THE existence of psychical abnormalities in the subjects of tics is no new observation. Charcot[18] used to say that tic was a psychical disease in a physical guise, the direct offspring of mental imperfection—an aspect of the question which has been emphasised by Brissaud and by ourselves on more than one occasion.[19]

How is the involuntary and irrational repetition of a voluntary and rational act to be explained? Why is inhibition of a confirmed tic so laborious? It is precisely because its victim cannot obviate the results of his own mental insufficiency. Exercise of the will can check the convulsive movement, but it is unfortunately in will power that the patient is lacking. He shows a peculiar turn of mind and a certain eccentricity of behaviour, indicative of a greater or less degree of instability (Brissaud). Noir writes in much the same strain, that careful examination will readily demonstrate the secondary nature of the motor trouble; behind it a mental defect lurks, which may pass for singularity of character merely, or childish caprice, but which none the less may be the earliest manifestation of fixed ideas and of mania.

It is a matter of some difficulty to describe adequately the features of this mental condition; their extreme variability has its counterpart in the diversity of the motor phenomena. In this polymorphism of psychical defect is justification for the numbering of the tic patient with the vast crowd of degenerates, and indeed Magnan[20] is content to consider tic one of the multitudinous signs of mental degeneration. As a matter of fact, one does find numerous physical and mental stigmata in those who tic, just as one finds them in those who do not.

It therefore becomes desirable to specify in greater detail the mental peculiarities of patients who, by reason of their motor anomalies, form a distinct clinical group both from the neuropathological and from the psychiatrical point of view. The pathogeny of these motor troubles will thus be elucidated and valuable indications for treatment obtained.

Whatever be our theory of tic, whatever be the shape the individual tic assumes, it is in essence always a perturbation of motility, corresponding to a psychical defect. No doubt appearances are deceptive, and the brilliance of the subject's natural gifts may mask his failings. His intelligence may be high, his imagination fertile, his mind apt, alert, and original, and it may require painstaking investigation to reveal shortcomings none the less real. This practice we have scrupulously observed in all the cases that have come under our notice, and we believe that the information gleaned in this way, coupled with the results of previous workers, warrants the attempt at a systematic description of the mental state common to all who tic.

Charcot[21] had already remarked the presence of certain signs or psychical stigmata indicative of degeneration, or of instability, as he preferred to say, inasmuch as the mental anomalies of these so-called degenerates were not only frequently unobtrusive, but in a great many cases associated with intellectual faculties of the first order. His contention has been amplified by Ballet:[22]

In the category of "superior degenerates"—to use Ballet's terminology—will be found the vast majority of sufferers from tic, of whom O. may serve for the model. A no less instructive example is that of J.:

In a word, as with physical imperfection, so with mental—it may consist either in absence, arrest, or delay, or in overgrowth, increase, exaggeration, and these contrary processes may co-exist in the same individual. Sufficient stress, however, has not been laid on a practically constant feature in the character of the tiqueur—viz. his mental infantilism, evidenced, as was noted by Itard in 1825, by inconsequence of ideas and fickleness of mind, reminiscent of early youth and unaltered with the attainment of years of discretion. We must remember that imperfection of mental equilibrium is normal in the child, and that perfection comes with adolescence. In the infant cortico-spinal anastomoses are awanting, and volitional power is dependent on their establishment and development. At first, cortical intervention is inharmonious and unequal: the child is vacillating and volatile; he is a creature of sudden desire and transient caprice; he turns lightly from one interest to another, and is incapable of sustained effort; at once timid and rash, artless and obstinate, he laughs or cries on the least provocation; his loves and his hates are alike unbounded.

These traits in the child's character pertain equally to the patient with tic, in whom retarded or arrested development of volition, physical and mental evolution otherwise being normal, is the principal cause of faulty mental balance. That this view is correct may be inferred from a comparison of the individual patient with healthy subjects of his own age. The chief element in mental infantilism is maldevelopment of the will. While in the child deficiency of what one might call mental ballast is usually atoned for by well-conceived discipline and education, it is accentuated by misdirected teaching. Now, it not infrequently happens that the upbringing of the predisposed to tic is not all that might be desired, seeing that mental defect on the part of the parents renders them unsuitable as instructors of youth. Parental indulgence or injustice is the fertile source of ill-bred or spoiled children, in whom, spite of years, persist the mental peculiarities proper to childhood. From the ranks of these spoiled children is recruited the company of those who tic, for tics, generally speaking, are nothing more than bad habits, which, in the absence of all restraining influence, negligence and weakness on the side of the parents have allowed to degenerate into veritable infirmities. These the patients themselves are incapable of inhibiting, for whatever be their age, they remain "big children," badly bred and capricious, and ignorant of any self-control. Hence one of the first indications in their treatment is to submit them to a firm psychical discipline, calculated specially to strengthen their hold over their voluntary acts. Take the following case:

An identical mental state obtains in infantilism, properly so called, where to arrest of mental development physical imperfection is superadded. In cases of infantilism the psychical level corresponds more or less intimately to the somatic level, an observation borne out in the case of J.:

Or take Mademoiselle R., aged twenty-six:

Or again:

Another of our patients is L.:

X. has a tic of the eyes and has reached the age of forty-eight, yet he told us he was not so much his children's father as their playmate. At the age of fifty-four O. could still remark on his youthfulness of character. The same is true of S., who has attained his thirty-eighth year.

