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Treatment of drug-induced stereotypy.

One adult of a minority ethnicity, who met criteria for amphetamine-induced psychosis in remission, received treatment for an amphetamine-induced stereotypic behavior. His stereotypic behavior was treated with habit reversal training (HRT), and the treatment's effects were assessed using direct observation procedures. As a result of a two hour intervention, his stereotypic behavior was reduced to near zero levels, and maintained at four month follow-up.

Key words: amphetamine, stereotypic behavior, treatment, habit reversal.


Amphetamines are quickly becoming one of the most commonly used and manufactured illicit drugs in the world. According to a United Nations report, over 35 million people regularly use amphetamine, compared to the 15 million who regularly use cocaine and the 10 million who use heroin (United Nations Office for Drug Control and Crime Prevention, 2000). Methamphetamine, a derivative of amphetamine, is also one of the fastest growing substance abuse problems in the United States (Yacoubian & Peters, 2004). Once considered largely a concern on the West Coast (e.g., Rawson, Anglin, & Ling, 2002), methamphetamine is becoming much more common in the midwest (Yacoubain & Peters, 2004). Methamphetamine is not only a problem in metropolitan areas; its usage is equally, if not more, common in rural areas (Leukefeld et al., 2002). The increase is due at least in part to the fact that methamphetamine is relatively easy to manufacture and can be created from ingredients that can be purchased legally. Additionally, the effects of methamphetamine last up to 10 to 12 hours, and typical use of methamphetamine costs only about 25% as much as typical cocaine use (Rawson et al., 2000). It is also easy to obtain; the U.S. Department of Justice statistics show that from 1990 to 1996, 64% of high school juniors and seniors reported that they could easily obtain methamphetamine.

Like any narcotic, there are both direct effects of the substance and side effects. The direct effects of methamphetamine include increased alertness and energy, elevated self-confidence, and a sense of well-being. The adverse side-effects of prolonged methamphetamine use can include paranoia, slurred speech, motor instability, violent behaviors (Hall, McPherson Twemlow, & Yudko, 2003), psychosis (Lin, Ball, Hsiao, Chiang, Ree, & Chen, 2004), and stereotypic behaviors such as purposeless physical activity, tremors, muscle tics, bruxism (teeth grinding), and athetosis (strange motor movements).

This relation between amphetamine use and stereotypic behaviors is well documented in the nonhuman literature (e.g., Canales & Graybiel, 2000, Balsara, Jadhav, Muley, & Chandorkar, 1979). The motor-activating effects of amphetamine in rats is often used for investigating the neurophysiological substrates in human stimulant abuse (Canales, Gilmour, & Iversen, 2000). Rats' behaviors will become increasingly focused and repetitive with increased dosages of amphetamine (Seiden, Sabol, & Ricaurte, 1993). This change in the rats' behavior has been directly liked to changes in the basal ganglia (Canales & Graybiel, 2000). Stereotypic behaviors in rats can be introduced by dopaminergic stimulation of the striatum and can be abolished by intrastriatal blockage of dopaminergic transmission (Arnt 1985; Fibiger, Fibiger & Zis, 1973; Creese & Iverson, 1972). This would seemingly suggest a medically-based intervention for substance-induced stereotypic behaviors; but research is beginning to show that environmentally-based interventions are effective at changing behavior that was the result of brain damage, while demonstrating reliable changes in brain physiology (Latsch, Thulborn, Krisky, Shobat, & Sweeney, 2004). Thus, stereotypic behaviors that are amphetamine-induced may be treatable through environmental manipulations.

To date there are no published accounts of the treatment of drug-induced stereotypic behaviors, but there are environmentally based treatment options. The most supported intervention is a relatively simple self-management procedure called habit reversal training (HRT; Azrin & Nunn, 1973). HRT has been shown to be useful with a variety of stereotypic behavior problems such as Trichotillomania, Tic disorders, nail biting (Miltenberger, Fuqua, & Woods, 1996), and skin picking (Twohig & Woods, 2001). Although the exact behavioral or biological mechanisms through which this procedure produces its effects are unknown, it has robust and strong effects with these types of problems. In this case study, the effectiveness of HRT was evaluated with one adult who was diagnosed with amphetamine-induced psychosis--in remission, who continued to exhibit stereotypic behaviors. The effects of the intervention were evaluated using direct observation procedures.



