Clark then proceeds to explain:
"If one is not permitted to draw deductions from a few data as to the further genesis of the tic disorders, we may still hold out a tentative hypothesis, pieced together from many sources that a certain type of nervous make-up is inherited. In such the emotional life is precocious much beyond the intellectual faculties. The ticquer in infancy has the emotional feelings of love and hate of an adult. Their very precociousness aids the parental fixation and adhesion, and makes it the more difficult for the libido to detach itself at the proper age. One should bear in mind that the parental fixation in itself does not directly produce the mishaps of adult life but this small fault in infancy generates wider and wider maladaptations as development progresses. It is these latter glaring faults and trends that make for the character defects, and these really break down the final effort at adaptations and adjustments producing the tic or obsessive disorder. But the essential nucleus of the defect is lack of balance, precocious parental fixation, and continued attachment to the parent-stem, that makes the adult defect possible. The very infantile precociousness of the emotions argues for the hereditary transmission of destructive temperamental qualities. Here, as elsewhere in tracing hereditariness in so-called functional nervosities, one should take as the unit character for study the mental traits or trends and exclude definite disease entities applied to ancestral disorders. I believe it is not too suppositious to think that many of these variant individuals are really atavistic in makeup and have continued from one generation to another special defective traits of emotional makeup which are fortunately denied the average individual."
The writer cannot understand how the theory which he has taken the trouble to so fully present in the above quotations can be maintained. Jones and Clark both assert that the tics or habit spasms as probably of the same nature as the obsessions in general. Moreover, Jones agrees that "familiar examples of compulsion in a slight degree are the obsessive impulses to touch every other rail of an iron fence as one walks past, to step on the cracks between the flagstones of the pavement, or not to step on them, and so on." A little reflection will show us the impossibility and illogicality of viewing all these conditions as being fundamentally of sexual origin. Let us follow the argument. If tics are of sexual derivation, as the Freudians here openly maintain, then it must follow that those familiar examples of compulsion, such as the obsessive impulse to touch every other post, etc., are likewise of sexual origin. This conclusion is forced upon us, since, even according to Jones, the only difference between the marked tics and the lesser manifestations is one of degree.[*] Now, these slighter impulsive tendencies to which we have here referred are very frequent in all children and by no means infrequent in grown-ups. They are habitual movements, which may be of transient duration only or may, by repeated performance, develop into more or less fixed habits. If, then, these habits are of sexual significance, it must follow that all other habits, especially if associated with a certain degree of consciousness or awareness, are in like manner symbolical of the past infantile and early childhood sexual activities and tendencies. This conclusion is, as is seen, inevitable, if we believe in the Freudian theory of the pathogenesis of the tics. However, since this leads us to a reductio ad absurdum, we must, of course, reject the explanation which has been offered by the Freudian school.
[*] The accompanying mental state characteristic of ticquers is absent in habits. We can stop doing the latter when our attention is directed to them; not so in tics Meige and Feindel have discussed these and other differences.
Perhaps I should also mention the fact that all of these symptoms or tendencies which one finds in ticquers occur in other individuals who do not present tics; and, furthermore, that all normal individuals possess these qualities or tendencies in varying degrees of intensity and in varying combinations, and that this applies to adults as well as to children, although, of course, they are seen most characteristically in children. I may further add that the difference between the mental infantilism which we find present in the tic psychoneurosis and that which we observe in other (normal and abnormal) conditions is one of degree rather than of kind. Therefore, the most we can say of the mental condition in ticquers is that there is an exaggeration of the mental infantilism or a fixation at or tendency toward regression to this type of thinking or of reaction. And this leads us to the further conclusion-and it is this point which I desire to bring out in this connection-namely, that since the difference between the mental infantilism in all of these conditions is relative, being one of degree and of proportionate relationship or at any rate of genesis, evolution and meaning, it naturally follows that what is in the conclusions of Clark, as mentioned above, asserted to be an absolute and basic principle or truth applicable to the tics, must consequently be true, but in different degree, of all the other conditions of a similar or allied nature. Surely the motive source is fundamentally the same in all of these conditions.
