Researcher paper by Internet addiction expert, Dr. Kimberly Young on reports of people becoming addicted to the Internet.

Kimberly S. Young
University of Pittsburgh at Bradford

Paper presented at the 104th annual meeting of the
American Psychological Association, Toronto, Canada, August 15, 1996.

ABSTRACT

Anecdotal reports indicated that some on-line users were becoming addicted to the Internet in much that same way that others became addicted to drugs or alcohol which resulted in academic, social, and occupational impairment. However, research among sociologists, psychologists, or psychiatrists has not formally identified addictive use of the Internet as a problematic behavior. This study investigated the existence of Internet addiction and the extent of problems caused by such potential misuse. This study utilized an adapted version of the criteria for pathological gambling defined by the DSM-IV (APA, 1994). On the basis of this criteria, case studies of 396 dependent Internet users (Dependents) and a control group of 100 non-dependent Internet users (Non-Dependents) were classified. Qualatative analyses suggests significant behavioral and functional usage differences between the two groups. Clinical and social implications of pathological Internet use and future directions for research are discussed.

Internet Addiction: The Emergence Of A New Clinical Disorder

Methodology

• Subjects
• Materials
• Procedures

Results

• Demographics
• Usage Differences
• Length Of Time Using Internet
• Hours Per Week
• Applications Used
• Extent Of Problems

Discussion

References

INTERNET ADDICTION:

THE EMERGENCE OF A NEW CLINICAL DISORDER

Recent reports indicated that some on-line users were becoming addicted to the Internet in much the same way that others became addicted to drugs, alcohol, or gambling, which resulted in academic failure (Brady, 1996; Murphey, 1996); reduced work performance (Robert Half International, 1996), and even marital discord and separation (Quittner, 1997). Clinical reseach on behavioral addictions has focused on compulsive gambling (Mobilia, 1993), overeating (Lesieur & Blume, 1993), and compulsive sexual behavior (Goodman, 1993). Similar addiction models have been applied to technological overuse (Griffiths, 1996), computer dependency (Shotton, 1991), excessive television viewing (Kubey & Csikszentmihalyi, 1990; McIlwraith et al., 1991), and obsessive video game playing (Keepers, 1991). However, the concept of addictive Internet use has not been empirically researched. Therefore, the purpose of this exploratory study was to investigate if Internet usage could be considered addictive and to identify the extent of problems created by such misuse.

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With the popularity and wide-spread promotion of the Internet, this study first sought to determine a set of criteria which would define addictive from normal Internet usage. If a workable set of criteria could be effective in diagnosis, then such criteria could be used in clinical treatment settings and facilitate future research on addictive Internet use. However, proper diagnosis is often complicated by the fact that the term addiction is not listed in the Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition (DSM-IV; American Psychiatric Association, 1994). Of all the diagnoses referenced in the DSM-IV, Pathological Gambling was viewed as most akin to the pathological nature of Internet use. By using Pathological Gambling as a model, Internet addiction can be defined as an impulse-control disorder which does not involve an intoxicant. Therefore, this study developed a brief eight-item questionnaire referred to as a Diagnostic Questionnaire (DQ) which modified criteria for pathological gambling to provide a screening instrument for addictive Internet use:

1. Do you feel preoccupied with the Internet (think about previous on-line activity or anticipate next on-line session)?
2. Do you feel the need to use the Internet with increasing amounts of time in order to achieve satisfaction?
3. Have you repeatedly made unsuccessful efforts to control, cut back, or stop Internet use?
4. Do you feel restless, moody, depressed, or irritable when attempting to cut down or stop Internet use?
5. Do you stay on-line longer than originally intended?
6. Have you jeopardized or risked the loss of significant relationship, job, educational or career opportunity because of the Internet?
7. Have you lied to family members, therapist, or others to conceal the extent of involvement with the Internet?
8. Do you use the Internet as a way of escaping from problems or of relieving a dysphoric mood (e.g., feelings of helplessness, guilt, anxiety, depression)?

Respondents who answered "yes" to five or more of the criteria were classified as addicted Internet users (Dependents) and the remainder were classified as normal Internet users (Non-Dependents) for the purposes of this study. The cut off score of "five" was consistent with the number of criteria used for Pathological Gambling. Additionally, there are presently ten criteria for Pathological Gambling, although two were not used for this adaptation as they were viewed non-applicable to Internet usage. Therefore, meeting five of eight rather than ten criteria was hypothesized to be a slightly more rigorous cut off score to differentiate normal from addictive Internet use. It should be noted that while this scale provides a workable measure of Internet addiction, further study is needed to determine its construct validity and clinical utility. It should also be noted that the term Internet is used to denote all types of on-line activity.

METHODOLOGY

Subjects

Participants were volunteers who respondent to: (a) nationally and internationally dispersed newspaper advertisements, (b) flyers posted among local college campuses, (c) postings on electronic support groups geared towards Internet addiction (e.g., the Internet Addiction Support Group, the Webaholics Support Group), and (d) those who searched for keywords "Internet addiction" on popular Web search engines (e.g., Yahoo).

Materials

An exploratory survey consisting of both open-ended and closed-ended questions was constructed for this study that could be administered by telephone interview or electronic collection. The survey administered a Diagnostic Questionnaire (DQ) containing the eight-item classification list. Subjects were then asked such qustions as : (a) how long they have used the Internet, (b) how many hours per week they estimated spending on-line, (c) what types of applications they most utilized, (d) what made these particular applications attractive, (e) what problems, if any, did their Internet use cause in their lives, and (f) to rate any noted problems in terms of mild, moderate, or severe impairment. Lastly, demosgraphic information from each subject such as age, gender, highest educational level achieved, and vocational background were also gathered..

Procedures

Telephone respondents were administered the survey verbally at an arranged interview time. The survey was replicated electronically and existed as a World-Wide-Web (WWW) page implemented on a UNIX-based server which captured the answers into a text file. Electronic answers were sent in a text file directly to the principal investigator's electronic mailbox for analysis. Respondents who answered "yes" to five or more of the criteria were classified as addicted Internet users for inclusion in this study. A total of 605 surveys in a three month period were collected with 596 valid responses that were classifed from the DQ as 396 Dependents and 100 Non-Dependents. Approximately 55% of the respondents replied via electronic survey method and 45% via telephone survey method. The qualitative data gathered were then subjected to content analysis to identify the range of characteristics, behaviors and attitudes found.

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RESULTS

Demographics

The sample of Dependents included 157 males and 239 females. Mean ages were 29 for males, and 43 for females. Mean educational background was 15.5 years. Vocational background was classified as 42% none (i.e., homemaker, disabled, retired, students), 11% blue-collar employment, 39% non-tech white collar employment, and 8% high-tech white collar employment. The sample of Non-Dependents included 64 males and 36 females. Mean ages were 25 for males, and 28 for females. Mean educational background was 14 years.

Usage Differences

The following will outline the differences between the two groups, with an emphasis on the Dependents to observe attitudes, behaviors, and characteristics unique to this population of users.

Length of Time using Internet

The length of time using the Internet differed substantially between Dependents and Non-Dependent. Among Dependents, 17% had been online for more than one year, 58% had only been on-line between six months to one year, 17% said between three to six months, and 8% said less than three months. Among Non-Dependents, 71% had been online for more than one year, 5% had been online between six months to one year, 12% between three to six months, and 12% for less than three months. A total of 83% of Dependents had been online for less than one full year which might suggest that addiction to the Internet happens rather quickly from one's first introduction to the service and products available online. In many cases, Dependents had been computer illiterate and described how initially they felt intimidated by using such information technology. However, they felt a sense of competency and exhilaration as their technical mastery and navigational ability improved rapidly.

Hours Per Week

In order to ascertain how much time respondents spent on-line, they were asked to provide a best estimate of the number of hours per week they currently used the Internet. It is important to note that estimates were based upon the number of hours spent "surfing the Internet" for pleasure or personal interest (e.g., personal e-mail, scanning news groups, playing interactive games) rather than academic or employment related purposes. Dependents spent a M = 38.5, SD = 8.04 hours per week compared to Non-Dependents who spent M= 4.9, SD = 4.70 hours per week. These estimates show that Dependents spent nearly eight times the number of hours per week as that of Non-Dependents in using the Internet. Dependents gradually developed a daily Internet habit of up to ten times their initial use as their familiarity with the Internet increased. This may be likened tolerance levels which develop among alcoholics who gradually increase their consumption of alcohol in order to achieve the desired effect. In contrast, Non-Dependents reported that they spent a small percentage of their time on-line with no progressive increase in use. This suggests that excessive use may be a distinguishable characteristic of those who develop a dependence to on-line usage.

Applications Used

The Internet itself is a term which represents different types of functions that are accessible on-line. Table 1 displays the applications rated as "most utilized" by Dependents and Non-Dependents. Results suggested that differences existed among the specific Internet applications utilized between the two groups as Non-Dependents predominantly used those aspects of the Internet which allowed them to gather information (i.e., Information Protocols and the World Wide Web) and e-mail. Comparatively, Dependents predominantly used the two-way communication functions available on the Internet (i.e., chat rooms, MUDs, news groups, or e-mail).

