The Research\ Studies section starts with an article on CES and chi, homeostasis and the bioelectrical system

The Research\ Studies section starts with an article on CES and chi, homeostasis and the bioelectrical system. Following this are some articles by

Ray Smith, Ph.D. that are recently completed summary studies or meta-analyses of different cogent CES topic areas. Following these articles are broad range database literature search results. I hope you enjoy these readings.

Charles McCusker, Ph.D. June 2006

Cranial Electrotherapy Stimulation (CES), Chi,

Homeostasis, and the

Bioelectrical System

Charles McCusker, Ph.D., Nicholas Mason, Ph.D.,

Eldon Taylor, Ph.D., and Lawrence Paros, Ph.D.

Chi is you, Chi is me (ancient proverb)

Optimal mental and emotional functioning depends on the whole body. Chi or vital force can be looked at in terms of its components as well as we might define them according to the measures and means (science with its language) that we want to do so. It depends especially on the brain. Our bodies have an elaborate system of checks and balances. This elaborate system protects the brain from changes in temperature, acceleration, and chemistry.

The current state of knowledge of bioelectrical systems is limited, as it is in many areas of biology. At the present time there is no uniform agreement on the mechanisms of action of CES (Cranial Electrotherapy Stimulation). To proclaim a model can be problematic because the paradigms are evolving very quickly these days.

Physiology

Physiology can be regarded as an aspect of Chi or Vital Force and so accordingly, the evidence of CES effectiveness in this domain is empirical. It is generally believed that the effects are primarily mediated through a direct action on the brain at the limbic system, the hypothalamus and/or reticular activating system. The primary role of the reticular activating system is the regulation of electrocortical activity. These are primitive brain stem structures. The functions of these areas and their influence on our emotional states have been mapped using electrical stimulation. Electrical stimulation of the periaqueductal gray matter (PAG) has been shown to activate descending inhibitory pathways from the medial brainstem to the dorsal horn of the spinal cord, in a manner similar to endorphins. Cortical inhibition is a factor in the Melzack-Wall Gate Control theory.

It is possible that CES may produce its effects through parasympathetic autonomic nervous system dominance via stimulation of the vagus nerve (CN X). Other cranial nerves such as the trigeminal (CN V), facial (CN VII), and glossopharyngeal (CN IX), may also be involved. Electrocortical activity produced by stimulation of the trigeminal nerve has been implicated in the function of the limbic region of the midbrain affecting emotions. Substance P and enkephalin have been found in the trigeminal nucleus, and are postulated to be involved in limbic emotional brain factors. The auditory-vertigo nerve (CN VIII) must also be effected by CES, accounting for the dizziness one experiences when the current is too high. Ideally, CES electrodes are placed on the ear lobes because that is a convenient way to direct current through the brain stem structures.

Neurotransmitters

Brain chemistry and how it works is another important aspect of chi or vital force, and includes nurturance and operation. We call the chemicals which the brain use to operate neurotransmitters. Each neurotransmitter has many functions. Neurotransmitters also have specific effects. Research has especially implicated serotonin in sleep, dopamine in euphoria, endorphins in pain control, and norepinephrine in depression and manic-depressive mood swings. Ordinarily these and other substances interact to maintain a balance for optimal physical, intellectual, and emotional well being.

On the cellular level, as well as intercellular and organic as well as interorganic systemic level we call this state homeostasis. For example, in the brain the levels of the above mentioned neurotransmitters have been demonstrated in published literature to be at certain levels with individuals demonstrating normal ranges of psychological and behavioral functioning in everyday living, whereas individuals with certain types of diagnosed pathologies, most noted and frequently measured in the literature being depression and anxiety related disorders, as well as individuals suffering from serious types of chemical dependencies.

Homeostasis

The notion here is that CES usage improves the homeostasis state or within its domain provides for a state of optimal homeostasis. Homeostasis is here defined as maintaining .... functions within very narrowly defined ranges. The body's ability to preserve the critical balance of its internal environment, regardless of external changes, is essential for its survival. Our body (including and especially the brain) reacts to changes in our environment. It constantly works to preserve optimal functioning as a whole which is defined as homeostasis or a homeostatic state. Its response and interaction with the environment is dynamic and continual, operating at many levels some within conscious awareness and many out of the range of our conscious perception. An example of a biological process not in a continual awareness state would be the digestion of food. Certainly we may respond to or be aware of eating, although after vigorous physical labor we may see the grand spread of food before us and wolf it down, not paying particular attention to savoring each tasty morsel, but eating quickly because our stomach says feed me .

