Psychotherapy Part 67

Besides these facial and throat tics any of the voluntary muscles of the body may be affected. There may be the gestures that accompany certain mental states, or there may be twisting or turning movements as if the patient were in an awkward position and wanted to get out of it, or as if the clothes were hampering movement and there was an effort to relieve some discomfort. The head may be lifted and lowered, or may be twisted from one side to the other and, indeed, various nodding tics are extremely common. Almost any ordinary movement may, in nervous people, come to be repeated so frequently as to be a tic.

Practically all of the convulsive or quasi-convulsive movements a.s.sociated with respiration are likely to become the subject of tics.

Yawning, for instance, involuntary to some degree, usually a reflex with a physical cause, but so readily the subject of imitation, may become so frequent as to be repeated a couple of times a minute and this repet.i.tion kept up for many days. Sneezing may also become a tic, though it is usually a definite reflex due to palpable physical causes. Hiccoughs may easily become the subject of a tic. The occurrence of a persistent hiccough is in popular medicine a sign of unfavorable prognosis in serious diseases, especially such as involve the abdominal region. In connection with neurotic affections of the abdomen, however, hiccoughs are not uncommon and are of no serious significance.

Varieties of Tics.--There are many more tics than are ordinarily supposed. Indeed, there are few of us who escape them entirely. Nearly all the curious phrases that people interlard so frequently into their conversation, usually quite unconscious of them, or of the ridiculous significance they often have, must be placed under the tics. Some men cannot say a dozen words without interpolating "don't you know."

Others use some such expression as "in that way." I once knew a distinguished professor of elocution who by actual count used this phrase forty times in an hour. Some say "hum" or "hem" every sentence or so. Whenever there is a bit of obscurity in their thought these voluntary but unconscious expressions are sure to pop out. No one who has had much experience in public speaking ever succeeds in keeping entirely out of such bad habits. It is curious how phrases will insist on repeating {566} themselves. One year one set of words, or a pet phrase, or mode of expression, creeps unconsciously here and there into an address. Then either because the speaker has been reading dictated copy, or because some good friend has the courage to tell him of it, he finds out the bad habit and suppresses it.

Word formulas senselessly repeated are only one of many forms of tics that public speakers are p.r.o.ne to indulge in. Gesture which begins as an artificial adornment of speech, very appropriate in itself, after a while may settle down into certain forms that not only often lack elegance but that are really disturbing to an audience. Of these gestures and movements men are often quite unconscious. They have become habitual and in the absorption of mind with the thought and the words, they are reproduced quite involuntarily though they are all originally voluntary movements. Nearly every public speaker needs a mentor to correct him of such faults. It is rather difficult to break some of these habits and it requires no little concentration of effort and attention to be successful in eradicating them. It can be done, however, provided the habit is not too inveterate, and this is the best evidence that tics of other kinds can also be eradicated if the patient really takes the matter in hand and is not of a weakened will.

_Teachers' Habits_.--Indeed it is almost impossible for public speakers and teachers not to acquire certain habits irritating to their auditors at first but amusing as they grow used to them, and students particularly learn to look kindly at the ridiculous side of many of them. I remember an old professor of literature who used to lecture at some length on each of the important contributors to English prose and poetry. We soon observed that whenever he came to their deaths he took out his handkerchief and blew his nose. This was as inevitable and as invariable a rule as the laws of the Medes and the Persians. It was, as it were, his tribute of sympathetic condolence with humanity for the loss of a brilliant contributor to English literature.

Occasionally the effort to break up these habits will seriously interfere with modes of thought and habits of expression, for the time being at least. A professor at a certain university had a habit every now and then of plucking at a b.u.t.ton on his coat. His students could tell when his hand was going to find this object of its occupation and knew from experience that he would twist it a certain number of times.

He was not what would ordinarily be called a nervous person. One day he happened to take off his coat shortly before a lecture and one of the students surrept.i.tiously removed the b.u.t.ton. At the end of the first few minutes of his lecture his hand went up to find the b.u.t.ton as usual but failed. For the moment there was a hesitancy in his speech; then he tried again. A little later his hand went up unconsciously and was disappointed; then he stammered and lost the thread of his discourse. The last half hour of that lecture was seriously impaired because of the absence of that b.u.t.ton.