Table 1: Internet Applications Most Utilized by Dependents and Non-Dependents

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Chat rooms and Multi-User Dungeons, more commonly known as MUDs were the two most utilized mediums by Dependents. Both applications allow multiple on-line users to simultaneously communicate in real time; similar to having a telephone conversation except in the form of typed messages. The number of users present in these forms of virtual space can range from two to over thousands of occupants. Text scrolls quickly up the screen with answers, questions, or comments to one another. Sending a "privatize message" is another available option that allows only a single user to read a message sent. It should be noted that MUDs differ from chat rooms as these are an electronic spin off of the old Dungeon and Dragons games where players take on character roles. There are literally hundreds of different MUDs ranging in themes from space battles to medieval duels. In order to log into a MUD, a user creates a character name, Hercules for example, who fights battles, duels other players, kills monsters, saves maidens or buys weapons in a make believe role playing game. MUDs can be social in a similar fashion as in chat room, but typically all dialogue is communicated while "in character."

News groups, or virtual bulletin board message systems, were the third most utilized application among Dependents. News groups can range on a variety of topics from organic chemistry to favorite television programs to the best types of cookie-dough. Literally, there are thousands of specialized news groups that an individual user can subscribe to and post and read new electronic messages. The World-Wide Web and Information Protocols, or database search engines that access libraries or electronic means to download files or new software programs, were the least utilized among Dependents. This may suggest that the database searches, while interesting and often times time-consuming, are not the actual reasons Dependents become addicted to the Internet.

Non-Dependents viewed the Internet as a useful resource tool and a medium for personal and business communication. Dependents enjoyed those aspects of the Internet which allowed them to meet, socialize, and exchange ideas with new people through these highly interactive mediums. Dependents commented that the formation of on-line relationships increased their immediate circle of friends among a culturally diverse set of world-wide users. Additional probing revealed that Dependents mainly used electronic mail to arrange "dates" to meet on-line or to keep in touch between real time interactions with new found on-line friends. On-line relationships were often seen as highly intimate, confidential, and less threatening than real life friendships and reduced loneliness perceived in the Dependent's life. Often times, Dependents preferred their "on-line" friends over their real life relationships due to the ease of anonymous communication and the extent of control in revealing personal information among other on-line users.

Extent of Problems

One major component of this study was to examine the extent of problems caused by excessive Internet use. Non-Dependents reported no adverse affects due to its use, except poor time management because they easily lost track of time once on-line. However, Dependents reported that excessive use of the Internet resulted in personal, family, and occupational problems that have been documented in established addictions such as pathological gambling (e.g., Abbott, 1995), eating disorders (e.g., Copeland, 1995), and alcoholism (e.g., Cooper, 1995; Siegal, 1995). Problems reported were classified into five categories: academic, relationship, financial, occupational, and physical. Table 2 shows a breakdown of the problems rated in terms of mild, moderate, and severe impairment.

Table 2: Comparison of Type of Impairment to Severity Level Indicated

Although the merits of the Internet make it an ideal research tool, students experienced significant academic problems as they surf irrelevant web sites, engage in chat room gossip, converse with Internet penpals, and play interactive games at the cost of productive activity. Students had difficulty completing homework assignments, studying for exams, or getting enough sleep to be alert for class the next morning due to such Internet misuse. Often times, they were unable to control their Internet use which eventually resulted in poor grades, academic probation, and even expulsion from the university.

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Marriages, dating relationships, parent-child relationships, and close friendships were also noted to be poorly disrupted by excessive use of the Internet. Dependents gradually spent less time with real people in their lives in exchange for solitary time in front of a computer. Initially, Dependents tended to use the Internet as an excuse to avoid needed but reluctantly performed daily chores such as doing the laundry, cutting the lawn, or going grocery shopping. Those mundane tasks were ignored as well as important activities such as caring for children. For example, one mother forgot such things as to pick up her children after school, to make them dinner, and to put them to bed because she became so absorbed in her Internet use.

Loved ones first rationalize the obsessed Internet user's behavior as "a phase" in hopes that the attraction would soon dissipate. However, when addictive behavior continued, arguments about the increased volume of time and energy spent on-line soon ensue, but such complaints were often deflected as part of the denial exhibited by Dependents. Dependents become angry and resentful at others who questioned or tried to take away their time from using the Internet, often times in defense of their Internet use to a husband or wife. For example, "I don't have a problem," or "I am having fun, leave me alone," might be an addict's response. Finally, similar to alcoholics who hide their addiction, Dependents engaged in the same lying about how long their Internet sessions really lasted or they hide bills related to fees for Internet service. These behaviors created distrust that over time hurt the quality of once stable relationships.

Marriages and dating relationships were the most disrupted when Dependents formed new relationships with on-line "friends." On-line friends were viewed as exciting and in many cases lead to romantic interactions and Cybersex (i.e., on-line sexual fantasy role-playing). Cybersex and romantic conversations were perceived as harmless interactions as these sexual on-line affairs did not involve touching and electronic lovers lived thousands of miles away. However, Dependents neglected their spouses in place of rendezvous with electronic lovers, leaving no quality time for their marriages. Finally, Dependents continued to emotionally and socially withdraw from their marriages, exerting more effort to maintain recently discovered on-line relationships.

Financial problems were reported among Dependents who paid for their on-line service. For example, one woman spent nearly $800.00 in one month for on-line service fees. Instead of reducing the amount of time she spent on-line to avoid such charges, she repeated this process until her credit cards were over-extended. Today, financial impairment is less of an issue as rates are being driven down. America On-line, for example, recently offered a flat rate fee of $19.95 per month for unlimited service. However, the movement towards flat rate fees raises another concern that on-line users are able to stay on-line longer without suffering financial burdens which may encourage addictive use.

Dependents reported significant work-related problems when they used their employee on-line access for personal use. New monitoring devices allow bosses to track Internet usage, and one major company tracked all traffic going across its Internet connection and discovered that only twenty-three percent of the usage was business-related (Neuborne, 1997). The benefits of the Internet such as assisting employees with anything from market research to business communication outweigh the negatives for any company, yet there is a definite concern that it is a distraction to many employees. Any misuse of time in the work place creates a problem for managers, especially as corporations are providing employees with a tool that can easily be misused. For example, Edna is a 48 year old executive secretary found herself compulsively using chat rooms during work hours. In an attempt to deal with her "addiction," she went to the Employee Assistance Program for help. The therapist, however, did not recognize Internet addiction as a legitimate disorder requiring treatment and dismissed her case. A few weeks later, she was abruptly terminated from employment for time card fraud when the systems operator had monitored her account only to find she spent nearly half her time at work using her Internet account for non-job related tasks. Employers uncertain how to approach Internet addiction among workers may respond with warnings, job suspensions, or termination from employment instead of making a referral to the company's Employee Assistance Program (Young, 1996b). Along the way, it appears that both parties suffer a rapid erosion of trust.

The hallmark consequence of substance abuse are the medical risk factors involved, such as cirrhosis of the liver due to alcoholism, or increased risk of stroke due to cocaine use. The physical risk factors involved with Internet overuse were comparatively minimal yet notable. Generally, Dependent users were likely to use the Internet anywhere from twenty to eighty hours per week, with single sessions that could last up to fifteen hours. To accommodate such excessive use, sleep patterns are typically disrupted due to late night log-ins. Dependents typically stayed up past normal bedtime hours and reported being on-line until two, three, or four in the morning with the reality of having to wake for work or school at six a.m. In extreme cases, caffeine pills were used to facilitate longer Internet sessions. Such sleep depravation caused excessive fatigue often making academic or occupational functioning impaired and decreased one's immune system leaving Dependents' vulnerable to disease. Additionally, the sedentary act of prolonged computer use resulted in a lack of proper exercise and lead to an increased risk for carpal tunnel syndrome, back strain, or eyestrain.

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Despite the negative consequences reported among Dependents, 54% had no desire to cut down the amount of time they spent on-line. It was at this point that several subjects reported feeling "completely hooked" on the Internet and felt unable to kick their Internet habit. The remaining 46% of Dependents made several unsuccessful attempts to cut down the amount of time they spent on-line in an effort to avoid such negative consequences. Self-imposed time limits were typically initiated to manage on-line time. However, Dependents were unable to restrict their usage to the prescribed time limits. When time limits failed, Dependents canceled their Internet service, threw out their modems, or completely dismantled their computers to stop themselves from using the Internet. Yet, they felt unable to live without the Internet for such an extended period of time. They reported developing a preoccupation with being on-line again which they compared to "cravings" that smokers feel when they have gone a length of time without a cigarette. Dependents explained that these cravings felt so intense that they resumed their Internet service, bought a new modem, or set up their computer again to obtain their "Internet fix."

DISCUSSION

There are several limitations involved in this study which must be addressed. Initially, the sample size of 396 Dependents is relatively small compared to the estimated 47 million current Internet users (Snider, 1997). In addition, the control group was not demographically well-matched which weakens the comparative results. Therefore, generalizability of results must be interpreted with caution and continued research should include larger sample sizes to draw more accurate conclusions.

Furthermore, this study has inherent biases present in its methodology by utilizing an expedient and convenient self-selected group of Internet users. Therefore, motivational factors among participants responding to this study should be discussed. It is possible that those individuals classified as Dependent experienced an exaggerated set of negative consequences related to their Internet use compelling them to respond to advertisements for this study. If this is the case, the volume of moderate to severe negative consequences reported may be an elevated finding making the harmful affects of Internet overuse greatly overstated. Additionally, this study yielded that approximately 20% more women than men responded which should also be interpreted with caution due to self-selection bias. This result shows a significant discrepancy from the stereotypic profile of an "Internet addict" as a young, computer-savvy male (Young, 1996a) and is counter to previous research that has suggested males predominantly utilize and feel comfortable with information technologies (Busch, 1995; Shotton, 1991). Women may be more likely to discuss an emotional issue or problem more than men (Weissman & Payle, 1974) and therefore were more likely than men to respond to advertisements in this study. Future research efforts should attempt to randomly select samples in order to eliminate these inherent methodological limitations.

