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Tics





Without any good reason in the etymology or the history of the word,
the term "tics" has now been generally accepted to signify certain
involuntary movements, frequently recurrent, of which, by habit,
certain persons usually of diminished nervous control, become the
victims. For the psychotherapeutist, however, they have an interest
quite beyond that which they have for the ordinary student of nervous
diseases. They represent the possibility of the formation of habits in
the nervous system, originally quite under the control of the will,
but which eventually become tyrannously powerful and quite beyond
management by the individual. They deserve to be studied with
particular care because it is probable that they represent objectively
what occurs also on the sensory side of the system, but which not
being manifest externally, is spoken of as entirely subjective. If
nerve explosions of motor character can, through habit, get beyond the
control of the patient, it is not unlikely that sensations, primarily
of little significance, may, in persons of low nervous control, become
by habit so likely to be repeated as to make the patient miserable.
Hence the study of tics as here presented.

As a result of the studies of Gilles de la Tourette, we realize that
there is an essential distinction between involuntary movements of
various kinds, and that spasms and tics must be separated from one
another. Tics consist of various movements of the voluntary muscles.
Probably the most familiar is that of winking. Everybody winks
both eyes a number of times a minute quite unconsciously, though the
unconscious movement accomplishes the definite and necessary purpose
of keeping the conjunctiva free from irritant particles. When this
same movement is done more frequently than is necessary, or is limited
more to one eye than to the other, or is repeated exaggeratedly in
both eyes, then it is a tic. There are many other facial tics. Most of
them represent movements of the lips or of the nose or of the skin of
the forehead and all of them are identical with movements that are
occasionally performed quite voluntarily. There are movements of the
lips as in sucking, or smacking sounds may be made, or such movements
of the features as are associated with sensations of taste or smell.
Sometimes changes of facial expression may be tics and without any
reason there may be recurring expressions of emotion, of joy, or
grief, or fright, or even pain. Sometimes the tics affect structures
that are internal, as various motions of the larynx accompanied by the
production of grunting or sighing sounds or sometimes even of
particular words. In children the tendency is prone to manifest itself
in the utterance of forbidden words, usually vulgar, sometimes
indecent.

Besides these facial and throat tics any of the voluntary muscles of
the body may be affected. There may be the gestures that accompany
certain mental states, or there may be twisting or turning movements
as if the patient were in an awkward position and wanted to get out of
it, or as if the clothes were hampering movement and there was an
effort to relieve some discomfort. The head may be lifted and lowered,
or may be twisted from one side to the other and, indeed, various
nodding tics are extremely common. Almost any ordinary movement may,
in nervous people, come to be repeated so frequently as to be a tic.

Practically all of the convulsive or quasi-convulsive movements
associated with respiration are likely to become the subject of tics.
Yawning, for instance, involuntary to some degree, usually a reflex
with a physical cause, but so readily the subject of imitation, may
become so frequent as to be repeated a couple of times a minute and
this repetition kept up for many days. Sneezing may also become a tic,
though it is usually a definite reflex due to palpable physical
causes. Hiccoughs may easily become the subject of a tic. The
occurrence of a persistent hiccough is in popular medicine a sign of
unfavorable prognosis in serious diseases, especially such as involve
the abdominal region. In connection with neurotic affections of the
abdomen, however, hiccoughs are not uncommon and are of no serious
significance.


Varieties of Tics.--There are many more tics than are ordinarily
supposed. Indeed, there are few of us who escape them entirely. Nearly
all the curious phrases that people interlard so frequently into their
conversation, usually quite unconscious of them, or of the ridiculous
significance they often have, must be placed under the tics. Some men
cannot say a dozen words without interpolating "don't you know."
Others use some such expression as "in that way." I once knew a
distinguished professor of elocution who by actual count used this
phrase forty times in an hour. Some say "hum" or "hem" every sentence
or so. Whenever there is a bit of obscurity in their thought these
voluntary but unconscious expressions are sure to pop out. No one who
has had much experience in public speaking ever succeeds in keeping
entirely out of such bad habits. It is curious how phrases will insist
on repeating themselves. One year one set of words, or a pet
phrase, or mode of expression, creeps unconsciously here and there
into an address. Then either because the speaker has been reading
dictated copy, or because some good friend has the courage to tell him
of it, he finds out the bad habit and suppresses it.

