A Cursing Brain? The Histories of Tourette Syndrome (review)

Howard I. Kushner. A Cursing Brain? The Histories of Tourette Syndrome. Cambridge: Harvard University Press, 1999. xiii + 303 pp. $29.95.

There could certainly be no better prototype than a study of Tourette syndrome to convince the reader that therapeutic Weltanschauung and sociopolitical bias play vital roles in medical diagnosis and treatment. And since the interplay of physical and psychological factors in Tourette's is so little understood, it matters greatly whom a sufferer chooses as a physician. Howard Kushner has laid out the full dimensions of these issues lucidly and vividly.

While never fatal, Tourette's--a "syndrome" rather than a "disease" because there is no universally agreed-upon etiology--can be extremely debilitating. Sufferers develop involuntary motor movements known as "tics" during childhood. These can be head- and neck-jerking, or eye-blinking, or the like, and there are also vocal tics: barks, grunts, yelps, and coughs. Often these symptoms take on a compulsivity, such as a repeated series of actions. Symptoms sometimes wax and wane; some disappear. Motor movements can be mild or incapacitating, as when head-jerking causes muscle pain or prevents the sufferer from reading. More florid symptoms include loss of temper, physical violence, cursing (sometimes in a devastating way), making explicitly sexual gestures, and obsessively repeating one's own or others' words.

The disease was first named by a young Paris neurologist, Georges Gilles de la Tourette, as "maladie des tics," and was then given the designation "maladie des tics de Gilles de la Tourette" by his chief, Jean-Martin Charcot, in 1885. From the start, the name and conception were controversial, with many arguing that it was not really a true illness but an example of other, already recognized conditions such as mental degeneration, hysteria, or a form of chorea.

In less than a generation a psychological view of Tourette's evolved as a result of a 1902 book by Henry Meige and E. Feindel, Les tics et leur traitement--translated into English in 1907 as Tics and Their Treatment--that argued that ticcing was a matter of will. The psychological view was buttressed both by contemporary eugenic views on degenerative inheritance and by psychoanalytic thinking. In 1921, the analyst Sandor Ferenczi wrote a paper on tics that became the official psychoanalytic position on the malady, even though he had never examined a ticcing patient; he argued that ticcers suffered from repressed masturbatory desires. (To be perfectly fair, however, it must be noted that Ferenczi joined a long line of "experts" who formulated their views only by reading case histories.) In the 1940s the psychoanalytic position was taken further by Margaret Mahler (who did treat ticcers) who wrote that "tic syndrome" had an organic substrate, but that the behaviors manifested themselves only in psychologically susceptible children who had experienced severe repressed familial conflicts usually involving a domineering mother.

Thirty years later the tide shifted, as the syndrome began to be treated empirically by psychoactive drugs. Based on the efficacy of the medications, North American specialists concluded that Tourette's was a neurological condition. The drugs, especially haloperidol, usually helped--although not universally, since the degree of efficacy varied from patient to patient and not all patients could bear the side effects. The triumph of the organic view was partly due to the parents of tic sufferers who organized in an Association and demanded physical treatment for their children. Interestingly, the psychoanalytic view continues to dominate in France, partly as a rebellion against what is seen as American cultural imperialism, and partly because French psychoanalysts take a dim view of laypersons' interfering in the decision-making of medical professionals. However, there do seem to be psychological dimensions to the syndrome that make it still impossible to formulate its underlying pathogenesis.

Kushner sums up today's state of affairs succinctly: "Motor tics and involuntary vocalizations can often be controlled by drugs that act to...