Sunday, October 31, 2010

Diagnostic Criteria for Demonic Possession

ABSTRACT: This article addresses the validity of viewing demonic possession as a phenomenon distinct from any other form of pathology. It does so by briefly examining the historical relationship of demon possession and other forms of illness; reviewing some of the psychological research into the phenomena of possession; and then presenting a description of possession derived from a study of fourteen possessed individuals.

The article concludes that possessions do exist as a phenomena independent of the current commonly accepted forms of psychopathology. A diagnostic description of possession is then presented to enable a greater ability to differentiate cases of possession from the present categories of the DSM-III.


Isaacs TC (1987). The possessive states disorder: The diagnosis of demonic possession. Pastoral Psychology 35:263-273.

Magnetism Revealed (1784). From a popular pamphlet. Reproduced in Lancet (2009).

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Wednesday, October 27, 2010

Media HSDD: "Hyperactive Sexual Disorder Detection"

You might have seen the news stories with their facile headlines:
Women with low libidos 'have different brains'

Women with low libidos have a different mental response to intimate situations than those with a 'normal' sex drive, researchers have found.

By Stephen Adams, Medical Correspondent, in Denver
Published: 5:59AM BST 26 Oct 2010

MRI scans show that women diagnosed with what is termed hypoactive sexual desire disorder (HSDD) - defined as a distressing lack of sexual desire - have different patterns of brain activity.

Certain areas of the brain that normally light up when thinking about sex fail to do so in women with HSDD, found medics at Wayne State University in Detroit, US, while other areas that don't normally light up, do.
...and even worse:
Libido problems 'brain not mind'

Scans appear to show differences in brain functioning in women with persistently low sex drives, claim researchers.

The US scientists behind the study suggest it provides solid evidence that the problem can have a physical origin.
[NOTE: The mind is separate from the brain? Really?? Then where is the mind located? In the big toe? The pancreas?]

Hypoactive Sexual Desire Disorder (HSDD) is a controversial diagnosis given to women who have a low (or nonexistent) libido and are distressed about it. Dr. Petra Boynton has written extensively about the problematic aspects of the HSDD diagnosis and the screening tools used to assess it, as well as the medicalization of sexuality for pharmaceutical marketing purposes.

The issue to be discussed here is the widespread press coverage given to an unpublished study presented at a conference. This is fairly standard practice, as professional organizations such as the Society for Neuroscience have a well-staffed press room where properly credentialed reporters have access to:
  • Embargoed annual meeting news releases
  • Lay-friendly summaries of newsworthy findings
  • Press conference slides and video footage

Here's the HSDD abstract in question, from an oral presentation at the American Society for Reproductive Medicine's 66th Annual Meeting:


T. L. Woodard, N. T. Nowak, S. D. Moffat, M. P. Diamond, M. E. Tancer, R. Balon. Wayne State University School of Medicine, Detroit, MI

OBJECTIVE: To identify and compare cerebral activation patterns of premenopausal women with acquired HSDD versus those with normal sexual function during viewing of sexually explicit film clips.

DESIGN: Prospective Cohort Study.

MATERIALS AND METHODS: After IRB approval, 19 premenopausal women with HSDD and 7 women with normal sexual function were recruited to participate in the study. The diagnosis of HSDD was confirmed using the Sexual Function Questionnaire (SFQ), Female Sexual Distress Scale (FSDS) and a clinical interview. Functional neuroimaging was performed on a 4 T Siemens Bruker Hybrid Scanner while participants viewed three categories of video stimuli (solid blue screen, neutral videos, and sexually explicit videos), which alternated every 60 seconds for 32 minutes in a block design. Data were analyzed using Statistical Parametric Mapping 2 (SPM2).

RESULTS: When cerebral activation patterns associated with viewing sexually-explicit videos in normal women was compared to that of women with HSDD, women with normal sexual function had greater activation in superior frontal and supramarginal gyri. Women with HSDD exhibited greater activation in the inferior frontal, primary motor, and insular cortices. Additionally, normal women had greater activation in the posterior cingulate cortex while women with HSDD appeared to recruit the midcingulate region.

CONCLUSION: Cerebral activation patterns in women with HSDD differs from those in women with normal sexual function and may reflect differences in how they interpret sexual stimuli.

Supported by: Wayne State University Departments of Psychiatry and Obstetrics and Gynecology.

Access to the meeting website requires registration, although one does not have to be a member of the ASRM to do so. Nonetheless, the barrier to finding this information online is rather high, and I imagine only 3 other people cared enough to do the proper searches.

Do these researchers have any peer reviewed publications related to neuroimaging studies of HSDD? There's a brief mention of fMRI and PET in one review paper (Woodard & Diamond, 2009). They also have a fun paper on how they chose their stimuli (i.e., erotic films). Q: What kind of erotic film clips should we use in female sex research? A: heterosexual vaginal intercourse.1 [See this summary by Scicurious.]

Let's return to the abstract and the major neuroimaging results:
When cerebral activation patterns associated with viewing sexually-explicit videos in normal women was compared to that of women with HSDD, women with normal sexual function had greater activation in superior frontal and supramarginal gyri. Women with HSDD exhibited greater activation in the inferior frontal, primary motor, and insular cortices. Additionally, normal women had greater activation in the posterior cingulate cortex while women with HSDD appeared to recruit the midcingulate region.
The supramarginal gyrus in the parietal lobe? Yeah, that's a real sexy area of the brain. So is the superior frontal gyrus, for that matter. Neither of these brain areas are implicated in sexual arousal, so the fact that these regions showed greater activation in the 7 women with "normal" libidos seems largely irrelevant.

