It may be mentioned here, as is clearly appreciated from what has been said before, that there is an interrelationship between the tics on the one hand and the symptoms which we discover in the psychoneuroses, psychoses and the mentally unstable on the other.
In all of these conditions we find a cortical origin for the disturbance, there is a lack of will power, of inhibition and of control of the lower centres, there is a nervous and mental instability with a tendency toward regression or dissociation, and the assumption of more or less independent, almost automatic activity, this activity being characterized by its almost (relatively) infantile, primitive, archaic makeup.
Were I to take up any one of the tics as an illustration, this general idea could be applied very nicely. But I shall not present any illustrative cases in this paper. I shall leave it to the reader, however, to explain the genesis and evolution of, for example, facial tics (which are so common) from this standpoint.
In passing I may say that the tic movements may have a special, individual, psychological significance. But this is by no means necessarily so. Frequently, I am inclined to believe usually, these movements result rather merely because there has been effected a psychobiological reaction, following the theory of psychophysical-progression, fixation and regression with involvement of the nervous paths most seriously affected or most easily disturbed.
In the case of the tics, therefore, it is as if the various tic movements are being used in reaction to or in adaptation to sources of internal or external, physical or mental irritation, for the protection, defense or self-preservation of this or that particular part of the nervous system-as if the movements which we find in the tics and which are the expressions of certain engrams, neurograms, mnemes or organic memories, are existing in and for themselves, except that, in the tics, they are reacting with and for the psychophysical organism, the organic make-up or personality.
The individual, as a biological unit, is reacting to the particular situation which presents itself by the tic mechanism.
By granting the phylogenetic, racial significance we also give the basic, psychophysical meaning of tics in all ticquers.
EXCITING FACTORS
How is it that these activities may come into play again? What brings them to the surface once more?
There are many factors which come in for consideration in this connection. In the first place the basic cause is the instinctive, organic, psychophysical make-up of the individual. Whether and which functions re-exist as of old and respond as means of adaptation and self-preservation, depends on the stability and the weaknesses or defects of the nervous mechanism or system with its various parts, systems, functions or inherent psychophysical dispositions on the one hand, and the life-experiences and the immediate inciting factor on the other hand.
A neuropathic or psychopathic or neuropsychopathic constitution with its usual causes (germinal, intrauterine or extrauterine, usually of a toxic, infectious or disturbed metabolic nature, and including particularly alcohol, syphilis and nutritional disorders) may form the ground work. This predisposition may be congenital-that is, present from the date of birth, although not necessarily germinal in origin, or it may be acquired at some period in life from physical or psychic causes. In this connection the infantile and early childhood history are very important. Consequently the diseases, training, example, education and opportunities in childhood and infancy are of very great significance, the parental training and example and the home conditions having a most intimate relationship to the development of many of these tics. Imitation and mimicry here play a decided role. Spoiled children, too quickly satisfied or over repressed, are apt to develop tics. External somatic irritations may be the starting point in some (not in all) cases. At other times an idea (normal or abnormal) may incite the tic movements. Auto and hetero-suggestion, hypochondriacal ideas, hysterical symptoms and obsessions may, particularly in adults, initiate tics. Obsessions are especially apt to produce habits or tics, if they produce any motor reaction. Tics may develop into obsessions and vice versa; or both may co-exist simultaneously and be unrelated. The original ideas which led to the movements vanish while the movements survive. In the insane various sorts of delusions may be the groundwork on which a tic may later develop. Habit movements, which represent purposive physiological acts which have become automatic and not inhibited (hence showing weak will power) and which seek strongly for expression, which the individual struggles against and endeavors consciously to inhibit and overcome after the tendency is fairly well developed, may eventually become impulsive and irresistible with the ultimate evolution of the psychic state which is characteristic of ticquers. Automatic habits and mannerisms or stereotyped acts are of course not tics but the latter are but caricatures of the former with an added characteristic mental state. Tics, as mentioned earlier in this paper, are thus pathological habits.