Word formulas senselessly repeated are only one of many forms of tics
that public speakers are prone to indulge in. Gesture which begins as
an artificial adornment of speech, very appropriate in itself, after a
while may settle down into certain forms that not only often lack
elegance but that are really disturbing to an audience. Of these
gestures and movements men are often quite unconscious. They have
become habitual and in the absorption of mind with the thought and the
words, they are reproduced quite involuntarily though they are all
originally voluntary movements. Nearly every public speaker needs a
mentor to correct him of such faults. It is rather difficult to break
some of these habits and it requires no little concentration of effort
and attention to be successful in eradicating them. It can be done,
however, provided the habit is not too inveterate, and this is the
best evidence that tics of other kinds can also be eradicated if the
patient really takes the matter in hand and is not of a weakened will.


Teachers' Habits.--Indeed it is almost impossible for public
speakers and teachers not to acquire certain habits irritating to
their auditors at first but amusing as they grow used to them, and
students particularly learn to look kindly at the ridiculous side of
many of them. I remember an old professor of literature who used to
lecture at some length on each of the important contributors to
English prose and poetry. We soon observed that whenever he came to
their deaths he took out his handkerchief and blew his nose. This was
as inevitable and as invariable a rule as the laws of the Medes and
the Persians. It was, as it were, his tribute of sympathetic
condolence with humanity for the loss of a brilliant contributor to
English literature.

Occasionally the effort to break up these habits will seriously
interfere with modes of thought and habits of expression, for the time
being at least. A professor at a certain university had a habit every
now and then of plucking at a button on his coat. His students could
tell when his hand was going to find this object of its occupation and
knew from experience that he would twist it a certain number of times.
He was not what would ordinarily be called a nervous person. One day
he happened to take off his coat shortly before a lecture and one of
the students surreptitiously removed the button. At the end of the
first few minutes of his lecture his hand went up to find the button
as usual but failed. For the moment there was a hesitancy in his
speech; then he tried again. A little later his hand went up
unconsciously and was disappointed; then he stammered and lost the
thread of his discourse. The last half hour of that lecture was
seriously impaired because of the absence of that button.


Tricks of Speech.--There are many other curious tricks of speech
that are really tics. Women often indulge in them and sometimes even
pretty women spoil their appearance by bad habits. All of us know the
pretty woman who talks very fast, but who every now and then projects
her tongue a little beyond her teeth. Occasionally there is a tendency
to wrinkle the nose or the forehead. Most of us have seen the woman
who sets her face into a definite smile of a particular kind whenever
her company manners are in use, though there is a vacancy behind
the smile that is rather disturbing. Some people have habitual
movements of the fingers that are really tics, and even positions
assumed on sitting down that are very ungraceful, or that are very
noticeable, sometimes partake of this character.


Fussiness.--A very common form of tic that is quite difficult to
control is that tendency to be doing something with some of their
muscles which characterizes many men. They must handle a pencil or a
knife, or they must swing on their chair or tilt back on it, or keep
one of their limbs swinging over the other, or twirl their moustaches
or stroke their beards, or rumple their hair, and they cannot find it
quite possible to sit still. The difference between men and women in
this regard is remarkable. Women are conceded to be much more nervous
than men, but men are ever so much more fidgety than women. The author
of "The Life of a Prig" in his book "The Platitudes of a Pessimist"
has some striking paragraphs with regard to this subject. He says:

To look nearer home, the British bar affords splendid examples of
nervous fidget. Observe barristers pleading a cause. How they
torture a piece of red-tape, how they twirl their eye-glasses or
spectacles, and how they hitch at their garments, as if they
momentarily expected them to desert their finely proportioned
figures. But worse than the Queen's Counsellors, and even worse than
the domestic peripatetic, is the villain who is abandoned to a
performance vulgarly known as "the devil's tattoo"--drumming with
the fingers.


