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The Journal of Abnormal Psychology vol 10

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With these brief prefatory remarks, I shall forthwith enter into the
discussion of the genesis and meaning of the tics.

I may say at once that this is not merely a theoretical and purely academic
proposition which has no practical bearings in the way of prognosis and
treatment. On the other hand, a real understanding of the nature, origin,
and significance of the tics is of decided value in giving us proper
standpoints and orientation with respect to the prevention, prognosis and
cure of the condition.

I need not enter into a description of the characteristics of tics in this
place. I may merely mention that tics have two aspects--a psychic and a
physical. It is, in other words, a psychoneurosis. The characteristic
mental state is one of doubt, of indecision, of inadequacy, of restlessness,
of tension, of discomfort and of dissatisfaction, which is more or less
unappeasable and irrepressible and uncontrollable until it finds vent in a
rather explosive series of motor expressions which, as it were, are the
safety valve for the peculiar feeling of tension and discomfort which the
individual has been experiencing and which is accompanied by a sense of
relief, satisfaction and a relative degree of comfort and mental rest. The
mental imperfection (Charcot) of the ticquer is a polymorphic psychic defect
(Brissaud, Meige and Feindel) characterized by mental infantilism; for
ticquers, like other psychoneurotics, are like big children. They have the
mind of children, in respect to the emotional make-up.

The mental condition of ticquers is especially characterized by the
imperfection or weakness of volition, by a certain degree of mental
instability and lack of inhibitory control of the desires, tendencies,
activities and motor expressions of the individual, this defect laying the
groundwork for the impulsions and obsessions, as also for hysterical,
so-called neurasthenic, hypochondriacal, depressive and so-called dementia
praecox reactions. The tic movement is the symbol of the psychic defect or
degeneration or instability.

The earlier investigators were responsible for the differentiation of the
tics from such other conditions as Sydenham's chorea, Huntington's chorea,
the spasms, the stereotypies, the habit movements, the myoclonias, and other
allied conditions. It is due to their pioneer work that tics were
recognized as a definite and distinct clinical entity. The process of
disintegration of these various movements and their differentiation one from
the other cannot be overvalued. Among those who have contributed most to
this subject may be mentioned Magnan and his pupils, especially Saury and
Legrain, Gilles de la Tourette, Letulle, Guinon Noir, Pitres, Cruchet,
Grasset, Trousseau, Charcot, Brissaud Meige and Feindel. Although Trousseau
recognized the the ticquer was mentally abnormal, it was Charcot who first
called definite attention to the psychic origin of the condition and to the
fact that tic was indeed a mental disorder, a psychoneurosis, a psychomotor
reaction. His lead was subsequently followed up by Brissaud, and by the
latter's pupils Meige and Feindel, the latter two authors giving us a
comprehensive discussion of the subject in their well-known classic. [1]More
recently the Freudian school has attempted to dig down into the roots of the
tree which ultimately sends forth its branches in the guise of tics.

[1] Tics and their treatment. English translation by S. A. K. Wilson. New
York, 1907. This book contains an extended bibliography.



VIEWS OF THE FRENCH SCHOOL

The usual conception of tics, as laid down by Brissaud, Meige and
Feindel,[1] may be stated as follows: Tic movements are physiological acts
which were originally functional and purposeful in character, but which have
become habits, apparently purposeless and meaningless. The motor reaction is
the result of some external stimulus or idea (normal or abnormal) or both,
which originally was necessary for the production of the tic movement, which
latter eventually became habitual and automatic, and, owing to repetition,
was executed, even in the absence of the external stimulus or idea, without
apparent purpose or meaning. At first but little more than purposive habit
movements, they finally became irrepressible acts which sought for
expression, which were but little under the control of the will, which
occurred in attacks varying in frequency, duration and severity, which
decreased under distraction and generally ceased during sleep, which were
increased in frequency and duration and severity by fatigue, emotional
upset, mental unrest, conflict and strain, while the lack of inhibition and
will power, the lack of self-control was the dominant mental state, leading
to feelings of insufficiency, doubt, indecision and incapacity, and making
the ground work for the psychasthenic reactions in the form of morbid
impulses and obsessions, and for the hysterical, so-called neurasthenic and
other morbid psychic trends.

