• Email
  • Single Page
  • Print

Tics

This is an aspect of “stimulus-bound behavior,” except here the stimuli are internal, the patient’s own fancies and thoughts. It may be difficult for such patients (as for volatile postencephalitics) to achieve so-called free association—that is, association seemingly random, which in fact circumscribes dominant affects and themes. “Free association” may not work with such patients, for their associations may be so loosely and superficially connected and determined as to have no real center or implicit theme. When I sent a tape of such a patient to the Russian neuropsychologist A. R. Luria, he compared it to “mental Brownian motion,” and to the ever-changing images and associations of his “Mnemonist” (Luria, 1968)9 :

There were many instances in which images that came to the surface in his mind steered him away from the subject of a conversation. At such moments his remarks would be cluttered with details and irrelevancies; he would become verbose, digress endlessly, and finally have to strain to get back to the subject of the conversation.

Is this not almost identical with Meige and Feindel’s description of their loquacious ticqueur? Thoughtless reaction, superficial association, overcharged (yet “factitious”) affects and images, lie in wait, seductive, for the unwary ticqueur.

My own patient “Witty Ticcy Ray” felt there was a close analogy between his wit and his tics. He spoke of his “ticcy witticisms” and “witty ticcicisms,” feeling both as expressions of the sudden, unexpected swerves and twists, the irruptions and interruptions, in his mental and motor stream. Similarly, when playing ping-pong, he would make (in his own words) “sudden, nervous, frivolous shots”—shots so frivolous, so unexpected, as to be completely unanswerable. And with music too: he was a weekend jazz drummer of real virtuosity, known for his sudden and wild extemporizations, which would arise from a tic or a compulsive hitting of a drum and would instantly be made the nucleus of a wild and wonderful improvisation, so that the “sudden intruder” would be turned to brilliant advantage. Thus the Touretter (as O. also intimates) may be active, not passive, in relation to his Tourette’s, and turn it into exhibition and performance. Whether this should be seen as the ego mastering, colluding with, or deferring to disease remains a tantalizing ambiguity.

These fragments show something of the extraordinariness and complexity of Tourette’s, how it is inseparably both physical and mental. And yet, as I intimated earlier, there have been the most persistent efforts, in this century, to “physicalize” or “mentalize” it, to make it one or the other, when it is so manifestly both. Charcot and his pupils were among the last of their profession with a combined vision of body and soul, “It” and “I,” neurology and psychiatry. By the turn of the century a split had occurred, into a soulless neurology and a bodiless psychology, and with this any full understanding of Tourette’s disappeared. The natural history, the clinical naturalism, of the last century has disappeared, a victim, paradoxically, of our advances in knowledge and thought, a physiological and psychiatric sophistication that was new to the world.

Meige and Feindel, writing in 1902, had probably not heard of Freud, and yet, as we see, some aspects of Tourette’s syndrome, at least in its “higher” forms, and in the most severe cases, have a strongly and unmistakably Freudian quality. Indeed, psychoanalytic formulations of tic and Tourette’s syndrome dominated thinking on the subject from the seminal work of Ferenczi in the early 1920s to the late 1950s, the formulations of Margaret Mahler (see Mahler, 1949) being particularly important. One cannot doubt the relevance and power of Mahler’s thought—in particular her conceptions of a “motor ego.”10 But the patients she analyzed showed little change in their Tourette’s, the inevitable consequence of seeing the disease as purely psychiatric and neglecting its neurological determinants. Many children, too many, with Tourette’s were diagnosed as “psychiatric” during this forty-year period, and submitted to penetrating but ultimately fruitless attempts at psychotherapy.

This, doubtless, was one factor in the demise of the psychogenic approach, the rise of our knowledge about neurotransmitters being the other. When dopamine deficiency in Parkinsonism was discovered in 1959, dopamine excess was at once suspected in Tourette’s, and trial of antidopaminergic agents made within a year. “The effect of the haloperidol treatment administered at this time [November 1960] was absolutely spectacular,” J.-N. Seignot wrote in 1976, adding, “The theory held by many psychiatrists, and in particular by many psychoanalysts…would seem to be contradicted by this experiment.” This precipitated an abrupt (and perhaps excessive) reaction against psychological formulations, and an emphasis on exclusively chemical formulations and therapies, which have (on the whole) dominated approaches to Tourette’s syndrome since the mid-1960s.

