Tics and Their Treatment
The striking feature of these "superior degenerates" or "unstables" it not the insufficiency, but the inequality, of their mental development. Their aptitude for art, literature, poetry, less often for science, is sometimes remarkable; they may fill a prominent place in society; many are men of talent, some even of genius; yet what surprises is the embryonic condition of one or other of their faculties. Brilliance of memory or of conversational gifts may be counteracted by absolute lack of judgment; solidity of intellect may be neutralised by more or less complete absence of moral sense.
In the category of "superior degenerates" – to use Ballet's terminology – will be found the vast majority of sufferers from tic, of whom O. may serve for the model. A no less instructive example is that of J.:
Of superior intelligence, lively disposition, and ingenious turn of mind, J. is dowered with unusual capabilities for assimilation. Everything comes easy to him. At school he was one of the foremost pupils, and his work elicited only expressions of praise. He is both musical and poetical; his quickness and neatness of hand find outlet in his passion for electricity and photography; for mathematics alone he has little inclination.
In a word, as with physical imperfection, so with mental – it may consist either in absence, arrest, or delay, or in overgrowth, increase, exaggeration, and these contrary processes may co-exist in the same individual. Sufficient stress, however, has not been laid on a practically constant feature in the character of the tiqueur– viz. his mental infantilism, evidenced, as was noted by Itard in 1825, by inconsequence of ideas and fickleness of mind, reminiscent of early youth and unaltered with the attainment of years of discretion. We must remember that imperfection of mental equilibrium is normal in the child, and that perfection comes with adolescence. In the infant cortico-spinal anastomoses are awanting, and volitional power is dependent on their establishment and development. At first, cortical intervention is inharmonious and unequal: the child is vacillating and volatile; he is a creature of sudden desire and transient caprice; he turns lightly from one interest to another, and is incapable of sustained effort; at once timid and rash, artless and obstinate, he laughs or cries on the least provocation; his loves and his hates are alike unbounded.
These traits in the child's character pertain equally to the patient with tic, in whom retarded or arrested development of volition, physical and mental evolution otherwise being normal, is the principal cause of faulty mental balance. That this view is correct may be inferred from a comparison of the individual patient with healthy subjects of his own age. The chief element in mental infantilism is maldevelopment of the will. While in the child deficiency of what one might call mental ballast is usually atoned for by well-conceived discipline and education, it is accentuated by misdirected teaching. Now, it not infrequently happens that the upbringing of the predisposed to tic is not all that might be desired, seeing that mental defect on the part of the parents renders them unsuitable as instructors of youth. Parental indulgence or injustice is the fertile source of ill-bred or spoiled children, in whom, spite of years, persist the mental peculiarities proper to childhood. From the ranks of these spoiled children is recruited the company of those who tic, for tics, generally speaking, are nothing more than bad habits, which, in the absence of all restraining influence, negligence and weakness on the side of the parents have allowed to degenerate into veritable infirmities. These the patients themselves are incapable of inhibiting, for whatever be their age, they remain "big children," badly bred and capricious, and ignorant of any self-control. Hence one of the first indications in their treatment is to submit them to a firm psychical discipline, calculated specially to strengthen their hold over their voluntary acts. Take the following case:
J. is nineteen years old, intelligent, educated, ready to graduate were it not for the interruptions his studies have undergone, and to all appearance arrived at manhood's estate. None the less he presents to-day the mental condition of nine years ago: he is fickle, pusillanimous, naïve, emotional; he laughs at trifles and is provoked to tears at the first harsh word; his nature is restless, his mind inconsequential; he is by turns elated or depressed for the most trivial of reasons. Notwithstanding his seventy-one inches, he must still be fed, dressed, and put to bed by his mother!
