Barton CD Jr. Mallik HS. Orr WB. Janofsky JS. Clinicians' judgement of capacity of nursing home patients to give informed consent. Psychiatric Services. 47(9):956-60, 1996 Sep.
OBJECTIVE: The study determined the rate of incapacity to give informed consent for medical treatment among patients admitted to a nursing home and assessed whether clinical staff members recognized this incapacity and whether they used alternative means to provide surrogate decision making for their patients' treatment.
METHODS: After 44 patients admitted to a nursing home affiliated with a major teaching hospital gave oral consent, two standardized tests, the Hopkins Competency Assessment Test (HCAT) and the Mini Mental State Examination (MMSE) were administered to them. Later a researcher blind to the test results reviewed subjects' clinical records to determine whether staff recognized any incapacity in giving informed consent for medical treatment.
RESULTS: Twenty of 44 subjects were identified by the HCAT as incompetent to give informed consent for medical treatment. Clinical staff had identified 13 of those subjects as clinically incompetent. None of the subjects whom clinical staff identified as clinically incompetent was provided with surrogate decision makers in accordance with procedures outlined in state law.
CONCLUSIONS: The prevalence of incapacity to give informed consent in the nursing home population was high. Clinical screening by staff did not identify all clinically incompetent patients, and staff had unresolved conflicting opinions about individual patients' capacity to give informed consent. Even when staff recognized a patient's incapacity to give informed consent, proper legal procedures for appointing surrogate decision makers were not followed.
Pitt SE.Brandt JD. Tellefsen C. Janofsky JS. Cohen ME. Bettis ED. Rappeport JR. Group dynamics in forensic pretrial decision-making. Journal of the American Academy of Psychiatry and the Law. 25(1):95-104, 1997.
This study examines how forensic evaluators' opinions that pertain to diagnosis, competency to stand trial, and criminal responsibility (Maryland's version of the not guilty by reason of insanity plea) are rendered at a state forensic hospital for defendants pleading not criminally responsible. Pretrial evaluations completed independently by a psychiatrist, a psychologist, and a social worker were presented at a forensic staff conference where psychiatrist and psychologists openly "voted" on diagnosis, competency to stand trial, and criminal responsibility. These results were then sent to the court. The purpose of this study was to assess the clinicians' level of agreement and the role that conformity played in the decision-making process. A sample of twenty court-ordered pretrial evaluations of defendants examined at the hospital between March and June 1991, with evaluators' opinions generated by a secret ballot, were compared with a matched control group from an earlier time, when opinions were generated by open ballot. The study was designed to compare the opinions of forensic evaluators in the issues of diagnosis, competency to stand trial, and criminal responsibility between the two samples. The defendants in the experimental group and the control group were matched on the basis of age, race, sex, and offense. It was hypothesized that with secret ballot voting there would be a greater disparity of agreement regarding diagnosis, competency to stand trial, and criminal responsibility opinions compared with the open method of voting. However, the results of this study did not support that hypothesis. There was little disparity on forensic opinions rated either by secret or open voting.
Janofsky JS. Vandewalle MB. Rappeport JR. Defendants pleading insanity: an analysis of outcome Bulletin of the American Academy of Psychiatry & the Law. 17(2):203-11,1989.
The authors examined the cohort of all defendants pleading not guilty by reason of insanity over a 12-month period in Baltimore City's superior trial court. During that time, 143 of the 11,497 defendants indicted (1.2%) pled not criminally responsible. Fourteen of those defendants (10%) were subsequently found not guilty by reason of insanity. The authors found marked agreement between the prosecution and defense with only two cases leading to full trials where the issue of insanity was argued. The evaluating physician's opinion as to criminal responsibility and Axis I diagnosis, and the most serious underlying charge discriminated between those defendants found not guilty by reason of insanity and those defendants found guilty or not guilty by the court. Other demographic factors such as age, number of dependents, educational level, severity of illness, and criminal background did not discriminate between the two groups.
Rappeport JR. Conti NP. Rudnick B. A new pretrial screening program. Bulletin of the American Academy of Psychiatry and the Law. 11(3):239-48,
Janofsky JS. Dunn MH. Roskes EJ. Briskin JK. Rudolph MS. Insanity defense pleas in Baltimore City: an analysis of outcome. American Journal of Psychiatry. 153(11):1464-8, 1996 Nov.