Furthermore, tics occur in animals, especially in horses; and the whole picture, physical and mental, of tics in horses resembles that which we find in human beings, particularly idiots and imbeciles, with tics. And the ultimate, fundamental meaning and motive source of tics in man is and must be the same as that of tics in horses.
To put Clark's idea in a nut-shell, it may be said that he believes that the primary purpose of tics is not that of a protective, defense mechanism against unpleasant situations in life but that of obtaining really pleasurable gratifications to the psyche, these autopleasurable acts being based on inherent defects and having a sexual significance in the sense in which sexuality is conceived by Freud. The protective, defense mechanism is, according to this view, but secondary to the primary and
fundamental purpose of obtaining the autopleasurable gratifications to the psyche.
Although approving of the analytic and genetic tendency displayed by Freud, Clark and the Freudian school in general, it is regrettable to me that the analytic tendency and reconstructive efforts of the Freudians in the field of neurology and psychopathology have been seriously marred by their insistence on forcing all observed physical and psychical phenomena and reactions into line with their fixed sexual theories and their special psychology, which is basically wrong in many fundamental and important standpoints.
The writer will agree with the Freudians that there must be a cause for the appearance of these tics. This cause existed in the past. It has in the course of time been forgotten, but still exists somewhere in the subconsciousness or memory. This forgetting has been brought about by a process of dissociation from the original exciting cause. But the writer will not agree that this dissociation has been, of necessity, brought about by psychic repression on the part of the individual, that by psychoanalysis the condition can be traced back to the sexual activities or tendencies of infantile or early childhood origin, or that the condition may be cured when the original cause is made known to the patient through psychoanalysis, without the training of the will so necessary in this condition.
Thus the analytic tendency of the Freudian school is to be highly commended. But this analysis should not be limited to sexual analysis, but should include a consideration of all of man's instincts. Nor should the analysis be limited to present-life psychic factors alone, but should be viewed from a psychobiological standpoint. In this way only will all antecedent causative factors-physical and mental-be included in our analytic observation and speculation.
To fully discuss or to prove the error of Clark in his conclusions would necessarily lead me into a general discussion of Freudism, which I cannot do in this place, since the ramifications are too numerous and the problems involved would lead to lengthy and tiresome discussion, pro and con. I must, however, mention the exclusively sexual standpoint assumed by the Freudian school in their interpretations of physical and psychical activities, their classifying of all activities characterized by a certain rhythmicity and periodicity, and accompanied by a certain degree of satisfaction- in other words of all autopleasurable activities-as sexual (in the Freudian sense), and the neglect of comparative and behavioristic psychology with proper consideration for man's phylogeny and ontogeny or of his true genetic history, from the racial and world history and not alone from the individualistic psychological standpoint. As a matter of fact the conception of sexuality assumed by Freud and his followers has undergone many changes and is by no means definite and clean cut in its outlines. A criticism of the conception of sexuality cannot be entered upon here. I may merely state that what is an absolute and fixed law for the tics, what is the fundamental and basic explanation or theory of the genesis and meaning of the tics must apply also to all habit movements wherever and whenever they occur, and, in like manner, to all habit formations of whatever nature. And since our habits are but the prolongations of our instincts, the latter also would be included within the purview of the same generalization. In other words, if all tics have a sexual meaning, then all instincts, which means the vital energy of man, has the same meaning. This question I have discussed in another place[7] and cannot enter upon here.
[7] A Critical Review of the Conception of Sexuality Assumed by the Freudian School. Medical Record, March 27, 1915.
Without furthur elaboration or discussion I am content to give the Freudian conception to you as I have outlined it above and to let it stand for what it is worth.
I may say that in the physical aspect of tics we have a specific somatic manifestation which, if explained, should, in a way, be the gateway toward the understanding of the many somatic symptoms which we find in the psychoneuroses and psychoses.
THE EVOLUTIONARY, PHYLOGENETIC STANDPOINT
A year or more before Clark's paper appeared, I had arrived at certain general conclusions regarding the subject of tics.
