A presentation by:

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Hiro KooPsychologist & Licensed Clinical HypnotherapistSpectrum Of Life Integrative Wellness CentreBSocSc(Hons) PsychologyMSc Clinical PsychologyDiploma in Clinical Hypnosis (Lond.)Certified Neurotherapist (Singapore)

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• Member of American Psychological

Association (APA) Division 30 - The

Society of Psychological Hypnosis

(Membership #: 59610305)

• Licensed Hypnotherapist (13-PM-041)

of The Association of Hypnotherapy

Practitioners, Malaysia (AHPM) –

Traditional and complementary

medicine department – Ministry of

Health Malaysia

• Committee Member of AHPM

(2016/2017)

• Full member (B288/14) of Malaysian

Psychological Association (PSIMA)

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Spectrum of Life (SOL) Integrative Wellness CentrePractitioners include integrative medical doctor, child

psychologist, neurotherapist, chinese physician, nutritional therapist,

naturopath and physiotherapist.

We offer non-pharmacological, natural and complementary medicine

modalities for common health issues.

Goal of the day

• Introduction: What is Tic Disorder and Tourette Syndrome

• Intervention: How to deal with it by using the technique of EEG biofeedback and Neuro-hypnotherapy

• Case study

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Tic disorder?

Tic Disorder

Tourette Syndrome

2 motor tics and

at least 1 vocal/phonic tics & more than 1 year

Chronic Tic Disorder

Either motor tics or vocal/phonic tics but

more than 1 year

Provisional Tic Disorder

Either motor tics or vocal/phonic tics but

less than 1 year

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Picture soucre: http://www.metrokids.com/MetroKids/May-

2015/Understanding-Tourettes-Syndrome/

Co-occuring condition

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(Start) 5- 7 years old

(More severe) 8-12 years old

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The Causes?

Tic Disorder

Genetics

developmental

Other factors

Environmental

8At present, no specific agent or event has been identified

Intervention: EEG Biofeedback

• Pharmaceutical intervention: Neurochemical or brain structure components

• EEG biofeedback intervention: Electrical components in the brain

• Regulate the part of the brain which is related to motor movement regulation

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Intervention for Tic

P/S: There is no cure but symptom management

•Psychotherapy•Deep brain stimulation

•EEG biofeedback

•ADHD or antiseizuremedication etc

Neurochemical

component

Electrical component

Other Brain structure

component

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EEG Biofeedback Intervention

(Central Sulcus)

• Certain abnormalities within the brain which related to motor movement regulation (Bronfeld M & Bar-Gad I., 2013)

• Primary motor area controls the voluntary movements of skeletal muscles and fine motor movements, including the lips, mouth, hands, and face.

• Issuing motor plans for movement that is generated subconsciously

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EEG Biofeedback

(Frontal Lobe)

• The area which responsible for the initiation and construction plan for primary cortex motor movement.

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EEG Biofeedback

(SMR brainwaves)

• The Sensorimotor Rhythm (SMR; 12–15 Hz) is linked with brain and body functions. It is known to increase when motor movement is inhibited.

• Motor movement or mental imagery related to motor task can cause SMR brainwaves to change as well (Shanbao Tong & Nitish Vyomesh Thakor, 2009).

• SMR brainwave is commonly measured and trained above the central sulcus related area. EEG biofeedback training on the central sulcus appears promising for Tic Disorder because training on this part of the brain has been related to motor movement regulation.

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EEG Biofeedback

(Theta brainwave)

• Research study has found excess theta wave activity in the TS patient's frontal lobes (Messerotti Benvenuti S, Buodo G, Leone V & Palomba D., 2011).

• Interestingly, excess theta wave activity in the brain’s frontal lobe is also a common feature of ADHD patient.

• Inhibit theta brainwaves on the frontal lobes to alleviate the symptoms of the Tic Disorder.

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Intervention:

Neuro-hypnotherapy

Neuro-Hypnotherapy

Clinical Hypnotherapy

Neuro-therapy/EEG biofeedback

Psychotherapy

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Psychoeducation

Functional intervention

-Triggers

Habit reversal therapy (HRT)

-premonitory urge

Hypno-desensitization

-- An intentional movement to replace

urge

Cognitive behavioral Hypnotherapy

-Comorbid symtoms

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Patient A

• Gender: Male

• Age: 25

• Diagnosis: Chronic Motor Tic Disorder

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EEG biofeedback session

Month Session Treatment Protocol

February Session 1 – Session 3 C3-C4 SMR,

T4 SMR,

P4 SMRMarch Session 4 – Session 6

April Session 7 – Session 10

Total sessions 10

*** T4 & P4 SMR is done by using simultaneous protocol, the reason of doing this is: Tics triggered by anxious feeling or

performance related anxiety.

