Ghostwriting: Time for a Name Change

There is a fascinating process playing out in academic medicine right now. The general public is understandably concerned that much of the medical literature has not been written by the named authors – what most people would call ghostwriting.  In response to these concerns, rather than ban the practice, it appears that several groups within academic medicine are simply trying to change the commonly accepted definition of ghostwriting so that medical papers can still have unnamed authors but not be considered ghostwritten. In other words, rather than ban the practice, change the definition so that the practice can continue. For anyone who is naïve about how medical papers are published, the recent letter by Dr. Jay Amsterdam relating to the ghostwriting charges at the University of Pennsylvania is required reading.

When accusations about ghostwriting are raised, one can count on new and novel defenses appearing in the media. One of the more common defenses that we see is: The Byline Doesn’t Matter Excuse. The thinking goes that as long as deserving authors are mentioned in the acknowledgement section then the paper wasn’t ghostwritten. The proponents of this theory usually use the ICMJE guidelines to support their argument. This narrow explanation is not satisfactory because the idea of appropriate authorship credit certainly predates the existence of ICMJE.

According, to the ICMJE guidelines, as long as an major contributor doesn’t sign off on the final copy of the paper they can opt out of being called an author. Someone who writes 90% of the paper can simply refrain from standing by the whole paper. In numerous articles we have tried to point out the ICMJE guidelines have a loophole in their guidelines that lets this practice continue. We are not alone in this observation as several ghostwriters have pointed out that the loophole lets them stay off the byline. The guidelines appear to be written to address honorary authorship rather than ghostwriting.

As a start, academic medicine should refocus the debate on the rights of the readers. Why should a reader have to question the byline? Why not give the medical writer the credit they deserve and call them an author so that the reader knows who wrote the paper? It seems like such a simple proposition.

Personally we think that a paper whose byline omits the author of the first draft should be considered ghostwritten, even if the paper thanks them for editorial assistance. This was the case for Study 329 and most people consider it to be ghostwritten. And while we have tried to point out that allowing authors to be mentioned in the acknowledgement section does not seem like a practice that academic medicine should allow, clearly our argument is not being heard. Our critics (including some medical writers who co-author these articles) keep falling back on the “ICMJE says it’s acceptable” excuse, and the debate falls into an argument about the semantics of the term “ghostwriting.” Recently, both the MPIP, which is a group of medical journal editors, and the University of PA appear to have sided with the idea that omitting corporate authors from the byline and mentioning them in the acknowledgment section is acceptable. We have discussed the University of Pennsyalvania case in a recent paper titled: Medical Ghostwriting: A University-Sanctioned Sleight of Hand?

So, instead of beating our heads against the wall about arguments over the definition of ghostwriting, and getting nowhere, we propose a more straightforward definition which more accurately describes what is going on. Let’s call it: “Unbylined Corporate Authorship” (UCA). Can everybody agree with this more descriptive and more straightforward term?

Granted, we think it will be hard for academic medicine to declare that it approves of the practice of publishing papers with unnamed coprorate authors on the byline but that is exactly what is happening.

Additional Note: Last week we were guest bloggers on Ed Silverman’s blog,  In our blog posting at Pharmalot we went into more detail about ghostwriting. Also of interest on that posting, are the subsequent comments, many of which were written by medical writers.


Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.


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  1. Good stuff as always. Do you sense the desparation in the folks that use the “ICMJE Defense”? As a friend of mine always says, “It’s like the last days of disco Dave.”

    I think it only a matter of time until we’re burning these “albums” at Comiskey park! Psychiatry Demolition Night indeed! Put something together MindFreedom, it’s a better idea than that damn chicken test for mental illness.

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  2. I just find this whole thing beyond comprehension. I work in Banking, the idea that a company a Bank covers in research could have their employees write any (let alone 90%!) of a research article, and send it to a Bank, which would then stick their logo on it and publish it masquerading as independent research is insane – hence it’s not allowed…it would be ILLEGAL for a Bank to do this.

    What I find particularly bizarre, is why this is not illegal for the medical profession. Giving bias finance research is bad, as someone could make a bad investment decision and lose a lot of money…however, if you write bad medical research, Doctors and their patients are misinformed and uh, people could die! Where are those *regulators* when you need them?!?!

    SUrely psychiatrists should know they’re doing wrong, when investment banks come off looking like the good guys in comparison!

