Friday, July 31, 2009

The "Golem" Syndrome

Actor and Director Paul Wegener in The Golem: How He Came Into the World (1920), a German Expressionist masterpiece.

Last week, we learned about the Zombie, the Nymphomaniac, and the Emotional Immaturity Masculine Protest Syndrome (Bierer, 1976a). In the second and final installment of the strange diagnoses of Austrian psychiatrist Joshua Bierer, M.D., F.R.C.PSYCH., D.ECON. & SOC.SC. (VIENNA), DIP.INDIV.PSYCH., we have the "Golem" syndrome:
This is a man, who as a child has neither experienced nor been trained in the three ingredients of emotional life: Attention, Love and Affection. The word "Golem", in mediaeval Jewish legend, describes a sort of machine man, a robot. Some 50 years ago it was the subject of a famous novel, by Gustav Meysink, made into a film.

A man who has lived such a life as a child has not developed the "emotional antenna" or the "love-receiving apparatus", to be able to receive or to acknowledge emotional signals. Such men go from woman to woman and are often considered to be excellent lovers. These women do not realise that they receive not love but hate, not compassion but revenge, not commitment but a desire to escape, that it is not a mutual emotional experience of beauty but a one-sided desire to hurt, and even to kill.

Julian McMahon as Dr. Christian Troy

I was immediately reminded of fictional plastic surgeon Dr. Christian Troy, a main character on the over-the-top American TV show, Nip/Tuck. Dr. Troy uses women sexually (including nearly all of his female patients) and then tosses them aside. However, dramatic revelations about his past ostensibly offer some explanation for his present behavior: he was molested as a child by his foster father, and his biological mother was raped and became pregnant with him.

In an article entitled, Love-making--an act of murder, the real-life Dr. Bierer (1976) continues his description of the "Golem" syndrome (G.S.) in a case study of one of his patients:
The husband’s girl friends considered him a "great lover", not realising that it was a dagger and not a loving penis, which he pushed into them. They did not realise that this man could not love, could not commit himself, was unable to develop a relationship, that he hated all women and wanted to kill them-but to avoid that he ran away as soon as he could.

The secret of all this goes back far into his childhood-and it was revealed during his analysis.

During the war the husband’s mother, who was a cold woman, unable to show any love or affection, was mainly away. The husband’s father left for abroad when the husband was six years of age, leaving him and his brother, who was then three years old, in the hands of a very cruel nanny. The nanny told him one day that she was going to kill his brother and tell everybody that he had killed him, as people knew that he hated his brother. (This has been confirmed.)

One can imagine the dreadful anxiety this poor boy had to suffer, not being able to ask anybody for help, being completely in the hands of this cruel nanny.
And there we have a convenient Freudian rationalization for inveterate cheating and for domestic violence, which was "cheerfully tolerated" by his wife the shrew who limited his freedom:
In this case it was imperative to part husband and wife, in order to prevent possible murder. The husband had been violent towards his wife in the past. She took it in good spirits and with courage, because she loved him and she loved their children, whom she did not want to harm by running away. Whenever he became violent she jumped on his back and tried to protect herself as best she could. This made him all the more furious, as he felt his freedom "physically curtailed". It was already mentally curtailed by her scenes of jealousy and tantrums, which she threw whenever she suspected that he had once again been unfaithful.
The couple separated for several months, during which time the wife fell for someone else. But then they got back together and...
...started sexual relations again-and although they are not quite as satisfactory as they were originally, I believe the chance of murder has been removed forever...
Let's hope so!


Bierer J. (1976a). Zombie. International Journal of Social Psychiatry, 22 (3), 200-201.

Bierer, J. (1976). Love--Making--An Act of Murder: The "Golem" Syndrome (G.S.) International Journal of Social Psychiatry, 22 (3), 197-199 DOI: 10.1177/002076407602200305

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Friday, July 24, 2009

Emotional Immaturity Masculine Protest Syndrome

From Bierer (1976).