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Findings

Presenting Problem Outcome

Throwing the head back as if to get hair out of the

eyes in public area (involuntary and rapid head jerk).

Touching the chest with his jaw in public area

(involuntary).

Moving his ear purposeless

Poor concentration

Able to control his head jerks/movements. No more

throwing his head back or touching his chest with his

jaw in public area.

His motor tics reduce significantly according to his

friends, family members, and himself. Now motor tics

will only happen in his bedroom before he sleeps.

Better concentration

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Patient B

• Gender: Male

• Age: 14

• Diagnosis: Tourette Syndrome

• Co-occuring: Obsessive Compulsive Behavior according to caregiver.

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EEG biofeedback and Neuro-

hypnotherapy sessionMonth Session Treatment Protocol

November Session 1 – Session 3 C3 SMR,

C4 SMR,

Fz Delta,

Neuro-hypnotherapy

December Session 4 – Session 8

January

February

Session 9 – Session 10

Session 11 – Session 13

March Session 14 – Session 15

April Session 16 – Session 20

Total sessions 20

*** Neuro-hypnotherapy was conducted for 6 sessions in total. Fz Delta to deal with his Obsessive Compulsive

Behaviour.

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FindingsPresenting Problem Outcome

Eye blinking

Looking to one side for a brief period of time as if he

heard noise

Nose twitching

Throwing the head back

Shrugging the shoulder

Shaking his legs

Tensing his buttocks

Obscene hand gestures

Vocal tic symptoms include coughing, throat clearing,

animal or barking noises, rude or obscene words,

repeating what someone else said, and sudden

changes in pitch.

When his phonic/vocal tics became worst, tics were

presented virtually all the time. Tic-free intervals

were difficult to identify and did not last longer than

5-10 minutes. Basically, his phonic/vocal tics

frequently disrupted what he was trying to do or say.

No more looking to one side motor tic symptom

No more nose twitching

No more throwing the head back

No more shrugging the shoulder

No more shaking his legs

No more tensing his buttocks

His vocal tics reduced significantly according to his

teacher, principal, friends, family members, and

himself. Now vocal tics happened occasionally when

he was watching an exciting movie.

His phonic/vocal tics only became worse occasionally.

Tic-free intervals as long as 3 hours were not

uncommon now. Basically, his phonic/vocal tics only

occasionally interrupted what he was trying to do or

say nowadays.

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Patient C

• Gender: Male

• Age: 16

• Symptoms: Vocal Tic Disorder

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EEG biofeedback session

Month Session Treatment Protocol

February Session 1 – Session 3 C3 SMR,

C4 SMR,

F3 SMR,

F4 SMR.

March Session 4 – Session 6

April Session 7 – Session 10

Total sessions 10

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FindingsPresenting Problem Outcome

High pitched hiccup and speech problem such as

sudden changes in volume or pitch. High pitched

hiccup sound occurred frequently whenever he

was focusing on task.

His caregiver found that his high pitched hiccup

sound reduced about 50-80% after 10 sessions.

High pitched hiccup sound only occurred occasionally

nowadays.

Better concentration

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Patient D

• Gender: Male

• Age: 11

• Diagnosis: Tourette Syndrome

• Co-occuring: ADHD

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EEG biofeedback session

Month Session Treatment Protocol

January Session 1 C3 SMR,

F3 Hibeta,

C4-T4 SMRFebruary Session 2 – Session 6

March

April

Session 7 – Session 9

Session 10 – Session 12

May Session 13 – Session 15

June Session 16 – Session 18

Total sessions 18 C4-T4 to deal with his ADHD symptoms

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Findings

Presenting Problem Outcome

Negative thinking such as suicidal thoughts

Motor tics include eye blinking, holding funny

expressions, nose twitching, touching the shoulder

with the chin or lifting the chin up, throwing his

head back, quickly flexing the arms or extending

them, and touching objects for no purpose

Vocal tic symptoms include coughing, throat

clearing, rude or obscene words, and sudden

changes in pitch

Stop schooling

ADHD symptoms such as difficulty in focusing and

hyperactivity

Positive mood and became happier

All vocal tic symptoms nearly diminished or

disappeared. His vocal tics reduced significantly

according to his teacher, principal, friends, family

members, and himself.

His motor tics was still noticeable but seldom

interrupted what he was trying to do or say

nowadays.

Back to school and his teachers were impressed by

his change

Focus and attention span had improved according

to caregiver.

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Conclusion

EEG biofeedback and Neuro-hypnotherapy could be a promising new treatment option for Tics disoder and

Tourette Syndrome.

More Clinical Trials and Studies are needed.