Excerpts from Must Read Books & Articles on Mental Health Topics
Articles- Part XXXIII

What's Normal?: Bipolar Diagnosis and Children
Jerome Groopman, The New Yorker- 4/9/2007

     In April, 2000, Steven Hyman, a psychiatrist who at the time was the director of the National Institute of Mental Health, convened a meeting of nineteen prominent psychiatrists and psychologists in order to discuss bipolar-disorder in children. The disorder has long been recognized as a serious psychiatric illness in adults, characterized by recurring episodes of mania and depression. (It is sometimes called manic depression.) People with bipolar disorder are often unable to hold down jobs; require lifelong treatment with powerful medications, many of which have severe side effects; and have high suicide rates. The disorder is thought to afflict between one and four per cent of Americans and tends to run in families, although no genes for it have been identified. At the time of the meeting, few children had been given a diagnosis of the illness, and it was considered to begin, typically, in adolescence or early adulthood.
     In the late nineteen-nineties, however, there was an increase in awareness of bipolar disorder in children, first in medical journals and then in places like BPParents, a Listserv founded by the mother of an eight-year-old boy who had been diagnosed with the disorder. Hyman himself had been consulted by parents of children who, he told me, were "really suffering and extremely disruptive, having violent outbursts at school and at home, and hard to contain under any circumstances." Many of the parents told Hyman that they believed their child had bipolar disorder, and they cited a book called "The Bipolar Child: The Definitive and Reassuring Guide to Childhood's Most Misunderstood Disorder." The book, which was written by Demitri Papolos, a psychiatrist affiliated with the Albert Einstein College of Medicine, in New York City, and his wife, Janice, the author of several how-to manuals, had been published in 1999. (It has sold more than 200,+!00 copies, and a third edition came out last summer.) "The first parents who visited me came with the Papolos book in hand," Hyman said.
     The Papoloses argued that bipolar disorder was often overlooked in children. In 1998, according to "The Bipolar Child," nearly four million children were given Ritalin or other stimulants for hyperactivity, of that number, the Papoloses contended, more than a million would eventually receive a bipolar diagnosis. They also cited researchers' estimates that anywhere from a third to half of the 3.4 million children thought to suffer from depression were actually experiencing the early onset of bipolar disorder. The book detailed the negative effects of bipolar disorder on patients (disruptive behavior, drug abuse, suicide attempts) but also prominently featured what might be described as its paradoxical benefits:

     This illness is as old as humankind, and has probably been conserved in the human genome because it confers great energy and originality of thought. People who have had it have literally changed the course of human history: Manic-depression has afflicted (and probably fueled the brilliance of) people like Isaac Newton, Abraham Lincoln, Winston Churchill, Theodore Roosevelt, Johann Goethe, Honore de Balzac, George Frederic Handel, Ludwig von Beethoven, Robert Schumann, Leo Tolstoy, Charles Dickens, Virginia Woolf, Ernest Hemingway, Robert Lowell, and Anne Sexton.

     She was always ahead of her time. She started talking at eight months with the words "kitty cat." She walked at nine months and was speaking in complete sentences by a year. She was writing small novels in the second grade. She acted and danced
and sang way beyond her years.
     At eighteen months he climbed out of the baby bed in the middle of the night, opened the fridge, got out three dozen eggs (it was Easter time), and proceeded to sit in his booster chair and crack three dozen eggs onto our hardwood floors. (He wanted to bake a real cake--he didn't like the toy mixing bowl I had given him to play with.) After the insurance company quit laughing they did pay to refinish our floors.

A Lifetime of Restless Isolation Explained
Tim Page, The New Yorker- 8/20/07

My second-grade teacher never liked me much, and one assignment I turned in annoyed her so extravagantly that the red pencil with which she scrawled "See me!" broke through the lined paper. Our class had been asked to write about a recent field trip, and, as was so often the case in those days, I had noticed the wrong things:

Well, we went to Boston, Massachusetts through the town of Warrenville, Connecticut on Route 44A. It was very pretty and there was a church that reminded me of pictures of Russia from our book that is published by Time-Life. We arrived in Boston at 9:17. At 11 we went on a big tour of Boston on Gray Line 43, made by the Superior Bus Company like School Bus Six, which goes down Hunting Lodge Road where Maria lives and then on to Separatist Road and then to South Eagleville before it comes to our school. We saw lots of good things like the Boston Massacre site. The tour ended at 1:05. Before I knew it we were going home. We went through Warrenville again but it was too dark to see much. A few days later it was Easter. We got a cuckoo clock.

     It is an unconventional but hardly unobservant report. In truth, I didn't care one bit about Boston on that spring day in 1963. Instead, I wanted to learn about Warrenville, a village a few miles northeast of the town of Mansfield, Connecticut, where we were then living. I had memorized the map of Mansfield, and knew all the school bus routes by heart—a litany I would sing out to anybody I could corner. But Warrenville was in the town of Ashford, for which I had no guide, and I remember the blissful sense of resolution I felt when I certified that Route 44A crossed Route 89 in the town center, for I had long hypothesized that they might meet there. Of such joys and pains was my childhood composed.
      I received a grade of "Unsatisfactory" in Social Development from the Mansfield Public Schools that year. I did not work to the best of my ability, did not show neatness and care in assignments, did not cooperate with the group, and did not exercise self-control. About the only positive assessment was that I worked well independently. Of course: then as now, it was all that I could do.
     In the years since the phrase became a cliché, I have received any number of compliments for my supposed ability to "think outside the box." Actually, it has been a struggle for me to perceive just what these "boxes were—why they were there, why other people regarded them as important, where their borderlines might be, how to live safely within and without them. My efforts have been only partly successful: after fifty-two years, I am left with the melancholy sensation that my life has been spent in a perpetual state of parallel play, alongside, but distinctly apart from, the rest of humanity.
     From early childhood, my memory was so acute and my wit so bleak that I was described as a genius—by my parents, by our neighbors, and even, on occasion, by the same teachers who gave me failing marks. I wrapped myself in this mantle, of course, as a poetic justification for behavior that might otherwise have been judged unhinged, and I did my best to believe in it. But the explanation made no sense. A genius at what? Were other "geniuses" so oblivious that they couldn't easily tell right from left and idly wet their pants into adolescence? What accounted for my rages and frustrations, for the imperious contempt I showed to people who were in a position to do me harm? Although I delighted in younger children, whom I could instruct and gently dominate, and I was thrilled when I ran across an adult willing to discuss my pet subjects, I could establish no connection with most of my classmates. My pervasive childhood memory is an excruciating awareness of my own strangeness.