Tics may also be but the symbol for a vague feeling of tension, irritation or stimulation, which seeks relief or expression by the performance of the tic.
Emotional stress and strain, fright, fear, excitement and mental shock can arouse a tic. Mental conflict and unrest has not received that degree of attention which it surely deserves. Clark and the Freudian school have definitely called our attention to this aspect. Bresler refers to tic as a motor reaction to original mental shock, so that it is in fact a psychic defense reaction of expression. Dupre has stated that emotional shock may act as a possible exciting cause of tics, as at times of obsessions. Meige and Feindel have asserted that fear may excite a movement of defense, and although the exciting cause has vanished, this movement may continue to persist as a tic. They also mention that in ticquers we frequently find the impulse to seek a sensation and to repeat to excess a functional act.
That there is a weakness of will power in the ticquer, with a lack of control or inhibition over the lower neurones normally regulated by the higher co-ordinating centres, so that certain automatic activities become dissociated and exist more or less independently, is generally acknowledged.
In fact it must be said that tics are reactions of the organism, of the organic make-up, the psychophysical personality, as a response to irritation, excitation or stimulation, sensory, nervous or psychic! It is a means of relief of tension, of organic reaction or adaptation, not necessarily conscious but frequently unconscious and automatic, as in fear. Starting in this way it may persist. In the tic we see a method by which the individual or organic personality has met a certain difficult or undesirable or disturbing situation. It is thus a constitutional, biological defense reaction, psychophysical in nature, with a reversionary tendency (when viewed from the evolutionary standpoint), and hence is indicative of degeneration, this term being used in the racial, biological, phylogenetic and ontogenetic sense.
There is not such a far cry from the simplest tic to Gilles de la Tourette's disease or maladie des tics with its more pronounced signs of psychophysical deterioration and dissociation. The tendency is a degenerative one- a prolapse to ancestral methods of reaction, a dissociation or disintegration of the personality, a lack of control over more elementary activities. We should therefore appreciate the need of early recognition and treatment of tics and fixed habit movements, especially since there is a tendency to spread, for the tics to multiply, and for mental symptoms and reactions of a hysterical and psychasthenic nature to appear, if they do not already exist or have not existed before the onset of the tic.
In brief, then, tics represent the emotional reactions and feelings of the individual-the loves and the hates, the likes and the dislikes, the wishes and the fears, the cravings and the dissatisfactions, the bodily and mental tension, unrest, excitement, discomfort and disequilibration. In other words the ticquer feels and speaks and acts by the tic. He lives by, in and for his tic. He is attempting to meet certain situations of a disturbing nature and to obtain equilibrium and equipoise by compensating for his feelings of inefficiency and unrest by the tics. It is an organic, constitutional, psychophysical, biological means of adaptation.
PROGRESSIVE EVOLUTION OF THE CONDITION
We now come to the progressive evolution of the motor manifestations and to the mental aspect of this condition.
Concerning the mental state characteristic of the ticquer it is generally agreed that there is a polymorphic psychic defect or disorder which shows itself particularly in a precocious or hyperemotional condition, in a lack of will power and of inhibitory control, leading to a state and feeling of doubt, indecision, incapacity, insufficiency and unreality, of inferiority and self-depreciation, with a tendency towards morbid self-absorption, egocentricity, self-observation, auto-and hetero-suggestion, with the consequent development in many instances of so-called neurasthenic, psychasthenic, hysteric and various psychotic reactions. I am not prepared to say definitely how frequently the mental state, in lessened degree, precedes the outbreak of the tic movements. This may be present in a certain proportion of cases, but is by no means always present and it is even questionable whether the predispositional mental condition is the ground work in the majority of patients.
