Clinical Services

Comprehensive Behavioral Intervention for Tics (CBIT) / Habit Reversal Training

Tics refer to involuntary, repetitive movements of the body or detectable vocalizations that are not typical behaviors for the context in which they occur. Tic disorders represent a class of interrelated conditions, which include the presence of isolated or co-occurring motor and vocal tics (e.g., Tourette's Syndrome). Individuals with tic disorder are at risk for experiencing social, emotional, and behavioral impairment in a variety of domains.

One of the most effective non-pharmacological treatments for tic disorders is Habit Reversal Training (HRT). Habit Reversal Training involves several components aimed at increasing tic awareness, developing competing responses to tics, and building and sustaining motivation and compliance. Awareness training is based on the premise that increased awareness of tic behaviors facilitates better self-control. A competing response is a response physically incompatible with the targeted tic. When the ability to reliably detect tic urges has been demonstrated, the person uses a competitive response at each occurrence of the urge and holds the response until the urge passes. The use of anxiety management techniques for tic control can also be implemented. It is based on the observation that increases in anxiety lead to concomitant increases in tic frequency, intensity, and duration. Deep breathing, progressive muscle relaxation, and imagery are the most frequently used anxiety management techniques for tic disorders.

Habit Reversal Training was first tested in the 1970s but two recent, large clinical trials (sponsored by the Tourette Association of America and the National Institutes of Health), one in adults and one in youth, found strong support for Habit Reversal Training as part of CBIT – or the Comprehensive Behavioral Intervention for Tics.

CBIT is a behavioral treatment that teaches patients a set of skills to manage tics and urges-to-tic. It also helps families learn to understand how the environment (setting, emotions, activities) impact tics – and more important, how to make small changes to help the patient better manage tics and the negative impacts of tics. CBIT has three main parts – training tic and tic urge awareness, HRT/competing response training, and functional interventions that help make day-to-day changes to decrease the impact of tics. The treatment trials that tested CBITS lasted 10 weeks – with 8 psychotherapy sessions; most patients showed improvement with no negative side effects. Most showed lasting improvement.

We also offer expert pharmacological interventions for tic disorders and, when clinically appropriate, a combination of medication management and Habit Reversal Training. Often, we will provide other forms of psychotherapy, such as cognitive-behavioral therapy, to help youth with tics deal with feelings of distress related to having tics. Many youth with tics struggle with anxiety, OCD, anger management, school problems, and ADHD – we offer individualized, family-based treatment to supplement CBIT for individuals who struggle with these and other problems in addition to tics/Tourette.

Habit Reversal Training

Habit Reversal Training is a multi-stage process. First, the individual is made aware the behaviors in question (e.g., hair-pulling or a particular tic) and any premonitory urges (i.e., a preceding urge to perform the behavior). Second, the individual is taught to replace the presenting behavior with a competing behavior. Third, relaxation training is utilized to diminish the presenting behavior as well as the competing replacement behavior.

Habit Reversal Training for Trichotillomania and Skin Picking

Trichotillomania is a disorder characterized by the chronic compulsion of pulling out one's own hair, and it is associated with noticeable hair loss, distress, and impairment. Individuals suffering from trichotillomania often feel a compulsion to engage in a ritual associated with their hair-pulling (e.g., a need to bite the hair or root, tactile stimulation of lips or face with the hair shaft, a need to pull the hair in a particular way, searching for hairs that do not feel right or look right). Trichotillomania is a chronic and often disabling illness with a lifetime prevalence of 0.6-2.5%.

One leading approach in the treatment of trichotillomania and skin picking, Habit Reversal Training (HRT), is a form of psychotherapy with proven efficacy. Habit Reversal Training involves several components: awareness training, development of competing responses to hair pulling/skin picking, and building and sustaining motivation and compliance. Awareness training is based on the premise that increased awareness of hair pulling/skin picking incidents facilitates better self-control. The goal of awareness training is to identify each hair-pulling/skin picking incident and any preceding sensations. At the heart of HRT is competing response training. The therapist and patient choose a competing response to hair pulling or picking (i.e., a behavior that is incompatible with hair pulling or skin picking), and the therapist demonstrates the competing response and its proper implementation. The patient then practices the competing response, contingent upon hair-pulling or skin picking warning signs or a simulated hair-pulling/skin picking, while receiving the therapist's feedback.

In addition, having helpful family/social support can be an important asset in treatment and this is why we tend to include parents (or a support person) of patients in our sessions. The therapist will teach the support person about trichotillomania and train him or her to help the patient with the treatment implementation. For example, the support person may learn to praise correct implementation of a competing response and to prompt the correct use of a competing response.

Habit Reversal Training for Tic Disorders

Tics refer to involuntary, repetitive movements of the body or detectable vocalizations that are not typical behaviors for the context in which they occur. Tic disorders represent a class of interrelated conditions, which include the presence of isolated or co-occurring motor and vocal tics (e.g., Tourette's Syndrome). Individuals with tic disorder are at risk for experiencing social, emotional, and behavioral impairment in a variety of domains.

One of the most effective non-pharmacological treatments for tic disorders is Habit Reversal Training. Habit Reversal Training involves several components aimed at increasing tic awareness, developing competing responses to tics, and building and sustaining motivation and compliance. Awareness training is based on the premise that increased awareness of tic behaviors facilitates better self-control. A competing response is a response physically incompatible with the targeted tic. When the ability to reliably detect tic urges has been demonstrated, the person uses a competitive response at each occurrence of the urge and holds the response until the urge passes. The use of anxiety management techniques for tic control can also be implemented. It is based on the observation that increases in anxiety lead to concomitant increases in tic frequency, intensity, and duration. Deep breathing, progressive muscle relaxation, and imagery are the most frequently used anxiety management techniques for tic disorders.

We also offer expert pharmacological interventions for tic disorders and, when clinically appropriate, a combination of medication management and Habit Reversal Training. Often, we will provide other forms of psychotherapy, such as cognitive-behavioral therapy, to help youth with tics deal with feelings of distress related to having tics.