BEHAVIOR THERAPY 11, 169--178 (1980)

Habit Reversal vs. Negative Practice Treatment of Nervous Tics

N. H. AZRIN

R. G. NUNN

S. E. FRANTZ

Anna Mental Health and Developmental Center and Rehabilitation Institute, Southern Illinois University

Nervous tics without an apparent physical cause may occur in such forms as jerking of the head, twitching of the eyes, coughing, arm or shoulder jerking, nasal wheezing, facial grimaces, and rapid eyeblinking. The incidence of tics among adults is known primarily from patients whose problem has been sufficiently severe to seek treatment for the problem. For just one type of tic, spasmodic torticollis, Paterson (1945) found an incidence of about 1% among psychiatric admissions and .02% among general hospital admissions.

Controlled experimental evaluations of specific treatments with suffi- cient patients have been rare. Although lacking a control or comparison group, the following descriptive studies indicate that some types of treat- ment of muscular tics have not been notably effective. In psychotherapy with 10 Tourette patients, 40% were found to be slightly or not at all improved (Mahler & Luke, 1946). Garnett and Elbirlik (1953) found that only ½ of nine cases of spasmodic torticollis were "appreciably im- proved" by psychotherapy and other treatments. Patterson and Little (1943) found 73% of the torticollis cases were not "appreciably im- proved." In studies of surgery procedures, 71% were classified as "un- improved" in the study by Meares (1971), 54% by Rynearson and Wolt- man (1932), 39% by Poppen and Martinez-Niochet (1951), and 36% by Patterson and Little (1943).

Grateful acknowledgement is given to R. deVito for providing facilities and assistance, to J. Maedke for statistical assistance, and to P. K. Levison for his general assistance and encouragement. Requests for reprints should be sent to N. H. Azrin, Department of Treat- ment Development, Anna Mental Health and Developmental Center, 1000 N. Main St., Anna, IL 62906, Dr. R. Gregory Nunn is now at Kaiser Permanente, 7060 Claremont Mesa Blvd., San Diego, CA 92111.

169 0005-7894/80/0169-017851.00/0 Copyright 1980 by Association for Advancement of Behavior Therapy

All rights of reproduction in any form reserved.

170 AZRIN, NUNN, AND FRANTZ

Haloperidol has been used in large scale studies and has been found to be relatively effective, reducing tics by 79%, although 51% of the patients showed side effects (Bruun, Shapiro, Shapiro, Sweet, Wayne, & Solo- mon, 1976).

Behavioral studies of tics have been promising but also have been characterized by the lack of a control group and by very small numbers of patients, usually only one or two. The specific treatments have in- cluded feedback (Bernhardt, Hersen, & Barlow, 1972; Raft, 1962; Clee- land, 1973), response contingencies (Barrett, 1962), token economy (Do- leys & Kurtz, 1974), shock punishment (Brierley, 1967), self-monitoring (Hutzell, Platzek, & Logue, 1974), relaxation (McPherson, 1967), and systematic desensitization (Meares, 1973).

Negative practice training (Dunlap, 1932) has been one of the most common behavioral treatments for tics and consists of deliberate acting out of the tic in a massed practice schedule. Negative practice has been found to be at least somewhat effective with Tourette's Syndrome (Sav- icki & Carlin, 1972; Clark, 1966), eyebrow raising (Browning & Stover, 1971), eyeblinking (Costello, 1963; Frederick, 1971; Yates, 1958; Knepler & Sewall, 1974), multiple tics (Walton, 1961, 1964; Yates, 1958), mouth grimacing (Chapel, 1970), and head jerking (Feldman & Werry, 1966; Agras & Marshall, 1965; Turner, Hersen, & Alford, 1974). As was true of the other behavioral treatments, the above studies of negative practice have not included a control group and have not treated more than one or two patients except for Meares' (1973) study of eight patients.