_Tricks of Speech_.--There are many other curious tricks of speech that are really tics. Women often indulge in them and sometimes even pretty women spoil their appearance by bad habits. All of us know the pretty woman who talks very fast, but who every now and then projects her tongue a little beyond her teeth. Occasionally there is a tendency to wrinkle the nose or the forehead. Most of us have seen the woman who sets her face into a definite smile of a particular kind whenever her company manners are in {567} use, though there is a vacancy behind the smile that is rather disturbing. Some people have habitual movements of the fingers that are really tics, and even positions a.s.sumed on sitting down that are very ungraceful, or that are very noticeable, sometimes partake of this character.

_Fussiness_.--A very common form of tic that is quite difficult to control is that tendency to be doing something with some of their muscles which characterizes many men. They must handle a pencil or a knife, or they must swing on their chair or tilt back on it, or keep one of their limbs swinging over the other, or twirl their moustaches or stroke their beards, or rumple their hair, and they cannot find it quite possible to sit still. The difference between men and women in this regard is remarkable. Women are conceded to be much more nervous than men, but men are ever so much more fidgety than women. The author of "The Life of a Prig" in his book "The Plat.i.tudes of a Pessimist"

has some striking paragraphs with regard to this subject. He says:

To look nearer home, the British bar affords splendid examples of nervous fidget. Observe barristers pleading a cause. How they torture a piece of red-tape, how they twirl their eye-gla.s.ses or spectacles, and how they hitch at their garments, as if they momentarily expected them to desert their finely proportioned figures. But worse than the Queen's Counsellors, and even worse than the domestic peripatetic, is the villain who is abandoned to a performance vulgarly known as "the devil's tattoo"--drumming with the fingers.

_Writers' Tics_.--Writers, and above all writers for the daily press and such as have to do their writing in a rush and therefore get nervous and anxious about it, are especially p.r.o.ne to develop tics, though others who write leisurely may do so. Some of these are curious and others are only expressions of nervousness common to all people.

Many of them chew their nails, some of them bite at their fingers round the nails and make them sore, many of them chew the ends of their pens and find it practically impossible to keep a pen with a long handle to it. Some of them run their hands through their hair until it is in a greatly rumpled condition, some of them pluck at their eyebrows. I have one patient who when he is going through a particular nervous strain plucks out the middle portion of his right eyebrow so that he has a distinct bald spot at this point.

The tradition in newspaper offices is that these curious expressions of the tendency of the body to occupy itself with something while the mind is occupied are more or less inevitable in nervous people. They continue for many, many years. They are only habits, however, that it would have been rather easy to break in the beginning, though they become extremely difficult to modify after they have once secured a firm hold. Occasionally I have fastened a piece of adhesive plaster over a much battered eyebrow, but that made it difficult for the man to go on with his work. His hand would go up involuntarily time after time and while plucking at his eyebrow would not disturb in the slightest his train of thought, just as soon as his fingers touched the unusual object a serious distraction occurred and work was not only slower, but much more difficult.

_In Games_.--The tendency to the formation of curious habits of a.s.sociated movements can be seen very well in most games where skill is combined {568} to a certain degree with chance. It is most noticeable, perhaps, in bowling. Few men are able to restrain themselves from making some special movement just as the ball strikes the pin. This is sometimes a motion of the head, oftener it is a jerk of the trunk, sometimes it is an a.s.sociated movement of the arms, occasionally it is a kick or a stamp. In billiards the same movements are noticeable if a man is much interested in making a difficult shot.

Usually there is some movement of the body or of the hands or of the head that would indicate his desire to move the ball in a particular direction. Women who play these games do not usually have these a.s.sociated movements to such a marked degree and this may be due either to their better restraint to movement in general, for as we have said men do not acquire the habit of self-restraint in small matters of deportment as women do, or to the fact that such a.s.sociated movements might disarrange their clothes. Perhaps, also, they are not as much interested in the games as a rule as are the men. Of course, similar a.s.sociated movements may be seen in outdoor sports that require skill yet have an element of chance in them. For it is, as it were, to overcome this that the additional movement is made.

_Children's Tics_.--Some tics consist of some very curious habits.

