Oral Quals & Severe Tics - How to Prepare?

[smallcleanrat]

I am a graduate student in the sciences preparing for my oral qualifying exam (which is in a few weeks). I have had tics since childhood, but for the past few years they have been quite mild and unobtrusive. However, in recent months the tics have greatly intensified in severity, variety, and frequency; probably the worst I've had in my entire life. I have had some medication adjustments and I know there are some cognitive/behavioral techniques to reduce tics, but I am not confident I will have the issue under control by the time of my exam.  I am wondering if and how I ought to warn my committee members that I may be exhibiting some odd behaviors during my talk.

I have had extensive interactions with these professors earlier in the program (taking their courses, serving as a TA, etc...) when my tics were still mild and possibly unnoticed, so part of me is worried that if I try a preemptive warning (like an email) it will come across as overly dramatic or they will think I am playing it up.

Categorizing my tics from least to most obtrusive (and uncomfortable for an observer to witness):

Level 1 (mild; probably require no explanation): rapid or forceful blinking; throat clearing; sniffing; sharp exhalation; eye twitching; repeated swallowing

Level 2 (mild, but odd; might require explanation so as not to be misinterpreted): eye rolling (sometimes eyes will stay rolled back for several seconds at a time), vocalizing (can sometimes sound like moans of pain or whimpers), head shaking (like when an animal wants to get a fly off their ear), teeth chattering, repetitive arm or leg jerks

Level 3 (disruptive and possibly disturbing for observer; probably requires explanation): banging my hands/forearms against my torso, leg, or nearest hard surface (hard enough to bruise); biting or scraping my teeth across my hands or forearms (does not usually break skin, but can still unsettle an observer)

Level 4 (highly disruptive and possibly alarming for observer): full body tics that can come in 'fits' lasting anywhere from a few minutes to a few hours (these have been mistaken for seizures, and it can be very difficult to maintain enough control of my body to speak an explanation or even to breathe properly; my PI has witnessed these and knows what they are, so it's possible he could provide an explanation to the committee while this is going on); my body goes rigid and trembles while my abdominal muscles repeatedly contract, whipping my head and torso forward and my knees up towards my chest (if I am sitting; if I am standing I likely won't be able to do so for long); often accompanied by repeated grunting as the contractions force air out of my lungs

I'm not sure how best to handle this. I don't tic 24/7 and the milder tics are more frequent than the more severe ones, so there is a decent chance that I can get through the two hours without any major issues. If I give forewarning and it turns out not to have been necessary it will be very embarrassing. However, if I give no warning and some of the more severe or bizarre tics occur I think my professors would be more uncomfortable than they would be if they knew in advance that I tic. Level 4 tics worry me the most. Sometimes I can work through them, but usually the full body tic fits are show stoppers; my worst one so far lasted nearly four hours. I would be mortified if I had to reschedule my exam because of this.

What is the best way to communicate with my committee about this issue? If I should send an explanatory email before the exam, how should I word it so as to prepare them without getting into TMI territory?

[Parasaurolophus]

I think that what you say in your very first paragraph is probably enough information. And I think you could tell them either via email, in-person, or at the start of proceedings, depending on what you're most comfortable with. I do think it's in your interests to tell them, though.

It's good that your advisor knows. That puts someone in your corner in case someone needs reminding not to read into your tics, and to halt proceedings on your behalf if necessary.

I hope it goes well though!

[Hegemony]

I would just say it calmly in the first few minutes of your exam, or just before, after people have gotten settled.  If you put it in an email, unfortunately they may not actually read it immediately, this being a rather frantic time of year.

[Caracal]

While the manifestations vary by person, really stressful events like qualifying exams exacerbate existing health problems, both mental and physical for a lot of people. My anxiety really spiked in the lead up to my exams and I was not doing great for a period of time. If your advisors are reasonable, kind people, this isn't something that should seem all that strange for them. Maybe they haven't seen your particular symptoms, but I'm sure most of them have seen people having various reactions to the stress of exams and this shouldn't be a big deal, especially if you give the sort of matter of fact explanation that you did here. I know from dealing with undergrads who had similar issues, that it really helps when you can put these sorts of behaviors in context. It is far more alarming for an observer when they have to try to figure out for themselves what is happening, or what unusual behaviors mean.

The only thing that gave me pause here was your description of the level 4 tics. I don't in any way mean to imply that such things are disqualifying or shameful, but given that this is an extreme flare up, it might be worth at least considering the idea of postponing the exams while you figure out how to get things stabilized. The problem, obviously, is that you will probably have an easier time with everything once the exams are in your rear view mirror and I'm sure you don't want to draw the whole thing out. On the other hand, exams are stressful enough without having to worry about a medical condition making it impossible for you to continue in the middle of them. If stress is a factor in the condition in the first place, then there's a feedback loop here.

It might help your decision making if you can imagine that this is some different sort of medical problem you were having. It can be really hard not to bring feelings of shame into anything that touches on mental health, but basically the question is whether now is a good time to push through and get this over with, even though things are far from ideal, or whether the temporary flare up of a medical problem might make it hard right now to perform at the level you are capable of.