While these limitations are significant, this exploratory study provides a workable framework for further exploration of addictive Internet use. Individuals were able to meet a set of diagnostic criteria that show signs of impulse-control difficulty similar to symptoms of pathological gambling. In the majority of cases, Dependents reported that their Internet use directly caused moderate to severe problems in their real lives due to their inability to moderate and control use. Their unsuccessful attempts to gain control may be paralleled to alcoholics who are unable to regulate or stop their excessive drinking despite relationship or occupational problems caused by drinking; or compared to compulsive gamblers who are unable to stop betting despite their excessive financial debts.

The reasons underlying such an impulse control disability should be further examined. One interesting issue raised in this study is that, in general, the Internet itself is not addictive. Specific applications appeared to play a significant role in the development of pathological Internet use as Dependents were less likely to control their use of highly interactive features than other on-line applications. This paper suggests that there exists an increased risk in the development of addictive use the more interactive the application utilized by the on-line user. It is possible that a unique reinforcement of virtual contact with on-line relationships may fulfill unmet real life social needs. Individuals who feel misunderstood and lonely may use virtual relationships to seek out feelings of comfort and community. However, greater research is needed to investigate how such interactive applications are capable of fulfilling such unmet needs and how this leads to addictive patterns of behavior.

Finally, these results also suggested that Dependents were relative beginners on the Internet. Therefore, it may be hypothesized that new comers to the Internet may be at a higher risk for developing addictive patterns of Internet use. However, it may be postulated that "hi-tech" or more advanced users suffer from a greater amount of denial since their Internet use has become an integral part of their daily lives. Given that, individuals who constantly utilize the Internet may not recognize "addictive" use as a problem and therefore saw no need to participate in this survey. This may explain their low representation in this sample. Therefore, additional research should examine personality traits that may mediate addictive Internet use, particularly among new users, and how denial is fostered by its encouraged practice.

A recent on-line survey (Brenner, 1997) and two campus-wide surveys conducted at the University of Texas at Austin (Scherer, 1997) and Bryant College (Morahan-Martin, 1997) have further documented that pathological Internet us is problematic for academic performance and relationship functioning. With the rapid expansion of the Internet into previously remote markets and another estimated 11.7 million planning to go on-line in the next year (Snider, 1997), the Internet may pose a potential clinical threat as little is understood about treatment implications for this emergent disorder. Based upon these findings, future research should develop treatment protocols and conduct outcome studies for effective management of this symptoms. It may be beneficial to monitor such cases of addictive Internet use in clinical settings by utilizing the adapted criteria presented in this study. Finally, future research should focus on the prevalence, incidence, and the role of this type of behavior in other established addictions (e.g., other substance dependencies or pathological gambling) or psychiatric disorders (e.g., depression, bipolar disorder, obsessive-compulsive disorder, attention deficit disorder).

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REFERENCES

Abbott, D. A. (1995). Pathological gambling and the family: Practical implications. Families in Society. 76, 213 - 219.

American Psychiatric Association. (1995). Diagnostic and Statistical Manual of Mental Disorders. (4th ed.). Washington, DC: Author.

Brady, K. (April 21, 1996). Dropouts rise a net result of computers. The Buffalo Evening News, pg. 1.

Brenner, V. (1997). The results of an on-line survey for the first thirty days. Paper presented at the 105th annual meeting of the American Psychological Association, August 18, 1997. Chicago, IL.

Busch, T. (1995). Gender differences in self-efficacy and attitudes toward computers. Journal of Educational Computing Research, 12, 147-158.

Cooper, M. L. (1995). Parental drinking problems and adolescent offspring substance use: Moderating effects of demographic and familial factors. Psychology of Addictive Behaviors, 9, 36 - 52.

Copeland, C. S. (1995). Social interactions effects on restrained eating. International Journal of Eating Disorders, 17, 97 - 100.

Goodman, A. (1993). Diagnosis and treatment of sexual addiction. Journal of Sex and Marital Therapy, 19, 225-251.

Griffiths, M. (1996). Technological addictions. Clinical Psychology Forum, 161-162.

Griffiths, M. (1997). Does Internet and computer addiction exist? Some case study evidence. Paper presented at the 105th annual meeting of the American Psychological Association, August 15, 1997. Chicago, IL.

Keepers, G. A. (1990). Pathological preoccupation with video games. Journal of the American Academy of Child and Adolescent Psychiatry, 29, 49-50.

Lacey, H. J. (1993). Self-damaging and addictive behavior in bulimia nervosa: A catchment area study, British Journal of Psychiatry. 163, 190-194.

Lesieur, H. R., & Blume, S. B. (1993). Pathological gambling, eating disorders, and the psychoactive substance use disorders, Journal of Addictive Diseases, 12(3), 89 - 102.

Mobilia, P. (1993). Gambling as a rational addiction, Journal of Gambling Studies, 9(2), 121 - 151.

Morahan-Martin, J. (1997). Incidence and correlates of pathological Internet use. Paper presented at the 105th annual meeting of the American Psychological Association, August 18, 1997. Chicago, IL.

Murphey, B. (June, 1996). Computer addictions entangle students. The APA Monitor.

Neuborne, E. (April 16, 1997). Bosses worry Net access will cut productivity, USA Today, p. 4B.

Quittner, J. (April 14, 1997). Divorce Internet style. Time, pg. 72.

Rachlin, H. (1990). Why do people gamble and keep gambling despite heavy losses? Psychological Science, 1, 294-297.

Robert Half International, Inc. (October 20, 1996). Misuse of the Internet may hamper productivity. Report from an internal study conducted by a private marketing research group.

Scherer, K. (1997). College life online: Healthy and unhealthy Internet use. Journal of College Life and Development, (38), 655-665.

Siegal, H. A. (1995) Presenting problems of substance in treatment: Implications for service delivery and attrition. American Journal of Drug and Alcohol Abuse. 21(1) 17 - 26.

Shotton, M. (1991). The costs and benefits of "computer addiction." Behaviour and Information Technology, 10, 219-230.

Snider, M. (1997). Growing on-line population making Internet "mass media." USA Today, February 18, 1997

Weissman, M. M., & Payle, E. S. (1974). The depressed woman: A study of social relationships (Evanston: University of Chicago Press).

Young, K. S. (1996a). Pathological Internet Use: A case that breaks the stereotype. Psychological Reports, 79, 899-902.

Young, K. S. (1996b). Caught in the Net, New York: NY: John Wiley & Sons. p. 196.

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Melissa Holliday sang at a Chrysler convention, landed a job as an extra on the Baywatch television series, appeared as a Playboy foldout model in January 1995 and, at times, was making $5,000 a day.

Now she lives at her father's apartment in Seabrook, gets $525 a month from Social Security, has not worked in a year and, instead of singing This is My Country for Lee Iacocca, is poised to become an entirely different sort of performer.

Her new topic is electroshock therapy. Her message is, it has ruined her life.

"I was making $2,500 to $5,000 a day," she recalled Wednesday. "I had opportunities other people only dream about. I would've become a star and made a lot of money. I'd have a life.

"Now, everyday is like the Olympics for me. I don't want another person to go through what I've been through. Electroshock is not a form of therapy. Doctors are getting rich off doing brain damage to people."

Holliday on Wednesday filed a civil lawsuit accusing a Santa Monica, Calif., hospital and three physicians of assault and battery and personal injury over what she said was done to her from June 26-July 12, 1995.

Holliday, 26, said she had worked hard at singing, dancing and acting for years, and finally was achieving success. She was modeling and doing voice-overs for TV commercials. She had meetings with people from Warner Bros. and Columbia Pictures.

But through it all, she said, she was in constant pain from a uterine problem. It left her depressed, and at 24, she was told, her only medical solution was a full, unwanted hysterectomy.

Her depression worsened. Finally, she was referred to a female doctor in Santa Monica.

Before long, Holliday said, she was checked into St. John's Hospital and Health Center in Santa Monica and placed on a lengthy regimen of drugs. Her father, Randy Halberson, said his daughter was given uppers, downers and every shade in between.

Although she wasn't informed of it at the onset, Holliday said, she soon learned she was due for electroshock therapy.

"They'd given me so many drugs, I didn't know if I was coming or going," she said, "A week after I got there, the doctor mentioned shock. She didn't ask me if I wanted it. She said if I didn't want it, I'd go to the fourth floor, a lock-up ward. Then nobody could see me and I couldn't go outside."

Nine times she was shocked, Holliday said.

"I've been through a rape, and electroshock therapy is worse," she said. "If you haven't gone through it, I can't explain it."

When it ended, she said, her show-business career was over. "I couldn't leave my house for six months," she said. "I couldn't drive my car for eight months."

Holliday's relatives tell of nine suicide attempts, a total loss of self-confidence, continual anxiety and depression worse than when she went to the Santa Monica hospital.

Holliday's situation has caught the attention of Jerry Boswell of Austin, director of the Citizens Commission on Human Rights of Texas, a group that champions the rights of medical patients. Boswell is leading the charge to abolish electroshock therapy in Texas.

About 1,800 people underwent electroshock therapy in Texas last year, Boswell said, and 70 percent were women.

"Now," he said, "the main target is elderly people. There is a 36 percent increase in shock treatment between age 64 and age 65. When you turn 65, you become eligible for Medicare, and Medicare pays for electroshock. For a few seconds of electricity, the hospital gets $300."

State Rep. Senfronia Thompson, D-Houston, tried last year to push legislation aimed at banning electroshock therapy. Now she is preparing for another try.

"My bill died in committee, but the chairman was kind enough to give me a hearing," Thompson said. "It lasted until the wee hours and we heard from 150 people."

