Tics and Their Treatment Part 6

TIC AND WILL.

It might be imagined that a tic would cease to exist as such were a voluntary element to enter into its const.i.tution. The fact, however, that tic is the sequel to frequent repet.i.tion of a primarily voluntary act, and that it may be arrested, transformed, or aborted, is proof to the contrary of which there is no gainsaying.

The truth is, once a tic is established, it has all the appearance of an involuntary movement, but that nevertheless its manifestations may be either modified or inhibited by an effort of the will is patent from clinical observation. This is a fact of great importance.

Spasm knows no control (says Brissaud). Nothing will arrest the bolus of food as it pa.s.ses into the pharynx, unless by the inversion of the whole function of deglut.i.tion.... As regards tic, however, inhibition is possible because the phenomenon is cortical.

In almost every case, reinforcement of the will can momentarily at least check it.

Consensus of opinion admits diminution of will power to be the cardinal mental symptom of the tic patient. Inhibitory insufficiency, as Blocq and Onanoff say, allows the persistence of fixed ideas of movement which reveal themselves by involuntary acts. Noir has admirably supplemented the researches of Ribot in this direction:

The infant's activity is purely reflex, and manifested by a profusion of movements, to suppress or restrain the majority of which is the task of education. It is highly probable that any co-ordinated tic whose evolution can be traced at all has its origin in the infant's spontaneous muscular play. From this point of view the frequency of these movements in idiots is readily explicable, since their intellectual development never gets beyond the stage of childhood. The more confirmed the idiocy and the more rudimentary their mind, the more p.r.o.ne are their tics to be complex and inveterate.

These remarks are pertinent to the case not only of idiots, imbeciles, or backward children, but of all the subjects of tic. In them some degree of mental infantilism is of invariable occurrence. The tic patient has the weak and capricious will of the child; young or old, he does not know how to _will_; if his willing be sometimes excessive, it is never resolute. Were it otherwise, he might control his meaningless gestures, but his efforts are both feeble and ephemeral.

TIC AND HABIT

The view which regards tic as a "pathological muscular habit" provides emphatic ill.u.s.tration of the sinister influence of volitional infirmity.

This aspect of the question is of deep significance. If we define a habit, in the words of Littre, as a "disposition acquired by the repet.i.tion of the same acts," we can easily conceive how intimate is the relation between habit and automatism, and how constant rehearsal of the same movement in the same manner will create a mode of motor reaction independent of the function of the will. It has been made clear already that the phenomena of tic, regarded from the motor standpoint, reveal an identical process at work; but the fundamental difference between the habits of normal individuals and those of tic subjects is that the former can be checked or modified by voluntary effort, whereas the latter gradually acquire the pathological features of tenacity and irresistibility.

In a typical case of tic (says Dupre)[14] the establishment of a reflex sensorimotor diastaltic arc, via the cortex, between peripheral stimuli of whatever nature and corresponding muscular reaction, is a sign that predisposition has changed the physiological to the pathological, and transformed a habit into a tic.

Guinon argues, however, that tic ought not to be cited in the catalogue of diseases, since it is ultimately a deep-rooted "bad habit" only, not a pathological fact.

We are not prepared to maintain, of course, that all motor "bad habits"

are tics, for a whole host of familiar gestures, tricks, and mannerisms do not merit the name, superfluous and even detestable though they may be. It is true they are the product of education, and become, since the will has less and less to do with their appearing, at the last purely automatic; they may thus developmentally bear a close resemblance to tics. As Letulle says:

The infant who is constantly sucking its thumb, the individual who never ceases picking his teeth, or rubbing his eyes, or lips, or chin, or ear, who is for ever scratching his head or his beard--all have no doubt, originally, been driven to the repet.i.tion of the trick by some real necessity in the shape of dental caries, or ciliary blepharitis, or pityriasis capitis; but removal of the cause is not followed by cessation of the gesture. A man will learn the habit of perpetually smoothing his hair, and will not desist from his favourite trick though he become absolutely bald.

