Bad Habits
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Assessment and Treatment of Habit Disorders 137
Chapter 6
Assessment and Treatment of Habit Disorders
Raymond G. Miltenberger North Dakota State University
Douglas W. Woods University of Wisconsin, Milwaukee
Habit behaviors are repetitive or stereotyped responses that serve no apparent social function yet appear to be maintained by operant contingencies (Adesso, 1990; Hansen, Tishelman, Hawkins, & Doepke, 1990; Woods & Miltenberger, 1995). When such behaviors result in direct (i.e., physical damage) or indirect (i.e., poor social acceptability by others) harm to a person, they are considered habit disorders. Although habit disorders are thought to be maintained by automatic reinforcement in the form of self-stimulation or arousal reduction, they are typically defined topographically rather than functionally (Woods, Miltenberger, & Flach, 1996). Although many types of habit disorders can require treatment, in this chapter we only review the four that are likely to be encountered in a clinical setting: tic disorders, trichotillomania, thumb sucking, and nail biting.
Definition, Description, and Prevalence
Tic Disorders There are three types of tic behavior patterns. Motor tics are rapid, repetitive,
and often jerking muscle movements that are not caused by spasms, chorea, or tremors (Woods & Miltenberger, 1995). Examples include excessive or forceful eye- blinking, facial grimacing, and arm or neck jerking. Research suggests that approxi- mately 1% of the population has a motor tic disorder (Ollendick, 1981). Vocal tics are “sudden, rapid, recurrent, nonrhythmic vocalizations” (American Psychiatric Association, 1994, p. 104; APA). Examples include barking sounds, coughing and throat clearing (unrelated to illness), snorting, and coprolalia (i.e., swearing; Woods & Miltenberger, 1995). The prevalence of vocal tics is unclear. However, Woods, Miltenberger, and Flach (1996) reported that as many as 6.5% of college students engage in throat clearing at least 5 times per day and identify it as a habit. Tourette’s syndrome (TS) is diagnosed when a person exhibits motor and vocal tics (APA). The prevalence of TS is approximately .04-.05% and is more common in males (APA).
Individuals with tic disorders (especially TS) sometimes have concurrent problems such as obsessive-compulsive behaviors, attention deficit/hyperactive
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behavior, aggression management problems, and sleep problems. In some cases the tic itself causes physical damage such as cuts, burns, and bruises (Shimberg, 1995). Research has also demonstrated that adults who exhibit tics are viewed more negatively than those who do not (Woods, Long, Fuqua, Miltenberger, & Outman, 1998). These results extend to children (Friedrich, Morgan, & Devine, 1996) and developmentally disabled adults (Long, Woods, Miltenberger, Fuqua, & Boudjouk, in press). In addition, Long, Woods et al. demonstrated that individuals who exhibit tic behaviors are less likely to be hired for jobs than individuals who do not exhibit tics.
Trichotillomania Trichotillomania refers to chronic hair pulling which results in noticeable hair
loss (APA, 1994). Hair pulling (usually from the head) is sometimes followed by rubbing, chewing, or eating the pulled hair (Graber & Arndt, 1993). Individuals exhibiting trichotillomania often experience a feeling of tension/anxiety that is relieved after pulling the hair (APA). Approximately 1-4% of the population is diagnosed with trichotillomania, and adult females are 3 times more likely to receive the diagnosis than males (Graber & Arndt). Chronic hair pulling can result in hair- follicle damage (Muller & Winkelmann, 1972) or severe gastrointestinal difficulties when the hair is ingested (Mouton & Stanley, 1996). In addition, individuals who engage in chronic hair pulling are at greater risk for negative social evaluation (Long, Woods et al., in press).
Thumb Sucking Thumb sucking occurs in up to 46% of children under the age of 4 (Traisman
& Traisman, 1958) and continues in 19% of children over the age of 5 (Infante, 1976). Thumb or finger mouthing occurs in approximately 2.8% of college-age adults (Woods, Miltenberger, & Flach, 1996). Females are more likely to engage in thumb sucking, although the exact sex ratio is unclear (Friman, Larzelere, & Finney, 1994).