Half the witnesses raved about the good things electroshock treatment had done for them, Thompson said, and the other half related horror stories, how it caused memory loss and even seizures that continued long afterward.

A Houston psychiatrist, Charles S. DeJohn, said electroshock therapy nowadays is unlike that in decades past when it was a more common medical tool for treating depressed people who could not otherwise be helped.

Now it is done with more careful monitoring of "seizure duration and oxygenization levels," DeJohn said. Anesthesiologists typically are present during sessions. Care is taken to prevent patients from breaking their own bones during electrically induced seizures.

"There is no significant deficit,"DeJohn said. "It's reserved for people who haven't responded to treatment and whose condition is such that you can't wait for a response (from drug therapy). It is perceived as a legitimate form of treatment."

DeJohn said he has referred educated patients -- attorneys, professors and others -- for shock treatments and "all responded well."

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Research-Able, Inc.
Contract No. 0353-95-0004
April, 10, 1996

Project Summary

This project will provide the Director of CMHS with a background paper advising him of the current major concerns and criticisms of electroconvulsive therapy (ECT), and identifying gaps in knowledge and differences in points of view among the medical, legal and lay/patient communities. The background paper will recommend steps for CMHS to take to address the identified gaps and differences (such as the possibility of convening a consensus conference on the topic similar to the 1985 NIMH Consensus Project.) It will provide information on which CMHS can base communications to potential patients and their families to assist them in making informed decisions regarding the use of ECT.

Project Components and Technical Approach

Within approximately nine weeks, Research-Able, Inc. and the Policy Resource Center will complete the following major tasks:

• Summarize the major areas of concern raised by consumers and others since 1985 regarding the validity of research on ECT and the extent to which these concerns have been resolved in previously conducted or active research. (Areas of concern will be identified through literature review and by interviewing up to five national and local consumer organizations.) Research questions still to be addressed will be identified.

• Review the methodologies of no more than five major studies of ECT since 1985, (determined by the GPO through input from CMHS staff and the Contractor), identifying and summarizing their strengths and deficiencies. Areas for further study will be identified.

In the performance of these tasks, we will address a number of related research and policy questions:

Review of Literature

• 1985 NIMH Consensus Project: To the extent that this information is readily available through CMHS, we will answer the question: What were the major findings of the 1985 NIMH Consensus Project and what comments were received from the field?

• Summary Literature Since 1985: What does the major summary literature since 1985 have to say about a range of ECT-related topics? (For this, we will use electronic bibliographic databases currently available at the Mental Health Policy Resource Center (PRC) - to include: Dialog and Medline - and will provide CMHS with a source list. The specific topics to be addressed will be determined among the Contractor, the GPO, and CMHS staff.)

Current Status of the Issue from Multiple Perspectives

• Federal: Which Federal agencies are currently involved in ECT and how?

• Research: What major research efforts - medical, legal and others - are currently underway regarding the use of ECT?

• Consumers: What are the major issues with regard to ECT that have been publicly debated since 1985? How and to what extent have these issues been resolved?

• Demographics: What is known about the demographics of persons receiving ECT since 1985? What are the major strengths and limitations of available information to accurately depict the characteristics of this population? (For this, we will use research studies, consumer reports and other appropriate sources.)

• Case Law and Judicial Findings: What major case law and judicial findings have there been since 1985 regarding ECT, and are there notable trends? What State laws regarding the use of ECT are referenced in the case law and judicial findings? Should CMHS engage in a full-blown compilation of State laws?

• Policy: What major policy directions and practice trends with regard to ECT are suggested by current literature, Federal activities, and research efforts?

What next steps should CMHS consider initiating or participating in?

Upon completion of the foregoing, Research-able, Inc., and the Policy Resource Center will meet with the Government Project Officer (GPO) to discuss the conclusions and design the most appropriate presentation for the materials.

Project Implementation

Attached is our budget estimate in accordance with the technical proposal. This project is estimated to be accomplished within nine weeks after approval by CMHS of the technical proposal and budget estimate.

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What to Look for If You Suspect an Emotional or Behavioral Disorder

Among all the dilemmas facing a parent of a child with emotional disorders or behavioral problems, the first question-whether the child's behavior is sufficiently different to require a comprehensive psychological evaluation by professionals may be the most troublesome of all. Even when a child exhibits negative behaviors, members of a family may not all agree on whether the behaviors are serious. For instance, children who have frequent, severe temper outbursts or who destroy toys may appear to have a serious problem to some parents, while others see the same behavior as asserting independence or showing leadership skills.

Every child faces emotional difficulties from time-to-time, as do adults. Feelings of sadness or loss and extremes of emotions are part of growing up. Conflicts between parents and children are also inevitable as children struggle from the "terrible two' s" through adolescence to develop their own identities. These are normal changes in behavior due to growth and development. Such problems can be more common in times of change for the family - the death of a grandparent or family member, a new child, a move to the city. Generally, these kinds of problems tend to fade on their own or with limited visits to a counselor or other mental health professional as children adjust to the changes in their lives. At times, however, some children may develop inappropriate emotional and behavioral responses to situations in their lives that persist over time.

Parents May Search for Options to Seeking Professional Help

The realization that a child's behavior needs professional attention can be painful or frightening to parents who have tried to support their child, or it may be accepted and internalized as a personal failure by the parent.

Many parents are afraid that their child may be inappropriately labeled, and point out that the array of diagnoses, medicines, and therapies have not been agreed upon by all specialists. Still, others become alarmed after obtaining an assessment for their child only to discover that the evaluator believed emotional disturbances originate in family dynamics and that "parenting skills" classes were the best way to address the problem. While many parents will concede that they may need to learn new behavior management or communication techniques in order to provide a consistent and rewarding environment for their child, many also express deep anger about the blame that continues to be placed on families with children who behave differently.

Before seeking a formal mental health assessment, parents may have tried to help their child by talking to friends, relatives or the child's school. They may try to discover whether others see the same problems and to learn what others suggest they might try. Parents may feel that they also need help in learning better ways of supporting the child through difficult times, and may seek classes to help them sharpen behavior management skills or conflict resolution skills. Modifications in a child's routine at home or school may help to establish whether some "fine tuning" will improve performance or self-esteem. If the problems a child is experiencing are seen as fairly severe, and are unresponsive to interventions at school, in the community or at home, an assessment by a competent mental health professional is probably in order. An assessment will provide information which, when combined with what parents know, may lead to a diagnosis of an emotional or a behavioral disorder, and a recommended treatment program.

When Should Parents Reach Out for Professional Help?

So when is that magical moment when parents should recognize their child's behavior has surpassed the boundary of what all children do and has become sufficiently alarming to warrant a formal assessment? There probably isn't one. It is often a gradual awareness that a child's emotional or behavioral development just isn't where it should be that sends most parents on a quest for answers.

Perhaps the most important question of all for parents of school-age children to consider is, "How much distress is your child's problems causing you, the child, or other members of the family?" If a child's aggressive or argumentative behaviors or sad or withdrawn behaviors are seen as a problem for a child or members of his or her family, then the child' s behaviors are a problem that should be looked at, regardless of their severity.

While there is no substitute for parental knowledge, certain guidelines are also available to help families make the decision to seek an evaluation. In Help for Your Child, A Parents Guide to Mental Health Services, Sharon Brehm suggests three criteria to help in deciding whether a child's behavior is normal or a sign that the youngster needs help:

• The Duration of a Troublesome Behavior - Does it just go on and on with no sign that the child is going to outgrow it and progress to a new stage?

• The Intensity of a Behavior - For instance, while temper tantrums are normal in almost all children, some tantrums could be so extreme that they are frightening to parents and suggest that some specific intervention might be necessary. Parents should pay particular attention to behaviors such as feelings of despair or hopelessness; lack of interest in family, friends, school or other activities once considered enjoyable; or behaviors which are dangerous to the child or to others.

• The Age of the Child - While some behavior might be quite normal for a child of two, observation of other children of the youngster's age may lead to the conclusion that the behavior in question is not quite right for a five-year-old. Not all children reach the same emotional milestones at the same age, but extreme deviations from age-appropriate behaviors may well be cause for concern.

Attempts at self-injury or threats of suicide, violent behaviors, or severe withdrawal that creates an inability to carry on normal routines must be regarded as emergencies for which parents should seek immediate attention, through a mental health or medical clinic, mental health hotline, or crisis center.

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Parents will also want to consider whether their child's behavior could be influenced by other factors:

• whether a specific physical condition (allergies, hearing problems, change in medication, etc.) could be affecting the behavior;
• whether school problems (relationships, learning problems) are creating additional stress;
• whether the adolescent or older teen might be experimenting with drug use or alcohol; or
• whether changes in the family (divorce, new child, death) have occurred which may be causing concern for the child.

Considerations for Young Children

Special consideration needs to be given to identifying behaviors of concern in very young children. Their well-being is so connected with that of the family that services must be developed with and directed to the family as a unit. The goal of assessing and providing services to a young child should include helping families to articulate their own stresses and strengths. It is in the context of family that a child first explores his or her world and learns to adapt to the varied demands of families and the world at large.

Historically, many professionals have not been anxious to have a child "labeled and judged" at an early age. On the other hand, the earlier that parents and professionals can intervene in the life of a young child with delays in emotional and behavioral development, the better it is for both the child and the family. Early assessment and intervention require that parents be involved in both giving and receiving information about their child's development. Interviews with families and observations of their child to assess how well he or she communicates, plays, relates to peers and adults and is able to self-regulate behavior is useful in deciding whether the child has a developmental problem that needs attention.