The theoretical basis of the present behavior approach derived from behavioral studies with profoundly retarded and autistic persons who exhibited stereotyped, repetitive, nonfunctional movements such as body rocking, head shaking, and hand gazing. Such behavioral stereotypy has been found in about 2~ of profoundly retarded persons (Berkson & Dav- enport, 1962). An effective method of eliminating behavioral stereotypy was developed (Azrin, Kaplan, & Foxx, 1973; Foxx & Azrin, 1973) based in part on a competing response rationale in which the patients were required to practice movements which were topographically incompatible with the stereotypic response. The similarity of the head-jerking move- ments of spasmodic torticollis to the head shaking of the profoundly re- tarded persons suggested that a similar treatment might be effective for muscle tics of nonretarded persons. Accordingly, the method was mod- ified and tested with 11 nonretarded outpatients, 4 of whom suffered from tics such as head shaking, head jerking, arm jerking, tongue thrusting, and shoulder jerking, the others suffering from other nervous habits (Azrin & Nunn, 1973). The method, termed habit reversal, resulted in a mean decrease of 90% of the habit or tic on the first day, 95% after 1 month, and 99% after 3 months. No control group was used.

The success of the habit reversal method with the four tiqueurs in Azrin and Nunn (1973) suggested further and more extensive evaluation. The present study, therefore, used a larger number of patients, a longer follow-up, a greater variety of tics, and an experimental comparison of the habit reversal method with the negative practice method.

HABIT REVERSAL AND NEGATIVE PRACTICE 171

TABLE 1 COMPARISON OF THE CLIENTS IN THE TWO GROUPS WITH RESPECT TO SEVERAL

DIMENSIONS OF POSSIBLE RELEVANCE TO THEIR TIC PROBLEM AND ITS TREATMENT

Habit Negative reversal practice All patients patients patients

Number of patients 10 12 22 Female 2 3 5 Male 8 9 17 Average age 30 yrs 31 yrs 30 yrs Range of ages 12-62 yrs 11-57 yrs 11-62 yrs Age at onset of tic 11 yrs 13 yrs 12 yrs Average duration of tic 20 yrs 17 yrs 19 yrs Median daily frequency of tic 425/day 450/day 450/day Mean daily frequency of tic 1,130/day 1,572/day 1,360/day Range of frequency of tic 50-5,500/day 6-9,000/day 6-9,000/day No. of patients seeking

other treatments* 8 12 20 Currently receiving drugs

for tic 1 3 4 Received drugs for tic in past 6 10 16

* All saw neurologists.

METHOD Subjects and Experimental Design

A newspaper advertisement in a large city was used to obtain patients. All patients were required to be examined by a neurologist and all 22 were included whose tics were not judged to have a medical etiology. A coin flip was used to assign patients to the two treatment conditions, resulting in 10 patients in the habit reversal and 12 patients in the negative practice treatment.

Table 1 compares the clients in the two groups with respect to several dimensions of possible relevance to their tic problem and its treatment. All patients had been examined and/or treated by a neurologist as re- quired by the criterion for inclusion in the study; in addition, 20 of the 22 patients had been treated by other kinds of therapists, such as psy- chologists and psychiatrists. Of the 22 patients, 16 had been treated in the past by drugs, primarily Valium, Haloperidol, and Librium; 4 were receiving these drugs at the start of the study. For all of these dimensions of age, sex, tic frequency, etc. shown in Table 1, analysis by Chi Square or t test showed no statistically significant difference between the two groups for any of these dimensions.

Tic

Table 2 provides a brief description of the tics for each patient in both treatment conditions. Many patients had multiple tics, in which case the

172 AZRIN, NUNN, AND FRANTZ

TABLE 2 BRIEF DESCRIPTION OF THE TIC FOR EACH PATIENT IN BOTH TREATMENT CONDITIONS.

