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Tics

Etude sur une affection nerveuse caracterisée par de l’incoordination motrice accompagnée d’echolalie et de copralalie”

by Georges Gilles de la Tourette
Arch. Neurol. Vol. 9, (Paris, 1885)

Gilles de la Tourette on Tourette Syndrome”

by C.G. Goetz, by H.L. Klawans. in Arnold J. Friedhoff and Thomas N. Chase, eds., Advances in Neurology, Vol. 35 (1982): Gilles de la Tourette Syndrome
Raven Press, 454 pp., $63.00

Postencephalitic Respiratory Disorders

by Smith Ely Jelliffe
Nervous and Mental Disease Publishing Company (Washington, DC, 1927, out of print)

Psychopathology of Forced Movements and the Oculogyric Crises of Lethargic Encephalitis

by Smith Ely Jelliffe
Nervous and Mental Disease Publishing Company (Washington, DC, 1932, out of print)

Tics and Related Disorders

by A.J Lees
Churchill Livingstone (New York, 1985), 276 pp., $45.00

Psychoanalytic Evaluation of Tic in Psychopathology of Children”

by Margaret S. Mahler. in Psychoanalytic Study of the Child
International University Press (New York, 1949, out of print)

Tics and Their Treatment

by H. Meige, by E. Feindel. translated and edited by S.A.K. Wilson from 1902 original
William Wood and Co. (1907, out of print)

Limbic Innervation of the Striatum”

by Walle J.H. Nauta. in Arnold J. Freidhoff and Thomas N. Chase, eds. Advances in Neurology, Vol. 35: Gilles de la Tourette Syndrome

Awakenings

by Oliver Sacks
Dutton (1983), 338 pp., $8.95 (paper)

Acquired Tourettism in Adult Life”

by Oliver Sacks. in Arnold J. Friedhoff and Thomas N. Chase, eds., Advances in Neurology, Vol. 35: Gilles de la Tourette Syndrome

The Possessed”

in The Man Who Mistook His Wife for a Hat and OtherClinical Tales
Harper & Row, 243 pp., $7.95 (paper)

Witty Ticcy Ray”

in The Man Who Mistook His Wife for a Hat and Other Clinical Tales

A Case of Gilles de la Tourette’s Disease After 10 Years’ Treatment with Haloperidol (R.1625)”

by Jean-N. Seignot. in F.S. Abuzzahab and F.O. Anderson, eds., Gilles de la Tourette’s Syndrome: Vol. 1, International Registry
Mason Publishing Co. (St. Paul, 1976)

1.

I want to edge into my subject indirectly and personally, by recalling my own education as a neurologist, and how this served—or failed to serve—me in later years, when I encountered the realities of various syndromes and afflictions, in particular encephalitis lethargica and Tourette’s syndrome,1 a syndrome of multiple convulsive tics. As a resident in neurology, I “rotated” through psychiatry, just as psychiatric residents “rotated” through neurology. These short rotations did nothing for us in terms of bringing about any unity of the two. One gained a little extraneous psychiatric knowledge, or a little extraneous neurological knowledge, but no real sense that the two were, or could be, related. I even think it encouraged, rather than prevented, some dissociation between neurological and psychiatric orientations, between body and mind, a dissociation which common experience, life itself, contradicts at every point.

When I emerged from residency to encounter the full reality of patients, I often found I had to be as much a psychiatrist as a neurologist. I felt this strongly when seeing patients with migraine, whose moods and feelings, attitudes and perceptions, could alter pari passu with their neurophysiologies: these patients showed me the absolute continuity of body and mind. But it was another affliction that was my real education, my education, that is, as a neuropsychiatrist. This was the lethargic encephalitis, the great sleeping sickness that affected nearly 5 million between 1918 and 1927. The moment of truth, or revelation, or “conversion” for me was when I encountered some eighty-odd postencephalitic patients at a hospital in New York. These patients had a myriad of disorders both “neurologic” and “psychiatric”: Parkinsonism, myoclonus, chorea, tics, strange compulsions, phobias, obsessions, gusts of passion. A “pure” neurologist or a “pure” psychiatrist with such patients would be utterly lost. The neurological, the psychiatric, had to be conjoined. One had to be as observant and knowledgeable about the psychological, the psychodynamic, as about the physiological, the neurodynamic.

