Habit reversal training

Habit reversal training (HRT) is a "multicomponent behavioral treatment package originally developed to address a wide variety of repetitive behavior disorders". Behavioral disorders treated with HRT include tics, trichotillomania, nail biting, thumb sucking, skin picking, temporomandibular disorder (TMJ), lip-cheek biting and stuttering. It consists of five components: awareness training, competing response training, contingency management, relaxation training, and generalization training. Research on the efficacy of HRT for behavioral disorders have produced consistent, large effect sizes (approximately 0.80 across the disorders). It has met the standard of a well-established treatment for stuttering, thumb sucking, nail biting, and TMJ disorders. According to a meta-analysis from 2012, decoupling, a self-help variant of HRT, also shows efficacy. In case of a tic, these components are intended to increase tic awareness, develop a competing response to the tic, and build treatment motivation and compliance. HRT is based on the presence of a premonitory urge, or sensation occurring before a tic. HRT involves replacing a tic with a competing response—a more comfortable or acceptable movement or sound—when a patient feels a premonitory urge building. Controlled trials have demonstrated that HRT is an acceptable, tolerable, effective and durable treatment for tics; HRT reduces the severity of vocal tics, and results in enduring improvement of tics when compared with supportive therapy. HRT has been shown to be more effective than supportive therapy and, in some studies, medication. HRT is not yet proven or widely accepted, but large-scale trials are ongoing and should provide better information about its efficacy in treating Tourette syndrome. Studies through 2006 are "characterized by a number of design limitations, including relatively small sample sizes, limited characterization of study participants, limited data on children and adolescents, lack of attention to the assessment of treatment integrity and adherence, and limited attention to the identification of potential clinical and neurocognitive mechanisms and predictors of treatment response".