CLINICAL
AND
RESEARCH
Am
REPORTS
sician is not always aware of the syndrome. In some cases, the diagnosis had been delayed for years and the patients had undergone expensive and intrusive investigations and received prolonged, unnecessary anticonvulsive medications for seizures of undetermined origin that were almost certainly due to water intoxication. Electrolyte estimates at the time of the seizure in those patients with a history of compulsive water drinking are essential in establishing the proper diagnosis of water intoxication.
Insanity BY
Plea:
RICHARD
Although guilty by psychiatric empirical characteristics
Legislators’
REFERENCES I. Rountree
PH.D., AND
2. Barahal
HS:
12:767-
Water
intoxication.
Arch
Int
Med
32:157-174,
Water
intoxication
in a mental
case.
Psychiatr
Q
771, 1938
3. Bartter FC: The Syndrome of Inappropriate Secretion of Antidiuretic Hormone. Chicago, Year Book Publishers, 1973 4. Jose CJ, Mehta 5, Perez-Cruet J: The syndrome of inappropriate secretion of antidiuretic hormone (SIADH): an overview in relationship to psychiatry. Can Psychiatr Assoc J (in press)
MARK
L. PANTLE,
to our knowledge,
M.A.
with a median of 3,025.50 and a range of 018,567. The mean estimate of the number of persons adjudicated NGRI was I ,794.28 (median=501 .00, range=0-l3,600). In fact, 102 defendants made this plea and only 1 was so adjudicated. Consistent with respondents’ overestimation of the frequency and success rate of NGRI plea was their response to the statement, ‘The insanity plea is used too much. Too many people escape responsibility for crimes by pleading insanity’ : 15 respondents agreed strongly, 1 1 agreed somewhat, 2 disagreed somewhat, and 2 disagreed strongly.’ Asked whether ‘there is ever a situation in which a person accused of a crime should be excused from responsibility for it because of mental illness,’ 21 legislators responded affirmatively and 10 negatively. Thus, a large majority of legislators expressed agreement with the basic philosophy underlying the NGRI
4,457.84,
‘
‘
been,
LG:
1923
philosophic discourses on the plea ‘not reason of insanity’ (NGRI) abound in the and legal literature, there have been few studies, most of which have examined the and disposition of persons who enter
have
1979
View
A. PASEWARK,
the plea. There
J Psychiatry 136:2, February
no stud-
ics directed toward the beliefs held by individuals or groups about the plea. The present investigation surveyed state legislators in Wyoming to ascertain their estimates of the incidence and success rate of the insanity plea in Wyoming and their beliefs about certain procedures that govern the operation of the plea.
‘
‘
‘
Method
‘
A questionnaire of the Wyoming
was state
mailed to all members (N =92) legislature in December 1977. The return rate was 35% (N=32). Although this is a minority return, we think that the responses provide some information on legislators’ knowledge of the plea. Of the respondents, 27 were male, 3 female, and 2 did not specify their sex. Five were attorneys and 24 were not (3 respondents did not indicate occupations). Thirteen reported that they or members of their immediate families had been the victim of a crime at some time. The types of crimes they reported ranged from murder (one case) to petit larceny (five cases).
plea.
As a group, the legislators were even more emphatic in rejecting the notion, as proposed in Illinois and New York, that acquitted NGRI defendants should be treated in the same fashion as convicted individuals. Only 4 respondents agreed that ‘if a person has been found not guilty by reason of insanity to a criminal charge the consequences and/or punishment should be the same as for a person found guilty of the same crime who is not mentally ill’ ; 26 disagreed. Respondents indicated a fairly good awareness of procedures involved in the NGRI plea. Twenty-six of the legislators indicated that either the jury or the judge was responsible for the ultimate decision on a defendant’s sanity; two believed psychiatrists made the decision, and one thought it was the county attorney. Most legislators were also aware of the disposition of acquitted NGRI defendants. Nineteen in‘
.
In estimating incidence of the NGRI plea and its success rate, respondents were told that during the penod considered (1970-1972) there were 21,012 felony indictments in Wyoming (1). The legislators’ mean estimate of the number of persons who pled NGRI was
July
17, 1978; revised
Oct.
Dr. Pasewark is Professor and Training, University of Wyoming, Pantle is a doctoral candidate.
222
.
‘
Results
Received
.
6, 1978; Director Laramie,
accepted
Nov.
3, 1978.
of Clinical Psychology Wyo. 82071, where Mr.
0002-953X/79/02/0222/02/$00.35
©
‘Not all respondents cies varied.
1979
American
answered
Psychiatric
each
Association
question,
so response
frequen-
Am
J Psychiatry
136:2,
February
CLINICAL
1979
dicated that the person is mandatorily committed to the state hospital until he/she is considered sane, which is the requirement of a Wyoming statute. Ten stated that the NGRI patient was hospitalized for a stipulated time; and I expressed the belief that the individual was placed under the jurisdiction of the probation department.
