Noteworthy News Articles on Mental Health Topics, September 24-31, 2001

Children Struggle to Cope With Terror Attacks
Michele Norris, ABC News- 9/24/2001

W A S H I N G T O N— Ask any parent how their child is faring in these days after terrorists destroyed the World Trade Center and attacked the Pentagon and you are likely to get an earful. Nightmares. Headaches. Bouts of vomiting. All common as children try to cope with emotions they are not yet ready to handle. But troubled emotions can surface in more subtle ways as well, said John Mack, the Harvard psychiatrist who conducted landmark studies on children's fears of nuclear war. "They don't know how to tell us that they are on overload. We as adults have to look for the signs."
    Children, Mack says, often express what they are thinking through play. One Washington, D.C., teacher, who asks not to be named, describes how she watched in horror as her fifth-grade students made 3-foot high stacks of books and then toppled them with makeshift airplanes. "My first instinct was to yell at them," she said. "I thought how could they be so insensitive but then I realized they were trying to tell us something in the only way they could. Even though they were smiling and laughing. I knew that they were hurting inside."

To Help Them Cope
Psychologists say one of the best ways to help children cope with trauma is to involve them in activities like drawing, writing, games and other projects. Not only does it help keep troubled minds preoccupied, it can give children a sense of control and help them work though a troubling thicket of emotions. That's what Jackie Snowden had in mind when she asked her sixth-grade students at Lafayette Elementary School in Washington, D.C. to start a journal in the days following the attacks. Realizing that soothing words could only do so much to help ease her students' fears, Snowden thought her rattled sixth-graders would find some measure of relief if they could translate confusing emotions into prose. "It's like letting the steam off a pot," Snowden said. "This is a nightmare and I'll never forget this and my life will never be the same," said Zoe Schroeder, reciting words she'd written in her journal. "So many people died because of this, people jumping off holding hands. It was raining people." Lena Solow wrote: "I'm so overwhelmed by all this. Yesterday I had this terrible headache and I don't know what to saw, think or do. Now, I'm afraid to go in a plane because there could be hijackers or something." The verdict in Snowden's class was unanimous. It worked. The students say they were able to express feelings on paper they couldn't — or wouldn't — share with friends and family.

The Scariest Things
Those expressions can be unsettling to adults unaccustomed to seeing complex issues such as evil and death pierce a child's innocence. One parent dissolved on the job this week when a counselor from her daughter's school called about a disturbing drawing that featured a burning building where "all the mommies died." Peter Breggin, author of Reclaiming our Children; A Healing Solution for a Nation in Crisis, said such expressions naturally send off alarm bells, but parents should react with calm. "One of the scariest things for children, if not the scariest, is the thought that parents are in danger," Breggin said. "It's important for parents to not act scared at a time like this. To directly reassure their children that they are safe, that their parents are safe. "The single most important thing is how the adults are comporting themselves. If the adults are acting in a way that says we are in charge. We can take care of you. Everything's OK. That is the first and most important lesson to the children."
    And while it may he a tough sell to convince youngsters that everything is OK with all the talk of war and the continued threat of terrorism, Mack says parents can help comfort children by talking about what kind of future they want to create: "As horrible as these events have been there is a tremendous opportunity here, a tremendous teaching moment to say, 'Let's work to create a just world, a fair world, a safe world. And let's talk about what we can do as a family and what you can do as an individual to get there.'"

Road Deaths Caused by Alcohol Increase in 2000
Nedra Pickler, Associated Press- 9/24/2001

WASHINGTON -- The number of people killed by drunken drivers increased last year for the first time in five years, according to federal data released Monday. Overall highway deaths increased slightly in 2000 to 41,812, up from 41,717 in 1999, according to the National Highway Traffic Safety Administration. Forty percent of those, or 16,653, involved alcohol, up from 38 percent, or 15,976, the previous year. It is only the second time alcohol-related deaths have increased since 1986, when 24,045 people were killed. The number of deaths rose 4 percent from 1994 to 1995.
    Over the past two decades, auto safety advocates have pushed for tougher impaired-driving laws and made drinking and driving a social taboo. Advocates say more needs to be done to reach problem drinkers. "We've already deterred virtually all of the social drinkers," said Chuck Hurley of the National Safety Council. "We're now down to the hard core of people who continue to drink and drive in spite of public scorn, and obviously the only thing they will respond to is increased enforcement."
    Safety advocates are pushing for state legislatures to lower the legal standard for drunken driving to 0.08 percent blood alcohol content. Many states now have a 0.10 standard. They also want tougher penalties for people who repeatedly break drunken driving laws and are involved in many of the fatal crashes.
    On the Internet: National Highway Traffic Safety Administration: www.nhtsa.dot.gov

Therapists Hear Survivors' Refrain: 'If Only'
Erica Goode, New York Times- 9/25/2001

