When talking about neurological disorders of excess, Oliver Sacks discusses a clinical case of Ray.
Ray has Tourette syndrome, a disorder of the central nervous system associated with an excess of nervous energy, which manifests itself in the form of ticks, grimaces and involuntary movements. The syndrome is named after Gilles de la Tourette, who in 1885 outlined the diagnostic picture of the syndrome.
In the religious perspective, those with Tourette’s fit best into the category of the devil-possessed ones. Gilles de la Tourette himself considered the syndrome possession by primitive impulses.
Tourette syndrome can affect all levels of the mind’s life — thinking, emotions, imagining, but in its common form it is reduced to the abnormal movements and impulsivity. There are quite a lot of Touretters, it is easy to encounter them on the street, a person previously unknown to you who publicly informed you that your mother sucks dicks — probably has Tourette’s.
From the age of four, Ray’s life was accompanied by multiple tics of extreme violence, he was always the object of merciless attention of others, though his high intelligence and his strength of character enabled him to pass successfully through college and to get married.
Because of his ticks Ray had difficulty finding a job, he was fired many times.
Despite the relative social success and clownish image of a cheerful person, Ray was at odds with himself, particularly poorly getting along with “his impatience, his pugnacity, and his coarse, brilliant ‘chutzpah’.” Sacks also points out that Ray’s marriage was “threatened by involuntary cries of ‘Fuck!’ ‘Shit!’, and so on, which would burst from him at times of sexual excitement.”
Having outlined Ray’s life in general, Sacks then only briefly explains the role of music in his life:
“He was (like many Touretters) remarkably musical, and could scarcely have survived — emotionally or economically — had he not been a weekend jazz drummer of real virtuosity, famous for his sudden and wild extemporizations, 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.”
Sacks advised Ray to take haloperidol (Haldol), an antipsychotic that temporarily eliminate ticks. Ray was inspired at first, but the decision on whether or not to get rid of his tics was not an easy one. His whole life was accompanied by tics, he learned to exploit his condition in a various ways. He had little sense of his identity except as a ticqueur, he spoke of himself in a third person as ‘witty ticcy Ray’. He could not imagine life without Tourette’s, “Suppose you could take away the tics, what would be left? I consist of tics — there is nothing else. ”
Ray was in despair, he scarcely understand whether his syndrome was a gift or a curse. It took three months of weekly conversations for Sacks to convince Ray to try living without ticks. According to Sacks, communication with Ray “in which (often against much resistance and spite and lack of faith in self and life) all sorts of healthy and human potentials came to light: potentials which had somehow survived twenty years of severe Tourette’s and ‘Touretty’ life, hidden in the deepest and strongest core of the personality.”
Sacks seemed to himself a benefactor, offering Ray to restore “the ‘existential’ balance,” which replaced “a severe physiological imbalance”.
Ray began to take haloperidol, got rid of ticks and remained free from them for the next nine years. Sacks was proud of himself and considered the outcome of their conversations and Ray’s new life a miraculous therapeutic success:
“The past nine years, on the whole, have been happy ones for Ray — a liberation beyond any possible expectation. After twenty years of being confined by Tourette’s, and compelled to this and that by its crude physiology, he enjoys a spaciousness and freedom he would never have thought possible […]. His marriage is tender and stable — and he is now a father as well […] He plays an important part in his local community; and he holds a responsible position at work.”
Nevertheless, Ray himself didn’t come to terms with the fact that he had exchanged his old life for the life of the sober citizen. Together with ticks, obscenities, impatience, bold impertinence and hot temper, Ray has lost spontaneity, impulse, playfulness, and his ability to improvise.
Most importantly, Ray changed as a musician:
“Most […] disabling, because this was vital for him — as a means of both support and self-expression — he found that on Haldol he was musically ‘dull’, average, competent, but lacking energy, enthusiasm, extravagance and joy. He no longer had tics or compulsive hitting of the drums — but he no longer had wild and creative surges.”