OBJECTIVE: The authors studied all defendants in Baltimore City's circuit and district courts who pleaded not criminally responsible, Maryland's version of the not guilty by reason of insanity plea, during a 1-year period. The study was designed to compare the perception that the insanity plea is misused to actual outcome data.
METHOD: The cohort of defendants who pleaded not criminally responsible in both the circuit and district courts during calendar year 1991 was identified. Data on demographic characteristics, crimes committed, diagnoses, and psychiatrists' opinions on criminal responsibility were collected. Trial outcome data were obtained through a search of the circuit and district court computer systems.
RESULTS: Of the 60,432 indictments filed in the two courts, 190 defendants (0.31 per 100 indictments) entered a plea of not criminally responsible. All but eight defendants (0.013 per 100 indictments) dropped this plea before trial. For these eight cases, both the state and the defense agreed that the defendant should be found not criminally responsible, and the plea was uncontested at trial. The remaining defendants had their charges dropped before trial, remained not competent to stand trial at the time of the study, or withdrew their pleas of not criminally responsible before trial.
CONCLUSIONS: There were no trials that contested the plea of not criminally responsible. The state and defense agreed with each other for all of the defendants who actually retained the plea at trial. The perception that the insanity defense is overused and misused is not borne out by data.
Janofsky JS: The Mental Health System and the Law. In: Breakey, William. Integrated Mental Health Services: Modern Community Psychiatry. Oxford University Press. New York. 1996.
Janofsky JS. Competency assessment of medical and psychiatric patients under Maryland's Health Care Decisions Act. Maryland Medical Journal. 44(2):105-16, 1995 Comment in: Md Med J 1995 Apr;44(4):273
The Health Care Decisions Act provides considerable flexibility and autonomy for patients regarding advance directives and surrogate decision making and clarifies how patients can tell their physicians and the world in general what they would like to have happen if they become incapable of making their own health care decisions. The law, however, is complex. This article provides help for physicians in interpreting some of the Act's clinical and legal ramifications.
Janofsky JS. The Munchausen syndrome in civil forensic psychiatry. Bulletin of the American Academy of Psychiatry & the Law. 22(4):489-97, 1994.
The diagnosis of Munchausen syndrome requires that a patient intentionally produce or feign physical symptoms with a psychological need to assume the sick role. To differentiate the disorder from malingering one must document the absence of an external incentive for the patient's behavior. Although malingering is a major topic of interest in forensic psychiatry, there has been no literature that looks at the Munchausen syndrome presenting in the civil forensic setting. This paper reports on two cases of the Munchausen syndrome that occurred in the areas of medical malpractice and workers' compensation. The cases highlight how the psychiatrist should approach these cases in the civil forensic setting. The malpractice case also illustrates how the disorder is viewed by an appellate court.
Janofsky JS. Rovner BW .Prevalence of advance directives and guardianship in nursing home patients. Journal of Geriatric Psychiatry & Neurology. 6(4):214-6, 1993 Oct-Dec.
The Patient Self-Determination Act (PSDA) now requires federally funded nursing homes to inform newly admitted patients of their right to determine their future medical care. Many nursing home patients may not be able to understand these rights, given the high prevalence of mental disorders, particularly dementia, in this population, and well need family members for assistance. Prior to the onset of the PSDA we surveyed the families of all residents of a large, proprietary nursing home to determine whether family members understood the concept of advance directives and guardianship. We also ascertained the rate of use of these instruments in the population studied. We found that the majority of family member respondents understood these concepts, but that substantial proportions of both competent and incompetent patients lacked surrogate decision-making authority, either in the form of a court-appointed guardian or a written advance-directive instrument. Informing newly admitted patients and their families about advance directives is warranted because many lack these plans. However, the high proportion of incompetent patients among nursing home patients indicates the need to encourage currently competent patients to formulate advance directives prior to nursing home placement.
Baile WF. DiMaggio JR. Schapira DV. Janofsky JS.
The request for assistance in dying. The need for psychiatric consultation. Cancer. 72(9):2786-91, 1993 Nov 1.
BACKGROUND: Public initiatives and legislative proposals have increased the likelihood that some states will legalize euthanasia and assisted suicide as a means of ending the suffering of patients with terminal illness. However, suggested safeguards that would guide physicians in such cases have not properly addressed the need to evaluate psychosocial factors that could motivate patients' requests for premature death.
METHODS: Four cases of patients with cancer who expressed a wish to end their lives prematurely are described. These cases were evaluated with regard to mental and emotional functioning.
