Kevin Sutton wrote:

>I recently read a portion of a recent Gould bio written by a friend of
>his who was a psychologist.  He allowed for the possibility that Gould
>had a rare form of Autism, one that caused his idiosyncracies, but did
>not disable him in other ways It would be interesting to hear another
>professional opinion on the subject.

Since this line of thought seems to persist with respect to the discussion
on Glen Gould tics, and other involuntary movement disorders I thought I
would throw in my five cents worth.  Although I am not (yet) a full time
neurology trainee, as an Internal Medicine Trainee at the hospital with the
largest tertiary neurological referral centre for movement disorders in the
whole of Australia I have a strong interest in this field and thought I
would try to contribute some medical discussion to this area.  I will soon
be working again in this department, and will be keen to ask Professor
Morris (et al), perhaps the leading expert in movement disorders in the
country what his opinion on this matter might be.  Can people PLEASE send
me more detailed clinical data about his background?

Georges Gilles de la Tourette published "La Maladies des Tics Convulsif,"
the first paper on behavioural and emotional aspects of Tourette syndrome
in 1899.  I must personally admit to approaching the subject with
scepticism when it comes to trying to pin a definitive neuropsychiatric
movement disorder onto Glen Glould.  Everyone has tics, or mannerisms.  As
usual some suffer more than others, and there will of course be your usual
subtle gradient from normal to pathological - just like that between
eccentricity and madness.  Tourrette's syndrome is usually far more
pervasive and debilitating than the isolated simple tic of vocalisation
during a particular activity such as during piano playing.  In Tourette's
syndrome (TS) there are multiple complex tics which in 5-40% of cases
involves coprophilia: the involuntary utterances of obscene words, often
emitted in a loud, abrupt fashion and which are often quite embarrassing.
I do not hear any such thing on my recording of Gould's Goldberg
Variations.

The following is the Tourette's Syndrome Classification Study Group
criterion for its diagnosis:

Definite TS

1.  Both multiple motor and one or more phonic tics at some time but not
necessarily concurrently

2.  The tic occurs many times during the day, nearly every day, or
intermittently throughout more than a year.

3.  The anatomic location, number, frequency, type, complexity or severity
of tics changes over time

4.  Onset before 40 years of age

5.  Tics cannot be explained by other medical condition

6.  Motor and/phonic tics must be witnessed by an expert or recorded (by
video/tape)

Probable TS

Type 1 Meets all above criteria except 3 and/or 4

Type 2 Meets all criteria except 1.  Includes either single motor tics with
phonic tics or multiple motor with possible phonic tic(s).

I must admit I lack reliable accounts of details of the case but from what
I am aware of Gould does not really fit this criterion that well at least
for definite TS.  Just about anyone meets the criterion for type 2 probable
TS.

The disorder is also inherited and I am not aware that there is a family
history in Gould's case.  Also in TS tics tend to be abrupt rather than
more complex and structured like the vocalisations ubiquitous in Gould's
recordings.  Jankovic (a leading US authority on movement disorders)
mentions that in TS tics often tend to be inappropriately intense and
timed, whereas Gould's are predictable and constant.  Jankovic also mention
that elements of TS are present in all of us.  Some studies have noted that
TS sufferers tend to believe that their tics are voluntary whereas benign
tics are more likely to be reported as being involuntary - as by Gould.
It also tends to improve significantly with age.

Those who have read up on TS will note that other behaviours such as being
antisocial, having poor self-esteem, depression, anxiety, low frustration
tolerance and impulsivity are also characteristic.  However in frank TS
this manifests as outburst of violence, swearing, or even inappropriate
self-exposure.  The proper psychiatric use of the word 'antisocial' does
not denote just a tendency to be reclusive.

I believe the higher form of autism being referred to here may well be
Asperger's syndrome.  This is clearly way off as patients with this
condition have inappropriate content of speech, and inappropriate gestures.
It is much more profoundly socially disabling.

So in conclusion:

   'TS is a complex neuropsychiatric disorder characterized by
   disinhibition and dysregulation of motor, cognitive, affective, and
   behavioural functions.  Although multiple motor and vocal tics are
   the key diagnostic phenomena, hyperactivity, impulsivity, inattention,
   obsessive compulsive, and emotional symptoms are common in many
   patients.  ' (Coffey and Park, Neurologic Clinics of North America,
   Vol 15, Nr 2, May 1997).

I do not believe a definitive diagnosis can be made in Glen Gould, although
keeping in mind the fact that all of us have features of Tourette's
syndrome, I am open to the fact that a case could be made to the contrary.
I conclude for now that Gould was more of an eccentric individual with some
an odd tic.

Keep in mind that I will be asking for a really expert second opinion so
please watch this space, and as I say please send me more background
information.

Satoshi Akima MBChB, FRACP Trainee
Sydney, Australia
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