LETTERS
TO
THE
Dr. Adebimpe
SIR:
EDITOR
Replies
A more
Subcategorizing
leisurely
reading
of the
article
might
reassure
Dr. Doss attempted
that rather than adopting an omniscient posture, I to acquaint the court with medical and psychiatric considerations that would have been applied to a decision for discharge
had
Mr.
A been
a voluntary
patient.
These
ed information about the intra- and interpersonal in the case. They were probability statements, edra
pronouncements,
were
intended
Psychiatric carceration. py required ting. ‘‘ His
from
and
none
of
the
includ-
dynamics not cx cath-
recommendations
that assaulting
his wife and daughter
had been
the
a better
‘ ‘ His
chance
vious record Obviously, cretely stated.
for optimal
response
to therapy.
of outpatient attendance the point of the article There was no question
the doctor’s
testimony
was
prediction
that
low. The critical
the
was bad. needs to be of ‘ ‘refusing
of dangerousness,’
risk
of deliberate
acts
issue is that if, as a result
was
ill-ad-
the 10-day patient
pre-
more conto comply
‘ since
my
of violence
ofmental
was
illness,
a
man’s actions are unintentionally detrimental to his own health and to the social and economic well-being of his family, do we need to wait for him to hold a gun to his head or theirs before deciding that some decisions must be made for him until he gets better? Opinions are still divided on the issue, because one of those decisions is that his liberty be temporarily curtailed. This case illustrated some possible consequences of insist-
ing on liberty
at all costs.
Mr. A became
estranged
from
his
and daughter, not the kind of ‘ ‘independent existence” most people might envy. His heart condition became worse, and the decision to see a cardiologist was no longer optional. The necessity of discontinuing lithium carbonate showed that his physician’s concern about monitoring the early stages oftherapy with this drug wasjustified. The continuation of his mania for 2 more months may have been the result ofoutpatient treatment, but we cannot be sure. In this locality the average length of inpatient stay for his condition is much shorter than that. wife that
The outcome
in this case
suggests
that if we define
dan-
only as ‘ ‘the probability that the individual will harm on himself or others in a specific physical manwe are obliged to give some patients liberty at the risk
gerousness
inflict ncr,”
of consequences selves.
In addition,
that we would we
may
not ordinarily
deprive
them
wish for our-
of the
right
type of treatment they themselves might have requested their judgment been intact. The question is, ‘ ‘Which is preferable: worsening
to the
had
Untreated heart disease, prolonged episode of mania, forced estrangement from family and home, and transfer to another state, or 3 weeks of inpatient treatment?’ ‘ Although some of these outcomes are the result of the unique court ruling, it is clear that when neither alternative is desirable, it is common sense to choose the lesser of two evils. Liberty is fine, but
the best should
not be the enemy
of the good.
R.
ADEBIMPE,
Pittsburgh, Am J Psychiatry
of our syndrome
134:7,
July
1977
M.D. Pa.
study (1),
or subcategories
Syndrome
of 450 patients with Gilles we suggest that there are
of movement
disorders
present-
and their characteristics
are as follows:
1. Transient tic of childhood. The symptoms are indistinguishable from the initial symptoms of Tourette’s syndrome. The only difference is that the symptoms remit spontaneously within one year. 2. Subacute multiple tic of childhood or adolescence. The symptoms and clinical course are indistinguishable from Tourette’s syndrome and last longer than one year, but complete remission occurs before or during adolescence. 3. Dystonic variant of Tourette’s syndrome. This group includes patients whose movements have both a fast and slow or dystonic component. The tics of Gilles de Ia Tourette’s syndrome are frequent, brief, rapid, sudden (lightninglike), and jerky. Patients in this subgroup have dystonic movements as well. These movements are slow, stretching, writhing, or manneristic squeezes, somewhat (but not exactly) like the symptoms characteristic of focal dystonia.