RESULTS: Pain and suffering, organic mental disease, depression, and personality issues play significant roles in patients' requests for assistance in dying.
CONCLUSION: Comprehensive psychosocial assessment is needed when evaluating requests for assistance in dying. This assessment may reveal hidden problems or conflicts that affect rational decision making, a prerequisite to informed consent for any procedure or intervention.
Janofsky JS. McCarthy RJ. Folstein MF. The Hopkins Competency Assessment Test: a brief method for evaluating patients' capacity to give informed consent Hospital & Community Psychiatry. 43(2):132-6, 1992 Feb. Comment in: Hosp Community Psychiatry 1992 Jun;43(6):646; discussion 648, Comment in: Hosp Community Psychiatry 1992 Jun;43(6):646-7; discussion 648, Comment in: Hosp Community Psychiatry 1992 Jun;43(6):647-8; discussion 648, Comment in: Hosp Community Psychiatry 1992 Jun;43(6):648
The Hopkins Competency Assessment Test (HCAT), a brief instrument for evaluating the competency of patients to give informed consent or write advance directives, consists of a short essay and a questionnaire for determining patients' understanding of the essay. In a study to validate the instrument, 41 medical and psychiatric inpatients answered the questionnaire after reading the essay while bearing it read aloud. A forensic psychiatrist who was blind to the HCAT scores later examined the patients for competency. A subject's number of correct answers to the HCAT questionnaire was an accurate indicator of clinical competency as assessed by the psychiatrist. The results suggest that the HCAT is a useful tool for rapidly screening patients for competency to make treatment decisions.
Jayaram G. Janofsky JS. Fischer PJ.The emergency petition process in Maryland. Bulletin of the American Academy of Psychiatry & the Law. 18(4):373-8, 1990.
Maryland's Emergency Petition statute allows a violent or suicidal person with a mental disorder to be brought to an emergency facility for rapid evaluation regarding the need for emergency treatment. Although many states have similar laws, little has been written in the psychiatric literature about the emergency petition process. The investigators evaluated emergency petition documents, demographic data, and the adequacy of emergency room records for all patients brought to a large county hospital in Prince Georges County, Maryland, by emergency petition during a one-month period. All emergency petition patients in Prince Georges County are brought to this hospital site. Of 94 petitioned patients examined during the study period, 92 records were available for review. The emergency petition was found to meet appropriate legal criteria in 94 percent of cases. More than half of all patients evaluated were intoxicated on alcohol or illicit drugs, and the majority of these patients were released from the emergency room as no longer dangerous after their acute intoxication resolved. In contrast to previous studies most of the patients evaluated were affluent, had health insurance, and were employed.
Janofsky JS.Assessing competency in the elderly Geriatrics. 45(10):45-8, 1990 Oct.
The doctrine of informed consent requires that a patient understand the medical procedure being proposed, that consent be voluntary, and that the patient be competent to give consent. Because of declining cognitive functioning, elderly patients are at significant risk of becoming incompetent and, therefore, unable in the eyes of the law to give informed consent. Advance directives allow competent patients to tell their doctors and the world in general what their health care choices are should they not be able to make their choices clear in the future. The living will and durable power of attorney are two types of advance directives that are legally binding in most states.
Janofsky JS. Munchausen syndrome in a mother and daughter: an unusual presentation of folie a deux. Journal of Nervous & Mental Disease. 174(6):368-70, 1986 Jun.
The author describes a mother and daughter, both admitted to a major medical center on the same day to the same room, and both with a clinical presentation consistent with Munchausen syndrome. To the author's knowledge, this is the first report of Munchausen syndrome presenting as a folie a deux.
Janofsky JS. Spears S. Neubauer DN. Psychiatrists' accuracy in predicting violent behavior on an inpatient unit Hospital & Community Psychiatry. 39(10):1090-4, 1988 Oct.
Courts and legislators continue to assume psychiatrists are able to predict dangerousness, but research has shown they have no special ability to do so. In this study, two psychiatrists examined 47 new inpatient admissions to a short-term psychiatric treatment unit and predicted whether they would commit battery or demonstrate threatening or suicidal behavior within seven days. The psychiatrists were not accurate in predicting battery or suicidal behavior but had some efficacy in predicting threatening behaviors. The presence of assaultive or threatening behavior on admission, hallucinations on mental status examination, and a discharge diagnosis of mania were useful for predicting battery. A discharge diagnosis of mania was useful for predicting threatening behavior. The use of likelihood ratios to conceptualize predictive data is described.