[Puget]

A tic disorder is a neurological condition -- it is truly nothing to be ashamed of and should be accommodated like any other disability. I hope you can feel comfortable explaining it to your committee without apology and asking for whatever accommodations might be necessary to help you manage it during your exam.

[Aster]

What Para said. Tell your committee members ahead of time. Especially your committee chair. If people already know, but your symptoms have appreciably changed, it is good to communicate those updates.

Your committee is made up of people who are invested into your academic success. For your prelims, they will be focusing strictly on your academic competencies, not your public speaking skills. Their objective is to ensure that you "know enough" for them to endorse you into Candidate status.

Who knows, maybe knowing that your committee knows about your challenges might reduce some anxiety and maybe tamp down some of the symptoms.

Anything that can bring down your stress and anxiety levels is a good thing.

[Kron3007]

As an examiner, I would definitely appreciate knowing this ahead of time and would have no problem working around it so you should definitely let them know one way or another. 

Personally, I would send an e-mail to the committee as you can take your time to craft the message well rather than telling them verbally on the spot.  The day of the exam, you can always make sure they received the e-mail.

If you are not comfortable with this, you could also get your advisor to bring it to their attention on your behalf.  Where I am, we meet privately before the exam to discuss the student and the process, and this type of thing would be appropriate for the advisor to mention during this time.

Good luck!   

[AJ_Katz]

I also have a stage-induced reaction -- turning red in the face and with bright blotches on my neck.  Some people have thought I am having an allergic reaction before, so I know this can be distracting for the audience.  Unfortunately, it's also one of those things that if I mention it to someone in conversation, I immediately turn red in the face.  So, I am not be a fan of the strategy to mention the tics just before starting the exam.   

If I were in this situation, I would send an email to the committee beforehand.  My email might be something like:

Dear Committee Members,

I am looking forward to my upcoming qualifying exam.  Before the exam, I wanted to let you know that I occasionally experience tics, which are involuntary muscle contractions.  I am working with my physician to manage this, but stress and stressful situations can cause more tics to occur.  Since I anticipate more tics during the upcoming exam, I just wanted to let you know in advance that this would be a normal reaction for me.  Although potentially distracting, these are nothing to be worried about.  If you have any questions or concerns, please let me know.

Thanks,
AJ_Katz

[AJ_Katz]

And since your advisor has seen Level 4, it shouldn't be a big deal if that happens during the exam. 

Overall, I would advise you not to worry about this.  Even if you have to reschedule the exam, that shouldn't be a big deal either. These types of reactions are really not under your control, so there's not much you'd be able to do about it if it did happen.

[Caracal]

And since your advisor has seen Level 4, it shouldn't be a big deal if that happens during the exam. 

Overall, I would advise you not to worry about this.  Even if you have to reschedule the exam, that shouldn't be a big deal either. These types of reactions are really not under your control, so there's not much you'd be able to do about it if it did happen.

Yes, I think that's right. Perhaps along with the email to everyone you might also talk to your advisor and work out a contingency plan with him about how you might handle it. If you have a plan, you can have a lot less anxiety around the whole thing.

[smallcleanrat]

Hello, everybody.

Thanks so much for your responses. I really appreciate the advice and encouragement!

So the consensus is that I should definitely inform my committee in some way. Caracal and AJ_Katz, I agree that situation and anxiety can have a significant affect; exam nerves are definitely going to make tics more likely. I think I would email beforehand and then, at the start of the exam, quickly verify everyone got the message (as Kron3007 suggests).

I am not keen to attempt to reschedule the exam in advance; I think I really would feel a lot better to have it over and done with. With the medication adjustments, level 4 tic fits have gradually been reduced from multiple attacks per day to once per day to several times per week. I have also noted that they are at their worst in the evening through the early morning. As my exam is in the late morning, I have hope I won't have to deal with level 4 fits at all. Generally, in the daytime, the worst that happens with level 4 is that my body is only locked up for 3-5 contractions and then there will be at least 5-10 minutes before another set. This should still allow me to continue to function with only brief pauses. But with the added variable of exam nerves, I can't perfectly predict what will happen.

My lingering worries:

1) When some people think of tics, they think of twitches or vocalizations but are not aware that some tics can look like voluntary behavior (e.g. level 3 tics). However, since none of the fora members responding to this thread have indicated that the level 3 tics would be an issue for them so long as there is an explanation, maybe I'm fretting for nothing. It's just hard not to worry you are putting people off when you start literally beating yourself up.

2) In the past, I have had instructors tell me that they felt they had to refrain from asking tough questions during my oral presentations because they were worried about 'setting me off'. A few went so far as to suggest that, because of this, a rigorous academic environment was not the right place for me. Hopefully, if i structure my message similar to AJ_Katz's suggestion (emphasizing that the tics are nothing to be concerned about and that the exam should proceed as normally as possible) it might head off any assumptions that they have to treat me with kid gloves.

Caracal, contingency planning with my PI sounds like a good idea. He has been really great with taking all this in stride and not treating me any differently.