G. Stanley Hall has arrived at similar conclusions in his inspiring Synthetic Genetic Study of Fear[8] and I wish here to acknowledge my indebtedness to his paper for making my own ideas clearer to me, for having given me broader standpoints and for clearly presenting a theory which shall form the basis of the remainder of this paper.
[8] In the American Journal of Psychology, Vol. XXV, in the July issue et seq.
Let us first take up the tic movements and see whether we can arrive at a rational explanation for their appearance.
The different varieties of tic movements embrace the entire field or range of systematic, physiologically coordinated voluntary muscular activities.
The main types of tics may be enumerated at this point: facial tics, which are the most frequent and which may be tonic or clonic, are tics of mimicry and express emotions; tics of the ear or auditory tics; nictitation and vision tics, particularly of the eyelids; tics of sniffing; tics of sucking; tics of licking; tics of biting and of mastication, and mental trismus; tics of nodding, tossing, affirmation, negation, salutation and mental torticollis; trunk, arm and shoulder tics; snatching tics; the professional or occupational spasms, which are really a special atypical form of tics; walking and leaping tics; tics of spitting, swallowing, vomiting, eructation and wind sucking (aerophagia); tics of snoring, sniffing, blowing, whistling, coughing, sobbing, hiccoughing; tics of speech, including all sorts of sounds, stammering (in some cases), habit expressions, echolalia and echopraxia.
It is thus seen that we have here physiological and biological acts of different manifestations and purposes.
The tic movements have a certain significance at the time of their performance. The physiological functions are definite.
The Magnan school insisted that tics are not morbid entities but episodic syndromes of mental degeneration. Charcot referred to tic as a sort of hereditary aberration, which, I may add, is surely true when we view it from the phylogenetic standpoint, as representing a resurrection of what was at one time a normal tendency or reaction. Noir has called attention to the fact that the movements found in the tics correspond to the infant's spontaneous muscular play, which means the muscular play of all mankind.
These authors were directing their efforts in the right direction. To appreciate this we need but remember that the mechanisms or the potentialities for the movements are inherited and have a phylogenetic significance. At a lower psychic level, far back in our phylogenetic racial history, all of these movements, perhaps then in a rudimentary form, had a single, original meaning. This meaning was self-preservation, and it was because of its value as a means of adaptation or reaction to the environment, with the consequent maintenance of self-preservation; that the movements or the mechanisms of the movements were selected for survival and for hereditary transmission as inherent, unconscious, organic mechanisms, processes or engrams. The original, phylogenetic significance attained at a low cultural or psychic level, relatively unconscious, may or may not later be consciously associated or dominate its subsequent functioning. But its primary, biological significance, its real raison d'etre is to be found in the phylogenetic, racial history of man. The present life history with its varied experiences do but act as stimuli or as exciting factors to bring once more into activity functions which have been preserved in the organic structure of the nervous system.
In our return to phylogenetic, ontogenetic, rudimentary, unconscious, organic reactions, to atavistic, prehistoric, performed, embryonic, immature methods of response, the vestigial remnants, revivals of long ago, which have been submerged but which now reappear due to our reversionary tendencies-uprooted by dissociation, disintegration or regression, with its lapse or descent to low cultural or psychic levels-these old components which reappear or rather fall apart and appear as independent activities, are exaggerated, inflated, caricatured or excessively performed. In our devolutionary tendency toward ancestral methods of reaction, the individual, resolved, so to speak, into his proximate elements, permits or is compelled by biological determinism to permit these split off tendencies to break forth once more, albeit in exaggerated fashion, as if let loose from the leash of control by the higher nervous centres, and reanimified, intensified, and magnified, our infantile, archaic, instinctive, inherited, hidden, phylogenetic tendencies or activities held sway.
It seems to me that it is well worth while to quote at some length from G. Stanley Hall, that great exponent of genetic psychology and all that it stands for. His very stimulating and inspiring paper on fear, to which I have already referred, is freely quoted in the following paragraphs.