Janofsky J. Starfield B. Assessment of risk in research on children.
Source Journal of Pediatrics. 98(5):842-6, 1981 May.
Proposed federal regulations regarding clinical research require that institutional review boards determine whether a research project involving children is justified and, if so, whether the child's assent and parent's permission should be required before the child becomes a research subject. A key factor in the IRB's decision is assessment of the risk to the child from participation in the research. Since data on frequency of risks associated with many pediatric procedures that may be employed in clinical research is lacking, a survey of pediatric department chairmen and pediatric clinical research center directors was conducted to ascertain their opinions of the risks of some procedures at various ages of childhood. Although most of these procedures were thought to be of minimal or less than minimal risk, a few (certain types of venipuncture, arterial puncture, and gastric and intestinal intubation) were thought to pose greater than minimal risk, especially in young children. Respondents were also asked to indicate the criteria used to decide whether a child is capable of giving assent to participate in an experimental procedure. In the majority of institutions (73%), it appears that this decision is left to the clinical judgment of the investigator or a member of the research group.
Lyketsos CG. Hanson A. Fishman M. McHugh PR. Treisman GJ. Screening for psychiatric morbidity in a medical outpatient clinic for HIV infection: the need for a psychiatric presence International Journal of Psychiatry in Medicine. 24(2):103-13, 1994.
OBJECTIVE: To ascertain the prevalence and type of psychiatric morbidity present in HIV infected patients presenting for the first time to a specialty HIV medical clinic. Also, to develop a way of screening for psychiatric cases in this setting using established self-report questionnaires.
METHOD: Fifty patients who presented consecutively for medical care at the Johns Hopkins Hospital General HIV Clinic participated in this study. These patients were first screened using the General Health Questionnaire and the Beck Depression Inventory and subsequently underwent a comprehensive neuropsychiatric evaluation.
RESULTS: Fifty-four percent were found to suffer from a psychiatric disorder with an additional 22 percent from an active substance use disorder. These rates are one-and-one-half to two times higher than those reported from other medical clinics. The GHQ and BDI used together as screens could identify psychiatric "cases" with a sensitivity of 81 percent and a specificity of 61 percent, an efficacy similar to that found in other clinics.
CONCLUSIONS: Given the high prevalence of psychiatric disorders in HIV infected patients presenting for medical care, screening, evaluating, and treating for these disorders is crucial and should be pursued systematically. This is best done through the presence of a psychiatric team within HIV medical clinics rather than in affiliation with such clinics.
Lyketsos CG. Hanson AL. Fishman M. Rosenblatt A. McHugh PR. Treisman GJ. Manic syndrome early and late in the course of HIV American Journal of Psychiatry. 150(2):326-7, 1993 Feb. Comment in: Am J Psychiatry 1994 Dec;151(12):
In a chart review at a hospital's infectious disease AIDS clinic, manic syndromes affected 8% of patients who had AIDS. Of the 14 patients with manic episodes, those without a family or personal history of mood disorder presented later in the course of HIV infection and had a higher prevalence of comorbid dementia.
Treisman GJ. Lyketsos CG. Fishman M. Hanson AL. Rosenblatt A. McHugh PR. Psychiatric care for patients with HIV infection. The varying perspectives. Psychosomatics. 34(5):432-9, 1993 Sep-Oct.
This article reviews the literature on the classification and treatment of psychiatric morbidity associated with infection from the human immunodeficiency virus (HIV). The psychiatric disorders seen in HIV-infected patients are formulated by using one of the following four perspectives as treatment guides: 1) the syndromal or disease perspective, 2) the dispositional or personality perspective, 3) the behavioral or addictive perspective, and 4) the life story perspective.
Fedoroff JP. Hanson A. McGuire M. Malin HM. Berlin FS. Simulated paraphilias: a preliminary study of patients who imitate or exaggerate paraphilic symptoms and behaviors. Journal of Forensic Sciences. 37(3):902-11, 1992 May.
