Tik Tok Tics

Recently, an epidemic of motor tics erupted among teenage girls who were users of Tik Tok. The press reported that the doctors were “stumped” and wondered what could have caused a cluster of Gilles de la Tourette cases. I had to wonder: “Who were these doctors?” Occasionally, a person turns up in a city having forgotten their own identity. Again, the newspapers report the doctors were “mystified” by the “strange” case of amnesia. Later he is traced to another town where he had left his wife and a list of creditors behind. Several employees of the US Embassy in Cuba came down with ringing in the ears and cognitive difficulties that they attributed to an attack by an evil empire. How happy this must have made Mr. Putin. Without spending a ruble, he was able to enhance his reputation of the evil genius with technologies too advanced for us to understand. When I was growing up in the 1950s many movies were allegories of this theme. The best of them was Invaders from Mars where alien beings with no bodies, only advanced brains, came to Earth and used the bodies of innocent earthlings to control the world—and only our powerful military could fend them off. Other films used giant ants, flies, and other monsters to represent the USSR. After every catastrophe in recorded history, there is a tale of mysterious illness characterized by fatigue, headache, and brain fog. Hilary Evans and Robert Bartholomew have published a remarkable volume that they call the Encyclopedia of Extraordinary Social Behavior, in which they describe hundreds of similar events over centuries.

The proper name for this phenomenon is pithiatism, meaning caused by suggestion and cured by persuasion. The term was suggested by the eminent French neurologist, Joseph Jules Francois Felix Babinski,^, allegedly the favorite to succeed Charcot. He never did because he was failed repeatedly on the exam necessary to become a faculty member at the university by a jealous, xenophobic, anti-immigrant rival, Charles Bouchard. Babinski was born in France and served in the army twice, but his name was Polish because his parents had emigrated to France to escape bias in Poland (sound familiar?). Ironically almost no one remembers Bouchard (his only contribution being the Charcot-Bouchard aneurysm, which may be the cause of some intracerebral hemorrhages), but there is no doctor on Earth who does not know Babinski's name. This is one of many reasons why Babinski is my neurological hero.

Babinski chose the term from Greek roots combining the Greek words “pitho-” (persuasion, as in Peitho, the mythical Goddess of persuasion) and “-iatos” (curable, an adjective with the same roots as iatros, meaning doctor). Doctors all know the famous painting by Pierre Aristide André Brouillet of Jean Martin Charcot's Tuesday afternoon sessions at the Salpȇtrière in Paris. Babinski is portrayed as a tall young man standing behind Charcot supporting the fainting figure of Blanche Whitman, one of Charcot's famous muses, as the professor demonstrated the features of what was called hysteria, named such by the school of Hippocrates because they believed it was caused by a rampant uterus, roaming about the body, causing mischief, not unlike the Invaders from Mars. Charcot himself was also misled, by the acquisition bias, into thinking this was a disease of woman as he worked in the Salpȇtrière, which, more than a hospital, was a haven for homeless women. Babinski, the chef de Clinique (the chief resident), was secretly skeptical of the concept of hysteria, one reason for which was his experience in the then all-male military in which he saw the same syndrome in men. Babinski's view was that the stimulus for the syndrome was, as articulated by Ivan Pavlov, a life-threatening stress with little or no chance of escape or control. In civil society, the syndrome may, indeed, be seen more often in women because women are more often placed in a hostile situation with little or no chance of escape or control and not because of some constitutional difference between the sexes.

Babinski's most lasting contribution came as he followed Charcot on ward rounds on the open wards of the Salpȇtrière. It was allegedly said that Charcot's habit was to greet each patient with a pat on the bottom of the foot. Babinski noticed that in the patients with motor neuron disease (ALS) and multiple sclerosis, both of which were described by Charcot using his method of clinical pathological correlation, the great toe went up (ie, dorsiflexed) whereas in the patients with “hysteria” it went down (ie, plantar flexed). Shortly after Charcot's death, Babinski published a 22-line, single-author paper with no references (have you seen one of those lately?) articulating the “toe sign” as a reliable indicator of corticospinal tract (upper motor neuron) disease. This is arguably the most influential paper in the history of neurological medicine. Its major use today remains the diagnosis of pithiatism.

With his colleague, Jules Froment, Babinski wrote an entire monograph titled Pithiatism and the Neurology of War. In this book, Babinski and Froment made the point that all of these extraordinary social behaviors had in common that they could be exactly reproduced by suggestion (ie, hypnosis) and could usually be cured by persuasion, provided there was no ulterior motive (conscious or unconscious). “Hysteria is a pathological state manifested by disorders which it is possible to reproduce exactly by suggestion . . . and can be made to disappear by the influence of persuasion (counter-suggestion) alone.” In the preface by the eminent British neurologist, E. Farquhar Buzzard, it was suggested that the principles were correct, but the term “pithiatism” might “not be destined for general adoption. . . . There is no doubt that there has been much confusion as to the meaning of hysteria in the mind of the public as well as in that of the medical profession. Perhaps a new name may be associated with a clearer understanding and may escape the obloquy attaching to its predecessor.”

Since this time, the medical community has struggled with the nomenclature for this class of disorder. Sigmund Freud, another acolyte of Charcot, introduced the concept of conversion, meaning the unconscious conversion of a psychological stress into a physical symptom—in other words, a form of body language. The Freudian influence reached its peak in the mid-20th century but then waned with the biological psychiatry movement, which not only displaced the Freudian concepts but disparaged them. Dissociative states became the vogue as an example of self-hypnosis (suggestion) that normally acted as a defense mechanism against acute stress. Most recently the term “functional” has come to be used, but it is quite unsatisfactory because many functional (meaning nonstructural) disorders, such as migraine, epilepsy, and irritable bowel syndrome, are truly functional but are not reminiscent of the types of disorders meant by hysteria in the past. It is simply a euphemism.

It's time for the return of pithiatism. It is not pejorative or sexist and includes in its name the important issue of treatment. In the past, only people in the immediate environs of a catastrophe (eg earthquake, flood, illness) were susceptible to pithiatism, but the modern person is deluged with an enormous magnification of news, mostly bad, coming from the far corners of the Earth at the speed of light. As I am writing this, the whole world was exposed to the tragic event of a small child in Morocco trapped in the bottom of a well, a scenario sympathetically portrayed in the Woody Allen film, Radio Days. Agent Orange was the “cause” in the Viet Nam war. Russia and China were the “cause” in Havana. A coronavirus is the cause at the moment. There will always be a “cause” for the “long haulers.”

This is not a question about whether pithiatism is real. Of course it is real. Nor is it a question of whether it causes suffering. Of course it causes suffering. It is simply that the cause is not a virus, a beam, a foreign power, or a toxin in the water. The cause is within the brain. Yes, it is indeed all in one's head. For a neurologist this is not an insult. It is the epicenter of my professional life. This is also not a question of will. I don't spend any time trying to determine whether a symptom is willed or not because there is no gold standard for this distinction. From a practical standpoint, as Babinski warned, persuasion will not work if an ulterior motive is present, whether “conscious” or not. If one's disability payments depend on remaining sick, one would have to be crazy to get better (Catch-22). The ulterior motive need not be money. It can just as well be recognition, love, revenge, or stature. Thus, the treatment is removal of the ulterior motive to the extent possible followed by persuasion by the doctor.

Every day in the office, I channel Babinski, harnessing the power of the ophthalmoscope, the stethoscope, the tuning fork, the reflex hammer, and persuasion by the aged doctor.