And, with this, there has been a loss of phenomenological fullness, of attention to the total experience and world of the Touretter. Tics have been classified, or reclassified, as “movement disorders,” to be ranked with dyskinesias, dystonias, myoclonus, chorea. Not that tics may not (as in postencephalitic patients) coexist with these, or, indeed, emerge or evolve from these. But the one thing which is crucial about tics—the sense of compulsion and intention that drives them, the idea or “content” that informs them—has been forgotten again. And as for the peculiar mental Tourettism of Tourette’s—the loose, rapidly changing associations and fancies, so beautifully described by Meige and Feindel, and present to some degree, or at times, in all Touretters—this now tends to be completely ignored. Thus, if one may say this without disrespect, the ninety-odd papers presented at the First International Tourette Symposium in 1981, while presenting a vast amount of new and exciting information, gave no feel whatever of what it was like to have Tourette’s. I remember this vividly, for I went with a Touretter friend, and he said, “I don’t know what they’re talking about, they’re not talking about me. They don’t put across what Tourette’s is really like.”

What Tourette’s is really like—this has been forgotten, and we can only recapture it if we listen minutely to our patients, and observe them, everything about them, with a comprehensive eye; or go back, as I have done here, to the older descriptions, where verisimilitude has not been sacrificed to narrow formulations or theories. But, clearly, we cannot merely go back. We need the new knowledge and concepts of our own time; we need, equally, to recover the full realism of a past time; we need, above all, somehow to combine the two.

I encountered precisely this phenomenon when I came to explore my first realm in medicine, migraine, and concluded that the present century had been characterized by both advances and retrogressions, a real gain of knowledge coupled with a real loss in general understanding.

Some very beautiful words, which go to the heart of what I am saying, were spoken by William James in remembering his old teacher Agassiz. Agassiz was a naturalist, not a theorist or abstractionist—“the hours I spent with him,” writes James, “so taught me the difference between all possible abstractionists and all livers in the light of the world’s concrete fullness, that I have never been able to forget it.” But already, in Agassiz’s own lifetime, his mode of mind, naturalism, was becoming obsolete:

In the fifty years that have sped since he arrived here [James is writing in 1896]…our knowledge of Nature has penetrated into joints and recesses which his vision never pierced. The causal elements and not the totals are what we are now most passionately concerned to understand; and naked and poverty-stricken enough do the stripped-out elements and forces occasionally appear to us to be. But the truth of things is after all their living fullness, and some day, from a more commanding point of view than was possible to anyone in his generation, our descendants, enriched with all the spoils of our analytic investigations, will get round again to that higher and simpler way of looking at Nature.

When Freud came to give his lectures at Clark University in Massachusetts, he was met by the aged and ailing William James. And James said to him, “Yours is the psychology of the future.” I find here an echo of his words on Agassiz, his sense that analytical investigations, if they are of the right kind, will not only lay out the workings of the world, but will enhance, restore the sense of its fullness. This, indeed, is precisely what Freud does—at least in his marvelous case histories. And this too is what Luria does, in his marvelous histories—above all in The Mind of a Mnemonist (see my earlier note). And this is what we have to do with Tourette’s—make use of the methods and models of the masters. What we need is to go beyond a naturalistic description—or picture, as we are given by Meige and Feindel—to a dynamic, analytical description combining the neurodynamic and the psychodynamic, the neuroanalytic and the psychoanalytic, such as Luria and Freud together might give us. Only by doing so, or so it seems to me, can we preserve the seemingly anarchic fullness of Tourette’s but also go beyond this and make sense of it all.

Recently, when I was exploring, as minutely but also as generally as I could, a remarkable patient with the severest Tourette’s, I kept three books on my bedside table—The Interpretation of Dreams, Wit and the Unconscious, and The Mind of a Mnemonist. In Tourette’s of ultimate severity, there are not only convulsions of Mnemonist-like perception and imagery, and of inner (often “Freudian”) passions and impulses, but instant exhibitions of these in tic and sign form. Thus the external and the internal, the perceptual and the instinctual, all ticcishly transformed, burst forth in a sort of visible, public, phantasmagoria or dream. This can show us, as nothing else can, not only the surface stream of consciousness, but the deeper, unconscious associations, drives, images—the entire but normally hidden, “inner life”—of the patient. These externalized dream flashes and ticcy figments, of which dozens may occur in the course of a second, being largely beyond the power of the unaided senses to register or analyze, require high-speed videotaping, with slowmotion playback and analysis of individual frames, to reveal their full character, connection, and meaning.11 Given this, Tourette’s can make possible a veritable microscopy of mind, such as Freud and Luria dreamed of but never saw.