Infants

Most often, the first indications that an infant may be experiencing significant problems will be delays in normal development. An infant who is unresponsive to his or her environment (doesn't show emotion, such as pleasure or fear that is developmentally appropriate; doesn't look at or reach for objects within reach or respond to environmental changes such as sound or light), who is over-responsive (easily startled, cries), or who shows weight loss or inadequate weight gain that is not explainable by a physical problem (failure to thrive), should have a thorough evaluation. If parents have questions about their child's development, they should call their child's pediatrician or family physician. Many doctors who include young children in their practice will have materials available for parents on normal childhood development.

Toddlers

Toddlers may have a tremendous range of behaviors that would be considered developmentally appropriate, depending on the child's own history. However, any significant delays (six months or more) in language development, motor skills or cognitive development should be brought to the attention of the child's pediatrician. Children who become engrossed in self-stimulating behavior to the exclusion of normal activities or who are self-abusive (head banging, biting, hitting), who do not form affectionate relationships with care providers such as babysitters or relatives, or who repeatedly hit, bite, kick or attempt to injure others should be seen by their pediatrician or family physician and, if indicated, by a competent mental health professional.

First Children

Especially with a first child, parents may feel uneasy, uncomfortable, or even foolish about seeking an evaluation for their very young child. While sorting out problems from developmental stages can be quite tricky with infants and toddlers, early identification and intervention can significantly reduce the effects of abnormal psychosocial development. Careful observation of infants and toddlers as they interact with caregivers, their family or their environment is one of the most useful tools that families or physicians have since many mental health problems cannot be diagnosed in any other way.

The Individuals with Disabilities Education Act (IDEA) requires states to provide services for children from ages three through twenty-one who have disabilities and established an Early Intervention State Grant Program (part H of the IDEA) to serve infants and toddlers from birth through the age of two. The law specifies that states who apply for and receive funds under Part H must provide a multi-disciplinary assessment of infants or toddlers who are experiencing significant delays in normal development, and identify services appropriate to meet any identified needs in a written Individual Family Services Plan (IFSP). As of this writing, all states are receiving funds to provide services to infants and toddlers. Parents who have questions related to preschool or early intervention programs should call their local school district offices or their state Department of Health or Human Services for guidance.

Cultural Considerations

Appropriate assessment of a child's mental health or emotional status is key to developing appropriate school or mental health services. For children who are cultural or racial minorities, parents will want to know how, or if, those differences will affect assessment results.

Tests, by their very nature, have been developed to discriminate. If everyone taking a test scored the same, then the test would be of no use. What's important, though, is that tests discriminate only in those areas they were designed to measure - such as depression, anxiety, etc. - and not along measures such as cultural background, race, or value systems.

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If the professional who is responsible for assessment is not of the same cultural background as the child, parents should feel free to ask what his or her experiences have been in cross-cultural assessment or treatment. Professionals who are sensitive to issues of bias related to language, socioeconomic status or culture found in assessment tools should willingly share such information with parents.

One way of minimizing the effects of cultural bias in obtaining an appropriate diagnosis is to utilize a multidisciplinary approach to assessment involving persons from different backgrounds (teacher, therapist, parent, social worker) in completing the assessment. Several questions to consider are:

• Do the various professionals agree with one another?
• Did the professionals use family information about the child's functioning at home and in the community to aid in making a diagnosis?
• Does the family believe the assessment is accurate?

When a multidisciplinary approach is not practical or available, the person providing the assessment should give a battery of tests to reduce the effects of bias in an individual test when making a determination that a child needs mental health services.

If children from specific ethnic or cultural groups appear to be over-represented in the program that has been selected or recommended for a child, parents should carefully examine the procedures for determining their child's placement.

If parents decide that the placement decision was not influenced by racial or cultural bias, that perspective can increase confidence in the therapeutic program selected for their child.

Where Should Parents Seek Assessment for Their Child?

Once parents have decided that their child or adolescent has behaviors that deserve at least a look by a mental health professional, the question then becomes where to turn for an evaluation.

If the child is of school age, a first step could be to approach the school's special education director and request an assessment by the school psychologist or teacher. If the family doesn't want to involve the school at this point, there are several other places to turn for an evaluation.

A family doctor can rule out physical health issues and refer families to an appropriate child or adolescent psychologist or psychiatrist. Also, many hospitals and most community mental health centers offer comprehensive diagnostic and evaluation programs for children and adolescents.

An assessment can be costly, but there are some supports available for families. For instance, most insurance companies will cover all or a portion of the costs of an assessment or, Medical Assistance Medicaid) will cover costs for eligible families.

For Medicaid-eligible children, the Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT) provides preventive health care, including screening (assessment), diagnosis, and appropriate mental health services.

Under EPSDT, a screen is a comprehensive health evaluation, including the status of a child's emotional health. A child is entitled to periodic screenings, or an interperiodic screening (between normal screening times) whenever a physical or emotional problem is suspected and is entitled to receive health services to address such problems from any provider (public or private) who is a Medicaid provider. Because of the number of changes being proposed in the Medicaid program at the time of this writing, it is a good idea for parents to check with their state Medicaid office if they are concerned about services under the EPSDT program.

Other parents, particularly those in rural areas, may want to first approach their county's public health nurse or mental health services director. Either may be able to direct them to an evaluation program available in their area.

Community mental health centers are also a good source of help, and can be less expensive than seeking out a private doctor or mental health professional. Parents will want to ask for professional staff with experience in evaluating the mental health needs of children if in doubt, ask for the credentials and expertise of the professional who is assigned to work with the child. Credentials should be offered and should be displayed in the professional's workplace.

© 1996. PACER Center, Inc.

I extend my grateful thanks to PACER for graciously allowing me to reprint this timely, informative article.

HealthyPlace.com comprehensive information on Childhood Mental Disorders.

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Job very stressful? Ways to cut down on your workload, relieve stress, anxiety and depression. Keep from being emotionally drained, burned out.

You haven't seen the bottom of your in-box in months.

You've gone from 9-to-5 to 8-to-7 -- and that's on a easy day.

In short, you've got too much to do with too few resources and not enough patience to deal with the stress that's building in you every day.

You're not alone.

In recent insurance industry studies, nearly half of American workers say their job is "very or extremely stressful" and 27 percent said their job was the greatest source of stress in their life.

More specifically, a study by the Northwestern National Life Insurance Company found that 53 percent of supervisors and 34 percent of non-supervisors consider their jobs highly stressful.

The following tips can help you cut down on your workload -- and your stress:

• If possible, don't take on any new projects that will demand a lot of your time or come due during the time of another large project.
• Take care of as much routine work in advance of the stressful time as possible.
• Ask yourself: Can someone else do it? Can something be delayed? Can I substitute something else? Is it essential?
• Find a time-planning system that helps you.
• Concentrate on the most important tasks first.

Some national studies suggest that, on average, corporations lose about 16 days annually in productivity per worker due to stress, anxiety and depression.

Researchers find that employees are "emotionally drained" and "burned out" at the end of the day. One primary cause of those feelings is working too much or taking on more responsibility than one can handle.

Wanting to do more for the office team is an honorable goal. But when you take on too much and start to slip -- you should step back and examine what you're doing.

There are ways to handle stress and your workload before they get the best of you -- and that's the one thing you always want to contribute to your job.

Copyright © 1996 American Psychological Association

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USA Today Series
12-06-1995

The electrodes were placed on her head. With the push of a button, enough electricity to light a 50-watt bulb passed through her skull.

Her teeth bit hard into a mouth guard. Her heart raced. Her blood pressure soared. Her brain had an epileptic-style grand mal seizure. Then, Ocie Shirk had a heart attack.

Four days later, on Oct. 14, 1994, the 72- year-old retired health department worker from Austin, Texas, was dead of heart failure - the leading cause of shock-related death.

After years of decline, shock therapy is making a dramatic and sometimes deadly comeback, practiced now mostly on depressed elderly women who are largely ignorant of shock's true dangers and misled about shock's real risks.

Some lose already fragile memories. Some suffer heart attacks or strokes. And some, like Ocie Shirk, die.

A four-month USA TODAY investigation found: The death rate for elderly patients who receive shock is 50 times higher than patients are told on the American Psychiatric Association's model ECT consent form. The APA sets the chance of dying at 1 in 10,000. But the death rate is closer to 1 in 200 among the elderly, according to mortality studies done over the past 20 years and death reports from Texas, the only state that keeps close track.

Shock machine manufacturers greatly influence what patients are told about shock's risks.

Virtually all "educational" videos and brochures shown to patients are supplied by shock machine companies. And the APA's 1-in-10,000 death rate estimate is attributed to a book written by a psychiatrist whose company sells about half the shock machines sold each year.

Shock therapy is strongly regaining favor among psychiatrists as a treatment for depression. Although exact figures are not kept, one indication of the trend comes from Medicare, which paid for 31% more shock treatments in 1993 than it did in 1986.

The elderly now account for more than half of the estimated 50,000 to 100,000 people who receive shock each year, with women in their 70s getting more shock than any other group. In the 1950s and 1960s, young male schizophrenics got most shock therapy.

Shock therapy is the most profitable practice in psychiatry, and economics strongly influences when shock is given and who gets it.

In Texas, the only state that keeps track, 65-year- olds get 360% more shock therapy than 64-year-olds. The difference: Medicare pays.

Shock treatment may shorten the lives of the elderly, even if it doesn't cause immediate problems.

In a 1993 study of patients 80 and older, 27% of shock patients were dead within one year compared to 4% of a similar group treated with anti-depressant drugs. In two years, 46% of shocked patients were dead vs. 10% who had the drugs. The study, by Brown University researchers, is the only study of long-term survival rates in the elderly.