Tics, it is true, are especially apt to develop in individuals with a neuropathic or psychopathic history or heredity. In other cases this history is not obtainable, the individual having been apparently perfectly normal up to the time of the outcropping of the tic. In these cases shock is apt to bring on the outbreaks and so one may say that the instability had been latent and that a severe shock was sufficient to bring it to the surface. We must remember, in all these cases, that the mental state which we see in the ticquer is but an exaggeration of that which appears in many children, and is similar to that which appears also in other psychoneurotic states, and in fact the germs of this condition may occur transiently in any of us. This psychic condition may frequently but does not always precede the appearance of the tic movement. But it is only after the appearance of the motor manifestations of tic that the mental state becomes prominent or develops where it was not noticeable if not absent before.
Be that as it may, or even granting that in most patients the characteristic mental state or the neuropathic or psychopathic make-up exists in some measure to an abnormal extent, we do know that once the tic movements have made their appearance and begin to spread, so that the individual is thrown into the struggle to perform or not to perform the movement, the development of the psychic state which we find so patent in the more pronounced forms of tic, thereafter more or less rapidly occurs, no matter what the mental condition of the ticquer may have been previously. I am also not prepared to discuss here at any length the phylogenetic or ontogenetic significance and the biological genesis and meaning of the various mental trends of the ticquer, but I may say that they too have been acquired in the course of evolution, for certain very definite reasons which need not concern us here, although it can be appreciated that the biological motive of self-preservation played a most important role in their genesis and fixation.
APPLICATION OF ADLER'S THEORY OF THE NEUROTIC TO TICS
The progressive spreading of the tic movement which so commonly occurs, as well as the evolution of the mental aspect which develops subsequent to the appearance of the tic movement, may be very nicely understood if we adopt, for our present purposes the recent theories of Alfred Adler,[16] of Vienna, concerning the makeup and development of the neurotic. This we may do without committing ourselves, at this moment, one way or the other, with regard to the correctness or incorrectness of Adler's views as applied in toto to the neurotic.
[16] Ueber den Nervosen Charakter, 1912. See also Adler's Studie uber Minderwertigkeit von Organen, 1907.
One should note that Meige and Feindel were, in a way, on the threshold of this theory when they said that tic, like the other psychoneuroses, is due to some congenital anomaly, an arrest or defect in the development of cortical or subcortical association paths-unrecognized teratological malformations.
In a very few words Adler's theory may be given as follows: Adler assumes that there is definite somatic inferiority (based on anatomical and physiological changes) as the basis or foundation for the neurotic soil. The neurotic consciously comes to realize the unconscious, organic, somatic inferiority, and the endeavor to effect a psychic compensation or to make up for these organic deficiencies by certain definite mechanisms, frequently results in an overreaction or over-compensation. He thus overdoes himself in efforts to make up for his inferiority, and in these endeavors he necessarily makes use of unusual means and devices. It is this effort which is the great motive force which dominates the life activities of the individual and which compels him to seek as his ultimate object or final goal a state which is best described as one of complete masculinity, of full manhood, of self-maximization, of the will to live, to become powerful and to seek supremacy or "the will to power" (Nietzsche). In following this goal he goes to extremes and employs peculiar methods and devices, most of which have for their object the concealment of his defects, and it is these overcompensatory efforts and these peculiar devices resorted to, which go to form the peculiarities or traits of the neurotic. According to Adler's theory, the conscious efforts of the individual for psychic compensation or overcompensation (for the unconscious, organic deficiencies) leads to a resulting feeling of insufficiency, of incompleteness, of inferiority, of unreality, of anxiety, of inability to face reality. Thus the mental symptoms or characteristic mental state, being but the conscious recognition of the unconscious inferiority, become especially pronounced when there is a failure of compensation, or, in other words, when the individual is unable to meet with or adapt to the situation which at the moment presents itself. In these forced efforts at defense and compensation there is a resort or regression to older, infantile, child-like, archaic types of reaction, of a physical or mental nature, which are thus the protective defense mechanisms or symbols. The struggle of the neurotic consists particularly in the conscious appreciation of his goal and of his deficiencies of makeup and in the attempt to reach his goal of full manhood and self-maximization in spite of his handicapping deficiencies.
