Between 1973 and his death in 1977, I enjoyed the privilege of corresponding with the great neuropsychologist A.R. Luria, and often sent him observations, and tapes, on Tourette’s. In one of his last letters, he wrote to me: ‘This is truly of a tremendous importance. Any understanding of such a syndrome must vastly broaden our understanding of human nature in general ... I know of no other syndrome of comparable interest.’
When I first saw Ray he was 24 years old, and almost incapacitated by multiple tics of extreme violence coming in volleys every few seconds. He had been subject to these since the age of four and severely stigmatised by the attention they aroused, though his high intelligence, his wit, his strength of character and sense of reality enabled him to pass successfully through school and college, and to be valued and loved by a few friends and his wife. Since leaving college, however, he had been fired from a dozen jobs—always because of tics, never for incompetence—was continually in crises of one sort and another, usually caused by his impatience, his pugnacity, and his coarse, brilliant ‘chutzpah’, and had found his marriage threatened by involuntary cries of ‘Fuck!’ ‘Shit!’, and so on, which would burst from him at times of sexual excitement. He was (like many Touretters) remarkably musical, and could scarcely have survived—emotionally or economically— had he not been a weekend jazz drummer of real virtuosity, famous for his sudden and wild extemporisations, which would arise from a tic or a compulsive hitting of a drum and would instantly be made the nucleus of a wild and wonderful improvisation, so that the ‘sudden intruder’ would be turned to brilliant advantage. His Tourette’s was also of advantage in various games, especially ping-pong, at which he excelled, partly in consequence of his abnormal quickness of reflex and reaction, but especially, again, because of ‘improvisations’, ‘very sudden, nervous, frivolous shots’ (in his own words), which were so unexpected and startling as to be virtually unanswerable. The only time he was free from tics was in post-coital quiescence or in sleep; or when he swam or sang or worked, evenly and rhythmically, and found ‘a kinetic melody’, a play, which was tension-free, tic-free and free.
Under an ebullient, eruptive, clownish surface, he was a deeply serious man—and a man in despair. He had never heard of the TSA (which, indeed, scarcely existed at the time), nor had he heard of Haldol. He had diagnosed himself as having Tourette’s after reading the article on ‘Tics’ in the Washington Post. When
I confirmed the diagnosis, and spoke of using Haldol, he was excited but cautious. I made a test of Haldol by injection, and he proved extraordinarily sensitive to it, becoming virtually tic-free for a period of two hours after I had administered no more than one-eighth of a milligram. After this auspicious trial, I started him on Haldol, prescribing a dose of a quarter of a milligram three times a day.
He came back, the following week, with a black eye and a broken nose and said: ‘So much for your fucking Haldol.’ Even this minute dose, he said, had thrown him off balance, interfered with his speed, his timing, his preternaturally quick reflexes. Like many Touretters, he was attracted to spinning things, and to revolving doors in particular, which he would dodge in and out of like lightning: he had lost this knack on the Haldol, had mistimed his movements, and had been bashed on the nose. Further, many of his tics, far from disappearing, had simply become slow, and enormously extended: he might get ‘transfixed in mid-tic’, as he put it, and find himself in almost catatonic postures (Ferenczi once called catatonia the opposite of tics—and suggested these be called ‘cataclonia’). He presented a picture, even on this minute dose, of marked Parkinsonism, dystonia, catatonia and psychomotor ‘block’: in reaction which seemed inauspicious in the extreme, suggesting, not insensitivity, but such over-sensitivity, such pathological sensitivity, that perhaps he could only be thrown from one extreme to another—from acceleration and Tourettism to catatonia and Parkinsonism, with no possibility of any happy medium.
He was understandably discouraged by this experience—and this thought—and also by another thought which he now expressed. ‘Suppose you could take away the tics,’ he said. ‘What would be left? I consist of tics—there is nothing else.’ He seemed, at least jokingly, to have little sense of his identity except as a ticqueur: he called himself ‘the ticcer of President’s Broadway’, and spoke of himself, in the third person, as ‘witty ticcy Ray’, adding that he was so prone to ‘ticcy witticisms and witty ticcicisms’ that he scarcely knew whether it was a gift or a curse. He said he could not imagine life without Tourette’s, nor was he sure he would care for it.
I was strongly reminded, at this point, of what I had encountered in some of my post-encephalitic patients, who were inordinately sensitive to L-Dopa. I had nevertheless observed in their case that such extreme physiological sensitivities and instabilities might be transcended if it were possible for the patient to lead a rich and full life: that the ‘existential’ balance, or poise, of such a life might overcome a severe physiological imbalance. Feeling that Ray also had such possibilities in him, that, despite his own words, he was not incorrigibly centred on his own disease, in an exhibitionistic or narcissistic way, I suggested that we meet weekly for a period of three months. During this time we would try to imagine life without Tourette’s; we would explore (if only in thought and feeling) how much life could offer, could offer him, without the perverse attractions and attentions of Tourette’s; we would examine the role and economic importance of Tourette’s to him, and how he might get on without these. We would explore all this for three months—and then make another trial of Haldol.
There followed three months of deep and patient exploration, in which (often against much resistance and spite and lack of faith in self and life) all sorts of healthy and human potentials came to light: potentials which had somehow survived twenty years of severe Tourette’s and ‘Touretty’ life, hidden in the deepest and strongest core of the personality. This deep exploration was exciting and encouraging in itself and gave us, at least, a limited hope. What in fact happened exceeded all our expectations and showed itself to be no mere flash in the pan, but an enduring and permanent transformation of reactivity. For when I again tried Ray on Haldol, in the same minute dose as before, he now found himself tic-free, but without significant ill-effects—and he has remained this way for the past nine years.
The effects of Haldol, here, were ‘miraculous’—but only became so when a miracle was allowed. Its initial effects were close to catastrophic: partly, no doubt, on a physiological basis; but also because any ‘cure’, or relinquishing of Tourette’s, at this time would have been premature and economically impossible. Having had Tourette’s since the age of four, Ray had no experience of any normal life: he was heavily dependent on his exotic disease and, not unnaturally, employed and exploited it in various ways. He had not been ready to give up his Tourette’s and (I cannot help thinking) might never have been ready without those three months of intense preparation, of tremendously hard and concentrated deep analysis and thought.