Chasing Tourette’s: Time, Freedom, and the Missing Self 303119103X, 9783031191039

Table of contents :
Acknowledgments
Contents
Chapter 1: Introduction: First Crossings
References
Chapter 2: Clock Time and Tic Nosology
2.1 A Slippery Explanandum
2.1.1 Tourette’s in DSM-5
2.1.2 Timeless Tokens
2.2 Masking Change
2.2.1 Chronicity
2.2.2 Ontological Transmutations
2.2.3 Transience, Remission, and Tic-Free Time
2.3 The Future of Time and Tics
References
Chapter 3: Volition in the Ticcing Brain
3.1 Taking Stock of the Contemporary Debate
3.1.1 A Potpourri of Terms
3.1.2 Volition and Motor Control
3.1.3 Philosophical Tensions
3.2 Libet’s Heritage
3.2.1 Readiness Potential or Not?
3.2.2 The Vetoing Window
3.2.3 Suppressibility Remains Elusive
3.3 Consciousness Reconsidered
3.3.1 To Feel or Not to Feel, That is the Question
3.3.2 A Note from Sartre
References
Chapter 4: Freedom in a Tourettic World
4.1 Critiquing the Dominant View: Are We Getting at Freedom?
4.1.1 Minds Bent Upon Larger Purposes
4.1.2 Three Types of Intentions
4.2 Acting Freely
4.2.1 The Trouble with Too Much Control: Disrupting Skilled Habits
4.2.2 Quality of Life as Freedom in Action
4.2.3 Four Scenarios: Interactions Between Tics and Other Intentional Actions
4.3 On the Therapeutic Use of Consciousness
4.3.1 Bottom-Up or Top-Down
4.3.2 Losing Autopilot: Modes of Being in the World
4.4 Acceptance and Reappraisal
4.4.1 Can Distal Intentions Alter Tic Expression?
4.4.2 Affective Valence and Agency
References
Chapter 5: Agency and Ownership in Tic Disorders
5.1 What Experience, Please?
5.1.1 Volition-as-Experience and Volition-as-Ability
5.1.2 Pablo’s Eye-Blinking Tic (Again)
5.2 A Complex Pair: Multiple Aspects of Agency and Ownership
5.2.1 Defining the Terms
5.2.2 ‘Not Mine’ or ‘Not Me’? Understanding Alienation
5.3 Situating Tics
5.3.1 More Susceptible to Illusions of Agency
5.3.2 Less Susceptible: The Rubber Hand Illusion
5.3.3 Sense–Attribution Mismatch: Contrasting Schizophrenia and TS
5.3.4 Returning to the Narrative Scale: ‘Who’s Making that Noise?’
5.4 Toward a Psychopathology of Tic Disorders
References
Chapter 6: Tics as Intentional Actions: A Revised Taxonomy
6.1 The Trouble with Unintendedness
6.1.1 Intentional Is Not Voluntary Is Not Free
6.1.2 Enactive Spillage and Normative Load: When Things Happen Anyhow
6.1.3 The Intention-Action-Outcome Triad: Four Match-Mismatch Scenarios
6.1.4 Nonintentional Actions Revisited
6.2 Testing Our Taxonomy
6.2.1 Challenging Dichotomies
6.2.2 A Tic for Every Category?
6.2.3 Not Just Right Experiences (NJRE)
6.2.4 Tics as Nonintentional Actions
6.3 Honouring Complexity: Tics as ‘Action (Pheno)Types’
References
Chapter 7: On Reflexes and Stimuli: Tics as Nonactions
7.1 Chickens and Eggs
7.1.1 From Nonaction to the Urge-for-Action
7.1.2 Enabler or Response? Reconsidering the Urge
7.1.3 Introducing NIAT, SIAT, and EIAT
7.2 Mapping the Causal-Temporal Sequence of a Tic
7.2.1 Neural Signals and Other Stimuli
7.2.2 Premonitory Phenomena and Urges
7.2.3 Behavioural Responses: Ticcing and Tic Suppression
7.2.4 Other Behavioural Responses: Tic Facilitation and Modification
7.2.5 Cognitive-Affective Responses: Impacting Experience
7.3 Coming Full Circle
7.3.1 NIAT’s Last Straw
7.3.2 No Candy Machines or Mars Rovers
7.3.3 Hyper-Circularity: The Echo Chamber of Tics
7.4 Beginnings and Ends
References
Chapter 8: ‘No ill will’: Ticcing on Moral Grounds
8.1 Morality Is Interactive
8.1.1 Promises and Pitfalls of Neuro-Reductionism
8.1.2 The Cost of Moral Misattributions
8.1.3 Against the Interpretative Grain
8.2 Ticcing for Ticcing’s Sake
8.2.1 Criterion 1: Relative Absence of Reasons for Acting
8.2.2 Functional Tics as a Litmus Test for Our Theory
8.2.3 Four Notations for ‘Functional Overlay’
8.3 Zoning Out and Tuning In
8.3.1 Criterion 2: Directedness of Attention
8.3.2 Toward an Ethics of Moral Responsibility in Tic Disorders
References
Chapter 9: Conclusion: Beyond Causes and Cures
References

Citation preview

Philosophy and Medicine

P&M

Lisa Curtis-Wendlandt

Chasing Tourette’s: Time, Freedom, and the Missing Self

Philosophy and Medicine Founding Editors H. Tristram Engelhardt Jr. Stuart F. Spicker

Volume 145

Series Editors Søren Holm, The University of Manchester, Manchester, UK Lisa M. Rasmussen, UNC Charlotte, Charlotte, USA Editorial Board Members George Agich, National University of Singapore, Singapore, Singapore Bob Baker, Union College, Schenectady, NY, USA Jeffrey Bishop, Saint Louis University, St. Louis, USA Ana Borovecki, University of Zagreb, Zagreb, Croatia Ruiping Fan, City University of Hong Kong, Kowloon, Hong Kong Volnei Garrafa, International Center for Bioethics and Humanities, University of Brasília, Brasília, Brazil D. Micah Hester, University of Arkansas for Medical Sciences, Little Rock, AR, USA Bjørn Hofmann, Norwegian University of Science and Technology, Gjøvik, Norway Ana Iltis, Wake Forest University, Winston-Salem, NC, USA John Lantos, Childrens’ Mercy, Kansas City, MO, USA Chris Tollefsen, University of South Carolina, Columbia, USA Dr Teck Chuan Voo, Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore

The Philosophy and Medicine series is dedicated to publishing monographs and collections of essays that contribute importantly to scholarship in bioethics and the philosophy of medicine. The series addresses the full scope of issues in bioethics and philosophy of medicine, from euthanasia to justice and solidarity in health care, and from the concept of disease to the phenomenology of illness. The Philosophy and Medicine series places the scholarship of bioethics within studies of basic problems in the epistemology, ethics, and metaphysics of medicine. The series seeks to publish the best of philosophical work from around the world and from all philosophical traditions directed to health care and the biomedical sciences. Since its appearance in 1975, the series has created an intellectual and scholarly focal point that frames the field of the philosophy of medicine and bioethics. From its inception, the series has recognized the breadth of philosophical concerns made salient by the biomedical sciences and the health care professions. With over one hundred and twenty five volumes in print, no other series offers as substantial and significant a resource for philosophical scholarship regarding issues raised by medicine and the biomedical sciences.

Lisa Curtis-Wendlandt

Chasing Tourette’s: Time, Freedom, and the Missing Self

Lisa Curtis-Wendlandt Murdoch Children’s Research Institute Royal Children’s Hospital Parkville, VIC, Australia

ISSN 0376-7418     ISSN 2215-0080 (electronic) Philosophy and Medicine ISBN 978-3-031-19103-9    ISBN 978-3-031-19104-6 (eBook) https://doi.org/10.1007/978-3-031-19104-6 © Springer Nature Switzerland AG 2023 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

For Ray

Acknowledgments

This book was conceived before and written during the global SARS-CoV-2 pandemic, which saw me tucked away at home in Melbourne, Australia, a city with one of the highest number of days spent in hard ‘lockdown’ globally. Many people have supported me in writing this book. I’d like to begin by acknowledging the Tourette Syndrome Association of Australia (TSAA) and the many families and individuals affected by Tourette’s which I have met over the years. Connecting with them at a time of confusion following our son’s diagnosis in 2015 has helped me tremendously in coming to terms with the experiences that were unfolding for our family. I thank Daryl Efron for taking an interest in my early notes on this manuscript, and for inviting me to join the Murdoch Children’s Research Institute as an Honorary Fellow in late 2018. His encouragement and mentorship played an important role in my ‘reimagining’ life as a researcher after many years outside the academic sector. The same holds true for Jack Reynolds, who I thank for his invaluable feedback on the chapters of this book, and for seeing the relevance of philosophy to a life with Tourette Syndrome and vice versa. I credit Dirk Baltzly for helping me to see that my position on the margins of academia is not one of disadvantage. His certainty that I could write this book left no room for doubt, and his envy at my freedom on the fringes provided much food for thought about the fraught nature of academic jobs in a hyper-competitive system that still lacks gender equity across its many fields. On that note, I thank the many women (and some men) in academia who I have coached through my business Mind Your Way (mindyourway.com.au) over the last decade, and who have allowed me to witness the ups and downs of academic life. A special thank-you goes to my former colleague Jacquie Broad and also to Amelia Liu, whose career paths show that being ‘on the other side’ – i.e., outside academia and with no research funding – for a period of time need not curtail one’s scholarly pursuits. They kept writing and researching in their own spare time, and so I knew it could be done. I am similarly grateful to Nicola Markus for modelling a successful freelance life and for upholding the values that made her embrace this life in the

vii

viii

Acknowledgments

first place. I owe her my sincere thanks for providing editorial feedback and encouragement during the final pre-submission phase of writing this book. Thanks also to Deakin University for granting a Science and Society Network grant for a pilot project led by Tim Silk, and to Jack Reynolds and Tim Silk for inviting me onto the investigator team. The unpublished interview data from this pilot has been used in some chapters of this book. A special word of thanks goes out to Ivan Mathieson for his outstanding work with our son Ray at a time when the latter really wanted to gain some control over his tics. Those CBIT (Comprehensive Behavioural Interventions for Tics) sessions were challenging, but they helped Ray regain confidence and notably improved his well-being. I conclude with a note of gratitude to my family. A big thank-you to my parents for instilling in me both a deep curiosity about the world and a profound love of learning. My mother’s library still houses the most interesting collection of books I will ever encounter, and my father’s will to turn thought into word and word into deed has rubbed off as a credo. Last but not least, I thank my husband and son for making this extraordinary time spent in Melbourne’s lockdown such a tolerable one at home together. Jim, for his unwavering support of my flights of fancy (such as this book), and for the freedom and respect that characterise our relationship. Ray, for his resilience during all these months in home schooling – it is the same resilience that I have seen him bring to his life with Tourette syndrome. This book would not have been written without Ray, and I dedicate it to him. Melbourne 27 September 2021

Contents

1

Introduction: First Crossings������������������������������������������������������������������    1 References��������������������������������������������������������������������������������������������������    8

2

Clock Time and Tic Nosology ����������������������������������������������������������������   11 2.1 A Slippery Explanandum������������������������������������������������������������������   11 2.1.1 Tourette’s in DSM-5 ������������������������������������������������������������   12 2.1.2 Timeless Tokens��������������������������������������������������������������������   15 2.2 Masking Change�������������������������������������������������������������������������������   18 2.2.1 Chronicity ����������������������������������������������������������������������������   18 2.2.2 Ontological Transmutations��������������������������������������������������   21 2.2.3 Transience, Remission, and Tic-Free Time��������������������������   24 2.3 The Future of Time and Tics ������������������������������������������������������������   27 References��������������������������������������������������������������������������������������������������   30



3





4

 Volition in the Ticcing Brain ������������������������������������������������������������������   35 3.1 Taking Stock of the Contemporary Debate ��������������������������������������   35 3.1.1 A Potpourri of Terms������������������������������������������������������������   35 3.1.2 Volition and Motor Control��������������������������������������������������   38 3.1.3 Philosophical Tensions����������������������������������������������������������   40 3.2 Libet’s Heritage��������������������������������������������������������������������������������   43 3.2.1 Readiness Potential or Not?��������������������������������������������������   43 3.2.2 The Vetoing Window������������������������������������������������������������   45 3.2.3 Suppressibility Remains Elusive������������������������������������������   49 3.3 Consciousness Reconsidered������������������������������������������������������������   51 3.3.1 To Feel or Not to Feel, That is the Question������������������������   51 3.3.2 A Note from Sartre���������������������������������������������������������������   53 References��������������������������������������������������������������������������������������������������   57 Freedom in a Tourettic World����������������������������������������������������������������   63 4.1 Critiquing the Dominant View: Are We Getting at Freedom?����������   63 4.1.1 Minds Bent Upon Larger Purposes��������������������������������������   63 4.1.2 Three Types of Intentions ����������������������������������������������������   66 ix

x





5

6





Contents

4.2 Acting Freely������������������������������������������������������������������������������������   69 4.2.1 The Trouble with Too Much Control: Disrupting Skilled Habits������������������������������������������������������������������������   69 4.2.2 Quality of Life as Freedom in Action ����������������������������������   72 4.2.3 Four Scenarios: Interactions Between Tics and Other Intentional Actions ����������������������������������������������   76 4.3 On the Therapeutic Use of Consciousness����������������������������������������   80 4.3.1 Bottom-Up or Top-Down������������������������������������������������������   80 4.3.2 Losing Autopilot: Modes of Being in the World������������������   82 4.4 Acceptance and Reappraisal ������������������������������������������������������������   87 4.4.1 Can Distal Intentions Alter Tic Expression?������������������������   87 4.4.2 Affective Valence and Agency����������������������������������������������   91 References��������������������������������������������������������������������������������������������������   93  Agency and Ownership in Tic Disorders ����������������������������������������������   99 5.1 What Experience, Please? ����������������������������������������������������������������   99 5.1.1 Volition-as-Experience and Volition-as-Ability��������������������   99 5.1.2 Pablo’s Eye-Blinking Tic (Again)����������������������������������������  103 5.2 A Complex Pair: Multiple Aspects of Agency and Ownership��������  106 5.2.1 Defining the Terms����������������������������������������������������������������  106 5.2.2 ‘Not Mine’ or ‘Not Me’? Understanding Alienation������������  110 5.3 Situating Tics������������������������������������������������������������������������������������  115 5.3.1 More Susceptible to Illusions of Agency������������������������������  115 5.3.2 Less Susceptible: The Rubber Hand Illusion������������������������  118 5.3.3 Sense–Attribution Mismatch: Contrasting Schizophrenia and TS ����������������������������������������������������������������������������������  122 5.3.4 Returning to the Narrative Scale: ‘Who’s Making that Noise?’ ��������������������������������������������������������������������������  126 5.4 Toward a Psychopathology of Tic Disorders������������������������������������  128 References��������������������������������������������������������������������������������������������������  132  Tics as Intentional Actions: A Revised Taxonomy��������������������������������  137 6.1 The Trouble with Unintendedness����������������������������������������������������  137 6.1.1 Intentional Is Not Voluntary Is Not Free������������������������������  137 6.1.2 Enactive Spillage and Normative Load: When Things Happen Anyhow ��������������������������������������������  143 6.1.3 The Intention-Action-Outcome Triad: Four Match-Mismatch Scenarios������������������������������������������  148 6.1.4 Nonintentional Actions Revisited ����������������������������������������  153 6.2 Testing Our Taxonomy����������������������������������������������������������������������  155 6.2.1 Challenging Dichotomies�����������������������������������������������������  155 6.2.2 A Tic for Every Category?����������������������������������������������������  160 6.2.3 Not Just Right Experiences (NJRE)��������������������������������������  165 6.2.4 Tics as Nonintentional Actions ��������������������������������������������  167 6.3 Honouring Complexity: Tics as ‘Action (Pheno)Types’ ������������������  169 References��������������������������������������������������������������������������������������������������  173

Contents

7





8





9

xi

 Reflexes and Stimuli: Tics as Nonactions����������������������������������������  177 On 7.1 Chickens and Eggs����������������������������������������������������������������������������  177 7.1.1 From Nonaction to the Urge-for-Action ������������������������������  177 7.1.2 Enabler or Response? Reconsidering the Urge��������������������  181 7.1.3 Introducing NIAT, SIAT, and EIAT��������������������������������������  185 7.2 Mapping the Causal-Temporal Sequence of a Tic����������������������������  186 7.2.1 Neural Signals and Other Stimuli ����������������������������������������  186 7.2.2 Premonitory Phenomena and Urges��������������������������������������  188 7.2.3 Behavioural Responses: Ticcing and Tic Suppression����������  190 7.2.4 Other Behavioural Responses: Tic Facilitation and Modification ������������������������������������������������������������������  194 7.2.5 Cognitive-Affective Responses: Impacting Experience ������  196 7.3 Coming Full Circle����������������������������������������������������������������������������  200 7.3.1 NIAT’s Last Straw����������������������������������������������������������������  200 7.3.2 No Candy Machines or Mars Rovers������������������������������������  203 7.3.3 Hyper-Circularity: The Echo Chamber of Tics��������������������  207 7.4 Beginnings and Ends������������������������������������������������������������������������  211 References��������������������������������������������������������������������������������������������������  214  ‘No ill will’: Ticcing on Moral Grounds������������������������������������������������  219 8.1 Morality Is Interactive����������������������������������������������������������������������  219 8.1.1 Promises and Pitfalls of Neuro-Reductionism����������������������  219 8.1.2 The Cost of Moral Misattributions ��������������������������������������  224 8.1.3 Against the Interpretative Grain��������������������������������������������  228 8.2 Ticcing for Ticcing’s Sake����������������������������������������������������������������  232 8.2.1 Criterion 1: Relative Absence of Reasons for Acting ����������  232 8.2.2 Functional Tics as a Litmus Test for Our Theory ����������������  235 8.2.3 Four Notations for ‘Functional Overlay’������������������������������  239 8.3 Zoning Out and Tuning In����������������������������������������������������������������  244 8.3.1 Criterion 2: Directedness of Attention����������������������������������  244 8.3.2 Toward an Ethics of Moral Responsibility in Tic Disorders��������������������������������������������������������������������  249 References��������������������������������������������������������������������������������������������������  251  Conclusion: Beyond Causes and Cures��������������������������������������������������  255 References��������������������������������������������������������������������������������������������������  261

Chapter 1

Introduction: First Crossings

Abstract  This introductory chapter sets the scene for the book’s philosophical investigation into contemporary Tourette Syndrome (TS) scholarship. It begins with a personal anecdote about the experience of sudden-onset tic symptoms and their impact on family life. I sketch the gap in our current understanding of ‘what it is like’ to live with TS and point at two burgeoning fields of research that have completely bypassed tic disorders to date: scholarship at the broader intersection of philosophy and psychiatry on the one hand, and work in the specific field of phenomenological psychopathology on the other. I argue that it is time to fill the ‘phenomenological vacuum’ evident in tic disorder scholarship today and proceed to offer a brief introduction to the chapters of this book, which touch on age-old philosophical questions and controversies about time, freedom, and the self. By highlighting the relevance of these questions to Tourette Syndrome research and care, new pathways for scholarly and clinical practice will emerge. Keywords  Tourette Syndrome · Tics · Sudden onset · Symptoms · Family · Parenting · Subjective experience · Psychopathology · Phenomenological psychiatry · Philosophy “I – hate – you.” My son’s tongue poked out, cautiously, only to withdraw into the mouth again swiftly. “I – hate – you.” The tongue shot out once more, a pointy little children’s tongue. “I – hate – you.” An embarrassed tongue, a hesitating tongue. His eyes looked scared. We didn’t understand. We did not know what was unfolding on that sunny spring day in November 2015. I had just turned 39, and we were out to celebrate my birthday. “I  – hate  – you.” What was going on? He could not stop although we begged him to. This was the first of many crossings. We live inside invisible lines that keep our lives in check, thresholds of taboo and convention that guard our every move. Cross one, and your conscious mind sounds the alarm. Tourette’s shines a light on these thresholds by skipping along their boundary lines – now jester, then tyrant – for fun, for fear, or for both. Sitting at the restaurant that evening felt deeply uncomfortable; the tension was palpable and the silence awkward. How could a simple tongue-poke © Springer Nature Switzerland AG 2023 L. Curtis-Wendlandt, Chasing Tourette’s: Time, Freedom, and the Missing Self, Philosophy and Medicine 145, https://doi.org/10.1007/978-3-031-19104-6_1

1

2

1  Introduction: First Crossings

capsize our world? He was huddled on my lap, resting his head against my shoulder. No tongue to see now, in the comfort of the embrace. “I – hate – you”, whispered so softly under his breath. We ordered food but it was all consumed by uncertainty. The days that followed remain a haze, and the sinkhole deepened quickly. As with a switch, normality had been turned off as we tried to contain the mess evoked by the escalating crossings of Tourette’s – now jester, then tyrant – which swept through the kitchen and into the bedrooms of our house. As we hid knives that were suddenly seized by eight-year-old little hands, doctors gasped bewildered, dishing out too much advice and too little consolation. Thus began our life with Tourette Syndrome (TS), a condition I had barely heard of back then. What began, too, was an existential quest to understand what we were experiencing, to make sense of symptoms that seemed so meaningless, so sudden, so bizarre. Their impact on our daily lives and interactions was acute yet barely visible to others: No one dropped by with a casserole.1 As I grappled with the isolation so commonly felt by carers of children with TS, reading offered a way to cope – at first, with such practical questions as: “What do I need to know about pharmacotherapy to have an informed conversation with my son’s paediatrician?” Soon these readings fanned a deeper curiosity: “Why is the question of volition – whether tics are voluntary or not – so central to, and yet so contested in, our definition of Tourette’s? And what does this mean for our everyday life with tics?” I realised how relevant these questions were when I took on the role of local support group leader for the Tourette Syndrome Association of Australia (TSAA) soon after our son’s diagnosis. The role involved organising meetings with and taking many phone calls from families affected by this condition. Often parents would share with me the complicated ethical dilemmas that are daily staples in a life with Tourette’s: “Is that my child swearing at me and his little sister or is that just his tics? How can I discipline behaviours that mortify my child in the very moment they occur?” This was philosophy in action; philosophy grounded in the daily experience of care, which Kristeva et  al. (2018, 56) call a “messy temporal space in which humans live and where sickness and healing actually occur simultaneously.” And yet, the more peer-reviewed articles I read on Tourette’s, the clearer it became to me that these lived philosophical questions families grapple with are barely discussed or acknowledged in the literature.2 From my first-person perspective as parent and witness of others’ struggles, an important insight emerged: that gaps in research can become visible in lived experience; and that lived experience can breathe new life into scholarship.

 Travis and Juarez-Paz (2020, 8) note that caregivers of children and teenagers with TS commonly report feeling unsupported and isolated because their experiences are not adequately understood (or are simply dismissed or misjudged) by others. The ‘casserole’ comment is taken from a caregiver they interviewed, who contrasts the ‘automatic support’ received by carers of children with other conditions with the lack of such support granted to caregivers of children with TS. 2  For some important exceptions, see the qualitative studies of parental experiences in caring for children with Tourette’s by De Lange and Oliver (2004), O’Hare et al. (2017), Ludlow et al. (2018), and Travis and Juarez-Paz (2020). 1

1  Introduction: First Crossings

3

The gaps, as I saw them, pertained to the ‘what it is like’ to live with Tourette Syndrome, that profoundly altered sense of being in the world which I witnessed in my child and, by extension, within myself. The gaps also pertained to the unspeakable nature of these experiences: few within the scholarship were developing a vocabulary or methodological approach to describe the profound impact which Tourettic symptoms can have on a person’s body, mind, and world. At a time when the Preface to the Oxford Handbook of Philosophy and Psychiatry had boldly contended that “there is nowadays hardly a psychiatric stone that philosophers have left unturned” (Fulford et al. 2013a, V), Tourette Syndrome was being bypassed completely by the field of phenomenological psychiatry, a rich tradition known for exploring patients’ abnormal experiences associated with their conditions. In this growing body of work, philosophers and psychiatrists offer insightful discussions of such conditions as schizophrenia, bi-polar disorder, obsessive compulsive disorder, affective disorders, dementia, autism, and even movement disorders like anarchic hand and alien hand syndrome.3 And yet there is no single reference to TS or other tic disorders in the entire comprehensive Oxford Handbook of Phenomenological Psychopathology (Stanghellini et  al. 2019). As I have argued elsewhere (Curtis-­ Wendlandt and Reynolds 2021), it is time to extend this important work to the study of Tourette Syndrome and to encourage similar conversations about consciousness, selfhood, embodiment, and agency in this condition. The absence of TS from the growing literature on phenomenological psychiatry may not be a coincidence, however; it might rather be a testament to the success with which Tourette Syndrome was erased from the psychiatric memory by the late twentieth century. In his seminal book, A cursing brain? The histories of Tourette Syndrome, Kushner (1999) observed the turn away from earlier functional (psychogenic) explanations of the syndrome toward organic (biological) explanations of TS as a neurodevelopmental condition. In the last 20 years since Kushner’s book was published scientific interest in Tourette Syndrome has exploded, and the resulting research faithfully depicts the reductionist biomedical Zeitgeist that has fuelled Western notions of scientific ‘progress’ in the age of the brain sciences. Among the roughly 3500 peer-reviewed publications on TS that appeared between 1999 and 2021, the majority focus on genetics, drug therapy, pathophysiology, and immunology. Less sizable but important is a body of work that explores emerging behavioural treatments, most notably studies into the efficacy of habit reversal training and the closely related ‘Comprehensive Behavioural Interventions for Tics’ (CBIT; see Woods et al. 2008), an approach now considered a first-line treatment.4

 For chapters in book-length collections, see Kendler and Parnas (2008, 2012, 2015, 2017); Fulford et al. (2013b); Broome et al. (2012); and Chap. 7 in Zahavi (2005). 4  See the recent Practice Guidelines developed for the American Academy of Neurology (Pringsheim et  al. 2019), which are endorsed by the European Academy of Neurology and the Child Neurology Society, among others. 3

4

1  Introduction: First Crossings

And yet, despite millions of dollars invested in international research collaborations5 devoted to uncovering the causal mechanisms that underlie Tourette’s, the aetiology of this intriguing syndrome remains elusive (see O’Hare et al. 2016, 238). What’s going on? Has the ‘triumph’ of the organic narrative over earlier functional explanations which Kushner (1999) observed two decades ago reached its zenith? Controversies continue to abound, not only about the unitary nature of the s­ yndrome, but about the very criteria that are meant to define it in internationally accepted manuals like DSM and ICD (see Robertson and Mary 2015, 68). Meanwhile, individuals and families struggling with Tourette’s remain under-­serviced as pharmacological and behavioural therapies provide relief for some but not all who are affected, and drug side-effects and the cost of behavioural therapy prevent access for many who need support. At this crucial point in the history of Tourette Syndrome research, we urgently need new impulses and approaches capable of advancing a field at risk of chasing its own explanatory tail. It is time to critically re-examine the “historically conditioned hermeneutic situation” (Svendsen 2006, 16) in which this research takes place and to ask: What foundational theoretical assumptions underlie this work? And how do these assumptions shape our scholarly and clinical conversations about Tourette’s? The historical shift from psychogenic to organic explanations of TS has left a gap on the map – a phenomenological vacuum of first-person insights into ‘what it is like’ to live with this condition, and a dearth of philosophically grounded work on any ‘structural invariants’ which enable that experience to be as it is. How does living with Tourette Syndrome impact people’s experiences of their own body in space and time and of their sense of self and agency in the world (see Curtis-Wendlandt and Reynolds 2021)? This book lays the foundations needed for answering these questions. Drawing on the toolkit of philosophy – and particularly, on ideas from enactivism and philosophical phenomenology – I will zoom in on the much-debated controversies and neglected lacunae which have dominated scholarship on Tourette Syndrome since the turn toward organic explanations of TS (see Kushner 1999). Enactivism – a variety of philosophical approaches to the study of mind – will serve as a critical backdrop for Chaps. 4, 6, and 8. Arising from the anti-cognitivist work of Varela et al. (1991), enactivist approaches to philosophy argue against a ‘mind-as-computer’ model that equates cognition with the processing and manipulation of mental models or representations of the world (see Ward et al. 2017, 365). Enactivists contend that this overlooks a fundamental fact – namely, that cognition is grounded in sensorimotor activity and thus irreducibly embodied and embedded in the environment. Relatedly, these philosophers have proposed new theories of action which argue that any ‘doing’ on the part of an individual is irreducibly constituted by interactions with an environment that affords some but not other  To name just a few examples, see TS Eurotrain (http://ts-eurotrain.eu), European Multicentre Tic Studies (https://emtics.eu/), and research conducted by the US Centre for Disease Control and Prevention (https://www.cdc.gov/ncbddd/tourette/research.html), as well as the NJ Centre for Tourette Sydrome and Rutgers University (https://njcts.org/njcts-and-rutgers-scientists-contributeto-worldwide-study-uncovering-possible-new-causes-of-­tourette-­syndrome/). 5

1  Introduction: First Crossings

5

behaviours (e.g. Gallagher 2020). I will explore the relevance of an enactivist view of cognition and the related affordance-based view of action, suggesting that these views can help us reframe – if not resolve – some of the central questions evident in scholarship on TS. The book is structured around three guiding themes – time, freedom, and the self – which exemplify the controversies and the lacunae evident in this field. Chapter 2 begins with a summative overview of Tourette Syndrome facts and figures (prevalence, comorbidities, etc.) and introduces readers to the important role played by clock time (homogenous, chronological, and objectified time) in the current classification of primary tic disorders. We will observe that the durative aspects of Tourettic symptoms are privileged in the contemporary nosology, a fact which sidelines the syndrome’s transient aspects (at the level of individual tics). I argue that this leaves a common Tourettic experience unaccounted for – namely, that of spontaneously remitting individual tics. The DSM’s reference to the condition’s well-known ‘waxing and waning cycles’ does not capture this phenomenon but only describes the fluctuating intensity of the overall symptoms. What would happen to our view of the primary tic disorder triad if we switched to an impermanence perspective and began studying tic transience and remission in Tourette’s? And how about related temporal phenomena such as tic cessation and tic-free intervals? The chapter highlights several theoretically and clinically relevant questions arising from our use of relative temporal qualities (like ‘persistence’ or ‘transience’) in tic nosology and concludes that a fuller, more nuanced look at the temporality of tics could open new doors to phenotyping and classification. It concludes by reflecting on the need to complement research on clock time and tic nosology with phenomenological perspectives on time and tics. For example, does the lived experience of time in Tourette Syndrome differ from that of people without tic disorders? And how do the temporal aspects of tic disorder symptoms (such as repetition, temporal clustering of tic events, etc.) impact other structural aspects of experience such as notions of self, self-awareness, intersubjectivity, and embodiment (see Fuchs and Pallagrosi 2018, 289–290)? I argue that understanding these phenomenological perspectives on time and tics would complement the traditional ‘patient-as-object’ approach to medicine and psychopathology and go some way to countering the current neuro-reductionism apparent in the literature. Chapter 3 turns toward volition (or ‘free will’) which, as a concept, is equally central – and equally problematic – to tic nosology. I outline how dominant philosophical views of volition and free will have shaped the study of tic disorders and Tourette Syndrome by asking: Are primary tics voluntary or involuntary? And is voluntary action affected more broadly by the presence of tics? Responses to these questions vary in the scholarship, but most contributions draw on the classic experimental paradigm pioneered by Benjamin Libet in the 1980s. I show how Libet’s notion of volition as a conscious ‘veto power’ commonly expressed through motor control has led to the view that tic suppression is paradigmatic of free will in Tourette’s. Alternative views proposed by some authors suggest that actions are voluntary when they are consciously intended, not necessarily inhibited. This latter emphasis on consciousness has re-focused the debate on subjective experience and

6

1  Introduction: First Crossings

particularly on the contested role of premonitory urges and sensory phenomena in TS. By drawing on insights from philosophical phenomenology, I propose that we should reconsider what it means to be conscious of an experience (such as an urge to tic), and that doing so promises to advance our understanding of the elusive link between the experience and inhibition of tic disorder symptoms. Chapter 4 switches gears to pursue an alternative understanding of freedom in tic disorders. Rather than defining freely willed actions as events or processes that occur at an elemental timescale (the milliseconds of Libet’s experiments), this chapter frames volition as the ability to act in accordance with one’s cares and concerns in the world. Drawing on the distinction between pre-reflective and reflective consciousness introduced in Chap. 3, I ask what role each plays in this alternative notion of freedom. On the one hand, we will see that being too reflectively conscious of one’s actions can get in the way of acting freely. People with tic disorders are at heightened risk of such ‘hyperreflexivity’ since symptoms often demand their own and others’ explicit attention and interfere with everyday activities. On the other hand, reflective consciousness can serve a positive therapeutic role in behavioural and acceptance-based interventions for tics. In these approaches consciously attending to aspects of symptoms – such as the urge to tic – can help individuals manage their condition and enhance their sense of agency. While current therapeutic paradigms remain symptom-centric and focus on reducing tics, the chapter concludes by outlining alternative, strength-based strategies for treating tic disorders which transcend the deficit-model of disease. Chapter 5 foregrounds the first-personal experience of ticcing and everyday action in people with Tourette Syndrome and other primary tic disorders by asking what we know about such experience today. It draws attention to the phenomenological vacuum in existing research on volition (Chap. 3), which has investigated aspects of anomalous voluntary action in people living with these conditions without providing a clear picture of how such action is experienced by these subjects. Drawing on discussions of the multiple aspects of ‘agency’ and ‘ownership’ in philosophical phenomenology and phenomenological psychiatry, I use examples of involuntary action and schizophrenic alienation offered in the literature to explore what kind of experiential dynamics, or variations in experience, we might expect to find in primary tic disorders like TS. These considerations are juxtaposed with the existing experimental studies on agency and ownership in adults with TS (none of which investigate the experience of ticcing or extended everyday actions), with an eye to integrating this work into a broader phenomenological framework or psychopathology of primary tic disorders. The chapter concludes with a systematic overview of how agency and ownership dynamics may be studied in tic disorders and beyond and offers guiding questions for future research and practice. Chapter 6 returns to us to the broader question of tic nosology with which we began this book but this time approaches the topic from the vantage point of theories of action. I argue that the complexity and heterogeneity of Tourette Syndrome, which are routinely acknowledged today, invite us to differentiate tics based on the different ‘action types’ they represent across the clinical spectrum. Toward this end, I develop the first taxonomy of tics as intentional actions by critiquing a historical

1  Introduction: First Crossings

7

source: Culver and Gert’s (1982) influential framework of human behaviour. We will adopt the authors’ useful distinction between intentional, voluntary, and free actions while also addressing a range of conceptual problems embedded in their classification. For example, the idea of ‘unintendedness’ challenges the validity of their framework and raises problems which are commonly discussed in theories of action. I offer two new concepts – enactive spillage and normative load – to illustrate why unintended actions cannot constitute a separate action class. Instead, the distinct interrelationships between intentions, actions, and their outcomes are offered as an alternative basis for classification. Next, I critique Culver and Gert’s notion of a ‘volitional disability’ and their division between internal versus external stimuli of actions as ill-suited to capturing the complex phenomenology of tics. I propose that an affordance-based view of action enables more fine-grained phenotyping of action types in tic disorders and beyond. Chapter 7 debunks arguments against the view that tics are intentional actions by suggesting that these arguments rely on a misguided understanding of the temporality of human action and perception. We will reconnect with the discussion of temporality introduced in Chap. 2, although our temporal frame will be smaller here: Instead of exploring the relationships between various tic events (tic tokens) and their role in the classification of tic disorders discussed earlier, we will zoom in on the genesis of a single tic token – from its emergence in a perceptual trigger to its behavioural expression or suppression – to better understand the controversy surrounding intentions and tics. I begin with two chicken-or-egg debates in tic disorder scholarship which revolve around the question what comes first – acting or perceiving? – and what this means for the intentionality of symptoms. I then zoom in on the construct of a single tic sequence, where these debates take place. As I will show, nonaction proponents of tics posit a linear causal-temporal model of symptoms which assumes that neural stimuli cause tics from the bottom up. This reductionist stimulus–response model has spawned such ill-fated questions as: When do intentions enter the process of ticcing? Or: Which part of a tic sequence is intentional? Drawing on a range of thinkers past and present  – from Dewey’s critique of the reflex arc to Wu’s work on attention – I highlight the structural circularity intrinsic to all acting and perceiving, which suggests that intentions do no ‘enter’ tic sequences but are always already present from the get-go. Tics, however, are uniquely hyper-circular due to their repetitiveness and sameness. I conclude by exploring how this hyper-circularity could impact phenomenal experience and what its psychiatric relevance might be. Lastly, Chap. 8 pivots to discuss the implications of the book’s preceding chapters for an ethics of moral responsibility in Tourette Syndrome. If tics are intentional actions as I propose in Chaps. 6 and 7, then should we not hold people responsible for their tic disorder symptoms? I argue that this does not follow, and that tics should be considered less blameworthy than other intentional actions, although we often misconstrue them as morally salient behaviours. The chapter begins by highlighting the costs of these moral misattributions for people living with tics and shows that our own interpretative habits drive such ‘misreadings’. A first step toward an ethics of moral responsibility in Tourette’s and other tic disorders must therefore be the

8

1  Introduction: First Crossings

search for an alternative, epistemically and socially just description of tics which helps us better understand what these symptoms are and are not about. I propose that existing brain-based explanations are not sufficient in this regard. Instead, I develop an alternative description grounded in the notion of ‘abstractly situated’ intentions which allows us to spell out two typical features of primary tics: their relative absence of reasons for acting, and their attentional focus on embodied aspects of the tic action. Both features illuminate why tics should not be considered morally salient actions and why people deserve less blame for what might go wrong when they tic. Further, the notion of situated intentions also provides us with a new basis for distinguishing between primary and functional(ised) tics. Evident across all chapters of this book are traces of age-old philosophical questions and controversies about time, freedom, and the self which cut across the sciences and the humanities, and which intersect with Tourette Syndrome scholarship and clinical practice in ways that have advanced but also limited their progress. Chasing Tourette’s seeks to highlight the significance of these big questions and to inspire further work on the philosophical foundations of our scholarly approaches to, and clinical treatments of, Tourette Syndrome. It is only by re-integrating the field into a larger humanist conversation that we can free it from its exhaustive reliance on the explanatory and curative power of the biomedical sciences, which  – despite much promise – cannot speak some of Tourette’s most important truths. This must involve a commitment to integrate TS scholarship into the broader project of phenomenological psychiatry, with its concomitant shift from studying patients as objects to working with patients as subjects “whose perceptions and experiences are heard, accepted, and valued” (Boyce 2021, 169). As Boyce notes in his recent editorial in The Lancet Psychiatry, this approach “can redress power imbalances and generate collaborative projects in which all parties bring equally valued perspectives” (169). I suspect that such an approach will also offer individuals and families – like us – the discursive opportunities we need to explain what it means to have one’s world turned upside down by the enigma that remains Tourette Syndrome, one tongue-poke at a time.

References Boyce, Niall. 2021. Editorial. The Lancet Psychiatry 8 (3): 169. Broome, Matthew R., Robert Harland, Gareth S.  Owen, and Argyris Stringaris, eds. 2012. The Maudsley reader in phenomenological psychiatry. Cambridge: Cambridge University Press. Culver, Charles M., and Bernard Gert. 1982. Philosophy in medicine. Conceptual and ethical issues in medicine and psychiatry. London: Oxford University Press. Curtis-Wendlandt, Lisa, and Jack Reynolds. 2021. Why Tourette syndrome research needs philosophical phenomenology. Phenomenology and the Cognitive Sciences 20 (4): 573–600. De Lange, Naydene, and M.A.J.  Oliver. 2004. Mothers’ experiences of aggression in their Tourette’s syndrome children. International Journal for the Advancement of Counselling 26 (1): 65–77. Fuchs, Thomas, and Mauro Pallagrosi. 2018. Phenomenology of temporality and dimensional psychopathology. In Dimensional psychopathology, ed. Massimo Biondi, Massimo Pasquini,

References

9

and Angelo Picardi, 287–300. Springer International Publishing. https://link.springer.com/ book/10.1007/978-­3-­319-­78202-­7 Fulford, K.W.M., Martin Davies, Richard G.T. Gipps, George Graham, John Z. Sadler, Giovanni Stanghellini, and Tim Thornton. 2013a. Preface. In The Oxford handbook of philosophy and psychiatry, ed. K.W.M.  Fulford, Martin Davies, Richard G.T.  Gipps, George Graham, John Z. Sadler, Giovanni Stanghellini, and Tim Thornton V–VI. Oxford: Oxford University Press. ———, eds. 2013b. The Oxford handbook of philosophy and psychiatry. Oxford: Oxford University Press. Kendler, Kenneth S., and Joseph Parnas, eds. 2008. Philosophical issues in psychiatry: Explanation, phenomenology, and nosology. Baltimore: John Hopkins University Press. ———, eds. 2012. Philosophical issues in psychiatry. II, nosology. Oxford: Oxford University Press. ———, eds. 2015. Philosophical issues in psychiatry. III, the nature and source of historical change. Oxford: Oxford University Press. ———, eds. 2017. Philosophical issues in psychiatry. IV, classification of psychiatric illness. Oxford: Oxford University Press. Kristeva, Julia, Marie Rose Moro, JOhn Ødemark, and Eivind Engebretsen. 2018. Cultural crossings of care: An appeal to the medical humanities. Medical Humanities 44 (1): 55–58. Kushner, Howard I. 1999. A cursing brain? The histories of Tourette syndrome. Cambridge, MA: Harvard University Press. Ludlow, Amanda K., Rachel Brown, and Joerg Schulz. 2018. A qualitative exploration of the daily experiences and challenges faced by parents and caregivers of children with Tourette’s syndrome. Journal of Health Psychology 23 (14): 1790–1799. O’Hare, Deirdre, Valsamma Eapen, Edward Helmes, Kerry McBain, John Reece, and Rachel Grove. 2016. Recognising and treating Tourette’s syndrome in young Australians: A need for informed multidisciplinary support. Australian Psychologist 51 (3): 238–245. O’Hare, Deirdre, Valsamma Eapen, Rachel Grove, Edward Helmes, Kerry McBain, and John Reece. 2017. Youth with Tourette syndrome: Parental perceptions and experiences in the Australian context. Australian Journal of Psychology 69 (1): 48–57. Pringsheim, Tamara, Michael S.  Okun, Kirsten Müller-Vahl, Davide Martino, Josef Jankovic, Andrea E. Cavanna, Douglas W. Woods, Michael Robinson, Elizabeth Jarvie, Veit Roessner, Maryam Oskoui, Yolanda Holler-Managan, and John Piacentini. 2019. Practice guideline recommendations summary: Treatment of tics in people with Tourette syndrome and chronic tic disorders. Neurology 92 (19): 896–906. Robertson, Mary M., and M. Mary. 2015. A personal 35 year perspective on Gilles de La Tourette syndrome: Prevalence, phenomenology, comorbidities, and coexistent psychopathologies. The Lancet Psychiatry 2 (1): 68–87. Stanghellini, Giovanni, Matthew R.  Broome, Anthony Vincent Fernandez, Paolo Fusar-Poli, Andrea Raballo, and René Rosfort. 2019. Oxford handbook of phenomenological psychopathology. Oxford: Oxford University Press. Svendsen, Lars. 2006. Fashion: A philosophy. London: Reaktion Books. Travis, Eryn, and Anna Victoria Ortiz Juarez-Paz. 2020. Experiences of Tourette syndrome caregivers with supportive communication. Qualitative Health Research 30 (10): 1480–1490. Varela, Franciso J., Evan Thompson, and Eleanor Rosch. 1991. The embodied mind: Cognitive science and human experience. Cambridge, MA: MIT Press. Ward, Dave, David Silverman, and Mario Villalobos. 2017. Introduction: The varieties of Enactivism. Topoi 36: 365–375. Woods, Douglas W., John Piacentini, Susanna Chang, Thilo Deckersbach, Golda Ginsburg, Alan Peterson, Lawrence D.  Scahill, John T.  Walkup, and Sabine Wilhelm, eds. 2008. Managing Tourette syndrome: A behavioral intervention for children and adults. Therapist guide. New York: Oxford University Press. Zahavi, Dan. 2005. Subjectivity and selfhood: Investigating the first-person perspective. Cambridge, MA: MIT Press.

Chapter 2

Clock Time and Tic Nosology

Abstract  This chapter explores the central role played by clock time (homogenous, chronological, and objectified time) in the current classification of primary tic disorders. Noting a nosological privileging of the durative aspects of Tourette’s (at the level of overall symptomatology) over the syndrome’s transient aspects (at the level of individual tics), I argue that this leaves a common Tourettic experience unaccounted for: that of spontaneously remitting individual tics. This phenomenon is not captured by the DSM’s reference to the condition’s well-known ‘waxing and waning cycles’, which merely describe the fluctuating intensity of the overall symptoms. What would happen to our view of the primary tic disorder triad if we switched to an impermanence perspective and began studying tic transience and remission in Tourette’s? And how about related temporal phenomena, such as tic cessation and tic-free intervals? The chapter highlights a number of theoretically and clinically relevant questions arising from our use of relative temporal qualities (like ‘persistence’ or ‘transience’) in tic nosology. I conclude by showing how a fuller, more nuanced look at the temporality of tics could open new doors to phenotyping and classification. Keywords  Clock time · Nosology · Tic disorder · Provisional Tic Disorder · Chronic Tic Disorder · Tourette Syndrome · Types · Tokens · Occurrences · Temporality · Subjective experience · Phenomenology

2.1 A Slippery Explanandum The last two decades have seen a dramatic increase in scientific publications on Tourette Syndrome (TS), but the etiology of this common neurodevelopmental condition is still unknown (O’Hare et al. 2016, 238). Many questions remain – about the unitary nature of the syndrome, and the criteria used to define it in such Chapter 2 first appeared under the title ‘Time and the Tic Disorder Triad’. Copyright © 2020 Johns Hopkins University Press. This article first appeared in Philosophy, Psychiatry, & Psychology, Volume 27, Number 2, June 2020, pp. 183–199 © Springer Nature Switzerland AG 2023 L. Curtis-Wendlandt, Chasing Tourette’s: Time, Freedom, and the Missing Self, Philosophy and Medicine 145, https://doi.org/10.1007/978-3-031-19104-6_2

11

12

2  Clock Time and Tic Nosology

internationally accepted manuals as the DSM and the ICD (Robertson 2015, 68). Meanwhile, individuals and families affected by Tourette’s remain under-serviced as pharmacological and behavioral therapies provide relief for some but not all who need support (Dale 2017; Roth 2018). We urgently need new impulses and approaches capable of advancing the field. It is time to ask: What tacitly operating theoretical concepts underlie this work? And how do they impact approaches to nosology and treatment? This chapter re-examines the scholarship by focusing on one philosophical concept central to tic nosology: time or, more specifically, clock time (homogenous, chronological, objectified time). As I will show, clock time plays a central role in distinguishing between the ‘primary tic disorders’. While their classification is considered controversial (Cavanna 2018), the literature lacks sustained critical reflections on how nosological concepts have shaped our thinking about tics and Tourette’s. This chapter investigates the ‘epistemic slant’ that results from the use of clock time as a defining concept in tic nosology. What do we mean by saying that tics which endure differ from those that don’t? And how do we define such temporal thresholds, and interpret the tics that fall on either side? Do we infer anything about the pathogenesis of tics based on the objective temporal features we ascribe to them? These are no armchair philosophy questions; they are pertinent to future research and practice. We will see that the current tic disorder classification relies on a subset of temporal concepts that have focused scholarly attention on symptom endurance over time. With endurance, I refer to the sense of duration or chronicity that is built on clock time and described as ‘earlier than A’, or ‘later than B’, rather than experienced time, which I briefly discuss at the end of this chapter. While important, this focus on endurance observed at different time scales (e.g., weeks, months, years) only constitutes one side of the clock time coin. Taking homogenous, objectified time as a concept seriously means we owe it full, systematic consideration  – and this includes attending to the common yet neglected impermanence and transience of tics, particularly in Tourette Syndrome.

2.1.1 Tourette’s in DSM-5 Meet 11-year-old Pablo. It’s night time; he sits in bed, pleading with his mother to bandage his hands. Why? To stop his fingers from repeatedly pushing his eyeballs into their cavities – it’s too painful and means he can’t settle to sleep. Or imagine seven-year-old Mia. Playing hide-and-seek with her friends, she closes the pantry door behind her, catching her breath. But immediately, her high-pitched squeals give her away; she is the first one to be found, steaming with frustration. Now picture 16-year-old Ibrahim. On his overseas holiday, he repeatedly licks toilet seats, causing him tummy-upsets and fears about his health. What unites Pablo, Mia, and Ibrahim? It is Tourette Syndrome and its hallmark feature, tics – “certain types of sudden, rapid, recurrent, nonrhythmic motor movements or vocalizations” (American Psychiatric Association [APA] 2013).

2.1  A Slippery Explanandum

13

Today, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) – similar to the International Classification of Disorders (ICD) – groups Tourette’s among the neurodevelopmental disorders. Here, it features as a tic disorder characterized by (a) multiple motor and one or more vocal tics at some time during the illness, (b) the waxing and waning of tics over a period of more than 1 year, and (c) onset before the age of 18 years. Lastly (d), the tics must also not be attributable to the effect of a substance or other medical condition (APA 2013). Prevalence of TS is thought to approach 1%, and the condition occurs 3–4 times more frequently in males than in females (Dale 2017; Robertson 2015; Knight et  al. 2012). Tics themselves are extremely diverse, ranging from simple motor and vocal tics (e.g. blinking, sniffing) to complex movements and utterances that can appear purposeful  – for example, sexual or obscene gestures (copropraxia), imitation of someone else’s movements (echopraxia), repetition of one’s own sounds or words (palilalia) or of the last-heard word or phrase (echolalia), as well as the uttering of “socially unacceptable words, including obscenities, or ethnic, racial, or religious slurs (coprolalia)” (APA 2013). Interestingly, it is not the individual tics but their combination and recurrence over time that qualifies them as Tourettic tics. We can therefore note an implied distinction between the level of symptomatology (combined set of tic symptoms) on the one hand, and individual tics on the other. Further, Tourette’s rarely materializes as nothing but tics – this is called ‘pure TS’ and only occurs in approximately 15% of Tourette Syndrome patients. The other 85% of patients will exhibit one or more co-occurring conditions over time, with onset usually seen between 4 and 10 years of age. ADHD and OCD are the most common, affecting 72% of individuals with Tourette’s; mood and anxiety disorders, as well as disruptive behaviors, occur in 30%, and up to 15% are diagnosed with comorbid ASD (Dale 2017, 666; Dell’Osso et al. 2017; Darrow et al. 2017). Importantly, comorbidity is associated with worse functional outcomes (Dale 2017; Robertson 2015; Hirschtritt et al. 2015).1 Some research has explored the complex relationship between tics and their accompanying sensory, emotional, and cognitive phenomena. For example, the unpleasant physical sensations (‘premonitory urges’, or PUs) that often precede tics have been shown to be strongly correlated with tic-related beliefs (see Steinberg et  al. 2013), as well as with certain dimensions of anxiety such as physiological arousal (Rozenman et al. 2015). Further, cognitive approaches based on acceptance and willingness to experience discomfort have been shown to reduce tic expression and the frequency, intensity, and discomfort of PUs (Gev et al. 2016). Research into PUs has also shifted how we think about agency and volition in TS. It is now the urges that are thought to be out of the subject’s direct control (i.e., involuntary), while tics are variably described as un-, semi-, or even fully voluntary (compare, for example, Conelea et al. 2018; Delorme et al. 2016; Ganos et al. 2015). As Ganos writes, “tics are the only jerky hyperkinesia that can be completely inhibited on demand” (Ganos et  al. 2016, 516). Whether voluntary tic inhibition requires

 Evidence suggests that it is not comorbidity per se, but the number of comorbidities and presence of coprophenomena that most impact Quality of Life (see Eapen et al. 2016). 1

14

2  Clock Time and Tic Nosology

interoceptive awareness of sensory urges or motor intention remains unclear (Conelea et al. 2018; Ganos 2016), but current first-line treatments such as Comprehensive Behavioural Interventions for Tics (CBIT) rely on urge awareness to teach subjects to execute a competing behavioural response instead of the tic (Woods et al. 2008). The question of volition and tics is complex and central to nosology; for example, the distinction between functional and primary (organic) tic disorders rests on its delicate shoulders (Ganos et  al. 2016). While this chapter cannot pursue this point in detail, research into PUs and tic suppressibility will likely challenge our reliance on volition as a nosological differentiator between certain tic disorders (and possibly other movement disorders) in the future. Returning to the interplay of sensory, affective, and cognitive phenomena so typical of Tourette’s, the clinical implications of this complexity are clear: Therapy may need to address not just the tics themselves, but the cognitions and emotions known to exacerbate or ameliorate them. In this context, a comprehensive clinical assessment (usually aided by a number of parent- or self-report and clinician-rated scales) is required to identify appropriate treatment and care. However, while it is likely that the sensory, emotional, and cognitive phenomena accompanying tics impact individuals’ self-experience, this has not been explored systematically from the perspective of time and temporality (see Sect. 2.3 below). In sum, Tourette’s is not just a motor problem, a fact highlighted by pathophysiological research showing that “sensory, limbic, and executive cortex CBG [cortico-basal ganglia] loops are also affected” (Dale 2017, 667; see also Ganos 2016; Yael et al. 2015). The pervasiveness of co-occurring conditions, and the diverse clinical presentation of symptoms grouped under Tourette Syndrome, have led Robertson to conclude that the very definition of TS, “even in accepted international criteria, could be argued to be controversial” (Robertson 2015, 68). In this spirit, many agree today that “Tourette syndrome is not a unitary syndrome” (Dale 2017, 667). Co-occurring obsessive compulsive symptoms in particular challenge the additive model of comorbidity expressed in such formulations as ‘TS + OCD’. Are these really two distinct conditions? Or should they rather be understood as symptom dimensions of “a more severe disorder than either TS or OCD” (Eddy and Cavanna 2014, 364), perhaps “a specific subtype of illness, which we might refer to as Obsessive-­ Compulsive Tic Disorder (OCTD)” (Dell’Osso et al. 2017)? These and similar discussions illustrate that our slippery explanandum is riddled with controversy surrounding such questions as: What are the core criteria that define Tourette’s, and how do these criteria relate to the syndrome’s co-occurring conditions? If TS is not to be construed as a unitary syndrome, then how can we categorize its various instantiations? These questions point to uncertainty with classification – they go to the heart of “psychiatric systematics” (Kendler in Zachar 2008a, 328). DSM-5 defines the core criteria of Tourette Syndrome by referring to a certain combination and temporal distribution of motor and vocal tics. As mentioned, this makes the definition of Tourette’s ambiguous, because it conflates different ways of speaking about TS. I will borrow Wetzel’s distinction between types, occurrences, and tokens (Wetzel 2009) to explore how these concepts relate to our understanding of the primary tic disorder triad.

2.1  A Slippery Explanandum

15

2.1.2 Timeless Tokens The primary tic disorders grouped together in the DSM-5 are Provisional Tic Disorder (PTD, called Transient Tic Disorder in the DSM-4), Persistent Motor or Vocal Tic Disorder (previously called Chronic Tic Disorder, shortened here to CTD), and Tourette’s Disorder (elsewhere and here called Tourette Syndrome, TS). While the DSM-5 presents them as distinct conditions based on observed phenotypic differences, we lack diagnostic tests to confirm this distinction. This highlights the importance of asking why we classify tic disorders in the way we do, and why clock time is so central to our current nosology. To set up the distinction between types, tokens, and occurrences, consider the famous sentence from Getrude Stein’s poem, Sacred Emily: “Rose is a rose is a rose is a rose” (Stein 1998). How many words are in this sentence? We can rightly reply with either ‘three’ or ‘ten’ (three recurring types of words, or ten individual word instances). At a higher level of abstraction, we could say that the different word types in this sentence are tokens of the general concept ‘word’. Or we could say that the individual words are each an occurrence of the type ‘word’. But not all occurrences of a type are necessarily tokens – occurrences can be purely conceptual, whereas tokens are, by definition, concrete spatio-temporal objects or events (Wetzel 2009). The DSM-5 does not explicitly distinguish between types, occurrences, and tokens of tics, but the distinction is relevant and implied. In separating vocal from motor tics, the manual differentiates tic types in the higher-order family of primary tics. As abstract categories, these types of tics can occur in different ways  – for instance, as eye blinks or head jerks. Let’s call these different occurrences of a given tic type. If a head jerk is an occurrence of a motor tic, however, it is still an abstract concept requiring no spatial-temporal location; it is ‘type-like’ in that it can exist without a concrete particular that instantiates it. Only the discrete tic behaviors – let’s call them tic tokens  – represent specific events located in space and time. Without these tic tokens (observed by clinicians or reported by patients), we would not diagnose the presence of a tic disorder in an individual; we would not say that ‘X has tics’. The token level of analysis therefore has epistemic and diagnostic primacy: tic tokens ‘activate’ conversations about tic types and their various occurrences; they are foundational to any need for classification. Now, recall that we currently define primary tic disorders along two axes: the source (vocal and/or motor apparatus) and the duration of tic symptoms. However, we apply the temporal descriptors differently to each disorder. In Provisional Tic Disorder (PTD), the tic type can be motor and/or vocal (combined type is permitted but not required), and “the tics have been present for less than 1 year since first tic onset” (APA 2013). A PTD notation might look like this:



  1vocal     1 year ; or :   1motor     1 year ; or :   1vocal   1motor     1 year .

16

2  Clock Time and Tic Nosology

‘First tic onset’ here implies a concrete spatio-temporal event (token). But the ascription of time – under 12 months – does not seem to apply to individual events (single tic events rarely last longer than a few seconds, although complex tics can). When the DSM speaks of ‘the tics’ that have been present for less than a year, the intended meaning rather seems to be that there were tic events corresponding to any type of tic within a period of less than a year. In other words, the criterion of homogenous, objectified time is applied at the family level of tics, not at the level of types or occurrences and their instantiating tokens. The case looks different for CTD, which involves a single tic type – vocal or motor – persisting for over a year (combined type is not permitted, as this would constitute Tourette’s). Time is therefore predicated on the type level of tics. Here is a basic notation for CTD:

  1 vocal     1 year  ; or :   1 motor     1 year  .

As in PTD, CTD tic tokens have no temporal features ascribed to them; they remain ‘timeless’. This is true in Tourette’s, too, for which our notation would read:

  1 vocal   1 motor     1 year  .

However, in TS – like in PTD – time is predicated on the family level of tics (the period with any tics). Marking this diagnostic interval are the first and the most recent tic events; as privileged tokens, they provide the temporal frame deemed relevant for classification. Within this frame, much remains unspecified at the level of tic tokens and occurrences in the DSM-5: • The duration of individual tic tokens (how long – milliseconds, seconds, even minutes – does a single tic event last? We can expect some variation based on which tic occurrence the token is an expression of, as well as based on the context and complexity of the tic event) • The number of tic tokens required for diagnosis (a single tic event would not meet the ‘recurrent’ criterion; it would go unnoticed as a tic event) • The length of time for which specific tic occurrences are instantiated via their own ‘first-to-latest’ tic events (i.e., how persistent or transient are certain tic occurrences?) • The spread of tic tokens within the measured timeframe, i.e., the temporal relationship (proximity) between all tic tokens other than the first and latest ones DSM-5 refers to this last aspect as ‘frequency’ or rate of recurrence of tic events, noting significant variation on this point: “Tics may wax and wane in frequency but have persisted for more than 1 year since first tic onset” – i.e., since first tic token. But what, precisely, waxes and wanes? It is not the tic types (these persist over time). Rather, what seems to wax and wane are tic events, and possibly also the tic occurrences they instantiate. While either or both may become fewer or more numerable at any point, there is no necessary correlation between a rise or drop in each. In other words, a person might experience a waxing in their tic occurrences

2.1  A Slippery Explanandum

17

(increasing number of different vocal tics), while simultaneously experiencing a waning in concrete tic events. Put more simply: the person might not tic very often, but when she does, her tic events might be highly diverse. The inverse is equally conceivable, with fewer tic occurrences but more tic events (more ‘sameness’ in exhibited tic behavior). Waxing and waning can thus be understood as fluctuating numbers of tic occurrences or tic events (tokens) across time. DSM-5 does not disambiguate its use of ‘waxing and waning’; but its reference to tic frequency suggests a fluctuation in spatio-temporal tic events (tokens).2 And yet most of these tokens escape the manual’s attention, which only affords the first and latest tic events with nosological weight. It is in this sense that we could call most tic tokens ‘timeless’: their objective temporal features and relationships are not measured or deemed relevant for classification. Is the temporal spread of all other tic tokens inconsequential for the classification of tic disorders, or could it reveal meaningful patterns? Among the few who discuss this point, Leckman suggests we should assess tic patterns at various time scales – from seconds to days, and from weeks to months. “These episodes are characterized by stable intra-tic [sic] intervals—i.e., time between successive tics—of short duration, typically 0·5–1·0 s. Less well known is the so-called self-similarity of these patterns across different times” (Leckman et al. 2006, p. 1577). It is not entirely clear on what evidence Leckman bases his suggestion of a ‘typical’ inter-tic duration of half to one second (no direct reference is provided). It possibly refers to a cited study by Peterson and Leckman (1998), or to an earlier paper by Chappell et al. (1994), both of which analyze the temporal occurrence of tics during replays of video recordings (maximum 30 min) of subjects with TS. Given the limited data available from these studies, and the likely impact of contextual factors on tic expression during recordings (subjects being seated alone in a room during records, or being interviewed by clinicians about their symptoms), any generalizations about the duration of ‘typical’ inter-tic intervals seem premature. And yet Leckman’s broader suggestion that such temporal token–token relationships could hold cues for science remains highly relevant: “A deeper understanding of the multiplicative processes that govern these timing patterns might clarify neural events arising every few milliseconds and the natural history of tic disorders over the first two decades of life” (Leckman et al. 2006, p. 1577). Similar benefits may extend into clinical practice: Knowledge of the temporal patterning of tics is important for the doctor, because it informs decisions about when to initiate anti-tic drugs, when to change drugs, and when to be patient and simply provide close monitoring and support to the family. Stated simply, if a clinician begins or changes a treatment at the end of a waxing period, the patient’s condition will improve irrespective of the efficacy of the intervention (Leckman 2002, p. 1577). Does Leckman envision some kind of predictability to emerge from looking at individuals’ tic event patterns? While highly desirable, this would require that

 A qualitative reading of ‘waxing and waning’ is also common, denoting ups and downs in the intensity and functional impact of tics (see Leckman 2002, 1577; Peterson and Leckman 1998). 2

18

2  Clock Time and Tic Nosology

similar ‘bouts’ or ‘episodes’ of tics (terms left undefined by Leckman) recur across time. Whether such stable token–token relationships could be found is unknown. A longitudinal study in children with TS or OCD found high intrasubject variability of symptoms over time and was able to derive clinically valid exacerbation thresholds (Lin et al. 2002). While more empirical work is needed, we have no prima facie reason to assume that these temporal patterns between tic tokens matter less for diagnosis and treatment than time elapsed between the first-to-latest tic events. What if such patterns related meaningfully to diagnostic variables like co-occurring conditions, response to pharmacotherapy or behavioral treatment, etc.? We cannot answer this question here, but the concept of chronicity deserves closer attention.

2.2 Masking Change 2.2.1 Chronicity To recap: The idea that tics are either chronic or impermanent (they endure or go away again) plays a central role in tic nosology, providing the names for two primary tic disorders: Persistent (Chronic) Tic Disorder (CTD) and Provisional Tic Disorder (PTD). We also saw that the current classification predicates chronicity on a single token–token relationship: namely, that between the first-to-latest tic events. If time elapsed between these diagnostically privileged tokens is ≥1 year, we can infer the chronic nature of the condition. This ‘chronicity criterion’ is applied at different levels across the tic disorder triad. Take CTD: the first-to-latest tic events assessed for diagnostic purposes have an unambiguous relationship to a single type of tic. Put differently, our privileged token pair expresses the same tic type (Fig. 2.1). Type endurance is clearly visible in Fig. 2.1, with a straight line of crosses running through the center column. (A second possible configuration would see the line of crosses sitting below the vocal tic type.) However, endurance is not measured at the type level in either PTD or TS.  In Provisional Tic Disorder, the relationship between type and time is weaker than in CTD. By definition, the chronicity criterion must not be met, meaning we lack a minimum positive duration for the first-to-latest token interval. (In practice, this simply means that PTD can be diagnosed at any time within the first 12 months of tics appearing.) Further, since vocal and motor

Fig. 2.1  One of two possible scenarios where diagnostic time indicates type persistence in CTD

2.2  Masking Change

19

tics are permitted during the diagnostic interval, the first and latest tic tokens may not express the same type of tic. The diagnostic interval thus need not indicate type persistence. Four scenarios are possible in PTD: Two where diagnostic time corresponds with type persistence, and two where it does not (Fig. 2.2 and 2.3). In sum, while in CTD the chronicity criterion is applied at the level of tic types, in PTD it takes hold at the family level of primary tics. Once we move up to this level, we get the same necessary correlation between diagnostic time and tic family as we got for diagnostic time and tic type in CTD (Fig. 2.4). The same is true for Tourette Syndrome, which meets the chronicity criterion. Since the DSM-5 does not require persistence of both tic types across the diagnostic interval, the latter can be framed by two tic events of a different type. As in PTD, among the four possible scenarios relating diagnostic time to the expressed tic type, only two confirm type persistence across the measured interval. To consistently

Fig. 2.2  One of two possible scenarios where diagnostic time indicates type persistence in PTD

Fig. 2.3  One of two possible scenarios where diagnostic time does not indicate type persistence in PTD

Fig. 2.4  Diagnostic time always indicates tic family persistence in PTD

20

2  Clock Time and Tic Nosology

Fig. 2.5  Diagnostic time always indicates tic family persistence in TS

meet the chronicity criterion for Tourette’s, endurance must therefore be predicated on the family level of tics (Fig. 2.5). But why does this matter? The fact that chronicity (what we could call diagnostically relevant endurance over time) is assessed differently across the tic disorder triad is problematic, particularly for our view of Tourette’s. By privileging a family-­ level measure of tic endurance, we miss important nuance and temporal variation at the type and occurrence levels of tics and their associated tokens, particularly as the condition continues past one year. Conceptually, this may mask varying degrees of impermanence in observed or experienced tic events and event patterns. This masking effect is less pronounced in PTD, since we cannot claim symptom persistence past 12 months. Diagnostically, the focus is already on transience, so exploring time at the occurrence and token levels will only reveal further degrees of impermanence in PTD. A contrasting picture emerges in Tourette’s, which also predicates chronicity at the tic family level. Once the 1-year diagnostic interval is reached, we may notice: a) type impermanence (extended periods with no vocal or motor tic events); b) variable and fluctuating tic occurrences (a tic type may occur in many different shapes and forms); and c) extended tic-free intervals (no tic events). Phenotypically, this could mean that specific tic occurrences, as expressed by spatiotemporal tic events, may in some cases persist for longer in Provisional Tic Disorder than they do in CTD or TS. An example: A person diagnosed with PTD has an eye-blinking tic that lasts 8 months; another person diagnosed with CTD or TS has the same eye-­blinking tic, but the instantiating tic events cease after 4 weeks. With regard to this tic occurrence, we could say that the eye-blink is more chronic in the person diagnosed with PTD than in the person with CTD or TS respectively. But this flies in the face of our nosology, which defines PTD as the transient and TS and CTD as chronic conditions. Why does this seem contradictory? Because the DSM-5 does not recognize the temporal features of tic occurrences and their instantiating tokens as relevant to phenotyping and classification. This need not stop us from posing questions about them though  – and from acknowledging the varying degrees of chronicity and transience evident behaviorally across all primary tic disorders. Rather than understanding chronicity in relation to tic type or family, we could measure time at the level of occurrences and their instantiating tokens (‘how long is a particular motor tic expressed in corresponding tic events?’). This very idea of capturing tic occurrences has found its way into ‘tic

2.2  Masking Change

21

inventories’ featured in clinical handbooks and tic severity scales. While these inventories attempt to group common tics based on certain criteria (body region, tic complexity, social impact, self-harm potential, etc.), they remain largely silent on the temporality of tic occurrences and their instantiating tokens. More research is needed to answer such questions as: Does the relative chronicity of tic occurrences in PTD correlate with the likelihood of an eventual TS diagnosis? Is there any meaningful relationship between the relative transience of tic occurrences in Tourette’s and the likelihood of successful behavioral or pharmacological interventions? It would be difficult to ignore the temporal features of tic tokens and occurrences if they were found to hold any predictive and clinical relevance in future. For now, one thing is clear: The complex ways in which chronicity and transience can materialize at different levels across the primary tic disorders challenges the notion of a causal-­ structural model of disease.

2.2.2 Ontological Transmutations The question of what causes Tourette Syndrome and other tic disorders is far from resolved. There is consensus that TS involves “polygenic and environmental vulnerability factors” (Dale 2017, 667), and a broad range of studies indicate pathophysiological, genetic, and immunological contributors. Since no established diagnostic test can tell apart the primary tic disorders, and since the defining temporal features of one can also be used to describe the others (as in, ‘there are degrees of transience in Tourette’s, and degrees of chronicity in PTD’), our triad might share some underlying causal mechanisms. In other words, the features we select as salient for our nosology may not be salient etiologically. Zachar calls this the first problem arising from phenotype-based classification: “The observed similarity or dissimilarity between disorders may be superficial and elide deeper connections with other disorders” (Zachar 2008a, 338). A second problem is “deciding which observable characters should be used to define a group or … differentiate between groups” (Zachar 2008a, 338). As noted, the DSM-5 distinguishes primary tic disorders based on tic type (combined or single) and duration. We saw that duration is defined as a relational property between certain (privileged) tic tokens. This means that observing an individual tic event – for example, Pablo’s eye-blink just now – leaves us with a multitude of explanations. There is nothing about the individual tic event that identifies it as a Tourettic tic, rather than a chronic or transient tic. Looked at in isolation, Pablo’s eye-blink may not be a tic; or it could be a provisional tic (PTic), a chronic tic (CTic), a tic caused by another medical condition such as Huntington’s or postviral encephalitis (OMTic), a functional tic (FTic), or a Tourettic tic (TSTic). The same eye-blink event could have many different causes; how we interpret it depends on the background conditions. While these are spelled out in DSM-5, our reading of the symptoms in context remains speculative, given the lack of reliable diagnostic testing and

22

2  Clock Time and Tic Nosology

unknown pathophysiology. Speculative, too, is our selection of background conditions: From infinitely many aspects we could focus on, we choose some as relevant and others as irrelevant to the condition (Zachar 2008a, 338). Our classifications thus largely depend on which background conditions we privilege. Does that mean our grouping of tics into different disorders relates to etiological assumptions? Do we base our interpretation of Pablo’s eye-blink on what we infer about its causes? If so, it seems we are suggesting that Provisional Tic Disorder causes PTic eye-blinks, other medical conditions cause OMTic eye-blinks, functional or psychogenic factors cause FTic eye-blinks, etc. To pre-empt my argument below, this is problematic. Zachar describes the above causal-structural approach to classification as desirable for psychiatric disorders with diverse etiologies, such as Alzheimer’s disease: “If one adopts a robust causal-structural model, then different cause equals different disease. That means that there are at least four disorders in the Alzheimer family, not one” (Zachar 2008a, 336). It is not clear whether our current tic nosology fits such a causal-structural model, nor whether such a model would be useful. Some causal assumptions are definitely at play in the distinction between OMTics and TSTics: The DSM-5 clearly states for Tourette’s that “the symptoms must … not be attributable to the effects of any substance or other medical condition” (APA 2013). A Tourettic tic thus cannot be caused by these conditions, implying distinct causal pathways for OMTics and TSTics. Further, since a condition such as Huntington’s can be confirmed via genetic testing, the distinction between OMTics and other types of tics is clearly etiological. But as the following thought experiment illustrates, the situation is less straightforward with regard to primary tic disorders. Recall that the chronicity criterion for diagnosing TS or CTD is one year of observed tic events. When tics are present for longer, PTD ‘turns into’ CTD or Tourette’s, “regardless of any intervening asymptomatic period” (Black et al. 2016, Appendix 1). Now recall Pablo’s eye-blinking tic. Imagine that he has never had any other tics since the eye-blinking first started on Christmas Day 2017. It is now Christmas Eve of the following year, 364 days after the first eye-blinking tic event. Pablo settles into bed, annoyed by the rapid movement of his eye lids while he tries to fall asleep. Diagnosis: PTD. But as Pablo wakes in the morning of Christmas Day 2018, his first eye-blink suddenly has a different name: it’s a chronic tic. Pablo now has CTD. What changed so mysteriously as the clock struck 12 at midnight? And how should we imagine the transformation Pablo underwent? Surely, we are not positing some overnight ontological transmutation, whereby Pablo’s eye-blinking tics mysteriously switch causal pathways. Rather, what seems to change is our interpretation of his eye-blink – we experience an epistemic shift. This shift does not happen suddenly at midnight, but gradually, as Pablo’s eye-blink persists for weeks, months, and eventually a full year. Looking back, then, what do we say? ‘Pablo had provisional tics to start with, but now he has chronic tics’? Or do we simply claim that ‘Pablo has CTD’, knowing now that it lasted for a year, and accepting that he never had PTD after all? Philosophically, a continuum view of tics – assuming some shared etiology between primary tic disorders – would get us into less trouble when faced with the need to explain sudden jumps between our classificatory categories, particularly when these

2.2  Masking Change

23

rely on the (more or less arbitrary) posit of a meaningful temporal threshold. To avoid midnight ontological transmutations of sleeping ticcers, we may therefore note a theoretical preference for the continuum view of tics. The nosological – and related etiological – debate on this topic is inconclusive: “Many experts conclude that Provisional Tic Disorder (PTD) … is probably a different disease than chronic tic disorders including Gilles de la Tourette syndrome. Others conclude that all tic disorders lie on a continuum, with no appropriate arbitrary duration boundary, and may share the same causes” (Black et al. 2016, 3; see also Dooley 2006). If the continuum view was true, why would we keep distinguishing between primary tic disorders in the way we do? Might practical utility, not ontology, be the point of our classification? We should certainly heed Mitchell’s warning against a reified understanding of psychiatric nosology (Mitchell 2008). The problem of Pablo’s transmutation only arises if we believe that abstract entities like primary tic disorders literally represent what tic disorders are, and that one definite etiology should be tied to each: “In physics, Cartwright refers to that move as fundamentalism, the view that a fixed set of generalizations can always be invoked to explain what needs explaining” (Zachar 2008b, 45; see also Cartwright 1983). Once we leave behind this ‘fundamental misunderstanding’ that nosological entities literally represent the complex phenomena they describe, the question of utility – how useful is our nosology? – becomes more pressing. Without a clear foothold in etiological assumptions, the current tic disorder classification offers little theoretical value. In the scholarly literature, a certain literalism about diagnostic criteria appears to have narrowed the scope of research on primary tic disorders more than necessary – certainly in relation to the concept of time. Fittingly, the temporal features of tics deemed irrelevant to classification in the DSM-5 (recall our list in Sect. 2.3) have also been the least explored in research. And clinically? The current nosology offers practitioners criteria for an initial diagnosis before or after the 1-year threshold for observed tic events has been met. The DSM-5’s emphasis on this diagnostic interval (the time elapsed between first and latest tic events) may help clinicians justify an initial period of ‘wait and see’ in patient care, prior to commencing treatment; or it may help affirm treatment decisions once chronicity is established and tic severity warrants therapeutic intervention. But beyond early diagnosis and care, the current classification contains little to support clinicians’ longer-term work with CTD and TS patients. Could we group and classify tic disorders differently – perhaps in a way that aligns more closely with evolving etiological hypotheses or clinical needs? Müller-Vahl et  al. (2019) recently proposed the diagnostic term, “tic spectrum disorders”, to encompass and replace DSM-5 and ICD-10 diagnoses of TS, CDT, and PTD (for an earlier proposal, see Robertson and Eapen 2014). This has triggered an important debate, with a response from Conelea and colleagues urging scholars to take patient perspectives into account (Conelea et al. 2019). However this discussion will unfold, the concept of time remains tied to its classificatory questions. In this context, we can ask: Should we continue using such a limited subset of temporal concepts – ones that emphasize symptom endurance at the type or family level of tics – to differentiate between tic disorders? What if we tried to group tic disorders based on other

24

2  Clock Time and Tic Nosology

temporal features unexplored by the current nosology? Moving to a less haphazard, more systematic understanding of time and tics should also involve studying the many ways in which tics remit or ‘disappear’ across the tic disorder triad.

2.2.3 Transience, Remission, and Tic-Free Time As noted, DSM-5’s emphasis on symptom endurance – particularly in Tourette’s – masks other, more fleeting temporal experiences that are also part of tic disorders. Broadly construed, these involve the temporary or permanent disappearance of tics at various time scales: • Tic occurrences may only materialize briefly via tokens (tic events). Certain tic occurrences often only materialize for short periods of time via instantiating tokens: A headshaking tic may appear one day and disappear a few days later. We could call these tics transient, fleeting, temporary, time-limited, or the like. • Tic-free periods exist across all primary tic disorders. These are shorter or longer time intervals with no tic events (and with no urge to tic, i.e. different from suppression). Relevant evidence may include research on contextual and attentional factors impacting tic expression (e.g., Misirlisoy et al. 2015; Conelea and Woods 2008). • Tic remission or cessation can be thought of at the occurrence, type, and family level of tics. It is usually understood at the family level (no tic tokens of any sort). The idea of remission or cessation entails a more enduring notion of tic-free time. In DSM-5, the possibility of spontaneous tic remission is explicitly acknowledged in the context of PTD (previously termed Transient Tic Disorder): Tic events may emerge and completely disappear again within a period of less than one year. But stipulating permanent remission is speculative, since tics may re-appear in future; we can only ever say that the tics have ‘remitted for now’. A diagnosis of PTD might therefore say less about the condition itself, and more about the timing of the observation. While remission is always relative to the observer’s point in time, it loses diagnostic relevance when tics have been present for over a year. This is despite the fact that spontaneous tic remission can and does occur at any point in one’s life with Tourette’s or CTD, and at any level of analysis (tic family, type, occurrence): A certain vocal tic occurrence may remit and never be instantiated by tic events again (although other tic occurrences might be present). An entire type of tic may remit, meaning there would no longer be any vocal or motor tic events at all. Or tics may remit at the family level, meaning all tic events would cease. Further, in a medical context, remission can be construed as meaning either less severe or no symptoms. In the former sense, it may relate to a period of time when an illness is less noticeable or not affecting someone; this understanding seems implied in the notion of ‘waning’ when we speak of the waxing and waning cycles commonly observed in Tourette Syndrome. In the latter sense, it describes the

2.2  Masking Change

25

disappearance of any symptoms referred to as ‘complete remission’ or ‘no evidence of disease’ (NED). The word cure may be used when complete remission continues uninterrupted for some time. Scholars debate whether tics ever remit completely in TS (Müller-Vahl 2014, 69),3 and little is known about tic recurrence in adulthood after long periods of latency (see Schaefer et al. 2017). To summarize, degrees of impermanence can be observed across all primary tic disorders and are permitted to varying degrees within the current nosology. Figures 2.6, 2.7, and 2.8 depict permitted remission scenarios for our primary tic disorder triad implied (but not spelled out) in DSM-5.

Fig. 2.6  Permitted remission scenarios in Provisional Tic Disorder

Fig. 2.7  Permitted remission scenarios in Chronic Tic Disorder

Fig. 2.8  Permitted remission scenarios in Tourette Syndrome

 Research findings on this topic diverge widely; compare Burd et  al. (2001); Ohta and Kano (2003); Pappert et al. (2003). 3

26

2  Clock Time and Tic Nosology

Despite the fact that tic remission regularly occurs at various levels in CTD and TS, both before and after the 1-year threshold, impermanence patterns have not been studied systematically. Just like Leckman speaks of “bouts of bouts of bouts of tics” (Leckman 2002, 1578, Fig.  1) at increasing timescales, we could ask what meaningful patterns might emerge if we studied tic-free intervals in tic disorders. Could remission dynamics observed at the occurrence or type level relate to eventual remission at the family level of tics, or to features of co-occurring conditions commonly seen in Tourette’s? Concepts like transience, remission, and tic-free time clearly look relevant for analyzing phenotypic diversity, not just in PTD, but in CTD and TS as well. Nosologically, this means that the notion of impermanence may not serve as the solid differentiator DSM-5 makes it out to be. For one, the limited data on Provisional Tic Disorder does not seem to support the broad prognostic consensus of published reviews that recent-onset tics in children will “almost always disappear in a few months, having remained mild while they lasted” (Black et al. 2016, 1). Summarizing the available data, the team concludes “that a child with tics who had no tics prior to 1 year ago has a favorable prognosis overall, but has only about a one in three chance of remaining completely tic-free over the next 5–10 years. Many of those who do remit probably remit only after meeting criteria for TS/CTD at some point” (1, emphasis added). In other words, remission is not as common as we think in PTD, and not unique to PTD, since it also occurs in CTD and TS. A Provisional Tic Disorder thus often turns out to be more permanent than expected; and inversely, full or partial remission can also apply to the two tic disorders hypothesized to be more enduring, i.e., CDT and TS. This latter point is an often-overlooked aspect of Tourette Syndrome in particular, which – ironically – is riddled by transience in the very moment that it endures. We have already explained this seeming paradox by distinguishing between the various levels at which we can speak of tics (a person with TS may experience highly transient tic occurrences while their overall tics – at the family level – persist). Having ‘new tics’ (tic events that instantiate new tic occurrences) on a regular basis is a common experience for people with Tourette’s, as is the sudden cessation of certain tic occurrences within various time frames (a day, a week, etc.). We should therefore expand upon Black and colleagues’ claim that tic remission in PTD deserves more attention. As they rightly point out, the notion of spontaneous remission is central in PTD but often overlooked by scientific studies, which tend to focus more on positive tic symptomatology and chronic or Tourettic tics. Remission in PTD is of interest to science, because “it provides an opportunity to prospectively observe the spontaneous remission of tics. Such prospective studies may aid identification of genes or biomarkers specifically associated with remission rather than onset of tics” (Black et al. 2016, 1). From this, they conclude, we could gain exciting new strategies for treating and even preventing tic disorders. Building on this argument, I suggest that the transient nature of Tourettic tics also deserves greater scientific attention. If tics remit spontaneously not only in PTD but also (and frequently!) in TS, then individuals with Tourette’s represent a promising target group

2.3  The Future of Time and Tics

27

for study, too – and potentially a more accessible one, given the likelihood of an existing clinical diagnosis and ongoing care. It remains to be discussed whether we can compare transient tics in non-­remittent TS with transient tics in PTD. Also, how does syndrome remission resulting from developmental maturation – a well-known possibility in Tourette’s, with about 37% “outgrowing” earlier significant symptoms completely (Bloch and Leckman 2009, 498, Fig. 2) – relate to, or differ from, individual tic remission (at the occurrence or type level of tics) during simultaneous syndrome persistence (at the tic family level)? Clinically, understanding the mechanisms underlying spontaneous tic remission seems highly desirable in our continuing quest to improve treatment and care for people with tic disorders. More research is needed; and this research should also consider how time impacts the first-person experiences of people with tics and TS.

2.3 The Future of Time and Tics First-person experiences of tic disorders and Tourette Syndrome remain a sorely understudied topic. This is despite the fact that a growing body of work in neurophenomenology and phenomenological psychiatry has shown that such experiential data holds more than just descriptive value. It can also feed back into etiological hypotheses, allowing us to check whether the core features enshrined in our nosology align with what feels most salient about the condition to those who are affected by it (see Sass and Parnas 2006; Zahavi 2005, 135–137). What can we learn from this work? Could there be comparable phenomena – anomalous experiences of selfhood, agency, embodiment, time, and space – in TS and other tic disorders? Here, we can distinguish between two related but distinct approaches to exploring the phenomenological relevance of time to research and clinical care. Experienced Time  How do people with TS and other tic disorders experience time? Is their subjective experience of time different from that of people without tic disorders? The phenomenologically oriented psychiatric literature has paid much attention to anomalous experiences of time, “because temporality constitutes the bedrock of any experience, and its integrity is fundamental for the sense of coherence and continuity of selfhood and personal identity” (Stanghellini et al. 2016, 45). Fuchs and Pallagrosi present schizophrenia, melancholic depression, and borderline personality disorder as paradigmatic cases in support of a psychopathology of temporality (Fuchs and Pallagrosi 2018, 292). The EASE scale – a symptom checklist for semi-structured, phenomenological examinations of anomalous self-­experience – is designed for schizophrenia spectrum conditions and includes an item that checks for disturbances in the experience of time (Parnas et al. 2005). Extending this work to tic disorders and to Tourette Syndrome in particular could open up important new understandings of the subjective dimensions of these conditions. Such phenomenological research could also fruitfully engage with experimental studies on time processing in individuals with TS, a topic on which little research has been conducted to date (but compare Vicario et al. 2010).

28

2  Clock Time and Tic Nosology

Time and Self-Experience  How do the temporal aspects of tics and tic disorders impact other structural aspects of experience such as notions of self, self-awareness, intersubjectivity, and embodiment (Fuchs and Pallagrosi 2018, 289–290)? This is currently not captured diagnostically nor treated clinically. Understanding these two (and potentially other) phenomenological perspectives on time and tics would complement the traditional ‘patient-as-object’ approach to medicine and psychopathology. For Fuchs and Pallagrosi, this is a crucial endeavor: Not attending to the aspect of lived time means that we cannot “articulate the subjectivity of the affected person in a comprehensive way” (Fuchs and Pallagrosi 2018, 289). A similar concern can be raised in scholarship on Tourette’s and tic disorders: “Without patient input, researchers risk making recommendations that ultimately do not best capture actual disorder phenomenology (i.e., lived experience of symptoms) nor serve the needs of those with tics” (Conelea et al. 2019). Bringing such lived experience into research and practice may also soften the dominant focus on finding a cure – a focus not shared by many Touretters, who positively identify with their condition and would neither wish to have their genes edited nor to swallow a magic pill that rids them of their TS.4 Lastly, from a nosological perspective, exploring first-person experiences of temporality an selfhood in tic disorders and their co-occurring conditions might highlight experiential similarities that belie their current phenotyping into separate conditions. While the above are programmatic remarks – we need, but do not yet have, clinical research grounded in philosophical phenomenology that explores temporality and first-person experience in primary tic disorders – I conclude by offering some tentative hypotheses. In general terms, I hypothesize that the experience of ticcing can, and often does, lead to both an altered “temporal structure of experience” and to “changing attitudes toward past, present, and future” (Moscalewicz 2016). Frequent, repetitive, bothersome or painful tics, when they disrupt normal functioning and push themselves into the subject’s conscious awareness, are likely to disrupt the ‘normal’ experience of an uninterrupted and cohesive flow or stream of time. In making the individual constantly aware of herself (via interfering self-generated movements or sounds and their preceding or ensuing cognitive, affective, and social feedback loops), ticcing may heighten and problematize the experience of the present moment. It might become harder for ticcers to ‘inhabit the now’ – in the sense of feeling at home or at ease in the present – or to maintain faith in the continuity of experience (Binswanger 1957; Hemsley 1998). Drawing on Heidegger, Trubody reads tics as continually drawing individuals into the present, and as leading to an “excessive present-at-hand” state (2014, 275) that represents a new mode of being in the world. I explore these ideas in Chap. 4 of this book. In a similar vein, we could argue that the unpredictability of tics may threaten something akin to Blankenburg’s “common sense” and its facilitative relationship to the future. As Blankenburg writes: “The healthiness of commonsense rests on  Many episodes on Ben Brown’s Tourette’s Podcast (https://tourettespodcast.libsyn.com/) feature interviewees who consider their TS a positive part of their identity. 4

2.3  The Future of Time and Tics

29

habituality. The natural self-evidence of everyday existence draws its nourishment from just such a habituality” (1969, as quoted in Mishara 2002). With such natural habituality disrupted by the unpredictability of intruding tics  – which can make many taken-for-granted, daily behaviors and projects impossible  – short- and longer-­term goal-directed action may become more difficult. We can compare this to Von Gebsattel’s and Straus’s observations of people with compulsions, whose repetitive behaviors keep them so busy that they cannot take part in the “real life” (Von Gebsattel 1954; see also de De Haan et al. 2013, 8), or in what Straus calls sympathetic relations with the world (Straus 1938, 1966). But while Von Gebsattel views compulsive repetition as an attempt to bring order into chaos and destruction, and Straus casts it as a defensive response to the “disgust” felt toward the invasions of decay, I propose that repetition in primary tic disorders does not respond to but rather creates chaos in the first place. In other words, intrusive repetitive tics may disrupt rather than reinstate order; threaten rather than protect a “self under siege” (Leckman et al. 2006). In TS the meaningless repetition of unwanted movements and sounds may itself become the source of fear and alienation from the world, engendering a crisis of confidence in the person, a too-much of doubt and uncertainty, an eroding of hope regarding one’s agency and ownership of action. This perceived loss of agency and diminished freedom could, in turn, be tied to the sense of a “foreshortened future” deemed symptomatic of post-traumatic stress disorder (PTSD) and explored in detail in the context of trauma by Ratcliffe et al. (2014). Intriguingly, individuals with Tourette’s exhibit many of the co-occurring affective disorders found in trauma patients with PTSD, such as anxiety and depression. Might such affective symptoms in TS be caused, at least in part, by an altered temporal structure of experience and a resulting change in attitude toward the present and future? I will briefly explore these questions in Chap. 7 (see Sect. 7.3.3) of this book. In sum, this chapter has shown that clock time plays a central role in the current classification of primary tic disorders, which privileges the durative aspects of Tourette’s (at the family and type levels of tics) over the syndrome’s transient aspects (at the occurrence and token levels). I have shown that chronicity and transience as temporal features of tics apply to all primary tic disorders, a fact that interferes with the idea of a robust, causal-structural approach to classification. As a concept, clock time does not confirm but rather challenges the idea of three separate tic disorders, providing theoretical support for a continuum view of tics and shared etiologies. We can conclude that a fuller, more nuanced look at the temporality of tics is likely to open new doors to phenotyping and classification. Future research should: • Disambiguate references to ‘tics’ by applying the tripartite terminology of tic tokens, occurrences, and types proposed in this chapter. • Switch to an impermanence perspective and study tic transience, remission, and tic-free times in TS and other tic disorders. • Study the longitudinal patterns of tic tokens and occurrences across larger intervals of time and during different developmental periods.

30

2  Clock Time and Tic Nosology

• Develop new measures to assess chronicity and transience in tic occurrence patterns and their instantiating tokens. • Assess correlation between temporal features of tics and other variables such as co-occurring conditions, response to therapy, pathogenesis, etc. • Explore the phenomenology of first-person experience in relation to temporality and tics. Research on these last two topics would help us move beyond a ‘tics-only’ understanding of TS. Despite the fact that the majority of those with tics “meet criteria for another DSM diagnosis, and many have other symptoms that go uncaptured by current DSM categories” (Conelea et  al. 2019), our current nosology remains tic-­ centric. With Conelea and colleagues, we should ask: “If these conditions are accepted to be part and parcel of a tic syndrome, why are they not reflected in diagnostic criteria? At what point is a symptom not a comorbidity, but rather a core symptom of the disorder?” (Conelea et  al. 2019). I would like to think that the temporal features of tics and their co-occurring conditions, when explored more fully, will help us answer these questions and devise a nosology that matches patients’ experienced symptoms more closely.

