Hypnosis and Biofeedback in the Treatment of Tics And

Home , Biofeedback

Biofeedback ⎪ Summer 2005 69 One goal of this kind of training is to help children One goal of this kind of training is to curiosity to facilitate tic regulation.curiosity to facilitate using biofeed- By back or hypnosis, engage more actively in their children own treatment process. Action for Self- Mechanisms of Regulation Approaches successful use of Although Kohen (1995) described the TTS,self-hypnosis for little is known about the mecha- nism of therapeutic change on a psychophysiological level. relaxation train- In the case of biofeedback-based ing, one possible explanation for benefit has to do with balance.autonomic nervous system (ANS) Children increased frequency and TTS frequently experience with of emotions (pos- severity of tics with heightened levels stress itive or negative) and also when experiencing nervous system (with resultant increases in sympathetic activity). Clinical experience has strongly suggested that and strategies training children in emotional regulation nervous sys- that create lowered levels of sympathetic to assist them in devel- tem arousal is an effective way TTS symptoms in key oping better voluntary control of situations. TTS selectively determine when,with where, and how much they will tic. can be very adaptive and does This not mean they will not or should not tic at all, but rather “selectively”allows them the control to tic that in a way is less functionally impairing. Morbidity from tics can be experienced in several ways. One of the most common TTS is that tics can be socially challenges for kids with problematic and result in teasing, reprimands, and other and adults. peers from unkind behaviors Other compli- TTS,cations of such as coprolalia, can create additional social problems. intense tics Children with frequent and can also experience muscle pain or other bodily injury from recurrent, strong motor or phonic tics. In the aca- demic setting, find it children with frequents tics may difficult to focus and sustain attention while reading and be disruptive to others.writing and also may It is impor-

TTS can have a significant impact on a child’s func- a significant impact on a child’s TTS can have tioning at home, school, and with peer relationships. One TTS that can be very difficult for a child is that aspect of want it to do.” “my body is doing something that I don’t The need for self-control and self-management repre- sents a strong developmental drive for all children. such as biofeedback and hypnosis can assist Techniques children by harnessing this innate developmental drive for mastery and autonomy and applying it for therapeu- TTS symptoms.tic benefit in the control of their Self- and strong imagination hypnosis also utilizes a child’s Motor and vocal tics and Tourette syndrome (TTS) are Tourette Motor and vocal tics and of variable intensity that are neurobiologic disorders Table).common in childhood (see the Although psy- considered the chopharmacologic management is often treatment approach of choice,TTS many children with strategies such benefit from learning self-management can realize mean- as self-hypnosis and biofeedback and ingful symptom control with these techniques. In general, found these techniques to be more effective we have in the control of mild to moderate tics than of severe tic behaviors. These self-regulation strategies can be used successfully in conjunction with pharmacologic intervention. Introduction: Strategies Self-Regulation for Tic Disorders Tics (vocal and motor) and Tourette syndrome are neu- Tourette and (vocal and motor) Tics that commonly present in child- robiologic disorders hood. of treatment has been the Although the mainstay use of psychotropic medications, evidence and clinical strategies experience support the use of self-regulation effective adjuncts including hypnosis and biofeedback as or, in some cases, first-line treatments.these treatment reviews the rationale for using article This approaches, gives a case study example, outlines specific biofeedback modalities that are useful, and describes as applied appropriate hypnotic language and technique syndrome. Tourette to the treatment of Integrative Medicine Program,Integrative Hospitals and Clinics, Children’s Minneapolis, MN Keywords: syndrome, Tourette tics, pediatrics, hypnosis, biofeedback of Tics and Tourette of Tics Syndrome and Tourette Harrington,Kevin PhD, P.Timothy and Culbert, MD Hypnosis and Biofeedback in the Treatment the in Biofeedback and Hypnosis SPECIAL TOPICS SPECIAL 70 Summer 2005 ⎪ Biofeedback Hypnosis andBiofeedbackin Tourette Treatment rl or[eintdbd at.Sinceyouaretheboss trols your[designatedbody part]. Findonethatcon- controls adifferentpartofyour body. Eachknobandlever board withalotofknobsand levers. room withabigcomfortable chairthatisinfrontofa “Gotoanother partofyourbraintoacontrol ed further: thechildisinstruct- Afterstrengtheningtheimage, at.” somethingyouarereallygood self doingsomethingfun, Thechildisaskedto “Picture your- hypnotic induction. thetherapistthenteacheschilda something fun,” Afterthechildagreesto “learn a senseofempowerment. andpromote