The
symptoms
are not fully
developed,
however,
and
re-
semble partial, incomplete, or abortive forms of blephorospasm, torticollis, or writer’s cramp. These dystonic symptoms respond less successfully to treatment with haloperidol. 4. Invariant tic symptoms beginning in childhood. These patients’ symptoms begin in childhood and are characteristically more stable and constant than the variable and changing symptoms in Tourette’s syndrome. In Tourette’s syndrome, symptoms change slowly over time, with new symptoms replacing or being added to old ones. Symptoms wax and wane spontaneously, and the clinical course characteristically fluctuates. In this subgroup, although the symptoms also include variable, spontaneously changing multiple tics, the symptoms are fewer and less variable, show less spontaneous changing, wax and wane less, are more stable and stereotypic, and tend to remain the same throughout life.
Our
impression
ferentiate
is that
acter. These dol, although sic
myographic
recordings
would
dif-
tics from
tend to be slightly are less frequent
these muscular movements because they stronger, definite, and vigorous. Vocal tics and intense and have a different tonal char-
symptoms somewhat
respond to treatment with haloperiless successfully than the more clas-
tics
of Tourette’s syndrome. tic symptoms beginning in adulthood. Symptoms in this group are similar to those described for group 4, except that they begin in adulthood, frequently during or after middle age. Only one or, occasionally, two tic symptoms are present. 6. Polymorphous perverse variant. These patients have a m#{233}lange of symptoms characterized by vivid, changing, and primitive sadomasochistic and polymorphous perverse sexual fantasies; excessive intense and bizarre thoughts and ideas; obsessive, compulsive, and echo phenomena; thought
5. Invariant
scribed VICTOR
de Ia Tourette’s
ly subsumed under this diagnosis. The syndrome is a chronic, multiple-tic condition that begins in childhood and is characterized by involuntary, sudden, rapid, and purposeless movements and vocalizations that can include sounds, words, and coprolalia.
fixation;
818
basis
The eight subtypes
diagnosis was not invoked as a basis for inThe patient’s heart condition and lithium theramedical surveillance ‘ ‘ideally in an inpatient setimproved but continuing mania prevented him
seeing
SIR: On the Ia Tourette’s
eight types
to be instructions.
out of character. Therefore, ‘ ‘immediate release vised [because] treatment for a week or 2 beyond period of the emergency commitment might give
with
de
Gilles
and fog states. by
Confessions scriptions
Meige
and
A classic Feindel
of a Victim to in the older
appear
case of this type
(2) in a chapter Tic,’ ‘ and several
literature.
was de-
entitled ‘ ‘The other case de-
LETTERS
7. Self-mutilation variant. Self-mutilation a small number of patients with symptoms to those of Tourette’s syndrome. First
Woert
and
associates
(3) and
is a symptom of otherwise similar described by Van
suggestive
NIH
of but not identical
with the severe self-mutilation that occurs in children with Lesch-Nyhan syndrome, such patients have a tendency to severely bite their tongues, lips, or cheeks. 8. Treatment-resistant type. Patients in this group fulfill the classic criteria for Tourette’s syndrome but fail to respond adequately to treatment. Despite considerable effort in titrating the dosage of haloperidol and the management of side effects over a long period of time, these patients (who reprsent less than 5% of the total group) develop side effects that offset the benefit of halopenidol. The side effects appear to be more of a problem than the tics. Clinically, these patients seem to be extremely sensitive to the extrapyramidal side effects of halopenidol. The possibility that they have another subcategory of movement disorder should be considered. These variations in symptoms and clinical course may be different manifestations ofessentially one illness or may represent different disease entities. These initial and preliminary clinical observations should be further evaluated by careful, controlled clinical and biochemical studies.
REFERENCES 1. Shapiro AK, Shapiro E, Bruun RD. et al: Gilles de Ia Tourette Syndrome. New York, Raven Press (in press) 2. Meige H, Feindel E: Tics and Their Treatment. Translated and edited by Wilson SAK. New York, William Wood and Co. 1907 3. Van Woert MH, Yip LC, Balis ME: Purine phosphoribosyltransferase 296:210-212,
in Gilles 1977
de
Ia Tourette
syndrome.