I have just discovered a treasure trove of surprising stupefying psychoanalytic articles that appeared in the International Journal of Social Psychiatry from 1976-1980. They were written by Austrian psychiatrist Joshua Bierer, M.D., F.R.C.PSYCH., D.ECON. & SOC.SC. (VIENNA), DIP.INDIV.PSYCH.

The Jun. 23, 1961 issue of Time magazine described Dr. Bierer as a proponent of tearing down mental hospitals:
Hospitals Without Locks

In Western countries, mental hospitals are big and numerous—yet crowded beyond capacity; they cost too much—yet cannot get enough psychiatrists to staff them. The solution to these paradoxes, says British Psychiatrist Joshua Bierer: tear down most of the hospitals.

With a prophet's zeal, the modern Joshua who wants the walls to come tumbling down has preached his doctrine more than 120 times in the last three months to hundreds of U.S. and Canadian psychiatrists and mental health workers. Many of his hearers sputtered, "You don't really mean it!" But Dr. Bierer does. He seriously proposes the wiping out of most of the present mental hospitals, and certainly the big ones where patients are kept round the clock for months and years.
Dr. Bierer ran the Marlborough Day Hospital in London, which was part of the therapeutic community movement. According to Campling (2001),
The term ‘therapeutic community’ is usually used in the UK to describe small cohesive communities where patients (often referred to as residents) have a significant involvement in decision-making and the practicalities of running the unit. Based on ideas of collective responsibility, citizenship and empowerment, therapeutic communities are deliberately structured in a way that encourages personal responsibility and avoids unhelpful dependency on professionals.
The community is "informed by systems theory and organisational management theory as well as psychoanalytical and group-analytical ideas." It seems to me, however, that some of Dr. Bierer's ideas -- his diagnoses and treatments -- were... um... "unusual" to say the least. Here's the trigamist syndrome (Bierer 1980):
A BIGAMIST is a man who is "legally" married to two women. A "TRIGAMIST" (according to my definition) is a PERSON who is "married" (in the sense of being deeply attached) three times over to such an extent that there is little or no room left for a "permanent" commitment. The three "marriages" are to: a) a parent b) an occupation c) an ideal figure which exists only in the mind of the beholder. Parts of this syndrome have been described separately in scientific and literary form innumerable times but the syndrome as a WHOLE has never been recognised or described in spite of the fact that it is responsible for influencing millions of human relationships and destroying the life of countless people.
After that abstract, the text of the article begins in a rather colloquial fashion:
"HOW is it, that I, a psychiatrist of 55 years’ experience who has, through his work, helped thousands of people to gain insight and live a happier life, should have to marry four times?"
In a stroke of LONG-delayed genius and insight, the good doctor then diagnoses himself with the trigamist syndrome: "...I only now made the great discovery that every one of my marriages was bound to fail since I had already been married three times..."

But my favorite is the titular E.I.M.P.S., which appeared in his 1976 Zombie article [yes, really]:
The "Zombie" is brought up, from early childhood, in an emotional and social desert. Such women never learnt to develop the ability innate in most humans, the ability to accept and reciprocate the emotional signs given out by other people. This makes them unable to communicate with other people-and no wonder they land in the mental hospital, with a label of "schizophrenia" pinned on them. In the past the label "catatonic" was not unusual-sometimes it was "deep depression". These labels mean very little...

. . .

Zombies have, on the whole, a poor prognosis, unless one is able to establish a strong transference and able to help the patient to train very slowly the "Emotional Antenna" or the "Love Receiving Apparatus", without which no-one can accept, register and acknowledge the emotional signals.
I, too, have always thought that zombies have a poor prognosis given they are already dead.

And who hasn't heard of the next sad type?
The nymphomaniac female is well known and well documented. Their complete frigidity by various factors, more often than not of traumatic nature makes them run from man to man, trying to find the solution to their problem instead of looking into themselves and trying to change themselves and their whole outlook on LIFE.

