The Journal of Abnormal Psychology | ||
ON THE GENESIS AND THE MEANING OF TICS
BY MEYER SOLOMON, M. D.
Associate in Neurology, Maimonides Hospital,
Chicago
THE problem of the genesis and meaning of the strange manifestations which we find in that peculiar disorder which goes by the accepted name of tics is indeed difficult of solution. The analytic and genetic standpoint only comparatively recently assumed in the domain of neurology and psychiatry is having an ever wider and wider application. The problems in neurology and psychiatry which still cry loudly for solution and rational explanation are indeed numerous. Some of these questions are so baffling that at times they seem almost beyond the ken of the human mind. Nevertheless, with persistence and the "Don't give up the ship" spirit keenly imbued into us, and with that irrepressible spirit of investigation and of research born of optimism and of curiosity, we may expect to see many of these problems which now seem to us so hopelessly unsolvable gradually rescued from the uncertain waters of speculation and theorization and brought to the more sound shores and land of the knowable and the known. If our theories be but tinctured with due admixture of that sound self-criticism that comes of prolonged and serious reflection and deliberation, and if the results of observation and investigation be brought forth in support of these theories, then we need have no hesitancy in permitting freedom in theorization and speculation. Let us also remember that unsound theories or standpoints do not come to stay, but, after surviving for a certain time, give way before that which is more sound, more tangible, more near the truth, which, to be sure, is always but approximately attained. If, therefore, the theory which I intend to set before you for consideration may seem on first thought far-fetched and unsupported, I beg you to remember that in a field where but comparatively little is known with absolute certainty, it behooves us to take notice of all theories or conclusions
With these brief prefatory remarks, I shall forthwith enter into the discussion of the genesis and meaning of the tics.
I may say at once that this is not merely a theoretical and purely academic proposition which has no practical bearings in the way of prognosis and treatment. On the other hand, a real understanding of the nature, origin, and significance of the tics is of decided value in giving us proper standpoints and orientation with respect to the prevention, prognosis and cure of the condition.
I need not enter into a description of the characteristics of tics in this place. I may merely mention that tics have two aspects—a psychic and a physical. It is, in other words, a psychoneurosis. The characteristic mental state is one of doubt, of indecision, of inadequacy, of restlessness, of tension, of discomfort and of dissatisfaction, which is more or less unappeasable and irrepressible and uncontrollable until it finds vent in a rather explosive series of motor expressions which, as it were, are the safety valve for the peculiar feeling of tension and discomfort which the individual has been experiencing and which is accompanied by a sense of relief, satisfaction and a relative degree of comfort and mental rest. The mental imperfection (Charcot) of the ticquer is a polymorphic psychic defect (Brissaud, Meige and Feindel) characterized by mental infantilism; for ticquers, like other psychoneurotics, are like big children. They have the mind of children, in respect to the emotional make-up.
The mental condition of ticquers is especially characterized by the imperfection or weakness of volition, by a certain degree of mental instability and lack of inhibitory control of the desires, tendencies, activities and motor expressions of the individual, this defect laying the groundwork for the impulsions and obsessions, as also for hysterical, so-called neurasthenic, hypochondriacal, depressive and so-called dementia praecox reactions. The tic movement is
The earlier investigators were responsible for the differentiation of the tics from such other conditions as Sydenham's chorea, Huntington's chorea, the spasms, the stereotypies, the habit movements, the myoclonias, and other allied conditions. It is due to their pioneer work that tics were recognized as a definite and distinct clinical entity. The process of disintegration of these various movements and their differentiation one from the other cannot be over-valued. Among those who have contributed most to this subject may be mentioned Magnan and his pupils, especially Saury and Legrain, Gilles de la Tourette, Letulle, Guinon Noir, Pitres, Cruchet, Grasset, Trousseau, Charcot, Brissaud Meige and Feindel. Although Trousseau recognized the the ticquer was mentally abnormal, it was Charcot who first called definite attention to the psychic origin of the condition and to the fact that tic was indeed a mental disorder, a psychoneurosis, a psychomotor reaction. His lead was subsequently followed up by Brissaud, and by the latter's pupils Meige and Feindel, the latter two authors giving us a comprehensive discussion of the subject in their well-known classic. [1]More recently the Freudian school has attempted to dig down into the roots of the tree which ultimately sends forth its branches in the guise of tics.
VIEWS OF THE FRENCH SCHOOL
The usual conception of tics, as laid down by Brissaud, Meige and Feindel,[1] may be stated as follows: Tic movements are physiological acts which were originally functional and purposeful in character, but which have become habits, apparently purposeless and meaningless. The motor reaction is the result of some external stimulus or idea (normal or abnormal) or both, which originally was necessary for the production of the tic movement, which latter eventually became habitual and automatic, and, owing to repetition, was executed, even in the absence of the external stimulus or
The inherent or acquired neuropathic and psychopathic state is the basic condition which prepares the subsoil.