N
EngI
The authors
J Med
did not comment
status of the NIH group lot Study of Schizophrenia
group
were
K.
ELAINE
Higher
social outcome
Side
A third
flaw
involves
The
the National
Institutes
indicate
of Health
haphazard drug
(NIH)
authors
conclude
without
drugs
is
patients
treated
without
zation that
rate these
within patients
that
‘ ‘feasible.
treating ‘‘
drugs
9 months did
terrifically
acute
However, at NIH
use
extrapyramidal
well.
NIH patients
the
fact
that
does
treated
side
effects
or
use
of
with mcd-
address major misinterpreted
I . Turner RJ: Class and mobility in schizophrenic outcome. Psychiatr Q 42:721-725, 1968 2. Hollingshead AB, Redlich FC: Social Class and Mental Illness. New York, John Wiley & Sons, 1958 3. Schooler NR, Goldberg SG, Booth H, et al: One year after discharge: community adjustment of schizophrenic patients. Am J Psychiatry 123:986-995, 1967 4. Rifkin A, Quitkin F, Klein DF: Akinesia. Arch Gen Psychiatry 1975
M. KANE,
and Associates
We had hoped
M.D.
Oaks,
N. Y.
would
encour-
Reply
that our communication
age further consideration of several issues in the treatment of schizophrenia rather than evoking polemics. We have received several other communications that, by the nature of their praise or criticism, suggest we missed the mark. Perhaps this response will enable us to come closer to achieving
our goal. Our review of the literature suggests treatment considerations in schizophrenic
very narrow tant
questions
report
information
operating
observations
pare
different our
be regarded
scientific
based
study.
not from a study
indicated
designed
we certainly
as
any
not have
come
comparisons.
with little receiving
controlled
that
to corndid
definitive
treatment
not an-
conditions
in
and this does limit the value of the outIt was
addressed evidence
providing
as In our
on our experience
we carefully
approaches;
patientgroup,
A second
may seem to be imporactually
treatment
either
there
the predominant patients rest on a
observations
We did
treatment with those
that
of careful at NIH,
were
swers.
we
What
should
and thoughts
program
these
Was
in need
of observations a treatment
represent
base.
assumptions
urgently
question
not suggest
with
REFERENCES
with
the
test).
antiparkinsonian
It is unfortunate when serious investigators issues with poorly designed studies and easily data that only serve to increase confusion.
in
schizophrenics
in social
agents.
of
was related
had a 35% rehospitali-
of discharge
those
Glen
to the patient’s date of admission rather than symptom or prognostic status. Ifdrug prescription was determined in this way, one must question both the objectivity of the staff in making key treatment decisions and the validity of the drug versus no drug comparison.
The
to be
and then withdrawn from it (after an average of 46 significant improvement was noted during the no-drug period is not surprising given the following examples cited by the authors: ‘ ‘more spontaneity, fuller affect, less psychomotor retardation, and more social and work initiative. “ It appears that the authors were rating drug side effects, particularly akinesia (4), as psychopathology. This could certainly account for the ‘ ‘ improvement’ ‘ in these patients when drugs were withdrawn. No mention is made of examinations for
JOHN
prescription
sample
likely
in the
,
The fact that, among
SIR:
that
more
P1-
Patients
ication days),
Effects?
the apparently
authors
International
sample.
M.D. PH.D. York, N.Y.
SIR: The article entitled ‘ ‘The Treatment of Acute Schizophrenia Without Drugs” by William T. Carpenter, Jr., M.D., and associates (January 1977 issue) raises several interesting questions. The authors suggest that these questions could be answered by careful scientific study, but their investigation was neither careful nor scientific. They acknowledged two major flaws in their study: 1) the failure to control treatment in either patient group, which reduces the value of any outcome comparison, and 2) differences in timing of follow-up, which also hinders meaningful comparison.
medication.
socioeconomic
the
(1-3).