Recommended Treatment: syntho-analytic re-training

I did not realize that 1976 was in the 19th century!! Have we identified the true source of Dr. Bierer's marital problems?

Finally, we have T.S.T. for E.I.M.P.S. (Bierer 1976b).

Recommended Treatment: Total Separation Treatment
Over 50 female patients (both in-patients and out-patients) were found and studied, who had in common the points previously enumerated. Theye [sic] were variously diagnosed as suffering from manic depressive insanity, agitated melancholia, reactive depression, obsessional neurosis, hysteria and anxiety state, but it is noteworthy that there was no case of schizophrenia among the group. In addition it was found that they all had one feature in common-a kind and considerate husband.
Dr. Bierer said the T.S.T. method of treatment is especially valid under the following conditions:

1. When the female is an active, extroverted person.
2. She was considered to have been a tom-boy.
3. She looked for and had the admiration of many men.
4. She had a traumatic experience in childhood, usually with her father.
5. She felt that her parents interfered unduly with her development to complete independence.
6. She had a strong, subconscious desire to leave home.
7. For that reason she believed that she had fallen in love with the first man who came along.
8. She looked younger than her age.
9. She remained unaware that she had married, not of her volition, but forced by circumstances.
10. She was emotionally immature, not being ready for married life. She was unable to experience any emotions when intimate relations with her husband took place (frigidity).
. . .
15. She felt like a cornered rat, who hits out, bites and scratches blindly in the fury of a desperate struggle for self-preservation.

I suppose the simplest way of letting a cornered rat feel that it is not cornered is to remove either its aggressors or the walls around it and let it feel that it can run wherever it likes.
If a ‘therapeutic community’ psychiatrist calls most of his female patients frigid, sex-hating cornered rats who may hate and/or despise men [what's the difference??], it's time to bring on the drugs and a get new shrink...


Bierer J. (1976). Zombie. International Journal of Social Psychiatry, 22 (3), 200-201 DOI: 10.1177/002076407602200306.

Bierer J. (1976b). The total separation treatment (T.S.T.) A method for the treatment of marital difficulties and disharmonies in patients suffering from the E.I.M.P. syndrome. Int J Soc Psychiatry 22:206-13.

Bierer J. (1980). The trigamist syndrome: (A syndrome not described so far which is responsible for the breakup of innumerable marriages). Int J Soc Psychiatry 26(4):242-5.

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Monday, July 20, 2009

Neurological Injuries from Car Surfin' USA

Car surfing (for those who don't know) is...
...a form of acrobatics (or an illegal stunt if performed in public traffic) in which passengers of moving vehicles perform various stunts, including hanging out of the car or 'surfing' on the hood, trunk or on the roof of the vehicle while it is in motion. Car surfing has caused several people to be killed during the course of such stunts.

The 1985 movie Teen Wolf was one movie which inspired many young people to try car surfing.[citation needed]
The Urban Dictionary has a more graphic take:
A way to commit suicide by driving a car on a very busy highway/freeway/interstate at a very high speed, setting the car into cruise control and then climbing out of the car through the window and standing on top of the car as if the driver were surfing until the car hits something.

"Some dude in Arizona went car surfing on the freeway and killed himself."
Actually, some dude [the 55 year old chief financial officer for the city of Phoenix] did die in this manner in 2004:
Keogh climbed onto the roof of his moving car after setting the cruise control around 50 miles an hour Wednesday afternoon. He then "surfed" on the top of his car on Camelback Road before falling to his death. The car eventually came to stop when it rear-ended a car waiting for a traffic light...1
A new paper in the Journal of Neurosurgery: Pediatrics (Wang et al., 2009) took the unique approach of consulting national statistics and searching the local pediatric trauma registry for cases of head injuries due to car surfing, as well as examining portrayals of this dangerous activity in the media:
A retrospective search of all major US newspaper articles was conducted using LexisNexis to help identify the factors leading to the population of car surfers. ... A search of newspaper articles reporting car-surfing accidents between June 1998 and June 2008 was conducted using the term “car surfing.” Each article was analyzed for information regarding the motivations behind the car-surfing activity and the circumstances surrounding the accident. ... This information was then correlated with the number of car-surfing fatalities identified from FARS [Fatality Analysis Reporting System, national database] between 1998 and 2006.
During the period 1995-2008, the authors identified 7 patients (11-16 yrs of age) from the local pediatric trauma records in Cleveland, OH as outlined in the table below (click to enlarge).