According to geneticism, Stanley Hall tells us, all responses to shock are vestiges of once useful reactions. In fact, the shock neuroses and shock psychoses, if analyzable psychogenetically, "would be found to be reversions to, and also perhaps more often than we suspect, magnifications of acts and psychic states that were at one time the fittest of which our forebears were capable.[9] However, all the pathological phenomena of today are not mere revivals of the acts and states of primitive man and his ancestors, but "they are often, on the other hand, grotesque variants and intensifications of phylogenetic originals that were more sane and simple if also more generic. Shock symptoms may thus be symbols of long past racial experiences which when we have learned to interpret them more fully will tell us much of the early history of our phylum."[10] It is the outbreaks of emotion which "mark the incursions of the race into the narrow life of the individual."[11]
[9] Loc. cit., pp. 178-179.
[10] Loc. cit., p. 179.
[11] Loc. cit., p. 183.
Furthermore, "the central nervous system differs from all others in that it is par excellence the organ of registration and of physiological memory. It is there that the traces of ancestral experience are stored so that almost nothing that was ever essential in the development of the phylum is ever entirely lost. Hence suggestive as are many physical traits of our racial history, the intangible psychophysic traits must be assumed to be both far more numerous and more indelible.
"While these faint tendencies often crop out in a behavioristic way, by far the most of them need some stimulus of individual experiences to awaken them, and still more exist only in the slight facilitization of impulses or permeability of nervous centres, lability of molecular or neural tensions, or as preferential re-enforcements, in one rather than in another direction or manner."[12]
[12] Loc. cit., p. 351-352.
It is obvious that motor expressions of shock or motor methods of adaptation or reaction are much older and far more prominent than psychic. But although a changed environment made the old types of defense obsolete, they still persist, "in a sthenic if somewhat now inco-ordinated way, and when they are called into action now they evoke a faint phosphorescence of the old primordial feeling."[13]
[13] Loc. cit., p. 197.
In brief it should be said that no matter how refined and how highly cultured we are, we still fear and react to emotions "in the same terms of the same old gross organs and functions as do the brutes."[14]
[14] Loc. cit., p. 197.
REGRESSION
As I have stated in a previous paper,[15] the pathogenesis of tics and allied conditions can best be appreciated by viewing the subject from an evolutionary standpoint. In our reactions and adaptations to the varying experiences with which we meet we respond by one or more of several methods of motor reaction. These motor expressions are of increasing complexity as we ascend the scale of evolution and development. One of the simplest kinds of adaptation is by simple, reflex muscular action, the response being anatomical and not physiological in its extent. Then come our simple physiological reactions. A more complex reaction is by those physiologically co-ordinated motor reactions or movements which go to comprise our pantomimic movements. This is seen most characteristically in our facial expressions, gestures, mimicry and dancing. Still higher up in the scale we find our conduct and feelings as exemplified in our speech. And finally, highest of all, we must place our conduct as shown in written or printed language. This is a brief outline of our evolutionary and developmental ascent and of the increasing complexity and refinement of our social conduct.
[15] Tics. Interstate Medical Journal, January and February, 1915.
In our motor adaptations we respond in one or more of these ways. When for some reason or another one outlet us denied us, we find avenues of expression through one or more of the other paths. Now, the manner and degree of our response is dependent on our stage in evolution and development, on the development of our senses, on our instincts, feelings and emotions, on our intellect and experiences. Unable to find expression by means of writing or speech, we instinctively fall back upon and seek expression by a less refined method, one earlier acquired and thus lower in the scale of evolution. This has a more or less general application throughout the scale of human (individual and social) conduct. It is an application of the universal law of adaptation to existing conditions in the best manner possible under the circumstances. We may thus lay down in a general sort of way a conception which I like to call the theory of psychophysical progression, fixation and regression along evolutionary and developmental lines. In the case of tics the regressive or devolutionary aspect comes in for special consideration. We may react mainly physically, or mainly psychically. But as a rule we react by both physical and psychic means, the manner and degree of our conduct being determined, as above mentioned, by our stage in evolution and development.
