Habit and Tic Disorders

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Chapter 22 Habit and Tic Disorders

Habit Disorders

Habits are common and can range from benign transient habits (e.g., skin picking) to significantly problematic repetitive behavior (e.g., bruxism). The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) defines stereotypic movement disorders (habit disorders) as repetitive, seemingly driven, and nonfunctional motor behavior that markedly interferes with normal activities or results in self-inflicted bodily injury that requires medical treatment. The behavior persists for 4 wk or longer and is not better accounted for by a compulsion, a tic, a stereotypy that is part of a pervasive developmental disorder, or hair pulling (as in trichotillomania).

Clinical Manifestations

A child’s presentation depends on the nature of the habit and level of the child’s awareness of the behavior. Habit behaviors can be described as either automatic or focused, depending on the child’s level of awareness. It has been suggested that a focused style (e.g., having awareness and receiving gratification from performing the behavior) is associated with higher levels of co-occurring habits. This style in hair pulling has been linked with increased depression, anxiety, and impairment in functioning, particularly during stressful events and onset of puberty.

Teeth grinding, or bruxism, is common, can begin in the first 5 yr of life, and may be associated with daytime anxiety. Untreated bruxism can cause problems with dental occlusion. Helping the child find ways to reduce anxiety might relieve the problem; bedtime can be made more relaxing by reading or talking with the child and allowing the child to discuss fears. Praise and other emotional support are useful. Persistent bruxism requires referral to a dentist and can manifest as muscular or temporomandibular joint pain.

Thumb sucking is normal in infancy and toddlerhood. Like other rhythmic patterns of behavior, thumb sucking is self-soothing. Basic behavioral management, including encouraging parents to ignore thumb sucking and instead focus on providing the child with praise for substitute behaviors, is often effective treatment. Simple reinforcers, such as giving the child a sticker for each block of time that he or she does not suck the thumb, can also be considered. Although some literature suggests that the use of noxious agents (bitter salves) may be effective in controlling thumb sucking, this approach should rarely be necessary.

Trichotillomania is the repetitive pulling of hair resulting in loss and strand breakage of hair (Chapter 654). The usual age of onset of trichotillomania is around 13 yr, although preschoolers have been described with this disorder. Children with trichotillomania have an increasing sense of tension immediately before pulling or when resisting the behavior, followed by pleasure or relief when pulling out the hair. The prevalence of trichotillomania in children is not well known but is believed to be 1-2% in college students. Although trichotillomania often remits spontaneously, treatment of those whose disorder has been present for >6 mo is unlikely to remit and requires behavioral treatment. Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine have some success as adjuncts.

Tic Disorders

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