The inherent or acquired neuropathic and psychopathic state is the basic
condition which prepares the subsoil.

From a consideration of the motor symptom we may say that it is but a
pathological habit, which, however, is apt to lead to the tendency toward or
generation of an increasing number of such pathological habits.

Characteristic of tics we may mention their being conscious before and after
but not during their execution, their being disordered functional acts,
their impetuous, irresistible demand for execution, the antecedent desire,
and the subsequent satisfaction.

The etiology of tics, as laid down by Meige and Feindel, may be summed up by
stating that they occur most frequently in young subjects, less frequently
in savages and animals than in the civilized, there is a psychic
predisposition based on heredity (of a similar or dissimilar neuropathy or
psychopathy) upon which Charcot laid great stress, imitation (especially in
the young) plays a role, as also brain fatigue (emotion, mental upset and
worry) and indolence, with the frequent exciting cause of an external or
internal stimulus or an idea, which is the explanation of the origin,
source, situation and form of the tic or tics present in any particular
case.

Scattered references to emotional shock acting as a possible exciting cause
of tics, as at times of obsessions, can be found in the literature. Dupre[2]
has made such reference. Meige and. Feindel[3] themselves make the
statement that "Fear may elicit a movement of defense, to persist as a tic
after the exciting cause has vanished." They also state that "in ticquers
the impulse to seek a sensation is common and also to repeat to excess a
functional act."

[2] Soc. de Neur. de Paris, April 18, 1901, quoted by Meige and Feindel,
page 54, of the English translation (reference 1).

[3] Loc. cit., p. 62.

Bresler[4] has called attention to the fact that the movements are in the
nature of defensive and protective movements of expression and mimicry and
originally in reaction to some external irritant or as the result of some
idea, and he proposed the name "mimische Krampfneurose" for them. This is
somewhat allied to Breuer and Freud's theory of hysteria.

[4] Quoted by Meige and Feindel, Loc. cit., p. 267.

The object of tic is some imaginary end, the influence of the will always
being present in the beginning, although later it may be absent. Tics are of
cortical origin, being coordinated and synergic, clonic or at times tonic[*]
muscular movements, physiologically and not anatomically grouped,
premeditated, purposive, of abnormal intensity, apparently causeless and
inopportune.

[*] Cruchet objects to calling these tonic reactions tics.

Insufficiency of inhibition is the cause of the beginning and of the
persistence of bad habits and of tics.

Tic is a sign of degeneration, in the biological and evolutionary sense, a
degenerative neuropathic and psychopathic basis, as mentioned previously,
being present, although often latent.

The maladie des tics is but the extreme form.

The onset is as a rule insidious, with a tendency to spread.

Spontaneous cures may occur, while Gilles de la Tourette's disease is but
the extreme form of a condition in which antagonistic gestures are
frequently adopted by the patient to adapt himself and to get to a state of
rest.

This, as I see the situation, is as far as the French students of this
subject (including Brissaud, Meige and Feindel, and even Janet) have
permitted themselves to go. And, in my opinion, their observations and
conclusions seem to be quite accurate.



VIEWS OF THE FREUDIAN SCHOOL

Recently the Freudian school has endeavored to penetrate more deeply to the
nucleus of the problem and to solve it. Freud has delimited what he calls
obsessional or compulsion neurosis (Zwangsneurosis), which is classed under
psychasthenia by the French and under neurasthenia by others. The Freudians
regard this as a distinct neurosis, sometimes complicated by neurasthenic or
hysterical symptoms. The characteristic symptom is a feeling of compulsion.
The symptoms may be motor (obsessional acts, impulsions), sensory
(obsessional hallucinations or sensations), ideational (obsessions), and
affective (obsessive emotions, particularly doubt and fear). In this
condition we find that there is an excessive psychical significance attached
to certain thoughts. Obsessions are characterized by dissociations from the
main personality. They thus exist in the unconsciousness. The original
unconscious mental processes have brought about, by displacement, an excess
of psychical significance to these thoughts. Ernest Jones[5] states that
Freud found, by his work in psychoanalysis, that obsessions represented,
symbolically, the return of self-reproaches of ancient, infantile and early
childhood origin, which had been repressed and buried until the obsession
made its appearance. "They always refer to active sexual performances or
tendencies;" and, as Jones further explains, "there occurs early in life an
exaggerated divorce between the instincts of hate and love, and the conflict
and antagonism between the two dominate the most important reactions of the
person. A fundamental state of doubt, an incapacity for decision, results
from this paralyzing doubt. The patient oscillates between the two
conditions of not being able to act (when he wants to), and of being obliged
to act (when he doesn't want to). The symptom symbolizes the conflicting
forces. These are not, as in hysteria, fused into a compromise-formation,
but come to separate and alternating expression; one set of manifestations,
therefore, symbolizes the repressed forces, another the repressing."