What I found for myself here was no more than a repetition of what had been found in the 1920s, when the epidemic encephalitis burst upon the world. And of all the pioneer observers of that time, I found Smith Ely Jelliffe and his writings the most penetrating and the most faithful to experience. Jelliffe was both a neurologist and an analyst,2 equally “Sherringtonian” and “Freudian” in outlook, as indeed one has to be if one is to observe such patients, for they are equally Sherringtonian and Freudian. Thus Jelliffe felt impelled to write in 1927:

In the monumental strides made by neuropsychiatry in the past ten years, no single advance has approached in importance that made through the study of epidemic encephalitis…. An entirely new orientation has been made imperative.

This “new orientation” of which Jelliffe spoke, and of which he himself was a notable exemplar, did not involve merely combining neurological and psychiatric knowledge (as every neurologist and psychiatrist does to some extent), but conjoining them, seeing them as inseparable, seeing how psychiatric phenomena might emerge from the physiological, or how, conversely, they might be transformed into it—and, thus, how both approaches had to be used, together, if one were to understand oculogyric crises, respiratory disorders, tics. Thus, although the respiratory disorders could in part be explained as the consequence of excitatory lesions in the respiratory systems of the upper and lower brain stem, they had also to be seen as “respiratory behavior.” This “new orientation,” it must be stressed, was thus something quite beyond the “old” neuropsychiatry, and also, to my mind, quite different from what we now call behavioral neurology or biological psychiatry (though both of these also stemmed from the experience with post-encephalitic patients, from the observation of dramatic behavioral disorders with a clear organic basis). And the difference lies in a sense of process, the dynamics, both neural and psychic, of the disorders.

When I gave my postencephalitic patients L-dopa they “awakened,” and their “awakenings” were simultaneously physical and mental: motor, intellectual, perceptual, affective, all at once and inseparably (see my Awakenings, 1983). I have to say that such a total awakening or animation was in contradiction to our concepts of neuroanatomy at the time (1969), a neuroanatomy that (as Professor Nauta has reminded us) was essentially compartmentalized in character, seeing the motor, the intellectual, and the affective in quite separate and noncommunicating compartments of the brain. The anatomist in me, subservient to this notion, said, “This can’t be. Such an ‘awakening’ should not happen”—but clearly it was happening, and common experience, furthermore, said it should. After some conflict, I deferred to my experience, and saw and described these awakenings as global, even though this meant abjuring various anatomical and physiological suppositions. Sooner or later, I thought, anatomy would catch up to reality.

One of the great delights of the last two decades is to have been present at a creative revolution, to have seen just such a “new” anatomy (and new orientation) emerge at the hands of Nauta and others. He has shown us, in innumerable ways, how the motor and affective and intellective parts of the brain are inseparably entwined and integrated at every point, so that, though separate, they act as a unity. I bring up this point because all of us who first saw the effects of L-dopa found ourselves in a situation of conflict, and many of us dealt with this by distorting or reducing or denying our own experience. We spoke of the motor effects of L-dopa as the effects and anything else (if we admitted it at all) as incidental, adventitious, mere “side” effects, neurologizing them, so to speak, out of existence.