     Despite their roseate talk, my parents and my school put a good deal of effort into finding out precisely what was wrong with me. It was obvious that I was not "normal," especially by the straitened standards of the early nineteen-sixties. I have sometimes wondered whether the I.Q. scores with which I was credited were nudged upward by my father, who was both a professional educator with a keen interest in gifted children and the person who administered my most triumphant examinations. Whatever the case, while my younger brother and sister soared through school, academically and socially, I was consistently at or near the bottom of the class, and decidedly out of control—half asleep or aggressively assertive—much of the time.
     And so, between the ages of seven and fifteen, I was given glucose-tolerance tests, anti-seizure medications, electroencephalograms, and an occasional Mogadon to shut me down at night. I suffered through a summer of Bible camp; exercise regimens were begun and abandoned; and the school even brought in a psychiatrist to grill me once a week Somehow, every June, I was promoted to the next grade, having accomplished little to deserve it. Meanwhile, the more kindly homeroom teachers, knowing that I would be tormented on the playground, permitted me to spend recess periods indoors, where I memorized vast portions of the 1961 edition of the World Book Encyclopedia.
     A brown carton in my basement contains most of the surviving documents of my childhood, and they present a pretty fair portrait of my pre-teen obsessions. There are meandering and implausible stories, none with happy endings; intricately detailed street maps of make-believe cities on which I worked silently for hours; and countless crayon drawings of grinning girls with shoulder-length hair and U-shaped smiles, their stick figures fleshed out only by exaggerated biceps. Other children collected coins or baseball cards; I tore obituaries of Sophie Tucker and David O. Selznick from the Hartford Courant and pasted them sloppily into a scrapbook
     In my darker moods, I think that the rest of my life can be encapsulated in a single sentence: I grew up and grew into other preoccupations, some of which have served me well. I became a music critic and culture writer, first for the SoHo News, and then for the Times, Newsday, and the Washington Post. In the middle of all this, I became enamored of the American author Dawn Powell, whose life and works I absorbed in much the same manner I had the World Book, and I spent five years editing her novels, short stories, plays, diaries, and letters and writing her first biography. I look back on these projects with a certain mystified satisfaction; I'm glad they were done, but it is as though they had been accomplished by somebody else, for the particular furies and fevers that impelled them have long since evaporated.
     In the fall of 2000, in the course of what had become a protracted effort to identify—and, if possible, alleviate—my lifelong unease, I was told that I had Asperger's syndrome. I had never heard of the condition, which had been recognized by the American Psychiatric Association only six years earlier. Nevertheless, the diagnosis was one of those rare clinical confirmations which are met mostly with relief. Here, finally, was an objective explanation for some of my strengths and weaknesses, the simultaneous capacity for unbroken work and all-encompassing recall, linked inextricably to a driven, uncomfortable personality. And I learned that there were others like me—people who yearned for steady routines, repeated patterns, and a few cherished subjects, the driftwood that keeps us afloat.
     The syndrome was identified, in 1944, by Hans Asperger, a Viennese pediatrician, who wrote, "For success in science or art, a dash of autism is essential." Yet Oliver Sacks makes a clear distinction between full-fledged autism and Asperger's syndrome. In The New Yorker some years ago, Sacks wrote that "people with Asperger's syndrome can tell us of their experiences, their inner feelings and states, whereas those with classical autism cannot. With classical autism there is no `window,' and we can only infer. With Asperger's syndrome there is self-consciousness and at least some power to introspect and report."
     In his 1998 book "Asperger's Syndrome: A Guide for Parents and Professionals," Tony Attwood observed, "The person with Asperger's syndrome has no distinguishing physical features but is primarily viewed by other people as different because of their unusual quality of social behavior and conversation skills. For example, a woman with Asperger's Syndrome described how as a child she saw people moving into the house up the street, ran up to one of the new kids and, instead of the conventional greeting and request of 'Hi, you want to play?,' proclaimed, 'Nine times nine is equal to 81.'"
     David Mamet, in his recent book "Bambi vs. Godzilla," discerned redeeming qualities in the condition. Considering filmmakers past and present, he stated that "it is not impossible that Asperger's syndrome helped make the movies. The symptoms of this developmental disorder include early precocity, a great ability to maintain masses of information, a lack of ability to mix with groups in age-appropriate ways, ignorance of or indifference to social norms, high intelligence, and difficulty with transitions, married to a preternatural ability to concentrate on the minutia of the task at hand."
     The Asperger's spectrum ranges from people barely more abstracted than a stereotypical "absent-minded professor" to the full-blown, albeit highly functioning, autistic. Symptoms of Asperger's have been attributed ex post facto to successful figures, but these are the fortunate ones—persons able to invent outlets for their ever-welling monomanias. Many are not so lucky, and some end up institutionalized or homeless. (In the late nineteen-seventies, I saw a ragged, haunted man who spent urgent hours dodging the New York transit police to trace the dates and lineage of the Hapsburg nobility on the walls of subway stations.) For some—record collectors with every catalogue number at hand, theatre buffs with first-night casts memorized, children who draw precise architectural blueprints of nineteenth-century silk mills—a duster of facts can be both luminous and lyric, something around which to construct a life.
     We are informally referred to as "Aspies," and if we are not very, very good at something we tend to do it very poorly. Little in life comes naturally—except for our random, inexplicable, and often uncontrollable gifts—and, even more than most children, we assemble our personalities unevenly, piece by piece, almost robotically, from models we admire. (I remember the deliberate decision to appropriate one teacher's mischievous grin and darting eyes, which I found so charming that I thought they might work for me, too.)
     So preoccupied are we with our inner imperatives that the outer world may overwhelm and confuse. What anguished pity I used to feel for pinatas at birthday parties, those papier-mâché donkeys with their amiable smiles about to be shattered by little brutes with bats. On at least one occasion, I begged for a stay of execution and eventually had to be taken home, weeping, convinced that I had just witnessed the braining of a new and sympathetic acquaintance.
     Caring for inanimate objects came easily. Learning to make genuine connections with people—much as I desperately wanted them—was a bewildering process. I felt like an alien, always about to be exposed. Or, to adapt another hoary but useful analogy, not only did I not see the forest for the trees; I was so intensely distracted that I missed the trees for the species of lichen on their bark.
     My first and most powerful obsession was music—the same records played again and again while I watched them spin, astonished at their evocation of aural worlds that I not only instinctively understood even as a toddler but in which I actually felt comfortable. I was both terrified of and tantalized by death (which was absolutely real to me from earliest childhood), and by the way recordings restored Enrico Caruso and Nellie Melba to life for a few minutes, ghostly visitors who had returned to sing for me at 78 r.p.m., through a hiss of shellac and antiquity.