They are an uneasy current running beneath the stories of close calls, courageous acts and sudden losses: regrets shaped by hindsight, what-ifs and if-only's, wishes to undo what cannot be undone. A woman replays over and over in her mind the argument she had with her husband on the morning of September 11th. It was a silly spat, about where the two would meet that evening, says a therapist the woman confided in. Her husband left in a huff, without kissing her or saying goodbye. Within hours, he was missing in the rubble. A group of firefighters in Brooklyn retrace an endless circle of lost possibilities. "If only we had left a moment later," they tell a counselor. "If only the traffic pattern had been different." An investment banker, late to work that Tuesday, cannot stop imagining the last moments of each of his colleagues in the World Trade Center, how this one would have been frightened, how that one would have been a fighter.
    "The sense is, he should have been killed with everyone else," said Dr. Yael Danieli, the clinical psychologist that the man consulted. In the wake of devastation, especially that wrought by humans, often come feelings of guilt and regret, said Dr. Daineli, a founder of the International Society for Traumatic Stress Studies, who has worked with survivors in Rwanda and Argentina, and other experts on the psychological impact of trauma. The joy of being alive is tinged with shame at having survived when others did not. Or as one firefighter put it, "I feel guilty that I'm glad I wasn't there." Dr. Edna Foa, a psychologist at the University of Pennsylvania, said she had not seen a trauma victim that did not feel guilty about something.
    And faced with events that evoked, at least momentarily, images of nuclear war--a resonance given eerie echo in the designation of the World Trade Center site as "ground zero"--even people spared immediate losses may feel they must somehow make up for being alive when so many died. "There are concentric circles of survivor experience," said Dr. Robert Jay Lifton, a psychiatrist at Harvard, who has studied the survivors of Hiroshima, the Holocaust and other human-inflicted terrors. "At the center are those people who are directly affected by the planes attacking," Dr. Lifton said. "But in New York, the survivor experience is more broad. There is a feeling of self-condemnation unless one can offer one's energies to those who have suffered."
    A collective sense of debt incurred by survival, Dr. Lifton and other experts said, may well have contributed to the almost desperate need to feel useful expressed by many people in the days after the attacks. Blood donors lined up for hours and many were distraught at being turned away. Volunteers flooded crisis lines and other services. Firehouses and police stations over-flowed with gifts and tributes.
    Guilt may seem an irrational response to events that were impossible to predict and even more impossible to control. But, at least in the immediate aftermath of disaster, Dr. Danieli said, the idea that one could somehow have prevented what happened may help ward off the even more frightening notion that the events were completely random and senseless. This attempt to hold on to some vestige of control, she said, can be discerned in many survivors' distress. "You can't sleep, you can't let go," she said. "There is a fear of dreaming and particularly of nightmares. It sounds terrible, but one would rather suffer the torment instead of letting oneself truly experience total helplessness, and to take that helplessness into the image of the world around us." Dr. Danieli added that regrets also could be a way for relatives and friends to maintain continuity by holding on to those who have died and begin the process of mourning. Some, she said, may be afraid to go to sleep "because in their sleep they may forget the person and that feels disloyal."
    Researchers have found that some aspects of the way people cope with sudden losses appear to be an integral part of the mind's basic equipment for interpreting the outside world. For example, in studies beginning in the 1970's, Dr. Baruch Fischoff, a professor of social and decision science at Carnegie Mellon University, and other psychologists have demonstrated that once people know the outcome of an event, they routinely overestimate how much predictive information they had beforehand. "If I ask you to remember how you saw things in the past, before you knew how they were going to turn out, you can't reconstruct your own previous perspective," Dr Fischhoff said. This "hindsight bias," he believes, may be an adaptive mechanism, crafted by evolution as a way to integrate new information with old.
    But for survivors, it can translate into a conviction that they should have known what was about to happen--and done something about it. A husband who urged his wife not to continue working at the World Trade Center after the 1993 bombing there, for example, might in hindsight feel responsible, though the impossibility of foreseeing hijacked planes hitting the towers may be obvious to everyone around him. "You can't be obligated to prevent unforeseeable events," said Dr. Edward Kubany, a psychologist affiliated with the University of Hawaii at Manoa, who studies survival guilt. "There is only one satisfactory action to a why question," Dr. Kubany said, "and that is bad luck, wrong place, wrong time."
    The urge to mentally "undo" horrible events by going over in one's mind all the things that could have kept them from happening is also a basic psychological response, according to work by Dr. Daniel Kahneman, a professor of psychology at Princeton, and his colleagues. "It's very easy to imagine an alternative to what actually happened and for some reason, people are really driven to do this," Dr. Kahneman said in an interview. He began studying the mental need to run through alternative outcomes after his nephew died in a 1975 plane crash while in the Israeli military. "We just kept thinking, 'if only,'" Dr. Kahneman said. The obsession with what could have been can be especially intense, he added, when the victim was present at the scene only by chance, rather than as part of a normal routine. For the survivors of the terrorist attacks, for example, the sense of regret is probably most palpable for the relatives of those who, in the ordinary course of events, should not have been there: emergency workers who switched shifts that morning, people attending a one-day event at the World Trade Center or those who were there to deliver a package or visit a friend. Dr. Kahneman noted that when he was in the Israeli army, the officers did not permit troops to exchange assignments or shifts because if a soldier was killed after such a trade, "the survivor was in deep trouble" emotionally.
    For most people, the guilt, regret and other emotions traumatic losses inspire will dissipate in time, healed in the company of family members and friends, by the rituals and traditions of bereavement and by the outpouring of support that Americans have offered the victims. But survival guilt that persists for months or even years is also a feature of post-traumatic stress disorder, a severe reaction to trauma, both in its acute and chronic form.
    Many experts believe that how well people recover depends in part on the meaning that is eventually derived from those losses. Dr. Viktor Frankl, himself a concentration camp survivor, wrote that on forced labor marches, he kept himself alive by summoning the image of his wife. "I heard her answering me, saw her smile, her frank and encouraging look," he wrote. "Real or not, her look then was more luminous than the sun which was beginning to rise."
    Dr. Lifton, in interviewing survivors of Hiroshima, said that "what many came to as a kind of meaning was their having been the first to experience these dreadful weapons." "They could therefore know something about what the weapons do to people," he said, " and could warn the world about their dangers." Dr. Lifton added, "We, as human beings and as survivors, have to create that meaning in relation to the event. The meaning can be enormously varied and the experience itself doesn't give you meaning automatically."
    Dr. Michael Garrett, the deputy director of psychiatry at Bellevue Hospital, tried to convey a similar message when he counseled firefighters in Brooklyn. "These firemen are tough guys, and getting them to talk about this is difficult," Dr. Garrett said. While the Red Cross fliers the firefighters receive tell them to eat regularly and get enough rest, he noted, "the response of most of these guys is 'When I'm off duty, I go to a funeral.'" Dr. Garrett said he encouraged them to focus on what they accomplished at the scene, on how much they helped other people. "Retrospective thinking torments people," he said. "Real life moves forwardly."