From a consideration of the motor symptom we may say that it is but a pathological habit, which, however, is apt to lead to the tendency toward or generation of an increasing number of such pathological habits.
Characteristic of tics we may mention their being conscious before and after but not during their execution, their being disordered functional acts, their impetuous, irresistible demand for execution, the antecedent desire, and the subsequent satisfaction.
The etiology of tics, as laid down by Meige and Feindel, may be summed up by stating that they occur most frequently in young subjects, less frequently in savages and animals than in the civilized, there is a psychic predisposition based on heredity (of a similar or dissimilar neuropathy or psychopathy) upon which Charcot laid great stress, imitation (especially in the young) plays a role, as also brain fatigue (emotion, mental upset and worry) and indolence, with the frequent exciting cause of an external or internal stimulus or an idea, which is the explanation of the origin, source, situation and form of the tic or tics present in any particular case.
Scattered references to emotional shock acting as a possible exciting cause of tics, as at times of obsessions, can
Bresler[4] has called attention to the fact that the movements are in the nature of defensive and protective movements of expression and mimicry and originally in reaction to some external irritant or as the result of some idea, and he proposed the name "mimische Krampfneurose" for them. This is somewhat allied to Breuer and Freud's theory of hysteria.
The object of tic is some imaginary end, the influence of the will always being present in the beginning, although later it may be absent. Tics are of cortical origin, being coordinated and synergic, clonic or at times tonic[5] muscular movements, physiologically and not anatomically grouped, premeditated, purposive, of abnormal intensity, apparently causeless and inopportune.
Insufficiency of inhibition is the cause of the beginning and of the persistence of bad habits and of tics.
Tic is a sign of degeneration, in the biological and evolutionary sense, a degenerative neuropathic and psychopathic basis, as mentioned previously, being present, although often latent.
The maladie des tics is but the extreme form.
The onset is as a rule insidious, with a tendency to spread.
Spontaneous cures may occur, while Gilles de la Tourette's disease is but the extreme form of a condition in which antagonistic gestures are frequently adopted by the patient to adapt himself and to get to a state of rest.
This, as I see the situation, is as far as the French students of this subject (including Brissaud, Meige and Feindel, and even Janet) have permitted themselves to go. And, in
VIEWS OF THE FREUDIAN SCHOOL
Recently the Freudian school has endeavored to penetrate more deeply to the nucleus of the problem and to solve it. Freud has delimited what he calls obsessional or compulsion neurosis (Zwangsneurosis), which is classed under psychasthenia by the French and under neurasthenia by others. The Freudians regard this as a distinct neurosis, sometimes complicated by neurasthenic or hysterical symptoms. The characteristic symptom is a feeling of compulsion. The symptoms may be motor (obsessional acts, impulsions), sensory (obsessional hallucinations or sensations), ideational (obsessions), and affective (obsessive emotions, particularly doubt and fear). In this condition we find that there is an excessive psychical significance attached to certain thoughts. Obsessions are characterized by dissociations from the main personality. They thus exist in the unconsciousness. The original unconscious mental processes have brought about, by displacement, an excess of psychical significance to these thoughts. Ernest Jones[6] states that Freud found, by his work in psychoanalysis, that obsessions represented, symbolically, the return of self-reproaches of ancient, infantile and early childhood origin, which had been repressed and buried until the obsession made its appearance. "They always refer to active sexual performances or tendencies;" and, as Jones further explains, "there occurs early in life an exaggerated divorce between the instincts of hate and love, and the conflict and antagonism between the two dominate the most important reactions of the person. A fundamental state of doubt, an incapacity for decision, results from this paralyzing doubt. The patient oscillates between the two conditions of not being able to act (when he wants to), and of being obliged to act (when he doesn't want to). The symptom symbolizes the conflicting forces. These are not, as in hysteria, fused into a compromise-formation,
To put the matter plainly, the Freudians contend that obsessions are symbolical representations of the repressed sexual activities and tendencies of infantile and early childhood origin. It must be remembered that the Freudians employ the term sexual in a very broad sense, including under it the most indirect and distant physical, mental and moral reverbations. conscious or "unconscious," of the relations between the sexes. The sexual impulse is here conceived of as having incestuous, bisexual and polymorphous perverse sexual tendencies. The word sexual is not only used as synonymous with love, but practically all emotional surgings, all feelings, all affectivity, all sense-cravings and bodily heavings are classed by certain members of the Freudian school as sexual. This latter interpretation and extension of the connotation generally accorded by us to the term sexual we surely have no right to give it.