All 7 patients sustained their injuries between the years 2001 and 2008. In 3 of these patients, the mechanism of injury involved surfing on the back trunk of the moving vehicle; these patients accidently fell off as the vehicle braked or accelerated rapidly. Two patients fell from the hood of the vehicle, 1 patient fell from the side of the vehicle, and 1 patient jumped off after surfing on the exterior of the vehicle. All patients sustained their injuries from striking their heads on the pavement. Four patients had a loss of consciousness. ... One patient required craniotomy for emergency evacuation of an acute SDH [subdural hematoma] ... Four patients suffered long-term neurological complications, including impaired impulse control, emotional instability, chronic headaches, and memory difficulties.
Results of the Lexis-Nexis search did not surprise loyal MTV viewers and gamers:
...the television show Jackass, the video game Grand Theft Auto, and the video-sharing website YouTube depict car surfing as a popular activity. These media sources frequently portray car surfing in warm, sunny climates. To estimate whether regional differences in car-surfing fatality rates exist, we analyzed the 8 states with the highest fatality rates related to car surfing: California, Florida, New York, Texas, Michigan, New Jersey, Ohio, and Pennsylvania. ... The 3 states with the highest number of fatalities during this period of time were California (51 children), Texas (42), and Florida (40)—all states with warm, sunny climates.
In other words, Car Surfin' USA.

A sizeable literature on car surfing injuries already exists [OK, 7 articles in Pubmed]. My favorite is this one by a pair of Belgian forensic experts (Hooft & van de Voorde, 1994):
Reckless behaviour related to the use of MDMA (ecstasy): apropos of a fatal accident during car-surfing.

A 26-year-old man died from severe brain contusion after falling from a moving car during an attempt at car-surfing. Toxicological urine screening was positive for amphetamines, the blood analysis revealed a MDMA level of 0.63 mg/l and a blood alcohol concentration of 1.23 g/l. The case is another example of the bizarre and reckless behaviour which may result from the euphorogenic activity of ecstasy and the circumstances in which it is commonly used.
In conclusion, Wang et al. (2009) suggest that appropriate educational materials from health care providers and community leaders should warn of the dangers of car surfing. Media depictions of such stunts should include disclaimers, perhaps like this one:


1 The news article continues:
Phoenix officials said Keogh was suffering from a tropical parasitical disease he picked up while vacationing in Mexico a few years ago. The disease, unnamed by city officials, recently flared up.
In a neurological digression, I was curious the tropical brain parasite... could it have been neurocysticercosis? Cerebral schistosomiasis mansoni? A subsequent autopsy, however, ruled out a parasitic infection. Apparently, Keogh was under tremendous pressure at work. He may have been depressed and he may have committed suicide. But the case was declared a medical mystery when evidence of brain damage was discovered, "consistent with his symptoms being due to an underlying disease process."


Hooft PJ, van de Voorde HP. (1994). Reckless behaviour related to the use of 3,4-methylenedioxymethamphetamine (ecstasy): apropos of a fatal accident during car-surfing. Int J Legal Med. 106:328-9.

Wang A, Cohen AR, Robinson S. (2009). Neurological injuries from car surfing. Journal of Neurosurgery: Pediatrics. Published online July 17, 2009. DOI: 10.3171/2009.4.PEDS08474.