How about the women with HSDD? They showed greater activity in the insula, which has been implicated in feelings of disgust, but it's also been associated with interoceptive awareness of bodily states and many other functions (e.g., subjective emotional feelings, perception, cognition, performance, and attention). Moving right along (so to speak) to the motor cortex... now that's an interesting finding. Greater motor resonance or "mirroring" of action in the film clips for those with HSDD? With top-down control involving the inferior frontal cortex preventing actual movement? Mirror neurons have, in fact, been found in the primary motor cortex of monkeys (Tkach et al., 2007). These cells showed similar activity during both the execution and observation of actions. So if anything, this finding might suggest that the women with HSDD were actually more engaged while watching the erotic films!

The abstract concludes by saying "Cerebral activation patterns in women with HSDD differs from those in women with normal sexual function and may reflect differences in how they interpret sexual stimuli", which doesn't tell us very much. It seems the authors need to take their own advice from another paper (Woodard & Diamond, 2009):
Many physiologic methods [of sexual function in women] exist, but most are not well-validated. In addition there has been an inability to correlate most physiologic measures with subjective measures of sexual arousal. Furthermore, given the complex nature of the sexual response in women, physiologic measures should be considered in context of other data, including the history, physical examination, and validated questionnaires...


1 The participants in the study were:
21 women [who] have viewed pornography in the past. Informed consent was obtained. The mean age of the subjects was 31.2 ± 10.46 years (range: 18–57 years). The majority of the participants were Caucasian (66.7%) and 23.8% were black, 4.8% were Asian and 4.8% did not respond. ... With regard to sexual orientation, 76.2% [n=16] described themselves as heterosexual while 19% [n=4] were bisexual and 4.8% [n=1] were unknown.
NOTE: Why include the one participant with unknown sexual orientation? Why not drop her? And don't you imagine the bisexual women might have liked some clips that were not preferred by the heterosexual women?


Tkach D, Reimer J, Hatsopoulos NG. (2007). Congruent activity during action and action observation in motor cortex. J Neurosci. 27:13241-50.

Woodard TL, Collins K, Perez M, Balon R, Tancer ME, Kruger M, Moffat S, Diamond MP. (2008). What kind of erotic film clips should we use in female sex research? An exploratory study. J Sex Med. 5:146-54.

Woodard TL, Diamond MP. (2009). Physiologic measures of sexual function in women: a review. Fertil Steril. 92:19-34.

Figure 4 (Woodard & Diamond, 2009). The Genitosensory Analyzer is used to measure temperature and vibratory sensation of the genitalia.

Blogging against UnReviewed Research icon
Brain in a Vat.

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Monday, October 25, 2010

Dennis Rodman-Mindy McCready Mind Meld

Dennis Rodman (left) and Mindy McCready (right) prepare for SPECT scanning at the Amen Clinic in Newport Beach.

Celebrity Rehab with Dr. Drew, part of VH1's Celebreality block of programming, is an American reality show that exploits the addictions of the rich and formerly famous. The previous post, Celebrity Neurostigma, examined the medical ethics (or lack thereof) of practicing physicians who disclose the personal information of patients in their care. Furthermore, Dr. Drew Pinsky regularly offers unsolicited diagnoses of celebrities not in his care, which proved to be embarrassing in the wake of the Joaquin Phoenix hoax.

In Season 3 of the show, Dr. Drew joined forces with self-help author and psychiatrist Dr. Daniel Amen, who was criticized in the American Journal of Psychiatry for his Scientifically Unfounded Claims in Diagnosing and Treating Patients. In his defense, Amen wrote:

"...I would never engage in a charade where I was expected to give a diagnosis from a scan. That is not how imaging is or should be practiced."

-Daniel Amen, M.D. (2010). Brain SPECT Imaging in Clinical Practice. Am J Psychiatry 167: 1125.

Yet, we see him doing just that for two of the celebrity rehab patients, as shown in these short video clips: Dennis's Brain and Mindy's Brain. The images below illustrate their "serious" and "quite dramatic" scans. Rodman is said to have "an unusual pattern of temporal lobe dysfunction" while McCready's temporal lobes "look like they've been hurt."1

This is the Brain of Dennis Rodman, age 48

This is the Brain of Mindy McCready, age 34

Notice any similarities??

ADDENDUM: Obviously, someone is being deceived here. It's either:

(1) The viewers - this is the more acceptable option. Rodman and McCready were actually shown images of their real brains, but judicious off-camera editing replaced this private medical information with stock footage of an archival scan. Or maybe they knew about the farcical aspects and were told to play along as part of the script. OR it's:

(2) The patients - this sort of medical deception, for theatrical "scared straight" purposes, is unethical. Being shown a stranger's brain scan and then being told that it's your damaged temporal lobe, that you're at risk of dementia, that you have alcohol damage, can be considered medical fraud.


1 The best part of the clip is when McCready gives a more credible account for the putative abnormalities in her brain: the terrible assault that potentially caused temporal lobe injury.