References American Psychiatric Association. 2013. Neurodevelopmental disorders. In Diagnostic and statistical manual of mental disorders, 5th ed. Arlington: Author. Binswanger, L. 1957. Schizophrenie. Pfullingen: Neske. Black, Kevin J., Elizabeth Rose Black, Deanna J.  Greene, and Bradley L.  Schlaggar. 2016. Provisional tic disorder: What to tell parents when their child first starts ticcing. F1000Research 5: 696. 1–18. Blankenburg, Wolfgang. 1969. Ansaetze zu einer Psychopathologie des ‘common sense’. Confiinia Psychiatrica 12: 144–163. Bloch, Michael H., and James F. Leckman. 2009. Clinical course of Tourette syndrome. Journal of Psychosomatic Research 67 (6): 497–501. Burd, Larry, Jacob Kerbeshian, Amy Barth, Marilyn G.  Klug, Karilyn Avery, and Becky Benz. 2001. Long-term follow-up of an epidemiologically defined cohort of patients with Tourette syndrome. Journal of Child Neurology 16 (6): 431–437. Cartwright, Nancy. 1983. How the laws of physics lie. Oxford: Oxford University Press. Cavanna, Andrea E. 2018. Gilles de La Tourette Syndrome as a paradigmatic neuropsychiatric disorder. CNS Spectrums 23 (3): 213–218. Chappell, Phillip B., Maureen T.  Mcswiggan-Hardin, Lawrence Scahill, Michelle Rubenstein, David E.  Walker, Donald J.  Cohen, and James Leckman. 1994. Videotape tic counts in the assessment of Tourette's syndrome: Stability, reliability, and validity. Journal of the American Academy of Child & Adolescent Psychiatry 33 (3): 386–393. Conelea, Christine A., and Douglas W. Woods. 2008. The influence of contextual factors on tic expression in Tourette’s syndrome: A review. Journal of Psychosomatic Research 65 (5): 487–496. Conelea, Christine A., Brianna Wellen, Douglas W.  Woods, Deanna J.  Greene, Kevin J.  Black, Matthew Specht, Michael B. Himle, Han-Joo Lee, and Matthew Capriotti. 2018. Patterns and predictors of tic suppressibility in youth with tic disorders. Frontiers in Psychiatry 9: 1–10.

References

31

Conelea, Christine A., Jaleesa Jenkins, Ben Brown, and Louise Beljaars. 2019. A patient-­centred perspective on the future of tic disorder diagnosis: Response to ‘tic disorders revisited: Introduction to the term “tic spectrum disorders”’ by Müller-Vahl et al. (letter to the editor). European Child & Adolescent Psychiatry 29 (8): 1165–1167. Dale, Russell C. 2017. Tics and Tourette. Current Opinion in Pediatrics 29 (6): 665–673. Darrow, Sabrina M., Marco Grados, Paul Sandor, Matthew E. Hirschtritt, Cornelia Illmann, Lisa Osiecki, Yves Dion, Robert King, David Pauls, Cathy L.  Budman, Danielle C.  Cath, Erica Greenberg, Gholson J. Lyon, William M. McMahon, Paul C. Lee, Kevin L. Delucchi, Jeremiah M.  Scharf, and Carol A.  Mathews. 2017. Autism spectrum symptoms in a Tourette’s disorder sample. Journal of the American Academy of Child & Adolescent Psychiatry 56 (7): 610–617.e1. De Haan, Sanneke, Erik Rietveld, and Damiaan Denys. 2013. On the nature of obsessions and compulsions. In Anxiety disorders. Modern trends in Pharmacopsychiatry 29, ed. David S. Baldwin and Brian E. Leonard, 1–15. Basel: Karger. Dell’Osso, Bernardo, Donatella Marazziti, Umberto Albert, Stefano Pallanti, Orsola Gambini, Antonio Tundo, Carlotta Zanaboni, Domenico Servello, Renata Rizzo, Luciana Scalone, Benatti Beatrice, A.  Carlo Altamura, and Mauro Porta. 2017. Parsing the phenotype of obsessive-­ compulsive tic disorder (OCTD): A multidisciplinary consensus. International Journal of Psychiatry in Clinical Practice 21 (2): 156–159. Delorme, Cécile, Alexandre Salvador, Valerie Voon, Emmanuel Roze, Marie Vidailhet, Andreas Hartmann, and Yulia Worbe. 2016. Illusions of agency in patients with Gilles de la Tourette syndrome. Cortex 77: 132–140. Dooley, Joseph M. 2006. Tic disorders in childhood. Seminars in Pediatric Neurology 13 (4): 231–242. Eapen, Valsamma, Corina Snedden, Rudi Črnčec, Anna Pick, and Perminder Sachdev. 2016. Tourette syndrome, co-morbidities and quality of life. Australian and New Zealand Journal of Psychiatry 50 (1): 82–93. Eddy, Clare M., and Andrea E.  Cavanna. 2014. Tourette syndrome and obsessive compulsive disorder: Compulsivity along the continuum. Journal of Obsessive-Compulsive and Related Disorders 3: 363–371. Fuchs, Thomas, and Mauro Pallagrosi. 2018. Phenomenology of temporality and dimensional psychopathology. In Dimensional psychopathology, ed. Massimo Biondi, Massimo Pasquini, and Angelo Picardi, 287–300. Springer International Publishing. Ganos, Christos. 2016. Tics and Touretteʼs: Update on pathophysiology and tic control. Current Opinion in Neurology 29 (4): 513–518. Ganos, Christos, Luisa Asmuss, Jens Bongert, Valerie Brandt, Alexander Münchau, and Patrick Haggard. 2015. Volitional action as perceptual detection: Predictors of conscious intention in adolescents with tic disorders. Cortex 64: 47–54. Ganos, Christos, Mark J. Edwards, and Kirsten Müller-Vahl. 2016. “I swear it is Tourette’s!”: On functional coprolalia and other tic-like vocalizations. Psychiatry Research 246: 821–826. Gev, Ella, Tammy Pilowsky-Peleg, Sylvana Fennig, Noa Benaroya-Milshtein, Douglas W. Woods, John Piacentini, Alan Apter, and Tamara Steinberg. 2016. Acceptance of premonitory urges and tics. Journal of Obsessive-Compulsive and Related Disorders 10: 78–83. Hemsley, David R. 1998. The disruption of the ‘sense of self’ in schizophrenia: Potential links with disturbances of information processing. The British Journal of Medical Psychology 71: 115–124. Hirschtritt, Matthew E., Paul C. Lee, David L. Pauls, Yves Dion, Marco A. Grado, Cornelia Illmann, Robert A.  King, Paul Sandor, William M.  McMahon, Gholson J.  Lyon, Danielle C.  Cath, Roger Kurlan, Mary M. Robertson, Lisa Osiecki, Jeremiah M. Scharf, Carol A. Mathews, and Tourette Syndrome Association International Consortium for Genetics. 2015. Lifetime prevalence, age of risk, and genetic relationships of comorbid psychiatric disorders in Tourette syndrome. JAMA Psychiatry 72 (4): 325–333.

32

2  Clock Time and Tic Nosology

Knight, Tristan, Thomas Steeves, Lundy Day, Mark Lowerison, Nathalie Jette, and Tamara Pringsheim. 2012. Prevalence of tic disorders: A systematic review and meta-analysis. Pediatric Neurology 47 (2): 77–90. Leckman, James F. 2002. Tourette’s syndrome. Lancet 360: 1577–1586. Leckman, James F., Michael H.  Block, Lawrence Scahill, and Robert A.  King. 2006. Tourette syndrome: The self under siege. Journal of Child Neurology 21 (8): 642–649. Lin, Haiqun, Chin-Bin Yeh, Bradley S. Peterson, Lawrence Scahill, Heidi Grantz, Diane B. Findley, Liliya Katsovich, Jessica Otka, Paul J.  Lombroso, Robert A.  King, and James F.  Leckman. 2002. Assessment of symptom exacerbations in a longitudinal study of children with Tourette’s syndrome or obsessive-compulsive disorder. Journal of the American Academy of Child and Adolescent Psychiatry 41 (9): 1070–1077. Mishara, Aaron L. 2002. On Wolfgang Blankenburg, common sense, and schizophrenia. Philosophy, Psychiatry & Psychology 8 (4): 317–322. Misirlisoy, Erman, Valerie Brandt, Christos Ganos, Jennifer Tübing, Alexander Münchau, and Patrick Haggard. 2015. The relation between attention and tic generation in Tourette syndrome. Neuropsychology 29 (4): 658–665. Mitchell, Sandra D. 2008. Explaining complex behavior. In Philosophical issues in psychiatry: Explanation, phenomenology, and nosology, ed. Kenneth S. Kendler and Joseph Parnas, 19–38. Baltimore: John Hopkins University Press. Moscalewicz, Marcin. 2016. Disturbed temporalities. Insights from phenomenological psychiatry. Time & Society 25 (2): 234–252. Müller-Vahl, Kirsten. 2014. Tourette Syndrom und andere Tic-Erkrankungen im Kindes- und Jugendalter. Berlin: Medizinisch Wissenschaftliche Verlagsgesellschaft. Müller-Vahl, Kirsten R., Tanvi Sambrani, and Ewgeni Jakubovski. 2019. Tic disorders revisited: Introduction of the term “tic spectrum disorders”. European Child & Adolescent Psychiatry 28: 1129–1135. O’Hare, Deirdre, Valsamma Eapen, Edward Helmes, Kerry McBain, John Reece, and Rachel Grove. 2016. Recognising and treating Tourette’s syndrome in young Australians: A need for informed multidisciplinary support. Australian Psychologist 51 (3): 238–245. Ohta, Masataka, and Yukiko Kano. 2003. Clinical characteristics of adult patients with tics and/or Tourette’s syndrome. Brain and Development 25 (1): S32–S36. Pappert, Eric J., C.G. Goetz, E.D. Louis, L. Blasucci, and S. Leurgans. 2003. Objective assessments of longitudinal outcome in Gilles de la Tourette’s syndrome. Neurology 61 (7): 936–940. Parnas, Joseph, Paul Møller, Tilo Kircher, Jørgen Thalbitzer, Lennart Jansson, Peter Handest, and Dan Zahavi. 2005. EASE: Examination of anomalous self-experience. Psychopathology 38 (5): 236–258. Peterson, Bradley S., and James F. Leckman. 1998. The temporal dynamics of tics in Gilles de la Tourette syndrome. Biological Psychiatry 44 (12): 1337–1348. Ratcliffe, Matthew, Mark Ruddell, and Benedict Smith. 2014. What is a “sense of foreshortened future?” A phenomenological study of trauma, trust, and time. Frontiers in Psychology 5: 1–11. Robertson, Mary M. 2015. A personal 35-year perspective on Gilles de la Tourette syndrome: Prevalence, phenomenology, comorbidities, and coexistent psychopathologies. The Lancet Psychiatry 2 (1): 68–87. Robertson, Mary M., and Valsamma Eapen. 2014. Tourette’s: Syndrome, disorder or spectrum? Classificatory challenges and an appraisal of the DSM criteria. Asian Journal of Psychiatry 11: 106–113. Roth. 2018. The colorful spectrum of Tourette syndrome and its medical, surgical and behavioral therapies. Parkinsonism and Related Disorders 46 (1): S75–S79. Rozenman, Michelle, Olivia E. Johnson, Susanna W. Chang, Douglas W. Woods, John T. Walkup, Sabine Wilhelm, Alan Peterson, Lawrence Scahill, and John Piacentini. 2015. Relationships between premonitory urge and anxiety in youth with chronic tic disorders. Children's Health Care 44 (3): 235–248.

References

33

Sass, Louis, and Josef Parnas. 2006. Explaining schizophrenia: The relevance of phenomenology. In Reconceiving schizophrenia, ed. Man Cheung Chung, Bill Fulford, and George Graham, 63–96. Oxford: Oxford University Press. Schaefer, Sara M., Christopher A. Chow, Elan D. Louis, and Daphne Robakis. 2017. Tic exacerbation in adults with TS. Tremor and Other Hyperkinetic Movements 7: 450. (1-6). Stanghellini, Giovanni, Massimo Ballerini, Simona Presenza, Milena Mancini, Andrea Raballo, Stefano Blasi, and John Cutting. 2016. Psychopathology of lived time: Abnormal time experience in persons with schizophrenia. Schizophrenia Bulletin 42 (1): 45–55. Stein, Gertrude. 1998. Emily. In Gertrude Stein: Writings 1903–1932, ed. Harriet Chessman and Catherine R. Stimpson, 387–396. New York: Library of America. Steinberg, Tamar, Adva Harush, Meirav Barnea, Rueven Dar, John Piacentini, Douglas Woods, Sharona Shmuel-Baruch, and Alan Apter. 2013. Tic-related cognition, sensory phenomena, and anxiety in children and adolescents with Tourette syndrome. Comprehensive Psychiatry 54 (5): 462–466. Straus, Erwin. 1938. Ein Beitrag zur Pathologie der Zwangserscheinungen. Monatsschrift für Psychiatrie und Neurologie 98 (1): 61–101. ———. 1966. The pathology of compulsion. In The selected papers of Erwin Straus: Phenomenological psychology. Translated by E. Eng. New York: Basic Books. Trubody, Ben. 2014. ‘Ticced off’. An interpretative phenomenological analysis of the experience of Tourette’s syndrome. Existential Analysis 25 (2): 269–283. Vicario, Carmelo Mario, Davide Martino, Felice Spata, Giovanni Defazio, Roberta Giacchè, Vito Martino, Gaetano Rappo, Anna Maria Pepi, Paola Rosaria Silvestri, and Francesco Cardona. 2010. Time processing in children with Tourette’s syndrome. Brain and Cognition 73 (1): 28–34. Von Gebsattel, Viktor E. 1954. Die Welt des Zwangskranken; Prolegomena einer medizinischen Anthropologie. Berlin: Springer. Wetzel, Linda. 2009. Types and tokens: On abstract objects. Cambridge, MA: MIT Press. Woods, Douglas W., John Piacentini, Susanna Chang, Thilo Deckersbach, Golda Ginsburg, Alan Peterson, Lawrence D. Scahill, John T. Walkup, and Sabine Wilhelm. 2008. Managing Tourette syndrome: A behavioral intervention for children and adults: Therapist guide. Oxford: OUP. Yael, Dorin, Esther Vinner, and Izhar Bar-Gad. 2015. Pathophysiology of tic disorders. Movement Disorders 30 (9): 1171–1178. Zachar, Peter. 2008a. Real kinds but no true taxonomy: An essay in psychiatric systematics. In Philosophical issues in psychiatry: Explanation, phenomenology, and nosology, ed. Kenneth S. Kendler and Josef Parnas, 327–355. Baltimore: John Hopkins University Press. ———. 2008b. Comment: Psychiatry, scientific laws, and realism about entities. In Philosophical issues in psychiatry: Explanation, phenomenology, and nosology, ed. Kenneth S. Kendler and Josef Parnas, 38–47. Baltimore: John Hopkins University Press. Zahavi, Dan. 2005. Subjectivity and selfhood: Investigating the first-person perspective. Cambridge, MA: MIT Press.

Chapter 3

Volition in the Ticcing Brain

Abstract  This chapter traces how dominant philosophical views of volition and ‘free will’ have shaped the study of tic disorders and Tourette Syndrome (TS). Are primary tics voluntary or involuntary? And is voluntary action affected more broadly by the presence of tics? While responses to these questions vary in the scholarship, most contributions draw on a classic experimental paradigm: That pioneered by Benjamin Libet in the 1980s. I show how Libet’s notion of volition as a conscious ‘veto power’ commonly expressed through motor control has led to the view that tic suppression is paradigmatic of free will in Tourette’s. Alternative views proposed by some authors suggest that actions are voluntary when they are consciously intended, not necessarily inhibited. I show how this latter emphasis on consciousness has re-­ focused the debate on subjective experience, and particularly on the contested role of premonitory urges and sensory phenomena in TS. By drawing on insights from philosophical phenomenology, I propose that we should reconsider what it means to be conscious of an experience such as an urge to tic, and that doing so promises to advance our understanding of the elusive link between the experience and inhibition of tic disorder symptoms. Keywords  Volition · Free will · Tic disorder · Tourette Syndrome · Premonitory urge · Pre-reflective consciousness · Reflective consciousness · Intention · Action · Motor control · Suppressibility · Subjective experience

3.1 Taking Stock of the Contemporary Debate 3.1.1 A Potpourri of Terms Tourette Syndrome is idiosyncratic, bizarre, irritating and draining, but ultimately it is about an imbalance in neurological functioning and a curtailment of the freedom which one would otherwise take for granted. (Mansley 2003, 7) The TS sufferer does not have that freedom of choice to anything like the same extent as normal people. (Oliver 2003, 146) © Springer Nature Switzerland AG 2023 L. Curtis-Wendlandt, Chasing Tourette’s: Time, Freedom, and the Missing Self, Philosophy and Medicine 145, https://doi.org/10.1007/978-3-031-19104-6_3

35

36

3  Volition in the Ticcing Brain

What kind of freedom do Chris Mansley and Ruth Oliver  – both ‘sufferers’1 of Tourette’s – have in mind when they speak of its loss in those who are afflicted with the syndrome? What do ‘normal people’ take for granted in their daily life, and what choices can they make freely that Ruth and Chris cannot? These questions run deep, and they touch on a long history of research and speculation on the role of the will and volition in Tourette Syndrome. In fact, this story is so conflicted – both in contemporary research, and in the historical literature – that we should declare Tourette’s the neurodevelopmental disorder par excellence for putting our theories of volition and free will to the test. Definitions of tics, for example, have oscillated between unconscious goal-­ directed behaviour (the ‘functional narrative’) on the one hand, and involuntary neuropathological impulses (the ‘organic narrative’) on the other (see Kushner 1999). Today, the concept of volition carries nosological weight: For some, the distinction between functional tic disorder and primary (i.e., organic) tic disorders rests on its delicate shoulders (e.g., Ganos et al. 2015, 2016; see also Chap. 8). Meanwhile, researchers concede that this distinction is problematic, since organic tics themselves sit “at the phenomenological edge between volition and involuntariness” (Ganos et al. 2016, 825). A more complex reality is emerging – but views of free will and volition still differ widely, and both the theoretical approaches and vocabulary used to discuss the topic have not been critically and systematically assessed. This chapter embarks on such an assessment of the contemporary literature in the context of tic disorder nosology. Wherever we look, contemporary discourse on volition in Tourette Syndrome and chronic tic disorders revolves around several related yet distinct questions: Firstly, are tics voluntary or involuntary? Secondly, can individuals control them (and if so, how)? Further, does the former have anything to do with the latter – i.e., is volition related to control? And what role do consciousness and intentionality play in our response to these questions? An astonishing diversity of views has been expressed about these matters, often using contradictory language or coining new terms, and driven not only by scientific but also socio-political interests. Interestingly, the DSM-5 abstains from any ontological commitments in response to the first question, noting that tics in primary tic disorders “are generally experienced as involuntary but can be voluntarily suppressed for varying lengths of time” (APA 2013; emphasis added). This flies in the face of both earlier studies (e.g. Lang 1991; Kwak et al. 2003) and existing accounts of subjects with TS (e.g. Bliss et al. 1980; Turtle and Robertson 2008) who report experiencing their tics as clearly “voluntary”. Such conflicting evidence aside, we may ask why a manual like the DSM, which does not usually foreground subjective experience, here refers to the first-person phenomenology of ticcing. Is this a strategic move – designed, perhaps, to bypass the persistent ontological uncertainties that underlie a complex and slowly-evolving debate about an elusive syndrome such as TS?

 Not all people with TS and other tic disorders embrace or identify with the term ‘sufferer’: I use it here to honour Ruth Oliver’s sentiment. 1

3.1  Taking Stock of the Contemporary Debate

37

A look at the websites of public advocacy organisations around the world clearly illustrates this complexity. While English-speaking advocacy groups in the West usually assure readers that tics are “involuntary (outside the patient’s control)”,2 continental Europe seems less sure on this point. In Italy, for example, Tourette Roma Onlus describes tics as “semi-voluntary”,3 while the German Tourette Gesellschaft Deutschland explains that tics “happen without the will of the sufferer and are not tied to a purpose”.4 The insistence that tics are involuntary, particularly on the part of the English-speaking advocacy groups, less likely stems from deep-­ seated ontological commitments than from a practical concern for the safety and wellbeing of individuals and families with TS. As Kushner (1999) has shown, this emphasis on the organic and thus “involuntary” nature of tics, which gathered momentum in the US of the 1960s, was a liberating reaction to decades of psychiatric treatments that presumed tics were psychogenic in origin. In other words, the ‘no control’ narrative offered important advantages from an advocacy point-of-view – considerations to which we will return in Chap. 8. Leaving these socio-political considerations aside here, we must sift through the potpourri of concepts – volition, will, purpose, control, and more – used to describe tics, and ask how they might relate to the loss of freedom Chris Mansley and Ruth Oliver bemoaned at the start of the chapter. A look at the peer-reviewed academic literature of the last few decades reveals a dearth of first-person accounts of ticcing (despite the DSM-5’s nod to subjective experience), and an intriguing array of terms used to resolve the uncertainty that surrounds the volitional status of tics. In 2016, Delorme and colleagues still noted that the “voluntary or involuntary nature of tics, which are the hallmark of Gilles de la Tourette Syndrome (GTS), is unclear” (Delorme et al. 2016, 132). Other researchers employ (but often do not explain) new terms that raise subtle yet profound questions. For example, how are we to understand the term “quasivolitional” (Morand-Beaulieu and Lavoie 2019, 1054), which evokes an ‘almost’ or ‘as if’ quality? Are we meant to think tics are like voluntary movements, without simply being voluntary? Or are they unlike voluntary action, but also different somehow from involuntary ones, requiring a separate descriptor such as “unvoluntary” (Jankovic 1997, as quoted in Eddy 2018)5?

 See Tourette Association of America (2021). See also the Tourette Syndrome Association of Australia (2014), the UK-based Tourettes Action (2021), and Tourette Canada (2021). 3  “I sintomi includono principalmente i cosiddetti tic che, sebbene siano atti semi-volontari, risultano sopprimibili solo temporaneamente e con grande dispendio di energie da parte del tourettico” (see Tourette Roma Onlus 2021). Poetically, the Italian wording here also refers to Tourette Syndrome as the maladie of thousand tics – “la malattia dei mille tic”. 4  “Unter Tics versteht man spontane Bewegungen, Laute oder Wortäußerungen, die ohne den Willen des Betroffenen zustande kommen und nicht zweckgebunden sind” (Tourette-Gesellschaft Deutschland e.V. 2021). 5  Jankovic’s views regarding the link between volition and suppressibility of tics seems to have changed throughout his career. While the earlier work suggests he deemed these to be separate matters, his later work tends to connect them. See, for example, Jankovic (2001, note 150) and Patel et al. (2014), on which Jankovic is a co-author. 2

38

3  Volition in the Ticcing Brain

Of the more frequently used terms, “semi-voluntary” (see Porta et al. 2008; Stern 2014; Hawksley et al. 2015; Matsuda et al. 2016; Eddy 2018) is interesting because it allows for at least two readings: Tics could be ‘half’ or partially voluntary, i.e., they might share features of voluntary actions. On this reading, it is not clear how we should think of the other ‘half’, i.e. the other aspects of tics. Alternatively, ‘semi-­ voluntary’ could be a shorthand for tics being ‘half-half’  – that is, both semi-­ voluntary and semi-involuntary. On this reading, they would share some features of voluntary actions (as in the first reading), and some features of involuntary actions, however we might define those. While none of the papers that use the term ‘semi-­ voluntary’ spell out its precise meaning, all of them link the volitional aspect of tics to their controllability. Stern, for example, writes that: “Unlike seizures, tics are suppressible, an act which can be tiring, stressful or even painful”. He interprets these characteristics as pointing towards “movements that are semi-voluntary or irresistible like a sneeze, blink or yawn rather than strictly involuntary” (Stern 2014, 447). The volitional aspect, here, is based on the (temporary) suppressibility of tics.

3.1.2 Volition and Motor Control In the wake of growing interest in the sensory phenomena preceding tics, earlier ideas regarding their involuntary sensory origin (e.g., Lees 1985; Shapiro et  al. 1988) resurfaced and gained popularity. Whether or not this was influenced by the broader, philosophical debates evoked by Libet’s famous experiments on unconscious cerebral potentials and the role of “conscious will” in motor control (e.g. Libet et al. 1983; Libet 1985) is not clear, but several studies on TS, which draw directly on Libet’s work, suggest this (e.g. Moretto et al. 2011; Ganos et al. 2015). These studies found that subjects’ delayed experience of volition correlated with tic severity in a group of adults with TS (Moretto et al. 2011), and with the intensity of premonitory urges (PU) in youths with TS (Ganos et al. 2015). The emergence of research focused specifically on PU provided an alternative ‘no control’ story, in which urges, not tics, are deemed to be out of subjects’ control. This shift from tics to urges – or from action to interoception – is captured by Matsuda et al. (2016, 234), who describe tics as “voluntary responses to involuntary internal sensations (premonitory urge)”. Similar to Stern (2014), they also ground the idea that tics are voluntary in the observation that tics are sometimes suppressible: “About two thirds of children with TS can suppress tics for at least a short period of time, which improves as they grow up” (234). This suggests that the majority of subjects can exercise some control over their behavioural response to these urges. However, since this ability to suppress is incomplete, Matsuda and colleagues go on to change their description of tics from “voluntary” in the preceding sentence to “semi-­ voluntary” (Matsuda et al. 2016, 234), without acknowledging or explaining this change in terminology. This looks inconsistent, but the two suggestions (first that tics are voluntary, then that they are semi-voluntary), also occur side-by-side in other papers (e.g. Hawksley et al. 2015).

3.1  Taking Stock of the Contemporary Debate

39

What’s going on here? A conceptual tension seems to arise from the assumed link between motor control and volition in the quoted papers. Put differently, volition is cast as a quality of certain types of movements, namely those that the individual can control somehow. To spell out the implied argument here: If not all children can suppress their tics all the time, then the voluntary nature of their tics seems diminished in practice; the tics are therefore only ‘semi-voluntary’. On this reading, which ties the voluntariness of tics to their suppressibility, volition is not merely about the availability of choice (‘tic or do not tic, but choose!’). Rather, tics only seem to become fully voluntary in the moment that they are restrained – suppressed, or perhaps redirected. Returning to our terminology of tic types, occurrences, and tokens developed earlier (see Chap. 2), we can now situate the discussion about volition at the token-level of analysis – that is, at the level of concrete behaviours. Volition, it seems, consists in the prevention of tic tokens occurring. The only truly voluntary action, then, would be the individual’s suppressing their tic response, and not its execution. But this would mean that tic tokens (behavioural tic events) could never be deemed fully voluntary (only ‘semi-voluntary’) when they are executed rather than inhibited. Put differently, concrete tic events would diminish the actuality of volition in the very moment they occur. Is this what Stern or Matsuda and colleagues have in mind when they describe tics as both voluntary (they are, in theory, suppressible; that is, they are a suppressible type of behaviour) and semi-­ voluntary (they are not always suppressed in practice, i.e. tic tokens still occur)? It’s hard to know since both terms are used without much explanation. What is clear is that the literature on primary tic disorders has come to be dominated by the view that motor control constitutes volition. This was not always the case: In the early 1990s, Jankovic offered a suite of terms designed to differentiate between various movements, which did not tie the idea of volition to that of motor control – or, in the case of tics, to their suppressibility. He distinguishes between movements that are “autonomic (learned, occur without conscious effort), voluntary (either intentional or responsive), semi-voluntary (induced by inner stimulus or compulsion) and involuntary, which are either non-suppressible (e.g. reflexes) or suppressible” (Jankovic 1992). This definition is interesting for several reasons. Firstly, volition is conceptually independent from suppressibility and the motor control it entails. In other words, even suppressible movements can be deemed involuntary, meaning suppressibility alone is not indicative of a volitional action (see also Jankovic 2001, 1184; Lang 1991, 223). Secondly, Jankovic ties volition to intention – broadly construed perhaps as some kind of psychological state that wills or causes the movement. Further, this psychological state seems to be a conscious state, because learned, unconscious movements are not deemed to be voluntary but ‘autonomic’. We will return to these important concepts of consciousness and intentionality, and to their contested role in definitions of volition and freedom shortly. For now, let us pause to note some initial points of interest. Volition can be construed in several ways: We can attribute voluntariness to types of behaviours (at the type-level of tics), or we can attribute voluntariness to actual behavioural events (at the token-level of tics; see Chap. 2). Further, we can tie volition to motor control or to something else – for example, to the ‘freedom of choice’ Ruth Oliver mentioned

40

3  Volition in the Ticcing Brain

at the start of this chapter; to something like Jankovic’s notion of intention; or to a host of other concepts yet to be explored below. If we define the voluntariness of tics as founded on the individual’s ability to choose one among several possible behavioural responses to a preceding sensation (e.g., the urge which encourages, but may not necessitate, the tic), then ‘choosing to tic’ could be deemed just as voluntary as ‘choosing to suppress’ – although we will have to see what role consciousness and intentions play in such choice. Put differently, ticcing and tic suppression could both be deemed volitional acts. I will tentatively term this the ‘any-choice model’ of volition, as it contains no bias toward one particular behavioural response. But this is not the view favoured by much of the scientific literature on primary tic disorders, which emphasises motor control and considers tic suppression paradigmatic of volition – its fullest, perhaps its only true expression. In what follows, I will call this the ‘one-choice model’ of volition, because it selects a particular behavioural response as the privileged site of freedom. As we will now see, this neatly aligns contemporary research on primary tic disorders with the “standard philosophical approaches” to action (Proust 2003, 202; Gallagher 2017, 138), which understand volition as the question of whether we can consciously control how our bodies move.

3.1.3 Philosophical Tensions The philosophical discourse on free will and volition fills innumerable library shelves and extends across centuries, indeed millennia. To sketch briefly what is relevant for our current debate, we can focus on one key question fuelling this ‘hot topic’ in philosophy: How can human agents choose and act freely in the world if the universe is governed by natural laws that causally determine everything that happens? This idea of causal determinism implies that “any action one performs at a given time is the only action one could have performed at that time” (Glannon 2017, 3). But if free will requires that we are able to do otherwise “and causal determinism rules out this ability, it seems to follow that we lack free will” (3). Among the many responses to the problem posed by causal determinism for human agency and the notion of freedom, two broad strands can be distinguished: compatibilism and incompatibilism. The first, compatibilism, argues that free will is compatible with a law-governed natural world. The second, incompatibilism, argues that it is not  – leading some to reject free will, and others to reject causal determinism (Glannon 2017, 4; see also McKenna and Pereboom, 2016). For compatibilists, one need not sacrifice one for the other, because the kind of control we execute as agents does not rely on metaphysical features of the universe. Rather, it resides in mental capacities such as our ability to respond to reasons for acting or refraining from acting (Fischer and Ravizza 1998, as quoted in Glannon 2017, 4). Put differently, “we have free will when we can control the sorts of mental states we have and whether and how they issue in our actions” (Glannon 2017, 5).

3.1  Taking Stock of the Contemporary Debate

41

As we will see later in this book (see Chap. 4), many philosophers who write in the tradition of Phenomenology object to this internalised, psychological conception of freedom. But even if we accept – for now – that free will is “a deliberative and executive process extending from beliefs and motivational states to actions” (Glannon 2017, 5), determinism could still haunt us. The problem arises if we posit that all mental states can be reduced to, and explained by, the neurobiological processes and events that underlie them. This reductive, mechanistic view of mental states allows only for ‘bottom-up’ causation: Our neurobiology causes our mental states, but the latter cannot causally affect our neurobiology, even if our subjective experience suggests otherwise (although some philosophers suggest that “top-­ down” or “downward” causation is possible; see Voosholz and Gabriel 2021; Murphy et al. 2009). In discussions of free will, this view has led some philosophers to claim that our first-person experience of acting freely is just an illusion – an “epiphenomenon”, i.e., a deceptive by-product of our brain activity (e.g., see Harnad 1982, Wegner 2002, 2003; see also Smilansky 2000). A contrast or tension thus emerges between how we perceive of ourselves in this world, and how we (or some philosophers and scientists at least) think this world truly functions. On this view, such questions as ‘Am I free?’, or ‘Can I act freely?’ are entirely different from questions like ‘Do I feel free?’ or ‘Do I feel like I act freely?’. The former type of question regards ontology and metaphysics; academic discussions that focus on it seek to determine whether or not free will exists, and how to explain it. The second type of question regards the phenomenology of subjective experience; relevant research focuses on ‘what it is like’ to feel like a free agent, and under what conditions we experience ourselves as such. Interestingly, this tension – between experience and reality, or between the phenomenological and the metaphysical plane – also pervades the literature on Tourette Syndrome and primary tic disorders. Here, we find claims about what tics are (for example, based on neurophysiological data from studies of Tourettic brains) juxtaposed with claims about how tics are experienced (citing psychological data provided by individuals with tics). Delorme and colleagues’ work illustrates this mixing of pathophysiological and psychological perspectives when they suggest that tics are “generated in the same neural pathways as voluntary movements”, while at the same time noting that they “are often experienced as escaping voluntary control” (Delorme et al. 2016, 133; emphasis added; see also Hallet 2001; Ganos et al. 2015; Ganos 2016). This pairing of claims – that tics look like voluntary movements in the brain but are commonly not experienced as such – finds its direct opposite in Patel and colleagues’ research on sensory aspects of movement disorders, where tics and their premonitory sensations are deemed to be involuntary, whereas “the movement is typically perceived by the patient as a voluntary action to relieve the preceding, underlying discomfort” (Patel et al. 2014, 104; emphasis added). What do we make of this apparent contrast between phenomenology and ontology; this tension between first- and third-person perspectives, or between persons and their brains? Can they be reconciled at all? Some research in the cognitive sciences attempts to illuminate the relationship between both aspects by juxtaposing neuroimaging data, measurements of brain

42

3  Volition in the Ticcing Brain

activity, and behavioural observations with experiential self-reports from subjects participating in lab-based experiments. A well-known example of such research are Libet’s experiments from the 1980s, in which he sought to determine the role of consciousness in the execution of voluntary motor action. In Libet’s words: “How does a voluntary act arise in relation to the cerebral processes that mediate it?” (Libet 1985, 529). He was particularly interested in comparing “the time of onset of the conscious intention to act and the time of onset of associated cerebral processes” (530). To conduct the experiment, Libet instructed subjects to flex the fingers or wrist of their right hand at a time of their own choosing, and to report the exact time when they became conscious of their intention to do so (a clock-like device with a rapidly rotating dot was used to help subjects determine the exact point in time). At the same time, the electrical activity occurring in certain brain regions was scalp-­ recorded via the use of electroencephalography (EEG) (for technical details see Libet et al. 1982, 1983). As is well known, Libet’s findings showed that unconscious brain processes (observable on the EEG, but not experienced by the subject) precede the conscious intention to act. The so-called “readiness potential” (RP)  – a premovement build-up of electrical potential – was found to occur at an average of 550 milliseconds before the movement began (Libet 1985, 532). In contrast, participants’ conscious awareness of “wanting to move” (W) did not occur until approximately 200 ms before movement onset – that is, approx. 350 milliseconds after the RP could be registered on the EEG. From these results, Libet concluded that “cerebral initiation even of a spontaneous voluntary act of the kind studied here can and usually does begin unconsciously. […] Put another way, the brain ‘decides’ to initiate or, at least, to prepare to initiate the act before there is any reportable subjective awareness that such a decision has taken place” (1985, 536). But what does this mean? If we do not experience any will to move until after such movement is initiated in the brain, does this not leave us with a causally impotent consciousness that can only witness but never affect our own biophysical reality? Libet does not think so. In his eyes, our consciousness can still affect the action outcome, because we can freely decide whether to execute or block the unconsciously initiated movement once we become aware of it. In other word, our consciousness has vetoing power: “In a veto, the later phase of cerebral motor processing would be blocked, so that actual activation of the motoneurons to the muscles would not occur” (Libet 1985, 537). This notion of volition as conscious veto control of movement at a millisecond time scale has been both critiqued and applauded by innumerable commentators. We will not delve into the history of this reception here, but instead look at the impact Libet’s work has had on research into Tourette Syndrome and tic disorders more specifically. From these studies, we can draw some general lines of criticism regarding the ‘standard philosophical view’ of volition and its implications for how we conceptualise free will in TS.

3.2  Libet’s Heritage

43

3.2 Libet’s Heritage 3.2.1 Readiness Potential or Not? While Libet’s experiments sought to illuminate the relationship between brain activity (measured via EEG) and subjective experience (elicited via participants’ self-reports) within a single study, research on TS and tic disorders has more commonly pursued these paths of inquiry separately.6 We can thus distinguish between studies that generate data about participants’ brains and those that generate data about participants’ behaviour and subjective experience. Among the first group are papers that look for the neural substrates of tics and tic urges, asking, for example, whether or not tics are preceded by the sort of readiness potentials (RPs) that Libet observed in his experiment on voluntary action. Findings on this are inconclusive. An early study by Obeso et  al. (1981) worked with a small sample of six male patients (5 adults, one teenager) to compare EEG events preceding tics with changes in the EEG “when the same subjects voluntarily mimicked their own tics” (Obeso et al. 1981, 735). Interestingly, all subjects showed a premovement potential under the mimicking condition, but none prior to their genuine tics (with one exception, where a small premovement potential occurred in one patient). From this they concluded that simple tics in TS “are physiologically distinct from normal self-paced willed movements” (Obeso et al. 1981, 735), and can be “classified as true abnormal automatic movements, which reinforces the idea of a neurological basis” for TS (738). In a similar study, Karp et al. (1996) confirmed this physiological distinction, but noted “that tics do have associated pre-motor negativity7 in some patients” (106). Therefore, the absence of a premotor (readiness) potential in some patients with tics should not be taken as evidence that tics are involuntary in nature. Put differently, we cannot conclude that a movement is involuntary just because it lacks premotor potential (105). Karp and colleagues also asked participants to select one of several descriptors (voluntary, involuntary, or both) to indicate how they experience their tics. Unfortunately, we do not learn much about how this information was elicited. The paper only states that, during the “initial evaluation, the patients answered a series of questions about their perception of their tics” (Karp et al. 1996, 103), but these questions are not shared with the reader. Responses varied and showed no correlation between premotor potentials and subjective perceptions of tics (105). The  Karp et al. (1996) is an exception; this EEG study into premotor potentials in simple tics briefly reports whether participants perceived of their tics as voluntary, involuntary, or both. 7  “Pre-motor negativity” here refers to a surface negative, slow electroencephalographic (EEG) potential recorded in the human brain prior to voluntary movements. As Papa et al. (1991) explain: “The Bereitschaftspotential (BP) [also known as readiness potential] is thought to reflect neuronal activity in frontocentral midline structures, mainly the supplementary motor area (SMA), in preparation for action… The BP is enhanced by executing complex motor tasks such as simultaneous and sequential contraction of the upper limb, writing, and other elaborate movements” (Papa et al. 1991, 217). 6

44

3  Volition in the Ticcing Brain

authors conclude that the observed electrophysiological difference between self-­ paced voluntary movements and tics need not constitute a difference in their volitional status (i.e. both types of movement could be voluntary). Rather, the observed differences in brain activity may relate to whether the movement responds to a stimulus or not: “Tics may be more similar to movements made in response to stimuli [rather] than to self-paced, voluntary movements. In patients with Tourette’s syndrome, the triggering stimuli might be internal sensations” (Karp et  al. 1996, 106). This suggestion has subtle but profound implications, offering a potential alternative approach to phenotyping movements in tic disorders – not via the contested voluntary–involuntary divide, but by distinguishing different ‘initiation strategies’ underlying voluntary movements. In their research on cortical activity preceding self-initiated versus externally triggered voluntary movement, Papa et  al. (1991) observed that “substantial change in EEG cortical activity preceding voluntary movements can occur depending on the initiation strategy, i.e., self-paced versus stimulus-induced movements” (221). Like Karp and colleagues, they highlight that “not all voluntary movements in humans are necessarily preceded by the earlier, slow components of the BP [Bereitschaftspotential, also known as readiness potential]” (Papa et al. 1991, 222). In their eyes, the BP (or RP) is not indicative of voluntary movements per se, but of the initiation and execution of a certain type of voluntary movements: namely, internally generated ones. The BP or readiness potential, they suggest, “consists of different cortical processes taking place for self-­ induced movements, such as the development or selection of the plan and preparation to act, the decision to move, and, finally, the neuronal activity required to actually undertake the movement” (222). Not all of these cortical processes are required in externally referenced movements – e.g. “the phases of movement preparation and timing” are left out (222). While still voluntary, such a sequence is “short-­ circuited” and will not record the same electrophysiological activity as can be observed in auto-induced (self-initiated) movements. Jankovic’s classification of movements, which we briefly introduced earlier, clearly references this idea in both letter and spirit when he defines voluntary movements as either “intentional (planned and self-induced) or responsive (generated in response to an external stimulus)” (1992, 8; emphasis added). In contrast, recall that he deems movements induced by (inner) “stimulus or compulsion” to be “semi-voluntary” in nature. Now, Karp and colleagues’ paper expands on this idea of responsive voluntary movement, and suggests that we scrap the distinction between external and internal stimuli. If movements can be deemed voluntary that respond to an external stimulus, why could they not also be deemed voluntary if the triggering stimulus is an internal one, such as the sensory phenomena preceding tics? Indeed, their EEG recordings of spontaneous tic movements show an electrophysiological signature similar to that of movements induced by external stimuli (Papa et al. 1991). Might a similar “short-circuiting” of cortical processes be at play in tics, as Papa and colleagues hypothesised to occur in externally triggered voluntary movements? Karp and colleagues do not expand on this idea. But grouping movements triggered by internal stimuli with other responsive voluntary movements (Jankovic 1992) is a

3.2  Libet’s Heritage

45

promising proposal, which I will build on in my proposed taxonomy of tics as intentional actions in Chap. 6. It also aligns with neuroimaging research which shows that tics are “associated with premovement activation of voluntary motor structures, such as supplementary motor area (SMA) and anterior cingulate cortex, supporting the ‘voluntary’ character ascribed to tics” (Moretto et  al. 2011, 1324; see also Hampson et al. 2009; Bohlhalter et al. 2006; Ganos 2016; Niccolai et al. 2019). Today, electrophysiological studies on TS are more nuanced than the early works and explore a range of event-related potentials – including, but not limited to, premotor potentials – in greater detail. And yet, despite a surge in publications on this topic over the last decade, many uncertainties remain. A recent systematic review (Morand-Beaulieu and Lavoie 2019) notes a few consistent insights emerging from this literature, such as the finding that adults and children with TS show a reduced early phase of the “contingent negative variation” (CNV),8 and that their motor-­ related potentials dependably differ from those of healthy controls (Morand-­ Beaulieu and Lavoie 2019, 1053). However, we still don’t understand “why some patients present such cerebral [premotor] potential before tics and some do not” (1054), and whether this relates to premonitory urges. We need more research, “with large samples and good control of comorbidity” (1055), to better understand whether electrophysiological abnormalities in TS are causative or adaptive, how they interact with treatments, and how they evolve throughout life. At the same time, mounting evidence that somatosensory and motor processing are altered in TS (see Moretto et al. 2011; Thomalla et al. 2009; Nowak et al. 2005; see also Morera Maiquez et al. 2021) has also strengthened interest in the subjective experience of tic disorder symptoms. In line with Karp et  al.’s (1996) call to consider internal stimuli as potential triggers of voluntary movements, the last two decades have seen a growing body of work on premonitory urges and sensory phenomena in tic disorders. These urge phenomena are emerging as highly relevant to the experience of volition and agency in TS (see Sect. 3.3 and Chap. 5).

3.2.2 The Vetoing Window In a study replicating Libet’s behavioural task (but not his measurement of brain activity) in a group of adults with TS and controls, Moretto et al. (2011) hypothesised that subjects would have an “abnormal experience of voluntary action” (1324). The study defines voluntary action as implying: (a) “a conscious decision and

 The contingent negative variation (CNV) is one of the slow cortical potentials. It consists of two waves, the early and the late CNV. The early CNV follows the presentation of a warning stimulus; it “represents an orientation response, while the late CNV is linked to expectancy and response preparation” (see Taylor et  al. 2016, as quoted in Morand-Beaulieu and Lavoie 2019, 1053). “These potentials have generators located in the primary and supplementary motor areas, the premotor area, the primary sensory area, and the prefrontal, parietal, and occipital cortices (Hultin et al. 1996; Hamano et al. 1997)” (Morand-Beaulieu and Lavoie 2019, 1053). 8

46

3  Volition in the Ticcing Brain

intention to act”; and (b) “the neural control of motor execution” (1324). When participants with TS were asked to estimate the time at which they became consciously aware of their intention to perform the required simple keypress movement, subjects showed a significant delay in this experience compared to controls (1324–1325). Indeed, the conscious experience of wanting to move – i.e. Libet’s “W judgements” – occurred “only very slightly before their experience of actually executing the action” (1326). Notably, “this delay in W judgements increased with the severity of TS tics” (1326). From these findings, the authors infer that “the experience of volition is weaker and delayed in TS, even for actions that are clearly voluntary, such as the keypresses in this experiment” (1326; emphasis added). But how might this impact the way in which people with Tourette Syndrome experience their own tics? Even if tics were voluntary (which, as we saw, is still debated), wouldn’t the delayed experience of volition make it harder for people with TS to recognise their own tics as such? Moretto et al. (2011) suggest so: “As the experience of volition is weak in TS, stereotyped and repetitive actions such as tics might be misperceived as involuntary, even if they in fact arise from the brain’s voluntary motor pathways” (1326; emphases added). In other words, things may not be as they seem to people with TS – at least with regard to the volitional status of their tics. Here, the perennial tension between phenomenology and metaphysics resurfaces with a twist. No longer is humanity accused of believing in a free will that does not exist, as some philosophers argue (see Sect. 3.1.3). To the contrary: It is now the ticcers who are accused of not perceiving the freedom they truly possess. The dynamic has been flipped – from the human illusion of being free in spite of determinism, to the Touretter’s illusion of being determined in spite of libertarianism. If we run with this idea for a moment, then what is the metaphysical argument here? What qualifies the tics as ‘voluntary’ in the context of Moretto et al.’s experiment (which, notably, does not actually study tics but rather Libet’s purportedly voluntary keypress movement)? The authors’ suggestion that tics could be misperceived as involuntary seems to derive from their experimental observation of a shorter (but nevertheless remaining) time window between Libet’s ‘W judgements’ (conscious intention to move) and the actual execution of the movement. Recall that Libet (1985) defended the existence of free will based on the idea of a vetoing window between these two time points. In the group of adults with TS studied by Moretto et al. (2011), this window was found to be notably shorter than in the control group: “They reported the conscious intention to move only 93 ms … before movement onset” (1325) – that is, 154 milliseconds later than the adults without TS. But if experiencing the conscious intention to move is required for our ability to ‘veto’ a movement, then having Tourette’s means having less time to do so. In other words, while freedom is not lost, the intervention window shrinks (at a magnitude of milliseconds). Moretto and colleagues speculate that this could explain why tics “are not always detected in advance and inhibited before execution” (2011, 1326). Drawing a link between conscious awareness of tic urges and the capacity to veto these movements – i.e., to suppress tics – may sound plausible, but it does not align with some of the evidence emerging in the literature on tic suppression. One way to think through this idea is to flip the question and ask: If the experience of volition

3.2  Libet’s Heritage

47

were not delayed in subjects with TS (i.e., if their ‘W judgements’ occurred at a similar time as those of controls), would this mean vetoing (inhibiting or suppressing) tics would be easier, or occur more frequently? Not necessarily, it seems. Interestingly, when Ganos et al. (2015) replicated Moretto and colleagues’ Libetian experiment in a group of adolescents with Tourette’s, they did not find the same delay in the experience of volition. In other words, as a group, adolescents with TS experienced the conscious intention to move at a similar time as adolescent controls. If the idea of a simple association between delayed ‘W judgements’ and greater difficulty at detecting urges and suppressing tics was true, we could expect adolescents to be better than adults at tic suppression, because they have more time to intervene. But this does not appear to be the case. Conelea et al. (2018) found that, in studies using the Tic Suppression Task (TST),9 “better tic suppressibility was related to older age and more frequent tics but unrelated to other clinical variables” (5)  – although with “older age” they refer to older children, not adults. Both increased age and tic frequency could aid learning of skills required for suppression (Conelea et al. 2018, 8) – skills which would likely be retained from adolescence into adulthood, irrespective of the intriguing find of a delayed experience of volition in adults with TS (Moretto et al. 2011). This finding and its explanation potentially jar with Ganos and colleagues’ hypothesis about why adults but not adolescents with TS show a delayed awareness of conscious intention to move (Moretto et  al. 2011; Ganos et  al. 2015). While Conelea and colleagues speculate that longer and more frequent exposure to tics during developmental maturation makes it easier to suppress tics, because there is more time to learn the skills required for suppression, Ganos et al. (2015, 51) propose the opposite: In healthy adults, the normal experience of intention prior to voluntary action may reflect prolonged perceptual learning at discriminating the internal signals that characterise volition. Persistent co-occurrence of voluntary and involuntary movement in GTS [i.e., TS] could make this discrimination problem harder. Therefore, patients with GTS may show delayed learning about their own volition, or may extinguish such learning after it has occurred, as a result of prolonged tic behaviour.

Granted, Ganos and colleagues have a different kind of learning in mind; while Conelea et al. speak of skills required for tic suppression (i.e. motor control), Ganos  The Tic Suppression Task (TST) was developed by Woods and Himle (2004; see Conelea et al. 2018) for the purpose of studying voluntary tic inhibition. To reduce reactivity effects induced by direct observation, the TST uses a deception strategy: The participant (usually a child) is placed in front of a computer or token dispenser described to them as a “tic detector”. Meanwhile, the experimenter observes the child unobtrusively (for example, through a one-way mirror), with the goal to code for tic frequency across all experimental conditions. Standard conditions tested by the TST include baseline (BL), where the child is instructed to let tics happen freely; and reinforced suppression (SUP), where the child is instructed to suppress tics and receives a reward –delivered by “tic detector” – for every 10 s tic-free interval (see Conelea et al. 2018, 2). A limitation of the TST lies in the fact that it only measures tic frequency. “How suppression efforts impact other symptom dimensions, such as tic intensity or complexity, remains unknown and should be tested in future research” (Conelea et al. 2018, 8). 9

48

3  Volition in the Ticcing Brain

et al. discuss skills required for recognising “the discriminative perceptual markers of volition” (51). Aren’t these two separate conversations? Not really, I propose. Ganos et al. (2015) offer both theoretical reasons and empirical evidence for a link between the “failure of perceptual learning for volition-related signals” (51) in adults with TS and their ability to suppress tics. Theoretically, this connection is grounded in the idea that voluntary motor control depends on conscious awareness of an intention to move (we will challenge this idea below; see Sect. 3.3.1; see also Chap. 4). Haggard, who is senior author on both the Moretto et al. (2011) and the Ganos et al. (2015) study, has consistently described volition as involving a range of conscious decision-making processes that occur in the human brain (e.g. Haggard 2008; see also Haggard et al. 2002). His foundational theoretical works are quoted in both studies on volition in TS (Moretto et al. 2011; Ganos et al. 2015), as well as in a recent follow-up study into “learning volition” in TS (Mainka et al. 2020), on which Haggard is also senior author. But if adults with TS have “a more conservative criterion for detecting the [volitional] signal among noise” (Ganos et al. 2015, 51), and if, as a result, they may “lack the normal anticipatory awareness of intentional action”, then should we not expect this to reduce the capacity for voluntary tic inhibition over time? Put differently, if Ganos and colleagues are right, and longer exposure to tics and their urges extinguishes the learning of volition, should individuals not also get worse at suppressing their tics as their condition persists – rather than better, as Conolea et al. (2018) observe for adolescence? Several factors could be at play that might explain both seemingly contradictory findings. Mainka et al.’s (2020) longitudinal study followed up with a subgroup of TS adolescents studied by Ganos et  al. (2015). Participant age shifted from 10–17 years at time point T1 (Ganos et al. 2015) to 15–22 at time point T2 (Mainka et al. 2020), thus covering a crucial developmental window. Findings consolidate Ganos et al.’s (2015) earlier hypotheses regarding the impaired perceptual learning of volition in TS: While their cross-sectional sample of age-matched controls showed “a growing [time] gap between action and intention awareness, corresponding to the developmental emergence of the distinctive experience of one’s own voluntary actions” (Mainka et al. 2020, 39), this gap grew notably less for TS patients, and was reduced proportionately to the duration of the disease. The idea that the duration of the condition progressively interferes with the detection of neural signals for voluntary action during maturation, while simultaneously enhancing individuals’ ability to suppress tics, is intriguing and deserves further attention. Conelea et al. (2018) in fact offer several alternative explanations for why tic suppressibility might improve with age. In addition to their ‘more time = more practice = better skills’ hypothesis, they speculate that better suppressibility could also be due to the “altered or compensatory neurofunctional organization of motor control networks as a result of tic suppression experience”, or it could be experimentally induced given “heightened responsiveness to reward in adolescence vs. both childhood and adulthood, which has been attributed to imbalanced maturation of limbic regions relative to cortical control regions” (7; see also Casey et al. 2008). For our purposes, it is not immediately clear if and how these alternative explanations can be reconciled with the observed maturational decline in the ability to detect volitional signals in people

3.2  Libet’s Heritage

49

with Tourette Syndrome (Ganos et al. 2015, Mainka et al. 2020). Further research would be useful in this area. For example, “[t]esting youth longitudinally with the TST may inform developmental models of tic suppression” (Conelea et al. 2018, 7); and we could design longitudinal studies that assess the development of both volition and tic suppressibility in subjects with tic disorders over time. This latter point alerts us to an important distinction we have not spelled out yet – namely, the distinction between a synchronic and a diachronic perspective on tic suppressibility.

3.2.3 Suppressibility Remains Elusive While Conelea et al. (2018) found an association between tic suppressibility and older age, and while they speculate that this can be explained developmentally, we currently still lack the longitudinal research to confirm this hypothesis. Put differently, we have synchronic evidence on tic suppressibility in youth, but no diachronic data yet. In contrast, Ganos et al. (2015) and Mainka et al. (2020) offer empirical evidence that illness duration progressively interferes with the detection of volitional signals during maturation, and these two synchronous data sets allow us to draw inferences about the diachronic development of volition. Importantly, Ganos et al. (2015) also offer synchronous data on a correlation between suppressibility and volition.10 Their study found that patients who were better at voluntary tic suppression also “showed significantly earlier conscious intention, suggesting that the perceptual discrimination between different action classes may also contribute to voluntary control of tics” (Ganos et  al. 2015, 47). What this does not tell us is whether the correlation between better tic suppression and an earlier experience of volition (i.e. awareness of intention) indicates a causal relationship of some sort, and if so, in which direction such causality might run (Ganos et al. 2015, 52–53). Does the earlier experience of intentions cause or enable better tic suppressibility? Or does, inversely, a greater ability to suppress tics facilitate an earlier experience of volition? It is possible that neither is a necessary or sufficient condition for the other, despite the fact that “perception of volition, and voluntary self-control” were found to be clearly associated in Ganos and colleagues’ study (2015). Suppressibility itself has been looked at from a number of perspectives, but the factors that contribute to it remain elusive. Apart from evidence suggesting a positive correlation with age (Conelea et al. 2018), research into the link between tic suppressibility and presence of comorbidities (particularly ADHD),11 use of  Since Mainka et al. (2020) do not comment on suppressibility in relation to volition, a diachronic perspective on this topic remains unavailable at this time. 11  Interesting but conflicting data exists on the association between tic suppression and attention: “Somewhat more evidence from studies using the TST [Tic Suppression Task] suggests a possible relationship between tic suppression and attention problems (e.g., those related to attention deficit hyperactivity disorder; ADHD), although findings are mixed and derived from small samples. Significant associations have been found between decreased tic suppressibility and increased 10

50

3  Volition in the Ticcing Brain

psychotropic medication, or tic severity have generated only little or conflicting ­evidence of positive associations (Conelea et al. 2018). The same is true for research on the link between suppressibility and PU. In so far as tic suppressibility is commonly construed as a marker of volition in Tourette Syndrome, and since PU are hypothesised to interfere with the experience of volition, the relationship between urges and suppressibility is clearly of interest to us here. Ganos and colleagues suggest that PU – elicited via the Premonitory Urge for Tics Scale (PUTS; see Woods et al. 2005) – contribute to higher levels of “motor noise” in tic disorders, which makes detection of volitional signals more difficult. While their study found no average delay in the experience of volition in adolescents with TS compared to controls, it did show a relatively later onset of the intention to move in youth with stronger premonitory urges. From this, the authors speculate that “stronger premonitory urges preceding involuntary movements could impair detection of the distinctive experience of volition” (51). Findings from Mainka et al.’s (2020) follow-up study, however, do not show any correlation between the strength of PUs and the timing of the experience of volition (38). On the other hand, Bliss’s detailed self-­ observations of his own TS, assembled over decades and co-published as an excerpt with Cohen and Freedman in 1980, support the idea that urge awareness facilitates tic suppression – or, as he calls it, the “extinguishing [of] symptoms at emergence” (Bliss et al. 1980, 1343). This notion also forms the basis of behavioural models and associated treatments of tics, which utilise urge awareness to initiate tic inhibition (see Woods et al. 2008b; Conelea et al. 2018). But while noticing one’s urges may assist with inhibiting tics, stronger urges could also make ticcing more likely, or suppression less likely. A study by Specht et al. (2014) showed that youth with tics were “more compelled to tic in response to high-intensity urges” and less “in response to low-intensity urges” during the free-to-tic condition of their experiment, although this difference disappeared when tic suppression was contingently rewarded (312–313). Conflicting data also exist on the potential correlation between tic suppressibility and individuals’ self-rated urge severity on the PUTS.12 Two studies using objective attention problems on a parent-rated scale (Himle and Woods 2005) and continuous performance task (Woods et  al. 2008a). Interestingly, Greene et  al. (2015) reported significant correlations between tic suppression and parent-rated attention problems but in the opposite direction, such that those with more inattention symptoms demonstrated greater tic suppression” (Conelea et al. 2018, 2; emphasis added). 12  Importantly, recent psychometric testing of the PUTS suggests that it “does not show strong associations with real-time urge intensity monitoring and may measure more than one dimension of the urge experience” (Conelea et al. 2018, 8; see also Brandt et al. 2016). Further development of the PUTS should differentiate between multiple dimensions of urge experience, as the Individualised Premonitory Urge to Tic Scale (I-PUTS) has attempted to do (McGuire et al. 2014), while also broadening the scope of sensory phenomena assessed, as the University of São Paulo Sensory Phenomena Scale (USP-SPS) has attempted for OCD (Rosario et al. 2009; for the English version, see Sampaio et al. 2014). McGuire and colleagues stress that “additional dimensions of premonitory urge may exist”, and “rigorous qualitative research on premonitory urge phenomena in youth and adults with TD [tic disorders] may be useful to identify other possible dimensions of premonitory urges” (McGuire et  al. 2014, 182). We have argued elsewhere that philosophical

3.3  Consciousness Reconsidered

51

observations did not find any associations between video-rated tic suppression capacity and subjective urge intensity in adults (see Ganos et al. 2012; Müller-Vahl et al. 2014). Conelea et al. (2018, 7–8) also found no significant correlation between tic suppressibility and the severity of both premonitory urges (measured with PUTS) and the tics themselves (measured with Yale Global Tic Severity Scale, YGTSS). On the other hand, trials investigating the efficacy of CBIT (Comprehensive Behavioural Interventions for Tics; see Woods et al. 2008b) showed that more severe urges predicted lower tic reduction in response to behaviour therapy (Sukhodolsky et  al. 2017). In sum, whether or not premonitory urges facilitate or hinder tic suppression remains a subject of debate. Several authors have suggested that “urges and tic inhibition are not directly related” (Ganos et al. 2012, 975), and that their relationship is “more nuanced than once thought” (Conelea et al. 2018, 8). Neuroimaging studies support the suggestion that distinct neural circuits underlie the generation of tics and premonitory urges, respectively (Wang et al. 2011; Worbe et al. 2015; Jackson et al. 2020), making both processes “at the least dissociable, even if not necessarily dissociated under all conditions” (Conelea et al. 2018, 8; see also Ganos et al. 2012, 975). We can thus ask: If the presence and conscious awareness of urges is not (or not always) required for successful tic suppression, could there be a range of strategies at play? What if urge awareness is just one means to suppress, and if other strategies exist that that do not involve the experience of a conscious intention to move in the moment preceding a tic? We will return to these important questions in Chap. 4. For now, we can conclude that research on tic suppression invites us to look more closely at how, precisely, consciousness, volition, and suppressibility may be connected.

3.3 Consciousness Reconsidered 3.3.1 To Feel or Not to Feel, That is the Question A poignant expression of the assumed link between volition and urge awareness is offered by Ganos et al. (2012, 975), who distinguish between voluntary tics (those that are preceded by sensory urges that ‘stir’ an awareness), and involuntary tics (those that go unnoticed). Here, the experience of a conscious intention to move is deemed foundational to the question of whether or not tics are voluntary in nature. Conscious awareness of performing tics was already built into Lang’s (1991) definition of volition when he asked 60 subjects with tic disorders to classify their subjective experiences of tics using four descriptors (voluntary, involuntary, both, not sure). His study did not ask about premonitory urges but focused purely on the

“Phenomenology – with its explicit focus on, and methodological repertoire for, attending to structural aspects of experience  – is ideally suited to this task” (see Curtis-Wendlandt and Reynolds, 2021).

52

3  Volition in the Ticcing Brain

experience of executing the tic. Lang initially suggests that the concept of volition should be separated from the question of motor control and whether subjects can suppress their tics. Keen to avoid the use of confusing new terms such as ‘unvoluntary’ in relation to tics, he asserts that volition only designates the willed, intentional nature of the movement or sound, any triggering stimuli notwithstanding: “We prefer to simply emphasize that movements or phonations described as VOL in response to our questioning were intentionally produced but irresistible” (Lang 1991, 226). In the same breath, however, Lang bows to another definition – that of “truly voluntary” movements proposed by Culver and Gert (1982) and adopted in DSM-3-R12 (APA 1987). Despite his best intentions, Lang here re-introduces the sort of ambiguous phrase that he was keen to avoid, leaving us to wonder how Culver and Gert’s ‘truly voluntary’ movements might differ from his own.13 Is Lang’s definition of voluntary movements less true somehow? It turns out the difference lies in the role attributed to motor control – that is, how ‘resistible’ the intentionally produced movements or sounds are. According to Lang’s reading of Culver and Gert, an action only classifies as voluntary if the subject can veto it – that is, if they can “also will not to do the act” (Lang 1991, 226). For this reason, they distinguish between two types of actions, namely “intentional voluntary” (those that can be vetoed) and “intentional unvoluntary” ones (those that cannot be inhibited; see Culver and Gert 1982, 114). In Lang’s view, however, both of these types of actions, by virtue of being intentional, should be included in the class of voluntary actions. His insistence that consciously willed movements are voluntary irrespective of their controllability reminds us of the ‘any-choice-model’ of volition introduced earlier (see Sect. 3.1.2). For Culver and Gert, intentionality or conscious willing is not enough; their added requirement of freedom from coercive incentives that drive the action (1982, 115) implies motor control (i.e., the ability to veto the action), and illustrates what we termed the ‘one-choice-model’ of volition earlier.14 But, as we already observed, this requirement remains ambiguous. Having the ability is not the same as manifesting it behaviourally; we can imagine cases where a person is able but chooses not to suppress a particular tic token. What is the volitional status of that tic? Is it voluntary, because the person could have vetoed it but chose not to; or is it involuntary, because they did not inhibit that particular action? One of the problems here is that discussions of volition, certainly in the  Culver and Gert distinguish between free and unfree voluntary actions (1982, 114). When Lang speaks of ‘truly voluntary’ movements, I take him to refer to Culver and Gert’s notion of free voluntary action, rather than unfree voluntary action. For Culver and Gert, the distinction rests on the presence (unfree) or absence (free) of “coercive incentives [that] have been responsible for the occurrence of the [voluntary] action” (1982, 115). We will return to this distinction in our discussion of OCD and TS in Chapter X 14  What Lang completely overlooks, or perhaps considers irrelevant, is the fact that Culver and Gert actually do not consider Tourette Syndrome symptoms to be actions in the first place, but rather “nonactions” (1982, 114). As such, none of the common terms used to describe actions (free or unfree; voluntary or involuntary; intentional or unintentional) apply to Tourette’s symptoms (124). We will return to this point in more detail in our discussion of agency in Chap. 5 and in our discussion of tics as intentional actions in Chap. 6. 13

3.3  Consciousness Reconsidered

53

context of tic disorders, are not clearly allocated a “level of analysis” (see Chap. 2), which would spell out whether volition is attributed to tic types, occurrences, or tokens. It seems Culver and Gert’s emphasis on the “will to refrain” (1982, 118) from an action as a central criterion for volition has come to dominate how we think about tic disorders. It certainly influenced how tics were defined in the DSM-3-R12 (APA 1987), and it reverberates through Moretto et al.’s (2011) paper, which claims that voluntary actions not only require “a conscious decision and intention to act” but also “the neural control of motor execution” (Moretto et al. 2011, 1324). Entangled in this definition is an irreducibly subjective component: the first-personal data on how subjects experience their tics (or their actions at large). As we noted earlier, this phenomenological information is different from the sorts of ontological claims we might want to make about tics and their underlying brain processes. For example, it is one thing to ask whether premonitory urges are present as signals or processes in the brain, and quite another to ask if they are noticed by, and reflectively available to, an individual. While this mixing of subjective (first-person experiential) and objective (third-person observational) data in a definition of volition need not, in principle, be problematic, its implications have not been fully explored in the literature on tic disorders, and in discussions of suppressibility of tics in particular. The subjective experience of premonitory urges is often cast as a dichotomous concept (yes/no), for example – people have or do not have noticeable urges preceding some or all of their tics. Implicit ontological inferences may be drawn from this (‘someone who doesn’t report feeling any PU doesn’t have any’). As a result, we might rule them out for behavioural treatments that require urge awareness. Younger children with TS and tic disorders are generally said to experience fewer urges because they lack “a strong phenomenal awareness of all their actions, both voluntary and involuntary” (Ganos et al. 2015, 48). Increasing awareness of the urge to tic may depend on a maturational process that marks a “transition from simple sensory perceptions to fully fledged consciousness” (Kyriazi et al. 2019, 4; see also Cavanna et al. 2017). And yet, apart from age-related development, it is also conceivable that children and adults who initially present without urge awareness could be taught to attend to, and even describe, what may be very subtle sensory phenomena preceding tics. This would require us to revisit what we mean by such concepts as conscious awareness and experience, which are extensively debated in philosophy. Instead of delving into this debate, I will draw on a useful line of thought originating in the tradition of Phenomenological philosophy to illuminate some questions at stake here.

3.3.2 A Note from Sartre Phenomenologists tend to reject the idea that “all conscious states are states we pay attention to”, arguing instead that there are “unnoticed or unattended experiences” (Zahavi 2008, 24). Sartre, for examples, proposed that consciousness exists in a pre-­ reflective and a reflective mode, and that the latter depends on, and pre-supposes,

54

3  Volition in the Ticcing Brain

the former: “Reflection has no kind of primacy over the consciousness reflected-on. It is not reflection which reveals the consciousness reflected-on to itself. Quite the contrary, it is the non-reflective consciousness which renders the reflection possible” (Sartre 1943, 19–20; as quoted in Zahavi 2008, 22). Importantly, however, we ignore many of our tacit experiences; they simply remain unattended to. This means that pre-reflective self-awareness (sometimes also referred to as ‘minimal self-­ consciousness’)  – can be accompanied by “a fundamental lack of knowledge” (Zahavi 2008, 22). This idea has much to recommend it in the context of tic disorders and the question of premonitory urges and sensory phenomena in a range of neurological conditions. Adopting Sartre’s distinction between two modes of consciousness, we could hypothesise that what younger children lack is not the minimal, pre-reflective experience of PU, but rather the skill required to reflect on and express these experiences. Of interest, Sambrani et al. (2016, 10) found that: Both PU and tic suppressing ability is already present in a high number of TS patients before the age of 8 […] – much earlier than previously thought. This indicates that PU and suppression exist right from the beginning, and do not develop during the course of TS. From our data, therefore, it is suggested that the only reason that PU and tic suppression cannot be seen in (very) young children is because they are unable to either introspect or express them well-enough.

This would fit with the developmental observations of a gradual increase in reflective awareness of sensory phenomena preceding tics, which requires that ‘something is there’ than can increasingly be attended to consciously. This ‘something’ could be the minimal, pre-reflective awareness of the sensory phenomena preceding tics. No research to date has tested this phenomenological hypothesis in a group of children or adults with tic disorders, but other studies support the principle that underlies it. For example, Petitmengin and colleagues’ research into epilepsy has shown that, when interviewed using the “explication interview” or micro-­ phenomenological interviewing method, patients were able to describe subtle prodromal sensations preceding seizures (Petitmengin et al. 2006).15 Interestingly, this study also showed that “patients spontaneously develop cognitive countermeasures [to] prevent a seizure or to interrupt a seizure once it has started” (303). But not all of the subtle prodromal sensations seem to have been immediately reflectively available to interviewees; rather, it was the interview itself that allowed these tacit experiences to emerge into full awareness, and to become the object of reflective attention. The micro-phenomenological or explication interview has also been used successfully with children as young as 5 years of age (Thabuy and Maurel, 2014), giving us reason to wonder whether we may underestimate children’s capacity for reflective interoception under appropriate guidance. Age, while presumably a contributing factor, may not suffice to explain all variations in individuals’ reflective and interoceptive skills.

 See also Petitmengin (2006); Petitmengin et al. (2007). On cognitive interventions for the control of epileptic seizures, see Gallagher and Brøsted Sørensen (2006, 125). 15

3.3  Consciousness Reconsidered

55

A recent paper by Miyahara et al. (2020), which outlines methodological lessons from their development of a short-term phenomenological training program trialled with adults, showed “a considerable degree of individual difference related to the ability to produce phenomenological descriptions” (2020, 15). To what extent such variation in ‘phenomenological aptitude’ is due to innate or acquired qualities is not clear and warrants further research. “What kinds of qualities are associated with that of being apt to engage in phenomenological description? How do they make some people better than others at attending to and articulating features of their experience?” (15). The authors speculate that, apart from the nature and quality of any training or guidance individuals receive, their phenomenological aptitude may relate to certain attentional and linguistic capacities, as well as other psychological factors (15). In the context of tic disorders, the idea that interoceptive awareness of sensory phenomena preceding tics is learnable – rather than just being developmentally ‘given’  – has received relatively little attention. One of the problems with laboratory-­based studies assessing the presence of premonitory urges in tic disorders is their reliance on standardised scales that offer readymade descriptions of PU, not all of which may capture or resonate with the tacit experiences of participants. More importantly, studies tend to assume that any PU, if present, will be immediately available reflectively to participants when asked. It would be interesting to trial the alternative assumption that – at least for some individuals (adults and children) – the skills required to describe any sensory phenomena preceding tics can be learned through appropriate guidance and practice.16 This would shift treatment conversations away from whether or not someone ‘has’ urge awareness to what support they may require to develop it. Relatedly, the notion of pre-reflective self-awareness or minimal consciousness might also shed new light on the results from Banaschewski et  al. (2003), who found that “children without premonitory sensations are also able to inhibit tics by employing other behavioural strategies” (Ganos et al. 2012, 977). We are reminded, too, of Oliver Sack’s short story, A Surgeon’s Life, in which he recounts how Dr. Bennett, a surgeon with TS, suppresses a socially inappropriate vocal tic (the word ‘hideous’) while examining a patient with an unsightly skin condition (Sacks 2012, 89): Bennett … let fly a brief ‘Hid--,’ the end of the word omitted by a tactful apocope. This, I learned later, was not a conscious suppression – Bennett had no memory of the tic – and yet it seemed to me there must have been, if not a conscious, then a subconscious solicitude and tact at work.

Like the children in Banaschewski et al.’s (2003) study, it is possible that Bennett, the adult surgeon, simply had no premonitory sensations, and that PU are not required for tic suppression. Alternatively, we could ask whether urges were tacitly

 The idea that such skills are not simply given but can be developed over time and with practice is central to another method, called Descriptive Experience Sampling (DES); see, for example, Heavey et al. (2010). 16

56

3  Volition in the Ticcing Brain

perceived (minimally conscious) but not reflectively available and reported on.17 In either case, we can note that little is known about the strategies that individuals might use to suppress their tics (see Herrmann et al. 2019, 477), and about the precise role that consciousness plays in this process. Different strategies appear to exist – for example, “distraction, effortful top-down control” (477) – and these may differ across different age groups (see Ganos et al. 2012). It is not clear that reflective consciousness is always required, or indeed, that it is always the preferred strategy for tic suppression, although current best-practice behavioural treatments built on habit reversal principles adopt this route. What is not yet clear is whether alternative forms of suppression (those that do not rely on reflective awareness of an urge or stimulus preceding tics) require at least pre-reflective consciousness of such premonitory phenomena (e.g., via learned behavioural responses that have become automatic or “autonomic”, to use Jankovic’s earlier term; see Jankovic 1992), or whether suppression is possible without them. We will return to consciousness and its role in voluntary actions in Chap. 4, where I will critique the impact of the ‘dominant view’ of volition on the study of TS and outline alternative ways to think about free will in the context of tic disorders. To conclude, let us return to Chris Mansley and Ruth Oliver, the two Tourette’s ‘sufferers’ whose comments on freedom we featured at the start of this chapter. Have we captured the loss they bemoan? Have we captured that precious good which others take for granted, but which Chris and Ruth cannot behold? I suggest we have not, for their freedom is a different beast – one not at home in Libet’s lab. Their freedom is a bigger thing: A thing of lives lived well, and opportunities seized. It does not emerge from the crevices of the electroencephalogram (EEG). And yet that is precisely where the tic disorder literature has searched for it: In the millisecond processes of the ticcing brain. In line with prevailing definitions in contemporary philosophy and the cognitive sciences, research on tic disorders has construed volition at a minimum as involving a conscious intention to move, and more commonly also as requiring the ability to control (inhibit) such movement. As this chapter has shown, ontological claims about what tics are, and phenomenological claims regarding how tics are experienced, are frequently intertwined, as are the types of (observational and experiential) data used to substantiate them. Despite reliance on some first-personal data in research on volition and tic disorders, investigations of subjective experience have remained phenomenologically ‘thin’. Clearly, the focus on motor control and conscious intention to move as requirements for volition has limited research to the study of subpersonal processes occurring at an elemental

 A closely related philosophical question that intersects with our discussion of PU and suppressibility of tics is whether or not there can be perception without awareness (e.g. Dretske 2006). As Dretske aptly puts it, “the way to go about determining what subjects are consciously aware of is not by asking them. Many of them (animals and infants) can’t tell you. And of those who can tell you (adult human beings), many don’t know” (176). He proposes that the most accurate test of what is consciously experienced is to look “at what an agent finds it reasonable to do” and “what, therefore, […] the agent is motivated to do” (176). 17

References

57

timescale. In what follows, I will explore the implications of this reductivist view and offer some alternative approaches to conceptualising free will in Tourette’s.

References American Psychiatric Association. 1987. Diagnostic and statistical manual of mental disorders (3rd rev. ed.). Washington, DC: American Psychiatric Association. ———. 2013. Neurodevelopmental disorders. In Diagnostic and statistical manual of mental disorders, 5th ed. Arlington: Author. Banaschewski, Tobias, Wolfgang Woerner, and Aribert Rothenberger. 2003. Premonitory sensory phenomena and suppressibility of tics in Tourette syndrome: Developmental aspects in children and adolescents. Developmental Medicine and Child Neurology 45: 700–703. Bliss, Joseph, Donald J. Cohen, and Daniel X. Freedman. 1980. Sensory experiences of Gilles de la Tourette syndrome. Archives of General Psychiatry 37: 1343–1347. Bohlhalter, Stephan, S.  Andrew Goldfine, Gaëtan Garraux Matteson, Takashi Hanakawa, Kenji Kansaku, Rachel Wurzman, and Mark Hallett. 2006. Neural correlates of tic generation in Tourette syndrome: An event-related functional MRI study. Brain 129: 2029–2037. Brandt, Valerie C., Christian Beck, Valeria Sajin, Magdalena K. Baaske, Tobias Bäumer, Christian Beste, Silke Anders, and Alexander Münchau. 2016. Temporal relationship between premonitory urges and tics in Gilles de la Tourette syndrome. Cortex 77: 24–37. https://doi. org/10.1016/j.cortex.2016.01.008. Casey, Betty J., Rebecca M. Jones, and Todd A. Hare. 2008. The adolescent brain. Annals of the New York Academy of Sciences 1124 (1): 111–26. Cavanna, Andrea E., Kevin J. Black, Mark Hallett, and Valerie Voon. 2017. Neurobiology of the premonitory urge inTourette’s syndrome: pathophysiology and treatment implications. Journal of Neuropsychiatry and Clinical Neuroscience 29 (2): 95–104. Conelea, Christine A., Brianna Wellen, Douglas W.  Woods, Dianna J.  Greene, Kevin J.  Black, Matthew Specht, Michael B. Himle, Han-Joo Lee, and Matthew Capriotti. 2018. Patterns and predictors of tic suppressibility in youth with tic disorders. Frontiers in Psychiatry 9: 1–10. Culver, Charles M., and Bernard Gert. 1982. Philosophy in medicine. Conceptual and ethical issues in medicine and psychiatry. London: Oxford University Press. Curtis-Wendlandt, Lisa, and Jack Reynolds. 2021. Why Tourette syndrome research needs philosophical phenomenology. Phenomenology and the Cognitive Sciences 20 (4): 573–600. Delorme, Cécile, Alexandre Salvador, Valerie Voon, Emmanuel Roze, Marie Vidailhet, Andreas Hartmann, and Yulia Worbe. 2016. Illusion of agency in patients with Gilles de la Tourette syndrome. Cortex 77: 132–140. Dretske, Fred. 2006. Perception without awareness. In Perceptual experience, ed. Tamar Szabo Gendler and John Hawthorne, 147–180. Oxford: Oxford University Press. Eddy, Clare M. 2018. Social cognition and self-other distinctions in neuropsychiatry: Insights from schizophrenia and Tourette syndrome. Progress in Neuropsychopharmacology & Biological Psychiatry 82: 69–85. Fischer, John M., and Mark Ravizza. 1998. Responsibility and control: A theory of moral responsibility. New York: Cambridge University Press. Gallagher, Shaun. 2017. Enactivist interventions. Oxford: Oxford University Press. Gallagher, Shaun, and Jesper Brøsted Sørensen. 2006. Experimenting with phenomenology. Consciousness and Cognition 15: 119–134. Ganos, Christos. 2016. Tics and Tourette’s: Update on pathophysiology and tic control. Current Opinion in Neurology 29: 513–518. Ganos, Christos, Ursula Kahl, Odette Schunke, Simone Kühn, Patrick Haggard, Christian Gerloff, Veit Roessner, Götz Thomalla, and Alexander Münchau. 2012. Are premonitory urges a prereq-

58

3  Volition in the Ticcing Brain

uisite of tic inhibition in Gilles de la Tourette syndrome? Journal of Neurology, Neurosurgery, and Psychiatry 83 (10): 975–978. https://doi.org/10.1136/jnnp-­2012-­303033. Ganos, Christos, Luisa Asmuss, Jens Bongert, Valerie Brandt, Alexander Münchau, and Patrick Haggard. 2015. Volitional action as perceptual detection: Predictors of conscious intention in adolescents with tic disorders. Cortex 64: 47–54. Ganos, Christos, Mark J. Edwards, and Kirsten Müller-Vahl. 2016. “I swear it is Tourette’s!”: On functional coprolaliaand other tic-like vocalizations. Psychiatry Research 246: 821–826. Glannon, Walter. 2017. Free will in light of neuroscience. In Free will and the brain. Neuroscientific, philosophical, and legal perspectives, ed. Walter Glannon, 3–23. Cambridge, UK: Cambridge University Press. Greene, Deanna J., Jonathan M.  Koller, Amy Robichaux-Viehoever, Emily C.  Bihun, Bradley L. Schlaggar, and Kevin J. Black. 2015. Reward enhances tic suppression in children within months of tic disorder onset. Developmental Cognitive Neuroscience 11: 65–74. Haggard, Patrick. 2008. Human volition: Toward a neuroscience of will. Nature Reviews Neuroscience 9: 934–946. Haggard, Patrick, Sam Clark, and Jeri Kalogeras. 2002. Voluntary action and conscious awareness. Nature Neuroscience 5 (4): 382–385. Hallet, Mark. 2001. Neurophysiology of tics. Advances in Neurology 85: 237–244. Hamano, Toshiaki, Hans O.  Lueders, Akio Ikeda, Thomas F.  Collura, Youssef G.  Comair, and Hiroshi Shibasaki. 1997. The cortical generators of the contingent negative variation in humans: A study with subdural electrodes. Electroencephalography and Clinical Neurophysiology 104 (3): 257–268. Hampson, Michelle, Fuyuze Tokoglu, Robert A. King, R. Todd Constable, and James F. Leckman. 2009. Brain areas co-activating with motor cortex during chronic motor tics and intentional movements. Biological Psychiatry 65: 594–599. Harnad, Stevan. 1982. Consciousness: An afterthought. Cognition and Brain Theory 5: 29–47. Hawksley, Jack, Andrea E. Cavanna, and Yoko Nagai. 2015. The role of the autonomic nervous system in Tourette syndrome. Frontiers in Neuroscience 9 (Article 117): 1–8. Heavey, Christoper L., Russell T.  Hurlburt, and Noelle L.  Lefforge. 2010. Descriptive experience sampling: A method for exploring momentary inner experience. Qualitative Research in Psychology 7 (4): 345–368. Herrmann, Katja, Andreas Sprenger, Leoni Baumung, Daniel Alvarez-Fischer, Alexander Münchau, and Valerie Brandt. 2019. Help or hurt? How attention modulates tics under different conditions. Cortex 120: 471–482. Himle, Michael B., and Douglas W. Woods. 2005. An experimental evaluation of tic suppression and the tic rebound effect. Behaviour Research and Therapy 43: 1443–1451. Hultin, L., P. Rossini, G.L. Romani, P. Hoegstedt, F. Tecchio, and V. Pizzella. 1996. Neuromagnetic localization of the late component of the contingent negative variation. Electroencephalography and Clinical Neurophysiology 98 (6): 435–448. Jackson, Stephen R., Joanna Loayza, Mira Crighton, Hilmar P. Sigurdsson, Katherine Dyke, and M. Georgina. 2020. The role of the insula in the generation of motor tics and the experience of the premonitory urge-to-tic in Tourette syndrome. Cortex 126: 119–133. Jankovic, Joseph. 1992. Diagnosis and classification of tics and Tourette syndrome. Advances in Neurology 58: 7–14. ———. 1997. Tourette syndrome. Phenomenology and classification of tics. Neurologic Clinics 15 (2): 267–275. ———. 2001. Tourette’s syndrome. New England Journal of Medicine 345: 1184–1192. Karp, Barbara I., Simone Porter, Camilo Toro, and Mark Hallett. 1996. Simple motor tics may be preceded by a premotor potential. Journal of Neurology, Neurosurgery, and Psychiatry 61: 103–106. Kushner, Howard I. 1999. A cursing brain? The histories of Tourette syndrome. Cambridge: Harvard University Press.

References

59

Kwak, Caroline, Kevin Dat Vuong, and Joseph Jankovic. 2003. Premonitory sensory phenomenon in Tourette’s syndrome. Movement Disorders 18: 1530–1533. Kyriazi, Maria, Efrosini Kalyva, Efthymia Vargiami, Konstantinos Krikonis, and Dimitrios Zafeiriou. 2019. Premonitory urges and their link with tic severity in children and adolescents with tic disorders. Frontiers in Psychiatry 10: 569. Lang, Anthony. 1991. Patient perception of tics and other movement disorders. Neurology 41: 223–228. Lees, Andrew J. 1985. Tics and related disorders. New York: Churchill Livingston. Libet, Benjamin. 1985. Unconscious cerebral initiative and the role of conscious will in voluntary action. The Behavioural and Brain Sciences 8: 529–566. Libet, Benjamin, Elwood W. Wright Jr., and Curtis A. Gleason. 1982. Readiness-potentials preceding unrestricted “spontaneous” vs. pre-planned voluntary acts. Electroencephalography and Clinical Neurophysiology 54: 322–335. Libet, Benjamin, Curtis A. Gleason, Elwood W. Wright, and Dennis K. Pearl. 1983. Time of conscious intention to act in relation to onset of cerebral activity (readiness-potential). The unconscious initiation of a freely voluntary act. Brain 106: 623–642. Mainka, Tina, Steven Di Costa, Friederike Borngräber, Ewgenia Barow, Alexander Münchau, Christos Ganos, and Patrick Haggard. 2020. Learning volition: A longitudinal study of developing intentional awareness in Tourette syndrome. Cortex 129: 33–40. Mansley, Chris. 2003. Preface. In Making allowances: Personal accounts of Tourette syndrome, ed. Chris Mansley, 7. Liverpool: The Bluecoat Press. Matsuda, Natsumi, Toshiaki Kono, Maiko Nonaka, Miyuki Fujio, and Yukiko Kano. 2016. Self-­ initiated coping with Tourette’s syndrome: Effect of tic suppression on QOL. Brain and Development 38: 233–241. McGuire, Joseph F., John Piacentini, Erin A. Brennan, Adam B. Lewin, Tanya K. Murphy, Brent J. Small, and Eric A. Storch. 2014. A meta-analysis of behavior therapy for Tourette syndrome. Journal of Psychiatric Research 50: 106–112. McKenna, Michael, and Derk Pereboom. 2016. Free will: A contemporary introduction. New York: Routledge. Miyahara, Katsunori, Takuya Niikawa, Hiro Taiyo Hamada, and Satoshi Nishida. 2020. Developing a short-term phenomenological training program: A report of methodological lessons. New Ideas in Psychology 58: 1–17. Morand-Beaulieu, Simon, and Marc E. Lavoie. 2019. Cognitive and motor event-related potentials in Tourette syndrome and tic disorders: A systematic review. Clinical Neurophysiology 130: 1041–1057. Morera Maiquez, B., Georgina M.  Jackson, and Stephen Jackson. 2021. Examining the neural antecedents of tics in Tourette syndrome using electroencephalography. Journal of Neuropsychology [First published: 05 May 2021], https://doi.org/10.1111/jnp.12245. Moretto, Giovanna, Petra Schwingenschuh, Petra Katschnig, Kailash P.  Bhatia, and Patrick Haggard. 2011. Delayed experience of volition in Gilles de la Tourette syndrome. Journal of Neurology, Neurosurgery, and Psychiatry 82: 1324–1327. Müller-Vahl, Kirsten R., Laura Riemann, and Stefanie Bokemeyer. 2014. Tourette patients’ misbelief of a tic rebound is due to overall difficulties in reliable tic rating. Journal of Psychosomatic Research 76 (6): 472–476. https://doi.org/10.1016/j.jpsychores.2014.03.003. Murphy, Nancey, George Ellis, and Timonthy O’Connor, eds. 2009. Downward causation and the neurobiology of free will. Berlin/Heidelberg: Springer. Niccolai, Valentina, Silvana Korczok, Jennifer Finis, Melanie Jonas, Götz Thomalla, Hartwig Roman Siebner, Kirsten Müller-Vahl, Alexander Münchau, Alfons Schnitzler, and Katja Biermann-Ruben. 2019. A peek into premonitory urges in Tourette syndrome: Temporal evolution of neurophysiological oscillatory signatures. Parkinsonism and Related Disorders 65: 153–158. Nowak, Dennis A., John Rothwell, Helge Topka, Mary M. Robertson, and Michael Orth. 2005. Grip force behavior in Gilles de la Tourette syndrome. Movement Disorders 20 (2): 217–223.

60

3  Volition in the Ticcing Brain

Obeso, Jose A., John C.  Rothwell, and C.  David Marsden. 1981. Simple tics in Gilles de la Tourette’s syndrome are not prefaced by a normal premovement EEG potential. Journal of Neurology, Neurosurgery, and Psychiatry 44: 735–738. Oliver, Ruth. 2003. A lifetime of bewilderment. In Making allowances: Personal accounts of Tourette syndrome, ed. Chris Mansley, 127–147. Liverpool: The Bluecoat Press. Papa, S.M., J.  Artieda, and José A.  Obeso. 1991. Cortical activity preceding self-initiated and externally triggered voluntary movement. Movement Disorders 6 (3): 217–224. Patel, Neepa, Joseph Jankovic, and Mark Hallett. 2014. Sensory aspects of movement disorders. Lancet Neurology 13 (1): 100–112. Petitmengin, Claire. 2006. Describing one’s subjective experience in the second person: An interview method for the science of consciousness. Phenomenology and the Cognitive Sciences 5: 229–269. Petitmengin, Claire, Michel Baulac, and Vincent Navarro. 2006. Seizure anticipation: Are neurophenomenological approaches able to detect preictal symptoms? Epilepsy and Behavior 9: 298–306. Petitmengin, Claire, Vincent Navarro, Michel Le Van, and Quyen. 2007. Anticipating seizure: Pre-­ reflective experience at the center of neuro-phenomenology. Consciousness and Cognition 16: 746–764. Porta, Mauro, Marco Sassi, Mario Cavallazzi, Maurizio Fornari, Arianna Brambilla, and Domenico Servello. 2008. Tourette’s syndrome and role of tetrabenazine: Review and personal experience. Clinical Drug Investigation 28 (7): 443–459. Proust, Joëlle. 2003. How voluntary are minimal actions? In Voluntary action: Brains, minds, and sociality, ed. Sabine Maasen, Wolfgang Prinz, and Gerhart Roth, 202–219. Oxford: Oxford University Press. Rosario, M.C., H.S. Prado, S. Borcato, J.B. Diniz, R.G. Shavitt, A.G. Hounie, et al. 2009. Validation of the University of São Paulo Sensory Phenomena Scale: Initial psychometric properties. CNS Spectrums 14 (6): 315–323. Sacks, Oliver. 2012 [1995]. An anthropologist on Mars. London: Picador. Sambrani, Tanvi, Ewgeni Jakubovski, and Kirsten R.  Müller-Vahl. 2016. New insights into clinical characteristics of Gilles de la Tourette syndrome: Findings in 1032 patients from a single German center. Frontiers in Neuroscience 10 (415): 1–13. https://doi.org/10.3389/ fnins.2016.00415. Sampaio, Aline S., Katherine D. McCarthy, S. Elizabeth Mancuso, Evelyn Stewart, and Daniel A. Geller. 2014. Validation of the University of São Paulo’s sensory phenomena scale–English version. Comprehensive Psychiatry 55 (5): 1330–1336. Sartre, Jean-Paul. 1943 [1976]. L’être et le néant. Paris: Gallimard; Being and nothingness. Trans. H. E. Barnes. New York: Philosophical Library, 1956. Shapiro, Arthur K., Elaine S. Shapiro, J. Gerald Young, and Todd E. Feinberg. 1988. Gilles de la Tourette syndrome, 1988. New York: Raven Press. Smilansky, Saul. 2000. Free will and illusion. Oxford: Oxford University Press. Specht, Matt W., Cassandra M. Nicotra, Laura M. Kelly, Douglas W. Woods, Emily J. Ricketts, Carisa Perry-Parrish, Elizabeth Reynolds, Jessica Hankinson, Marco A.  Grados, Rick S. Ostrander, and John T. Walkup. 2014. A comparison of urge intensity and the probability of tic completion during tic freely and tic suppression conditions. Behaviour Modification 38 (2): 297–318. Stern, Jeremy. 2014. Tourette syndrome. Paediatrics and Child Health 24 (10): 447–551. Sukhodolsky, Denis G., Douglas W. Woods, John Piacentini, Sabine Wilhelm, Alan L. Peterson, Lily Katsovich, John T. JamesDziura, and Lawrence Scahill Walkup. 2017. Moderators and predictors of response to behavior therapy for tics in Tourette syndrome. Neurology 88 (11): 1029–1036. Taylor, Brittany K., William J. Gavin, and Patricia L. Davies. 2016. The test-retest reliability of the visually evoked contingent negative variation (CNV) in children and adults. Developmental Neuropsychology 41 (3): 162–175.