In a consecutive series of admissions to the Johns Hopkins Sexual Disorders Unit, 4 out of 20 patients appeared to have simulated paraphilic symptoms that further assessment indicated were either exaggerated or not present. The paper presents case histories of these 4 patients. A descriptive comparison is made between these patients and control groups of patients who admitted having paraphilic symptoms and a group of patients accused of having paraphilic symptoms but who denied them. Patients who simulated paraphilias tended to be self-referred (75%) and without current legal charges (100%). None of these patients was referred or sought treatment for pedophilia, in contrast to the other two patient groups, in which pedophilia accounted for 75% of the referrals. Several possible explanations for why patients might simulate paraphilias and implications for therapists who evaluate or treat sex offenders are discussed.
Barton CD Jr. Dufer D. Monderer R. Cohen MJ. Fuller HJ. Clark MR. DePaulo JR Jr. Mood variability in normal subjects on lithium. Biological Psychiatry. 34(12):878-84, 1993 Dec
To investigate the effect of lithium carbonate on normal volunteers' moods, we randomly assigned 30 subjects to 5 weeks each of placebo and lithium treatment with crossover at midstudy. Lithium levels were maintained during the treatment period at a mean serum level of 0.54 mEq/L. All subjects completed visual analogue mood scales (VAMS) daily throughout the study period; segmented visual analogue scales (SVAS) measuring mood, anxiety, and energy and the Profile of Mood States (POMS) were completed weekly at testing sessions. Neither mean mood nor mood variability as assessed by the delta square (mean square successive difference) differed between placebo and lithium conditions. Segmented visual analogue scale mood ratings were highly correlated with the VAMS and similarly showed no difference between conditions. The self-rated mood variability, however, declined significantly in both experimental conditions as a function of time on study. None of the POMS factors differed between placebo and lithium conditions. These data suggest that lithium, in modest doses administered over 5 weeks, does not have a substantial mood-stabilizing effect in normal subjects.
Tellefsen C. Cohen MI. Silver SB. Dougherty C. Predicting success on conditional release for insanity acquittees: regionalized versus nonregionalized hospital patients. Bulletin of the American Academy of Psychiatry & the Law. 20(1):87-100, 1992.
This research compared the outcomes of two cohorts of insanity acquittees:one group was treated solely in the maximum security state forensic hospital before their release to the community (nonregionalized) and the other group was treated at the state forensic hospital and transferred for furthertreatment at less secure state regional hospitals (regionalized). This research describes the outcome of a group of insanity acquittees (regionalized patients) never previously studied. The applicability of aprediction model based on earlier research of insanity acquittees was tested on the patients. Findings on four outcome indicators are reported: rearrests within five years after release, overall functioning in the community five years after release, rehospitalizations for mental illness, and successfulcompletion of the terms of the five-year conditional release (nonrevocation).Discriminant analysis was performed on the four outcome variables. The model was found to accurately predict the four types of outcome from 69 percent to 94 percent accurately for the nonregionalized insanity acquittees and from 87.5 percent to 95.8 percent for the regionalized patients. This model is currently being adapted to classify patients into potential high- and low-risk groups at the time of conditional release for the purpose of determining the intensity of outpatient supervision.
Rappeport JR. Effective courtroom testimony. Psychiatric Quarterly. 63(4):303-17, 1992 Winter.
Participating in a medical/legal situation is quite different from the ordinary office or hospital experience and requires the expert to see that all of the new parameters are clarified. A thorough and complete evaluation with a review of all the pertinent records and interviews with ancillary individuals is necessary, as is good preparation by way of a pre-trial conference with the attorney. Review of all notes and records prior to deposition or testimony can put the expert at ease. Once under oath, the expert is expected to tell the truth and not advocate for the retaining party. On the other hand, the expert must advocate for his opinion. When the answer is not known, or when one is proven wrong because new data is presented, then the expert must readily admit this. The expert should take the necessary time, pausing, listening to the question, reflecting upon the answer, giving time to the attorney to object. This trip through the vagaries of the legal system should assist psychiatrists in feeling more at ease when participating in forensic matters.
Carpenter WT. Rappeport JR. The insanity defense and mental illness [letter; comment]. Science. 256(5055):292; discussion 293, 1992 Apr 17. Comment on: Science 1992 Feb 14;255(5046):777
Rappeport JR. Belegaled: mental health and the law in the United States, 1986. Canadian Journal of Psychiatry - Revue Canadienne de Psychiatrie. 32(8):719-27, 1987 Nov.