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Saturday, October 23, 2010

Celebrity Neurostigma

Celebrity SPECT scan from rehab patient

Celebrity Rehab is an American TV reality show on VH1 that exploits the addictions of the rich and C- or D-List famous.
“I thought REAL doctors talked to patients in offices behind closed doors.”
-Lindsay Lohan [who reportedly turned down six figures to appear on the show]
Privacy? Confidentiality? Those rights don't apply to the alcoholic and drug-addicted characters who appear on television and other public media outlets as a form of entertainment. How many of you professional psychology and mental health and cog neuro and pharmaceutical types have taken training courses such as the CITI Course in The Protection of Human Research Subjects? All of you?

Medical Ethics do not apply to Dr. Drew, the star and chief physician of the Celebrity Addiction franchise:
In 2009 [Dr. Drew] Pinsky drew criticism from experts for publicly offering professional opinions of celebrities he has never met or personally examined, based on media accounts, and has also drawn the ire of some of those celebrities.
In contradistinction, proper clinicians who make media appearances take great pains to avoid such unethical outbursts. As explained by Dr Petra Boynton:
They tried to make me talk about rehab but I said ‘no, no, no’

Yesterday I had over 25 emails and phone messages from journalists wanting me to comment on the mental state of several celebrities currently in the press with various drug/relationships problems.

And I’ve said no to all of them.

At the risk of sounding like a broken record here’s why psychologists (and other experts working with the media) can’t talk about celebrities.

If we know the celeb in person (for example as their therapist or healthcare provider) we are breaking their confidence if we speak about them in public. If we do not know them personally we’re simply speculating about them if we were to comment.

The same applies to case studies based on people who are not famous.

In Season 3 Episode #6, ('Triggers') Dr. Drew takes former NBA star Dennis Rodman to see our favorite neurohuckster, Dr. Daniel G. Amen, for a SPECT scan. Amen claims he can diagnose all sorts of psychiatric and neurological ailments using SPECT (single photon emission computed tomography)1 procedures performed at his clinics.

Drew Pinsky exacerbates the unprofessional circus-like atmosphere by making all sorts of unfounded dire predictions about the state of Rodman's brain.

Dr. Drew voiceover: It's day 13, and despite nearly 2 weeks of intense treatment, Dennis has rigidly refused to identify as an alcoholic. It's clear to me there's much more going on here. Probably on an organic basis, both in terms of his personality functioning and possibly damage caused by the alcohol itself. I've arranged for Dennis to receive a brain scan to show him objective evidence of what I suspect is going on.

Van arrives at the Amen Clinics in Newport Beach, CA and Rodman is placed in the scanner.

Cue colorful images of Mr. Rodman's brain appearing on the monitor. All very scientific. Then Dr. Drew introduces him to Dr. Amen.

Amen: "So, we did a study called SPECT that looks at how your brain works. And what we see on your scan here, there's some evidence of alcohol damage. When we see this bumpy appearance, I don't like that. I would worry that you could get something like Alzheimer's disease if you don't do a better job of taking care of your brain. Alcoholic dementia is the second most common cause of dementia in the country. The exciting thing is it can be better but without taking good care of it this is going to deteriorate and get worse."

Rodman: "Uh... it doesn't matter. All right." (Gets up and leaves).

Amen made some rather outrageous statements here. Even though he used the qualifying words something like, there is absolutely no evidence that alcoholism causes the amyloid plaques and neurofibrillary tangles of Alzheimer's disease. In fact, the pathologies are produced by entirely different mechanisms (Aho et al., 2009):
In the present study, no statistically significant influence was observed for alcohol consumption on the extent of neuropathological lesions encountered in the three most common degenerative disorders. Our results indicate that alcohol-related dementia differs from VCI [vascular cognitive impairment], AD [Alzheimer's disease], and DLB [dementia with Lewy bodies]; i.e., it has a different etiology and pathogenesis.
One meta-analysis even found that heavy drinkers did not have an increased risk of dementia of any kind,2 and regular drinkers had a reduced risk (Anstey et al., 2009).

Then brain imaging non-expert Dr. Drew narrates...

Dr. Drew voiceover: Dennis's scans were quite dramatic. In addition to there being an unusual pattern of temporal lobe dysfunction, which confirms my feelings about his personality, he also clearly has damage from alcohol.

Dr. Drew (to Amen): "It makes me sad thinking about it... if he doesn't change."

I see...

Where in the temporal lobe did Dr. Drew find the confirmatory evidence of personality disorder? Anterior temporal lobes (semantic memory)? Posterior/inferior temporal regions, such as the fusiform gyrus (high-level vision)? Superior temporal plane (audition)? Region of the left posterior superior temporal gyrus (Wernicke's area for language comprehension)? Area MT/V5 (perception of motion)? The medial temporal lobe memory system? The amygdala and other portions of the limbic system? Yeah, maybe that, but Amen's "bumpy appearance" was located in ventral visual areas.

Dramatic Brain of Dennis Rodman, age 48

(which looks a lot better than this 38 yr old with 17 years of heavy weekend use).