References

61

Thabuy, Agnès, and Maryse Maurel. 2014. L’entretien d’explicitation avec de jeunes enfants. Expliciter (Journal de l’Association GREX: Group de Recherche sur l’Explication, ISSN: 1621-8256), 1–94. https://www.grex2.com/assets/files/Dossiers/Ede%20avec%20de%20 jeunes%20enfants.pdf Thomalla, Götz, Hartwig R.  Siebner, Melanie Jonas, Tobias Bäumer, Katja Biermann-Ruben, Friedhelm Hummel, Christian Gerloff, Kirsten Müller-Vahl, Alfons Schnitzler, Michael Orth, and Alexander Münchau. 2009. Structural changes in the somatosensory system correlate with tic severity in Gilles de la Tourette syndrome. Brain 132 (3): 765–777. Tourette Association of America. 2021. https://tourette.org/about-­tourette/overview/diagnosis/. Accessed 9 Aug 2021. Tourette Canada. 2021. https://tourette.ca/about-­tourette-­syndrome/questions-­answers/what-­is-­ts/. Accessed 9 Aug 2021. Tourette Roma Onlus. 2021. https://www.touretteroma.it/sindrome-­di-­tourette/cos-­e-­la-­sindrome-­ di-­tourette.html. Accessed 9 Aug 2021. Tourette Syndrome Association of Australia Inc. 2014. https://tourette.org.au/about-­tsaa/what-­is-­ tourette-­syndrome/. Accessed 9 Aug 2021. Tourette-Gesellschaft Deutschland e.V. 2021. https://tourette-­gesellschaft.de. Accessed 9 Aug 2021. Tourettes Action. 2021. https://www.tourettes-­action.org.uk/67-­what-­is-­ts.html. Accessed 9 Aug 2021. Turtle, Lance, and Mary M. Robertson. 2008. Tics, twitches, tales: The experiences of Gilles de la Tourette’s syndrome. American Journal of Orthopsychiatry 78 (4): 449–455. Voosholz, Jan, and Markus Gabriel, eds. 2021. Top-down causation and emergence. Springer International Publishing. Wang, Zhishun, Tiago V. Maia, Rachel Marsh, Tiziano Colibazzi, Andrew Gerber, and Bradley S.  Peterson. 2011. The neural circuits that generate tics in Tourette’s syndrome. American Journal of Psychiatry 168 (12): 1326–1337. Wegner, Daniel M. 2002. The illusion of conscious will. Cambridge: MIT Press. ———. 2003. The mind’s best trick: How we experience conscious will. Trends in Cognitive Science 7 (2): 65–69. Woods, Douglas W., and Michael B. Himle. 2004. Creating tic suppression: Comparing the effects of verbal instruction to differential reinforcement. Journal of Applied Behavioural Analysis 50: 106–120. Woods, Douglas W., John Piacentini, Michael B. Himle, and Susanna Chang. 2005. Premonitory Urge for Tics Scale (PUTS): Initial psychometric results and examination of the premonitory urge phenomenon in youths with tic disorders. Journal of Developmental & Behavioral Pediatrics 26: 397–403. Woods, Douglas W., Michael B.  Himle, Raymond G.  Miltenberger, James E.  Carr, David C. Osmon, Amanda M. Karsten, Candice Jostad, and Amanda Bosch. 2008a. Durability, negative impact, and neuropsychological predictors of tic suppression in children with chronic tic disorder. Journal of Abnormal Child Psychology 36: 237–245. https://doi.org/10.1007/ s10802-­007-­9173-­9. Woods, Douglas W., John Piacentini, Susanna Chang, Thilo Deckersbach, Golda Ginsburg, Alan Peterson, Lawrence D. Scahill, John T. Walkup, and Sabine Wilhelm. 2008b. Managing Tourette syndrome: A behavioral intervention for children and adults therapist guide. New York: Oxford University Press. Worbe, Yulia, Stephane Lehericy, and Andreas Hartmann. 2015. Neuroimaging of tic genesis: Present status and future perspectives. Movement Disorders 30 (9): 1179–1183. Zahavi, Dan. 2008 [2005]. Subjectivity and selfhood. Investigating the first-person perspective. Cambridge: The MIT Press.

Chapter 4

Freedom in a Tourettic World

Abstract  This chapter pursues an alternative understanding of freedom in tic disorders, which frames it as the ability to act in accordance with one’s goals and values (or ‘cares and concerns’) in the world. Drawing on the distinction between pre-reflective and reflective consciousness introduced in Chap. 3, I ask what role each plays in this alternative notion of freedom. On the one hand, I argue that being too reflectively conscious of one’s actions can get in the way of acting freely. People with tic disorders are at heightened risk of such ‘hyper-reflexivity’ since symptoms often demand their own and others’ explicit attention and interfere with everyday activities. On the other hand, reflective consciousness can serve a positive therapeutic role in behavioural and acceptance-based interventions for tics. In these approaches, consciously attending to aspects of symptoms  – such as the urge to tic – can help individuals manage their symptoms and enhance their sense of agency. While the current therapeutic paradigm remains symptom-centric and focused on reducing tics, the chapter concludes by outlining alternative, strength-based strategies for treating tic disorders which transcend the deficit-model of disease. Keywords  Free will · Action · Intention · Skilled habits · Tic disorder · Tourette Syndrome · Modes of being · Pre-reflective consciousness · Reflective consciousness · Hyper-reflexivity · Attention · Acceptance

4.1 Critiquing the Dominant View: Are We Getting at Freedom? 4.1.1 Minds Bent Upon Larger Purposes We find it difficult to realise that there may exist a freedom which is not an attribution of the will but an accessory of doing and acting (Arendt 2006, 163).

Recall Ruth Oliver and Chris Mansley’s comments from the start of Chap. 3 bemoaning the loss of freedom. When they grieve a certain “freedom of choice”, a freedom © Springer Nature Switzerland AG 2023 L. Curtis-Wendlandt, Chasing Tourette’s: Time, Freedom, and the Missing Self, Philosophy and Medicine 145, https://doi.org/10.1007/978-3-031-19104-6_4

63

64

4  Freedom in a Tourettic World

that others “take for granted”, do they refer to the ability to inhibit their tics (see Oliver 2003; Mansley 2003a)? Is their loss that of diminished motor control? Perhaps to an extent; perhaps very much so. We need not doubt that motor control contributes to a person’s sense of freedom. But we should question their common equation, which suggests that the story of free will is nothing but the story of how we wilfully control the way our bodies move. Over the last 30 years of (neuro)scientific inquiry into primary tic disorders, the issue of ‘freedom’ in Tourette Syndrome has largely been reduced to laboratory-based studies of volition (see Chap. 3). Here, scientific scholarship has focused on two related yet distinct questions: whether tics are voluntary actions, and whether voluntary action is altered in people with tics. As outlined in Chap. 3, the notion of consciousness played a central role in answering these questions. I concluded the chapter by introducing two notions of consciousness or self-awareness derived from philosophical phenomenology: pre-reflective and reflective consciousness. We will now expand on the importance of this distinction and explore how it can help us better understand Tourette Syndrome and the experience of freedom – or its loss – reported by people who tic. Many now acknowledge that motor control processes rarely rely on reflective consciousness, i.e., higher-order states in which we are reflectively aware of ourselves and our actions. As Gallagher (2017, 141) writes: Both phenomenology and neuropsychology support a combination of perceptual and non-­ conscious explanations of how we control bodily movements, and they rule out reflective theory in the normal case. That is, in the normal situation, we do not require a second-order consciousness of bodily movement; we do not have to be reflectively conscious of the onset of the action or the course of the movement as we execute it.

But if motor control largely occurs via perceptual (or pre-reflectively conscious) and non-conscious processes, and if we insist on conscious intentions as a requirement for volition, then not many actions will count as voluntary because reflective consciousness is rarely involved in motor control. This, Gallagher suggests, need not lead us to dismiss the idea of volition; rather, it should lead us to change how we pose the question of free will, which is “not about bodily movements, but about intentional actions. The kinds of actions that we freely decide are not the sort of involuted bodily movements described by Libet’s experiments” (145; see Chap. 3 on the legacy of Libet’s research on tic disorder scholarship). A good 30 years earlier, Danto (1985) had already voiced a similar critique in a published comment on Libet’s target article (1985), which appeared in the same issue of the journal, The Behavioural and Brain Sciences. In his eyes, the “deliberation of alternative choices of action” prior to the motor acts we perform has little to do with free will, since these choices result from “deliberations of which we are barely conscious, if at all” (Danto 1985, 541). Danto dismisses Libet’s idea that free will resides in a conscious veto of basic motor action as “metaphysical hysteria” requiring urgent philosophical correction (1985, 541). The source of this hysteria – the feared conclusion that free will does not exist – can be addressed if we distinguish between different sorts of deliberative processes. On the one hand, there is the bulk of our “deliberative action [which] transpires without becoming conscious to the agent  – because its being conscious would reduce our efficiency as agents” (541). As Danto stresses, this efficiency is a

4.1  Critiquing the Dominant View: Are We Getting at Freedom?

65

fortuitous fact – one that enables rather than undermines our capacity to act freely. On the other hand, there is a special type of deliberation – “evolution’s gift to us” (541) – that does involve consciousness, and that deals with “courses of action” and “projects”, the sorts of things that responsibility and free will are also about. These projects have “horizons wider than the circumscribed boundaries of [Libet’s] laboratory” (541); they involve decisions that result from “a reflective consciousness that is embedded in a pragmatically or socially contextualised situation” (Gallagher and Marcel 1999, 25). In these situations, our reflection is not usually introspective or focused on our body (Gallagher 2017, 145). As Danto (1985), 541) describes: We do not simply move our hands; we do so with larger purposes in mind – to wave away a canape, to signal the death of a gladiator, to stifle by gesture the cackle of subordinates, to set up perturbations for the distraction of a wasp, or to express some agitation or other through the language of the body. Our minds bent upon these, consciousness simply assures us we are in contact with ourselves.

Research on volition in tic disorders has never approached the question of volition and voluntary action in this way – as the freedom to align one’s actions with larger purposes. From this perspective, asking whether tics themselves are voluntary or not makes little sense, nor does searching for free will at a millisecond timescale in the neurophysiological processes that immediately precede actions (Gallagher 2017, 25). As movements or sounds, tic tokens cannot qualify eo ipso as voluntary or involuntary, at least on Danto and Gallagher’s accounts. For “voluntary actions are not about neurons, muscles, body parts, or even movement” (Gallagher 2017, 147), although these all play a part in what we call voluntary actions. Freely willed actions rather extend across the integrative and narrative timescales, the latter of which involves “larger processes of distal intentions and action in social contexts” (25). This social situatedness means that we cannot construe freely willed actions as occurring purely in the head or brain; they also have a foot in the world. For enactivist philosophers like Gallagher, volition pertains to a situated mind–body system that is dynamically coupled with its physical-social environment. If we are looking purely at “mind–body or mind–brain interactions, [we] are looking in the wrong place” (147). Enactivism, a variety of philosophical approaches to the study of mind, arose from the work of Varela et al. (1991), who opposed the dominant cognitivism of the time. In the enactivist view, the cognitivist notion of mind as a sophisticated computer that produces, transforms, and manipulates inner models or representations of the world (see Ward et al. 2017, 365) neglects a fundamental truth about cognition: That it emerges from sensorimotor activity and is thus irreducibly active, embodied, and embedded in the environment. But research on tic disorders has not yet heeded the enactivist call. Scientific studies on volition have largely focused on mind–body or mind–brain interactions at the elemental timescale, and asked questions about motor control rather than about the pursuit of larger-scale ‘projects’ and ‘courses of action’. From an enactivist perspective, we thus lack vital information about how freely willed actions may be impacted in Tourette Syndrome and other tic disorders. To help us move toward the narrative horizons that Danto and Gallagher have in

66

4  Freedom in a Tourettic World

mind when they speak of free will, we shall now look at the kinds of intentions involved in freely willed actions. In particular, we will draw on Gallagher’s tripartite definition of intentions (2017, 148) to pinpoint gaps in discussions of volition and freedom in the tic disorder literature.1

4.1.2 Three Types of Intentions Motor Intentions  Freely willed actions involve “motor intentions that are close to motor control processes, built into the action itself, and measurable in the Libet elementary timeframe”. We are not consciously aware of these motor intentions – they represent the “non-conscious aspects of intentional action” (Gallagher 2017, 148; see also Dennett 2003). In so far as research on volition in tic disorders uses Libetian experimental paradigms to assess unconsciously initiated motor control processes measurable in milliseconds (e.g., Moretto et al. 2011; Ganos et al. 2015), we can situate this work here. However, Libet (and the related tic disorder literature that builds on his work) is particularly interested in determining the moment in time when subjects become consciously aware of their intention to move (‘Wanting to move’ judgement, or short: ‘W judgement’). Since W judgements are measured in milliseconds, they seem to relate to the elementary timeframe ascribed to motor intentions; but insofar as W judgements are consciously experienced by the subject, they may be better described as ‘intentions-in-action’ (see below). However, Pacherie and Haggard (2010, 71) question whether W judgements represent genuine experiences of immediate conscious intention, or whether the experimental context induces an awareness that would otherwise remain unconscious.2 Intentions-in-Action  Gallagher describes these as immediate, conscious, and context relative (see also Pacherie and Haggard 2010), as well as measurable in the integrative timeframe (seconds); they may also motivate “situated affordance-based reflection” (Gallagher 2017, 148; on affordances, see Chap. 6). Pacherie and Haggard explain that, from a neural point of view, these “immediate intentions are  See Pacherie (2008) for a similar, three-tiered hierarchical model of intentions. Philosophical scholarship on intentions and intentionality is extremely diverse, with divergent meanings and approaches applied to both terms in such fields as philosophy of mind and phenomenology, for example. The same is true of how consciousness is understood. As Breyer and Gutland (2016, 6) observe, while “‘intentionality’ in much of analytical philosophy of mind usually does not presuppose conscious phenomena”, for many phenomenologists “intentionality is the defining structure of consciousness”. In the phenomenological tradition itself, a unified notion of intentionality does not exist; “often it is used as an umbrella term for any kind of directedness or aboutness of conscious experiences; sometimes it receives very specific meanings”. 2  This is conceivable, since Libet instructs participants to identify when (not whether!) they feel an “urge to act”. This primes subjects to report having an experience (of an immediate intention) which they might otherwise not have. Pacherie and Haggard note that such priming could make these experiments “vulnerable to sceptical attack, or even scientifically worthless” (2010, 71). 1

4.1  Critiquing the Dominant View: Are We Getting at Freedom?

67

conscious experiences of impending action, generated by the motor system of the medial frontal cortex” (2010, 75). Psychologically, they are predictive “in the sense that they precede actions” and also have “an episodic, time-locked quality” tied to the presenting context. Importantly, these immediate intentions, or intentions-in-­ action, link to actions in motor-specific ways; their content “prefigures at least some of the specific motor details of the action itself” (75). In the context of tic disorders, this raises questions about the intentional status of ‘premonitory urges’ preceding tics. Are PU intentions-in-action or not? On the one hand, PU often seem linked to tic events in motor-specific ways, by prefiguring motor details of the tic in question (although some people also report less localised, more diffuse urges not tied to a particular body region or part; see Cavanna et al. 2017, 97). On the other hand, as we noted in Chap. 3, premonitory urges are not always present, or not always experienced consciously, which makes them less like intentions-in-action and more like unconscious motor intentions, or something else. Pacherie and Haggard suggest that the use of the popular term ‘urge’ in the neurosurgical and neuroscientific literature is ambiguous, conflating two distinct meanings and phenomena. In one sense an urge involves an anticipatory “conscious experience of being about to act”; in another it involves a strong motivation to perform a specific action, resembling “a feeling of compulsion, or having to” (2010, 72). These two components are said to be localized to the preSMA (presupplementary motor area) and the CMA (cingulate motor area), respectively (72). To differentiate between them, Pacherie and Haggard suggest that we discard the term “urge” and instead adopt the more appropriate terms “immediate intention and motivation to act” (72), respectively. They apply this distinction to Tourette’s: In conditions such as Tourette’s syndrome and restless leg syndrome, the urge to move is strongly associated with, or simply described as, a sensory quality localized in the specific body parts, and relieved by movement of those body parts. If urges were essentially sensory in nature, they clearly would not be a good model for conscious intention (72).

Based on this distinction, PU in tic disorders may not qualify as intentions in the first place but rather as “strong motivations to act”, however these are defined. The contrast set up here clearly resonates with Haggard’s earlier work, which distinguishes stimulus-driven actions from voluntary (i.e., stimulus-independent) action (Haggard 2008, 934). And yet we do have evidence of increased SMA activation before the onset of tics (Hampson et  al. 2009; Bohlhalter et  al. 2006; see also Moretto et al. 2011, 1324) that would support the voluntary reading of at least some tics as involving both motor and immediate intentions (intentions-in-action). We also know that premonitory urges are generated by different neural circuits than tics (Wang et al. 2011; Worbe et al. 2015), meaning their exact interrelationship remains unclear. For example, we would want to find out whether the premonitory phenomena we call PU themselves qualify as intentions, or whether they might give rise to, or be accompanied by, a conscious intention to tic (or neither of these options). In any case, the clear-cut distinction between purely sensory urges on the one hand, and conscious intentions on the other (Haggard 2008; Pacherie and Haggard 2010) will be difficult to uphold in the case of tic disorders as research increasingly

68

4  Freedom in a Tourettic World

highlights the cognitive and affective dimensions of experience preceding tics (e.g., Steinberg et al. 2013; see also Chap. 7). We need more in-depth phenomenological research to determine the range and nature of these experiences, and to assess how well they fit such concepts as intentions-in-action, motor intentions, or alternative constructs like motivations to act (Pacherie and Haggard 2010; see also Curtis-­ Wendlandt and Reynolds 2021). Further, we also need to take distal intentions into account if we want to embrace a broader notion of free will as espoused by Danto and Gallagher. Distal Intentions  Some freely willed actions involve earlier intentions that are “more detached from the immediacy of action” and “require a more developed deliberative reflection” (Gallagher 2017, 148; see also Gallagher 2012; Pacherie 2008). They are measured in the narrative timescale (Gallagher 2017, 148). As Pacharie and Haggard explain, these long-range prospective intentions can stretch across large time intervals (years, even decades), and it may be for this reason that “experimental studies of voluntary action deal hardly at all” with them (75). This is despite the fact that “long-range intentions appear to be effectively connected with short-range intentions, and therefore with action itself” (75) – for example, through such future-directed cognitive activities as planning, coordination, imagination, and mental time travel (78). We do not currently know whether and how tic disorders affect cognitive activities involved in the formation of future-directed intentions, and whether symptom interference at the motor level impacts the experience of free will at a narrative timescale. It seems likely that any such interactions between the elementary, integrative, and narrative timescales (and between motor intentions, intentions-in-action, and distal intentions) would be complex rather than “straightforwardly linear or additive” (Gallagher 2020, 31). To illustrate the relevance of probing for such interactions, let us consider the case of CBIT (Comprehensive Behavioural Interventions for Tics), now regarded as the first-line behavioural treatment for tics.3 Based on principles from habit reversal therapy (HRT), CBIT has shown impressive efficacy in longer-term tic reduction (e.g., Piacentini et al. 2010; Wile and Pringsheim 2013; McGuire et al. 2014; Blount et  al. 2018). It works by helping individuals identify, practice, and consistently implement a sustainable competing behaviour instead of a bothersome tic. Ideally the tic will be fully prevented through an anticipatory response, but in the learning phase the competing behaviour may also be used at tic onset (Woods et al. 2008, 44). But what is this anticipatory response if not an example of the interplay of motor intentions and intentions-in-action? Perhaps distal intentions are at play here too: the sort of general intention to participate in therapy, to learn how to reduce one’s tics, and – perhaps more importantly – to improve one’s aim on the basketball court, to cook pancakes more safely for breakfast on Sundays, or to be teased less by one’s peers?  See the recent Practice Guidelines developed for the American Academy of Neurology (Pringsheim et  al. 2019), which are endorsed by the European Academy of Neurology and the Child Neurology Society, among others. 3

4.2  Acting Freely

69

While CBIT’s success as a behavioural treatment for tics is well documented, it is not clear exactly what factors are responsible for its efficacy. Intentionally doing the competing response may stop the basal ganglia from producing a tic; alternatively, attending to premonitory sensations may help people habituate to the urge (Woods et al. 2008, 44). Recent research applying a TEC (theory of event coding) framework to the study of tics suggests that “HRT/CBIT modulates factors playing an important role in perception-action bindings”, leading not only to an effective reduction in tics but also normalising “alterations in higher level cognitive functions” (Petruo et al. 2020, 4). Further, the efficacy of CBIT might also impact or rely on causal dynamics – unexplored to date – that are situated at the level of distal intentions (for example, via an enhanced sense of agency). It seems plausible to propose that the experience of learnable, intentional motor control over immediate actions at the elemental and integrated timescales may also boost individuals’ long-­ range, future-directed optimism about their prospects of living an agentic life. Mastering competing behavioural responses  – by replacing tics with other intentional, deliberately chosen actions – would then become synonymous with a broader realignment of one’s actions and intentions, and help individuals reclaim control over their lives “one tic at a time” (Curtis-Wendlandt 2019, 368). And yet we can also think of cases where intentional deliberate control may decrease rather than enhance how free we feel, or where a remedial focus on behavioural control at the level of intentions-in-action might have unintended consequences that could hinder one’s pursuit of life’s larger purposes. In short, we can imagine both virtuous and vicious cycles, or negative and positive feedback loops and interactions, unfolding across all levels of intentions and their respective timescales. Obsessive compulsive disorder (OCD) provides an instructive example of such a vicious cycle, showing how a ‘too much’ of reflective conscious control at the level of intentions-in-action can severely curtail an individual’s freedom.

4.2 Acting Freely 4.2.1 The Trouble with Too Much Control: Disrupting Skilled Habits The idea that “voluntary action is … a form of decision making” (Haggard 2008, 937), which requires us to consciously deliberate and choose between alternatives, is challenged by De Haan et al. (2017) in their phenomenological inquiry into free will in Obsessive Compulsive Disorder (OCD). In OCD, they argue, “exercising an increased conscious control over actions can in fact diminish the sense of agency rather than increase the experience of freedom” (84). Like Gallagher, Danto, and others before them, they stress that unconscious action control often helps us to feel free, while deliberation can “disturb the flow of unreflective action”. In OCD, the balance between deliberative control and unreflective actions thus appears

70

4  Freedom in a Tourettic World

disturbed: Individuals with the disorder seem to be “exerting too much conscious control over their thoughts and actions” (84; emphasis added). An OCD patient’s first-person account powerfully illustrates how such excessive deliberation and control can impact normal functioning: I am constantly worried that I might say something that would hurt other people. When I talk to someone, I pay close attention to what I say, but afterwards I am never sure whether I did not unintentionally say something offensive. I am constantly aware of all the possibilities for being offensive or insulting. Therefore I avoid people as much as I can. I hate it: I feel trapped inside my own head (quoted in De Haan et al. 2017, 85).

The dynamic at play here  – termed the “hyper-reflectivity trap” (De Haan et  al. 2017, 95) or simply “hyperreflexivity” (e.g., Fuchs 2011) – can be found in many psychopathological conditions and involves someone excessively reflecting on, and attending to, their thoughts and actions. Paradoxically, the intense conscious effort involved in trying to control an action outcome undermines the person’s confidence in being able to do so successfully, fuelling in turn a perceived need for further deliberation and control. Importantly, this process is not accompanied by a feeling of freedom but rather by a sense of its loss. The OCD patient quoted above no longer interacts freely with others; trapped in her own thinking, she retreats from the world. Using our earlier, tripartite distinction between different types of intentions involved in freely willed actions, we could say that this hyperreflexivity accompanies and disrupts the flow of the intentions-in-actions and their associated motor intentions (for example, via constant questioning of the content and manner of speech as the conversation unfolds). This hyperreflexivity also seems guided by a more general, affectively charged distal intention (e.g., of not wanting to insult others, grounded perhaps in negatively valenced memories of past experience, or fearful projections of future experience), suggesting that different intentions could interact in complex ways across the elemental, integrated, and narrative timescales. Clearly, the OCD patient’s fraught exchange with her offendable others  – her “interactional awkwardness”, as De Jaegher et al. (2017, 491) might call it – does not signal a lack of deliberate attention to her own spoken words. What she lacks instead is her “spontaneous, bodily responsiveness to the situation at hand” (De Haan et al. 2017, 90), that fortuitously functional way of acting tacitly in the world (see Fuchs 2011, 239; see also De Jaegher et al. 2017). For De Haan and colleagues, this spontaneous responsiveness rests on our “ability to rely on our skills” (83) – learned skills which once required deliberate attention, and which then became second nature as we practiced and eventually mastered them. Such mastery not only marks the end of a learning process, but it also makes conscious deliberation obsolete: “The hallmark of skill acquisition is the transfer from consciously controlled to intuitive habitual actions” (De Haan et al. 2017, 89; see also Dreyfus 2002). The idea of spontaneous bodily responsiveness, which De Haan and colleagues identify as central to our experience of freedom, thus rests on a notion of habituality that is informed and learned: “Our spontaneous, unreflective actions … are the result of cultivation, or Bildung, within our socio-cultural practices” (Rietveld 2008; as quoted in De Haan et al. 2017, 89). In contrast to reflexes and instincts, our skilled

4.2  Acting Freely

71

habitual responses are “flexible and context-sensitive, and it has taken time and energy to turn them into habits” (De Haan et al. 2017, 97). It is not so much that reflection is unnecessary, but rather that it is no longer necessary, in order for us to respond spontaneously and intuitively to relevant contexts and opportunities. Since we once learned how to do so, wilful choice is not required anymore to ensure that “what we care about” nevertheless motivates our actions (see Rietveld 2008, 152; see also De Haan et al. 2017, 91) – or, as we might say, that our actions align with our distal intentions. Significantly, this account does not dismiss the importance of deliberation to our experience of freedom. For De Haan and colleagues, deliberation plays a serving role that is both remedial (when it comes “to the aide of the unreflective flow of action in case of disturbances or problems”) and preparatory (when it helps us “to learn something new”; De Haan et al. 2017, 90). As such, deliberation itself does not seem to be a qualitative aspect of “what it is like” to feel free; it only facilitates or reinstates that experience at select points in time. As conditio sine qua non, it allows us to respond to and affect the world intuitively and skilfully, in accordance with what is important to us (91). Extending Arendt’s (2006) notion of freedom in action, De Haan and colleagues describe freedom as a measure of such accordance: “That is, the freedom one experiences will increase the more one is able to act in accordance with what one cares about. If I can act according to what matters to me, I will feel free – regardless of the amount of conscious control I exert during this action” (91; emphasis added). The inconspicuous adverb of time used here (i.e., “during”) reminds us that conscious control is not off the cards entirely; it just need not happen simultaneously with the free action itself but can take place before or after (recall the preparatory and remedial role of deliberation). This temporal uncoupling of conscious deliberation and action control, which underlies De Haan and colleagues’ definition of freedom as “coherence between my concerns and my actions” (91), leads us back to Danto’s larger purposes and Gallagher’s distal intentions and their role in freely willed action. It also raises questions about how to rethink free will in the context of tic disorders. Do tic disorder symptoms impact individuals’ ability to act in accordance with what matters to them, or to align their immediate actions with the narrative horizons of their projects and concerns? What about the idea that feeling free requires us to rely on embodied habitual skills that allow us to respond intuitively to our surrounding world – do tic disorder symptoms interfere with the execution of such skills? Might people with TS and tic disorders be at greater risk of suffering from hyperreflexivity and the psychopathological conditions in which it is implicated? Some self-reports from people with TS suggest so. Peter Maisey, for example, writes: “I’d love to be able to stop [vocal tics] or even switch to a muscular tic, but I don’t have that control. There’s that word “control” again. TS is one aspect of my life over which I have no control. Is this why I need to have control over all the other aspects?” (2003, 95). Here, the perceived loss of motor control leads to compensatory efforts to control ‘all the other aspects’ of life, a response which is likely to disrupt the balance between conscious deliberation and intuitive reliance on skilled habits. How free might Maisey feel? What does his need to control other aspects of his life mean on

72

4  Freedom in a Tourettic World

a daily basis? In the absence of any phenomenological research devoted to these sorts of questions, we can only speculate. And to do so, I propose we draw on an existing body of work in the tic disorder literature that comes closest to looking at the narrative horizons of people with tic disorders: research into Quality of Life (QoL).

4.2.2 Quality of Life as Freedom in Action If we construe freedom as an individual’s ability to pursue her prized projects and concerns, then we need broader information about the lives of people with tic disorders to know (a) whether and how their symptoms might impact their sense of freedom, and (b) how motor control (deemed central to the scientific concept of volition) might interact with this sense of freedom at the narrative timescale. Applied philosophical phenomenology is ideally suited to probing such first-person experiences and to answering questions like the above (see Curtis-Wendlandt and Reynolds 2021). But in the absence of any such work on Tourette Syndrome and tic disorders to date, we can glean some indirect evidence from the Quality of Life (QoL) data collected in these populations.4 Definitions of QoL differ across studies, as do the general and TS-specific scales designed to test it.5 A good operational definition of QoL, which suits our discussion of free will and volition in TS, describes it as “the discrepancy between patients’ expectations about life and their actual experiences” (Eapen et  al. 2016a, 3). In line with our earlier discussion of intentions, we can translate the notion of ‘expectations about life’ into long-range intentions that involve imagination, planning, time travel, etc. Similarly, patients’ ‘actual experience’, in so far as it involves their own actions, can be related to their current intentions-­in-action and any impediments these might confront or give rise to. Further, we can intuit that any mismatch between expectations and actual experience (or between current actions and distal intentions) would not only impact people’s QoL but also their sense of being able to act freely and in line with what they care about. To clarify up front: My approach is not reductive here. I do not intend to say that the ‘expectations’ referenced in the above definition of QoL can be reduced to, or are nothing but, intentions. I am merely suggesting that one’s intentions will likely  There is, of course, a range of qualitative research studies which offer invaluable insights into people’s lives with TS (for a meta-synthesis of qualitative studies, see Smith et al. 2015). These studies vary in their methodological approaches and thematic focus, and they do not address the questions I pose here. 5  An instrument designed to assess QoL specifically in people with TS is the Gilles de la Tourette Syndrome-Quality of Life Scale (GTS-QoL; Cavanna et al. 2008; see also Eapen et al. 2016b, who used this scale in their study). There is also the general 23-item Paediatric quality of life inventory (PedsQL; see Varni et  al. 1999; see also Storch et  al. 2007a, 219). Further, the general KIDSCREEN-52 self-report instrument is used in children and adolescents to measure ten Rasch scaled dimensions of health-related QoL (see Lee et al. 2019). 4

4.2  Acting Freely

73

play a part in those expectations. The same holds for the notion of ‘experience’ referenced in QoL: One’s own actions will contribute to, but cannot fully constitute, one’s experience (the environment also shapes this). To my knowledge, the potential connection between people’s QoL and their perceived sense of freedom or volition has not been investigated explicitly, but many studies have found reduced QoL scores in adults and children with TS and chronic tic disorders over the last two decades (see Eapen et al. 2016a; Cavanna et al. 2013a; see also Lee et al. 2019). The results are heterogenous but confirm the “wide-ranging impact of TS on health-­ related QoL of patients of all ages”, with impairments observed across six general QoL themes involving “physical, psychological, occupational, social, obsessional, and cognitive domains” (Eapen et al. 2016a, 3). Two findings from this research are of particular interest to us here: Firstly, that tic severity alone does not predict QoL in any simple or straightforward manner; and secondly, that social factors strongly impact QoL. On the first point, we should note that the physical impact of tics themselves can certainly be debilitating and interfere with normal functioning. Those with more severe symptoms “may suffer from physical consequences such as the pain and discomfort of the repetitive movements” (Eapen et al. 2016a, 1–2) and injuries or physical damage are not uncommon. These physical aspects of QoL are further affected by comorbidities such as ADHD and OCD (3). The exact relationship between tic severity, comorbidities and QoL requires further research as divergent findings have emerged on this topic (Cavanna et al. 2013b; Eddy et al. 2011; Hoekstra et al. 2004; as quoted in Eapen et al. 2016b, 89). Storch et al. (2007a) found that youths “with a higher rate of tic severity endorsed greater impairment in social functioning and felt more limited in their capabilities than those with mild or moderate tics” (218). But it is not clear whether these more limited capabilities are a direct effect of tic severity or rather result from these youths’ difficulties in social functioning. Lee et al.’s (2019) recent study in a group of children and young adults found no significant correlations between tic severity (measured using the YGTSS) and QoL scores (measured using the KIDSCREEN instrument). Instead of viewing the severity of tic symptoms as the main determinant of QoL, they suggest that relational factors such as “family climate can [have] more of an effect” (2056). To assess family climate, their study employed the concept of “Expressed Emotion” (EE), which refers to “critical or overinvolved communication styles within the family”. These communication styles are called “high EE” and have been shown to be “a reliable predictor of poor outcomes in adults and children with a variety of psychiatric disorders”, as well as “a good predictor of relapse and prognosis in patients with those psychiatric diagnoses” (Gottschalk and Keatinge 1993; Hooley 2007; see Lee et al. 2019, 2052). High EE has even been related to youths’ biological vulnerabilities to diseases (Peris and Miklowitz 2015; see Lee et al. 2019, 2052). The salience of these relational and social factors impacting QoL is supported by Eapen et al.’s (2016b, 89) finding that, among complex tics, it is the socially most sanctioned and stigmatised ones – i.e., those that involve coprophenomena – which show the greatest adverse impact on QoL. Experiences of stigma and social sanctions resulting from tic disorder symptoms may occur within or beyond the home

74

4  Freedom in a Tourettic World

environment and have frequently been studied in the context of schooling and adolescent peer relationships (e.g. Nussey et  al. 2014; Packer 2005; Rivera-Navarro et al. 2014; Storch et al. 2007b; Wadman et al. 2016). Less common but promising is the renewed interest in familial interactions and parenting behaviours as impacting QoL in youth with tic disorders: “Considering that children and adolescents are not yet independent from their families, they are more vulnerable to the effects of family atmosphere, both negatively and positively, and EE can be the most important aspect in determining their QoL” (Lee et al. 2019, 2055; see also Erbilgin Gün and Kilincaslan 2019). Notably, the mean total score for Expressed Emotion within the families of Lee and colleagues’ 56 tic disorder patients was even higher than that reported for families of schizophrenia patients, and these young patients’ KIDSCREEN scores revealed notable levels of mental distress (Lee et  al. 2019, 2055). The emotional toll of these relational experiences should not be underestimated. Caregiver criticism and negatively expressed emotions, as well as teasing or bullying by peers, may make children and adolescents with tic disorders feel anxious about ticcing in front of others and “depressed from difficulties at school or lack of educational/vocational or employment opportunities” (Eapen et  al. 2016a, 1–2). Returning to our question of volition and the intuitive proposition that how free one feels will correlate with QoL, we may infer that individuals’ perceived freedom to align their immediate actions with their distal intentions is heavily influenced by their social and familial interactions  – more so, perhaps, than by their physical symptoms per se. A positive, supportive, and enabling environment may thus be a better predictor of whether or not individuals with tic disorders feel free to act in accordance with what matters to them than any measure of their symptom severity could be. (This has important implications for how we might frame an ethics of responsibility and care in TS, a topic we will turn to in Chap. 8.) In sum, the above research on Quality of Life in TS and tic disorders supports the notion that feeling free is not just about controlling physical symptoms but dependent on social “affordances” too (Gibson 1979; Heras-Escribano 2019; Gallagher 2020).6 No necessary correlation seems to exist between tic severity, tic control (or lack thereof), and ability to pursue one’s projects and purposes. Many real-life examples illustrate that people with relatively severe tic disorder symptoms and complex comorbidity are able to live fulfilling and successful lives. I suspect that this supports an alternative conception of freedom – one that defines it as a socially situated freedom in action. On such an account, we cannot just peek inside the individual’s brain to look for markers of volition; we also need to ask how the individual interacts with her world. Hannah Arendt famously critiqued the historical shift toward an internalised notion of freedom concerned with “the amount of control one exerts over oneself, as opposed to the amount of influence one has in the outer world” (De Haan et al.  Gibson’s (1979) ecological psychology introduced the idea of affordance to specify the relation between an agent and some aspect of the environment. Building on this work, Gallagher has developed the notion of action affordance more specifically, which supports a theory of action as irreducibly interactive (2020, 12). I discuss this important concept in more detail in Chap. 6. 6

4.2  Acting Freely

75

2017, 87–88). In “What is Freedom” (Arendt 2006), Arendt calls for a return to an earlier conception of freedom as freedom to act, characterised by “the capacity to start something new; to participate in a community or a political realm”, and more broadly “to take part in the (social) world” (De Haan et al. 2017, 87; Arendt 2006). Importantly, “this implies that individuals in fact need other people and social practices to be free” (De Haan et al. 2017, 87). On this account, the question of freedom in tic disorders and Tourette Syndrome should not (or not primarily) be framed as a question about self-control (e.g., suppressing or redirecting tics), but as a question about the individual’s opportunities to participate in her social lifeworld. Even though symptom control may affect those opportunities, describing freedom as a socially situated freedom in action means we can no longer think of it as a property or quality that is generated and maintained by an autonomous brain or mind. Rather, the possibility for acting freely arises through the embodied, embedded, and extended self’s interactions with its world. Such a conception of freedom is a far cry from the notion of volition discussed in the contemporary tic disorder literature (see Chap. 3), which mirrors the dominant concept of ‘inner freedom’ (and its fixation with conscious deliberation) critiqued by Arendt and other phenomenologists. Heidegger, for example – on whom Arendt draws explicitly – also insisted on the “primacy of our practical engagement with the world over deliberation”, stressing that deliberation is usually not required when we are immersed in our actions  – unless something goes wrong (De Haan et al. 2017, 88; see Heidegger 1927/2001). The liberating experience of immersive action is well-known among people with tic disorders, who describe how their tics temporarily disappear while they engage in absorbing activities  – for example, during singing, dancing, playing music or video games (e.g., Beste and Muenchau 2018, 238; Albin 2018, 333). These examples not only illustrate the peculiar fit of the notion of ‘freedom in action’ in the context of tic disorders. They also highlight the therapeutic potential of skilful practice. By entrusting themselves to their own tacit know-how and enacting their intentions and projects in the world, individuals are freed of their tic disorder symptoms – not by consciously attending to them or deliberating alternative action choices, but by relinquishing control to the potent flow of their embodied habitual skills. This leads us right back to De Haan et al.’s (2017) idea that our skilled habits facilitate the experience of freedom because they allow us to respond spontaneously and intuitively to our surrounding world. But what is the relationship between tics and skilled habits? And can we say more about the potential therapeutic effect of the latter? To answer these questions, we need to take a closer look at both concepts, their possible interactions, and the way in which existing behavioural approaches to treating tic disorders have utilised some (but neglected other) interactions between tics and other skilful actions. Their interplay is such that it can both reduce and enhance freedom in action.

76

4  Freedom in a Tourettic World

4.2.3 Four Scenarios: Interactions Between Tics and Other Intentional Actions Recall that the concept of skilled habits entails a temporal progression implicit in the notion of learning, from an initially conscious and intentional attending-to-an-­ action to a state of unconscious mastery (De Haan et al. 2017). Skilled habits thus have a conscious and intentional past. Many tics do not come with such historical credentials, and certainly not with the experience of ‘freedom in action’ thought to accompany skilled habits. Even if tics result from a learning process of some sort, as has been proposed,7 and even if some tics require great motor coordination that had to be learned and practised at some point, they do not usually enable but more commonly obstruct individuals’ intuitive and spontaneous responsiveness to the world. People may feel free despite their tics, rather than because of them. Put differently, while the idea of freedom in action suggests that we feel free because we can rely on these habits, tics do not anchor our freedom in this way. They don’t tend to ‘do’ what skilled habits do for us; they function differently (if they have a function at all). Albin notes that tics have been persuasively conceptualised “as a form of habits gone awry” (2018, 333). They can closely resemble other sorts of habits or body-focused repetitive behaviour (BFRB, for example hair-pulling, skin-picking, nail-biting, etc.), which clearly differ from the skilled habits De Haan et al. describe. Similarly, O’Connor et al. (2017) consider disorders involving tics and BFRB to be part of the same spectrum, noting their common co-occurrence and the fact that both are repetitive, difficult to resist, often appear automatic, and respond similarly to treatment. Both tics and BFRB seem to respond to feelings of sensory discomfort but otherwise serve no obvious function (O’Connor et al. 2017, 12; see Chaps. 8 and 9 for a discussion of functional tics). Differences between tics and BFRB notwithstanding, a key point to note is that both differ from skilled habits with regard to their “aboutness” (Searle 2003) or intentional directedness. Skilled habits often reflect or align with our distal intentions and broader life projects; they point beyond the immediate action in question, toward matters we care about in the world. But tics and BFRB do not point beyond themselves in this way; they do not express distal intentions or contribute to our projects, unless we assign them such an identity-affirming role wilfully and in retrospect. Put differently, tics and BFRB may well be intentional (I will develop this view in Chap. 6), but their intentionality is purely immediate, fulfilled within the moment the tic or BFRB is executed (for example, to ease a sensory tension). Bliss speaks of “‘intentional’ capitulations to virtually irresistible sensory invitations” (as quoted in Leckman et al. 2006, 645), capturing in this phrase the peculiar push-and-­ pull dynamic that characterises his experience of tics. Leckman and colleagues use  For example, evidence suggests that movement observation automatically induces motor activation in TS. This automatic imitation of movements has been ascribed to “highly overlearned behavior that can be triggered without interference by external, incompatible movement stimuli” (Brandt et al. 2016). 7

4.2  Acting Freely

77

the term “forced intentionality” (645) to describe this dynamic, whereby someone with tics is forced to want to do the action that the preceding impulse or sensory discomfort “invites” them to do. But how does this forced intentionality of ticcing impact people’s ability to rely on their skilled habits and the associated experience of freedom in action? We can distinguish several possible interrelationships between tics, skilled habits, and other intentional actions. Scenario 1 (‘Narrative Disruption’)  Tics interfere with other intentional actions and the expression of skilled habits. I call this ‘narrative disruption’ because tics here prevent the successful execution of other meaningful actions at the integrative and narrative timescales. Suppose you are a passionate computer gamer. You have spent the last 2 years perfecting your technical and strategic skills to increase your chances of winning in a particular game. Now, imagine yourself right in the middle of a fast-paced game with other advanced players. Suddenly, you have an on-screen freezing tic, where your character stands still and is immobilised for a few seconds (the tic pauses your finger movements on the controller which you hold in your hands). Other players seize the opportunity – you are an easy target, they shoot you, and you are out. End of your game. You are frustrated: It was not your skills that let you down. Rather, your tics wrought havoc with your gameplay and the unreflective flow of your know-how (De Haan et al. 2017, 98; see also Reynolds 2018, 155). You were distracted by what we might call the ‘intentional noise’ of your tic, which disrupted your pre-reflectively conscious, immersed activity. With this disruption, reflective (self-)consciousness, blissfully absent before, returns to the scene: What did you do? How could this have happened? The return of this reflective awareness of yourself and your actions marks the loss of your freedom in action; it is indicative of the fact that something went wrong (see De Haan et al. 2017, 88; see Heidegger 1927/2001). When tics interfere with skilled habits and other intentional actions, they may thus entail a perceived loss of freedom. Amy Wilensky’s memoir of growing up with TS and OCD offers a powerful example of this scenario (1999, 78–79): For me, loss of control represented all of the ways in which my body was betraying me, changing me from an extrovert who liked to be the centre of attention into a hunched form huddled in a bathroom stall for hours at a time, a dancer whose greatest source of pride has been mastery over her limbs to a broken-down robot, whose short circuits were causing a total system breakdown.

Scenario 2 (‘Narrative Imposition’)  Tics are misinterpreted as other intentional actions. Suppose you have a complex vocal tic that leads you to utter the phrase ‘I’ve got a bomb!’ each time you enter an airport or board an airplane. You neither carry a bomb with you nor do you intend to cause any trouble. In fact, you are mortified by your own tic, and feel tense and anxious each time you need to travel by air. On one occasion you are intercepted by security personnel and questioned. Upon showing the medical certificate from your doctor, stating that you have Tourette’s and that you are prone to utter socially inappropriate vocal tics in public, the security staff conduct an extensive search of you and your luggage and eventually agree to let you go. You rush to the gate, but alas, it is too late: you have missed your flight.

78

4  Freedom in a Tourettic World

In this scenario, your verbal tic was interpreted as meaningful in a literal sense, rousing suspicions that were completely ill-founded. The fact that this vocal tic is contextually cued (i.e., you say it more frequently at airports than elsewhere) is nothing unusual, but rather typical of socially inappropriate tics. Of course, this contextual fit encourages a literal interpretation of the words you utter; others are more prone to think that you mean what you say (and dare not take your comments lightly). Ironically, the misattribution of meaning here is itself the result of skilful habits, albeit not your own: It results from the security personnel’s once-learned, now intuitive and spontaneous response to any environmental cues that might signal a threat to public safety. These staff were trained (and are paid) to interpret the world in this way. As masters of suspicion, they happily over-apply their skilled habits to potentially benign situations. Suspending these habits and understanding that complex vocal tics neither function like normal speech nor represent the sorts of intentional actions they appear to be goes right against the ‘intentional grain’ of these professionals’ expertise. This scenario embodies another kind of ‘forced intentionality’, different from Leckman et al.’ (2006) use of the term. Intentionality here is also forced upon the individual, yet not by her own impulses or ‘sensory invitations’, but rather by the meaning-making processes and skilled interpretative habits of people in her environment. I call this process ‘narrative imposition’ (we will come back to this in Chap. 8). Since it constitutes a misinterpretation of the tic action, narrative imposition may also diminish the ticcing person’s freedom in action, although counterexamples exist. Amy Wilensky, for example, who declares herself to be “an expert on the misinterpreted gesture” (1999, 126) due to her TS, purposely encouraged such narrative imposition as a way to disguise her tics: It was at Nashoba that I learned to harness my tics and compulsions, conceived and perfected ways of concealing them as socially acceptable, if odd, behaviours. Tiny shoots of legitimate personality traits or characteristics – being hyperactive, a show-off, a know-it-all, a fidgeter, a slow – watered by the seductive attention of my peers, who interpreted oddness as renegade rebellion, obsession as identifiable style, became certifiable identity markers, clear-cut indications that I was me, even as I grew increasingly less sure who that was (Wilensky 1999, 67).

Here, Wilensky encourages others to misinterpret her ‘odd’ symptom-behaviours, induced by her TS and OCD, as meaningful aspects of her identity. In doing so, her ‘disordered’ symptom expressions disappear from view and are replaced by socially legitimate displays of personality. The strategy makes tics invisible as tics and resembles Buckser’s (2008, 177) notion of “misattribution”, which describes people with tics “putting tics into other categories” of behaviour. Scenario 3 (‘Narrative Integration’)  Tics become meaningful aspects of other intentional actions. In this scenario, the tics may or may not stand out as symptoms in the experience of the ticcing person; in either case, they become part of, and contribute to, the meaningful actions she is engaged in, often in positive ways. Oliver Sacks’s short story, ‘Witty ticcy Ray’ (2015) recounts the example of a Tourettic

4.2  Acting Freely

79

patient who was a brilliant jazz drummer and ping-pong player, and whose virtuosity in both domains was greatly enhanced by his Tourette’s (2015, 102–103): He was … 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.

Clearly, tic disorder symptoms can also come in handy; they can enhance, not just thwart, other meaningful activities the person is engaged in. The simultaneity here is crucial to attain the effect: the tics must co-occur with and during the meaningful activity (e.g., playing drum or ping-pong) to become an integral aspect of it. This temporal integration into other, ongoing activity marks a crucial point of difference from another scenario we could add here, i.e., ‘Narrative Functionalisation’, where tics are used to enact other intentions. Since this scenario represents the functionalisation of primary tics, I will dedicate a separate discussion to this complex topic later in the book (see Chap. 8). Scenario 4 (‘Narrative Easing’)  Other intentional actions interfere with the expression of tics. This is the inverse of Scenario 1 (where tics interfere with other intentional actions), and it may be associated with greater rather than reduced freedom in action. The effect can be achieved accidentally or by design, and via bottomup or top-down intentional processes. Recall our earlier mention of people’s ­ absorption in meaningful activities such as singing, dancing, playing music or video games (e.g., Beste and Muenchau 2018, 238; Albin 2018, 333). Here, the intentional actions involved in such skilled performance inhibit the expression of tics, possibly leading to an immersive sense of freedom in action. (It is conceivable that people who tic, if we asked them “when do you feel most free?”, would respond by saying “when I do x” – i.e., sing, dance, play music, or whatever other skilled activity they might enjoy.) We could call this way of interfering with tics a top-down process, in so far as the intentional focus of the action is not motor control of tics from the bottom up (as in CBIT, for example), but skilled performance that aligns with the person’s broader cares and concerns. This alignment between a person’s intentions-in-action and her distal intentions (the ‘stuff she cares about’) also happens to inhibit her tics, but this inhibition is by-the-by, neither the primary intention nor the conscious focus of the action. Another way to interfere with tics is to wilfully replace them with specifically chosen and consciously learned competing behaviours, as is done in the current best-practice behavioural treatment for tics, CBIT (Comprehensive Behavioural Interventions for Tics). We can consider CBIT to be a type of skilled habit formation that requires initial conscious learning and control. The effectiveness of CBIT at reducing tic symptoms is well-established (e.g. Wile and Pringsheim 2013; McGuire et al. 2014; Blount et al. 2018), but it’s impact on individuals’ QoL and sense of self

80

4  Freedom in a Tourettic World

has not yet been studied in any detail.8 Further, while drug treatments are routinely studied for their ‘side-effect profile’, this is not the case with behavioural interventions, which are commonly touted as side-effect free and thus contrasted positively with pharmacotherapy. In their Practice Guidelines for the treatment of tics in people with Tourette Syndrome and chronic tic disorders, Pringsheim et al. (2019, 899) speak of CBIT’s “benign safety profile”. Among the eight behavioural therapy and supportive psychotherapy studies listed, six did not discuss adverse effects (Deckersbach et al. 2006; Wilhelm et al. 2003; Verdellen et al. 2004; Yates et al. 2016; Ricketts et al. 2016; Himle et al. 2012), and two reported a worsening of tics in a small number of individuals studied (Piacentini et  al. 2010; Wilhelm et  al. 2012). In other words, those studies that explicitly comment on adverse effects only note a worsening of the very symptoms (i.e., tics) which the treatment sought to reduce rather than looking more broadly at a range of possible impacts on the person and her life during and after treatment. From a phenomenological perspective, this represents a potential blind spot, albeit one that is far from unique to the treatment of, and research on, tic disorders.

4.3 On the Therapeutic Use of Consciousness 4.3.1 Bottom-Up or Top-Down Phenomenologically speaking, we should want to know as much as possible about whether and when CBIT might fail to have the desired effect, and – perhaps even more importantly – whether it could have other effects than its stated therapeutic aim. The literature does show an interest in the first question when it ponders the criteria that may prevent effective CBIT treatment (young age, medication status, participant motivation, and the presence of comorbidities are factors debated in this context; see Sukhodolsky et  al. 2017). The second question, however  – whether CBIT could have other unintended (positive or negative) effects that differ from its stated therapeutic aim – has barely been posed to my knowledge. And yet the range of implicit assumptions that seem to underlie behavioural interventions such as CBIT lead us right back to asking how tics and other intentional actions may interact, and how these interactions in turn shape individuals’ sense of freedom in action. One of the operative assumptions in CBIT is that directing conscious attention to tics and tic urges can serve a therapeutic end in so far as it enables the development of new skilled habits (i.e., executing competing responses) that prevent ticcing. As

 A few papers and qualitative studies have looked at patient perspectives of different treatment strategies for tics, particularly in children and adolescents with Tourette Syndrome (e.g. Cuenca et al. 2015; Hollis et al. 2016). Deckersbach et al. (2006) investigated multiple aspects of treatment response including effects of habit reversal therapy and supportive psychotherapy on psychosocial functioning and life-satisfaction. 8

4.3  On the Therapeutic Use of Consciousness

81

we observed, this aligns with our Scenario 4 (Other intentional actions interfere with the expression of tics). Now also recall the idea that consciousness can serve freedom in action (De Haan et al. 2017). Could we say that the skilled habits individuals acquire through CBIT enhance their ability to respond intuitively and spontaneously to the world and its opportunities? The aim of CBIT is not cast in such narrative terms; rather, the “goal of this program is to teach the patient effective tic management skills” (Woods et al. 2008, 1), with a firm focus on reducing ticcing behaviour. And yet by reducing tics, it is implied, we might see an improvement in other areas (social, educational, occupational) of the person’s life: “Effective treatment strategies to reduce tics may reduce the overall impairment associated with TS” (4). Therefore, while the program’s lever for change lies in the control of individual behaviours (preventing the occurrence or completion of tic tokens) at the level of motor intentions and intentions in action, a connection with the person’s distal intentions and broader life is assumed. Enacting the skilled habits acquired in CBIT does not in itself constitute an engagement with the world or one’s distal intentions, but it may facilitate such engagement indirectly. We could call this a bottom-up approach to increasing freedom in action in so far as the intentional focus of the intervening action is specifically on motor control of tics. Here, tic inhibition (achieved by executing an alternative competing behaviour) is the primary intention and the conscious focus of the action. In this regard, CBIT is similar to pharmaceutical treatments (although these obviously work via a biochemical rather than behavioural mechanism). Both seek to reduce the occurrence and intensity of individual tics with the expectation that this will ameliorate social and educational functioning, for example, and improve overall wellbeing (on enhanced self-esteem following CBIT, see Weingarden et al. 2018). CBIT and pharmacotherapy thus both reinforce the ‘one-choice model’ of volition mentioned in Chap. 3, which portrays tic control as the primary (or even the only) path to increased freedom. But while the effectiveness of pharmacotherapy requires no conscious attending to individual tics when they occur (or are about to occur), CBIT relies on a reflectively conscious learning process based on the principles of habit reversal therapy (HRT). A clinician teaches “the child to become more aware of tic urges and behaviours and engage in a behaviour that prevents the completion of the tic” (Woods et al. 2008, 8). The approach thus involves a purposeful inward-directing of conscious attention to one’s own tics and their accompanying sensory phenomena. But could such increased self-directed consciousness also carry a risk? Ideally, as mentioned, CBIT would lead to the habitual embedding of competing behavioural responses and, by means of these, not only reduce tics but also increase the person’s freedom in action (i.e. her ability to act in accordance with what she cares about). But this two-step route to freedom may not always be travelled by a patient; as De Haan et al. (2017) showed for OCD, consciousness is not always a liberating tool but can entrap us too: Too much inward directedness [of conscious attention] leads to closing oneself off in one’s own inner world. Now, the problem in many forms of psychopathology is precisely that

82

4  Freedom in a Tourettic World patients ‘live in their own world’…. Patients are trapped in themselves, and their inward directedness attributes to the continuation of the pathologies (91–92).

Many people with tic disorders already have a heightened sense of self-awareness, and for some, the incessant and intrusive nature of their tics leads them to feel separated from the world. Ruth Oliver, whom we heard at the start of Chap. 3, describes how her tics occupy her consciousness at all times (2003, 128): [Tourettic tics] are uncontrollable movements of the body which are embarrassing, futile, and sometimes dangerous. They create a wall between the sufferer and the world. Behind that wall, the whole consciousness consists of a raging battle that ceases only when forced into sleep… The tics are the first thing that enter the mind on waking … Every scrap of energy is spent trying to control them in order to get through the daily routine with some semblance of normality, and a constant sense of failure can lead to attacks of aggression and sometimes violence  – in my case, toward myself, although violence toward others, and wanton destruction, can be a feature of the illness. This is brought about by frustration and a feeling of helplessness, of being trapped in some sort of nature warp.

My point is not to suggest that CBIT could not be helpful for Ruth Oliver and others with tic disorders. Rather, I want to point out that she is already experiencing an excessive amount of self-directed consciousness. Admittedly, it is not an enabling consciousness: it does not serve her in the sense that it restores her confidence in her own ability to engage with the world. It does not reinstate her freedom in action – a promise that CBIT may legitimately hold (via the ‘detour’ of a targeted, body-­ focussed learning process). Drawing on Ben Trubody’s (2014) phenomenological analysis of living with Tourette’s, we can describe the kind of self-awareness Ruth is experiencing as an “excessive present-at-hand” mode of being in the world.

4.3.2 Losing Autopilot: Modes of Being in the World Trubody uses Heidegger’s distinction between two relational modes of being, namely the “present-at-hand” (PaH) and the “ready-to-hand” (RtH) (270). “When we are RtH with the world we do not think about it as a thing, we just use it” (273). In this mode, we are commonly not aware of ourselves (or only tacitly so) and experience what we earlier termed freedom in action  – that skilled, spontaneous and intuitive way of responding to the world without any interfering self-consciousness or alienation from our environment. Employing a metaphor of sight and seeing, Trubody describes the ready-to-hand (RtH) mode of relating to the world as one where we “live our lives unaware… to the point that our being becomes invisible” to us (270). In contrast, the present-at-hand (PaH) mode is characterised by the “objective attitude” that makes ourselves and the world visible to us as epistemic objects. “It is within this relationship that the discussions of consciousness are normally framed, where we can describe objective or subjective states” (272). The PaH arises when we confront something unfamiliar in our world or ourselves, exposing both to our conscious attention: “It takes an abrupt or incongruous act, such as a faulty brake for us to become mindful again” (273). Tourette’s has often been

4.3  On the Therapeutic Use of Consciousness

83

described as a condition of disinhibition, so the reference to a ‘faulty break’ (e.g. in the neurological system) is fitting here.9 Tics and their resulting social interactions can be just the kind of abrupt and incongruous acts that disrupt the person’s immersive, ready-to-hand mode of being, pulling her back into the self-aware present-at-­ hand (PaH).10 Chris Mansley (2003b, 10) describes this contrast between RtH and PaH with his own pair of metaphors: You could view it as though ‘normal’ people are on automatic pilot. Every day they act naturally without thinking about their movements, whereas the more severe Tourette’s sufferer, with motor tics, has to think about every movement, as though on manual pilot.

Mansley’s “manual pilot” resembles Trubody’s “excessive PaH” suffered by people with Tourette’s, and possibly other psychopathologies. This (self-)conscious state is reinforced by a complex array of experiences: A ‘tic’ may not only interrupt whatever one is doing, but it may also bring unwanted attention. A ‘tic’ may be interpreted as an act of aggression or intoxication. Even if the ‘tic’ draws no attention, because one is aware of the potential for embarrassment one is still self-reflecting on how they [the tics] are. All of this, from the inward monitoring, to the intrusion on one’s life, to the apparent or real attention the ‘tic’ may elicit from others, is ‘excessive present-at-hand’. The more disruptive TS is for that person the more it reveals the world, where people may intentionally cross the street or avoid eye-contact, making the ‘Touretter’ socially invisible. This in turn raises issues with the individual about how they wish to be perceived and the level of control they possess in self-determination (Trubody 2014, 276).

Trubody’s use of the notion of visibility is complex and designates both desirable and problematic experiences. In the RtH mode (Mansley’s autopilot), our being becomes invisible to us because we need not consciously attend to our doing in the world. This type of invisibility, Trubody and Mansley suggest, is desirable and commonly gets lost in Tourette Syndrome. But tic disorder symptoms ‘reveal the world’ to the ticcing person – that is, they make the world visible to the Touretter, because they disrupt the flow of the autopilot or RtH mode of being. This is the objective mode or PaH, which people with tics experience excessively. And yet, at the same time as the world and the person’s own existence within it become visible to the Touretter, she herself becomes invisible to her social world. But how does this

 Trubody seems to use the phrase literally, referencing the act of riding a bike as something we do habitually and without conscious attention. A bicycle with a ‘faulty brake’ would disrupt this habitual flow of riding. However, we can also interpret the faulty brake metaphorically, as a symbol of motor disinhibition in Tourette Syndrome. 10  Another related way of describing this absence of the RtH is through what Heidegger and Wheeler call the “un-ready-to-hand”, which occurs “when objects are conspicuous, unavailable, and our efforts to use them are frustrated” (Wheeler 2005; as quoted in Reynolds 2018). Tics often interfere with the routine use of objects by the ticcing person, making these ‘unavailable’ to her in a RtH mode of engaging with the world. An example would be a food-centred tic, where a person feels the urge to grab and squish certain foods (e.g., hot items, such as pies, which can lead to burns on the hands; or soft fruits, like blueberries or raspberries, which end up as a dripping mess). In these instances, certain foods become problematic and ‘unavailable’ to the ticcing person keen to avoid burns or messy kitchen benches. 9

84

4  Freedom in a Tourettic World

apparent social invisibility arise? I take Trubody to mean here that it arises from the very visibility of the tic disorder symptoms. It is only because the tics stand out as ‘faulty brakes’ – abrupt, unusual, and unexpected occurrences – in the world that they attract social attention; and by doing so, they obstruct the social visibility of the ticcing person as a person (to herself and others). Here, the ‘It’ vanquishes and reigns over the ‘I’.11 Eventually, this becoming invisible as a social self to oneself no longer relies on others actually crossing the street or avoiding eye contact: the mere potential to be seen while ticcing is enough to perpetuate the Touretter’s excessive present-at-hand mode (Trubody 2014, 274). Factors that reinforce this self-conscious mode may thus range from the individual’s awareness of herself as ‘someone who tics’, and of the potential to be stigmatised and feel embarrassed, to her awareness of any premonitory sensations, of attempts to suppress tics, of capitulations to the urges, and of the tics themselves (274). CBIT, as a behavioural intervention program, capitalises on – and even seeks to develop – some of these forms of self-consciousness, particularly the awareness of any premonitory sensations and behaviours, and of the tics too (Woods et  al. 2008, 39–40). It thus requires individuals to adopt the ‘objective mode’ of relating to themselves, thereby reinforcing PaH. To my knowledge, Trubody is the first to note the irony of this approach: “Classically we may want to treat the ‘cause’ of the ‘tic’, and thus re-enforce the PaH aspect, i.e., the tic stands distinct from the individual (i.e., deficits in the basal ganglia, limbic system, and cerebral cortex), yet the ‘tic’ is symptomatic (in the phenomenological sense) of the PaH” (2014, 274; emphasis added). Put differently, attempts to control the process that leads to ticcing actually strengthen the individual’s present-at-hand relationship with the tic. Bliss remarked that the inward vigilance required to control tics in this manner is accompanied by a state of divided attention (Bliss et al. 1980, as quoted in Trubody 2014, 275), a point emphasised by Buckser (2008, 177) too. And yet what people with TS and tic disorders most lack (and likely desire) is the mode of being in which any such self-consciousness disappears: the autopilot, which allows them to “act naturally without thinking about their movements” (Mansley 2003b, 10), or the ready-to-hand (RtH) which renders their tics invisible to themselves and restores freedom in action. Perhaps this is the kind of freedom Mansley says we usually “take for granted” (2003a, 7) but that is lost in TS? In the RtH, there is another kind of invisibility: tics disappear as tics (at least phenomenologically); there is no more experience of tics, “no urge, no inward attention, no awareness of situation” (Trubody 2014, 275), even if certain vocalisations or movements persist. The Touretter’s symptoms, then, become invisible to herself. Sometimes, as mentioned earlier, these symptoms cease objectively as well, as is often the case during immersive activities (what we called ‘Narrative Easing’ in Sect. 4.2.3). By getting “lost in some activity without interruption” (276), the excessive PaH is alleviated (272). Importantly, not all Touretters suffer from an excessive  This is a reversal of a sentence from Oliver Sack’s short story, ‘Witty ticcy Ray’, where he writes: “When the galvanised Touretter sings, plays or acts, he in turn is completely liberated from his Tourette’s. Here the ‘I’ vanquishes and reigns over the ‘It’” (2015, 102). 11

4.3  On the Therapeutic Use of Consciousness

85

PaH or regard their condition as a condition. In those cases, “the TS is not PaH as an affliction, but is instead RtH as part of their lives (277): The in-themselves-­ meaningless symptoms are integrated into, and aligned with, the person’s broader intentions and purposes – for example, by contributing to other meaningful activities, projects and interactions with the world (see Scenario 3 above). When this happens, the symptoms may well disappear from sight and are no longer recognisable as ‘faulty brakes’ in the story of the person’s life. This type of extinguishing or disappearing of symptoms – through narrative integration, not motor control  – is radically different from the behavioural treatment approaches that dominate current clinical work with tic disorder patients. It raises the question whether an alternative treatment approach could target the RtH mode directly, without the paradoxical detour through the PaH. Trubody does not spell out how this could be done, but the role of immersive meaningful activities seems key to his fledgling idea of therapeutic innovation. In contrast to CBIT, which we described as a bottom-up approach to managing symptoms (and, possibly, to increasing freedom in action), we could call the idea of narrative integration a ‘top-­ down’ approach. It encourages – perhaps by building and strengthening – the person’s immersion in skilled habits which directly relate to and embody her distal intentions, thus actualising that which she cares about. This approach would not be symptom-centred and would not operate through conscious awareness of tics and their preceding sensory phenomena – a fact which could help us mitigate the risks associated with strategies that rely on conscious motor (and self-)control. As De Haan et al. (2017) have illustrated powerfully for OCD, too much conscious control can entrap and further separate an individual from her world, and this experience resonates with that of many who struggle with Tourette’s (Mansley 2003a, b; Oliver 2003; Bliss et al. 1980; Trubody 2014). It is thus warranted to ask whether directing more conscious attention to tics – required in CBIT – could also reinforce rather than free the individual from their reliance on conscious motor control as a preferred coping strategy. Particularly in individuals with TS and obsessive-compulsive behaviours or co-occurring OCD, might such a treatment approach worsen (or otherwise interact with) obsessive-compulsive symptoms, irrespective of any treatment success achieved with regard to tics? Whatever the answer to this question, we must avoid creating the impression that ‘bottom-up’ motor control of tics is the only route to improved quality of life or to greater freedom in action. Since it will not always be possible for people with tic disorders to use CBIT (or pharmacotherapy, for that matter) to effectively manage their symptoms, behavioural (or pharmacological) tic reduction should not be cast as the be-all and end-all of available treatments. We need to explore alternative ‘top-­ down’ approaches to managing tics  – and ultimately, to increasing freedom in action – which could, for example, intervene directly in skilled habits that reflect distal intentions and meaningful life projects. These ideas expand on the therapeutic potential inherent in Scenarios 3 and 4 (‘Narrative Integration’ and ‘Narrative Easing’; see Sect. 4.2.3), in which intentional actions are said to integrate or interfere with the expression of tics. We can now distinguish between bottom-up and top-down ways of delivering on this potential. As we have seen, behavioural

86

4  Freedom in a Tourettic World

approaches like CBIT involve an explicit bottom-up focus on motor control (tic reduction being the aim), and this reduction in tics serves as the intervention’s very measure of success. In top-down approaches, on the other hand, tics may – but need not – be reduced or eliminated as a treatment effect. That is, tics may be utilised for, or integrated into, other actions and experiences, rather than being objectively eliminated behaviourally. This in turn may transform how (and whether) tics are experienced by the individual (recall that tics are not experienced as tics in the RtH mode of being). Strictly speaking, then, Scenarios 3 and 4 do not require a commitment to the one-choice model of volition introduced in Chap. 3; they permit various approaches to dealing with tics and entail no bias toward bottom-up motor control and symptom reduction as the primary pathway to feeling free. We can expand our wording of Scenario 4 (‘Narrative Easing’) to include an explicit reference to first-person experience: Intentional actions can affect the expression and the experience of tics. This wording is preferable to our earlier wording for two reasons. First, it is better to say that other intentional actions ‘affect’ rather than ‘interfere with’ tics, since the former does not imply a reduction of symptoms. And second, even when the expression of tics does not change in response to an intervention (i.e., symptoms are objectively still observable, and may remain stable), the subject’s experience of her tics might change. The same holds true for Scenario 3 (‘Narrative Integration’), which we can expand to read: Tics become, or are experienced as, meaningful aspects of other intentional actions. Adding this subjective experiential component to both scenarios is important, since the notion of freedom we have proposed here is phenomenological in nature (i.e., we hypothesise that it reflects subjects’ first-­ person experiences rather than any objective observational data we might collect about them). To conclude, we can note that the difference between bottom-up and top-down approaches to freedom is not that one calls consciousness to aide and the other doesn’t. Both rely on the remedial effect of consciousness in its serving role. Their difference rather boils down to: (a) The intentional level at which we intervene (motor, immediate, or distal intentions); (b) the direction of consciousness (toward or away from symptoms); and (c) the intervention’s measure of success (observational or phenomenological). In the bottom-up approach associated with the one-choice model of volition, we call consciousness to the aide of skilled habit formation (e.g., in CBIT) to create intentional actions (competing responses) that directly interfere with the expression of tics at the level of motor and immediate intentions. In the top-down approach associated with the any-choice model of volition, on the other hand, we can intervene in two different ways: we either direct consciousness away from symptoms, as in Scenarios 3 and 4 outlined earlier. Or we direct consciousness at individuals’ higher-­ order mental states that relate to their condition  – for example, the attitudes and beliefs they hold about their symptoms. We will now look at two examples from the tic disorder literature that explore this latter, top-down approach to therapeutic intervention.

4.4  Acceptance and Reappraisal

87

4.4 Acceptance and Reappraisal 4.4.1 Can Distal Intentions Alter Tic Expression? Many philosophers challenge the idea that mental states can causally affect physical properties, and this contentious issue intimately shapes their theories of volition and free will. The issue is also relevant to our discussion of therapeutic interventions. For if we stipulate that someone’s thoughts, attitudes, and beliefs can alter the expression of their tic disorder symptoms (as some studies in the literature suggest), then it looks as if we are claiming that top-down causation is possible. Some libertarian philosophers reject this view, arguing instead for a range on non-causal theories of free agency (e.g., Ginet 1990; McCann 1998; Goetz 2008; see McKenna and Pereboom 2016, 255). Others insist that agent-causation is defendable, but that we should not seek to reconcile it “with our best physical theories” (McKenna and Pereboom 2016, 259). When causality is narrowly construed “on the traditional billiard ball model of determined mechanisms” (Gallagher 2017, 146), the idea that mental events can cause physical events becomes more difficult to defend. Haggard, for example, writes that consciousness “cannot cause brain activity, nor can it cause actions” (2011, 18; as quoted in Glannon 2017, 11). Yet others disagree. Even if our conscious mental states or events do not initiate our actions, this “does not mean that they have no causal role in our performing them” (Glannon 2017, 9). Inversely, the fact that an action is unconsciously initiated by a neural event does not mean that this neural event can explain everything there is to explain about the temporally extended process that leads “from the formation of an intention to act to its execution in action” (9). (We will return to the important distinction between action initiation and maintenance in Chap. 7, where I will counter the view that tics are merely reflex-like behaviours.) Drawing on Mele’s (2009) distinction between proximal and distal intentions – which resemble what Gallagher (2017) calls intentions-in-action and distal intentions, and what Pacherie and Haggard’s (2010) term immediate and prospective intentions – Glannon insists that long-range planning and decision-making are key to explaining how certain actions come about. “Even if neural events initiate particular actions, conscious distal intentions may influence neural events and their causal role in these actions” (2017, 10; see also Bayne 2011). Evidence for a causal interplay between different levels of intentions – and in particular, for the role of distal intentions in the formation and execution of intentions-in-action and motor intentions – can be found in a number of studies ranging from the well-known placebo effect in medicine (where conscious expectation impacts bodily response; see Benedetti 2014) and the impact of cognitive behavioural therapy (CBT) on the brain (e.g. by rewiring circuits in cortical-limbic pathways in depressed patients; see Goldapple et  al. 2004), to the promising results of neurofeedback in modulating brain activity and symptoms in a range of disorders (Glannon 2017, 11–12). The tic disorder literature also features research on the interplay between mental states and the way in which symptoms are expressed and experienced. Steinberg

88

4  Freedom in a Tourettic World

et  al. (2013), for example, examined “the interrelationships between tic-related beliefs, the premonitory urges preceding tic expression and tic severity” (463), showing that “negative beliefs about tic suppression are associated with more subjective impairment from tics and with depression” (465). This study established correlations but did not attempt to test a top-down intervention aimed at changing beliefs in order to change symptom expression and experience (although such an intervention could be developed and tested in future research). Similarly, Hagstrøm et  al. (2020) recently studied the effect of cognitive reappraisal as a strategy for regulating emotions in children with TS, ADHD, TS + ADHD, and controls. They found that the “use of cognitive reappraisal reduced negative affect across all participants”, concluding that it appears to be a “beneficial strategy for children regardless of diagnostic status” (Hagstrøm et al. 2020, 1). Given that emotional regulation is an important capacity when engaging in social environments, we can hypothesise that intervening on this capacity in children and youths with tic disorders (i.e., instructing them in how to cognitively reappraise negative affect) would have positive flow-on effects on their disorder-specific symptoms and experiences. Again, future research could develop and test such an intervention. The only research that actually intervened on a cognitive state and tested how doing so would affect the experience and expression of symptoms in young people with tic disorders is Gev et al.’s (2016) study on acceptance of premonitory urges and tics. Given the debated role of the urge-relief cycle in reinforcing tics (see Specht et al. 2014), this study examines the effect of an acceptance-based approach on premonitory urges in 45 participants aged 8–17 years with Tourette Syndrome (78). Three experimental conditions, each lasting 2 minutes, were compared: in the first one (‘free-to-tic’ or baseline), participants were told that they could tic freely during the measured time period, but did not have to. They were instructed to record all urges on a tablet, and to rate the intensity of each urge on a scale from 1 to 9 (with 9 being the most intense). In the second condition (‘tic suppression’), participants were told to try as hard as possible to suppress their tics, while continuing to record all urges and their intensity for the full duration of the test interval (80). Lastly, in the third condition (‘urge acceptance’), participants were instructed not to struggle with their urges but simply to watch them in an observational manner, using guiding imagery provided by the researchers (while again recording PU frequency and intensity): Imagine that they [the urges] are soap bubbles coming out of your body…that the urge is leaking out of your body and turning into soap bubbles that march in front of your eyes like soldiers in a little parade. Do not argue with the urges, or avoid them, or make them go away. Just watch them as they turn to soap bubbles and join the other bubbles as they march by (Gev et al. 2016, 80).

The mental imagery is vivid but also raises questions left unexplored in the paper. Why choose the word ‘soldiers’ in a task designed to move away from any belligerent ‘fighting’ of tics, as acceptance is meant to do? And why ‘leaking’ if that term carries potentially unfavourable connotations in the bodily realm, risking to upset the imaginary scene with negative affect? Nor is it clear how soap bubbles could

4.4  Acceptance and Reappraisal

89

‘march’, airy and delicate as they are, and without any legs. There is a substantial literature on the use and design of imagery in hypnotherapy, cognitive behavioural therapy (CBT), and its integration in cognitive-behavioural hypnotherapy (CBH), which could be usefully employed to review and fine-tune the imagery used in Gev and colleagues’ experiment (e.g., Golden 2012; Elkins et  al. 2010; Boltin et  al. 2015). We will not delve into the matter here but simply note that the effectiveness of certain imagery can differ across individuals (see Elkins et al. 2010), and that this in turn can impact experimental and therapeutic outcomes. Returning to Gev and colleagues’ study design, we can note that participants’ self-reports of their PU and urge intensity across all three experimental conditions was supplemented by video-­ recordings aimed at objectively assessing tics. The results are striking, showing that participants not only ticced much less frequently during the tic suppression condition compared to baseline (as might be expected), but also during urge acceptance. Further, the subjective experience of premonitory urges changed most significantly during urge acceptance, where participants reported notably fewer, less intense, and less uncomfortable urges. This was not achieved during the free-to-tic and suppress-­ tic conditions (Gev et al. 2016, 81). A core motivation of the study was to establish the feasibility of a cognitive, top-­ down approach to treating tic disorders, and the initial findings are promising: Children who are taught to “view the aversive and ostensibly inevitable urges in a more mindful way” seem to experience fewer and less intense internal sensations (81). The teaching part of this process deserves some attention here; for while the experiment itself lasted only 2 minutes for each condition, there were, in fact, other preceding events that likely impacted the positive results achieved during ‘urge acceptance’. Firstly, in a psychoeducational stage prior to the experiments, participants were told that accepting unwanted private events can be more beneficial than attempting to control them – i.e., they were “taught to shift from an effort to decrease or suppress PUs to a willingness to experience them” (79). Secondly, the urge acceptance experiment was also preceded by a relaxation exercise, where participants were instructed in a relaxation technique that utilises diaphragmatic breathing (79). Strictly speaking, then, at least three factors contributed to the ‘success’ of the urge-acceptance condition: (a) Positive priming about the value of acceptance (psychoeducation stage); (b) instruction to relax; and (c) instruction to accept urges during 2-min experiment using mental imagery. The relaxation exercise (which appears to have only occurred prior to the urge-­ acceptance condition, and not prior to the free-to-tic and tic-suppression conditions) is a complicating factor, since it means we cannot directly compare all three conditions with each other. It is possible that the results would have looked different had the relaxation exercise not occurred, or had it occurred prior to all three conditions. Further research would be required to determine which factors (a, b, or c) were most impactful in this experimental design. Further, as the authors themselves caution, “the short duration of the experimental conditions makes it difficult to rule out a transient effect for each condition” (Gev et  al. 2016, 82). The short two-minute

90

4  Freedom in a Tourettic World

intervals were chosen because prior data indicated that children struggle to focus on internal sensations for longer periods (79). The experiment thus highlights conscious processes at a reasonably small timescale, involving motor and immediate intentions, as well as short-range distal intentions. Priming via a distal intention occurred in all conditions in so far as the experiment occurred under the premise of a certain behavioural response (free-to-tic, tic-suppression, or urge-acceptance). But in the case of urge acceptance, more emphasis was placed on forming a positive expectation regarding its efficacy: “The children were […] shown the two-scale metaphor of Hayes et al. […] which demonstrates the benefits of accepting unwanted private events over attempts to control them” (79; see Hayes et al. 1999). This means tic-suppression was negatively valenced as a less beneficial response to PU, while no affective valence seems to have been attributed to the free-to-tic condition prior to the experiment. We do not know whether and how this psychoeducational priming may have shaped participants’ symptom expression and experience during the three experimental conditions. But it is conceivable that receiving valenced information about two of the three conditions prior to the experiment would have led participants to form implicit expectations about how they might act and feel under each. Put differently, we do not know whether the study proved the power of an acceptance-­based approach specifically, or of positive priming and expectation-­ setting commonly seen in placebo effects more generally. In either case, an “intentional cascade” (Pacherie 2008, 188) may be at play, where distal intentions formed during the psychoeducation stage (e.g., ‘I will give this acceptance-based approach a shot’, ‘I will imagine the urges as soap bubbles passing by’, ‘I will feel better when I accept my urges’) generate intentions-in-action and related motor intentions during the 2-min urge-acceptance condition. We could argue that the guiding soap-­ bubble imagery offered by the researchers serves to provide the “episodic detail” (Pacherie and Haggard 2010, 19) required to translate the abstract goal-state of urge acceptance “into a concrete episode of instrumental action directed toward that goal” (18). Pacherie and Haggard point out that such episodic detail can be generated at various points in time, before or during an action (19). In Gev and colleagues’ study, the guiding soap-bubble imagery equipped participants with a conscious mental image of how they will respond to any urges arising during the acceptance condition, thus helping with advance action planning. The finding that cognitive change can alter how individuals express and experience their symptoms is exciting, no matter whether this change relates to a specific attitude (e.g., willingness to experience the urge to tic) or to a general positive expectation that symptoms will improve ‘if x’ (where x need not be an acceptance-based response to PU). What speaks in favour of acceptance as specifically efficacious is the change in affective valence brought about by this approach.

4.4  Acceptance and Reappraisal

91

4.4.2 Affective Valence and Agency Other research also suggests that accepting unpleasant experiences can reduce their aversive impact and associated discomfort (e.g. Hayes et  al. 1999; Marcks and Woods 2005; as quoted in Gev et al. 2016, 78). Further, affective valence has been shown to be tightly linked to perceived agency, a concept we will explore in more detail in Chap. 5. Chang et al. (2017) showed that “the more positive or the less negative a person’s affect is, the more agency the person will see in herself […], and the more agency others will attribute to her” (304). This valence–agency link may also be at play in Gev et al.’s (2016) study. By learning to accept rather than fight or resist their premonitory urges, participants seem to reduce negative affect associated with these PU. Whether or not the resulting reduction in discomfort experienced by participants correlates with an increase in their perceived agency is not clear, since the study did not test for this; it would be interesting to know. The question is relevant for our discussion of volition and freedom, and for their complex relationship with the notion of control – which, as we saw, can both serve and hinder freedom in action. Reflecting on the findings from their study, Gev et al. (2016) wonder whether mindfulness techniques and acceptance-based approaches could put subjects at greater risk of losing their sense of control: “[P]atients are instructed to give up their attempts to control and eliminate the PU by ticcing, which may miss the benefits of feeling in control” (Gev et  al. 2016, 82). Here, control is positively valenced as agentic, but we saw earlier that it can be experienced in the opposite way, and that we may sometimes need to “lose control” in order to feel free (De Haan et al. 2017). Also, we should note that Gev and colleagues’ instruction to participants is only to desist from motor control as a means to responding to premonitory urges (i.e., via tics) – and, perhaps implicitly, to desist from attributing negative affect to the PU. If the research on affective valence and agency is right, then mindfulness techniques and acceptance-based approaches should not lead to a perceived loss but rather an increased sense of control in children dealing with PU. While bottom-up motor control is relinquished, a cognitive top-down response takes its place. Ironically, then, not wanting to control or fight the urges behaviourally (via motor intentions) may indeed give individuals a greater sense of control over them – rather than making them feel “passively […] subjected to unpleasant stimuli” (Gev et al. 2016, 82). Further research should explore these hypotheses toward a deeper understanding of the complex interrelationships between the scientific construct of volition, the phenomenology of freedom in action, and the use of various intentional states as strategies to control tic disorder symptoms. Questions worth exploring might include, for example, whether CBIT also impacts the affective valence of PU (as we just hypothesised acceptance-based approaches do), and how this in turn impacts sense of agency and perceived freedom in action. Also, can we learn more about the advantages and disadvantages of therapeutic interventions that employ bottom-up motor control (e.g., CBIT and habit reversal therapy) or top-down cognitive control (e.g. acceptance-based approaches) as strategies to manage tic disorder

92

4  Freedom in a Tourettic World

symptoms? Are there scenarios when either approach may be more or less appropriate than the other? While we have good data showing the sustainability of CBIT longer-term (suggesting that competing behavioural responses, once learned, can become skilled habits that no longer require reflective attention), we do not yet know whether acceptance as a cognitive response to PU can be ‘automated’ too, or whether it always requires conscious, momentary attention. Future studies testing the viability of acceptance-based approaches in tic disorders across real-life therapeutic settings should help answer this question (see Gev et al. 2016, 82). Further, we should ask whether interventions can be thought of that do not require patients to develop symptom-specific skilled habits, but that utilise and strengthen existing skills and practical know-how directed at, and central to, individuals’ positively valenced projects and life goals. Notably, neither CBIT nor the acceptance-based approach trialled by Gev et  al. (2016) take such a route, since both rely on a conscious ‘attending-­to-symptoms’ (at least in the initial learning phase). Just as CBIT requires individuals to adopt the ‘objective mode’ of relating to themselves, acceptance as a conscious strategy also reinforces the present-at-hand (PaH) which Trubody (2014) wishes ticcers could leave behind more often, and which Bliss et al. (1980) notes leads to a state of divided attention. In both approaches (CBIT and acceptance), participants must learn to consciously attend to, and then intervene on, their symptoms: their attention is directed specifically at the sensory phenomena and urges which precede or accompany tics (see Gev et  al. 2016, 79). Therefore, both approaches rely on consciousness in its serving, facilitative and intermediary role as a ‘pivot point’ for reinstating or increasing freedom in action. The only comment in the literature that comes close to sketching an alternative approach akin to Trubody’s focus on the RtH mode and immersive activities – which aligns with what I called ‘narrative integration’ earlier – can be found in O’Connor et al. (2017), who also promote acceptance over resistance but then move explicitly beyond symptoms. In their eyes, tics and habits originate in “tension built up as a result of the way action is planned and executed” (1). Given this broader context of action and action planning, they suggest that the tic or habit, which often arises locally, should not be the sole focus. Rather, they recommend “developing a flow of action and moving past the tic or habit toward goals, and heading smoothly and effortlessly toward goal-directed planning activity” (1). Noting the contextual nature of tics and habits, they acknowledge that symptom expression varies based on “the type of goal being pursued and to what extent the person is engaged or not”, pointing also to the symptom-extinguishing power of immersive activities (58). Further, they assert that “situations and activities where the tic or habit is less likely to occur or absent are important in realising how habits vary but can also be a revelation, as well as revealing strengths” (58).12  This ties in well with our observation in Chap. 2 that research into the temporal aspects of tic disorders is overwhelmingly focused on measuring time in relation to presenting symptoms, rather than studying those intervals and time periods in which symptoms are absent in a person’s life, and attempting to learn from these. 12

References

93

And yet, despite these promising nods to a strength-based, non-symptom-focused approach to managing tic disorders that utilises the flow of action generated by tic-­ unrelated activities, O’Connor and colleagues do not develop these nascent ideas further. Instead, their handbook focuses on therapeutic interventions aimed at increasing patients’ awareness of the various psychophysiological processes that occur before and during the tic or habit, from muscular tensions in specific body-­ parts to maladaptive thoughts and beliefs (58). The tendency is clear: Current behavioural and psychotherapeutic approaches to managing tic disorders, whether they attempt to reduce symptom expression (and improve wellbeing) via bottom-up or top-down processes, invariably direct conscious attention at the genesis and experience of symptoms, and anchor ‘healing’ in the development of new symptom-­ oriented skills. In doing so, tic disorder therapies presuppose (and arguably reinforce) a normative, deficit-model of disease that reifies difference as biopsychosocial dysfunction (see Carel 2018; Glackin 2019). Interestingly, current therapies do not explore or address the first-person experience of freedom or volition, although they seem to wish to enhance this experience (at least indirectly) by means of the interventions outlined here. It is thus time to take a closer look at what, if anything, the tic disorder literature can tell us about how subjects with chronic tics or Tourette Syndrome experience their symptoms, as well as their freely willed actions more broadly construed.

References Albin, Roger L. 2018. Tourette syndrome: A disorder of the social decision-making network. Brain 141: 332–347. Arendt, Hannah. 2006 [1954]. What is freedom? In Between past and future, 142–169. New York: Penguin Classic. Bayne, Tim. 2011. Libet and the case for free will scepticism. In Free will and modern science, Richard Swinburne, 25–46. Oxford University Press. Benedetti, Fabrizio. 2014 [2009 first edition]. Placebo effects: Understanding the mechanisms in health and disease. Oxford: Oxford University Press. Beste, Christian, and Alexander Muenchau. 2018. Tics and Tourette syndrome  — Surplus of actions rather than disorder? Movement Disorders 33 (2): 238–242. Bliss, Joseph, Donald J. Cohen, and Daniel X. Freedman. 1980. Sensory experiences of Gilles de la Tourette syndrome. Archives of General Psychiatry 37: 1343–1347. Blount, Tabatha H., Jeslina J. Raj, and Alan L. Peterson. 2018. Intensive outpatient comprehensive behavioral intervention for tics: A clinical replication series. Cognitive and Behavioral Practice 25 (1): 156–167. Bohlhalter, Stephan, Goldfine Andrew, S. Matteson, Gaëtan Garraux, Takashi Hanakawa, Kenji Kansaku, Rachel Wurzman, and Mark Hallett. 2006. Neural correlates of tic generation in Tourette syndrome: An event-related functional MRI study. Brain 129: 2029–2037. Boltin, Doron, Nadav Sahar, Efi Gil, Shoshana Aizic, Keren Hod, Rachel Levi-Drummer, Yaron Niv, and Ram Dickman. 2015. Gut-directed guided affective imagery as an adjunct to dietary modification in irritable bowel syndrome. Journal of Health Psychology 20 (6): 712–720. Brandt, Valerie Cathérine, Praveetha Patalay, Tobias Bäumer, Marcel Brass, and Alexander Münchau. 2016. Tics as a model of over-learned behavior-imitation and inhibition of facial tics. Movement Disorders: Official Journal of the Movement Disorder Society 31 (8): 1155–62.

94

4  Freedom in a Tourettic World

Breyer, Thiemo, and Christopher Gutland. 2016. Introduction. In Phenomenology of thinking: Philosophical investigations into the character of cognitive experiences, ed. Thiemo Breyer and Christopher Gutland, 1–24. New York: Routledge. Buckser, Andrew. 2008. Before your very eyes: Illness, agency, and the management of Tourette syndrome. Medical Anthropology Quarterly 2 (2): 167–192. Carel, Havi. 2018 [paperback; first edition 2016]. Phenomenology of illness. Oxford: Oxford University Press. Cavanna, Andrea E., Anette Schrag, David Morle, Michael Orth, Mary M. Robertson, Eileen Joyce, Hugo D. Critchley, and Caroline Selay. 2008. The Gilles de la Tourette Syndrome-Quality of Life Scale (GTS-QOL): Development and validation. Neurology 71 (18): 1410–1416. Cavanna, Andrea E., Kate David, Valentina Bandera, Cristiano Termine, Umberto Balottin, Anette Schrag, and Caroline Selai. 2013a. Health-related quality of life in Gilles de la Tourette syndrome: A decade of research. Behavioural Neurology 27 (1): 83–93. Cavanna, Andrea E., Chiara Luoni, Claudia Selvini, Rosanna Blangiardo, Clare M. Eddy, Paola R. Silvestri, Paola V. CalÌ, EManuela Gagliardi, Umberto Balottin, Francesco Cardona, Renata Rizzo, and Cristiano Termine. 2013b. Parent and self-report health-related quality of life measures in young patients with Tourette syndrome. Journal of Child Neurology 28: 1305–1308. Cavanna, Andrea E., Kevin J. Black, Mark Hallett, and Valerie Voon. 2017. Neurobiology of the premonitory urge in Tourette’s syndrome: Pathophysiology and treatment implications. Journal of Neuropsychiatry and Clinical Neuroscience 29 (2): 95–104. Chang, Yen-Ping, Sara B. Algoe, and Lung Hung Chen. 2017. Affective valence signals agency within and between individuals. Emotion 17 (2): 296–308. Cuenca, José, Cris Glazebrook, Tim Kendall, Tammy Hedderly, Isobel Heyman, Georgina Jackson, Tara Murphy, High Rickards, Mary Robertson, Jeremy Stern, Penny Trayner, and Chris Hollis. 2015. Perceptions of treatment for tics among young people with Tourette syndrome and their parents: A mixed methods study. BMC Psychiatry 15: 46. (12 pages). Curtis-Wendlandt, Lisa. 2019. Treating Tourette syndrome without drugs. Journal of Paediatrics and Child Health 55 (3): 367–368. Curtis-Wendlandt, Lisa, and Jack Reynolds. 2021. Why Tourette syndrome research needs philosophical phenomenology. Phenomenology and the Cognitive Sciences 20 (4): 573–600. Danto, Arthur C. 1985. Consciousness and motor control. The Behavioural and Brain Sciences 8 (4): 540–541. De Haan, Sanneke, Erik Rietveld, and Damiaan Denys. 2017. Being free by losing control: What obsessive compulsive disorder can tell us about free will. In Free will and the brain. Neuroscientific, philosophical, and legal perspectives, ed. Walter Glannon, 83–102. Cambridge, UK: Cambridge University Press. De Jaegher, Hanne, Barbara Pieper, Daniel Clénin, and Thomas Fuchs. 2017. Grasping intersubjectivity: An invitation to embody social interaction research. Phenomenology and the Cognitive Sciences 16 (3): 491–523. Deckersbach, Thilo, Scott Rauch, Ulrike Buhlmann, and Sabine Wilhelm. 2006. Habit reversal versus supportive psychotherapy in Tourette’s disorder: A randomized controlled trial and predictors of treatment response. Behaviour Research and Therapy 44 (8): 1079–1090. Dennett, Daniel. 2003. Freedom evolves. New York: Viking. Dreyfus, Hubert L. 2002. A phenomenology of skill acquisition as the basis for a Merleau-Pontian non-representationalist cognitive science. Unpublished paper. Available at http://www.irafs.org/ irafs_1/cd_irafs02/texts/dreyfus.pdf (also here: https://philpapers.org/archive/DREAPO.pdf). Eapen, Valsamma, Andrea E.  Cavanna, and Mary M.  Robertson. 2016a. Comorbidities, social impact, and quality of life in Tourette syndrome. Frontiers in Psychiatry 7 (97): 1–6. https:// doi.org/10.3389/fpsyt.2016.00097. Eapen, Valsamma, Corina Snedden, Rudi Črnčec, Anna Pick, and Perminder Sachdev. 2016b. Tourette syndrome, co-morbidities and quality of life. Australian and New Zealand Journal of Psychiatry 50 (1): 82–93.