Our results indicate that Wyoming legislators grossly overestimate the frequency and success rate of the NGRI plea in the state and seem to believe the defense is overused. However, a large majority still ascribes to the basic philosophy of the NGRI plea. We suspect the widespread publicity given by the media to the more notorious NGRI cases contributes to legislators’ gross overestimates. Although it would be easy to decry the lack of knowledge of legislators in this
BY LEWIS
A Case
M. COHEN,
M.D.,
I . Pasewark RA, Lanthorn BW: Disposition the insanity plea in a rural state. Journal I 977
A 26-year-old
Received
Sept.
woman
NED
H. CASSEM,
was seen for seven
psychoendocrinologic lactation. A planned
6, 1978: accepted
of persons of Humanics
utilizing 5:87-96,
of Galactorrhea M.D.,
MARK
E. MOLITCH,
Sept.
sessions evaluation and largely
as part of perunevent-
29, 1978.
Dr. Cohen is Clinical Fellow in Psychiatry, Harvard Medical School and Massachusetts General Hospital, Boston, Mass. 02214. Dr. Casscm is Chief, Psychiatric Consultation Service, Massachusetts General Hospital, and Associate Professor of Psychiatry, Harvard Mcdical School. Dr. Molitch is Assistant Physician, New England Med,cal Center Hospital, where Dr. Biller is Associate Staff Physician: he is also Assistant Professor of Medicine, Tufts University School of Medicine, where Dr. Biller is Instructor of Medicine. Dr. B,ller is also Staff Physician, Massachusetts Institute of Technology Medical Department.
0002-953X179/02/0223/02/$00.35
©
M.D.,
AND
BRUCE
J. BILLER,
M.D.
ful pregnancy had been followed by the delivery in October 1976 of a healthy first-born male child. Breast feeding was experienced as mutually pleasurable and was used to cornfort and pacify dysphoric feelings in both mother and child. The patient continued to nurse despite her return, at 3 months postpartum, to her position as a pediatric radiology technician and an exhausting trip, 7 months postpartum, to her sister’s university graduation. According to the patient’s journal this trip marked the onset of a sexual dysfunction characterized by diminished libido, anorgasmia, and decreased coital frequency. At 10 months postpartum she developed uterine cramps, her intrauterine device was removed, she resumed oral contraception, and discontinued nursing. Her son had become at this point ‘ ‘ a very independent child . . . so active that he broke his playpen . . . and seemed on the verge of weaning himself anyway. ‘ ‘ At 20 months postpartum, her galactorrhea persisted and she sought an endocrinologic evaluation. Her other complaints were the sexual disturbance, neurasthenia, and heightened irritability with her child and husband. Physical examination showed expressible milk in one breast, which did not decrease with a trial off of the oral contraceptives. The serum prolactin was normal (5. 1 ng/ml). Formal visual field testing, sellaturcica polytomography , computerized tomography, and other pituitary and thyroid hormone levels were also normal. Psychiatric referral was made to investigate links between her physical condition and emotional life. The patient had a brother 4 years older and a sister 6 years younger. She was the acknowledged favorite of her father, an alcoholic laborer, and the confidante of her mother. The mother, a chronically unhappy woman, was locked in a sexually impaired and vituperative relationship with her hus-
Report
of a comprehensive sistent postpartum
REPORTS
REFERENCE
Galactorrhea, or inappropriate lactation, has been recognized for centuries. Within the past decade, mcdical investigators have reexamined this condition and delineated syndromes according to the presence or absence of menstrual dysfunction and alterations of serum prolactin. Although prolactin secretion is regulated by the brain (I), and this hormone is known to influence behavior in lower animals (I), little is known about the psychological correlates and/or etiologic role of emotional factors in galactorrhea. The following case report is prompted by the highlighting during time-limited psychotherapy of the unique psychophysiologic aspects of galactorrhea. In contrast to the more traditional psychosomatic diseases, this case of pseudonursing, like those of pseudocyesis, proved to be unusually responsive to a relatively superficial cxploration of dynamics and underlying depression. Case
RESEARCH
sphere, we believe that the blame rests with members of the mental health and legal professions. In this belief, we are influenced by the written statements of a number of legislators who returned uncompleted questionnaires with remarks indicating that their task was to promulgate law, while ours was to provide them with the appropriate data. Considering the extreme paucity of objective information concerning the NGRI plea in the literature, we find ourselves forced to agree with this position, but we hope that this deficiency will be rectified through systematized studies of the NGRI defense.
Comment
Pseudonursing:
AND
1979
band.