But such automatic habits and mannerisms are not genuine tics so long as the movement executed conserves in form the characters of a normal gesture. Be it never so inopportune or absurd, it is not a tic. It comes rather under the heading of _stereotyped acts_, whose kinship with, and difference from, the tics, have been well demonstrated by Seglas.

While the stereotyped act has all the appearance of a normal movement, the tic, on the contrary, is a "corrupt" muscular contraction; its subject is irresistibly impelled to its performance, and any attempt at repression is painful, sometimes even agonising. Victory is perhaps not entirely impossible, but any arrest is, as a rule, only temporary, and entails suffering which well deserves to be considered pathological.

On the other hand, the thousand illogical and absurd mannerisms of which we have been speaking betray no irresistible imperiousness in their execution, and require no agonising struggle for their repression. They are not tics. The crucial point in the differential diagnosis is the presence or absence of mental suffering.

The distinction may be further elaborated. Concentration of the attention may diminish the intensity or even inhibit the occurrence of a tic; inversely, a simple bad habit is manifested preferably during this very concentration. In the heat of physical or intellectual labour, we have all our favourite and characteristic tricks: we curl our moustache, we twist our beard, we scratch our forehead, we rub our chin, we nod our head, we fidget with our fingers in reading, speaking, reciting--in any mental or physical exercise requiring our attention we reveal innumerable little oddities of movement; but let our thoughts be directed for an instant to these gestures of distraction, and they disappear forthwith, to reappear afresh when we are absorbed in our work again. Charcot used to twist his hair round his index finger so intricately that to disentangle the finger one day a lock of hair had actually to be cut off. It was a trick of his, not a tic.

In the case of the latter, leisure of mind and body is the signal for the apparition of the inopportune movements. Any form of effort demanding the attention will, as a general rule, lessen their frequency or abolish them altogether.

Trousseau quotes the case of a young girl afflicted with severe tic who could play through any piece on the piano without the slightest interruption. Guinon similarly has known cases, one of whom could juggle accurately with knives, and another whose infirmity did not prevent her from taking a successful part in operatic ballet. Young L. is pa.s.sionately fond of dancing, but he never tics in the ballroom. O. is an excellent amateur billiard player and never handicapped by his tic when playing, or, for that matter, when fishing or fencing; but if his attention be not thus absorbed, it is only with the utmost difficulty that he can master his tic.

We all have met the young man who cannot strike a ball at tennis without protruding his tongue at the same moment; his partner bites his lips at any difficult stroke. At other times neither betrays the slightest grimace; neither is conscious of any effort in maintaining repose. The occurrence of these movements during active concentration of the attention, and the absence of either difficulty or distress in checking them, justify their cla.s.sification as stereotyped acts, in subjects psychically normal.

Tic is a pathological habit, to use Brissaud's phrase, and its description as a habit disease is in harmony with the facts. We must expect, of course, to meet every intermediate variety between the bad habit and the true tic, but this need not deter us from drawing the above-noted distinction, the application of which will be found not without value in the great majority of instances.

TIC AND IDEA

As we have already seen, a peripheral stimulus may originate a cortical reflex whose expression is a motor reaction, or the reaction may take place where the stimulus is entirely cortical; in other words, an idea may be the starting-point of a movement which may in its turn degenerate into a tic. All that has been already said of these phenomena is applicable to this movement of ideational origin. It too will be transformed into a tic when it is repeated without exciting cause and for no definite end, when its reiteration becomes imperious and irresistible, its suppression accompanied with malaise and its execution with relief.

Tics of this sort are numerous enough. "To think an act," as Charcot used to say, following Herbert Spencer and Bain, "is already to accomplish it. When we think of the movement, say of extension of the hand, we have already sketched it in our minds; and, should the idea be too strong, we execute it."