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  3. Ghost writing? Or ghost functioning guys? The ghost in our internal Machine? Consider;


    The Emotional Projection Process:

    A sense of self involved in how we function is always won with the perception of “lesser than,” those weaker others that need our help, our pity, or those worse than that need our scorn?

    Entering the 21st century A.D. can we really afford to carry on in denial about what we really are, and the way we function? Do not owe it to our children and grandchildren to be brave and fearless, in addressing the reality of human nature, before we all go down, on this self-deceiving ship?

    Please consider the family project process and its “unconscious” foundation of a societal, emotional projection process?


    Bowen family systems theory is a theory of human behavior that views the family as an emotional unit and uses systems thinking to describe the complex interactions in the unit. It is the nature of a family that its members are intensely connected emotionally. Often people feel distant or disconnected from their families, but this is more feeling than fact. Family members so profoundly affect each other’s thoughts, feelings, and actions that it often seems as if people are living under the same “emotional skin.” People solicit each other’s attention, approval, and support and react to each other’s needs, expectations, and distress. The connectedness and reactivity make the functioning of family members interdependent. A change in one person’s functioning is predictably followed by reciprocal changes in the functioning of others. Families differ somewhat in the degree of interdependence, but it is always present to some degree.

    The emotional interdependence presumably evolved to promote the cohesiveness and cooperation families require to protect, shelter, and feed their members. Heightened tension, however, can intensify these processes that promote unity and teamwork, and this can lead to problems. When family members get anxious, the anxiety can escalate by spreading infectiously among them. As anxiety goes up, the emotional connectedness of family members becomes more stressful than comforting. Eventually, one or more members feel overwhelmed, isolated, or out of control.

    These are the people who accommodate the most to reduce tension in others. It is a reciprocal interaction. For example, a person takes too much responsibility for the distress of others in relationship to their unrealistic expectations of him. The one accommodating the most literally “absorbs” anxiety and thus is the family member most vulnerable to problems such as depression, alcoholism, affairs, or physical illness.

    Dr. Murray Bowen, a psychiatrist, originated this theory and its eight interlocking concepts. He formulated the theory by using systems thinking to integrate knowledge of the human species as a product of evolution and knowledge from family research. A core assumption is that an emotional system that evolved over several billion years governs human relationship systems. People have a “thinking brain,” language, a complex psychology and culture, but people still do all the ordinary things other forms of life do. The emotional system affects most human activity and is the principal driving force in the development of clinical problems. Knowledge of how the emotional system operates in one’s family, work, and social systems reveals new and more effective options for solving problems in each of these areas.

    Differentiation of Self
    Nuclear Family Emotional System
    Family Projection Process
    Multigenerational Transmission Process
    Emotional Cutoff
    Sibling Position
    Societal Emotional Process

    Elsewhere I’ve pointed to the groundbreaking discovery by Stephen Porges, of the reality of our hidden nervous system functioning, and how life becomes an EXPECTED reality with the first years of our experience of life.

    Here in the 21st century A.D. most of us are “sleep-walking,” unconscious to the reality of our hidden motivation. Yet science & spirituality are converging, as we begin the process of becoming Buddha (awake).

    We are falling fast, into the age of enlightenment, its what all the current chaos is really about, as the “system” enters a state transition, to a higher order of stability? Its a chaos theory thing, something to do with the underlying nature of reality.

    Consider a great American’s advise? And his unique understanding?

    “Sit in a room and read–and read and read. And read the right books by the right people. Your mind is brought onto that level, and you have a nice, mild, slow-burning rapture all the time.” _Joseph Campbell.

    “Man should not be in the service of society, society should be in the service of man. When man is in the service of society, you have a monster state, and that’s what is threatening the world at this minute. …

    Certainly Star Wars has a valid mythological perspective. It shows the state as a machine and asks, “Is the machine going to crush humanity or serve humanity?” Humanity comes not from the machine but from the heart. What I see in Star Wars is the same problem that Faust gives us:

    Mephistopheles, the machine man, can provide us with all the means, and is thus likely to determine the aims of life as well. But of course the characteristic of Faust, which makes him eligible to be saved, is that he seeks aims that are not those of the machine.

    Now, when Luke Skywalker unmasks his father, he is taking off the machine role that the father has played. The father was the uniform. That is power, the state role.” _Joseph Campbell.

