Repetitive throat clearing, blinking, and grimacing

Tourette’s disorder requires the presence of multiple motor tics and at least one vocal tic that have been present for at least one year. A tic is a sudden, rapid, recurrent, nonrhythmic motor movement or vocalization. Tics are often associated with a premonitory urge and may be temporarily suppressed. They typically begin between the age of four and six years, peak in severity in early adolescence, and then diminish. The majority of individuals spontaneously achieve remission by early adulthood. Because tic disorders commonly co-occur with psychiatric disorders, they should be screened for in every psychiatric interview. Treatment should begin with psychoeducation and focus on symptom reduction rather than remission. Behavioral interventions, including habit reversal therapy, may be considered. Medications, such as antipsychotics and alpha2 adrenergic agonists, should be considered if tics cause severe impairment and are moderate to severe.

Trichotillomania and Skin Picking Disorder

This chapter summarizes the clinical characteristics and treatment of trichotillomania and skin picking disorder (excoriation), collectively known as body focused repetitive behavior disorders. These two conditions are found in the new chapter on OCD and related disorders in DSM-5; skin picking disorder is a new DSM diagnosis. They are conceptualized as related to OCD due to the repetitive nature of the symptomatology, but they also differ in important ways. The neural underpinnings of these disorder are only beginning to come into focus, and much work is needed. The best-proven psychotherapy for these conditions is a form of CBT known as habit reversal therapy. Principles of pharmacotherapy are not clearly established, though there have been promising early studies of a number of agents.

A Preliminary Investigation of Metacognitive Therapy and Habit Reversal as a Treatment for Trichotillomania

Background: Not all patients suffering from trichotillomania (TTM) recover completely using CBT and of those that do, only a few maintain their recovery over time. Aims: The purpose of the present study was to investigate the effectiveness of metacognitive methods combined with habit reversal (MCT/HRT) in trichotillomania with a relatively long-term follow-up. Method: A case series (n = 8) and a randomized wait-list controlled trial (n = 34) design were conducted in this study. In the case series, three of the eight patients dropped out of the study. Therefore, TTM-related symptoms were evaluated in five patients suffering from TTM before and after brief metacognitive plus habit reversal therapy during 1-month, 6-month, and 12-month follow-ups. The treatment consisted of detached mindfulness (DM) techniques, ritual postponement and habit reversal training (HRT) in eight sessions. Results: All patients were responders at post-treatment in case series. After the 12-month follow-up, the results were associated with higher pre-treatment levels of self-esteem and global functioning and lower pre-treatment levels of depression and anxiety with nearly complete abstinence from hair pulling immediately after treatment. A randomized wait-list controlled trial with experimental (n = 17) and waiting list group (n = 17) was then conducted to confirm the case series results. There were significant differences between the two groups regarding changes in MGH-HPS, Y-BOCS-TM, RSES, GAF, BDI, BAI and self-monitoring. Therefore, the MCT/HRT treatment was found to be more effective than the waiting list group. Conclusions: A combined treatment including metacognitive and habit reversal techniques is remarkably effective in patients with TTM.