In this connection Gra.s.set most appropriately cites the fact that the peoples of mid-France evince a peculiar apt.i.tude for mimicking by suitable gesture the various ideas which occur in the course of conversation. "You will always succeed," he says, "with the following little experiment. In a drawing-room ask ten individuals consecutively to tell you what a rattle (_crecelle_) is. The answer will in every case be accompanied by a gesture expressive of an object that turns. To think an act is already to perform it; the thought and the gesture are wellnigh inseparable."

The truth of this observation is not a question of geography. Examples are met with on every hand. It is a law, abundant evidence for which is furnished by all who tic. But however exuberant be accompanying movements of explanation, they must present the additional features of inappositeness and irresistibility to be denominated tics.

A case that has come under our own notice is worth mentioning because of its peculiarity and instructiveness. The patient was an artistic, well-educated, and well-travelled man, gifted to a remarkable degree with the faculty of a.s.similation. Apart from genuine tics in the shape of sudden jerks of face, arm, or leg, he had acquired the trick of accompanying his conversation with a peculiar mimicry of its content.

Not satisfied with providing a gesture for nearly every word, he divided the words themselves into syllables for each of which he had an appropriate action, whence arose a series of mimicry puns of most unexpected effect.

For instance, during the enunciation of the following sentence, "We were on a paddle steamer, with captain, commissaire, and doctor," he first of all imitated the movement of paddles; he then put his hand, with three fingers apart, to his forehead (the captain's cap has three lace bands); to mimic the word commissaire he shook hands with himself (_commissaire_--_comme il serre_); to express the word doctor he pretended to touch imaginary b.r.e.a.s.t.s on his body (_medecin_--_mes deux seins_); and so on throughout all his conversation.

Voluntary execution of these puns had been succeeded by complete automatism, yet they were not tics, because, however singular the mimicry, it was appropriate; whereas his facial grimaces, the shrugging of his shoulders, the tapping of his heels, repeated every minute for no reason or purpose, were real tics.

If, when asked what a rattle is, we make a turning movement with our hand, or if when asked to explain the word _brandebourg_ we indicate an imaginary arrangement of braid on our coat--these two experiments always succeed--we are attempting to express an idea by mimicry at the actual moment of its arising in the mind; but the subject of a tic--which may primarily have been the representation by mimicry of an idea--continues the gesture long after the idea which provoked it has vanished.

A woman speaking with animation at a telephone will make with face or hand a thousand useless gestures, useless since her friend cannot see them, but they are not tics, even though they may be justly described as functional, automatic, superfluous, and inopportune. If we are normally const.i.tuted, we betray a pleasant idea by a smile, we express our conviction by an appropriate gesture of affirmation; if we smile or gesticulate with no motive for doing either, we have begun to tic. It is not sufficient that the act be untimely at the moment of execution; we must be persuaded that it no longer stands in any relation to the idea which called it forth at the first, and that its repet.i.tion is excessive, its inappositeness constant, its performance urgent, and its inhibition transient, before we can say it is a tic.

Should the cortex be functioning harmoniously, afferent impulse and efferent reaction stand in due proportion one to the other; but any disturbance of psychical equilibrium--_e.g._ the fixity of some idea combined with inhibitory weakness--will effect a corresponding disturbance on the motor side. Charcot used to speak of tics of the mind revealing themselves by tics of the body. Fear may elicit a movement of defence, to persist as a tic after the exciting cause has vanished.

It is of course quite incorrect to say that each and every motor reaction to a pathological idea is a tic. The psychasthenic who in his fear of draughts shakes the door-k.n.o.b a hundred times a day to make sure the door is shut, is not a martyr to tic; in spite of the absurdity of his action, it is logically connected with the idea that originated it, and it is the idea which is absurd. To make an involuntary movement of defence against some purely imaginary ill, on the other hand, and to continue when all fear is past, is to tic.

In practice it may not always be a simple matter to uphold the distinction, but some such demarcation of the tic's limits is called for if we are to avoid its being applied to any act performed under the compulsion of a pathological mental state.