New Study Provides Clues as to What Causes Schizophrenia
Jenette Restivo, ABC News- 9/25/2001

Schizophrenia, one of the most debilitating of mental illnesses, is also one of the most mysterious. Though treatment can control the illness in more than half of patients, little is known about what actually causes the disorder — which affects about one in every 100 persons worldwide — and how it affects the mind. UCLA researchers may have just unraveled part of the mystery. Using magnetic resonance imaging, or MRI, and a new analysis technique, they have created the first images showing the toll the disease takes on the brain. The results are reported in the Proceedings of the National Academy of Sciences.
    Throughout the five-year study, the researchers performed brain scans every two years on a group of 34 teenagers. The study population was made up of clinically diagnosed schizophrenics taking antipsychotic medications, another group of patients taking the same medications for mood disorders, and normal teens. The schizophrenic patients were diagnosed with the illness before adolescence, an unusual group that represents about 5 percent of all schizophrenic patients.
    The images that resulted from the study "stunned" the scientists, according to lead researcher Paul Thompson. Rather than small, gradual changes, Thompson and his colleagues noted a dramatic wave of destruction of the gray matter in brain tissue of schizophrenic patients. Thompson described the wave as moving across the brain "like a forest fire." While the healthy teens lost an average of 1 percent of gray matter per year, the schizophrenic patients lost up to 5 percent a year, with loss greatest among individuals with the most severe symptoms.
    Additionally, the movement of tissue loss across the brain seemed to be in sync with the appearance of disease symptoms that would originate in those parts of the brain. Starting off in the brain's logic center, the parietal cortex, tissue loss continued at a dramatic rate into the auditory part of the brain and then onto motor areas. Thompson says this sequence corresponds with the typical course of the disease. The first signs include confused or illogical thinking. As the illness progresses, more bizarre symptoms such as psychosis (unusual perceptions) and hallucinations occur.
    "The study represents another step forward in our understanding of schizophrenia," says Dr. Steve Lamberti, associate professor of psychiatry at the University of Rochester Medical Center. Lamberti says the strength of the study is the detail on the nature of deterioration and progression of the illness in young people, and the evidence that brain changes were not related to antipsychotic medications but to the disease process itself.
    Though experts acknowledge the importance of the study's findings, they say it is limited for now. "Though there is no direct therapy application at this point … there is a window of hope here." says Dr. Robert Freedman, Chairman of the Department of Psychiatry and the University of Colorado Health Sciences College. "Most of us thought the damage was done in utero," says Freedman, but "the study suggests the changes can possibly be observed during adolescence." Freedman calls the study groundbreaking as it has "opened up a window to a very complicated piece of biology that none of us completely understand." Yet, he says, "A lot of work still has to be done."