In search of a compromise, Ray decided to take Haldol only throughout the working week. After this decision, there appeared “two Rays — on and off Haldol.” Nonetheless, Ray’s life has not become an ideal one, he does not feel balance and freedom: during the working week he feels the unfreedom of soberness, and without haloperidol there is unfreedom of wildness. The life of each Ray is unbalanced in its own way.
Disorders of Excess
Sacks criticizes classical neurology for a static approach that cannot grasp the life of the mind — a fundamentally dynamic process. From the point of view of mechanistic neurology, “Either the function (like a capacitor or fuse) is normal — or it is defective or faulty: what other possibility is there for a mechanistic neurology which is essentially a system of capacities and connections?”
In search of the other possibility, Sacks reproaches neurology for focusing on disorders of deficit and being oblivious to the disorders of excess (such as Tourette syndrome).
Deficit is a favorite word for neurology to describe abnormalities. It does not capture the possibility of the opposite — an excess and superabundance of function. It does not recognize the productive and the forming power of the disorders, being only capable of perceiving them as phenomena opposite to formative.
The formative power of deviations, which does not fit into the conceptual framework of classical neurology, corresponds to what is in anatomy and pathology called hypertrophies — excessive morbid formations, teratomas (from Greek, τέρας — monster, deformity). Classical neurology is not capable of conceptualizing a monstrous growth of cerebral functions: thinking, memory, imagination, perception — “a sort of teratoma of the mind.”
Sacks considers it necessary to supplement limited neurological concepts by “concepts more dynamic, more alive”, capable of capturing the formative power of the disorders of excess. According to him, in addition to any purely therapeutic or medical approach, there must also be an ‘existential’ approach, which Sacks understands as a more sensitive understanding of the antagonism between healthy and pathological processes.
A more sensitive understanding of the mind, introduced by Sacks, captures that the danger of deviation is rooted in a normal healthy process, and is not opposite to it. Disorders of excess , “a sort of animation gone extravagant, monstrous, or mad — not merely an excess, but an organic proliferation, a generation; not just an imbalance, a disorder of function, but a disorder of generation”. The normal vital activity is fraught with the threat of excess. There is always the danger that growth will become excessive — “growth can become over-growth, life ‘hyper-life’ ”, “monstrous, perverse aberration” of normality.
In the ‘alive’ model, in addition to the term ‘deficit’, a new term should be introduced that would grasp the monstrosity of the dynamism, convey the threatening character of the excess of life.
Sacks speaks of the paradoxical, ironic and cruel nature of the danger of excess inherent to normality. At the subjective level, this paradox is felt by patients as a deceptive euphoria, dangerous wellness — simultaneously an alluring state, but also unhealthy, “the simultaneous gift and affliction, the delight, the anguish, conferred by excess”.
Patients with Tourette syndrome feel this irony especially acutely. “I have too much energy. Everything is too bright, too powerful, too much. It is a feverish energy, a morbid brilliance”. According to Sacks, the main danger of such irony is a very real risk of becoming fully possessed by the disease:
“In disorders of excess there may be a sort of collusion, in which the self is more and more aligned and identified with its sickness, so that finally it seems to lose all independent existence, and be nothing but a product of sickness.”
It was this risk of becoming fully possessed by the disease that Sacks tried to eliminate in his treatment of Ray, who claimed that he consists of tics. Fortunately for Sacks, healthy potential at the core of Ray’s personality was strong enough to prevent him from fully becoming possessed by the monster of disease.
While justly criticizing classical neurology for its inability to recognize the other possibility (in addition to the normal work of the function and its breakdown), Sacks nonetheless remains within a limited perspective. He introduces the concept of excess in order to conceptualize it as a deviation and to oppose it to the norm. Sacks perspective still suggests a binary division into norm and pathology, although he classifies pathology into two types: the system is either damaged with a minus value (deficit) or damaged with a plus value (hyperactivity). The other possibility is still missing.