An identical mental state obtains in infantilism, properly so called, where to arrest of mental development physical imperfection is superadded. In cases of infantilism the psychical level corresponds more or less intimately to the somatic level, an observation borne out in the case of J.:
From the morphological point of view he shows one or two stigmata of infantilism: his great height need not be held to disprove this, for gigantism and retardation of sexual development are often in association. In spite of his nineteen years, J. has still a eunuch's voice and a minimum of axillary and pubic hair – in fact, one might say that physically he is thirteen years old, and mentally ten.
Or take Mademoiselle R., aged twenty-six:
Her intellectual attainments are those of a child of twelve, her age when her first tics made their appearance. Her artlessness and timidity are simply childish, and at the same time she lacks womanly charm and feminine ways.
Or again:
Young thirteen-year-old M. has been afflicted with tics of face, head, and shoulders for the last three years. Though small, he is well enough built, and has no obvious physical anomaly except an odd admixture of blonde and brown in his hair and eyebrows. His teeth are bad and misplaced, and several of the first dentition persist. There is no sign of pubic or axillary growth. As a general rule he is mild-mannered and docile; sometimes, however, he is irritable, impatient, emotional beyond his years. His degree of intelligence is very fair, but idleness and inconstancy are prominent traits in his character. The ease with which he apprehends is counterbalanced by the readiness with which he forgets, while his reason and judgment are those of a child of seven. The discordance between his actual age and his mental standard is therefore striking enough.
Another of our patients is L.:
Her intellect is quite up to the average, but the exaggerated importance attached by her parents to her "nervous movements" has only served to intensify her whims. Her eighteen years do not prevent her from revealing signs of mental infantilism in every action of her daily life, but, thanks to suitable treatment, she has been astonishing her father by unheard-of audacities – has she not recently ventured to cross the street alone, and alone to go an errand to a neighbouring shop?
X. has a tic of the eyes and has reached the age of forty-eight, yet he told us he was not so much his children's father as their playmate. At the age of fifty-four O. could still remark on his youthfulness of character. The same is true of S., who has attained his thirty-eighth year.
It is as arduous a task to define the term "stability of the will," as it is to explain what is meant by physical or mental health. But as it is not essential to preface descriptions of disease with a disquisition on the signs of good health, so anomalies of voluntary activity may surely be noted without a preliminary excursus on normal volition.
Will power may deviate from the normal in either of two directions – in the direction of excess or of insufficiency. To both of these two forms of volitional disturbance the subjects of tic have become slaves. Weakness of will is seen in irresoluteness of mind, flight of ideas, want of perseverance; exuberance of will in sudden vagary or imperious caprice. The man who tics has both the debility and the impulsiveness of the child; to his impatience his incapacity for sustained effort acts as a set-off; he is impressionable, wavering, thoughtless, even as he is mettlesome and irascible. He does not know how to will; he wills too much or too little, too quickly, too restrictedly.
As a single example of volitional activity, let us take the attention. Diminution of attention on the part of tic patients has been judiciously commented on by Guinon:
It is impossible for them to address themselves to any subject: they skip unceasingly from one idea to another, and apply themselves with zest to some occupation only to forget it immediately. No further proof of this need be sought than the inability of the patient, if he be at all severely affected, to read, a proceeding at once intellectual and mechanical, and absolutely familiar to most. Read the patient cannot, and though the attempt to concentrate the attention diminishes or inhibits the tic at once, there is no sequence in his effort; his eye jumps erratically from one line to another, and his many unavailing trials end in his throwing the book away.
Excess of voluntary activity is disclosed in the whole series of impulsions.
The germ of homicidal or suicidal tendencies, which we have indicated in the case of O., is discoverable also in one of Charcot's patients.23
M. Charcot (to the patient) – Tell us what you said the other day about razors.
The Patient– Whenever I see a razor or a knife, I begin to thrill and feel afraid. I imagine I am going to kill some one, or that some one is going to kill me. I have the same sensation when I see a gun, or even if the notion of a gun comes to my mind. The mere thought of it agonises me. The fancy of murdering some one strikes me, and up to a certain point I am envious of fulfilling the desire. Often I am conscious of an irresistible longing to fight somebody, and I am frequently impelled to it by the sight of a cabman. Why a cabman more than any one else, I have not the remotest idea.