For Partygoers Who Can't Say No, Experts Try to Reduce the Risks
Jeff Stryker, New York Times- 9/25/2001

Despite frequent admonitions to "just say no," some people--from their teens to well past middle age--will use drugs anyway. Acknowledging that reality, some experts on drug abuse are advocating an approach called harm reduction, which says, in essence, that while drug use should be discouraged, people who do take drugs should be taught to do so in the least dangerous way possible.
   Harm reduction is controversial. Proponents say it can save lives, but critics say it means giving up on the drug problem, and may condone drug use and lull people into thinking drugs are safe. Dr. Alan I. Leshner, director of the National Institute on Drug Abuse, said, "I'm against anything that sends a message that if you do it well it is O.K., because it is not O.K." Harm reduction gained prominence with the AIDS epidemic. The spread of HIV among drug users who shared needles prompted the establishment of programs to distribute needles and exchange used ones for clean ones--essentially helping drug users shoot up more safely.
    Patterns of drug use evolve, and harm reduction advocates have moved to dance clubs and raves, all-night dance parties fueled by loud music and, often, drugs. "Harm reduction is about meeting the drug users where they are," said Amu Ptah, the director of policy at the Harm Reduction Coalition, a nationwide nonprofit group based in Manhattan.
    One of the most popular drugs among clubgoers is Ecstasy (also known as MDMA). It appeals to users because it seems to melt away their defenses and inhibitions and often gives them warm and loving feelings toward those around them. Last year, 11 percent of high school students surveyed reported that they had used Ecstasy at least once, according to a survey of 50,000 students around the country conducted by University of Michigan researchers. The Drug Enforcement Administration seized three million Ecstasy tablets in 2000, about three times as many as were confiscated the previous year.
    Ecstasy can cause a range of adverse effects, including nausea, chills, sweating, muscle cramps and blurred vision. Dr. Leshner called it dangerous and "clearly neurotoxic." Ecstasy users at clubs and raves dance energetically in stuffy quarters, increasing the risk of heat exhaustion, which can result in dangerous dehydration leading to convulsions and, on occasion, death. Last month, the federal Drug Abuse Warning Network, a survey covering 21 metropolitan areas, reported more than 4,500 Ecstasy-related emergency room visits in 2000, up 58 percent from 1999.
    Several organizations have been formed to combat the risks by applying harm reduction principles to club drugs. One is DanceSafe, a nonprofit national network of volunteers in two dozen local chapters, which promotes guidelines for "safe settings" for Ecstasy use. The guidelines encourage club owners and rave promoters to provide "free and accessible cold drinking water," "adequate ventilation" and "a separate chill-out room."
    Because Ecstasy is illegal and not made by any legitimate manufacturer, users risk taking pills contaminated with other drugs, like PMA, a powerful stimulant easier to make than Ecstasy but far more dangerous. Concerns about poison pills drive DanceSafe's most controversial harm reduction program--"adulterant screening" by volunteers who test illicit pills for content and purity. The volunteers douse a tiny scraping from a partygoer's pill with a few drops of a reagent. A color change instantly reveals whether MDMA is present, but not how much or whether any other ingredients contaminate the pill. Volunteers maintain a nonjudgmental approach, never telling a person whether or not to take a particular pill. But a spokesman for the group said teenagers almost always threw the pills away if they were shown to contain no MDMA.
    DanceSafe also negotiates with the local police to give volunteer testers and Ecstasy users amnesty from arrest. "If the police started arresting users who sought out these health services, they would no longer be utilized, and people would die," the group says on its Website. "We see a lot of bad pills out there," said DanceSafe's executive director, Tim Santamour, who has been involved in harm reduction since the early days of the HIV epidemic. He maintains that merely threatening to test deters purveyors of bogus or adulterated pills. DanceSafe volunteers record the popular name, size, color and shape of pills, along with any distinguishing logos. The testing helps monitor waves of pills flowing through the illicit market. A pill from a certain distributor may become popular, only to be followed by a copycat pill that looks the same but contains different ingredients.
    Marcie Chambers of Louisville, Colorado, thinks parents need to know more about the risks of club drugs, which are spreading beyond the dance and rave scene,. Ms. Chambers' 16-year-old daughter, Brittney, died earlier this year from brain damage after taking Ecstasy in her own home. The drug was a birthday gift from a girlfriend. Ms. Chambers praised DanceSafe for its educational efforts, but expressed reservations about the drug-testing program. "I struggle with that one," she said. "They are giving kids a false sense of safety by handing back a pill and saying it's MDMA. I can tell you from personal experience that MDMA by itself is not safe."
    DanceSafe also offers more sophisticated testing. A gas chromatography analysis is available (with results posted to the Internet in a few weeks) to those who mail a sample pill to a laboratory in Sacramento. No questions are asked. The test identifies the presence and amounts of virtually all known illicit or pharmaceutical drugs in the pill.
    Senator Bob Graham, Democrat of Florida, thinks there needs to be more awareness of Ecstasy's dangers. "We need to get the word out--and fast--before one more teenager 'raves' himself to death," says his Website, promoting the Ecstasy Prevention Act of 2001, which was introduced July 19 to increase financing for research into long-term effects of Ecstasy and education about its risks and harms. "Arguably, organizations such as DanceSafe promote Ecstasy use," said Tandy Barrett, a legislative aid to Senator Graham. "These organizations are giving a mixed message, a very dangerous message to people who use this drug." Ms. Barrett said if teenagers heard the real dangers of Ecstasy, "they would' need to go to an organization like DanceSafe because they wouldn't be wanting to use this drug."
    Last year Congress voted to enhance penalties under federal sentencing guidelines for large-scale Ecstasy sales. Senator Graham's pending bill would provide federal financing for local initiatives to combat Ecstasy use, giving priority to communities "passing ordinances restricting rave clubs" and "seizing lands under nuisance abatement laws to make new restrictions on an establishment's use." Proponents of harm reduction say banning rave clubs will simply drive drug users underground, beyond the reach of public health programs.
    Graham Boyd, who is with the New Haven office of the American Civil Liberties Union and directs the group's drug policy litigation project, is one of the lawyers representing the owners and promoters of a New Orleans electronic music club, the State Palace. A young woman died at the club a few years ago. Last year, three men who operated the club were indicted under the federal Crack House Statute, enacted in 1986 during the crack cocaine epidemic. It was the first application of the statute to defendants not charged with selling or trafficking in drugs. Mr. Boyd said, "Worst of all, law enforcement officials decided to identify some of the safety precautions that promoters take, like making water and chill rooms and ambulances available, as actually being evidence of criminality--running a crack house." But ultimately, a plea bargain resulted in no prison time for the defendants.