So we choose at some level to be partially only partially conscious of the sensation of taste because the biological requirement of providing energy to fuel the body (remember, survival first ) blocks the more sensate focus of enjoying each tasty morsel of food. This is adaptive and common sense that most of us understand on a very basic level.

Continuing with this example, much less conscious awareness would typically be available to the digestion process, this process where food is broken into useful and usable components is something we don't pay much attention to, it is relatively automatic. Imagine how maladaptive it might be to be consciously contemplating and focusing in the digestion process while driving down a road on the side of a mountain while in the middle of a blizzard. Under these circumstances driving off the side of a mountain while consciously focusing on digestion of our lunch could be much less adaptive than keeping our eye (and corresponding muscle and bodily movements) attending to staying on the road and successfully completing the task of driving to our destination.

Events we might define as stressful can alter our body systems to change its homeostasic range, which can be adaptive for that moment. The startle response and body reaction to manipulate our motor vehicle seeing a deer running out in front of us to stay on the road and hopefully not injure the animal can change the bodily homeostasis while in this situation. After this event the various systems react to bring it back, that is alter the balance back to the regular driving the vehicle mode.

Ecotropic

The term Ecotropic refers to creating a balanced inner environment in a person, cures rather than ameliorates, has multilevel and multidisciplinary integrity, creates an environment for growth, deals with effects at the level of cause, encompasses a wide spectrum, is dynamic in its innovation, is harmless with only positive side effects , deals directly with the structure of the being, ecological - holistic - does not harm, creates consciousness, aids in creating an individual homeostasis state directly related to more authentic (real) being - again multilevel brain chemistry, cognitive, psychodynamic - energy in a body, wide spectrum, deals with effects at the level of cause, creates an environment for growth, creates a balanced inner environment within a person.

Pressure and Stress

Efforts, challenges, threats, or perceived threats or damage (physical and/or psychological) puts pressure on our biosystem. We thrive on various pressures to experience, adapt, survive, learn, and to live. Muscles can develop from putting pressure on them and they will atrophy without that work. The same principle applies throughout our physical system, and our brain as well (emotion and intellect). We depend on pressure and grow by challenging ourselves. We will define healthy systemic pressure as eustress. This is differentiated from what we commonly call stress. In engineering terms the concept of stress say on a steel I beam in a high rise building can lead to metal fatigue and the actual physical breaking of that beam, which could potentially lead to the breaking and even collapse of that building. We will follow the convention of using stress to mean bad stress. Despite this, please regard stress as basically good. People can subject themselves to so much exercise that they loose strength and endurance. They use up their muscle tissue faster than they rebuild it. Then the healthy stress on their muscles becomes destructive.

Chemically, we need adrenaline and choline systems, adrenergic and cholinergic systems. We need our bodies’ hormonal systems to use and build our muscles. The body's hormonal systems also keep a homeostatic balance.

Psychological Distress

In psychological stress, the body shifts into the fight or flight mode. Our body prepares for immediate physical action. These systems too can suffer atrophy or exhaustion. We can directly see and feel the body’s responses to some kinds of stress. We sweat and flush from muscular effort; we get goose bumps and pale skin from cold. We can even hear fatigue or shivering in a person’s voice.

Insensible Stress

Primarily hidden symptoms accompany the shift from benign to pathological stress. We cannot so easily see, hear, or feel sleeplessness, irritability, and inability to concentrate. For most of us, only mechanical medically related instruments reveal blood pressure gradually elevating to dangerous levels, and body chemistry going out of balance. Sometimes the body cannot maintain the range of temperature necessary for adequate functioning. Sometimes people persist in exercising, working, or even playing to exhaustion. Either can lead to collapse and eventual death. The body also suffers other types of collapse when other types of stress press it beyond its limits.

When under stress, the brain shifts its transmitter balance. This prepares the body to deal with the stress. If the stressing agent remains present (stressful conditions on the job, in the home, etc.) the shift may become permanent. The body and the personality of the individual can suffer from such permanent shifts away from healthy homeostasis. This brings patients to medical treatment facilities.