It is as arduous a task to define the term "stability of the will," as it is to explain what is meant by physical or mental health. But as it is not essential to preface descriptions of disease with a disquisition on the signs of good health, so anomalies of voluntary activity may surely be noted without a preliminary excursus on normal volition.

Will power may deviate from the normal in either of two directions—in the direction of excess or of insufficiency. To both of these two forms of volitional disturbance the subjects of tic have become slaves. Weakness of will is seen in irresoluteness of mind, flight of ideas, want of perseverance; exuberance of will in sudden vagary or imperious caprice. The man who tics has both the debility and the impulsiveness of the child; to his impatience his incapacity for sustained effort acts as a set-off; he is impressionable, wavering, thoughtless, even as he is mettlesome and irascible. He does not know how to will; he wills too much or too little, too quickly, too restrictedly.

As a single example of volitional activity, let us take the attention. Diminution of attention on the part of tic patients has been judiciously commented on by Guinon:

Excess of voluntary activity is disclosed in the whole series of impulsions.

The germ of homicidal or suicidal tendencies, which we have indicated in the case of O., is discoverable also in one of Charcot's patients.[23]

We have already touched on the close affinity between an act and the idea of the act, and we have emphasised the absence of any appreciable interval between the idea and its execution, unless the brake of volitional interference be put on at the proper moment. It is in these circumstances that the feeble of will betray their debility; the inadequateness or inopportuneness of their will's activity allows the performance of the act they would fain repress.

A no less characteristic feature of the subject of tic is his impatience.

Mental instability is not uncommonly associated with a general restlessness and fidgetiness during intervals of respite from the actual tics. The patient experiences a singular difficulty in maintaining repose. Every minute he is moving his finger, his foot, his arm, his head. He passes his hand over his forehead, runs his fingers through his hair, rubs his eyes or his lips, ruffles his clothes, plays with his handkerchief or with anything within reach, crosses and uncrosses his legs, etc. None of these gestures can properly be considered a tic, for, however frequent be its repetition, it is neither inevitable nor invariable. If they are superfluous and out of place, the absence of exaggeration or absurdity negatives their classification as choreic. They are a sign not so much of motor hyperactivity as of volitional inactivity. They are tics in embryo.

The patient's emotions are similarly ill balanced. Any rearrangement in his habits he finds disconcerting; he is upset by an unexpected word, a deed, a look; his timidity and sensitiveness are extreme—fertile soil for the development of tics.

So, too, with his affections, his likes and dislikes, his friendships and enmities—there is commonly a disproportion about them that betokens mental deficiency. At one time it is fear or repulsion that actuates him; at another it is an unnatural tenderness, a sort of philia, if the term may be allowed.

Anomalies such as these, however, are met with in all the mentally unstable, and do not present any special feature when they occur in those who tic.

An acquaintance with the mental state of our patients enables us to understand the mode their tic adopts. As one thinks, so does one tic. To the transiency and mutability of the child's ideas correspond what are known as variable tics, which rarely have a definite localisation, and become fixed only when certain ideas become preponderant. The existence of a solitary tic, however, is not at variance with that disposition we have qualified as infantile, for mental infantilism is the original stock; on it, as a matter of fact, may be grafted further mental disorders in the shape of fixed ideas, phobias, or obsessions.

Should a fixed idea entail a motor reaction, it may give rise to a tic as ineradicable as the idea itself, and a series of fixed ideas may be accompanied by a succession of corresponding tics.

The frequency with which obsessions, or at least a proclivity for them, and tics are associated, cannot be a simple coincidence. Without defining the word obsession, let us be content to recall the excellent classification given by RÉgis, according to whom they mark a flaw in voluntary power, either of inhibition or of action. On the one hand we have impulsive obsessions, subdivided into obsessions of indecision, such as ordinary folie du doute; of fear, such as agoraphobia; of propensity, such as those of suicide or homicide. On the other we find the aboulic obsessions, such as inability to stand up (ananastasia), or to climb up (ananabasia), or the astasia-abasia of SÉglas, or the akathisia of Haskowec. Perhaps we ought also to place here sensory obsessions in the shape of topoalgia, and even hallucinatory affections.