Occasionally children hear some obscene or vulgar expression and repeat it. The repet.i.tion of it produces such a look of shock to propriety on the part of some of the other little ones who happen to be present that they repeat it in the spirit of bravado and then continue to utter it until it becomes a habit that is hard for them to break. After all, the use of blasphemy later on in life is really a tic, a habit of uttering words no longer expressive of any particular feeling, as a rule, unless in exceptional circ.u.mstances but just the result of a tendency for the speech organs to repeat certain words.

They tell a good story of the Rev. Sydney Smith who, wishing to break an acquaintance of the habit of indulging in expletives, interlarded his speech with "fire tongs and sugar tongs" every ten words or so and when his auditor protested that that added nothing to the significance of what he said the Rev. Sidney suggested that that was also true of various blasphemous expressions that his acquaintance was accustomed to use.

At the Salpetriere they tell the story of a little boy who had the habit of saying the French word which the corporal in Victor Hugo's "Les Miserables" made use of when anyone told him that it was because Wellington was a greater general than Napoleon that the French Emperor was defeated at Waterloo. Nothing seemed to be able to break the boy of the habit of interjecting this word into conversations sometimes in which he had no part and sometimes toward which he was expected to take only a respectful and childlike att.i.tude of silence. He was sent to the Salpetriere. The ordinary remedies had failed entirely. One day he was allowed to go outside of the hospital, or rather stole out of the gate and played marbles with some street gamins in front of it.

During the game he used the word in question and they proceeded to give him a good thrashing. It is Charcot who tells that this broke him effectually of the habit.

One of the childish customs that sometimes disturbs parents very much because it seems to be such an unaccountable lapse into barbarism, though it is really nothing more than a tic in the strict sense of the word, is the habit that some children acquire of removing portions of hardened material {569} from their nose and then putting it into their month. Refined parents are apt to be so seriously disturbed by this that they fear for the child's mentality. Really the habit is not nearly so rare as is usually thought by some grown-ups who have forgotten about their own and others' childhood. In country places the habit is very common. It is not alone the dull children who do it but some very bright ones. Indeed, the tendency to the habit is so common that one wonders whether there is not something in nature that tempts to it. Parents who are fearful lest their children may be seriously hurt in health by the awfully insanitary habit may be rea.s.sured that after all a certain amount of the drainage of the nose is normally carried off through the posterior nares to the stomach and that no danger to health seems ever to have resulted from the practice. As a rule, the habit can be broken rather easily by a little judicious care and insistence, though I know of cases where relapses occurred and the habit continued surrept.i.tiously.

_Motor Tics_.--Motor tics frequently develop as a consequence of some injury to a nerve or some intense overuse of it. Winking habits follow an herpetic involvement of the superior branch of the fifth nerve.

Bell's palsy is sometimes followed in the face by a tendency to twitching on the unaffected side that makes the patient quite uncomfortable. Herpes zoster is sometimes followed by a catching of the breath, probably due to a little spasm in the muscles supplied by the nerve thus affected. Some of the yawning tics have this origin.

Any neuritis may in the course of its betterment be followed by this curious tendency to explosion along the nerve that has been affected, as if the pathological process had more seriously interfered with inhibition than with the actual function of the nerve. Examples of over-exertion followed by twitchings are not rare. A scrubwoman who has seen better days and now has to carry a heavy bucket and use her right hand much with the brush may develop a twitching of the right arm. A janitor's wife who sweeps much may have a tendency to twitchings of the fingers as a consequence of the unusual exertion of holding the broom. Twitchings in the limbs of men who work at a foot lathe or other machine requiring foot power are not unusual though they are more often seen in the leg on which the workman habitually stands than in the other one and it seems to be oftener a strain on muscles than actual over-exercise that precedes the development of these tics.

Heredity.--Heredity plays as large a role in tics as it does in stuttering and other functional nervous disturbances. Occasionally the direct inheritance of some habit will be found, though there is nearly always more than a suspicion that a trick of speech or of act, which const.i.tutes the tic, was learned by imitation rather than transferred directly. Besides, it is a case of a similarly const.i.tuted nervous system reacting in the same way to a similar environment, rather than any definite tendency existing by heredity in the nervous system. It is surprising what close observers children are and how easily they learn to imitate any habitual action of father or mother or, for that matter, of nurses or those who are close to them.