Scientifically Unfounded Claims in Diagnosing and Treating Patients

That's the title of a Letter to the Editor of the American Journal of Psychiatry by Adinoff and Devous (2010). They responded positively to a critical review (Leuchter, 2009) of none other than Daniel Amen's book, Healing the Hardware of the Soul: Enhance Your Brain to Improve Your Work, Love, and Spiritual Life. The letter goes even further in critiquing Amen's methods:
Several years ago, following conversations with Dr. Amen on how to address such concerns, the Brain Imaging Council of the Society of Nuclear Medicine offered Dr. Amen the opportunity to submit his analyses of a blinded set of SPECT scans (to have been prepared by the Brain Imaging Council) to determine how effective his technique is at correctly diagnosing subjects. Although this proposed study could have provided support for his approach, the offer was declined. Nevertheless, for more than two decades, Dr. Amen has persisted in using scientifically unfounded claims to diagnose and treat patients (over 45,000 by his own count).

There are several dangers to patients that can accrue from this approach: 1) patients (including children) are administered a radioactive isotope without sound clinical rationale; 2) patients pursue treatments contingent upon an interpretation of a SPECT image that lacks empirical support; and 3) based on a presumed diagnosis provided by Dr. Amen's clinics, patients are guided toward treatment that may detract them from clinically sound treatments.

Amen published a rebuttal letter, Brain SPECT Imaging in Clinical Practice (Amen, 2010). Here, he portrays himself as an early adopter -- ahead of his time, persecuted by the unenlightened -- and highly ethical:
The Society of Nuclear Medicine has never formally approached me to perform a study. Plus, I would never engage in a charade where I was expected to give a diagnosis from a scan. That is not how imaging is or should be practiced. The notion of Adinoff and Devous that SPECT is dangerous is disingenuous.
Really? An appearance on Celebrity Rehab and a proclamation that Dennis Rodman is in danger of getting "something like Alzheimer's disease" (based on reading his scan) is NOT a charade?

Public Medical Disclosure

Why is that so inappropriate?
The HIPAA Privacy Rule provides federal protections for personal health information held by covered entities and gives patients an array of rights with respect to that information. At the same time, the Privacy Rule is balanced so that it permits the disclosure of personal health information needed for patient care and other important purposes.
Did Rodman understand all the medical procedures that would be performed on him? Did he sign a consent form in advance to allow the release of a stigmatizing diagnosis for public consumption? Did the fine doctors and television producers consider that if they wanted to portray Rodman as brain damaged, such a compromised mental status could potentially limit his capacity to give informed consent?

But it's only entertainment, after all.

So back to the scientifically unfounded claims... Without mentioning Celebrity Rehab and its diagnostic disclosure issues (perhaps he didn't watch this particular episode), the Editor of AJP felt strongly enough to publish his own Note, appended to the letter of Adinoff and Devous, which concludes:
We have published this exchange of letters as part of our responsibility to readers to point out when a procedure may lack sufficient evidence to justify its widespread clinical use.

For more on Amen and his practices, see The Neuroshrink.

ADDED BONUS! Watch the video for Dr. Drew's neuroanatomy lesson: Celebrity Rehab 3: Dennis's Brain Scan and read the follow-up post: Dennis Rodman-Mindy McCready Mind Meld.


1 SPECT (single photon emission computed tomography) is a less expensive cousin of PET scanning (positron emission tomography) with low spatial resolution. In case you're interested in learning more about it as a valid imaging method, read this from the experts (Committee on the Mathematics and Physics of Emerging Dynamic Biomedical Imaging, National Research Council).

2 The authors noted there could have been a sampling bias.


Adinoff, B., & Devous, M. (2010). Scientifically Unfounded Claims in Diagnosing and Treating Patients. American Journal of Psychiatry, 167 (5), 598-598 DOI: 10.1176/appi.ajp.2010.10020157

Aho L, Karkola K, Juusela J, Alafuzoff I. (2009). Heavy alcohol consumption and neuropathological lesions: a post-mortem human study. J Neurosci Res. 87:2786-92.

Amen D. (2010). Brain SPECT Imaging in Clinical Practice. Am J Psychiatry 167: 1125.

Anstey KJ, Mack HA, Cherbuin N. (2009). Alcohol consumption as a risk factor for dementia and cognitive decline: meta-analysis of prospective studies. Am J Geriatr Psychiatry 17:542-55.

Leuchter AF (2009): Healing the hardware of the soul: enhance your brain to improve your work, love, and spiritual life, by Daniel Amen (book review). Am J Psychiatry 166:625.

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Thursday, October 21, 2010

Alienists, Neurologists, and Heavenly Bridegrooms

While writing the last post on Dr. Charles Hamilton Hughes, it became apparent that his journal published some very unusual articles. As would be expected of late 19th-early 20th century psychiatry, the Alienist and Neurologist contained some material that is highly offensive by today's standards:
The Asexualization of the Unfit

Prevention of Growth and Extension of Care of our Feeble-Minded Population

Insanity in the Colored Race in the United States

Sexual Inversion among Primitive Races get the idea. So it was surprising to find a lengthy editorial that expressed relatively progressive ideas about mental illness:
The presence of insane persons in penal institutions is extremely detrimental to discipline for they cannot be punished as a normal prisoner should be, because of their defective sense of responsibility, and advantages are taken of this humanitarian leniency by the more intelligent prisoner to commit offences against the rules. No less than seventy-five per cent of the men who appear before the disciplinary officer of the Indiana State Prison are mentally defective.