Without discussing the exact status of this theory in the case of the psychoneuroses and their related conditions in general, we may, as mentioned previously, very conveniently use this theory in the elucidation and understanding of the further development of the tic condition.
Let us first consider the spreading of the tic movements. We know how in the ticquer one tic movement may disappear only to give way to another, or one after the other an increased number of tic movements and also of definite compensatory movements not of a tic nature but of the nature of antagonistic gestures and stratagems may make their appearance. The latter may in certain instances become habit movements and eventually real tic movements. One movement after the other may be resorted to, some perfectly consciously, others more or less unconsciously, as reactions of the personality, of the organic makeup or psychophysical constitution. These movements are adopted by the patient, frequently more or less unconsciously, in order to attain a state of equilibrium and rest, and in order to hide and make up for the defect (the tic movements) of which he is aware. In these efforts he overdoes himself and instead of hiding the movement he exaggerates it and even resorts to further movements in his struggles to compensate, to adapt, to conceal, and to flee from a state of mental disarrangement to a state of psychophysical equilibrium.
Now, most of our gross reactions are of a psychophysical nature, so that we find that when the old types of defense or of activity are called forth (as they are in the tics, as explained earlier in this paper, from the evolutionary and phylogenetic standpoint), the resulting actions, now reanimified, appear in exaggerated form, and also tend to "evoke a faint phosphorescence of the old primordial feeling." This probably results in the outcropping of the various psychic trends which appear in the ticquer and which increase in degree and in number. The most common of the resurrected psychic trends is the general tendency to dissociation or disruption of the personality with the reanimification, in varying degrees, of certain mental deficiencies and inferior types of reaction which are indicative of the relative failure of the patient to measure up to and efficiently deal with and adapt to the struggles of life as he must face and meet them. And so, many undesirable and inferior kinds of mental trends come forth and hold sway. The basis of their appearance is the lack of will power and of control over these various trends which were previously more or less completely held under control but which are now impulsively forcing their way to the surface and being unravelled. These trends are characterized by their relative immaturity, their infantile-like and archaic type. And so we have the states of indecision, of doubt, of uncertainty, of inferiority, of depression, of unrest, of self-depreciation, of self-observation, of auto and heterosuggestion, of egocentricity, of self-criticism, of inhibition of the expression of the personality along the broader, social lines of effort. The groundwork for added states (hysteric, psychasthenic, and others) is here very fertile.
The law of psychic ambivalence and ambitendency, as so nicely developed by Bleuler,[17] here shows itself in marked degree. There is both the positive and the negative tendency toward the performance and execution of these activities and reactions which are necessary for the living of a life of a high or low degree of efficiency, so that the ticquer is obsessed by the problem of "to do or not to do." This added factor leads to an exaggeration of all the unfavorable psychic tendencies which have made their appearance, and the intrapsychic struggle goes on with increased vigor.
[17] The Theory of Schizophrenic Negativism. Translated by William A. White. Nervous and Mental Disease. Monograph Series, No. II.
The entire mental picture which we find in the most extreme forms of tic could be beautifully elaborated along these general lines. For example, the ticquer becomes asocial, seclusive and shuns society because of the consciousness of the condition and the exaggerated sensitiveness. This represents compensatory, defensive methods of concealment. Absentmindedness and the inability to concentrate the attention are conditioned by the great degree of attention devoted to the tic. The mental dissociation or disintegration leads to an inflating of the emotional aspect of the patient's mental life with a resulting increased nervous irritability and reaction and a heightened degree of susceptibility to emotional disequilibration and fatiguability of the mental faculties. The lack of self-assertion, of confidence in himself, and the feeling of inferiority and insufficiency are natural consequences of the general picture. The inhibition of even, unhampered self-expression is always observed.
In tics, it must be noted, there is regression to more inefficient and inferior methods of response and adaptation, the types of activity being of a somatic and psychic nature. Following the regression and owing to constant repetition and habit formation there is a gradual fixation to certain methods of response which become the lines of least resistance and this is followed by progression and development of the general picture to other tics and psychic symptoms.