Stressors

Almost anything can cause stress. Identification as a stressor depends as much on interpretation as on substance. Being around strange people, loud noises, fast cars, and unfamiliar situations all cause stress reactions. Until the middle of this century, life accustomed us to small farms with a cow, maybe a goat, and three chickens. People went to bed when the sun set, got up when it rose, and had acquaintances whom they met every day of their lives.

Many people still live rural lives today. Such people do not regard themselves as having extended families and close communities. They regard us as having truncated families and splattered communities. Now we live in today's metroplex society. We drive on crowded highways, live in high rise buildings, and work with multitudes of strangers. The media present murders, rapes, and other violence, real and imagined, continuously. All these can and do cause the fight or flight response. All these can cause excessive stress.

Stress control programs have proliferated. Most work from assuming, Stress is bad. They teach stress reduction. A few actually teach stress management. Some teach conscious skills, often with cassette tapes or counselors. Sometimes these skills become habits. The body responds gradually. Other programs more directly address the body. They may include muscle balancers and toners, flotation tanks, massage, exercise, and more physical interventions. In these therapies, the body responds directly and the neurotransmitters of the brain respond gradually.

The most effective and efficient programs address both the body and the brain simultaneously. This establishes a balanced body-mind relationship. This approach has the added benefit of potentiation.

Potentiation

Some synergy always exists between the various factors in a situation. A small company made of similar people has a much lower chance of success than a similar company made of people who have different skills and experiences and preferences. Work done on the body, work to alter the brain's neurochemistry, and work with cognitive skills all abet each other.

Medications used separately may have nearly harmless effects. Used together, these same medications will have effects greater than the sum of their independent effects or different than those taken individually. In a negative sense these are commonly referred to as side effects and this term usually connotes as just stated, negative effects. Alcohol has become notorious for this. Potentiation demands that we use interventions with no harmful effects.

In the past, potentiation has been regarded almost exclusively as a problem. By combining exclusively benign interventions we can take advantage of it. We regard it as valuable. Our lives are a continuous process of potentiation.

The Body-Brain Continuum

Chi is dynamic. Our emotions, intellects, cognitive mind sets, perceptions, physiologies, chemistries, and much more all overlap and interact to make who we are. Simple examples can illustrate this complexity. A change in the environment can cause a hormonal shift. An argument causes a stress response - fight or flight. Such shifts, if repeated and inappropriate, can lead to a hormonal imbalance. Very few arguments could justify punching or running away from your opponent. People have a lot of arguments. They might have a lot of inappropriate responses to a lot of different stressors. This leads to changes, from subtle to dramatic, in the normal body functions.

Running could do you some good. Better yet, avoid people with whom you might have unpleasant arguments. Suppose you have excellent vision. You could easily avoid those people. You would see them before they saw you. Have you ever been nearsighted? Nearsighted people often squint to see farther. This tends to produce a characteristic facial expression. More, the pectoral muscles in their chest tend to contract in a reflexive effort to draw them nearer their point of optimum focus. They can become round shouldered or even somewhat hunchbacked.

Disturbing the normal functional relationship between the muscles, bones, tendons, ligaments, and other structures of the body leads to changes in the biochemistry of the brain. Painful or dysfunctional joints and muscles can turn the individual into a wounded animal that needs gentle handling. This hyperirritability reflects changes in the neurohormonal system of the brain.

The Role of CES

CES means to apply low voltage, low amplitude, pulsed current transcranially. It pulses 100 times per second (there are other frequencies as well, of course) on a twenty percent duty cycle. The pulse wave is a modified square wave with no D.C. bias (meaning that the pulse goes back and forth equally across the head, instead of pulsing more left to right or more right to left). Small rechargeable batteries provide the current. The device limits the stimulus to approximately 1.5 mA or less. CES has proven an effective prescription for the treatment of many debilitating pathologies. Improved cognitive function has also been demonstrated in terms of improved cognitive skills. This can certainly be considered an aspect of chi or vital force.

How CES Works.

Acetysalic acid, and its pharmacological ancestor, salic acid, had proven benefits long before we had any idea how they worked. We call it aspirin. CES has this in common with aspirin. Unfortunately, CES has not been marketed on a wide spread basis such as aspirin.