References

95

Eddy, Clare M., Rizzo Renata, M.  Gulisano, A.  Agodi, M.  Barchitta, CalÌ Paula, Mary M. Robertson, and Andrea E. Cavanna. 2011. Quality of life in young people with Tourette syndrome: A controlled study. Journal of Neurology 258: 291–301. Elkins, Gary, Joel Marcus, Jennifer Bunn, Michelle Perfect, Lynn Palamara, Vered Stearns, and Jacqueline Dove. 2010. Preferences for hypnotic imagery for hot-flash reduction: A brief communication. International Journal of Clinical and Experimental Hypnosis 58 (3): 345–349. Erbilgin Gün, Seda, and Ayse Kilincaslan. 2019. Quality of life among children and adolescents with Tourette disorder and comorbid ADHD: A clinical controlled study. Journal of Attention Disorders 23 (8): 817–827. Fuchs, Thomas. 2011. The psychopathology of hyperreflexivity. The Journal of Speculative Philosophy 24 (3): 239–255. Gallagher, Shaun. 2012. Multiple aspects of agency. New Ideas in Psychology 30: 15–31. ———. 2017. Enactivist interventions. Oxford: Oxford University Press. ———. 2020. Action and interaction. Oxford: Oxford University Press. Gallagher, Shaun, and Anthony J.  Marcel. 1999. The self in contextualised action. Journal of Consciousness Studies 6 (4): 4–30. Ganos, Christos, Luisa Asmuss, Jens Bongert, Valerie Brandt, Alexander Münchau, and Patrick Haggard. 2015. Volitional action as perceptual detection: Predictors of conscious intention in adolescents with tic disorders. Cortex 64: 47–54. Gev, Ella, Tammy Pilowsky-Peleg, Sylvana Fennig, Noa Benaroya-Milshtein, Douglas W. Woods, John Piacentini, Alan Apter, and Tammar Steinberg. 2016. Acceptance of premonitory urges and tics. Journal of Obsessive-Compulsive and Related Disorders 10: 78–83. Gibson, James J. 1979. The ecological approach to visual perception. Boston: Houghton Mifflin Harcourt. Ginet, Carl. 1990. On action. Cambridge: Cambridge University Press. Glackin, Shane N. 2019. Grounded disease: Constructing the social from the biological in medicine. The Philosophical Quarterly 69 (275): 258–276. Glannon, Walter. 2017. Free will in light of neuroscience. In Free will and the brain. Neuroscientific, philosophical, and legal perspectives, ed. Walter Glannon, 3–23. Cambridge, UK: Cambridge University Press. Goetz, Stewart. 2008. Freedom, teleology, and evil. London: Continuum. Goldapple, Kimberly, Zindel Segal, Carol Garson, Mark Lau, Peter Bieling, Sidney Kennedy, and Helen Mayberg. 2004. Modulation of cortical-limbic pathways in major depression: Treatment-­ specific effects of cognitive behaviour therapy. Archives of General Psychiatry 61 (1): 34–41. Golden, William L. 2012. Cognitive hypnotherapy for anxiety disorders. American Journal of Clinical Hypnosis 54 (4): 263–274. Gottschalk, Louis A., and Carolyn Keatinge. 1993. Influence of patient caregivers on course of patient illness: “Expressed emotion” and alternative measures. Journal of Clinical Psychology 49 (6): 898–912. Haggard, Patrick. 2008. Human volition: Toward a neuroscience of will. Nature Reviews Neuroscience 9: 934–946. ———. 2011. Does brain science change our view of free will? In Free will and modern science, ed. Richard Swinburne, 7–24. Oxford University Press. Hagstrøm, Julie, Katrine Maigaard, Anne Katrine Pagsberg, Liselotte Skov, Kerstin Jessica Plessend, and Signe Vangkilde. 2020. Reappraisal is an effective emotion regulation strategy in children with Tourette syndrome and ADHD. Journal of Behavior Therapy and Experimental Psychiatry 68 (article 101541): 1–7. Hampson, Michelle, Fuyuze Tokoglu, Robert A. King, R. Todd Constable, and James F. Leckman. 2009. Brain areas co-activating with motor cortex during chronic motor tics and intentional movements. Biological Psychiatry 65: 594–599. Hayes, Steven C., Kirk D.  Strosahl, and Kelly G.  Wilson. 1999. Acceptance and commitment therapy: An experiential approach to behavior change. New York: Guilford Press. Heidegger, Martin. 1927/2001. Sein und Zeit. Tübingen: Niemeyer.

96

4  Freedom in a Tourettic World

Heras-Escribano, Manuel. 2019. The philosophy of affordances. Palgrave Macmillan. Himle, Michael B., Malinda Freitag, Michael Walther, Shana A. Franklin, Laura Ely, and Douglas W.  Woods. 2012. A randomized pilot trial comparing videoconference versus face-to-face delivery of behavior therapy for childhood tic disorders. Behaviour Research and Therapy 50: 565–570. Hoekstra, Pieter J., Mark-Peter Steenhuis, Pieter W. Troost, Jakob Korf, Cees G.M. Kallenberg, and Ruud B. Minderaa. 2004. Relative contribution of attention-deficit hyperactivity disorder, obsessive-compulsive disorder, and tic severity to social and behavioral problems in tic disorders. Journal of Developmental and Behavioral Pediatrics 25: 272–279. Hollis, Chris, Mary Pennant, José Cuenca, Cris Glazebrook, Tim Kendall, Craig Whittington, Sarah Stockton, Linnéa Larsson, Penny Bunton, Suzanne Dobson, Madeleine Groom, Tammy Hedderley, Isobel Heyman, Georgina M.  Jackson, Stephen Jackson, Tara Murphy, High Rickards, Mary Robertson, and Jeremy Stern. 2016. Clinical effectiveness and patient perspectives of different treatment strategies for tics in children and adolescents with Tourette syndrome: A systematic review and qualitative analysis. Health Technology Assessment 20 (4): 1–450. vii–viii. Hooley, Jill M. 2007. Expressed emotion and relapse of psychopathology. Annual Review of Clinical Psychology 3: 329–352. Leckman, James F., Michael H.  Bloch, Lawrence Scahill, and Robert A.  King. 2006. Tourette syndrome: The self under siege. Journal of Child Neurology 21: 642–649. Lee, Hojun, Soyoung Park, Jongha Lee, and Moon-Soo Lee. 2019. Relationships among tic symptoms, expressed emotions, and quality of life in tic disorder patients. Journal of Child and Family Studies 29: 2051–2057. Libet, Benjamin. 1985. Unconscious cerebral initiative and the role of conscious will in voluntary action. The Behavioural and Brain Sciences 8: 529–566. Maisey, Peter. 2003. Light at the end of the tunnel. In Making allowances: Personal accounts of Tourette syndrome, ed. Chris Mansley, 91–99. Liverpool: The Bluecoat Press. Mansley, Chris. 2003a. Preface. In Making allowances: Personal accounts of Tourette syndrome, ed. Chris Mansley, 7. Liverpool: The Bluecoat Press. ———. 2003b. “Life” for Tourettes. In Making allowances: Personal accounts of Tourette syndrome, ed. Chris Mansley, 8–34. Liverpool: The Bluecoat Press. Marcks, Brook A., and Douglas W.  Woods. 2005. A comparison of thought suppression to an acceptance-based technique in the management of personal intrusive thoughts: a controlled evaluation. Behavior Research and Therapy 43 (4): 433–445. McCann, Hugh. 1998. The works of agency. Ithaca: Cornell University Press. McGuire, Joseph F., John Piacentini, Erin A. Brennan, Adam B. Lewin, Tanya K. Murphy, Brent J. Small, and Eric A. Storch. 2014. A meta-analysis of behavior therapy for Tourette syndrome. Journal of Psychiatric Research 50: 106–112. McKenna, Michael, and Derk Pereboom. 2016. Free will: A contemporary introduction. New York: Routledge. Mele, A. 2009. Effective intentions: The power of conscious will. New  York: Oxford University Press. Moretto, Giovanna, Petra Schwingenschuh, Petra Katschnig, Kailash P.  Bhatia, and Patrick Haggard. 2011. Delayed experience of volition in Gilles de la Tourette syndrome. Journal of Neurology, Neurosurgery, and Psychiatry 82: 1324–1327. Nussey, Claire, Nancy Pistrang, and Tara Murphy. 2014. Does it help to talk about tics? An evaluation of a classroom presentation about Tourette syndrome. Child and Adolescent Mental Health 19 (1): 31–38. O’Connor, Kieron, Marc Lavoie, and Benjamin Schoendorff. 2017. Managing tic and habit disorders: A cognitive psychophysiological treatment approach with acceptance strategies. Chichester, West Sussex: Wiley Blackwell. Oliver, Ruth. 2003. A lifetime of bewilderment. In Making allowances: Personal accounts of Tourette syndrome, ed. Chris Mansley, 127–147. Liverpool: The Bluecoat Press.

References

97

Pacherie, Elisabeth. 2008. The phenomenology of action: A conceptual framework. Cognition 107 (1): 179–217. Pacherie, Elisabeth, and Patrick Haggard. 2010. What are intentions? In Conscious will and responsibility: A tribute to Benjamin Libet, ed. Walter Sinnott-Armstrong and Lynn Nadel, 70–84. New York: Oxford University Press. Packer, Leslie E. 2005. Tic-related school problems: Impact on functioning, accommodations, and interventions. Behavior Modification 29 (9): 876–899. Peris, Tara S., and David J. Miklowitz. 2015. Parental expressed emotion and youth psychopathology: New directions for an old construct. Child Psychiatry and Human Development 46 (6): 863–873. Petruo, Vanessa, Benjamin Bodmer, Annet Bluschke, Alexander Münchau, Veit Roessner, and Christian Beste. 2020. Comprehensive Behavioural intervention for tics reduces perception-­ action binding during inhibitory control in Gilles de la Tourette syndrome. Scientific Reports (Nature Publisher Group) 10 (1): 1174. 1–8. Piacentini, John, Douglas W.  Woods, Lawrence Scahill, Sabine Wilhelm, Alan L.  Peterson, Susanna Chang, Golda S.  Ginsburg, Thilo Deckersbach, James Dziura, Sue Levi-Pearl, and John T.  Walkup. 2010. Behavior therapy for children with Tourette disorder: A randomized controlled trial. JAMA: The Journal of the American Medical Association 303 (19): 1929–1937. Pringsheim, Tamara, Michael S.  Okun, Kirsten Müller-Vahl, Davide Martino, Joseph Jankovic, Andrea E. Cavanna, Douglas W. Woods, Michael Robinson, Elizabeth Jarvie, Veit Roessner, Maryam Oskoui, Yolanda Holler-Managan, and John Piacentini. 2019. Practice guideline recommendations summary: Treatment of tics in people with Tourette syndrome and chronic tic disorders. Neurology 92 (19): 896–906. Reynolds, Jack. 2018. Phenomenology, naturalism and science. A hybrid and heretical proposal. New York: Routledge. Ricketts, Emily J., Amy R. Goetz, Matthew R. Capriotti, Christopher C. Bauer, Natalie G. Brei, Michael B. Himle, Flint M. Espil, Ívar Snorrason, Dagong Ran, and Douglas W. Woods. 2016. A randomized waitlist-controlled pilot trial of voice over Internet protocol-delivered behavior therapy for youth with chronic tic disorders. Journal of Telemedicine & Telecare 22 (3): 153–162. Rietveld, Erik. 2008. Situated normativity: The normative aspect of embodied cognition in unreflective action. Mind 117 (468): 973–1001. Rivera-Navarro, Jesús, Esther Cubo, and Javier Almazán. 2014. The impact of Tourette’s syndrome in the school and the family: Perspectives from three stakeholder groups. International Journal for the Advancement of Counselling 36 (1): 96–113. Sacks, Oliver. 2015. The man who mistook his wife for a hat. London: Pan Macmillan. Searle, John. 2003. Rationality in action. Cambridge, MA: MIT Press. Smith, Heather, John R.E. Fox, and Penny Trayner. 2015. The lived experiences of individuals with Tourette syndrome or tic disorders: A meta-synthesis of qualitative studies. British Journal of Psychology 106 (4): 609–634. Specht, Matt W., Cassandra M. Nicotra, Laura M. Kelly, Douglas W. Woods, Emily J. Ricketts, Carisa Perry-Parrish, Elizabeth Reynolds, Jessica Hankinson, Marco A.  Grados, Rick S. Ostrander, and John T. Walkup. 2014. A comparison of urge intensity and the probability of tic completion during tic freely and tic suppression conditions. Behaviour Modification 38 (2): 297–318. Steinberg, Tamara, Adva Harush, Meirav Barnea, Rueven Dar, John Piacentini, Douglas Woods, Sharona Shmuel-Baruch, and Alan Apter. 2013. Tic-related cognition, sensory phenomena, and anxiety in children and adolescents with Tourette syndrome. Comprehensive Psychiatry 54: 462–466. Storch, Eric A., Lisa J. Merlo, Caleb Lack, Vanessa A. Milso, Gary R. Geffken, Wayne K. Goodman, and Tanya K. Murphy. 2007a. Quality of life in youth with Tourette syndrome and chronic tic disorder. Journal of Clinical Child and Adolescent Psychology 36 (2): 217–227.

98

4  Freedom in a Tourettic World

Storch, Eric A., Tanya K. Murphy, Rhea M. Chase, Mary Keeley, Wayne K. Goodman, Maurice Murray, and Gary R. Geffken. 2007b. Peer victimization in youth with Tourette’s syndrome and chronic tic disorder: Relations with tic severity and internalizing symptoms. Journal of Psychopathology and Behavioural Assessment 29: 211–219. Sukhodolsky, Denis G., Douglas W. Woods, John Piacentini, Sabine Wilhelm, Alan L. Peterson, Lily Katsovich, James Dziura, John T. Walkup, and Lawrence Scahill. 2017. Moderators and predictors of response to behavior therapy for tics in Tourette syndrome. Neurology 88 (11): 1029–1036. Trubody, Ben. 2014. “Ticced off”: An interpretative phenomenological analysis of the experience of Tourette’s syndrome. Existential Analysis 25 (2): 269–283. Varela, Franciso J., Evan Thompson, and Eleanor Rosch. 1991. The embodied mind: Cognitive science and human experience. Cambridge, MA: MIT Press. Varni, James W., Michael Seid, and Cheryl A. Rode. 1999. The PedsQL™: Measurement Model for the Pediatric Quality of Life Inventory. Medical Care 37 (2): 126–139. Verdellen, Cara W.J., Ger P.J. Keijsers, Danielle C. Cath, and Cees A.L. Hoogduin. 2004. Exposure with response prevention versus habit reversal in Tourettes’s syndrome: A controlled study. Behaviour Research and Therapy 42 (5): 501–511. Wadman, Ruth, Cris Glazebrook, Charlotte Beer, and Georgina M.  Jackson. 2016. Difficulties experienced by young people with Tourette syndrome in secondary school: A mixed methods description of self, parent and staff perspectives. BMC Psychiatry 16 (14): 1–11. Wang, Zhishun, Tiago V. Maia, Rachel Marsh, Tiziano Colibazzi, Andrew Gerber, and Bradley S.  Peterson. 2011. The neural circuits that generate tics in Tourette’s syndrome. American Journal of Psychiatry 168 (12): 1326–1337. Ward, Dave, David Silverman, and Mario Villalobos. 2017. Introduction: The varieties of Enactivism. Topoi 36: 365–375. Weingarden, Hilary, Lawrence Scahill, Susanne Hoeppner, Alan L. Peterson, Douglas W. Woods, John T.  Walkup, John Piacentini, and Sabine Wilhelm. 2018. Self-esteem in adults with Tourette syndrome and chronic tic disorders: The roles of tic severity, treatment, and comorbidity. Comprehensive Psychiatry 84: 95–100. Wheeler, Michael. 2005. Reconstructing the cognitive world. Cambridge, MA: MIT Press. Wile, Daryl, and Tamara Pringsheim. 2013. Behavior therapy for Tourette syndrome: A systematic review and meta-analysis. Current Treatment Options in Neurology 15 (4): 385–395. Wilensky, Amy. 1999. Passing for normal. Tourette’s, OCD and growing up crazy. New  York: Pocket Books, Simon & Schuster. Wilhelm, Sabine, Thilo Deckersbach, Barbara J. Coffey, Antje Bohne, Alan L. Peterson, and Baer Lee. 2003. Habit reversal versus supportive psychotherapy for Tourette’s disorder: A randomized controlled trial. American Journal of Psychiatry 160 (6): 1175–1177. Wilhelm, Sabine, Alan L. Peterson, John Piacentini, Douglas W. Woods, Thilo Deckersbach, Denis G. Sukhodolsky, Susanna Chang, Haibei Liu, James Dziura, John T. Walkup, and Lawrence Scahill. 2012. Randomized trial of behavior therapy for adults with Tourette syndrome. Archives of General Psychiatry 69 (8): 795–803. Woods, Douglas W., John Piacentini, Susanna Chang, Thilo Deckersbach, Golda Ginsburg, Alan Peterson, Lawrence D. Scahill, John T. Walkup, and Sabine Wilhelm. 2008. Managing Tourette syndrome: A behavioral intervention for children and adults. Therapist guide. New York, NY: Oxford University Press. Worbe, Yulia, Stephane Lehericy, and Andreas Hartmann. 2015. Neuroimaging of tic genesis: Present status and future perspectives. Movement Disorders 30 (9): 1179–1183. Yates, Rachel, Katie Edwards, John King, Olga Luzon, Michael Evangeli, Daniel Stark, Fiona McFarlane, Isobel Heyman, Basak Ince, Jana Kodric, and Tara Murphy. 2016. Habit reversal training and educational group treatments for children with Tourette syndrome: A preliminary randomised controlled trial. Behaviour Research and Therapy 80: 43–50.

Chapter 5

Agency and Ownership in Tic Disorders

Abstract  This chapter asks what we know about the first-personal experience of ticcing and everyday action in people with Tourette Syndrome (TS) and other primary tic disorders. It notes a phenomenological vacuum in existing research on volition, which has investigated aspects of anomalous voluntary action in people living with these conditions without providing a clear picture of how such action is experienced by these subjects. Drawing on discussions of the multiple aspects of ‘agency’ and ‘ownership’ in philosophical phenomenology and phenomenological psychiatry, I use examples of involuntary action and schizophrenic alienation offered in the literature to explore what kind of experiential dynamics, or variations in experience, we might expect to find in primary tic disorders like TS. These considerations are juxtaposed with the existing experimental studies on agency and ownership in adults with TS (none of which investigate the experience of ticcing or extended everyday actions), with an eye to integrating this work into a broader phenomenological framework or psychopathology of primary tic disorders. The chapter concludes with a systematic overview of how agency and ownership dynamics may be studied in tic disorders and beyond and offers guiding questions for future research and practice. Keywords  Agency · Ownership · Attribution · Sense · Tic disorder · Tourette Syndrome · Subjective experience · Schizophrenia · Alienation · Illusion · Action · Experience

5.1 What Experience, Please? 5.1.1 Volition-as-Experience and Volition-as-Ability In the preceding chapters of this book (Chaps. 3 and 4), we distinguished between ontological (‘what is’) and phenomenological (‘what it feels like’) questions about volition and freedom or free will. We have also noted that these concepts cannot easily be reconciled, and that each term is understood and defined differently across © Springer Nature Switzerland AG 2023 L. Curtis-Wendlandt, Chasing Tourette’s: Time, Freedom, and the Missing Self, Philosophy and Medicine 145, https://doi.org/10.1007/978-3-031-19104-6_5

99

100

5  Agency and Ownership in Tic Disorders

disciplines, authors, and in common speech. But what role does subjective experience play in these discussions? As we saw, phenomenological explorations of the first-person perspective can challenge preconceived concepts that populate our scientific and philosophical research. De Haan et al.s’ (2017) study of OCD sufferers (see Chap. 4) illustrates this point well, showing that conscious control and deliberation are not always the epitome of freedom that Western philosophy has, for so long, made them out to be. Their alternative phenomenological notion of freedom, inspired by Arendt’s idea of freedom in action, assigns consciousness an important but more (sub)servient role. In the literature on Tourette Syndrome and tic disorders, critical phenomenological investigations – into subjective experience per se, and particularly into the experience of acting freely – don’t currently exist (see Curtis-Wendlandt and Reynolds 2021).1 Some of the aforementioned papers that study volition in TS do ask subjects questions about their purported experience of volition, but they take access to such experience for granted and presuppose its content. In these studies, investigations of subjective experience have remained phenomenologically ‘thin’. Take Moretto et al.’s (2011) study, which compares the point in time when adult subjects with and without TS report a conscious intention to move (‘W judgements’) in a version of Libet’s classic experiment (see Chap. 3 for details). The reported experience is predefined with regard to both its existence and content  – i.e., the experience just is the conscious awareness of an ‘intention to move’, and it is expected to occur as part of the experiment. Further, the experience is timed using objective, chronological clock time (not ‘felt’ or experienced time; see Chap. 2). But subjects’ reports do not tell us much about the phenomenal qualities of their experience of volition or the intention to move. Put differently, the finding that W judgements occur at all (or that subjects are compliant with the request to report an intention to move), and that these judgements are delayed in adults with TS, provides no qualitative insights into this purported experience. Despite the authors’ intention to provide the first experimental study into “the experience of voluntary action in TS”, their research strictly speaking only establishes when this experience occurs, not what it is like. Further, it is far from clear whether and how a “delayed experience of intention to move” constitutes an “abnormal experience of voluntary action” (Moretto et al. 2011, 1324, 1326). This would require us to deem ‘intention to move’ as synonymous with ‘voluntary action’, and ‘abnormal’ as synonymous with ‘delayed’. But neither of those are straightforward equations; for one, an experience that is delayed in time (relative to controls) may otherwise be identical, in qualitative terms, to that of controls. In other words, there may be nothing about the experience as an experience that distinguishes it from its comparator occurring at a different time. If this is true, then the ‘abnormal’ aspect established in this study regards the timing of the experience, not the experience itself.  Here, it is important to differentiate between psychologically oriented studies into different aspects (the ‘what’) of subjective experience, and phenomenologically oriented work in philosophy that seeks to understand structural aspects (the ‘how’) of experience. Curtis-Wendlandt and Reynolds (2021) offer an in-depth discussion of these distinctions and why they are important in the context of contemporary tic disorder scholarship. 1

5.1  What Experience, Please?

101

This potentially holds even if we consider the impact of premonitory urges (PU) on that experience, which Ganos et al. (2015) discuss in their own version of Libet’s experiment conducted in youths with and without Tourette Syndrome. Like Moretto et  al. (2011), they set out to “measure the experiences associated with voluntary action” (Ganos et al. 2015, 49), where that ‘experience’ is the conscious awareness of the intention to move, and the ‘measure’ is its time of occurrence. Subjects were also asked to complete the PUTS (Premonitory Urge for Tics Scale; see Woods et  al. 2005), which includes six statements expressing sensory and mental phenomena that subjects might experience before they tic (e.g. “Right before I do a tic I feel like my insides are itchy”, “…I feel pressure inside my brain or body”, “…I feel ‘wound up’ or tense inside”, etc.), and four statements eliciting the frequency and effect of these sensations, as well as tic suppressibility (“These feelings happen for every tic I have”, “After I do the tic, the itchiness, energy, pressure… go away, at least for a while”, “I am able to stop my tics even if only for a short period of time”, etc.). All statements are ranked on a four-point scale from “not at all” to “very much”. For the purpose of our discussion here, we can note that the PUTS clearly assesses the absence or presence, as well as the intensity and frequency, of certain pre-defined aspects of experience that precede tics. It is not open-ended and does not invite subjects to share other aspects of experience which may not be captured by the given statements. By predefining the terms used to describe phenomenology, the scale risks missing other aspects of experience not written into, or elicited by, the instrument.2 These criticisms aside, and put simply, the PUTS does intend to elucidate broader trends in people’s subjective experience – ‘what it tends to feel like’ – before they tic.3 They are broader trends of experience because the scale does not probe for a single, specific experience, i.e. it does not ask ‘what did you experience before this one particular tic just now’? To use our terminology introduced in Chap. 2: The scale does not investigate experience at the token level of analysis, but at the occurrence or type level of tics. This raises further questions regarding how accurate retrospective judgements about experience can be, but we shall leave those aside here.4 Since the PUTS elicits data about subjective experience at the type and occurrence level of analysis, it is not clear whether subjects in Ganos et al.’s (2015) study  The descriptors used in the PUTS are based on qualitative accounts of sensory phenomena reported by people with TS and tic disorders in a number of early studies (e.g., Shapiro et al. 1988; Kurlan et al. 1989; Lang 1991; Cohen and Leckman 1992; Leckman et al. 1993). However, this evidence is fairly slim; approaches used to elicit such qualitative data have varied in their method, and have combined adult and child data (Woods et al. 2005, 397–398). McGuire and colleagues call for more “rigorous qualitative research on premonitory urge phenomena in youth and adults with TD […] to identify other possible dimensions of premonitory urges” (2016, 182). 3  We have argued elsewhere that a full phenomenological investigation into the subjective experiences associated with tic disorder symptoms should neither reduce these to the pre-tic interval nor limit them to purely sensory phenomena. A fuller picture of sensory and cognitive-affective experiences that precede, accompany and, indeed, follow tics is likely to emerge from such research (Curtis-Wendlandt and Reynolds 2021). 4  To minimise the problem that retrospective reports of experience distort the latter, a particular research method called “Descriptive Experience Sampling” (e.g. Hurlburt and Akhter 2006; 2

102

5  Agency and Ownership in Tic Disorders

had or did not have such experiences there and then, during the actual experiment. However, the data from the PUTS is correlated with the timing of another experience – namely, the experimentally required conscious awareness of an intention to move (i.e. to execute the requested keypress action). This is a specific experience token that occurs and is reported on live in the lab. Ganos and colleagues are thus comparing two rather different kinds of experience, which we shall label ‘E1’ and ‘E2’. E1 designates subjects’ pre-tic experiences of PU (with some qualitative data about what these experiences tend to be like), while E2 stands for the pre-keypress intention to move (timed by subjects, but with no qualitative data). Interestingly, as mentioned earlier (see Chap. 3), this study in youths with TS did not replicate Moretto et  al.’s (2011) finding of overall delayed W judgements in affected adults. But it did find an association between the strength of PU and the timing of W judgements: “patients with stronger premonitory urges prior to tics showed significantly later conscious intentions” (Ganos et al. 2015, 47). That is, E1 (PU experience) seems to affect the timing – but not necessarily the phenomenal quality – of E2 (conscious intention to move). Since E1 and E2 need not necessarily co-occur (neither in the lab nor in daily life), Ganos and colleagues must envision a generalised effect of the former on the latter. The cumulative, repeated experience of PU, they argue, increases “motor noise” in Tourette Syndrome, making it harder for individuals to discriminate perceptually between the experience of involuntary urges on the one hand, and that of voluntary pre-movement signals on the other hand (47). To avoid excessive sensitivity to motor noise, individuals with TS might have “a more conservative threshold for detecting volition” (48), which could in turn explain their temporally delayed perception of voluntary motor signals. In this view, volition is not so much a subjective experience in its own right (which we could explore phenomenologically), but a “perceptual ability” (51) to discriminate between “the different subjective experiences” that accompany voluntary and involuntary movement as two distinct kinds of action (48). At this point, the argument risks becoming circular: The concept of volition-as-perceptual-ability is invoked to explain volition-as-experience, which in turn is stipulated to correspond with volition-­as-action-type. Ganos et al. (2015) do not explore these conceptual interdependencies; their interest lies clearly with the explanatory potential of volition as a perceptual ability that is learned during development and challenged in Tourette Syndrome (51–52). Impaired perceptual learning, they suggest, is associated with impaired control of voluntary body movements (53) – although they note that the causal direction of this association remains unclear. But what does all of this tell us about volition-as-experience, which we set out to explore in this section? Not much, really. If there is ‘something that it is like’ to act voluntarily (and, by extension, if there is ‘something that it is like’ to act involuntarily), as both Moretto et  al. (2011) and Ganos et  al. (2015) imply, then neither study offers any insights into the qualitative feel of such experiences and their

Heavey et  al. 2010), uses real-time reflections on momentary experience to avoid retrospective misattributions of the quality of such experience.

5.1  What Experience, Please?

103

constitutive features. We are thus no closer to describing the phenomenology of volition from a first-person perspective, and we have no way to relate such phenomenological concepts as Trubody’s (2014) Heideggerian ready-to-hand (RtH), Arendt’s freedom in action (1954/2006), or De Haan et al.’s freedom as coherence between our concerns and our actions (2017; see Chap. 4), to the scientific studies outlined above. Further, we still don’t know much about the subjective experience of ticcing, and whether that experience belongs to the purported class of voluntary or involuntary actions  – the topic continuously debated in the literature. Perhaps surprisingly, and despite the literature’s professed interest in the volitional status of tics, the actual experiences studied in the experimental literature are not tics but other types of voluntary actions (simple keypress actions and the like). So what are we interested in finding out? Do we want to know whether tics and PU affect volition, or do we want to know whether volition is implicated in tics and PU?

5.1.2 Pablo’s Eye-Blinking Tic (Again) Returning to our notion of E1 (experience of PU) and E2 (conscious intention to move), we can reframe this question as one regarding their interrelationship. Let’s consider a specific tic token – for example, one of Pablo’s eye blinking tics (see Chap. 2). If we are interested in finding out more about the volitional status of this particular tic occurrence – his eye-blinking tics generally – or more specifically of a single concrete tic token – i.e., an instance where he blinks his eye – we could ask: Does Pablo have E1 (an urge experience) and also E2 (a conscious intention to blink) prior to this particular eye-blink tic token? That is, does he have two separate, co-occurring (or closely occurring), distinguishable experiences before ticcing (urge plus intention)? Or is there just one phenomenologically discernible (at least pre-reflectively conscious) experience – i.e. E1, E2, or something else? Could the answer to this differ across individuals with tics, and also across tic tokens and occurrences experienced by the same person? For example, might Pablo report E1 (experience of PU) for some but not all of his eye-blinking tic tokens; or PU for some but not all of his various other tic types and occurrences?5 For tic tokens without a discernible PU, would Pablo just have E2 (conscious intention to move), or possibly no conscious experience at all (or a different experience)? Inversely, could those who report PU possibly just have E1, without a separate second experience like E2? These questions lead us back to our earlier discussion regarding the intentional status of premonitory urges and tics (see Chap. 4, Sect. 4.1.2). As we noted, it  Evidence suggests that even people with tic disorders who report PU do not consistently experience them prior to each and every tic: “Tics involving the head, neck, shoulders, or the midline abdomen tend to be most frequently preceded by urges, whereas simple tics that are more brisk in nature, such as eye blinking and mouth movements, are less likely to be preceded by urges” (Cavanna et al. 2017). 5

104

5  Agency and Ownership in Tic Disorders

remains unclear whether the premonitory phenomena we call PU themselves qualify as intentions, or whether they might give rise to, or be accompanied by, a conscious intention to move. Applied phenomenological research  – e.g. via micro-­ phenomenological interviews6 – could help us shed light on whether these conceptual distinctions between intentions and urges (or between voluntary and involuntary actions) correspond with distinct subjective experiences. This is different from presupposing that such a correspondence exists. As we saw earlier (see Chap. 3, Sect. 3.1.1), not only researchers but also people with tic disorders disagree on the experiential qualities and the volitional status of tics: While some state that they experience their tics as voluntary, others describe them as involuntary, and others yet struggle to decide (e.g. Karp et  al. 1996, 104). Do these divergent views reflect genuine phenomenological differences in experience, or merely differences in how these terms are used and understood? It is difficult to know as very little exploratory research exists on this topic, and definitions (whether explicit or implied) vary considerably across accounts. We would not only need to ask how the experience of voluntary action compares to that of involuntary action from a first-­person perspective, but we would also need to check whether applying this conceptual distinction to tics and PU makes sense phenomenologically in the first place. We risk putting the horse before the cart if we simply assume that voluntary and involuntary movements and actions correspond to different subjective experiences, and that these experiences are best described by contrastive terms such as ‘voluntary’ and ‘involuntary’, whether in tic disorders or beyond. As Gallagher rightly points out in his discussion of the phenomenology of agency (2012, 29), conceptual distinctions do not always map neatly onto our everyday phenomenology of experience, which tends to be “more holistic, qualitative, and ambiguous” and “open to a description in terms of degree” (Gallagher 2012, 29). What we need is to go back to the “things themselves” and simply investigate experience – for example, the experience of ticcing in the moments prior, during, and after a tic (see Curtis-Wendlandt and Reynolds 2021) – to better understand what is going on experientially for the subject. A rare example of a study that seeks to explore the experience of ticcing is Lang’s (1991) work, although this research does put the proverbial horse before the cart by assuming the phenomenological relevance of the ‘voluntary–involuntary’ binary for subjects suffering from a range of movement disorders. Lang confidently outlines the either–or choices of this binary definition, as presented to the study participants (223, emphases added): Do you feel that the abnormal movements (and/or vocalizations) that you experience… are completely involuntary, as if the body part affected has a mind of its own which is beyond your control, OR are the movements (and/or vocalizations) voluntary, in the sense that you

 A range of interview methods have been proposed in the literature that draw on philosophical phenomenology (see Giorgi 2009; Eatough and Smith 2017; Høffding and Martiny 2016; Hurlburt and Akhter 2006; Olivares et al. 2015; Petitmengin 2006; Miyahara et al. 2020). For a discussion of the controversial ‘phenomenological’ status of Interpretative Phenomenological Analysis, see Smith (2018), van Manen (2017a, b, 2018, 2019), and Zahavi (2019a, b). For IPA’s impact on tic disorder scholarship, see Curtis-Wendlandt and Reynolds (2021). 6

5.1  What Experience, Please?

105

are aware of consciously performing them yourself but in response to an inner need or involuntary urge which forces you to carry them out?

To confirm comprehension, Lang followed up by asking “if the affected body part was making the movement or sound on its own or if the patient was actually causing the body part to move on purpose” (223; emphasis added). As we noted in Chap. 3, Lang’s definition of volition presupposes conscious awareness and motor control, and this is clearly expressed in the language used here. Participants could select among four possible responses (VOL, INVOL, BOTH, NOT SURE), which yielded the following results: “Forty-one of the 60 patients with various tic disorders responded that all their movements and vocalizations […] were performed voluntarily. Most had no difficulty whatsoever with their response, immediately choosing the VOL category” (225). For Lang, these findings highlight the diagnostic potential of taking patients’ experience of their abnormal movements into account. While differentiating between various hyperkinetic movement disorders is often deemed difficult, “a knowledge of the patient’s subjective appreciation of the abnormal movements” (226) may assist diagnosis. He concludes that we could accept “a VOL response […] as representative of tic disorders and INV [as] representative of most non-tic disorders” (226). Despite the problematic presuppositions embedded in Lang’s suggestion, his insistence that first-person phenomenology can help us clinically differentiate between movement (and possibly other) disorders has lost none of its original appeal. In the three decades since, no other research has systematically expanded upon these ideas and attempted to explore the diagnostic and nosological potential of a first-person phenomenology of tic disorder symptoms. To move forward with such an endeavour, I propose that we look at the closely related field of research into agency and ownership, and particularly at work informed by philosophical phenomenology. As I will argue in the following sections of this chapter, research into the experience of agency and ownership can help us fill the current phenomenological vacuum in the tic disorder literature, which discusses volition but still lacks nuanced first-person accounts of what voluntary or involuntary action ‘feels like’ for people with tics, and whether tic disorder symptoms are experienced in these terms. Gallagher (e.g. 2007, 2012, 2020) has done important groundwork in untangling the complex semantics of agency and ownership, and of the phenomenological and scientific questions embedded in our varied ways of speaking about human subjects as agents. By juxtaposing his multiple aspects model of agency with our prior discussion of volition and freedom in tic disorders, I suggest we can reframe some of the entrenched dichotomies that continue to separate the scientific study of volition from the existential quest to understand the human experience of free will and intentional action in Tourette Syndrome.

106

5  Agency and Ownership in Tic Disorders

5.2 A Complex Pair: Multiple Aspects of Agency and Ownership 5.2.1 Defining the Terms The notion of agency has received much attention in research across numerous disciplines ranging from psychology (e.g., Aarts et al. 2005; Marcel 2003; Sato and Yasuda 2005) and philosophy (e.g., de Vignemont and Fourneret 2004; Eilan and Roessler 2003; Gallagher 2000, 2004; Pacherie 2007; Synofzik et al. 2008) to neuroscience (e.g., Chaminade and Decety 2002; Blakemore et al. 1999; Farrer et al. 2003; Tsakiris and Haggard 2005a) and psychopathology (e.g., Daprati et al. 1997; Franck et al. 2001; Frith et al. 2000; Stephens and Graham 2000). Gallagher (2007, 2012) observes a lack of consensus regarding how agency is defined across these disciplines, noting that it is sometimes “construed in terms of bodily movement or motor control” and sometimes “linked to the intentional aspect of action” (2007, 347). Interestingly, we noted a similar ambiguity in the tic disorder literature with regard to the concept of volition (see Chap. 3). Further, some theorists describe agency as “the product of higher-order cognitive processes”, and others as “a feature of first-order phenomenal experience” (347), which touches on our discussion of the contested role of consciousness in volition and free will in Chap. 4. For Gallagher, if agency is something we experience somehow, then it requires that we are at least pre-reflectively conscious of ourselves as agents; but this consciousness can be, and often is, only a “very thin phenomenal awareness” (2007, 347). Since research into agency has investigated aspects of subjective experience, it can lend some credence to the claim that voluntary and involuntary movements or actions are indeed experienced differently by subjects, as the aforementioned studies on volition in tic disorders presume (Lang 1991; Moretto et  al. 2011; Ganos et al. 2015). It remains to be seen, of course, whether any such differences in experience are best described by using a pair of concepts as blunt as the ‘voluntary–involuntary’ divide. Let’s begin with a basic distinction between agency (sometimes referred to as authorship or ‘me-ness’) and ownership (also termed subjectivity or ‘mine-ness’) as defined by Gallagher (2012, 18): The sense of agency (SA) is the experience that I am the one who is causing or generating the action (Gallagher 2000). SA can be distinguished from the sense of ownership (SO) for movement, which is the sense that I am the one who is undergoing the movement – that it is my body moving, whether the movement is voluntary or involuntary. In the case of involuntary movement, SA is missing, but I still have SO – the sense that I am the one moving.

This purported phenomenological link with voluntary and involuntary movement is important. Put differently, in voluntary movement or intentional action we may expect SA and SO to co-occur in such a way that they are indistinguishable and “tend to reinforce each other” (Gallagher 2020, 44). In involuntary movement, on the other hand, they become dissociated: while sense of agency is missing, sense of ownership is intact. Tsakiris and colleagues have shown that SA and SO rely on separate neural systems that “can be manipulated independently of each other”

5.2  A Complex Pair: Multiple Aspects of Agency and Ownership

107

(Gallagher 2020, 44; see Tsakiris et  al. 2010). Both senses are generated “at the level of primary sensory-motor processes that involve efferent and reafferent processes such as motor (efferent) commands and proprioception”, and they manifest “at the level of first-order phenomenal consciousness” (Gallagher 2012, 18; see also Gallagher 2000, 2005; Haggard 2005). This means that we do not usually need to attend to our own agency by consciously monitoring our bodily movements. Given their phenomenologically recessive nature, Gallagher contrasts our pre-reflective experience of SA and SO from any higher-order introspective reflective attitude which we may also take toward them (see also Synofzik et  al. 2008). (We first encountered this distinction between pre-reflective and reflective consciousness in our discussion of premonitory urges in Chap. 3, where we asked whether people with tics sometimes don’t experience PU or whether they are just not reflectively aware of them). The original dyad of SA and SO thus broadens out into four distinguishable concepts (see Gallagher 2020, 50)7: • The pre-reflective sense of agency. Here, I experience myself as the initiator or cause of my action or thought, over which I have some control. Previously called “SA(1)” by Gallagher (2012), but we will simply call it SA here. • The reflective attribution of agency. Here, I judge that an action or a thought was caused by me. Previously called “SA(2)” by Gallagher (2012), but we will call it AA here.8 This judgement usually occurs retrospectively but AA may also occur prospectively via action planning. • The pre-reflective sense of ownership. Here, I experience myself as the subject who is moving (or keeping still) or thinking. We will simply call it SO here. • The reflective attribution of ownership. Here, I realize or judge that I was the one who moved or had a specific thought. We will simply call this AO here. This judgement usually occurs retrospectively but AO may also occur prospectively via action planning. Importantly, some accounts of agency construe it as nothing more than a reflective attribution (e.g., Graham and Stephens 1994; Stephens and Graham 2000). “On this view our sense of agency for a particular action depends on whether we can reflectively explain our action in terms of our beliefs, desires, and intentions” (Gallagher 2012, 18). If this was all there is to our sense of agency, we could expect people with tic disorders to lack such a sense, since they would presumably struggle to explain their tics as actions that accord with their beliefs and desires as “mental states that would normally explain or rationalize the action” (18). Put differently, if agency just is AA, then people with tics will probably not experience their tics as intentional actions (although they might feel a sense of ownership over their tics), because tics  See also Table 1 in de Haan and de Bruin (2010), which depicts further nuances in the sense of agency discussed by Gallagher and Zahavi (2008), particularly the distinction into SAi (intentional aspect of SA) and SAm (motor aspect of SA). De Haan and de Bruin question whether it is “possible to make such a neat distinction between SAm and SAi” (2010, 377). 8  In the following, unless Gallagher (2012) is quoted in direct speech, I will refer to SA and AA rather than his own SA(1) and SA(2) when discussing these concepts. 7

108

5  Agency and Ownership in Tic Disorders

rarely involve “prior deliberation or occurrent metacognitive monitoring” required for AA (Gallagher 2012, 25–26). But this hypothesis of a lack of perceived agency over tics is not borne out by the limited data available, which includes anecdotal accounts from people with tic disorders (e.g., Bliss et al. 1980) as well as Lang’s (1991) study. The latter’s interview questions are not couched in terms of SA and SO (but rather “voluntary” and “involuntary”), and yet his wording resembles what we described as agency and ownership above. As involuntary, Lang defines an experience that assumes the subject’s perceived ownership (SO) of her symptoms, in so far as these are “abnormal movements (and/ or vocalizations) that you experience” (1991, 223; emphasis added). At the same time, the subject perceives a lack control or authorship over the movement, “as if the body part affected has a mind of its own which is beyond your control” (223). In contrast, a voluntary experience involves the subject’s perceived authorship over her symptoms, in the sense that “you are aware of consciously performing them yourself”. Here, the subject perceives of herself as the agent who is “actually causing the body part to move on purpose” (223; emphases added). But Lang’s construction of a voluntary experience of agency is not as straightforward as it looks. Interestingly, he adds an element of coercion into the mix, when he allows for the voluntary movements to occur “in response to an inner need or involuntary urge which forces you to carry them out” (223). So, while the subject has no perceived authorship over the urge, she apparently feels agentic in her response to it (by initiating the relevant movement). Lang’s definition of a voluntary experience of symptoms in tic disorders thus presumes that subjects lack SA for premonitory urges, but experience SA for tic expression. It is unfortunate that Lang’s definition of volition mixes two separate questions: how subjects perceive the urge, and how they experience their behavioural response to this urge. Further, it is regrettable that the “INVOL” response which interviewees could select contains no reference whatsoever to the presence of urges or premonitory sensations. It is thus conceivable that many participants selected “VOL” because they agreed with the description of the coercive urge experience, but not necessarily with the sense of agency over symptom expression. All of this means that we have to exercise great care in interpreting Lang’s findings. The fact that the majority of study participants with tic disorders selected “VOL” as their response to describe their symptom experience (Lang 1991, 225) might say less about the phenomenology of agency than it does about subjects’ dominant experience of premonitory urges. At a minimum, any interview instrument designed to probe such experiences would need to carefully delineate and separate these various aspects of experience (if they are distinguishable, that is) so as to elicit less ambiguous data. Further, any study focused on investigating agency in tic disorders should probe for both the motor and the intentional aspects of SA. As Gallagher has repeatedly pointed out, it is not enough to conceive of SA “as generated in efferent or motor-control related brain processes” (2012, 22); in addition to a sense of embodied movement, our pre-reflective sense of agency also involves an experience of acting on, and effecting something in the word. “Both of these aspects, the intentional aspect (what gets accomplished, or fails to get accomplished, by the action) and the motor (or efferent) aspect (the sense that I am causing or controlling

5.2  A Complex Pair: Multiple Aspects of Agency and Ownership

109

my bodily movement)” enter into SA (Gallagher 2007, 2008, 2012, 22; see also Haggard 2005, 292). Many brain imaging experiments fail to distinguish clearly between these two contributories to SA (Gallagher 2012, 22–23), and we can say the same of Lang’s interview questions designed to probe volition, which he reduces to motor control (see Chap. 3 for an in-depth discussion of this common reduction in the tic disorder literature). Attributions of agency are similarly complex. As contributories to AA, Gallagher refers to the role of what Pacherie calls future-directed and present-directed intentions (F-intentions and P-intentions, respectively) (Gallagher 2012, 17; see also Pacherie 2006, 2007). (We can compare F-intentions to our earlier discussion of distal intentions, while P-intentions compare with intentions-in-actions; see Chap. 4 for details.) If the subject plans the action – that is, if she deliberates about it in advance – she will form a future-directed intention. And if the subject consciously monitors whether the action achieves its end, then she will form a present-directed intention (i.e. an intention-in-action). Both of these conscious intentions contribute to AA (Gallagher 2012, 29). In addition, AA may involve an extended temporal experience of acting effectively and in alignment with one’s broader goals and projects over time (see Pacherie 2007, 6; Gallagher 2012, 29; see also Chap. 4.) Conceptually, we can speculate whether these contributories to SA and AA are likely to be present or not in the experience of ticcing. For example, is it likely that ticcing involves conscious planning of the vocal or motor tics before they occur – i.e., will the subject have a future-directed “intention to tic”? Probably not. If ticcing can be construed as an intentional action at all (an assumption we will query in Chap. 6), then prior conscious deliberation does not seem typical of how subjects commonly experience these actions. The case is less clear for the second contributory to AA, conscious action monitoring. Particularly in the context of ‘not just right experiences’ (NJRE), it is conceivable that the experience of ticcing involves present-directed intentions – that is, intentions-in-action – which monitor the execution and effect of the tic while it is being performed. (We will discuss NJRE in more details in Chap. 6.) So, if tics are accompanied by intentions-in-action (Pacherie’s P-intentions), then we might find that subjects have AA and reflectively attribute agency to their ticcing. Further, if their tic movements and vocalisations also contribute to (rather than interfere with) subjects’ self-narratives and sense of identity, their first-person attributions of agency may be even more pronounced. Alternatively, however, it is possible that subjects do not experience agency in the sense of AA when they tic at all. That is, they may not reflectively attribute any agency to their symptoms, and the latter may disrupt rather than strengthen their sense of themselves as efficacious goal-directed agents. But might they still experience SA? It’s likely they do. At a pre-reflective level, we might expect basic efferent motor-control processes associated with tics to endow subjects with a first-order sense of situated agency (and NJRE could be more about such pre-reflective perceptual monitoring too). Similarly, they might perceptually monitor the execution and effect of their tics at a pre-reflectively conscious level, which contributes to SA.

110

5  Agency and Ownership in Tic Disorders

However, phenomenologically some of these conceptual distinctions may be difficult to distinguish and even test for. For example, how should we separate the kind of reflective action monitoring said to contribute to AA from the pre-reflectively conscious perceptual monitoring described as a contributory to SA? Take Lang’s (1991) study: How do we know whether participants’ reported sense of agency (via selection of “voluntary” as a descriptor for their tic experience) reflects a retrospective attribution of agency (AA) – induced, perhaps, by the very nature of the experimental setup – or rather a genuine reflective sharing of how they pre-reflectively tend to feel when they tic (SA)? Is it possible to reflect and report on SA, or is such reporting and reflecting necessarily an expression of AA? The answers to these questions are far from clear, as are the implications for the experimental design of studies devoted to exploring the first-person phenomenology of ticcing.9 As Gallagher points out (2012, 29), just because we can distinguish between various conceptual contributories to SA and AA and even study these neuroscientifically (by looking at the different brain processes involved) does not mean that they correlate with distinct features of experience. Put differently, if ticcing involves an experience of agency, then this experience may be more ambiguous than our concepts suggest. We can ask similar questions about the ambiguous phenomenology of ownership.

5.2.2 ‘Not Mine’ or ‘Not Me’? Understanding Alienation De Haan and de Bruin (2010) challenge the assumption implicit in the literature that there is just one experience of ownership across broadly different domains to which we may apply the concept. We can expect qualitative differences, they suggest, in how we experience ownership for movements, thoughts, the body as a whole, and specific body parts (2010, 379–380). Regarding the sense of ownership of movement, we might experience a “weak” or a “strong” SO. De Haan and de Bruin spell out minimal or weak SO in terms of kinesthesia or proprioception (2010, 380). They distinguish this from a strong sense of ownership, where kinesthesia is accompanied by a sense of “mineness” over the movement. That we can have weak SO (without mineness) is evident, they suggest, in certain experiences of involuntary movement characterised by a sense of alienation – for example, when someone uses my hand to hit someone else: “Now in the example of counter-voluntary hitting, one could argue that I may not have the subjective feeling of mineness for the act of hitting, but it is surely still my hand that is being used here” (379). Put differently, I am

 While the literature distinguishes between explicit (subjective) and implicit (objective) markers of embodiment and agency, and while different experimental measures are used to study them, it is not clear that they map neatly and straightforwardly onto the pre-reflective sense of agency and ownership on the one hand and their reflective attributions on the other. We will discuss this in more detail throughout the chapter. 9

5.2  A Complex Pair: Multiple Aspects of Agency and Ownership

111

proprioceptively aware (weak SO) of the movement of my hand, but I don’t experience the movement as mine. Alienation from one’s movement, then, might rely on the absence of a strong sense of ownership, while weak SO is intact, “in the sense that these estranging experiences are happening to me. […] One cannot not have a weak sense of SO because it refers to the subjective character of all experiencing” (2010, 379). Similarly, regarding sense of ownership of the body as a whole, a weak SO might refer to our pre-reflective awareness of our body, “which could be cashed out in terms of proprioception” (380). But how about a weak SO for a specific body part? While implicit proprioceptive awareness of one’s whole body makes sense, de Haan and de Bruin consider it contradictory to suggest that such implicit awareness also exists for a localised body part, because such an experience would need to “stand out against the tacit background of my body as a whole” (380). As such, it is unlikely to be pre-reflective, and more likely to involve “an attention to that specific part that […] refers to the body as object”. If this holds true, then we cannot experience ownership of specific body parts in a pre-reflective manner; there cannot be SO for body parts. Instead, we can only attribute ownership reflectively. Accepting this argument would have an important consequence: it would mean that how we describe ownership (as a pre-reflective sense or a reflective attribution) also depends on its domain or referent, i.e. on what is ‘being owned’. All of this is highly relevant to our mission to better understand the experience of ticcing, because tics often involve specific body parts that make specific movements (or sounds), and premonitory urges are also often localised. We can thus expect tics to provide an interesting example for studying ownership across the relevant domains involved. We could ask: Do people with tics experience weak or strong SO for the movements or sounds that constitute their tics? If they only experience weak SO, is there also a sense of alienation, as has been argued for other involuntary movements inflicted upon subjects through external forces (see de Haan and de Bruin 2010)? How about ticcing subjects’ experience of ownership for the body part that moves – is SO lacking, as de Haan and de Bruin reason should be the case, so that ownership of the ticcing body part can only be attributed reflectively? And how do agency dynamics interact with ownership dynamics in people with tics? We could speculate that, with regard to ownership of the tic movement or vocalisation, subjects would have, at the very least, a pre-reflective proprioceptive awareness (weak SO) for their movement or sound, and maybe also a sense of mineness for it (strong SO). If they only had weak SO, they might feel alienated by their own ticcing; if they had strong SO, this would be less likely. Whether the tic movement or vocalisation then also triggers a kind of ‘attentional gear change’ from pre-reflective to reflective awareness is an interesting question, and touches on our earlier discussion of Trubody’s (2014) Heideggerian contrast between the ready-to-hand (RtH) and present-to-hand (PtH) mode of being in the world (see Chap. 4). Trubody argued that Tourettic tics create an “excessive present-­ at-­hand” state that throws the subject into a conscious, reflective relationship with her own body (or should we say, rather, with certain parts of her body?). In light of de Haan and de Bruin’s discussion of SO, we could ask whether the mechanism for

112

5  Agency and Ownership in Tic Disorders

this lies in the attentional foregrounding of specific body parts – effected by their anomalous and repetitive movements  – which triggers a switching from pre-­ reflective SO (for the body and its movements as a whole) to a conscious attribution of ownership over tics and the associated body parts. We would then have a situation where the dominant referent, or the most salient domain of ownership that is experienced or ‘active’ at a time, changes from a phenomenologically recessive, pre-­ reflective experience of ownership of the entire body and its movements, to a reflective focus on what are literally ‘attention-grabbing’ movements and their localised bodily sites. A similar shift from pre-reflective sense to reflective attribution may also affect the agency dynamics in tic disorders. All of this is speculative at this point, of course, since we lack sustained research into the phenomenology and first-person experience of ticcing. While agency and ownership have been investigated in the context of numerous pathologies (including two papers on tic disorders, to which we will turn shortly), these studies rarely distinguish between sense and attribution of agency and ownership, or between their various contributories. And yet these conceptual distinctions might help us uncover variations in experience across different conditions or different populations affected by the same condition. As Gallagher notes for sense of agency, it is not enough to say that SA is “present or absent, diminished or increased”; we also need to recognise that very different “processes or disruptions of processes at different levels” might be responsible for this. Therefore, when we speak of a loss of SA in conditions such as obsessive-compulsive disorder, schizophrenia, narcotic addition, or anarchic hand syndrome, we cannot assume that we are referring to the same kind of loss or, indeed, to the same kind of experience in each case (Gallagher 2012, 30).10 As an example of a certain type of loss of agency, Gallagher analyses schizophrenic delusions of control. In the case of these delusions, schizophrenic patients do not experience certain of their movements or thoughts as controlled by themselves (in the case of thoughts, this is often referred to as thought-insertions; see Riemer 2018).11 Some researchers (e.g. Frith 1992; Gallagher 2004; Pynn and DeSouza 2013) suggest that this is caused by disrupted mechanisms associated with efference copies, “those neural representations of motor outputs that predict reafferent sensory feedback and modulate the response of the corresponding sensory cortex” (Pynn and DeSouza 2013, 124). If this process is disrupted, sensory reafferents from motor outputs may not be recognized as self-generated, thus requiring “further sensory or cognitive processing of the feedback they produce” (124). Gallagher  Following Frankfurt (1988), Gallagher suggests that narcotic addiction involves the loss or disruption of AA due to “problems with retrospective higher-order cognition or the prospective formation of F-intentions”. A drug addict who invests himself in resisting drugs “may feel that something other than himself is compelling him to drug use. If he withdraws from taking the drug, when he starts using again he may not conceive of himself as the agent” (Gallagher 2012, 29–30). 11  Riemer (2018) argues that schizophrenics have a more veridical sense of the actual relationship between intentions and actions. He thinks the “intentional binding” that occurs in healthy subjects (i.e., the perceived temporal distortion whereby intentions and actions appear closer to each other in time than they actually are) is absent in schizophrenics, leading to a lesser or lacking sense of agency. 10

5.2  A Complex Pair: Multiple Aspects of Agency and Ownership

113

suggests that disrupted efference copy mechanisms in schizophrenia entail that subjects lack SA, a pre-reflective sense of agency for their actions (2012, 24): For the subject, there is still the proprioceptive sense that his hand is reaching for the cup, and all the sensory information associated with the intentional aspect is generated, but, [because of] absent efference copy which tells the motor system that it is generating the movement, the action seems alien to the subject. The subject’s report is that it is his hand (that he is the one) that (who) is reaching and grasping the cup (there is SO for the movement) but he has no feeling that he has issued the motor command and so has no SA(1) [SA] for the action. If that motor aspect is missing, the intentional aspect [of the sense of agency] is not phenomenologically anchored in the embodied agent.

De Haan and de Bruin would probably specify the domain-specific nature of the sense of ownership touched on here, and whether SO is weak or strong. The alienation experienced regards the reaching action (movement) of the subject’s hand (body part), which would indicate that at least a weak SO (kinesthesia or proprioception) is retained for the movement. But it is not clear whether their argument that alienation in involuntary movement can be explained as a lack of strong SO (absence of ‘mineness’) should also apply to delusions of control in schizophrenia. The schizophrenic’s alienation at his own hand’s grasping of a cup probably differs from the alienation felt by someone whose hand is being used by another person to hit someone else. And if we stipulate that there might be different ways of experiencing alienation, could the schizophrenic still have strong SO (kinesthesia plus mineness)? How, then, would we explain the felt alienation if not as absence of ‘mineness’ (strong SO)? Maybe – as Gallagher suggests – as SO without SA? This would lead us to stipulate at least two types of experiences of alienation, namely weak SO (proprioception without mineness; de Haan and de Bruin 2010), and lack of SA (sense of ownership without sense of agency; Gallagher 2012).12 Further, as soon as the referent of ownership becomes the body part (e.g. the reaching hand in Gallagher’s example above), according to de Haan and de Bruin (2010) we would need to stipulate a shift from sense to attribution of ownership, meaning the schizophrenic would reflectively attribute rather than pre-reflectively experience ownership of their moving hand. It is not quite clear which domain of  In fact, de Haan and de Bruin (2010) propose a third way of experiencing alienation, exemplified by thought insertions in schizophrenia. Thought insertions, they suggest, completely lack SO (even weak SO), and alienation arises by comparing a local or specific experience with global experiential trends of the person. Put differently, the experience of alienation arises from the comparative difference between what is generally experienced as some sense of ownership but occasionally (in some context) not experienced as such. In their own words: “Although we agree that alienation is only possible on the basis of some experience of mineness, we would argue that the SO (and SA) that are still retained and that serve as this basis are for the patients’ other thoughts and their mind in general. For the inserted thought, even a weak SO is lacking” (387). If this was true, the schizophrenic would not have any SO for inserted thoughts (thought insertions). This model of alienation resonates strongly with our distinction between three levels of analysis (type, occurrence, token) introduced in Chap. 2. We could re-frame de Haan and de Bruin’s suggestion by saying that specific thought tokens can be experienced as alienating against the comparative background of thoughts at the occurrence and type level (all thoughts, or certain kinds of thoughts, depending on context). 12

114

5  Agency and Ownership in Tic Disorders

ownership is meant to be phenomenologically dominant and why (and de Haan and de Bruin do not offer clues about how to decide this in practice), but Gallagher seems to take the movement of the schizophrenic’s hand as the relevant referent in his example above. And yet, while he hones in on this “reaching and grasping of the cup”, other referents are touched on in passing – the hand as object, and the whole body or person as subject  – as if they were equivalents. The use of brackets in Gallagher’s sentence reinforces the impression that he views these referents as interchangeable. But is it really the same to say that “his hand is reaching” and that “he is reaching”? Not if we run with de Haan and de Bruin’s (2010) idea that there are different referents of ownership. Given Gallagher’s sustained interest – in this and other works – in understanding action, it should not surprise us to note his focus on the movement in the example of the schizophrenic. This focus might also explain why he locates alienation in a lack of SA, rather than in the dynamics of ownership highlighted by de Haan and de Bruin (2010). We can thus pinpoint a structural bias that is commonly left unacknowledged. Any emphasis on action as the thing we want to understand comes with a double gravitational pull: Firstly, it favours agency considerations, because the referent of agency is always and necessarily an action (which integrates motor and intentional aspects). And secondly, in so far as ownership is considered, the action will be deemed the primary referent of such ownership experiences and attributions (although, unlike agency, ownership need not take action as its referent). In sum, if action is what we are after, then we will be prone to dismiss those nuances of ownership that do not take the action as its referent. This raises some questions about Gallagher’s conclusion that SA – i.e., a pre-reflective sense of agency – is lacking because disrupted efferent copy mechanisms prevent perceived authorship over the movement. For example, if ownership (unlike agency) does not have an intentional component, why should we consider the action  – defined as such because of its intentional nature  – to be the primary referent with regard to ownership experiences? And more broadly construed, what is the degree of interaction or separation in the first-person phenomenology of agency and ownership? Pyasik et al. (2018) have recently commented on the ongoing controversy surrounding this relationship, noting that “it is still unclear how and to which extent they are related” (220).13 De Haan and de Bruin have argued that SA and SO are not as dissociable as Gallagher seems to suggest, and that schizophrenia does not illustrate their coming apart but rather exemplifies a disturbance to both senses, while attributions of ownership are still intact, at least in the early stages of the condition (2010, 384–386).

 The authors contrast two models – the additive and the independence model – emerging from the literature on agency and ownership. While the additive model suggests that sense of agency and ownership are strongly interlinked, the independence model sees them as separate mechanisms (Pyasik et  al. 2018, 220). Studies attempting to investigate the relationship between sense of agency and ownership have yielded conflicting results, and have highlighted the possibility that neurological observations and subjective reports may not always be correlated (e.g., Tsakiris et al. 2010; see Pyasik et al. 2018, 220). 13

5.3  Situating Tics

115

We can summarise that how we explain the agency and ownership dynamics of various pathologies rests in part on how we understand these concepts. On the one hand, there are conditions that have been construed as signalling a loss of agency but not of ownership, as Gallagher’s discussion of schizophrenia suggests. Similarly, in motor conditions like anarchic hand syndrome, subjects could be said to experience a body part as their own, but not as being under their wilful control (Della et al. 1994). A more extreme version occurs in alien hand syndrome, where the person does not recognise her arm or leg as her own at all (that is, she neither experiences agency nor ownership for it). Inversely, ownership may be lost while agency is retained, as is true for neurological conditions where people lose proprioception or kinesthesia from the neck down. Ian Waterman is a famous case mentioned in the literature (see Gallagher 2005; Cole 2016), because his agency compensated for his loss of proprioception and touch. Through deliberate execution and monitoring of his own (‘un-experienced’) movements, and guided by visual feedback, Waterman was able to regain functional control over his own body, mimicking with astonishing similitude what are usually automatic proprioceptive processes. Where on this spectrum – from agency but no ownership, to ownership but no agency – do we situate the experiences of people with tics?

5.3 Situating Tics 5.3.1 More Susceptible to Illusions of Agency In primary tic disorders like Tourette Syndrome, proprioception is not compromised neurologically, so we can expect at least the weak sense of ownership (kinesthesia) to be intact. But how about the ‘mineness’ component de Haan and de Bruin define as belonging to strong SO? And what about the sense and attribution of agency? Experiments designed to test sense of agency commonly rely on Libet’s clock paradigm or certain computerised game tasks (e.g. Metcalfe and Greene 2007; Metcalfe et al. 2010), while the Rubber Hand Illusion is used to study different aspects of embodiment (ownership, location, but also agency; see below). Versions of these experimental paradigms have been employed to study people with tic disorders, although the overall number of studies remains small. Since we extensively reviewed the Libet-style experiments on volition conducted in tic disorder populations earlier (see Chap. 3), we can focus here on those studies that explore agency (Delorme et  al. 2016; Zapparoli et  al. 2020) and ownership (Rae et  al. 2018) explicitly in Tourette Syndrome. Neither of them investigates the experience of ticcing itself but rather looks at agency or ownership in the context of carefully defined behaviours and experiences that form part of the laboratory experiments. Delorme et al. (2016) were the first to use an explicit agency task in research on TS – that is, a task designed to capture reflective (and thus subjective) markers of agency. Since earlier implicit (objective) agency studies using Libet’s paradigm had

116

5  Agency and Ownership in Tic Disorders

yielded conflicting results (see Chap. 3; Moretto et al. 2011; Ganos et al. 2015), the authors chose to study metacognitive judgements (i.e., reflective attributions) of agency instead. Two groups of adults – one with TS, the other controls – participated in a computerised game task designed to eliciting subjects’ degree of authorship and control over the action. The task (see Metcalfe and Greene 2007; Metcalfe et al. 2010) required them to judge their control and performance after completing a game in which they had to catch moving “X” targets (and avoid moving “O” distractors) with a cursor on a black computer screen by moving the computer mouse. When hit, targets and distractors would disappear from the screen. Unknown to participants, several conditions were tested: In the “control” or baseline condition, participants’ objective control over the cursor was normal (i.e. mouse and cursor movements corresponded perfectly); under “Turbulence”, participants’ cursor control was disrupted by random spatial and temporal interference; in the “Lag condition”, participants’ cursor control lagged behind; and in the “Magic” condition, it was artificially enhanced (the “X” targets would disappear if they came within 10 pixels from the cursor without being touched; see Delorme et al. 2016, 134). The task’s main outcome measure was a summary agency score, which reflected agency relative to perceived performance and to baseline. “In healthy volunteers, as participants realize that their performance is not entirely due to their own control […], this summary score is negative in all experimental condition. A higher score indicates an illusion of agency” (135). Interestingly, Delorme and colleagues found a greater propensity to such an illusion of agency under the “Magic” condition in the group of adults with TS, but not in the other conditions where their cursor control was disrupted. This suggests that these adults (wrongly) attributed the externally enhanced performance to their own actions, but not their externally diminished performance. What might explain this intriguing finding? The authors point out that, if actions and their consequences are closely monitored, people are usually able to detect any discrepancy between them. Does this mean that intentional action monitoring – a contributory to attributions of agency, or AA, via intentions-in-action or P-intentions (see Sect. 5.2.1) – is reduced in the group of adults with TS? Not necessarily, since they are able to detect discrepancies between intended actions and action outcomes in the interference conditions. Instead, we could ask whether the second contributory to AA – action planning via F-intentions or distal intentions (see Sect. 5.2.1) – may override any perceived interference with the action if the outcome aligns with that intention. In Delorme and colleagues’ words, “if the participant bases his judgment of agency on the matching between his intention and the outcome, he will detect no discrepancy and will experience an illusion of agency” (135). Is there something about having Tourette Syndrome that inflates authorship attributions to non-self-generated (or better, to not solely self-generated) actions? Might people with TS learn to (over-)attribute agency above and beyond perceived distractors or interference? If so, Delorme

5.3  Situating Tics

117

et al.’s (2016) findings might showcase a generalised effect resulting from the over-­ learning of such attributions.14 Clearly, people with TS are routinely confronted with self-generated distractors (or better, with distractors occurring in their own bodies) – i.e., their tic symptoms – which can interfere with the execution of their intentional actions. In cases where they successfully generate an intended action outcome in spite of interfering tics, it is conceivable that they learn to ‘override’ or attenuate perceived interference and affirm authorship reflectively. Something similar, albeit with externally rather than internally generated distractors, may be going on in the “Magic” condition of Delorme and colleagues’ experiment. In Chap. 6, I will argue that the location of a stimulus (within oneself or the environment) is less important than commonly thought to our understanding of actions in context. Pre-empting this idea here, we might hypothesise that the learned attribution of agency to ‘intended outcomes’ despite self-generated (embodied) distractors like tics generalises to similar agency attributions when external factors co-contribute to the intended action outcome. On the other hand, when fewer intentions are met because the impairment caused by tic disorder symptoms reaches a certain threshold (resembling chronic ‘turbulence’ or ‘lag’ conditions that decrease performance), subjects might have fewer opportunities to consolidate their agency via learned reflective attributions, leading to a weaker agency effect under the “Magic” condition. This aligns with Delorme et al.’s (2016) finding that the higher summary agency score of adults with TS does not correlate with tic severity per se, but rather with global symptom severity and impairment: “Patients with less severe overall impairment had higher summary agency scores” (136) and were more prone to illusions of agency. Could these subjects have had more opportunities for learning to attribute agency and dismiss interference, because their action outcomes more often (and more closely) align with their intentions? If so, tic disorder symptoms might support illusions of agency, as long as subjects get to ‘practice’ attributing agency in spite of perceived interference. If overall impairment is too high and subjects experience a frequent mismatch between their intentions and action outcomes, such practice opportunities – and the learning they entail – may be reduced. We can relate Delorme et al.’s (2016) finding of a lesser propensity for illusions of agency in subjects with more severe symptoms to Ganos et al.’s (2015) study of volition in TS, which we discussed in detail in Chap. 3. This study suggests that more severe symptoms might “induce a motor noise that blurs intentional signals and reduce binding between intention and outcome, leading to a disruption of the sense of agency” (see Delorme et al. 2016, 136). A recent study by Zapparoli et al. (2020) using an fMRI temporal-­ judgement task confirms both this reduced intentional binding effect and its  As they point out, illusions of agency are frequent in young children (Metcalfe et al. 2010) and decrease with age, although they can still be found in adults (Weisz 1980; Weisz et al. 1982; see Delorme et al. 2016). This raises questions about the developmental process by which maturation may ‘correct’ illusions of agency in healthy subjects under normal conditions, and how anomalous or disease-specific experiences (such as those associated with Tourette Syndrome) may counteract such learning. 14

118

5  Agency and Ownership in Tic Disorders

correlation with symptom severity in adults with TS.  From these findings, the authors deduce an impaired sense of agency (SA) in Tourette Syndrome: “GTS patients do not implicitly experience agency [SA] in circumstances where they should” (11) – i.e., for self-generated action outcomes. So what might all of this tell us about the interaction between ownership and agency in Tourette Syndrome? If Tourette Syndrome entails anomalies in AA – specifically, a tendency to ‘take credit for’ and over-attribute agency to oneself in cases where action outcomes match intentions but are not (solely) caused by oneself – could this be a compensatory mechanism for weak or lacking experiences of agency or ownership? Put differently, do tic disorder symptoms threaten the pre-reflective sense of agency or ownership, triggering a ‘hyper-agentic’ metacognitive response? It’s worthwhile having a look at Rae et al.’s (2018) study on embodiment in Tourette Syndrome to see whether we can draw any inferences about how agency and ownership interact in people with tic disorders.

5.3.2 Less Susceptible: The Rubber Hand Illusion Like most experimental research on TS, Rae and colleagues’ work focuses neither on the experience of ticcing nor on the sense of ownership and agency associated with tics. Rather, their work employs a common neuropsychological experiment, the Rubber Hand Illusion (RHI), to compare the relationships between a subjective and an objective “embodiment measure” in a group of adults with TS and healthy controls. The RHI involves a “tantalizing illusion” (Rohde et al. 2011), where participants feel that a rubber hand belongs to their body (ownership) because they can see a visible rubber hand being stroked while their own occluded hand is also being stroked with a brush (either synchronously or asynchronously). If this stroking occurs simultaneously – i.e., the real and the rubber hand are stroked at the same time – subjects who complete a questionnaire after the experiment usually rank their perceived ownership of the rubber hand as high. (This is not the case in the asynchronous condition, unless stroking continues for some time; see Tsakiris and Haggard 2005b). This subjective “embodiment” measure, modelled on a self-report questionnaire developed by Longo et al. (2008), invites subjects to use a 7-point Likert scale to rank their experience of rubber hand ownership (5 statements), perceived location of their own hand in relation to the rubber hand (3 statements), and agency (2 statements).15 Rae and colleagues asked subjects the 10 questions in a randomised order across four testing blocks (Rae et al. 2018, 370).  The 10 statements are worded as follows. Ownership statements: (1) It seemed I was looking directly at my own hand, rather than at a rubber hand. (2) It seemed like the rubber hand began to resemble my real hand. (3) It seemed like the rubber hand belonged to me. (4) It seemed like the rubber hand was my hand. (5) It seemed like the rubber hand was part of my body. Location statements: (6) It seemed like my hand was in the location where the rubber hand was. (7) It seemed like the rubber hand was in the location where my hand was. (8) It seemed like the touch I felt was 15

5.3  Situating Tics

119

A closer look at the respective statements allows us to define more clearly what kind of ownership and agency are at stake. First of all, we can comment that the instrument elicits retrospective judgements or attributions of ownership and agency, rather than tapping into their pre-reflective experience (the latter is done via the implicit or ‘objective’ measure, see below). The referent of ownership is the rubber hand (body part) rather than the body as a whole, a particular movement, or a thought. Further, the attribution of ownership is “‘as object’ and based on vision, and not ‘as subject’” (de Haan and de Bruin 2010, 388–389; see also Gallagher and Zahavi 2008, 214, footnote 6). The three location-based statements similarly provide reflective judgments of proprioception and touch. The two agency statements (“It seemed like I could have moved the rubber hand if I had wanted”, and “It seemed like I was in control of the rubber hand”) are particularly interesting, since they reflect judgements about hypothetical rather than actual movement or action. Since the rubber hand does not move in the experiment, there is no ‘action’ (in the classic sense) to which agency could be attributed. Instead, the self-report measure elicits agency in relation to potentially intended movement and to the ‘passive’ experience of being stroked. Is this a legitimate measure of agency? And further, can there be agency for ‘receiving’ another’s action, such as the stroking of the real or the rubber hand? De Haan and de Bruin (2010, 380–381) have argued – compellingly, and with important consequences – that this is indeed legitimate, and that agency pervades all manner of experiences, with the exception of reflexes. Asking whether “receiving a massage” could count as an action, they propose that what might look like the purely passive enduring of someone else’s agency is in fact agentic too, involving attitudinal responses that shape what the sensation feels like: To maintain that there would be no SA involved in experiencing these sensations, one would have to take a synchronic series of snapshots, leaving out the flow of experiencing, the situational context, and the developmental history. Furthermore, one would […] need to insist on a crude stimulus–response model. A diachronic perspective, on the other hand, immediately reveals the embeddedness in agency, especially when we adopt an interactional concept of agency that is not confined to my self-initiated acts but encompasses receptivity as well.

This notion of action as irreducibly interactive, and as resisting the classic stimulus-­ response model, will be centrally important to our discussion of tics in Chap. 7. Here, it helps us affirm that the experience associated with the RHI  – i.e., being stroked by a brush – can indeed be used to study aspects of agency. However, the two agency-related statements in Longo et al.’s (2008) questionnaire used by Rae et  al. (2018) do not actually elicit any attitudinal qualities related to this kind of agentic experience. Instead, they ask subjects to judge whether they felt as if they could have moved or controlled the rubber hand. In principle, the answer to this question about potential motor control may differ from subjects’ descriptions of their “responsive receptivity” and its agentic qualities throughout the experiment. caused by the paintbrush touching the rubber hand. Agency statements: (9) It seemed like I could have moved the rubber hand if I had wanted. (10) It seemed like I was in control of the rubber hand.

120

5  Agency and Ownership in Tic Disorders

And yet both are legitimate questions about or aspects of SA. As de Haan and de Bruin (2010, 393) assert, the sense of agency “can also be present in the form of a potential capacity, as a Husserlian ‘I can’”, and we can expect SA to increase the more this potential is actualised – a clear limitation in the RHI, where no real control over the rubber hand could ever be actualised and thus experienced by subjects, no matter the strength of the reported illusion. The second aspect of the RHI experiment conducted by Rae et  al. (2018) in adults with and without TS involved measuring proprioceptive drift, an implicit (objective) marker of embodiment that captures the pre-reflective sense of ownership. Proprioceptive drift, also referred to as a “displacement effect” (Rohde et al. 2011), occurs when subjects are given a reaching task during which they can see the rubber hand but not their own hand, which is located inside a box covered by a black cloth. Instructed to place their right index finger on a coloured dot (which is initially shown but then covered by the cloth on the box too), participants will reach closer to or further away from this dot, depending on whether the visuo-tactile stimulation (brush-stroking) of the hands is synchronous or asynchronous (Rae et  al. 2018, 369). Previous studies in healthy adults (e.g. Tsakiris and Haggard 2005b) showed that proprioceptive drift toward the rubber hand occurs during synchronous but not during asynchronous stimulation, and that “the magnitude of the proprioceptive drift correlated with the strength of the feeling of ownership reported in the questionnaire” (Rohde et al. 2011). Rae and colleagues’ guiding question was whether individuals with Tourette Syndrome would display the same plasticity in bodily perception – as measured by proprioceptive drift toward the rubber hand – as individuals without TS (2018, 369). They also asked whether the relationship between objective and subjective embodiment ratings would differ across both groups, and whether these ratings correlated with symptom severity. The findings are intriguing. While Delorme et al. (2016) showed that people with TS are more prone to illusions of agency in the Magic condition of their experiment, Rae et al.’s (2018) RHI study showed that they are less prone to illusions of ownership. In other words, participants with TS were less susceptible to the rubber hand illusion – their implicit sense of body ownership was not as plastic or malleable as that of controls (or as that of people with schizophrenia, who show enhanced proprioceptive drift; see Thakkar et al. 2011). A reason for this limited plasticity could be that people with TS have “overly precise expectations around sensory experiences, leading to heightened subjective sensitivity to bodily feelings and thus premonitory sensations” (Rae et al. 2018, 369; see also Rae et al. 2019; Eddy et al. 2014; see Belluscio et al. 2011 for an example of a study showing increased sensitivity to external stimuli). In this context, it is interesting to note that the subjective embodiment ratings of participants with TS were more consistent with controls, and that the discrepancy “between subjective feelings of ownership and proprioceptive drift predicted severity of premonitory sensations in participants with TS” (Rae et al. 2018, 374). Put differently, the weaker individuals’ implicit sense of ownership of the rubber hand, and the stronger their reflective attribution of embodiment, the more severe were their reported PUs. Rae and colleagues call this mismatch between proprioceptive drift and subjective embodiment ratings, or between actual

5.3  Situating Tics

121

and expected sensory experience, an “embodiment prediction error”, a concept previously employed to explain “aberrant experiences of selfhood in body illusions” (Rae et al. 2018, 369; see Apps and Tsakiris 2014). Comparing the findings from Delorme et al. (2016) and Rae et al. (2018), can we speculate about the agency and ownership dynamics at play in Tourette Syndrome and tic disorders? For one, we might want to caution against inferring a generally reduced SO in TS from the fact that people with TS are less prone to illusions of ownership in the RHI experiment. The fact that their sense of ownership is less malleable, and that they are less susceptible to embodying an object which resembles but does not belong to their own body, need not translate into reduced SO for their own body, movements, thoughts, etc. Rather, it could indicate an adaptive ability to recognise and maintain self–other distinctions perceptually. In her comparative review of social cognition research in schizophrenia and TS, Eddy (2018, 78) comments that, for a motor system that is readily ‘hijacked’ by external stimuli, ticcing may represent a compensatory mechanism aimed at bringing the system back under internal control, allowing self–other distinction. Tics could be “protective in terms of maintaining a sense of physical self”, an effect not found in schizophrenia, which lacks more obvious motor symptoms while exhibiting “much more evident psychosis.” It is thus conceivable that “the motor system and basal ganglia in particular may have an important role to play in terms of behavioural and neural compensation processes” (Eddy 2018, 80; see also Eddy 2016). We can summarise that, in the RHI experiment, reduced proprioceptive drift – compensatory or otherwise – means that subjects with TS maintain more accurate perceptual distinctions between what is, and what is not, ‘their own’ (when compared to controls). But it is difficult to know what this tells us about their sense of ownership for their own body, body parts, thoughts, and movements, a topic that clearly warrants further inquiry.16 If the illusionary agency attributions observed by Delorme et al. (2016) in adults with TS and their reduced embodiment of the rubber hand observed by Rae et al. (2018) are adaptive responses of some sort, then they may well point to a disrupted SO and SA in Tourette’s. A weak sense of agency – a kind of ‘hypo-SA’ – could underlie the over-attributions of agency – a kind of ‘hyper-AA’ – observed in the Magic condition, where subjects take credit for intended action outcomes that are not solely self-generated but artificially enhanced. Similarly, if adults with TS more easily ‘disown’ alien objects (perhaps due to very precise expectations of sensory experience that leave them less susceptible to visuo-tactile illusions), might they also be prone to ‘disown’ aspects belonging to their minimal self, such as their own body, body parts, or movements? In other words, could their strong sense of ownership (mineness) be threatened, but not their weak SO (proprioception or kinesthesia)? If so, we should look out for experiences of alienation of some sort – i.e. the sense that the tic movements or sounds, the ticcing body parts, or the body as a  Some philosophers will disagree with my contention that agency and ownership of foreign objects cannot tell us much about the agency and ownership dynamics that apply to our own bodies. Hohwy (2015, 114), for example, holds that our relation to our body is not different in kind from our relation to other objects in the external world. 16

122

5  Agency and Ownership in Tic Disorders

whole feel strange or unfamiliar to the subject. We encountered two models of alienation earlier (three, in fact; see footnote 12): weak SO (proprioception without mineness; de Haan and de Bruin 2010), and lack of SA (sense of ownership without sense of agency; Gallagher 2012). Which of these, if any, might be more suited to describing potential experiences of alienation in TS? The answer presumably depends on the referent(s) of ownership we posit as phenomenologically dominant or salient in the experience of tic disorder symptoms. Gallagher’s action-focus in his example of the schizophrenic who feels alienated by the grasping movement of his hand looks like a useful comparator in so far as we often think of tic events as actions (whether rightly or wrongly will be discussed in Chaps. 6 and 7). But the mere fact that we consider certain movements and vocalisations to be paradigmatic of tic disorders – their symptoms par excellence – does not mean that they are the primary referent of ownership experiences in tic disorders, or that there is nothing else to subjects’ experience of these conditions. Ownership dynamics could be more complex than that, and less exclusively tied to motor or vocal tic events as “action-­ like” referents. This raises several questions. For example, how should empirical work differentiate between the various potential referents of ownership? And how problematic is the ‘mixing’ of data about experience at different analytical levels, such as Rae et al.’s (2018) comparison of PUTS ratings (which elicit trends of experience at the type level of tics) with token-level experiential data from the RHI experiment? If people with TS experienced some form of alienation, and if this alienation referred to the subject’s experience of their ticcing, we could ask whether that experience feels more like the ‘not-mine-ness’ of weak SO (de Haan and de Bruin’s version of alienation), or the ‘not-me-ness’ of lacking SA (Gallagher’s version of alienation), or perhaps a combination of the two. While de Haan and de Bruin say little about how the sense of agency is affected in ‘weak SO’ cases of schizophrenic alienation, their main point was to emphasise that schizophrenia not only affects the sense of agency, but also the sense of ownership. I suspect something similar could be said of SO and SA in Tourette Syndrome. We will now compare two examples of an intriguing mismatch between sense and attribution in TS and schizophrenia, with the aim of teasing out their differences and similarities.

5.3.3 Sense–Attribution Mismatch: Contrasting Schizophrenia and TS To clarify: Our purpose here is not to over-stretch the comparison between schizophrenia and Tourette Syndrome. Research comparing both conditions is still sparse, but we should note some curious emerging differences and similarities. Recall the mismatch between implicit perception and reflective judgement that Rae et  al. (2018) observed in their study participants with TS. Their reduced embodiment of the rubber hand (elicited via the implicit or objective measure) was not reflected in

5.3  Situating Tics

123

their explicit self-reports (the subjective measure), which showed normal embodiment ratings comparable with controls. Interestingly, de Haan and de Bruin (2010) comment on a similar mismatch between sense and attribution of ownership in schizophrenia: These patients … report a disturbing discrepancy between what they feel and what they know: the experience at the sense level and the knowledge at the attribution level run contrary to each other. Thus, although they might feel compelled to make an attribution of ownership, this does not guarantee an according sense of ownership at all (385–386).

That SO may be lacking completely in some cases of schizophrenic thought insertion or delusions of control is supported by patient narratives, which clearly outline not just a loss of authorship experiences (e.g., that they don’t generate the thought or movement), but also a loss of ownership of these thoughts and movements, which are attributed to an alien source (for examples, see de Haan and de Bruin 2010, 385). For first-onset schizophrenic patients, the experienced gap between sense and attribution of ownership can be very distressing, because “although they know that it is their body that is moving and realize that it must be their thought – after all, it is going on in their mind! – the utterly disturbing experience is that it just does not feel that way” (385). The fact that they might be compelled to attribute ownership to these thoughts or movements therefore does not ensure that they will have the relevant sense of ownership as well. As Parnas (2003, 219) notes, the first-onset schizophrenic’s doubting of their own anomalous experience dissipates in chronic schizophrenic patients: “Repeated experiences of rationally unjustifiable phenomena apparently lead to favouring the experiences above the reasons that denies [sic] their realness” (see also de Haan and de Bruin 2010, 385, note 16). The ‘as if’ feel of prodromal or early schizophrenia seems to disappear over time, and with it the disturbing conscious experience of a mismatch between sense and attribution, which may in turn weaken the capacity for self–other distinctions as the condition progresses. In Tourette Syndrome, patients do not report feeling ‘disturbed’ by a similar mismatch – evident from Rae et al.’s (2018) RHI experiment – between their reduced perceptual ownership of the rubber hand, and their reported subjective embodiment of it. While there is clearly a gap between their sense and attribution of ownership (a gap which, as we saw, correlates with the severity of their premonitory urges), there is little evidence that subjects are conscious of it. Put differently, while the sense–attribution mismatch stands out as deeply unsettling in the schizophrenic’s experience of their own symptoms, in Tourette Syndrome it may not be experienced at all (or perhaps not with such negative affect). What explains this difference? Firstly, the referent of ownership is not the same. In the RHI experiment, subjects disown an alien object (the rubber hand); in the examples cited for schizophrenia, subjects disown their own movements or thoughts. This fundamental difference means that we cannot really compare what is going on in both conditions until we have data about TS patients’ ownership experience of their own movements or thoughts – although I suspect that thoughts will be a less relevant referent of ownership in tic disorders. People with tic disorders may never experience a lack of

124

5  Agency and Ownership in Tic Disorders

ownership over their ‘normal’ movements or thoughts (such as reaching for a cup) but they may experience weak SO if these movements are symptoms of their condition, e.g. tics. Secondly, the sense–attribution mismatch observed in Tourette Syndrome varies from that noted in schizophrenia with regard to the objective accuracy of the perception that underlies SO. Rae et al.’s (2018) group of adults with TS rightly perceive that they do not own the rubber hand. In schizophrenia, subjects wrongly perceive of their thought or movement as not belonging to (or generated by, for SA) themselves. While both thus experience a ‘not-mine-ness’ of some sort, in TS this seems based on enhanced perceptive accuracy, and in schizophrenia on a loss thereof. (Recall that RHI experiments conducted with schizophrenic patients show enhanced embodiment of the rubber hand over controls, as opposed to reduced embodiment found in people with TS and also autism; see Rae et al. 2018, 374). This raises several phenomenological questions: Is there a qualitative difference between an experience of ownership when the perception that underlies SO is objectively ‘accurate’ (i.e., it corresponds with other inter-subjectively testable data) and an experience of ownership that is based on an objectively ‘inaccurate’ perception (i.e., it conflicts with other inter-subjectively testable data)?17 We can ask the same for agency experiences and also for attributions of ownership and agency – i.e., does it feel different to the subject when their agency or ownership attributions are based on accurate or inaccurate judgements of what is or is not the case? And, further, can there even be experiences of attributions, or experiences of the interaction between sense and attribution? The example of the schizophrenic’s negative affective response to their own sense–attribution mismatch suggests so and points to another crucial difference from the comparable mismatch dynamics in TS.  The attribution of ownership in schizophrenia responds to the perceived lack of ownership at the sense level; it is directed at the lack of SO, and seeks to correct it. In the words of a first-onset patient who feels as if he is in two different places at the same time: “I know it cannot be true. That would be nuts. But I feel that way” (quoted in de Haan and de Bruin 2010, 385). In Tourette Syndrome, at least in the RHI experiment, there is nothing ‘nutty’ about the perceived lack of ownership over the rubber hand, and the retrospective attribution of ownership does not seem to constitute a conscious corrective response to lacking SO. Here, sense and attribution appear to sit side by side, existing in a parallel fashion; or at least, the attribution of ownership is not experienced as a reflective response to a lacking perceptual counterpart. When the person with tics senses that the rubber hand is not theirs, but they judge it to belong to them, then this judgement may simply reference a belief or ‘knowledge’ about what is the case. It  Merleau-Ponty (2002) pursues similar questions in his work on hallucination, which also constitutes “an experience that is subjectively indistinguishable from perception, but which, unlike perception, presents the world incorrectly” (see Romdenh-Romluc 2007, 76). He does conclude that there is a phenomenal difference between hallucinations and normal perceptions, and he grounds this difference in the malfunctioning of two perceptual capacities which he calls “the power of summoning” and “perceptual faith”. 17

5.3  Situating Tics

125

may not refer to, and express doubt or disbelief about, their own perception and experience at the sense level. The person with TS may not experience or reflect on the interaction between their sense and attribution of ownership or agency (we cannot be entirely sure about this, of course, since Rae and colleagues did not test for this). Structurally, then, we could postulate different relationships between sense and attribution  – and possibly different experiences of, and judgements about, their interaction – where they do or do not refer to each other. In the RHI example of adults with TS (Rae et al. 2018), we look at parallel constructs like the sense and attribution of ownership and agency; but in the example of the schizophrenic, two other constructs emerge as highly relevant phenomenologically (and ultimately clinically, too): namely, the experiences of, and the judgements pertaining to, the sense–attribution interaction. To recap: The schizophrenic not only makes a judgement about his ownership of his own thoughts or movements, he also judges that his lacking sense of ownership contrasts with his knowledge of his own relation to the world. Here, SO becomes the direct referent of a secondary judgement or attribution. This means that there are two relevant attributions or judgements occurring in the schizophrenic example, which seem to constitute a unique experience expressed by schizophrenic patients’ strong (negative) affective response to the sense–attribution mismatch. Qualitatively, this second judgement (about SO) seems to connote doubt, disbelief, and carries unsettling implications about the cohesion of the self. This referential dynamic or ‘responding to’ can only proceed in one direction, from reflection to pre-reflective experience. Therefore, attributions can but need not reference experiences, while experiences (in so far as they are precisely not reflective) cannot reference attributions. However, it is conceivable that such judgments could, in turn, change or shape those very pre-reflective experiences in a complex, interactive process. How relevant is this construct of a sense–attribution interaction, and of secondary judgements and experiences resulting from such interaction, to the phenomenology of ticcing in TS? To answer this question, we will need more research into the sense and attribution of ownership and agency in Tourette Syndrome and primary tic disorders where the referents of ownership and agency are subjects’ own movements, body parts, or thoughts (symptom-related or otherwise). Given the crucial differences outlined above between the sense–attribution mismatch experienced in schizophrenia and TS, it is unlikely that people with tics would experience the same radical and disturbing loss of even weak SO that de Haan and de Bruin suggest occurs in certain cases of schizophrenic thought insertions and delusions of control (de Haan and de Bruin 2010, 386). Even in extreme cases of Tourette Syndrome, I suspect that people who report feeling “possessed” or “taken over”18 by their tics still experience these tics as occurring in their own bodies – after all, it is they who feel that their body is possessed! – so that the proprioceptive awareness of being

 These terms were used by people who have Tourette Syndrome when they described their experiences to me in conversations. 18

126

5  Agency and Ownership in Tic Disorders

moved (kinesthesia, or minimal SO) is intact, but the feeling of mineness for this movement (strong SO) may be lacking. And if strong SO is lacking, then the experience of this movement may be alienating or estranging, a hypothesis that aligns with the intriguingly common practice observable in people with TS of giving their tics a persona with a name (“it was Mr Tic, not me”, or “Fred did it!”). Anecdotally, the names and personalities people choose for their tics are commonly of the opposite sex, which may assist with the function of othering, distancing, and externalising that could underlie this practice. White (2007) has written extensively about the therapeutic power of “externalising conversations”, which aim to unravel “negative identity conclusions” (26) and help the person revise their relationship with their condition. In the phenomenological tradition, Ricoeur’s Oneself as Another (1992) examines the dialectic of self and other intrinsic to our narratives of personal identity. These and other works provide rich – and still un-tapped – resources for future research on Tourette Syndrome and tic disorders.