Kenneth Gray, an attorney as well as a psychiatrist, was the leader in the development of law and psychiatry in Canada prior to his death in 1970. He lived during the post WWII years which saw a phenomenal growth of psychiatry as well as the beginnings of the modern era of a renewed concern for human rights. This later concern has caused the belegalment of many areas of psychiatric practice. Kenneth Gray would have to learn a new set of rules for commitment, the use of ECT and informed consent. He would discover that a patient has a right to treatment that must be buttressed by an individual treatment plan. He would discover that a committed patient has a right to refuse treatment and that some courts in the United States have said that anti-psychotic medications are mind-altering and thus an invasion of the patients 1st amendment rights. He would see untreated refusing patients languishing in the hospital or the homeless mentally ill on the streets because of restrictive commitment laws. As an attorney he would also be concerned about the proposed solution to the homeless, outpatient commitment. He certainly would have been impressed with some of the recent decisions in the United States on our duty to warn or protect known and unknown victims. Seeing patients' advocates on the hospital wards would be a real surprise to him. These controls on the practice of psychiatry for the protection of our patients cut both ways. Dr. Gray's medical/legal education would be tested to its full.
Rappeport JR. Halpern AL. Seymour Pollack and the American Board of Forensic Psychiatry. Bulletin of the American Academy of Psychiatry & the Law. 13(2):173-5, 1985.
Reasonable medical certainty. Bulletin of the American Academy of Psychiatry & the Law. 13(1):5-15, 1985.
Pretrial screening of defendants for competency to stand trial and responsibility at the time of the crime reduces unnecessary hospitalization. It can be developed on a statewide basis at little cost, resulting in great savings. Such programs should be established in every state.
Rappeport JR. The insanity plea: getting away with murder?. Maryland State Medical Journal. 32(3):202-7, 1983 Mar.
Rappeport JR. Differences between forensic and general psychiatry. American Journal of Psychiatry. 139(3):331-4, 1982 Mar.
There are important differences between general and forensic psychiatry. In forensic psychiatry the psychiatrist serves a third party rather than the patient; both the patient and the psychiatrist must understand this to avoid misrepresenting the doctor's role to the patient and to enable the doctor to adequately serve the law. Psychiatric opinions that are useful for treatment may not be useful in determining whether a person can be considered responsible or competent. In forensic work the psychiatrist's role is not that of a therapist; it is that of an evaluator and an opinion giver but not a decision maker.
Rappeport JR. Gov. Wallace, Arthur Bremer and Dr. Rappeport, Part 1. Inside Arthur Bremer: Portrait of the assailant. Maryland State Medical Journal. 27(3):35-8, 1978 Mar.
Rappeport JR. Dietz PE. Professional activities of Maryland and US psychiatrists. Maryland State Medical Journal. 27(3):45-8, 1978 Mar.
Rappeport JR. The new Patuxent legislation. Bulletin of the American Academy of Psychiatry & the Law. 5(2):256-67, 1977.
Rappeport JR. Patuxent experiment [editorial]. Bulletin of the American Academy of Psychiatry & the Law. 5(2):v-vii, 1977.
Rappeport JR. Editorial: "Belegaled". Bulletin of the American Academy of Psychiatry & the Law. 5(1):iv-vii, 1977.
Rappeport JR. Patuxent revisited. Bulletin of the American Academy of Psychiatry & the Law. 3(1):10-6, 1976.
Letter: Opinion is property. Journal of Legal Medicine. 3(5):10, 1975 May.
Rappeport JR. A functional information retrieval system for forensic psychiatrists (one man's system). Bulletin of the American Academy of Psychiatry & the Law. 2(4):216-9, 1974 Dec.
Rappeport JR. Psychiatrist as an amicus curiae. II. Medical Trial Technique Quarterly. :297-313, 1972.
Rappeport JR. Psychiatrist as an amicus curiae. I. Medical Trial Technique Quarterly. 18(2):183-9, 1971 Dec.
Rappeport JR. Lassen G.The dangerousness of female patients: a comparison of the arrest rate of discharged psychiatric patients and the general population. American Journal of Psychiatry. 123(4):413-9, 1966 Oct.
Rappeport JR. Sex in marriage counseling Maryland State Medical Journal. 15(9):35-40, 1966 Sep.
Blumberg N . Battered woman syndrome [letter]. mAmerican Journal of Psychiatry. 149(5):714-5, 1992 May.
Blumberg NH . Arson update: a review of the literature on firesetting.Bulletin of the American Academy of Psychiatry and the Law. 9(4):255-65, 1981.