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          • Anonymous:)) The post above is about an unconscious “emotional projection process” inherent in generational family learning about “how to BE in life.”

            The unconscious way we teach our children through our emotional reactions towards them. A generational learning passed on in each family, during the first three years of life.

            “A major task of the first year is the evolution of affective tolerance for increasingly higher levels of arousal, and that this is facilitated by the mother’s modulation of the infant’ highly stimulated states. Indeed regulatory processes are the precursors of psychological attachment and its associated emotions, and psychobiological attunement is now thought to be the mechanism that mediates attachment bond formation. The positive emotions of pleasure and interest are the major indicators of affect attunement.
            (p, 8)

            The right cortex is known to be specifically impacted by early social experiences, to be activated in intense states of elation, and to contribute to the development of reciprocal interactions within the mother-infant regulatory system. The child uses the output of the mother’s emotion-regulating right cortex as a template for the imprinting, the hard wiring of circuits in his own right cortex that will come to mediate his expanding affective capacities. (p, 9) (mania seeks to imprint positive state? Seeking positive attachment to environment to overcome too much caution/apprehension?)

            In fact, the mothers face is triggering high levels of endogenous opiates in the child’s growing brain. These endorphins are biochemical responsible for the pleasure qualities of social interaction, social affect, and attachment, as they act directly on sub cortical reward centers of the infant’s brain. (p, 10)

            In view of the fact that attachment experiences induce high levels of activity in neurons that selectively respond to faces, it is important to note that this fronto-limbic structure (like the amygdala and temporal cortex) contains neurons that specifically respond to the emotional expression of faces. (p, 15) (mum & dad)

            Most significantly, in the cerebral cortex, the orbito-frontal region is uniquely involved in social and emotional behaviors and in self-regulation of body and motivational states. (p, 15)

            Success in regulating smoothness of transition between states is a principal indicator of the organization and stability of the emergent and core self. The “nonverbal”, prerational stream of expression that binds the infant to its parent continues throughout life to be the primary medium of intuitively felt affective-relational communication between people. (p, 23)

            It is now established that emotion expression changes developmentally as a function of the experience-dependant maturation of neural inhibitory mechanisms, and that the maturation of the frontal region in the second year is responsible for affect regulation and the development of complex emotions. The emergence of the adaptive capacity to self-regulate affect is reflected in the appearance of more complex emotions which result from the simultaneous blending of different affects, and in an expansion of the “affect array.” (p, 24)

            Developmental psychoanalytic researchers suggest that a psychic structural system involved in the self-regulation of affect and therefore an autonomous emotional functioning appears in the middle of the second year. At the same time an internal signaling system emerges in which affect, especially negative affect that conveys information about threat and lack of social success can be used as a signal function.

            Affect tolerance, which allows for the experience of emotion to enter into consciousness, is related to the adaptive capacity to bear pain. The external regulation of maternally induced negative affect states in this critical period facilitates the emergence of evocative memory at 18 months. It is now accepted that the symbolic representational system of evocative memory allows the child to evoke an image of a comforting other when the other is not physically present and to gain access to one’s self-soothing, self-regulating functions. (p, 24)

            It is now held that the molding of temperamental traits into stable characteristics of personality is a transformation occurring in frontal, temporal, or limbic cortical areas, and that infant temperament can be defined as individual differences in tendencies to express the primary emotions. (p, 25)

            The psychologically attuned caregiver maintains her child’s arousal within a moderate range that is high enough to maintain interactions (by stimulating the child up out of low arousal sates) but not too intense as to cause distress and avoidance (by modulating high arousal states). This entails her actively initiating and participating in not only mirror-refueling (arousal amplifying) and shame socializing (arousal braking) transactions, but also interactive repair (optimal arousal recovering) transactions after attachment breaks. (p, 26) (acting out the missing experience of self mastering affect reg, in couples who fight?)

            Optimal arousal refers to the maintenance of autonomic balance between sympathetic ergo tropic and parasympathetic trophotropic states of arousal It is known that moderate levels of arousal (within the optimal activation band) are associated with positive affect and focused attention, while extreme levels of arousal (high or low) are related to negative emotion and distracted attention. (p, 26)

            The insecure avoidant child habitually utilizes averted (non-face-to-face) gaze, an arousal modulating mechanism. What is avoided is a disorganizing emotional communication expected to emanate from the mothers face (bells palsy) gaze aversion and avoidance of (withdrawal from) the mother who herself withdraws from her infant is proposed to reflect a state of conservation/withdrawal, a primary regulating process for organism homeostasis.