Although typically harmless, chronic thumb sucking can cause physical damage such as dental malocclusion, atypical root resorption, and increased risk of acciden- tal poisoning (Friman & Schmitt, 1989). In addition, children who continue to suck their thumbs are perceived more negatively by their peers (Friman, McPherson, Warzak, & Evans, 1993). Frequent thumb sucking is common in children under 4 years, and except in unusual cases, does not require clinical attention. However, a child who engages in chronic thumb sucking after the age of 4 is at greater risk of developing the problems mentioned above and should be considered for treatment (Friman & Schmitt).
Nail Biting Nail biting includes placing any digit into the mouth and biting either the nails
or the skin around the nails. Despite being a very common habit among children (41.6%; Massler & Malone, 1950) and adults (10%; Woods, Miltenberger, & Flach, 1996), chronic nail biting can result in damage or inflammation of the tissue around the nail, possible infection, and shortening of the roots of the teeth (Silber & Haynes,
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1992). There is also preliminary evidence that individuals who bite their nails are viewed as less socially acceptable than those who do not bite their nails (Long, Woods et al., in press).
Development and Current Etiological Theories of Habit Disorders. In this section, we trace the history and describe the biological and behavioral
explanations for the etiology of each of the common habit disorders.
Tic Disorders TS and other tic disorders are believed to have occurred for a number of
centuries, although TS was not classified until 1885 when Georges Gilles de la Tourette described similar behaviors in nine individuals (Shimberg, 1995). Accord- ing to the biological perspective, tic disorders result from both genetic and neurological variables. Genetic research has shown a 77% concordance rate among monozygotic twins as compared to a rate of 23% for dizygotic twins. Neurologically, an excess of the neurotransmitter dopamine may be responsible for tics, although this has not yet been clearly demonstrated (Bruun & Bruun, 1994). It appears that the etiology of tic disorders has some biological basis, despite the preliminary nature of the research database.
Behavioral theorists combine biological and learning explanations to suggest that some individuals with tic disorders are biologically predisposed for the occurrence of tics to be reinforced via tension reduction in the tic musculature. This view suggests that individuals experience heightened tension in specific muscle groups and that tics may be maintained by tension reduction in those muscles. In such a case, the muscles are tense prior to the occurrence of the tic, and this tension is temporarily reduced following an occurrence of the tic (Evers & van de Wetering, 1994). Although there is little evidence in support of, or opposing this theory, studies have shown that tics can be increased by positive and negative reinforcement (Carr, Taylor, Wallander & Reiss, 1996; Scotti, Schulman, & Hojnacki, 1994) and the presence of an anxiety provoking person (Malatesta, 1990).
Trichotillomania Trichotillomania was first described in 1889 by the French dermatologist
Hallopeau (Franzini & Grossberg, 1995). Etiological explanations of the behavior began to be presented in the 1940s (Franzini & Grossberg). Biological theories have not established a causal link between neurological activity and trichotillomania. However, the limited success of some psychoactive drugs such as fluoxetine and clomiprimine have led some theorists to posit that trichotillomania may be related to a seratonin deficiency (Iancu, Weizman, Kindler, Sasson, & Zohar, 1996). In addition, some studies suggest that differences in brain function are responsible for some hair pulling (e.g., Swedo et al., 1991).
The behavioral explanation of trichotillomania suggests that hair pulling produces automatic reinforcing consequences such as tactile stimulation resulting from stroking or manipulating the hair, or tension/anxiety reduction (Franzini &
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Grossberg, 1995). In addition, the behavior may be maintained through social consequences. Indeed, many people engaging in trichotillomania report a feeling of tension that is relieved following an episode of hair pulling (APA, 1994), and at least one study has shown that hair manipulation increases when individuals are anxious (Woods & Miltenberger, 1996b).
Thumb Sucking Biological theorists offer virtually no explanation for the etiology of thumb
sucking. However, behavioral theorists have suggested that the behavior is learned (Friman, Finney, & Christophersen, 1984). Behavioral theorists suggest that thumb sucking begins in infancy as it modulates arousal (i.e., comforts the anxious child or arouses the bored child). As the child’s verbal repertoire and other functional skills develop, more adaptive behaviors replace the functions of thumb sucking in most children,…