But we could not perceive these “awakenings” in their totality without a neuropsychiatric, or Jelliffian, perspective. And if this was so for the initial “awakening,” how much more so was it of the later effects, the excitation not merely of motor excesses, but of perceptual, intellectual, and affective excesses. Parkinsonism itself is not “purely” motor; there is, for example, in many akinetic patients a corresponding “stickiness” of mind or bradyphrenia, the thought stream as slow and sluggish as the motor stream. The thought stream, the stream of consciousness, speeded up in these patients with L-dopa, often speeding too far, into a veritable tachyphrenia, with thoughts and associations almost too fast to follow. Again, there is not merely motor but perceptual inertia in Parkinsonism: a perspective drawing of a cube or a staircase, for example, which the normal mind perceives first this way and then that, in alternating perceptual configurations or hypotheses, may be absolutely frozen in one configuration for the Parkinsonian patient; it will unfreeze as he “awakens” and may then trust in the opposite direction, with a near delirium of perceptual hypotheses alternating many times a second. Again there may be, at least in postencephalitic patients, an apathy as profound as the lack or impoverishment of movement. This too is reversed by L-dopa, and they may then be thrust into the other direction, into a state of heightened, excessive, and (so to speak) convulsive emotion.

This amplification, often sudden and convulsive, affecting motor, intellectual, perceptual, and affective life, might produce a peculiar hyperanimation, very similar to that of Tourette’s syndrome. It was indeed in such a context, with these overenergized, overcathected patients, that I first saw and spoke of “Tourettism,” two years before I actually saw a patient with Tourette’s syndrome. (See my “Acquired Tourettism in Adult Life,” 1982.) I need to stress that this was my own path to Tourette’s syndrome—it was, from the start, a neuropsychiatric path, brought about by observation of postencephalitic patients and syndromes. Thus I was neither tempted to “neurologize” nor “psychiatrize” Tourette’s, tendencies which have been all too common in this century.

2.

Tourette’s syndrome was described a century ago by Georges Gilles de la Tourette, a singularly imaginative and gifted pupil of Charcot, like his contemporaries Babinski and Freud. The atmosphere around Charcot and of Paris at that time was one of rare imaginativeness and excitement—an atmosphere in which natural history, clinical naturalism, flourished as it had never done before, and in a most heightened, and sometimes dramatic, form. Such an atmosphere was a prerequisite for the perception and delineation of such a syndrome. The compartmentalizing and conceptualizing characteristic of medicine today had only just started on their huge and arduous journey, and a free and untrammeled (at times almost novelistic) naturalism was still open to the clinical minds of the time. If Tourette, like so many of the superspecialists of our own time, had thought narrowly in terms of “motor disorders,” he could have described the movements but nothing else of what we now call Tourette’s syndrome.

Fortunately, he was able to describe the echolalia, the coprolalia, the imitations, the impulsions, all of the complex “mental” aspects of the syndrome. He described it, in short, as a neuropsychiatric syndrome, although no such portentous word would have occurred to him in this context. He simply considered himself a clinical naturalist, describing whatever he saw with an open, unbiased, undivided fullness. Tourette sketched the outlines of his syndrome; others were to add detail, flesh it out. Tourette made it possible to see the syndrome, by first seeing it—there always has to be someone who sees something first, and thereby makes it possible for everyone else to see what they had failed to see before. Following his description in 1885, new cases were seen and described by the score, often with a wonderful richness beyond anything that had hitherto existed in clinical medicine, and that was all too soon to vanish completely.

This was a time when medical descriptions were full of a precision, delicacy, and (not least) humor, a time when naturalism (or what we now call phenomenology) had not yet collapsed under the advances of science. It was, by the same token, a time in which patients and physicians still spoke the same language—and thus it was possible for both to collaborate, producing between them a perfect balance of description and comment. I want here to quote from one of the finest examples of such a collaboration I know, the anonymous “Confessions of a Ticqueur,” interlarded with the comments of his physicians, H. Meige and E. Feindel (1907). The ticqueur, O., introduces himself—at least, the tic or Tourette part of himself (we can judge later how deeply, and in what ways, this is related to, or has interacted with, his “real,” or non-Tourette, self):

I have always been conscious of a predilection for imitation.3 A curious gesture or bizarre attitude affected by anyone was the immediate signal for an attempt on my part at its reproduction, and is still. Similarly with words or phrases, pronunciation or intonation, I was quick to mimic any peculiarity.

When I was thirteen years old I remember seeing a man with a droll grimace of eyes and mouth, and from that moment I gave myself no respite until I could imitate it accurately…. For several months I kept repeating the old gentleman’s grimace involuntarily. I had, in short, begun to tic.