Clark, of New York City, is the author who has carried out the Freudian idea to its ultimate conclusion. I refer to his series of three papers[7] in the Medical Record, and call particular attention to his last (third) paper in which he has fully elaborated his theory of the meaning of tics.[8]
Clark's conception of the meaning of tic movements and of the mental state characteristic of ticquers must be here given. Although not denying the basic neurotic constitution present in ticquers, Clark sums up by giving the following definite and fully developed theory:
"The ticquer has a strong sexual attachment; this is so strong that the love instinct ineffectually sublimates the hate instinct and in the warring conflict doubt and physical and psychic inadequacy arise. The situation continues and generates mental, and physical infantilism, which in turn
By these who have studied Freudism this will, in a way, be understood. For these who have not it may be more difficult of understanding without somewhat further elaboration or explanation. In this connection I must again mention that the Freudians include tics under their obsessive (obsessional) neuroses. The theory of the mental mechanisms and evolution of these states is given in the attached quotation, which is taken verbatim from Clark's paper.
"The affect of the painful idea does not become transformed into physical symptoms, as in the conversion mechanism of hysteria, but affixes itself to other ideas not in themselves unbearable, thus producing by this false relationship a substitutive symptom or obsession.
" . . . In all such obsessive neurotics the transformed reproaches which have escaped repressions are always connected with some pleasurably accomplished sexual act of childhood but may be almost entirely lost. The obsessive acts really represent the conflict between impulses of opposite instincts, love and hate, which are usually of equal value. The warring conflict engendered makes for a curiosity to discover the meaning of life forces (sexual largely) and the desire to know the end thereof. The nuclear-complex of all this is a precociousness of emotional life and an intensive fixation on one or the other parent or brother or sister. The intensive love fixation waxes the stronger as the unconscious hate requires increased barriers against its breaking through into the main or everyday personality. As a result
Clark then proceeds to explain:
"If one is not permitted to draw deductions from a few data as to the further genesis of the tic disorders, we may still hold out a tentative hypothesis, pieced together from many sources that a certain type of nervous make-up is inherited. In such the emotional life is precocious much beyond the intellectual faculties. The ticquer in infancy has the emotional feelings of love and hate of an adult. Their very precociousness aids the parental fixation and adhesion, and makes it the more difficult for the libido to detach itself at the proper age. One should bear in mind that the parental fixation in itself does not directly produce the mishaps of adult life but this small fault in infancy generates wider and wider maladaptations as development progresses. It is these latter glaring faults and trends that make for the character defects, and these really break down the final effort at adaptations and adjustments producing the tic or obsessive disorder. But the essential nucleus of the defect is lack of balance, precocious parental fixation, and continued attachment to the parent-stem, that makes the adult defect possible. The very infantile precociousness of the emotions argues for the hereditary transmission of destructive temperamental qualities. Here, as elsewhere in tracing hereditariness in so-called functional nervosities, one should take as the unit character for study the mental traits or trends and exclude definite disease entities applied to ancestral disorders. I believe it is not too suppositious to think that many of these variant individuals are really atavistic in makeup and have continued from one generation to
The writer cannot understand how the theory which he has taken the trouble to so fully present in the above quotations can be maintained. Jones and Clark both assert that the tics or habit spasms as probably of the same nature as the obsessions in general. Moreover, Jones agrees that "familiar examples of compulsion in a slight degree are the obsessive impulses to touch every other rail of an iron fence as one walks past, to step on the cracks between the flagstones of the pavement, or not to step on them, and so on." A little reflection will show us the impossibility and illogicality of viewing all these conditions as being fundamentally of sexual origin. Let us follow the argument. If tics are of sexual derivation, as the Freudians here openly maintain, then it must follow that those familiar examples of compulsion, such as the obsessive impulse to touch every other post, etc., are likewise of sexual origin. This conclusion is forced upon us, since, even according to Jones, the only difference between the marked tics and the lesser manifestations is one of degree.[9] Now, these slighter impulsive tendencies to which we have here referred are very frequent in all children and by no means infrequent in grown-ups. They are habitual movements, which may be of transient duration only or may, by repeated performance, develop into more or less fixed habits. If, then, these habits are of sexual significance, it must follow that all other habits, especially if associated with a certain degree of consciousness or awareness, are in like manner symbolical of the past infantile and early childhood sexual activities and tendencies. This conclusion is, as is seen, inevitable, if we believe in the Freudian theory of the pathogenesis of the tics. However, since this leads us to a reductio ad absurdum, we must, of course, reject the explanation which has been offered by the Freudian school.
Perhaps I should also mention the fact that all of these symptoms or tendencies which one finds in ticquers occur
Furthermore, tics occur in animals, especially in horses; and the whole picture, physical and mental, of tics in horses resembles that which we find in human beings, particularly idiots and imbeciles, with tics. And the ultimate, fundamental meaning and motive source of tics in man is and must be the same as that of tics in horses.
To put Clark's idea in a nut-shell, it may be said that he believes that the primary purpose of tics is not that of a protective, defense mechanism against unpleasant situations in life but that of obtaining really pleasurable gratifications to the psyche, these autopleasurable acts being based on inherent defects and having a sexual significance in the sense in which sexuality is conceived by Freud. The protective, defense mechanism is, according to this view, but secondary to the primary and
Although approving of the analytic and genetic tendency displayed by Freud, Clark and the Freudian school in general, it is regrettable to me that the analytic tendency and reconstructive efforts of the Freudians in the field of neurology and psychopathology have been seriously marred by their insistence on forcing all observed physical and psychical phenomena and reactions into line with their fixed sexual theories and their special psychology, which is basically wrong in many fundamental and important standpoints.
