Cognitive-Behavioral Management of Tic Disorders - Softcover

O'Connor, Kieron

Softcover

ISBN 10: 0470093803 ISBN 13: 9780470093801

Verlag: John Wiley & Sons Inc, 2005

Inhaltsangabe

Tics affect more than 10% of the population, and can be an unpleasant and disruptive problem. They include chronic tic disorder, Tourette?s syndrome and habit disorders such as hair pulling, nail biting and scratching. Treatment is either by medication (without convincing evidence) or psychological means. Before the introduction of habit reversal psychologists had no real alternatives to offer, and even this method lacks evidence for its efficacy and is not widely used. Illustrated throughout with case study examples and containing detailed guidelines for patient and therapist on the use of CBT, this book provides a comprehensive review of what is known about the occurrence and diagnosis of tics. Kieron O'Connor explores the various theories currently available to explain the causes and progression of these disorders, and discusses the assessment and treatment options available. Finally he takes the most widely accepted psychological therapy ? cognitive behaviour therapy - and applies it for the first time to the treatment of tics.

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Kieron O'Connor began his research career working as a research officer at the Medical Research Council (UK) Clinical Psychiatry Unit at Graylingwell Hospital, Chichester, Sussex. In 1979, he was awarded a Master of Philosophy (MPhil) by thesis in experimental psychology from the University of London. He completed the British Psychology Society clinical diploma training course in 1986, and transferred to the University College, Institute of Laryngology and Otology, working partly as a research lecturer, investigating psychological aspects of vertigo and dizziness, and also as a clinical psychologist at Bloomsbury Health Authority.
In 1988, he was awarded the first of a series of fellowships by the Fonds de la recherche en Santè du Quèbec, and established a clinical research program at the Fernand-Seguin Research Center, Louis-H. Lafontaine Hospital, University of Montreal, Canada. The multidisciplinary research program, which focuses on obsessive-compulsive disorder (OCD), Tourette and tic disorder and delusional disorder, is currently funded by the Canadian Institutes of Health Research. He is actively involved in several community-based initiatives to provide support and information to people with OCD and Tourette's syndrome and their families, and is scientific advisor to the Quebec OCD Foundation.
He is currently associate research professor at the Psychiatry Department of University of Montreal, and also holds an honorary cross appointment as associate professor in the department of Psychology, University of Quebec at Montreal. He is author or co-author on over 1000 scientific publications. He is also co-authored with Frederick Aardema and Marie-Claude Pèlissier of Beyond Reasonable Doubt: Reasoning Processes in ODC Disorder and Related Disorders, published in 2005 by Wiley.

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Tics can be very distressing and severely disabling for sufferers. Cognitive-Behavioral Management of Tic Disorders uses cognitive behavioral approaches and related psychoeducational and psychophysiological methods to aid management of tics in people with Gilles de la Tourette’s syndrome and chronic tic disorder.

Kieron O’Connor undertakes a review of relevant literature and research in this area, and presents a cognitive psychophysiological model of tics, together with an outline of empirical studies testing the model. A comprehensive and original treatment program for use in tic management is included, with case studies and appendices to illustrate the approach. The program focuses on preventing tic onset and addresses wider aspects of the person’s functioning. Both client and therapist manuals are provided.

Cognitive-Behavioral Management of Tic Disorders provides a much needed, effective reference for the psychological treatment of tic and habit disorders. It will be a valuable resource for clinical psychologists, cognitive-behavioral therapists, psychiatrists and other mental health professionals.

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Cognitive-Behavioral Management of Tic Disorders

By Kieron Philip O'Connor

John Wiley & Sons

Copyright © 2005 Kieron Philip O'Connor
All right reserved.
ISBN: 9780470093801

Chapter One

THE NATURE OF TIC DISORDERS

* DEFINITION

Tics are defined, rather vaguely, in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) nosology as a recurrent, non-rhythmic series of movements (of a non-voluntary nature) in one or several muscle groups. Tics are usually divided into simple and complex tics of a motor, sensory, phonic or cognitive nature. In practice, simple tics have to be differentiated from behaviors such as routines, automatisms and stereotypes; from spasms of neurological or neurochemical origin, and from dystonias and torticollis of a possibly psychoneurological origin. Also, complex tics, which are complex if they involve sequences of several distinct muscle movements, can visibly resemble the ritualized compulsions of obsessive-compulsive disorder (OCD).