FOR PATIENTS HAVING MULTIPLE TICS, THE PRIMARY TIC PROBLEMS ARE IN ITALIC

Habit reversal patient Type of tic

HR 1

HR 2

HR 3

HR 4

HR 5

HR 6

HR 7

HR 8

HR 9

HR 10

Negative practice patient

Neck and right shoulder tic, jerking accompanied by touching hand to neck as if getting comfortable in collar

Head

Tightening and relaxing neck muscles, stretching neck from side to side

Wrist jerking upward, knuckle and wrist cracking, tightening and jerking arms and legs, jerking neck slightly backwards, vocal noises

Moving arm and shoulder as if trying to disengage shirt sleeve from coat sleeve, accompanied by squinting right eye, turning head to left, tightening neck and face muscles, occasionally tightening stomach muscles and rotating torso toward left

Tremors and shaking of head with head tilted slightly

Stretching neck and blinking eyes

Head jerking to right

Head jerking side-to-side and up and down, accompanied with mouth grimacing and clicking teeth

Stretching neck, accompanied with twitching of right eye and right corner of mouth

NP i

NP 2

NP 3

NP 4

NP 5

NP 6

NP 7

NP 8

NP 9

NP 10

NP 11

NP 12

Head turning to right and locking in place

Head tremor, occasionally leg and jaw tremor

Hand shaking and tremors, occasionally body shaking

Jerking right fist accompanied by eyeblinking and saying "Now, there, forever," rubbing back of hand across nose, closing eyes and counting to ten

Head jerking, right leg jerking inward, torso jerking inward

Head jerking to left, eyes blinking, touching right side of nose

Torso jerking up accompanied by eye squinting, grimacing and leg jerking

Torso jolting up and shoulders and hips jiggling back and forth

Head jerking slightly backwards and to the right, tightening neck muscles, flexing arm and leg muscles

Head shaking, tensing neck muscles

Head shaking, shoulders going up as arm is tensed, throat clearing, blow- ing air through mouth

Shrugging right shoulder, clearing throat, tightening right leg

H A B I T REVERSAL A N D N E G A T I V E PRACTICE 173

primary and most frequent tic(s) are indicated in Table 2 by italic. Most of the tics involved the head, neck, or shoulders, but some patients also had eyeblinking, hand jerking, vocalization, torso jerking, grimacing and throat clearing, or leg movements. Treatment was given primarily for the primary tic movements, and all the daily response rec- ords were also for the primary tics.

Habit Reversal Treatment

The habit reversal treatment consisted of two sets of procedures, the first of which was specific to the immediate control of the tic, whereas the second set was general behavior therapy procedures. The primary corrective procedure was the competing reaction in which the patient learned to exert isometric pressure of the muscles that were opposed to the tic movement. Table 3 briefly describes the competing response used for the primary tics exhibited by the patients in the habit reversal treat- ment. The patient was taught to perform this competing reaction in such a manner that it was not apparent to an observer, this being done by practicing in front of a mirror and the therapist. The amount of tension exerted was that amount just sufficient to " lock" the body part in place and to prevent even deliberate attempts to perform the tic movement. The competing reaction was to be performed for 3 minutes whenever a tic movement occurred, or was likely to occur, as well as being practiced daily at home in front of a mirror. In those few instances in which the isometric competing reaction was not sufficient to block the tic, the pa- tient was taught to use other bodily assist measures even though they were obtrusive, but to discontinue them as the simpler isometric con- traction proved sufficient. These temporary assist measures are listed parenthetically in Table 3. The general behavior therapy procedures in- cluded a review of the inconveniences caused by the tic, identification of the situations and persons associated with either a high or low probability of tic episodes, heightening awareness of the tic by deliberately perform- ing and describing it in front of a mirror, relaxation training, daily self- recording of the tic episodes, social support by the presence of a family member during treatment, behavior rehearsal of the competing reaction, relaxation exercises, and deliberate immediate display of the improve- ment to provide reinforcement for treatment adherence. The general pro- cedure has been described in detail elsewhere (Azrin & Nunn, 1973, 1977).

