Mystery Joker Parodies Neuroscience

Someone has created a hilarious spoof paper poking fun at neuropsychoanalysis (but all of fMRI takes some hits too): A Triple Dissociation of Neural Systems Supporting ID, EGO, and SUPEREGO.

Featuring gems such as

• Authors "Steven Z. Fisher and Stephen T. Student" with contact details "mother@amaliastate.edu".
• "Twenty-four healthy participants (all 19-year-old white, male undergraduates who sat near each other in an Introductory Psychology course and were raised in upper middle class suburban New
  England neighborhoods) were scanned but 17 were excluded for not following instructions or falling asleep in the scanner."
• "If you’re like us, you’ve probably been thinking that Social Neuroscience, Neuroeconomics, and Developmental Social Cognitive Affective Clinical Neuroscience are just not cutting edge enough
  anymore. Do not despair. This study represents the first of what is likely to be a productive and active new field of Psychoanalytic Neuroscience."

It really is very funny, but it's also deadly accurate in its highlighting serious problems that plague a certain genre of neuroimaging papers. Who made it? The PDF appeared on Dropbox a couple of weeks ago and, while a few people have Tweeted about it, no-one has claimed ownership, yet.

For the record, it wasn't me.

The Plight of Psychoanalysis?

A New York psychoanalyst reveals her concerns about the profession in A Letter to Freud: On the Plight of Psychoanalysis

Dinah M. Mendes's letter covers several topics, but I was struck by the sections that deal with the contemporary challenges facing American analysts. She paints a rather sad picture of analysts who spend years in training, only to find a shortage of people out there who want their treatment:

At psychoanalytic training institutes it is often difficult for candidates to secure control or training cases—prospective analysands who sign on with analysts-in-training, usually at a low rate (sometimes as low as $10 a session). Here the issue is not the cost of the analysis but the low valuation of the opportunity offered—what might be regarded as the gift of self-knowledge.

The gratifications of instantaneous communication—texting, Facebook, and blogging—are immediate and obvious and erode the value of the slow and arduous route to communication and understanding offered by psychoanalysis. We seem to be transfixed in our culture by the allure of performance and public presentation, and a climate in which the exterior signifies the interior, where what you see and hear is what is true and real (no matter how often this fantasy is belied) is not receptive to the ideals of psychoanalysis.

She goes on to examine the increasing popularity of psychodynamic psychotherapy, approaches which draws on Freud's ideas but is much shorter (and hence cheaper) than classical psychoanalysis which involves hourly sessions, three times per week, over a period of years -

To judge from the mushrooming of new institutes of psychotherapy and shorter training programs within established psychoanalytic institutes, many people are interested in becoming psychotherapists, while there are fewer candidates for traditional psychoanalytic training and for psychoanalysis as a treatment choice.

For those who elect full-scale psychoanalytic training, the supply of certified psychoanalysts exceeds the demand in the population, and as psychotherapists they compete with psychotherapists of all stripes and denominations. The analytic institute can feel like a sequestered haven in which psychoanalysis is an “in house” specialty, tendered by training analysts (who have to earn their institutional stripes) to analytic candidates...

In my years of training, the contemporary challenges facing the would-be practitioner of psychoanalysis were rarely if ever openly addressed, although many recent graduates find themselves with few and sometimes no analytic cases...

All this, she says, can be seen in the context of

A zeitgeist in which the intrinsic and often intangible value of knowledge and education, and of self-knowledge and self-examination, has been supplanted by the appeal of material and pragmatic goals.

Of course this is all anecdotal. I wonder if any analysts amongst my readers have thoughts on this?

Mendes, D. (2011). Letter to Freud: On the Plight of Psychoanalysis The Psychoanalytic Review, 98 (6), 755-774 DOI: 10.1521/prev.2011.98.6.755

Cognitive Behavioural Therapy vs. Psychoanalysis

Clinical trials of cognitive behavioural psychotherapy (CBT) for depression are often of poor quality - and are no better than trials of the rival psychodynamic school.

So says a new American Journal of Psychiatry paper that could prove controversial.

CBT is widely perceived as having a better evidence base than other therapies. The "creation myth" of CBT (at least as I was taught it) is that it was invented by a psychoanalyst who got annoyed at the unscientific nature of psychodynamic i.e. Freudian-influenced therapy. CBT has always looked on clinical trials more favorably than the dynamic school.

However, the authors of this meta-analysis found that while there are certainly lots of published CBT trials for depression, they're actually no better quality than the psychodynamic trials.

"Surprisingly" (their word), they found no difference between the CBT for depression trials, and the psychodynamic trials, on a rating score of trial methodology.