In general we note that the psychophysical reaction which we come upon in the tics leads to the unearthing of various psychophysical types of reaction, this unearthing consisting of disintegration or regression or dissociation, the repressed, hidden, unconscious, phylo and ontogenetic, archaic and relatively infantile-like activities, tendencies and possibilities coming to the fore and unfolding themselves.
It is here seen that this broad genetic standpoint is one of the greatest contributions to psychopathology and is of infinite aid to us in the understanding of the problems which confront us in the domain of psychopathology and psychiatry.
Comparative and animal psychology and the study of the reactions of children, of primitive races, and of the mentally disordered give us a splendid opportunity for studying it and unravelling the meaning of the many somatic and psychic manifestations which are exhibited to us in the psychoneuroses and psychoses and in tracing out the racial history of man. Is it not plain that an understanding of the genesis and meaning of tics opens the gateway to the elucidation of the origin and significance of the psychoneuroses and functional psychoses-of reaction types of various kinds?
REVIEWS
THE INDIVIDUAL DELINQUENT. By William Healy, A. B., M. D. (Little, Brown & Co., Boston, 1915.) It is a rare and pleasant experience to meet a book on such a general topic as delinquency, which has not as its raison d'etre the exploitation of some over-worked hypothesis. The Director of the Psychopathic Institute of the Juvenile Court in Chicago has, however, not only avoided this danger but has given psychologists, jurists, and penologists such a report of his five years work as not one of them can afford to overlook. As the title of the work implies, the material is drawn from the individual study of the delinquent. He presents the results of the unbiased investigation of the discoverable factors in the production of criminality in 1000 recidivists, who were mostly, though far from exclusively, adolescents- the period when factors, both internal and external, are most easily determined and modified.
A careful perusal of the introductory chapter on methods reveals both the thoroughness and open-mindedness of the author. He demonstrates that no satisfaction was gained by the finding of any special mental or physical abnormality, unless a more direct relation could be shown with the crime committed than is established by mere coincidence. It is particularly satisfying to note the precautions taken in the application of set tests, how careful Dr. Healy and his assistants have been to determine the completeness of cooperation on the part of the subject and to weigh this factor in evaluating the results. One soon reaches the conclusion that the author's own series of tests are much more likely to lead to reliable diagnosis than the series of Binet, which demands so much of the rather specialized capacity of abstract formulation. Healy's tests, on the other hand, deal fairly with the primitive, untaught mind and that which has an unequal and deceptive development of language ability. In connection with these tests, it is interesting to note, by the way, that he finds irregularity in results (or cooperation) to be so often associated with epilepsy and depletion from sex over-indulgence that it may be taken as a suggestive diagnostic feature.
The value for the reader in discovering the eclectic view-point and critical conservatism of an investigator lies in the confidence which these qualities beget in the reliability of results. One can read most of "The Individual Delinquent" to learn facts without the distraction of critical uncertainty. With this in mind, therefore, a few of his conclusions, picked mostly at random, may be quoted. An important factor in the production of delinquency he finds to lie in the premature appearance of adult sex development-a precocity which he regards as dangerous because it seems to be correlated with a stimulation of sex instinct before adult inhibitions appear. In girls (not in boys) he finds a distinct tendency to general physical over-development as compared with the norm of the same age. In this connection it is striking to find how many of his cases, which seem to exhibit ingrained criminal tendencies, are delinquents only during the period of adolescent instability. The various statistics are naturally also of extreme interest, particularly since they are the result of examination of 1,000 cases, chosen for this purpose only when there were sufficient data secured to make the individual study relatively complete, and since they are so at variance with the publications of others who have approached criminal statistics to prove a theory rather than to learn facts. He finds alcoholism in one or both parents in 311 cases. He cannot determine any direct inheritance of criminal tendencies as such, but regards them as indirectly of great importance as there were 61% who showed distinct defects in the family antecedents. He thinks that stigmata of degeneration are probably better correlated with mental defect and also with nutritional or environmental conditions than with criminalism as such. Followers of Lombroso will be disappointed to read that he found only 83 epileptics, or possible epileptics, among his 1,000 cases. A full two-thirds of the cases presented no symptoms of mental abnormality while only one tenth were definitely feeble-minded. These are but scattered data; no digest, which might be taken as substitute for the book itself, would be advisable.