Mental Treatment.--The most important element in the psychotherapy of tics is their prophylaxis. They run in families, not by any inevitable hereditary influence, but as a consequence partly of imitation and of corresponding tendencies resulting from certain weaknesses in the family. Wherever they are known to be likely to occur, parents should be warned of the {570} possibility and the first symptom of any motor habit should be considered the beginning of a tic. As we have said, they are likely to begin in muscles that have been overstrained for any reason, especially when patients are run down. They are often seen after herpes and certain facial neuralgias.

There is probably no tic, no matter how long or how serious, that can not be eradicated, or greatly modified, if the patient will take the trouble and if the treatment is conducted so as gradually to get rid of it. Peculiar movements cannot be done away with at once. They can be lessened in intensity and in frequency and then gradually the patient will be encouraged by their becoming less noticeable than before to make renewed efforts. The habit must be gradually undone and this will take as long as it did to form it originally. The exercise of contrary muscular movements carefully carried out, and of gentle repression with definite times of exercise during the day, gradually increasing the length of the intervals of repression, in the end proves successful. Only a determined struggle will effect a cure. It depends on the patient's will. Like a drug addiction, or a tendency to overeat, or a craving for alcohol, it must be gradually overcome and then care must be exercised to prevent relapses; for when the condition is somewhat better, to relax vigilance and give up effort will allow the old condition to rea.s.sert itself with startling rapidity. People suffering from severe tics will often give up.

Without the patient's hearty co-operation cure is impossible. With good will its gradual diminution gives the patient a confidence in self and an uplift in character that is extremely valuable, not only for physical but for mental conditions.

CHAPTER IV

STUTTERING, ATAXIA IN TALKING, WALKING, WRITING, ETC.

The difficulty of speech called stuttering has usually been considered rather as an unfortunate lack of control over the organs of articulation, somewhat corresponding to muscular awkwardness of any other kind, than as a pathological condition deserving the physician's attention. If anything was done for it formally, the first effort of the parents or the teacher was to correct the supposed bad habits and this failing the affection was relegated to someone who claimed to produce wonderful results by some special method. Perhaps, even oftener, stuttering was considered one of those affections, fortunately decreasing in number, that the child may be expected to outgrow. Often there was noted an hereditary element which was supposed to indicate incurability.

Stuttering deserves special treatment in a work on psychotherapy because it ill.u.s.trates very strikingly one phase at least of mental influence over bodily function. While in the study of the etiology of the disease much has been made of anatomical features, nerves and muscles and anatomical anomalies of the speech organs and the respiratory tract, the sufferers from stuttering are certainly quite up to the average both in the physiology and anatomy of these regions.

They are of all ranks and conditions of life, of all sizes and build, and it is evident that the trouble is not physical, but mental. They {571} pay too much attention to their speech and to the co-ordination of the many muscles engaged in speech production and the consequence is that they impair their power to use these organs. Practically all the cures recommended contain some element which distracts the attention from the speech to something else and so permits the function of the speech organs to proceed undisturbed.

A number of conditions develop in nervous individuals that resemble stuttering. There are disturbances of swallowing, disturbances of walking (astasia abasia), neurotic disturbances of writing, and of other uses of the hands and of the legs.

State of Mind.--It is perfectly clear to anyone who has closely observed the ways of stutterers that the state of mind is extremely important in these cases and indeed probably const.i.tutes the underlying factor in the speech disturbance. Stuttering and all speech defects are much worse when the patient is laboring under excitement.

This is so amusingly true that the impotence of a stutterer to say a word when he wants very much to say it is a commonplace in the cheap drama and never fails to raise a laugh. In ordinary conversation with friends the stutterer may have little difficulty. As soon, however, as he begins to talk with those with whom he is unfamiliar his speech defect becomes noticeable. When the others present are entire strangers and, above all, strangers whom he wishes to impress favorably, then his stuttering becomes p.r.o.nounced. The mental element is the most important factor. Just as soon as consciousness of the task supervenes his power of co-ordination fails and stuttering begins.

Stuttering in Complex Activities.--There are many actions that become habitual and people are thus saved from the necessity of constantly performing them under the control of the will and the consciousness.