* DIAGNOSIS

Tics occur over all cultures, and have been reported anecdotally since classical times. The first clinical descriptions, however, were provided in the nineteenth century by Itard (1825), who reported a case of an aristocrat exhibiting tics, barking and obscenities, and later Gilles de la Tourette (1885), who gave a detailed description of eight additional cases. Currently, the DSM-IV distinguishes transitory tics from chronic tic disorders (TD) and Gilles de la Tourette's syndrome (TS). Transitory tics are those occurring for a short period, usually in early childhood, which slowly disappear or show spontaneous remission later in adolescence. In TD, typically, one or several simple or complex tics are present. Often the tics are stable over a period of years since childhood. The tics occur daily and cause distress. Although the diagnostic criterion specifies onset prior to age 18, tics may develop in adulthood. TS is recognized in the DSM-III and DSM-IV as a distinct diagnostic category with multiple tics including at least one phonic tic occurring several times a day, every day, throughout a period of more than one year and whose location, number, frequency and severity can change over time with onset before the age of 18 years. Although clinician consensus tends to view TD as a milder form of TS, diagnosis of TS is categorical not dimensional. Kraemer et al. (2004) point well to the pitfalls of using categorical instead of dimensional approaches to classification, and although both have uses in different settings, the reliance entirely on categorization of TS and TD in the complete absence of a dimensional model could be problematic. There seems to be a consensus among researchers that TD and TS share enough common aspects to be considered on a continuum of severity (e.g., Spencer et al., 1995). But the diagnosis of TS is currently dichotomous, not dimensional, and depends crucially on the existence of a vocal tic, although there has been controversy about current criteria for TS (e.g., First et al., 1995; Tourette Syndrome Classification Study Group, 1993). Some current assessment instruments do adopt a dimensional approach (see Table 6.1).

Tics may be simple or complex. A simple tic involves one principal muscle group. Simple tics include blinking, cheek twitches, head or knee jerks and shoulder shrugs. Tics are mainly confined to the upper body and the most common occur in the eye, head, shoulders and face, and follow a rostral-caudal development. Tics can also be vocal and include coughs, tongue clacking, sniffing, whistling, throat clearing, hiccing, barking and growling. Some recurrent involuntary somatic sensations are classified as sensory tics. These are identified as heavy, warm or tingling premonitory sensations, often muscle focused and leading to muscle tension (Lohr & Wisniewski, 1987; Shapiro & Shapiro, 1986; Shapiro et al., 1988) but the term "premonitory sensation" is now preferred over sensory tic (Cath et al., 2001a). Table 1.1 gives examples of common tics.

Tics are classified as complex if there is a contraction in more than one group of muscles (Comings & Comings, 1984). Complex tics may involve sequences of movements, and may take the form of bizarre mannerisms involving several limbs or extremities. J's complex tic begins with a turn of the head towards the right, his hand comes up across his forehead and descends over his head, while his head makes a full semi-circle rotation, and he exhales at the same time. M's complex tic begins with an extension of the shoulder and then a contraction back to the center while his left shoulder repeats the same action. He repeats this back and forth until he "feels right". Complex tics may also take the form of self-inflicted repetitive injurious actions such as head or face slapping, face scratching, teeth grinding, neck cracking, tense-release hand-gripping cycles, or finger twiddling. In neck cracking, the person may manually lift, turn and replace the head on the cervical vertebrae, producing a clicking or grinding sound. Similarly, in knuckle cracking, the person will force the fingers down onto the knuckle joints.