What have been the reasons that this outrage has been permitted to exist as a blot upon the escutcheon of our social justice? Why have we stigmatised mentally sick individuals as criminals? The answer is to be found in our ignorance of the psychology of crime...

—Paul E. Bowers, M. S., M. D., Medical Superintendent, Indiana Hospital for Insane Criminals, Michigan City, Indiana.
But beyond the good, the bad and the ugly, the strangest article has to be Heavenly Bridegrooms, which is the text of an unpublished book written by Ida Craddock, who has been called a "Sexual Mystic and Martyr for Freedom".

Despite her many accomplishments, however, she appears to have held the delusional belief that she had an angel for a lover:
It has been my high privilege to have some practical experience as the earthly wife of an angel from the unseen world. In the interests of psychical research, I have tried to explore this pathway of communication with the spiritual universe, and, so far as lay in my power, to make a sort of rough guidebook of the route.
Craddock's manuscript was obtained by free speech lawyer Theodore Schroeder a number of years after her death. Alienist and Neurologist (Volume XVI, 1895) published the treatise in its entirety, along with this introduction by Schroeder (who managed to put himself as first author):

By Theodore Schroeder
AND Ida C.
Explanatory Note.—In the course of my studies on the erotogenesis of religion I became interested in the life work and mental characteristics of one Ida C, a woman who committed suicide in her forty-fifth year. I first heard of her after her death, but it seemed to me that a psychologic study of her would yield rich materials as a contribution to the psychology of religion. Consequently, I bestirred myself to secure information, both biographical and auto-biographical. Among the materials gathered was her life long correspondence with friends, a number of published essays written by her, some scraps of manuscripts, and two completed but unpublished book manuscripts. This material will later constitute the subject of my analysis. Ida C was for a number of years a college teacher and for a long time associated with various kinds of free-thinking heretics. She was never married. In due time she became the victim of erotic hallucinations to which she gave a "spiritual" interpretation. Later, when her conduct brought her to the verge of incarceration in a jail or in an asylum, she endeavored frankly to meet the issue of her own insanity. The resultant investigation to her mind seemed a complete vindication, not only of her sanity, but also, of the objective reality and spirituality of her erotic experiences. This vindication she reduced to writing. The manuscript is now in my possession. It seems to me under the circumstances of this case and the future studies which I am going to make, partly from other papers of the same author, that this is too valuable a document to be mutilated by editing...
Craddock's other writings included Right Marital Living [somewhat NSFW], which strongly endorsed sex for pleasure and not just procreative purposes. This publication was considered obscene and pornographic by her nemesis Anthony Comstock, censorial Postal Inspector and Victorian prude. According to Wikipedia:
Mass distribution of Right Marital Living through the U.S. Mail after its publication as a featured article in the medical journal The Chicago Clinic1 led to an 1899 Chicago Federal indictment of Craddock. She pled guilty and received a suspended sentence. A subsequent 1902 New York Federal trial on charges of sending The Wedding Night through the mail during a sting operation ended with her conviction. She refused to plead insanity as a condition to avoid prison time and was sentenced to three months in prison... Upon her release, Comstock immediately re-arrested her for violations of the federal Comstock law and on October 10 she was tried and convicted; the judge declaring that The Wedding Night, was so “obscene, lewd, lascivious, dirty” that the jury should not be allowed to see it during the trial. At age forty-five, she saw her five year sentence as a life term and so committed suicide, by slashing her wrists and inhaling natural gas from the oven in her apartment, on October 16, 1902 the day before reporting to Federal prison.
Craddock was an independent, educated feminist, a prolific writer with visionary views on human sexuality and religious visions of sexual union.2 Sexual Outlaw, Erotic Mystic: The Essential Ida Craddock will be published in paperback on December 1, 2010. Here's what contemporary sexologists have to say in their reviews:
"Sexual Outlaw, Erotic Mystic is an excellent book about fascinating topics! A great addition to any respectable sex library." -Annie Sprinkle Ph.D., Sex Worker turned author and Ecosexual Sexecologist

"While many of her ideas would be laughable by the standards of sexologists today, they were visionary in the late 1800's. Simply by being willing to discuss sexuality at all and espousing its enjoyment as a right for women as well as men, Ida Craddock was a pioneer and deserves to be known. Vere Chappell's Sexual Outlaw, Erotic Mystic: The Essential Ida Craddock informs us thoroughly on the life and work of this remarkable woman." -Isadora Alman MFT, Ask Isadora columnist


1 This appears to be a different version of the article.

2 Hypergraphia, obsession with religious and sexual themes, delusions, ...

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Saturday, October 16, 2010

Dr. Charles Hamilton Hughes, Alienist and Neurologist

Charles Hamilton Hughes (1839-1916) was the founder and editor of The Alienist and Neurologist. The journal was published from 1880 until his death in 1916, making him the sole editor for all 37 volumes. Remittances for subscriptions ($5 for four issues per year) and "articles or photographs from subscribers or friends and material acceptable for publication" were sent to his address in St. Louis.