The writer will agree with the Freudians that there must be a cause for the appearance of these tics. This cause existed in the past. It has in the course of time been forgotten, but still exists somewhere in the subconsciousness or memory. This forgetting has been brought about by a process of dissociation from the original exciting cause. But the writer will not agree that this dissociation has been, of necessity, brought about by psychic repression on the part of the individual, that by psychoanalysis the condition can be traced back to the sexual activities or tendencies of infantile or early childhood origin, or that the condition may be cured when the original cause is made known to the patient through psychoanalysis, without the training of the will so necessary in this condition.
Thus the analytic tendency of the Freudian school is to be highly commended. But this analysis should not be limited to sexual analysis, but should include a consideration of all of man's instincts. Nor should the analysis be limited to present-life psychic factors alone, but should be viewed from a psychobiological standpoint. In this way only will all antecedent causative factors—physical and mental—be included in our analytic observation and speculation.
To fully discuss or to prove the error of Clark in his conclusions would necessarily lead me into a general discussion of Freudism, which I cannot do in this place, since the ramifications are too numerous and the problems involved would lead to lengthy and tiresome discussion, pro and con. I must, however, mention the exclusively sexual
Without further elaboration or discussion I am content to give the Freudian conception to you as I have outlined it above and to let it stand for what it is worth.
I may say that in the physical aspect of tics we have a specific somatic manifestation which, if explained, should, in a way, be the gateway toward the understanding of the many somatic symptoms which we find in the psychoneuroses and psychoses.
THE EVOLUTIONARY, PHYLOGENETIC STANDPOINT
A year or more before Clark's paper appeared, I had
G. Stanley Hall has arrived at similar conclusions in his inspiring Synthetic Genetic Study of Fear[11] and I wish here to acknowledge my indebtedness to his paper for making my own ideas clearer to me, for having given me broader standpoints and for clearly presenting a theory which shall form the basis of the remainder of this paper.
Let us first take up the tic movements and see whether we can arrive at a rational explanation for their appearance.
The different varieties of tic movements embrace the entire field or range of systematic, physiologically co-ordinated voluntary muscular activities.
The main types of tics may be enumerated at this point: facial tics, which are the most frequent and which may be tonic or clonic, are tics of mimicry and express emotions; tics of the ear or auditory tics; nictitation and vision tics, particularly of the eyelids; tics of sniffing; tics of sucking; tics of licking; tics of biting and of mastication, and mental trismus; tics of nodding, tossing, affirmation, negation, salutation and mental torticollis; trunk, arm and shoulder tics; snatching tics; the professional or occupational spasms, which are really a special atypical form of tics; walking and leaping tics; tics of spitting, swallowing, vomiting, eructation and wind sucking (aerophagia); tics of snoring, sniffing, blowing, whistling, coughing, sobbing, hiccoughing; tics of speech, including all sorts of sounds, stammering (in some cases), habit expressions, echolalia and echopraxia.
It is thus seen that we have here physiological and biological acts of different manifestations and purposes.
The tic movements have a certain significance at the time of their performance. The physiological functions are definite.
The Magnan school insisted that tics are not morbid entities but episodic syndromes of mental degeneration. Charcot referred to tic as a sort of hereditary aberration, which, I may add, is surely true when we view it from the
These authors were directing their efforts in the right direction. To appreciate this we need but remember that the mechanisms or the potentialities for the movements are inherited and have a phylogenetic significance. At a lower psychic level, far back in our phylogenetic racial history, all of these movements, perhaps then in a rudimentary form, had a single, original meaning. This meaning was self-preservation, and it was because of its value as a means of adaptation or reaction to the environment, with the consequent maintenance of self-preservation; that the movements or the mechanisms of the movements were selected for survival and for hereditary transmission as inherent, unconscious, organic mechanisms, processes or engrams. The original, phylogenetic significance attained at a low cultural or psychic level, relatively unconscious, may or may not later be consciously associated or dominate its subsequent functioning. But its primary, biological significance, its real raison d'etre is to be found in the phylogenetic, racial history of man. The present life history with its varied experiences do but act as stimuli or as exciting factors to bring once more into activity functions which have been preserved in the organic structure of the nervous system.
In our return to phylogenetic, ontogenetic, rudimentary, unconscious, organic reactions, to atavistic, prehistoric, performed, embryonic, immature methods of response, the vestigial remnants, revivals of long ago, which have been submerged but which now reappear due to our reversionary tendencies—uprooted by dissociation, disintegration or regression, with its lapse or descent to low cultural or psychic levels—these old components which reappear or rather fall apart and appear as independent activities, are exaggerated, inflated, caricatured or excessively performed. In our devolutionary tendency toward ancestral methods of reaction, the individual, resolved, so to speak, into his proximate elements, permits or is compelled by biological determinism
It seems to me that it is well worth while to quote at some length from G. Stanley Hall, that great exponent of genetic psychology and all that it stands for. His very stimulating and inspiring paper on fear, to which I have already referred, is freely quoted in the following paragraphs.