Complex vocal or, more precisely, phonic tics (Jankovic, 1997) take the form of repeated sounds, words or phrases or swear words, and, in rare cases, coprolalia (swearing). Normal actions and words of the person may also be repeated or exaggerated, and copying others can itself evolve into a complex repetitive movement either by echopraxia (motor mimicry) or by echolalia (repeating others' words, phrases or sounds). Complex tics can resemble habit disorders (HD) such as trichotillomania (hair pulling), bruxism (teeth grinding), scabiomania (skin scratching or picking), onychophagia (nail biting), which are, however, classified among the impulse control disorders. There is a covariation between tics and HD and among different types of HD (Woods et al., 1996a). So a person with tics is more likely, than normal, to suffer also from HD. Although complex tics by their semi-voluntary nature may have some intentional aim even if the intention is sensory adjustment (making symmetrical movements to feel "just right"), simple tics seem to serve no purpose.

Tics generally appear in the superior part of the body, including eyes, forehead, mouth, face, neck, shoulders, and can occur anywhere between one and 200 times per minute. Simple facial tics generally have a higher frequency. The onset of simple tics generally precedes complex tics, and simple tics can develop at any time in childhood from 0 to 5 years. Vocal tics develop after motor tics and it is rare for tics to develop post-adolescence, although they can develop in adults (Cohen et al., 1992), often following trauma or surgery. For example, eye blinks may develop as a defensive reaction to light following eye surgery. However, tics seem to wax and wane in severity throughout life and may in the case of TS be substituted by completely different tics or may even spontaneously remit (Nomoto, 1989).

Technically speaking, complex tics are distinguishable from stereotypies and compulsive rituals, routines and habits, since tics are neither completely conscious purposeful rituals, nor totally non-sensical repetitions. In fact, the term "behavioral stereotypy" is usually applied to abnormal repetitive actions associated with organic loss and mental deficiency. In practice, however, it is sometimes difficult to distinguish tics, routines, habits and repetitive movements. The relationship between these three is puzzling since some movements have impulsive as well as compulsive elements. Shapiro and Shapiro (1986) referred to "impulsive compulsions" to highlight the confusion, and Rasmussen and Eisen (1992) and other authors have equally underlined the importance of understanding the relationship between impulsion and compulsion for clarifying diagnosis. In normal automated routines, there may be little awareness but there is overall volitional control. In rituals, there may be awareness but no control. In reflexes and tics, there may be neither awareness nor control.

* WHAT COUNTS AS A TIC?

People themselves often refer to a number of movements and habits as tics. They may consider playing with a paper clip or toying with an object as a tic, but obviously to qualify as a clinical problem, a tic must produce distress and be sufficiently uncontrollable. Playing with a paper clip can be stopped by focusing attention on it. Similarly, routines of the day such as tying shoe laces, driving to work, the way we walk or eat a sandwich are automated habits and may even become endearing or irritating personal characteristics, but they are essentially under voluntary control and we can change them with practice in the same way that we can learn other motor skills (eg., sport activities) through practice. Of course, where habits are motivated by fear or strongly held self-interest or are tied to pleasurable sensory states, they may be more difficult to change.

The paradox of tics is that they take place in voluntary muscles. The muscles concerned with regulating heart rate, breathing or other autonomic functions are not considered to produce tics. So tics occur in muscles used usually for voluntary control, and yet they appear non-voluntary; not only non-voluntary but often undetected by the person. Here again we have another paradox since although at the time they occur, tics are non-voluntary and often non-conscious, the urge to tic can be wilfully mentally suppressed or physically held in for often considerable periods of time. Although some simple tics resemble neurological spasms, more complex tics can resemble complex, willful actions. A man feels compelled to stand up and adjust his shoulders back and forth for five minutes to an exact frequency and symmetry in order to feel just right. Is this a tic, a habit or a compulsion? It is not surprising that tics have caused diagnostic problems.