     When I was ten, I became fascinated by silent films, the visual complement to my old records. I spent hours at the library of the University of Connecticut, a few minutes' walk from home, researching the lives of actors and actresses on microfilm, and recall the genuine sense of mourning that came over me when I saw Barbara La Marr's sad, youthful face on an obituary page from 1926. Not surprisingly, "Sunset Boulevard" was my favorite "talkie" (I actually called them that—in 1965!), and I'd regularly set the alarm and wake in the middle of the night to watch Chester Conklin or Louise Dresser take on minor roles in some B movie that the Worcester, Massachusetts, UHF station put on when nobody else was watching.
     “I despise the Beatles and their ilk," this remarkably Blimpish young man proclaimed in a school paper shortly after the first Ed Sullivan show, when other boys my age were growing their hair long and learning to play the guitar. My favorite pop musician then was the Scottish comedian Harry Lauder, a star in vaudeville and music halls at the beginning of the last century, who told obscure jokes in brogue and sang through exaggerated hiccups in a state of pretend intoxication. The depth of my admiration for Lauder now baffles me as much as the steady diet of hore­hound drops I adopted as snack food, or my insistence, much of one autumn, that I wear a rabbit's foot in each buttonhole of my shirt, which I kept tightly fastened up to the neck. But nobody could have persuaded me to abandon these quirks, and any attempt to do so would have been taken as a physical threat and reduced me to hysteria.
     A friend published a sweet autobiography entitled "Thank You, Everyone," in which she expressed gratitude to everybody who had influenced her, ranging from Woody Allen to my sister Betsy. If I were to create a similar book, I would call it "Sorry, Everyone," and apologize for my youthful cluelessness: To the girl in seventh grade with the protruding jawbone (it never occurred to me that she would not share my enthusiasm for her unusually simian features). To the boy who came over to my house in the middle of my Caruso phase and endured a precious weekend afternoon comparing recordings of "Celeste Aida." To the perplexed young women from early adolescence who might have become lovers had I understood that their sudden friendship and proximity had any sort of physical impetus. Instead, I chattered on about this and that, rarely making eye contact, and soon they vanished, in search of more game and grounded potential partners. Sorry, everyone. I didn't understand.
     It was hard for me to be touched. I froze when I was hugged by anybody who was not a relative, and I made love like the Tin Man until I was well into adulthood. Like many children before and since, I recoiled when fundamental facts about the reproduction of the species were explained to me (there was, typically for the time and the place, no suggestion that new pleasures might be involved, and the physical act, examined through an anxious, pre-sexual eye, sounded bizarre). Shortly after this enlightenment, my parents threw a party, attended by their closest friends. I watched their athletic, fortyish bodies, properly clothed, in mortified amazement, and then took a recount of their children. Oh, my God, I thought. They did that three times!
     Anything related to the human body seemed to me bad news. In the fourth grade, when my affliction was most intense, I would be herded out to play kickball during our physical-education classes. Teams were chosen, and I was embedded among the strongest kids, to provide some chance of even battle. In memory, it is forever bases loaded with two outs when my turn at the plate comes, and I am as well suited as a giraffe to meet the big red ball that rolls toward me with frightening speed.
     Still, for a moment the same people who generally disdained or bullied me became my friends, cheering me on to hitherto unsuspected athletic glory: "You can do it, Tim!" If I could make the ball lose its gravity, as my best pal, Annie, did so effortlessly with those balletic whomps from her long legs, I might redeem myself. Our gym teacher, Miss B.—scowling, beefy, and, after four decades, the only person in the world I just might swerve to hit on a deserted road—had no such illusions and waited for the inevitable, with her festering contempt and ready whistle. Grinning stupidly, shirttail out and flapping, underwear pulled halfway up my back, I would lope toward the ball, which would eventually collide with my ankle or heel and then bounce off into the woods or into the waiting arms of the catcher. My chance was up, and I was a freak once more.
     "So?" I wanted to scream. "There are things that I know; things that I can do. Can you name the duet from La Bohême that Antonio Scotti and Geraldine Farrar recorded in Camden, New Jersey, on October 6, 1909? What was the New York address of D. W. Griffith's first studio? How many books by David Graham Phillips have you read? Who was Adelaide Crapsey? I learned to play the entire Chopin Prelude in E Minor in a single night!" And then tears, of course, and the taunts redoubled.
     The class work, hardly less humiliating, was at least more private. If I wasn't deeply interested in a subject, I couldn't concentrate on it at all—those dreadful algebra classes, those Bunsen burners, the mystifying and now deservedly extinct slide rule! Late in each semester, when it became obvious to me that I had no idea what I was supposed to have learned, I'd attend some makeup classes and try desperately to pay attention. As the teacher rattled on, I would grind my teeth, twirl the tops of my socks around my index finger—once I poked myself repeatedly through my pocket with a pin—anything to keep my mind engaged. But it was impossible: a leaf would fall outside the open window, or I'd notice the pattern of the veins on a girl's hand, or a shout from the playground would trigger a set of irresistible associations that carried me back to another day.
     And then the dream was ruptured by the sound of a bell; the class was irrevocably over, and I knew no more about quadratic equations or beryllium than I did an hour before. Failure was now assured, and the countdown began to the Dies Irae, when my report card would land me in trouble again, for my father was incredulous that a boy who blithely recited the names and dates of the United States' Presidents and their wives couldn't manage to pass elementary math and science. I grew enormously fond of my father in later life, but he terrified me then. He lived until 2005, long enough to recognize, through my diagnosis, some of the problems that had vexed him throughout his own career and, better yet, to know and delight in my three children, to whom he showed a serene gentleness.
     My grades, always disastrous, only worsened as I grew older and more was expected of me. Nevertheless, by the age of twelve I was able to storm through idiosyncratic renditions of most of the easier Chopin pieces and of the simpler passages in his larger works. That was also the year that I finished my first novel—fifty pages of it, filled with a narrative invention that I've never been able to recapture. The manuscript was lost long ago, but I do recall that I killed off my central character, a cat, by having him eat "badly prepared fish." I am still in possession of a school report on "Making a Living in the Amazon," which we had been required to work on for a week. My contribution read, in its entirety, "In the dense, rainy, rain forest, it is hard to make a living. One way is fishing in the river that is from a mile wide to a 100 miles wide. Brazil nut collecting is another way. You can gather manioc. You are very limited as to what to do for a living in the Amazon rain forest."
     By way of comparison, here is the beginning of a twenty-five-hundred-word story that I wrote the same month, typing it on my father's gray oversized IBM electric in a single evening:

Nobody knew why the rain had not stopped. The weather report had said four in ten for light showers in the early morning. But here it was: 5 o'clock. And it was pouring. There was nothing to stop Lady Lieg from leaving the library. She had all the equipment, a fold-up umbrella, galoshes, et­cetera and so on. But there was this book on Alla Nazimova that just begged to be taken. How could she resist it?