All phases of this case study took place within a maximum security forensic psychiatric hospital. This is a locked facility where the general treatment model incorporates psychopharmacological, psychoeducational, recreational/skills based, and milieu-based interventions as appropriate. The client was not participating in any other structured psychological treatments at the time of this intervention.


The client was an adult male of a minority ethnicity. He was admitted to the forensic psychiatric hospital because he had exhibited significant symptoms of psychosis while incarcerated. He had previously experienced visual hallucinations and illusions, paranoid delusional thinking, and had been unpredictably physically aggressive toward other individuals. According to the client's report, the psychosis developed concurrently with his increased methamphetamine use. The client has a somewhat complicated chemical abuse history that was further clouded by his spotty recollection of some periods of chemical use. He reported daily use of marijuana since his mid-teen years, extensive use of methamphetamine including a period week-long daily use prior to his arrest, and use of other drugs including cocaine, heroin, ecstacy, and LSD. It appeared that his primary drugs were methamphetamine and marijuana. He has been diagnosed with amphetamine-induced psychotic disorder with delusions, onset following withdrawal-remission, methamphetamine dependence, marijuana dependence, and cocaine abuse. The client's diagnoses were determined by a clinical treatment team including multiple licensed psychologists and a psychiatrist. He was treated initially with an SSRI (sertraline), a mood stabilizer (valproic acid), and a conventional antipsychotic medication (haloperidol) which were effective at decreasing his hallucinations and illusions, and moderately effective at reducing his paranoid thinking and impulsive aggressive behaviors. These medications were later discontinued and he was treated with an atypical antipsychotic (olanzapine) with further positive results. After a time, this medication was discontinued as well with no apparent relapse of psychotic symptoms or aggressive behavior.

A stereotypic behavior developed concurrent with his psychosis. The client described the severity of this stereotypic behavior as paralleling his methamphetamine use; as his use increased, so did the occurrence of this behavior. Even after his psychosis remitted, and three years after his last use of methamphetamine, the stereotypic behavior remained. This behavior involved touching his thumb to each of his other four fingers, on the same hand, in a rhythmic fashion. He would do this with both hands and was observed doing it every day by the facility staff. He stated that the behavior commonly occurred outside of his awareness, but that he also experienced an "urge" to engage in the behavior. Thus, at times he was aware that he was engaged in this behavior, but the "urge" to continue was too strong for him to stop. The client stated that he did not like that he did it, he received embarrassing comments from other clients, and he could not stop on his own. Therefore, he requested assistance with this problem.

Procedure and Treatment

The client's rate of the stereotypic behavior was monitored during 15-minute sessions using a 15-second partial interval recording procedure. In order to maintain consistency in the recording, the client was always recorded in the same situation. Because he often played chess in front of a one-way mirror, all recordings were done from behind the one-way mirror while he was playing chess. His particular stereotypic behavior was defined as 'touching his fingers to the thumb, on the same hand, more than one time, in one bout."

Each recording session involved the client sitting across from second individual and playing chess. He was asked to play chess by the first author; therefore he was aware that he was being recorded during these sessions. On one occasion, he was recorded without his knowledge to assess for the validity of the recordings. To assess for observer bias, two of the 12 sessions were independently recorded by a second individual. Interobserver agreement rater reliability was found to be 96 and 100%.

After three days of recording, the treatment team agreed that he could cease his psychiatric medication (olanzapine) because he was no longer exhibiting psychotic symptoms and he was displeased with the side-effects of the medication. Therefore, even thought a steady baseline was present, the therapists waited 30 days after he discontinued this medication and began recording again. This was done to assess if the stereotypic behavior was influenced by the medication. His behavior was recorded for an additional three days and a steady baseline was observed; therefore, treatment began.