Writers' Tics.--Writers, and above all writers for the daily press
and such as have to do their writing in a rush and therefore get
nervous and anxious about it, are especially prone to develop tics,
though others who write leisurely may do so. Some of these are curious
and others are only expressions of nervousness common to all people.
Many of them chew their nails, some of them bite at their fingers
round the nails and make them sore, many of them chew the ends of
their pens and find it practically impossible to keep a pen with a
long handle to it. Some of them run their hands through their hair
until it is in a greatly rumpled condition, some of them pluck at
their eyebrows. I have one patient who when he is going through a
particular nervous strain plucks out the middle portion of his right
eyebrow so that he has a distinct bald spot at this point.

The tradition in newspaper offices is that these curious expressions
of the tendency of the body to occupy itself with something while the
mind is occupied are more or less inevitable in nervous people. They
continue for many, many years. They are only habits, however, that it
would have been rather easy to break in the beginning, though they
become extremely difficult to modify after they have once secured a
firm hold. Occasionally I have fastened a piece of adhesive plaster
over a much battered eyebrow, but that made it difficult for the man
to go on with his work. His hand would go up involuntarily time after
time and while plucking at his eyebrow would not disturb in the
slightest his train of thought, just as soon as his fingers touched
the unusual object a serious distraction occurred and work was not
only slower, but much more difficult.


In Games.--The tendency to the formation of curious habits of
associated movements can be seen very well in most games where skill
is combined to a certain degree with chance. It is most
noticeable, perhaps, in bowling. Few men are able to restrain
themselves from making some special movement just as the ball strikes
the pin. This is sometimes a motion of the head, oftener it is a jerk
of the trunk, sometimes it is an associated movement of the arms,
occasionally it is a kick or a stamp. In billiards the same movements
are noticeable if a man is much interested in making a difficult shot.
Usually there is some movement of the body or of the hands or of the
head that would indicate his desire to move the ball in a particular
direction. Women who play these games do not usually have these
associated movements to such a marked degree and this may be due
either to their better restraint to movement in general, for as we
have said men do not acquire the habit of self-restraint in small
matters of deportment as women do, or to the fact that such associated
movements might disarrange their clothes. Perhaps, also, they are not
as much interested in the games as a rule as are the men. Of course,
similar associated movements may be seen in outdoor sports that
require skill yet have an element of chance in them. For it is, as it
were, to overcome this that the additional movement is made.


Children's Tics.--Some tics consist of some very curious habits.
Occasionally children hear some obscene or vulgar expression and
repeat it. The repetition of it produces such a look of shock to
propriety on the part of some of the other little ones who happen to
be present that they repeat it in the spirit of bravado and then
continue to utter it until it becomes a habit that is hard for them to
break. After all, the use of blasphemy later on in life is really a
tic, a habit of uttering words no longer expressive of any particular
feeling, as a rule, unless in exceptional circumstances but just the
result of a tendency for the speech organs to repeat certain words.
They tell a good story of the Rev. Sydney Smith who, wishing to break
an acquaintance of the habit of indulging in expletives, interlarded
his speech with "fire tongs and sugar tongs" every ten words or so and
when his auditor protested that that added nothing to the significance
of what he said the Rev. Sidney suggested that that was also true of
various blasphemous expressions that his acquaintance was accustomed
to use.

At the Salpetriere they tell the story of a little boy who had the
habit of saying the French word which the corporal in Victor Hugo's
"Les Miserables" made use of when anyone told him that it was because
Wellington was a greater general than Napoleon that the French Emperor
was defeated at Waterloo. Nothing seemed to be able to break the boy
of the habit of interjecting this word into conversations sometimes in
which he had no part and sometimes toward which he was expected to
take only a respectful and childlike attitude of silence. He was sent
to the Salpetriere. The ordinary remedies had failed entirely. One day
he was allowed to go outside of the hospital, or rather stole out of
the gate and played marbles with some street gamins in front of it.
During the game he used the word in question and they proceeded to
give him a good thrashing. It is Charcot who tells that this broke him
effectually of the habit.