     How indeed? In no way am I making a case that I possessed any innate talent for fiction (although it took a certain prescience to hypothesize a biography of Nazimova some thirty years before Gavin Lambert's volume was published). But, amid the usual obfuscating data, there are flashes of verisimilitude and understanding, all of which was new to me. By then, I had discovered Maugham, and Hemingway, and Camus, and had begun to trace in literature some emotional pathways that would fulfill me infinitely more than the road map of a Connecticut town.
      Oddly, the book that helped pull me into the human race was Emily Post's "Etiquette," which I had picked up in a moment of early-teen hippie scorn, fully intending to mock what I was sure would be an "uncool" justification of bourgeois rules and regulations. Instead, the book offered clearly stated reasons for courtesy, gentility, and scrupulousness—reasons that I could respect, understand, and implement. It suggested ways to inaugurate conversations without launching into a lecture, reminded me of the importance of listening as well as speaking, and convinced me that manners, properly understood, existed to make other people feel comfortable, rather than (as I had suspected) to demonstrate the practitioner's social superiority. I revelled in Post's guidance and absorbed her lessons. And, typically, I took them too far: even today, I would never dream of addressing a teen-age busboy in a small-town diner as anything other than "sir."
     I found Emily Post among my mother's paperbacks, but most of the books I read came from the UConn library, where I was always made to feel at home, even in high rabbit's-foot regalia. Every room held treasures, but my favorite spot was the listening station at the Music Library, where, one blessed afternoon, I put on some bulbous headphones that made me look like Mickey Mouse and heard the prelude to "Das Rheingold" for the first time.
     The word that year was "psychedelic," and I had no idea what it meant, although I had gleaned that "Sgt. Pepper's Lonely Hearts Club Band," Peter Max posters, certain novels by Hermann Hesse, and the whole city of San Francisco were awash in this new and magical quality. And then Wagner's depiction of the River Rhine started to play and a flowering drone filled my head; time was suspended, and I was transformed.
     Much has been made of Wagner's harmonic restlessness—of the way that a work such as "Tristan and Isolde" led inexorably to the so-called "atonality" of Arnold Schoenberg and his myriad disciples. But what astonished me in "Das Rheingold," although I couldn't have stated it then, was the opposite quality: the opera's unprecedented harmonic stasis, the manner in which it explored the churning inner life of sustained chords, from the three amazing minutes of E-Flat Major that set the score in motion through the affirmation of the Gods, Valhalla, and the eternal D-Flat Major at the end.
     This was music that one could dwell in, a sort of sonic weather. I loved its resistance to change, its protracted unfolding, its mantric sense of perpetual return. A large part of my career has been devoted to writing about music, and I date my first more or less mature criticism to the world premiere of another composition that shared some of these same qualities, Steve Reich's "Music For 18 Musicians," which I heard in New York, at the Town Hall, in April of 1976.
     I arrived back at my Third Avenue walkup, knowing that I'd never fall asleep, with an urgent need to react to the work. What I had heard struck me as so beautiful and unusual, so distinctly of its time but in such radical opposition to most "new music" of the seventies, that I wrote through the night, attempting to summarize my impressions. Five years later, I published a study of what by then had come to be known as minimalism, and it incorporated some of what I wrote that night:
    Minerva-like, the music springs to life fully formed—from dead silence to fever pitch. . . . Imagine concentrating on a challenging modern painting that becomes just a little different every time you shift your attention from one detail to another. Or trying to impose a frame on a running river—making it a finite, enclosed work of art yet leaving its kinetic quality unsullied, leaving it flowing freely on all sides. It has been done. Steve Reich has framed the river.
     Today, I find myself wondering if I would have responded so profoundly to this starkly reiterative, rigidly patterned music had I not had Asperger's syndrome. This is not an aesthetic cop-out: I can make an intellectual case for minimalism, and I am hardly the only writer who has done so. But its initial appeal for me was purely visceral. As the Quakers might say, this music spoke to my condition. (I would later experience a similar, curiously mechanical limbic ecstasy upon a first encounter with the movie "Last Year at Marienbad.")
     It was never difficult for me to articulate my feelings about anything external. I've rarely run short of opinions, well founded or otherwise. But deeper emotions reduced me (and, to some extent, reduce me still) to aching silence, especially when I feared that I would be exposed, misunderstood, or ridiculed. I empathized with Rostand's Cyrano (a serious rival to Ferdinand the Bull in my private pantheon of literary heroes), who was too terrified to utter the crucial words to the woman he loved. I suffer little stage fright when it comes to public speaking or appearances on radio or television, but I continue to find unstructured participation in small social gatherings agonizing. It would be easier for me to improvise an epic poem at a sold-out Yankee Stadium than to approach an attractive stranger across the room and strike up a conversation.
     Falling in love surprised me; I had never imagined sustained contentment, and certainly not in the company of another person. Yet here it was: even making the bed together in the morning, an act that had hitherto struck me as Sisyphean, took on meaning, as the prelude to another gloriously ordinary day, to be followed by tea, the newspapers, a couple hours of work, and then lunch in the neighborhood. While it lasted, everything was enhanced; I just wish this were the time and place to write that first happy ending.
     The fact that my understanding of affection, comradeship, and human empathy has been hard-won rather than being wired in from the start does not make these feelings less genuine. I am still friends with most of the people I was friends with thirty years ago, and I worry about them daily (here I concur with Virgil Thomson, who once said that worry was one form of prayer that he found acceptable). My intimates, new and old, are permanent fixtures in my experience, and that some of them—too many—are no longer living has not diminished my devotion.
     I've transcended Lauder and hore-hounds, and my passions range widely, if spottily, through any number of fields. Laughter, meditation, therapy, Valium, antidepressants, liberal helpings of wine and beer, loyal and patient friends, forgiving children, a congenial work situation that allows me to spend much of my time alone—all these have helped me to carry on. Over-stimulation remains a positive horror, and I am most comfortable in dark or neutral clothing, under gray skies. I thrive on routines: I like to walk into the same restaurants, sit in the same seats, and order the same meals, and I took it personally when the PanAm Building started passing itself off as MetLife.
     There is no cure for Asperger's syndrome, and there is even some question whether it should be considered an affliction or merely a "difference"—one of many human variants. The reporter Amy Harmon wrote in the Times that some autistics view themselves as part of "an ad hoc human rights movement," and view autism itself as "an integral part of their identities, much more like a skin than a shell, and not one they care to shed." A group called Aspies for Freedom runs a Web site that celebrates what it calls "neurodiversity," arguing that there are advantages as well as disadvantages in an autistic condition.