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Saturday, July 18, 2009

Before You Take That Paxil

I'm bringing Paxilback (yeah)
Generic brands just don't know how to act (yeah)
I pop a couple with that water back (yeah)
Bottomless coffee and a half a pack

The Gray Kid: PaxilBack
A very interesting "debate"1 over the issue of screening new mothers for postpartum depression erupted in the blogosphere this week. The original point of contention is the Melanie Blocker Stokes MOTHERS Act (H.R. 20: Melanie Blocker Stokes Mom's Opportunity to Access Health, Education, Research, and Support for Postpartum Depression Act). The bill proposes "To provide for research on, and services for individuals with, postpartum depression and psychosis." The full text of H.R. is here.

In one corner is J. Douglas Bremner M.D., a professor of psychiatry and radiology at Emory University. He writes a blog called Before You Take That Pill, named after the title of his book.2 Dr. Bremner is a very prolific physician scientist, with numerous publications in the field of biological psychiatry. In addition, he receives millions of dollars in funding from federal agencies that include the NIH, the Department of Veterans Affairs, and the Department of Defense. He specializes in researching the neurological and physiological effects of PTSD other conditions resulting from trauma exposure. He is the Principal Investigator on a clinical trial of Early Intervention for PTSD, which involves administration of the SSRI antidepressant paroxetine (generic for Paxil3) or placebo to Iraq War veterans with PTSD.

In the other corner is John M. Grohol Psy.D., CEO and Founder of the mental health site PsychCentral. After training to become a clinical psychologist, Dr. Grohol was the first to establish an online mental health portal (in 1995), and he has published on internet use and social support. He runs the flagship World of Psychology blog and hosts a number of other blogs that highlight different concerns in mental health and psychology. PsychCentral reprints pertinent press releases on its News page, has an Ask the Therapist advice column, runs online support groups (forums), and posts comprehensive information on symptoms and treatment of mental disorders, psychotropic medications, and clinical trials.

I found the whole debate rather interesting because it involved a role reversal of sorts, with the prescribing psychiatrist warning of the evils of over-medication, and the therapy-favoring clinical psychologist vilified as a tool of the pharmaceutical industry. It all started when Bremner published this post, Motherhood is Not a Medical Disorder. Here he argued that the MOTHERS act is a bad idea because it mandates screening [I could not find that particular clause in H.R. 20] and pathologizes motherhood.
First of all, there is no evidence that women without a prior history of anxiety and depression have any increased risk of getting post partum depression. So to screen all moms as if giving birth is a risk factor for depression is ridiculous. And whenever you start screening the general population, you get into problems with over-identification of people and an increase in the number of people that go on antidepressants. I am opposed to mandatory screenings of the population, like Teenscreen, which are bonanzas for the pharmaceutical industry, but a major intrusion into the privacy and autonomy of American citizens.
Note the passage in bold [my addition]. Grohol took exception to that claim (and others therein) and responded with Bremner’s False Claims about Postpartum Depression. Some considered this post to be very controversial (note the 120 comments), and others found it to be a very well-reasoned summary of the published literature (I fall into the latter camp). Grohol states:
My BS alert goes off whenever someone tries to change the argument from a reasonable effort to help increase education and information about a stigmatized mental health issue, to hyperbole, suggesting that a piece of legislation is trying to turn motherhood into a psychiatric disorder. It goes off again when a professional makes an extraordinary claim like, “there is no evidence that women without a prior history of anxiety and depression have any increased risk of getting post partum [sic] depression.” Really? Absolutely no evidence? That’s quite a strong statement, and easily proven false with a literature review.
He then proceeds to provide a literature review strongly suggesting that risk factors other than a prior history of anxiety and depression can predispose a new mother to postpartum depression. He explains further:
Now, I understand Bremner’s point — let’s not medicalize and catastrophize ordinary motherhood. I agree. And of course a woman’s pre-birth depression or anxiety is strongly correlated to postpartum depression. But not exclusively, as Bremner claims.

