of treatment with psycho-education and eclectic supportive counselling as an adjunct (Peterson & Cohen, 1998). A contributing reason for the lack of acceptance by clinicians of behavioural analysis and therapy may be the lack of a convincing model of behavioral processes operating in tic aetiology. BEHAVIORAL PRINCIPLES AND BEHAVIORAL PROCESS IN TICS Whereas most BT methods naturally espouse behavioral principles, the techniques appeal to a number of diverse behavioral mechanisms, some in apparent contradiction to one another. For example, the technique of massed practice which has shown some early success (Feldman & Werry, 1966), attempts to negatively reinforce ticcing through building up reciprocal inhibition, whilst techniques of relaxation emphasize lowering tension rather than increasing it, also with apparent success (Bergin, Waranch, Brown, Carson, & Singer, 1998). Conversely, exposure and response prevention would encourage tolerating the urge to tic without either tensing or relaxing the tic affected muscle group (Verdellen, Keijsers, Cath, & Hoogduin, 2004). Other behavioral intervention strategies have relied more or less exclusively on different aspects of contingency management to control tics. But even here the contingencies vary considerably and can include environmental, social or attentional task demand (Miltenberger, Fuqua, & Woods, 1998). Hence the theoretical considerations driving functional analysis in BT may often be in conflict, and may hamper development of a standard model of managing behavioural processes in tics. Although there is consensus that tics and habit disorders are auto-reinforced, there is disagreement as to the role of negative versus positive automatic reinforcement contingencies. For example, some authors report social reinforcement as a key maintaining factor (Watson & Sterling, 1998) whilst others report lack of attentional state as a precursor (Roane, Piazza, Cercone, & Grados, 2002). So, applying time out to negatively reinforce ticcing within a social reinforcement model may conflict with according additional attention to positively reinforce task engagement as a means of reducing tic frequency. As Miltenberger et al. (1998) have noted, the paucity of systematic behavioural and functional analysis of tic behaviour means that little is known about the function of behaviours treated with BT. …

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