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A presentation by: Hiro Koo Psychologist & Licensed Clinical Hypnotherapist Spectrum Of Life Integrative Wellness Centre BSocSc(Hons) Psychology MSc Clinical Psychology Diploma in Clinical Hypnosis (Lond.) Certified Neurotherapist

  1. A presentation by: Hiro Koo Psychologist & Licensed Clinical Hypnotherapist Spectrum Of Life Integrative Wellness Centre BSocSc(Hons) Psychology MSc Clinical Psychology Diploma in Clinical Hypnosis (Lond.) Certified Neurotherapist (Singapore) 1

  2. • 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) • Member of American Psychological Association ( APA ) Division 30 - The Society of Psychological Hypnosis (Membership #: 59610305) • Full member (B288/14) of Malaysian Psychological Association ( PSIMA ) 2

  3. Spectrum of Life (SOL) Integrative Wellness Centre Practitioners 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. 3

  4. 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 4

  5. Tic disorder? Tourette Syndrome 2 motor tics and at least 1 vocal/phonic tics & more than 1 year Tic Disorder Provisional Tic Chronic Tic Disorder Disorder Either motor tics or Either motor tics or vocal/phonic tics but vocal/phonic tics but more than 1 year less than 1 year Picture soucre: http://www.metrokids.com/MetroKids/May- 2015/Understanding-Tourettes-Syndrome / 5

  6. Co-occuring condition 6

  7. (Start) 5- 7 years old (More severe) 8-12 years old 7

  8. The Causes? Genetics Tic Environmental developmental Disorder Other factors At present, no specific agent or event has been identified 8

  9. 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 9

  10. Intervention for Tic P/S: There is no cure but symptom management • ADHD or • EEG antiseizure biofeedback medication etc Neurochemical Electrical component component Brain structure Other component • Deep brain • Psychotherapy stimulation 10

  11. 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 11

  12. EEG Biofeedback (Frontal Lobe) • The area which responsible for the initiation and construction plan for primary cortex motor movement. 12

  13. 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. 13

  14. 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. 14

  15. Intervention: Neuro-hypnotherapy Psychotherapy Neuro- therapy/EEG biofeedback Clinical Hypnotherapy Neuro-Hypnotherapy 15

  16. Psychoeducation Cognitive behavioral Functional intervention Hypnotherapy -Triggers -Comorbid symtoms Hypno-desensitization Habit reversal therapy -- An intentional (HRT) movement to replace - premonitory urge urge 16

  17. Patient A • Gender: Male • Age: 25 • Diagnosis: Chronic Motor Tic Disorder 17

  18. EEG biofeedback session Month Session Treatment Protocol February Session 1 – Session 3 C3-C4 SMR, T4 SMR, P4 SMR March 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. 18

  19. Findings Presenting Problem Outcome   Throwing the head back as if to get hair out of the Able to control his head jerks/movements. No more eyes in public area (involuntary and rapid head jerk). throwing his head back or touching his chest with his  Touching the chest with his jaw in public area jaw in public area.  (involuntary). His motor tics reduce significantly according to his  Moving his ear purposeless friends, family members, and himself. Now motor tics  Poor concentration will only happen in his bedroom before he sleeps.  Better concentration 19

  20. Patient B • Gender: Male • Age: 14 • Diagnosis: Tourette Syndrome • Co-occuring: Obsessive Compulsive Behavior according to caregiver. 20

  21. EEG biofeedback and Neuro- hypnotherapy session Month Session Treatment Protocol November Session 1 – Session 3 C3 SMR, C4 SMR, December Session 4 – Session 8 Fz Delta, Neuro-hypnotherapy January Session 9 – Session 10 February 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. 21

  22. Findings Presenting Problem Outcome   Eye blinking No more looking to one side motor tic symptom   Looking to one side for a brief period of time as if he No more nose twitching  heard noise No more throwing the head back   Nose twitching No more shrugging the shoulder   Throwing the head back No more shaking his legs   Shrugging the shoulder No more tensing his buttocks   Shaking his legs His vocal tics reduced significantly according to his  Tensing his buttocks teacher, principal, friends, family members, and  Obscene hand gestures himself. Now vocal tics happened occasionally when  Vocal tic symptoms include coughing, throat clearing, he was watching an exciting movie.  animal or barking noises, rude or obscene words, His phonic/vocal tics only became worse occasionally. repeating what someone else said, and sudden Tic-free intervals as long as 3 hours were not changes in pitch. uncommon now. Basically, his phonic/vocal tics only  When his phonic/vocal tics became worst, tics were occasionally interrupted what he was trying to do or presented virtually all the time. Tic-free intervals say nowadays. 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. 22

  23. Patient C • Gender: Male • Age: 16 • Symptoms: Vocal Tic Disorder 23

  24. EEG biofeedback session Month Session Treatment Protocol February Session 1 – Session 3 C3 SMR, C4 SMR, March Session 4 – Session 6 F3 SMR, F4 SMR. April Session 7 – Session 10 Total sessions 10 24

  25. Findings Presenting Problem Outcome  High pitched hiccup and speech problem such as His caregiver found that his high pitched hiccup sudden changes in volume or pitch. High pitched sound reduced about 50-80% after 10 sessions.  hiccup sound occurred frequently whenever he High pitched hiccup sound only occurred occasionally was focusing on task. nowadays.  Better concentration 25

  26. Patient D • Gender: Male • Age: 11 • Diagnosis: Tourette Syndrome • Co-occuring: ADHD 26

  27. EEG biofeedback session Month Session Treatment Protocol January Session 1 C3 SMR, F3 Hibeta, February Session 2 – Session 6 C4-T4 SMR March Session 7 – Session 9 April 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 27

  28. Findings Presenting Problem Outcome   Negative thinking such as suicidal thoughts Positive mood and became happier   Motor tics include eye blinking, holding funny All vocal tic symptoms nearly diminished or expressions, nose twitching, touching the shoulder disappeared. His vocal tics reduced significantly with the chin or lifting the chin up, throwing his according to his teacher, principal, friends, family head back, quickly flexing the arms or extending members, and himself.  them, and touching objects for no purpose His motor tics was still noticeable but seldom  Vocal tic symptoms include coughing, throat interrupted what he was trying to do or say clearing, rude or obscene words, and sudden nowadays.  changes in pitch Back to school and his teachers were impressed by  Stop schooling his change   ADHD symptoms such as difficulty in focusing and Focus and attention span had improved according hyperactivity to caregiver. 28

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