How does all this preliminary and general discussion apply to the problem of the tics? The relation seems to me to be most intimate and most important. The tics are methods of response or reaction to certain external irritations or ideas, this response being the manner of adaptation. The response may be mainly motor or mainly psychic, most frequently psychomotor. When the source of irritation and the cause for action is known, our conduct is more specific and is apt to be less diffuse, less inadequate, less indefinite. In our reactive adaptations, which, as explained above, are greatly dependent upon our psychophysical make-up or constitution, we protect ourselves consciously or more or less unconsciously against disagreeable, inimicable, unpleasant or irritating environmental factors, physical or psychical, by bringing into activity certain psychical or physical or psychophysical reactions or processes. The special defense reactions brought into the foreground are those which follow the line of least resistance, due to hereditary or environmental construction, or are those which were most intensely stimulated or irritated and the most biologically useful and adaptive at the particular moment or under the special circumstances. The young child's reactions are preponderately motor, or at any rate psychomotor and not purely psychic. When there are sources of irritation or bodily or mental discomfort, there is a more or less general bodily reaction, psychophysical in nature. When the irritation is definite and clearly recognized by the child, the local motor response is also apt to be definite. When, on the other hand, the irritation is but vaguely perceived and not clearly appreciated or localized, we find that the child may show a general diffuse reaction, or even, in some cases, a reaction limited to certain regions as determined by the reaction taking place along the line of least resistance. This is plainly seen in the conduct of the physically sick child. Every pediatrician will find ample proof in support of this statement in his observations of the defensive reactions of the ill child.
When this irritation along a certain nerve path is oft repeated or quite constant, we have a consequent repetition of the defensive reaction, whatever it may be. This performance may be so frequently repeated that the idea of irritation or mental conflict or the anticipation or the expectation of a repetition of same may be quite sufficient in itself to arouse this reaction. It may become so habitual that, even though no such idea be in the mind, there may be a repetition of the movement whenever the individual is nervously excited or upset, whenever there is any mental stress, strain or discomfort. And we may go even further and say that as a result of some unusual mental struggle, some excessive mental strain, defense or adaptation is brought about by regression or resort to a tic, this being conditioned by the fact that for the particular individual under discussion this is the easiest, most convenient or most immediate form of reactive response. The discharge is, as is seen, along the line of least resistance. This line of least resistance is determined by the organic nervous constitution and by certain life-experiences or habit-formation factors. In some cases the movement, once initiated, may be continued long after the disappearance or cessation of the external irritation, because of the sense of relief or satisfaction or pleasure[*] which is obtained by the performance of the tic. In many instances the habit has become rather fixed, and, as a relief from the struggle to do or not to do the movement, and because of fatigue in the effort to inhibit or control the movement, the individual adopts the path of least resistance, best for immediate relief from mental struggle; and as a psychobiological effort at self-preservation and self-gratification, as immediately as possible and at any cost to be paid in the future, he gives vent, as it were, to the movement.
[*] This is not, of course, of a sexual nature the Freudian school notwithstanding.
The psychic symptoms may come on at a later date than the motor symptoms or simultaneously, although, of course, the early life history, in childhood and puberty, for example, if we are dealing with an adult, may show, at least in a certain proportion of cases, that the individual was of a psychopathic type, perhaps somewhat shut-in or asocial. If the appearance of the psychical symptoms be simultaneous with that of the physical symptoms, we can understand at once how, like the motor symptoms, they may be repeated time and again. In many instances, at least, the psychic symptoms arise later, being added to the motor symptoms. These later psychic symptoms may be a direct reaction to the source of irritation, or may be occasioned by the dissatisfaction at being unable to control the movement in question.
The degree of reaction, its duration and severity, depend upon the hereditary and developmental make-up of the individual and the severity, frequency and duration of the irritation, physical or psychical. The psychic element is particularly apt to vary. The more neuropathic and psychopathic the make-up the greater is the reaction.
Where mental enfeeblement or mental disorder exist, the severity and chronicity are apt to be still greater.
There is thus a fixation, or rather a regression or reversion, oft repeated, to a type of reaction of a very infantile, primitive sort, farther down in the scale of evolution and development.
This picture may be further complicated by so-called neurasthenic, psychasthenic, hysterical or other reactions. Naturally one would expect to find these conditions, especially the more aggravated forms, in individuals of a neuropathic and psychopathic family strain, and who themselves are neuropathic or psychopathic or both.