5.3.4 Returning to the Narrative Scale: ‘Who’s Making that Noise?’ It is not clear yet precisely what motivates people with TS to spontaneously name their tics as an ‘other’, but I suspect it is not just a psychological coping mechanism but also, and perhaps primarily, an expression of their lived experience of symptoms. As such, this practice intuitively ties in with our discussion of agency and ownership. When a 16-year-old girl calls her tics ‘Fred’ (who sometimes takes over), she can express her lack of felt agency – and perhaps a lack of strong ownership, too – over some of her own actions. In his autobiographical short story, ‘A Plague of Tics’, David Sedaris (1997) recounts his childhood growing up with TS and OCD, and here too, we encounter nuanced narratives of intricately interwoven agency and ownership experiences: It had come out of nowhere, my desperate urge to summon high-pitched noises from the back of my throat. These were not words, but sounds that satisfied an urge I’d never before realized. The sounds were delivered not in my voice but in that of a thimble-sized, temperamental diva clinging to the base of my uvula. ‘Eeeeeeee  – ummmmmmmm  – ahhhh  – meeeeeee.’ I was a host to these wailings but lacked the ability to control them. When I cried out in class, the teachers would turn from their blackboards with increasingly troubled expressions. ‘Is someone rubbing a balloon? Who’s making that noise?’ (19–20, emphases added).

Yes, who is making that that noise? Possessive pronouns indicate ownership over “my urge”, “my throat”, and “my uvula”, the last two indicating ownership over body parts, and thus perhaps constituting reflective attributions rather than a sense of ownership. The ownership experience of the urge could be perceptual, akin more to kinesthesia (weak SO) than mineness (strong SO), but this is ambivalent here. Interestingly, while the ultimate action – crying out in class – is couched in agentic terms (“I cried out”), this too looks more like a reflective attribution of agency. At

5.3  Situating Tics

127

the sense level, David feels like a host to the sounds that he cannot control. Both the motor and the intentional aspect of agency are lacking – or rather, they lie with that thimble-sized diva who clings to, and wails through, his uvula. Contrast this with Amy Wilensky’s memoir, Passing for Normal (2006), and we find no temperamental divas but rather ticcing body parts that take on an agency of their own. Confronted with others’ response to a rapid head-jerking twitch, Wilensky reflects: “Other people had noticed what I was doing with my head – what my head was doing to me, really” (42, emphasis added). Here, the issue with agency is not just a lack of motor control (“The motion was involuntary, although I had a certain amount of control over it”, 43–44), but rather that it lacks intentionality. Wilensky recalls “standing in front of the mirror watching my head move with no conscious instruction from me”, or “jutting out my chin or elbow for no apparent reason” (71, 69; emphases added). In other words, she has no sense of herself as the intentional author of these movements. In light of the ongoing debate in the literature on tic disorders, which tends to reduce questions of volition to motor control (see Chap. 4), Wilensky’s example highlights that such a reduction fails to capture an important aspect of the experience of agency – namely, its intentional aspect. At the sense level Wilensky perceives of her body parts as acting on her, but at the level of judgement she struggles to attribute agency to herself for these movements reflectively because they do not align with her (consciously held) intentions or reasons for acting. Literary examples like those offered by Sedaris and Wilensky provide a welcome starting point for exploring the richness and interplay of agency and ownership dynamics in tic disorders and Tourette Syndrome. They also highlight that we should expect to find “a pervasive interwovenness of SO and SA” and “a strong interaction between the two” (de Haan and de Bruin 2010, 382; see also Gallagher 2020; Longo et  al. 2008, 995). Put differently, if tic disorder symptoms impact agency dynamics it is unlikely that ownership remains unaffected, and vice versa. Further, literary examples also remind us of the importance of studying agency and ownership at the narrative scale, which – as we saw in Chaps. 3 and 4 – is all but absent from research into volition and free will in tic disorders. Experiments like the Rubber Hand Illusion and Libet’s paradigm are designed to probe ownership and agency at an elemental timescale; they cannot be used to study extended experiences of embodiment and intentionality that are, arguably, more representative of our everyday lives. For example, it is unlikely that we could “build a house” while participating in the RHI experiment, or “skilfully play Tetris” (Reynolds 2018, 161). And yet these kinds of complex, everyday embodied and intentional experiences should be of interest to us if we truly want to understand what it is like to live with a condition like Tourette Syndrome. Another issue with the RHI experiment is that it tempts us to over-rate the malleability of our bodily sense of self. As Reynolds notes, it would be wrong to conclude from the RHI that our bodily sense is nothing but “a fragile and only temporarily stable solution” (Hohwy 2013, 226). The experiment does not capture the pervasiveness of “a basic bodily awareness that serves as the fulcrum for narrative selves and is held to be a central problem for reductive explanations of any sort” (Reynolds 2018, 161).

128

5  Agency and Ownership in Tic Disorders

How the pervasively given, basic bodily awareness that constitutes our minimal (pre-reflectively conscious) sense of self is disrupted in conditions of disease and psychopathology is of central interest to research in applied philosophical phenomenology and phenomenological psychiatry. It also invites conversations with the cognitive sciences, toward a relationship of productive “reciprocal constraint” (Varela 1996) or “mutual enlightenment” (Gallagher 1997; see also Wheeler 2013, Dorfman 2013; Gallagher and Zahavi 2008, Carel 2016). If we remember that the quality of our everyday experiences may be quite ambiguous and “open to a description in terms of degree” (Gallagher 2012, 29), we can devise future studies that harness our nuanced theoretical constructs (e.g. of agency and ownership) – not to conflate these with, but rather to better understand, such lived experiences. I suspect that, for research on Tourette Syndrome and other tic disorders, a fruitful dialectic would see us juxtaposing phenomenological work on the universal characteristics of disease experiences with work on the particularity of what it is like to live with specific conditions like TS (e.g., Carel 2016; Toombs 1987). Future research on agency and ownership in tic disorders and Tourette Syndrome could link this broader work on the phenomenology of illness back to the existing research on agency and ownership, as well as on the purported experience of volition in tic disorders, which has emerged from experimental studies in the cognitive sciences over the last few decades (see Chaps. 3 and 4). Here, a more rigorous focus on qualitative aspects of experience, and a dual turn toward the experience of both symptomatic and everyday actions will be needed. Such qualitative insights into tic disorder symptoms beyond the ubiquitous reference to PU as experiential ‘givens’, and into the impact of these symptoms on other everyday experiences and actions more broadly, will help us to develop a more comprehensive psychopathology of tic disorders like TS.

5.4 Toward a Psychopathology of Tic Disorders We began this chapter by noting that despite some research into volition and agency in tic disorders the experience of ticcing itself is still not well understood. We looked at the example of a specific tic token, Pablo’s eye-blinking tic, and asked: What do we know about his experience of this particular tic event on the one hand, and about how these kinds of events tend to feel over time? Following this chapter’s discussion of the complex dynamics of the sense and attribution of agency and ownership, we can further expand on these questions: • If PU constitute a discrete experience distinguishable from tics, do subjects experience them as embodied and self-generated  – that is, as owned and authored – or not? In other words, what are the agency and ownership dynamics for premonitory urges? • The same can be asked of tics: If tics constitute a discrete experience distinguishable from PU, do subjects experience them as embodied and self-generated – that

5.4  Toward a Psychopathology of Tic Disorders

129

is, as owned and authored  – or not? In other words, what are the agency and ownership dynamics for tics? • Similarly, if urges and tics constitute distinct experiences, how do they affect each other  – i.e., what is their interrelationship? Put differently, how do the agency and ownership dynamics of subjects’ PU experiences impact the agency and ownership dynamics of their tic experiences, and vice versa? • Further, how do the agency and ownership dynamics of PU and/or tics impact how subjects experience other everyday actions and interactions? • And lastly, how do we reconcile phenomenological information about specific tic or other action tokens with information about broader trends of experience relating to certain types or occurrences of tics or other actions? Future research can use these questions as exploratory starting points toward developing a more comprehensive psychopathology of Tourette Syndrome and primary tic disorders. The wealth of work that remains to be done is laid out systematically in Fig.  5.1, which provides an overview of how agency and ownership and their respective interactions may be studied, both during symptom expression and during other actions. As Fig. 5.1 illustrates, we could devise a range of single-construct studies that focus on agency or ownership at the sense or attribution level during symptom expression or other everyday actions and experiences (a total of 8 combinations are possible). ‘Symptoms’ is used broadly to include tics, premonitory urges or sensations, certain thoughts, or obsessive-compulsive symptoms. In addition to these single-construct studies, we can envision many different multi-construct studies (a total of 28 possible combinations) that examine several constructs in parallel

Fig. 5.1  Overview of agency and ownership constructs and their respective interactions, which may be studied during symptom expression (e.g. tics) or other everyday actions

130

5  Agency and Ownership in Tic Disorders

(separate, but in one study), or that explicitly investigate their interaction. For example, Rae et al. (2018) studied sense of ownership (SO) perceptually and compared this with self-reported attributions of agency and ownership (AA and AO) for non-­ symptomatic action. When using Fig.  5.1, we should keep in mind that single-­ construct studies investigating SA commonly do not differentiate between the various contributories to a concept (e.g. motor and intentional aspects of agency; see Gallagher 2012). Future research should therefore delineate what aspect is being investigated and how. The same applies to the analytical level studied: Are we investigating concrete actions (tokens) or kinds of actions (occurrences or types)? It is also important to note that agency and ownership, and what we deem to be their contributories, are evolving concepts, and that different authors propose different ‘takes’ on what constitutes SO and SA. Here, we discussed de Haan and de Bruin’s notion of kinesthesia and mineness (weak and strong SO), as well as Gallagher’s multiple aspects approach above, but other approaches have been proposed (for example, see Lukitsch 2020). These nuances are simply absorbed under the headings of SA and SO in Fig.  5.1 but warrant explication in future taxonomies we might devise. Further, populating Fig.  5.1 with published research on volition, agency, and ownership in tic may not always be a straight-forward exercise. For example, while studies on volition inspired by Libet’s paradigm (e.g. Moretto et al. 2011; Ganos et  al. 2015; Mainka et  al. 2020; Zapparoli et  al. 2020) clearly do not investigate agency in the context of symptom expression but for a pre-defined experimental action (key-press), it is less clear how implicit or explicit the experience under investigation is. When subjects are requested to notice the emergence of a ‘conscious intention to move’ and to press a button when this conscious experience occurs, what is the act of pressing the button an expression of? Is it indicative of subjects’ pre-reflective sense of agency, or rather expressive of a reflective judgment about such perceptual experience occurring at the time? Perhaps both? For now, I have grouped these studies under single-concept SA research, but Libet’s paradigm and experimental measures are probably not implicit enough to warrant this. An alternative placement would see this work grouped under attributions of agency in non-symptomatic action, together with Delorme et al. (2016). These placements in Fig. 5.1 clearly deserve further discussion and are intended to stimulate future interdisciplinary efforts to systematize and compare how we employ constructs like agency and ownership in research on volition and voluntary action in tic disorders and beyond. Since we can expect experiences of agency and ownership to be phenomenologically ambiguous (in contrast to our neatly partitioned theoretical concepts), we should also think more deeply about these concepts’ seemingly straight-forward testability in the lab. Current experiments in the cognitive sciences employ implicit (objective) and explicit (subjective) measures of agency and ownership and imply that these distinctions are unproblematic. But it is not clear that the distinction between implicit and explicit measures maps neatly onto what we have described as pre-reflective experience and reflective judgement, respectively. As we noted, for example, it is not quite clear whether studies that use Libet’s paradigm elicit

5.4  Toward a Psychopathology of Tic Disorders

131

information about subjects’ pre-reflective sense of agency or about their reflective judgments regarding such perceptual experience. This problem may be more pervasive than what is commonly appreciated. We should thus confront ambiguity, not only within the first-person phenomenology of experience but also in the design of experiments aimed at eliciting it. While many have commented on the likelihood that subjective experience will be too ambiguous to reflect our nuanced theoretical concepts, it is just as likely that our concepts and related experimental measures are too blunt to capture important nuances of experience. From a clinical perspective, understanding such nuance in patients’ agency and ownership experiences, and recognizing when these present differently in people with tic disorders, promises several potential benefits. Firstly and fundamentally, better understanding the experience of illness-as-lived “can improve patient–clinician communication, increase patient compliance and trust, assist in medical teaching and training, and enable patients to better understand and order their own experiences” (Carel 2016, 35–36). Secondly, understanding when patients’ agency and ownership experiences are disturbed may also aid early intervention and care. We know from research into schizophrenia that anomalous self-experiences can already be elicited via patient interviews in the early, prodromal phase of the disease, a finding which has enabled better prediction and early intervention (see Sass and Parnas 2006). The EASE scale was developed specifically for this purpose (see Parnas et al. 2005). Such applied, disorder-specific research is of interest to Tourette Syndrome scholarship and care since it has fueled a critical debate about what aspects of experience are unique to schizophrenia and whether terms such as ‘self-­ disorder’ commonly applied in that context may legitimately be employed to describe other conditions as well (see Sass et  al. 2013). This body of work, and research aimed at establishing a broader comparative context for anomalous experiences of selfhood, agency and ownership, could help us develop and test new ways to capture experiential phenotypes in tic disorders, identify associated vulnerabilities for disease progression, secondary symptoms, and comorbidities, and ultimately align treatment priorities with such insights. To this end, it is paramount that we move beyond the philosophical straitjacket of the voluntary–involuntary divide, which has led scholarship to pursue the ill-­ fated goal of defining ‘the’ volitional status of tics (see Chap. 3), as if all tics are necessarily the same kinds of action or behaviours. This has foreclosed opportunities to explore the diversity of people’s experiences of their own tic disorder symptoms and other everyday actions. To truly understand this phenomenological diversity, we should expect similar nuance and complexity to emerge from the analysis of tics as intentional actions as our discussion of agency and ownership has yielded in the current chapter. When people tic or act affected by their symptoms, the world does not fall easily into a voluntary or involuntary camp. There are more fine-grained ways of speaking about the intentional action dynamics involved in ticcing, which we will explore in Chap. 6.

132

5  Agency and Ownership in Tic Disorders

References Aarts, Henk, Ruud Custers, and Daniel M. Wegner. 2005. On the inference of personal authorship: Enhancing experienced agency by priming effect information. Consciousness and Cognition 14: 439–458. Apps, Matthew A.J., and Manos Tsakiris. 2014. The free-energy self: A predictive coding account of self-recognition. Neuroscience and Biobehavioral Reviews 41: 85–97. Arendt, Hannah. 1954/2006. What is freedom? Between past and future. New  York: Penguin Classic. Belluscio, Beth A., Lily Jin, Veronica Watters, Tiffany H. Lee, and Mark Hallett. 2011. Sensory sensitivity to external stimuli in Tourette syndrome patients. Movement Disorders 26 (14): 2538–2543. Blakemore, Sarah-J, Chris D.  Frith, and Daniel M.  Wolpert. 1999. Spatiotemporal prediction modulates the perception of self-produced stimuli. Journal of Cognitive Neuroscience 11 (5): 551–559. Bliss, Joseph, Donald J. Cohen, and Daniel X. Freedman. 1980. Sensory experiences of Gilles de la Tourette syndrome. Archives of General Psychiatry 37: 1343–1347. Carel, Havi. 2016. Phenomenology of illness. Oxford: Oxford University Press. Cavanna, Andrea E., Kevin J. Black, Mark Hallett, and Valerie Voon. 2017. Neurobiology of the premonitory urge in Tourette’s syndrome: Pathophysiology and treatment implications. Journal of Neuropsychiatry and Clinical Neuroscience 29 (2): 95–104. Chaminade, Thierry, and Jean Decety. 2002. Leader or follower? Involvement of the inferior parietal lobule in agency. Neuroreport 13 (15): 1975–1978. Cohen, A.J., and James F.  Leckman. 1992. Sensory phenomena associated with Gilles de la Tourette’s syndrome. Journal of Clinical Psychiatry 53 (9): 319–323. Cole, Jonathan. 2016. Losing touch: A man without his body. Oxford: Oxford University Press. Curtis-Wendlandt, Lisa, and Jack Reynolds. 2021. Why Tourette syndrome research needs philosophical phenomenology. Phenomenology and the Cognitive Sciences 20 (4): 573–600. Daprati, Elena, Nicolas Franck, J. Nicolas Georgieff, Elisabeth Pacherie Proust, Jean Dalery, and Marc Jeannerod. 1997. Looking for the agent: An investigation into consciousness of action and self-consciousness in schizophrenic patients. Cognition 65 (1): 71–86. de Haan, Sanneke, and Leon de Bruin. 2010. Reconstructing the minimal self, or how to make sense of agency and ownership. Phenomenology and the Cognitive Sciences 9: 373–396. de Haan, Sanneke, Erik Rietveld, and Damiaan Denys. 2017. Being free by losing control: What obsessive compulsive disorder can tell us about free will. In Free will and the brain. Neuroscientific, philosophical, and legal perspectives, ed. Walter Glannon, 83–102. Cambridge, UK: Cambridge University Press. de Vignemont, Frederique, and Pierre Fourneret. 2004. The sense of agency: A philosophical and empirical review of the “who” system. Consciousness and Cognition 13: 1–19. Della Sala, Sergio, Clelia Marchetti, and Hans Spinnler. 1994. The anarchic hand: A frontomesial sign. In Handbook of neuropsychology, ed. Francois Boller and Jordan Grafman, vol. 9, 233–255. Amsterdam: Elsevier. Delorme, Cécile, Alexandre Salvador, Valerie Voon, Emmanuel Roze, Marie Vidailhet, Andreas Hartmann, and Yulia Worbe. 2016. Illusion of agency in patients with Gilles de la Tourette syndrome. Cortex 77: 132–140. Dorfman, Eran. 2013. Naturalism, objectivism and everyday life. In Human experience and nature: Examining the relationship between phenomenology and naturalism, ed. Havi Carel and Darian Meacham, vol. 72, 127–134. Cambridge: Cambridge University Press. Eatough, Virginia, and Jonathan A. Smith. 2017. Interpretative phenomenological analysis. In The SAGE handbook of qualitative research in psychology, ed. Carla Willig and Wendy Stainton Rogers, 193–211. London: Sage Publications Ltd. Eddy, Clare M. 2016. The junction between self and other? Temporo-parietal dysfunction in neuropsychiatry. Neuropsychologia 89: 465–477.

References

133

———. 2018. Social cognition and self-other distinctions in neuropsychiatry: Insights from schizophrenia and Tourette syndrome. Progress in Neuropsychopharmacology and Biological Psychiatry 82: 69–85. Eddy, Clare M., Hugh E.  Rickards, and Andrea E.  Cavanna. 2014. Physiological awareness is negatively related to inhibitory functioning in Tourette syndrome. Behavior Modification 38 (2): 319–335. Eilan, Naomi, and Johannes Roessler. 2003. Agency and self-awareness: Mechanisms and epistemology. In Agency and self-awareness: Issues in philosophy and psychology, ed. Johannes Roessler and Naomi Eilan, 1–47. Oxford: Clarendon Press. Farrer, Chloe, Nicolas Franck, Nicolas Georgieff, Christopher D.  Frith, Jean Decety, and Marc Jeannerod. 2003. Modulating the experience of agency: A positron emission tomography study. NeuroImage 18: 324–333. Franck, Nicolas, Chloe Farrer, Nicolas Georgieff, Michel Marie-Cardine, Jean Dalery, Thierry d’Amato, and Marc Jeannerod. 2001. Defective recognition of one’s own actions in patients with schizophrenia. American Journal of Psychiatry 158 (3): 454–459. Frankfurt, Harry G. 1988. The importance of what we care about: Philosophical essays. Cambridge: Cambridge University Press. Frith, Christopher D. 1992. The cognitive neuropsychology of schizophrenia. Hillsdale: Erlbaum. Frith, Christopher D., Sarah-Jayne Blakemore, and Daniel M. Wolpert. 2000. Abnormalities in the awareness and control of action. Philosophical Transactions of the Royal Society of London 355: 1771–1788. Gallagher, Shaun. 1997. Mutual enlightenment: Recent phenomenology in cognitive science. Journal of Consciousness Studies 4 (3): 195–214. ———. 2000. Philosophical conceptions of the self: Implications for cognitive science. Trends in Cognitive Science 4 (1): 14–21. ———. 2004. Neurocognitive models of schizophrenia: a neurophenomenological critique. Psychopathology 37: 8–19. ———. 2005. How the body shapes the mind. Oxford: Oxford University Press. ———. 2007. The natural philosophy of agency. Philosophy Compass 2 (j.1747–9991.2006.00067.x). ———. 2008. Self-agency and mental causality. In Philosophical issues in psychiatry: Natural kinds, mental taxonomy and the nature of reality, ed. Josef Parnas and Kenneth S. Kendler, 286–312. Baltimore: Johns Hopkins University Press. ———. 2012. Multiple aspects in the sense of agency. New Ideas in Psychology 30: 15–31. ———. 2020. Action and interaction. Oxford: Oxford University Press. Gallagher, Shaun, and Dan Zahavi. 2008. The phenomenological mind: An introduction to philosophy of mind and cognitive science. London: Routledge. Ganos, Christos, Luisa Asmuss, Jens Bongert, Valerie Brandt, Alexander Münchau, and Patrick Haggard. 2015. Volitional action as perceptual detection: Predictors of conscious intention in adolescents with tic disorders. Cortex 64: 47–54. Giorgi, Amedeo. 2009. The descriptive phenomenological method in psychology: A modified Husserlian approach. Pittsburgh: Duquesne University. Graham, George, and G. Lynn Stephens. 1994. Mind and mine. In Philosophical psychopathology, ed. G. Graham and G.L. Stephens, 91–109. Cambridge, MA: MIT Press. Haggard, Patrick. 2005. Conscious intention and motor cognition. Trends in Cognitive Sciences 9 (6): 290–295. Heavey, Christopher L., Russell T.  Hurlburt, and Noelle L.  Lefforge. 2010. Descriptive experience sampling: A method for exploring momentary inner experience. Qualitative Research in Psychology 7 (4): 345–368. Høffding, Simon, and Kristian Martiny. 2016. Framing a phenomenological interview: What, why and how. Phenomenology and the Cognitive Sciences 15 (4): 539–564. Hohwy, Jakob. 2013. The predictive mind. Oxford: Oxford University Press.

134

5  Agency and Ownership in Tic Disorders

Hohwy. 2015. Prediction, agency and body ownership. In The pragmatic turn: Toward action-­ oriented views in cognitive science, ed. Andreas K. Engel, Karl J. Friston, and Danica Kragic, 109–120. Cambridge, MA: MIT Press. Hurlburt, Russell T., and Sarah A.  Akhter. 2006. The descriptive experience sampling method. Phenomenology and the Cognitive Sciences 5: 271–301. Karp, Barbara I., Simone Porter, Camilo Toro, and Mark Hallett. 1996. Simple motor tics may be preceded by a premotor potential. Journal of Neurology, Neurosurgery, and Psychiatry 61: 103–106. Kurlan, Roger, David Lichter, and David Hewitt. 1989. Sensory tics in Tourette’s syndrome. Neurology 39: 731–734. Lang, Anthony. 1991. Patient perception of tics and other movement disorders. Neurology 41: 223–228. Leckman, James F., David E. Walker, and Donald J. Cohen. 1993. Premonitory urges in Tourette’s syndrome. American Journal of Psychiatry 150 (1): 98–102. Longo, Matthew R., Friederike Schüür, Marjolein P.M.  Kammers, Manos Tsakiris, and Patrick Haggard. 2008. What is embodiment? A psychometric approach. Cognition 107 (3): 978–998. Lukitsch, Oliver. 2020. Effort, uncertainty, and the sense of agency. Review of Philosophy and Psychology. (Published 31 may 2020). https://doi.org/10.1007/s13164-­020-­00486-­6, 955, 975, 11. Mainka, Tina, Steven Di Costa, Friederike Borngräber, Ewgenia Barow, Alexander Münchau, Christos Ganos, and Patrick Haggard. 2020. Learning volition: A longitudinal study of developing intentional awareness in Tourette syndrome. Cortex 129: 33–40. Marcel, Anthony J. 2003. The sense of agency: Awareness and ownership of action. In Agency and self-awareness: Issues in philosophy and psychology, ed. Johannes Roessler and Naomi Eilan, 48–93. Oxford: Clarendon Press. McGuire, Joseph F., Nicole McBride, John Piacentini, Carly Johnco, Adam B.  Lewin, Tanya K. Murphy, and Eric A. Storch. 2016. The premonitory urge revisited: An individualized premonitory urge for tics scale. Journal of Psychiatric Research 83: 176–183. Merleau-Ponty, Maurice. 2002. Phenomenology of perception. 2nd ed. London: Routledge. Metcalfe, Janet, and Matthew Jason Greene. 2007. Metacognition of agency. Journal of Experimental Psychology: General 136 (2): 184–199. Metcalfe, Janet, Teal S. Eich, and Alan D. Castel. 2010. Metacognition of agency across the lifespan. Cognition 116 (2): 267–282. Miyahara, Katsunori, Takuya Niikawa, Hiro Taiyo Hamada, and Satoshi Nishida. 2020. Developing a short-term phenomenological training program: A report of methodological lessons. New Ideas in Psychology 58: 1–17. Moretto, Giovanna, Petra Schwingenschuh, Petra Katschnig, Kailash P.  Bhatia, and Patrick Haggard. 2011. Delayed experience of volition in Gilles de la Tourette syndrome. Journal of Neurology, Neurosurgery, and Psychiatry 82: 1324–1327. Olivares, Francisco A., Esteban Vargas, Claudio Fuentes, David Martínez-Pernía, and Andrés Canales-Johnson. 2015. Neurophenomenology revisited: Second-person methods for the study of human consciousness. Frontiers in Psychology 6: 1–12. Pacherie, Elisabeth. 2006. Towards a dynamic theory of intentions. In Does consciousness cause behavior? An investigation of the nature of volition, ed. Susan Pockett, William P. Banks, and Shaun Gallagher, 145–167. Cambridge, MA: MIT Press. ———. 2007. The sense of control and the sense of agency. Psyche 13 (1): 1–30. http://psyche. cs.monash.edu.au/. Parnas, Josef. 2003. Self and schizophrenia: A phenomenological perspective. In The self in neuroscience and psychiatry, ed. Tilo Kircher and Anthony David, 217–241. Cambridge: Cambridge University Press. Parnas, Joseph, Paul Møller, Tilo Kircher, Jørgen Thalbitzer, Lennart Jansson, Peter Handest, and Dan Zahavi. 2005. EASE: Examination of anomalous self-experience. Psychopathology 38: 236–258.

References

135

Petitmengin, Claire. 2006. Describing one’s subjective experience in the second person: An interview method for the science of consciousness. Phenomenology and the Cognitive Sciences 5: 229–269. Pyasik, Maria, Dalila Burin, and Lorenzo Pia. 2018. On the relation between body ownership and sense of agency: A link at the level of sensory-related signals. Acta Psychologica 185: 219–228. Pynn, Laura K., and Joseph X. Desouza. 2013. The function of efference copy signals: Implications for symptoms of schizophrenia. Vision Research 76: 124–133. Rae, Charlotte L., Dennis E.O. Larsson, Jessica A. Eccles, Jamie Ward, and Hugo D. Critchley. 2018. Subjective embodiment during the rubber hand illusion predicts severity of premonitory sensations and tics in Tourette syndrome. Consciousness and Cognition 65: 368–377. Rae, Charlotte L., Hugo D. Critchley, and Anil K. Seth. 2019. A Bayesian account of the sensory-­ motor interactions underlying symptoms of Tourette syndrome. Frontiers in Psychiatry 10: 1–29. Reynolds, Jack. 2018. Phenomenology, naturalism and science: A hybrid and heretical proposal. London: Routledge. Ricoeur, Paul. 1992. Oneself as another. Chicago: The University of Chicago Press. Riemer, Martin. 2018. Delusions of control in schizophrenia: Resistant to the mind's best trick? Schizophrenia Research 197: 98–103. Rohde, Marieke, Massimiliano Di Luca, and Marc O.  Ernst. 2011. The rubber hand illusion: Feeling of ownership and proprioceptive drift do not go hand in hand. PLoS One 6 (6): e21659. Romdenh-Romluc, Komarine. 2007. Merleau-Ponty’s account of hallucination. European Journal of Philosophy 17 (1): 76–90. Sass, Louis, and Josef Parnas. 2006. Explaining schizophrenia: The relevance of phenomenology. In Reconceiving schizophrenia, ed. Man Cheung Chung, Bill Fulford, and George Graham, 63–96. Oxford: Oxford University Press. Sass, Louis, Elizabeth Pienkos, and Barnaby Nelson. 2013. Introspection and schizophrenia: A comparative investigation of anomalous self experiences. Consciousness and Cognition 22 (3): 853–867. Sato, Atsushi, and Asako Yasuda. 2005. Illusion of sense of self-agency: Discrepancy between the predicted and actual sensory consequences of actions modulates the sense of self-agency, but not the sense of self-ownership. Cognition 94: 241–255. Sedaris, David. 1997. Naked. London: Abacus. Shapiro, Arthur K., Elaine S. Shapiro, J. Gerald Young, and Todd E. Feinberg. 1988. Gilles de la Tourette syndrome. New York: Raven Press. Smith, Jonathan A. 2018. “Yes it is phenomenological”: A reply to Max Van Manen’s critique of interpretative phenomenological analysis. Qualitative Health Research 28: 1955–1958. Stephens, G. Lynn, and George Graham. 2000. When self-consciousness breaks: Alien voices and inserted thoughts. Cambridge, MA: MIT Press. Synofzik, Matthis, Gottfried Vosgerau, and Albert Newen. 2008. Beyond the comparator model: A multifactorial two-step account of agency. Consciousness and Cognition 17 (1): 219–239. Thakkar, Katharine N., Heathman S.  Nichols, Lindsey G.  McIntosh, and Sohee Park. 2011. Disturbances in body ownership in schizophrenia: Evidence from the rubber hand illusion and case study of a spontaneous out-of-body experience. PLoS One 6 (10): e27089. https://doi. org/10.1371/journal.pone.0027089. Toombs, S.K. 1987. The meaning of illness: A phenomenological approach to the patient-physician relationship. The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine 12 (3): 219–240. Trubody, Ben. 2014. “Ticced off”: An interpretative phenomenological analysis of the experience of Tourette’s syndrome. Existential Analysis 25 (2): 269–283. Tsakiris, Manon, and Patrick Haggard. 2005a. Experimenting with the acting self. Cognitive Neuropsychology 22 (3/4): 387–407.

136

5  Agency and Ownership in Tic Disorders

———. 2005b. The rubber hand illusion revisited: Visuotactile integration and self-attribution. Journal of Experimental Psychology: Human Perception and Performance 31 (1): 80–91. Tsakiris, Manon, Matthew R.  Longo, and Patrick Haggard. 2010. Having a body versus moving your body: Neural signatures of agency and body-ownership. Neuropsychologia 48 (9): 2740–2749. van Manen, Max. 2017a. But is it phenomenology? Qualitative Health Research 27 (6): 775–779. ———. 2017b. Phenomenology in its original sense. Qualitative Health Research 27 (6): 810–825. ———. 2018. Rebuttal rejoinder: Present IPA for what it is—Interpretative psychological analysis. Qualitative Health Research 28 (12): 1959–1968. ———. 2019. Rebuttal: Doing phenomenology on the things. Qualitative Health Research 29 (1): 1–18. Varela, Francisco. 1996. Neurophenomenology: A methodological remedy for the hard problem. Journal of Consciousness Studies 3 (4): 330–349. Weisz, John R. 1980. Developmental change in perceived control: Recognizing noncontingency in the laboratory and perceiving it in the world. Developmental Psychology 16 (5): 385–390. Weisz, John R., Keith O. Yeates, Dan Robertson, and Jean C. Beckham. 1982. Perceived contingency of skill and chance events: A developmental analysis. Developmental Psychology 18 (6): 898–905. Wheeler, Michael. 2013. Science friction: Phenomenology, naturalism and cognitive science. In Human experience and nature: Examining the relationship between phenomenology and naturalism, ed. Havi Carel and Darian Meacham, vol. 72, 135–168. Cambridge: Cambridge University Press. White, Michael. 2007. Maps of narrative practice. New York: W. W. Norton & Company. Wilensky, Amy. 2006 [1999]. Passing for normal. London: Pocket Books (Simon & Schuster). Woods, Douglas W., John Piacentini, Michael B. Himle, and Susanna Chang. 2005. Premonitory urge for tics scale (PUTS): Initial psychometric results and examination of the premonitory urge phenomenon in youths with tic disorders. Journal of Developmental and Behavioral Pediatrics 26: 397–403. Zahavi, Dan. 2019a. Getting it quite wrong: Van Manen and Smith on phenomenology. Qualitative Health Research 29 (6): 900–907. ———. 2019b. Applied phenomenology: Why it is safe to ignore the epoché. Conntinental Philosophy Review (9 April 2019), 1–15. Zapparoli, Laura, Silvia Seghezzi, Francantonio Devoto, Marika Mariano, Giuseppe Banfi, Mauro Porta, and Eraldo Paulesu. 2020. Altered sense of agency in Gilles de la Tourette syndrome: Behavioural, clinical and functional magnetic resonance imaging findings. Brain Communications 2 (2): 1–14.

Chapter 6

Tics as Intentional Actions: A Revised Taxonomy

Abstract  While the complexity and heterogeneity of Tourette Syndrome are routinely acknowledged today, we still lack attempts to understand this complexity through the lens of different ‘action types’ evident across the spectrum of primary tics. In this chapter, I develop the first taxonomy of tics as intentional actions by critiquing a historical source: Culver and Gert’s influential framework of human behaviour. Although their distinction between intentional, voluntary, and free actions is useful, I highlight several conceptual problems embedded in their classification. First, the idea of ‘unintendedness’ challenges the validity of their framework and raises problems common to theories of action. I offer two new concepts  – enactive spillage and normative load  – to illustrate why unintended actions cannot constitute a separate action class. Instead, the distinct interrelationships between intentions, actions, and their outcomes are offered as an alternative basis for classification. Next, I critique Culver and Gert’s notion of a ‘volitional disability’ and their division between internal versus external stimuli of actions as ill-suited to capturing the complex phenomenology of tics. I propose that an affordance-­based view of action as brain–body–environment interactions enables more fine-grained phenotyping of behavioural symptoms in tic disorders and beyond. Keywords  Intentional action · Nonaction · Action types · Tic disorder · Tourette Syndrome · Affordance · Interaction · Volition · Coercion · Not Just Right Experiences (NJRE) · Premonitory urge · Compulsion

6.1 The Trouble with Unintendedness 6.1.1 Intentional Is Not Voluntary Is Not Free We should not impose descriptive categories that fail to describe the full range of clinical manifestations. (Eapen et al. 1994, 855)

The complexity and heterogeneity of Tourette Syndrome are routinely acknowledged in contemporary tic disorder scholarship, but – surprisingly – no one to date © Springer Nature Switzerland AG 2023 L. Curtis-Wendlandt, Chasing Tourette’s: Time, Freedom, and the Missing Self, Philosophy and Medicine 145, https://doi.org/10.1007/978-3-031-19104-6_6

137

138

6  Tics as Intentional Actions: A Revised Taxonomy

has sought to understand this complexity through the lens of different ‘action types’ evident across the clinial spectrum of primary tics. This chapter addresses this gap by developing the first taxonomy capable of depicting the full phenotypic diversity of tics as intentional actions. In Chaps. 3 and 4, we saw that the volitional status of tics has been debated for decades, while a range of studies have also explored anomalies in voluntary, non-tic-related actions in people with Tourette Syndrome. However, explicit references to philosophical theories of action rarely appear in this body of work, or in the various versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The fact that the third, revised edition (APA 1987) explicitly references Culver and Gert’s Philosophy in Medicine (1982) in its definition of tics as ‘involuntary’ is remarkable, because it makes transparent the theoretical – and specifically philosophical – underpinnings that inform the Manual’s attempt at classifying behavioural symptoms. Later versions of the DSM no longer reference philosophical theories of action, nor their respective authors, in their entries on Tourette Syndrome and primary tic disorders, although the debate remains unresolved today. Given the ongoing complexity of discussions surrounding the volitional status of tics and the nature of freely willed action, it is worth us having a closer look at Culver and Gert’s taxonomy of human behaviour  – not because it nails the classification of such phenomena as tics and compulsions (I suggest it doesn’t), but because the framework provides welcome conceptual nuance which has all but disappeared from the contemporary debate. In their chapter entitled Volitional Disabilities, Culver and Gert (1982) provide a hierarchically structured classification system of human behaviour that distinguishes actions from nonactions, and then differentiates actions into those that are intentional or nonintentional, voluntary or involuntary, and free or unfree. That these three terms are not used synonymously is a key point of the taxonomy, as illustrated in Fig. 6.1. Central to this taxonomy is the idea that willing to do an action is not the same as having the volitional ability to will to do the action. The latter, but not the former, requires that the person who wills to do an action can also will not to do the action: “To have the ability one must be able both to will (do) and refrain from willing (doing). This is why one can do something intentionally (will to do it) and yet not do it voluntarily (not have the volitional ability to will to do it)” (Culver and Gert 1982, 112). The authors assert that “there is no temporal gap between willing and doing”, so that willing just is doing – or more precisely, “one wills to do X if and only if one intentionally does or tries to do X” (112). While this equation of willing and acting may evoke contemporary enactivist notions (on enactivism, see Sect. 4.1.1), Culver and Gert are far from espousing such ideas. On the contrary, they essentialise and internalise the ability to act as something solely about the person and her capacities, without regard for the agentic situation and what it affords the

6.1  The Trouble with Unintendedness

139

Fig. 6.1  Depiction of Culver and Gert’s (1982, 114) framework for classifying human behaviour

agent.1 Further, the author’s emphasis on the capacity to refrain from willing (doing) an action resonates with the tic disorder literature’s tendency to define tics as voluntary in so far as they are suppressible (i.e. the individual can will not to do the tic, and inhibit it). As we saw in Chap. 3, this requirement of (motor) controllability or inhibitory control is ambiguously ascribed to either tic tokens or tic occurrences in the contemporary literature, leaving the analytical level of attribution undefined. Although Culver and Gert do not use the same conceptual triad of tokens, occurrences, and types we introduced earlier (see Chap. 2), they do specify clearly that the volitional ability they speak of “is always related to a kind of action” (110). Put differently, as an ability it need not constantly be demonstrated behaviourally – at the token level – in order for it to be attributed. Rather, what matters is whether the person’s behaviour is responsive to coercive or noncoercive incentives. The former

 While Culver and Gert are not committed to “some special faculty of the will or to some special internal act of willing” (1982, 112), their concept of volitional ability does invoke certain philosophical assumptions regarding rationality and human behaviour. As they explain: “A complete understanding of volitional ability requires understanding the ability to believe” – for example, believing that there are incentives for and against doing X. Irrational beliefs are seen as indicative of the loss of this ability to believe and thus of the volitional ability to will to do (or not to do) a certain action: “It is interesting to note the strong connection between holding an irrational belief […] and lacking the ability to believe. We suggest that irrational beliefs are symptoms of mental maladies because they count as the lack of the ability to believe” (113). Rationalist theories of human action have since had many critics and proponents; for a classic work that equates rationality and free will, see Searle (2003). 1

140

6  Tics as Intentional Actions: A Revised Taxonomy

incentives are associated with “significant evil” (such as threat to one’s life, well-­ being, etc.) and they “almost always” guide the actions of people whose volitional ability is intact. Also, these people’s actions are guided at least sometimes by noncoercive incentives (see Culver and Gert 1982, 111). But those who have lost their volitional ability (i.e. who are ‘volitionally disabled’) fail to act on such incentives. For Culver and Gert, a clear case of a volitional disability is compulsive hand-­ washing, where someone “acts intentionally yet not voluntarily” (112): [The] compulsive hand washer […] believes that there are both coercive and noncoercive incentives for not washing his hands once every waking hour and yet does not act in ­accordance with these incentives, and indeed laments his failure to act. Such a person lacks the volitional ability to will to wash his hands.

Accordingly, the authors place compulsions into action Category C (unvoluntary actions). While I will argue shortly that this description of compulsive behaviour is problematic for a number of reasons (as is the authors’ grouping of tics with nonactions in Category E), the distinction between intentional and voluntary action offered here is relevant and useful. In fact, Culver and Gert assert that this very distinction is missing from the DSM-III, which wrongly conflates several action categories – particularly B and C (unfree and unvoluntary actions), as well as D and E (nonintentional actions and nonactions). We will now have a brief look at how each action category is defined in their framework of human behaviour before asking how these categories can disrupt and inspire our contemporary understanding of tics. Free Actions (Category A)  These are described as intentional (willed) and voluntary actions, i.e. the person has the volitional ability to will to do, or not to do, the action. There are no coercive incentives that necessitate the action, although noncoercive incentives may play a role. Category A actions are paradigmatic of the sorts of actions for which we attribute full responsibility to people in moral and legal contexts (see Chap. 8). A brief notation for this type of action could be: Free ( A ) = int + vol − coerc





Unfree Actions (Category B)  Like Category A (free) actions, these are described as intentional (willed) and voluntary actions. What makes them unfree is the presence of coercive incentives imposed by the environment (i.e., externally). The example given by Culver and Gert (1982) is that of Aristotle’s sea captain who, “in order to save his ship and crew, jettisons his cargo in a storm” (115).2 The external nature of this coercive incentive, the storm, is important; a point which reminds us of the emphasis placed by other authors on distinguishing between internal and

 The reference seems to be to Aristotle’s Nicomachean Ethics 1110a (see Aristotle and Brown 2009).

2

6.1  The Trouble with Unintendedness

141

external stimuli in their definition of movements and actions.3 Culver and Gert assert that, in a moral and legal context, we are less likely to hold someone fully accountable for these sorts of actions: The coercive incentive can be invoked as a type of excuse “to lessen or eliminate responsibility for doing something wrong or for the bad consequences of something one has done” (1982, 114). A brief notation for unfree actions might read like this:

Unfree ( B) = int + vol + coerc



Soon, we will challenge this distinction between external and internal factors that impact our actions in the context of an enactive, affordance-based approach to human agency (see Sects. 6.1.2 and 6.2.1 below). Unvoluntary Actions (Category C)  As mentioned, these are described as intentional (willed), but not as voluntary, because the person lacks the volitional ability to will to do, or not to do, the action in response to appropriate coercive or noncoercive incentives. The action thus results (and the person thus suffers) from a volitional disability. Returning to their example of the compulsive hand-washer, Culver and Gert assert that this “patient carries out his compulsion intentionally… but he does not do so voluntarily since he cannot will to refrain from washing his hands” (118). A notation could look like this:

Unvoluntary ( C ) = int − vol



We do not need to add any external incentives (coercive or noncoercive) to this notation, because Culver and Gert assert that their presence would have no effect on the action  – which is precisely the point of a “volitional disability”. Whatever such incentives, “in no normal situation would such a person act differently than he did in fact act” (116). We will come back to several issues this raises with regard to distinguishing unvoluntary (C) from unfree (B) and nonintentional (D) actions below. Nonintentional Actions (Category D)  These are described as actions that have an unintended outcome, as in the case of accidents and mistakes (for which we are held less responsible than for actions with intended outcomes). Importantly, Culver and Gert still consider these actions as willed in the sense that they involve doing something intentionally (124). At the same time, however, this intentional ‘doing’ also does something else that is not intended (as when a hunter shooting a bird in the woods accidentally injures a picnicker seated nearby). As the authors put it, “a person […] is intentionally doing something but not intentionally doing the action” (115). We will see below that this is framed awkwardly, for the intentional doing  In Chap. 3, for example, we discussed how Jankovic (1992, 8) describes movements generated by external, but not internal, stimuli as “responsive”, although he does not discuss how coercive these are. We also considered Karp et al.’ (1996) critique of this conceptual distinction between internal and external stimuli in the context of tic disorders.

3

142

6  Tics as Intentional Actions: A Revised Taxonomy

that is not the action is also an action (by way of its being done intentionally). How are we meant to capture this complexity in a notation? Are we clear on the relationship between intention and action, how many actions occur in this scenario, and what distinguishes actions from their outcomes? We cannot simply subtract intention from the action by writing ‘– int’ (minus intention) in our notation, because this would suggest that the action was entirely nonintentional, which Culvert and Gert insist it is not; only nonactions (E) are, which we should take care to define in their own right. The need for a more nuanced notation for intentional actions with unintended consequences confronts us with several conceptual challenges, which we will discuss shortly. Nonactions (Category E)  This final category purportedly describes behaviours or body movements (or lack of such movements) that involve no willing at all, meaning the person is not doing anything intentionally. Put differently, the movement or behaviour in question does not relate to or reflect an intention, meaning it is neither a failed nor a successful enactment of any intention. In so far as these movements or behaviours are not considered to be actions, we need no notation for them here; but for completeness sake, if we attempted one, we might start off with a negative description: Nonaction (E) = −int. A behaviour that lacks intentionality can never be described as voluntary or involuntary – the latter descriptors are not applicable to nonactions. (I will contest Culver and Gert’s placing of tics into Category E in Chap. 7.) But our purely negative notation for nonactions looks incomplete; we still need a positive descriptor (e.g. ‘do’ or ‘doNOT’) for the movement or behaviour (or its lack) in question:

Nonaction ( E ) = do / do NOT − int



We could, retrospectively, add this descriptor to all action categories, as ‘do/doNOT’ plus intention (‘int’) would apply to all of them as a baseline. Put differently, we could describe all actions, qua actions, as ‘do/doNOT + int’, and then add specifiers to describe the different categories of actions. But our notation for nonintentional actions (D) is still missing. Since (‘–int’) is reserved for notating nonactions (E), how should we depict the nonintentional aspect of what Culver and Gert awkwardly term nonintentional actions (D)? Since something is done intentionally that leads to an unintended outcome, we need to better define the relationship between intentions, actions, and action outcomes. After all, the notion of unintended consequences of actions is highly relevant to our understanding of tic disorders – for example, when symptoms involve obscene or socially inappropriate behaviours or self-­ injurious tics.

6.1  The Trouble with Unintendedness

143

6.1.2 Enactive Spillage and Normative Load: When Things Happen Anyhow Almost every action, as an ‘intentional doing or not doing of something’, may fail or succeed at enacting the actor’s intention and, by doing so, fail or succeed at having the intended effect. Searle (1983) acknowledges this possibility of failure or success by describing an action as “the condition of satisfaction of the intention to perform it” (92). Further, we can expect that any action, irrespective of whether it fails or succeeds at enacting the actor’s intention, may have other consequences that either correspond with and enact other intentions the actor does have (this could occur intentionally or accidentally) or that enact none of the actor’s intentions at all. This means that any ‘unintendedness’ is not a feature of an action per se (i.e. we cannot ascribe it purely by observing the doing) but of the relationship between an actor’s intention and the effect of her attempted enacting of this intention in the world. But if all actions, qua actions, are intended, then how can we speak of them as ‘nonintentional’? Further, if we can think of most enacted intentions as ‘doings’ that also have other, secondary effects (which may or may not correspond with the actor’s other intentions), then what is so special about unintended effects of actions? These are the conceptual challenges embedded in Culver and Gert’s notion of Category D actions, which we will revise below, and for which we are yet to develop a notation. What is special about ‘unintended effects’ of actions, I suggest, is not that some actions exhibit them and others don’t. Most actions do have unintended consequences, or effects that exceed the intention of the actor. The notion of unintended consequences is thus ill-suited as a foundation for a category of actions on, since all actions would be in that category. This relates to the famous notion of the “accordion effect” coined by Feinberg (1970, 34), which Searle (1983) discusses at some length in his analysis of complex intentions. Searle suggests that the unintended consequences of some actions should not be described as actions at all, but rather as “unintended occurrences that happened as a result of [an] action” (100). This makes sense in so far as these occurrences do not function as what Searle terms the “Intentional object” (101) of an actor’s intention: “The complex event which constitutes the action will also have all sorts of other features not presented by the Intentional content of the intention in action” (101). But does this mean we should discard any talk of “nonintentional actions” as defined by Culver and Gert (1982)? Not quite if we hear out Searle, who asserts that the accordion effect characteristic of complex enacted intentions involves different kinds of unintended action outcomes, some (but not all) of which may still be deemed actions. Take the example of Oedipus, who intends to marry Jocasta and, by doing so, happens to marry his mother. As Searle puts it, “‘marrying his mother’ was not part of the Intentional content of the intention in action, but it happened anyhow” (101). Put differently, “the total action had elements which were parts of the conditions of satisfaction of the intention in action and other elements which were not” (101). These other elements might be such things as the fact that, by marrying Jocasta, Oedipus also

144

6  Tics as Intentional Actions: A Revised Taxonomy

“moved a lot of molecules, caused some neurophysiological changes in his brain and altered his spatial relationship to the North Pole” (102), none of which Searle considers to be actions of any sort (not even unintended ones). Therefore, the ‘event accordion’, if we may call it that, extends well beyond the boundaries of the complex intention, or as Searle puts it, “the complex intention does not quite set the boundaries of the action, because of the possibility of unintended actions” (100). In other words, we could say that the total action may overspill the intended enaction (i.e., the intended part of the action). We end up with what I will coin ‘enactive spillage’ here, where the (failed or successful) attempt to enact an intention has unintended consequences. But what makes Oedipus’s moving molecules and causing neurophysiological brain changes different from marrying his mother? I argue that Searle is misguided in calling the latter an unintentional action and the former mere occurrences. The distinction does not hold up to scrutiny, and Searle himself is not quite sure how to explain the difference between both terms. A spatial metaphor of distance comes to his aid when he teases apart “those aspects of the complex event under which it is an unintentional action and those aspects which are so far from the intention that under them it is not an action at all” (102; emphasis added). He goes on to offer Dascal and Gruengard’s (1981) notion of a “field of possibility” of an agent’s intentional actions as a criterion that demarcates actions from occurrences. Based on this notion, an event would count as an unintentional action (rather than a mere occurrence) when it falls “within the field of possibility of intentional actions of the agent as seen from our point of view. Thus, marrying his mother is in the field of possibility for being an intentional action by Oedipus, but moving molecules is not” (Searle 1983, 102). We may object on two grounds. Firstly, and less importantly, we might counter that moving molecules could have been much closer to the ‘field’ of Oedipus’s possible intentional actions than marrying his mother (what could be further from his mind?). Secondly, and more importantly, I suggest – contra Searle – that this criterion for distinguishing between unintentional actions and mere occurrences fails to capture what is essential to the intuited difference. This essential feature is hidden in plain sight in Searle’s own suggestion, when he describes that it is we who judge whether an event falls “within the field of possibility of intentional actions of the agent as seen from our point of view” (102; emphasis added). As observers of Oedipus’s actions (or readers of his story), we enter a narrative social space infused with norms, rules, and values  – both our own and those we assume to hold in Oedipus’s life. Any judgements we may pass about whether or not an event falls into the field of possibility of his intentional actions will thus be relative to, and informed by, these contextual norms, rules, and values. Put differently, what we judge to be within the field of possibility of anyone’s intentional actions depends not on the events themselves, but on their pertinence to the very norms, rules, and values that pervade the actors’ and observers’ lifeworld – or, in Gallagher’s enactivist terms, the agentive situation with all its affordances (2020, 13). Gibson’s (1979) ecological psychology introduced the idea of affordance as specifying the relation between an agent and some aspect of the environment.

6.1  The Trouble with Unintendedness

145

Building on this broader relational concept, Gallagher develops his notion of action affordance more specifically, which supports a theory of action as irreducibly interactive. An action affordance has many sides: The “agent side” of the affordance contributes the physical details of the agent’s movement, but also her skills, intentions, motivations, knowledge, her perception of the action, and her interactions with others, while the “world side” of the affordance contributes objects and artefacts, as well as physical, social, and cultural aspects of the environment, and the effects or consequences of the action (2020, 12). Importantly, there is a “third side” to the action affordance too: “The side of the interpreters of the action” (12). When Searle introduces “our point of view” (1983, 102) as decisive in determining whether Oedipus’s marrying his mother could fall within the field of possibility of his intentional actions, he touches on this third side of the action affordance – that is, on us as interpreters of Oedipus’s possible intentions. And yet, despite his fleeting reference to the interpretive context of all actions, Searle insists on some intrinsic difference between unintended actions and mere occurrences in the way they ‘fit’ an actor’s possible intentions. This denies the very relational notion of action affordance that Searle himself intuits by referring to our observer’s perspective and its role in judging such fit. Here, Searle is tripped up by the accordion effect of his own ideas: He suggests more than he is aware of, and he pens thoughts that spill beyond his intended arguments on the page. Not unlike Oedipus, Searle unwittingly courts a different muse. If we take seriously the idea – intuited and then dismissed by Searle in the same breath  – that circumstance and perspective shape how ‘intendable’ we judge the outcome of an action to be, then Searle’s distinction between unintended actions and mere occurrences is in serious trouble. For the dictum that “actions carry along their full circumstances” (Gallagher 2020, 7) also means that there cannot be a single, fixed “field of possibility” (Searle 1983, 102; Dascal and Gruengard, 1981) of intentional actions that we could step into or out of. Such a field only forms around someone’s point of view; it can shift and is tied to the circumstantial perspectives of the actors and observers who judge its boundaries. Put differently, the notion of a ‘field of possibility’ is too unstable to accomplish what Searle wants it to accomplish: It cannot support the distinction between unintended actions and mere occurrences. There is nothing about Oedipus marrying his mother or moving his molecules that precludes one but not the other from being a possibly intended action. As long as we can see how either might be relevant to given circumstances, we can easily construe both consequences of his action as principally ‘intendable’. Of course, as long as we do not have reasons to attend to Oedipus’s moving of molecules or changing his brain chemistry, we will judge these events to be ‘outside the field’ of his possible intentions; but as soon as these events gain narrative significance, we will change our minds and attribute (unintended) agency to what we deemed to be mere occurrences before. I thus propose that Searle’s distinction between mere occurrences and unintended actions is not about some intrinsic features of action outcomes, but grounded in what I will call their ‘normative load’: We deem some occurrences not to be actions because they ‘add nothing to the story’ in our eyes – i.e. we judge them to

146

6  Tics as Intentional Actions: A Revised Taxonomy

be irrelevant with regard to the social norms, rules, and values that guide our actions and interactions. Again, it is worth stressing the relativity of these judgements. There is nothing intrinsic about Oedipus changing the neurophysiology of his brain or marrying his mother that makes one of these occurrences more action-like than the other. Both are ‘intendable’, or ‘within the field of possibility of intentional actions’, as we can easily imagine a scenario where Oedipus is so afflicted by some neurological condition that changing his brain chemistry becomes highly desirable and may greatly impact the narrative course of his life. But in most cases, the fact that he incidentally marries his mother when he marries Jocasta will be infinitely more interesting to us – and consequential to him – than the sort of subpersonal brain processes he is thereby affecting as well, which we are less inclined to attribute to his agency.4 We can conclude from this that the notion of unintended consequences alone is ill-suited to serving as a basis for a distinct class of action à la Culver and Gert’s Category D, since most or all actions would belong in that category (as would other events or doings not described as actions). Enactive spillage is pervasive, but in most cases, this spillage – like invisible ink – remains hidden in the background of the pages of our lives. Usually, the nonintentional aspects of what Searle calls the “total action” are not consciously attended to. It’s not that they aren’t there, it’s just that we are not focusing on them when they don’t matter to the story. Drawing on Gallagher (2020), we could say that there are certain possible descriptions of an action and its consequences that do not reflect or relate back to an actor’s intention; but we don’t usually describe actions in these ways – that is, we don’t use these possible descriptions unless they communicate something of relevance to us. But when touched by the ‘hot iron’ of what we care about, the invisible ink takes on a readable shade of its own: Writ across our storied lives, the enactive spillage’s normative load makes it stand out like a figure against the ground. The idea that different descriptions of an action capture different aspects of its context allows Gallagher to maintain that there is still just one action going on (see also Anscombe 1957): Oedipus marrying Jocasta is the same action as Oedipus marrying his mother, but both descriptions relate to different sets of circumstances of this action (2020, 9). Returning to Culver and Gert’s taxonomy, we can easily see that how we describe an action determines in which category we place it. On the one hand, we will want to say that the intentional dynamics of Oedipus marrying Jocasta are those of a free action (Category A) – or at least, that the action probably feels  Philosophers’ discussions of unintended actions commonly revolve around high-stakes examples of moral wrong-doings and tragedies involving incest, murders, and deaths. Evidently, their (and our) interest in unintended action is skewed toward normatively loaded cases. Apart from Searle’s incestuous example of Oedipus and Jocasta, there is Chisholm’s (1966) example of a nephew who intends to kill his uncle (originally introduced by Ducasse 1925), Davidson’s (1980) falling mountaineer, and others (see Thalberg 1984). Gallagher (2020) also recently worked with Anscombe’s (1957) example of the man who operates a water pump and thereby inadvertently poisons a household. But the risk of discussing unintended actions solely in the context of such highly loaded, normatively charged examples is that we overlook the simple fact that enactive spillage is pervasive, even though it does not always carry normative load. 4

6.1  The Trouble with Unintendedness

147

like that to Oedipus before he realises the unintended consequence. He intentionally and voluntarily marries Jocasta without being coerced to do so (do/ doNOT + int + vol − coerc). But the fact that this action also amounts to him marrying his own mother is a case of intentional spillage with high normative load which, had he known about it in advance, may have changed his plans to marry Jocasta in the first place. So, if we focus our description of the action on the fact that Oedipus marries his mother, we are less likely to label the action as free (Category A) in Culver and Gert’s sense, because we recognise that Oedipus lacked the information required for not willing to do so. As Gallagher writes: “Intention, motive, knowledge, skill level – these are aspects on the agent side of the affordance that contribute to the definition of the circumstance” (2020, 11). Without knowing who Jocasta truly was, Oedipus could not decide freely whether he wanted to marry his mother or not. Put differently, we could say that the situation did not afford Oedipus the opportunity to revise his intention and refrain from the action. So how do we label the action then? It clearly falls under what Culver and Gert (1982, 124) term Category D (nonintentional) actions, which are willed in the sense that they involve doing something intentionally (here, Oedipus’s marrying Jocasta), but which are not willed in regard to other salient consequences of this action (here, Oedipus’s marrying his mother). Culver and Gert’s own example – of a hunter who aims to shoot a bird in the woods but injures a nearby picnicker instead  – stresses the accidental yet consequential nature of what I have termed intentional spillage with normative load. Drawing on Gallagher’s notion of action affordance, we can now reframe the complex ‘intended but not intended’ nature of these actions, for which we are yet to find a viable notation. Since shooting a picnicker or marrying one’s own mother are socially salient (and morally and legally sanctioned) actions, it is impossible to describe them in purely motoric terms. We cannot neglect their social context or what Gallagher calls the actions’ “highest realised affordance” (Gallagher 2020, 11). This notion invites us to think of the different descriptions we can give of each action as hierarchically structured: The highest realised affordance describes the action “relative to the context that reflects a complete ordering of its different aspects”, and that “incorporates all of the other (lower-level) aspects of the action” (2020, 11). Not all of these aspects are intended; in fact, in the case of actions with socially salient but unintended consequences, the highest realised affordance of the action typically does not reflect the actor’s intention. There is, then, a gap between an actor’s description of her own action (which reflects her intention) and the description of that same action which specifies other salient meanings in context (as observed by others, or as offered by the agent herself in retrospect). In cases of unintended actions discussed by philosophers, the unintendedness of the action usually regards a higher (often socially salient) level of affordance. This is true of most examples of the accordion effect in the literature, among them Searle’s example of Oedipus, Culver and Gert’s example of the hunter who shoots a picnicker, and also Gallagher’s (2020) use of Anscombe’s (1957) example of a man who uses a water pump and thereby poisons a household that includes a head of state. But intentional spillage with normative load need not always be socially salient; the unintended consequences of an action may impact the actor without

148

6  Tics as Intentional Actions: A Revised Taxonomy

affecting her social lifeworld or interactions with others. In such cases, the unintendedness of the action regards a parallel or lower level of affordance. Notably, Culver and Gert’s (1982, 123–124) description of Category D actions does not commit us to a particular affordance level at which we should locate the gap between intention and outcome (or, more precisely, between the affordance level that reflects an actor’s intention and the affordance level of some salient yet unintended consequence of her action). It only commits us to the view that there is something salient about the intentional spillage that highlights it as accidental or unintended in the first place. As we noted before, in cases of intentional spillage without normative load (social or otherwise), the gap between intention and outcome remains invisible; but under normative load, we suddenly see it. If, in Culver and Gert’s example of the hunter who intends to shoot a bird, the bullet had hit a nearby tree instead of the picnicker, we would probably not feel normative pressure to attend to the effect of the ‘doing something intentionally’ (the failed enaction of the intention) in the same way as we are forced to do when confronted with the wounded human victim. The wounded human victim is the socially most salient description of the action, in a way that a wounded tree is not (unless it is a sacred tree or under heritage overlay, perhaps). Both failures to enact the intention are just that: failures to enact an intention; yet in the bullet-hits-tree scenario, we will likely only comment on the intention–action relationship (which is a mismatch qua failed attempt to shoot the bird), while we are free to disregard the tree-­ hitting effect of the action (which I suspect Searle would call an unintended occurrence, not a nonintentional action). In the bullet-hits-picnicker scenario, on the other hand, we will not only reflect on the failed enaction but also attend to the relationship between the intention and the action outcome, since the latter involves a wrongdoing for which the actor will be held responsible (and for which she may require what Culver and Gert call ‘excuses’). It is as if, under normative load, the intention, the action, and its consequence break apart; they appear incongruous, a triad of distinguishable entities. Conceptually, we should thus differentiate between various relationships: that of intentions and actions on the one hand, and that of intentions and action outcomes on the other. By identifying four possible match/ mismatch scenarios for the intention-action-outcome triad, we will be able to pinpoint the precise dynamics at play in Culver and Gert’s Category D (nonintentional) actions.

6.1.3 The Intention-Action-Outcome Triad: Four Match-Mismatch Scenarios Double-Match (Effective Enaction)  In a double-match scenario, the intention matches the action and its outcome. Any enactive spillage remains free of normative load. In the absence of a standard symbol depicting enactive fit, we could notate this as: INT [(int ↔ act) + (int ↔ out)]. We could shorten this to: INT (int ↔ act ↔ out),

6.1  The Trouble with Unintendedness

149

or just: int ↔ act ↔ out (see Fig. 6.2). We can call this double-match scenario an ‘effective enaction’, where an enaction just is the successful attempt to enact an intention, and it is effective because its outcome successfully references (or is coextensive with) the intended outcome (what Searle terms the “Intentional object”; see 1983, 101). An example of a double-match or ‘effective enaction’ scenario would be the hunter who intends to kill the bird and successfully does so. As mentioned earlier, this is an example of a Category A (free) action. We can also imagine a double-­ match scenario in the form of an unfree (Category B) action, where the intention is co-determined by, or responds to, coercive factors within the agentive situation (‘coerc’). The notation for this intentional action dynamic would be: INT [(intcoerc ↔ act) + (intcoerc ↔ out)]. We could shorten this to: INT (intcoerc ↔ act ↔ out), or just: intcoerc ↔ act ↔ out (see Fig. 6.2). Therefore, effective enactions characterise the intentional action dynamics of volition. As such they cannot represent the intentional dynamics of actions which Culver and Gert describe as lacking volition: namely, Category D (nonintentional) or C (unvoluntary) actions. Regarding the first-person experiences of agency and ownership, we can expect these to be intact in double-match scenarios, although in unfree actions the sense of agency may be impacted by the coercive contextual factors impacting the subject’s intention. By re-defining voluntary actions as effective enactions, I propose that we can re-­frame the question ‘Are tics voluntary actions?’ and instead ask ‘Are tics effective enactions?’. As I will argue, some tics may be just that, while many others probably are not. If we understand the term ‘voluntary’ as indicative of a match-match scenario between intentions and actions on the one hand, and actions and their outcomes on the other, then the tic disorder literature is right in questioning the use of this concept as a general descriptor for primary tics. By zooming in on their intentional action dynamics, we can see that not all tics are effective enactions, but feature a mismatch somewhere in the relationship between intentions, actions, and action outcomes.

Fig. 6.2  A taxonomy of primary tics as intentional actions

150

6  Tics as Intentional Actions: A Revised Taxonomy

Match-Mismatch (Ineffective Enaction)  In a match-mismatch scenario, the intention matches the action but not the outcome, so that: INT [(int ↔ act) + (int ⇹ out)]. We could shorten this to: INT (int ↔ act ⇹ out), or simply: int ↔ act ⇹ out (see Fig. 6.2). We can call this match-mismatch scenario an ‘ineffective enaction’, because the successful attempt to enact an intention fails to have the intended effect. But how is this even possible? Would we not say that an enaction which fails to generate the intended outcome is a failed enaction in the first place? Or can we enact an intention successfully without generating the intended consequence? The answer is yes, we can, because actions – or rather their descriptions – are perspectival. From the subject’s perspective (what we called the agent-side of the action affordance earlier; see Sect. 6.1.2), an action may be, or be perceived as, an effective enaction – at least initially, or for a certain period of time. Let’s return to our example of the hunter who intends to kill the bird: Imagine that she succeeds at doing all that is required to kill the bird (e.g. charging the rifle, aiming precisely, and firing the shot in a way which, all things being equal, should be lethal for the bird). Imagine now that the hunter’s friend is a bird lover who, earlier that day, secretly replaced the metal bullets in the rifle with benign rubber ones. Unaware of the deceit, the hunter fires her perfect deadly shot but – alas! – the bird fails to die as the feather-light rubber bullet drops to the ground well before reaching the animal. Now, we may argue over whether this interference by circumstance or other actors (here, the bird-loving friend) foils not just the hunter’s intended action outcome, but also her attempt to enact the intention, meaning we would have a double-mismatch scenario instead. In some sense that’s true, but in another sense it’s not – and first-person phenomenology is crucial in explaining the difference. From the hunter’s point of view, paraphrasing Searle, we can say that she did everything “in the right way” (1983, 82) to bring about an intended event – which then fails to occur, because the action does not meet all of the criteria that describe the conditions of satisfaction of the intention (92). Drawing on Gallagher (2020, 11–15), we could say that some of the aspects of the action – e.g., certain motor aspects – are successfully executed, but other aspects – e.g., those relating to the situation’s pragmatic and social context  – are not. We can imagine the hunter’s belated surprise upon realising that the bullets had been swapped without her knowledge. In retrospect, she will realise that her intended action failed, although she thought that she was doing everything right in the moment that she did it. Once she realises that there were rubber bullets in her gun all along, she will re-evaluate the action to have been an unsuccessful enaction of her intention (double-mismatch). Her perspective thus changes over time. And yet her bird-loving friend, the traitor, will not undergo such a change in perspective: She expects that her hunter friend’s attempt to kill the bird will fail, because she secretly replaced the bullets. In other words, she is banking on the hunter’s assumption to be doing everything that is required to kill the bird. Put differently, the bird lover predicts the situation to be a double-mismatch (an unsuccessful attempt to enact the intention to kill the bird), because she expects the hunter not to find out about the rubber bullets until she fires her first shot.

6.1  The Trouble with Unintendedness

151

So where does this leave us? We can note that this match-mismatch scenario describes a unique intentional action dynamic that cannot be understood unless we specify an agent’s subjective perspective and temporal dynamic tied to the enaction. In our example above, the hunter’s perspective is characterised by a lack of knowledge regarding some given factors that will thwart her action  and that, factually, make the attempted enaction unsuccessful. From our observer’s point of view the action dynamic is one of a double-mismatch all the way through, but from the hunter’s perspective the enaction is predicted to be, and initially perceived as being, successful (whether and how quickly an agent becomes aware of a factual doublemismatch can vary; we can imagine scenarios where she never finds out that the enaction failed to have the predicted outcome). But not all match-mismatch scenarios are necessarily double-mismatch cases from an objective point of view. As we saw in the example of Oedipus, the enaction can be genuinely successful (i.e. nobody would argue that Oedipus didn’t marry Jocasta) but people would say that this is only a partial description of the truth because the action has other salient consequences (normative load) that are not intended. In comparison, then, the examples of Oedipus and the hunter illustrate differences in the way that match-­ mismatch cases can materialise. While the hunter ultimately fails to do that which she intends to do, Oedipus succeeds but gets more than he bargained for. Both think they are doing one thing while doing another thing. In the hunter’s case, she is simply not doing what she thinks she is doing. In Oedipus’s case, he is doing what he thinks he is doing, and he is doing something else. What unites both cases experientially is a unique kind of ‘unintendedness’ that distinguishes match-mismatch scenarios from other cases of actions which lack volition. This unintendedness is characterised by a lack of knowledge about salient factors that impact the agentive situation – a lack which, once realised, leads to a retrospective change in perspective. Given this lack of knowledge, neither Oedipus nor the hunter have the opportunity to address those salient factors which, unbeknown to them, shape the outcome of their actions. We can thus say that they do not act with volition – although they still act intentionally. A match-mismatch scenario thus exhibits the intentional action dynamics of unvoluntary (Category C) actions, which we will distinguish from Category D actions in more detail below. For now, we can note that the coercion encountered in match-mismatch scenarios impacts the action, not the intention (which differs from voluntary unfree – Category B – actions, where coercive incentives shape the actor’s intention). However, as I will propose below, not all match-mismatch scenarios or Category C actions are characterised by a lack of knowledge, and thus a retrospective change in perspective, on the part of the agent. It is also possible that the agentive situation does not afford the agent certain resources or context conditions that would enable her to successfully enact her intention. Here, the agent may well be aware of the lack of these resources or context conditions that constrain her action, and she may experience an intentional conflict as a result. As we will see, tics can take the form of match-mismatch scenarios that lack volition and that may or may not involve conflicting intentions to act (see Sect. 6.2.2).

152

6  Tics as Intentional Actions: A Revised Taxonomy

Mismatch-Match (Effective Erraction)  In this scenario, the intention does not match the action but does match the outcome, so that: INT [(int ⇹ act) + (int ↔ out)]. We can shorten this to: INT (int ⇹ act ↔ out), or simply: int ⇹ act ↔ out (see Fig.  6.2). In our example of the hunter who intends to kill the bird, this would involve her failing to do that which, all things being equal, is required to kill the bird, but the bird dies anyway. Here, the hunter does not do what she intends to do, but the intended outcome still occurs by other means. Perhaps the hunter’s hand sways slightly to the left as she pulls the trigger (did she lose focus by suppressing a sneeze?), while the bird, stirred by the noise of some passers-by, flies right into the path of the swerving bullet that would have missed its target otherwise. We could call this an ‘effective erraction’, where ‘erraction’ denotes an erroneous attempt to enact an intention, and ‘effective’ denotes the fact that the intended outcome is nevertheless achieved. In our example, the agent’s behavioural error (the swaying hand) causes her to do something other than the intended action (not shooting straight at the sitting bird), but this error – ironically, we could say! – causally contributes to the intended action outcome occurring (the bird dies because it flies into the path of the swerving bullet). Note that not all mismatch-match scenarios require this causal link between the erraction (the failed attempt to enact the intention) and the intended outcome. Other factors could be entirely responsible for this, or at least co-contribute to the outcome. (In our example, the bird would not have died had the noisy passers-by not stirred the bird into motion.) So from a causal perspective these mismatch-match cases are complex. What we want to ask is how they are experienced by the acting subject. When Searle writes that: “Even though an event represented in the content of my intention occurs, it isn’t necessarily the satisfaction of my intention” (1983, 82), we want to know if and how this mismatch affects the subject’s experience of her own agency. Phenomenologically speaking, what is it like to act erroneously and yet to still ‘achieve’ the intended outcome? In our example of the hunter, she would likely still feel that she caused the bird to die, although the experience of her own erraction might diminish her sense of ownership and agency over the outcome. If the hunter had Tourette’s, her agency might not be so diminished, given her susceptibility to ‘illusions of agency’ (see Chap. 5’s discussion of a study by Delorme et al. 2016, which found that adults with TS wrongly attributed self-agency to externally manipulated outcomes that aligned with their intention). In cases where the causal chain of events is longer, less clearly tied to the agent, or further removed in time, mismatch-match scenarios may not feel like actions at all; they may look more like ‘freak’ occurrences (presumably also to people with Tourette’s, but this has not been tested empirically – that is, we don’t yet know how far we could push these illusions of agency in adults with TS, and whether they occur in children too). Phenomenologically, any surprise the agent experiences in mismatch-match scenarios regards the seeming effectiveness of her failed enaction achieving the originally intended outcome. The surprise is that the outcome did occur, despite the failed (or erroneous) attempt to enact the intention precisely as intended. This is the

6.1  The Trouble with Unintendedness

153

inverse “surprise experience” from match-mismatch scenarios, where the retrospective change in perspective relates to the failed or different outcome of the action. Often, and less surprisingly for the agent, behavioural errors or accidents land us in double-mismatch scenarios, where the intended outcome is not achieved. Since both mismatch-match and double-mismatch scenarios involve errors and accidents in the person’s enaction of an intention (erraction = int ⇹ act), we can group both under what Culver and Gert describe as nonintentional (Category D) actions, which – similar to Category C (unvoluntary) actions – still involve intentions but lack volition. Double-Mismatch (Ineffective Erraction)  Here, the intention neither matches the action nor the outcome: INT [(int ⇹ act) + (int ⇹ out)]. This can be shortened to: INT (int ⇹ act ⇹ out), or simply: int ⇹ act ⇹ out (see Fig. 6.2). We can call this double-mismatch scenario an ‘ineffective erraction’, because the failed attempt to enact the intention also fails to have the intended effect. Our original example of the hunter who tries to shoot the bird but injures the picnicker is just such a scenario, although our attention is quickly diverted from the surviving bird (which represents the failed outcome) to the normatively loaded yet unintended consequence of the hunter’s misfired shot: the wounded victim. Similar to mismatch-match scenarios, in a double-mismatch case the agent can usually attribute some error or imprecision to the execution of the movements and behaviours that constitute the failed enaction. The unintendedness associated with double-mismatch scenarios relates to the discrepancies between the intention and its failed enaction, and between the intention and the thwarted outcome. Any surprise or conscious attending to this unintendedness on the part of the actor (or an observer) will result from the fact that neither a successful enaction nor the intended outcome occurred, or because something else occurred that holds normative significance (as in the example of the wounded picnicker above). Ineffective erractions may or may not hold narrative interest; there is nothing about them per se that makes them more or less relevant than other action types from the perspective of social norms, rules, and values. Together with mismatch-match scenarios, double-mismatch cases involve errors and accidents in the person’s enaction of an intention (erraction = int ⇹ act) and can be grouped under what Culver and Gert describe as nonintentional (Category D) actions.

6.1.4 Nonintentional Actions Revisited Our analysis of both mismatch-match and double-mismatch scenarios has highlighted the idea that behavioural mistakes or accidents are crucial for a certain kind of ‘unintendedness’ of actions – the kind of unintendedness where the actor fails to enact her intention properly. So far, so clear. But Culver and Gert do not stop there: They offer two further examples of double-mismatch cases to illustrate what else

154

6  Tics as Intentional Actions: A Revised Taxonomy

constitutes nonintentional actions (Category D)  – namely, the so-called Freudian slip of the tongue (parapraxis), and a certain condition called ‘accident-proneness’. Neither of these are deemed genuine accidents or errors, which can be attributed to chance or bad luck (something we all experience on occasion). Freudian slips or accident-proneness, as Culver and Gert describe them, rather constitute meaningful behaviours or patterns of behaviour caused by, and expressive of, the individual. In the Freudian slip case, someone fails to say what they intended to say, but what they say instead is “often in basic conflict with the intended utterance” (1983, 124). The actual spoken words are “inconsistent with the meaning he intends to express but consistent with some second meaning, often opposed to the first, which seems to express attitudes or feelings that we know the speaker has” (124). Put differently, this sort of nonintentional action tells us something meaningful about the agent. Culver and Gert’s second example – accident-proneness – consolidates this point: As accident-prone, they describe individuals who “behave in ways that result in nonintentional self-injury” (123). We all occasionally injure ourselves by accident (hence the spectrum of actions describable as nonintentional), but Culver and Gert highlight cases “when an individual consistently does so with a frequency which seems too high to be due to chance alone” (123). In their eyes, these accidents are attributable to “unconscious needs or motives, such as guilt” (1983, 124). What emerges, then, is a meaningful behavioural pattern attributable to “the person himself” (124), where the nonintentional, accident-causing actions hold narrative and normative significance. If we accept the notion that unconscious needs and motives can ‘drive’ our actions (e.g. by derailing them, as in the case of Freudian slips or accident-­ proneness), then the question is how they can do so without being themselves intentional, or involving intentions. Put differently, if Culver and Gert want to suggest that unconscious needs or motives can intervene on intentional actions without themselves involving some ‘intention to act’, then we still need an explanation of how this works. Drawing on our earlier discussion of consciousness in Chap. 4, we may want to re-frame ‘unconscious’ to mean only pre-reflectively, not reflectively, conscious. If we were to permit for pre-reflectively conscious intention-formation (driven by unreflected needs or motives), then the examples of the Freudian slip and accident-proneness would be better described as cases of intentional conflict: that is, as cases where two intentions ‘vie’ for dominance over the actioned behaviour, or where the subject simultaneously tries to enact two different or competing intentions. In Category D (nonintentional) actions, the subject is not reflectively aware of this intentional conflict – by virtue of the underlying needs or motives being reflectively unavailable to the subject. But in Category C (unvoluntary) actions, we will encounter an intentional conflict that is fully experienced first-personally and that constitutes a match-mismatch case instead (see Sect. 6.2.4).

6.2  Testing Our Taxonomy

155

6.2 Testing Our Taxonomy 6.2.1 Challenging Dichotomies Equipped with this revised taxonomy, it is now time to consider the case of tics. As we saw in Chap. 3, many authors have suggested that tics are, or resemble, voluntary actions (e.g., Matsuda et al. 2016; Morand-Beaulieu and Lavoie 2019). Some of the reasons brought forward for this view are the partial suppressibility of tics (Matsuda et al. 2016; Stern 2014) and a perceived sense of volition accompanying the experience of ticcing (Lang 1991), as well as neuroscientific insights into cortical activity that suggests a voluntary component of tics (Niccolai et al. 2019). If we accept this view for a moment, the question arises whether any of the action categories in Fig. 6.2 can be employed to describe the symptoms of tic disorders. In the following, we will ‘test run’ our taxonomy in relation to symptom descriptions and examples from the tic disorder literature. The goal is to get clear on whether primary tics can be described as intentional actions, and how doing so would affect the longstanding debate about the volitional status of tics. Let’s begin with Culver and Gert’s ‘purest’ version of intentional voluntary actions. Could tics be Category A (free) actions, with an intentional action dynamic of: int ↔ act ↔ out? In principle, I suggest, there is no reason why some tics could not be deemed free actions, where the tic event (token) is the successful enaction of the person’s intention to make a movement or sound of some sort, perhaps to alleviate a sensory urge or pressure. The sort of intention at play here would probably be a basic motor intention and perhaps an intention-in-action but less likely a distal intention (see Gallagher 2017; see also Chap. 4). Such a description would only work if the stimulus inducing the latent tic action (e.g., the motor signal) was non-­ coercive, meaning the person could freely choose to act or not to act on that stimulus. Once urges or premonitory phenomena become what Culver and Gert call “coercive incentives” we would no longer describe the resulting tic action as free (Category A). Rather, we would look for an action category that contains some coercion or constraint – namely, unfree (B), unvoluntary (C), or even some nonintentional (D) actions. This is appropriate since, as we have seen, tics can be very difficult to resist behaviourally and are commonly preceded by premonitory phenomena. However, neither unfree nor unvoluntary or nonintentional actions as defined by Culver and Gert suitably describe the intentional action dynamics of tics. Why not? The problem lies in the way the authors allocate these action categories based on the stipulated source and impact of coercion. In unfree (Category B) actions, Culver and Gert insist that the coercion impacting the person’s intention is external (located within the environment) and situational – i.e. it only affects a particular action token (although we can easily imagine systemic and recurrent coercion suffered in certain political or even natural environments). This seems to rule out unfree (B) actions as a category for describing tics, given that the urges underlying tics are deemed to be pervasive and to arise within the agent herself, rather than externally. On the other hand, the coercion impacting

156

6  Tics as Intentional Actions: A Revised Taxonomy

the action in Category C actions (and also in Category D actions with an unreflected intentional conflict) is said to be internal (located within the agent) and pervasive – i.e. it affects entire kinds of actions (action types or occurrences). Does that mean tics are more like intentional unvoluntary (C) actions, which Culver and Gert ascribe to people suffering from obsessive-compulsive symptoms (recall their example of the compulsive hand-washer)? Although this sounds promising, Culver and Gert’s notion of a ‘volitional disability’ at play in Category C actions also prevents a good fit with tics (and, arguably, with Obsessive-Compulsive Disorder). To recap, having a volitional disability means that the person does certain types of actions irrespective of the presence or absence of coercive incentives that provide reasons for doing or not doing the action (Culver and Gert 1982, 112). Put differently, the person cannot will to do otherwise – she is not responsive to rational reasons for acting or not acting in this way.5 In unfree actions (B), where the coercion is merely external and situational (e.g. the storm threatening the captain’s ship), removing the coercion (storm) would free the person from the need to do the intended action (i.e., dump the cargo to save the ship). But with unvoluntary (C) actions, no matter how coercive the incentive or how good the person’s reasons to act differently, she would be highly unlikely to change how she acts (116). So are people with tics volitionally disabled in this kind of way? I suggest not; all the evidence suggests that tic expression and suppression are highly responsive to incentives and to reasons for acting or not acting – for example, in certain social situations. Put differently, we know that most people with tics can ‘will’ to tic or not to tic, up to a point – i.e., they can intentionally control their tics, at least partially and for some time, and even more so when incentivised to do so, as experiments have shown (e.g. Specht et al. 2014; see also Conelea et al. 2018). This responsiveness to contexts and reasons for acting thus also seems to rule out Category C as a description of tics. Similarly, the Category D actions that contain a coercive element (i.e., the unreflected intentional conflict scenario discussed earlier; see Sect. 6.1.4) are not a good fit, since primary tics are not thought to be caused by unreflected needs or motives – if they were, we would probably regard them as functional tics, or something similar (see Chap. 8). This leaves us with a problem, for neither Category B nor C actions, as defined by Culver and Gert, suitably describe the intentional action dynamics of tics. How, then, do we achieve ‘category fit’? Something has to give. Unless tics are not intentional actions after all (a view which I will rule out explicitly in Chap. 7), something must be wrong with Culver and Gert’s categories. As I will show, their definition of unfree (B) and unvoluntary (C) actions contains two unnecessary dichotomies: Firstly, the internal–external stimuli split, and secondly, the ability-versus-disability view of the ‘potential to do otherwise’. Neither of these, I propose, are necessary features of unfree (B) and unvoluntary (C) actions.  In fact, what is really different about B and C class actions – although Culver and Gert (1982) don’t spell this out – is that B actions are deemed rational but C actions are not. The volitionally disabled person is described as resistant to rational reasons for acting because she has lost the ‘ability to believe’ in what can reasonably be deemed to be true. 5

6.2  Testing Our Taxonomy

157

The External–Internal Stimuli Split  Theories of action commonly distinguish between external and internal drivers of actions. We touched on some of these theories discussed in the tic disorder literature earlier (see Chap. 3): Recall Jankovic’s classification which considers movements that respond to an external stimulus to be voluntary (1992, 8) and those that are induced by an inner stimulus to be ‘semi-­ voluntary’. Haggard (2008), who contrasts voluntary action with stimulus-driven actions more broadly, implies that external stimuli are less detrimental to volition than internal ones: “Whereas reflexes are immediate motor responses, […] the occurrence, timing and form of a voluntary action are not directly determined, or at best are only very indirectly determined, by any identifiable external stimulus” (934; emphasis added). Note that there is no mention of – and thus presumably no permission given to – even the faintest influence of an internal stimulus on voluntary action, no matter how very indirect such an effect might be. The stimulus-­ independence or ‘freedom from immediacy’ Haggard deems to be so central to voluntary action somehow seems more threatened by impulses located within the agent (2008, 934). I argue that this view is neither necessary nor satisfactory if we want to understand tics as intentional actions. Principally, there is nothing about the location of a stimulus that necessitates a categorical difference in the resulting action (although it may determine different experiences of such action on the part of the agent, as we saw in our discussion of agency and ownership in Chap. 5). Further, the dichotomous construction of external versus internal stimuli relies on a reductivist, individualist view of action which, while pervasive, is particularly ill-suited to explaining the action dynamics involved in ticcing. We already critiqued this internalist view of action earlier, when we used Gallagher’s (2020) notion of action affordance to argue against Searle’s (1983) essentialist distinction between unintended actions and mere occurrences (see Sect. 6.1.2). Here, we can use that same affordance-based view of action to critique the claim that the volitional status of externally triggered actions must differ categorically from that of actions which respond to internal stimuli. Tics don’t occur in a vacuum but are embedded in agentic situations that are co-­ determined by the agent, her environment, and any other observers or participants in the action (see Gallagher 2020, 12). Of course, tics tend to be discussed from an agent-centred perspective as if everything there is to say about tics is located within the ticcing person or, more reductivist even, within the ticcing brain. While it is undeniable that there is ‘something about the agent’ that makes her tic (which aligns tics with Category C, unvoluntary actions), and while it is also true that this ‘something’ (motor signals, urges, etc.) is pervasively present across a broad range of contexts, affecting entire kinds of actions (another Category C feature emphasised by Culver and Gert, 1982), we also know that environmental factors substantially contribute to, and act as known stimuli in, tic expression  – sometimes in surprisingly specific and context-dependent ways. In the case of tics, distinguishing internal from external stimuli that trigger tic expression thus becomes impossible at times – a point which resonates with Eapen et  al.’s earlier observations on stimulus-induced tics and obsessive-compulsive

158

6  Tics as Intentional Actions: A Revised Taxonomy

behaviours in Tourette Syndrome (1994): “There seems to be a continuum between internal and external phenomena that induce the[se] behaviours” (for example, from feeling a tightness in the chest to hearing other people cough or spit), and drawing neat dividing lines along this continuum is “extremely difficult” (855). I thus suggest that we cannot understand the action dynamics of tics appropriately if we do not embrace a more situated and embodied account of action as interaction. For one, inflating the difference between external and internal stimuli of action is counter-productive because it disregards the situated process of acting that cannot easily be subdivided into discrete events or “individual descriptive entities” (Eapen et al. 1994, 853) – we will try to do so anyway in Chap. 7, but it will get complex quickly. When Haggard comments that “responses to external stimuli usually have features of both reflex actions and voluntary actions” (2008, 936), we have good reason to think that the same holds true for certain intentional responses to intrapersonal stimuli like tic urges, too. This very idea was already put forward by Karp et al. (1996; see chapter 3), who suggested that different voluntary movements may have different “initiation strategies” and that in “patients with Tourette’s Syndrome, the [tic] triggering stimuli might be internal sensations” (106). The authors’ suggested expansion of what Jankovic (1992) called ‘responsive’ voluntary action elegantly avoids the rigid dichotomy of internal versus external stimuli, and invites us to revise Culver and Gert’s Categories B (unfree) and C (unvoluntary) actions accordingly. For there is nothing about internal stimuli per se that rules them out as ‘coercive incentives’ of voluntary unfree actions (B), or that necessitates the loss of one’s ability to respond to them intentionally (C), even when they affect entire kinds of actions. This is how I read Bliss’s reflections on his own Tourette Syndrome, in which he describes his responses to the “subtle, and dishearteningly insidious” sensations that precede tics as “almost inevitable”, yet intentional and voluntary (Bliss et al. 1980, 1343). Given Bliss’s emphasis on the intentional and ‘willed’ nature of these responses, he would most likely reject the suggestion that he suffers from a volitional disability à la Culver and Gert. The Inability to ‘Do Otherwise’ Under Coercion  The idea of a volitional disability, which is central to Culver and Gert’s Category C (unvoluntary) actions, may be an interesting construct, but it will rarely manifest in such absolute terms in tic disorders. It is beyond the scope of this chapter to explore whether this construct is useful for understanding phobias, addictions, and certain compulsions, which Culver and Gert also list as unvoluntary actions (1982, 119). For tic disorders, we can say that the notion of a volitional disability could at best mark the end point on a scale or continuum of an agent’s responsiveness to ‘incentives’ to tic or not to tic. As mentioned, people with tics often do intervene on their urge to tic, and they seem to do so intentionally. We also know that this ability to intervene on tics can be developed and strengthened clinically (e.g. via habit reversal therapy or acceptance-­ based approaches, see Chap. 4). This does not mean that such intervening is easy to achieve, but it shows that it is possible, at least sometimes and in some contexts. The ability to do so functions less like an on-off switch and more like a scale or continuum that reflects contextual factors in the person’s environment (the ‘world side’ of

6.2  Testing Our Taxonomy

159

the action affordance; see Sect. 6.1.2); the nature of the sensation or urge preceding the tic (internal stimuli); and certain skills, knowledge, and psychological resources that shape the ‘agent side’ of the action affordance (e.g. interoceptive awareness, emotional regulation, and attentional focus, at least in so far as certain suppression strategies require conscious attending-to-sensations; see Chap. 4). More fundamentally, we could argue that the construct of a volitional disability is flawed at heart, because it construes unvoluntary intentional actions as essentially irrational (Culver and Gert 1982, 113). But in the case of tics, the ability to intentionally intervene on sensory impulses or urges has nothing to do with individuals’ responsiveness to coercive reasons for acting, and everything to do with the requisite action affordance: the agent’s resources and practical know-how, but also the environmental aspects that enable or impede such interventions. As we will see, it also seems to have to do with the presence or absence of certain competing intentions (more on this below). With regard to practical know-how alone, developing the skills required to intervene on tics can be extremely difficult. Bliss describes the kind of interoceptive acuity required for individuals to perceive of tics as being under their intentional and voluntary control (Bliss et al. 1980, 1344): The inception and emergence of a single action and its passage into the overt phase is so faint, subtle, surreptitious, and lightning fast that rarely is it known to the subject that it exists at all. The assumption, then, is that there is only the flow of action almost from limbo to movement, unsignalled and involuntary, as uncontrollable as a twitching nerve.

But when the subject learns to detect these subtle signals, intentional action becomes possible: “The first [signal] seems irresistible, calling for an almost inevitable response. It is possible to apprehend it at this point, to recognize it, and to realize that it can be studied, modified, or even temporarily extinguished” (1344). Bliss’s example shows how developing certain skills can afford the individual new opportunities for intentional action, broadening her agentic horizon. His accounts cast intentional action in the context of tics as the conscious intercepting of tic signals and their near-automatic behavioural responses – a view which resonates strongly with contemporary behavioural therapies like CBIT (Comprehensive Behavioural Interventions for Tics; see Chap. 4). Surely, learning and consistently implementing the requisite skills will be easier for some than for others, and we should allow for a broad spectrum of greater or lesser ‘intervenability’ on tics in clinical populations, depending on intrapersonal and contextual factors. But positing an immovable volitional disability as a blanket descriptor of individuals’ relationship with their tics seems counterproductive and misses the characteristic variability observed in TS. Having critiqued these two dichotomies contained in Culver and Gert’s unfree (B) and unvoluntary (C) actions, we can now re-define how coercion plays out in both categories. Firstly, we need to discard Culver and Gert’s notion of ‘incentives’. We need to do this because we do not want to commit to the psychological nature – e.g. an irrational belief or volitional disability – of the constraint or coercion impacting the action in unfree or unvoluntary actions. Instead, I propose that coercion stands for constraining or enforcing factors located anywhere within the agentive situation (i.e. within the agent or the environment or both). We need not distinguish

160

6  Tics as Intentional Actions: A Revised Taxonomy

between internal and external factors, as these do not serve as appropriate dividing lines between action categories (although they may be helpful in differentiating subjective experiences of action). Similarly, in our notations (see Fig. 6.2), ‘coerc’ may include occasional or pervasive influences that affect individual actions (tokens) or entire kinds of actions (types or occurrences). With these amendments in place, fitting tics into our taxonomy becomes surprisingly easy.