Doctors rarely report shock treatment on death certificates, even when the connection seems apparent and death certificate instructions clearly indicate it should be listed.

For this story, USA TODAY reviewed more than 250 scientific articles on shock therapy, watched the procedure at two hospitals and interviewed dozens of psychiatrists, patients and family members.

Outside of medical journals, accurate information about shock is sketchy. Only three states make doctors report who gets it and what complications occur. Texas has strict reporting requirements; California and Colorado less stringent rules.

The information that is available raises serious questions about how shock therapy is practiced today, particularly on the elderly.

"We've learned nothing from the mistakes of my generation," says psychiatrist Nathaniel Lehrman, 72, retired clinical director of Kingsboro state mental hospital in New York. "The elderly are the people who can least stand" shock. "This is gross mistreatment on a national scale."

A changing image

Monday, Wednesday and Friday morning is shock therapy time in hospitals across the country.

Most patients get a total of six to 12 shocks: one a day, three times a week until the treatment is finished. Patients generally receive a one- or four-second electrical charge to the brain, which causes an epileptic-like seizure for 30 to 90 seconds.

The American Psychiatric Association information sheet for patients says: "80% to 90% of depressed people who receive (shock) respond favorably, making it the most effective treatment for severe depression." Psychiatrists who do shock therapy also are convinced of its safety.

"It's more dangerous to drive to the hospital than to have the treatment," says psychiatrist Charles Kellner, editor of Convulsive Therapy, a medical journal. "The unfair stigma against (shock) is denying a remarkably effective medical treatment to patients who need it." Psychiatrists say shock therapy is a gentler procedure today than it was in its heyday in the 1950s and 1960s, when it was an all-purpose treatment for everything from schizophrenia to homosexuality.

And advocates say it's nothing like its portrayal 20 years ago in the movie One Flew Over the Cuckoo's Nest, which showed electroshock being used to punish mental patients.

The movie helped send shock therapy into decline and prompted laws across the nation making it hard to give shock treatment without the patient's written consent.

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Because of abuse in the past, shock is seldom done now at state mental hospitals, but mostly at private hospitals and medical schools.

The language is softer today, too, reflecting an effort to change shock's image: Shock is "electroconvulsive therapy" or, simply, ECT. The memory loss that often accompanies it is called "memory disturbance." These changes come as doctors expand shock's reach - to high-risk patients, to children, to the elderly - altering the profile of who gets shock therapy so much that the typical patient now is a fully insured, elderly woman treated for depression at a private hospital or medical school.

Someone like Ocie Shirk.

Died in recovery room

Shirk, a widow coping with recurring depression, already had one heart attack and suffered from atrial fibrillation, a condition that causes rapid heart quivers.

On a Monday at 9:34 a.m., Oct. 10, 1994, she received shock therapy at Shoal Creek Hospital, a for-profit psychiatric hospital in Austin. She had a heart attack in the recovery room. Four days later, she died of heart failure.

Yet shock therapy isn't mentioned on Shirk's death certificate, despite repeated instructions on the form to include every event that may have played a role in the death.

The medical examiner confirms that shock should have been on the death certificate. "If it happens so close after (shock) therapy, it definitely should be listed," says Roberto Bayardo, Austin's medical examiner.

Gail Oberta, chief executive of Shoal Creek Hospital, declines comment on Shirk. But she says, "When I checked all our records and went through all the reviews we do, there were no deaths related to ECT." A Texas Department of Health investigation found Shirk's treatment didn't meet the required standard of care because her medical records did not include a current medical history or physical that would let doctors accurately assess shock therapy's risks. The hospital agreed to correct the problem.

In addition to Shirk, state records show two other patients died after shock therapy at Shoal Creek. Asked about these deaths, Oberta repeats: "We could find no correlation between deaths of patients and receiving ECT at this facility." Getting to the facts behind shock-related deaths is very difficult even in Texas, which in 1993 became the only state with a strict law on shock therapy. The law, passed after lobbying from shock opponents, requires all deaths that occur within 14 days of shock therapy be reported to the Texas Department of Mental Health and Retardation.

In the 18 months after the Texas law took effect, eight deaths - including the three at Shoal Creek - were reported out of the 2,411 patients who received shock therapy in the state. About half those who received shock were elderly.

Six of the eight dead patients were older than 65.

Stated another way: 1 in 197 elderly patients died within two weeks of receiving shock therapy. The state does not release enough information to know if shock caused the deaths.

Nationally, record-keeping is almost nonexistant.

The Centers for Disease Control reports shock therapy was listed on death certificates as a factor in only three deaths over the five years ending 1993 - a number so low that it contradicts even the most favorable estimates of shock mortality.

The CDC records shock-related deaths under a category called "Misadventures in Psychiatry." "For obvious reasons, doctors are reluctant to list anything that falls into this category," says Harry Rosenberg, head of mortality data at the CDC, "even though we encourage them to be forthright."

Elderly deaths: 1 in 200

The American Psychiatric Association shock therapy task force report has been the bible of shock practice since its publication in 1990. It says 1 in 10,000 patients will die from shock therapy.

This estimate is included on the APA's model "informed consent" form, which patients sign to prove they've been fully informed of the risks of shock treatment.

The source for this estimate: A textbook written by psychiatrist Richard Abrams, president and co- owner of shock machine manufacturer Somatics Inc. of Lake Bluff, Ill.

Somatics is a private company. Abrams won't say how much of the company he owns or how much he earns from it.

"I don't know where they got that (estimate) from," Abrams says of the 1-in-10,000 death rate.

When pointed to page 53 of his 1988 textbook Electroconvulsive Therapy, where the death rate appears twice, Abrams notes that the number was dropped from the 1992 edition.

His updated textbook states the death rate differently, but Abrams agrees it amounts to the same thing.

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Abrams' revised book says a death will occur once in every 50,000 shock treatments. He says it's fair to assume that the average patient gets five treatments, making the death rate about 1 in 10,000 patients. Five shocks is average because some patients stop their treatment early.

Abrams' figures are based on a study of shock deaths that psychiatrists report to California regulators. But USA TODAY found that shock deaths are significantly underreported in California and elsewhere.

At a recent professional meeting, for example, a California psychiatrist told how shock therapy caused a stroke in one of his patients. The man, in his 80s, died several days later. But the death was never reported to state regulators.

Consistently, the studies of elderly death rates conflict with the 1-in-10,000 estimate: A 1982 Journal of Clinical Psychiatry study found one death among 22 patients aged 60 and older. A 71-year-old woman had "cardiopulmonary arrest 45 minutes after her fifth treatment. She expired despite intensive resuscitative efforts." Two men in the study, ages 67 and 68, suffered life- threatening heart failure but survived. Seven more had less serious heart complications.

A 1984 Journal of American Geriatrics Society study - often cited as proof of shock therapy's safety - found 18 of 199 elderly patients developed serious heart problems while receiving shock. An 87-year-old man died of a heart attack.

Five patients - ages 89, 81, 78, 78 and 68 - suffered heart failure but were revived.

A 1985 Comprehensive Psychiatry study of 30 patients age 60 and older found one death. An 80-year-old man had a heart attack and died several weeks later. Four others had major complications.

A 1987 Journal of the American Geriatrics Society study of 40 patients age 60 and older found six serious cardiovascular complications but no deaths.

A 1990 Journal of the American Geriatrics Society study of 81 patients age 65 and older found 19 patients developed heart problems; three cases were serious enough to require intensive care. None died.

These studies looked only at complications that occurred while a patient was undergoing a series of shock treatments; long-term mortality rates were not considered.

Taken together, the five studies found three of 372 elderly patients died. Another 14 suffered serious complications, but survived. These results are similar to a study of shock therapy deaths done in 1957 by David Impastato, a leading shock researcher of the time.

He concluded: "The death rate is approximately 1 in 200 in patients over 60 years of age and gradually decreases to 1 in 3,000 or 4,000 in younger patients." Impastato found heart problems were the leading cause of shock-related death, followed by respiratory problems and stroke - the same pattern as in recent studies.

"The claim that 1 in 10,000 people die from shock is refuted by their own studies," says Leonard Roy Frank, editor of The History of Shock and a shock opponent. "It's 50 times higher than that." But Abrams, who has reviewed the studies, calls it "irrational and incomprehensible" to attribute so many of the deaths to shock itself. Even if a patient has a heart attack minutes later - as Ocie Shirk did - Abrams says, "it may very well not be ECT-related." Duke University psychiatrist Richard Weiner, chairman of the APA task force, also believes studies show the 1-in-10,000 estimate is accurate and disagrees the elderly death rate could be as high as 1 in 200.

"If it were anywhere near that high, we wouldn't be doing it," Weiner says. He says health problems, not age, cause the appearance of a higher death rate among elderly.

Still, some doctors who consider shock therapy a relatively safe treatment are concerned about the complications in elderly patients.

"Almost every death in the literature is an elderly person," says William Burke, a University of Nebraska psychiatrist who's studied shock and the elderly. "But it's hard to hazard a guess on a death rate because we don't have the data."

Shock is profitable The financial incentives of performing shock may be driving the increase in its use.

Shock therapy fits well into the economics of private insurance. Most policies don't pay for psychiatric hospital stays after 28 days. Drug therapy, psychotherapy and other treatments can take much longer. But shock therapy often produces a dramatic effect in three weeks.

"We're looking for more bang for the buck in health care today. This treatment gets people out of the hospital fast," says Dallas psychiatrist Joel Holiner, who performs shock.

It is also the most profitable procedure in psychiatry.