     I apply Romain Rolland's practical credo—"pessimism of the intelligence; optimism of the will"—to my aspirations, but I cannot pretend that Asperger's has not made much of my existence miserable and isolated (how will I get to sleep tonight?). I hope that young Aspies, informed by recent literature on the subject, will find the world somewhat less challenging than I have.
     By now, I am fairly used to myself, and my symptoms bloom publicly only on rare occasions. Waiting for the check after a Washington lunch in 2005,I realized that it was both the hundred and fortieth anniversary of Lincoln's assassination and exactly forty years since the murderers of the Clutter family ("In Cold Blood") were put to death in Kansas. I doubt that my companion was equally thrilled by this coincidence, especially when elaborated upon in such sudden, bursting detail in the middle of a lovely spring day, but at least I controlled the temptation to launch into a lengthy exculpation of Mrs. Surratt. I count that as progress.

Virtual Iraq
Sue Halpern, New Yorker- 5/19/2008

In November, 2004, when he was nineteen years old, a marine I'll call Travis Boyd found himself about to rush the roof of the tallest building in the northern end of Falluja in the midst of a firelight. Boyd, whose first assignment in Iraq was to the security detail at Abu Ghraib prison, had been patrolling the city with his thirteen-man infantry squad, rooting out insurgents and sleeping on the floors of abandoned houses, where they'd often have to remove dead bodies in order to lay out their bedrolls.
      With Boyd in the lead, the marines ran up the building's four flights of stairs. When they reached the top, "the enemy cut loose at us with everything they had," he recalled. "Bullets were exploding like firecrackers all around us." Boyd paused and his team leader, whom he thought of as an older brother, ran past him to the far side of the building. Moments after he got there, he was shot dead. Within minutes, everyone else on the roof was wounded. "We had to crawl out of there," said Boyd, who was hit with shrapnel and suffered a concussion, earning a Purple Heart. "That was my worst day."
     It is in the nature of soldiers to put emotions aside, and that is what Boyd did for three years. He "stayed on the line" with his squad and finished his tour of duty the following June, married his high school girlfriend, and soon afterward began training for his second Iraq deployment, not thinking much about what he had seen or done during the first. Haditha, where he was sent in the fall of 2005, was calmer than Falluja. There were roadside bombs, but no direct attacks. Boyd was now a team leader, and he and his men patrolled the streets like police. When drivers did not respond to the soldiers' efforts to get them to stop, he said, "we'd have to light them up." He was there for seven months.
     With one more year of service left on his commitment, and not enough time for a third deployment, Boyd was separated from his unit and assigned to fold towels and dean equipment at the fitness center of his Stateside base. It was a quiet, undemanding job, intended to allow him to decompress from combat. Instead, he was haunted by memories of Iraq. He couldn't sleep. His mind raced. He was edgy, guilt-racked, depressed. He could barely do his job.
     "I'd avoid crowds, I'd avoid driving, Pd avoid going out at night," he told me the first time we spoke. "I'd avoid people who weren't infantry, the ones who hadn't been bleeding and dying and going weeks and months without showers and eating M.R.E.s. I'd have my wife drive me if I had to go off the base. A few times, I thought I saw a mortar in the road and reached for the steering wheel. I was always on alert, ready for anything to happen at any time."
     Eventually, as part of a standard medical screening, Boyd was diagnosed as having chronic post-traumatic stress disorder. P.T.S.D., which in earlier conflicts was known as battle fatigue or shell shock but is not exclusively war-related, has been an officially recognized medical condition since 1980, when it entered the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders. (In an earlier edition, it was called "gross stress reaction.") P.T.S.D. is precipitated by a terrifying event or situation—war, a car accident, rape, planes crashing into the World Trade Center and is characterized by nightmares, flashbacks, and intrusive and uncontrollable thoughts, as well as by emotional detachment, numbness, jumpiness, anger, and avoidance. Boyd's doctor prescribed medicine for his insomnia and encouraged him to seek out psychotherapy, telling him about an experimental treatment option called Virtual Iraq, in which patients worked through their combat trauma in a computer-simulated environment. The portal was a head-mounted display (a helmet with a pair of video goggles), earphones, a scent-producing machine, and a modified version of Full Spectrum Warrior, a popular video game.
     When Travis Boyd agreed to become a subject in the Virtual Iraq clinical trial, in the spring of 2007, he became one of about thirty-five active-duty and former members of the military to use the program to treat their psychological wounds. Currently, the Department of Defense is testing Virtual Iraq—one of three virtual-reality programs it has funded for P.T.S.D. treatment, and the only one aimed at "ground pounders" like Boyd—in six locations, including the Naval Medical Center San Diego, Walter Reed Army Medical Center, in Washington, D.C., and Weill Cornell Medical College, in New York. According to a recent study by the RAND Corporation, nearly twenty per cent of Iraq and Afghanistan war veterans are suffering from P.T.S.D. or major depression. Almost half won't seek treatment. If virtual-reality exposure therapy proves to be clinically validated—only preliminary results are available so far—it may be more than another tool in the therapists' kit, it may encourage those in need to seek help.
     "Most P.T.S.D. therapies that we've seen don't seem to be working, so what's the harm in dedicating some money to R. & D. that might prove valuable?" Paul Rieckhoff, the executive director of Iraq and Afghanistan Veterans of America, said last November. In January, his group issued a lengthy report called "Mental Health Injuries: The Invisible Wounds of War," which cited research suggesting that "multiple tours and inadequate time at home between deployments increase rates of combat stress by 50%." Rieckhoff went on, "I'm not someone who responds to sitting with some guy, talking about my whole life. I'm going to go in and talk to some dude who doesn't understand my shit and talk about my mom? I'm the worst of that kind of guy. So V.R. therapy, maybe it will work. We're a video-game generation. It's what we grew up on: So maybe we'll respond to it."
     Strictly speaking, using virtual reality to treat combat-related P.T.S.D. is not new. In 1997, more than twenty years after the Vietnam War ended, researchers in Atlanta unveiled Virtual Vietnam. It dropped viewers into one of two scenarios: a jungle clearing with a "hot" landing zone, or a Huey helicopter, its rotors whirring, its body casting a running shadow over rice paddies, a dense tropical forest, and a river. The graphics were fairly crude, and the therapist had a limited number of sights and sounds to manipulate, but Virtual Vietnam had the effect of putting old soldiers back in the thick of war. Ten combat veterans with long-term P.T.S.D. who had not responded to multiple interventions participated in a clinical trial of Virtual Vietnam, typically lasting a month or two. All of them showed significant signs of improvement, both directly after treatment and in a follow-up half a year later. (P.T.S.D. is assessed on a number of scales, some subjective and others based on the observation of the clinician.) As successful as it was, though, Virtual Vietnam didn't catch on. It was an experiment, and when the experiment was over the researchers moved on.