We have begun to learn how CES produces its effects. Earlier studies on animals led researchers to postulate that CES has its effects in the hypothalamic center of the brain, and possibly in other primitive or emotion control centers within the brain. CES now appears to have its effect by stimulating the brain generally. This increases the brains manufacture and use of neurotransmitters, that leads to a homeostasis of brain biochemistry, another aspect of chi.

Cortical Learning

Our bodies can learn outside our awareness, and possibly independently of our brain. This has received notice as visceral learning . Similarly, our brains can learn responses outside our awareness. This would certainly apply to the amelioration of chi with CES stimulation. Laboratory experiments have even conditioned individual neurons to respond to receive molecules of cocaine. Obviously, networks of neurons can develop more complex responses.

Only immediate and detectible stimuli have a conditioning effect. Few people enter prolonged depression suddenly. A person may slowly sink into depression. It usually happens in slow small steps, often times undetectable consciously. Most efforts to relieve depression will result in at least some immediate unpleasantness. So they sink.

Suppose that using a particular network of neurons has immediately unpleasant results. The brain may soon learn not to use that network. Only a part of the network caused problems. Even that could have been repaired. The brain does not know that. Hence we may learn to forget an event or even whole skills associated with unpleasant feelings. Intuitively, it seems that taking parts of the brain off line could explain some pathology.

Why CES works

Cranial electrotherapy stimulation (CES) stimulates, rather than directs, the general function of the brain (effect on chi with an application of an external energy force). It gently adds energy diffused to essentially all parts of the brain. As a result, each part can more readily perform at optimum levels. Some parts of the brain manufacture neurohormones. They can turn off or on more readily. This brings the neurohormones to homeostasis. This brings the harmony that would exist if we freed ourselves from distress or other damage.

Normally the amount of one neurochemical in the brain influences manufacture of others. In turn, the amount of one or more of the other neurotransmitters act as a check on the production and use of the first neurotransmitter. This interaction reestablishes the check and balance system which maintains homeostasis.

The task of CES is to bring the brain to a healthy homeostatic condition. With this accomplished, CES has no additional effect. In this regard CES is not habit forming nor addictive.

How Long Does CES Need To Take Effect?

Most individuals respond within several minutes of wearing a CES device. They may immediately report relaxation, relief from pains, more energy, or an increased ability to concentrate. Some notice positive changes over time. Others can wear a CES device for days or weeks and not notice. This may stem from a lack of awareness.

Obstacles to CES

Two common factors can cut the effects of CES. The brain may lack what it needs to improve its function, and the brain may have something blocking its function. These can mask or prevent or mask the benefits of CES. A poor diet seems the most common cause. The brain's blood supply may lack the chemical precursors for the neurotransmitter(s) it needs to produce. CES stimulates brain centers that produce these chemical precursers to produce some neurotransmitters. Neurons cannot manufacture the neurotransmitters without the building blocks of those neurotransmitters present in the bloodstream.

Conversely, pathogens might override the new neurochemical response. A virus can divert resources to the immune system. Using cocaine can deplete norepinephrine faster than CES can stimulate its renewed production. Even having coffee or chocolate (caffeine), or a few beers (alcohol), before bedtime can override natural sleep induction by serotonin.

In both cases, clients must improve living habits. This leads to the further benefits of potentiation. Allow for these exceptions.

Common Applications of CES

Granted these exceptions, CES proves effective in many applications. In the western culture depression and anxiety seem the most common psychological problems of normal people in normal life. In both cases, clinicians distinguish between reactive and obscure pathology. Reactive pathology grows from an event. People feel anxiety when loved ones might die, and depression when bereaved. We label such normal feelings pathological when they persist past social norms and prevent normal productive behavior. In the Eastern culture flow of an improvement in oneness realization and improvement of chi and mastery could be emphasized. This would of course include an improved ability to learn and do.

In the western world obscure pathology has no apparent relationship to any specific event. It generally has a longer history and takes longer to respond to therapy. CES can alleviate reactive depression or anxiety in about a week with one forty-five minute session per day. More severe depression and/or anxiety requires three to five weeks or more of one or more forty-five minute daily sessions in its amelioration. In the Eastern world effect would likely be seen as an improvement in capacity or a strengthening of chi or vital force can be often immediately experienced with CES but can certainly take four to six weeks or longer of regular CES usage.

Other Therapies with CES

Many individuals receive CES as part of additional treatment programs. They usually enter the treatment program as a result of living in an environment that over stressed them. Their coping mechanisms, both physical and psychological, have failed.