Many other tics had such a historical origin or precipitation, given, of course, the constitutional predilection. O.’s physicians, who, as naturalists, paid due regard to every detail and, like psychoanalysts, often discovered significance in trifles, thus noted the origin of an adolescent sniffing tic:

He happened to be out one day for a walk with his sister during a snow-storm, and a flake entering his nostril made him sniff and sneeze half a dozen times. Long after the snow had ceased falling and the tickling sensation had vanished he repeated the performance, till it passed into a sniffing tic that continued some months.

Countless other tics, succeeding one another in kaleidoscopic patterns, are described with their origins by both patient and physician, accompanied by comments and interpretations not imposed, but emergent:

A large number of my head and face movements [continues the patient] owe their origin to the annoyance caused me by my seeing the tip of my nose or my moustache from time to time. The former organ appears to make a sort of screen in front of me, to avoid which I turn or raise my head: I can now see the object I am facing, but, at the same time, naturally, I see my nose again at the side, whence one more tilt of the head, and so on. I am well aware of how nonsensical all this is; but it fails to deter me from my desire of playing at hide-and-seek with my nose…. Similarly with my pincenez: no sooner have I put it on than I long to alter its position in innumerable ways. I must needs push it down or raise it up, must set it further on or further off…or attempt to displace it by tossing my head. Instead of looking tranquilly through the glasses, my eye is continually attracted to the rim, some point on which I try to focus or get into a line with the object at which I am gazing. I want to see the object and the pince-nez at the same time; as soon as I no longer see the former I wish to see it again, and similarly with the latter. My tics upset my pince-nez, and I have to invent another tic to get it back into place. The absurdity of this vicious circle does not escape my observation, and I know I am its author, yet that cannot prevent my becoming its victim.

In this same passage, the patient speaks about the relation of the ticcing, the ticqueur, to himself:

There seem to be two persons in me: the one that tics, the son of the one that does not, is an enfant terrible, a source of great anxiety to his parents, who become a slave to his caprices. I am at once the actor and the spectator; and the worst of it is, the exuberance of the one is not to be thwarted by the just recriminations of the other.

This description always reminds me of a patient of mine with Tourette’s whose self-recriminations took the form of loud exhortations and objurgations—“Stop that!” and “No, you don’t!”—whenever tics and “forbidden” impulses threatened to overwhelm him: the responses of the ego to the caprices and compulsions of his “Tourette-self.”4

This combination of fortuitous circumstances with forced reaction (neuropsychologists speak here of “stimulus slavery” and “stimulus-bound behavior”) is characteristic of frontal-lobe syndromes, as it is of early childhood, and of all states of insufficient selectivity and inhibition, not just Tourette’s, although it may take a particularly elaborate form in Tourette’s, where there is full consciousness of what is happening, combined with impotence to stop it. Thus the ticqueur, O., continues:

One day as I was moving my head I felt a “crack” in my neck, and forth-with concluded that I had dislocated something. It was my concern, thereafter, to twist my head in a thousand different ways, and with ever-increasing violence, until at length the rediscovery of the sensation afforded me a genuine sense of satisfaction, speedily clouded by the fear of having done myself some harm…. I cannot withstand the allurement or banish the sentiment of unrest.

H. Meige and E. Feindel comment here on “the fundamental importance of the psychical element that precedes the motor reaction, with the secondary psychical reaction in its turn, the impulse to seek a familiar sensation,” etc. This pattern needs to be stressed, especially in view of the current tendency to see tics as wholly motor, with no emotional or psychic component whatever. Yet it may give the psychic too large a place in the pathogeny of tics, for there are, as we shall see, many forms of ticcing in which a psychic component, though present, is clearly secondary, and has been added to some primary motor urge or impulse in order to give it sense. This elaboration and accretion of meaning was often very clear in my postencephalitic patients who found themselves “Tourettized” by L-dopa, as in the case of the patient Miriam H., whom I described in Awakenings:

An entirely novel symptom which had developed on the increased dose of L-DOPA was a tic, a lightning-quick movement of the right hand to the face, occurring about twenty times an hour. When I questioned Miss H. about this symptom, shortly after its inauguration, she replied that it was “a nonsense-movement,” which had no purpose that she was aware of, and which she did not wish to make: “I feel a tension building up in my hand,” she said, “and after a time it gets too much, and then I have to move it.” Within three days of its appearance, however, this tic had become associated with an intention and a use: it had become a mannerism, and was now used by Miss H. to adjust the position of her spectacles.