De Groot, Janus and Bornstein (1995), in a study of 20 symptoms in 92 children and adolescents, extracted five factors accounting for 63% of the variance and which were labeled in order of importance "aggressive movements", "oro-facial contractions", "body movements", "peripheral movements and simple phonic tics", and finally "complex motor and phonic tics". Alsobrook and Pauls (2002) conducted a factor analysis of 29 symptoms in 85 cases of TS and found a four-factor solution adequate to account for 61% of the variance. The factors grouped symptoms respectively into "temper fits and aggression", "motor and phonic tics", "compulsive behaviors" and "absence of grunting and the presence of tapping". However, the clusters in both these studies may reflect the peculiar diversity of the sample and not be stable clusters of symptoms for TS in general. In vocal tics, it is usually the content which determines complexity - a repeated sentence or phrase being considered complex, whereas a single sound or word, even if lasting a long time, would be simple. The status of sensory tics is more controversial, with some arguing that they are precursors to motor tics rather than a sensory phenomenon in themselves. One form of tic, mental or cognitive, is often underdiagnosed and poorly understood. These tics are frequently confused with obsessions or ruminations since the person repeats a song or a phrase or a scene over and over mentally. But in fact they have more in common with other tics than with obsessions.

* COMORBIDITY AND COVARIATION

One problem with subtyping by symptoms is that there is often a lot of covariation between simple and complex tics and also habit disorders. In TS, multiple tics are frequently found together with other behavioral and attentional problems, such as attention deficit and hyperactivity disorder (ADHD) (Knell & Comings, 1993).

The comorbidity of a tic disorder with OCD varies across studies between 25 and 63%. But where OCD occurs with either TS or TD, the tics and obsessions seem to develop independently (Swedo & Leonard, 1994). In the case of tic-related OCD, the compulsions seem to resemble more sensory-based rituals, and raises the question as to whether such rituals are better classified as impulsive than compulsive (see Table 1.2). George et al. (1990) have developed a clinical questionnaire with some clinical face validity to distinguish the sensory-based types from other compulsions. Although TDs do not seem to have any greater psychiatric comorbidity than normal, there is considerable concern over concurrent behavioral disorders. Indeed, for many patients and their families, it is the accompanying behavioral disorders such as ADHD that cause many of the apparent deficits in TS. In particular, severity of tic symptoms has been positively related to behavioral problems. There have also been tentative suggestions that TS may share comorbidity with bipolar disorder and schizophrenia. This comorbidity issue is particularly important in children where the presence of both TS and OCD may initiate behavioral disturbances such as rage syndrome. The relationship between childhood and adult comorbidities also remains uncertain. For example, the literature on adult manifestations of hyperactivity is sparse (Lamberg, 2003).

* SECONDARY DISTRESS

Tics are rarely life-threatening except in rare cases where they may provoke automutilation. Some complex tics can be quite severe and self-mutilating and involve head banging, eye gouging, neck dislocation. Even in the absence of mutilation, psychosocial distress in TD and TS can be considerable and can involve secondary phobias, depressions and social anxieties and worries over self-image, very low self-esteem and relationship problems. In our assessment of the interference of TD and HD in daily activities (see Appendix 1d), we found cases of unemployment, marital conflict, interpersonal difficulties, strained work relations, self-imposed travel restrictions, anxiety attending social or public functions, performance worries (e.g., about driving, speaking, teaching, dancing, sport), all of which were perceived (by the affected person) to be a result of the tic habit (O'Connor et al., 2001b). People with tics often experience low self-esteem and are (or become) hyperattentive to the judgment of others with consequent low self-satisfaction (Thibert et al., 1995). In TD, ironically, the very anticipation of experiencing a negative self-evaluation can provoke the tic (see later section).

Continues...

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Details zur Ausgabe

• Verlag: John Wiley & Sons Inc
• Erscheinungsdatum: 2005
• Sprache: Englisch
• ISBN 10: 0470093803
• ISBN 13: 9780470093801
• Einband: Tapa blanda
• Anzahl der Seiten: 328
• Kontakt zum Hersteller: Nicht verfügbar
• Verantwortliche Person: Nicht verfügbar