We have already touched on the close affinity between an act and the idea of the act, and we have emphasised the absence of any appreciable interval between the idea and its execution, unless the brake of volitional interference be put on at the proper moment. It is in these circumstances that the feeble of will betray their debility; the inadequateness or inopportuneness of their will's activity allows the performance of the act they would fain repress.
A no less characteristic feature of the subject of tic is his impatience.
J. bolts his food without waiting to masticate it, and the instant his plate is empty jumps up from the table to walk about the house. He returns for the next course, which he swallows as precipitately; delay makes him impatient, and all are forced to rush as he does. Meal time for the whole family has become a perfect punishment. Alarmed enough already at his tics, the parents are terror-stricken by the tyrannical caprices of this big baby, who outvies the worst of spoilt children in his behaviour.
Mental instability is not uncommonly associated with a general restlessness and fidgetiness during intervals of respite from the actual tics. The patient experiences a singular difficulty in maintaining repose. Every minute he is moving his finger, his foot, his arm, his head. He passes his hand over his forehead, runs his fingers through his hair, rubs his eyes or his lips, ruffles his clothes, plays with his handkerchief or with anything within reach, crosses and uncrosses his legs, etc. None of these gestures can properly be considered a tic, for, however frequent be its repetition, it is neither inevitable nor invariable. If they are superfluous and out of place, the absence of exaggeration or absurdity negatives their classification as choreic. They are a sign not so much of motor hyperactivity as of volitional inactivity. They are tics in embryo.
The patient's emotions are similarly ill balanced. Any rearrangement in his habits he finds disconcerting; he is upset by an unexpected word, a deed, a look; his timidity and sensitiveness are extreme – fertile soil for the development of tics.
So, too, with his affections, his likes and dislikes, his friendships and enmities – there is commonly a disproportion about them that betokens mental deficiency. At one time it is fear or repulsion that actuates him; at another it is an unnatural tenderness, a sort of philia, if the term may be allowed.
Anomalies such as these, however, are met with in all the mentally unstable, and do not present any special feature when they occur in those who tic.
An acquaintance with the mental state of our patients enables us to understand the mode their tic adopts. As one thinks, so does one tic. To the transiency and mutability of the child's ideas correspond what are known as variable tics, which rarely have a definite localisation, and become fixed only when certain ideas become preponderant. The existence of a solitary tic, however, is not at variance with that disposition we have qualified as infantile, for mental infantilism is the original stock; on it, as a matter of fact, may be grafted further mental disorders in the shape of fixed ideas, phobias, or obsessions.
Should a fixed idea entail a motor reaction, it may give rise to a tic as ineradicable as the idea itself, and a series of fixed ideas may be accompanied by a succession of corresponding tics.
The frequency with which obsessions, or at least a proclivity for them, and tics are associated, cannot be a simple coincidence. Without defining the word obsession, let us be content to recall the excellent classification given by Régis, according to whom they mark a flaw in voluntary power, either of inhibition or of action. On the one hand we have impulsive obsessions, subdivided into obsessions of indecision, such as ordinary folie du doute; of fear, such as agoraphobia; of propensity, such as those of suicide or homicide. On the other we find the aboulic obsessions, such as inability to stand up (ananastasia), or to climb up (ananabasia), or the astasia-abasia of Séglas, or the akathisia of Haskowec. Perhaps we ought also to place here sensory obsessions in the shape of topoalgia, and even hallucinatory affections.
In all these varieties of obsession increase or diminution of volitional activity is undeniable. But this alteration in the function of the will is no less distinctive of tic, and if we compare the psychical stigmata of obsessional patients – the asymmetry of their mental development, their intellectual inequalities and lack of harmony, their alternating excitability and depression, their unconventionalities, eccentricities, and imaginativeness, their timidity, whimsicalness, sensitiveness, and all the other indications of a psychopathic constitution – if these are compared with the mental equipment of the sufferer from tic, we cannot but notice intimate analogies between the two, analogies corroborated by a glance at their symptomatology.
