Further discussion of the side effects of the antipsychosis drugs is found in later chapters.
When idle, almost all individuals display a variety of fidgeting types of small amplitude movement, gestures, and mannerisms. They are slower and more complex than tics and spasms. Others, throughout their lives are given to odder and more intrusive but benign habitual movements. These range from simple, highly idiosyncratic mannerisms (e.g., of the lips and tongue) to repetitive actions such as sniffing, clearing the throat, protruding the chin, or blinking whenever these individuals become tense. Stereotypy and irresistibility are the main identifying features of these phenomena. The patient admits to making the movements and feels compelled to do so in order to relieve perceived tension. Such movements can be suppressed for a short time by an effort of will, but they reappear as soon as the subject’s attention is diverted. In certain cases the tics become so ingrained that the person is unaware of them and seems unable to control them. An interesting feature of many tics is that they correspond to coordinated acts that normally serve some purpose to the organism. It is only their incessant repetition when uncalled for that marks them as habit spasms or tics. The condition varies widely in its expression from a single isolated movement (e.g., blinking, sniffing, throat clearing, tongue clicking, or stretching the neck) to a complex of movements.
Children between 5 and 10 years of age are especially likely to develop these habit spasms. These consist of blinking, hitching up one shoulder, sniffing, throat clearing, jerking the head or eyes to one side, grimacing, etc. If ignored, such spasms seldom persist for longer than a few weeks or months and tend to diminish on their own. In adults, relief of nervous tension by sedative or tranquilizing drugs may be helpful, but the disposition to tics persists. A putative relationship to streptococcal infection is discussed below.
Special types of rocking, head bobbing, hand waving (in autism) or hand wringing (typical of Rett syndrome), and other movements, particularly self-stimulating movements, are disorders of motility frequent in the developmentally delayed child or adult. These “rhythmias” have no known pathologic anatomy in the basal ganglia or elsewhere in the brain. Apparently they represent a persistence of some of the rhythmic, repetitive movements of normal infants. In some cases of impaired vision and photic epilepsy, eye rubbing or moving the fingers rhythmically across the field of vision is observed, especially again in developmentally delayed children.
Multiple tics—sniffing, snorting, involuntary vocalization, and troublesome compulsive and aggressive impulses—constitute the rarest and most severe tic syndrome—Gilles de la Tourette syndrome (his complete surname). The problem begins in childhood, in boys three times more often than in girls, usually as a simple tic. As the condition progresses, new tics are added to the repertoire. It is the multiplicity of tics and the combination of motor and vocal tics that distinguish the disorder from the more benign, restricted tic disorders. The modern definition has expanded to include an attention deficit disorder that may not reach a severity appropriate for that diagnosis independently as summarized by Kurlan.
Vocal tics, sometimes loud and irritating in pitch, are characteristic. Some patients display repetitive motor behavior, such as jumping, squatting, or turning in a circle. Other common types of repetitive behavior include the touching of other persons and repeating one’s own words (palilalia) and the words or movements of others. Explosive and involuntary cursing and the compulsive utterance of obscenities (coprolalia) are perhaps the most dramatic manifestations. Interestingly, the latter phenomenon is reportedly uncommon in Japanese patients, whose decorous culture and language contain few obscenities. The full repertoire of tics and compulsions comprised by Gilles de la Tourette syndrome has been described by Tolosa and Bayes and in the reviews by Jankovic and by Leckman, which are recommended.