Treatment was given during one or two sessions of about 2½ hours duration per session. Thereafter the therapist maintained telephone con- tact during the first few days with the patient and family member, in- creasing the interval between calls as the patient gained control.

Negative Practice Treatment

The patients receiving the negative practice treatment completed the same intake questionnaires and discussion concerning difficulties caused by the tics, origin of the habits, previous treatments, and so forth, as did the habit reversal patients. They also received three pages of written

174 AZRIN, NUNN, AND FRANTZ

TABLE 3 DESCRIPTION OF THE COMPETING REACTION FOR VARIOUS TICS

Tic Competing reaction

Backwards head jerking

Sideways head jerking

Shoulder jerking

Head shaking

Wrist tics

Neck stretching

Moving shoulder and arm as if disengaging sleeve from jacket

With the head in a centered position, contract neck flexors so that head tilts slightly downward. Neck appears shortened and bulged. (If this reaction is inadequate, push the chin into the sternum. Gradually decrease the contraction so that the head is raised off the stenum in the more natural head-upright position.)

Keep head in center position and contract neck flexors so that head tilts slightly downward. (If this reaction cannot be maintained for 3 minutes, is inadequate, put hand on side of face and push the head in the direction opposite to the tic.) After strenghtening of opposing neck muscles, change to the isometric neck flexor reaction without the hand assist.

Contract shoulders by depressing the shoulders down as far as they will go while keeping the arms close to the body.

Shift head posture from very erect or angled to drooping or tilting the head slightly forward. Slightly contract neck muscles that oppose shaking movements.

Push hands on arms of chairs, desk, leg, etc. and contract the muscles so that hands are pushing opposite the tic movement (i.e., contract hands down if the wrist jerks upward).

Contract neck flexors and depress head so that neck appears shortened.

Contract shoulder by depressing the shoulder downward and pressing arm to side of body.

i n s t ruc t ions regarding nega t ive prac t ice t r e a t m e n t adap ted f rom Smith (1957), and the therapis t d i scussed the ra t iona le with them. The bas ic p rocedu re i nvo lved pa t ien ts pu rpose ly pe r fo rming the tic in f ront of a mirror for 30-sec periods over a 1-hour per iod in terspersed by br ief rests, and saying to themse lves , " th i s is what I ' m supposed n o t to d o . " T h e y were to c o n t i n u e the exerc ises each day unt i l 4 days after the habi t was b roken , after which they would gradual ly d i s c on t i nue the pract ice for an addi t iona l 2 weeks , bu t to r e s u m e pract ice if a re lapse occurred . Af ter t r ea tmen t , they were ins t ruc ted to prac t ice the nega t ive prac t ice tech- n iques in f ront of a mir ror for the 30-sec per iods a bou t eve ry hour. These pa t ien ts were g iven the same record ing sheets and record ing ins t ruc t ions as the habi t reversa l pa t ien ts and also rece ived one t r e a t me n t sess ion of abou t 2½ hours dura t ion .

H A B I T R E V E R S A L A N D N E G A T I V E P R A C T I C E 175

Recording The recording was the same for both treatment conditions. At the time

of the initial phone contact, the patients were instructed to attend to the number of tic episodes they were having, and their reports of that number were taken at the initial office visit as the baseline frequency. After the initial office visit, the patients recorded each episode on a recording card that they carried with them and totaled the number each day on a chart that was mailed in at regular intervals or reported by phone. Follow-up data were obtained for 4 weeks for patients in both treatments and up to 18 months for the habit reversal patients. No quantitative reliability or validity data were available. Qualitative checks were available in that all patients who reported at the office session that their tics were occurring every few seconds or minutes did actually exhibit the tics and at a rate roughly in accord with their reports. A posttreatment source of qualitative confirmation of the patients' reports were the reports of the family mem- bers of the eight patients who were contacted as part of the social support component of the habit reversal treatment. Their reports were also in rough agreement with the quantitative reports of the patients; for seven of the eight patients, the patients' reports of zero tic episodes were con- firmed by the family contacts' reports that the patients no longer exhibited the tic at that time.

