Am

J Psychiatry

135:7,

TO

LETTERS

July

THE

EDITOR

reactions to Journal articles, statements of opinion, comments on Association activities, etc. Letters should be submitted in duplicate to the Editor, who makes all decisions Letters must be typed double spaced throughout and should not contain more than 500 references. Criticisms of published articles will automatically be sent to the author(s) for be edited for clarity and conformance with Journal style. We regret that we cannot inform of letters or return those which are not printed.

This section contains requests for information, regarding publication. words and 5 pertinent response. Letters will writers of the disposition

Abnormal

in Tardive

Gaits

1978

Dyskinesia

from a highly to the attention

SIR: Tardive dyskinesia continues to present problems of both a practical and theoretical nature. The continuing attention this problem has received has resulted in a broadening of the definition of the syndrome and a further awareness of its complexity and importance. We would like to bring attention to the presence of abnormal gaits in patients suffering from severe tardive dyskinesia. The gaits were noted as patients walked about the wards and hospital grounds. When further examined, the patients showed other signs of dyskinesias (e.g. , buccolingual masticatory movements and choreoathetoid movements of the limbs). Abnormalities of postune have been reported previously (1), but we are not aware

of any detailed quency. We examined

descriptions

or any

42 patients

comments

selected

about

as having

2. What

of a steppage appeared

at least

gait,

with

the

of patients,

and

progressed

to this

dragging

of

we

bring

them

stage.

REFERENCE 1. Hunter R, Earl Cl, Thornicroft 5: An apparently syndrome of abnormal movements following medication. Proc R Soc Mcd 57:758-762, 1964

irreversible phenothiazine

GEORGE M. SIMPSON, RAM K. SHRIVA5TAVA,

M.D. M.D.

Orangeburg,

mod-

gait.

to be a spastic in 2 patients.

group

ofiournal readers as further evidence of the complexity of tardive dyskinesia and also as a possible help in the diagnosis of this condition, although the diagnosis should, of course, be made long before the disorder has

its fre-

erate symptoms of tardive dyskinesia (e.g. , oral abnormalities and choreoathetoid movements of the limbs). Of these 42 patients, 18 (43%) had “peculiar” gaits. The gaits of 9 (22%) were considered frankly abnormal, i.e. , neurological gaits, characterized as follows: I . Broad-based gait, i.e. , a wide gait with a wide arm swing and an unsteady gait. Of the 7 patients in this category, 3 had pelvic thrusting (forward movements of the pelvis on walking), and 2 walked predominantly on their heels, giving the

appearance

selected

Work

Stress

SIR:

For

number and

N.Y.

the

last

of seminars

private

two

years

employees

have included managers, and not required to the workshops

have

been

conducting

for government

experiencing

work

a

workers

problems.

We

such people as nursing executives, business rank-and-file employees. Participants were have problems, and many of them came to with an intent to learn something new rather

one foot, was seen The remaining 9 patients had what seemed to be an abnormal gait, but it was not typical ofany described neurological gait. More detailed descriptions of the gaits included unsteady,

than

that

about

two-thirds of work stresses stem lems. Another third report stresses sures. It would thus be useful for

from interpersonal that arise from time the helping professions

probpres-

wide-based gait; marked swinging of arms; steady, pelvic thrusts similar to a pregnancy

broad-based, unstrut; walking

understand of pressure.

techniques for both kinds stresses occur universally

on heels;

broad-based,

at one

deliberate,

steady walking on stamping type gait; a cerebellar quality, ments reminiscent

who

saw

1 patient

having ‘ ‘dystonic with occasional

careful

wide

steps;

for

evaluation

described

of the without

the

un-

patient

as

facial muscles together rigidity of the muscles

of the trunk or extremities with a mildly abnormal gait. The patient preambulated with a protrusion of the upper chest muscles and a somewhat steppage gait. The reflexes are normal and it would seem that these choreiform and dystonic movements are a result of tranquilizing drugs, i.e., tardive

health

be

emphasized

that

these

observations

come

measures.

observed

in surveys

time

or another,

problems.

even

among

We were

professionals

most tensity sionals

that

other

mental

of work themselves

job stresses. We found

health

organizations stresses, are

a number

participants

participants

chagrined

frequently

were

to counsel people experiencing of their lack of managerial indicate

ofthe

sources of and coping We found that work

identified

without

to learn not

to

that

any

mental

adequately

trained

work stress, perhaps because perspectives. Our observations centers

are

in terms

probably

of the

and that the mental often unable to cope

of realizations

worse

quantity

than

and

thority

One

exist

must

understand

in any organization.

that

to be very

power,

A second

in-

health profeswith their own

helpful

people experiencing stress at work. First is acceptance fact that political relationships are inherent in the work tion.

dyskinesia.”

It should

remedial

We have

heels; stiff, unsteady gait, dragging feet; and so forth. In some patients there was while others had wide arm swing moveof ballistic movements. A neurologist

movements grunting but

to seek

we

and workshops

influence,

realization

to

of the situaand

au-

is that 865

LETTERS

TO

THE

Am

EDITOR

the notion of coping with stress using only “fight or flight” reactions is insufficient. Fight or flight’ is more appropriate to the lower animals; man is more able to “fight, flight, or take things in stride.’ A third realization we found helpful is the need for individuals to be willing to listen to others cxpeniencing work stresses in the same organization. Perhaps “

‘

‘

this is consistent with the systems stresses as cumulative and interactive.

total oneself when when An

which one lowers

sees the

amount of stresses in an organization, one is helping as well. Fourth is respect for one’s coworkers, even liking others has become difficult if not impossible, or there is a need to discipline, criticize, or disagree. interesting observation occurred with respect to the

so-called burning-out ubiquitous, with people who report

ing a phenomenon loss

viewpoint, When

syndrome, which varying intensities

seems to be and reactions.

almost The

being burned-out generally were describofpartial disengagement from their work,

of motivation,

winding

down,

and

turning

off which

probably related to a form oftaking psychological out physical escape from the interaction. A.J.

flight

with-

wonder

Dy,

M.D. M.P.H.