[5] See his article on "The Treatment of the Psychoneuroses," White and
Jelliffe's Modern Treatment of Nervous and Mental Diseases, Vol I, pp.
408-409.

To put the matter plainly, the Freudians contend that obsessions are
symbolical representations of the repressed sexual activities and tendencies
of infantile and early childhood origin. It must be remembered that the
Freudians employ the term sexual in a very broad sense, including under it
the most indirect and distant physical, mental and moral reverbations.
conscious or "unconscious," of the relations between the sexes. The sexual
impulse is here conceived of as having incestuous, bisexual and polymorphous
perverse sexual tendencies. The word sexual is not only used as synonymous
with love, but practically all emotional surgings, all feelings, all
affectivity, all sense-cravings and bodily heavings are classed by certain
members of the Freudian school as sexual. This latter interpretation and
extension of the connotation generally accorded by us to the term sexual we
surely have no right to give it.

Clark, of New York City, is the author who has carried out the Freudian idea
to its ultimate conclusion. I refer to his series of three papers[6] in the
Medical Record, and call particular attention to his last (third) paper in
which he has fully elaborated his theory of the meaning of tics.[*]

[6] His three papers, which appeared in the Medical Record, New York, in the
issues of February 7 and 8, and March 8 1914, are entitled: (1) "Some
Observations upon the Etiology of Mental Torticollis," (2) "A Further Study
upon Mental Torticollis as a Psychoneurosis," and (3) "Remarks upon Mental
Infantilism in the Tic Neurosis." A fourth paper by Clark on tics appeared
in the Medical Record of January 30, 1915.

[*] J. Sadger has also come to similar conclusions.

Clark's conception of the meaning of tic movements and of the mental state
characteristic of ticquers must be here given. Although not denying the
basic neurotic constitution present in ticquers, Clark sums up by giving the
following definite and fully developed theory:

"The ticquer has a strong sexual attachment; this is so strong that the love
instinct ineffectually sublimates the hate instinct and in the warring
conflict doubt and physical and psychic inadequacy arise. The situation
continues and generates mental, and physical infantilism, which in turn make
for increased feelings of tension. Motor and psychic restlessness succeed.
The motor expression manifests itself most often in habit movements of
disguised sexual significance (autoerogenous pleasures) a form of physical
stereotypy, in its broadest psychophysical meaning. The mental state often
pari passu takes up obsessive thinking and various physical acts and
thoughts are formed as defense mechanisms, born of conscious guilt. The
motor habits are usually inhibited or displaced in part, and the tic remains
as a motor symbol, usually in itself non-sexual, as a fragment of the former
complete habit movement. The mechanism of the completely evolved tic is
either a conversion (hysteric) or substitution (obsessive) mechanism or
both."

By these who have studied Freudism this will, in a way, be understood. For
these who have not it may be more difficult of understanding without
somewhat further elaboration or explanation. In this connection I must again
mention that the Freudians include tics under their obsessive (obsessional)
neuroses. The theory of the mental mechanisms and evolution of these states
is given in the attached quotation, which is taken verbatim from Clark's
paper.

"The affect of the painful idea does not become transformed into physical
symptoms, as in the conversion mechanism of hysteria, but affixes itself to
other ideas not in themselves unbearable, thus producing by this false
relationship a substitutive symptom or obsession.