Sacks devoted himself to reconfiguring the border that separates health from pathology — the crudeness of unhealthy processes from the freedom of healthy ones. He draws this border between deficiency and excess — somewhere here one finds a healthy balance, the opposite of deviation. Moreover, Sacks considers a healthy state or its potential to be predetermined and lying at the core of a personality, while understanding pathologies (both of excess or deficiency) as secondary states that come to replace the original state of health.
Many times Sacks’ thinking points towards the direction of concluding that disease and pathology are not opposites, but he never goes further to fully recognize the relativity of the dividing line between them. The main problem is that Sacks, being a medical doctor and clinician, reflects within a medical discourse, the purpose of which is by definition to cure, that is to bring to a certain normality. Such discourse is not a suitable place for the relativization of the norm, since it is based on the concept of the norm and is essentially aimed at normalization.
The truly existentially sensitive approach that would capture the dynamism of life cannot be merely an addition to the therapeutic approach — the former debunks the essence of the latter, undermining the concept of norm. Besides, the concept of normality presupposes statics as its actualizing principle and cancels dynamism. A norm is an established static and constant parameters or, at best, their spectrum — everything dynamic goes beyond its scope.
Sacks is not mistaken in reasoning about the formative power of certain types of deviations, his mistake is that he does not realize to what extent he is right, that is, the universality of the principle he indicated. The existential approach (if not reduced to the addition of therapeutic function) captures the underlying constitutive role of deviation. According to Sacks, only some deviations are formative, however, from an existential point of view, the formation as such is, in fact, a monstrous aberration. Monstrosity is the substance of any formative power, not the formation in which something went wrong.
Evolution, understood as the process of coming-into-being of life, one of the products of which is a human mind, is alien to the normality, it does not involve any static ‘healthy’ state of balance and harmony. Existing teleological prejudice imputes nature, including human nature, with a kind of original state of pristine natural harmony, a deviation from which is considered a disease or pathology. But there is no such initial state, it never existed in the past and will never exist in the future.
According to Foucault, medical discourse has come to replace the religious one, it still retains in its foundation the dream of a paradise, a state of primordial harmony, to which human beings must be brought back by clearing/healing them from deviations. The idea of primordial sinlessness coincides here with the concept of health.
Thinking in terms of evolution abolishes teleology. Evolutionary metamorphoses of species (mutations and variations) are deviations in relation to the previous states, which in their turn are also deviations in relation to the previous ones and so on to infinity without ever getting to the ‘healthy’ core. To be even more sensitive to the dynamics of life, is not underlied by a harmonious equilibrium or natural balance, but an imbalance, disorder, pulsation of monstrous diversity — infinite deviation. Life at its core is a monstrous deviation, a perversion of itself. Evolutionary thinking invalidates teleological prejudice about primordial aberration and degradation into a monster that requires correction. The monstrosity is ubiquitous and indestructible. The concept of pathology is existentially applicable only if one considers life itself in all its manifestations to be a mosaic of pathological deviations.
From such a perspective, what is assigned as the norm by the therapeutic discourse is a certain range of deviations not the opposite of deviations. If normality really existed in evolution, it would cancel its dynamics. Any static, normal, healthy state is conditional, assigned to the evolutionary process or its fragment by human perception.
In the framework of the existential-evolutionary approach, the formative dynamics should rather be conceptualized as a deviation from the norm which does not exist. The phenomenon of deviation from a non-existing norm is paradoxical, but it is in the form of a constitutive paradox that the dynamics of life is comprehended most distinctly. The ironic paradox of the formative diseases of excess, indicated by Sacks, coincides with the very irony of life.
Sacks never goes further in his thinking to fully recognize there is no objective boundary between the abundance of health and monstrous, perverse aberration. He comes close to this thought when he compares formative abundance with the nature gone wild, that is, with its primitive state. But even this formulation suggests that normalization comes to replace a primitive state — the process which cancels the initial aberration. But this never happens, pathology itself is constitutive, while normality is conditional, it never neither replaces, nor precludes monstrosity. If life is healed from pathology, it itself disappears.
