Tics and Their Treatment

by Henry Meige; E. Feindel

TICS AND HYSTERIA

Our response to the question whether tics are hysterical in origin is a direct negative. Without attaching pathognomonic significance to stigmata, we may remark how seldom they are encountered among those who suffer from tic, and how rarely the latter exhibit any of the paroxysmal manifestations of hysteria.

Modifications of general sensibility such as anæsthesia or hyperæsthesia are unknown; the special senses are intact; in particular, contraction of the visual fields is never met with. Though these signs are negative, their importance from the point of view of diagnosis is none the less real.

The mental condition of patients with tic is no doubt analogous to that of hysterical cases, but it is no less common in many others that present no sign of that neurosis. There is little or nothing in tic characteristic of hysteria, and one sometimes questions whether the soi-disant hysteria of certain subjects of tic is the real disease.

In the same way as all who are predisposed, the sufferer from hysteria may develop a tic or tics, and although tic was held by Briquet, Axenfeld, Bouchut, and others, to be merely an accessory symptom of hysteria and nervosism, these doctrines were propounded prior to the analytic researches of Charcot.

Pitres,[155] whose opinion is so weighty in matters neurological, considered a predisposition to tic as a sign of hysteria, for which neurosis the subjects of tic were candidates, and supported his contention by various clinical examples:

A resin-gatherer of Landes carried all day from tree to tree a notched stake of wood by which to climb up the pine-trunks. The weight of it on his left shoulder began to cause a slight but persistent aching, which was followed by involuntary deviation of the chin to that side. The movements took place at the rate of ten to thirty a minute, but diminished materially in frequency and degree whenever the patient lay on his left side, or when he inclined his head voluntarily on either shoulder, and disappeared entirely if he was asleep, or if he sang, or whistled, or recited in a loud voice.

Examination of his visual fields revealed a marked restriction, and every effort to cure the condition proved ineffectual.

Pitres' conclusion is that the condition is one of tic, probably caused by the habit of carrying the stake, and probably also of hysterical origin. It is true the hysteria is reduced to its most simple elementary symptomatic expression, but it is difficult not to recognise its activity in the concentric contraction of the fields of vision.

Nothing is more likely, we think, than that we are dealing in this instance with a tic occasioned by a professional act, but we doubt whether alterations in the visual field are sufficient to justify a diagnosis of hysteria.

In another case of the same author, where a facial tic made its appearance in a hystero-neurasthenic after a series of worries, the association of the two is of course undeniable, but it does not follow that tic is in essence hysterical.

Take another example from Chabbert:

A little girl of twelve years, with a bad family history, began to exhibit involuntary movements as the result of a succession of frights, which led at the same time to the production of certain hysterical phenomena. The stigmata were unmistakable, and in addition the girl was an echolalic.

Here there seems to have been a combination of hysteria with the disease of convulsive tics. Charcot,[156] however, drew a sharp line of distinction between them, although they may co-exist in the same individual.

Apropos of this subject Raymond and Janet[157] call attention to the fact that in the somnambulistic state the memory may be much more extensive than in the waking state, and may recall events that have not passed the threshold of consciousness, which nevertheless have been the determining cause of various phenomena of the conscious life. In this way may be explained the genesis of certain tics, although it is not a necessary sequel that they themselves are stigmata of hysteria.

Sometimes, however, that disease does appear to play an indispensable part in originating convulsive movements. An interesting case in point has been published by Scherb[158] as "beggar's tic."

The patient is a young girl eighteen years old, born of an alcoholic father and an hysterical mother, and brought up amid deplorable surroundings, socially and morally. At the age of seven she contracted diphtheria, and a doctor was called to visit her. The mere sight of him so frightened her that the whole of the right side of her body went into a state of contracture, with mouth and eye deviated to the right, the arm pronated and adducted, the leg stiff and the heel raised off the ground. Some gradual improvement took place after a month, but her mother saw in the incident a means of attracting public sympathy, and encouraged the child to maintain the vicious attitude by sending her into the streets to beg. And so she appears to-day, her right foot trailing, her toes flexed, her forearm bent, her hand extended and fingers curled up. Whenever the patient is unobserved or forgets her professional attitude, at once the arm resumes its normal position and activity.

An examination of sensation reveals a hyperæsthesia of the right half of the body, with points douleureux over the left ovary and the left mamma, as well as over the larynx. There is no contraction of the visual fields; reflectivity is normal; Babinski's sign is absent.

The author considers the case one of "professional mental tic" in a predisposed patient—in other words, the tic is a "mental bad habit" in an individual psychically abnormal.

There is a certain analogy between this condition and mental torticollis in the insignificance of the effort by which the patient corrects the deformity, compared with the great force exerted by any one else to obtain the same result. Yet the symptoms strongly suggest hysteria; their unilaterality, and the combination of motor and sensory alterations, are altogether too special to have been caused by any other morbid process.

Of course everything depends on the exact interpretation to be put on the word hysteria. As far as we are concerned, to consider a symptom of hysterical origin because it seems to be purely functional is sadly to misunderstand the question. The absence of what we call organic signs is a negative feature common to all neuroses, each of which, hysteria included, ought to have definitely fixed limits.

According to Babinski,[159] hysteria is a mental state which renders its subject capable of auto-suggestion. The distinguishing mark of the condition is that its symptoms may be reproduced with mathematical accuracy by suggestion, and may by similar means be made to disappear.

Now, while auto-suggestion may undoubtedly be a factor in the evolution of tic, it is rather too much to maintain that an "evil suggestion" may constitute a tic by itself, and we question whether the influence of persuasion alone will suffice to bring about a cure. Nothing short of re-education, faithfully practised for months and years, will produce any effect, and even this method seldom results in more than a progressive amelioration. Sudden cures are familiar in hysteria, but unknown in tic. Treatment by hypnotism is rarely successful unless the patient is also a full-fledged hysteric, and this is quite the exception.