But whether primary or secondary, reason or rationalization, these psychic aspects confer a sort of absurd “significance” on the tics and relate them to the life and psychic economy of the ticqueur. This is admirably formulated by Meige and Feindel: “In this way factitious wants come into being which may be described as a sort of parasitic function…of which the patient is alike the creator and the dupe.” The relation of the “host,” the real self, to the “parasitic” tic self is further shown by the sudden “debauches” both forced upon and indulged by the ticqueur, the conflict between the real self’s will and that of the Tourette’s, a conflict which also has elements of collusion and compromise:

In O.’s case the inhibitory influence of the will is abundantly manifest. Should he find himself in the company of one from whom he would fain conceal his tics, he is able to repress them completely for an hour or two…. Nevertheless, the desire to let himself go obtrudes itself again, and if he can refrain no longer he will invent any pretext for leaving the room, abandoning himself in his moment of solitude to a veritable debauch of absurd gesticulations, a wild muscular carnival, from which he returns comforted, to resume sedately the thread of the interrupted dialogue.

The element of farce as well as force is very evident here, and brings to mind what I have quite recently had occasion to observe in a score or more Tourette’s patients of my own, where Tourettic tension, suddenly released, may erupt in an explosion of obscenities and profanities, bizarre animal and cartoon imitations, or mock assaults on inviting objects in the environment.

There may be an element of sadism, besides absurdity, in such “debauches,” and in other patients the affective and erotic elements of their Tourettic debauches are overwhelming: I have seen patients suddenly fall upon soft objects, such as overstuffed cushions, or parts of their own bodies, such as their arms or knees—stroking, squeezing, hitting, and kissing them, muttering coprolaliac endearments and imprecations. With one patient, baked onions at mealtimes always elicited a similar reaction. Another once reacted in this way to a moth.5 Anything may apparently precipitate—or, in ethological terms, “release”—such behaviors; anything may become the object of these sudden Tourettic and erotic attentions, and one sees why Arthur Shapiro, who has unrivaled experience of Tourette’s, speaks of “polymorphous perverseness” in these exceptionally severe cases.6

There is sometimes a provocative quality in such Tourettic behavior. I have known several such patients who would play with fire, seeing how close they could get to open flames without being hurt; others are attracted to fans, flywheels, and other revolving objects—which exert a teasing fascination and provoke dangerous (but exciting) test approaches. One patient has sudden impulsions to bite glasses—to “test” them by biting—and may sometimes end up with a bloodied mouth and broken glass. He also has sudden impulses to slam on the brakes—though he makes certain, first, that the coast is clear.

Obscene ejaculations and gestures (coprolalia, copropraxia) are common in Tourette’s; thus Lees describes this in a single English patient:

Vocalizations included “zing,” “Tottenham,” “Sieg heil,” “mod” and “monkey.” His repertoire of obscenities was equally extensive, with “fuck,” “fuck off,” “fucking wanker,” “oral sex,” “Suki’s crutch,” “tits,” “knickers” and “cunnilingus” being shouted in an aggressive voice…. Within a brief interview period he displayed…jerky obscene palm back V signs, striking of his chest with his arms, kissing his clothing and simulating masturbation [as well as a score of simpler, more banal tics].