Psychiatrists charge $125 to $250 per shock for the five- to 15-minute procedure; anesthesiologists charge $150 to $500.

This bill for one shock at CPC Heritage Oaks Hospital in Sacramento, Calif., is typical: $175 for the psychiatrist.

$300 for the anesthesiologist.

$375 for use of the hospital's shock therapy room.

The patient got a total of 21 shocks, costing about $18,000. The hospital charged another $890 a day for her room. Private insurance paid.

Those figures add up. For example, a psychiatrist who does an average of three shocks a week, at $175 per shock, would increase his or her income by $27,300 a year.

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Medicare pays less than private insurance - the payment varies by state - but it is still lucrative.

Before turning 65, many people are uninsured or have insurance that does not cover shock. Once someone qualifies for Medicare, the chance of getting shock therapy soars - as the 360% increase in Texas shows.

Stephen Rachlin, retired chairman of psychiatry at Nassau County (N.Y.) Medical Center, believes shock therapy is useful treatment. But he worries that financial rewards may influence its use.

"The rate of reimbursement by insurance is higher than anything else a psychiatrist can do in 30 minutes," he says. "I'd hate to think it's done solely for financial reasons." Psychiatrist Conrad Swartz, co-owner with Abrams of Somatics Inc., the shock equipment manufacturer, defends the financial rewards.

"Psychiatrists don't make much money, and by practicing ECT they can bring their income almost up to the level of the family practitioner or internist," says Swartz, who performs shock himself.

According to the American Medical Association, psychiatrists earned an average of $131,300 in 1993.

A doctor says 'no'

Michael Chavin, an anesthesiologist from Baytown, Texas, participated in 3,000 shock sessions before he stopped two years ago, worried he was hurting elderly patients.

"I began to get very disturbed by what I was seeing," he says. "We had many elderly patients getting repeated shocks, 10 or 12 in a series, getting more disoriented each time. What they needed was not an electroshock to the brain, but proper medical care for cardiovascular problems, chronic pain and other problems." In Chavin's view, when the cardiovascular system is dramatically stressed in the elderly, doctors risk triggering a fatal decline.

"As an anesthesiologist, what I do for three to five minutes can have serious consequences later," Chavin says. "But psychiatrists cannot bring themselves to admit any harm from ECT unless the patient gets electrocuted to death on the table while being videotaped and observed by a United Nations task force.

"These deaths are telling us something. Psychiatrists don't want to hear it." Chavin, then chief of anesthesiology at Baycoast Medical Center, stopped doing shock in 1993, reducing his income by $75,000 a year.

He says he feels ashamed that his waterfront home and pool were partially financed by what he considers to be "dirty money." In spite of his growing doubts, Chavin didn't quit doing shock right away. "It was hard to give up the income," he says.

First, Chavin turned away patients. "I'd tell the psychiatrist: 'This 85-year-old woman with high blood pressure and angina is not a good candidate for repeated anesthesia.' " Then, to confront his doubts, he began looking at the research on shock therapy. "I found it was done by psychiatrists who do electroshock for a living," Chavin says.

He finally quit doing shock and another anesthesiologist took over. Two months later, on July 25, 1993, a patient named Roberto Ardizzone died from respiratory complications that began as he received shock therapy.

The hospital stopped doing shock altogether.

By Dennis Cauchon, USA TODAY

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USA Today Series
12-06-1995

Although shock therapy has been performed for decades, researchers still don't know precisely how it works to combat depression.

"We've been looking for 50 years, but ECT causes many changes, and we haven't pinned down which one has the anti-depressant effect,'' says Charles Kellner, editor of Convulsive Therapy.

The major theories:

Neurotransmitter theory. Shock works like anti-depressant medication, changing the way brain receptors receive important mood-related chemicals, such as serotonin and dopamine and norepinephrine.

Anti-convulsant theory. Shock-induced seizures teach the brain to resist seizures. This effort to inhibit seizures dampens abnormally active brain circuits, stabilizing mood.

Neuroendocrine theory. The seizure causes the hypothalamus, part of the brain that regulates water balance and body temperature, to release chemicals that cause changes throughout the body. The seizure may release a neuropeptide that regulates mood.

Brain damage theory. Shock damages the brain, causing memory loss and disorientation that creates a temporary illusion that problems are gone. Shock supporters strongly dispute the theory, advanced by psychiatrist Peter Breggin and other shock critics.

"Not only hasn't the Breggin brain damage theory been proven, it's been disproven,'' says shock researcher Harold Sackheim of Columbia University.

By Dennis Cauchon, USA TODAY

USA Today Series
12-06-1995

For the first time in four decades, children and adolescents are being used as subjects of significant new shock therapy studies.

The studies are being done quietly at respected schools and hospitals such as UCLA, the Mayo Clinic and the University of Michigan.

Shock therapy's use is on the rise, especially among the elderly. Children and other high-risk patients are receiving more shock as well, mostly as a treatment for severe depression.

Children still account for a small percentage of shock patients, and no national estimates exist.

But at a seminar for shock therapy doctors in May, one-third of psychiatrists raised their hands when asked if they did shock on young people.

University of Pennsylvania neuroscientist Peter Sterling, a shock opponent, calls the child studies "horrifying. . . You're shocking a brain that is still developing."

California and Texas ban shock therapy on kids under 12. Most states permit it with approval of two psychiatrists and a parent or guardian.

Shock researchers met in Providence, R.I., in the fall of 1994 to discuss early results of the new studies, mostly unpublished.

"There's no evidence that electroconvulsive therapy affects brain development of children in any permanent way," says researcher Kathleen Logan, a Mayo Clinic psychiatrist.

"Parents and patients have been receptive in a vast majority of cases," Logan says. "We do a lot of education. We show them a video and the ECT suite. They're so desperate that they'll give it a try."

The latest child shock researchers compare their results to the pioneering work in the field: a 1947 study by psychiatrist Lauretta Bender.

Bender's study reported on 98 children (ages 3-11) shocked at Bellevue Hospital in New York. She reported a 97% success rate: "They were better controlled, seemed better integrated and more mature."

In 1950, Bender shocked a 2-year-old who had "a distressing anxiety that frequently reached a state of panic." After 20 shocks, the boy had "moderate improvement."

But in a 1954 follow-up, other researchers could not find improvement in Bender's children: "In a number of cases, parents have told the writers that the children were definitely worse," they wrote.

Today's researchers interpret Bender's study as evidence that shock works, at least temporarily.

The new studies are again reporting great success. A UCLA study had 100% success in nine adolescents. The Mayo Clinic found 65% were better. At Sunnybrook Hospital in Toronto, 14 who received shock spent 56% less time in the hospital than six who refused the treatment.

Ted Chabasinski, who as a 6-year-old foster child was shocked 20 times by Bender, says the research is unethical and should stop.

"It makes me sick to think children are having done to them what was done to me," says Chabasinski, a lawyer. "I've never met anyone other than myself who's functional after being shocked as a child."

By Dennis Cauchon, USA TODAY

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note: article written 11-95

The fate of persons born with ambiguous genitals (also called hermaphrodites, or intersexuals) was the focus of debate when sexual scientists from around the world met in San Francisco earlier this month. Before modern medical understanding of endocrinology and advances in surgical techniques, such individuals made their way in the world as best they could. For the past forty years, however, medical technologies have been widely used to force such unruly bodies to conform more closely to male or female shapes. This policy has been implemented almost entirely without public scrutiny, in hospitals throughout the US and other industrialized countries.

In a symposium titled "Genitals, Identity, and Gender," held at the annual convention of the Society for the Scientific Study of Sex, sex researcher Dr. Milton Diamond, of the University of Hawaii Medical School, and psychologist Dr. Suzanne Kessler, of State University of New York at Purchase, found a receptive audience for their criticism of medical treatment of hermaphrodites. Dr. Heino Meyer-Bahlburg, a member of the team which treats hermaphrodites at Columbia University's Presbyterian Hospital in New York, was on hand to offer the clinician's point of view.

Man without a penis-a woman?

Diamond had dramatic news for the assembled sexologists; he presented a follow-up on the famous case of the twin boys. One of these identical twins had lost his penis at age 7 months in a circumcision accident, in 1963. On medical advice, the boy was reassigned as a girl, plastic surgery used to make his genitals appear female, and female hormones administered during adolescence to complete the metamorphosis. The change of sex was facilitated and monitored at Johns Hopkins Hospital, a leading center for medical treatment of hermaphrodites.

In 1973 and 1975, Dr. John Money of Johns Hopkins, a leading expert in pediatric psychoendocrinology and developmental psychology, reported the outcome as favorable. In the ensuing twenty years, the case of the penectomized twin has taken on immense significance; it is cited in numerous elementary psychology, human sexuality, and sociology texts. Most importantly, the case influenced medical thinking about treatment of hermaphroditic infants. Medical texts now recommend that boys born with a penis that is "too small" be reassigned as girls, just as the twin was.Surgeons remove their penises and testes and construct a vagina, and a pediatric endocrinologist administers hormones to facilitate female puberty.

But in fact, according to Diamond's report, the penectomized twin steadfastly refused to grow into a woman, and now lives as an adult man. She didn't feel or act like a girl. She often discarded the estrogen pills which were prescribed at age 12, and she refused additional surgery to deepen the vagina which surgeons had constructed at 17 months of age, despite Hopkins staff's repeated attempts to convince her that life would be impossible without it. "You're not gonna find anybody unless you have vaginal surgery and live as a female," the twin recalls a Hopkins physician telling her.

The twin was not convinced. "These people gotta be pretty shallow, if that's the only thing I've got going for me. That the only reason people get married is because of what's between their legs. If that's all they think of me, I've gotta be a complete loser," the fourteen year old thought.