tapintofantasy andimagination, curiosity, Thepurposeofthisquestion istoelicitasenseof tics?” learn somethingelsefunsothatyoucanhave fewer “Would youliketo similar tothefollowingisasked: to noticethechangesintheirbodiesandminds. andfullbreaths slow, they areguidedtotakelong, Then belly orabdomenandfeeltheirownbreathing. Childrenareinstructed to placeonehandonthe ticed. Softbellybreathingistaughtandprac- body connection. strengthening thechild’s understanding about themind- session focusesonreviewingthecalendarwhile Thefollowing helps thechilddevelopself-awareness. the childisanactiveparticipantintreatmentand progress andidentifystressfulsituations. The stressrulerprovidesahelpfultooltotrackdaily children/teens ratethemselvesanywhereinbetween. andthe end oftherulermeans “most stress,” thehigh Thelowendoftherulermeans “no stress,” 10. ruler isavisualanaloguescalethatratesstressfrom0to Thestress with thestressrulerbetweenappointments. a calendarandaskedtomonitorhisorherstresslevel Thechildisgiven anddurationoftics. intensity, quency, is thengivenregardinghowstresscanaffectthefre- Information ings canbringaboutaphysiologicchange. learn fairlyquicklythatachangeinthoughtsandfeel- Achildcan fewertics). bring aboutadesiredchange(i.e., information onhowthemindandbodyworktogetherto thechildisprovided after acompletehistoryistaken, Inthefirst session increasing achild’s senseofcontrol. Providing informationisalways akeyelement in with TTS Clinical Approaches inChildren increasing thechild’s distressanddysfunction. furthercomplicatingthepictureand occur with TTS, attention deficit/hyperactivitydisorder(ADHD)canco- tant tonotethatobsessive-compulsivedisorderand fe h hl rcie h rahn,aquestion After thechildpracticesbreathing, This self-monitoringestablishestheexpectationthat are reviewed. andleveloftics practiceschedule, the child’s stresslevel, When thechildreturnsfornextappointment, child. chance ofapowerstrugglebetweentheparentand Thissupportsempowermentanddecreasesthe practice. therefore parentsdonotneedtoremindthechild and therapy practiceassignmentsarethechild’s plan, parentsshouldbeinformedthat the child’s presence, In andthepracticeschedule. hypnosis, belly breathing, soft and thechildexplainsmind-bodyconnection, to continuemonitorhisorherstresslevel. tice theself-hypnosisexercise outsideofthesessionand Thechildisaskedtoprac- the child’s feelingofsuccess. attention totheimagerychildusedandreinforcing paying theexperienceisprocessed, child isfullyalert, Afterthe andpracticearegiven. egostrengthening, cess, Posthypnotic suggestionsofsuc- during theinduction. room andreturntothefunactivityheorsheutilized Thechildisguidedtoleave thecontrol force success. Affirmationandegostrengtheningareusedtorein- tics. includingthepartsthatareaffectedby his orherbody, Thechildisguidedthroughdifferentpartsof charge.” body part]doesexactlywhatyouwantsincearein adjusttheleversothatyour[designated of yourbody, specific stressors atschoolastwoclassesinwhichthe Tom wasabletoidentifythe and afterdinnerathome. recorded thathisstressspiked intheafternoonatschool Tom Inapplyinghis “stress rulecalendar,” by stress. me ifIticinfrontofhim.” hereportedthat hisfather “yells at however, supportive; Tom reportedthathismotherwasvery other classmates. few closesupportivefriendsandinteractedlittlewith Tom had would goseveraltimesaweekfor30minutes. whenhe This wasanincreasefromthepreviousyear, Tom wasoutoftheclassroom75%schoolday. Atthetimeofreferral, a breakfromtheclassroom. the optionofgoingtocounselor’s officeifheneeded Schoolprovided andcrackinghisneck. shoulder rolling, severe swearing, tics includedfrequentvocalizations, Tom’s reported tohave increasedthefrequency oftics. Thestimulantwas not effectivewithticregulation. Hehadtriedavarietyofmedicationsthat were teristics. Tom alsohadsomeobsessive/compulsivecharac- type. inattentive Healsohadadiagnosisof ADHD, at age12. Tom isa16-year-old boywhowasdiagnosedwith TTS Hypnosisand TTS Case Study: The parentsarebroughtinattheendofsession Tom wasalreadyaware thathisticswereexacerbated Biofeedback ⎪ Summer 2005 71 Harrington, Culbert training, points in with biofeedback applied at various and complement the the therapy process to underscore relaxation/mental imagery component. Biofeedback found helpful are as follows. modalities that we have Surface Electromyography is used to teach Surface electromyography (SEMG) clients about body awareness, voluntary control of mus- cles, relaxation. and general muscle Progressive muscle commonly taught relaxation and autogenic training are as adjunctive techniques. The SEMG electrodes are usu- TTS-affected muscle groups so the ally attached to the of that area and child can get a sense of voluntary control tightness vs. develop a keener discrimination of muscle muscle relaxation Biofeedback Temperature Peripheral temperature biofeedback is used as an indirect Peripheral (SNS) arousal. marker of sympathetic nervous system Usually finger or hand temperature is monitored using a biofeedback device during the session. It has also been very helpful for kids to use stress dots or dermatherm temperature bands for home training purposes. Increases in hand temperature show kids