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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