As the analysis progressed his attacks diminished and shortly disappeared. Gradually the image of his wife took full possession of his mind and the image of Anna disappeared. Towards the end of the analysis as he was lying on the couch with his eyes shut, he saw Anna in the flames and felt the yearning but not so strongly as to lead to any impulsive movements. What do you think all this might mean, I asked. "I don't know," he answered, "it might mean I still cared for Anna and that if I let myself go it would break up my home." With his full realization of the meaning of this symbolization, it was assumed that he was cured.
Seven months later, in company with a colleague, I visited my former patient and he told me that he had not had a moment's illness since I last saw him. He told me that while occasionally the thought of Anna would come to his mind, it never disturbed him, and never distracted his attention from other things. He has prospered in his business, and I saw every evidence of a happy home.
This case merits consideration for a number of reasons. In the first place the attacks were cured by psychoanalysis. No one who saw the association of the symbolical imagery and the convulsive movements could fail to see that there was a causal connection between them. The subsidence in violence and frequency of the convulsive movements as the conscious grasp of the meaning of the mental symbolical imagery increased was also completely convincing of the therapeutic value of the analysis. The question of the permanence of the recovery is of course open, because seven months is far too short a time to carry complete conviction.
The comparison of this case with the one immediately preceding raises a very interesting question. Why is this patient apparently completely cured and the other one not? Several reasons may be noted. The patient is much younger. He had never been through anything like the same mental strains. His trouble was of short duration. But above all as he was successful in his business he was successful in his sublimation. Here is a sine qua non of a successful psychoanalysis: the capacity and the opportunity for successful sublimation. If these are present the prognosis is good.
It is interesting also to compare this case in its results with the contentions of Clark and of Stekel. It is hard to see any signs of a definite criminal tendency. Inasmuch as the temptation to go back to his early love is a sign of a tendency towards regression and erotism generally the patient shows what Clark has spoken of as a desire to return to the mother-body. This case is not very important, however, to the views of either Clark or Stekel as the analysis is relatively superficial, and there is no knowing what a more thorough analysis might reveal. From the point of view of superficiality, however, the case is important as it emphasizes Taylor's view of the value of a modified analysis. The patient was seen only five times.
On the basis of these, and a number of other similar cases, I should like to suggest, from a descriptive point of view, that the epileptiform seizure is of the nature of an orgasm. An orgasm is a sudden, explosive, discharge of nervous energy, raised to the breaking point of nervous tension. I should like to generalize the idea of orgasm. Ordinarily, of course, it is confined to the sexual sphere. In the last case I reported it seems to me fairly clear that the explosive actions, convulsive-like impulses, were closely associated in the mind of the patient with sexual ideas. That they were substitutes for the normal relief of sexual tension, seems to me also clear. This idea is perhaps more convincing if I add the fact, as stated by the patient, that his last attack started when he saw an attractive girl sitting at a nearby table in the Thorndike Hotel, and who started him dreaming about Anna, because she looked so much like her.
The second case I reported seems also easily brought under this conception. Here we know more about the earliest childhood of the patient and we can easily imagine that there was an especial predisposition for the form the symptoms took. This, however, does not militate against the descriptive value of the above conception. That the epileptiform attacks did not take place until after actual sexual orgasms had been experienced, lends weight to the conception I am presenting here. The first case is not so clear. This is partly due to the fact that it was impossible to make anything like a complete analysis. But it shows nothing contradictory to the conception, and indeed has some slight value as added evidence in favor of the conception, in as much as the original trauma consisted of a kick in the genitals, by her father.
This conception does not contradict either Stekel's or Clark's ideas, but rather supplements them. The essence of the criminal act lies in its unrestrained aggressive character. From this point of view anything getting in the way of the libido discharge has to take the consequences. This also agrees with Clark, only his idea seems to me perhaps a little too passive to describe fully the dynamic quality of the attack.
Here, as in Hysteria, the therapeutic effect of an analysis depends on the possibility of sublimation. The three cases I have given in some detail may easily be arranged in order. The last case having the best chances for sublimation shows the best results.
ON THE GENESIS AND THE MEANING OF TICS
BY MEYER SOLOMON, M. D.
Associate in Neurology, Maimonides Hospital, Chicago
THE problem of the genesis and meaning of the strange manifestations which we find in that peculiar disorder which goes by the accepted name of tics is indeed difficult of solution. The analytic and genetic standpoint only comparatively recently assumed in the domain of neurology and psychiatry is having an ever wider and wider application. The problems in neurology and psychiatry which still cry loudly for solution and rational explanation are indeed numerous. Some of these questions are so baffling that at times they seem almost beyond the ken of the human mind. Nevertheless, with persistence and the "Don't give up the ship" spirit keenly imbued into us, and with that irrepressible spirit of investigation and of research born of optimism and of curiosity, we may expect to see many of these problems which now seem to us so hopelessly unsolvable gradually rescued from the uncertain waters of speculation and theorization and brought to the more sound shores and land of the knowable and the known. If our theories be but tinctured with due admixture of that sound self-criticism that comes of prolonged and serious reflection and deliberation, and if the results of observation and investigation be brought forth in support of these theories, then we need have no hesitancy in permitting freedom in theorization and speculation. Let us also remember that unsound theories or standpoints do not come to stay, but, after surviving for a certain time, give way before that which is more sound, more tangible, more near the truth, which, to be sure, is always but approximately attained. If, therefore, the theory which I intend to set before you for consideration may seem on first thought far-fetched and unsupported, I beg you to remember that in a field where but comparatively little is known with absolute certainty, it behooves us to take notice of all theories or conclusions which may be propounded, since, even though they may not contain the whole truth, they may, perhaps, contain certain germs of truth, which may contribute, in some measure, however slight, toward the ultimate solution of the problem under consideration.
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."