If we don’t mind to linger a little in religious discourse, a comparison of Tourette’s syndrome with the devil’s obsession and the brute forces of nature works well to illustrate the formative dynamics of life. Demonic possession, that is, the state of deviation from the primordial harmony, is what constitutes not only the pathological personality (for instance, tourettic personality), but any personality. And yet the state of divine harmony at the core of the one possessed by the devil — doesn’t exist. The devil is real, god is an illusion.
In the case of Ray, Sacks put into practice his binary vision of the norm and pathology: Sacks released him from the devil , that is, performed an operation of bringing Ray back to norm, relying on the believe that a healthy core was preserved in his personality. As a result of this operation, the ‘pathological’ aspects of personality were supposed to disappear, but in reality Ray himself disappeared along with them. There appeared a sober citizen and a diligent family man — a faceless pattern of normality (more precisely, a specific pathological pattern that is not harmful to the eyes since it is considered the norm in our society).
Features of Ray’s personality, which distinguished him from the conditionally normal others, have disappeared, he indeed was entirely constituted of ticks. Ray was gone because he didn’t exist anywhere outside the devil operating on him.
Sacks took a convenient position by arbitrarily assigning a secondary role to music in Ray’s life, while assigning the first place to his family life and career. Convenient because it was music that the cured Ray has lost. If Sacks presented Ray as a genius musician, he would then have to blame himself for for the murder attempt.
While presenting current understanding of cultural evolution (as driven by meaningless deviations), Dennett suggests a hypothesis for the emergence of music. He never doubts that music is the highest manifestations of culture, which doesn’t prevent him from discussing music as a meaningless contagious deviation:
“One day one of our distant hominid ancestors sitting on a fallen log happened to start banging on with a stick — boom boom boom. For no good reason at all. This was just idle diddling, a byproduct, perhaps, of a slightly out-of-balance endocrine system. […] We would say that he had simply developed a habit, possibly therapeutic in that it “relieved anxiety,” but just as possibly a bad habit — a habit that did him and his genes no good at all […] Now introduce some other ancestors who happen to see and hear this drummer. They might pay no attention, or be irritated enough to make him stop or drive him away, or they might, again for no reason […] feel an urge to drum along with musical Adam.”
Modern humans appeared with the emergence of music — humans the way we know them in the present, but not in the future. In the future, those will be a new kind of monsters with a different set of equally meaningless deviations and, hopefully, without a stigmatizing norm.
Sacks’ remark about Ray’s pathological sexuality is revealing (“[Ray] found his marriage threatened by involuntary cries of “Fuck!” “Shit!”, and so on, which would burst from him at times of sexual excitement.”)
Sacks naively takes such behaviour as being an exception to patterns of sexuality (or the author of this essay naively doesn’t). Elaborating on Freud, Lacanian psychoanalysis considers sexuality as constituted by perversions. According to Zupančič, “sexuality is a paradox-ridden deviation from a norm that does not exist.” Freud naively reduced the principle of constitutive deviation to the sphere of sexuality, although, at the same time, he, perhaps even more naively, considered sexuality constitutive for humans as a species. Not only human sexuality, not only humans as a species, but also life in any of its manifestations is a perversion of itself, which does not imply any norm.
Not only Ray, but every person is a product of deviations from a nonexistent norm. We consist of ‘tics’ — there is nothing else. This does not mean that medicine and therapy should be abolished. Human evolution has been long entangled with technology and medicine — monsters have become cyborgs on drugs. Since there is no such thing as a natural, healthy state of being human and there is no norm to which we must existentially comply, we are free to experiment with ourselves and deviate who we are. Sacks is right in his own way, the a-sober-citizen pathology is more compatible with life in our society, but at the same time it is not a metaphysical imperative.
Our choice is limited to a set of pathologies, and is not a choice between health and illness. There is no holiness, norm or health in us: there are only perverted fantasies of the devil, some of whom think too much of themselves and raise themselves to the rank of saints.