Typically, these patients receive therapy, stress reduction and stress management training. During the course of treatment for outpatients, or following treatment for inpatients, they enter a non-therapeutic environment. This often requires some initial support. CES can has proven useful for preventing a recurrence of pathology.

People can learn more quickly when their being (at different levels) is improved. People can heal and learn much more easily when free from stress. The stress response makes any but the most immediate and reflexive learning difficult. Learning relaxation despite stress has proven particularly difficult. This difficulty also blocks healing. CES can free us from the effects of the stress response. We can learn anything, especially relaxation, better and faster.

The Role of Nutrition

Think of a typical car battery. It won't start your engine. You test the cells. It has three dry cells. The battery requires two factors to reestablish normal function. You must add water and at least a trickle charge of electricity. Similarly, the necessary nutritional elements as well as the trickle charge combine to reestablish normal affectively related cognitive function.

We get amino acids from food. Amino acids in the blood serve as precursors for neurohormones. That means the brain uses these amino acids to build neurohormones. The brain can do this much more efficiently when accompanied by CES treatment.

Cognitive Changes related to CES Intervention Charles McCusker, Ph.D. 12/7/05

These studies were conducted by Charles McCusker, Ph.D.& Delbert T. Goates, M.D. from 1992 to 1996 (unpublished manuscript) and the component of the data shown here describes the positive cognitive change results of CES for psychiatric outpatients. Our earliest formal case histories yielded the following cognitive data.

The Wechsler Adult Intelligence Scale-Revised (WAIS-R), with a sample size of 25:

Probability of IQ scores change due only to test-retest practice effects

Verbal Performance Full Scale practice effects

pre 101.6 107.2 104.12 p < .0001

post 110.0 122.12 116.52 p < .0001

difference +8.4 +14.92 +12.40 p < .0001

Verbal Subtest scores

Informa- Digit Vocab- Arith- Compre- Similari-

tion Span ulary metic hension ties

pre 9.4 10.0 10.8 9.4 10.8 9.5

post 10.0 10.0 12.0 10.4 12.5 11.1

difference +.6 0 +1.2 +1.0 +1.7 +1.6

Performance Subtest scores

Picture Picture Block Object Digit

Completion Arrangement Design Assembly Symbol

pre 10.6 10.4 10.3 9.6 8.7

post 12.1 12.0 12.1 13.0 10.5

difference +1.5 +1.6 +1.8 +3.4 +1.8

The WAIS-R scores displayed statistically significant (p<.0001) changes between pre- and post- treatment IQ, as well as positive changes in ten of eleven subtests on the same measure.

Quantum theory predicts and experiments have verified that so-called empty space (the vacuum) contains an enormous residual background energy known as zero-point energy ( ZPE). ZPE is derived from the fact that at temperatures of absolute zero (- 273^o Celsius) elementary particles continue to exhibit energetic behavior. Theoretical advances of zero-point energy, nonlinear thermodynamics, and connective physics open the practical purpose application of ZPE - in essence tapping the zero-point, and thereby accessing a universe sized source of energy.

Theoretical contributions have been done by such pioneers as Nobel laureates Ilya Prigogine, P. A. M. Dirac, John Wheeler, and Julian Schwinger. Prigogine, for example, has shown that the second law of thermodynamics can be expanded to include systems in which order evolves from randomness. This result has also been obtained by Puthoff who utilized theories of ZPE to obtain an equivalent result. The critical factor here is that linear systems tend toward increasing entropy (i.e. the result of two inputs being the sum of their corresponding outputs), whereas under certain conditions nonlinear systems have been shown to evolve toward macroscopic order. Such nonlinear systems imply transient or apparently uncontrolled systems, but the reality remains that clever designs can and do provide means to skirt traditional understandings of thermodynamic limitations and literally tap into the surrounding universe for unlimited amounts of useful energy.

It is sometimes assumed that the era of overunity energy research began with the pivotal work of Pons and Fleischman in their discovery of what came to be referred to as cold fusion. While the possibly premature nomenclature of “fusion” might not be strictly applicable, Patterson has taken this work even further, achieving significant results in both energy production and the transmutation of elements. In many respects, while this work cannot be overestimated in its profound importance to a better understanding of physics and chemistry, it nevertheless has shown greater potential for the transmutation of elements than it has for energy production as demonstrated in the work of Pappas at the University of Athens and his “cold fusion” model of cellular level sodium to potassium conversion.