It is to be expected, of course, that psychologists (and particularly those interested in dynamic psychology) will find mixed pleasure in reading this work. The section on "Mental Conflicts" must appeal to all with its practical demonstration of what can be done by psychological analysis to abolish anti-social tendencies in many puzzling cases. There will undoubtedly be disappointment in his failure to make general psychological formulations, but, as the critics would differ amongst themselves as to what these formulations should be, Dr. Healy's silence is here probably a wise conservatism. At the same time there is certainly exhibited a tendency to be rather too individual and give too few generalizations. This is evidenced by his failure to regard as a factor in one case what has been admitted as such in a slightly more obvious instance. To cite one example: On page 192, he speaks of the inheritance of hypersexual tendencies; on page 166, we find: "... immodest behavior and use of obscene language on the part of a parent, which we have so frequently found to be one of the main causes of a girl going wrong ... " Somewhat similar results are thus ascribed once to heredity and again to environment. At this stage of our knowledge it would, of course, be foolish to eliminate any specific inheritance as a factor, but it is surprising that in the former case he does not consider environment as a factor, although he elsewhere gives striking evidence of unconscious influence proceeding from one individual to another via sex initiation.
It is possible that this lack of a broad psychological view point- this example chosen is far from isolated-is connected with a specific, and most definitely serious, defect in the book. The treatment of the psychoses is distinctly unsatisfactory. Apparently the author has had to rely on the literature for his preparatory experience and has been fortunate only in some cases, if we may judge by his references. The most satisfactory group he describes is that of the traumatic psychoses and there he follows Meyer's admirable study. On the other hand, in introducing the Dementia praecox group, he makes no specific mention of any one of the cardinal symptoms of disassociation or shallowness of affect, scattering of thought, and delusions or hallucinations. His nearest approach is when he says: "Variations in the way of excitement, with dullness and paranoidal excitement are seen during the course of the disease." This is followed by the description of a case which he says contains the symptoms typical of the psychosis but in which no pathognomic abnormality is mentioned except negativism- a vague term whose meaning varies with the observer.
Not unnaturally with such unfamiliarity, the psychosis is a "dispensation of Providence." There is no evidence that to him psychiatry is as much a problem of every day life as it is of institutional care of the insane. We can, therefore, find such a statement as this:
"The mental findings and the conduct determined the fact of aberration and that is all that should be necessary for immediate court purposes. Further business of diagnosis should be left to a psychopathic hospital."
It is true that responsibility may and should be evaded when the psychosis is full-blown; but how about the innumerable cases of incipient psychotic disturbance which grade over into the "mental conflicts?"
In harmony with this diffidence is the repeated hope for aid from the Abderhalden. or some similar reaction. For instance: "The newer methods of diagnosis of Dementia praecox we look forward to for help in one place where discrimination is important."
But surely a psychologist cannot hope to predict conduct by physical findings! If Dementia praecox postulated criminality, the situation might be different, but, as it stands, the reaction would only be of value in the doubtful cases- cases which are so many of them non-institutional.
With this vague conception of the psychoses it is not surprising to find that diagnosis used faute de mieux. For instance, in describing Case 169, of "pathological lying," he says:
"We could not in any way find evidence of mental peculiarity but we did question his story because of intrinsic improbability." Rather conflicting statements! Later on, he explains, the case was diagnosed as one of "epileptic psychosis" because the subject developed convulsions, although there is no evidence, or even claim, presented that the lying was an equivalent, or in any way correlated with the epilepsy except as a coincidence!