Dr. Carpenter or Relief from
(IPSS)
SHAPIRO, SHAPIRO,
New
Improvement
with
EDITOR
the IPSS group (p
TO
THE
Dr. Adebimpe
SIR:
EDITOR
Replies
A more
Subcategorizing
leisurely
reading
of the
article
might
reassure
Dr. Doss attempted
that rather than adopting an omniscient posture, I to acquaint the court with medical and psychiatric considerations that would have been applied to a decision for discharge
had
Mr.
A been
a voluntary
patient.
These
ed information about the intra- and interpersonal in the case. They were probability statements, edra
pronouncements,
were
intended
Psychiatric carceration. py required ting. ‘‘ His
from
and
none
of
the
includ-
dynamics not cx cath-
recommendations
that assaulting
his wife and daughter
had been
the
a better
‘ ‘ His
chance
vious record Obviously, cretely stated.
for optimal
response
to therapy.
of outpatient attendance the point of the article There was no question
the doctor’s
testimony
was
prediction
that
low. The critical
the
was bad. needs to be of ‘ ‘refusing
of dangerousness,’
risk
of deliberate
acts
issue is that if, as a result
was
ill-ad-
the 10-day patient
pre-
more conto comply
‘ since
my
of violence
ofmental
was
illness,
a
man’s actions are unintentionally detrimental to his own health and to the social and economic well-being of his family, do we need to wait for him to hold a gun to his head or theirs before deciding that some decisions must be made for him until he gets better? Opinions are still divided on the issue, because one of those decisions is that his liberty be temporarily curtailed. This case illustrated some possible consequences of insist-
ing on liberty
at all costs.
Mr. A became
estranged
from
his
and daughter, not the kind of ‘ ‘independent existence” most people might envy. His heart condition became worse, and the decision to see a cardiologist was no longer optional. The necessity of discontinuing lithium carbonate showed that his physician’s concern about monitoring the early stages oftherapy with this drug wasjustified. The continuation of his mania for 2 more months may have been the result ofoutpatient treatment, but we cannot be sure. In this locality the average length of inpatient stay for his condition is much shorter than that. wife that
The outcome
in this case
suggests
that if we define
dan-
only as ‘ ‘the probability that the individual will harm on himself or others in a specific physical manwe are obliged to give some patients liberty at the risk
gerousness
inflict ncr,”
of consequences selves.
In addition,
that we would we
may
not ordinarily
deprive
them
wish for our-
of the
right
type of treatment they themselves might have requested their judgment been intact. The question is, ‘ ‘Which is preferable: worsening
to the
had
Untreated heart disease, prolonged episode of mania, forced estrangement from family and home, and transfer to another state, or 3 weeks of inpatient treatment?’ ‘ Although some of these outcomes are the result of the unique court ruling, it is clear that when neither alternative is desirable, it is common sense to choose the lesser of two evils. Liberty is fine, but
the best should
not be the enemy
of the good.
R.
ADEBIMPE,
Pittsburgh, Am J Psychiatry
of our syndrome
134:7,
July
1977
M.D. Pa.
study (1),
or subcategories
Syndrome
of 450 patients with Gilles we suggest that there are
of movement
disorders
present-
and their characteristics
are as follows:
1. Transient tic of childhood. The symptoms are indistinguishable from the initial symptoms of Tourette’s syndrome. The only difference is that the symptoms remit spontaneously within one year. 2. Subacute multiple tic of childhood or adolescence. The symptoms and clinical course are indistinguishable from Tourette’s syndrome and last longer than one year, but complete remission occurs before or during adolescence. 3. Dystonic variant of Tourette’s syndrome. This group includes patients whose movements have both a fast and slow or dystonic component. The tics of Gilles de Ia Tourette’s syndrome are frequent, brief, rapid, sudden (lightninglike), and jerky. Patients in this subgroup have dystonic movements as well. These movements are slow, stretching, writhing, or manneristic squeezes, somewhat (but not exactly) like the symptoms characteristic of focal dystonia.