            The infant thus develops a bias toward this parasympathetic-dominant state, one characterized by heart rate deceleration, helplessness, and low levels of activity. Indeed, Izard and colleagues reported that the insecure-avoidant infant has a relatively high level of parasympathetic tone. Its autonomic balance is parasympathetically dominated and geared to respond maximally to low levels of socio-emotional stimulation.

            Psychophysiologically, the over-controlled and restrained nature of insecure-avoidant topologies reflects a vagotronic pattern and a parasympathetically biased, inhibitory, orbit-frontal affective core that has a problem shifting out of parasympathetic low arousal states and in modulating sympathetic, high arousal states. This personality organization shows a pattern of “minimizing emotion expression,” a limited capacity to experience intense negative or positive affect, and is susceptible to overregulation disturbances and to over-controlled, “internalizing” developmental psychopathologies. (p, 28)

            Functional deficits associated with
            Developmental Psychopathology

            In securely attached infants, stress-induced negative affect does not endure for long periods beyond the conditions that elicit them; rapid recovery to positively toned emotion is typical, reflective of efficient regulatory capacities. A cardinal feature of a “high-resilient” child and his/her parents is the capacity of the dyad to fluidly transit from positive to negative back to positive affect. Indeed the ultimate indicator of attachment is seen as this resilience in the face of stress

            On the other hand, the reunion environment created by the insecure mother-infant dyad creates frequent and enduring high levels of negative and low levels of positive affect. As a result of the caregivers inability to participate in dyadic affect-regulating functions that modulate extreme levels of stimulation and arousal, this infant shows a greater tendency for negative emotional states to endure beyond the participating stimulus events. The young child of a depressed mother shows (like the mother) a difficulty in moving back from a negative affect state to a positive affect state of interest.

            As a result of the formation of an internal working model (experience) of a self-attuned-with-a-regulating-other, at later points in the lifespan, the individual classified as securely attached in infancy actively and directly seeks and maintains contact with others when distressed, and finds this contact to be reassuring and effective in terminating distress. (coping) (approach/avoidance in core physiological affects?) (Bowen’s anxiety sharing?)

            Early experiences of being with a psycho biologically deregulating other who initiates but poorly repairs shame-associated misstatement are also incorporated in long-term memory as an interactive representation, a working model (experience) of the self-mistuned-with-a-deregulating-other (predator/prey) As a result of episodes of caregiver-infant “misregulation” or “misstatement,” the infant comes to expect that he cannot benefit from the mothers participation in the management of his affect-arousal . Furthermore, these experiences are stored in memory “largely outside conscious awareness,” as typical of all interactions.

            (Attachment is vital for secure self states in a predator/prey world) (the excitement of “mania discoveries in 2010 & 11 mimicked mother/child reunion needs as I approach the Icarus group with “look what I found.” The need to experience and regulate positive affect?) (acting out the missing experience – experiencing their rapprochement?) (the core issue is physiological not psychological? Core affects concerning approach or avoidance, survival?) (Porges orienting in a defensive world)

            Failures of early attachment invariably become sources of shame, that impairments in the parent-child relationship lead to pathology through an enduring disposition to shame, and this results in chronic difficulties in self-esteem regulation found in all developmental psychopathologies.

            If an attachment figure frequently rejects or ridicules the child’s requests for comfort in stressful situations, the child develops not only an experience of the parent as rejecting but also one of himself as unworthy of support. There is now compelling evidence, from a number of separate disciplines at different levels of analysis, that all early forming psychopathology constitutes disorders of attachment and manifests itself as failures of self and/or interact ional regulation. Loss of ability to regulate the intensity of feelings is the most far-reaching effect of early trauma and neglect. (p, 31) (thwarted development stages & Levine’s thwarted escape reactions?)