What is an alienist?
An "alienist" is "one who treats mental diseases; a mental pathologist; a 'mad doctor'," according to The Oxford English Dictionary. The OED also defines "alienation" as in this sense as "mental alienation; withdrawal, loss, or derangement of mental faculties; insanity." The insane were thought estranged (alienated) from their normal faculties. The root of "alienist" is the Latin "alienare," to make strange. The word "alienist" came across the Channel to England from France where "aliene" meant insane and an "alieniste" was one who cared for the mentally ill: a psychiatrist.
What were Hughes's contributions to neurology and psychiatry? Notable excerpts from his obituary:
By the Death of the Founder of the Alienist and Neurologist one of the great pupils of the famed American School of Psychiatry of Rush, Stedman, Brigham, Gait and Ray has passed away. He had imbibed to the full the critical, judicial, radical, yet logically conservative, spirit of this school.

. . .

In 1880 he founded the Alienist and Neurologist, which soon assumed and kept a prominent position among medical journals. From the beginning it was recognized as of authority by the British Journal of Mental Science, the French Annales Medicopsychologiques, the Berlin Allgemeine Zeitschrift fur Psychiatric, [etc.]. Contributions to the Alienist and Neurologist were therefore widely quoted in Europe, even in circles hostile to America.

The personal contributions of Dr. Hughes to psychiatry and neurology were varied, valuable and original. His discovery of the virile reflex1 was widely cited...
However, an obituary in the Journal of Nervous and Mental Disease was less flattering:
...He early maintained an interest in neurology in what was hardly more than a frontier trading post and where the existence of neurology was hardly dreamed of according of the canons of to-day. It was then a crude product but it was sincere and as he upheld it, it was a light in the wilderness. As St. Louis grew and began to feel itself this early lamp shone less brightly in contrast, but Dr. Hughes, although he may not have kept in touch with the latest advances, still maintained a vital interest and enthusiasm.

...He became widely known through the Alienist and Neurologist, which he founded in 1880 and which he made the medium for an open discussion of neurological and psychiatrical problems. It was received among European publications, though it never definitely stood for vigorous research and the vigorous pushing forward into, progressive lines which marks the neurology of to-day.

Mental Alienation

In The Neurocritic's previous post on Arithmomania, Hughes was credited with an article on "Autopsychorhythmia," or repetition psycho-neurosis (Hughes, 1901). He was clear to distinguish this phenomenon from the related conditions of echolalia (automatic repetition of another's speech) and coprolalia (involuntary uttering of obscenities, which is seen in only 10% of patients with Tourette's syndrome).
The constant repetition of a rhythmical movement in the mind, regardless of time or place or circumstance, and which an enfeebled volition cannot regulate to conform to the requirements of environment, characterises this symptom of brain overstrain and psycho-motor automatic impulse. Neuropathic and consequent psycho-motor neurasthenia appear to be at the bottom of this condition...
There's an element of "nervous breakdown" and mental exhaustion in some of the case reports, particularly in the patients who made good recoveries. For instance,
A gentleman of extensive business affairs who came to me on the verge of financial and business bankruptcy, but who is now after many years of health successful in a new but less harassing line of business, would continuously say to himself : "Too many irons in the fire, too many irons in the fire." His intellect was clear but his brain was jaded and unstable-in that stage of cerebrasthenia that so often precedes the final brain-break of insanity. The closing out and winding up of his business saved him for recuperation and another and less harassing and more successful career.
Conversely, other patients remained mired in insanity:
I have heard a chronic alcoholic repeat over and over through the day, "Little Bo-Peep, he lost his sheep, and doesn’t know where to find them," etc., and have known chronic lunatics who would repeat some long-ago-learned distich or rhyme or some insanely-constructed jingle of words in maudlin monotone, from the day’s beginning to the ending thereof, in all their waking hours, some of them ringing their peculiar song, like the dying swan, to the end of their unfortunate lives.
He considered autopsychorhythmia to be a brain disease, which seems obvious to us today, but he apparently needed to distinguish the centrally located pathology from peripheral motor abnormalies:
The pathological lesion of autopsychorhythmia is evidently in the mind area of the brain cortex.2 It is truly transcortical and not localised exclusively in the speech area. It is a psychical and not purely psychomotor involvement-a psychical lesion shown in peculiarity of psychomotor expression.
Were there any treatments for such a malady? An 18 year old music student, a handsome and bright young lady, was prescribed a regimen of "rest, change of environment, cessation of study and piano practice, withdrawal from musical companionship, brain-tranquillising galvanisations, ether-menthol evaporating lotions to the head, chemical brain restraint, and pepsines and laxatives." Another charming young lady received "six weeks’ treatment with bromide of potassium, timely hypnotics, tonics, aloetic laxatives and gelsemium."

Oh, by the way, The Alienist and Neurologist accepted advertising...


1 From Hughes (1891):
In a previous communication on this subject (vide Alienist and Neurologist for January, 1891), I have called attention to the fact that in a perfectly healthy individual, whose spinal cord is entirely normal, especially in its genitospinal center, placed supine on a couch without headrest, nude about the loins, the sheath of the penis made tense by clasping the foreskin with the left index finger and thumb at about the place of the frænum, and pulling it firmly toward the umbilicus, placing the middle, ring and little finger low down upon the dorsum of the virile organ, the dorsum or sides of the penis, near the perineal extremity, then sharply precussed, a quick and very sensible reflex motor response or retraction of the bulbo-cavernous portion will be felt to result from this sudden percussional impression...
Hughes thought he had discovered an important diagnostic sign that would be widely adopted, "worthy a place in clinical neurology with Westphal's paradoxical contraction, Erb's reaction of degeneration, or any of the hitherto recognized diagnostic reflexes, or clonuses." This never happened, fortunately.