One of the childish customs that sometimes disturbs parents very much
because it seems to be such an unaccountable lapse into barbarism,
though it is really nothing more than a tic in the strict sense of the
word, is the habit that some children acquire of removing portions of
hardened material from their nose and then putting it into their
month. Refined parents are apt to be so seriously disturbed by this
that they fear for the child's mentality. Really the habit is not
nearly so rare as is usually thought by some grown-ups who have
forgotten about their own and others' childhood. In country places the
habit is very common. It is not alone the dull children who do it but
some very bright ones. Indeed, the tendency to the habit is so common
that one wonders whether there is not something in nature that tempts
to it. Parents who are fearful lest their children may be seriously
hurt in health by the awfully insanitary habit may be reassured that
after all a certain amount of the drainage of the nose is normally
carried off through the posterior nares to the stomach and that no
danger to health seems ever to have resulted from the practice. As a
rule, the habit can be broken rather easily by a little judicious care
and insistence, though I know of cases where relapses occurred and the
habit continued surreptitiously.


Motor Tics.--Motor tics frequently develop as a consequence of some
injury to a nerve or some intense overuse of it. Winking habits follow
an herpetic involvement of the superior branch of the fifth nerve.
Bell's palsy is sometimes followed in the face by a tendency to
twitching on the unaffected side that makes the patient quite
uncomfortable. Herpes zoster is sometimes followed by a catching of
the breath, probably due to a little spasm in the muscles supplied by
the nerve thus affected. Some of the yawning tics have this origin.
Any neuritis may in the course of its betterment be followed by this
curious tendency to explosion along the nerve that has been affected,
as if the pathological process had more seriously interfered with
inhibition than with the actual function of the nerve. Examples of
over-exertion followed by twitchings are not rare. A scrubwoman who
has seen better days and now has to carry a heavy bucket and use her
right hand much with the brush may develop a twitching of the right
arm. A janitor's wife who sweeps much may have a tendency to
twitchings of the fingers as a consequence of the unusual exertion of
holding the broom. Twitchings in the limbs of men who work at a foot
lathe or other machine requiring foot power are not unusual though
they are more often seen in the leg on which the workman habitually
stands than in the other one and it seems to be oftener a strain on
muscles than actual over-exercise that precedes the development of
these tics.


Heredity.--Heredity plays as large a role in tics as it does in
stuttering and other functional nervous disturbances. Occasionally the
direct inheritance of some habit will be found, though there is nearly
always more than a suspicion that a trick of speech or of act, which
constitutes the tic, was learned by imitation rather than transferred
directly. Besides, it is a case of a similarly constituted nervous
system reacting in the same way to a similar environment, rather than
any definite tendency existing by heredity in the nervous system. It
is surprising what close observers children are and how easily they
learn to imitate any habitual action of father or mother or, for that
matter, of nurses or those who are close to them.


Mental Treatment.--The most important element in the psychotherapy of
tics is their prophylaxis. They run in families, not by any inevitable
hereditary influence, but as a consequence partly of imitation and of
corresponding tendencies resulting from certain weaknesses in the
family. Wherever they are known to be likely to occur, parents should
be warned of the possibility and the first symptom of any motor
habit should be considered the beginning of a tic. As we have said,
they are likely to begin in muscles that have been overstrained for
any reason, especially when patients are run down. They are often seen
after herpes and certain facial neuralgias.

There is probably no tic, no matter how long or how serious, that can
not be eradicated, or greatly modified, if the patient will take the
trouble and if the treatment is conducted so as gradually to get rid
of it. Peculiar movements cannot be done away with at once. They can
be lessened in intensity and in frequency and then gradually the
patient will be encouraged by their becoming less noticeable than
before to make renewed efforts. The habit must be gradually undone and
this will take as long as it did to form it originally. The exercise
of contrary muscular movements carefully carried out, and of gentle
repression with definite times of exercise during the day, gradually
increasing the length of the intervals of repression, in the end
proves successful. Only a determined struggle will effect a cure. It
depends on the patient's will. Like a drug addiction, or a tendency to
overeat, or a craving for alcohol, it must be gradually overcome and
then care must be exercised to prevent relapses; for when the
condition is somewhat better, to relax vigilance and give up effort
will allow the old condition to reassert itself with startling
rapidity. People suffering from severe tics will often give up.
Without the patient's hearty co-operation cure is impossible. With
good will its gradual diminution gives the patient a confidence in
self and an uplift in character that is extremely valuable, not only
for physical but for mental conditions.





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Previous: Chorea



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