concretely the effects of relaxation. temperature biofeedback is often Peripheral combined with self-hypnosis training (mental imagery of warmth and warming). This approach adds a nice sense of wonder and curiosity about bodily changes with the idea of desirable nervous relaxation and underscores system balance. Biofeedback Electrodermal Electrodermal biofeedback is used as a more direct marker of sympathetic nervous system arousal. This modali- ty is helpful in showing clients how certain distressing tension” afterward significant functional impairment significant functional coughing Tom was able to utilize cognitive behavioral strategies was able to utilize cognitive behavioral Tom The following suggestions were given: “While you Tourette syndrome Tourette that results in for a period of at least 1 year in a manner vocal (also called phonic) and motor tics The combination of both Motor-involved muscle movements may be simple or complex Motor-involved “urge” associated with a prodromal sensory Tics of all kinds are commonly “release of to perform the tic and then a sense of Tics (may be transient or chronic) Tics (may tics involve movement of air, or phonic Vocal noises, breathing,words including sniffing, and snorting, blurting out words, and Table. Definitions The same treatment template seen in this case history could be applied using biofeedback-based relaxation Integrating Biofeedback TTS with Hypnotherapy in and soft belly breathing at school with almost an imme- and soft belly breathing at school with diate decrease in tics. During the initial interview, Tom and did not play mentioned that he was in the school on stage. tics when have hypnosis,Tom’s During his “safe place” next on the ground outdoors included lying to a lake. are at the lake,calm your part of you will know how to body. can use that part whenever you need to.” You He himself spent a considerable amount of time visualizing in the control room. During his initial hypnosis experience in the office, his tics changed from almost constant to no tics at all. He was able to talk about the dramatic change. asked, When “How did you do that?”responded, “I guess I did it with my brain.” he was Tom very compliant with practicing self-hypnosis. 2 Within to two office one months he was utilizing the counselor’s times a week for 15 minutes. reported significant Tom decrease in stress at home and school. reported a Tom 90% decrease in tics. and his Homework completion grades also significantly improved. kids and teacher did not know about his TTS. kids and teacher did not know about his In addition, was end- father came home usually when dinner Tom’s ing. to talk to the agreed to allow the school nurse Tom two afternoon classes. His father was brought into a session. able to identify his feelings of help- The father was and his Tom and lessness at not being able to help his son “doing a week together father agreed to spend 2 hours guy stuff.” 72 Summer 2005 ⎪ Biofeedback Hypnosis andBiofeedbackin Tourette Treatment oe,D .(95.Ericksoniancommunicationand (1995). P. D. Kohen, Reference tion intervention. benefit aswellbutmay alsoneedconcurrentmedica- Childrenwith moresevere TTS symptomsmay ication. many caseshave notneededtoaddpsychotropicmed- excellent controlwithself-regulationtechniquesandin children withmildtomoderateticshave achieved many Intheauthors’ experience, agement options. personalized self-man- allowingforcreative, enjoyable, nosis findthesetechniquesmutuallyreinforcing and Many clientswith TTS wholearnbiofeedbackandhyp- Summary progress inemotionalcontrolandmastery. measurablemarkerof and useHRV asaconcrete, tive expectationsforfuturecontrolindifficultsituations andpreparethemselveswithposi- “visually rehearse” Clientscan where theywanttobecalmandnothave tics. insituations used tohelpchildren “see themselves” imagerycanthenbe “Futureprojection” tress (fear). orinsituationsofemotionalarousal(anger)dis- flare, used inperformanceanxietysituationswhereticsmay whichmay be tool foremotionalregulationtraining, HRV biofeedbackisaverynice meditative breathing. suchasthoseaccompanyingslow and orderlyvariations, variationsinheartratearesmooth “coherent” speaking, Broadly levels. reflectedinhigh “coherence” balance, Thisresultsinamoreoptimalstateof ANS breathing. and mastercontrolledyeteffortlessdiaphragmatic the clienthowtobringaboutpositiveemotionalstates Heart ratevariability(HRV) biofeedbackisusedtoshow Heart Rate Variability Biofeedback stress anddaily TTS activity. andhelps thechildtoexplorelinkbetween well, Teaching diaphragmaticbreathingisausefuladjunctas therebypotentiallyintensifying TTS behaviors. ity, can have animmediateimpactonincreasingSNSactiv- serial7s) thoughts orcognitivestressors (spellingwords, ortesnrm ncide n dlset.InI. Tourette syndromeinchildrenandadolescents. hypnotic strategiesinthemanagementofticsand hlrnsHsiasadCiis M1-0,Mnepls MN55404, [email protected]. email: Minneapolis, #MS17-306, IntegrativeChildren’s MedicineProgram, HospitalsandClinics, PhD, Kevin Harrington, Correspondence: eg&S Lankton(Eds.), Zeig &S. py p.1618.NwYr:Brunner/Mazel. NewYork: 116–138). (pp. Harrington Kevin Difficult contextsforthera- Timothy Culbert