In its mildest form the mental trouble may consist of an ordinary psych.o.m.otor hallucination, but if it be not projected as an objective phenomenon it does not deserve to be called a tic. One of Seglas's patients met a ch.o.r.eic woman undergoing electrical treatment in the same room as herself; on leaving she felt as though her own right arm were the seat of spasmodic movements similar to those of the ch.o.r.eic patient, but as they did not betray themselves by any external sign they cannot be considered tics.

The exteriorisation of the hallucinatory phenomenon suffices at once to bring it within the scope of our definition. Innumerable tics arise in this way, provoked, mayhap, by some or other insignificant psych.o.m.otor hallucination. The att.i.tude adopted by certain patients, as remarked by Seglas, is an index to the nature and seat of their hallucinations. Some keep their tongue firmly bitten between the teeth; others cram their mouth with pebbles, or compress their epigastrium tightly, under the impression that it is the source of their voice. Should such gestures persist while the hallucination does not, they may give rise to what we are in the habit of calling "tonic tics," or "tics of att.i.tude," but we must repeat that the presence of a convulsive element is essential; however out of place or absurd the contractions are, if otherwise they are normal we are dealing with what Seglas designates stereotyped acts.

To this question we shall return later.

TIC AND CONSCIOUSNESS

According to Guinon, proof that "convulsive" tic is conscious is furnished by the accurate description and rational explanation patients supply of their affliction. Similarly Letulle's "co-ordinated" tic is a conscious act, at least in its commencement; it is a "bad habit" which finally pa.s.ses beyond the limit of consciousness.

Now, while no doubt most subjects show a keen appreciation of their tic when their attention is directed to it, they are none the less unconscious of it at the moment of its manifestation. This is the ground on which Letulle bases his statement that all tics, of whatsoever variety, are habitually outside the domain of consciousness. To this fact so much importance has been attached that the attempt has been made, more especially by Blocq and Onanoff,[15] to differentiate the conscious from the unconscious tic.

In our opinion, the distinction is ambiguous and tends needlessly to complicate our ideas on the subject. The patient with "convulsive" tic is conscious of it in the sense that he is well aware of its existence, yet how can the gesture be a conscious one if it is synchronous with mental preoccupation? On the other hand, the patient with "co-ordinated"

tic may bite his lips unconsciously, but he is by no means ignorant of his little failing.

This divergence of opinion depends entirely on the possibility of regarding the phenomena at different moments during their production.

The subject is in a position to appreciate his state both before and after the tic, not during it. In a sense it may be said that tic is alternately conscious and unconscious, in which respect it is comparable to the obsession; the close a.n.a.logy between the two conditions we shall indicate more fully later. As a matter of fact, the same holds true for every variety of spasm.

We are not disposed to introduce here a term sacred to the psychologist and to speak of the tic as subconscious. Pierre Janet does not admit the absolute unconsciousness of habit; even when the latter has degenerated into a tic, it is not outwith the realm of consciousness. We prefer not to venture, however, into the perilous region of the subconscious, in spite of our appreciation of the happy results attributable to its careful and discerning exploration by observers such as Janet himself.

According to Cruchet, certain so-called psychical tics are always subliminal--for instance, the imitation tics common in children and in idiots.

But if the consciousness of the normal adult be, as it admittedly is, a most elusive conception to define, how infinitely more precarious is the task in the case of idiots or infants! Cruchet says it is impossible to be sure whether at any given moment a tic has been above the threshold of consciousness or not; and we do not think the question will be elucidated by the introduction of data so difficult to comprehend as the consciousness, unconsciousness, or subconsciousness of the tic patient.

In any case, these conceptions are quite inadequate for the establishment of useful distinctions. All that we can say is that the partic.i.p.ation of consciousness in the phenomena of tic varies in time and degree. To hazard farther would be to invite disaster.