This has dramatic implications in beginning to understand that the application of CES field energy to a mass would have some predictable and measurable effect. According to the laws of quantum physics therefore, Chi can be predictively increased.

(Special acknowledgments and thanks for the inspiration from the authors to Elizabeth Lindsey; Mette Lindsley; N; Ravinder Taylor; Aram V. Tanielian; and Marilyn Whimpey, B.S.)

References

Readers are advised to look below at the other articles and literature searches to find a plethora of CES references.

A Summary Look at CES Studies of Addiction

By Ray B. Smith, Ph.D.

Executive Summary. Fifteen studies were analyzed, in which a total of 535 patients were treated for the substance abstinence syndrome with cranial electrotherapy stimulation (CES). The studies were combined statistically in order to get a more confident look at the effectiveness of CES for treating this condition. While most of the studies were of the classic double blind protocol, others used either the single blind or open clinical trial. The result of the analysis showed that the overall effectiveness of CES was 60% improvement. Elsewhere it has been noted (see cognitive dysfunction studies) that the “permanent brain damage” that was said to be a condition of long term substance abuse patients as late as the 1980s, has now been seen to return to within normal functional limits following 3 weeks of daily CES treatment.

Introduction

Meta-analysis is a way of combining the results of many separate studies to see the effectiveness of a treatment when different types of patients are studied, under different study conditions, with different study protocols, and who came to the various studies with differing symptoms accompanying their drug withdrawal.

The goal of clinical studies is always to first test the effectiveness of a potential treatment and secondly to discover which patients the treatment may be most effective in treating. Meta-analysis has the effect of allowing us to essentially study a larger number of patients than can usually be assembled for a single study, and the larger the combined study sample, the greater is the confidence that can be placed in the study outcome: that the study findings are true and accurate. Also, the more diverse the study group is in the combined sample, the more confident can we be in generalizing the study outcome to larger groups of people outside the study. That is, it increases the range of potential types of substance abuse patients that we can predict will be effectively treated with CES.

In the table below is a summary of 15 studies that were combined into the meta-analysis reported on here.

Studies of the Drug Abstinence Syndrome with CES

Study Design

Zr Score^a

Presenting

Group

No. Subjects

Measure Used^b

Reference

Double Blind

.987

Poly Substance

Withdrawal

Clinical Rating Scales

Double Blind

.397

Cocaine Withdrawal

Treatment Responses

Double Blind

1.029

Methadone Withdrawal

Treatment Records

Double Blind

.415

Alcohol Withdrawal

Self and Clinical Rating Scales

Double Blind

.403

Alcohol Withdrawal

Self and Clinical Rating Scales

Double Blind

.780

Poly Substance Withdrawal

Psychological Tests

Double Blind

.671

Poly Substance Withdrawal

Self Rating Scales

Totals

4.682

212

Average

.669

Effect Size^c

r = .58

Single Blind

.360

Alcohol Withdrawal

Psychological Tests

Single Blind

.772

Alcohol Withdrawal

Self Rating Scales

Single Blind

.725

Alcohol Withdrawal

Self Rating Scales

Single Blind

.737

Alcohol Withdrawal

Self Rating Scales

Totals

2.594

203

Average

.649

Effect Size

r =.57

Open Clinical

.678

Alcohol Withdrawal

Physiological Measure

Open Clinical

.775

Smoking Cessation

Reduced Smoking

Open Clinical

.549

Poly Substance Withdrawal

EEG

Open Clinical

1.065

Marijuana Withdrawal

Self Rating Scales, Physiological Measure

Totals

3.067

120

Average

.767

Effect Size

r =.65

SUMMARY, ALL ADDICTION STUDIES REPORTED ABOVE

Grand Total

10.343

535

Average

.690

Total Effect Size

r =.60

^a Most studies utilized several (up to 7) improvement measures, and since different percent improvement scores can not legally be averaged, they are converted into Zr scores, averaged, and then converted back to an overall percent improvement (effect size), with the average improvement on all measures reported for each study.

^b The Self Rating and Clinical Rating Scales used in the studies all have published reliability and validity measures.

^c Effect size, here, is a statistician’s basic estimate of the overall percentage improvement by the patients as a result of the treatment

Discussion