Grieving When the Lost Are Never Found
Jane Brody, New York Times- 9/25/2001

For many of the thousands of people who lost loved ones in the massacre of September 11th, the continuing search-and-rescue effort leaves a fragment of hope--either that the missing will somehow be found alive or that their bodies will be recovered so the process of mourning can begin. For some, even a declaration that no more victims will be found alive is difficult or impossible to accept.
   There may never be any tangible evidence of death for many of the more than 6,000 victims. And this can result in what Dr. Pauline Boss, a professor of family social science at the University of Minnesota, calls "ambiguous loss"--the unresolved grief and inability to move forward that can occur when there is no verification of a missing person's status as alive or dead.
    A Brooklyn man in his 40's said that in the days after the terrorist attacks he could not begin to grieve for his wife, who had been in the World Trade Center when it was destroyed, until he was certain she was dead. He diverted the consoling efforts of friends and instead discussed pedestrian matters like tennis schedules and drink machines. "Without knowing if the missing person will come back, the grief process is frozen and so is the coping process," said Dr. Boss, the author of "Ambiguous Loss: Learning to Live With Unresolved Grief."
    For some people--as with many of the families of servicemen and women missing in action and the parents of children who disappeared mysteriously--the uncertainty can last for years, leaving them in a kind of limbo, hoping against hope and unable to say goodbye. Still, Dr. Boss and other therapists have found, there are ways to cope with ambiguous losses--to make adjustments that allow people to keep hoping yet to accept the likelihood that their loved ones will never return. They can then get on with their lives. Last week, Mayor Rudolph W. Giuliani told people that "all hope is not lost," but at the same time he cautioned them to "prepare for the worst, that no more survivors will be found." The longest anyone has survived beneath the rubble of an earthquake was 13 days.

Normal, Natural Feelings
Dr. Boss said it was crucial for people facing the torment of an ambiguous loss to realize that their feelings are normal. "Ambiguity can erode the cognitive and emotional processes that begin us on a journey of grieving and coping," she said. "This happens to very competent people," Dr. Boss added. "It is not a sign of weakness. The situation is crazy, not the person, yet many people distrust their own sanity because they feel so helpless." She added that it was important for people suffering ambiguous losses to be tolerant of one another's beliefs, particularly within families in which one person may be more prepared than another to accept the finality of a loss.
    "If a belief isn't immobilizing a person, then people should be allowed to have the belief they want," Dr. Boss said. "But if a belief creates dysfunction and causes a person to become frozen and stuck--unable to make decisions, go to work or perform their usual tasks--or if it keeps a person depressed, then it would be helpful to talk with someone to help reframe it so that it becomes functional."
    As Dr. Evan Imber-Black, director of the Center for Families and Health at the Ackerman Institute for the Family in New York, put it, mourning an ambiguous loss does not mean that memories die. "People can honor their memories of what used to be, but they must move on into the present and not remain locked in the past." However, Dr. Imber-Black, among others, said that for many people, including those not directly affected by the tragedy, it is all right to move slowly, since reaching that point in recovery can sometimes take a long time.
    People can help themselves move forward in the face of an ambiguous loss by asking themselves what the missing person would have wanted them to do. Would that person have wanted them to be unable to work or to be as sad as they are? Would they have wanted them to cancel celebrations or fail to see beauty in the world? "Often this kind of thinking can help people break loose and move forward," Dr. Boss said.
    "No one could bear this disaster if life stopped moving on, with weddings, babies being born and other causes for celebration," she said. "People must look into the face of beauty because they've seen the face of evil. They can find beauty in the face of a baby, in nature, in music, art, a cathedral, synagogue or mosque. Each of us needs to find a place where we can look at some beauty, some sign of life to prevent us from getting frozen in place. You may cry when you see something beautiful, but that's O.K.; it's a normal reaction."
    Even without a formal announcement that the missing were indeed dead, some people were ready last week to acknowledge the permanence of their loss. For example, a neighbor's missing 39-year-old son--the father of a 5-month-old girl--was honored in a prayer and memorial service at which friends and relatives offered moving tributes to a glorious life cut much too short. Others with missing loved ones said they had begun to shift their thinking from hoping to find the lost person to accepting the fact that the person would never come back.
    Dr. Boss notes in her book that there is a natural tendency to place blame when things go so wrong. A woman in Boston blamed herself for insisting, in spite of a financial hardship, that her husband fly to the West Coast for his stepdaughter's wedding. He was on one of the planes that crashed into the twin towers. A more reasonable attitude, Dr. Boss said, is to let go of cause-and-effect thinking and self-blame and realize that sometimes bad things just happen. She wrote: "If we can't forgive ourselves--or others--we ruminate about the past; there is no closure. We cannot grieve." It is crucial, she said, to realize that the situation is not your fault.