     Like Virtual Vietnam, Virtual Iraq is a tool for doing what's known as prolonged exposure therapy, which is sometimes called immersion therapy. It is a kind of cognitive-behavioral therapy, derived from Pavlov's classic work with dogs. Prolonged-exposure therapy, which falls under the rubric of C.B.T., is at once intuitively obvious and counterintuitive: it requires the patient to revisit and retell the story of the trauma over and over again and, through a psychological process called "habituation,"and rid it of its overwhelming power. The idea is to disconnect the memory from the reactions to the memory, so that although the memory of the traumatic event remains, the everyday things that can trigger fear and panic, such as trash blowing across the interstate or a car backfiring—what psychologists refer to as cues—are restored to insignificance. The trauma thus becomes a discrete event, not a constant, self-replicating, encompassing condition.
     This process was explained to me by JoAnn Difede, the director of the Program for Anxiety and Traumatic Stress Studies at Weill Cornell, when I visited her in her office, last fall. Difede, a tough-minded New Yorker, began using virtual-reality exposure therapy with patients from the hospital's burn unit in the nineteen-nineties. She treated victims of September 11th with a program called Virtual W.T.C., which she designed with the creators of Virtual Vietnam, and is currently running a Virtual Iraq clinical trial as well as supervising therapists at other study sites.
     Difede says that therapists have been slow to adopt exposure therapy, because they worry that it might be cruel to immerse a patient in a drowning pool of painful memories. It's a worry that, she believes, misses the point of the therapy. "If you suddenly become afraid of the staircase because you had to walk down twenty-five flights of stairs to get out of the World Trade Center, the stairs went from being neutral to being negative," Difede explained. "What we should be doing is extinguishing the cues associated with the stimuli, which should allow for a more complete remission, as well as mastery of the experience. It also should allow for greater emotional engagement. Because numbing and avoidance are symptoms of P.T.S.D., you're asking the person to do in treatment the very thing their mind is avoiding doing. That's quite a dilemma."
     Its this dilemma that makes virtual reality especially attractive to clinical psychologists like Difede. Because the traumatic environment is produced in a computer graphics lab, and its elements are controlled by the therapist, virtual reality can nudge an imagination that is at once overactive and repressed. "Voila, you're there!" Difede said. "You don't have to do any work. You don't have to engage in any mental effort. We'll do it for you. We'll bring you there and then, gradually, we'll let you get involved in the experience in sensory detail."
     When Travis Boyd was first asked to consider enrolling in the Virtual Iraq clinical trial, he was hesitant. He had already decided not to talk to his division therapist, because "I didn't want to have it on my military record that I was crazy," he said. And he was a marine. "Infantry is supposed to be the toughest of the tough. Even though there was no punishment for going to therapy, it was looked down upon and seen as weak. But V.R sounded pretty cool. They hook you up to a machine and you play around like a video game." Telling his buddies that he was going off to do V.R. was a lot easier than telling them he was seeing a shrink.
     Before he was introduced to Virtual Iraq, the therapist asked him to close his eyes and talk about his wartime experiences. Without much prompting, he was back on the roof in Falluja, under fire, stalled at the top of the stairs, watching his friend and team leader run past him and die, and then he was dragging out his friend's body, looking at his messed-up face. When Boyd was finished, the doctor asked him to tell the story again. And, when he was finished that time, to tell it again. As he did, she asked him what he was smelling, and if the enemy was on the roof opposite or on the roof next door, and if there were planes overhead. She wanted to learn the details of his narrative and determine which moments were most troubling to him—she called them "hot spots"—and to figure out how she was going to use the sensory variables embedded in Virtual Iraq.
     Boyd was introduced to the V.R program in the third session. (There were twelve sessions in all, each about two hours long, over a period of six weeks.) Virtual-reality exposure therapy immerses the patient gradually, that first time Boyd just sat there with the V.R. gear on, looking at an Iraqi street scene, getting acquainted with the virtual world. Sound, which psychologists believe may stimulate memory more effectively than sight does, was added next, and, with it, touch. "I'm talking about the firelight and she turns on this vibrating thing so you feel like you're in a shaking building," Boyd said. "Each time she added something, like an I.E.D. going off, or a plane flying over, I'd become more emotional. We'd do it over and over, and it would become easier, and then she'd add something more and the same thing would happen. I'd talk for forty minutes about this one five-minute thing. When its only visual, its not really real—it's just a video game—but when the ground starts vibrating and you smell smoke and hear the AK-47 firing, it becomes very real. I'd be shaking. When it was over, I'd go home and cry."
     The inventor of Virtual Iraq is Albert Rizzo, a clinical psychologist at the University of Southern California, who goes by the nickname Skip. Rizzo, who is fifty-three, has thinning black hair that's down to his shoulders when its not pulled back in a ponytail, a stud earring, and a nose that looks like it has met a boot or two—he plays rugby. Rizzo rides a Harley 1200 Sportster ("It's not a girl's bike, no matter what anyone tells you"), plays blues harmonica (he taught himself a couple of years ago, in order to reduce stress when he was commuting daily in L.A. traffic), and has an affable, jeans­-and-untucked-shirt way about him that is particularly noticeable when he walks through Walter Reed or the Naval Medical Center-San Diego alongside his starched military counterparts. In 2003, not long after the United States invaded Iraq, Rizzo, who had been designing virtual-reality systems to diagnose attention deficits in children and memory problems in older adults, and was affiliated with the Institute for Creative Technologies, a U.S.C. offshoot that he likes to call "an unholy alliance between academia, Hollywood, and the military," had a hunch that, if the war went on for very long, its veterans were going to come home with serious emotional problems.
     "I thought we should be on this so we don't have another Vietnam, with all these guys suffering from P.T.S.D.," he told me one day last fall at Walter Reed, before he was to give a presentation to senior military officers. "I was working on a talk about virtual reality, just sniffing around the Internet, and I saw this link for the video game Full Spectrum Warrior." The game had, in fact, originated as a training device that the Institute had developed for the Department of Defense. "I said, 'Oh, my God, that's Iraq!' It was instant. I thought we should take this game and run it in a head-mounted display right out of the box, for therapy."
     Rizzo got in touch with Jarrell Pair, who had been the programmer on Virtual Vietnam, and convinced him to sign on to his as yet unfunded venture. By February, 2004, he and Pair had built a prototype of Virtual Iraq on a laptop, using a single street in an Iraqi market town which they had recycled from Full Spectrum Warrior. To this they added a few alternate realities that a therapist could insert with a keystroke a change from day to night, for example, or a switch from a deserted street to one where burka-clad shoppers strolled down the sidewalk. "That was our demo," Rizzo said. "We applied for money and we got nuked. Then the Hoge article comes out and everything changes overnight."