6.2.2 A Tic for Every Category? If voluntariness indicates that, all things being equal, the person intends to act the way she acts, could tics be such actions? We argued earlier that it is possible to conceive of some tics as free (Category A) actions, if the motor impulse is not perceived as coercive. But we could not fit tics into Category B, because Culver and Gert had defined those actions as externally coerced particulars (tokens). Now that we have redefined unfree (B) actions, the category applies whenever a person is constrained or coerced to act in the way she acts, and when she intends to act in this way given the constraint. This opens up Category B as a potential descriptor for tics. To see how this applies, let’s dive a little deeper here into the dynamics of volition. In both free (A) and unfree (B) voluntary actions, the intended outcome resulting from a person’s action looks preferable to her than that resulting from any other action she might take, which is why she intends to act in the way she does. In an important way, her intention reflects and aligns with the action outcome she attempts to enact, no matter whether she is responding to coercive influences (B) or not (A). While in unfree voluntary (B) actions, the person may wish for the situation to be different – i.e. by wishing the constraint away – she nevertheless has no intention to act otherwise in light of the constraint. Put differently, she experiences no ‘competing intention’ to act (or if she does, the enacted intention will be the preferable one). Any cognitive-affective responses she may have to the coercive situation (e.g. shock, resentment, anger, regret, shame, surprise, etc.) do not translate into the formation of what I will call here a ‘preferred competing intention’, i.e. an intention to act differently from the way she reacts to the coercion. As noted earlier, the coercion impacts the intention – that is, the person responds intentionally to the presence of this coercion or constraint (intcoerc ↔ act ↔ out; see Fig. 6.2). What is decisive for unfree actions, then, is that the action aligns with the person’s preferred intention for action, all things being equal. This may well describe certain tics. Let’s say a person with Tourette Syndrome experiences a strong build-up of tension in her neck and an urge to release this tension by flicking her head backwards. If there are no competing intentions to suppress the urge, or if relieving the urge seems preferable over other possible responses, we could say that the person who ‘does the tic’ acts unfreely but with volition (B). If ‘enacting the tic’ aligns with the person’s preferred intention for acting, all things being equal, then this tic could be described as an unfree effective enaction.

6.2  Testing Our Taxonomy

161

Importantly, not every person with tics may experience their tics in this way – but some might. Put differently, not all tics need to exhibit the intentional action dynamics characteristic of unfree voluntary (Category B) actions. Someone who advocates for this view of tics as intentional voluntary actions is Bliss, whom we quoted earlier. On intention, he writes: “The intention is to relieve a sensation, as surely as the movement to scratch an itch is to relieve the itch” (see Bliss et al. 1980, 1344). And yet, even for Bliss, there is something so relentlessly coercive and persistent about these sensations that he comes close to questioning the purported volition involved in ticcing: “Often the effort to control these wild sensations seems to be more than the human spirit can bear; there are really only two choices: let it all hang out or keep fighting” (1345). But if the urge to tic is “(almost) intolerable” (1345) as he suggests, perhaps we should consider tics to be intentional actions that lack volition instead? This might indeed be more appropriate in some cases. In fact, I propose that a special case of Category C actions will allow us to highlight the intentional conflict that seems to characterise many tics (and possibly compulsions, too). To spell out this dynamic, we need to remember how coercion impacts unvoluntary (C) actions. Here, the person is forced or compelled to act in the way she does, but all things being equal, the way she acts is not in line with her preferred intention for action. That is, the person would act differently if she could despite the constraint. (In Category B actions, the person wants to act the way she does because of the constraint.) Two quick examples will illustrate this subtle but important difference. First, imagine Mia, who has Tourette Syndrome, and who has learned to execute a competing behavioural response instead of a painful head-jerking tic that has troubled her in the past. She is all on her own, sitting comfortably on her bed and reading a book, when she feels the urge to jerk her head and – without attending to the sensation for long – decides to ‘let it out’, doing the tic. (At the dinner table she will use her competing response again to redirect this urge, so as to enjoy eating and talking with her parents without disruption.) Now compare this with Pablo, who also has TS and who is out with his family at a restaurant for his birthday. Sitting excitedly in his chair, he can feel the urge to jerk his head and instantly becomes anxious: Not here, not now! This is one of his worst and most painful tics! The dining room is noisy with fast-paced background music and the chatter of other guests, and Pablo feels on edge. He wants to get rid of the urge, which feels increasingly unbearable; and yet he also wants to avoid people staring at him, intrigued by his weird demeanour. Once Pablo succumbs to the urge to tic, an entire cascade of head-jerks follows in rapid succession, leaving him tense and exhausted before he has even ordered his meal. These two examples of Mia and Pablo illustrate the different intentional action dynamics that characterise unfree (B) and unvoluntary (C) actions respectively. Mia’s head-jerk while reading her book exemplifies an unfree action: coerced, yes, because the urge is strong enough to compel her to act on it. But Mia has no preferred competing intention – she would not rather act differently in response to the urge. (And if she did want to respond differently to the urge, we know she could, since she flexibly uses a competing response in other situations.) In an important

162

6  Tics as Intentional Actions: A Revised Taxonomy

way, then, we could say that the coercive factor (described here as the urge) does not limit Mia’s possible intentional responses to this very coercion. The situation still affords her other potential actions, facilitated by her skills. And yet, while she could respond differently to the urge if she wanted to, she quite happily forms an intention to act on it. This intention does not conflict with any other intentions she may have in the moment that she tics. In contrast, Pablo’s head-jerk at the restaurant exemplifies an unvoluntary (C) action: Coerced, because the urge is strong enough to compel him to act on it. But Pablo also has a competing intention – he would rather act differently in response to the urge, i.e. he would rather suppress his tic. But for a number of reasons, he is unable to do so in the given situation, which nicely illustrates the range of agentand environment-specific factors that can compound the coercion at play: For Pablo, it is not just the tic urge that eventually drives him to jerk his head, but it may also be his thoughts and feelings (excitement, fear), as well as environmental contributors such as the noise and the presence of strangers nearby. In an important way, then, we could say that these coercive factors, taken together, limit Pablo’s possible intentional responses to his perceived urge to tic. The situation affords few if any alternative actions. All things being equal, Pablo could not respond differently to the urge in this instance, although he would like to (and may be able to in other situations). So when he acts on the tic, he is not enacting his preferred intention. For his intention to alleviate the urge conflicts with his intention to fit in socially and to enjoy his birthday dinner without the embarrassment of unwanted public attention. In terms of the match/mismatch scenarios we discussed earlier, we could say that, in unvoluntary (Category C) actions, the action outcome matches an intention but does not match the preferred intention (i.e., the intention which the person would prefer to enact if she could). It is interesting to note that in Pablo’s scenario his intention to relieve his urge and thus to tic represents what Gallagher and Marcel (1999, 8–9) describe as a relatively “abstract” or decontextualized intention, here limited to a specific movement engendered by the urge to tic (see Chap. 8 for details). In comparison, Pablo’s competing intention – i.e. his intention to suppress the tic, which he would like to but cannot act on – could be described as an intention that responds to the affectively charged social context that Pablo finds himself in. Ironically and unfortunately, this very social context (and Pablo’s perception of it) amplifies the perceived coercion to enact the more abstract, decontextualised intention to jerk his head. Therefore, in unvoluntary (C) actions, the coercion that characterises the agentive situation directly impacts the agent’s action affordances, and thus the range of intentions they can enact. We could say that the coercion directly constrains the available actions, rather than merely shaping intentions as in unfree (B) actions. The difference is subtle but important: Where an agent who acts unfreely could but does not want to act differently, an agent who acts unvoluntarily wants to but cannot act differently. The latter agent, but not the former, experiences an intentional conflict. Our affordance-based view of coercion in Category C action is not only significant for understanding tics but actions more broadly construed. Rather than positing an agent-internal essential disability to act in a certain way (which Culver and Gert

6.2  Testing Our Taxonomy

163

found on the person’s inability to believe what seems true), the notion of action affordances drives home the limits of such rationalist explanations for action. As Gallagher notes, such explanations tend to be abstractions: “It’s also possible, and I tend to think this is usually the case, that … what is often driving action is a set of perceived affordances rather than a set of beliefs and desires” (2020, 21) – and we may add that the same holds true for what is constraining actions too. This means that “actions may be motivated more by ambiguous or problematic circumstances or other people’s action than by an agent’s desires and beliefs” (2020, 21). Clearly, the notion of an intentional conflict experienced in certain unvoluntary (Category C) actions resonates with the idea that the agent finds herself in an ambiguous or problematic situation that constrains her possibilities of action. Of course, not all Cagetory C actions are intentional conflict scenarios, but we already foreshadowed the differnt notations in Fig. 6.2 (see Sect. 6.1.3). To briefly explain this here: Our notation for standard cases of unvoluntary action (int ↔ actcoerc ⇹ out) suffices for those unvoluntary actions where no intentional conflict is present – for example, in the scenario of the hunter whose gun had been meddled with by her bird-loving friend. Since the hunter did not know that her metal bullets had been replaced with rubber ones, her enaction of the intention to kill the bird (while partially successful with regard to the motor execution of the required shooting action) was doomed to fail. Similar to Pablo’s example above, the coercion here also constrains the action affordances directly (i.e., the hunter could not have done otherwise). The difference is that Pablo experiences two competing intentions because he experiences the coercive constraints impacting the situation as it unfolds. The hunter, on the other hand, is not aware of such constraints initially and thus experiences no competing intentions, but is likely to feel surprise when the coercion (her friend’s secret interference) becomes apparent to her. Therefore, Pablo’s reasons for not being able to act otherwise at his birthday dinner differ from the hunter’s reasons for not being able to act otherwise at the park. And yet, while Pablo and the hunter may experience their unvoluntary actions differently (we might predict that sense of agency (SA) or sense of ownership (SO) will be weaker for the hunter, since the coercion is clearly extraneous to the agent), structurally they are very similar. In both cases, the coercion is such that the agent cannot intentionally respond to it in the way they would like to if they could. So, if (int ↔ actcoerc ⇹ out) accurately depicts the hunter’s unwitting rubber bullet shot, then how should we notate the intentional conflict that characterises Pablo’s unvoluntary tics at his birthday dinner? We need a way to notate the competing intentions at play. To do so, we will simply contrast two intentions, ‘int1’ and ‘int2’ (although theoretically there could be more at stake). We will assume that ‘int1’ is the intention enacted under the influence of coercion, but that it is not the intention the agent would like to enact, given the coercion. The preferred competing intention, ‘int2pref ’, is not enacted, because the situation does not afford the agent the opportunity to do so. The intention–action relationships thus looks like this: (int1 ↔ actcoerc) + (int2pref ⇹ act). Now, we also want to depict the relationship of the action outcomes linked to the relevant intentions, so we will number these accordingly as well: (int1 ↔ actcoerc ↔ out1)  +  (int2 ⇹ act ⇹ out2pref). We therefore have one

164

6  Tics as Intentional Actions: A Revised Taxonomy

double-­match and one double-mismatch dynamic: int1 is successfully enacted, but int2 is not. So why would we classify this as a match-mismatch scenario overall? I suggest that the structural similarity between standard match-mismatch scenarios (like the hunter’s rubber bullet shot) and intentional conflict scenarios (like Pablo’s tic-or-suppress battle) means that we can subsume the latter under the former via a simplified match-mismatch notation: int1 ↔ actcoerc ⇹ out2pref. That is, int1 is enacted (match) due to coercive constraints, while the outcome that represents the agent’s preferred intention, out2, is not achieved (mismatch). This leaves us with the following two possible notations for the ineffective enactions that characterise Category C (unvoluntary) actions: | out ( standard case ) int ↔ act coerc ↔



| out 2 int1 ↔ act coerc ↔ pref ( intentional conflict )



The example of Pablo at the restaurant served as an example of tics as unvoluntary actions, illustrating a particular intentional conflict that may be present.6 But can we also conceive of tics as standard match-mismatch cases, without an intentional conflict? The answer is yes. Here is an – admittedly far-fetched – example of a standard match-mismatch scenario for an unvoluntary tic without an intentional conflict, where ‘int’ stands for a basic motor intention to jerk the head backwards, which is triggered by a barely perceptible impulse to do such a backwards jerking movement with the head. Imagine now that a woman who is doing this tic stands at a busy intersection waiting to cross the road at the lights. Unknow to her, a man with an oversized advertising board has positioned himself right behind her at the traffic lights as well. As she throws her head backward, she hits the board and wails in pain. While she still ‘does the tic’ and executes the movement as intended, the expected effect (e.g. relieving the subtle impulse) is not achieved and the pain from the impact grips her instead. Here, the woman’s tic action fails to achieve the intended outcome because she is unaware of a contextual constraint (i.e., the man with the advertising board) that impacts the action. There is no intentional conflict, but the intended outcome is not achieved. We can thus conclude that tics may well take the form of unvoluntary (Category C) actions, both in their standard but more commonly in the ‘intentional conflict’ variety. The latter might even capture a quintessential truth about certain tics which are experienced as a struggle between the self and the intrusive urges it seeks to control. In the absence of such a struggle, tics may be better described as voluntary unfree (Category B) actions. But how about ‘not just right’ experiences (NJRE) commonly found in people with Tourette Syndrome and tic disorders? Do these intriguing symptoms challenge the idea that tics could ever be effective enactions,  We should note here that there is nothing about tic suppression that necessitates it being the agent’s preferred intention; it is equally conceivable that an individual would much prefer to enact a tic, but cannot do so, given coercive situational constraints. Int1 would then be tic suppression, and the preferred int2 that is not enacted would be doing the tic. 6

6.2  Testing Our Taxonomy

165

where the outcome of the action matches the intended action? We will briefly explore this question now, before discussing whether tics could take the shape of Category D (nonintentional) actions.

6.2.3 Not Just Right Experiences (NJRE) Patients with Tourette Syndrome commonly report experiencing “the urge to perform an action until it has been done ‘just right’” (Neal and Cavanna 2013, 559). The repetitive behaviours are said to result from the sense that the previous action was not done in the right way, meaning it has to be done again (and again). An early description of these ideas can be found in Pierre Janet’s seminal work on obsession and compulsion, Les Obsessions et la Psychasthénie (1903), which Leckman et al. reference in their work on “just right” perceptions associated with compulsive behavior in TS (1994, 676; see also Pitman 1987). While discussions in the literature have revolved around the question whether these ‘not just right’ experiences (NJRE) are more like tics or more like compulsions (Worbe et al. 2010; Eapen et al. 1997; Leckman et al. 1994; Miguel et al. 2000), Neal and Cavanna argue that they are “intrinsic to the clinical phenomenology of patients with TS and can present with higher frequency in the context of co-morbid OCD/OCS, suggesting they are more related to compulsions than tics” (2013, 559; see also Sambrani et al. 2016). And yet the relationship between premonitory tic urges and NJRE remains unclear. Qualitative differences between them, as reported by study participants in Leckman and colleagues’ work (1994, 678; see also Neal and Cavanna 2013, 559), revolve around the classic distinction between mental versus bodily phenomena, or cognitive-­affective versus sensorimotor experiences. So are premonitory urges (PU) to tics what NJRE are to compulsions? Put differently, are they separate but comparable phenomena? Perhaps; or alternatively, premonitory urges in TS may be a type of “not just right” experience – that is, a “specific and very common form” of obsessive compulsive behaviours (OCB) in Tourette Syndrome (Sambrani et al. 2016, 10). From an action perspective, and assuming that NJRE are indeed intrinsic to the phenomenology of TS, what interests us here are the intentional action dynamics at play in these repetitive behaviours (regardless of whether they are more like tics or compulsions). If premonitory urges are a type of ‘not just right’ experiences found in TS, then the repetition of tics may also relate to a perceived sense of ‘incompleteness’ or ‘imperfection’ – i.e., a perceived mismatch between the intended action (a certain tic token) and its outcome (the expected relief from doing the tic). If the person has no sense of doing anything wrong in their enaction (i.e., no obvious error in the execution of the tic, which would make it a Category D action), then we would have a standard Category C action (int ↔ actcoerc ⇹ out): The person is doing ‘everything they think is required’ to enact their intention (perceived intention– action match), and yet the expected outcome does not eventuate (perceived action– outcome mismatch). The ‘not just right’ experience would then relate to the action outcome not being, or not having been, achieved as intended. If this was so, the

166

6  Tics as Intentional Actions: A Revised Taxonomy

experience should occur during or after the action; however, this is not quite supported by evidence regarding the timing of these experiences. As Leckman et al. (1994, 678) report: Seventy-six percent (N = E45) of the 59 subjects with ‘just right’ perceptions reported that they were aware of these ‘just right’ needs and urges immediately before or concurrently with the initiation of compulsions. The remainder indicated that they were aware of this need only during the actual performance of compulsions.

Since the majority of people in this study experienced the ‘just right’ needs and urges before or during the initiation of the action, it seems less likely that they constitute a retrospective judgement of the action after it was executed. Instead, the intentional dynamics of NJRE seem to be that the ‘just right’ needs or urges accompany or co-occur with the enaction in a way that (at least partially) derails the successful attainment of the action outcome. The match-mismatch dynamic may thus be comparable to the hunter who did not know that her gun had been meddled with by her friend, except that in NJRE the coercive derailment of the intended action outcome is caused by something about the agent herself. An open question remaining is whether, in the case of tics, the need to do the tic ‘just right’ is separate from, and thus additional to, the urge to do the tic itself, or whether all tic urges just are urges to execute the relevant tics in a certain (right) way. In the latter case, all tic-related PU would then be ‘not just right’ experiences that lead to the repetitive behaviours we call tics. If this was so, all tics preceded by PU would most likely be standard match-mismatch cases of Category C actions. But how plausible is this? Didn’t we just argue that standard-case Category C actions are unlikely descriptors of tics (see Sect. 6.2.2)? The answer depends on whether the perceived urge to tic (and the recurrence of this urge) must always and necessarily originate in an experience of imperfection or incompleteness. Does the urge to tic recur because the tic is rarely enacted in a way that generates the intended outcome (e.g. relief from a sensation)? Put differently, do tics need to be repeated because they are usually not executed ‘just right’? If so, the urge would recur because of a perceived lack. What about the alternative notion that effective enactions reinforce the urge (i.e., relief attained from ticcing strengthens the urge to tic, so as to experience more of that relief)? Here, the urge would recur because of a perceived fulfilment, rather than its lack. We can imagine two alternative sequences of three tic tokens (shortened here to T1, T2, and T3) that embody these potential action dynamics:

Unvoluntary ( Category C ) tic sequence ( standard ineffective enaction ) :

(

)

(

)

(

| out → T 2 int ↔ act | | T1 int ↔ act coerc ↔ coerc ↔ out → T3 int ↔ act coerc ↔ out

)

Unfree ( Category B ) tic sequence ( efffective enaction ) : T1 ( int ↔ act coerc ↔ out ) → T 2 ( int ↔ act coerc ↔ out ) → T3 ( int ↔ act coerc ↔ out )



6.2  Testing Our Taxonomy

167

Whether either (or both, or neither) of these accurately represents the intentional dynamic responsible for repetition in tic event sequences is not clear and would require further research into the subjective experiences before, during, and after tics. The question is whether repetition is causally linked to the mismatch of intention and action outcome (an unfulfilled urge, despite an as-good-as-it-gets enaction), or to their match (a fulfilled urge, which is intensified by its very fulfillment), or possibly neither of those. We certainly have no prima facie reason to believe that the repetitiveness of tics must derive from a sense of imperfection or lack of fulfilment, and that all tic urges should thus be declared a form of NJRE. Bliss’s account of his own TS is ambiguous on this point (see Bliss et al. 1980). On the one hand, his comments lend themselves to a ‘not just right’ interpretation of premonitory urges, when he stresses that any satisfaction gained from ticcing is fleeting at best: “When extinction of symptoms is achieved, the symptoms will constantly recur and need to be confronted and extinguished endlessly” (1346). On this interpretation, the tics build up to a kind of ticcus interruptus, entailing “successively sharper movements [that] build up to a climax, a climax that never comes” (1344). On the other hand, Bliss does concede that the symptom is extinguished (a double-match scenario, Category B), which is not the same as claiming that the urge is never fully relieved (a standard match-mismatch scenario, Category C): “What is basic to the TS overt actions, and what differentiates them from normal bodily actions, is the (almost) intolerable need to produce a sharp punctuation that will at one and the same time gratify and terminate an almost intolerable urge” (1345). Given how transient and futile the desired effect appears, however, it may not matter very much experientially whether the endless repetition of urges is caused by a match or a mismatch between intention and action outcome. Even in a double-­ match scenario (int ↔ actcoerc ↔ out), the outcome, it seems, just does not last. Therefore, rather than attributing the ‘not just right’ experience to the specific intentional action dynamics of a single tic token, we could also employ it to describe entire sequences of tic events, where the ‘not right’ perception is linked to the speedy recurrence of the urge, no matter whether its fleeting fulfilment is complete or incomplete. This means NJRE could be characteristic of how subjects experience both unfree voluntary (Category B) and unvoluntary (C) tics over time.

6.2.4 Tics as Nonintentional Actions We have now reviewed almost all of Culver and Gert’s action categories in relation to tics. So far  – and perhaps surprisingly  – each category’s intentional action dynamic has provided us with a possible notation for tics. Put differently: It is likely that tics come in all shapes and sizes – they may be free or unfree voluntary actions, or they may be unvoluntary ones. We will discuss the implications of this soon (see Sect. 6.3), but let’s first turn our attention to Culver and Gert’s final action category, nonintentional actions (Category D). Could tics take their form, too? Like unvoluntary actions (Category C), nonintentional actions are said to lack volition. We saw

168

6  Tics as Intentional Actions: A Revised Taxonomy

earlier that Category D is characterised by behavioural errors or accidents in the enaction of intentions – that is, by double-mismatch (int ⇹ act ⇹ out) or mismatch-­ match (int ⇹ act ↔ out) scenarios. It is easy to see how tics could take this form too. More carefully worded, we might say that tics, like any other intentional action, may not be executed properly by the subject (who may or may not be aware of the failure). In these cases, a behavioural error or interference from the environment prevents the successful enaction of the subject’s intended tic action, and the intended outcome is not achieved (or not achieved in the intended way). On this reading, there is nothing about tics per se that requires the relationship between intention and action to be an erraction (i.e., a failed enaction). Tics might, but need not, take the form of nonintentional (Category D) actions. An alternative view, which we touched on earlier (see Sect. 6.2.3), might construe tics as paradigmatic nonintentional actions by building on the idea that premonitory urges are a type of ‘not just right’ experience (NJRE), and their behavioural expression is bound to fail. On this view, we could generalise the double-mismatch dynamics as applying to all tics associated with such urges. If it turns out that subjects experience their tics as actions that are never performed ‘just right’, and that never fully attain the intended outcome (e.g. relief from the urge), then this first-­ person phenomenology would support the view that tics just are ineffective erractions. This, in turn, would anchor tics firmly in Category D (nonintentional actions), and would exclude the possibility that tics may take the form of any of the other voluntary or involuntary actions outlined above. I think such a reading is too constrictive. Generalising the notion of ‘not just right’ experiences as characteristic of all tics is unhelpful, because it presumes the sameness of people’s subjective experiences of ticcing at a time when we have, in fact, still very little data about these experiences. We do know that PU, while pervasive, are not always present before tics, or not always perceived and reported by individuals (see also Chap. 4). We thus need more nuanced phenomenological investigations into people’s diverse experiences of ticcing and into such questions as whether, when, and how the intentional action dynamics of tics are impacted by what we call premonitory urges, NJRE, and other sensory or cognitive-affective phenomena. But what about Culver and Gert’s special case Category D actions, such as accident-­proneness and the Freudian slip – can tics take their form too? To answer this question, we need to better understand the intentional action dynamics that underlie these examples. As mentioned earlier, we can compare two ‘intentional conflict’ scenarios: Firstly, in unvoluntary (Category C) actions, where the competing intentions are fully experienced by the subject, but the preferred intention cannot be enacted. And secondly, in nonintentional (Category D) actions, where the preferred intention (which coercively ‘derails’ the action) is successfully enacted but not reflectively available to the person (int1 ⇹ actcoerc ↔ out2pref). Culver and Gert (1982, 123) offer a psychodynamic reading of this latter intentional conflict scenario but offer no clear criteria for how to distinguish genuine from psychologically motivated accidents of this sort. As they admit, “there are many borderline cases in which one is not certain whether to attribute a person’s frequent accidents to the person himself or to uncommonly bad luck” (124). And yet a noticeable

6.3  Honouring Complexity: Tics as ‘Action (Pheno)Types’

169

pattern of behaviour may indicate that the ‘accident’ is psychologically motivated. Interestingly, the very ‘unreflectedness’ of the preferred intention seems to be the coercive factor in this dynamic. Psychodynamically oriented therapeutic approaches support the subject to become aware of her unreflected needs or motives, so as to losen their coercive grip over her actions. This ‘bringing into reflective consciousness’ may change the intentional dynamics of the relevant action from nonintentional (D) to unvoluntary (C), or even to voluntary (A or B), thereby broadening the person’s action affordances. But this process does not describe how we think of primary tics today. Culver and Gert’s example of accident-proneness and its underlying idea that actions may be driven by unacknowledged needs and motives touches a delicate nerve in the tic disorder literature. A delicate nerve, because it took much of the twentieth century to rid psychiatry of the myth that primary tic disorders like Tourette Syndrome are psychogenic in origin. Tics were long thought to derive from a weakness of the will (Meige 1902) and then, during the rise of psychoanalysis, from repressed psychological conflict grounded in the traumatic displacement of libido (see Ferenczi 1921). Today, these earlier narratives no longer appear in standardised international definitions of primary tic disorders, but traces of them survive in the margins of the literature under the heading of functional tics (and functional movement disorders more broadly). For now, we can conclude that Culver and Gert’s special case Category D actions are ill-suited to describing the intentional action dynamics of primary tics. They demarcate a borderline between primary and functional tic disorders which we will investigate more closely in Chap. 8.

6.3 Honouring Complexity: Tics as ‘Action (Pheno)Types’ In this chapter, I have developed a taxonomy of tics as intentional actions by critiquing the historical source of Culver and Gert’s (1982) framework of human behaviour. I showed that tics can exhibit the intentional action dynamics of free (Category A), unfree (B), unvoluntary (C), or standard nonintentional (D) actions, depending on the situation and its agent- and environment-specific circumstances. The taxonomy honours the commonly acknowledged complexity and heterogeneity of Tourette Syndrome evident across the clinical spectrum of tics and translates this diversity into an integrated model of ‘action (pheno)types’. Among these phenotypes, two action categories have emerged as most representative or typical of people’s subjective experiences of their tics, namely, unfree (B) or unvoluntary (C) actions. Clearly, it no longer makes sense to apply a one-size-fits-all descriptor to tics at the family or type level of analysis, claiming that they are all involuntary or voluntary actions or the like. Such a global description of tics with regard to intentionality and volition is precisely what the tic disorder literature has attempted but failed to deliver for decades (see Chap. 3). Instead, attributions of volition and intentionality will need to occur in context – that is, by understanding particular tic events (tokens) within the agentic situations in which they occur.

170

6  Tics as Intentional Actions: A Revised Taxonomy

And yet the verdict that intentionality and volition are not fixed or generalizable attributes of all tics does not leave us empty-handed as these concepts are no less relevant for theory and practice. Quite the opposite, for acknowledging that the intentional action dynamics and associated subjective experiences of tics can vary greatly across individuals and contexts invites us to explore new approaches to phenotyping and classification. The taxonomy offered here provides a nuanced framework for such endeavours and better integrates with first-personal experiences of ticcing. Two main directions for future research and practice emerging from this chapter are outlined below. Intentional Action Dynamics of Tics in Context  How subjects experience the intentional action dynamics of their tics within and across contexts should guide us in classifying – and possibly treating – those tics. If the intentional action dynamics of tics are co-determined by complex factors in the agentic situation, then the same tic occurrence (e.g., a head-jerking tic) may feel more like a Category C (unvoluntary) action in one context – for example, at school – and more like a Category B (unfree) action in another context – for example, at home. This context-sensitivity might impact the agent’s ability to act or not act on her preferred intention. We can easily imagine a counter example, where a certain tic occurrence feels like an unvoluntary (Category C) action across most or all contexts of the person’s life. Here, context-sensitivity would be low, and the intentional action dynamics of the tic would be stable across different agentic situations. What might this tell us about how modifiable the intentional action dynamics of this tic occurrence are? Could tics with low context-sensitivity be less amenable to therapeutic interventions (pharmacological or behavioural) than tics which subjects experience differently across contexts? Notably, the question about context here is not whether certain tics only appear (or get triggered) in certain situations, and not in others – what we might call the context-dependence of a particular tic occurrence.7 What we are asking here is: Does the subject’s experience of the intentional action dynamics of a certain tic stay the same or change across those contexts in which that tic occurs? We might call this the context-sensitivity of the perceived intentional action dynamics of a tic occurrence. In sum, different agentic situations may determine both whether a tic gets triggered in the first place, and how the ticcing person experiences the tic action. We currently do not measure this kind of context-sensitivity of tics; that is, we do not ask whether subjects experience a certain tic occurrence as largely the same ‘action type’ or not across different real-life settings. Understanding more about such context-sensitivity with regard to the intentional action dynamics of tics could provide important clues to researchers and clinicians, and may even have predictive relevance with regard to treatment success (e.g., with behavioural

 This is an important question, too, on which little research has been done (however, see Capriotti et al. 2013 on contextual factors impacting urge severity). 7

6.3  Honouring Complexity: Tics as ‘Action (Pheno)Types’

171

interventions such as CBIT – a hypothesis worth testing). Relevant research questions include: • How variable is someone’s experience of the intentional action dynamics (IAD) of the same tic occurrence in different contexts? • How variable is someone’s experience of the IADs of the same tic occurrence in the same context? • How variable is someone’s experience of the IAD of different tic occurrences in the same context? • How variable is someone’s experience of the IAD of different tic occurrences in different contexts? Further, with regard to phenotyping, we should explore whether certain trait combinations  – say, low context-sensitivity and IAD-variability versus high context-­ sensitivity and IAD-variability – represent clinically relevant subgroups of patients. If they do, what does it mean for tic disorder patients to belong to either group? For example, we can easily imagine subjects who perceive their tics in largely the same way  – e.g., as unvoluntary (Category C) actions with an intentional conflict. Similarly, there might be subjects whose tic experiences match a broader range of action categories, meaning their perceived intentional action dynamics are more variable. In these cases, how do context-sensitivity and IAD-variability affect disease progression and treatment responses? Put differently, could there be correlations between IAD-variability, context-sensitivity, and other indicators we deem important for understanding and treating primary tic disorders like TS? A methodological question follows suit: How should we measure patients’ perceptions of the intentional action dynamics of their tics and how these vary within and across contexts? Can we develop and test an instrument that helps us to assess these variables? Research informed by philosophical phenomenology (Curtis-Wendlandt and Reynolds 2021; Høffding and Martiny 2016; Miyahara et al. 2020; Niikawa et al. 2020; Petitmengin 2006; Petitmengin et al. 2007) offers a useful starting point for eliciting the experiential qualia on which we could build any standardised scales or questionnaires. The Affordance-Based View of Action as Interaction  We must better account for the fact that tics are not abstract, isolated events but always embedded in agentic situations that evolve over time. Even if we maintain that tics are not actions at all (see Chap. 7), it is difficult to conceive of them as not being impacted by, and not interacting with, those complex intentional dynamics of the agentic situation in which they arise. Just as Gallagher (2020, 7) says for actions, we can concede that there are no tics simpliciter. This chapter has put forth an affordance-based view of action, in order to resolve several difficulties inherent in theories of action, the tic disorder literature, and Culver and Gert’s (1982) original taxonomy of human behaviour. Firstly, the notion of action affordance allowed us to reframe the problem of ‘unintendedness’ by showing that unintended consequences are a common feature of intentional actions and do not relegate the latter to a separate action class or category. As we saw, the pervasiveness of unintended action outcomes – which I

172

6  Tics as Intentional Actions: A Revised Taxonomy

termed intentional spillage – only becomes apparent to us under normative load: that is, when the unintended action consequences are meaningful and important for the agents or observers in a given context. These concepts are crucial for understanding many tics, especially those which can lead to affectively charged interactions since they violate social taboos – for example copro-phenomena (coprolalia, copropraxia), NOSIS (non-obscene socially inappropriate symptoms), and self-­ injurious tics. Further, the affordance-based view of action has allowed us to challenge the dichotomous distinction commonly made in the literature between internal versus external stimuli of actions. As the case of socially inappropriate, contextually cued tics illustrates, identifying a single originating stimulus and its location can be difficult (think multifactorial stimuli interrelationships instead), and attempting to do so tells us little about the intentional action dynamics of that tic. More simply put: The location of a stimulus does not determine which taxonomical category we should group an action under or what its volitional status may be. Building on our earlier observations regarding the context-dependence and -sensitivity of tics, we can expand the notion of action affordance to guide not only our search for causes (what triggered the tic?), but also for effective therapies (what might help patients to reduce, treat, or manage their symptoms?). If there are three sides to an agentic situation – that is, the agent, world, and interpreter side – then we can formalise these as three potential pathways to change or avenues for therapeutic interventions. This is not yet common practice: In so far as symptoms are understood as being ‘of the agent’ (residing within, and arising from, the ticcing person herself), current treatment approaches tend to be agent-centred too. Going beyond these agent-­ centred perspectives means taking seriously the idea that an agent’s physical, social, and cultural environment not only co-determines how she experiences the intentional action dynamics of her symptoms, but that it can also bring about and define these symptoms as signs of a disorder in the first place. By focusing on “disordered situations” instead, we could ask: How do the three sides of an agentic situation interact to determine the particular intentional action dynamics of tics? And what conceptual tools and empirical research methods should we draw on to study this? Lastly, these questions can make a critical contribution to how we understand such concepts as ‘treatment resistance’ in TS. Currently, scientific discussions of ‘treatment-refractory’ Tourette Syndrome stay wholly within the theoretical confines of agent-focused analyses and treatment interventions, without considering how world-side (environmental and contextual) determinants may shape symptom expression and disease progression (and, indeed, how these may interact with the effectiveness of agent-focused treatments). ‘Treatment-refractory’ in its current use should be re-defined as ‘resistant to subpersonal agent-centred interventions’, and treatment alternatives explored in the relevant publications (from deep brain stimulation, electroconvulsive therapy, and repetitive transcranial magnetic stimulation, to new pharmacological approaches; see Kious et al. 2016) currently also remain within these theoretical confines. Could a more integrative, affordance-based view of patients’ ‘disordered situations’ allow us to explore alternative treatment avenues

References

173

aimed at improving their lives; or even just to identify hidden factors that may limit or enable the success of existing agent-centred interventions? Put simply, treatment resistance may not just be about the individual; it may also be about the contexts and situations in which people with tic disorders experience their symptoms, and whether these contexts afford them opportunities to act – or tic – as they intend.

References American Psychiatric Association (APA). 1987. Diagnostic and statistical manual of mental disorders. 3rd ed. Washington: Author. Anscombe, G. Elizabeth M. 1957. Intention. Oxford: Blackwell Publishers. Aristotle, W.D.  Ross, and Lesley Brown. 2009. The Nicomachean ethics. Oxford: Oxford University Press. Bliss, Joseph, Donald J. Cohen, and Daniel X. Freedman. 1980. Sensory experiences of Gilles de la Tourette syndrome. Archives of General Psychiatry 37: 1343–1347. Capriotti, Matthew R., Flint M.  Espil, Christine A.  Conelea, and Douglas W.  Woods. 2013. Environmental factors as potential determinants of premonitory urge severity in youth with Tourette syndrome. Journal of Obsessive-Compulsive and Related Disorders 2 (2013): 37–42. Chisholm, Roderick M. 1966. Freedom in action. In Freedom and determinism, ed. Keith Lehrer, 11–44. New York: Random House. Conelea, Christine A., Brianna Wellen, Douglas W.  Woods, Dianna J.  Greene, Kevin J.  Black, Matthew Specht, Michael B. Himle, Han-Joo Lee, and Matthew Capriotti. 2018. Patterns and predictors of tic suppressibility in youth with tic disorders. Frontiers in Psychiatry 9: 1–10. Culver, Charles M., and Bernard Gert. 1982. Philosophy in medicine: Conceptual and ethical issues in medicine and psychiatry. London: Oxford University Press. Curtis-Wendlandt, Lisa, and Jack Reynolds. 2021. Why Tourette syndrome research needs philosophical phenomenology. Phenomenology and the Cognitive Sciences 20 (4): 573–600. Dascal, Marcelo, and Ora Gruengard. 1981. Unintentional action and non-action. Man 4 (2): 103–113. Davidson, Donald. 1980. Freedom to act. In Essays on actions and events, ed. D. Davidson, 63–81. Oxford: Clarendon Press. Delorme, Cécile, Alexandre Salvador, Valerie Voon, Emmanuel Roze, Marie Vidailhet, Andreas Hartmann, and Yulia Worbe. 2016. Illusion of agency in patients with Gilles de la Tourette syndrome. Cortex 77: 132–140. Ducasse, Curt J. 1925. Explanation, mechanism, and teleology. Journal of Philosophy 22: 150–155. Eapen, Valsamma, John Moriarty, and Mary M. Robertson. 1994. Stimulus induced behaviours in Tourette syndrome. Journal of Neurology, Neurosurgery, and Psychiatry 57: 853–855. Eapen, Valsamma, Mary M. Robertson, John P. Alsobrook II, and David L. Pauls. 1997. Obsessive compulsive symptoms in Gilles de la Tourette syndrome and obsessive compulsive disorder. American Journal of Medical Genetics 74 (4): 432–438. Feinberg, Joel. 1970. Doing and deserving. Princeton: Princeton University Press. Ferenczi, Sandor. 1921. Psycho-analytic observation on tic. International Journal of Psycho-­ Analysis 2: 1–30. Gallagher, Shaun. 2017. Enactivist Interventions. Oxford: Oxford University Press. ———. 2020. Action and interaction. Oxford University Press. Gallagher, Shaun, and Anthony J.  Marcel. 1999. The self in contextualised action. Journal of Consciousness Studies 6 (4): 4–30. Gibson, James J. 1979. The ecological approach to visual perception. Boston, MA: Houghton-Mifflin.

174

6  Tics as Intentional Actions: A Revised Taxonomy

Haggard, Patrick. 2008. Human volition: toward a neuroscience of will. Nature Reviews Neuroscience 9: 934–946. Høffding, Simon, and Kristian Martiny. 2016. Framing a phenomenological interview: What, why and how. Phenomenology and the Cognitive Sciences 15 (4): 539–564. Janet, Pierre. 1903. Les Obsessions et la Psychasthénie. Paris: Alcan. Jankovic, Joseph. 1992. Diagnosis and classification of tics and Tourette syndrome. Advances in Neurology 58: 7–14. Karp, Barbara I., Simone Porter, Camilo Toro, and Mark Hallett. 1996. Simple motor tics may be preceded by a premotor potential. Journal of Neurology, Neurosurgery, and Psychiatry 61: 103–106. Kious, Brent M., Joohi Jimenez-Shahed, and David R.  Shprecher. 2016. Treatment-refractory tourette syndrome. Progress in Neuro-Psychopharmacology & Biological Psychiatry 70: 227–236. Lang, Anthony. 1991. Patient perception of tics and other movement disorders. Neurology 41: 223–228. Leckman, James F., David E. Walker, Wayne K. Goodman, David L. Pauls, and Donald J. Cohen. 1994. “Just right” perceptions associated with compulsive behaviour in Tourette’s syndrome. American Journal of Psychiatry 151 (5): 675–680. Matsuda, Natsumi, Toshiaki Kono, Maiko Nonaka, Miyuki Fujio, and Yukiko Kano. 2016. Self-­ initiated coping with Tourette’s syndrome: Effect of tic suppression on QOL. Brain and Development 38: 233–241. Meige, Henry. 1902, June 5. La Genese des Tics. Journal de Neurologie, 201–206. Miguel, Euripides C., Maria Conceição do Rosário-Campos, Helena da Silva Prado, Raquel do Valle, Scott L. Rauch, Barbara J. Coffey, Lee Baer, Cary R. Savage, Richard L. O’Sullivan, Michael A. Jenike, and James F. Leckman. 2000. Sensory phenomena in obsessive-compulsive disorder and Tourette’s disorder. Journal of Clinical Psychiatry 61 (2): 150–156. Miyahara, Katsunori, Takuya Niikawa, Hiro Taiyo Hamada, and Satoshi Nishida. 2020. Developing a short-term phenomenological training program: A report of methodological lessons. New Ideas in Psychology 58: 1–17. Morand-Beaulieu, Simon, and Marc E. Lavoie. 2019. Cognitive and motor event-related potentials in Tourette syndrome and tic disorders: A systematic review. Clinical Neurophysiology 130: 1041–1057. Neal, Matthew, and Andrea Eugenio Cavanna. 2013. “Not just right experiences” in patients with Tourette syndrome: Complex motor tics or compulsions? Psychiatric Research 210 (2): 559–563. Niccolai, Valentina, Silvana Korczok, Jennifer Finis, Melanie Jonas, Götz Thomalla, Hartwig Roman Siebner, Kirsten Müller-Vahl, Alexander Münchau, Alfons Schnitzler, and Katja Biermann-Ruben. 2019. A peek into premonitory urges in Tourette syndrome: Temporal evolution of neurophysiological oscillatory signatures. Parkinsonism and Related Disorders 65: 153–158. Niikawa, Takuya, Katsunori Miyahara, Hiro Taiyo Hamada, and Satoshi Nishida. 2020. A new experimental phenomenological method to explore the subjective features of psychological phenomena: Its application to binocular rivalry. Neuroscience of Consciousness 2020 (1): niaa018. Petitmengin, Claire. 2006. Describing one’s subjective experience in the second person: An interview method for the science of consciousness. Phenomenology and the Cognitive Sciences 5: 229–269. Petitmengin, Claire, Vincent Navarro, Michel Le Van, and Quyen. 2007. Anticipating seizure: Pre-­ reflective experience at the centre of neuro-phenomenology. Consciousness and Cognition 16: 746–764. Pitman, Roger K. 1987. Pierre Janet on obsessive-compulsive disorder (1903): Review and commentary. Archives of General Psychiatry 44 (3): 226–232.

References

175

Sambrani, Tanvi, Ewgeni Jakubovski, and Kirsten R. Müller-Vahl. 2016. New insights into clinical characteristics of Gilles de la Tourette syndrome: Findings in 1032 patients from a single German centre. Frontiers in Neuroscience 10 (415): 1–13. Searle, John. 1983. Intentionality. An essay in the philosophy of mind. Cambridge University Press. ———. 2003. Rationality in action. MIT Press. Specht, Matt W., Cassandra M. Nicotra, Laura M. Kelly, Douglas W. Woods, Emily J. Ricketts, Carisa Perry-Parrish, Elizabeth Reynolds, Jessica Hankinson, Marco A.  Grados, Rick S. Ostrander, and John T. Walkup. 2014. A comparison of urge intensity and the probability of tic completion during tic freely and tic suppression conditions. Behaviour Modification 38 (2): 297–318. Stern, Jeremy. 2014. Tourette Syndrome. Paediatrics and Child Health 24 (10): 447–551. Thalberg, Irving. 1984. Do our intentions cause our intentional actions? American Philosophical Quarterly 21 (3): 249–260. Worbe, Yulia, Luc Mallet, Jean-Louis Golmard, Cécile Béhar, Franck Durif, Isabelle Jalenques, Philippe Damier, Pascal Derkinderen, Pierre Pollak, Mathieu Anheim, Emannuel Broussolle, Jing Xie, Valérie Mesnage, Karl Mondon, François Viallet, Pierre Jedynak, Mouna Ben Djebara, Michael Schüpbach, Antoine Pelissolo, Marie Vidailhet, Yves Agid, Jean-Luc Houeto, and Andreas Hartmann. 2010. Repetitive behaviours in patients with Gilles de la Tourette syndrome: Tics, compulsions, or both? PLoS One 5 (9): e12959.

Chapter 7

On Reflexes and Stimuli: Tics as Nonactions

Abstract  This chapter argues that nonaction views of tics rely on a misguided understanding of the temporality of human action and perception. First, I explore two ‘chicken-or-egg’ debates in tic disorder scholarship which revolve around the question what comes first  – acting or perceiving?  – and what this means for the intentionality of symptoms. I then zoom in on the construct of a single tic sequence, where these debates take place. As I will show, nonaction proponents of tics posit a linear causal-temporal model of symptoms which assumes that neural stimuli cause tics from the bottom up. This reductionist stimulus–response model has spawned such ill-fated questions as: When do intentions enter the process of ticcing? Or: Which part of a tic sequence is intentional? Drawing on the work of a range of thinkers past and present – from Dewey’s critique of the reflex arc to Wu’s work on attention – I highlight the structural circularity intrinsic to all acting and perceiving, which suggests that intentions do no ‘enter’ tic sequences but are always already present from the get-go. Tics, however, are uniquely hyper-circular due to their repetitiveness and sameness. I conclude by exploring how this hyper-circularity could impact phenomenal experience and what its psychiatric relevance might be. Keywords  Reflex · Stimulus-response model · Urge-for-action · Premonitory urge · Tic disorder · Tourette Syndrome · Intention · Temporality · Perception · Subjective experience · Circularity · Repetition

7.1 Chickens and Eggs 7.1.1 From Nonaction to the Urge-for-Action While Chap. 6 critiqued Culver and Gert’s (1982) taxonomy of actions and argued that this framework is useful for describing the intentional action dynamics at play in tics, we must now turn to past and present objections to this ‘intentional reading’. To do so, we will reconnect with the discussion of temporality introduced earlier in this book. In Chap. 2, we looked at the temporal relationships between various tic events (tic tokens) © Springer Nature Switzerland AG 2023 L. Curtis-Wendlandt, Chasing Tourette’s: Time, Freedom, and the Missing Self, Philosophy and Medicine 145, https://doi.org/10.1007/978-3-031-19104-6_7

177

178

7  On Reflexes and Stimuli: Tics as Nonactions

and their role in the classification of tic disorders. Here, we will zoom in on the genesis of a single tic token, from its emergence in a perceptual trigger to its behavioural expression or suppression. It is this temporal arc – from stimulus to behaviour – that we will call a tic sequence. Once we unpack the various concepts used to describe and define the causal-temporal structure of this sequence in the literature (as well as some concepts rarely discussed in scholarship), it will be easy for us to address objections to the ‘intentional reading’ of tics. First, however, let’s briefly review the history of these objections. Culver and Gert would insist that tics “are not merely nonintentional; they do not seem to be actions at all” (1982, 124). In their taxonomy, they placed Tourettic tics into Category E, nonactions, together with reflexes (like knee jerks and eye blinks), epileptic seizures, and – notably – hysterical seizures (124–125): As we use the term ‘action’, the movement (or lack of movement) must include, at least in part, willing to do something. Most nonintentional actions [Category D] … involve an intentional action … But the symptoms of Tourette’s Syndrome, such as the obscene words, involve no willing at all. Thus we do not regard these utterances as actions, in our sense of the term.

This view of tics as nonactions was likely informed by the pioneering work of the Shapiros and their colleagues, whose second-edition opus magnus, Gilles de la Tourette Syndrome, explicitly references Culver and Gert’s taxonomy (Shapiro et al. 1988, 347). The Shapiros’ research and clinical work with tic disorder patients was instrumental in forging the paradigm shift away from psychogenic interpretations and treatments of tics toward an appreciation of their organic basis. In their own words, “an essential feature for all tics […] is that they are involuntary, unintended, have no psychodynamic purpose, and are an end in themselves” (346). Tics have been misconstrued as intentional or voluntary movements, they assert, because of “the volitional or intentional aspects” associated with them – in particular, the fact that people can either inhibit tics for some time or allow or even facilitate “an incipient or subliminally beginning tic to occur” (346). How can these aspects be associated with tics while not being characteristic of them? We do not find out; but it seems that Shapiro and colleagues distinguish what we may call intentional responses to tics from the tics themselves.1 It would be tempting to infer that the authors consider the sensory phenomena preceding tics as involuntary and the actual ticcing behaviour (tic tokens) as the ‘volitional or intentional aspects’ associated with them, but this is not the case. For Shapiro and colleagues tics can be both sensory or behavioural; they come as complex or simple vocal and motor tics (behavioural tic tokens) and as ‘sensory tics’ (experiential tic tokens, so to speak; 1988, 356). Interestingly, sensory tics are not thought to be part of Tourette Syndrome, but both types of tics can occur in Tourettic individuals. Sensory tics are not observable but deemed to be as  Note their conflation of the terms intentional and voluntary, suggesting that their use of both is equivalent to Culver and Gert’s (1982) overarching term ‘intentional’ – that is, descriptive of all action categories, rather than designating a more specific use of ‘voluntary’ confined to what Culver and Gert define as Category A and B actions only (see Chap. 6). Unless I quote directly from Shapiro et al.’s work, I will use the term ‘intentional’ throughout, as this seems to be synonymous with what Shapiro and colleagues describe as ‘voluntary’. 1

7.1  Chickens and Eggs

179

involuntary as the behavioural motor and vocal tics, and both are thought to share a “similar […] pathophysiology” (357). Today we conceptualise uncomfortable somatic sensations and urges in tic disorders differently – namely, as experiences that commonly precede or possibly even drive vocal and motor tics. We now couple sensory phenomena to tics as their measurable antecedent, trigger, or potential cause, and this linear temporal coupling woos us into describing tics as “voluntary responses to involuntary internal sensations” (Matsuda et al. 2016, 234; see Chap. 3). Shapiro and colleagues describe sensory tics, but not Tourettic tics, in a similar way: The “recurrent, involuntary, somatic sensations in joints, bones, muscles, or other part of the body” are said to “evoke a dysphoric feeling to which the patient responds by executing an intentional (or voluntary) movement to relieve the disturbing internal sensations” (1988, 356; Specht et al. 2014). This intentional response to sensory tics relies on “voluntary muscles in any part of the body” and usually involves “tonic squeezes, stretches, tightening of muscles, or other movements often lasting 1 sec or more” (356). The relief attained is temporary, and thus the movements recur persistently. Is this not an early version of the idea of an urge– relief cycle which is still debated today? Yes, but a crucial difference remains with respect to the role these authors attribute to the dysphoric sensations. For Shapiro et al., these sensations are not precursors of tics but rather specific tics which precede voluntary movements. Put differently, what we might regard today as premonitory phenomena that precede motor or vocal tics in TS, they regard as a separate category of involuntary (non-intentional) tics themselves. We could depict the distinction as follows (see Fig. 7.1). A consequence of Shapiro and colleagues’ view is that tics come first: they remain temporally prior to any behavioural response. In this ‘before’ position, they might precede but never themselves be called intentional actions. This has shifted in contemporary scholarship. While we no longer consider dysphoric sensations to be tics themselves, we have made much of the idea that such sensations could lead to symptomatic behaviours aimed at relieving them. Primary tics have been behaviouralised – they now come last. In their temporal ‘after’ position, they always constitute a response to something that precedes them in time. The chicken has been swapped for the egg: If tics were once moments of origin which, like stimuli, evoked a response, they are now moments of closure that efface their prompting provocation. Given this shift, tics no longer sit comfortably in the ‘nonaction’ category where Shapiro et  al. (1988) and Culver and Gert (1982) had so famously placed them. Although the term nonaction has disappeared from the tic disorder literature, the debate whether tics are intentional actions or not lives on in attempts to

Fig. 7.1  Shapiro et al.’s (1988) tic categories and their associated voluntary responses

180

7  On Reflexes and Stimuli: Tics as Nonactions

distinguish urges to act from intentions to act. We encountered examples of this in Chap. 4,  where we explored Pacherie and Haggard’s (2010) distinction between urges and intentions or Haggard’s (2008) distinction between stimulus-driven and voluntary (i.e., stimulus-independent) action. The vitality and breadth of this debate is particularly evident in a paper by Jackson et  al. (2011a) and its various commentaries published in Cognitive Neuroscience, which explores the functional anatomy of the ‘urge-for-action’ in both everyday behaviours (like yawning, swallowing) and clinical conditions including TS. Here, Jackson and colleagues argue that tics should not be likened to voluntary movements because “the neural mechanisms responsible for triggering of tics may in fact differ from those involved in voluntary movements” (2011a, 230). They oppose Davenport et  al.’s (2002) motivation-to-action model according to which an urge to act gives rise to a desire to act before the action is executed (see Jackson et al. 2011a, 242). In Jackson and colleagues’ view this two-step model of action initiation is not appropriate for describing tics, which typically do not involve a conscious desire for action, although they are often preceded by uncomfortable premonitory phenomena that have been linked to “a strong urge for motor discharge” (Banaschewski et al. 2003; see Jackson et al. 2011a, 230–231). Jackson and colleagues speculate that the difference between actions originating in urges and those originating in desires is grounded in different neurological systems or mechanisms: “the formation of ‘urges-for-action’ is probably linked to the operation of the habit-learning system, whereas the formation of ‘desires-for-action’ is probably associated with goal-directed, action-planning mechanisms” (241; see also De Haan 2011, 248). At the same time, they assert that urges are not like reflexes either, because the urge-for-action only arises when actions are suppressed or deferred (Jackson et al. 2011a, 243). This raises an important point: Unlike other commentators, Jackson and colleagues do not equate sensory phenomena and urges but distinguish between “being aware of a bodily sensation and being aware of an urge-for-action” (229), although they grant that the distinction need not always translate into first-person experience. For example, they suggest that we may experience an itch (bodily sensation) and an urge to scratch the itch (urge-for-action); both could, in principle, be suppressed – that is, we could try to suppress the bodily sensation that gives rise to the urge in the first place, or we could suppress the urge-for-action resulting from the sensation (229). We can note the author’s ambiguity here: while the sensations-versus-urges distinction seems conceptually appealing, they concede that it may not be phenomenologically relevant and say little about its potential neurological grounding. And yet the distinction between sensory phenomena and urges-for-action has intriguing consequences for how we understand tics, not least because it increases our list of terms to be defined and correlated (see Fig. 7.2). It also complicates questions about the causal-temporal sequence of events or processes involved in ticcing, and how best to depict these as appropriate ‘units of analysis’ for research and study. As it turns out, we are in for another chicken-or-egg debate  – this time regarding the causal-temporal relationship between urge perception and tic suppression, which affects how we think of the contested (non)action status of tics.

7.1  Chickens and Eggs

181

Fig. 7.2  Overview of the action/nonaction status of concepts used to describe the causal-temporal sequence from a tic stimulus to a latent symptom behaviour or experience (see Chap. 6 for behavioural categories A–E)

7.1.2 Enabler or Response? Reconsidering the Urge Among the commentators on Jackson et al. (2011a) target article, Nachev (2011) stands out for his vocal support of the distinction between urges and sensations. The notion of urge, he asserts, is not only “radically at odds with one that gives it a critical role in voluntary action”, but urges “must also be dissociated from the sensations that in some cases prompt them” (247). This latter comment implies a phenomenological point: that urges may or may not be preceded by other sensory phenomena

182

7  On Reflexes and Stimuli: Tics as Nonactions

experienced by subjects. “The urge to yawn, for example, is not plausibly any kind of sensation: One can only describe it with reference to the action it compels. What is minimally constitutive of the notion of an urge is that it is an urge to do something: it is both transitive and directed at a specific action” (247). Interestingly, Thompson (2008) made a similar point about the intrinsic action-orientation of intentions three years prior. Just as Nachev argues that urges are not sensations but action-bound, Thompson argues that intentions are not mental states or propositional attitudes but goal-directed activity which unfolds in time (see Paul 2020). For Nachev, however, the reason why an urge cannot be thought of as separate from an action is that it arises from the perceived need to inhibit this very action. Without inhibition, there would be no urge: Since the urge is to perform the action, the necessary interval between it and the action during which the urge is experienced must involve inhibition of the action, for otherwise the action would be performed immediately. Inhibition is therefore an inevitable consequence of the notion of an urge (247).2

Let us note here the durative nature of the urge as an interval between its first occurrence and the eventual execution of an action (or, we might add, the successful extinction of the motor impulse). The experience of the urge coincides with this inhibitory interval. We can note also that the temporal placing of urges before tics is uncontroversial in the tic disorder literature, but Nachev’s suggestion that urges occur when actions are inhibited and not the other way around departs from the common suggestion that urge experiences could aid (rather than result from) tic suppression. The chicken and the egg have been swapped again: What was thought to precede tic suppression (the urge) is now assumed to follow it. In Nachev’s view, urges tell us that we are inhibiting an action right now; they are our first-personal evidence of an underlying “conflict between action and inaction” (247). This must be so, he argues, because urges are associated with certain (normal and pathological) actions – namely, those which we cannot actively choose but only withhold. Just as we cannot yawn or sneeze wilfully, if we cough or empty our bladder voluntarily we tend to do so pre-emptively of the normal action: “To the extent to which we have control over such actions, it is to keep them in check, to be released at the time when their performance is convenient” (247). The same, Nachev suggests, is true of tics in Tourette Syndrome, which are commonly “perceived as unwanted; where no such strong perception exists … patients do not complain of urges” (248).3

 This is awkwardly phrased by Nachev. I take him to suggest that inhibition is not a causal-­ temporal consequence of the urge (this would be contrary to the point he makes) but rather that the notion of the urge conceptually implies inhibition. 3  We could ask whether drawing analogies between (more or less) life-sustaining bodily functions and Tourettic tics is appropriate. For example, while emptying one’s bladder can only ever be delayed but not postponed indefinitely, it is clearly possible to inhibit a specific tic token without ever doing it (although new urges and tic tokens may arise). Analogies between tics and other functional bodily movements or actions are pervasive in the tic disorder literature, informing both neuropsychological research (e.g., Jackson et al. 2011a) and neuroimaging studies (e.g., via the use 2

7.1  Chickens and Eggs

183

This might strike us as counter-intuitive, since people with tic disorders also report experiencing urges when they don’t suppress their tics (see Specht et  al. 2013, 2014). But Nachev could argue that the experiences reported in these studies are not urges but other premonitory sensations – a potentially dissatisfying response if there is no way to distinguish between urges and other sensations within first-­ person experience. So what does Nachev’s account of the urge mean for the intentional action status of both tics and their suppression? Interestingly, he describes inhibited actions as “unwanted” actions which we have “reasons to suppress” (2011, 248), thus implicating certain attitudes or mental states in their suppression. Some philosophers argue that our having such attitudes or mental states (e.g., desires, beliefs) is precisely what makes our actions intentional (Paul 2020). Nachev’s commentary does not define intentional action, but his reference to unwanted actions and ‘reasons to suppress’ seems at odds with his insistence that urges do not drive voluntary (intentional) action. Urges, he asserts, arise because of our deferring certain actions, so they cannot be “a signature of the phenomenology that is argued to precede voluntary action and to take part in its self-ascription. For if an urge signifies the inhibition of an action, it can hardly be thought of as the ‘idea’ driving it” (2011, 248). If this chicken-and-egg swap is true and people inhibit their tics before they feel the urge, then it does seem to be more difficult to cast urges as precursors or enablers of voluntary (intentional) actions. On the other hand, Nachev posits some intention-­ like state (reasons, desires) as responsible for the inhibition that leads to the urge in the first place. We could interpret this scenario as one where tic suppression is intentional (although perhaps not voluntary, depending on one’s use of these terms; see Chaps. 3 and 6) while behaviours that follow the urge (like delayed tic tokens) are not, because they merely execute what the original stimulus demanded all along. In this view, tic suppression interrupts stimulus-response patterns, at least for some time. A similar idea is expressed in the commentary by De Haan (2011, 248), who describes the urge as an interrupted reflex, and who also mentions some of the reasons for why people might want to suppress their tics: The fact that this motor action is not socially or emotionally acceptable is in essence culturally defined, and therefore, is a learned response. Thus … the defining aspect of an urge is a learned interruption of a reflexive sequence. The result of this interruption is a conscious awareness of the pending action and the fact that this action is not acceptable in the current situation. (249)

De Haan’s reference to the social and psychological consequences of tics as reasons why they are consciously flagged as unwanted aligns well with our earlier observation that actions often carry a normative load (see Chap. 6). The urge experience, then, is indicative of prior learning and experience; a person inhibits her tics because she has learned that ticcing has undesirable consequences. Inversely, it seems that, without such learned negative associations between tics and their consequences

of blink suppression tasks). A critical engagement with the presuppositions that inform these analogies would be useful but exceeds the aims of this chapter.

184

7  On Reflexes and Stimuli: Tics as Nonactions

(and thus without reasons to suppress, to use Nachev’s terms) no action–inaction conflict would arise, because tics would not require conscious flagging and inhibiting. At the same time, we can imagine a learning context where tics are reinforced because of their positive consequences – that is, subjects might have reasons to tic which go beyond any basic motor intentions or intentions-in-action that respond to the underlying impulse or stimulus. Perhaps this is what Shapiro et al. (1988) mean when they write about different volitional or intentional aspects associated with tics, suggesting that people can not only inhibit tics “for varying periods of time” but also allow or even facilitate “an incipient or subliminally beginning tic to occur” (346). If De Haan (2011, 249) is right in suggesting that tic suppression is a learned behaviour (which may have become automatic over time), then it is worth asking how this skill could be acquired and repeatedly enacted without involving at least some basic motor intentionality.4 Recall that Gallagher (2017) describes motor intentions as the nonconscious aspects of intentional actions; they form an integral part of our intentions-in-action and distal intentions, both of which we are at least pre-reflectively conscious of. In Chap. 4, we also drew on the phenomenological notion of pre-reflective self-awareness or minimal (self-)consciousness (e.g. Sartre 1943; Zahavi 2008) to explain how we can be barely conscious of certain experiences when we don’t attend to them reflectively. Learned skills are a case in point: The fact that a second-order reflective consciousness is often not required to control our bodily movements, for example, only testifies to the fortuitous efficiency of our skilled habits; it does not prove that these actions are not intentional. But this diachronic and narrative perspective, which considers learning in social contexts over time, is not the standpoint commonly adopted in the current scholarship on tic disorders. Instead, we find a narrower focus on individual tic sequences – the process thought to unfold between a neural signal and a tic event. It is within the confines of this temporal interval that commentators debate whether tics are intentional actions, and that the kind of before-or-after, chicken-or-egg scenarios we encountered arise. The debate usually privileges and contrasts two apparent ‘events’: the doing of the stimulus-induced action, and the (potential) intervening on this latent action. Given this focus, the question usually boils down to asking whether executing a stimulus-induced action can be intentional, or whether only subjects’ facilitative or inhibitory responses to such stimuli should count as intentional actions – or both or neither of these. Broadly construed, we can outline three main positions regarding the involvement of intentions in primary tics, all of which entail different views about if and when intentions enter the complex process involved in ticcing.

 In Chap. 4, we argued that many behaviours are automatic because the subject has acquired the necessary knowhow to execute them without consciously attending to them. Automaticity, then, does not prove a lack of intentions or goal-directedness. Rather, intentional actions involving skilful knowhow are often only reflected upon, or consciously attended to, when something goes wrong. 4

7.1  Chickens and Eggs

185

7.1.3 Introducing NIAT, SIAT, and EIAT The first position we can demarcate in the action–nonaction debate is what I call the Nothing Intentional About Tics (NIAT) view. In this account, neither the stimulus-­ induced tic tokens nor their inhibition represent intentional actions. This view corresponds with Culver and Gert’s (1982) description of tics as nonactions (Category E) and Nachev’s (2011) position that tic suppression does not indicate voluntary or willed (i.e., intentional) action. It is not clear how proponents of this view would explain and categorise what Shapiro et al. (1988, 346) call “facilitative” responses to tic stimuli, where subjects do not inhibit but rather bring about or somehow allow their tics to occur. Is not inhibiting a stimulus-induced action the same as facilitating it, so that: (− inhibit) = (+ facilitate), or are they different? In other words, is there a difference between ‘simply ticcing’ and allowing or facilitating a tic? If there is a difference, what does facilitating a tic add over and above just letting it occur? In both cases, we end up with tic tokens (see Chap. 2), i.e. behavioural tic events. But what, if anything, distinguishes these tic tokens if one of them is purely stimulus-­ induced and the other one is actively ‘selected for’ by the subject? Proponents of NIAT might argue that the distinction doesn’t hold, or that any intentionally occurring tics should not be classified as symptoms of a primary tic disorder (see Chap. 8 on functional tics). The second position we can demarcate in the action–nonaction debate is what I call the Something Intentional About Tics (SIAT) view. In this account, primary tics are sometimes or partially intentional – that is, they may be actions or nonactions or both. For example, while the stimulus-induced tic tokens need not be intentional actions, subjects can intentionally intervene on them (e.g., by suppressing or facilitating them). As Rothwell and Edwards (2011) put it, certain “stimulus–response associations … can give rise to actions”. In these cases, “some other factor (perhaps only dimly perceived) is the trigger for this latent action, and when we become aware of the impending action, we are able to prevent it from being released by effort of will” (250–51). Shapiro et al. (1988) also seem to hold this view when they write about the volitional aspects associated with tics (see Sect. 7.1.1). With regard to expressed symptoms, proponents of SIAT (like NIAT) need to explain when and how behaviourally identical tic tokens can be merely stimulus-induced on some occasions, and intentionally chosen at other times. While NIAT proponents might relegate the latter tic tokens to a different disorder (not primary but perhaps functional tics; see Chap. 8), SIAT proponents would need to explain how the same disorder (i.e., a primary tic disorder) can generate symptoms that straddle the action–nonaction divide, and how to classify behavioural sequences that encompass both. Lastly, the third position we can demarcate in the action–nonaction debate is what I call the Everything Intentional About Tics view (EIAT). In this view, acting on the stimulus is always intentional, as are the inhibition and facilitation of such triggered action, irrespective of whether or not subjects are reflectively aware of the stimulus or their response to it. Enactivist accounts of action (e.g. Gallagher 2017;

186

7  On Reflexes and Stimuli: Tics as Nonactions

see Chaps. 5 and 7) lend themselves to interpreting tics in this way for two reasons: firstly, because they consider basic (unconscious) motor intentions as integral to all motor control processes and thus de-emphasise the role of consciousness in volition; and secondly, because they insist that acting intentionally is not primarily a matter of subpersonal brain mechanisms occurring at an elemental timescale, but rather involves complex, temporally extended processes through which subjects engage with their world. Put differently, intentional action pertains to a situated mind–body system that is dynamically coupled with its physical-social environment; we cannot find it purely by looking inside people’s heads (Gallagher 2017, 147; see Chap. 5). EIAT therefore rejects the assumption that we can draw a clear line between stimulus-response associations and intentional actions, since any such crude opposition fails to account for the contextually situated and temporally extended nature of all actions.5 This nod to temporality turns out to be important. As I will now show, the differences between our three main positions – NIAT, SIAT, and EIAT – boil down to divergent understandings of what constitutes a tic sequence; that is, the causal-­ temporal process which unfolds when a tic stimulus triggers a latent symptom behaviour or experience (or both). Once we unpack the various concepts used to describe and define the causal-temporal structure of this sequence in the literature (as well as some concepts rarely discussed in scholarship), it will be much easier for us to arbitrate between NIAT, SIAT, and EIAT, and thus to settle the question of intentions and tics.

7.2 Mapping the Causal-Temporal Sequence of a Tic 7.2.1 Neural Signals and Other Stimuli At the beginning of every temporally extended process or sequence of events that leads to ticcing is said to be a triggering stimulus – that is, a signal or impulse, “perhaps only dimly perceived”, which some suggest is not identical to the urge (see Rothwell and Edwards 2011, 250). This founding trigger is commonly said to arise in the ticcing person’s brain. While environmental and contextual triggers of tics are generally acknowledged (Conelea and Woods 2008; Capriotti et  al. 2013), and while these could certainly precede and interact with any brain signal, they are routinely excluded from scientific analyses and explanations of tic events. Therefore, the most basic and ubiquitous tic sequence can be depicted as: Neural signal (NS) → tic token (TT, a motor or vocal tic event). Let’s call this Sequence 1 (S1). However, if the neural signal was evoked by preceding contextual factors (environmental stimuli, or even other bodily experiences), it could be appropriate to widen

 In Chap. 8 I will also argue that tics don’t fit Rowlands’ (2011) concepts of ‘subintentional’ and ‘preintentional’ acts but meet the criteria for actions. 5

7.2  Mapping the Causal-Temporal Sequence of a Tic

187

our causal-temporal bracket, so that the tic sequence reads: Other stimulus (OS) → neural signal (NS) → tic token (TT). We will call this Sequence 2 (S2). ‘Other’ here refers to any non-brain-based stimulus in the subject’s environment or embodied experience that triggers a latent tic event – a very broad descriptor that can serve as a placeholder for what is commonly left out of scientific research on tics. Contemporary scholarship rarely uses S2 as the basis for analysing and explaining what happens when people tic, a fact which testifies to the neuro-reductivist approach to action that currently dominates the tic disorder literature. As discussed in Chap. 6, the ‘bracketing out’ of the intrinsic situatedness of all action highlights a shortcoming of contemporary neuroscientific analyses of tics as (non)actions. Here, everything we seek to explain about a person’s disorder-specific behaviour fits inside her head and occurs at a millisecond timescale unbeknown to its bearer. Accordingly, tic-triggering stimuli are usually not considered to be events or moments in time that involve any intentional doing on the part of the subject. This in turn supports NIAT or SIAT, which propose that nothing, or at least not everything, is intentional about tics. (Whether the stimulus part of the tic sequence can lead to or evoke such intentional action is then debated among these views; more on this below.) Figure 7.2 depicts this common ‘nonaction reading’ of the initial – and initiating  – part of the tic sequence via a cross placed in the nonaction column. Since the neural signal (NS) is a subpersonal event occurring at the elemental timescale, this placing looks non-controversial, and no scholarship to date has suggested that we think of these signals (or ‘neuronal activations’) as intentional actions themselves (although they may be component processes of such actions; see Gallagher 2020, 18). However, a cross in brackets has also been placed in the action column to suggest that an alternative reading is possible, which would integrate the neural signal into a broader intentional action (see below). The light grey shading of the adjoining cells reflects the fact that the action status of the NS is debatable, but currently not debated in the literature. The problem with S1 and the neuro-reductivism that often accompanies it is that we cannot explain intentional action purely by looking at an individual brain  – Tourettic or not – in isolation from the person’s embodied experience of her world (see Chap. 4). It is worthwhile returning to our more context-sensitive Sequence 2, which grants that other stimuli can trigger neural signals in the first place (meaning they temporally precede and possibly cause NS). Once we bring the broader agentic situation into view (see Chap. 6), it becomes easy to imagine how people could control their environments or embodied states in which such neural signals arise. In other words, people with tic disorders could intervene on a range of other tic-­ triggering stimuli (OS) and thus shape the subpersonal processes occurring in their brain – for example, by avoiding situations in which tics tend to worsen, or by proactively adopting an attitude which helps them manage and even reduce their symptoms. While we can place these interventions on neural signals or other stimuli in the intentional action column in Fig. 7.2, it is not clear how common or uncommon they are in practice. If we assume that generalised behavioural coping strategies (like avoidance, for example) are pervasive, we might suspect that intentional interventions on tic-triggering stimuli are common too. We will explore the notion of

188

7  On Reflexes and Stimuli: Tics as Nonactions

behavioural and cognitive-affective responses to emerging tics in more detail below (see Sect. 7.2.5). In sum, we can already see that EIAT – the view that everything is intentional about tics  – depends, first and foremost, on our conception of the tic-triggering stimulus. If we say that neural signals or other tic triggers involve no intentions or are not part of an intentional action, then there will always be something that’s not intentional about tics, making EIAT less defendable. In Sect. 7.3, we will critique this way of constructing stimuli and how it impacts both our theory of action and our understanding of tics. To foreshadow that critique: The idea of a passively endured stimulus relies on the view that actions can be broken down into linear causal-temporal chains of events  – a view encouraged by the term ‘sequence’.6 Once we challenge this view, stimuli can be re-defined as integral aspects of intentional actions; hence the placing of ‘X’ in brackets under intentional actions for NS and OS in Fig. 7.2. Secondly, even if there were EIAT scenarios – that is, situations where subjects intentionally create conditions that encourage or discourage tic signals to arise, so that tic-triggering stimuli would occur or not occur because of broader intentional actions  – then this might challenge our current definition of primary tic disorders. For if tics were intentionally triggered or brought about, could we still refer to them as the symptoms of a primary tic disorder (and if so, how would they differ from functional tics, for example)? We will return to these questions in our dedicated discussion of functional tics in Chap. 8.

7.2.2 Premonitory Phenomena and Urges Among the many tic-related experiences listed in Fig. 7.2, those that occur before ticcing have received by far the greatest scholarly attention. In contrast, how people feel during ticcing is rarely discussed, and post-tic experiences tend to be reduced to the notion of ‘relief’ from premonitory urges and sensations. The latter are usually described as somatosensory (e.g., Conelea et al. 2018; Kyriazi et al. 2019; Rae et al. 2019) but are sometimes also referred to as cognitive and affective in nature (e.g., Specht et al. 2013; Steinberg et al. 2013). In the following I will thus refer to them as ‘sensory and cognitive-affective phenomena’ (SCAP), and to premonitory urges (PU) in the standard fashion. Since SCAP and PU occur prior to the execution of any tic tokens, they could be associated with the tic-triggering stimulus or neural signal. But are they simply the experiential counterpart of that founding trigger or caused by other factors? The former view aligns with what Noë (2006) calls the  In philosophy this idea of discrete atomistic events is often couched in terms of so-called ‘basic actions’. Hornsby (2013) argues that this is a false abstraction: An activity or process is indivisible and cannot be chopped up into discrete segments. She recommends that we speak of ‘basic activity’ instead. Similarly, Gallagher critiques the atomistic notion of basic action as untenable because it leads to an infinite regress and construes basic activity as mindless movement (Gallagher 2020, 24). 6

7.2  Mapping the Causal-Temporal Sequence of a Tic

189

philosophical “dogma of internalism” which purports that “neural states are the sufficient basis for experience” (214). If we take SCAP or PU associated with tics to be nothing but the experiential counterpart of internal states of the brain (meaning these brain states are sufficient causes of, and explanations for, these experiences), then we might sit comfortably with Sequence 1 spelled out earlier, which depicts ticcing as a purely intra-subjective process. Doing so favours the view that nothing (NIAT) or only something (SIAT) is intentional about tics, because it grounds tics in subpersonal brain processes detached from the person’s situated interactions with her world. If, however, we question the dogma of internalism and pursue the “possibility that experience might supervene not on the brain, but rather on brain-animal-world systems” (Noë 2006, 218), then we should approach SCAP and PU differently. We could ask, for example, how interactions between a ticcing person’s brain, body, and world shape her experiences of tic-related premonitory phenomena and urges – a question which favours Sequence 2 depicted earlier, because it does not bracket out the context in which ticcing occurs. This vantage point may be favoured by proponents of EIAT, who will be inclined to interpret brain events and the latent actions they evoke as themselves impacted by the person’s broader agentic situation (see Chap. 6). Interestingly, however, not all individuals with TS report experiencing premonitory phenomena or urges associated with their tics. In these cases we can ask whether such experiences are genuinely lacking, or whether subjects merely don’t attend to them consciously and thus do not reflectively report them (for details, see Chap. 4). Further, SCAP and PU are commonly equated in the scientific literature, although some researchers (e.g., Jackson et al. 2011a; Nachev 2011) insist on distinguishing them, at least conceptually (if not phenomenologically). This has implications for how we depict our tic sequence. If sensory and cognitive-affective phenomena (SCAP) just are premonitory urges (PU), then we can use both terms synonymously and depict them as a single concept, as in Sequence 3 (S3): NS → SCAP/PU → TT. But if SCAP are not the same as PU, then we need two separate concepts to depict them, which in turn raises questions about their respective temporal relationship (does one precede the other?) and whether they always co-occur or not. If they are not identical and do not co-­ occur, a sequence without one or the other could look like this: NS → SCAP → TT (we will call this Sequence S4a). Alternatively, we could have: NS → PU → TT (Sequence S4b). If sensory phenomena and premonitory urges are not identical but do co-occur, we could represent them linearly as either: NS → PU → SCAP → TT (S5a) or as: NS → SCAP → PU → TT (S5b). This latter depiction assumes that the urge follows or results from SCAP which, in turn, is triggered by the neural signal. In the tic disorder literature, researchers seem to invoke the causal-temporal structure of S5b (or, alternatively, of S1, which equates PU and SCAP) when they ask whether premonitory urges could aid tic suppression (e.g., Conelea et al. 2018), an idea which places inhibition after the experience of the urge. In this view – opposed by Nachev (2011), as we saw – tic suppression constitutes an intentional (and possibly voluntary) response to the tic-triggering brain signal and its associated first-­ person experience.

190

7  On Reflexes and Stimuli: Tics as Nonactions

But what about the involvement of intentions in experiences like SCAP and PU? Just as the tic-triggering neural signals and other stimuli are not usually regarded as involving intentions (or as being part of intentional actions), so too with premonitory experiences – although unlike subpersonal brain signals, these experiences are person-level phenomena. Figure 7.2 shows that the dominant reading of these experiential phenomena casts them as nonactions. However, when subjects intervene on, or respond to, these experiences (e.g., by changing their attitude toward them; see Gev et al. 2016), their responses are more commonly regarded as involving intentions (see Fig.  7.2). The standard line between actions and nonactions is thus reflected in the line commonly drawn between action and perception. As Rothwell and Edwards (2011, 251) put it: “Paradoxically, an urge to act turns out to be an intention to suppress.” We already saw that Nachev (2011) challenges this reading, suggesting instead that premonitory urges are the experiential correlate of the subject’s inhibitory response (not its precursor). That is, instead of linking PU to the NS (neural signal), he links PU to STT (suppression of tic tokens). By doing so, Nachev denies the intentional action status of tic suppression, meaning STT would remain in the nonaction column in Fig. 7.2 (the dark grey shading of the relevant cells highlights this controversy). Other readings are possible (for example, PU may be a correlate of tic suppression, but suppression could still be intentional and facilitated by something other than the urge, such as SCAP). But all these readings and their associated debates pertain to versions of NIAT or SIAT, since they do not challenge the premise that tic sequences always contain subsidiary processes or events that are unaffected by, or that do not form part of, the person’s intentional acting. This means that contemporary controversies regarding the intentional action status of tics in the literature only ever revolve around the timing and scope of intentions in tics – that is, they disagree over whether and when intentions enter a tic sequence. Proponents of EIAT, on the other hand, would fundamentally challenge the line NIAT and SIAT draw between stimulus and response, between action and perception, and between an experience and the behaviour that may result from it. We will develop this alternative view in more detail in Sect. 7.3.

7.2.3 Behavioural Responses: Ticcing and Tic Suppression Our tic sequences so far all ‘ended’ with a tic token – i.e., the behavioural expression of a vocal or motor tic. We saw that ticcing has been variously construed as a nonaction or as an intentional (and even voluntary) action. We also noted that the action status of tic tokens is contested because ticcing is a stimulus-induced behaviour – i.e., a behaviour that responds to a subpersonal neural trigger unrelated to the person’s goals (or what we termed distal intentions earlier; see Chap. 4). Interestingly, tic suppression is equally controversial: Firstly, because it is not clear how suppression relates to experiences like SCAP and PU, and secondly, because it is not clear whether suppression relies on intentional states or is something the person does

7.2  Mapping the Causal-Temporal Sequence of a Tic

191

intentionally. Regarding the causal-temporal relationship between tic suppression and PU, we contrasted Nachev’s (2011) ‘inhibition first!’ view, which assumes that the urge follows tic suppression, with the standard assumption that the urge precedes inhibition (see Sect. 7.1.2). We can depict Nachev’s sequence in a couple of ways, depending on whether we stipulate that sensory and cognitive-affective phenomena differ from premonitory urges or not. If we presume that SCAP are distinct from PU and precede the suppression of tic tokens (STT), we get: NS → SCAP → STT  →  PU  →  delayed tic token (DTT) or signal extinction (SE; Sequence 6a). SCAP could also arise during tic suppression and precede or co-occur with PU, which could read: NS → STT → SCAP → PU → DTT or SE (S6b). This would fit cases of action inhibition where certain sensations prompt urges (Nachev 2011, 247). If the subject experiences no sensory or cognitive-affective phenomena but does experience urges, we would write: NS → STT → PU → DTT or SE (S6c). In Sequence 6a, where SCAP precede inhibition, we could ask whether they facilitate tic suppression (Nachev only argues that urges do not precede voluntary action, but he does not explain how inhibition – which causes the urge – occurs in the first place). SIAT proponents might argue that intentions could enter the tic sequence at this point. In Sequences 6b and 6c, however, inhibition occurs without any experiential aid; the subject does not perceive anything in relation to the neural signal or emerging tic token. Further, if the subject experiences neither SCAP nor PU, we would write: NS → STT → DTT or SE (S6d). It is not clear whether such a sequence lacking both SCAP and PU is possible, for it would mean that action inhibition may not be experienced nor rely on experience to occur. NIAT proponents might point to Sequences 6b–6d in support of their view, particularly if they tie intentionality to consciousness. At first sight, Sequence 6d looks just like what’s going on in some people with Tourette’s and other tic disorders, who can and do suppress their tics without reporting urges for (at least some of) these tics. But how can subjects know that they are suppressing their tics if they have no experience – sensory or otherwise – which tells them that a latent tic event is emerging and being suppressed? Should we not assume that people can only reflect and report on something when they experience it somehow? If so, statements like “I suppress my tics, but I don’t feel them coming on” may be self-contradictory.7 One way to avoid this contradiction would be to suggest that suppression is a generalised occurrence-level strategy that does not require subjective experiences of every single emerging tic token. We will consider this suggestion shortly. A second way out of this contradiction would be to argue that people who suppress their tics but do not report urges or sensory phenomena are just not reflectively and explicitly aware of these experiences. They may still have these experiences (and successfully suppress tics accordingly), but they are only pre-reflectively and implicitly conscious of them. As such, these tacit experiences are not attended to and may thus not be immediately identifiable or describable by subjects when they are asked about  But theorists like Ned Block, who coined the term “access consciousness” (1995) and distinguished it from phenomenal (experienced) consciousness, argue that this is indeed possible. This has been debated widely; for a recent critical discussion, see Overgaard (2018). 7

192

7  On Reflexes and Stimuli: Tics as Nonactions

them in a research context (see Chap. 4). If this was true, Sequences 6b–6d would depict what subjects think they experience (what they have reflective access to), not what they genuinely experience (the totality of their tacit experiences). Granted, this does not answer the question whether tic suppression could occur if subjects truly did not experience any phenomenal qualia associated with the neural signal or other tic-triggering stimulus. As noted in Chap. 3, the tic disorder literature is not conclusive on this point. When Ganos and colleagues (2012, 975) distinguish voluntary from involuntary tics by suggesting that the latter “go unnoticed” while the former are preceded by sensory urges that “stir” an awareness, they reinforce the notion that momentary consciousness is required for the action to be voluntary. In Chap. 4, we challenged this idea by drawing on de Haan et al. (2017), who suggest that alignment with what we care about across larger timescales is more important than momentary consciousness of action to determine volition. We also encountered Gallagher’s argument that conscious motor control should not be our yardstick for judging whether actions are voluntary and intentional (2017, 141), since many motor aspects of intentional actions routinely occur out of conscious awareness. But if we insist that pre-reflective momentary consciousness of some subtle experience accompanying the neural signal or other tic stimulus is required for tic suppression, then we might favour an inhibition sequence like S6a (where SCAP precedes but PU follows inhibition), or the – perhaps less likely – inverse case, which swaps the order of SCAP and PU: NS → PU → STT → SCAP → DTT or SE (S6e). Alternatively, we might favour sequences – contra Nachev – where SCAP and PU are either the same or different phenomena but always occur prior to inhibition. If SCAP and PU are the same phenomenon and precede tic suppression, we get: NS → SCAP/PU → STT → DTT or SE (S6f). If SCAP and PU are different phenomena and only one precedes (but none succeeds) suppression, we either get: NS → SCAP → STT → DTT or SE (S6g) or: NS → PU → STT → DTT or SE (S6h). If SCAP and PU are different phenomena and both precede suppression, then their causal-temporal relationship requires some thought. If one causes the other, we get: NS  →  SCAP → PU  →  STT  →  DTT or SE (S6i) or: NS  →  PU  →  SCAP → STT → DTT or SE (S6j). If SCAP and PU are not causally related, then we need not depict them linearly. They may both emerge from the preceding neural signal in a parallel and simultaneous fashion: NS → SCAP + PU → STT → DTT or SE (S6k). Importantly, what unites all these sequences is the token-level mechanism attributed to perception. In Ganos et al.’s (2012) spirit, intentional (and voluntary) tic suppression is coupled to the perception of a specific motor impulse or urge to tic – reminiscent of Libet’s veto encountered in Chap. 3. In other words, these SIAT-style inhibition sequences require that the person perceive any latent tics she wishes to suppress in each moment in which they emerge. Yet Shapiro et  al. (1988), who also defend a version of SIAT, challenge this token-level coupling between suppression and perception while retaining the idea that tic suppression is intentional (and voluntary). As they note: “The ability to inhibit a tic may not be preceded by perception of its imminence” (346). That is, we can suppress tics without noticing each and every one of them arise. Just as an involuntary eye-blink that lacks a preceding sensation can be intentionally inhibited for

7.2  Mapping the Causal-Temporal Sequence of a Tic

193

short periods through “a general counter-contraction of ocular muscles”, Tourettic tics can be inhibited through “general muscular vigilance” (346). Importantly, this counteraction does not rely on impulse-specific perceptions (at the token level of tics) but draws on a more generalised (presumably distal) intention – and its associated motor strategies, we might add – to prevent symptom expression at the occurrence or even type or family level of tics. In sum, token-level perception is not required for occurrence-level suppression. Or: We don’t need to be aware of every emerging tic to suppress it; a generalised (distal) intention can do that for us. In this view the intention to inhibit a tic does not arise from, or even during, a specific tic sequence itself but rather constitutes a higher-order, temporally extended intention to act in a certain way (for example, to activate the kind of ‘general muscular vigilance’ that Shapiro et al. talk about). This suggestion has two important implications: Firstly, it provides us with another way out of that seeming contradiction we noted earlier, when we questioned how subjects can suppress tics that they are unaware of. Secondly, it means that looking for intentions in actions requires more than just an atomistic, linear account of individual behaviour; we also need to consider intentions that operate at larger timescales which are enacted repeatedly and via different behavioural strategies over time. Some of these intentional behavioural strategies will not be visible if all we do is zoom in on individual event tokens. For example, if someone suppresses all their tics through generalised muscular vigilance for some time, then this constitutes an overarching intentional behaviour that will not ‘show up’ in the tic suppression sequences we have sketched here. Looking at these event tokens in isolation obscures the fact that they may interact with, and be causally impacted by, other actions that form part of the broader agentic situation – that is, we may miss top-­ down influences on behaviour and consequently fail to recognise its action status. Meanwhile, the idea that tic expression can be prevented by means of a generalised, temporally extended strategy is no stranger to the literature on therapeutic interventions for primary tic disorders. Comprehensive Behavioural Interventions for Tics (CBIT, see Woods et al. 2008) for example, utilises the idea of a counteraction by teaching individuals to perform a pre-selected ‘competing response’ instead of a certain tic. The chosen counteraction targets a specific tic occurrence (e.g., a jaw-opening tic), so that each time this tic occurs (or is about to occur), a competing action is executed instead. While the strategy is thus defined at the occurrence-level of tics (i.e., it is intended to target all instances of the said jaw-opening tic), CBIT still relies on the idea that subjects must be able to perceive individual tic urges (urge tokens) to successfully execute the competing response instead. It thus retains the idea that momentary consciousness of some pre-tic experience is required to inhibit symptom expression – at least in the initial learning phase, when subjects practice using a specific competing response to avert certain tic events (see Chap. 4).8

 It would be interesting to ask whether these skills, once they become automatic, still require conscious awareness of individual urge tokens or whether other generalised mechanisms may keep competing responses ‘activated’ over time. 8

194

7  On Reflexes and Stimuli: Tics as Nonactions

To sum up: Behavioural tic expression and suppression are the most contested concepts in any tic sequence because researchers disagree on their intentional action status (see Fig. 7.2). NIAT proponents might argue that tic tokens and their inhibition merely execute or block an underlying stimulus and are thus nothing like an intentional action. Proponents of SIAT could argue that at least tic suppression, and maybe ticcing as well, constitute intentional responses to tic-triggering stimuli and their associated experiences. Tic suppression itself can be thought of in different ways, namely as a response to stimulus perception or as a general counteraction. Whether these accurately represent what happens when people inhibit their tics is not clear, but our questions about the underlying causal mechanisms and the role of intentions in tic suppression pose themselves similarly for a range of related behavioural and experiential interventions on tics that are rarely discussed in the literature.

7.2.4 Other Behavioural Responses: Tic Facilitation and Modification While tic suppression is the most frequently discussed behavioural response to tics, it is not the only way in which subjects can intervene on their symptoms. By comparison, tic facilitation has received far less attention. Some commentators (e.g., Shapiro et al. 1988, 346) suggest that individuals can actively facilitate their tics or somehow allow them to occur. But in contrast to suppression – where subjects curb an action that would otherwise happen – it is not clear how facilitation changes the situation, and what it adds to simply ticcing or doing the action. If it adds nothing (for example, if the concept merely emphasises that tic tokens are executed intentionally, which we may assume anyway), then we can use any of our prior tic expression sequences to depict the process involved (e.g., S1–S5). Strictly speaking, in this case we would not need the term facilitation at all. But if it adds something, then we need to identify what that is, and when and how the facilitation of tic tokens (FTT) occurs in a tic sequence. Several depictions are possible, including: NS → SCAP/PU → FTT → TT (S7a). A SIAT proponent who does not regard all tic tokens as intentional actions could conceive of facilitation as a reflective agreeing to the latent tic action which the subject feels coming on, or an explicit decision to perform it. This could also happen in a combination sequence (e.g., inhibition plus facilitation). For example, a person might struggle with the experience of an urge (which Nachev argues accompanies inhibition). When the urge becomes too strong or unpleasant she might decide to stop inhibiting and do the tic anyway, which generates a delayed tic token: NS → STT → PU → FTT → DTT (S7b). But what would change if we dropped facilitation from this sequence and just wrote: NS  →  STT  →  PU  →  DTT (S7c); how would this differ from S7b? The answer depends on how we think about the role of intentions in the process of ticcing and in stimulus-response behaviours more broadly construed. If we posit that tics are generally not willed or intended, then the notion of facilitation can help us

7.2  Mapping the Causal-Temporal Sequence of a Tic

195

explain how subjects can intentionally do what are usually nonactions, which is precisely what Shapiro et al. (1988, 346) seem to have had in mind when they used the term. For proponents of SIAT, the notion of facilitation thus serves to distinguish primary tic events which involve an intentional aspect from those that don’t. For NIAT advocates, this very distinction would likely demarcate a classificatory boundary. For if there is nothing intentional about primary tics, then the idea that someone could intentionally bring about a tic event challenges the nosological fit of such actions with how primary tic disorders are defined. In this view, tic facilitation could be associated with functional tics – a reading that would reinforce the distinction between functional and primary tics along the action–nonaction divide (see Chap. 8). And what should EIAT proponents make of the idea of tic facilitation? It might not look useful to them at first. If doing a tic is always regarded as an intentional action of sorts (aimed at an experiential state like relief, for example), then a separate concept like facilitation is not needed to ‘make’ tics intentional – it would be like saying that someone intentionally does an intentional action, which is self-­ evident. But this doesn’t quite follow; for even if we think tics are always intentional, the notion of facilitation could help us distinguish different ways in which subjects attend to their tics. Put differently, it could help us describe if and how people consciously experience and execute their own tic events. For example, if we grant that tics are always intentional but often not executed in a reflectively conscious manner, then the notion of facilitation could be used to describe cases where subjects consciously attend to and reflect on their SCAP or PU experience, and consciously and reflectively execute the tic token. To say someone facilitates a tic would then mean that they are not just pre-reflectively aware of doing that tic, but they reflectively attend to it as they do it, and in order to do it. In sum, the concept of tic facilitation can be invoked for different purposes, depending on whether we hold that nothing, something, or everything is intentional about tics. It can serve us to differentiate between primary tics with and without intentional aspects (SIAT), between different tic disorders (NIAT), and between pre-reflective and reflective tic actions (EIAT). The same holds true for other behavioural responses to emerging tics such as tic modification. People with tics commonly report that they can modify their tics by changing some of their features – such as the pitch, speed, volume, intonation, or fluency in the case of vocal tics. For example, a teenaged girl with coprolalia reports that she either lowers or speeds up her voice when uttering ‘rude’ vocalisations.9 By speaking softly or more rapidly, she prevents people from understanding what she says, thus reducing the risk of negative feedback from her environment in response to the tic. She also modifies socially sanctioned tics by saying “something that sounds similar [to the rude word] and still gives [me] the same sensation of saying it” (we could call this a tic variation) or by delaying the completion of the utterance: “If I need to scream, like, the last letters … if that’s what will give me the sensation

 Unpublished interview data from pilot study (in progress).