Bremner claims, with no evidence, that all mental health screenings are simply pharmaceutical sales tactics to help increase prescriptions. That’s ridiculous. When I worked in community mental health, we ran annual mental health screenings in the clinic — with no funding from any pharmaceutical company — because it reduces stigma, decreases misinformation and increases education about mental health issues in the general population.
I don't want to (or need to) detail all the points pro and con. You can read 120 comments on that post or one of Bremner's followups (Motherhood is STILL Not a Medical Disorder: Response to Critics and Mommy Wars: John Grohol is Blocking My Comments from His Website So I Am Commenting Here).4

In the past, I have disagreed with Grohol over his view that mental illness is not a "brain disease" analogous to other medical ailments. And I have defended Bremner's right to be a poopy head say what he wants on his own blog5 (but also noted that referring to a rival's opposing statements as "retarded" isn't the best way to make a reasoned argument)6.

Just an observation, but the benefit vs. harm of treatment for psychiatric disorders is one of those volatile issues in which the adamantly opposing sides are never going to change each other's minds.


1 Complete with vitriolic flame wars in the comments.

2 From Amazon:
In Before You Take That Pill, Dr. J. Douglas Bremner, a researcher and clinician at Emory University whose study on Accutane and depression made headlines, offers an inside look at the pharmaceutical industry, as well as a scientifically backed assessment of the risks of more than three hundred prescribed medications, vitamins, and supplements.
3 Bremner used to be a paid consultant for GlaxoSmithKline, the makers of Paxil®, but not any more.

4 It seems unlikely that Grohol deliberately blocked his comments, because of such things as spam filters and comment moderation.

5 However, using Emory University letterhead to post a "doctor's letter" asserting the medical necessity of smoking in a bipolar person [even if it was meant satirically] may not have been a bright idea.

6 Oh yeah, I also made this comment over at David Dobb's excellent blog, Neuron Culture.

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Monday, July 13, 2009

I Just Finished the Boston Marathon! (but I can't remember your name)

Third place finisher Ryan Hall at the 2009 Boston Marathon.
Photo courtesy of
Martin Checkoway.

Running a 26.2 mile marathon is an exhausting endeavor for anyone, from the top Ethiopian and Kenyan runners to the astounding 75 year old Jim Schleisman (who finished in 3:45:33) to the back of the pack casual joggers runners. Two psychologists from Columbia university reckoned that the physical stress of marathon running might result in cognitive impairments (Eich & Metcalfe, 2009). Although the benefits of moderate aerobic exercise are well-documented, levels of cortisol [a "stress hormone" produced by the adrenal glands] after strenuous marathon running are four times greater than those observed after laboratory-based stress induction paradigms.
Indeed, cortisol levels recorded 30 min after completion of a marathon rival those reported in military training and interrogation (Taylor et al., 2007), rape victims being treated acutely (Resnick, Yehuda, Pitman, & Foy, 1995), severe burn injury patients (Norbury, Herndon, Branski, Chinkes, & Jeschke, 2008), and first-time parachute jumpers (Aloe et al., 1994).
Thus, along with parachute jumping, marathon running presents an ethical opportunity for studying the effects of extreme cortisol levels on cognitive processing. In particular, cortisol may disrupt hippocampal function and explicit memory -- the conscious recollection of previously learned information (Brunner et al., 2008). In contrast, implicit memory is thought to be unconscious and independent of the hippocampus, as demonstrated in studies of amnesic patients where impairments in explicit memory are accompanied by intact implicit memory performance (Squire, 2004).1