Treatment involved HRT (Woods & Twohig, 2001). The entire HRT procedure was taught to the client in a single one-hour session (indicated by the second dashed line on figure 1). HRT involves three components: awareness training, competing response training, and social support. Awareness training has two components: response description and response detection. Response description involved having the client describe his stereotypic behavior and any preceding behaviors. For example, he described his behavior as touching his thumb to each of his fingers, in order, and then running his thumb back and forth across the tips of all his fingers. He stated that before doing this, he would start tapping his fingers or he would feel an "urge" to do it. This phase was useful for him because he was not previously aware that these events occurred before the stereotypic behavior. Response detection involved therapist simulation of the preceding and target behaviors and client detection of the simulations. After the client was able to detect occurrences of the behaviors, he was asked to begin detecting in-session occurrences of his engaging in these behaviors. After the client was able to detect occurrences of his own preceding and stereotypic behaviors, he was taught how to use the competing response.

Competing response training involved teaching client to make fists with his hands for at least one-minute contingent on the occurrence of the preceding or stereotypic behavior. For example, if the client either started tapping his fingers together or had the urge to do so he was instructed to make fists for at least one minute. If he still felt the urge to engage in his stereotypic behavior he was instructed to continue to making fists. The therapist modeled the proper use of competing responses contingent on the emission of simulated target behaviors, and the client practiced in session. The client was instructed to continue to use the competing response out of session whenever the stereotypic or preceding behaviors occurred.

Finally, the client was instructed to solicit the assistance of either other clients or staff members in helping him to detect occurrences of his stereotypic behavior. He was instructed to tell these individuals to indicate when he was engaging in the behavior, and then to use the competing response. According to his reports, this phase of the procedure was used occasionally. The client then attended two additional 30-minute sessions over following weeks. During these sessions, the procedure was reviewed and any concerns or questions were addressed. In total, the intervention lasted two hours.

Results and Discussion

The rate of the client's behavior was monitored during three different phases: pretreatment while on psychotropic medications, pretreatment 30 days after ceasing psychotropic medicaments, post treatment and four month follow-up (see Figure 1). His mean rate of the stereotypic behavior while on medications was 34% of intervals, and pretreatment while not taking medications was also 34%. He showed an immediate and significant reduction in the behavior as a result of the treatment (M=3%). At follow-up the behavior was not present M=0%. The client reported being very pleased with the effects of the treatment.

These results need to be looked at as a preliminary test of the treatment for this population. As with all case studies, the possibility exists that the results of the study are due to some factor other than the intervention. The possibility that the effects were due to nonspecific features of the treatment were, at least partially, controlled because he was in contact with mental heath professions, before, during, and after treatment, so this was a stable factor; also, his decreases occurred immediately upon implementation of the intervention, and maintained for at least four months.

Evaluation of this procedure is notably important because methamphetamine usage is increasing in the US at an alarming rate. As methamphetamine use continues to increase, the need for simple, yet effective interventions to treat its side effects are necessary. One of the primary benefits to HRT is that it is easy to deliver, it is brief, and it has been found to be effective across a variety of individuals and disorders.

This procedure has proven clinically useful on the one hand. On the other hand, questions remain regarding the specific change mechanism involved in this treatment, either behavioral or neurological. Behaviorally, it was presumably useful for the client in this case study because 1) it increased his awareness of his stereotypic behavior, 2) it stopped the response chain and provided alternative behaviors, and 3) this results in a decrease in the behavioral events that occasioned the stereotypic behavior. It is less clear what affect this procedure had on the client neurologically.

Future research is needed in many areas. First, the relationship between stereotypic movement disorders and substance abuse needs to be studied more thoroughly in human participants. Second, the application of HRT to the treatment of substance-induced stereotypic movement disorders needs to be evaluated in a more controlled experimental design. Finally, additional research on the behavioral/psychological function of HRT is necessary. Regardless of these limitations, this investigation provides preliminary evidence on the effectiveness of HRT-a behavioral treatment-for a disorder that is presumed to be neurological in basis.



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Michael P. Twohig, University of Nevada & Lake's Crossing Center and Edward M. Varra, Lake's Crossing Center

Michael P. Twohig, University of Nevada & Lake's Crossing Center and Edward M. Varra, Lake's Crossing Center

Author contact information:

Michael P. Twohig, MS

University of Nevada, Department of Psychology

Mail Stop 298

Reno, NV 89557-0062

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Author:Twohig, Michael P.; Varra, Edward M.
Publication:The Behavior Analyst Today
Date:Mar 22, 2006
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