According to geneticism, Stanley Hall tells us, all responses to shock are vestiges of once useful reactions. In fact, the shock neuroses and shock psychoses, if analyzable psychogenetically, "would be found to be reversions to, and also perhaps more often than we suspect, magnifications of acts and psychic states that were at one time the fittest of which our forebears were capable.[12] However, all the pathological phenomena of today are not mere revivals of the acts and states of primitive man and his ancestors, but "they are often, on the other hand, grotesque variants and intensifications of phylogenetic originals that were more sane and simple if also more generic. Shock symptoms may thus be symbols of long past racial experiences which when we have learned to interpret them more fully will tell us much of the early history of our phylum."[13] It is the outbreaks of emotion which "mark the incursions of the race into the narrow life of the individual."[14]
Furthermore, "the central nervous system differs from all others in that it is par excellence the organ of registration and of physiological memory. It is there that the traces of ancestral experience are stored so that almost nothing that was ever essential in the development of the phylum is ever entirely lost. Hence suggestive as are many physical traits of our racial history, the intangible psychophysic traits
"While these faint tendencies often crop out in a behavioristic way, by far the most of them need some stimulus of individual experiences to awaken them, and still more exist only in the slight facilitization of impulses or permeability of nervous centres, lability of molecular or neural tensions, or as preferential re-enforcements, in one rather than in another direction or manner."[15]
It is obvious that motor expressions of shock or motor methods of adaptation or reaction are much older and far more prominent than psychic. But although a changed environment made the old types of defense obsolete, they still persist, "in a sthenic if somewhat now inco-ordinated way, and when they are called into action now they evoke a faint phosphorescence of the old primordial feeling."[16]
In brief it should be said that no matter how refined and how highly cultured we are, we still fear and react to emotions "in the same terms of the same old gross organs and functions as do the brutes."[17]
REGRESSION
As I have stated in a previous paper,[18] the pathogenesis of tics and allied conditions can best be appreciated by viewing the subject from an evolutionary standpoint. In our reactions and adaptations to the varying experiences with which we meet we respond by one or more of several methods of motor reaction. These motor expressions are of increasing complexity as we ascend the scale of evolution and development. One of the simplest kinds of adaptation is by simple, reflex muscular action, the response being anatomical and not physiological in its extent. Then come our simple physiological reactions. A more complex reaction is by those physiologically co-ordinated motor reactions or movements which go to comprise our pantomimic movements. This is seen most characteristically in our facial
In our motor adaptations we respond in one or more of these ways. When for some reason or another one outlet us denied us, we find avenues of expression through one or more of the other paths. Now, the manner and degree of our response is dependent on our stage in evolution and development, on the development of our senses, on our instincts, feelings and emotions, on our intellect and experiences. Unable to find expression by means of writing or speech, we instinctively fall back upon and seek expression by a less refined method, one earlier acquired and thus lower in the scale of evolution. This has a more or less general application throughout the scale of human (individual and social) conduct. It is an application of the universal law of adaptation to existing conditions in the best manner possible under the circumstances. We may thus lay down in a general sort of way a conception which I like to call the theory of psychophysical progression, fixation and regression along evolutionary and developmental lines. In the case of tics the regressive or devolutionary aspect comes in for special consideration. We may react mainly physically, or mainly psychically. But as a rule we react by both physical and psychic means, the manner and degree of our conduct being determined, as above mentioned, by our stage in evolution and development.
How does all this preliminary and general discussion apply to the problem of the tics? The relation seems to me to be most intimate and most important. The tics are methods of response or reaction to certain external irritations or ideas, this response being the manner of adaptation. The response may be mainly motor or mainly psychic, most frequently psychomotor. When the source of irritation and the cause for action is known, our conduct is more specific and is apt to be less diffuse, less inadequate, less indefinite.
When this irritation along a certain nerve path is oft repeated or quite constant, we have a consequent repetition of the defensive reaction, whatever it may be. This performance may be so frequently repeated that the idea of irritation or mental conflict or the anticipation or the expectation of a repetition of same may be quite sufficient in itself to arouse this reaction. It may become so habitual that, even though no such idea be in the mind, there may be a repetition of the movement whenever the individual is nervously excited or upset, whenever there is any mental stress, strain or discomfort. And we may go even further and say that as a result of some unusual mental struggle,
The psychic symptoms may come on at a later date than the motor symptoms or simultaneously, although, of course, the early life history, in childhood and puberty, for example, if we are dealing with an adult, may show, at least in a certain proportion of cases, that the individual was of a psychopathic type, perhaps somewhat shut-in or asocial. If the appearance of the psychical symptoms be simultaneous with that of the physical symptoms, we can understand at once how, like the motor symptoms, they may be repeated time and again. In many instances, at least, the psychic symptoms arise later, being added to the motor symptoms. These later psychic symptoms may be a direct reaction to the source of irritation, or may be occasioned by the dissatisfaction at being unable to control the movement in question.