So would completing a marathon differentially affect explicit and implicit memory? The authors predicted the following:
Our hypothesis was that when marathon runners had just undergone the stress of running a marathon as compared with several days earlier, their performance on the explicit cued recall task would be impaired. At the same time, we predicted that their performance on the implicit stem-completion task would be spared or might even be enhanced.
The participants were 261 individuals who had completed either the New York City Marathon or the Boston Marathon: 141 were tested within 30 min of finishing, while the other 120 were tested 1-3 days before the race. All participants were given an implicit memory test (word stem completion) and an explicit memory test (word stem cued recall). Both tasks involve studying a list of words, followed by a series of 3-letter word stems. The instructions dictated which form of memory was to be evaluated, as described in the Procedure:
Participants rated 26 words for pleasantness on a 5-point scale. Text on the second page informed participants that each of the cues on the subsequent page would be the beginning of an English word. Their task would be to write a few letters to make each cue into any English word, but they were instructed to write down the first one that came to mind. The next page, which presented the implicit word-stem completion task, contained word stems from 13 words that were previously rated for pleasantness as well as stems from 13 unrated (baseline) words, randomly intermixed. Following completion of the implicit memory task, participants were given instructions for the explicit memory cued recall task. They were told that each of the cues on the subsequent page was the beginning of a word for which they had provided a pleasantness rating earlier. They were instructed to try to complete each cue with the word from the pleasantness-rating list—that is, to explicitly remember the previously rated words. They were also instructed not to look back at the list. After reading these instructions, they turned to the last page, which contained the 13 remaining three-letter word stems presented in a random order, all of which they had previously rated for pleasantness. Given the cues, they then attempted to recall the words.
The brief example below gives a list of words seen during the study phase, followed by a series of word stems that are either completed with the first word that comes to mind (implicit memory), or used as cues to recall words from the study phase (explicit memory).




The results below illustrate that a dissociation between the two forms of memory was observed.

Figure 1 (Eich & Metcalfe, 2009). Performance on the implicit and explicit memory tasks. The left bars give the difference between the control (premarathon) and marathon (postmarathon) groups on the implicit memory word-stem completion task. The right bars give control group and marathon group performance on the explicit cued recall task. Priming is the difference in the proportions of correctly completed presented and unpresented (baseline) words.

As predicted, there was a significant decline in explicit memory after running a marathon. Less expected (but still not a complete surprise) was an increase in performance on the implicit memory task. The authors
interpret the results as suggesting that complex neuromodulation associated with extreme stress enhances some brain systems and inhibits others... As we acknowledged in our introduction, marathon running results in a host of other physiological changes [beyond increased cortisol], some of which may lead to decrements in explicit memory. However, consideration of those factors alone provides no obvious explanation as to why marathon running led to improved implicit memory.
Nevertheless, do they have a tentative conclusion about why that happened?
...Stress hormones, including norepinephrine, endorphins, and others, are surging in marathon runners. It is not unreasonable to suppose that these hormones serve to improve certain kinds of mental function.
But don't even try to remember where you parked your car...


1 But see Berry et al., 2008 for the opposing view that explicit and implicit memory are not independent and dissociable forms of memory.


Berry CJ, Shanks DR, Henson RN. (2008). A unitary signal-detection model of implicit and explicit memory. Trends Cog Sci. 12:367-73.

Brunner R, Schaefer D, Hess K, Parzer P, Resch F, Schwab S. (2006). Effect of high-dose cortisol on memory functions. Ann N Y Acad Sci. 1071:434-7.

Eich, T., & Metcalfe, J. (2009). Effects of the stress of marathon running on implicit and explicit memory Psychonomic Bulletin & Review, 16 (3), 475-479 DOI: 10.3758/PBR.16.3.475

Squire LR. (2004). Memory systems of the brain: a brief history and current perspective. Neurobiol Learn Mem. 82:171-7.

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Friday, July 03, 2009

Is CBT Worthless?