I have come full circle, and will conclude where I started. Neuropsychiatry is an old term which needs a new meaning. This new meaning has to do with the dynamics, the activities, of brain-mind—unlike biological psychiatry and behavioral neurology, which are static, diagrammatic—phrenology in new clothes.

A genuine, deep understanding of Tourette’s, perhaps the most striking neuropsychiatric syndrome of all, depends on such a neuropsychiatry. And such a neuropsychiatry, in turn, can validate itself by elucidating Tourette’s; such an elucidation, such a validation, are now perhaps within sight. I think that we will recapture and fully understand, in the 1980s, what Tourette half-guessed, half-hinted at, when he discovered his syndrome in the 1880s.

That it should take a century to do this is not surprising,12 for we are here in realms as complex and difficult as any in physics; but, more to the point, history takes its time, must pass through stages, cannot be hurried. The three-staged movement envisaged by William James—from naive naturalism, through analysis, to a “higher and simpler way”—would tend to take, he thought, a century or so. So, really, the timing is right, the time is ripe, for the full illumination of Tourette’s by a new neuropsychiatry.

  1. 9

    The “Mnemonist,” studied in such detail by Luria, had tremendously enhanced, though unselective, powers of imagery and memory—so that any stimulus, inner or outer, was apt to lead to a veritable explosion of imagery. The Mnemonist, partly controlling, partly controlled by, the compelling force of his imagery, found it difficult to lead a normal, “non-Mnemonist” life. There are striking resemblances to Tourette’s here, not only in the existential conflict between automatism and autonomy (or, as Luria put it, between an “It” and an “I”), but in their peculiar and specific neurodynamics, with very rapid, uninhibited, unselective associative neural processes in both—expressed in the Mnemonist solely as sensory imagery, but in the Touretter, additionally, as “motor images,” behaviors, enactments, or tics.

  2. 10

    Margaret Mahler’s life work centered on the exploration of ego development, the delineation of factors and circumstances—both interpersonal and intrapsychic—which might facilitate or retard its development. She observed, rightly, that with tics there might be fixation of, or regression to, a rather primitive ego level (or “motor ego”); but she attributed this wholly to repressed aggression, thus taking insufficient account of the organic factors influencing ego development, of which Tourette’s—with its ego-alien tics and impulsions—is so notable an example.

  3. 11

    Precisely such techniques are required to “crack” sign language, and were used by Edward S. Klima and Ursula Bellugi to show its hidden and unconscious character and grammar (see their book The Signs of Language, Harvard University Press, 1979).

  4. 12

    But a genius may be a century ahead of his time—thus Nietzsche, in his final (1888) notes on “Physiology and Art,” made some astounding comments which apply equally (or better) to Tourette’s: “Physiological states that are in the artist as it were moulded into a ‘personality.’

    …The extreme sharpness of certain senses, so they understand a quite different sign language—and create one—the condition that seems to be a part of many nervous disorders—; extreme mobility, that turns into an extreme urge to communicate…a need to get rid of oneself, as it were, through signs and gestures…an explosive condition. One must think of this condition as a compulsion and urge to get rid of the exuberance of inner tension through muscular activity and movements of all kinds; then as an involuntary coordination between this movement and the processes within (images, thoughts, desires)—as a kind of automatism of the whole muscular system impelled by strong stimuli from within—; inability to prevent reaction; the system of inhibitions suspended, as it were.

    …The compulsion to imitate: an extreme irritability through which a given example becomes contagious—a state is divined on the basis of signs, and immediately enacted—An image, rising up within, immediately turns into a movement of the limbs…” etc. (The Will to Power, translated by Walter Kaufmann, Vintage, 1968, section 811, March–June 1888, p. 428).

  • Email
  • Single Page
  • Print