" . . . In all such obsessive neurotics the transformed reproaches which
have escaped repressions are always connected with some pleasurably
accomplished sexual act of childhood but may be almost entirely lost. The
obsessive acts really represent the conflict between impulses of opposite
instincts, love and hate, which are usually of equal value. The warring
conflict engendered makes for a curiosity to discover the meaning of life
forces (sexual largely) and the desire to know the end thereof. The
nuclear-complex of all this is a precociousness of emotional life and an
intensive fixation on one or the other parent or brother or sister. The
intensive love fixation waxes the stronger as the unconscious hate requires
increased barriers against its breaking through into the main or everyday
personality. As a result of these conflicts the will is partially weakened,
there is an incapacity for resolution, first in the realm of love alone;
then later succeeds a diffusion or displacement of the mechanism all over
the field of activity. A series of secondary defense mechanisms are now
brought in and these may enable the obsessive person to get square in a
limited way (as religious practices enable many to do). Some special
adaptation is required sooner or later, and the individual, having used up
all the helps, then falls back upon the different forms of obsessive acts
and thinking. Thus the obsessive neurosis is generated."

Clark then proceeds to explain:

"If one is not permitted to draw deductions from a few data as to the
further genesis of the tic disorders, we may still hold out a tentative
hypothesis, pieced together from many sources that a certain type of nervous
make-up is inherited. In such the emotional life is precocious much beyond
the intellectual faculties. The ticquer in infancy has the emotional
feelings of love and hate of an adult. Their very precociousness aids the
parental fixation and adhesion, and makes it the more difficult for the
libido to detach itself at the proper age. One should bear in mind that the
parental fixation in itself does not directly produce the mishaps of adult
life but this small fault in infancy generates wider and wider
maladaptations as development progresses. It is these latter glaring faults
and trends that make for the character defects, and these really break down
the final effort at adaptations and adjustments producing the tic or
obsessive disorder. But the essential nucleus of the defect is lack of
balance, precocious parental fixation, and continued attachment to the
parent-stem, that makes the adult defect possible. The very infantile
precociousness of the emotions argues for the hereditary transmission of
destructive temperamental qualities. Here, as elsewhere in tracing
hereditariness in so-called functional nervosities, one should take as the
unit character for study the mental traits or trends and exclude definite
disease entities applied to ancestral disorders. I believe it is not too
suppositious to think that many of these variant individuals are really
atavistic in makeup and have continued from one generation to another
special defective traits of emotional makeup which are fortunately denied
the average individual."

The writer cannot understand how the theory which he has taken the trouble
to so fully present in the above quotations can be maintained. Jones and
Clark both assert that the tics or habit spasms as probably of the same
nature as the obsessions in general. Moreover, Jones agrees that "familiar
examples of compulsion in a slight degree are the obsessive impulses to
touch every other rail of an iron fence as one walks past, to step on the
cracks between the flagstones of the pavement, or not to step on them, and
so on." A little reflection will show us the impossibility and illogicality
of viewing all these conditions as being fundamentally of sexual origin. Let
us follow the argument. If tics are of sexual derivation, as the Freudians
here openly maintain, then it must follow that those familiar examples of
compulsion, such as the obsessive impulse to touch every other post, etc.,
are likewise of sexual origin. This conclusion is forced upon us, since,
even according to Jones, the only difference between the marked tics and the
lesser manifestations is one of degree.[*] Now, these slighter impulsive
tendencies to which we have here referred are very frequent in all children
and by no means infrequent in grown-ups. They are habitual movements, which
may be of transient duration only or may, by repeated performance, develop
into more or less fixed habits. If, then, these habits are of sexual
significance, it must follow that all other habits, especially if associated
with a certain degree of consciousness or awareness, are in like manner
symbolical of the past infantile and early childhood sexual activities and
tendencies. This conclusion is, as is seen, inevitable, if we believe in
the Freudian theory of the pathogenesis of the tics. However, since this
leads us to a reductio ad absurdum, we must, of course, reject the
explanation which has been offered by the Freudian school.

[*] The accompanying mental state characteristic of ticquers is absent in
habits. We can stop doing the latter when our attention is directed to
them; not so in tics Meige and Feindel have discussed these and other
differences.