According to a new meta-analysis in Psychological Medicine (Lynch et al., 2009), Cognitive Behavioral Therapy (CBT) is not helpful for those with schizophrenia and bipolar disorder, and any improvements seen in major depression are rather small:
Conclusions: CBT is no better than non-specific control interventions in the treatment of schizophrenia and does not reduce relapse rates. It is effective in major depression but the size of the effect is small in treatment studies. On present evidence CBT is not an effective treatment strategy for prevention of relapse in bipolar disorder.
CBT is a form of psychotherapy that attempts to change the patient's unhealthy thoughts and actions. The patient learns to identify distorted thought patterns and beliefs, and to replace them with more productive ways of thinking and acting. Frequently the treatment is very brief, and also "highly structured, problem orientated and prescriptive, and individuals are active collaborators." The short duration of 5-20 weeks in most cases is appealing to insurance companies. Previous studies have endorsed CBT as one of the most effective treatments for major depression and many other disorders (see this review of CBT meta-analyses by Butler et al., 2006). Recommendations for CBT primarily as an adjunct treatment in schizophrenia are fewer, and have been more common in the UK (Rosack, 2002) than in Canada and the US (but see Rector & Beck, 2002). CBT may have beneficial effects during the depressive phase of bipolar disorder, but previous studies have been variable and inconclusive (Miklowitz & Scott, 2009).

Lately we've been treated to a plethora of articles and press releases saying that antidepressants are worthless and no better than placebo. The present meta-analysis by Lynch et al. (2009) came to the same conclusion about CBT in schizophrenia, and ratcheted down its effectiveness in major depression. The press release is quite blunt:
Cognitive Therapy Is Of No Value In Schizophrenia, Analysis Of Studies Suggests

ScienceDaily (June 26, 2009) — Research co-led by an academic at the University of Hertfordshire, concludes that cognitive behavioural therapy (CBT) is of no value in schizophrenia and has limited effect on depression.

. . .

The results of the review suggest that not only is CBT ineffective in treating schizophrenia and in preventing relapse, it is also ineffective in preventing relapses in bipolar disorder.

The review also suggests that CBT has only a weak effect in treating depression, but it has a greater effect in preventing relapses in this disorder.
The meta-analysis included studies examining the effectiveness of CBT against symptoms in schizophrenia and depression, and in reducing relapse in schizophrenia, depression, and bipolar disorder. Rigorous criteria were used when selecting only well-conducted clinical trials of CBT for inclusion:
The studies were required to use a control intervention that the study investigators either explicitly considered not to have specific therapeutic effects or which might reasonably be regarded as lacking these (e.g. supportive therapy, psycho-education, relaxation). We also included studies comparing CBT to pill placebo (which have only been carried out in major depression). Blindness of evaluations was not specified as a requirement for inclusion, but was examined as a moderator variable. In keeping with the general approach of meta-analysing methodologically rigorous trials, we did not include studies with small sample sizes (less than 10 participants in either group) or studies that were identified by the authors as pilot studies.
Lynch et al. provided a list of excluded studies in their Supplementary Materials, and I imagine there will be much debate in the field over the inclusion and exclusion criteria. The authors end on a cautionary note:
The authors of meta-analyses of CBT for depression seem unperturbed by the fact that they are basing their conclusions on studies that have often been carried out against TAU [treatment as usual] or a waiting list control; that have not always been randomized; that sometimes failed to use diagnostic criteria; and that so far have ignored the moderating effect of blindness altogether. These issues are not trivial; the findings of our meta-analysis could be viewed as an object lesson on the importance of taking such sources of bias into account.

Butler AC, Chapman JE, Forman EM, Beck AT. (2006). The empirical status of cognitive-behavioral therapy: a review of meta-analyses. Clin Psychol Rev. 26:17-31.

Lynch, D., Laws, K., & McKenna, P. (2009). Cognitive behavioural therapy for major psychiatric disorder: does it really work? A meta-analytical review of well-controlled trials. Psychological Medicine DOI: 10.1017/S003329170900590X.

Miklowitz DJ, Scott J. (2009). Psychosocial treatments for bipolar disorder: cost-effectiveness, mediating mechanisms, and future directions. Bipolar Disord. 11 Suppl 2:110-22.

Rector NA, Beck AT. (2002). A clinical review of cognitive therapy for schizophrenia. Curr Psychiatry Rep. 4:284-92.

Rosack J (2002). Psychiatrists Assess CBT As Schizophrenia Treatment. Psychiatric News 37:18

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