Hawaii

Violence

and

Dangerousness

in Mental

Patients

analyzed quire. Napa ization

separately,

Mateo by these

he used

is possible.

‘Crime and Violence Among Mental Patients Rein View of the New Legal Relationship Between and the Mentally Ill’ (January 1978 issue), Larry Sosowsky, M.P.P. implied that former San Mateo County Mental Health Division patients are an extraordinary danger to the community because they have a higher incidence of arrest records for criminal behavior, including violent offenses, than the general population. He also implied that this study took place with the approval and assistance of the San Mateo Mental Health Services Division. Neither implication SIR:

In

‘

received and has

proposed

with

a psychotic pleas for did not segthey

procedure

that approximately caseload during such penal code

are

not

would

re-

12% of San Mateo’s this pivotal hospitalcases. Including this

Sosowsky’s the annual

County and several the author and backup data, no independent

This article has Associated Press,

are associated

apparently cases, and

‘

1978

since some of these criminal justice sys-

research

group clearly adds bias to Mr. The procedure for calculating for San described Without

July

who experienced entered “insanity”

as good

We estimate State Hospital period were

135:7,

rates

State Hospital, through the

their alleged crimes, etc. The author regate the data of these ‘ ‘penal code’

report. arrest rate figures

U.S. cities data are assessment

is not clearly not provided. of the rates

wide notice, was picked up by the already been cited in an editorial

amendments

to the Mental

Health

Act

of one state legislature-amendments which would tighten criteria for involuntary admission to state hospitals. The cditonal cited the study’s findings to the effect that the crime rate of former mental health patients has increased by a facislation Thus,

and a half since

limiting the article

all mentally considered the State

high arrest

tem. This would include those break while in jail, those who

tor of three

On Assessing

that

being admitted to Napa admissions came directly

(1) opposing

E. KAY, Honolulu,

KATHLEEN

is

It is little

J Psychiatry

which

passage

the duration is being used

ill as criminally

they

are

of California’s

of involuntary to perpetuate

dangerous

1969 leg-

hospitalization. the stereotype

and

violent

of

persons,

not.

‘

REFERENCE

,

I . Mental

health

Democrat,

trends

Ian 28,

boost 1978,

crime

rate

(editorial).

Tallahassee

p 4A M. RANKIN, M.D. GARY M. HEYMANN, San Mateo,

ROBERT

,

M.P.H. PH.D. Calif.

is correct.

Mr. Sosowsky’s implied conclusion that San Mateo County patients released from Napa State Hospital subsequently committed violent crimes at a higher rate than the general population is invalid. Although a certain percentage of the patients had arrest records. no data are provided indicating the number of actual convictions, which could be the only acceptable basis for characterizing people as ‘violent offenders.” The majority of the arrests may well have occurred before the pivotal hospitalization, not after discharge (see p. 35 of the article, indicating a 19-month study period from June 1972 through December 1973). ‘

The broader January 81/4-year

1966

survey

aspects through period

of this report

deal with arrests

March 1974, so that fall before the pivotal

6’/2

years

from of the

hospitalization. dealing with rates

The more focused

aspects of the report, of violent crime during the ‘postreform’ period (p. 38), counted arrests for a 43/4 year period (July 1969-March 1974), 3 years of which were before pivotal hospitalization. ‘

Indeed,

28 of the

301

‘

survey 1 , 1974

individuals had not been discharged as of January (p. 37). What the author’s data do show is that before pivotal hospitalization this survey group of state hospital admissions

had a higher rate of arrests for violent counterparts (in terms of age, sex, and San Mateo County population, assuming od of estimating those rates is correct. 866

offenses than their race) in the general the author’s meth-

SIR:

sented Journal

The

data

on the

dangerousness

by Mr. Sosowsky have important

cifically,

Mr.

commitment

Sosowsky

appears

and release

al to effectively patients.

ofthe

mentally

in the January 1978 implications for public policies

protect

the

to

agree

that

may have

public

California

become

from

ill pre-

issue of the policy. Spetoo liber-

dangerous

mental

It behooves us to take a careful look at this research to ensure that hospitalized patients are as dangerous as the data suggest. In our view there are problems with this research that

render

Mr.

its

interpretation

Sosowsky

extremely

examined

the arrest

hazardous.

rates

of persons

who

are admitted to Napa State Hospital from San Mateo’s community mental health program. This group is highly select in that a decision has been made that they are inappropriate for outpatient treatment because they are deemed dangerous to themselves or others. The criteria for assessing dangerousness no doubt include previous criminal history, and

the reason for referral was probably an arrest for a criminal offence in many cases. In view of these considerations, the only conclusion possible is that the admission screening process is working, as it should, to identify truly dangerous persons. Certainly, no inference can be drawn regarding the dangerousness of mental patients

from

Mr. Sosowsky raised

this

highly

selected

has gathered

in his discussion

section

group.

do not even regarding

In fact,

address the

the data

the issue

societal

costs

that

he of