The degree of reaction, its duration and severity, depend upon the hereditary and developmental make-up of the individual and the severity, frequency and duration of the
Where mental enfeeblement or mental disorder exist, the severity and chronicity are apt to be still greater.
There is thus a fixation, or rather a regression or reversion, oft repeated, to a type of reaction of a very infantile, primitive sort, farther down in the scale of evolution and development.
This picture may be further complicated by so-called neurasthenic, psychasthenic, hysterical or other reactions. Naturally one would expect to find these conditions, especially the more aggravated forms, in individuals of a neuropathic and psychopathic family strain, and who themselves are neuropathic or psychopathic or both.
It may be mentioned here, as is clearly appreciated from what has been said before, that there is an inter-relationship between the tics on the one hand and the symptoms which we discover in the psychoneuroses, psychoses and the mentally unstable on the other.
In all of these conditions we find a cortical origin for the disturbance, there is a lack of will power, of inhibition and of control of the lower centres, there is a nervous and mental instability with a tendency toward regression or dissociation, and the assumption of more or less independent, almost automatic activity, this activity being characterized by its almost (relatively) infantile, primitive, archaic makeup.
Were I to take up any one of the tics as an illustration, this general idea could be applied very nicely. But I shall not present any illustrative cases in this paper. I shall leave it to the reader, however, to explain the genesis and evolution of, for example, facial tics (which are so common) from this standpoint.
In passing I may say that the tic movements may have a special, individual, psychological significance. But this is by no means necessarily so. Frequently, I am inclined to believe usually, these movements result rather merely because there has been effected a psychobiological reaction, following the theory of psychophysical-progression, fixation
In the case of the tics, therefore, it is as if the various tic movements are being used in reaction to or in adaptation to sources of internal or external, physical or mental irritation, for the protection, defense or self-preservation of this or that particular part of the nervous system—as if the movements which we find in the tics and which are the expressions of certain engrams, neurograms, mnemes or organic memories, are existing in and for themselves, except that, in the tics, they are reacting with and for the psychophysical organism, the organic make-up or personality.
The individual, as a biological unit, is reacting to the particular situation which presents itself by the tic mechanism.
By granting the phylogenetic, racial significance we also give the basic, psychophysical meaning of tics in all ticquers.
EXCITING FACTORS
How is it that these activities may come into play again? What brings them to the surface once more?
There are many factors which come in for consideration in this connection. In the first place the basic cause is the instinctive, organic, psychophysical make-up of the individual. Whether and which functions re-exist as of old and respond as means of adaptation and self-preservation, depends on the stability and the weaknesses or defects of the nervous mechanism or system with its various parts, systems, functions or inherent psychophysical dispositions on the one hand, and the life-experiences and the immediate inciting factor on the other hand.
A neuropathic or psychopathic or neuropsychopathic constitution with its usual causes (germinal, intrauterine or extrauterine, usually of a toxic, infectious or disturbed metabolic nature, and including particularly alcohol, syphilis and nutritional disorders) may form the ground work. This predisposition may be congenital—that is, present from the date of birth, although not necessarily germinal in origin, or it may be acquired at some period in life from physical or
Tics may also be but the symbol for a vague feeling of tension, irritation or stimulation, which seeks relief or expression by the performance of the tic.
Emotional stress and strain, fright, fear, excitement and mental shock can arouse a tic. Mental conflict and unrest has not received that degree of attention which it surely deserves. Clark and the Freudian school have definitely called our attention to this aspect. Bresler refers to tic as a
That there is a weakness of will power in the ticquer, with a lack of control or inhibition over the lower neurones normally regulated by the higher co-ordinating centres, so that certain automatic activities become dissociated and exist more or less independently, is generally acknowledged.
In fact it must be said that tics are reactions of the organism, of the organic make-up, the psychophysical personality, as a response to irritation, excitation or stimulation, sensory, nervous or psychic! It is a means of relief of tension, of organic reaction or adaptation, not necessarily conscious but frequently unconscious and automatic, as in fear. Starting in this way it may persist. In the tic we see a method by which the individual or organic personality has met a certain difficult or undesirable or disturbing situation. It is thus a constitutional, biological defense reaction, psychophysical in nature, with a reversionary tendency (when viewed from the evolutionary standpoint), and hence is indicative of degeneration, this term being used in the racial, biological, phylogenetic and ontogenetic sense.