Some patients will suddenly, for no obvious reason, begin kicking and banging, yelling and screaming, stamping and “punding,”7 or they will giggle, or make faces, or posture, or curse. Many patients are prone to bizarre rituals, compulsions, obsessions—the need to touch a particular spot on the wall, to arrange or rearrange objects in different patterns, to add or multiply numbers on license plates (“arithmomania”), to comment or interject while others are speaking, to mutter meaningless litanies and mantras (“tic d’incantation“), to give a little jump, or toss the head, on every fifth step.8 It is understandable that such behavior—like coprolalia—may sometimes cause patients to be diagnosed as “psychiatric” or “schizophrenic,” especially if they have no tics, when in fact they have only “mental Tourette’s” in the context of an otherwise harmonious personality.

Meige and Feindel also speak of the mental quality of such patients. They describe O.’s “mobile and impulsive temperament,” and (though he is not schizophrenic) his “looseness of thought”:

His conversation is a tissue of disconnected thoughts and uncompleted sentences; he interrupts himself to diverge at a tangent on a new train of ideas—a method of procedure not without its charm, as it frequently results in picturesque and amusing associations. No sooner has he expressed one idea in words than another rises in his mind, a third, a fourth, each of which must be suitably clothed; but as time fails for this purpose, the consequence is a series of obscure ellipses, which are often captivating by their very unexpectedness.

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. 1

    Properly speaking, “Gilles de la Tourette syndrome,” but for brevity’s sake, often “Tourette’s syndrome” or just “Tourette’s.”

  2. 2

    It is of interest that Jelliffe could not be accepted as both, and tended to be seen by neurologists as an analyst, and by analysts as a neurologist. The notion of a neuropsychiatrist, apparently, was anathema to both.

  3. 3

    Imitation may become positively frenzied in that special and most severe form of Tourette’s I have called super-Tourette’s—I describe this in a short sketch, “The Possessed” (Sacks, 1985). One sees here every level of imitation from the echoic to the parodic, the mimic, the pantomimic. The very physiology of Tourette’s seems to dispose to hypermimia and histrionism—as is also seen in dopa-activated Parkinsonism and chorea.

  4. 4

    Or—should we say?—of his (Tourettized) superego to the impulses of his (Tourettized) id. It subsequently became apparent that “No, you don’t,” ejaculated with convulsive, ticlike force and speed, was uttered in the voice of his father: in short, the introjection of the father as tic. Such complex “personal” vocalizations, which are especially common in super-Tourette’s, may have a role similar to the hallucinatory voices in psychosis. Melanie Klein speaks of such introjections as “internal objects”—but in Tourette’s they may be exteriorized, ecphorized, as pantomimes and tics.

  5. 5

    The sudden, convulsive hyperattention and hyperreaction has a dramatic sensory component as well (Tourette’s is sensory, no less than affective and motor). Thus the knees, the onion, the cushion, the moth, were suddenly seen with over-whelming intensity, filling the whole visual and attentional field with a peremptory, almost hallucinatory vividness and force. The stimulus, seemingly trivial and insignificant in itself, becomes endowed with a “factitious” significance and force, to which neural and psychic mechanisms equally contribute—sudden limbic (or limbic-sensory) stimulation, and sudden hypercathexis, symbolism, projection, themselves mutually reinforcing and linked.

  6. 6

    A.J. Lees, in his excellent recent book on the subject (Lees, 1985), gives a wealth of further examples: “Popular items to touch include fires, irons, hot plates, lighted cigarettes, door handles, railings, floors and fabrics with an erotic texture such as fur, velvet, satin and silk. Touching of breasts, bottoms and hair also occurs…[as well as] heads, noses, lips, rounded stones and sharp knives.”

  7. 7

    This term has been used by neurobiologists to refer to stereotyped circling and other repetitive behaviors observed in amphetaminism.

  8. 8

    Samuel Johnson had many such compulsions or rituals, especially on entering houses, when he would twirl about or gesticulate in the doorway, then give a sudden spring, followed by a vast stride over the doorsill. He also exhibited litanic muttering, talking to himself, sudden ejaculations, echoing others, strange vocalizations, and ceaseless tics. It seems almost certain that Dr. Johnson had Tourette’s.

  9. 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.

  10. 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.

  11. 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).

  12. 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).

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