     The article to which Rizzo was referring was written by Charles Hoge and his colleagues in the Department of Psychiatry and Behavioral Sciences at Walter Reed and was published in the New England Journal of Medicine that summer. It was the first assessment of mental-health problems emerging from service in Iraq and Afghanistan, and even its conservative estimate—that around sixteen or seventeen per cent of those who fought in Iraq and eleven per cent who served in Afghanistan were suffering from P.T.S.D. symptoms (an estimate that four years later has been revised dramatically upward)—caught the public and the military by surprise. Then Rizzo got a call from somebody in the Office of Naval Research. "He says, 'I hear you've got a prototype of Full Spectrum Warrior for P.T.S.D.,'" Rizzo recalled. " We're going to try to get it funded: " The money came through in March, 2005, and by the next fall, right around the time that Travis Boyd was being deployed to police Haditha, the first patients were recruited to try it out.
     Before Skip Rizzo started designing virtual-reality systems, he was a conventional clinical psychologist, schooled in a variety of therapeutic methods. Rizzo grew up just outside Hartford, attended the University of Hartford as an undergraduate, received a doctorate from Binghamton University, and did his internship at the V.A. hospital in Long Beach, California, not far from where he now lives. Then he took a job as a cognitive-rehabilitation therapist at a hospital in Costa Mesa, working with people who had suffered traumatic brain injuries. "A lot of young males are in that population," he said. "The high-risk-takers. The drunk drivers. Gang members—all of that. With that population, it was sometimes hard to motivate them to do the standard paper-and-pencil drill and practice routines. Then, in the early nineteen-nineties, Game Boys came on the scene, and it seemed to me that all my male clients, at every break, at every meal, had become Tetris warlords. It showed me that they were motivated to do game tasks, and that the more they did them the better they got, and it hit me that there could be a link between cognitive rehabilitation and virtual reality." Rizzo left his job, and accepted a postdoc at the Alzheimer Disease Research Center at U.S.C., where he began to design rudimentary virtual-reality systems with the help of programmers in the computer-science department. At the end of the postdoc, he moved to the engineering school at U.S.C. and started "building this stuff like crazy."
     To make Virtual Iraq, Rizzo started with two basic scenarios: the market-town street scene and a Humvee moving along an Iraqi highway, where all the exit signs are in Arabic and the road cuts through sand dunes. Then he gave therapists a menu of ways visual, aural, tactile, even olfactory—to customize them. At the click of a mouse, the therapist can put the patient in the driver's seat of the Humvee, in the passenger's seat, or in the turret behind a machine gun, and the vehicle moves at a speed determined by the patient. Maybe the gunner in the turret is wearing night-vision goggles—the landscape goes grainy and green. A sand­storm could be raging (the driver can turn on the windshield wipers and beat it back); a dog could be barking, the inside of the vehicle could be rank. Rizzo's idea is that giving the therapist so many options—dusk midday, with snipers, without snipers; driving fast, creeping along; the sound of a single mortar, the sound of multiple mortars; the sound of people yelling in English or in Arabic—increases the likelihood of evoking the patient's actual experience, while engaging the patient on so many sensory levels that the immersion in the environment is nearly absolute.
     "Tell me what you want me to add, anything," I overheard Rizzo asking a therapist at Walter Reed in February, a few days after she had completed a fourteen-session Virtual Iraq protocol in three months with the first soldier at the facility enrolled in the trial. (The patient didn't think he had got much better, though he was able to ride the subway again and no longer avoided large crowds.) "You're the one in the trenches hearing the stories. We'll keep evolving this to make it more relevant. What do you think about adding the smell of burning hair?"
     Rizzo was sitting in a tiny, windowless room in front of a table ringed by a loth skirt that partly hid the electrodes and other equipment that monitor a person's blood pressure, respiration, heart rate, and stress level during treatment, and were connected to two computers. He had flown in the night before to install the latest software upgrade, which he was introducing to the therapist, a slight young woman in her thirties.
     "O.K.," Rizzo said as he clicked the computer mouse rapidly, "this is really cool." On the screen was the basic Virtual Iraq market scene: a few nearly empty vender stalls in the middle of a plaza and a row of small, ground-floor shops in dun-colored buildings lining the sidewalk. "You walk to the end of this street"—the sound of footsteps could be heard—"it's market east. Now, let's see if this works. Let me blow up this car." He clicked again and a small car about the size of a Toyota Corolla, which had been parked at the curb, burst into flames. "Ifs a good effect. Now, when you blow up the car, put in 'add stunned civilian' One more thing—you have to learn where the R.P.G. guys are." He was referring to figures toting rocket-propelled grenades. "There's one here," he said, and on the screen there was another explosion. "Now we're going to head over there," he said, moving forward—more footsteps—toward a set of stairs. "Here's the deal with going up the stairs. You've got to hit it square on, otherwise you'll get caught up in the collision bather. It just breaks the presence. You'll have to guide them. From here, there's a variety of things you can do. First off, you've got the insurgent on the roof over there. The insurgents just pop up. You have to learn where they are, too."
     The therapist looked over Rizzo's shoulder while he brought a Black Hawk helicopter in for a flyover and then blew up another car on the street. "One thing I have to be careful about is not hitting something by accident," she said. "One time, I mistakenly clicked my mouse and all of a sudden a bullet came flying out, and I had to tell the patient that I was sorry and didn't mean to do that."
     The first time I put on a head-mounted display and headphones and entered Virtual Iraq had been in this same room, at Walter Reed, a few months earlier, after Rizzo presented preliminary results from a study site to a small gathering of military officials. Rizzo was having trouble linking his laptop's PowerPoint presentation to the Walter Reed audio­visual system, and he had to speak without notes, often from a crouch behind the podium as he picked through a jumble of cables searching for one that was live. "The last one hundred years, we've studied psychology in the real world," Rizzo told the group. "In the next hundred, we're going to study it in the virtual world." He threw out some numbers. Of the five subjects who had completed treatment, four no longer met the diagnostic criteria for P.T.S.D. A fifth soldier showed no gain. (To these he would add, a few months later, the results for ten others, eight of whom had got better. Of the six research sites, San Diego was the first to have preliminary results.) After talking more generally about the features of Virtual Iraq, Rizzo invited everyone present to the fourth-floor psychiatric wing to try it out.