2 "...the mind area of the brain cortex" (wherever that may be). How quaint.




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Sunday, October 10, 2010



Rhythmic Psycho-neuroses and Morbid Impulses
DR. C. H. HUGHES of St. Louis, editor of the Alienist and Neurologist, in a paper which we publish this week on page 1124, calls attention to certain interesting and medico-legally important forms of mental derangement characterised by a morbid rhythmic activity of the brain and grouped by him under the heading "Autopsychorhythmia," or repetition psycho-neurosis. He refers at the outset to a pathetic story of an accountant who in a state of nervous exhaustion and mental confusion was carried to an asylum pitifully exclaiming, "Once one is two, once one is two," the mistaken calculation having ruined him.


Editorial. Rhythmic Psycho-neuroses and Morbid Impulses. The Lancet, Volume 157, Issue 4051, 20 April 1901, Pages 1150-1151.

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Wednesday, October 06, 2010

The Tragedy of Othello Syndrome

Benjamin Evett, John Douglas Thompson, and Mirjana Jokovic in the American Repertory Theatre's production of Othello.

O! beware, my lord, of jealousy;
It is the green-ey'd monster which doth mock
The meat it feeds on.

Othello syndrome is a rare psychiatric condition marked by morbid, pathological, or delusional jealousy (Miller et al., 2010). It can occur in the context of schizophrenia, bipolar disorder, alcoholism, or epilepsy, but sometimes it's observed in relative isolation from other delusions (Todd & Dewhurst, 1955). As in the Shakespearean tragedy, the modern day patient with Othello syndrome presents with the potential for violence against his spouse and/or self because of the imagined infidelities.

A recent article by Miller and colleagues (2010) provides a helpful overview of this delusional disorder for nurses and other clinicians. They consider treatment options (antipsychotics for those with psychosis, dialectical behavioral therapy for those without), safety issues, nursing care, and best practices. Although cases from the recent literature were reviewed, a classic article from over 50 yrs ago (Todd & Dewhurst, 1955) is a more entertaining treasure trove of paranoid sexual jealousy. Excerpts from several cases are presented below.
Case 2: A married man, 43 years old, was first admitted to a mental hospital in June 1951. He complained of feeling "tensed up" as a result of the belief that his wife was unfaithful to him. Careful enquiries showed that there was not a scrap of evidence to support his suspicions, which began when a workmate allegedly asked him whether he had ever suspected his wife of having an affair with another man. His suspicions increased considerably when one day she failed to give what he deemed to be a satisfactory explanation for the origin of a smart pair of bootees in her possession. ... Once, he attempted to strangle his wife but was stopped in the nick of time by the intervention of neighbors. Another time, he rushed scantily clad from the house in a fruitless attempt to catch his wife with a paramour.
Although the patient was not deemed to be a chronic alcoholic, his jealousy was closely related to bouts of drinking. His identical twin brother suffered from grand mal epilepsy and committed suicide. The patient's own EEG showed epileptiform discharges, but he never had an overt seizure.

Diagnosis: epilepsy with delusions of infidelity.

Case 3: A married man, 49 years old, was first admitted to a mental hospital in July 1952. He complained of chronic anxiety arising from a belief that his wife was "carrying on" with a number of men. ... At times, his behavior had been distinctly bizarre. One day, which searching her handbag for "evidence", he had chanced upon a discarded pair of knickers which she had pressed into service as a duster. He insisted that the dilapidated and soiled condition of the garment proved beyond doubt that she had been her employer's mistress. He had, on several occasions, attempted to strangle his wife as a result of his delusions.
Diagnosis: paranoid schizophrenia with delusions of infidelity.

Case 7: A married man, 39 years old, was admitted to a mental hospital in May 1951, as the direct result of disorderly behavior arising from delusions concerning his wife's fidelity. During the previous year, he had rendered his wife (a virtuous woman) miserable by repeatedly accusing her of infidelity on an enormous scale. He would use field glasses to spy on her from afar, and, after pretending to leave the house, he was wont to re-enter surreptitiously in an attempt to trap her with a lover. ... He threatened several men in the neighborhood with violence because he suspected them of a liaison with his wife, and developed a sinister habit of going abroad with an open razor in his pocket.
He also had the charming practice of expressing remorse that he couldn't keep his wife perpetually pregnant, he threatened her with violence, and once even grabbed her by the throat. This bad behavior ran in the family. His brothers were drunk, impotent, jealous, and "unfit to be trusted with a dog, never mind a woman." His father was:
a drunkard and libertine, [who] had rendered his wife pregnant on 28 occasions [how can that be possible??]; in addition, he had many extramarital affairs.
Diagnosis: epilepsy with delusions of infidelity.

Case 7 was given "a course of electro-shock therapy" which isn't such a great idea for someone with epilepsy, and it didn't cure his delusions, either. Chlorpromazine wasn't yet widely available in 1951, but the anticonvulsant Dilantin (phenytoin) was on the market in the 1930s.

He was still hospitalized four years later.

In their Study in the Psychopathology of Sexual Jealousy, Drs. Todd and Dewhurst (1955) did not seem to prescribe medications of any sort, but they did give a wonderful literary discussion of Boccaccio, Shakespeare, Tolstoy, and Burton's The Anatomy of Melancholy.