RESULTS Fig. 1 shows the mean percentage reduction of the tic episodes. Neg-

ative practice reduced the tic episodes by about 1/3 during the 4-week follow-up that was obtained. Positive practice reduced the tic episodes by 84% on the first day. The tics decreased progressively thereafter by 92% by the fourth week, by 97% during the second month, 99% during the fourth, fifth, and sixth months and at the 18-month follow-up showed a 97% reduction. These follow-up data were obtainable for all 10 habit reversal patients during the first 4 weeks, from 7 patients up to the fourth month, and from 5 patients after the fourth month.

Analysis of variance of repeated measures yielded F(1,20) = 16.43, p < .001 for the difference between treatments, but no significant difference between time periods or for the interaction between time and treatment. Separate t tests showed that the reduction in the tics was significantly greater for the habit reversal treatment for each of the 10 time periods (p < .01).

The individual data showed that during the fourth week, 2 of the 12 (17%) negative practice patients were virtually free of their tics (one or less tic episodes per day) vs. 8 of the 10 (80%) habit reversal patients. During the third month, 86% of the habit reversal patients were virtually free of their tics and 80% at the 18-month follow-up. All five of the habit reversal clients who were unavailable for the 18-month follow-up had less than one tic episode per day at their last available follow-up dates.

Of the 10 habit reversal patients, 8 reported at their last follow-up that their secondary tics, which had not been treated directly, disappeared along with the primary tic or were not a significant problem.

176 A Z R I N , N U N N , A N D F R A N T Z

PRE TREATMENT

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

POST TREATMENT

NEGATIVE PRACTICE TREATMENT

N = 22

J ~ ~ W ~ ~ ~ ERLTREATMENT

, , , , i , , , , i i , T T 1 2 3 4 5 6 7 2 3 t~ 2 3 i+

DAYS WEEKS MOtQTHS

TIME SINCE TREATMENT

A

I !

5 6 18

FIG. 1. Reduction of tics by two treatment methods. The tic frequency is expressed as the average percentage reduction relative to the pretreatment frequency which is 0% re- duction by definition. The vertical dotted line designates the time when treatment was given. Time since treatment is expressed in days for the first week, in weeks for the first month, and in months thereafter plus an 18-month follow-up. The day designated "0" is when treatment was given. The upper curve is for the patients receiving negative practice and the lower curve is for those receiving habit reversal treatment.

DISCUSSION The habit reversal treatment appears to be an effective approach to

treating diverse nervous tics. The tics decreased by 84% on the first day and decreased further to a 99% reduction at 4-6 months. The 18-month follow-up still showed a 97% reduction. The treatment required one or two training sessions plus follow-up telephone calls. The habit reversal treatment was more effective than the negative practice treatment which reduced tics by about ½. The use of the control group, larger sample size, and longer follow-up in the present study extends the findings of the previous study of this method (Azrin & Nunn, 1973) and indicates that the habit reversal method reduces diverse nervous tics for an extended duration and is more effective than the alternative negative practice meth- od. Evaluation of its effectiveness relative to other treatments for tics must await controlled studies. Such controlled studies for other types of habits have found that the habit reversal method was more effective than desensitization in treating stuttering (Azrin, Nunn, & Frantz, 1979) and wait list control for treating nailbiting (Nunn & Azrin, 1976).

HABIT REVERSAL AND NEGATIVE PRACTICE 177

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178 AZRIN, NUNN, AND FRANTZ

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RECEIVED" July 9, 1979; REVISED: August 7, 1979 FINAL ACCEPTANCE: August 21, 1979