            I conclude that these functional vulnerabilities reflect structural weaknesses in the affective core, the psychobiological system that regulates positive mood and interactive behavior, and defects in the organization of the orbit-frontal cortex, the neurobiological regulatory structure that is centrally involved in the adjustment or correction of emotional responses. (p, 32)

            The developing infant is maximally vulnerable to non-optimal and growth inhibiting environmental events during the period of most rapid brain growth. During these critical periods of synapses overproduction followed by synapses elimination, the organism is sensitive to conditions in the external environment, and if these are outside the normal range a permanent arrest of development occurs. (p, 32)

            Social environments that provide less than optimal psychobiological attunement histories retard the “experience-dependant” development of fronto-limbic regions, areas of the cortex that are influenced by attachment experiences and prospectively involved in homeostatic functions. (p, 33)

            The casual relationship between these early experiences and the genesis of predispositions to pathology may be explained by the fact that the genetic systems that program the structural connections within the limbic system are extremely active during critical periods of infancy. Alterations in gene-regulating hormones, such as opioids, corticosteriods, and other neuropathies, are induced and indeed regulated by interacting with the “external environment,” and these changes trigger the activation of genetic programs and thereby the micro-architecture of growing brain regions in the “internal-environment.” (p, 33)”

            Exerts from “Affect Dysregulation & Disorders of The Self” by Allan N Schore.

            And of coarse our two young, highly educated PhD’s know all about this, as they “act out” their self-differentiation needs?

            This particular reply shows the generational progression of understanding in America’s brightest, bravest and most genuine mind’s. Its all in your own backyard, yet you continue to focus on “big bad them” and perpetuate the “us & them” stupidity of it all.

            Your reality, is an “unconscious” expectation of life, “acting out” just like the fabulously smart young people above.

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  4. Sorry I forgot to add that bracketed comments like (thwarted development stages & Levine’s thwarted escape reactions?) are mine.

    “Sit in a room and read–and read and read. And read the right books by the right people. Your mind is brought onto that level, and you have a nice, mild, slow-burning rapture all the time.” _Joseph Campbell.

    Having sat in room and read and re-read the right books by the right people, my “acting out” of four full term PSYCHOSIS is beginning to show a natural metamorphosis, perhaps?

    Yet readers will bring their “unconscious” hard wired wary suspicion to anything “new” in the environment?

    Never mind, beyond the foreground focus of HEADLINE attention, science & spirituality ARE converging in this 21st century A.D. because this is the way a reflective universe, remembers itself?

    by Frank Barr, MD

    Why? How? What’s the purpose? How does one know? Questions relating to the cosmic dilemma have been considered in various ways at different times throughout human history. The cosmic dilemma, of course, concerns “ultimates”–absolutes or invariants. Do ultimates pertain to “objective” domains or to “projective” (non-objective) domains? In other words, which domain has ultimate priority: 1) the projective domain of intuitive insight, revelation, inner experience, faith, belief, emotional charge, motivational drive, intention, and volition; or, 2) the objective domain of physical sense data, observable behavior, measurement, relationship, pattern, form, formulation, concept, and hypothesis? Should ultimate questions center on projective purpose and value or objective fact and theory? Put another way, are ultimate questions to be relegated to the realm of religion or to the realm of science? Can mystical revelation and intuitive insight “project” a teleological pattern which is ultimately accessible to “objective” study, as many ancient mystic-philosophers believed? Is the objective search for the origin or cause of the laws of nature ultimately a projective religious quest, as many leading contemporary physicists now claim? How can the following “apparent” paradoxes and/or dichotomies be ultimately reconciled:

    1) random chance/uncertainty vs. control/certainty
    2) free will/freedom vs. determinism/constraint
    3) mystical insight vs. empirical fact
    4) mind vs. matter
    5) creationism vs. natural evolution
    6) teleology vs. reductionism
    7) religion vs. science
    8) God vs. Nature?

    The philosopher/cosmologist Arthur M. Young (1974) maintains that:
    Both religion and science have a common origin in the search for truth, but have approached this goal differently. Religion depends on revelation or inspired teachers, science on experiments and theories. It would appear that religion has declined in dignity and importance from those early times when all art was dedicated to it and architecture created its temples and cathedrals. Science. on the contrary, began humbly and piece by piece constructed an edifice which is yet to be completed.

    What is PSYCHOSIS for?

    I wonder? Per chance to dream, perhaps?

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  5. Back to the article — whatever happened to academic integrity? When did intellectual dishonesty take over? How can any academic allow someone else to write his or her paper?

    What the heck is going on? Is this all part of the trend towards university-business partnerships? If so, the university is selling its soul. I hope it gets a good deal.

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