Advice for Moving On
Her advice to people facing an ambiguous loss is to talk to others about how you feel; to keep hoping, but at the same time not feel that it's wrong to think about a future without the loved one; to talk with others about the stress of not knowing; not to be a loner, but to let others help you; and to do some daily activity, even a small one, where you feel more in control. Many have said, for example, that exercise helps, as does doing something useful for someone else.
    Dr. Boss says it is also helpful to honor the missing person in whatever way seems fitting--perhaps with a memorial service, a book of tributes, a work of art or a contribution to the person's favorite charity. In her book, she points out that there are lessons to be learned from ambiguity. "It can make people less dependent on stability and more comfortable with spontaneity and change," she wrote. "With ambiguous loss, the task is to let go, to risk moving forward, even when we do not know exactly where we are going."
    The comedian Gilda Radner, who died of ovarian cancer in 1989, at the age of 42, wrote of her acceptance of ambiguity in her book "It's Always Something": "Now I've learned, the hard way, that some poems don't rhyme, and some stories don't have a clear beginning, middle and end. Like my life, this book is about not knowing, having to change, taking the moment and making the best of it, without knowing what's going to happen next. I may never be able to control the fear and the panic, but I have learned to control how I live each day." That is the task of people facing an ambiguous loss: to learn to live life as fully as possible despite the uncertainty and the persistent sorrow it can create.

An Anguish of Recent Events Can Awaken Old Trauma
Erica Goode & Robin Pogrebin, New York Times- 9/25/2001

In the dreams, George Humphrey is running for his life through a dark tunnel, his pursuer close behind him. He startles awake, his sheets drenched in sweat. Mr. Humphrey's nightmares originated in a war fought three decades ago in the jungles of Vietnam. But the terrorist attacks have reopened old psychological wounds for Mr. Humphrey and for others who carry the scars of earlier traumas, as well as for people who were already struggling with depression, anxiety disorders or other psychiatric illnesses before September 11th.   "New trauma awakens old trauma," said Dr. Rita Seiden, executive director of the Park Slope Center for Mental Health in Brooklyn.
    Hot lines, clinics, hospital emergency rooms and private therapists reported last week that they were beginning to see a steady stream of people. Many, said Dr. John Draper, director of the LifeNet hot line of the Mental Health Association of New York City, "are either a bit numb, like many of us, and some are trying desperately to process the events and are doing exactly what they are supposed to do, and that is talking about it."
    Dr. Phillip Wilner, the medical director of behavioral health at New York Weill Cornell Center, said he counseled a man who worked in the World Financial Center and was evacuated after the attacks. The man had lost his mother when he was 6 and the family had gone through difficult times when he felt an overwhelming helplessness. "He is a highly functional executive who has had very little contact with the mental health community," Dr. Wilner said. But as a result of the chaos and terror of the evacuation, "what he's experiencing now is more severe and he is also dwelling on what he experienced before."
    Dr. Wilner said another man, who suffers from schizophrenia and on average days is "mildly paranoid," came to the hospital the day after the twin towers fell, convinced that the attacks were a personal message directed at him. "People with anxiety disorders are more anxious, people prone to worrying are worrying more," Dr. Wilner said.
    In the post-traumatic stress disorder program at Bronx Veterans Affairs Medical Center, where Mr. Humphrey spends most days, many men whose wartime memories had quieted are experiencing renewed symptoms, said Dr. Rachel Yehuda, director of the program. Private therapists in Manhattan and other boroughs also said they were dealing with the impact of the events in sessions with regular clients, often while struggling at the same time to cope with their own anxiety and grief. "What's impressed me the most is that everyone is filtering this through their own psychology," said Dennis Haseley, a psychoanalyst in private practice. "Whatever issues or conflicts they have are being interwoven with this."
    A variety of treatments, mental health professionals said, can help people with immediate distress and with long-term problems. But they cautioned that treatment must be tailored for the person receiving it and should include specific techniques for coping with traumatic distress. The goal, some experts said, is to help people feel less helpless and stirred up, emotionally and physiologically.
    Dr. Francine Cournos, a professor of clinical psychiatry at Columbia University and the organizer of a training session held yesterday for mental health professionals, said therapists needed information about which crisis intervention methods were likely to be most helpful. Many clinicians who came to the workshop, she said, already understood the issues "and just needed training in specific techniques." "You don't want to go to a site once, stir up a lot of feeling and never follow through," Dr. Cournos added.
    Feelings of numbness and unreality that persist for a week or more after the attacks can be warning signs, many experts said, as can complete avoidance of discussions, people or places that carry reminders of the events. Yet what is most crucial, mental health experts agreed, is having the support of family members, friends and the community at large.

