Experts divide repetitive, nonfunctional motor behaviors into three overlapping, and not always agreed upon, categories. First, there are classic tics, which typically involve quick, jerky motions of the head, neck or arms preceded by an urge, akin to an itch that needs to be scratched. Tics can also be phonic such as grunting, throat-clearing or sniffing.
Next are stereotypies (pronounced steer-ee-AH-ta-peez), which usually don’t have a premonitory feeling and are more fluid and rhythmic like body rocking, finger drumming and leg bobbing. Lastly, there are body focused repetitive behaviors, which are essentially grooming gone awry like compulsive nail-biting, hair-pulling and skin-picking.
All of these behaviors are what experts call “unvoluntary,” as opposed to an involuntary muscle twitch or tremor. You can stop the tic or motor habit when asked to or when distracted but the problem is, sooner or later, you go back to doing it. In some circumstances the behavior is distressing to the person, particularly if it is injurious or embarrassing, but more often the movement or mannerism is just maddening to those in proximity.
“If we dive into the research and look at disordered, unwanted repetitive behaviors as well as nonclinical, non-impairing repetitive behaviors, they all involve the region of the brain called the basal ganglia, which is involved in motor control,” said Ali Mattu, a clinical psychologist who specializes in body focused repetitive behaviors at Columbia University Medical Center.
Though still poorly understood, the basal ganglia are sort of like the movement command center of the brain that responds to situations by choosing from a menu of motions or gestures that you’ve learned. The theory is that when situations are frustrating or stressful because you are either over- or under-stimulated (i.e. strung out or bored) your basal ganglia manage by selecting (or perhaps failing to inhibit) a default motor behavior, which would be the tic, stereotypy or motor habit.
In this way, we are not so different from animals. Go to many zoos and you’ll see anxious or bored animals rocking, jerking their heads and necks, plucking out their feathers or fur, pacing in circles, swinging their arms (or trunks in the case of elephants) and mouthing themselves or various objects.
“The whole point of a habit is you don’t have to use cognitive resources to do it,” said Doug Woods, a professor of psychology at Marquette University in Milwaukee who studies and treats people with tics and other repetitive behaviors. He said that for many of his patients, the tics somehow become associated with a reward — whether it’s temporary distraction, satisfaction or release.
Most repetitive behaviors, regardless of etiology, begin in childhood. The immature brain, unable to recognize and process emotions as an adult does, resorts to motor activity to cope. Except for children with severe autism, most kids grow out of habits like head-shaking, arm-flapping and grimacing as they become better able to understand and manage their feelings. Or they just find a way to convert the behavior into something more socially acceptable and “adult.” Rocking might morph into leg-bobbing, mouth-stretching turns into gum-chewing or finger-wiggling may become iPhone-fiddling (yet another reason people can’t put down their phones).
“These behaviors persist, it’s just the person learns to have more control over it or learns to do it in private or under the table,” said Dr. Harvey Singer, professor of neurology at Johns Hopkins School of Medicine and specialist in childhood stereotypies.
Most people don’t seek treatment and indeed, many find their repetitive behavior comforting. Help is generally only sought when the movement or vocalization becomes so insistent and frequent it impairs daily functioning or is a turnoff in relationships. Neck tics can harm vertebrae, for example; skin-picking can lead to unsightly scabs and scarring and employers tend not to hire people who can’t stop blinking or clicking a pen during an interview. It probably goes without saying that such behavior is not an asset in dating.
To help people stop, doctors first rule out drugs such as antihistamines, antidepressants, A.D.H.D. medications, methamphetamine or heroine as a cause or aggravating factor. Assuming this isn’t the case, treatment begins with raising the person’s awareness of the tic or motor habit since it’s become so automatic. This usually involves describing it to a therapist in excruciating detail including any urges that precede it and every aspect and nuance of the movement.
Also important is to look at when it’s happening. “People don’t realize it, but there’s a situational profile to all these problems,” said Dr. Kieron O’Connor, a professor of psychiatry at Institut Universitaire en Santé Mentale in Montreal, who develops treatment programs for people with tic and motor habit disorders. “Tics and motor habits, people tend to do in some situations and not others so we work on helping patients to evaluate those problematic situations differently.”
The repetitive behavior is often the result of situations that make people feel overwhelmed with emotion because either they didn’t see something coming or don’t know how to deal with it. “We try to figure out on what dimension they are lacking whether it’s awareness of emotion, recognition of emotion or coping with emotion,” Dr. O’Connor said.
In addition to the cognitive component, therapies often also include a behavioral or habit reversal component where the person finds a more acceptable competing or inhibitory action. These can include strategies like squeezing a koosh ball instead of knuckle-cracking, pulling in the chin to avoid chronic head-nodding or getting rid of magnifying mirrors to prevent face-picking.
For more severe and debilitating cases, antipsychotic medication, botulinum toxin injections and implantation of a deep brain stimulation device might be considered, although all of those options are riskier, can have unpleasant side effects and are not entirely effective.
There’s growing consensus among experts that behavior is a form of communication and it’s important to first understand what the tic or habit is telegraphing (anxiety, boredom, anger, sadness, agitation, tension, etc.) in order to help the person cope rather than just trying to stop, modify or provide a substitute behavior. Alas, prescribing a fidget spinner is not a long-term fix.