9

196

7  On Reflexes and Stimuli: Tics as Nonactions

of having that tic … I might have to say one part … and then, like, wait a while [laughs] … and then say the other part” (we could call this a temporal distortion).10 All these examples of how tics can be modified are difficult to explain without recourse to intentions; when a person modifies her tics by intervening on the emerging tic token behaviourally, she seems to be acting intentionally and with volition. By doing the tic a little bit differently to how it would otherwise materialise without her intervention, the ticcing person exercises some control over her symptoms and their impact on her life – even when she cannot suppress them. As before, we can depict a sequence showing the modification of a tic token (MTT) in several different ways. A simple sequence might look like this: NS  →  SCAP/PU  →  MTT  →  TT (S8a). A more complex sequence is conceivable too, for example when a subject first inhibits a tic but then facilitates and modifies its expression: NS → STT → PU → FTT + MTT → TT (S8b). Even if, following Nachev (2011), we grant that inhibition and its resulting urge experience are not themselves markers of volition (a contested view, as we saw earlier), it would be difficult to explain how subjects can facilitate or modify their tics without resorting to the notion of intentional action. These sequences thus lead us straight into the arms of SIAT (and EIAT, as we will see). This is true for the way in which people with tics intervene on their symptom behaviours, but also for how they intervene on their experiences of these symptoms by targeting their own thoughts, beliefs, or attitudes toward them.

7.2.5 Cognitive-Affective Responses: Impacting Experience Is it possible to intervene on ‘what it feels like’ to have tics – i.e., to suppress, facilitate, or modify how symptoms are experienced (and not just whether and how they are expressed)? We know very little about this in the context of tic disorders, but some evidence suggests that people’s cognitive and affective responses to their tics and tic-related experiences can play an important role in how they cope with symptoms. In Chap. 4 we explored acceptance-based therapeutic approaches to working with tic disorder patients, which do not target behavioural tic expressions directly (as CBIT does, for example), but rather aim to change the experience of urges and sensations associated with tics. In Gev et  al.’s (2016) study, subjects who were instructed in how to accept their urges reported experiencing them differently as a result – they had fewer, less intense, and less uncomfortable urges, a change that was not achieved when subjects were asked to suppress their tics behaviourally

 Neither strategy (tic variation or temporal distortion) is the same as using a competing response in CBIT because the modified behaviour is still aimed at creating the desired sensation tied to the original tic (e.g. relief from the urge). In the case of competing responses practiced in CBIT subjects learn to tolerate but do not fulfill the perceived experiential need or urge. The quoted example illustrates a situation where a person modifies her tic expression while still facilitating the desired sensation. Put differently, her choice of behavioural modification is influenced by an experiential goal state (see Sect. 7.2.5). 10

7.2  Mapping the Causal-Temporal Sequence of a Tic

197

(81). The example is instructive as it reinforces our earlier observation that responses to emerging tics can be both specific or general – that is, aimed at concrete experiences and behaviours (at the token level of tics) or at an entire class of experiences and behaviours (at the occurrence, type, or family level of tics; see Chap. 2). Notably, in Gev and colleagues’ study (2016) the intention to accept whatever urge experience may arise is not spontaneously formed during ticcing but conceived independently and applied to all tic urges. We could call this a (short-range) distal intention, which temporally precedes those moments in which concrete urges arise and in which this attitude must be embodied. Put differently, the plan to accept one’s urges must be enacted each time an urge arises, requiring subsidiary intentions-in-­ action and motor intentions that are activated momentarily. Pacherie’s (2008, 188) notion of an “intentional cascade” provides a useful term to describe this interrelationship. For example, embodying acceptance might require a certain degree of muscular relaxation, deeper or slower breathing, evocation of mental imagery as described by Gev et al. (2016), and so on. Without such “episodic detail”, subjects could not translate the abstract goal state of urge acceptance “into a concrete episode of instrumental action directed toward that goal” (Pacherie and Haggard 2010, 18–19; see also Chap. 4). But if attitudes are embodied in this way, then what does this mean for how we describe the intentionality of tic sequences that involve cognitive-­affective interventions like the one described above? On their own, the single token-level tic sequences discussed in this chapter cannot adequately depict this interaction across timescales and organisational levels of the human system (brain-body-environment). And yet, if distal intentions interact with these token-level processes, then we can rule out NIAT (the view that there is nothing intentional about tics) at least in instances where subjects intervene experientially or behaviourally on their emerging symptoms. For example, there must be something intentional (SIAT) about tic sequences in which subjects modify their experience of premonitory phenomena or urges (MSCAP or MPU in Fig. 7.2) or both, even if such intervening does not change the resulting tic token: NS → SCAP/ PU → MSCAP/MPU → TT (S9a). What this sequence does not depict visually is how MSCAP (i.e., the  modification of sensory or  cognitive-affective phenomena) interacts with the distal intention – for example, the intention to accept this and other sensations or urges. Importantly, this intention is causally implicated in, but not caused by or during, Sequence 9a. To represent the intention to accept one’s experience of SCAP or PU – let’s call this IA(SCAP/PU) – we would need to introduce another structural layer in our notation, which visualises the relevant causal-­ temporal interrelationship: －－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－IA ( SCAP / PU ) －－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－ ↓



NS → SCAP / PU → MSCAP / MPU → TT

↓ NS → SCAP / PU → MSCAP / MPU → TT



Here, the intention to accept (IA) one’s experience of SCAP/PU is temporally extended, persisting above and beyond the momentary instances (two are shown) in which tic tokens may emerge from neural signals. The vertical downward-facing

198

7  On Reflexes and Stimuli: Tics as Nonactions

arrows signal that IA(SCAP/PU) is activated or embodied during a tic sequence, probably via motor intentions and intentions-in-action which translate the goal state (acceptance) into concrete behaviour (e.g., muscle relaxation, slower breathing, evocation of mental imagery, etc.). As with all our previous tic sequences, we can easily imagine several interventions occurring simultaneously. For example, a subject may intervene on her urge experience via acceptance, thereby reducing the intensity of that urge. As a result she is better able to modify the resulting tic token (MTT) or even suppress it (STT) behaviourally as well. Put differently, experiential interventions may aid behavioural ones (S9b): －－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－IA ( SCAP / PU ) －－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－－ ↓



NS → SP / PU → MSCAP / MPU → MTT / STT

↓ NS → SP / PU → MSCAP / MPU → MTT / STT

Interestingly, in Gev et al.’s (2016) study acceptance not only modified subjects’ experience of their tic urges (how they experienced them) but also seems to have had a mildly suppressive effect on that experience itself (whether they experienced tic urges) – at least in so far as subjects reported fewer and less intense urge experiences, not just different ones. Some cognitive-affective responses to the momentary experience of SCAP/PU thus seem to affect future symptom-related experiences. In the case of positively valenced interventions like acceptance, looking at just a single SCAP/PU experience token cannot depict this cumulative and temporally extended effect, because it is the repeated modification of experience tokens (MSCAP/MPU) which appears to contribute to the suppression of these very experiences (SSCAP/SPU).11 Two interesting questions arise from this: Firstly, could MSCAP/MPU not only lead to SSCAP/SPU, but also to the suppression of the underlying neural signals (SNS) over time? And secondly, what about negatively valanced cognitive-affective responses to tic disorder symptoms, such as fear, anger, resentment, or shame? Could these responses have the opposite effect by exacerbating or proliferating future SCAP/PU experiences rather than aiding their decline? While empirical research into these questions is lacking, the examples above clearly push us to the limits of the neuro-reductionist frame so commonly applied to experimental studies on tics and Tourette’s. As we saw earlier, this interpretative frame privileges analyses of individual tic sequences presumed to play out entirely at a micro timescale in the person’s brain. Our example of acceptance as a positively valenced response to premonitory urge experiences clearly reveals what goes missing when we try to understand tics purely through a single sequence window. This perspective obscures the ‘situatedness’ of token-level processes by bracketing out the influence of both distal intentions (narrative frame; see Chap. 4) and salient

 Exposure Response Prevention (ERP) draws on a similar principle, but in the inverse direction. While acceptance-based therapeutic approaches modify experience and thereby commonly effect a change in symptom behaviours, ERP-based therapeutic approaches modify behaviour (by withholding the action the subject feels urged to do) and thereby change the associated experiences (for example, see Wetterneck and Woods 2006). 11

7.2  Mapping the Causal-Temporal Sequence of a Tic

199

contextual factors inherent in the agentive situation (enactive frame; see Chap. 6). This is true not only of acceptance as a particular way to modify ‘what it feels like’ to have SCAP/PU, but of any behavioural or cognitive-affective interventions on tics discussed in this chapter. Facilitation – our last concept to be discussed here – is a case in point. We briefly touched on the behavioural facilitation of tics before, which Shapiro et  al. (1988, 346) describe as a “volitional or intentional aspect” associated with tics. But the idea that subjects could not only bring about their vocal and motor tics intentionally, but also certain experiences associated with tics has rarely been discussed. Conceptually, modification and suppression work with what is ‘given’ in experience (by intervening on it), but facilitation implies that subjects somehow create these experiences in the first place. What do we mean by that, and how likely is this to occur? The answer might depend on which experience we have in mind. For example, it seems unlikely that subjects would or could intentionally cause their own SCAP or PU experiences to arise, since these are consistently described as uncomfortable (e.g., Jackson et al. 2020). Similarly, some evidence casts doubt over the urge–relief cycle or negative reinforcement hypothesis, which stipulates that people tic to alleviate unpleasant urges and premonitory sensations (for a discussion, see Specht et al. 2013; Niccolai et al. 2019). In this view, ‘doing the tic’ could be seen as an intentional action aimed at experiencing that relief. The tic event could then exemplify two different kinds of facilitation – a behavioural (symptom expression) and an experiential (relief) one, depicted here as Sequence 10: NS → SCAP/ PU → FTT → FPTE. While we await further empirical research on the negative reinforcement model of tics, we can apply our broader reflections on behavioural facilitation (see Sect. 7.2.4) to the present discussion of experiences too. For as we noted, the idea of facilitation raises different questions and opportunities for proponents of NIAT, SIAT, and EAIT. If we posit that people with TS and other primary tic disorders can intentionally bring about certain post-tic experiences by ticcing, then we would have to allow that at least something is intentional about some primary tics (SIAT). SIAT proponents might draw on the notion of facilitation to distinguish cases where such experiences are intentionally brought about from those where this is not the case. Alternatively, if we defended the view that nothing is intentional about primary tics (NIAT), we would need to either deny that such intentional facilitation is occurring or assign these cases to another tic disorders. Lastly, if we posited that everything is intentional about tics (EIAT) anyway, then the notion of facilitation may look superfluous, but we could still use it – for example, to distinguish between pre-reflective and reflective ways of bringing about the desired experiential states associated with tics. Sequence 10 highlights that the boundaries between behaviour and experience can be blurred and that their causal-temporal relationship may be complex and multi-directional. By doing a tic action (or by intentionally facilitating a behaviour that is usually not intended), we can bring about an intended experiential state. Similarly, by modifying one experience (of an urge, for example), we can facilitate other experiences or behaviours; and by intervening on a behaviour (e.g., by

200

7  On Reflexes and Stimuli: Tics as Nonactions

suppressing or modifying it), we may also simultaneously facilitate, modify, or suppress certain experiences. In Sect. 7.2.4 we encountered the example of a teenager with TS who modifies her socially inappropriate vocal tics (behaviour) in a way that still facilitates a certain sensation she wants to feel (experience). This case illustrates the sorts of complex intentional interventions people perform – perhaps routinely  – on their tic disorder symptoms. Much of this complexity remains unacknowledged in the scientific literature, which currently lacks a systematic language for describing the full spectrum of these phenomena. Once we face this complexity, however, we see intentions seeping deep into the cracks of many of the different tic sequences spelled out above, making it increasingly difficult to deny their action status.

7.3 Coming Full Circle 7.3.1 NIAT’s Last Straw Proponents of NIAT will insist that our arguments thus far about the involvement of intentions in tics need not apply to certain basic or simple tic tokens. Pointing at the nonaction column in Fig. 7.2, they will argue that certain tic sequences (S1–S5) can be depicted without recourse to intentions. But Fig. 7.2 also highlights that these very sequences rely on two contested concepts: tic expression and tic suppression. The tic disorder literature continues to debate their action status – that is, whether vocal and motor tic tokens occur or are suppressed intentionally. Less debated (yet no less worthy of debate) are a range of other philosophical questions linked to our take on NIAT, SIAT, and EIAT.  How should we distinguish between stimulus-­ induced behaviour and planned or goal-directed (intentional) action? (We touched on this question in Sect. 7.2.2 and in Chap. 3.) Relatedly, how should we differentiate action and perception, or action and experience, in the context of tic disorder symptoms? If there is action in perception, as Noë (2006) famously argued, then how can we demarcate a nonintentional sphere of human doing or experiencing (and specifically of ticcing and experiencing one’s tics)? And why would we want to do this in the first place? To highlight the relevance of these questions, Fig. 7.2 lists all tic-related experiences in both the action and nonaction columns. The placement in the action column is my own suggestion (hence the brackets placed around the ‘X’) and based on arguments I will spell out below; it is not reflective of how tic-related experiences are viewed in current scholarship (the associated cells are shaded in a lighter grey to indicate that the placement is debatable, but currently not debated in the tic disorder literature). Lastly, Fig. 7.2 also touches on the search for ‘basic actions’ in philosophy and the question whether actions should be construed as events or processes (e.g., Paul 2020; Gallagher 2020). While we cannot dive deeply here into the specialist scholarship that exists for each of these philosophical issues, we should note that all of them revolve around

7.3  Coming Full Circle

201

time and how we conceptualise the temporality of our doing and experiencing. A good way to demonstrate this is by tracing NIAT’s reliance on a linear causal-­ temporal view of tics as generated neurologically from the bottom up. When proponents of NIAT insist that (at least some) tics are not actions, they must draw on the idea that a stimulus and its response occur successively, with the latter following reflexively from the former, and both representing separate and distinguishable events or processes. Given the ‘firstness’ of the stimulus, what comes thereafter cannot redeem itself as freely chosen or intended in the same way as our planned and wanted actions can. In this view the firstness of the stimulus designates both a temporal prior and a causal and explanatory origin. And yet, if NIAT relies on such a rigid distinction between stimulus-induced behaviours and intentional action, then this view could be difficult to uphold. Jackson et al. (2011b) themselves emphasise in their response to commentaries that “the boundaries between the concepts of reflex, urge, and intention are rather artificial” (252). This is not to deny findings from neuroscientific experiments, which show that what happens in the brain before tics differs from what happens in the brain before certain voluntary actions. In a recent EEG study, for example, Morera Maiquez et al. (2021, 16) found that “movement-related mu and beta band oscillations” – which are commonly observed prior to voluntary action – “are not observed prior to tics in individuals with TS”. But even if the generation of tics reflects a “greater involvement of a network of brain areas, including the insular and cingulate cortices, basal ganglia nuclei, and the cerebellum”, and even if this means that the mechanism for inhibiting physiological responses is impaired in people with TS, this does not settle our question whether tics involve intentional states or not. The latter’s absence is not proved by the observed (oscillatory) difference in the brain. Instead, different types of intentional and associated neural processes might be at play. As Niccolai et al. (2019, 157) suggest, it is possible that “the intention to tic in order to reduce or eliminate intense sensory or motor urge might still differ from the intention to start a normal movement”. Over two decades earlier Karp et al. (1996) made a similar point, suggesting that the observed electrophysiological difference between self-paced voluntary movements and tics does not rule out that both types of movement are voluntary (what we would call intentional; see Chap. 6). Rather, the difference in brain activity may relate to whether the movement responds to a stimulus or not: “Tics may be more similar to movements made in response to stimuli than to self-paced, voluntary movements” (106; see Chap. 3). The idea that our responses to stimuli can be intentional, or form part of broader intentional actions, only appears counter-intuitive if we conceive of ourselves as passively suffering from the impact of such stimuli. Where is the action (or the intention) in my experiencing an almost indomitable urge to jerk my body every few seconds, much to the amusement of my classmates who never tire of mocking my tics? Am I not merely passively suffering from and through the experience of this recurrent urge, the movements it incites, and through my classmates’ mocking as well? We are reminded of our discussion of agency and ownership in Chap. 5, where we noted that seemingly passive experiences – like receiving a massage (De Haan and De Bruin 2010)  – are agentic too because they require us to respond

202

7  On Reflexes and Stimuli: Tics as Nonactions

attitudinally to the experience, during the experience, in a way that shapes how the experience feels to us as it unfolds. For De Haan and De Bruin (2010) the attempt to draw a line between action and reaction is thus misguided. Drawing on Dewey’s (1896) famous critique of the ‘reflex arc’, they oppose any rigid division between stimulus and response: “It would be artificial to draw a sharp line between what is an action and what is a reaction—not only at the microlevel of bodily movements but also from a broader, developmental perspective” (De Haan and De Bruin 2010, 394). So, if we claimed that tic tokens, their suppression, and the subjective experiences associated with them are all just mechanical consequences of stimuli that arise and take their course without our further ado, would we not be guilty of replicating the sort of dualism that Dewey urged us to discard well over a century ago? At the cusp of the twentieth century, John Dewey critiqued what for him was the ‘new’ dualism of stimulus and response, because it provided no genuine departure from the earlier dualism of body and soul (1896, 357–358). Both conceptual pairs, he asserts, rely on similarly problematic conceptions of the nature of sensation and of action (357). To explore Dewey’s perspective in the context of tic-related experiences (such as premonitory sensations and urges, or experiences which occur during or after a tic), we need to remember that these experiences are currently not ‘up for grabs’ as actions in contemporary scholarship. That is, the current tic disorder literature presumes that these experiences just are the (unintended) phenomenological correlates of underlying neural processes on which they supervene and that, as such, they do not reflect any agency or intentionality on the part of the person who experiences them. But as Noë (2006) and others have pointed out, internalist assumptions like these are far from being empirically settled, and we have reason to believe that our experiences don’t supervene on our brains alone but rather emerge from complex systemic interactions between our embodied selves and the environments we inhabit. What’s problematic about internalist explanations of tic-related experiences is the causal reductionism that tends to accompany this view. That is, we tend to think of these experiences as happening purely in the heads of people with tic disorders and as supervening only on internal states of their brains. To be clear, this is different from simply asserting that neurological facts about the brain play an important role in primary tic disorders and in the experiences associated with symptoms. As a matter of fact, we do not actually know the necessary and sufficient causes of tic-related experiences; in other words, we have not yet established empirically if and when people with tic disorders experience SCAP, PU, TE, or PTE (see Fig. 7.2). Primary tic disorders like Tourette Syndrome are now deemed so obviously neurological that suggesting other causal contributories edges on a taboo. But if we hold an internalist and reductionist view of tic-related experiences (that certain brain states are all that’s needed for a subject to have SCAP, PU, TE, or PTE), we eliminate the need to think of them as shaped by the subject’s complex embodied states and interactions with her world. This, in turn, makes it easy to claim that experiences are nothing like intentional actions, a claim that is far from Dewey’s (1917) insistence that experience is not passive but “an active attitude”, a “matter of simultaneous doings and sufferings”. For him, “both sensation and movement lie inside, not outside the act”

7.3  Coming Full Circle

203

(1896, 359) – or we might rephrase: they are integral to the idea of action. Fast forward to the twenty-first century, and we find a similar emphasis on the simultaneous ‘doing and suffering’ involved in our response to sensory stimuli in Wu’s (2014) recent book-length study of attention.

7.3.2 No Candy Machines or Mars Rovers Just as Dewey critiqued the dualistic accounts of the sensorimotor circuit popular in his day, Wu (2014) grapples with the dualism that runs rife in contemporary scholarship on attention. As he illustrates, the literature on attention commonly posits a dichotomy by contrasting top-down controlled attention which reflects a subject’s intention (for example, if you tell me to follow the man in the fedora) with bottom­up automatic attention which apparently does not reflect a subject’s intention (for example, if you are startled by a loud noise while reading a book). The difference seems intuitive – after all, I intended to follow the man with the fedora, but I didn’t intend to be disrupted by a noise! – but Wu shows that the two are not as distinct as we might think. Drawing on a wealth of empirical evidence, he shows that many cases of so-called ‘attentional capture’ (like the unexpected sound that distracts me while reading) are not pure cases of a stimulus ‘grabbing’ our attention automatically and from the bottom up. Rather the point at which I attend to the stimulus is already the point at which I begin selecting for an action: “I hear the sound and subsequently intend to figure out where it is coming from, so attention thereby takes on a controlled aspect. It is sustained according to my intentions” (Wu 2014, 35). If attention is selection for action, as Wu proposes, then it makes little sense to insist on a categorical distinction between goal-directed and stimulus-driven attention, since the selection of action usually involves both. As Gibson and Kelsey (1998, 699) suggest, “stimulus-driven attentional capture may be caused by goal-directed processes” (see also Wu 2014, 37). This appears true even for classic cases of attentional pop-out, where some feature in the environment captures our attention in a seemingly automatic fashion (that loud noise I heard earlier, or a single red shape in a sea of green shapes – here, the red shape seems to literally pop out at me without my further ado). Folk et al. (1992) have also argued that there are no pure cases of bottom-up, stimulus-driven attention (see also Burnham 2007, as quoted from Wu 2014, 37). But what about tics? Are the premonitory sensations and urges known to precede tics in TS not a prime example of stimulus-induced ‘selection for action’ leading to automatic behavioural responses (i.e., tic tokens) from the bottom up? Could SCAP and PU be a more genuine case of attentional pop-out than the examples discussed in the literature on attention? It seems intuitively right to suggest that premonitory sensations and urges force themselves into subjects’ consciousness, often against their will. They are attention-grabbing experiences, disruptive like noises which startle us, and they often interfere with other goal-directed activities. When Wu notes that “it is hard to accept the claim that there is never attentional capture

204

7  On Reflexes and Stimuli: Tics as Nonactions

contrary to one’s goals” (Wu 2014, 38), we might nod and point to tics as a case in point. But if we think that attention can be “independent of the goals of the perceiver” (38), then we are playing the ball into NIAT’s court. While Wu does not write about Tourette Syndrome, I propose that his broader arguments about attention challenge the view that there is nothing intentional about tics. To show how this follows, we first need to clarify that Wu’s notion of attention does not require what we called ‘reflective consciousness’ earlier (see Chap. 4). This is important, because it means that attention – as selection for action – can be automatic, requiring no self-reflective guidance from the individual. If there was full automaticity, however, then there would be fully goal-independent actions free from subjects’ intentions: “In the limiting case where intentions are not involved at all in input-output coupling, a process is fully automatic” (83). But the point is that Wu does not think such cases exist in the context of human behaviour. Put differently, he thinks that selection for action in humans is almost never purely automatic – perhaps not even in the case of reflexes. The latter must involve behaviours that do not require any selection for action (89): This implies that there were no additional behavioural paths beyond the one path taken (this includes the path of not acting). Thus the behaviour space consists of a simple one-one mapping from target to response. All the creature could do was to act on one target in one way. This, however, is just a reflex. In particular, to emphasize the very rigid structure at issue, I will speak of this reflex as a pure reflex. It is not clear that normal human reflexes are pure reflexes in the sense just noted.

Clearly Tourettic tics are not one–one mappings from target to response; they come with multiple possible behavioural paths, including the path of not ticcing, ticcing differently, or changing one’s attitude toward the tic (and thereby often changing the tic). Tic tokens, despite their obvious automaticity, still require selection for action and thus an attentional – albeit not necessarily consciously reflected – process that is guided by the person’s intentions (which also need not be consciously reflected; more on this below). Wu, as I interpret him here, would thus disagree with Culver and Gert’s (1982) placing of tics into the category of nonactions (Category E in their taxonomy; see Chap. 6) alongside reflexes and epileptic seizures. He would deem tics to be actions qua being attentively selected by an agent, and this attentive selection of behaviour cannot be fully automatic and bottom-up but must also be guided by top-down intentional processes. Attention for Wu “is a personal-level state that exhibits intentionality” (97) and which distinguishes action from other forms of non-attentional selection for behaviour – think candy machines or Mars rovers – in the world (2014, 87–88). It is not possible for an action to be controlled only by sub-­personal states of the subject, because the behaviour space in which this action unfolds must also be a psychological space: “[T]he inputs imply that the subject bears an appropriate psychological attitude toward them when perceiving, remembering, or thinking. Thus, in coupling an input to an output, a necessary condition on the subject’s involvement is secured at the get-go” (88–89). What is at stake here is the relationship between the psychological and the physiological, two terms which echo the very dualism Wu is keen to leave behind. His insistence that action cannot be reduced to subpersonal processes but should remain

7.3  Coming Full Circle

205

anchored to the personal level of an agent who does something (88) aligns with De Haan’s (2020, 14) call to see the person in her world as the common magnitude to which we must relate both someone’s (neuro)physiology and their experience: “Since both are part of a larger whole, we cannot map physiological and experiential processes onto each other”. For De Haan this larger whole is “the complex system of a person coupled to her world”, a notion which reminds us of Noë’s brain-­ animal-­world systems (2006, 218). The relationship between the psychological and the physiological should be thought of as mereological (part–whole), rather than linear and sequential. But what does this mean for our earlier depiction of tic sequences and the relationship they suggest might hold between the various tic-­ related concepts discussed in the literature? If we take Wu and De Haan’s comments to heart, it means that depicting these processes in the way we have in earlier parts of this chapter – and in the way the literature tends to do – is deeply problematic because it entails this linear, sequential, and causally reductivist reading of what goes on when someone tics. Recall our most basic tic sequence, S1: NS → TT. Here, the placement of the arrow and our reading convention (left to right) suggest a causal-temporal first–then relationship between the neural signal and the tic token, whereby the former brings about the latter. This makes it look as if subpersonal processes are entirely sufficient for guiding action – the very idea which Wu opposes in his study of attention. What S1 brackets out as seemingly irrelevant are the interdependencies that exist within such complex dynamic systems as persons in their world, in which experience and physiology can mutually influence each other. Sequence 3 (NS → SCAP/PU → TT) explicitly juxtaposes (neuro)physiology and experience in a way that maps the latter onto the former: Someone experiences premonitory phenomena because an underlying motor signal causes that experience. Again, this way of depicting things suggests that experience is straightforwardly reducible to neurophysiology, as if there could only be local (subpersonal) to global (person-level) causation and not the other way around. In philosophy the question whether downward or top-down causation (e.g., from ‘mind’ to ‘body’) is possible without committing to dualism remains hotly debated (see Murphy et al. 2009). Many argue, however, that causality can go both ways in complex dynamical systems – so “that drugs can change my mood, for instance, and that psychotherapy can change my brain” (De Haan 2020, 13). To recap what should be clear by now: The point is not to deny that motor signals commonly precede (and are probably necessary for) the tic-related experience of premonitory phenomena and urges (SCAP and PU), but rather to say that we cannot deduce from this that these signals are all that’s required for someone to feel them. Given the role of cognitive-affective and environmental factors in the expression of tic disorder symptoms, a complex system’s perspective promises to yield more appropriate explanations of what goes on when people tic. Such explanations should be multi-factorial and diachronic – not only in psychiatric disorders, as De Haan suggests (2020, 15), but also and particularly in tic disorders, I propose. This is because tic disorder symptoms entail a unique temporal structure (and probably a unique experience of time) which disrupts attempts to understand causality in a

206

7  On Reflexes and Stimuli: Tics as Nonactions

linear and reductivist fashion. Tics are rarely singular events spaced out over large intervals of time, but rather present as more or less dense clusters of repeating behaviours that fluctuate in intensity across contexts and timescales. Recurrence and repetition are key features of tics, and individuals will report their own patterns of symptoms often referred to as “waxing and waning cycles” in the literature (see Chap. 2). When tics and their associated experiences recur incessantly, sometimes relentlessly, it becomes difficult to distinguish between what both Wu (2014) and De Haan (2020) describe as the ‘initiating’ and ‘maintaining’ causes of an action. If one tic is swiftly followed by another and yet another, we can no longer individuate actions in the same way as we are able to do when analysing discrete singular events or processes that clearly differ from other proximate events or processes. Put differently, given the sameness (or near-sameness) of the repeating vocal or motor tic tokens, we are dealing with an extended temporal enaction of a certain tic occurrence (see Chap. 2), which means we cannot ‘bracket out’ the preceding or succeeding moments in the way we usually would when analysing other actions. The ‘before’ and ‘after’ are more of the same rather than constituting distinct agentic book ends to a discrete interval in someone’s meaningful activity. We already touched on the tendency – particularly evident in neuroscientific studies – to bracket out the intrinsic situatedness of tics within their broader agentic situations (see Sect. 7.2.3), which explains why our earlier tic sequence S2 (OS → NS → TT) has not been studied to date. If we took S2 seriously as an analytic frame for individuating discrete tic events, we would have to re-think what constitutes ‘initiating’ and ‘sustaining’ causes of actions. The idea that we can distinguish an initiating stimulus from an intentionally guided response to this stimulus is expressed in Wu’s suggestion that “attentional capture gives way to controlled attention” (2014, 93; emphasis added). That is, the agent intentionally maintains attention to the stimulus and is thus causally implicated in her own resulting action. While there is a residual linearity to Wu’s ‘first–then’ model of a causal relation between stimulus and response, De Haan (2020) points out that the distinction between initiating and maintaining causes should not be overrated. Psychiatric research often seeks to find the initiating causes of a disorder (which is legitimate from both a treatment and future prevention perspective), but factors responsible for maintaining the disorder also play a crucial role: “In many cases, the factors that keep someone in a specific state are at least as important [and] … can thus also be proper targets for interventions” (De Haan 2020, 16). In tic disorders I suggest that this very distinction between initiating and maintaining causes of symptoms becomes blurred due to the quick succession of almost identical tic tokens. Here, overlapping cycles of the same movements or sounds distort what is future, present, and past: The motor signal which is said to precede and give rise to a certain tic token suddenly seems prompted by the subject’s affective response to the ceaseless storm of tics she endures. What appears as an initiating cause from one vantage point quickly looks like a maintaining cause from another. My aim here is to point out that this causal-temporal blurring between stimulus and response, and between the physiological and the psychological, is rarely

7.3  Coming Full Circle

207

acknowledged and explored. As long as we classify disorders based on their initiating causes only, describing Tourette Syndrome as a movement disorder and grouping it among other neurodevelopmental conditions makes perfect sense. But what this obliviates is the important fact that symptoms of Tourette’s can have powerful psychological effects which may in turn maintain these very symptoms, thus contributing to future symptoms. Put differently, Tourette Syndrome may not qualify as a psychiatric condition if the latter is defined as originating in “disordered patterns of sense-making” that arise from a person’s difficulty in relating with reality (De Haan 2020, 18). But such difficulties in sense-making and relating to one’s world often do arise in people with TS, as is exemplified by staggeringly common psychiatric comorbidities such as anxiety, depression, and elevated risk of suicidal ideation (Johnco et  al. 2016; Dale 2017). These cases can be complex and severe; calling TS ‘just’ a movement disorder simply doesn’t capture the full picture. As I will now argue, these common existential disturbances that accompany Tourette’s are not an accidental by-product of the condition. Rather, there is something peculiar about the symptoms of Tourette Syndrome and other tic disorders that makes these conditions psychiatrically relevant – namely, the altered temporality of movements and actions described above: that temporal blurring between past, present, and future brought about by the incessant repetitiveness of tics, and intensified by their lacking integration with the subject’s meaningful activities. As I briefly proposed  in Chap. 2,  tic disorder symptoms can induce abnormal experiences of time – and of oneself in time – which may become stimuli or ‘originating moments’ for psychiatric problems. We can draw on Husserl to develop this idea.

7.3.3 Hyper-Circularity: The Echo Chamber of Tics A central idea in Husserl’s writings and explored by many philosophers since regards the intrinsic temporality of experience. In listening to a melody, for example, we are never just conscious of the present moment – a singular note of music – but we retain the past (some previous notes) and anticipate the future (how the melody might continue). Husserl (1991) calls this ‘retention’ and ‘protention’, and he deems both to be structural features of consciousness. Gallagher argues, however, that this intrinsic temporal structure also applies to action, perception, and cognition more generally, as well as to “movement and motor processes that are not conscious” (2020, 28, 34). His useful diagram of Husserl’s model depicts the perceptual sequence of a subject listening to four notes in a melody (A, B, C, D; my own Fig. 7.3 is modelled and expands on Gallagher’s diagram). Each note in the melody is consciously perceived by the subject in the present moment in which it occurs – Husserl calls this a primal impression (I). This present perception of the musical note, however, also retains previous phases of consciousness and their intentional content (retention, R). We can imagine this as a ‘retentional continuum’ – R3(R2[R1]), and so on – which stretches back to the preceding experiences. At the same time, the current conscious perception of the musical note already

208

7  On Reflexes and Stimuli: Tics as Nonactions

Fig. 7.3  The future-directedness of the field of consciousness when perceiving four notes in a melody. (Modelled on Gallagher 2020, 28; Husserl 1991)

anticipates what will happen next (protention, P), imbuing consciousness with an intentional directedness (see Gallagher 2020, 28). Since action exhibits the same flow and intentional direction as consciousness, Gallagher suggests that we replace Husserl’s ‘primal impression’ with the term ‘primal enaction’. This better describes the dynamic temporal structure of both consciousness and action, neither of which are merely passive impressions but always constituted through simultaneous protention and retention which complicate “the immediacy of the present” (Gallagher 2020, 34–36). Given the dynamic interplay of protention, retention, and the primal enaction in each ‘now’ phase of the living present, thinking of each of these concepts individually is merely an abstraction. Importantly, primal enaction is “really nothing on its own” but always realises (or fails to realise) previously retained protentions and thereby feeds the current protentional process (Gallagher 2020, 35–36). The present moment is thus no singular point that we can isolate from its past or future. Speaking meaningfully about action, consciousness, and even motor processes that are not conscious always requires us to integrate the ‘now’ with its constitutive ‘before’ and ‘after’. This phenomenological perspective powerfully challenges the appropriateness of the neuro-reductivist frame and its tendency to analyse individual tic sequences as a chronological succession of discrete events. As Dewey notes in his critique of the reflex arc, there is a unity and circularity to our experience of stimulus and response; a unity and circularity, we might add, that resonates with Husserl’s thoughts on the protentional and retentional nature of our living present. Rather than constituting a “patchwork of disjointed parts, a mechanical conjunction of unallied processes”, we should think of them as forming a “comprehensive, or organic unity” (Dewey 1896, 358; see also De Haan and De Bruin 2010, 378). Put differently, stimulus and response do not exist as distinct experiences but are always integrated in a bigger “coordination” which ensures the “unity

7.3  Coming Full Circle

209

of activity” (Dewey 1896, 359–360). The reflex arc idea is faulty because it does not recognise this unity, leaving us instead with a disjointed psychology: It still leaves us with sensation or peripheral stimulus; idea, or central process (the equivalent of attention); and motor response, or act, as three disconnected existences, having to be somehow adjusted to each other, whether through the intervention of an extra-experimental soul, or through mechanical push and pull.

With Husserl and Gallagher we could say that this disjointed psychology fails to reflect the simultaneity of past, present, and future which characterises any ‘now’. And yet it is precisely in this manner that we have treated tic sequences in the earlier parts of this chapter: as chronological processes or series of events which begin with a stimulus and its perception and then progress to a motor or other response. This means that we have committed the mistake of treating this so-called response as one that reacts to a stimulus rather than as one that acts into it (Dewey 1896, 359). This contrast – of acting into rather than responding to – evokes a simultaneity that is lacking from the notion of a linear sequence or reflex arc. Our Fig. 7.2 (see Sect. 7.2.1), which we have referred to repeatedly in this chapter, is built on the same misconception since it treats stimuli as separate from experiences and behaviours – the tripartite division of which Dewey is so critical. Figure  7.2 thus exemplifies what is wrong with the neuro-reductivist frame, which invites us to adjudicate if and when intentions enter into a tic sequence. But the question is jinxed since intentions are always already there – they do not ‘enter’ the process but enable it from the start. Figure 7.2 also reinforces a simplistic view of the causal-temporal structure of tics which favours explanatory models that trace each symptom back to a singular originating moment (the neural signal), as if such origins were always clear and context played no role in their occurrence. But tics don’t come in single scoops. They rarely exist as solitary events but rather form a constant chorus, repeating a common refrain, or they emerge as clusters of similar notes which echo themselves ad infinitum. Since most tic tokens are sandwiched by their identical twins, there is usually a tic before the next tic and an urge before the next urge and a moment of relief before the next moment of relief. To claim that we can privilege and isolate one such tic sequence; lay it out flat in front of us to meet our need for a two-dimensional notation (from NS to TT); and describe it coherently without considering how it interacts with its fellow category members – proximate or distant – is absurd. At the very least, we should devise a three-dimensional model (as attempted in Sect. 7.2.5) to represent these dynamics. Given the often-incessant repetition and sameness of tics, their beginnings and ends are far less clear or discernible as the notes in Husserl’s melody, and there is less of a sense of progress or progression toward an anticipated future. In some sense the experiential structure of ticcing may thus be more truly circular than that of listening to Husserl’s melody, where we can perceive each note as a discrete impression against a background of ‘otherness’ and change. Both Dewey’s notion of a coordination and Husserl’s idea of a retentional continuum still contain a sense of directedness in time which we can depict as a spiralling process (see Fig. 7.3), a

210

7  On Reflexes and Stimuli: Tics as Nonactions

progression of circular loops mapped onto Gallagher’s figure of Husserl’s notes in a melody. Importantly, this depiction retains a certain linearity grounded in the perception of a change in experience over time. A melody moves through a sequence of harmonious shifts, where the relation of one note to the next determines whether we can perceive them as a melody in the first place. Anticipating the next note – and anticipating that it may sound different to the last – is a crucial protentional feature of how we experience music. This holds true for other non-pathological experiences too: “As in the case of action, the intrinsic temporality of experience is pragmatically directed towards the meaningful possibilities the agent sees in the world” (Gallagher 2020, 36). Tic tokens, however, may not evoke or lend themselves to such a pragmatic and meaningful directedness of experience. If there is anticipation, it is of sameness, not change; the experience is not ‘towards’ but on replay – trapped, perhaps, in what Ruth Oliver aptly called “some sort of nature warp” (2003, 128; see Chap. 3). Figure 7.4 depicts what this non-directedness of experience may be like across moments of similitude and repetition (as when the same tic token occurs again and again): Does time slow down or come to a standstill in this scenario, turning the now into a temporal limbo or tyrannical present from which no path promises an escape? Or does time speed up here, spinning the now around itself, only to be sucked into the vortex of an ever noisier and more vacuous present? We are left to speculate and hope that future phenomenological research will shed light on these questions. And yet there are some principled guesses we can take, based purely on the structure of experience posited in Fig. 7.4. For the image of revolving circles or ellipses is not a stable one unless something holds it in place. For Dewey this integrated feel – the unity of experience – relates to and derives from larger purposes (1896, 359) which imbue the act with meaning. For Husserl and Gallagher, too, the integration of past

Fig. 7.4  The non-directedness of the field of consciousness when perceiving near-identical tic tokens that repeat themselves in short succession over time

7.4  Beginnings and Ends

211

and future in the now of each primal impression (or enaction) is held in place by a meaningful directedness. This directedness acts like a pulling along or ‘toward’ which gives sensations, thoughts, and movements a meaningful place and function. Dewey’s unified ‘coordination’ is thus also a narrative coordination that sees us transported – in Husserlian protentive-retentive loops – to the next (usually different) primal enaction (see Fig. 7.3). But tics do not exhibit such directedness or purpose beyond their own imminent fulfilment; their “anticipatory intentionality” (Gallagher 2020, 36) aims purely at the possibility of their own completion and for their own completion. They point inward, onto themselves (see Fig.  7.4). Heightened by repetition, this self-­ enclosedness – or self-referentiality – lends tic disorder symptoms a hyper-circular experiential structure. Without a sense of progress or toward, tics may thus lack the – slightly de-centred! – purposive or narrative pull which could stabilise and unify the experience of the present for the ticcing person (unless she has found strategies to integrate her tics into broader, meaningful activities or life narratives; see our discussion of ‘narrative integration’ in Chap. 4). The implication is that tic disorder symptoms may ultimately shatter Dewey’s unified coordination, evoking the “disjointed psychology” he made a parody of (1896, 360): It breaks continuity and leaves us nothing but a series of jerks, the origin of each jerk to be sought outside the process of experience itself, in either an external pressure of ‘environment’, or else in an unaccountable spontaneous variation from within the ‘soul’ or the ‘organism’.

Dewey is not writing about tics here, but his passage eerily well describes how aimless and recurrent movements (‘jerks’, a term commonly used for certain motor tics) could chip away at and dissolve that meaningful unity of experience he associates with normal (non-pathological) stimulus-induced actions. The phrase ‘unaccountable spontaneous variation’ fits tics rather well, although we would no longer ground such symptoms in the ‘soul’ but rather in the brain, or – less reductively – in the organism’s interactions with its world if we adopt the enactive perspective. Ironically, then, while Dewey’s mockery seeks to expose the flaws of the reflex arc concept, he ends up crafting a description that captures something vital about tics and how they might affect experience. Phenomenologically speaking, I suggest that having tics could feel just like the disjointed psychology which Dewey and others have taken such care to critique. But what does all of this mean for the debate about tics as actions or nonactions, and for the way we research and treat Tourette Syndrome and other tic disorders?

7.4 Beginnings and Ends We began this chapter by zooming in on arguments for the nonaction view of tics. Through the lens of two ‘chicken-and-egg’ debates found in the tic disorder literature, we explored the central role played by our conception of the temporality of

212

7  On Reflexes and Stimuli: Tics as Nonactions

human doing and perceiving in whether we regard tics as intentional actions. In our first example we noted the historical shift from tics as sensory or behavioural nonactions (Culver and Gert 1982; Shapiro et al. 1988) to an action-like construct of tics as behavioural responses to sensory phenomena. In our second example we explored the discussion surrounding the causal-temporal relationship between action inhibition (tic suppression) and urge experiences, noting that their temporal placing impacts whether we view tics as intentional actions (e.g. Matsuda et  al. 2016) or not (Nachev 2011). I have argued that these chicken-and-egg debates are all founded on a misguided understanding of the nature of action and perception that has led us to frame this ill-conceived question: When and where do intentions enter a tic sequence  – the process thought to unfold between a neural signal and a tic event – if, indeed, they enter it at all? The question is ill-conceived for several reasons. Firstly, because it leads us to favour a neuro-reductionist frame of analysis at the expense of considering more complex causal-temporal interactions between the ticcing person and her world. We saw, for example, that the linear, token-level depiction of individual tic sequences adopted in this chapter (which reflects discussions in the literature) cannot show everything there is to show about intentions and tics. For example, when an intention to intervene on tic-related behaviours or experiences does not arise spontaneously during a token-level sequence but is formed earlier and endures over time, we need to find ways of relating this distal intention to the largely automatic motor (or other) responses occurring at the token level of tic events and experiences. If we don’t widen our analytic frame to span the integrative and even narrative timescales, we will miss these crucial top-down (person-level) influences on the expression of tic disorder symptoms. A second reason why the question of ‘whether and when’ intentions enter a tic sequence is ill-conceived relates to its underlying view of human acting and perceiving, which promotes an unproblematic split between stimuli and our (seemingly separate) responses to them. As I have shown, proponents of NIAT and SIAT, who hold that nothing or only something is intentional about tics, rely on this conceptual split. And yet the nature of tic disorder symptoms, perhaps more than that of other non-pathological actions, exposes the linear ‘first–then’ conception of stimulus-­ induced actions as a problematic abstraction. In tic disorders the beginnings and ends of symptom expressions  – or the originating and maintaining causes of tic events – are not as clear as the neuro-reductivist sequence view of tics suggests. To posit the neural signal as a simple beginning of a tic is as much of a myth worth abandoning as the idea that a “primal enaction is a direct, straight, and simple apprehension of some now-point of a stimulus, or simple beginning point of some action, unaffected by retention and protention” (Gallagher 2020, 36). Drawing on Dewey’s critique of the research arc and Wu’s work on attention, I have argued that intentions are always already there in our perception of each stimulus, guiding whatever action we select from the get-go. In De Haan and De Bruin’s words: “Instead of two separate, categorical modalities of experience, we might rather appreciate the differences between volitional actions and habitual body movements as poles on one axis of more or less deliberate intentionality” (2010, 394; emphasis added). But if this is

7.4  Beginnings and Ends

213

so and we cannot separate out a nonintentional beginning or a point in time where intentions enter tic sequences, then this rules out the premise on which both NIAT and SIAT are built – namely, the idea that there is nothing (or only something) that is intentional about tics. Adopting EIAT, however  – the view that everything is intentional about tics – does not commit us to any claims about the controllability or voluntary nature of tics, since many intentional actions are involuntary due to the coercion involved (see Chap. 6). Regarding future research into tic disorders, it would be useful to complement existing experimental work on the neural dynamics of tic disorder symptoms with studies that adopt a diachronic and enactive approach to action and perception that explicitly investigates the embodied, narrative, and normative (social) contexts in which the ticcing person’s symptoms play out. What we need is an integrative methodology to better understand the elusive aetiology of tic disorders and the behaviours and experiences we attribute to them. How do subpersonal factors – which operate at the genetic, neurological, biochemical, and physiological level of the human system – interact with a person’s learning, their social behaviours, and other traits observable in people with Tourette Syndrome? These questions are admittedly complex and have rarely been pursued in tic disorder scholarship, although research on other aetiologically complex conditions provides instructive guidance. As Mitchell (2015) notes, for example, we cannot currently explain Major Depressive Disorder (MDD) via a purely or even partially reductivist strategy that points at component genes to predict the likelihood of a depressive episode (32). While it is possible that we simply have not yet fully understood the contribution of lower-­ level, subpersonal mechanisms that could fully explain and predict MDD, some evidence suggests that the condition is more likely “the behaviour of an integrative system” (33; see also Kendler et  al. 2006). If this is the case, then a bottom-up reductionist strategy will not work but a top-down approach is needed, because in integrative systems “the behaviour of the parts themselves is a function of properties of the whole system” (Mitchell 2015, 29). We can only speculate to what extent these considerations apply to a clinically diagnosed syndrome as complex and heterogeneous as Tourette’s, whose aetiology remains elusive despite emerging evidence of genetic, epigenetic, and immunological risk factors (see Dale 2017; Efron and Dale 2018). What seems clear is that current tic disorder research largely assumes, rightly or wrongly, that either an aggregate or a component system explanation (Mitchell 2015) of TS is both possible and desirable – that is, an explanation which assumes that Tourette Syndrome is caused by the properties of some part of the human system (e.g., genes) or by the way in which these individual parts are organised (Mitchell 2015, 28; see also Bechtel and Richardson 1993). If we adopted a top-down, integrative systemsapproach instead, what properties of the whole human system  (brain-­organism-­ world) might determine the Tourettic behaviours we observe in parts of this system? It is these sorts of questions that scholarship should turn toward, and which allow us not only to query aetiology (how TS arises and develops in an individual over time) but also the expression of individual symptoms (how a tic token develops at a particular moment). Put differently, adopting an integrative systems-­ approach to

214

7  On Reflexes and Stimuli: Tics as Nonactions

Tourette Syndrome promises to further our understanding of tics as a condition, and also of tics as actions. Lastly, from a clinical point of view further research into the experiential structure of tic disorder symptoms (for example, by drawing on philosophical phenomenology; see Curtis-Wendlandt and Reynolds 2021) will likely yield important insights into the existential dimension of life with Tourette’s. I have argued that the incessant repetition of almost identical vocal and motor tics could change a person’s experience of time – and of herself in time – in psychiatrically relevant ways. In particular, the hyper-circularity of tic disorder symptoms has the potential to threaten the future-directedness and unity of experience which characterises most ‘normal’ (non-pathological) actions. Further research into this existential dimension could elucidate treatment-relevant links between the symptom-induced alteration of experience and other co-occurring conditions commonly found in TS (e.g., mood disorders, obsessive-compulsive disorder, etc.). In the next chapter we will turn to an existential challenge confronted by many people with TS – yet largely ignored in scholarship – which arises from the enaction of tic disorder symptoms in the world: the vexed issue of moral responsibility for one’s actions and, relatedly, the experience of shame and guilt which often accompanies TS.

References Banaschewski, Tobias, Wolfgang Woerner, and Aribert Rothenberger. 2003. Premonitory sensory phenomena and suppressibility of tics in Tourette syndrome: Developmental aspects in children and adolescents. Developmental Medicine and Child Neurology 45: 700–703. Bechtel, William, and Robert C. Richardson. 1993. Discovering complexity: Decomposition and localization as strategies in scientific research. Princeton University Press. Block, Ned. 1995. On a confusion about the role of consciousness. Behavioural and Brain Sciences 18: 227–287. Burnham, Bryan R. 2007. Displaywide visual features associated with a search display’s appearance can mediate attentional capture. Psychonomic Bulletin and Review 14 (3): 392–422. Capriotti, Matthew R., Flint M.  Espil, Christine A.  Conelea, and Douglas W.  Wood. 2013. Environmental factors as potential determinants of premonitory urge severity in youth with Tourette syndrome. Journal of Obsessive-Compulsive and Related Disorders 2: 37–42. Conelea, Christine A., and Douglas W. Woods. 2008. The influence of contextual factors on tic expression in Tourette’s syndrome: A review. Journal of Psychosomatic Research 65: 487–496. Conelea, Christine A., Brianna Wellen, Douglas W.  Woods, Dianna J.  Greene, Kevin J.  Black, Matthew Specht, Michael B. Himle, Han-Joo Lee, and Matthew Capriotti. 2018. Patterns and predictors of tic suppressibility in youth with tic disorders. Frontiers in Psychiatry 9: 1–10. Culver, Charles M., and Bernard Gert. 1982. Philosophy in medicine. Conceptual and ethical issues in medicine and psychiatry. London: Oxford University Press. Curtis-Wendlandt, Lisa, and Jack Reynolds. 2021. Why Tourette Syndrome research needs philosophical phenomenology. Phenomenology and the Cognitive Sciences 20 (4): 573–600. Dale, Russell C. 2017. Tics and Tourette. Current Opinion in Paediatrics 29 (6): 665–673. Davenport, Paul W., Christine M. Sapienza, and Donald C. Bolser. 2002. Psychophysical assessment of the urge-to-cough. European Respiratory Review 12 (85): 249–253. De Haan, E.H. 2011. Unaware urges? Let’s not complicate matters further. Cognitive Neuroscience 2 (3–4): 248–249.

References

215

De Haan, Sanneke. 2020. An enactive approach to psychiatry. Philosophy, Psychiatry, and Psychology 27 (1): 1–25. De Haan, Sanneke, and Leon de Bruin. 2010. Reconstructing the minimal self, or how to make sense of agency and ownership. Phenomenology and the Cognitive Sciences 9: 373–396. Dewey, J. 1896. The reflex arc concept in psychology. Psychological Review 3: 357–370. Dewey, John. 1917. The need for a recovery of philosophy. In Creative intelligence: Essays in the pragmatic attitude, ed. John Dewey. New York: Holt. Efron, Daryl, and Russell C. Dale. 2018. Tics and Tourette syndrome. Journal of Paediatrics and Child Health 54: 1148–1153. Folk, Charles L., Roger W. Remington, and James C. Johnston. 1992. Involuntary covert orienting is contingent on attentional control settings. Journal of Experimental Psychology, Human Perception and Performance 18: 1030. Gallagher, Shaun. 2017. Enactivist interventions. Oxford: Oxford University Press. ———. 2020. Action and interaction. Oxford University Press. Ganos, Christos, Ursula Kahl, Odette Schunke, Simone Kühn, Patrick Haggard, Christian Gerloff, Veit Roessner, Götz Thomalla, and Alexander Münchau. 2012. Are premonitory urges aprerequisite of tic inhibition in Gilles de la Tourette syndrome? Journal of Neurology, Neurosurgery, and Psychiatry 83 (10): 975—978. Gev, Ella, Tammy Pilowsky-Peleg, Sylvana Fennig, Noa Benaroya-Milshtein, Douglas W. Woods, John Piacentini, Alan Apter, and Tammar Steinberg. 2016. Acceptance of premonitory urges and tics. Journal of Obsessive-Compulsive and Related Disorders 10: 78–83. Gibson, Bradley S., and Erin M. Kelsey. 1998. Stimulus-driven attentional capture is contingent on attentional set for displaywide visual features. Journal of Experimental Psychology: Human Perception and Performance 24 (3): 699–706. Haan, De, Erik Rietveld Sanneke, and Damiaan Denys. 2017. Being free by losing control: What obsessive compulsive disorder can tell us about free will. In Free will and the brain. Neuroscientific, philosophical, and legal perspectives, ed. Walter Glannon, 83–102. Cambridge, UK: Cambridge University Press. Haggard, Patrick. 2008. Human volition: Toward a neuroscience of will. Nature Reviews Neuroscience 9: 934–946. Hornsby, Jennifer. 2013. Basic activity. Aristotelian Society Supplementary 87 (1): 1–18. Husserl, Edmund. 1991. On the phenomenology of the consciousness of internal time (1893–1917). Collected Works IV. Trans. J. Brough. Dordrecht: Kluwer Academic. Translation of (1966). Zur Phänomenologie des inneren Zeitbewußtseins (1893–1917), Husserliana 10. Den Haag: Martinus Nijhoff. Jackson, Stephen R., Amy Parkinson, So Young Kim, Martin Schürmann, and Simon B. Eickhoff. 2011a. On the functional anatomy of the urge-for-action. Cognitive Neuroscience 2 (3–4): 227–243. Jackson, Stephen R., Amy Parkinson, So Young Kim, Martin Schüermann, and Simon B. Eickhoff. 2011b. Reply to commentaries: Resolving confusions about urges and intentions. Cognitive Neuroscience 2 (3–4): 252–254. Jackson, Stephen R., Joanna Loayza, Mira Crighton, Hilmar P. Sigurdsson, Katherine Dyke, and Georgina M. Jackson. 2020. The role of the insula in the generation of motor tics and the experience of the premonitory urge-to-tic in Tourette syndrome. Cortex 126 (May 2020): 119–133. Johnco, Carly, Joseph F.  McGuire, Nicole M.  McBride, Tanya K.  Murphy, Adam B.  Lewin, and Eric A. Storch. 2016. Suicidal ideation in youth with tic disorders. Journal of Affective Disorders 200: 204–211. Karp, Barbara I., Simone Porter, Camilo Toro, and Mark Hallett. 1996. Simple motor tics may be preceded by a premotor potential. Journal of Neurology, Neurosurgery, and Psychiatry 61: 103–106. Kendler, Kenneth S., Charles O.  Gardener, and Carol A.  Prescott. 2006. Toward a comprehensive developmental model for major depression in men. American Journal of Psychiatry 163: 115–124.

216

7  On Reflexes and Stimuli: Tics as Nonactions

Kyriazi, Maria, Efrosini Kalyva, Efthymia Vargiami, Konstantinos Krikonis, and Dimitrios Zafeiriou. 2019. Premonitory urges and their link with tic severity in children and adolescents with tic disorders. Frontiers in Psychiatry 10: 569. Matsuda, Natsumi, Toshiaki Kono, Maiko Nonaka, Miyuki Fujio, and Yukiko Kano. 2016. Self-­ initiated coping with Tourette’s syndrome: Effect of tic suppression on QOL. Brain and Development 38: 233–241. Mitchell, Sandra D. 2015 [2008]. Explaining complex behaviour. In Philosophical issues in psychiatry: Explanation, phenomenology, and nosology, eds Kenneth S. Kendler and Josef Parnas, 19–47. John Hopkins University Press. Morera Maiquez, B., G.M. Jackson, and S.R. Jackson. 2021. Examining the neural antecedents of tics in Tourette syndrome using electroencephalography. Journal of Neuropsychology 16, no. 1: 1–20. https://doi.org/10.1111/jnp.12245. Murphy, Nancy, George F.R. Ellis, and Timothy O’Connor. 2009. Downward causation and the neurobiology of free will. Berlin, Heidelberg: Springer. Nachev, Parashkev. 2011. Urges, inhibition, and voluntary action. Cognitive Neuroscience 2 (3–4): 247–248. Niccolai, Valentina, Silvana Korczok, Jennifer Finis, Melanie Jonas, Götz Thomalla, Hartwig Roman Siebner, Kirsten Müller-Vahl, Alexander Münchau, Alfons Schnitzler, and Katja Biermann-Ruben. 2019. A peek into premonitory urges in Tourette syndrome: Temporal evolution of neurophysiological oscillatory signatures. Parkinsonism and Related Disorders 65: 153–158. Noë, Alva. 2006. Action in perception. MA: MIT Press. Oliver, Ruth. 2003. A lifetime of bewilderment. In Making allowances: Personal accounts of Tourette Syndrome, ed. Chris Mansley, 127–147. Liverpool: The Bluecoat Press. Overgaard, Morten. 2018. Phenomenal consciousness and cognitive access. Philosophical Transactions of the Royal Society B 373 (1755): 1–6. Pacherie, Elisabeth. 2008. The phenomenology of action: A conceptual framework. Cognition 107 (1): 179–217. Pacherie, Elisabeth, and Patrick Haggard. 2010. What are intentions? In Conscious will and responsibility: A tribute to Benjamin Libet, ed. Walter Sinnott-Armstrong and Lynn Nadel, 70–84. New York, NY: Oxford University Press. Paul, Sarah K. 2020. Philosophy of action: A contemporary introduction. Routledge. Rae, Charlotte L., Dennis E.O.  Larsson, Sarah N.  Garfinkel, and Hugo D.  Critchley. 2019. Dimensions of interoception predict premonitory urges and tic severity in Tourette syndrome. Psychiatric Research 271: 469–475. Rothwell, John C., and Mark J. Edwards. 2011. An urge to act or an urge to suppress? Cognitive Neuroscience 2 (3–4): 250–251. Rowlands, Mark. 2011 [2006]. Body language: Representation in action. The MIT Press. Sartre, Jean-Paul. 1943 [1976]. L’être et le néant. Paris: Gallimard; Being and nothingness. Trans. H. E. Barnes. New York: Philosophical Library, 1956. Shapiro, Arthur K., Elaine S. Shapiro, J. Gerald Young, and Todd E. Feinberg. 1988 [1978]. Gilles de la Tourette syndrome. New York: Raven Press. Specht, Matt W., Douglas W. Woods, Cassandra M. Nicotra, Laura M. Kelly, Emily J. Ricketts, Christine A. Conelea, Marco A. Grados, Rick S. Ostrander, and John T. Walkup. 2013. Effects of tic suppression: Ability to suppress, rebound, negative reinforcement, and habituation to the premonitory urge. Behaviour Research and Therapy 51 (1): 24–30. Specht, Matt W., Cassandra M. Nicotra, Laura M. Kelly, Douglas W. Woods, Emily J. Ricketts, Carisa Perry-Parrish, Elizabeth Reynolds, Jessica Hankinson, Marco A.  Grados, Rick S. Ostrander, and John T. Walkup. 2014. A comparison of urge intensity and the probability of tic completion during tic freely and tic suppression conditions. Behaviour Modification 38 (2): 297–318. Steinberg, Tamara, Adva Harush, Meirav Barnea, Rueven Dar, John Piacentini, Douglas Woods, Sharona Shmuel-Baruch, and Alan Apter. 2013. Tic-related cognition, sensory phenomena, and

References

217

anxiety in children and adolescents with Tourette syndrome. Comprehensive Psychiatry 54: 462–466. Thompson, Michael. 2008. Life and action. Cambridge, MA: Harvard University Press. Wetterneck, Chad T., and Douglas W. Woods. 2006. An evaluation of the effectiveness of exposure and response prevention on repetitive behaviors associated with Tourette’s syndrome. Journal of Applied Behavior Analysis 39 (4): 441–444. Woods, Douglas W., John Piacentini, Susanna Chang, Thilo Deckersbach, Golda Ginsburg, Alan Peterson, Lawrence D.  Scahill, John T.  Walkup, and Sabine Wilhelm, eds. 2008. Managing Tourette syndrome: A behavioral intervention for children and adults. Therapist guide. New York, NY: Oxford University Press. Wu, Wayne. 2014. Attention. Routledge. Zahavi, Dan. 2008. Subjectivity and selfhood. Investigating the first-person perspective. Cambridge: The MIT Press.

Chapter 8

‘No ill will’: Ticcing on Moral Grounds

Abstract  Should we hold people responsible for their tic disorder symptoms? This chapter argues that tics are less blameworthy than other intentional actions, but that we often misconstrue them as morally salient behaviours. I begin by highlighting the costs of these moral misattributions for people living with tics and show that our own interpretative habits drive such ‘misreadings’. A first step toward an ethics of moral responsibility in Tourette’s and other tic disorders must therefore be the search for an alternative, epistemically and socially just description of tics which helps us better understand what these symptoms are – and are not – about. I argue that existing brain-based explanations are not sufficient in this regard. Instead, I develop an alternative description grounded in the notion of ‘abstractly situated’ intentions, which allows us to spell out two typical features of primary tics: their relative absence of reasons for acting and their attentional focus on embodied aspects of the tic action. Both features illuminate why tics should not be considered morally salient actions and why people deserve less blame for what goes wrong when they tic. Further, the notion of situated intentions also provides a new basis for distinguishing between primary and functional(ised) tics. Keywords  Moral responsibility · Tic disorder · Tourette Syndrome · Blameworthiness · Interpretative habits · Situated intentions · Reasons for acting · Functional tics · Functional overlay · Attention · Coercion

8.1 Morality Is Interactive 8.1.1 Promises and Pitfalls of Neuro-Reductionism Tics as actions do things in the world. They not only affect the ticcing person but her environment as well. Tics, then, are not just actions, they are also interactions. As such, they pose many practical, some moral, and occasional legal challenges which unfold in the sphere of our sociocultural and political lives. Understanding tics as special kinds of actions – intentional or otherwise – thus requires us to attend to these © Springer Nature Switzerland AG 2023 L. Curtis-Wendlandt, Chasing Tourette’s: Time, Freedom, and the Missing Self, Philosophy and Medicine 145, https://doi.org/10.1007/978-3-031-19104-6_8

219

220

8  ‘No ill will’: Ticcing on Moral Grounds

challenges emerging from life with tics and Tourette’s. Of course, many tics don’t ‘show up’ in social settings because people with tics are masters of disguise or suppress their symptoms in public. But some Tourettic behaviours can transgress others’ boundaries or inflict damage of some sort. As Chris Mansley (2003a, 7) describes: I would nip, squeeze and tease my sisters, slam cups down to establish how hard I could do it before they would break, throw household articles around the room, even touch people’s genitals and kick footballs through windows, but the irony of it all was that I really did not want to do it.

How should we respond to these behaviours? For many of us, the answer will depend on how we interpret both the action and the actor’s intention. Should we hold Chris responsible for the broken window and his sisters’ pain? Or should we exempt him from such responsibility and blame his Tourette’s instead? These day-­ to-­day questions of practical morality are deeply intertwined with our theories of action. This chapter traces these interconnections and the concerns they evoke, chief among them the concern that we are prone to misunderstand people with TS and, consequently, that we will not be able to do them justice. I seek to lay the foundations for an ethics of moral responsibility in Tourette Syndrome and tic disorders that can guide us toward responding fairly, and perhaps even virtuously, to people with tics. Developing such an ethics not only requires us to ask whether and how individuals with tic disorders are responsible for things that might go wrong when they tic; it also requires us to reflect on how we interact with them and what principles should guide these interactions. This chapter thus lands us firmly on what Gallagher (2020, 12) calls the “world side” and the “interpreter side” of agentic situations. To recap: In Chap. 6, we drew on the notion of action affordance to describe the irreducibly interactive nature of all action. Given that actions are always situated in contexts, the “agent side”, the “world side”, and the “interpreter side” (12) co-determine what actions are possible in each situation. Importantly, when we describe actions we can focus on their different aspects (e.g., motoric, pragmatic, social, cultural), but we tend to integrate the lower-level (e.g., motoric) aspects into descriptions of the higher-level (e.g., social) aspects. Put differently, when we individuate actions we tend to do so “relative to the context that reflects a complete ordering of its different aspects according to its highest realised affordance” (Gallagher 2020, 11). This highest realised affordance of an action often relates to and describes its socially salient aspects and thus invites moral judgements. But our tendency to describe and interpret actions in this way is highly problematic when it comes to tics because it means that we commonly misconstrue them as normatively loaded intentional actions that are meaningful in a narrative sense (a dynamic we termed ‘narrative imposition’ in Chap. 4). Since it is other people – the interpreters of Tourettic actions – who misconstrue tics in this way, we must not only pinpoint such mis-­ readings but also offer alternative interpretations of tics that do not complicate the lives of people with TS. At its heart, this very book represents the search for such alternative perspectives on Tourette Syndrome; it constitutes my own attempt – as an intimate daily witness of the condition, and as a parent of a child with TS – to re-write the interpreter’s side of all those complex situations that arise in a life with

8.1  Morality Is Interactive

221

Tourette’s. It thus seems appropriate to point out here that one of the central arguments developed in this book – that tics are intentional actions – may itself invite misinterpretations: It may rekindle the familiar fear that tics are portrayed as more controllable than they really are; as behavioural choices which individuals can freely make or choose not to make; and thus as expressions of a weak or deprived will which calls for guilt and punishment. But that is not the intended point: This is no historical déjà vu. Calling tics intentional actions does not mean we deny their difference. In Chap. 6, for example, we explored the intentional action dynamics involved in tics and argued that many are best described as involuntary actions characterised by a highly coercive feel. We noted that tics are unlikely candidates for free actions (Category A), which are paradigmatic of the sorts of actions for which we attribute full responsibility to people in moral and legal contexts (see Chap. 6). Instead, we noted that tics more likely take the form of unfree (Category B) or unvoluntary (Category C) actions, both of which are characterised by coercion and invite attributions of reduced blame in moral and legal contexts. In an ethics of moral responsibility in tic disorders, we could call this argument for reduced blameworthiness the Argument from Coercion. As I argue below, a key strength of this argument is that it retains the irreducibly agentic language we use to describe what people do when they tic. Even proponents of the nonaction view of tics cannot escape this irreducibly agentic ‘pull’ of our descriptions of tics when they say that it is people who act on the urge to tic, or who “choose to act in a way which they are being driven to act” by their brains (Schroeder 2005, 119; emphasis added).1 The nonaction view of tics played a crucial role in pivoting the medical construction of Tourette Syndrome away from psychogenic and toward organic explanations of tics (see Chap. 7; see also Kushner 1999). Accordingly, the last few decades of scholarship on tic disorders have seen a clear trend toward reductionist, subpersonal explanations of symptoms. From a moral and legal perspective, the nonaction view of tics is tied to what we might call the Organic Deficit Argument for reduced blameworthiness in tic disorders; it offers us a medicalised, subpersonal explanation for why people with tic disorders deserve less blame for their symptom-related behaviours. But I suggest that we do not need to throw out the proverbial baby with the psychoanalytic bathwater to arrive at a sensitive ethics of moral responsibility in tic disorders that can honour the needs and experiences of people with TS. Rather, the most robust and compelling ethics arises from the intentional reading of tics promoted in this book. For it is only through the lens of agency and intentionality that we can reconcile some curious facts about Tourette Syndrome and other primary tic disorders – for example, that tics are highly suggestible, context-­dependent, suppressible, and modifiable. Sceptics who cite these features as proof that  The only philosophical paper published on the question of moral responsibility in TS (Schroeder 2005) unfortunately resorts to the ‘nonaction’ view of tics, which I rejected earlier in this book (see Chap. 7). Schroeder’s case for reduced blameworthiness in Tourette Syndrome is founded on the neuro-reductionist claim that tics involve no willing at all (that is, they are not intentional actions of any sort) but result from a failure of inhibitory mechanisms in the brain. 1

222

8  ‘No ill will’: Ticcing on Moral Grounds

individuals should have full volitional control over their symptoms are best countered by pointing at the limits of such control, not by a blanket claim to its absence. Put differently, we must illustrate how agency and intentionality play out in Tourette’s – not claim that they don’t exist – to help others better comprehend the Syndrome. Of course, it is easy to see the appeal of neuro-reductionism to anyone advocating for the rights of people with TS and seeking to reduce the stigma tied to the condition. The idea that it is ‘just some faulty brain wiring’ (rather than a defective personality or family dynamics, as was suggested earlier in history) that leads to the panoply of symptom expressions typical of Tourette’s has been embraced enthusiastically by affected individuals and families alike. As a liberating slogan, it has found its way onto numerous t-shirts, caps, and coffee mugs in advocacy circles around the world. When invoked as a ‘says-it-all’ explanation, this faulty (or better: just different) brain wiring gladly exempts us from the temptation to blame persons for their symptoms. This is no trivial point: When first confronted with the inexplicable, often sudden onset or worsening of tic disorder symptoms  – to the point where they demand constant attention, call for an urgent diagnosis, and fundamentally disrupt well-planned and unsuspecting lives – one can find instant relief and consolation in the assurance that there is nothing wrong with the ticcing self. At its best, then, neuro-reductionism offers individuals and families a sanity-preserving, resilience-boosting explanation that sidesteps feelings of inadequacy, guilt, or shame at a time when coping and survival are critical priorities. Put differently, it may help reduce self-stigma (see Pescosolido et al. 2010), a hypothesis which has not been investigated to date in tic disorders. And yet, despite this positive potential, the brain-based explanation also exempts us from the need to confront other questions ranging from the delicate to the uncomfortable and the taboo. It frees us from asking about the impact of environmental factors, of familial relationships, of patterns of relating, of crucial life experiences and much more on the aetiology and expression of tic disorder symptoms. Further, research on psychiatric disorders suggests that neuro-reductionism may not actually reduce received stigma – that is, prejudicial attitudes that discredit individuals and lead to their discrimination in employment, housing, medical care, and social relationships (Pescosolido et al. 2010, 1322). As Pescosolido and colleagues reported in their survey-based study on public perceptions of schizophrenia, major depression, and alcohol dependence, “holding a neurobiological conception … either was unrelated to stigma or increased the odds of a stigmatizing reaction. […] In no instance was a neurobiological conception associated with significantly lower odds of stigma” (2010, 1324). Concerningly, some research even points to an increase in stigma and the public’s desire for social distance from people with mental illnesses (like schizophrenia and depression) when neurobiological explanations for such illness are increasingly endorsed (Angermeyer and Matschinger 2005; Bag et  al. 2006; Dietrich et al. 2004). Whether or not a similar dynamic could be observed between stigma and brain-based explanations of Tourette Syndrome remains an open question, given the relative scarcity of research on stigma in TS (for a useful review of the literature, see Malli et al. 2016), and the absence of any work on the

8.1  Morality Is Interactive

223

relationship between stigma and neurobiological explanations in this condition. Unknown too is the impact of another potential side-effect of neuro-reductionism on individuals and families with TS, namely, the ethical risk of defeatism. As De Haan (2020, 5) explains: By labelling psychiatric disorders as brain diseases, neuro-reductionists risk shrinking the scope of patients’ agency in dealing with their problems. If it is all just a matter of ‘bad wiring luck’ patients become the passive victims of their unfortunate brains. Besides, because patients cannot look into their own brains, the professionals’ expertise on the patients’ condition outweighs that of the patients themselves, impacting their relationship.

An unintended effect of focusing on neurobiology to decrease feelings of blame in affected individuals and families may thus be an increased sense of dependence on expert external help as well as a sense of hopelessness and permanence (see also Pescosolido et al. 2010, 1329). In Tourette’s this could be complicated by the simultaneous hope that symptoms may naturally lessen or even disappear with maturation, since this is reported to occur in in many (but far from all) cases (Black et al. 2021). Living with TS, then, could be like drawing a triple ‘wild card’: Individuals and families are at the mercy of what their brains and time have in stall for them, and at the mercy of what doctors can do about this. All these factors – the elusive brain, that uncertain future, and the reliance on experts – may challenge their agency. But if the ethical risks tied to neuro-reductivism are so considerable, what should we do about it? Can we conceive of an explanatory approach to TS that minimises attributions of blame while also preserving and fostering individuals and families’ sense of agency and control? Surely the consequence cannot be that we abandon (neuro)science from our accounts of Tourette Syndrome, but rather that we engage critically with such science and resist temptations to construe scientific knowledge as a panacea for the vital and still broadly unmet needs of affected individuals and families. Research into the human brain is often misperceived as yielding complete causal explanations for disorders like Tourette’s, but this is inaccurate. Atkinson-Clement et  al. (2020) rightly speak of a correlation of, or association between, observed symptom behaviour and brain differences. Such caution seems appropriate, for even if a bottom-­up causal direction (from brain to behaviour) could be proven, we would still need to establish whether any identified neurophysiological cause is a necessary and sufficient condition for the symptoms we wish to explain (see Chap. 7). When Corrigan and Watson (2004) call for a “multidimensional approach” which can provide the public “with facts that challenge the variety of myths that maintain mental illness stigma” (478), we can say the same about TS today. Many myths persist about Tourette’s, from the prevalence of explosive swearing (coprolalia) which is misconstrued as a core symptom, to the purposeful execution of tics which are misperceived as being ‘naughty’ and easily controlled by will. We want to be able to say that people with TS have a harder time controlling certain actions and that this difficulty is at least co-determined by complex organic factors associated with the Syndrome. Some behavioural therapies  – e.g., Comprehensive Behavioural Interventions for Tics (CBIT; Woods et al. 2008a) and

224

8  ‘No ill will’: Ticcing on Moral Grounds

Acceptance and Commitment Therapy (ACT; Hayes et al. 1999; Gev et al. 2016; O’Connor et al. 2017) – offer promising examples of how we can work with a neurobiological model of tic disorders (embraced particularly in CBIT) in a way that does not victimise individuals or feed defeatism. Both approaches support agency and control at the level of the person by helping individuals to build behavioural or attitudinal strategies that allow them to ‘intervene on’ the underlying neurobiology and its associated symptoms and experiences (see Chap. 7). In doing so, both approaches also honour the irreducibly agentic language we use when we describe tics. Tics, then, stubbornly resist attempts to reduce them to mere neurological events; they invite descriptions that cast them as actions done by persons. And even if they are not intended to convey meaning, they still occur in the normative social sphere in which we act morally or immorally, and in which all discussions of morality take place. Our search for an ethics of moral responsibility in TS must treat this vital assumption of agency as its descriptive home base. From here, we can proceed to uncover the hidden costs of moral misattributions suffered by people with tic disorders and explore further arguments for reduced blameworthiness in Tourette’s.

8.1.2 The Cost of Moral Misattributions If we want to understand what is different about tics as actions that are willed (intentional) but that deserve less blame than other actions, we need to first ‘unsee’ their apparent normative aboutness or narrative directedness. This is not easy to do: Recall our discussion in Chap. 4, which noted how prone we are to attribute meaning to tics – the kind of meaning which relates to the context in which a person tics or to her thoughts, values, beliefs, or goals. Put differently, we almost inevitably ‘read’ tics as intentional actions that bear narrative significance. This is particularly true of tics which materialise as coprophenomena – i.e., coprolalia (obscene utterances, swearing) or copropraxia (explicit gestures)  – or as non-obscene socially inappropriate symptoms (NOSIS) which interfere with other social norms and taboos. When confronted with these symptoms, we are instantly pulled in an interpretative direction, as if we knew exactly what these utterances or gestures mean. NOSIS and coprophenomena thus drive home the point that tics are not the only behaviours which can be described as highly overlearned; our routine responses to certain semantic cues are too. These interpretive habits pervade our communicative interactions and pertain to all kinds of social or cultural norms; they coerce us into near-automatic responses which are as difficult to halt in their track as the tics that trigger them. Therefore, what turns everyday interactions into morally difficult situations for people with tic disorders is not just their own symptoms but others’ responses to these symptoms. Our inability to refrain from reading meaning into certain tics can make life with Tourette Syndrome just as difficult as the symptoms themselves. It is in this sense that we could say that certain Tourettic symptoms, particularly NOSIS and coprophenomena, are not really (or not just) symptoms of the ticcing person but symptomatic of the world she inhabits; they resist a purely internalist,

8.1  Morality Is Interactive

225

‘in-the-head’ view of action as done by an agent outside a restraining or enabling context. Situations solicit and call for these tics: Without an overweight person nearby, the Tourettic person would not feel the urge to yell ‘fatso!’; and without a society that discourages (and often punishes) such expressions for being offensive, she would have no taboo to violate and react to. The irony – and sometimes tragedy – is, of course, that many situations invite tics which the person does not want to do (e.g., uttering racial slurs or obscenities, or calling a friend’s haircut ‘hideous!’). In turn these situationally solicited tics can foreclose other opportunities for action which the ticcing person would dearly like to pursue. The ticcing person with NOSIS or coprophenomena is often painfully aware of the social impact of their tics and tormented and embarrassed by them, even before they take place (that is, the urge experience may coincide with an anticipation of these negative social consequences). Unlike other types of unintended action outcomes that occur accidentally or due to ignorance (see Chap. 6), NOSIS and coprophenomena are enacted with awareness, but usually not voluntarily. I have called this an ‘intentional conflict’ scenario, a certain type of Category C action which we introduced in our taxonomy of tics developed in Chap. 6. The experience of this intentional conflict in morally precarious situations, which are often engendered by NOSIS and coprophenomena, affects people with tics in profound ways. As Morris (1993, 197) describes: Coprolalia is surely among [the Syndrome’s] most troublesome symptoms, and the distress radiates in many directions. Adults may live like recluses. ‘Children,’ one group of researchers report, ‘are punished by parents, disciplined by teachers, ostracized by classmates, and shunned by strangers.’ Parents will often confess with guilt that they ‘washed the child’s mouth with soap.’ (Morris quotes Shapiro et al. 1973, 1988, 153)

A legitimate question to ask here is who the victims of these tics really are or for whom they cause the greatest burden. Is it the Touretter’s friend who cops an offensive ‘fatso!’, or is it the ticcing person herself who needs to live with the consequences of a condition that urges her to insult people against her own will? How we answer this question will determine where we focus our discussion of moral responsibility in tic disorders and TS. There is much evidence to suggest that a fair share of the burden imposed by tics is carried by the ticcing person herself, particularly but not exclusively when coprophenomena are involved (see Eapen et al. 2016). In her biographical account, ‘A lifetime of bewilderment’, Ruth Oliver (2003) reflects on the agonising shame, pain, and isolation she experienced when ceaselessly repeating a certain explicit tic for an extended period of time: Given the sexually-oriented nature of some of my tics, perhaps only a woman could take on board the terrible stress that they engendered. Perhaps only a woman could understand the overwhelming feelings of physical as well as mental pain, paramount of which is unadulterated shame, caused by the beating of my breasts and pubic area with a relentless fist, hour after hour, day after day; and perhaps it needed the instincts of a woman to realise that I was not just neurotic. The young psychologist who made the initial diagnosis [of TS] was also a woman (128).

The shame engendered by copropraxia is not some price Ruth Oliver pays for doing something pleasurable yet taboo. There is no guilty pleasure. “Sex … has nothing to do with it – there is nothing sexually satisfying in my actions. They are, in fact, very

226

8  ‘No ill will’: Ticcing on Moral Grounds

painful” (131). Further, the shame engendered by these tics is not socially restorative either – Ruth cannot ‘learn’ from her transgression or redeem herself by pleading never to tic so ‘improperly’ again. If shame responds to a perceived lack of “approving reciprocity”, as Zahavi (2015) suggests, then it is not only a self-­ conscious emotion but one which entails a critical view of the self. Importantly, it differs from other negative self-evaluations “by directly affecting our social relatedness, by always going hand in hand with a feeling of social isolation” (643). In Ruth Oliver’s case this isolation is both gendered (“only a woman could understand”) and institutional (she is at risk of being mislabelled as neurotic by the medical establishment). But while her epistemic isolation is momentarily resolved when the psychologist correctly identifies her symptoms as Tourette Syndrome, Ruth’s social isolation remains unaddressed. She is still stressed, ticcing, ashamed; her social connectedness and self-esteem are not restored. Chris Mansley (2003b, 12) also describes this as a breakdown of reciprocity in relationships brought about by certain symptoms of TS: When a Tourette’s child reaches out for emotional warmth to his family, it is often carried out in a compulsive way, for example with a nip or a nudge… Human contact is something you long for, but instead of being able to reciprocate, along comes the Tourette’s compulsion to nip and squeeze. I felt, and still do feel such remorse, guilt and shame for all that I did, despite friends telling me that I wasn’t to blame. The words, ‘naughty, bad, disobedient, little boy’ still haunt me today.

Even Chris’s friends cannot alleviate his torment: While they declare him not blameworthy for his tics, Chris is still troubled by the hurtful misnomers of his childhood, when others accused him of acting with ill will. Those attributions of ‘naughtiness’ and ‘disobedience’ proved that others did not understand; they did not see the longing for connection in Chris’s nippy squeezy tics. Research shows that people with TS pervasively experience negative moral judgements of their symptom-related behaviours, and that this experience victimises and marginalises them not only “in the public arena but also within their homes growing up” (Malli et al. 2019, 13). These experiences fuel the epistemic and social isolation that so many people with tics must contend with at least sometimes in their life. Clearly, misattributing moral ill will to people who tic is thus itself a morally blameworthy action, lessened at best by ignorance. But few will be held accountable for the psychological and other damage they inflict on people with tic disorders since we largely lack the concepts to describe and theorise the inequitable and offensive treatment of these individuals. Fricker’s (2007) notion of epistemic injustice, on which I loosely draw here, as well as the critical literature which responds to Fricker’s work (e.g., Kidd et al. 2017), provides promising starting points for such an exploration. Malli et  al.’s (2019) qualitative phenomenological research on adults living with TS also draw on some useful theoretical concepts to explore how social and familial interactions can stigmatise and isolate people with TS. Take, for example, the negative role of “stigma coaches” (Schneider and Conrad 1985; see Malli et al. 2019) which some parents assumed and through which they taught their children “that their tics represented an undesired differentness or moral weight they had to carry” (Malli et al. 2019, 13; see also Todd and Shearn 1997). In

8.1  Morality Is Interactive

227

her book-length memoir of growing up with TS and OCD, Amy Wilensky provides a visceral account of her own father as stigma coach, a father who she calls “the primary source of tension” (1999, 155) in her life with TS. His disparaging reactions to her tics morphed from verbal explosions in the early days to “a more insidious approach” as time wore on (51–52): An appalled stare, eyebrows raised in amazement at my ‘willingness’ to act like that in front of anyone, [52] and a simultaneous slow shaking of the head from side to side, as if all the degeneracy in the world had been condensed into a four-foot package and was sitting across from him at the dinner table. Sometimes, this was accompanied by a low-pitched ‘crazy’, in a voice just soft enough to be out of my mother’s earshot, just loud enough for me to hear, even as I defiantly turned my head and looked away. Alison [Amy’s sister] saw an opportunity, found in my father’s uncharacteristic and strictly defined lack of sensitivity an opening for her to attack without customary interference or rebuke.

Where can parents and carers (and teachers, friends, siblings, and others) learn strategies for avoiding such stigmatising ways of relating to, and of shaping the meaning of Tourette’s for those they care for? Similarly, how can we avoid perpetuating “interaction discrimination” (Link and Phelan, 2014; see Malli et al. 2019) – those subtle, unconscious, often unintended yet degrading and stigmatising communications toward people with tics (imagine, for example, a condescending or excessively polite way of speaking to them)? Curiously, few doctor’s offices will have brochures on the topic available for carers of children with tic disorders who – often desperately  – seek support; and few medical practitioners will be willing and able to engage families in conversations about the ethical responsibilities that come with caring for someone with Tourette Syndrome. But if we are to develop an ethics of moral responsibility in TS, then this must also provide us with principles of care: We must confront the fact that how we understand the actions of people with this Syndrome, and how we choose to act and react to them interpersonally, are themselves morally valenced acts. As carers we confront both an epistemic and a practical social duty: The duty not to isolate and harm people with tics by misunderstanding their condition, or by burdening them further with attributions of ill will and moral blame. Inversely we can do good by helping those we care for avoid forming the sort of conviction Wilensky grew up with – namely, that her tics were “my problem, my weakness, my fault” (1999, 73). This belief had been instilled in her by her father’s constant insistence that she could stop her tics if she only tried a little harder: “And although I couldn’t prove it at the time, I knew he wasn’t capable of shaming me into stillness; if he had been, trust me, I’d have been cured” (51). Here too, blame and shame go hand in hand, and both are futile: nothing changes as a result, at least not with regard to Wilensky’s ever-­ present tics and other symptoms. There is nothing ego-syntonic or cathartic about this experience of shame, and nothing socially restorative about the blame perpetuated by Wilensky’s dad. The epistemic and social isolation Wilensky endured as a child thus highlight the injustice inflicted upon her, a term which reaffirms the need noted earlier to extend our ethics of moral responsibility in TS by certain principles of care which help us define what it means to act in morally praiseworthy ways toward people with Tourette’s.

228

8  ‘No ill will’: Ticcing on Moral Grounds

Peter Maisey (2003) reminds us of the central role society plays, knowingly or not, in shaping the lives of people with tics: “If other people weren’t around, would I have a problem? Of course the tics are debilitating, but how much of what I personally perceive to be problems are the result of having to mix with others” (93). The point is, how we act towards people with tics is intimately tied to how we interpret their actions – and our automatic or ‘default’ interpretations will likely not be useful, particularly in response to socially inappropriate tics. As Finkelstein et al. (2016, 237) note: “Coprolalia’s sensitivity to culture affords its performative effectiveness in hurting its hearer. Therefore, reducing the automaticity of the hearer’s interpretation of the coprolaliac’s intention can reduce the hurtful effect.” Less automaticity is good advice, but the authors provide no guidance on how to achieve thoughtful alternative interpretations of tics. What ‘reading’ of the coprolalic tic should displace the hurtful one? And how can we ensure that new ways of describing tics lead to socially and epistemically just interpretations of these actions? Whatever the answers, it seems they should enable us to cut some slack for individuals living with tics. In Chris Mansley’s words, “it takes compassion, empathy and understanding to care for Tourette’s sufferers, and … all we ask from society is for people to make an allowance for our behaviour” (2003a, 7). Such an allowance, I suggest, becomes easier to make once we loosen our own interpretative habits and see primary tics as the abstractly situated intentional actions that they are.

8.1.3 Against the Interpretative Grain I propose that the best possible description of tics is not the one that individuates them in relation to the action’s highest realised affordance (Gallagher 2020, 12), which portrays its socially salient aspects and thus invites moral judgements. While we individuate most actions in this way, I suggest that this descriptive and interpretive habit is counterproductive in the case of tics because it tempts us to misjudge their moral status. Rather, the best possible description we can give of tics is an abstract one, and with ‘best possible’ I mean that description which enables the most socially and epistemically just interpretation of tics as actions. So, what are ‘abstract’ descriptions of tics? In essence they specify a particular way in which someone’s intention to tic relates to the situation in which the tic occurs. We should note straight up that the ensuing discussion does not defy a core argument of this book – namely, that context and situation are central to the operative intentionality of tics, which can be triggered by or respond to features of the environment and other agents in a given situation (see Chaps. 4 and 6). This is true of all actions, and tics are no different. But the fact that they may be triggered by or respond to contextual features of agentic situations does not mean that the best descriptions we can give of tics relate to their highest realised affordance in these contexts. As we saw, describing tics in this way almost inevitable leads us to the kind of misinterpretations which I termed ‘narrative imposition’ in Chap. 4. There is, then, a way in which situated actions – and I stress again: all actions are situated – can be situated

8.1  Morality Is Interactive

229

differently in relation to context. This is what Gallagher and Marcel (1999) suggest, not that some actions are situated while others aren’t. Gallagher and Marcel (1999, 8–9) distinguish between three different kinds of “situated intentions” which are relevant to our discussion of the moral status of tics. Specifically, they suggest that intentions can be formed (1) in relatively abstract or decontextualised situations, (2) in pragmatically contextualised situations, and (3) in socially contextualised situations (see also Gallagher 2020, 15). As examples of intentions formed in abstract or decontextualised situations, Gallagher and Marcel (1999) mention certain tests or experiments as well as physical activity routines involving discrete movements of certain body parts. In these situations, “the agent is detached from what would ordinarily be considered a significant context”: They have “no normal or good reason for doing what is asked other than voluntary compliance; for example, a neurological examination in which the patient is asked to move her arm up and down” (Gallagher 2020, 15). The resemblance with tics is striking. We could say that people who tic – e.g., by jerking their head repeatedly throughout the day  – also have no “normal or good reason” to do so, other than compliance (voluntary or involuntary; see Chap. 7) with an urge or sensory phenomenon that precedes these symptoms. They too are being asked, so to speak, to make certain isolated movements or sounds, although this demand does not come from an external person (like a neurologist), but from the perception of an embodied stimulus. As one 14-year-old male interviewee in our recent pilot study put it: “It’s something that’s almost telling me, giving me a body part, telling me exactly what I need to do”. He is quick to clarify that this telling is “not like I’m hearing a voice or something. But it’s almost just an urge that I just know exactly what it wants me to do”. The tics “have asked to be done, I guess” (unpublished data). So far, tics thus clearly fit the notion of intentions which are formed in abstract or decontextualised situations. They highlight that these situations do not depend on certain environmental features (e.g., conditions outside the individuum) but can also be created internally, by conditions inside the person. Put differently, certain features of agents  – e.g., their propensity to tic  – can turn agentive situations into abstract or decontextualised ones; partially, as we will see, because they require the individual to divert attention away from other meaningful activities, and partially because the meaning of the tic action cannot be explained straightforwardly by pointing to its context (we will come back to this below). Notably, Gallagher and Marcel’s (1999) examples of decontextualised situations do not include such a disorder-­specific scenario, but this does not mean they would not permit it. Their examples of abstract situations all involve features beyond the agent which give rise to the actions in question and lend them meaning, be that by interacting with a neurologist who has reasons to conduct a test or exam, by participating in a (scientific or medical) experiment aimed at establishing some fact or information, or by engaging in physical activity routines, perhaps as part of doing sports or undergoing rehabilitation, which constitute cultural practices aimed at attaining an extrinsic end beyond the movement itself (healing a joint, strengthening a muscle, etc.). Tics are different: They are, in a sense, more abstract and decontextualised than the examples offered by Gallagher and Marcel (1999) because they do not have

230

8  ‘No ill will’: Ticcing on Moral Grounds

such extrinsic ends shared situationally or culturally with others. They also rely less on features of context to qualify as abstractly situated intentional actions. People with tics may find themselves in, and in a sense create, abstract or decontextualised situations in any context while and because they are ticcing. To repeat, this is not to say that context and environment do not impact tic expression. On the contrary, we have established repeatedly (see Chaps. 4 and 6) that many situational aspects contribute to whether and how people tic. But crucially, situations often cloud rather than expose the abstract and decontextualised nature of tics as intentional actions, a fact most powerfully illustrated by socially inappropriate symptoms that trigger normatively loaded interpretations. When Gallagher (2020, 15) notes that “no specific type of action per se can be exclusively assigned to any one kind of situation” (i.e., abstract, pragmatic, or socially contextualised), this may be true for most normal actions. An example should help illustrate this point: Imagine two people  – Sarah with TS and Dale without – each of whom make the same offensive remark (‘hideous!’) toward a friend who greets them with a brand-new haircut (see Schroeder 2005). We will want to say that Sarah deserves less blame for her vocal tic than Dale for uttering the same word, and we can do so by arguing that her tic action relates differently to the situation at hand. From a behavioural perspective, the action (i.e., saying ‘hideous!’) thus seems to under-determine the reasons that might motivate it in different contexts. Or, put differently: Uttering the word ‘hideous’ cannot be exclusively assigned to a particular situation since Sarah’s vocal tic exemplifies an abstractly situated intention in action (which her friend misinterprets by taking offence), while Dale’s utterance exemplifies a socially situated intention (identified as such by the offended friend). But a closer look reveals that Schroeder’s (2005) example of Sarah and Dale does not truly support Gallagher’s point, which concerns certain occurrences of actions rather than individual action tokens (see Chap. 2 for this distinction). The example of Sarah and Dale, on the other hand, revolves around two concrete instances (tokens) of the same word  – ‘hideous!’  – uttered in similar situations. From this token comparison we cannot derive claims about the intentional situatedness of action types: Arguably, the type of action Sarah is exhibiting (i.e., a primary tic) differs from the type of action we are dealing with in Dale’s case (defined negatively, at least, as not a tic), although other situational features remain the same. I thus propose that we need to qualify the types of action to which Gallagher’s original statement applies. We could claim, for example, that ‘no specific type of normal (non-pathological) action per se can be exclusively assigned to any one kind of situation’ (i.e., abstract, pragmatic, or socially contextualised). This is still a big claim that we cannot test here. What precisely does Gallagher mean with action types, and could there be counterexamples? But in the realm of pathological or disordered actions, we already have a counterexample on hand – tics. I propose that primary tics (and possibly other body-focused repetitive behaviours) are a special type of decontextualised abstract intentional action, and that this is principally true of all primary tics (although we will discuss the pervasive functionalisation of primary tics and what this means for their situatedness in context below). Broadly put, each time a person with a primary tic disorder forms an

8.1  Morality Is Interactive

231

intention to tic, this intention is abstractly situated within the agentic situation, no matter its apparent contextual ‘fit’. In other words, context cannot change the intrinsically abstract situatedness of primary tics as intentional actions – it cannot make them relate to the situation in more pragmatic or socially contextualised ways even when this context triggers or evokes the tics in the first place. It is also worth stressing here that we should not overstate the context-dependence of tics. While tics are commonly expressed differently in different contexts, and while some contexts clearly evoke certain tics, symptoms do occur across different contexts and can even be observed during sleep (Efron and Dale 2018, 1149). Conelea and Woods (2008, 495) raise the important point that apparent fluctuations in tic expression across different contexts could rather be fluctuations in tic inhibition instead: Finally, an interesting question for future research to address is whether it is tics themselves that are impacted by contextual factors or if it is suppression or inhibitory behaviours that are modifiable. What past researchers have labelled ‘tic exacerbations’ may instead be situations in which there is little or no reinforcement for tic inhibition. Thus, ‘tic exacerbations’ may represent naturally occurring frequencies of tics.