     Although I had seen Virtual Iraq in one dimension on a computer monitor, encountering it in three dimensions, with my eyes blinkered by the head­set and my ears getting a direct audio feed, was different. It still felt like make-believe, but I was fully engaged. Rizzo placed a dummy M4 rifle in my hands, and guided my fingers to a video controller fixed to the barrel. (By design, patients who use Virtual Iraq do not fire weapons; the M4 is a mood-setting device, for verisimilitude.) One toggle moved me forward, another moved me back, and a third sped me up or slowed me down. Because the display tracked with the orientation of my head, which ever way I moved determined not only what I saw but where I went. I pressed the forward button and strolled down the market street and, at Rizzo's instruction, turned at a doorway and entered a house. Inside were two insurgents, one on his knees, with his hands tied behind his back, the other dead on the ground. A baby was crying. I moved on.
     The next time I put on the headset was in Marina del Rey, California, at an Institute for Creative Technologies lab space called FlatWorld, most of which was given over to life-size "mixed reality" worlds that could be negotiated without special equipment. (It was so realistic that when a virtual insurgent popped up across the virtual street from the virtual building in which I was standing, his bullets made successive holes in the virtual wall behind me and seemed to shower plaster dust through the air.) The Virtual Iraq design team, two artists and a programmer, worked out of FlatWorld, and it was their system, with the most recent improvements and additions, that I was using. This time, Rizzo sat me in a chair placed over a bass shaker, which is also known as a tactile transducer, a device that transmits the feel of sound. I slipped on the display and the headphones, and Rizzo pressed some keys on his computer and made me the driver of a Humvee, with a soldier in desert fatigues sitting next to me and another in the back. (Because the gunner was in the turret, when I looked in the rearview mirror I saw only his boots and his pant legs.) As soon as I started up the vehicle, the floor under me began to vibrate and my ears filled with the hum of tires on pavement. Suddenly, a gunman appeared on the overpass above me and started to shoot. Off to my right, a car burst into flames. Half a second later, the explosion entered my body through my feet and ears. It was startling, the way any unexpected loud noise is, but it wasn't frightening. Even when the guy in the seat next to me was shot, and his shirt sprouted a red bloom, it wasn't frightening. I had never been to Iraq. I had never been to war. The scene did not conjure any memories for me, traumatic or otherwise. It was, as JoAnn Difede said of stairs on September 10th to a person who worked in the World Trade Center, neutral.
     I had seen, though, what might happen if it triggered an emotional response, when an actor named Ed Aristone, who had been cast in a movie about the Iraq conflict and wanted to get a sense ofwhat combat was like, put on the head-mounted display at FlatWorld and found himself in the midst of a war. Rizzo cued up car bombs, shouting soldiers, ambient city sounds, blinding smoke, inert bloody bodies, the call to prayer, a child running across the street, the cough of an AK-47, snipers, a nighttime gale all ten plagues and their cousins at once. Aristone started to sweat. His heart was racing. His hands were numb. He was having a hard time holding the rifle. His face went white. He bit his lips. After ten minutes, he said he'd had enough.
     "This shows you why you need a trained therapist," Rizzo said, turning off the machine and watching Aristone, who was bent over, with his hands on his knees, taking deep breaths. "Someone who knows exposure therapy, who knows how little things can set people off. You have to understand the patient. You have to know which stimuli to select. You'd never do what I just did—you'd never flood them. You have to know when to ramp up the challenges. Someone comes in and all they can do is sit in the Humvee, maybe with the sound of wind, and may have to spend a session or two just in that position. For P.T.S.D., its really intuitive. We provide a lot of options and put them into the hands of the clinician."
     One of these is Karen Perlman, a civilian psychologist who uses Virtual Iraq with patients at the Naval Medical Center San Diego. Perlman is an apple­cheeked, middle-aged native Californian with cascading brown hair, who, when I met her, was wearing an elegant short black dress with a pink-blue-and-purple tie-dyed silk scarf. At first glance, Perlman does not seem to be the sort of person a young marine would cotton to, but Rizzo says that she has a gift, and so far eight of the nine patients she has treated no longer meet the criteria for P.T.S.D. (This number does not account for those who dropped out.) "It's a very collaborative relationship," she told me in February, when Skip Rizzo and I drove down to San Diego. "I know which stimuli I'm going to add as the therapy progresses. I'm not going to overwhelm them. There are no surprises. I say, 'I think you're ready for the I.E.D. blast or for more airplanes.' I'm not only adding more, but increasing the duration of each one. It's intensive, but for P.T.S.D. you need a treatment that is intensive."
     Although Perlman had been a clinician for more than twenty years before she began work with marines at the Naval Medical Center, she had never used prolonged-exposure therapy with patients, and she was surprised by its therapeutic power. (She had spent four days in Philadelphia being trained by Edna Foa, the director of the Center for the Treatment and Study of Anxiety at the University of Pennsylvania, who initially developed the prolonged-exposure technique while treating rape victims, and a day with JoAnn Difede, learning how to integrate virtual reality with exposure therapy.) "I've seen patients recover in five to six weeks," she said. "To see someone respond in such a dramatic way is very gratifying. What we're doing is very structured and systematic. It treats the core fear, the avoidance and the anxiety that are part of P.T.S.D., in a potent way. V.R. augments the therapeutic process. When the patients start to see results, usually by the fifth session, they turn the corner and get motivated."
     Outside his therapist's office, Travis Boyd had "homework." He had been told to listen to an audiotape of the previous session, and to do the very things he had been avoiding—going to the mall, driving a car, calling his family back home and telling them what was really going on with him and answering their questions. He also called every one of the men who had been on the roof that day and asked them to tell him their recollections. He was surprised to learn that not one of them thought, as he had for so long, that he was responsible for their team leader's death. In fact, as they remembered it, the man had told Boyd to wait at the top of the stairs. "I had been walking around with all this guilt about getting my brother killed," Boyd said. "It just weighs on you. He was not the only friend I lost, but I was closest to him. Everyone thought it was awful that he died, but nobody thought it was my fault."
     The first thing Boyd noticed, after a few weeks of Virtual Iraq exposure therapy, was that he was able to sleep without medication. He was more relaxed, and he could joke around. "Before, I felt like there were two people in me," Boyd said. "The marine, who was numb, who was a tough guy, and the civilian me, the real me, the guy who isn't serious all the time, the guy who can take a joke. By the end of therapy I felt more like one person. Toward the end, it was pretty easy to talk about what had happened over there. We went over all the hot spots in succession. I could talk about it without breaking down. I wasn't holding anything back. I felt like the weight of the world had been lifted. I was ready to be done. The last two sessions, I didn't think I needed to be there anymore."
     The last time I talked to Travis Boyd, it was his third wedding anniversary. Boyd is now twenty-two, and works for a commercial construction firm in the Midwestern town where he grew up. "Most of the intrusive thoughts have gone away," he said. "You never really get rid of P.T.S.D., but you learn to live with it. I had pictures of my team leader that I couldn't look at for three years. They're up on my wall now."