The
symptoms
are not fully
developed,
however,
and
re-
semble partial, incomplete, or abortive forms of blephorospasm, torticollis, or writer’s cramp. These dystonic symptoms respond less successfully to treatment with haloperidol. 4. Invariant tic symptoms beginning in childhood. These patients’ symptoms begin in childhood and are characteristically more stable and constant than the variable and changing symptoms in Tourette’s syndrome. In Tourette’s syndrome, symptoms change slowly over time, with new symptoms replacing or being added to old ones. Symptoms wax and wane spontaneously, and the clinical course characteristically fluctuates. In this subgroup, although the symptoms also include variable, spontaneously changing multiple tics, the symptoms are fewer and less variable, show less spontaneous changing, wax and wane less, are more stable and stereotypic, and tend to remain the same throughout life.
Our
impression
ferentiate
is that
acter. These dol, although sic
myographic
recordings
would
dif-
tics from
tend to be slightly are less frequent
these muscular movements because they stronger, definite, and vigorous. Vocal tics and intense and have a different tonal char-
symptoms somewhat
respond to treatment with haloperiless successfully than the more clas-
tics
of Tourette’s syndrome. tic symptoms beginning in adulthood. Symptoms in this group are similar to those described for group 4, except that they begin in adulthood, frequently during or after middle age. Only one or, occasionally, two tic symptoms are present. 6. Polymorphous perverse variant. These patients have a m#{233}lange of symptoms characterized by vivid, changing, and primitive sadomasochistic and polymorphous perverse sexual fantasies; excessive intense and bizarre thoughts and ideas; obsessive, compulsive, and echo phenomena; thought
5. Invariant
scribed VICTOR
de Ia Tourette’s
ly subsumed under this diagnosis. The syndrome is a chronic, multiple-tic condition that begins in childhood and is characterized by involuntary, sudden, rapid, and purposeless movements and vocalizations that can include sounds, words, and coprolalia.
fixation;
818
basis
The eight subtypes
diagnosis was not invoked as a basis for inThe patient’s heart condition and lithium theramedical surveillance ‘ ‘ideally in an inpatient setimproved but continuing mania prevented him
seeing
SIR: On the Ia Tourette’s
eight types
to be instructions.
out of character. Therefore, ‘ ‘immediate release vised [because] treatment for a week or 2 beyond period of the emergency commitment might give
with
de
Gilles
and fog states. by
Confessions scriptions
Meige
and
A classic Feindel
of a Victim to in the older
appear
case of this type
(2) in a chapter Tic,’ ‘ and several
literature.
was de-
entitled ‘ ‘The other case de-
LETTERS
7. Self-mutilation variant. Self-mutilation a small number of patients with symptoms to those of Tourette’s syndrome. First
Woert
and
associates
(3) and
is a symptom of otherwise similar described by Van
suggestive
NIH
of but not identical
with the severe self-mutilation that occurs in children with Lesch-Nyhan syndrome, such patients have a tendency to severely bite their tongues, lips, or cheeks. 8. Treatment-resistant type. Patients in this group fulfill the classic criteria for Tourette’s syndrome but fail to respond adequately to treatment. Despite considerable effort in titrating the dosage of haloperidol and the management of side effects over a long period of time, these patients (who reprsent less than 5% of the total group) develop side effects that offset the benefit of halopenidol. The side effects appear to be more of a problem than the tics. Clinically, these patients seem to be extremely sensitive to the extrapyramidal side effects of halopenidol. The possibility that they have another subcategory of movement disorder should be considered. These variations in symptoms and clinical course may be different manifestations ofessentially one illness or may represent different disease entities. These initial and preliminary clinical observations should be further evaluated by careful, controlled clinical and biochemical studies.
REFERENCES 1. Shapiro AK, Shapiro E, Bruun RD. et al: Gilles de Ia Tourette Syndrome. New York, Raven Press (in press) 2. Meige H, Feindel E: Tics and Their Treatment. Translated and edited by Wilson SAK. New York, William Wood and Co. 1907 3. Van Woert MH, Yip LC, Balis ME: Purine phosphoribosyltransferase 296:210-212,
in Gilles 1977
de
Ia Tourette
syndrome.