Miller, M., Kummerow, A., & Mgutshini, T. (2010). Othello Syndrome. Journal of Psychosocial Nursing and Mental Health Services, 48 (8), 20-27 DOI: 10.3928/02793695-20100701-05

TODD J, & DEWHURST K (1955). The Othello syndrome; a study in the psychopathology of sexual jealousy. The Journal of nervous and mental disease, 122 (4), 367-74 PMID: 13307271

What noise is this? Not dead — not yet quite dead?
I that am cruel am yet merciful;
I would not have the linger in thy pain
So, so.

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Sunday, October 03, 2010

Is There Any Evidence for the "Porn-Addicted Brain"?

No definite peer reviewed work that I could find...

However a recent blog post by Dr. Donald L. Hilton, Jr., a Mormon spine surgeon and Clinical Associate Professor of Neurosurgery at University of Texas Health Sciences Center, claimed otherwise:
Can pornography use become an actual brain addiction?

. . .

Ten years ago evidence began to point to the addictive nature of over-consumption of natural behaviors which cause a dopaminergic reward to be experienced in the brain. For instance, Dr. Howard Schaffer, Director of Addiction Research at Harvard University, said in 2001, “I had great difficulty with my own colleagues when I suggested that a lot of addiction is the result of experience … repetitive, high-emotion, high-frequency experience. But it’s become clear that neuroadaptation–that is, changes in neural circuitry that help perpetuate the behavior–occurs even in the absence of drug-taking.” In the decade since he said this, he has focused his research more and more on the brain effects of natural addictions such as gambling...

The experts are fond of saying that addiction occurs when a habit “hijacks” brain circuits that evolved to reward survival- enhancing behavior such as eating and sex.
Pretty typical stuff about behavioral addictions and the overworked "neuroplasticity" concept. Is it even worth writing about any more? It is when a scholarly sounding science article written by a neurosurgeon appears on the website of a recovery organization driven by religious motives. The S.A. Lifeline Foundation condones only one type of sex: that between a married man and his wife. Everything else is wrong. Banish masturbation entirely. What if you're not married? You can look forward to a life of celibacy! No sex of any kind for you. And it's no surprise they promote reparation therapy to cure homosexuality:

Same Sex Attraction

For individuals experiencing unwanted same-sex-attraction (SSA), or same-gender-attraction (SGA), achieving sexual sobriety and recovery is crucial. Often they can feel a deep level of shame because of society’s tendency to automatically label all such as actively “gay” or “lesbian”. Many with these attractions have never experienced this lifestyle and many are married to a spouse who is heterosexual. Most have kept their attractions secret – which in many cases fuels a secret addiction to homosexual pornography or fantasy. Others wish to leave their former lifestyle and are seeking understanding and acceptance, but cannot seem to get past the continued pull of pornography and masturbation. Sexaholics Anonymous (SA) can help. SA is the only fellowship dealing with this addiction which defines “sobriety” for married persons as: no form of sex with self or with persons other than the spouse – meaning one’s partner in a marriage between a man and a woman. For the unmarried, sobriety means freedom from sex of any kind. For both the goal is progressive victory over lust.
What good is that?? The proscriptions of S.A. Lifeline Foundation are not only boring, they're harmful. The propagation of such degrees of guilt and shame throughout society is one reason why LGBT youth like Tyler Clementi kill themselves at alarming rates. So whatever your position on pornography and sexual addiction (Yes It Exists: the sex addicted brain! and Cupid's Poisoned Arrow; No It Doesn't: The Rogue Neuron and Dr Petra), it's clear that cloaking prudish sexual morality in the guise of science will make it more palatable to a wider audience.

In this video, Dr. Hilton stretches the truth about the existence of evidence demonstrating that pornography addiction changes the brain.

"A study looking at a form of sexual addiction showed the same thing [as studies on cocaine addiction and obesity], that those frontal lobes actually got smaller in addiction, in sexual addiction."

What he doesn't tell you is that the paper is on adult male pedophiles, convicted child molesters incarcerated at high-security forensic treatment facilities in Germany (Schiffer et al., 2007). These individuals go well beyond the pale of your average teenage wanker. In fact, it's rather offensive that he covertly uses a flagrant example of sexual pathology to illustrate his point. But he has to, because there are no other studies out there.

Hilton is more forthcoming about these results in his blog post:
So what about sexual addiction? In 2007 a VBM [voxel-based morphometry] study out of Germany looked specifically at pedophilia, and demonstrated almost identical finding to the cocaine, methamphetamine, and obesity studies. The significance of this study in relation to our topic cannot be overemphasized. It demonstrates that a sexual compulsion can cause physical, anatomic change in the brain, i.e., harm.
Sure, compulsive overconsumption of porn that intrudes upon one's daily life and hinders the ability to have healthy relationships is problematic, even when the viewer is not a criminal. And the escalating levels of violence, and weirdness, of internet video can add fuel to the fire. Religious organizations use this as an excuse for promoting campaigns to condemn any form of sex that occurs outside of holy matrimony.

Incorporation of the "addiction" and "dopamine" and "neuroplasticity" buzzwords is a new addition to their strategy. In the end, secular neuroscientists (i.e., most of us) should be upset that our work is being used for such purpose.

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