Interestingly,
which ter.
lasted
American
for
she 20 years
Psychiatric
too
had
after
the
Association
developed birth
of
galactorrhea, the patient’s sis-
223
AND
RESEARCH
Am
REPORTS
sician is not always aware of the syndrome. In some cases, the diagnosis had been delayed for years and the patients had undergone expensive and intrusive investigations and received prolonged, unnecessary anticonvulsive medications for seizures of undetermined origin that were almost certainly due to water intoxication. Electrolyte estimates at the time of the seizure in those patients with a history of compulsive water drinking are essential in establishing the proper diagnosis of water intoxication.
Insanity BY
Plea:
RICHARD
Although guilty by psychiatric empirical characteristics
Legislators’
REFERENCES I. Rountree
PH.D., AND
2. Barahal
HS:
12:767-
Water
intoxication.
Arch
Int
Med
32:157-174,
Water
intoxication
in a mental
case.
Psychiatr
Q
771, 1938
3. Bartter FC: The Syndrome of Inappropriate Secretion of Antidiuretic Hormone. Chicago, Year Book Publishers, 1973 4. Jose CJ, Mehta 5, Perez-Cruet J: The syndrome of inappropriate secretion of antidiuretic hormone (SIADH): an overview in relationship to psychiatry. Can Psychiatr Assoc J (in press)
MARK
L. PANTLE,
to our knowledge,
M.A.
with a median of 3,025.50 and a range of 018,567. The mean estimate of the number of persons adjudicated NGRI was I ,794.28 (median=501 .00, range=0-l3,600). In fact, 102 defendants made this plea and only 1 was so adjudicated. Consistent with respondents’ overestimation of the frequency and success rate of NGRI plea was their response to the statement, ‘The insanity plea is used too much. Too many people escape responsibility for crimes by pleading insanity’ : 15 respondents agreed strongly, 1 1 agreed somewhat, 2 disagreed somewhat, and 2 disagreed strongly.’ Asked whether ‘there is ever a situation in which a person accused of a crime should be excused from responsibility for it because of mental illness,’ 21 legislators responded affirmatively and 10 negatively. Thus, a large majority of legislators expressed agreement with the basic philosophy underlying the NGRI
4,457.84,
‘
‘
been,
LG:
1923
philosophic discourses on the plea ‘not reason of insanity’ (NGRI) abound in the and legal literature, there have been few studies, most of which have examined the and disposition of persons who enter
have
1979
View
A. PASEWARK,
the plea. There
J Psychiatry 136:2, February
no stud-
ics directed toward the beliefs held by individuals or groups about the plea. The present investigation surveyed state legislators in Wyoming to ascertain their estimates of the incidence and success rate of the insanity plea in Wyoming and their beliefs about certain procedures that govern the operation of the plea.
‘
‘
‘
Method
‘
A questionnaire of the Wyoming
was state
mailed to all members (N =92) legislature in December 1977. The return rate was 35% (N=32). Although this is a minority return, we think that the responses provide some information on legislators’ knowledge of the plea. Of the respondents, 27 were male, 3 female, and 2 did not specify their sex. Five were attorneys and 24 were not (3 respondents did not indicate occupations). Thirteen reported that they or members of their immediate families had been the victim of a crime at some time. The types of crimes they reported ranged from murder (one case) to petit larceny (five cases).
plea.
As a group, the legislators were even more emphatic in rejecting the notion, as proposed in Illinois and New York, that acquitted NGRI defendants should be treated in the same fashion as convicted individuals. Only 4 respondents agreed that ‘if a person has been found not guilty by reason of insanity to a criminal charge the consequences and/or punishment should be the same as for a person found guilty of the same crime who is not mentally ill’ ; 26 disagreed. Respondents indicated a fairly good awareness of procedures involved in the NGRI plea. Twenty-six of the legislators indicated that either the jury or the judge was responsible for the ultimate decision on a defendant’s sanity; two believed psychiatrists made the decision, and one thought it was the county attorney. Most legislators were also aware of the disposition of acquitted NGRI defendants. Nineteen in‘
.
In estimating incidence of the NGRI plea and its success rate, respondents were told that during the penod considered (1970-1972) there were 21,012 felony indictments in Wyoming (1). The legislators’ mean estimate of the number of persons who pled NGRI was
July
17, 1978; revised
Oct.
Dr. Pasewark is Professor and Training, University of Wyoming, Pantle is a doctoral candidate.
222
.
‘
Results
Received
.
6, 1978; Director Laramie,
accepted
Nov.
3, 1978.
of Clinical Psychology Wyo. 82071, where Mr.
0002-953X/79/02/0222/02/$00.35
©
‘Not all respondents cies varied.
1979
American
answered
Psychiatric
each
Association
question,
so response
frequen-
Am
J Psychiatry
136:2,
February
CLINICAL
1979
dicated that the person is mandatorily committed to the state hospital until he/she is considered sane, which is the requirement of a Wyoming statute. Ten stated that the NGRI patient was hospitalized for a stipulated time; and I expressed the belief that the individual was placed under the jurisdiction of the probation department.
