Tics and Their Treatment

by Henry Meige; E. Feindel

However complex and bizarre may appear the convulsive phenomena known as tics, they are not always as irregular, inco-ordinate, and contradictory as superficial examination might lead one to believe. On the contrary, they are, as a general rule, systematised; in a given case they recur always in an identical manner, reproducing, and simultaneously exaggerating, complex, automatic, purposive movements which are essentially physiological; they are in a sense the caricatures of ordinary acts and gestures. The tic is not in itself absurd; it appears so only because it occurs inappositely, without obvious motive. Source of irritation is absent, yet the patient scratches himself; he blinks, but no foreign body is to be detected in his eye.

Mere repetition does not, cannot, evolve a tic in every case. Not all who would may tic; psychical predisposition in the shape of volitional enfeeblement is a sine qua non.

Of the rôle played by mental insufficiency in the genesis of tic we shall have much to say later. The point we are desirous of emphasising now is that the first manifestations of tic have their origin in, and are dependent on, cortical activity, at least in a majority of cases.

Notwithstanding painstaking investigation, determination of the initial cause may no doubt be difficult in some instances, owing to the patient's ignorance or forgetfulness; for that matter, the observer may not know how to set about his task. Prolonged interrogation, however, and due consideration of the patient's environment, will generally enable him to reconstruct the pathogeny of the condition.

It has been our practice for some years now to examine with especial care into the mode of onset, and to scrutinise the reasons for the particular localisation, of any given tic; and we have been able, in practically every case, to rediscover the exciting cause, and consequently to explain the form taken by the tic in its earliest manifestations as a voluntary response to the stimulus. Time may have distorted the original movement, but a little patient analysis will facilitate its recognition even in the caricature made of it by the tic.

A few concrete instances will help us better to understand the nature of this psycho-physiological mechanism.

An individual is wearing a collar too small for him, and its frayed edge chafes his skin; the neck is at once abruptly inclined away from the irritating point—a simple spinal reflex movement of defence. Now that he is warned by the sensation of pain, he wishes to avoid it, which he does by bending his head to the opposite side. The act is similar to the preceding, but of a totally different nature; it is voluntary, not involuntary; cortical, not bulbo-spinal.

Next day the collar is replaced by another of ampler proportions. There is no further irritation of the skin, and accordingly no occasion for deviation of the head. Memory of the disagreeable sensation may perhaps incite him to verify the disappearance of the irritation by a few movements of the head, and in the normal individual the matter ends there. Even should the idea of repeating the gesture, now become meaningless, occur to him, he banishes it by an effort of the will.

With the candidate for tic things pass in quite a different fashion. Uncalled for though it be, he performs the brusque movement of yesterday perhaps with a view to satisfying himself that the pain is non-existent, but he is not thus satisfied. He does not limit his experiments to one or two attempts. He repeats it frequently and complacently. The original source of irritation is gone; the movement intended at first to relieve it persists. Soon the whole trouble is forgotten, but the reiterated gesture becomes habitual and automatic; it may have been rational yesterday, but to-day it is superfluous, if not actually prejudicial; it is a tic. In its evolution the cortex has had a part, and the very untimeliness of this cortical intervention indicates a certain disorder of psychical function.

Or again: a speck gets under my eyelid, and I wink—a spasmodic act independent of the cortex. The speck is removed, but the conjunctiva remains a little tender, and I wink again—still only a spasm. All trace of irritation vanishes, yet the blinking persists: it is degenerating into a tic.