Walking is a typical ill.u.s.tration of this and is seldom disturbed by consciousness, but there may be a stuttering in the gait of sensitive persons if they become overconscious when pa.s.sing people who are watching them. Talking is even a more striking example of elaborate co-ordination without conscious effort. We have to bring into play more than a score of muscles whose movements are nicely and accurately co-ordinated, or else the effort at articulate speech is a failure. We have to change the positions of most of these muscles many times every minute, yet we do it without a thought of how it is done and most of us accomplish it with ease and perfection.

_Stuttering Walk_.--Stuttering, after all, comes most naturally under the head of dreads in the cla.s.sification of the psychoses. Stuttering is not a physical difficulty so much as a nervous apprehension, and there may be a stuttering in any co-ordination as in speech. I have a patient under observation who, if people are looking at her, finds so much difficulty in walking because of a trembling that comes over her that she fears she may not be able to keep from falling. Boys at school whistle a certain air that requires a little halt in the gait to keep time with it, as their schoolgirl friends go by, and it is impossible for these not to drop into the peculiar gait indicated by the time of the tune.

_Stuttering Writing_.--There are many men who become so nervous about writing their signatures that they cannot sign while anyone is present. There are others whose penmanship becomes very irregular, or at least exhibits many signs of nervousness, whenever they think someone is watching them. Most of {572} the difficulties seen in speech may, indeed, be exhibited in writing. The same difficulty in beginning, the same elision of letters under stress of excitement, may occur.

Writer's cramp is, after all, much more of the nature of a stuttering in writing than a real cramp. Over-action, added motions, and, finally, incomplete power to act as desired are seen in both cases. It might be expected that this would not affect so simple and familiar a set of motions as those required for a personal signature, but it does, as many cases ill.u.s.trate. A typical example was the treasurer of a large trust company who had to sign a number of bonds, some thirty thousand. At the rate of 200 an hour, over three a minute, as he did the first day with others making it easy for him, it looked as though he could complete the task, huge as it was, in a month. At the end of a week, however, the rate had fallen to 120 an hour and, toward the end of the second week, one a minute on the average was all that could be accomplished. At the end of the month his signature, while retaining certain of its original characteristics, had become very different from what it was at the beginning and signing had become an extremely difficult matter. He had to take a rest from business for several weeks after accomplishing this apparently mechanical procedure.

Emotional Ataxia.--Dr. S. Weir Mitch.e.l.l in his article on "Motor Ataxia from Emotion" in the May number (1910) of _The Journal of Nervous and Mental Disease_, discusses some cases in which inability to write even a signature came as a consequence of nervousness and emotional disturbance.

In one of Dr. Mitch.e.l.l's patients, other manifestations of ataxia occurred as the result of the consciousness that people were watching the patient. At times he is compelled to leave a dinner table, since with strangers it is almost impossible for him to eat. If there are two or three at the table with him, however, and especially if he is worried about himself, he may become almost helpless, requiring both hands to get a cup of coffee or a gla.s.s of water to his mouth. A patient of mine with like symptoms has described to me equivalents of various kinds to his own difficulties in his sisters. One of them cannot play the piano before strangers, though an excellent musician.

The other cannot crochet with any success if any but intimate friends are present. How much of this family trait is due to suggestion or psychic contagion would be hard to say. The state that comes over amateur actors and which makes them forget their lines, stammer in their speech, walk awkwardly, and trip easily, are really manifestations of this same incapacity to control even familiar sets of actions when there is great self-consciousness and over-attention.

Mental Influence.--The correction of these conditions comes through soothing the mind of the patient and getting him or her not to be so self-conscious as to disturb action by thought about it. It is easy to say this and extremely difficult to do it. In certain nervous organizations it is quite impossible to overcome the tendency to this ataxia or inco-ordination of voluntary movements. Much can be accomplished, however, by proper training and discipline in all cases, and, while the patient can never be completely cured, great improvement may be brought about by patient habituation under favorable circ.u.mstances. In Dr. Mitch.e.l.l's cases the taking of a gla.s.s of whiskey or of wine sometimes stimulated the patient so that co-ordination became possible where it was impossible before. In nearly all cases of writer's cramp {573} and writing difficulties the power to write is restored for a time by such stimulation. Strong coffee will sometimes serve the purpose as well as alcohol. It is easy to understand, however, how dangerous is the resort to such stimulation.