[AJ_Katz]

In the past, I have had instructors tell me that they felt they had to refrain from asking tough questions during my oral presentations because they were worried about 'setting me off'. A few went so far as to suggest that, because of this, a rigorous academic environment was not the right place for me.

--- rant warning ---

That is complete B.S.  ...  they're just uncomfortable with it so, rather than getting over it, are recommending that you leave the academic environment.  It's academia, people, not the stock market floor or the emergency room.  Sheesh!

--- end rant ---

In response to the rest of your message, I think you're overly worried about your committee members' reactions.  They should be supportive of you and understand that the stress can trigger these reactions, and it shouldn't be a reason for them to hold back on hard questions.  Granted, I am assuming you have a supportive committee and I know that not everyone has that.

If it was me on the committee, I would easily be able to recognize that the level 3 reactions you described are involuntary.  Since your advisor has seen level 4, does that mean he has also seen level 3 and knows those are involuntary?  If so, then your advisor should know what your pattern of involuntary reactions are and speak up if any of the committee members seem uncomfortable.  Even if he hasn't seen that, if you've sent an email to the committee members beforehand about this, it would make is so that when you do have an odd looking tic that you can point it out to the committee members "Oh hey, one of my tics! please just ignore that, it's normal." 

Do you have any deep breathing techniques or other ways to help calm down?  It seems like your level of worry about this larger than it needs to be.  You just don't want this stress to interfere with your studying or preparation for the exam.  Maybe you could do a practice exam with some of the other graduate students in your department who have already gone through the exam, and make sure to pick out people who could also give you feedback about your tics (but only pick supportive people!).

At the end of the day, if a student demonstrates adequate knowledge in their subject area to justify passing the exam, there's no way I'd let something like tics prevent me from passing the student.

 

[Puget]

In the past, I have had instructors tell me that they felt they had to refrain from asking tough questions during my oral presentations because they were worried about 'setting me off'. A few went so far as to suggest that, because of this, a rigorous academic environment was not the right place for me.

This is discrimination on the basis of a disability plain and simple-- in the US (and I'm guessing also Canada and EU) this is illegal.

Smallcleanrat, it might be empowering for you to educate yourself a bit about law and university policy regarding this so you can feel confident in advocating for yourself and speaking up forcefully if this happens again, or asking your PI to do so on your behalf. Your tics have no bearing on your abilities as a scientist, and it's not your job to make other people comfortable.

As a psychologist/neuroscientist (and frankly as a human) this kind of thing makes me so angry-- surely these people would not have suggested such a thing to someone with what they perceived as a physical disability (unless they are truly clueless), but because they perceived your tics as a "mental" problem they felt free to, never mind that tics are a neurological problem, and never mind that there is no dichotomy between "neurological" and "mental" since the brain is running the show whatever we call it. It's not OK and it perpetuates stigma and discrimination.

[mamselle]

I just wanted to say that

A. I have always appreciated your wisdom and care in your posts on this forum, and I think you should keep remembering that you are appreciated for who you are in this situation: someone who has worked hard and wants to make a positive contribution in your life and to the world.

We don't ever have enough people like that. Stick to your vision.

B. There are some movement therapies that can help with stress reduction that are better known to dancers and musicians that might also be worthwhile In the long run but I'm not saying you should go out right now to start them!

Alexander Technique and Reike are two that come to mind. Bartineff's book, " Human Movement Potential" done after her work in the 50s on this is also interesting.

But I don't think you have to "fix yourself" to be acceptable, nor should you.

M.

[Caracal]

1) When some people think of tics, they think of twitches or vocalizations but are not aware that some tics can look like voluntary behavior (e.g. level 3 tics). However, since none of the fora members responding to this thread have indicated that the level 3 tics would be an issue for them so long as there is an explanation, maybe I'm fretting for nothing. It's just hard not to worry you are putting people off when you start literally beating yourself up.

Yeah, absolutely. The key is to just be matter of fact and give your committee members the context they need. From the other side, I've had a number of undergraduate students who I think had tics of some sort in the category 3 level you describe. Mostly it involved loud and somewhat angry sounding muttering. I don't know for sure, because they never talked to me about any of it. On one hand, that's their prerogative, nobody is required to explain a medical condition to their instructor. However, I did find it to be hard to manage in a classroom, just because I didn't know how to interpret the behaviors. I wanted to be kind and understanding to the student, but I have to admit that it was hard, mostly because, lacking any context, it can be hard to not be unnerved by someone who seems angry. It would have helped me, and I think the student, tremendously, if they could have told me "I have a medical condition where I have involuntary movements and speech sometimes. Sometime I mutter, but it isn't because I'm angry or making comments under my breath about you or others." I could have then treated it basically like someone was coughing.

Basically, if your committee members are decent people, they will just want some guidance on how to respond to something that otherwise might seem alarming. If you make it clear, that it isn't anything to be alarmed about, they should follow your lead. Even for the level 4 tics, you can create a context where if you have one, your advisor can just suggest a break and the committee members can go get a cup of coffee and come back in ten minutes.