Our results indicate that Wyoming legislators grossly overestimate the frequency and success rate of the NGRI plea in the state and seem to believe the defense is overused. However, a large majority still ascribes to the basic philosophy of the NGRI plea. We suspect the widespread publicity given by the media to the more notorious NGRI cases contributes to legislators’ gross overestimates. Although it would be easy to decry the lack of knowledge of legislators in this
BY LEWIS
A Case
M. COHEN,
M.D.,
I . Pasewark RA, Lanthorn BW: Disposition the insanity plea in a rural state. Journal I 977
A 26-year-old
Received
Sept.
woman
NED
H. CASSEM,
was seen for seven
psychoendocrinologic lactation. A planned
6, 1978: accepted
of persons of Humanics
utilizing 5:87-96,
of Galactorrhea M.D.,
MARK
E. MOLITCH,
Sept.
sessions evaluation and largely
as part of perunevent-
29, 1978.
Dr. Cohen is Clinical Fellow in Psychiatry, Harvard Medical School and Massachusetts General Hospital, Boston, Mass. 02214. Dr. Casscm is Chief, Psychiatric Consultation Service, Massachusetts General Hospital, and Associate Professor of Psychiatry, Harvard Mcdical School. Dr. Molitch is Assistant Physician, New England Med,cal Center Hospital, where Dr. Biller is Associate Staff Physician: he is also Assistant Professor of Medicine, Tufts University School of Medicine, where Dr. Biller is Instructor of Medicine. Dr. B,ller is also Staff Physician, Massachusetts Institute of Technology Medical Department.
0002-953X179/02/0223/02/$00.35
©
M.D.,
AND
BRUCE
J. BILLER,
M.D.
ful pregnancy had been followed by the delivery in October 1976 of a healthy first-born male child. Breast feeding was experienced as mutually pleasurable and was used to cornfort and pacify dysphoric feelings in both mother and child. The patient continued to nurse despite her return, at 3 months postpartum, to her position as a pediatric radiology technician and an exhausting trip, 7 months postpartum, to her sister’s university graduation. According to the patient’s journal this trip marked the onset of a sexual dysfunction characterized by diminished libido, anorgasmia, and decreased coital frequency. At 10 months postpartum she developed uterine cramps, her intrauterine device was removed, she resumed oral contraception, and discontinued nursing. Her son had become at this point ‘ ‘ a very independent child . . . so active that he broke his playpen . . . and seemed on the verge of weaning himself anyway. ‘ ‘ At 20 months postpartum, her galactorrhea persisted and she sought an endocrinologic evaluation. Her other complaints were the sexual disturbance, neurasthenia, and heightened irritability with her child and husband. Physical examination showed expressible milk in one breast, which did not decrease with a trial off of the oral contraceptives. The serum prolactin was normal (5. 1 ng/ml). Formal visual field testing, sellaturcica polytomography , computerized tomography, and other pituitary and thyroid hormone levels were also normal. Psychiatric referral was made to investigate links between her physical condition and emotional life. The patient had a brother 4 years older and a sister 6 years younger. She was the acknowledged favorite of her father, an alcoholic laborer, and the confidante of her mother. The mother, a chronically unhappy woman, was locked in a sexually impaired and vituperative relationship with her hus-
Report
of a comprehensive sistent postpartum
REPORTS
REFERENCE
Galactorrhea, or inappropriate lactation, has been recognized for centuries. Within the past decade, mcdical investigators have reexamined this condition and delineated syndromes according to the presence or absence of menstrual dysfunction and alterations of serum prolactin. Although prolactin secretion is regulated by the brain (I), and this hormone is known to influence behavior in lower animals (I), little is known about the psychological correlates and/or etiologic role of emotional factors in galactorrhea. The following case report is prompted by the highlighting during time-limited psychotherapy of the unique psychophysiologic aspects of galactorrhea. In contrast to the more traditional psychosomatic diseases, this case of pseudonursing, like those of pseudocyesis, proved to be unusually responsive to a relatively superficial cxploration of dynamics and underlying depression. Case
RESEARCH
sphere, we believe that the blame rests with members of the mental health and legal professions. In this belief, we are influenced by the written statements of a number of legislators who returned uncompleted questionnaires with remarks indicating that their task was to promulgate law, while ours was to provide them with the appropriate data. Considering the extreme paucity of objective information concerning the NGRI plea in the literature, we find ourselves forced to agree with this position, but we hope that this deficiency will be rectified through systematized studies of the NGRI defense.
Comment
Pseudonursing:
AND
1979
band.
Interestingly,
which ter.
lasted
American
for
she 20 years
Psychiatric
too
had
after
the
Association
developed birth
of
galactorrhea, the patient’s sis-
223