An obsession may be of idiopathic origin, or it may be causally connected with some particular incident, sensation, or emotion. A conflagration may determine fear of fire, or a carriage accident amaxophobia. Further, the obsession is irresistible, as is the tic: opposition endures but for a moment, and is therefore vain. Nor is the inhibitory value of attention or distraction any less ephemeral. This feature of tic was noted as long ago as 1850 by Roth, who held its motor manifestations to be phenomena of "irresistible musculation."
Consciousness is maintained in its integrity both before and after, but not during, an obsessional attack, and this is equally true of tic, as are the preliminary discomfort and subsequent satisfaction that attend the obsession. Noir makes the appropriate remark that idiots affected with krouomania, in whom sensory disturbance is awanting, so far from suffering pain through sundry self-inflicted blows and mutilations, seem, on the contrary, to be thus afforded a certain feeling of relief, if not of actual relish.
Whenever Lam., who exhibits incessant balancing and rotatory movements of the head, is seated in proximity to a wall, he knocks his head sideways against it until a bruise results, and appears to find therein a source of genuine satisfaction.24
If, then, an obsession provokes a motor reaction at all, it may originate a tic, and, in the case of tonic tics, this is a very common mode of derivation, as one may well understand how an obsession may occasion an attitude.
Grasset cites the example of a young girl who would never lean backwards in a railway carriage or on any chair or bench, preferring to sit bolt upright on the edge. In this instance the adoption of a stereotyped attitude was directly attributable to an obsession.
Another example of an attitude tic is furnished by the case of young J.:
Standing or seated, he always has his half-flexed left arm firmly pressed against the body in the position assumed by hemiplegics. Its pose and inertia and the awkwardness of its movements unite to suggest some real affection, the existence of which the constant use of the right arm and the elaboration by the patient of intricate devices to obviate disturbing the other tend to substantiate. Nevertheless, the impotence is entirely imaginary. To order he can execute any movement of the left arm with energy and accuracy; his left hand will button or unbutton his clothes, lace his boot, handle a knife, and even hold a pen and write.
It seems that the position of the arm was chosen deliberately to alleviate a supposed pain in the shoulder, and unceasing resort to this subterfuge of his own inventing, which he considered a sovereign remedy, ended in its voluntary adoption being succeeded by its automatic reproduction.
The assumption of this position for his arm was at first attended with satisfactory results, but, as might have been foreseen, its inhibitory value decreased gradually, so he had recourse to other means. It was then that the right hand was made to grip the left and press it more energetically than ever against the epigastrium. In this complex attitude both arms simultaneously participated, but again its efficacy was purely transitory. Evidently dissatisfied with his methods of immobilisation, and convinced that experimentation would end in the discovery of the desired arrangement, J. proceeded to employ the right hand in impressing every variety of passive movement on the left hand, wrist, forearm, and upper arm, and soon there was no checking these gymnastic exercises. He would suddenly grasp the wrist and pull and screw it, while the left shoulder and elbow resisted nobly; or he would bend, or unbend, or twist his fingers, or seize the arm below the axilla and knead it or rub it, forcing it against or away from the thorax; he would pound the muscles and pinch the tendons, sometimes in a brutal fashion; in short, the situation degenerated into nothing more nor less than a pitched battle between the left arm and the right hand, in which the latter endeavoured by a thousand tricks to bring the former into subjection. Victory rested always with the affected arm.
Each time that this absurd combat recommenced, the patient experienced a sensation of relief; resignation to the imperious motor obsession was even followed by a sense of well-being. On the other hand, resistance was accompanied by actual anguish – he would fidget desperately in his chair, cross and uncross his legs, sigh, grimace, rub his eyes, bite his lips and nails, twist his mouth about, pull at his hair or his moustache, he would look anxious or alarmed, would become by turns red or pale, and beads of perspiration would gather on his face. At length he would be compelled to yield, and the bloodless battle of his upper limbs would close more furiously than ever.