In all these varieties of obsession increase or diminution of volitional activity is undeniable. But this alteration in the function of the will is no less distinctive of tic, and if we compare the psychical stigmata of obsessional patients—the asymmetry of their mental development, their intellectual inequalities and lack of harmony, their alternating excitability and depression, their unconventionalities, eccentricities, and imaginativeness, their timidity, whimsicalness, sensitiveness, and all the other indications of a psychopathic constitution—if these are compared with the mental equipment of the sufferer from tic, we cannot but notice intimate analogies between the two, analogies corroborated by a glance at their symptomatology.

An obsession may be of idiopathic origin, or it may be causally connected with some particular incident, sensation, or emotion. A conflagration may determine fear of fire, or a carriage accident amaxophobia. Further, the obsession is irresistible, as is the tic: opposition endures but for a moment, and is therefore vain. Nor is the inhibitory value of attention or distraction any less ephemeral. This feature of tic was noted as long ago as 1850 by Roth, who held its motor manifestations to be phenomena of "irresistible musculation."

Consciousness is maintained in its integrity both before and after, but not during, an obsessional attack, and this is equally true of tic, as are the preliminary discomfort and subsequent satisfaction that attend the obsession. Noir makes the appropriate remark that idiots affected with krouomania, in whom sensory disturbance is awanting, so far from suffering pain through sundry self-inflicted blows and mutilations, seem, on the contrary, to be thus afforded a certain feeling of relief, if not of actual relish.

If, then, an obsession provokes a motor reaction at all, it may originate a tic, and, in the case of tonic tics, this is a very common mode of derivation, as one may well understand how an obsession may occasion an attitude.

Grasset cites the example of a young girl who would never lean backwards in a railway carriage or on any chair or bench, preferring to sit bolt upright on the edge. In this instance the adoption of a stereotyped attitude was directly attributable to an obsession.

Another example of an attitude tic is furnished by the case of young J.:

In this case the typical features of obsession are excellently illustrated—its irresistibility, as well as the concomitant distress and succeeding content.

Conversely, however, a tic may be said to develop into an obsession if the exciting cause of the latter be the motor reaction.

There is frequently no direct or obvious connection between a patient's obsession or obsessions and his tics. The former may consist, both in children and in adults, in extraordinary scrupulousness, perpetual fear of doing wrong, absolute lack of self-confidence, sometimes simply in excessive timidity, exaggerated daintiness, or interminable hesitation. We have often seen youthful subjects betray in their disposition weak elements such as the above, which at a later stage have proved the starting-point for more definite obsessions. Their intelligence and capacity for work earn the approbation of their teacher, yet they are for ever dissatisfied, haunted by the dread of having overlooked some iota in their task; they dare not affirm that they know their lessons, they stammer over their answers, mistrust their memory, make no promises and take no pledges, and thus bear witness to an absence of confidence in themselves which affects them profoundly, for they are well enough aware of its consequences.

An admirable instance of this is furnished by the case of young F., or by little G., ten years old, who suffers from a facial tic, and constantly hesitates when asked to give a measurement, an hour, a date, a figure, solely by reason of a conscientious fear of not being absolutely accurate in his reply.

In children the emotional excitement of their first Communion often favours the development of religious scruples. By a sort of metastasis, diminution of the convulsive movements goes pari passu with aggravation of the mental phenomena, until such a time as the devotional exercises are done with, when there is a return to the previous state.

Arithmomania betokens an analogous turn of mind. Certain patients are compelled to count up to some number before performing any act. One cannot rise from his seat without counting one, two, three, four, five, seven, leaving out six since it is disagreeable to him. Another must repeat the same movement two, three, ten times, must turn the door-handle ten times ere opening it, must take five steps in a circle before beginning to walk (Guinon). A patient of Charcot's used insanely to count one, two, three, four, used to look under his bed three or four times, and could not lie down until assured that his door was bolted. A further example is reported by Dubois:

Onomatomania is another form of obsession which may be mentioned, exemplified by the dread of uttering some forbidden word, or by the impulse to intercalate some other. The term folie du pourquoi has been applied to the irresistible habit of some to unearth an explanation for the most commonplace of facts: "Why has this coat six buttons?" "Why is so-and-so blonde?" "Why is Paris on the Seine?" etc. This mode of obsession is frequent among those who tic, and is curiously reminiscent of a familiar trait in the character of children, thereby supporting our contention of the mental infantilism of all affected with tics.

Prominent among the mental anomalies of the subjects of tic are found different sorts of phobia: fear of death or of sickness, of water, knives, firearms—topophobia, agoraphobia, claustrophobia, etc.

The following most instructive case has been observed by one of us over a period of several months:

A singular tic of genuflexion occurred in a case reported by Oddo, of Marseilles:

The dominant note in the young girl's character is her cowardice; she is afraid of everything. Every evening before the return of her father she repeatedly looks into the corridor to see that no one is there; as soon as her parent arrives, she locks the door behind him hurriedly to prevent any one else appearing; every now and then in her fear of a footstep she listens at the door, and it is this gesture, this attitude of listening, that has degenerated into a tic which no amount of remonstrance or derision seems to affect.