Perhaps I should also mention the fact that all of these symptoms or
tendencies which one finds in ticquers occur in other individuals who do not
present tics; and, furthermore, that all normal individuals possess these
qualities or tendencies in varying degrees of intensity and in varying
combinations, and that this applies to adults as well as to children,
although, of course, they are seen most characteristically in children. I
may further add that the difference between the mental infantilism which we
find present in the tic psychoneurosis and that which we observe in other
(normal and abnormal) conditions is one of degree rather than of kind.
Therefore, the most we can say of the mental condition in ticquers is that
there is an exaggeration of the mental infantilism or a fixation at or
tendency toward regression to this type of thinking or of reaction. And this
leads us to the further conclusion--and it is this point which I desire to
bring out in this connection--namely, that since the difference between the
mental infantilism in all of these conditions is relative, being one of
degree and of proportionate relationship or at any rate of genesis,
evolution and meaning, it naturally follows that what is in the conclusions
of Clark, as mentioned above, asserted to be an absolute and basic principle
or truth applicable to the tics, must consequently be true, but in different
degree, of all the other conditions of a similar or allied nature. Surely
the motive source is fundamentally the same in all of these conditions.

Furthermore, tics occur in animals, especially in horses; and the whole
picture, physical and mental, of tics in horses resembles that which we find
in human beings, particularly idiots and imbeciles, with tics. And the
ultimate, fundamental meaning and motive source of tics in man is and must
be the same as that of tics in horses.

To put Clark's idea in a nut-shell, it may be said that he believes that the
primary purpose of tics is not that of a protective, defense mechanism
against unpleasant situations in life but that of obtaining really
pleasurable gratifications to the psyche, these autopleasurable acts being
based on inherent defects and having a sexual significance in the sense in
which sexuality is conceived by Freud. The protective, defense mechanism
is, according to this view, but secondary to the primary and

fundamental purpose of obtaining the autopleasurable gratifications to the
psyche.

Although approving of the analytic and genetic tendency displayed by Freud,
Clark and the Freudian school in general, it is regrettable to me that the
analytic tendency and reconstructive efforts of the Freudians in the field
of neurology and psychopathology have been seriously marred by their
insistence on forcing all observed physical and psychical phenomena and
reactions into line with their fixed sexual theories and their special
psychology, which is basically wrong in many fundamental and important
standpoints.

The writer will agree with the Freudians that there must be a cause for the
appearance of these tics. This cause existed in the past. It has in the
course of time been forgotten, but still exists somewhere in the
subconsciousness or memory. This forgetting has been brought about by a
process of dissociation from the original exciting cause. But the writer
will not agree that this dissociation has been, of necessity, brought about
by psychic repression on the part of the individual, that by psychoanalysis
the condition can be traced back to the sexual activities or tendencies of
infantile or early childhood origin, or that the condition may be cured when
the original cause is made known to the patient through psychoanalysis,
without the training of the will so necessary in this condition.

Thus the analytic tendency of the Freudian school is to be highly commended.
But this analysis should not be limited to sexual analysis, but should
include a consideration of all of man's instincts. Nor should the analysis
be limited to present-life psychic factors alone, but should be viewed from
a psychobiological standpoint. In this way only will all antecedent
causative factors--physical and mental--be included in our analytic
observation and speculation.

To fully discuss or to prove the error of Clark in his conclusions would
necessarily lead me into a general discussion of Freudism, which I cannot do
in this place, since the ramifications are too numerous and the problems
involved would lead to lengthy and tiresome discussion, pro and con. I must,
however, mention the exclusively sexual standpoint assumed by the Freudian
school in their interpretations of physical and psychical activities, their
classifying of all activities characterized by a certain rhythmicity and
periodicity, and accompanied by a certain degree of satisfaction-- in other
words of all autopleasurable activities--as sexual (in the Freudian sense),
and the neglect of comparative and behavioristic psychology with proper
consideration for man's phylogeny and ontogeny or of his true genetic
history, from the racial and world history and not alone from the
individualistic psychological standpoint. As a matter of fact the
conception of sexuality assumed by Freud and his followers has undergone
many changes and is by no means definite and clean cut in its outlines. A
criticism of the conception of sexuality cannot be entered upon here. I may
merely state that what is an absolute and fixed law for the tics, what is
the fundamental and basic explanation or theory of the genesis and meaning
of the tics must apply also to all habit movements wherever and whenever
they occur, and, in like manner, to all habit formations of whatever nature.
And since our habits are but the prolongations of our instincts, the latter
also would be included within the purview of the same generalization. In
other words, if all tics have a sexual meaning, then all instincts, which
means the vital energy of man, has the same meaning. This question I have
discussed in another place[7] and cannot enter upon here.

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