Trials got better over time, but the two groups improved equally (see above). The mean score was 25.5 for CBT and 25.1 for dynamic, on a scale that goes from 0 to 48. Anything over 24 points is deemed acceptable but this is clearly an arbitrary cut-off.

The RCTP-QRS scale is relatively new and it was developed by the people who wrote this paper (albeit with the input of other experts.) There's 24 items and each gets a score from 0 (bad) to 2 (good). Items are things like "Adaquate sample size", "Patients randomly assigned to group", etc.

Worryingly, better CBT trials tended to find smaller benefits of CBT over the comparison treatment. The overall results showed that while CBT was clearly better than doing nothing, it was pretty much the same as antidepressants, and other psychotherapies, in adults with depression:

The article follows one from the same group, Gerber et al, who reviewed the evidence for psychodynamic therapy in more detail. And last year, another team reported evidence of publication bias in psychotherapy trials. In this study, the authors report possible publication bias, but they don't go into detail.

Overall this is interesting stuff, and a reminder that while CBT has the most evidence of any psychotherapy, this is not the same thing as saying that it has the best evidence...

Nathan C. Thoma et al (2011). A Quality-Based Review of Randomized Controlled Trials of Cognitive-Behavioral Therapy for Depression: An Assessment and Metaregression American Journal of Psychiatry

Le Pack It In

Earlier this year, a large group of autism experts signed a consensus statement condemning "Le Packing", a certain procedure used in children with autism.

They said:

This alleged therapy consists of wrapping the patient (wearing only underclothes or naked in the case of young children) several times a week during weeks or months in towels soaked in cold water (10°C to 15°C). The individual is wrapped with blankets to help the body warm up in a process lasting 45 minutes, during which time the child or adolescent is accompanied by two to four staff...

The alleged goal of this technique is to “allow the child to rid him- or herself progressively of its pathological defense mechanisms against archaic anxieties,” by achieving “a greater perception and integration of the body, and a growing sense of containment..."

We have reached the consensus that practitioners and families around the world should consider this approach unethical.

 Le Packing is almost unheard of outside France, where it was invented some years ago by M. A. Woodbury, an American psychiatrist. It's controversial even there.

Now Pierre Delion, a French packer who's previously defended the approach, and even wrote the book on it, has penned an article which discusses the towel-based treatment: Towards a dialogue between psychoanalysis and neuroscience: Connections that are both possible and necessary

The piece (part of a special issue on psychoanalysis and neuroscience) starts out with some general scholarly remarks about previous authors who have discussed Freud and the brain, but it moves on to autism, with some, well, puzzling remarks:

During the first months of life, an infant will actively practice his or her archaic reflexes. Of these, the grasping, which will progressively disappear as voluntary prehension emerges around the age of 4–5 months, is of great interest. The facilitation and/or anaclitic relationships between this reflex and adhesive identification are even more interesting to study together because, for instance, in an autistic child, the first model will integrate under the form of pathological adhesive identification.

In such an example, a strategy for thinking about these two phenomena and making them compatible is using a third term (e.g., Peircean logic, in which adhesive identification is an icon of grasping). If we refer to this important principle from this great American semiotician, the icon is part of the logical representation scheme from the most elementary, the icon, to the most evolved, the symbol, passing by the intermediate, the index...

The relationships between neurological wiring and pre-wiring enable the effective installation of the theory of mind and the phenomenon of projective identification described by Melanie Klein and her students...

Hmm.

On Le Packing itself we get a curious paragraph which seems to be saying that the therapy itself works via a neurophysiological mechanism, but that Freudian theory can explain why the child and their caregivers are anxious. What the anxiety in question is about is not clear. About the packing? That seems the most natural reading:

Another example taken from Pierre Delion’s practice as a therapist for children with autistic disorder is the ‘‘packing’’ technique (Goeb et al., 2008). This is the use of humid wrapping to prevent self-mutilation by using these two different levels [i.e. neuroscience and psychoanalysis] that are nonetheless joint during treatment. This technique uses a neurophysiological hypothesis to try to explain the therapeutic effects, but, at the same time, the psychopathological hypothesis that is given by psychoanalysis helps to format the anxieties that are experienced by the children and invariably shared by their caretakers.

Clinical research regarding this topic is currently being undertaken in Pierre Delion’s child psychiatry department following a hospital program for clinical research (PHRC, NoEudra CT: 2007-A01376-47) entitled ‘‘Demonstration of the efficiency of packing treatments in children affected by autistic disorders with severe behavioral disorders’’.

Delion P (2011). Towards a dialogue between psychoanalysis and neuroscience: Connections that are both possible and necessary. Journal of physiology, Paris PMID: 21963531