Aetna Dropping HMO Coverage in Several States
Associated Press, 9/26/2001

CONCORD, N.H. -- Aetna U.S. Healthcare is getting out of the health maintenance organization market in New Hampshire and other states because it is unprofitable, according to the state Insurance Department. ''Aetna has not turned a profit on its New Hampshire HMO business since 1996,'' said Deputy Commissioner Alex Feldvebel. But it will continue to offer preferred provider organization coverage.
    Aetna told the New Hampshire State Insurance Department it has been reviewing its competitive position in HMO markets across the country and decided to leave markets where it is not competitive, he said. It also is withdrawing from HMO markets in Louisiana, Rhode Island, South Carolina and certain areas in California, Georgia, Indiana, Missouri and Pennsylvania, Feldvebel said.
    ''Aetna has attributed the lack of competitiveness ... in the New Hampshire market to their relatively small market share. Without market share, Aetna has been unable to negotiate competitive contracts with health care providers,'' according to an Insurance Department statement. Aetna's HMO enrollment in New Hampshire has never exceeded 20,000. Aetna's enrollment in Massachusetts is 91,000, and in Maine 89,000. The company's withdrawal of HMO services and continuation of its preferred provider organization ''is consistent with the national trend of decreasing HMO enrollment and increasing PPO enrollment,'' Commissioner Paula Rogers said.
    Tufts has dropped the New Hampshire market, and more recently, Anthem Blue Cross and Blue Shield of New Hampshire folded its Matthew Thornton HMO into its other coverages. Aetna's withdrawal from the HMO market will be done over six-month period, beginning April 1, Rogers said, to give employers and employees sufficient notice to seek other coverage.
 

Southern California Autism Center Opens; Focus Is Early Treatment, Research
Daniel Yi, Los Angeles Times- 9/27/2001

Benjamin Dynes is a spirited 4-year-old with intense brown eyes and a predilection for stuffed animals. But he didn't start speaking until he was 3, said his mother, Brigitt Minieri, and ceiling fans and airplane noises often stopped him cold. Then, last year, Minieri and her husband, Joseph Dynes, both 39, received a diagnosis: autism. "I was devastated," said the Irvine woman. "When he was 2, the doctor was telling us that because we had a Spanish-speaking baby-sitter, Benjamin might be confused."
    Such tales are too common, said Dr. Pauline A. Filipek, director of an autism center in Orange that opened Wednesday. The signs of autism, especially in mild forms, are often dismissed by pediatricians and other doctors as normal developmental delays, said Filipek, an associate professor of pediatrics and neurology at UC Irvine Medical School. Yet early detection is crucial, Filipek and other experts say, because prompt intervention greatly improves the chances that autistic children will develop social and communication skills into adulthood. The brain is more malleable at a young age and better suited to treatment.
    The new center, called For OC Kids and developed by the UC Irvine Medical Center's Department of Pediatrics, is the first of its kind in Orange County. It will focus on early diagnosis, treatment and research of the perplexing mental disorder, which experts estimate affects as many as one in 250 children worldwide.
    The number of autism cases has soared worldwide during the last two decades, although experts cannot say how much of it is the result of better diagnosis rather than an actual increase. Autism is a neurological disorder characterized by poor communication skills, often causing children to become isolated from the world around them. Nearly 15,000 children with autism are enrolled in programs provided by the California Department of Developmental Services, about three times the number a decade ago. In the Los Angeles Unified School District, the number of students eligible for special education services because of autism has grown more than fourfold, from 623 a decade ago to 2,797. In Orange County, special education students in kindergarten through 12th grade diagnosed with autism jumped from 105 in 1992 to more than 1,000 last year.
    Last year, Filipek and a panel of experts created guidelines for doctors and parents to recognize possible signs of autism in children as young as 2. According to the standards, children should babble or gesture by 12 months and be able to speak single words by 16 months and two-word phrases by 24 months. Hearing and developmental testing are suggested for a child who misses those milestones. If the results continue to suggest autism, a neurological evaluation is recommended. Filipek said most doctors tend to reassure parents whose children are slow to develop skills, saying that they will grow out of it or, in the case of boys, that they usually start speaking later than girls.
    The new center, funded by a $1.8-million grant from the tobacco tax approved by voters in 1998, will also create questionnaires for local doctors to improve awareness about autism. The center offers language and physical therapy designed to help autistic children develop social skills so they can function relatively independently in the world.

Experts Offer Advice on How to Cope With Fears in Aftermath
Jenette Restivo- ABC News- 9/28/2001

More than two weeks after the terrorist attacks on Washington and New York, many Americans still find themselves beset by a host of fears. Some cardiologists have reported seeing more patients with significant elevations in blood pressure, shortness of breath and chest pain. Fearing another attack, some Americans have invested in gas masks, guns, freeze-dried foods, bulletproof vests and parachutes, according to news reports in numerous outlets.
    But are such people taking their fears to an extreme? Mental health experts say such reactions are to be expected in the "anxiety phase" the country is currently in. And other experts say preparations — even seemingly extreme ones — may help some people deal with their worries by giving them the feeling that they can do something to help themselves. "Anything that allows people to have a sense of control is good. It's therapeutic to think that you're having an impact," says Eric Hollander, director of the Compulsive, Impulsive and Anxiety Disorders Program at Mount Sinai School of Medicine in New York. "Uncertainty is very toxic to society."