There is not such a far cry from the simplest tic to Gilles de la Tourette's disease or maladie des tics with its more pronounced signs of psychophysical deterioration and dissociation. The tendency is a degenerative one—a prolapse to ancestral methods of reaction, a dissociation or disintegration of the personality, a lack of control over more elementary activities. We should therefore appreciate the need of early recognition and treatment of tics and fixed habit movements, especially since there is a tendency to spread, for the tics to multiply, and for mental symptoms and reactions of a hysterical and psychasthenic nature to
In brief, then, tics represent the emotional reactions and feelings of the individual—the loves and the hates, the likes and the dislikes, the wishes and the fears, the cravings and the dissatisfactions, the bodily and mental tension, unrest, excitement, discomfort and disequilibration. In other words the ticquer feels and speaks and acts by the tic. He lives by, in and for his tic. He is attempting to meet certain situations of a disturbing nature and to obtain equilibrium and equipoise by compensating for his feelings of inefficiency and unrest by the tics. It is an organic, constitutional, psychophysical, biological means of adaptation.
PROGRESSIVE EVOLUTION OF THE CONDITION
We now come to the progressive evolution of the motor manifestations and to the mental aspect of this condition.
Concerning the mental state characteristic of the ticquer it is generally agreed that there is a polymorphic psychic defect or disorder which shows itself particularly in a precocious or hyperemotional condition, in a lack of will power and of inhibitory control, leading to a state and feeling of doubt, indecision, incapacity, insufficiency and unreality, of inferiority and self-depreciation, with a tendency towards morbid self-absorption, egocentricity, self-observation, auto-and hetero-suggestion, with the consequent development in many instances of so-called neurasthenic, psychasthenic, hysteric and various psychotic reactions. I am not prepared to say definitely how frequently the mental state, in lessened degree, precedes the outbreak of the tic movements. This may be present in a certain proportion of cases, but is by no means always present and it is even questionable whether the predispositional mental condition is the ground work in the majority of patients.
Tics, it is true, are especially apt to develop in individuals with a neuropathic or psychopathic history or heredity. In other cases this history is not obtainable, the individual having been apparently perfectly normal up to the time of the outcropping of the tic. In these cases shock is apt to
Be that as it may, or even granting that in most patients the characteristic mental state or the neuropathic or psychopathic make-up exists in some measure to an abnormal extent, we do know that once the tic movements have made their appearance and begin to spread, so that the individual is thrown into the struggle to perform or not to perform the movement, the development of the psychic state which we find so patent in the more pronounced forms of tic, thereafter more or less rapidly occurs, no matter what the mental condition of the ticquer may have been previously. I am also not prepared to discuss here at any length the phylogenetic or ontogenetic significance and the biological genesis and meaning of the various mental trends of the ticquer, but I may say that they too have been acquired in the course of evolution, for certain very definite reasons which need not concern us here, although it can be appreciated that the biological motive of self-preservation played a most important role in their genesis and fixation.
APPLICATION OF ADLER'S THEORY OF THE NEUROTIC TO TICS
The progressive spreading of the tic movement which so commonly occurs, as well as the evolution of the mental aspect which develops subsequent to the appearance of the tic movement, may be very nicely understood if we adopt,
One should note that Meige and Feindel were, in a way, on the threshold of this theory when they said that tic, like the other psychoneuroses, is due to some congenital anomaly, an arrest or defect in the development of cortical or subcortical association paths—unrecognized teratological malformations.
In a very few words Adler's theory may be given as follows: Adler assumes that there is definite somatic inferiority (based on anatomical and physiological changes) as the basis or foundation for the neurotic soil. The neurotic consciously comes to realize the unconscious, organic, somatic inferiority, and the endeavor to effect a psychic compensation or to make up for these organic deficiencies by certain definite mechanisms, frequently results in an overreaction or over-compensation. He thus overdoes himself in efforts to make up for his inferiority, and in these endeavors he necessarily makes use of unusual means and devices. It is this effort which is the great motive force which dominates the life activities of the individual and which compels him to seek as his ultimate object or final goal a state which is best described as one of complete masculinity, of full manhood, of self-maximization, of the will to live, to become powerful and to seek supremacy or "the will to power" (Nietzsche). In following this goal he goes to extremes and employs peculiar methods and devices, most of which have for their object the concealment of his defects, and it is these overcompensatory efforts and these peculiar devices resorted to, which go to form the peculiarities or traits of the neurotic. According to Adler's theory, the conscious efforts of the individual for psychic compensation or overcompensation (for the unconscious, organic deficiencies) leads to a resulting feeling of insufficiency, of incompleteness, of inferiority, of unreality,
Without discussing the exact status of this theory in the case of the psychoneuroses and their related conditions in general, we may, as mentioned previously, very conveniently use this theory in the elucidation and understanding of the further development of the tic condition.