By age 14, the twin was able to convince her local physicians, if not the specialists at Hopkins, to help her to live as a male once again. He received a mastectomy and a phalloplasty, he began a regimen of male hormones, and he adamantly refused to ever return to Hopkins.

Although the Hopkins staff were aware of the twin's resistance to medical intervention intended to make a woman of him, for nearly two decades they have dismissed questions about the outcome of this important case because the twin was "lost to followup." In discussion following Diamond's presentation, sexologists expressed shock and dismay that they had been allowed continued to teach and to write that the penectomized twin had been successfully transformed into a woman, for twenty years after the care providers involved knew that the experiment had been a tragic failure. Vern Bullough, the distinguished historian, stood to denounce the Hopkins team and John Money as having acted unethically in the matter.

Who has the power to name?

"Medical standards allow penises as short as 2.5 cm to mark maleness, and clitorises as large as 0.9 cm to mark femaleness. Infant genital appendages between 0.9 cm and 2.5 cm are unacceptable." The audience laughed, but Kessler had accurately summarized mainstream medical practice in "managing" infants and children with unusual genitals. At most hospitals, surgeons will remove clitoral tissue from a child born with such in-between genitals, to produce more acceptable female genitals. In others, surgeons transfer tissue from other parts of the body to try to build a larger penis. No one has ever performed studies to determine the long term effect on sexual function of these genital surgeries.

Kessler noted that physicians and parents refer to such genitals as "deformed" before surgery and "corrected" after surgery. In contrast, many of those who have been subjected to surgery label their own genitals as having been "intact" before surgery, and "mutilated" afterward. These individuals are beginning to come together to form an intersex advocacy movement, most notably in the form of the San Francisco-based Intersex Society of North America (ISNA, PO Box 31791 SF CA 94131, ).

Kessler presented a poll of college students' feelings about "corrective" genital surgery. Women were asked to imagine that they had been born with a larger than normal clitoris, and that physicians had recommended surgery to reduce its size. One fourth of the women indicated that they would not have wanted the clitoral reduction surgery under any circumstance; one quarter would have wanted surgery only if the clitoris caused health problems, and the remaining 1/4 would have wanted the size of their clitoris reduced only if the surgery would not have entailed any reduction in pleasurable sensitivity.

Men were asked to imagine that they had been born with a smaller than normal penis, and physicians had recommended reassigning the boy as female and surgically altering the genitals to appear female. All but one man indicated that they would not have wanted surgery under any circumstance. They seem to be saying that they believe they could live as men in our culture, even with tiny penises.

Finally, Kessler presented communications from parents of girls whose clitorises had been deemed "too large" by physicians, and surgically reduced. In some cases, the parents had noticed nothing unusual about their daughters' clitoral size; physicians had to teach the parents that the clitoris was unusual enough to warrant genital surgery.

A clinician's point of view

Meyer-Bahlburg defended the practice of genital surgery on children. Without surgery, he said, they are likely to be rejected by their parents, and teased by other children. He offered the example of one infant whose father was so disturbed by her large clitoris that he attempted to rip it off with his fingers, resulting in a trip to the emergency room. An ISNA representative stood to denounce the father's action as child abuse, which cannot justify surgery on the infant.

Medical intervention has been predicated on the notion that quality of life is possible only for individuals who conform to male or female sex and gender. But in recent years, the possibility of a third gender, of non-conformance, has come to the fore. There are several threads to this discourse. Anthropologists and ethnographers have identified third gender categories in many cultures, such as the Berdache in Native America, the Hijra in India, the Xanith in Oman, and many others. Non-conforming gender roles are also in evidence in the growing transgender movement, which has rebelled against medical policy which offered services to transsexuals only if they conformed adequately to mainstream heterosexual male or female roles.

But most important, Meyer-Bahlburg acknowledged, is the growing intersex advocacy movement. This movement, represented most forcefully by ISNA, is beginning to speak out against the harm of genital surgery and of secrecy and taboo surrounding intersexuality. "I believe that this new third gender philosophy is going to have a beneficial and quite profound effect on medical intersex management, but that it will take quite a while," said Meyer-Bahlburg. In response to a question from the audience, he indicated that he would begin to advocate less surgery for "minor" cases of genital abnormalities.

Bo Laurent, a doctoral student at the Institute for Advanced Study of Human Sexuality in San Francisco, is a consultant to the Intersex Society of North America.

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Skeptics cling to old images, psychiatrists say

By Andrew Fegelman
CHICAGO TRIBUNE

Unbeknownst to her, Lucille Austwick became the poster girl for patient-rights advocates and psychiatry's skeptics.

"The Rosa Parks of electroshock" is how one publication described the 82-year-old retired telephone operator, a patient in a North Side nursing home.

Across the country, psychiatrists closely monitored her court case in Chicago. It examined whether Austwick, without her consent, could be given electroshock therapy to try to lift her out of depression that had caused her to stop eating. Psychiatrists believed that a ruling preventing the treatment would represent a serious setback for electroshock.

Ultimately, Austwick never received the treatment after doctors concluded that her condition had improved. But her case, and an Illinois Appellate Court ruling earlier this month prohibiting the treatment even after Austwick no longer needed it, has crystallized one of the most controversial and unusual debates in psychiatry.

Critics call it shock treatment. Doctors prefer the more benign "electroconvulsive therapy," or ECT. It is the administration of electrical charges to the brain to treat mental disorders, usually severe depression.

It isn't the first line of psychiatric treatment, but neither is it infrequently used. Experts estimate that 50,000 to 70,000 electroshock treatments are administered annually in the United States.

Electroshock first was deployed to treat mental illnesses in 1938. And for decades, controversy has surrounded its use, misuse and associated problems, ranging from broken bones to death.

While psychiatrists say techniques have vastly improved over the decades, the image of electroshock remains unsettling for many Americans.

There is R.P. McMurphy, the character played by Jack Nicholson in the film version of "One Flew Over the Cuckoo's Nest," undergoing doses of electricity to render him docile.

And then there is a humbled U.S. Sen. Thomas Eagleton (D-Mo.), bumped out as George McGovern's vice presidential running mate in 1972 after shamefully confessing to receiving ECT in the way a politician would admit marital infidelity.

Those lingering images have aided a movement that has continually battled to discredit electroshock.

One of the movement's soldiers is David Oaks, a community activist who runs the 1,000-member Support Coalition in Eugene, Ore.

The group bills itself as a patient-rights organization, but the tone of its pleadings have been decidedly anti-electroshock.

"The claims seem to be that anyone who would criticize psychiatry must be under the powers of some evil cult, and that is ridiculous," Oaks said. "What we are is pro-choice, that people get a range of alternatives, and that no force be used."

Oaks said his organization was attracted to Austwick's case by the question of whether electroshock could be used on a woman who never had consented to it.

To the dismay of psychiatrists, the group was allowed to file a brief in the Austwick case describing problems with electroshock.

The guru of the anti-electroshock movement is Dr. Peter Breggin, a Maryland psychiatrist.

Breggin once likened the treatment to a "blow to the head," saying it delivered the same kind of brain damage.

But most psychiatrists dismiss electroshock opponents as kooks and zealots. There is no better evidence, they say, than the fact that among the leaders of the anti-electroshock movement is the anti-psychiatry Church of Scientology and its Citizens' Commission on Human Rights.

"A lot of these groups aren't just against ECT, they are against psychiatry in general," said Dr. Richard Weiner, an associate professor of psychiatry at Duke University and chairman of the American Psychiatric Association's task force on electroshock.

"ECT has been the subject of a lot of public hearings, and it has always come out OK," Weiner said.

Still, no one can dismiss the successes of electroshock's critics. Their pinnacle came in 1983, when they pushed through a ban on electroshock within the city limits of Berkeley, Calif. The ban was later overturned in court.

But the legacy has lingered. California continues to have one of the toughest electroshock laws in the country, requiring full disclosure to the patient of reasons for the treatment, its duration and all possible side effects. Illinois law requires court approval of the treatment when the patient isn't able to consent to it.

That's how Austwick's case ended up in court.

But it became more than a case about her, creating an arena for much broader questions about the treatment in general. And it may have resulted in a serious setback to use of electroshock.

It wasn't supposed to be this way. During a hearing before the Appellate Court in May, Judge Thomas Hoffman warned that the Austwick matter was not supposed to be a case about the pros and cons of electroshock.

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Instead, he said, the issue was whether Austwick should have been given the treatment and what standards should be applied for answering that question, the judge said.

Although Austwick no longer needed the treatment, the Appellate Court decided that the precedent-setting case raised too many critical issues. It issued a ruling anyway saying shock therapy wouldn't be in Austwick's best interests.

The court noted the "substantial risks" associated with the treatment, including broken bones, memory loss and even death.

The ruling reflected the thinking of the opponents, and the Illinois Psychiatric Association criticized it for ignoring all the scientific evidence.

The use of anesthesia and muscle relaxants, psychiatrists said, have eliminated the incidence of broken bones.

As for memory loss, they conceded that it does occur but usually disappears.

Some patients, however, report some long-term memory loss that never dissipates.

Pyschiatrists also note that statistics show a death rate of only 1 for every 10,000 procedures performed.

Some doctors say the Austwick case illustrates the dangers of the courts trying to deal with science.

The Austwick ruling presented "not a very clear and fair description of a treatment that is really life-saving," said Dr. Philip Janicak, medical director of the Psychiatric Institute at the University of Illinois at Chicago.

"It is rooted more in impressions that go back 20 years than the facts about what modern techniques are involved."

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