N
EngI
The authors
J Med
did not comment
status of the NIH group lot Study of Schizophrenia
group
were
K.
ELAINE
Higher
social outcome
Side
A third
flaw
involves
The
the National
Institutes
indicate
of Health
haphazard drug
(NIH)
authors
conclude
without
drugs
is
patients
treated
without
zation that
rate these
within patients
that
‘ ‘feasible.
treating ‘‘
drugs
9 months did
terrifically
acute
However, at NIH
use
extrapyramidal
well.
NIH patients
the
fact
that
does
treated
side
effects
or
use
of
with mcd-
address major misinterpreted
I . Turner RJ: Class and mobility in schizophrenic outcome. Psychiatr Q 42:721-725, 1968 2. Hollingshead AB, Redlich FC: Social Class and Mental Illness. New York, John Wiley & Sons, 1958 3. Schooler NR, Goldberg SG, Booth H, et al: One year after discharge: community adjustment of schizophrenic patients. Am J Psychiatry 123:986-995, 1967 4. Rifkin A, Quitkin F, Klein DF: Akinesia. Arch Gen Psychiatry 1975
M. KANE,
and Associates
We had hoped
M.D.
Oaks,
N. Y.
would
encour-
Reply
that our communication
age further consideration of several issues in the treatment of schizophrenia rather than evoking polemics. We have received several other communications that, by the nature of their praise or criticism, suggest we missed the mark. Perhaps this response will enable us to come closer to achieving
our goal. Our review of the literature suggests treatment considerations in schizophrenic
very narrow tant
questions
report
information
operating
observations
pare
different our
be regarded
scientific
based
study.
not from a study
indicated
designed
we certainly
as
any
not have
come
comparisons.
with little receiving
controlled
that
to corndid
definitive
treatment
not an-
conditions
in
and this does limit the value of the outIt was
addressed evidence
providing
as In our
on our experience
we carefully
approaches;
patientgroup,
A second
may seem to be imporactually
treatment
either
there
the predominant patients rest on a
observations
We did
treatment with those
that
of careful at NIH,
were
swers.
we
What
should
and thoughts
program
these
Was
in need
of observations a treatment
represent
base.
assumptions
urgently
question
not suggest
with
REFERENCES
with
the
test).
antiparkinsonian
It is unfortunate when serious investigators issues with poorly designed studies and easily data that only serve to increase confusion.
in
schizophrenics
in social
agents.
of
was related
had a 35% rehospitali-
of discharge
those
Glen
to the patient’s date of admission rather than symptom or prognostic status. Ifdrug prescription was determined in this way, one must question both the objectivity of the staff in making key treatment decisions and the validity of the drug versus no drug comparison.
The
to be
and then withdrawn from it (after an average of 46 significant improvement was noted during the no-drug period is not surprising given the following examples cited by the authors: ‘ ‘more spontaneity, fuller affect, less psychomotor retardation, and more social and work initiative. “ It appears that the authors were rating drug side effects, particularly akinesia (4), as psychopathology. This could certainly account for the ‘ ‘ improvement’ ‘ in these patients when drugs were withdrawn. No mention is made of examinations for
JOHN
prescription
sample
likely
in the
,
The fact that, among
SIR:
that
more
P1-
Patients
ication days),
Effects?
the apparently
authors
International
sample.
M.D. PH.D. York, N.Y.
SIR: The article entitled ‘ ‘The Treatment of Acute Schizophrenia Without Drugs” by William T. Carpenter, Jr., M.D., and associates (January 1977 issue) raises several interesting questions. The authors suggest that these questions could be answered by careful scientific study, but their investigation was neither careful nor scientific. They acknowledged two major flaws in their study: 1) the failure to control treatment in either patient group, which reduces the value of any outcome comparison, and 2) differences in timing of follow-up, which also hinders meaningful comparison.
medication.
socioeconomic
the
(1-3).
Dr. Carpenter or Relief from
(IPSS)
SHAPIRO, SHAPIRO,
New
Improvement
with
EDITOR
the IPSS group (p
