This post is part of a series of guest posts on GPS by the graduate students in my Psychopathology course. As part of their work for the course, each student had to demonstrate mastery of the skill of “Educating the Public about Mental Health.” To that end, each student has to prepare two 1,000ish word posts on a particular class of mental disorders.
Habit Reversal Training: An Applied Behavioral Approach to Stereotypic Movement Disorder by Kayla Ethridge
What’s your stim? The word stim is short for self-stimulation and everyone has one. Each of us create self-soothing mechanisms that are as unique as we are when it comes to stimulating and soothing ourselves in times of thinking, stress, anxiety, or just plain boredom. The known causes for stimming behavior include but are not limited to overstimulation, understimulation, pain reduction, management of emotions, and self-regulation to serve a purpose of soothing or comforting.
What these self-stimulating and soothing mechanisms are to us differ in age and etiology. For those younger individuals these self-soothing mechanisms may be sucking of the thumb, rocking back and forth, or sensory tactile touch such as rubbing a soft blanket between fingers. Those older individuals may have stimulating mechanisms that include; foot movement, hair twirling, biting one’s nails, listening to music, and even saying the word “um” that interrupt sentences while speaking. What ever your self-stimulating mechanism may be they all have one thing in common; most often times these are involuntary and automatic movements. These stimulating mechanisms have become habits and you are most likely blind to them as you are doing them.
Most of these self-stimulating and soothing mechanisms are harmless and do not cause any real damage. To avoid causing any disruption to one’s life we have learned when these behaviors are appropriate versus when they are not. For example, if your self-soothing mechanism is to suck your thumb as an adult, this behavior is okay to do while in the comfort of your own home watching a scary movie on the couch, but it is not appropriate to be sucking your thumb sitting at a stressful business meeting at work. When the behavior is appropriate and when it is not is very socially constructed. Who says sucking your thumb at a business meeting isn’t the proper circumstance? Most likely you’re your coworkers do, your boss, and society. Society determines which behaviors are socially deviant and appropriate and which are not.
As explained by the DSM-5, Stereotypic Movement Disorder‘s most essential feature are repetitive, seemingly driven, and apparently purposeless motor behavior. Common stereotypies include hand shaking or waving, body rocking, head banging, self-biting, and hitting own body. These repetitive motor behaviors are considered a disorder because they interfere with social, academic, and other activities and may result in self-injury. These repetitive movement presentations can range in severity from mild, symptoms that are easily suppressed, moderate, symptoms require explicit protective measures and behavioral modification, and severe, with continuous monitoring and protective measures are taken to avoid self-injury. These behaviors are variable in repertoire and each individual presents his or her own individual patterned “signature” behavior. Stereotypies typically have an earlier age of onset (<3 years) and they are consistent of patterns and most often involve the arms, hands, or the entire body.
These stereotypies vary in frequency and context. These movements can occur when the individual is absorbed in other activities, when excited, stressed, fatigued, or bored. Criterion of the DSM-5 for Stereotypic Movement Disorder is that these movements be “apparently” purposeless. However, it can be hypothesized that these stereotypic movements might be used to reduce anxiety in response to external stressors. Sounds a lot like our self-stimulating mechanisms no? Many may describe their stereotypies as an itch that needs to be scratched or a sneeze and that its just incontrollable. Or is it? Imagine you are sitting in church in a silent room in the middle of a prayer. You feel that well known little tingle in your nose and you know a massive sneeze is making its way into existence. You are known for your loud obnoxious sneezes, but for some reason here in this silent room in church you can control your sneeze and it expresses itself in a tiny, almost inaudible, timid way.
Why not let your true sneeze come through? In a silent room in church during prayer it is socially deviant and unacceptable to sneeze loudly and obnoxiously no matter how involuntary it may appear. But even with sneezes we have a way of controlling and suppressing them. We all have learned little actions to take to quiet the sneeze or withdraw the sneeze completely. These actions may be holding your nose, holding your breath, or covering your nose and mouth together. Like a sneeze, stereotypic movements, although they may feel involuntary than can be trained. Being able to learn how to control or suppress these stereotypic movements for when its socially acceptable can greatly improve interference with social, academic, and other activities.
There is limited treatment options that exist for stereotypies and even fewer studies have looked at treatment in otherwise healthy children. Pharmacological interventions are available as an important option but they are usually associated with side-effects that are undesirable in themselves. If pharmacological medications aren’t a preferred option, the behavioral approach that has strong potential for treating chronic stereotypies is habit reversal training (HRT). This behavioral approach uses a patient-driven intervention to help treat and decrease repetitive behaviors. There are four phases of HRT that are compiled of ten different components: awareness training, development of a competing response training, building motivational procedures, and generalization of skills.
Let’s look a little closer at these phases individually. Awareness training is used to bring greater attention to the stereotypies of the affected person. This awareness allows the individual to gain a better self-control of their movements and can later replace the undesirable stereotypies with more appropriate movements. There are many different ways of awareness training Many ways includes the person describing each time they carry out the behavior, identifying the earliest warning of the impulsive behavior including urges, sensations or thoughts, and lastly, the person is able to identify all the situations in which the impulsive behavior may occur.
After coming into awareness of one’s stereotypies the next step would be to develop a competing response that can replace the undesirable stereotypic behavior. Most often times the competing response is similar in muscle involvement but opposite of the stereotypic movement. Often times the replacement movement blocks the individual’s ability to carry out the stereotypic movement. This competing response is something that is usually longer in duration than the stereotypic movement. It is also helpful to replace the stereotypic movement with a behavioral that is less unnoticeable by others and typically more socially acceptable.
Building the motivation to continue HRT and to keep the stereotypic behavior from reverting the individual should keep record of the interference of the stereotypic behavior and also helpful to demonstrate and practice their ability to suppress the stereotypic behavior to others. It has also been advised for close family and friends to provide praise and positive reinforcement for the individual’s success and efforts of suppressing the stereotypic behaviors.
Lastly, the individual should practice their new skills in a range of different contexts of environmental and emotional situations. For example, an individual may be able to master a stereotypic behavior in the classroom, but it should also be practiced in the comfort of home, at work, or in other environments that the stereotypic movement may be more prone to. It is also advised that the individual practice the skills and generalize them to times of different emotions, for example, when they are excited, stressed, or bored.
It should be noted that, HRT with children typically may not be as effective with children who are younger than 8 years of age because of the lack of patient’s awareness of movement and motivation to self-monitor or self-initiate treatment. For individuals who are younger than 8 years old HRT responsibility would be shifted to the parents to identify the occurrence of stereotypies and prompt a competing response.
Although the empirical research appears to be lacking in Habit Reversal Training for normally developing individuals it is commonly used and successful to treat Stereotypic Movement Disorder. This behavioral approach is an alternative method to pharmacological medications that present negative side effects that are often times worse than the stereotypic movement themselves. Although this approach is designed for older individuals who are capable of identifying the behavior and possess a desire to change it, it has also been effective for younger children with the help of the parents taking on the responsibility of effective intervention implementation.