Let us first consider the spreading of the tic movements. We know how in the ticquer one tic movement may disappear only to give way to another, or one after the other an increased number of tic movements and also of definite compensatory movements not of a tic nature but of the nature of antagonistic gestures and stratagems may make their appearance. The latter may in certain instances become habit movements and eventually real tic movements. One movement after the other may be resorted to, some perfectly consciously, others more or less unconsciously, as reactions of the personality, of the organic makeup or psychophysical constitution. These movements are adopted by the patient, frequently more or less unconsciously, in order to attain a state of equilibrium and rest, and in order to hide and make up for the defect (the tic movements) of which he is aware. In these efforts he overdoes himself and instead of hiding the movement he exaggerates it and even resorts to further movements in his struggles to compensate, to adapt, to conceal,
Now, most of our gross reactions are of a psychophysical nature, so that we find that when the old types of defense or of activity are called forth (as they are in the tics, as explained earlier in this paper, from the evolutionary and phylogenetic standpoint), the resulting actions, now reanimified, appear in exaggerated form, and also tend to "evoke a faint phosphorescence of the old primordial feeling." This probably results in the outcropping of the various psychic trends which appear in the ticquer and which increase in degree and in number. The most common of the resurrected psychic trends is the general tendency to dissociation or disruption of the personality with the reanimification, in varying degrees, of certain mental deficiencies and inferior types of reaction which are indicative of the relative failure of the patient to measure up to and efficiently deal with and adapt to the struggles of life as he must face and meet them. And so, many undesirable and inferior kinds of mental trends come forth and hold sway. The basis of their appearance is the lack of will power and of control over these various trends which were previously more or less completely held under control but which are now impulsively forcing their way to the surface and being unravelled. These trends are characterized by their relative immaturity, their infantile-like and archaic type. And so we have the states of indecision, of doubt, of uncertainty, of inferiority, of depression, of unrest, of self-depreciation, of self-observation, of auto and heterosuggestion, of egocentricity, of self-criticism, of inhibition of the expression of the personality along the broader, social lines of effort. The groundwork for added states (hysteric, psychasthenic, and others) is here very fertile.
The law of psychic ambivalence and ambitendency, as so nicely developed by Bleuler,[21] here shows itself in marked degree. There is both the positive and the negative tendency toward the performance and execution of these activities and reactions which are necessary for the living of a life
The entire mental picture which we find in the most extreme forms of tic could be beautifully elaborated along these general lines. For example, the ticquer becomes asocial, seclusive and shuns society because of the consciousness of the condition and the exaggerated sensitiveness. This represents compensatory, defensive methods of concealment. Absentmindedness and the inability to concentrate the attention are conditioned by the great degree of attention devoted to the tic. The mental dissociation or disintegration leads to an inflating of the emotional aspect of the patient's mental life with a resulting increased nervous irritability and reaction and a heightened degree of susceptibility to emotional disequilibration and fatiguability of the mental faculties. The lack of self-assertion, of confidence in himself, and the feeling of inferiority and insufficiency are natural consequences of the general picture. The inhibition of even, unhampered self-expression is always observed.
In tics, it must be noted, there is regression to more inefficient and inferior methods of response and adaptation, the types of activity being of a somatic and psychic nature. Following the regression and owing to constant repetition and habit formation there is a gradual fixation to certain methods of response which become the lines of least resistance and this is followed by progression and development of the general picture to other tics and psychic symptoms.
In general we note that the psychophysical reaction which we come upon in the tics leads to the unearthing of various psychophysical types of reaction, this unearthing consisting of disintegration or regression or dissociation, the repressed, hidden, unconscious, phylo and ontogenetic, archaic and relatively infantile-like activities, tendencies and possibilities coming to the fore and unfolding themselves.
It is here seen that this broad genetic standpoint is one of the greatest contributions to psychopathology and is of
Comparative and animal psychology and the study of the reactions of children, of primitive races, and of the mentally disordered give us a splendid opportunity for studying it and unravelling the meaning of the many somatic and psychic manifestations which are exhibited to us in the psychoneuroses and psychoses and in tracing out the racial history of man. Is it not plain that an understanding of the genesis and meaning of tics opens the gateway to the elucidation of the origin and significance of the psychoneuroses and functional psychoses—of reaction types of various kinds?
Tics and their treatment. English translation by S. A. K. Wilson. New York, 1907. This book contains an extended bibliography.
Soc. de Neur. de Paris, April 18, 1901, quoted by Meige and Feindel, page 54, of the English translation (reference 1).
See his article on "The Treatment of the Psychoneuroses," White and Jelliffe's Modern Treatment of Nervous and Mental Diseases, Vol I, pp. 408-409.
His three papers, which appeared in the Medical Record, New York, in the issues of February 7 and 8, and March 8 1914, are entitled: (1) "Some Observations upon the Etiology of Mental Torticollis," (2) "A Further Study upon Mental Torticollis as a Psychoneurosis," and (3) "Remarks upon Mental Infantilism in the Tic Neurosis." A fourth paper by Clark on tics appeared in the Medical Record of January 30, 1915.
The accompanying mental state characteristic of ticquers is absent in habits. We can stop doing the latter when our attention is directed to them; not so in tics Meige and Feindel have discussed these and other differences.
A Critical Review of the Conception of Sexuality Assumed by the Freudian School. Medical Record, March 27, 1915.
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