In this case the typical features of obsession are excellently illustrated – its irresistibility, as well as the concomitant distress and succeeding content.
Conversely, however, a tic may be said to develop into an obsession if the exciting cause of the latter be the motor reaction.
In various psychopathic conditions (says Dupré25), especially where the genito-urinary apparatus is concerned, this pathogenic mechanism is encountered. Some source of peripheral irritation in bladder, urethra, prostate, etc., provokes cortical reaction, and a reflex arc is established with centrifugal manifestations in the guise of motor phenomena, which in their turn originate all sorts of fixed ideas, impulsions, and obsessions, forming an integral part of the syndrome.
There is frequently no direct or obvious connection between a patient's obsession or obsessions and his tics. The former may consist, both in children and in adults, in extraordinary scrupulousness, perpetual fear of doing wrong, absolute lack of self-confidence, sometimes simply in excessive timidity, exaggerated daintiness, or interminable hesitation. We have often seen youthful subjects betray in their disposition weak elements such as the above, which at a later stage have proved the starting-point for more definite obsessions. Their intelligence and capacity for work earn the approbation of their teacher, yet they are for ever dissatisfied, haunted by the dread of having overlooked some iota in their task; they dare not affirm that they know their lessons, they stammer over their answers, mistrust their memory, make no promises and take no pledges, and thus bear witness to an absence of confidence in themselves which affects them profoundly, for they are well enough aware of its consequences.
An admirable instance of this is furnished by the case of young F., or by little G., ten years old, who suffers from a facial tic, and constantly hesitates when asked to give a measurement, an hour, a date, a figure, solely by reason of a conscientious fear of not being absolutely accurate in his reply.
In children the emotional excitement of their first Communion often favours the development of religious scruples. By a sort of metastasis, diminution of the convulsive movements goes pari passu with aggravation of the mental phenomena, until such a time as the devotional exercises are done with, when there is a return to the previous state.
Arithmomania betokens an analogous turn of mind. Certain patients are compelled to count up to some number before performing any act. One cannot rise from his seat without counting one, two, three, four, five, seven, leaving out six since it is disagreeable to him. Another must repeat the same movement two, three, ten times, must turn the door-handle ten times ere opening it, must take five steps in a circle before beginning to walk (Guinon). A patient of Charcot's used insanely to count one, two, three, four, used to look under his bed three or four times, and could not lie down until assured that his door was bolted. A further example is reported by Dubois:
A young woman twenty years of age first began to suffer from convulsive tics five years ago. Without any warning she used to bend down as if with the intention of picking up something, but she had to touch the ground with the back of her hand, else the performance was repeated. Twenty or thirty times a day this act was gone through; in the intervals she kept turning her head to the right, looking up at the curtains in a corner of the window, and at the same time making a low clucking sound that attracted the attention of those in the room. For nine or ten years these two tics have prevailed, and have been accompanied with certain obsessions, such as the impulse to count up to three, to regard any person or object three times, etc. With the generalisation of the convulsive movements various phobias have made their appearance – viz. fear of horned animals, of earthworms, of cats, of blight, etc.
Onomatomania is another form of obsession which may be mentioned, exemplified by the dread of uttering some forbidden word, or by the impulse to intercalate some other. The term folie du pourquoi has been applied to the irresistible habit of some to unearth an explanation for the most commonplace of facts: "Why has this coat six buttons?" "Why is so-and-so blonde?" "Why is Paris on the Seine?" etc. This mode of obsession is frequent among those who tic, and is curiously reminiscent of a familiar trait in the character of children, thereby supporting our contention of the mental infantilism of all affected with tics.
Prominent among the mental anomalies of the subjects of tic are found different sorts of phobia: fear of death or of sickness, of water, knives, firearms – topophobia, agoraphobia, claustrophobia, etc.