If this were true, then different contexts would provide different reasons for inhibiting or not inhibiting tics, and observed changes in tic expression would actually constitute different interventions (or a lack of interventions) on a presumed baseline of naturally occurring tics. Put differently, what looks like context-sensitive tics could instead be context-sensitive functional responses to tics – the sort of (voluntary or involuntary) suppression, facilitation, or modulation of symptoms that we discussed at length in Chap. 7. Whether and how we could ever witness the presumed natural ‘baseline’ of primary tics would then become an important question. Of course it is not just symptom management behaviours (suppression, facilitation, modulation) that can be driven by pragmatic or socially contextualised intentions; the tics themselves can be too. But when they are, I suggest that they take on a functional role and may be better regarded as functional tics. This adds complexity to how we judge observed symptom exacerbation in context: Are these exacerbations a positive sign of increasing tic symptoms (over and above baseline) due to the functionalisation of primary tics, or rather a negative sign of decreasing tic inhibition (revealing baseline symptoms) due to functionalised behavioural responses to symptoms? The answer could have repercussions for how we define functional tic disorders. In Sect. 8.2.2 we will interrogate the much-debated distinction between primary and functional tics in light of Gallagher and Marcel’s (1999) three types of situations (abstract, pragmatic, socially contextualised) in which we act intentionally. But first we need to ask: What tells us whether the intention that informs someone’s action relates to the situation in an abstract, pragmatic, or socially contextualised way? Gallagher (2020) offers two key criteria to look out for. Firstly, we should identify the “different reasons for action or the relative absence of reason” (16), the latter of which is said to be typical of abstractly situated intentions (Criterion 1: Reasons for action). Gallagher does not clarify what he means by a ‘relative absence’ of reasons for acting, so we still need to figure out whether abstractly

232

8  ‘No ill will’: Ticcing on Moral Grounds

situated intentions reflect no reasons for acting, or fewer reasons, or different reasons (and if the latter, then how they are different). Secondly, Gallagher suggests that we should observe where the agent directs her attention during the action (Criterion 2: Directedness of attention). In an abstract or decontextualised situation, for example, the agent will display “some degree of relatively high-level cognition or conscious attention directed to the bodily movement”. In the case of normal, nonpathological actions, this might involve “understanding instructions and consciously translating them into motor actions that involve self-movement” (16). In a pragmatically or socially contextualised situation, on the other hand, the actor’s attention will be “directed more toward the situation or task and less (if at all) towards [their own] bodily movement” (16). How do these two criteria stack up in cases of primary tics? Do both criteria apply, and are they necessary and sufficient conditions for identifying the uniquely abstract ways in which primary tics relate to the agentic situations in which they occur?

8.2 Ticcing for Ticcing’s Sake 8.2.1 Criterion 1: Relative Absence of Reasons for Acting Criterion 1 has been debated in various guises in the scholarship on primary tic, where discussions revolve around the question whether tics have a ‘meaning’, a ‘purpose’, or an ‘end’. Schroeder, in line with his neuro-reductionist reading of tics, calls them a “meaningless behavioural tendency” which lacks any sign of a “means– end behaviour” (2005, 117–118). Similarly, Shapiro et al. (1988) write that tics are “purposeless” but also consider them an “end in itself” (349). By contrast, TS sufferer Bliss deems tics to be “‘intentional’ capitulations to virtually irresistible sensory invitations” (as quoted in Leckman et al. 2006, 645; see Chap. 5 for details), suggesting that the reason for ticcing is to extinguish these sensations. More recently Beste and Muenchau (2018) challenged the definition of TS as a movement disorder and proposed that tics are a “disorder of purposeful action selection and execution” (239). They note that “single tics [tic tokens] are indistinguishable from single spontaneous movements [movement tokens] in healthy controls”; their key difference emerges at what we called the occurrence or type level of analysis (see Chap. 2), since tics are “repetitive, patterned, and misplaced in context and time” (238; emphasis added). This last point is crucial and aligns well with my contention that primary tics are abstract, decontextualised intentional actions. They resemble (and may have derived from) normal actions, but they no longer relate to context in the way that normal actions commonly do, and their meaning is not straightforwardly rooted in context. Put differently, the meaning of primary tics – and I am defending the view that they are meaningful – can be abstractly constituted as immediate ends in themselves, a term I will use to describe their autotelic and self-directed nature.

8.2  Ticcing for Ticcing’s Sake

233

While Shapiro et  al. (1988, 349) also describe tics as an “end in itself”, they equate this with “purposeless”, an interpretation from which I will diverge here. I argue that tics are not entirely purposeless – or meaningless, as Schroeder (2005) calls them – but rather lack contextual integration into normal goal-directed activity from which they may or may not have evolved (see also Shapiro et al. 1988, 353 on this hypothesis). Niccolai et al. (2019, 157) are right to suggest that “the intention to tic in order to reduce or eliminate intense sensory or motor urge might … differ from the intention to start a normal movement”; we can now explain this difference as one founded in the divergent contextual situatedness of these respective actions. Importantly, the claim that tics are intentional responses to perceptual processes does not rely on the consciously perceived (and reflected) presence of uncomfortable urges and sensations – i.e., it is not a claim about first-person experience. As we noted earlier (see Chap. 4), many children, adolescents, and adults appear to be unaware of some of their tics and do not report experiencing urges prior to ticcing. The distinction between pre-reflective and reflective (self-)consciousness allowed us to explain this purported lack of experience as indicative of a recessive awareness of perceptual triggers that is unavailable to retrospective reflection. Similarly, Beste and Muenchau (2018) suggest that the lack of reported urge experiences does not imply that these tics “are not composed of both action and perception elements”. Rather “certain sensory or more generally perceptual processes that might trigger action elements (tics) through previously established perception action bindings might go unnoticed by those who tic” (241). We can re-state this point by drawing on our earlier tripartite distinction between motor intentions, immediate intentions (or intentions-in-action), and distal intentions (see Chap. 4). For example, simple motor tics which are triggered and executed outside subjects’ reflective awareness could be described as involving unconscious motor intentions and, perhaps, pre-reflectively or reflectively conscious intentions-in-action. They are self-directed and detached from context in so far as ‘doing the tic’ is aimed at the perceptual processes that give rise to it at the elemental and integrative timescale. The tic is done for the tic’s sake in the present moment in which it occurs. It is not directed at, or integrated into, a nested hierarchy of other intentional goal-directed activities, nor part of the person’s broader sense-­ making at the narrative timescale.2 Tics can become part of such goal-directed,  Oliver Sack’s story, ‘A Surgeon’s life’, contains many examples of the perceptual rather than semantic reasons someone might have for ticcing. Bennet, the surgeon portrayed by Sacks, has a range of vocal tics that have a certain musical or sound quality to them (2012, 83): “As soon as the rhythmic cycling stopped, a flurry of tics and compulsions took over; he kept digging at his belly, which was trim, and muttering, ‘Fat, fat, fat...fat, fat, fat...fat, fat, fat,’ and then, puzzlingly, ‘Fat and a quarter tit.’ (Sometimes the ‘tit’ was left out.) ‘What does it mean?’ I asked. ‘I have no idea. Nor do I know where “Hideous” comes from – it suddenly appeared one day two years ago. It’ll disappear one day, and there will be another word instead. When I’m tired, it turns into “Gideous.” One cannot always find sense in these words; often it is just the sound that attracts me. Any odd sound, any odd name, may start repeating itself, get me going. I get hung up with a word for two or three months. Then, one morning, it’s gone, and there’s another one in its place.’ Knowing his appetite for strange words and sounds, Bennett’s sons are constantly on the lookout for ‘odd’ 2

234

8  ‘No ill will’: Ticcing on Moral Grounds

meaningful activities – a process I called ‘narrative integration’ in Chap. 4, but as we will see below, this changes the situatedness of the tic. In Chap. 7 I argued that this dissociation from other meaningful activities and contexts so typical of primary tics, when coupled with high symptom severity, frequency, and repetitiveness, could alter the person’s temporal structure of experience by creating a hyper-circular ‘tyrannical presence’ which lacks the future-directedness of normal, non-­ pathological activity. The abstractly situated nature of primary tics may thus also be grounded in their temporality. By contrast, tic suppression provides a useful example of a pragmatically or socially situated intentional action since it is oriented toward, and often responds to, contextual features of the agentic situation in a way that the intention to tic does not. Tic suppression may involve both immediate intentions (intentions-in-action) and distal intentions, since the motivation to suppress usually relates to at least a pragmatic end (e.g., avoiding pain from repeated ticcing) and often to immediate or longer-term social ends (e.g., not distracting classmates with vocal tics during an exam; being liked and accepted by one’s group of peers, etc.). Recall Pablo’s ‘intentional conflict’ scenario from Chap. 6: On his birthday, Pablo and his family go out for a special dinner at a local restaurant. The moment Pablo sits down excitedly to browse the menu, he feels a strong urge to jerk his head; at the same time, he is highly conscious of the many strangers sitting nearby and eager not to become the focus of their curious attention. This scenario perfectly illustrates the conflict between two differently situated intentions: the intention to tic (decontextualised, abstract) and the intention to suppress (socially situated). Again, this is not to say that the intention to tic cannot be evoked contextually (excitement or environmental noise could exacerbate or bring it on, for example), but rather that the reason for ticcing is perceptual and self-directed; it is best explained by ‘abstracting away from’ the situation. The opposite is true for Pablo’s tic suppression, which is best explained by showing how social context informs his reasons for wanting to suppress his tics (in other scenarios, however, tic suppression could be driven by an abstractly situated intention too). Similarly, we can now offer a new explanation for ‘tic facilitation’, a concept which we introduced in Chap. 7. If ‘just doing a tic’ is not the same as consciously ‘facilitating’ or ‘bringing about’ a tic somehow, then one way to explain the difference would be to point at the situatedness of the intention involved: Someone who proactively facilitates or decides to do one of their tics might have additional reasons for ticcing which relate to the agentive situation at hand. Put differently, the tic may be motivated by pragmatically or socially situated reasons for acting, taking on a meaning that exceeds its immanently constituted response to perceptual stimuli. Here we run into the complex and contested discussion of functional tics, which

names – names that sound odd to an English-speaking ear, many of them foreign. They scan the papers and their books for such words, they listen to the radio and TV, and when they find a ‘juicy’ name they add it to a list they keep. Bennett says of this list, ‘It’s about the most valuable thing in the house.’ He calls its words ‘candy for the mind.’”

8.2  Ticcing for Ticcing’s Sake

235

we have touched on at various points throughout this book. A brief discussion is overdue and fitting in the present context.

8.2.2 Functional Tics as a Litmus Test for Our Theory It is fair to say that the history of Tourette Syndrome is the history of attempts to identify and disentangle psychogenic and organic causes of tics. Psychogenic explanations of TS dominated psychiatry for several decades of the twentieth century until organic – and particularly neurological – explanations of the Syndrome gained prominence in North America in the 1960s (see Kushner 1999). Today the debate about organic versus psychogenic explanations of tics is no longer fought out in Tourette Syndrome scholarship but continues in the borderland between primary tics (deemed to be neurological) and functional tics (deemed to be psychological in nature). Both are thought to exist as ‘pure’ conditions or co-occur in the same individual (Ganos et al. 2019, 755). Contemporary scholarship (e.g., Ganos et al. 2016, 2019) readily acknowledges that the distinction is clinically challenging because the behaviours in question are often similar and no clear biomarkers have been identified to aid a differential diagnosis. A small number of recent studies investigate the electrophysiological (Vial et al. 2019), neurophysiological (Versace et al. 2019), as well as behavioural and clinical (Demartini et al. 2015; Ganos et al. 2016; Ganos et al. 2019) differences between primary and functional tics, often with inconclusive results. Among the clinical and behavioural indicators listed in the scholarship, many are not useful as isolated or definitive criteria; they do not provide necessary or sufficient conditions for distinguishing between primary and functional tics. For example, age of symptom onset is not a decisive criterion as functional tics can occur in childhood, while tics first diagnosed in adulthood may indeed be primary tics if they simply weren’t detected or attended to earlier in the person’s life. Similarly, the experience of sensory phenomena before tics is commonly regarded as typical of organic tic disorders, but this experience is sometimes also reported by people diagnosed with functional tics (see Ganos et al. 2019, 751). Given the phenomenological overlap between both purported conditions and the noted difficulties in establishing a clinical diagnosis with certainty, it seems crucial to confront the possibility that both may co-occur. Rather than conceiving of primary and functional tics as binary opposites, we should expect that “patients with tics may also exhibit functional tic-­ like movements, and the overlay may be more common than currently recognized”. Crucially, “overlapping clinical features may point toward an overlap in the mechanisms that produce tics and functional tic-like movements” (752). The idea that a functional ‘overlay’ can develop for primary tics is not new: I take Shapiro et al. (1988) to gesture toward this when they note that a “tic is defined as a primary involuntary symptom that may or may not have psychological interactions” (347). It is easy to conceive of everyday scenarios where primary tics could become functionalised, so to speak, or where functional tics arise alongside, or on the back

236

8  ‘No ill will’: Ticcing on Moral Grounds

of, primary tics. Imagine a 14-year-old child called Dennis with TS. Dennis experiences a strong urge to bang his head onto solid surfaces (like walls, shelves, tables). One morning, the self-injurious tic recurs so frequently that the resulting headache leaves him unable to go to school, a fact which, while not intended, he doesn’t mind at all. In the following weeks, the same situation repeats a few more times and Dennis stays home from school following aggravated episodes of his head-banging tic. His parents notice that these tic episodes begin to follow a meaningful pattern: they suddenly flare up when Dennis does not want to go to school, in the leadup to an exam, a dreaded excursion, or the athletics carnival (he is sporty but hates competitions). It seems, then, that Dennis originally had few context-sensitive reasons for his head-banging tic when it originally arose but he quickly acquired new reasons – and highly context-dependent ones at that! – which reinforced his painful and repetitive symptoms. The scenario illustrates a shift in the situatedness of Dennis’s intention to tic: While his initial head-banging is detached from context (abstractly situated) in so far as its end (i.e., relieving a perceptual tension) is immanently attained by the action,3 his later head-banging tic tokens draw additional meaning from the interactive situations in which they occur. As Gallagher explains, a “socially contextualised situation is clearly qualified by social and personal circumstances that involve cultural categorisations of activities and/or social interactions” (2020, 15). Importantly, however, actions “do not need to be performed in the presence of others to have a social signification” (15, footnote 4). In other words, regardless of whether Dennis tics in front of his parents or alone in his room, the pain his head-­ banging tic generates has become socially significant, engendering a situation where he is allowed to stay home from school and thus avoid a range of challenging situations which he would rather not confront. Here the “functional overlay” (Ganos et al. 2019) which forms on the back of the primary head-banging tic is not brought to life by Dennis alone; his parents vitally contribute to it by affording opportunities for the tic to gain new meaning. There is a moral point to these insights – this time, a point about good-willed but ill-fated affordances enacted interactively in relationships of care and within broader societal contexts. Do we have a responsibility to ensure that primary tics remain abstractly situated in their respective agentic situations? If so, how can we best avoid functionalising others’ tics, inadvertently or otherwise? Practical guidance for families and educators is sparse yet greatly needed. In scholarship the main caregiver responses which have been discussed as factors that may reinforce or exacerbate symptoms include ‘attention’ and ‘escape’ – i.e., positively or negatively attending to tics, or permitting escape from aversive contexts following tics. Goldman and DeLeon (2020, 310–311) call for more research into the specific variables at play in each of these response variables:

 This attainment may of course be incomplete or fleeting, necessitating further tics. See Chap. 6 for a discussion of ‘just right’ feelings and the potential link between tic repetition and the unusually high specificity requirements of tics as actions (see also Sect. 8.3.1). 3

8.2  Ticcing for Ticcing’s Sake

237

For example, rather than testing ‘generic’ attention as a consequent variable, it might be important to consider the form (e.g., reprimand, consolation, teasing, perceived observation) and the delivering agent (e.g., parent, therapist, peer, stranger) of the attention. When testing escape as a consequence, it might be important to consider the form of the aversive stimulus (e.g., work, school, unfamiliar individuals, places associated with increases in tics) being escaped as well as the context to which an individual is escaping (e.g., free time, noncontingent attention, access to preferred items, places devoid of attention for engaging in tics).

Behavioural intervention programs such as CBIT (Comprehensive Behavioural Interventions for Tics) do include function-based assessments of tics as an integral treatment component (e.g., Woods et al. 2008a, 27–38). These are therapist-guided explorations of the relational contexts in which tics occur and of their situational antecedents and consequences. Families are invited to complete a Functional Assessment Self-Report Form (Woods et al. 2008b, 19) while paying close attention, over the course of a week, to all the child’s tics and the contexts in which they are most likely to happen. The aim is to “isolate the factors that make tics worse for the patient and modify those factors to bring about tic reduction and decreased impairment” (Woods et al. 2008a, 27). Not responding to tics – i.e., ignoring them when they occur – is commonly promoted as a good strategy to reduce the risk that tics are socially maintained or reinforced (Woods et  al. 2008a; Goldman and DeLeon 2020). What these resources do not address explicitly is the potential for these functional overlays to lead to perceived benefits rather than impairments for children and their families; not all reasons for ticcing make things worse for the patient, at least at first sight (Dennis clearly likes the idea of staying home from school, although his avoidance behaviour will likely come with social and educational costs and be unsustainable longer-term). Further, the functionalisation of primary tics can complicate treatment decisions and increase the risk of misdiagnosis and inappropriate therapeutic interventions. We know, for example, that “patients with functional tic-­ like movements characteristically lack a sustained response to classic anti-tic medication” (Ganos et  al. 2019, 754; see also Baizabal-Carvallo and Jankovic 2014; Demartini et al. 2015; Ganos et al. 2016), and invasive interventions like deep-brain stimulation (DBS) are not recommended in refractory tics suspected to be psychogenic in origin (see Ganos et  al. 2019, 755). Above all, the fact that to this day diagnosing either apparent ‘disorder’ remains a delicate matter  – requiring clinicians to carefully assess the evidence and “weigh[…] up the meaning” (755) of symptoms – shows that the risk of epistemic injustice lurks in the clinical setting too. Doctors can get in wrong; patients can feel misunderstood. Even research and scholarship can be impacted negatively when we fail to distinguish cases of pure functional and primary tic disorders or of primary tics with functional overlay: “Results from genetic studies, pathophysiologic studies, and therapeutic clinical trials may be ‘contaminated’ by combining participants with different phenomena and/or rating tics and functional tic-like movements as if they were the same phenomenon” (755).

238

8  ‘No ill will’: Ticcing on Moral Grounds

The idea of situated intentions introduced earlier not only provides a new philosophically grounded distinction between primary and functional tics but it also allows us to explain how they might interact at the token level of analysis (i.e., during a concrete tic event): • Primary tic tokens are autotelic, abstractly situated intentional actions. As ends in themselves, their meaning is not constituted by or derived from context (although context can trigger them; see Chap. 7). The person’s reason for ticcing is to respond to a perceptual stimulus or to eliminate an urge. The best possible description for these tics is given when we “abstract away” (Gallagher 2020, 12) from the context of the highest realised affordance of these actions and focus on specific aspects of their embodied performance. • Primary tic tokens with functional overlay are hybridly situated intentional actions: While they still retain their original, decontextualised reason for acting (e.g., a response to a perceptual stimulus or urge), they also enact a pragmatically or socially situated reason for ticcing which the situation affords. The best descriptions we can give of these tics pinpoint how their embodied performance becomes a vehicle to achieving other, meaningful ends. • Functional tic tokens are pragmatically or socially situated intentional actions. They are driven by context-derived reasons for ticcing afforded by the situation in which they occur. The best explanation we can give of these tics refers to a higher (pragmatic) or to the highest (socially situated) “semantic or functionally useful level” of the action, and thus to its highest realisable affordance (see Gallagher 2020, 17). Primary tics may become functional tics over time (diachronic shift); in this case individual tic tokens could still be conceptualised as pure tokens (primary or functional), with the change observed at the occurrence level of tics – although it is not clear how and when the switch from primary to functional would take place. Alternatively, a certain tic occurrence (e.g., head jerk) could transition through all three stages – from pure primary, to hybrid, to pure functional. Again, it is not clear what would initiate these transitions and how to identify or intervene on them. For cases of ‘functional overlay’ (be they part of a transition from pure primary to pure functional tics or a more permanent hybrid manifestation), we would assume that both primary and functional tic mechanisms are present simultaneously. In short, functional overlay can be thought of as adding reasons for ticcing, while a shift from pure primary to pure functional tics can be thought of as changing reasons for ticcing. The same would hold for causal factors too: these may change entirely (primary to functional shift) or they may gain complexity (primary with functional overlay). However, what need not change is the volitional status of the tics in question, since tokens of pure functional or primary tics, as well as those of primary tics with functional overlay, can all be voluntary or involuntary intentional actions. Volition thus cannot serve us as a suitable differentiator between functional and primary tics (see also Ganos et al. 2019). This fact holds true of their consciousness status too: People can be both pre-reflectively or reflectively conscious of their primary and functional tics. And yet there is a point of difference, as I have outlined

8.2  Ticcing for Ticcing’s Sake

239

here: Functional and primary tics differ with regard to the situatedness of the intentions involved. What is less clear, however, is whether ‘pure’ forms of these exist or whether we should regard them as theoretical end points on a clinical continuum.

8.2.3 Four Notations for ‘Functional Overlay’ Returning to our taxonomy of intentional actions developed in Chap. 6, we can now attempt a notation for Dennis’s head-banging tic as a case of ‘functional overlay’ involving hybridly situated intentions. One of the questions we will confront is whether adding reasons for ticcing (here, socially situated reasons) changes the intentional action dynamic of the tic in question. Put differently, does functionalisation induce a ‘category shift’, requiring us to allocate the functionalised tic to a different action category (see Fig. 6.2, Chap. 6) than its underlying primary tic? As we will see, this can but need not happen: A category shift may occur when functionalisation obstructs volition – i.e., when it ‘enforces’ repeat enactions of a primary tic which the person would otherwise have had volitional control over. A category shift can also occur in unvoluntary primary tics if these repeatedly and perhaps inadvertently enact a meaningful consequence (functional overlay) which is initially open to voluntary control but becomes entrenched over time. To arrive at this insight let us spell out the possible notations for functionalised primary tics using Dennis’s head-bang scenario as our point of reference. We begin with the component notations for the primary and functional intentions, respectively, before combining them in the next step. Primary Intention(s)  First there is Dennis’s abstractly situated intention to bang his head into a solid surface to alleviate a perceived tension or urge (Int1). The most likely intentional action dynamic for this head jerk would be a Category B (unfree) or C (unvoluntary) action, depending on how coercive the impulse or urge to tic is, and whether Dennis can respond to it with volition or not (i.e., whether the agentive situation affords him the resources to act otherwise; for details, see Chap. 7). If the head bang is a Category B (unfree but voluntary) action, then Dennis genuinely wants to tic and does so (Int1coerc↔ act ↔ out1). If the head bang is a Category C (unvoluntary) action, then he has two conflicting intentions and experiences an intentional conflict: The abstractly situated intention to bang his head (Int1) contradicts his intention to suppress the tic (Int2)  – e.g., to avoid the resulting pain (a pragmatically situated intention). In Category C actions this second intention aligns with the preferred action outcome (out2pref) but it cannot be enacted due to the coercive forces acting on the situation (Int1 ↔ actcoerc ⇹ out2pref). In Dennis’s scenario we would say that he does not want to tic but has to do so. Interestingly, the presence of an intentional conflict (Category C action) seems to change the situatedness of the action; it is highly unlikely that the second, conflicting intention would also be a decontextualised one. Rather, the conflicting intention will likely be motivated by pragmatically (e.g., avoid pain) or socially situated (e.g., avoid embarrassment) rea-

240

8  ‘No ill will’: Ticcing on Moral Grounds

sons for acting. In our example with Dennis, tic suppression is thus a hybridly situated action. But instead of a pragmatically or socially situated intention ‘piggybacking’ on a decontextualised one (as is the case in functionalised primary tics), the former counteracts the latter when tics are suppressed. Put differently, instead of adding reasons for ticcing, the situation provides a reason not to tic. Functional Overlay Intention(s)  As Dennis realises that doing the head-banging tic can also help him stay home from school, a socially situated intention piggybacks on the primary tic (Int3  =  skip school). We could describe this functional overlay as a Category B action (Int3coerc↔ act ↔ out3) if Dennis has some volitional control over it (and could have acted otherwise if he had wanted to). That is, in Category B actions the outcome aligns rather than conflicts with the actor’s intention since the intention responds to the coercion (see Chap. 6 for details). In our example, this would mean that Dennis genuinely wants to stay home and has no conflicting or preferred intention to confront the anticipated challenges at school. Alternatively, we could describe the functional overlay as a Category C action that involves an intentional conflict, where Dennis’s intention to skip school (Int3) contradicts his intention to confront the anticipated challenges at school (Int4). Although confronting these challenges is his preferred outcome (out4pref), he is unable to do so and feels forced to skip school (Int3 ↔ actcoerc ⇹ out4pref) by doing his painful head-banging tic. Since functional tics are commonly experienced as involuntary and outside agents’ control (Ganos et al. 2019, 753; see Stenner and Haggard 2016), Category C actions (with intentional conflict) might be the more appropriate descriptor.4 By combining the primary tic intentions (Int1, Int2) and the functional overlay intentions (Int3, Int4), we can now devise four possible notations for the intentional action dynamics of functionalised tic tokens: (1) double-B double-­ match; (2) double-C match-mismatch; (3) C-to-B match-mismatch; and (4) B-to-C match-mismatch (compare Fig. 6.2 in Chap. 6). Double-B Double-Match: Int1coerc↔ Act ↔ out3 If Dennis’s functionalised head-banging tic was a ‘double-B double-match’ action, then both the underlying primary tic (Int1coerc↔ act ↔ out1) and the functional overlay (Int3coerc↔ act ↔ out3) could be described as Category B actions. Dennis intends to tic and to skip school, with no other conflicting or preferred intentions contradicting his ticcing. While the action is coerced, volition is retained – Dennis could act  It is, of course, conceivable that someone might ‘fake’ tics in an entirely voluntary and premeditated fashion, for any pragmatic or socially situated reasons. I am purposely not discussing such cases her since they are regarded as rare and do not capture the affliction of functional tics (perceived lack of volition; inability to do otherwise). Culver and Gert (1982, 117) describe the faking of any symptoms (not just tics), as cases of ‘malingering’, which they deem to be free (Category A) actions: “Malingering is an example of a voluntary action which sometimes confronts physicians. The person who feigns symptoms does so intentionally and has the volitional ability to will to feign or not to feign. One regards the malingerer as having acted both intentionally and voluntarily and therefore as being fully responsible for his behaviour.” See Chap. 6 for a detailed critique of Culver and Gert’s taxonomy of actions in the context of tic disorders. 4

8.2  Ticcing for Ticcing’s Sake

241

otherwise if he wanted to. Since the volitional status of the primary tic and the functional overlay are the same, no category shift is induced by the added reasons for ticcing. Put differently, the primary tic’s action Category (B) does not change following its functionalisation (i.e., the functionalised tic is still a Category B action). From a treatment perspective this is a great scenario to work with since interventions could target either or both levels. Behavioural treatments like CBIT, for example, could help Dennis re-direct his head-banging tic while also supporting him with strategies for dealing with challenging situations at school. Given Dennis’s degree of volitional control over both the primary and the functional aspects of the tic in question, he might be able to exercise good will and thus act with moral agency. Double-C Match-Mismatch: Int(1 + 3) ↔ actcoerc ⇹ out(2 + 4)pref If Dennis’s functionalised head-banging tic was a ‘double-C match-mismatch’ action then both the underlying primary tic (Int1 ↔ actcoerc ⇹ out2pref) and the functional overlay (Int3 ↔ actcoerc ⇹ out4pref) could be described as Category C actions. Here, Dennis would prefer to suppress his tic and to confront the challenges he faces at school, but coercive factors prevent him from doing so. Instead he enacts his other intentions (to tic and to skip school). This is a double intentional conflict scenario. Again the volitional status of the primary tic aligns with that of the functional overlay, but this time neither is under volitional control – Dennis cannot act otherwise. No category shift occurs because the tic’s action Category (C) remains unchanged despite functionalisation. From a treatment perspective this is a more difficult scenario to work with given the unvoluntary nature of both intentional aspects of the action. Recall that our enactive definition of the term ‘unvoluntary’ (see Chap. 6) describes a lack of action affordances available to the acting person in a given situation. Therefore, the lack of volition need not be due to some agent-­ intrinsic feature (e.g., an essential inability or disability of some sort) but may derive from other aspects of the situation such as the environment or other actors who constrain the agent’s opportunities for action. In Dennis’s case, for example, we could work with his parents (who enabled the functionalisation of his primary tic in the first place) to ‘loosen’ the coercive grip of the situation by removing the functional link between the head-bang and skipping school. This might mean that they will need to send Dennis to school even if his head-banging tic is strong, and devising positive strategies to reinforce and reward school attendance. However, simply ‘undoing’ functional overlay (i.e., severing the link between the tic and its functional outcome) may not always be straightforward or even possible in some circumstances. Therefore, behavioural interventions like CBIT, which enhance opportunities for agency by teaching tic management strategies, could be an important complement to any parent-focused interventions when working with Dennis in this scenario. In so far as CBIT might help Dennis acquire a degree of volitional control over the primary aspect of the tic in question, he could experience increased opportunities for moral agency – for example, by exercising good will in situations impacted by his symptoms.

242

8  ‘No ill will’: Ticcing on Moral Grounds

C-to-B Match-Mismatch: Int(1 + 3coerc) ↔ actcoerc ⇹ out2pref In this scenario unvoluntary primary tics reinforce and consolidate functional overlay over time. If Dennis’s functionalised head-banging tic was a ‘C-B match-­ mismatch’ action, we would describe the underlying primary tic as a Category C intentional conflict (Int1 ↔ actcoerc ⇹ out2pref) and the functional overlay as a Category B action (Int3coerc↔ act ↔ out3). Here Dennis has to tic although he does not want to – the sensory pressure or urge to tic is too compelling to stop the action, and the situation does not afford resources or opportunities to suppress the tic. On the other hand Dennis has some volitional control over his genuine intention to skip school; he could do otherwise if he wanted to. In this scenario, working with Dennis on a competing intention – i.e., one that motivates him to confront the envisioned challenges at school  – may be a more rewarding therapeutic avenue than simply telling his parents to send him to school with an out-of-control and painful head-­ bang, because it would foster Dennis’s experience of agency. Once (or while) functionalisation is addressed in this way, his underlying unvoluntary head-banging tic could still be addressed via standard therapeutic approaches to treating primary tics (e.g., pharmacotherapy, behavioural therapy, etc.). A risk to look out for in this ‘C-to-B match-mismatch’ scenario (unvoluntary primary tic with voluntary functional overlay) is the possibility of a bottom-up reinforcement of the functional aspect of the action over time. Put differently, while the functional overlay is initially open to voluntary control, over time (and without intervention) the C-to-B dynamic could turn into a C-to-C dynamic through repeat coupling of the socially situated consequence to the abstractly situated tic action. If Dennis keeps skipping school due to his painful head-banging tic, the functionalised tic may become more entrenched and less amenable to voluntary intervention. Here we encounter the risk of category shift – that is, the possibility that the functional overlay may start off as a Category B action but over time turn into a Category C action. Early intervention seems particularly important in this scenario because volitional control over the functional aspect of the action is still possible. From the perspective of moral agency, too, intervening early on Dennis’s avoidance behaviour and associated intention to skip school would maximise his opportunities for moral agency – for example, by acting with good will toward himself (and possibly toward others) in the relevant situations. B-to-C Match-Mismatch: Int(1coerc + 3) ↔ actcoerc ⇹ out4pref In this scenario functionalisation obstructs the exercise of volition in primary tics. If Dennis’s functionalised head-banging tic was a ‘B-C match-mismatch’ action, then the underlying primary tic could be described as a Category B action (Int1coerc↔ act ↔ out1) and the functional overlay as a Category C intentional conflict (Int3 ↔ actcoerc ⇹ out4pref). Here, while Dennis has volitional control over his primary head-­ banging tic (at least in some contexts), his intention to skip school coercively re-­ enforces the tic action. Even though Dennis would prefer to confront the challenges he faces at school, he is unable to act on (and thus lacks volitional control over) this preferred intention. Functionalisation here prevents tic suppression, and Dennis loses volitional control over his primary motor tic. This is a different version of

8.2  Ticcing for Ticcing’s Sake

243

category shift: The added reasons for ticcing enforce repeat enactions of a primary tic which Dennis would otherwise be able to inhibit. When functionalisation obstructs the exercise of volition in this way, the voluntary but unfree (Category B) primary tic turns into an unvoluntary (Category C) one. Problematically, this ‘reifies’ the tic by moving it out of the agent’s realm of control. The treatment approach would be similar to ‘double-C double-match’ cases: Parents would be guided to adopt a different behavioural response to their son’s tic (to avoid reinforcing the functional overlay), while Dennis’s existing voluntary control over his head jerking tic would be strengthened and extended via interventions such as CBIT (which, we could argue, affords a fortuitously decontextualised or merely pragmatically situated treatment situation that is unrelated to the functionalised, socially situated school-skipping context). From an agency perspective, intervening early by consolidating Dennis’s existing behavioural control over his head-banging tic might afford him opportunities to extend his motor control from decontextualised or pragmatically situated settings to more complex, socially situated ones. Such increased agency could, in turn, open opportunities for Dennis to override coercive constraints and act virtuously, that is, from moral principles or good will. What strikes me as interesting in reflecting on these four possible notations for functionalised primary tics is the extent to which interactive contexts can impact both symptom progression and treatment pathways. Importantly, when functionalisation occurs, it need not be driven by the ticcing person herself but may well be enacted by others. Put differently, the additional reasons for ticcing, or the meaningful ends attained by their performance, may not be those of the ticcing person but could be imposed on her. Functionalisation can thus be suffered; it need not be endorsed by the person with tics. This is morally problematic since, as noted earlier, cases of category shift risk reifying (and reinforcing) both tic symptoms and the meanings and reasons associated with them. By obstructing opportunities to exercise volition (at the level of the action’s primary or functionalised intentions, or both), certain cases of functional overlay can shrink the agentic horizon for the person with tics by curtailing alternative possibilities for action. In the context of an ethics of moral responsibility in tic disorders, it seems important to recognise that functionalisation of primary tic symptoms is not necessarily a feature of actions but of interactions. The best description we can give of functionalised primary tics is one that illuminates the shift in the situatedness of intentions – from abstract to contextualised  – which occurs as new reasons for ticcing are attributed to the behavioural symptom. To appreciate this new situatedness and to grab functionalisation at its root, we must look at more than just agent-specific features (from brain states to clinical symptoms) and study these seemingly ‘pathological’ actions in their social and environmental contexts. Doing so might challenge the very definition of disorder at the heart of our current nosology. If functionalisation is a process by which the same action generates new context-specific outcomes because additional meanings and reasons for acting are attributed to it, then this captures a fundamental potential of human agency, not just some quirk of pathology. As such we may expect to find that the functional

244

8  ‘No ill will’: Ticcing on Moral Grounds

reinforcement of primary tics is ubiquitous to a certain degree. We live socially situated lives in which actions are prone to take on new meanings, intended or otherwise; and we are prone to find new reasons for doing what we do when the situation affords us the opportunity. But if most people with primary tics experience a functionalisation of some of their tics at some stage or other, then where do we draw the line? At what point do we speak of functional overlay, and when does it become a diagnostically and treatment-relevant concept? Further, how should we distinguish between functionalised primary tics and ‘pure’ functional tics hypothesised to have a different aetiology? We cannot answer these questions conclusively here. But it is worth recognising that pure cases of primary tic disorders, where all symptomatic actions are nothing but abstractly situated actions, may be harder to find in practice than our medical theories would have us believe. Even in the most well-informed and well-meaning families or school environments, for example, it would be unrealistic to expect that everyone at all times masters ‘non-responsiveness’ to tics. Not reacting to symptoms, although this may well be a key ingredient to avoid the inadvertent functionalising and reinforcing of tics, is not always possible or practical. And while individuals with TS seek to conceal their symptoms skilfully from us, we too require skills to unsee and stop reacting to those symptoms which escape their wizardly camouflage. At a disorder level, I suggest, pure primary tics are thus more of a theoretical posit – a nosological fiction, perhaps – than a reality. While we can conceive of individual tic occurrences as abstractly situated intentional actions (inconspicuous ones which may not become functionalised so easily), it seems unlikely that someone’s entire range of symptoms remains untouched by the near-automatic functionalisation of actions that so commonly occurs in real-life contexts.

8.3 Zoning Out and Tuning In 8.3.1 Criterion 2: Directedness of Attention A second ‘proof’ of the abstractly situated intentions which characterise primary tics (and thus of their reduced blameworthiness) relates to the directedness of the person’s attention (Criterion 2). We can distinguish between decontextualised, pragmatic, or socially contextualised situations by observing where the agent directs her attention during the action. For example, Gallagher (2020, 16) suggests that in an abstract or decontextualised situation the agent will display “some degree of relatively high-level cognition or conscious attention directed to the bodily movement”. In the case of normal, non-pathological actions, this might involve “understanding instructions and consciously translating them into motor actions that involve self-­ movement”. In pragmatically or socially contextualised situations, on the other hand, the actor’s attention will be “directed more toward the situation or task and less (if at all) towards [their own] bodily movement”. We can distinguish two

8.3  Zoning Out and Tuning In

245

aspects  – a positive and a negative one  – in Gallagher’s description, which are implied but not fully spelled out. Extracting these will help us clarify whether and how Criterion 2 applies to primary and functional(ised) tics. The positive aspect in Gallagher’s description relates to what the agent is attending to, while the negative aspect relates to what the agent is not attending to. For example, in abstractly situated intentional actions we might see one or both of the following: • Agent attends to bodily movement (or other embodied aspects of the action). • Agent does not attend to the broader situation or task at hand. The first describes the positive aspect: a turn toward specific features of the embodied action. The second describes the negative aspect: a turn away from meaningful context. In the case of pragmatically or socially contextualised situations, these aspects are reversed, meaning we might see one or both of the following: • Agent attends to the broader situation or task at hand. • Agent does not attend to specific aspects of the bodily movement (or less so). Here, the positive aspect involves a turn toward meaningful context, characterised by a degree of absorption in broader meaningful activity. By contrast, the negative aspect involves a turn away from specific features of the embodied action while one enacts it. It is important to note that Gallagher uses relative terms here: ‘more’ and ‘less’ and ‘if at all’. This means that we should envision these criteria as falling on a spectrum, rather than as constituting binary opposites. If we adopt a diachronic perspective, the learning of new skills provides a great example of a temporal shift in the directedness of attention along this continuum. Initially, learning a skill commonly involves abstractly situated intentions, where a person’s full attention is directed at acquiring and practising the new bodily movement or series of movements. Once learned, however, the movement may become more automatic, meaning the person will be able to execute it without needing to pay conscious attention to it any longer. We are reminded here of Gallagher’s earlier point that the type of action does not dictate how the action is situated in context – i.e., the same action can occur in abstractly or socially contextualised situations, as is illustrated by the conscious learning of new skills which become ‘second nature’ over time. I emphasise this diachronic perspective because I want to argue that something similar holds true for the directedness of attention in primary tics. These can occur both with the person’s full conscious attention being directed at the tic but also in a pre-reflectively (or recessively) conscious state. This would seem to suggest that Criterion 2’s positive definition of abstractly situated intentions (agent attends to bodily movement) is not always met, since some people are unaware of their tics while they tic. Further, these pre-reflectively conscious tics do not seem to disrupt normal activity: The occur while the agent is positively engaged in, and fully attends to, the broader situation or task at hand. Imagine Mia, who is happily baking a cake while she does some subtle eye-blinking tics. How can this be? If Gallagher is right about abstractly situated intentional actions, and if I am right in arguing that tics are such actions, then shouldn’t Mia’s attention be drawn toward her eye-blink, and away from the activity of baking her cake? After all, Gallagher notes that “actions

246

8  ‘No ill will’: Ticcing on Moral Grounds

tend to break down and become disintegrated in abstract situations”, whereas they “tend to be more meaningfully coherent” in pragmatically and socially contextualised situations (Gallagher 2020, 17). So, if Mia’s baking continues happily and with the appropriate focus despite her tics, aren’t we wrong in suggesting the latter meet Criterion 2 for abstractly situated intentional actions? Not really. There is an important difference we need to appreciate, which explains how Criterion 2 for abstractly situated intentional actions still applies to primary tics. This difference lies in the role plaid by the tic in the broader agentic situation. Importantly, even in these instances of barely noticeable tics, the ticcing (e.g., Mia’s eye-blink) does not form part of the broader meaningful activity in which the person is engaged (e.g., Mia’s baking). We could say that the eye-blinking tic happens during and despite Mia’s baking a cake, but it does not contribute to her baking. The tic thus flies under the proverbial radar of the broader meaningful action. The tic and the baking sit side-by-side. This is different from the scenarios in which Gallagher (2020) describes a loss of coherence in actions that are executed in abstract (rather than pragmatically or socially situated) situations, where attending to specific yet subsidiary aspects of that very action disrupts its flow. In our example, this would involve Mia attending to certain motor aspects of baking: how she whips the batter, separates the eggs, or slices the sponge cake – all of which are common occasions for disastrously ill-placed self-consciousness (with predictably bad outcomes for any cake). But this is not what we are talking about when Mia tics while baking, a situation where an abstractly situated activity (tics) and a pragmatically or socially situated activity (baking) coexist smoothly. Barely being conscious of one’s tics during absorption in other meaningful activity does not turn tics into pragmatically or socially contextualised actions; and it does not mean that Criterion 2 for tics as abstractly situated actions is not met.5 While tics are not always attended to reflectively, living with tics for many people still entails a constant degree of attention to symptoms and one’s body. Rare and reportedly liberating are occasions where symptoms completely disappear from the person’s conscious attention and observable behaviours  – for example, during singing, dancing, playing music or video games (see also Beste and Muenchau 2018, 238). In these moments, tics seem to be temporarily ‘crowded out’ by engagement in meaningful tasks that require concentration (what we called ‘narrative easing’ of tics in Chap. 4). For Wilensky smoking pot had a similar effect, inducing a rare state of bodily unawareness and self-restauration: It struck me that for the past half hour or so I hadn’t been thinking about my body at all […]; for the first time in a decade I felt unburdened, unfettered: ‘normal’. […] The pot, I knew,

 There are cases where abstractly situated (primary) tics can contribute to other pragmatically or socially contextualised actions  – what we called ‘narrative integration’ in Chap. 4. In his short story, ‘Witty ticcy Ray’, Oliver Sack (2015) describes a patient who utilises his tics during his performances as a jazz drummer. This kind of utilising of symptoms within and toward other meaningful activities changes the situatedness of tics in context; tics stop being abstractly situated and acquire a (positive) functional – or we could say narrative – role in the person’s life. 5

8.3  Zoning Out and Tuning In

247

had rendered me me again, but it was a version of me I only faintly recognized now. (1999, 122–123)

The blissful normalcy of being engaged in activity without consciously attending to oneself and one’s body is what Heidegger (1927/2001) described as being ‘ready-­ to-­hand’ (RtH), a mode of being in the world which we likened to the experience of freedom in action in Chap. 4. And yet Trubody (2014) noted that people with TS often live in a state of being excessively ‘present-at-hand’ (PaH), a mode of relating which involves being hyperaware of oneself and one’s surroundings – a shift, we might say, from contextual to abstract agency. If people with primary tic disorders like TS are so commonly – and often constantly – aware of their bodily symptoms and experiences, then all may not be as it seems in our example of Mia the baker either. For one, her ability to bake a cake quite uninterruptedly despite her tics does not mean that she does not attend to them when they arise. Interference can happen at any time; as micro-distractions her tics might cause Mia to disengage from her baking for split seconds at a time without anyone else ever noticing. Such subtle turning away from meaningful context (the negative aspect of abstractly situated intentional actions, as defined in Gallagher’s Criterion 2) is commonly reported by people with TS. As Amy Wilensky writes, “sometimes a ticcing episode caused me to zone-out for a number of seconds and re-emerge blinking like a newborn” (1999, 44). Similarly, a 16-year-old interviewee, whom we invited to describe her tic experiences as a movie scene, paints a vivid picture of how context fades away during a tic: “It almost feels as if my senses are toned down for a split second. […] In the movie, I’d probably make the lighting go dark, but not completely off, and the music would be muffled” (interview conducted 16 April 2021). Such inward attending to tics, I suggest, is so normal in TS that it becomes part of the person’s way of being in the world. The spectrum of such inward attending to tics can range from a subtle, recessively conscious background activity (unnoticed by others) to an explicit and observable interference with other meaningful actions (what we called ‘narrative disruption’ in Chap. 4). A key feature of tics which demands such inward attention is the high degree of specificity – and sometimes complex technical skills! – required for their execution. This point illustrates both the positive aspect (attending to details of the embodied action) and the negative aspect (not attending to other meaningful activities) contained in Gallagher’s Criterion 2 for abstractly situated intentional actions. Curiously, the skilfulness and even aesthetic value of tics as actions are rarely acknowledged in the academic scholarship, but Buckser’s (2008, 175) anthropological study provides a welcome exception: Tourettic movements … are, in fact, often quite elegant. One of my informants performed a tic every few minutes that involved touching a pen that was lying on his desk. His hand would sweep smoothly across the desk surface, and during the pass he would lightly tap each finger on the pen, touching but not moving it, and never interrupting the larger motion of the hand. I tried it myself, after the interview, and found that I invariably knocked the pen off the table. Not all tics require such dexterity, but all require movement in a very controlled way. Indeed, people with TS often repeat a tic over and over, not as a rhythmic pattern but in an effort to get the movement exactly right.

248

8  ‘No ill will’: Ticcing on Moral Grounds

Mastering this tic movement would, at least at some point in time, have required high-level attention to detailed aspects of the embodied action in a similar fashion to how we learn other skills. And yet some tics are never fully ‘learned’ but call for constant attention. Unlike other skills which, once mastered, recede into effortless practice, many tics do not loosen their grip on the person’s consciousness over time but continue to demand explicit attention to how they are executed. In the tic disorder literature, this is referred to as Not Just Right Experiences (NJRE), and their relationship to sensory urges and premonitory phenomena is still debated (see Chap. 6). The need to find just the right way of doing a certain tic can be stressful and fully absorb the person’s attention. In the words of a 14-year-old boy with Tourette Syndrome who we interviewed: It’s something that’s almost telling me, giving me a body part, telling me exactly what I need to do, but sometimes I’ll get it wrong. I know with my shoulder, there’s five different tics that I’ll do with it. I’ll bend it behind my back, pull it forward, stretch it over like that. They’re all different. And sometimes I’ll really struggle to find the right one. And then that’ll make me… It’ll cause me to have a lot of other tics. Because I’m getting really stressed because I just can’t find the right tic to do. Because it’s like an itch, sometimes you’ll have an itch on your back or something, and you can’t find where you’re [supposed to be] itching, and you keep going and trying to find it. Because it’s still there. It is still there. (Unpublished data)

This high demand for specificity should give us pause to question the common scholarly comparison of the urge to tic with other bodily urges like micturition (urinating). We will rarely feel upset about having urinated in the wrong way; what matters is that we empty our bladder, not how we do so. If frustration emerges, it may be because we could not empty our bladder fully and a residual urge remains; but not because we feel we failed at some specific aspect of the urine-releasing action. In contrast, the way people with tics not only attend to their symptoms but also to how they enact them while they enact them highlights that primary tics are neither just subintentional nor preintentional acts but proper intentional actions (Rowlands 2011; see also O’Shaugnessy 1980). Unlike in cases of subintentional acts, where “the subject has no awareness of what would or would not count as completion of the act” (Rowlands 2011, 101), people who tic often have a clear sense of what would count as success or failure in ticcing  – for example, when attempting to get rid of an urge. Tics thus do not suffer from “an indeterminacy of satisfaction conditions” (101), although striving to do them in “just the right way” can be difficult and stressful, as the 14-year-old boy’s account of his shoulder tic illustrates. If anything, the satisfaction conditions of tics may be overly determinate, contributing to the perceived difficulty to meet their specificity requirements. Similarly, tics don’t match Rowlands’ definition of preintentional acts, which are said to fail easily once we turn our attention to them (103) since they are integral to our doing other things: playing music, doing sports – what we would call socially situated actions. Attending to the technicalities of one’s hand movement while playing the piano quickly disrupts the flow of the play; it de-contextualises and fragments the action. In contrast, there is nothing awkward about turning our attention to the execution of tics in all their technicality (they often demand it!). This abstractly

8.3  Zoning Out and Tuning In

249

focused attention does not rob tics of context, as they already occur in a decontextualised situation. Lastly, the distinction between preintentional acts and tics also applies to the memories we form of each. Since the former are part of larger things we do (e.g., playing sports or music), we remember those things but not the specific bodily details involved in these actions: You … do not remember it as a case of your body doing certain things. It is not as if you remember your fingers doing things of their own accord – that would be a very strange, and presumably disturbing, sort of memory indeed, and not one that is typically prevalent in one’s recollection of one’s sporting or musical endeavours. (Rowlands 2011, 103)

And yet this is precisely how primary tics are typically recalled: as body parts doing certain things “of their own accord” – for example, a head doing something to its bearer, and legs that pursue their own agenda (Wilensky 1999, 20, 42). For people with tics, this isn’t quite as strange and disturbing as Rowlands makes it out to be, although the experience of living with tics can be challenging, as we have noted many times throughout this book. Contrasting primary tics with Rowlands’ sub- and preintentional acts has reaffirmed the view proposed throughout this book: That primary tics are neither just reflexive behaviours nor sensory-motor contingencies of larger goal-directed actions. They are intentional actions proper, and the fact that coercion often plays a central role in their execution is no argument to the contrary. Both Gallagher’s Criterion 1 (Reasons for acting) and Criterion 2 (Directedness of attention) offer useful conceptual tools for showing that primary tics are decontextualised, abstractly situated intentional actions which are usually enacted under coercive constraints. That many tics cannot be done any one way but require to be done in a certain way speaks to their highly determinate satisfaction conditions and contributes to our understanding of their characteristic coercive feel. Taken together, these insights consolidate this chapter’s Argument from Abstraction for the reduced blameworthiness of tics.

8.3.2 Toward an Ethics of Moral Responsibility in Tic Disorders This chapter has yielded important insights for an ethics of moral responsibility in Tourette Syndrome and other primary tic disorders. Firstly, I have shown that the notion of situated intentions is ideally suited to explaining what goes wrong when we misinterpret tics as morally valenced actions. Instead of individuating tics in relation to their ‘highest realised affordance’ in the social sphere of norms and values, we should ‘abstract away’ from such contexts to better understand what these tics are about. Gallagher’s (2020, 15–16) criteria for determining the situatedness of intentions proved helpful in this regard: Criterion 1 (Reasons for action) allowed us to define primary tics as abstractly situated, decontextualised actions which are characterised by a relative absence of reasons for acting – we called them ends in

250

8  ‘No ill will’: Ticcing on Moral Grounds

themselves. Further, Criterion 2 (Directedness of attention) enabled us to show how the body-centred, self-directed attentional focus characteristic of primary tics as well as their high specificity requirements can ‘silence’ context in sometimes subtle, sometimes dramatic ways. This can help us explain how tics are directed at something (e.g., at a perceptual process) without being morally directed actions. These criteria also provided a new basis for distinguishing primary and functional tics, the latter of which were defined here as pragmatically or socially situated actions characterised by context-derived reasons for acting. Future attempts to argue for the reduced blameworthiness of tics in moral or legal settings can draw on the notion of situated intentions to spell out the meaning of tics as actions, and the attentional impact they have on the ticcing person. In such moral or legal contexts, drawing on the Argument from Abstraction should encourage epistemically and socially just interpretations of primary tics, as should its twin, the Argument from Coercion. Fortuitously, the latter offers reasons for reduced blameworthiness in both primary and functional tics, which share coercive traits. As we noted earlier, both types of tics appear to fit the intentional action dynamics of Category B and C actions (see Chap. 6), although their source of coercion may be different. For people diagnosed with functional tics, the Argument from Coercion may provide welcome relief from the unique stigma attached to disorders or symptoms deemed to be psychological in nature by countering the misperception that they are under volitional control. Also, if functional overlay in primary tics is as pervasive as I have suggested here, then any subpersonal arguments for reduced blameworthiness become more difficult to uphold. The very fact that primary tics are so easily conscripted into meaningful interactions (where they become ‘means to other ends’) reinforces my contention that they are not just subpersonal brain events, but rather special kinds of actions done by persons. It is at this narrative level of personhood that moral and legal agency are negotiated and denied, and both the Argument from Abstraction and the Argument from Coercion are pitched appropriately at this level. By contrast, the Organic Deficit Argument for reduced blameworthiness, which is commonly promoted by advocates of the nonaction view of tics, relies on subpersonal descriptions of brain dysfunction (or brain differences) to explain why people should not be held responsible for their tics. In a legal context such reliance on neuroscience may be as problematic in Tourette Syndrome as it is in other ‘pathologies’ – not just because we still don’t fully understand the link between brain activity and behaviour (see Aronson 2010, 100), but also because the criteria for moral and criminal responsibility are fundamentally normative and thus person-centred in nature. As Morse (2006, 405) puts it: If the person meets the behavioural criteria for responsibility, the person should be held responsible, whatever the brain evidence may indicate, such as the presence of an abnormality. If the person does not meet the behavioural criteria, the person should be held not responsible, however normal the brain may look. Brains are not held responsible. Acting people are.

References

251

Clearly we have good arguments on hand to show that in primary (and functional) tic disorders, the behavioural criteria for responsibility are not always met when people’s tics cause others harm. Drawing on the Argument from Coercion we can show that people with tics often cannot act otherwise because the agentive situation does not afford them alternative opportunities for action. Here we can point at disinhibitory (neuro)biological factors as contributing to the operant coercion. But we don’t want to reduce coercion to such biological explanations of disease as there may well be other factors, including our own interpretive practices, which ‘coerce’ people with tics into enacting their symptoms in certain ways. Drawing on the Argument from Abstraction developed in this chapter, we can explain that the reasons for ticcing typically lack any ‘ill will’ or criminal (or immoral) intent. Further, by pointing at the directedness of attention we can show that ticcing often involves a preoccupation with embodied aspects of the tic action, which in turn entails a withdrawal of attention away from context at the expense of contextually appropriate actions. Uptake of these insights by legal scholarship and practice is desirable, particularly since awareness of tic disorders and how to assess and respond to people with tics is still limited among the professional legal community in many areas of the world (see Jankovic et al. 2006, 93; see also Gullucayir et al. 2009; Porta et al. 2018; Freckelton 2019). Although Tourette Syndrome rarely leads to criminal behaviour, Jankovic and colleagues found that “patients with TS who have behavioural comorbidities are at risk of being involved with the legal system” (2006, 86). For most people affected by tics, however, the main risks associated with their symptoms are not legal ones and never involve the courts of law; rather, they lie in the innumerable interactions of daily life, in the school yards, homes, and shopping malls. They lie in the eyes and the gaze of others, in the flood of their moral misattributions, the ascriptions of character to happenstance. More than anything, they lie in the loss of agency and freedom entailed by the suffering of epistemic and social injustice, inflicted on people who tic by those who love, teach, play with, and care for them. We must first face our guilt and then keep our side of the bargain too: For there can be no ethics of moral responsibility in tic disorders without acknowledging the role we play in portraying tics as ‘disordered’ actions. Morality, as we saw, is interactive. If we can loosen the grip of our own interpretative habits and learn to see tics as the abstractly situated intentional actions that they are, we may stand a chance of treating people who tic with the good will and virtue they deserve.

References Angermeyer, Matthias C., and Herbert Matschinger. 2005. Causal beliefs and attitudes to people with schizophrenia: Trend analysis based on data from two population surveys in Germany. British Journal of Psychiatry 186 (4): 331–334. Aronson, Jay D. 2010. The law’s use of brain evidence. Annual Review of Law and Social Science 6 (1): 93–108.

252

8  ‘No ill will’: Ticcing on Moral Grounds

Atkinson-Clement, Cyril, Fuaad Sofiad, Emilio Fernandez-Egeae, Astrid de Liege, Benoit Beranger, Yanica Klein, Emmanuelle Deniau, Emmanuel Roze, Andreas Hartmann, and Yulia Worbe. 2020. Structural and functional abnormalities within sensori-motor and limbic networks underpin intermittent explosive symptoms in Tourette disorder. Journal of Psychiatric Research 125: 1–6. Bag, B., S. Yilmaz, and I. Kirpinar. 2006. Factors influencing social distance from people with schizophrenia. International Journal of Clinical Practice (Esher) 60 (3): 289–294. Baizabal-Carvallo, José Fidel, and Joseph Jankovic. 2014. The clinical features of psychogenic movement disorders resembling tics. Journal of Neurology, Neurosurgery and Psychiatry 85 (5): 573–575. Beste, Christian, and Alexander Muenchau. 2018. Tics and Tourette syndrome – surplus of actions rather than disorder? Movement Disorders 33 (2): 238–242. Black, Kevin J., Soyoung Kim, Nancy Y. Yang, and Deanna J. Greene. 2021. Course of tic disorders over the lifespan. Current Developmental Disorders Reports 8 (2): 121–132. Buckser, Andrew. 2008. Before your very eyes: Illness, agency, and the management of Tourette syndrome. Medical Anthropology Quarterly 22 (2): 167–192. Conelea, Christine A., and Douglas W. Woods. 2008. The influence of contextual factors on tic expression in Tourette’s syndrome: A review. Journal of Psychosomatic Research 65 (5): 487–496. Corrigan, Patrick W., and Amy C. Watson. 2004. At issue: Stop the stigma: Call mental illness a brain disease. Schizophrenia Bulletin 30 (30): 477–479. Culver, Charles M., and Bernard Gert. 1982. Philosophy in medicine. Conceptual and ethical issues in medicine and psychiatry. London: Oxford University Press. De Haan, Sanneke. 2020. An enactive approach to psychiatry. Philosophy, Psychiatry & Psychology 27 (1): 3–25. Demartini, Benedetta, Lucia Ricciardi, Isabel Parees, Christos Ganos, Kailash P. Bhatia, and Mark J. Edwards. 2015. A positive diagnosis of functional (psychogenic) tics. European Journal of Neurology 22 (3): 527–e36. Dietrich, Sandra, Michael Beck, B. Bujana Bujantugs, Denis Kenzine, Herbert Matschinger, and Matthias C. Angermeyer. 2004. The relationship between public causal beliefs and social distance toward mentally ill people. Australian and New Zealand Journal of Psychiatry 38 (5): 348–354. Eapen, Valsamma, Corina Snedden, Rudi Črnčec, Anna Pick, and Perminder Sachdev. 2016. Tourette syndrome, co-morbidities and quality of life. Australian and New Zealand Journal of Psychiatry 50 (1): 82–93. Efron, Daryl, and Russell Dale. 2018. Tics and Tourette syndrome. Journal of Paediatrics and Child Health 54 (10): 1148–1153. Finkelstein, Shlomit Ritz, Rob Poh, and Jorge L. Juncos. 2016. Swearing: Language for feeling. Cognitive Semantics 2 (2): 237–261. Freckelton, Ian. 2019. Tourette’s disorder and the criminal law. Journal of Law and Medicine 27 (2): 223–238. Fricker, Miranda. 2007. Epistemic injustice: Power and the ethics of knowing. Oxford: Oxford University Press. Gallagher, Shaun. 2020. Action and interaction. Oxford University Press. Gallagher, Shaun, and Anthony Marcel. 1999. The self in contextualised action. Journal of Consciousness Studies 6 (4): 4–30. Ganos, Christos, Mark J. Edwards, and Kirsten Müller-Vahl. 2016. “I swear it is Tourette’s!”: On functional coprolalia and other tic-like vocalizations. Psychiatry Research 246: 821–826. Ganos, Christos, Davide Martino, Alberto J. Espay, Anthony E. Lang, Kailash P. Bhatia, and Mark J. Edwards. 2019. Tics and functional tic-like movements: Can we tell them apart? Neurology 93: 750–758.

References

253

Gev, Ella, Tammy Pilowsky-Peleg, Sylvana Fennig, Noa Benaroya-Milshtein, Douglas W. Woods, John Piacentini, Alan Apter, and Tammar Steinberg. 2016. Acceptance of premonitory urges and tics. Journal of Obsessive-Compulsive and Related Disorders 10: 78–83. Goldman, Kissel J., and Iser G. DeLeon. 2020. A review of functional analyses of tics. Behavior Modification 44 (2): 296–315. Gullucayir, Sibel, M. Mahmut Asirdizer, Sunay Yavuz, Yildiray Zeyfeoglu, and Tarik Ulucay. 2009. Criminal and legal responsibilities in Tourette’s syndrome. Israelian Journal of Psychiatry and Related Sciences 46 (3): 221–225. Hayes, Steven C., Kirk D.  Strosahl, and Kelly G.  Wilson. 1999. Acceptance and commitment therapy: An experiential approach to behavior change. New York: Guilford Press. Heidegger, Martin. 1927 [2001]. Sein und Zeit. Tübingen: Niemeyer. Jankovic, Joseph, Carolyn Kwak, and Richard Frankoff. 2006. Tourette’s syndrome and the law. The Journal of Neuropsychiatry and Clinical Neurosciences 18 (1): 86–95. Kidd, Ian James, José Medina, and Gaile Pohlhaus, eds. 2017. The Routledge handbook of epistemic injustice. Abingdon, Oxon; New York: Routledge, an imprint of the Taylor & Francis Group. Kushner, Howard I. 1999. A cursing brain? The histories of Tourette syndrome. Cambridge: Harvard University Press. Leckman, James F., Michael H.  Block, Lawrence Scahill, and Robert A.  King. 2006. Tourette syndrome: The self under siege. Journal of Child Neurology 21 (8): 642–649. Link, Bruce G., and Jo Phelan. 2014. Stigma power. Social Science & Medicine 103: 24–32. Maisey, Peter. 2003. Light at the end of the tunnel. In Making allowances: Personal accounts of Tourette syndrome, ed. Chris Mansley, 91–99. Liverpool: The Bluecoat Press. Malli, Melina A., Rachel Forrester-Jones, and Glynis Murphy. 2016. Stigma in youth with Tourette’s syndrome: A systematic review and synthesis. European Child & Adolescent Psychiatry 25 (2): 127–139. Malli, Melina Aikaterini, Rachel Forrester-Jones, and Paraskevi Triantafyllopoulou. 2019. “Tourette’s is a lonely place”: An interpretative phenomenological analysis of the personal experience and identity of adults with Tourette’s syndrome. Journal of Developmental and Physical Disabilities 31 (6): 819–845. Mansley, Chris. 2003a. Preface. In Making allowances: Personal accounts of Tourette syndrome, ed. Chris Mansley, 7. Liverpool: The Bluecoat Press. ———. 2003b. “Life” for Tourettes. In Making allowances: Personal accounts of Tourette syndrome, ed. Chris Mansley, 8–34. Liverpool: The Bluecoat Press. Morris, David B. 1993. The neurobiology of the obscene: Henry Miller and Tourette syndrome. Literature and Medicine 12 (2): 194–214. Morse, Stephen J. 2006. Brain overclaim syndrome and criminal responsibility: A diagnostic note. Ohio State Journal of Criminal Law 3: 397–412. Niccolai, Valentina, Silvana Korczok, Jennifer Finis, Melanie Jonas, Götz Thomalla, Hartwig Roman Siebner, Kirsten Müller-Vahl, Alexander Münchau, Alfons Schnitzler, and Katja Biermann-Ruben. 2019. A peek into premonitory urges in Tourette syndrome: Temporal evolution of neurophysiological oscillatory signatures. Parkinsonism and Related Disorders 65: 153–158. O’Connor, Kieron, Marc Lavoie, and Benjamin Schoendorff. 2017. Managing tic and habit disorders: A cognitive psychophysiological treatment approach with acceptance strategies. Wiley-Blackwell. O’Shaughnessy, Brian. 1980. The will: A dual aspect theory. Vol. 2. Cambridge: Cambridge University Press. Oliver, Ruth. 2003. A lifetime of bewilderment. In Making allowances: Personal accounts of Tourette syndrome, ed. Chris Mansley, 127–147. Liverpool: The Bluecoat Press. Pescosolido, Bernice A., Jack K. Martin, J. Scott Long, Tait R. Medina, Jo C. Phelan, and Bruce G. Link. 2010. “A disease like any other”? A decade of change in public reactions to schizophrenia, depression, and alcohol dependence. The American Journal of Psychiatry 167 (11): 1321–1330.

254

8  ‘No ill will’: Ticcing on Moral Grounds

Porta, Mauro, Domenico Servello, Bernado Dell’Osso, Carlotta Zanaboni Dina, Alberto Bona, and Guido Carlo Alleva. 2018. Critical aspects in the legal defence of patients with Tourette’s syndrome: An Italian case series. International Journal of Law and Psychiatry 61: 1–5. Rowlands, Mark. 2011 [2006]. Body language: Representation in action. Cambridge/London: The MIT Press. Sacks, Oliver. 2012 [1995]. A surgeon’s life. In An anthropologist on Mars, ed. Oliver Sacks, 73–101. London: Picador. ———. 2015 [1985]. Witty ticcy Ray. In The man who mistook his wife for a hat, ed. Oliver Sacks, 97–107. London: Picador. Schneider, Joseph W., and Peter Conrad. 1985. Having epilepsy: The experience and control of illness. Philadelphia: Temple University Press. Schroeder, Timothy. 2005. Moral responsibility and Tourette syndrome. Philosophy and Phenomenological Research 71 (1): 106–123. Shapiro, Arthur K., et  al. 1973. Tourette’s syndrome: Summary of data on thirty-four patients. Psychosomatic Medicine 35: 419–435. Shapiro, Arthur K., Elaine S. Shapiro, J. Gerald Young, and Todd E. Feinberg. 1988 [1978]. Gilles de la Tourette syndrome. New York: Raven Press. Stenner, Max-Philipp, and Patrick Haggard. 2016. Voluntary or involuntary? A neurophysiologic approach to functional movement disorders. Handbook of Clinical Neurology 139: 121–129. Todd, Stuart, and Julia Shearn. 1997. Family dilemmas and secrets: Parents’ disclosure of information to their adult offspring with learning disabilities. Disability & Society 12 (3): 341–366. Trubody, Ben. 2014. “Ticced off”: An interpretative phenomenological analysis of the experience of Tourette’s syndrome. Existential Analysis 25 (2): 269–283. Versace, Viviana, Stefania Campostrini, Luca Sebastianelli, Mirco Soda, Leopold Saltuari, Sigrid Lun, Raffaele Nardone, and Markus Kofler. 2019. Adult-onset Gilles de la Tourette syndrome: Psychogenic or organic? The challenge of abnormal neurophysiological findings. Frontiers in Neurology 10: 461. Vial, Felipe, Sanaz Attaripour, and Mark Hallett. 2019. Differentiating tics from functional (psychogenic) movements with electrophysiological tools. Clinical Neurophysiology Practice 4: 143–147. Wilensky, Amy. 1999. Passing for normal. Tourette’s, OCD and growing up crazy. Pocket Books (Simon & Schuster). Woods, Douglas W., John Piacentini, Susanna Chang, Thilo Deckersbach, Golda Ginsburg, Alan Peterson, Lawrence D. Scahill, John T. Walkup, and Sabine Wilhelm, eds. 2008a. Managing Tourette syndrome: A behavioral intervention for children and adults. Therapist guide. New York: Oxford University Press. ———, eds. 2008b. Managing Tourette syndrome: A behavioral intervention for children and adults. Parent workbook. New York: Oxford University Press. Zahavi, Dan. 2015. On self, empathy, and shame. International Journal of Philosophical Studies 23 (5): 638–644.

Chapter 9

Conclusion: Beyond Causes and Cures

Abstract  This chapter synthesises the central themes laid out in this book, which investigates the relevance of philosophical ‘big topics’ such as time, freedom, and the self to contemporary Tourette Syndrome scholarship and care. I foreground recent calls for more research on the everyday experience of living with TS and recap how ‘the toolkit of philosophy’ – and particularly perspectives from enactivism and philosophical phenomenology  – can equip us with the tools needed to undertake this work. Brief chapter summaries serve to highlight the tacit assumptions that have defined tic disorder research and care for decades, while also asserting the place and promise of the medical humanities in furthering conversations about ‘what it feels like’ to live with Tourette’s. Keywords  Tourette Syndrome · Tics · Advocacy · Daily life · Patient perspectives · Treatment gap · Research gap · Philosophical phenomenology As I write this conclusion, a new umbrella organisation representing tic and Tourette Syndrome advocacy groups around the world has formed under the auspices of the European Federation of Neurological Associations (EFNA). Called Tics and Tourette’s Across the Globe (TTAG), this umbrella organisation seeks to “campaign for equality, participation and equal opportunities for people with tics and TS in all contexts of life” (EFNA 2020). In its envisioned bridging role between researchers, clinicians and patients, it undertook a survey of patient perspectives on research and treatment in the context of the recently updated European clinical guidelines for Tourette Syndrome and other tic disorders (Anderson 2021).The survey reflects a broader push to involve patients and the public more closely in research design and governance, and to centre clinical care around patients’ needs and perspectives (Anderson 2021, 1–2; see also Abma et al. 2015). Findings from the survey highlight the need for research to focus on practical issues arising from daily life with Tourette’s (Anderson 2021, 3): The most prominent topic on research priorities for patients with TS in Europe is ‘daily living issues’ (such as dealing with TS at home, work and school); however, this aspect receives little attention in the regular treatment of tic disorders, which mainly focuses on tic reduction. © Springer Nature Switzerland AG 2023 L. Curtis-Wendlandt, Chasing Tourette’s: Time, Freedom, and the Missing Self, Philosophy and Medicine 145, https://doi.org/10.1007/978-3-031-19104-6_9

255

256

9  Conclusion: Beyond Causes and Cures

These prominent concerns about daily life with tics and Tourette’s are the concerns of persons in their world: They pertain to the way in which people with tics and others in their environment deal with the myriad challenges brought about by a life with tic disorders and their common comorbidities. The issues at stake regard actions and interactions in everyday contexts: The socially complex, normative and narrative spaces in which symptoms are enacted and responded to. And yet, as Anderson rightly points out, issues pertaining to daily life with TS receive little attention in current clinical care – and, we might add, in contemporary scholarship. Over the last few decades, scientific research has advanced our understanding of the genetic, pathophysiological and potential immunological factors thought to underly primary tic disorders, but their aetiology remains elusive. At the same time, clinical research and care have remained largely symptom-focused and emphasise tic reduction as a desirable treatment outcome. As I have outlined in Chap. 4, this symptom focus is evident in current psychological interventions for tics, which either take a ‘bottom-up’ or ‘top-down’ approach to treatment. On the one hand, CBIT (Comprehensive Behavioural Interventions for Tics; see Woods et al. 2008), which is now regarded as a first-line treatment for tics (Pringsheim et al. 2019), relies on motor control (via urge awareness and prevention of tic tokens) as a strategy to manage symptoms and thereby increase patients’ wellbeing. I called this a ‘bottom-up’ approach because it targets specific symptoms with the aim to also benefit overall quality of life. On the other hand, acceptance-based approaches (e.g., Gev et al. 2016) teach patients to adopt a positive attitude toward unpleasant urge perceptions. I called this a ‘top-down’ approach because the general change in attitude which persists over time improves the momentary experience of specific symptoms, thereby often also reducing symptom expressions (although this is not its immediate goal). What CBIT and acceptance-­based approaches share is that they require patients to direct their conscious attention to aspects of tic symptomatology. Positive change thus relies on the development of new symptom-oriented skills – e.g., the ability to execute competing responses instead of tics (CBIT) or to change one’s affective response to urge experiences (acceptance). We noted that this conscious attending to symptoms may not only create the desired treatment outcomes (better coping, enhanced wellbeing and quality of life) but that it may also entail risks – in particular, the risk of reifying a ‘hyper-­reflective’ and overly self-conscious mode of being in the world which reduces rather than increases subjects’ perceived sense of freedom and agency. I argued that people with tic disorders are already more prone to suffering from such ‘hyper-reflexivity’ since symptoms, even outside therapeutic settings, often demand their own and others’ explicit attention and interfere with everyday activities. We thus concluded Chap. 4 by asking whether there could be other, non-symptom-centred approaches to managing tic disorders which do not require patients to consciously attend to their symptoms or to develop new symptom-related skills. Such alternative, strength-­ based strategies would aim to enhance subjects’ socially situated freedom in action, defined as the ability to act in accordance with one’s goals and values (or ‘cares and concerns’) in the world. Two strategies  – which I termed ‘narrative easing’ and

9  Conclusion: Beyond Causes and Cures

257

‘narrative integration’ – stood out as particularly promising in this regard. ‘Narrative easing’ describes the commonly observed fact that immersion in other meaningful activities temporarily reduces or even eliminates symptom expression, while ‘narrative integration’ describes the process whereby tics positively contribute to, or become part of, other meaningful activities. While individual clinicians might utilise similar strength-based approaches when working with tic disorder patients, little is known about their efficacy. No research exists on how to operationalise the therapeutic potential of these strategies or how to determine the patient groups that would stand to benefit most from them. This gap in research on factors and interventions that enhance (or reduce) perceived freedom and agency in people with tic disorders also stood out as a key finding in Chap. 5, which introduced the conceptual vocabulary required for such investigations. Drawing on discussions of the multiple aspects of ‘agency’ and ‘ownership’ in philosophical phenomenology and phenomenological psychiatry, I used examples of involuntary action and schizophrenic alienation offered in the literature to ask whether agency and ownership experiences could be altered in people with TS. I juxtaposed these considerations with the few existing experimental studies on agency and ownership in adults with Tourette’s with the aim to integrate this work into a broader phenomenological framework or psychopathology of primary tic disorders. Interestingly, we saw that people with TS may be less susceptible to illusions of embodiment  – for example, the illusion that a foreign object such as a rubber hand is their own – when compared to adults without TS. At the same time, adults with Tourette’s may be more susceptible to illusions of agency, where they believe to have caused certain action outcomes that were in fact externally enhanced. Since none of the existing experimental studies on agency and ownership in TS currently investigate first-person experiences of ticcing and everyday action in people with tic disorders, these experiences remain poorly understood. A wealth of work remains to be done, as summarised in Chap. 5’s systematic overview of potential single-and multi-concept studies (see Fig. 5.1). These could probe agency and ownership dynamics and their complex interactions in tic disorders both during symptom expression and during everyday extended actions. From a clinical perspective, better understanding patients’ agency and ownership experiences and recognizing when these are disturbed in people with tic disorders could improve patient–clinician communication and enhance opportunities for early intervention and care. From a scholarly perspective, this could help us develop and test new ways to capture experiential phenotypes in tic disorders, identify associated vulnerabilities for disease progression, secondary symptoms and comorbidities, and ultimately align treatment priorities with such insights. Beyond the question of how agency and ownership dynamics are impacted by tics, any research into anomalous experiences in TS would do well to engage with contemporary philosophical work on ‘structural invariants’ in phenomenological psychopathology. Could having a tic disorder like Tourette’s alter certain existential dimensions of experience – also referred to as ‘existentials’ in the phenomenological tradition – which relate to people’s sense of self, time, embodiment, and their relationship with the world? Fernandez calls these existentials the “basic structural features of human

258

9  Conclusion: Beyond Causes and Cures

experience and existence, which hold for all experiencing human subjects” (2019, 4). If people affected by Tourette Syndrome showed alterations in these fundamental dimensions of experience, such changes could carry explanatory power in relation to the psychiatric risks so evident in TS. Further, such phenomenological work could pose important questions back to our medical nosology, our approach to psychiatric classification, and also to the practice of philosophy itself. Returning to the discussions laid out in this book, such work should enable researchers to move beyond the philosophical straitjacket of the voluntary–involuntary divide which has fuelled the ill-fated, decades-long attempt to define ‘the’ volitional status of tics explored in Chap. 3. There, I showed how studies of volition in tics were strongly influenced by Libet’s scientific paradigm, which explores the millisecond timing of people’s reported experience of an intention to act (or rather, their reported intention to execute a certain key-press movement required in these experiments). We noted that Libet’s notion of volition as a conscious ‘veto power’ expressed through motor control resembles the view commonly held in the tic disorder literature that tic suppression is paradigmatic of free will in Tourette’s. Alternative conceptions of voluntary action which did not reduce free will to motor control failed to take hold in research on tics – e.g., views which suggest that actions are ‘free’ when they align with and enact our intentions. The millisecond timeframe of Libetian experiments is not conducive to understanding voluntary actions in this way because our intentions often span larger temporal intervals – what we called the ‘narrative timescale’ of our lives. Chapter 3 concluded by observing that the dominant influence of reductionist views of voluntary action (of which Libet is a key example) has sidelined opportunities in tic disorder scholarship to explore the full diversity of people’s experiences of their symptoms and of other everyday actions at the narrative timescale. While Chap. 5’s discussion of agency and ownership dynamics provided the vocabulary we need to investigate such experiences, Chap. 6 developed the first-ever taxonomy capable of operationalising the often-noted complexity and heterogeneity of tic disorder symptoms. This taxonomy resists a simplistic binary classification of tics as either voluntary or involuntary and instead explains their diverse clinical presentations through the lens of different ‘action types’. Central to my approach to classifying tics as action types in Chap. 6 was an enactive and affordance-based view that construes symptom behaviours as contextually situated brain–body–environment interactions. An important consequence of this view was that volition can no longer be defined as an essential and immovable feature of agents, but rather becomes a context-dependent feature of some agents in certain situations. Put differently, I argued that whether or not someone can ‘will’ to tic or not to tic may be less about their intrinsic ability and more about context and situation, which solicit and afford some but not other behaviours. The implications of this enactive affordance-based view are potentially radical for how we classify tics: It means that we can no longer make sweeping judgements about their voluntary or involuntary nature but only about possible trends in people’s context-­ specific symptom expressions. Questions emerging from these insights in Chap. 6 are relevant for future research and practice. For example, could the

9  Conclusion: Beyond Causes and Cures

259

context-­sensitivity and context-variability of someone’s tics tell us anything about the likelihood that certain treatment interventions will be successful? And could the degree to which someone’s tics vary across contexts or respond to different contexts have any predictive relevance with regard to symptom progression and comorbidity profiles? Related questions pertaining to the classification of tic disorders already took centre stage in Chap. 2 of this book, where I argued that we do not pay enough attention to the variability and impermanence of symptoms in Tourette Syndrome. While the concept of clock time (homogenous, chronological, and objectified time) is currently used to distinguish between the triad of primary tic disorders, we noted that this distinction relies heavily on the idea of a relative persistence of symptoms over time (e.g., a Tourette Syndrome diagnosis requires that both vocal and motor tics recur over a period of at least 12 months). This classificatory focus on the durative aspects of tic symptomatology in TS has entailed a relative neglect of the highly transient nature of many Tourettic tics (some of which only last for a day, a week, or the like). I argued that the common experience of spontaneously remitting individual tics in Tourette’s is not sufficiently acknowledged or understood, and that it challenges the causal-structural robustness of the tic disorder triad. At the least, switching to an impermanence perspective highlights similarities between Transient Tic Disorder and Tourette’s that would otherwise remain obscure, and it invites us to ask how the ‘remissibility’ of symptoms correlates with other clinical features (e.g. age of onset, symptom severity and complexity, comorbidity profiles, response to therapy, and symptom progression over time). We concluded Chap. 2 by noting that neither the transience nor the spontaneous remission of tics is currently captured as a notable feature in tic scales and questionnaires used to diagnose and treat TS. Similarly, research has neglected the question whether and how tic disorder symptoms impact on people’s subjective experience of time and on other structural aspects of subjective experience such as sense of self, intersubjectivity, and embodiment. In Chap. 7, I took up this question in a speculative manner by exploring how the incessant repetition and sameness of tics may alter subjects’ sense of being in time. I proposed that tics as actions could evoke a certain hyper-circularity of phenomenal experience that may have psychiatric relevance (e.g., by impacting the person’s capacity to engage in future-directed, goal-­ oriented actions). Further, Chap. 7 also returned us to the topic of clock time or objectified time introduced at the start of the book. Just as the skewed use of clock time was shown to bias the DSM’s classification of tic disorders in Chap. 2, I now showed it to be responsible for the view that tics are not actions. In particular, I argued that nonaction proponents of tics rely on a misguided understanding of the temporality of human action and perception, which separates stimuli as passive ‘priors’ from any agentic and intentional response to them. Instead of asking whether and when intentions ‘enter’ an unfolding tic sequence, we concluded that tics are intentional from the get-go and thus that the nonaction view does not hold. This affirmation – that tics are actions, not mere reflexes – finally shaped our discussion of moral responsibility in tic disorders in Chap. 8. Drawing on the enactive and affordance-based view of tics proposed in Chaps. 6 and 7, we explored the

260

9  Conclusion: Beyond Causes and Cures

role that social interactions with other people play in turning tics into ‘disordered’ behaviours in the first place. Although tics should be deemed less blameworthy than other intentional actions, I argued that our own interpretive habits often belie this intuition: We still tend to ‘misread’ tics as meaningful and socially directed actions, leading to much futile shaming and blaming of people with tics. The first step toward an ethics of moral responsibility in tic disorders should therefore be the search for an alternative, epistemically and socially just description of tics which better captures what these symptoms are ‘about’. The chapter critiqued existing brain-based explanations as not sufficient in this regard and offered an alternative description grounded in the notion of abstractly situated intentions. This allowed us to spell out two typical features of primary tics: their relative absence of reasons for acting and their attentional focus on embodied aspects of the tic action. Both features illuminate why tics should not be considered morally salient actions and why people deserve less blame for what goes wrong when they tic. Further, the notion of situated intentions also provided a new basis for distinguishing between primary and functional(ised) tics, although we flagged this distinction as a conceptual abstraction. The many insights, arguments, and questions arising from the chapters of this book highlight that doing philosophy in a biomedical research context can be both epistemically and clinically productive. By drawing on ‘the toolkit of philosophy’ – and particularly on perspectives from enactivism and philosophical phenomenology – I have revealed and challenged some of the foundational assumptions that underlie current research on tic disorders and Tourette Syndrome. This has raised questions of broad relevance for researchers and practitioners alike. Importantly, my point was not for philosophy to provide the field with new foundations, but rather “to forestall premature closure” (Fulford et al. 2013a, b, 3) on the field’s own philosophical problems. With Kendler, this book proclaims that “philosophers can be good allies and collaborators for psychiatry in the twenty-first century” (2008, 4) – and, I would add, for the biomedical sciences and the health humanities at large. If we want to tackle those “daily living issues” (Anderson 2021, 3) which most concern people with tic disorders and Tourette Syndrome and which arise from dealing with tics at home, work and school, we need to look beyond genes and brains to see the affected people in their everyday life contexts. Philosophy and the humanities more broadly have much to contribute to this person-centred perspective and can deepen our understanding of ‘what it is like’ to live with tics and TS. At this point in time, however, philosophy and the humanities have barely placed a foot on the map of TS scholarship and care. Beyond occasional references to Oliver Sack’s profound literary work on neurological disorders, a growing body of published first-person accounts of living with Tourette’s, and a handful of academic articles espousing humanities perspectives on the Syndrome (all of which were frequently quoted throughout this book), research on tic disorders has remained almost exclusively a domain of and for the biomedical sciences. It is time that we loosened this exclusionary grip of biomedicine and the life sciences on tic disorder scholarship and care, and that we welcomed other perspectives and contributions to the field. When we do so, it will matter how we construe the relationship between the

References

261

biomedical sciences and the humanities. As Kristeva et al. (2018) note, there is a ‘naïve’ or ‘romantic’ account of what the burgeoning field of the medical humanities can and should accomplish, which construes the medical humanities “as a humanistic perspective on medicine” (56). This is wrong because it suggests that biomedicine is in need of repairing, and that the medical humanities can provide it with the “wholeness” it lacks. The humanities, Kristeva and colleagues assert, are not a “critical and potentially liberating perspective that can be applied to medicine as an object in need of repairment” (56), but rather constitute a biocultural practice just like the medical sciences it may critique. At their best, the medical humanities should be seen as a “cross-disciplinary and cross-cultural space for a bidirectional critical interrogation of both biomedicine (simplistic reductions of life to biology) and the humanities (simplistic reductions of suffering and health injustice to cultural relativism)” (56). It is only when we adopt such a bidirectional critical perspective that we can break with the ‘culture–nature dichotomy’ which has wrongly pigeonholed both fields of inquiry. As the Lancet Commission on Culture and Health from 2014 noted, the distinction between the objectivity of science and the subjectivity of culture is “itself a social fact” (Napier et al. 2014, 1607). Taking these insights seriously means acknowledging that the humanities – and among them philosophy – can provide more than just a critical commentary on the foundations of contemporary scientific work on tic disorders and TS. Philosophy, as a biocultural practice with cultural, symbolic, and linguistic attachments, can also be materially productive and – for better or worse – create bodies and physical conditions with direct medical implications. With Kristeva et al. (2018, 57), we can hope that philosophy will use its “creative and healing agency” as an instrument not only of care but of cure as well. It is in this spirit that I wrote Chasing Tourette’s, and that I hope future philosophical work on tic disorders will stand to benefit the everyday lives of people who are affected by tics and Tourette Syndrome.

References Abma, Tineke A., Carina A.C.M.  Pittens, Merel Visse, Janneke E.  Elberse, and Jacqueline E.W. Broerse. 2015. Patient involvement in research programming and implementation. Health Expectations 18 (6): 2449–2464. https://doi.org/10.1111/hex.12213. Anderson, Seonaid Morag, on behalf of Tics and Tourette Around the Globe (TTAG) representing Tic and Tourette Syndrome (TS) patient associations around the world. 2021, August 9. European clinical guidelines for Tourette Syndrome and other tic disorders: patients’ perspectives on research and treatment. European Child & Adolescent Psychiatry. https://doi. org/10.1007/s00787-­021-­01854-­y. European Federation of Neurological Associations (EFNA). 2020. Tics and Tourettes Across the Globe (TTAG). https://www.efna.net/members/ttag/ Fernandez, Anthony Vincent. 2019. Clarifying a dimensional approach to phenomenological psychopathology. Philosophy, Psychiatry & Psychology 26 (1): 81–85. Fulford, K.W.M., Martin Davies, Richard G.T. Gipps, George Graham, John Z. Sadler, Giovanni Stanghellini, and Tim Thornton. 2013a. The next hundred years: Watching our Ps and Qs.

262

9  Conclusion: Beyond Causes and Cures

In The Oxford handbook of philosophy and psychiatry, ed. K.W.M. Fulford, Martin Davies, Richard G.T. Gipps, George Graham, John Z. Sadler, Giovanni Stanghellini, and Tim Thornton, 1–11. Oxford: Oxford University Press. ———, eds. 2013b. The Oxford handbook of philosophy and psychiatry. Oxford: Oxford University Press. Gev, Ella, Tammy Pilowsky-Peleg, Sylvana Fennig, Noa Benaroya-Milshtein, Douglas W. Woods, John Piacentini, Alan Apter, and Tammar Steinberg. 2016. Acceptance of premonitory urges and tics. Journal of Obsessive-Compulsive and Related Disorders 10: 78–83. Kendler, Kenneth S. 2008. Introduction. Why does psychiatry need philosophy? In Philosophical issues in psychiatry: Explanation, phenomenology, and nosology, ed. Kenneth S. Kendler and Josef Parnas, 1–16. Baltimore: JHU Press. Kristeva, Julia, Marie Rose Moro, John Ødemark, and Eivind Engebretsen. 2018. Cultural crossings of care: An appeal to the medical humanities. Medical Humanities 44 (1): 55–58. Napier, A.  David, Clyde Ancarno, Beverley Butler, Joseph Calabrese, Angel Chater, Helen Chatterjee, François Guesnet, et  al. 2014. The lancet commissions: Culture and health. The Lancet 384 (9954): 1607–1639. https://doi.org/10.1016/S0140-­6736(14)61603-­2. Pringsheim, Tamara, Michael S.  Okun, Kirsten Müller-Vahl, Davide Martino, Josef Jankovic, Andrea E. Cavanna, Douglas W. Woods, Michael Robinson, Elizabeth Jarvie, Veit Roessner, Maryam Oskoui, Yolanda Holler-Managan, and John Piacentini. 2019. Practice guideline recommendations summary: Treatment of tics in people with Tourette syndrome and chronic tic disorders. Neurology 92 (19): 896–906. Woods, Douglas W., John Piacentini, Susanna Chang, Thilo Deckersbach, Golda Ginsburg, Alan Peterson, Lawrence D.  Scahill, John T.  Walkup, and Sabine Wilhelm, eds. 2008. Managing Tourette syndrome: A behavioral intervention for children and adults. Therapist guide. New York, NY: Oxford University Press.