Fear of Biological Attack
Some people have tried to enlist their doctors in their protective efforts, asking them for antibiotics or vaccine in case of a biological or chemical attack, family physicians tell ABCNEWS. Some doctors recommend such drugs not be prescribed, but others say they may prescribe them in certain circumstances. "It's probably a healthy fear to have, and if it could help someone function, why not?" says Dr. Mark Cucuzzella, assistant professor of Family Medicine at the University of Colorado Health Sciences Center and a major in the Colorado Air National Guard. But Cucuzzella says the decision to prescribe an antibiotic would depend on the individual's state, "If I felt it would make an individual more stable, I would," he says. But he says he "wouldn't give anyone a 60-day supply" and would emphasize how and when to use it.
    While fears of a future attack aren't necessarily unreasonable, it's important to have trust in our leaders, some expert say. "If there's anything we need to do, we can bet we'll be told," says Barbara Rothbaum, director of the Trauma and Anxiety Recovery Program at the Emory University School of Medicine in Atlanta. "It's important to keep in mind what is constructive," she adds. "Sitting around worrying is not constructive." And while it's good to know what's going on, obsessing about all the possibilities is not helpful. "Keeping informed is constructive, but to a degree," Rothbaum says. It's also smart for people to return to doing the things they normally did before the Sept. 11 attacks. "Maintaining your routine is important," says Hollander.

Fear of Flying
The hijackings have left many people afraid to fly — even though statistics show more than 20 times the number of Americans die on the roads than are killed in air and water accidents combined. Rothman says those fears will take some time to subside. "We're in a period of recovery right now," she says. "We have to understand that it's normal to fear flying right now. … After you fly a couple of times, those anxieties will decrease." Rothbaum says people just have to wait until they feel comfortable getting on an airplane; pressuring them to get over it won't help. "We have to give people a lot of leeway now," she says. Just when Americans will feel ready to fly is too hard to say. Certainly time without future incidents will help the healing process, but the decision to take to the skies will depend on the individual. "Everybody needs to do what they feel confident with," says Rothbaum. "When you're ready to fly, you'll do it."

Fear of Living Near a Potential Target
After watching on TV as the World Trade Center towers and a section of the Pentagon collapsed, many Americans have said in numerous broadcast interviews they are apprehensive about working in or even walking by such icons as the Empire State Building, Prudential Tower and Sears Tower and the Golden Gate Bridge. Some people say privately that have even considered moving out of the nation's big cities, while others have already done so.
    But while the anxiety attached with living or working in a big city can be significant, the decision to move or leave a job because it could be the next target should be approached with care, say mental health experts. "It's not a wise idea to make big decisions on an impulse," says Hollander. "It's better to cope with the immediate symptoms and figure out what makes sense in the long run."
    Plus, experts remind us that anxiety is not always a bad thing. "It tells you that something is important in the environment," says Hollander. "It alerts people to a potential threat." Anxiety can help keep us out of harm's way. But when anxiety becomes disruptive, consuming and irrational, it becomes a disorder requiring professional help.  An anxiety disorder differs from normal feelings of fear and nervousness, as the symptoms often occur for no apparent reason and do not go away. They make simple, everyday functioning impossible.
    One way to keep anxiety from disrupting your life, say experts, is to regain control. Actions like giving blood, volunteering, or just readopting your normal routines can help take the edge off. One way not to deal with anxieties, experts say, is through alcohol and drug use. These depressive agents can only give a false sense of control, and will make matters worse.

You're Not Alone
And though experts can't say how much time will elapse before many Americans' anxieties subside, they say people should remember that they're not going through the emotions alone. "It's important to remember that this is a natural, normal response to what happened," says Rothbaum. "I think we were first in shock, then grieving, and now we seem to be either anxious or angry." This, she says, is just "where we are in the process."

Massachusetts Psychiatrist Faces Fraud Charges
Anne Barnard, Boston Globe, 9/28/2001

A Lowell psychiatrist traded prescription drugs for sexual favors, lived with a patient who was a known heroin user, and may have prescribed narcotics to feed the habits of dozens of drug addicts, authorities said yesterday. Dr. Michael Louis Mavroidis, 53, pleaded not guilty yesterday to a single charge of prescribing drugs without a legitimate medical purpose. He was arrested Wednesday and barred from practicing medicine after authorities accused him of coercing a patient into performing sexual acts in return for Xanax and other medications. Mavroidis denied any wrongdoing.
    The allegations stem from a two-year investigation involving the state medical board, Lowell police, and Attorney General Thomas Reilly's Medicaid fraud control unit. The investigation is continuing, but police said it acted this week ''to get him off the street.'' ''It was pretty well known that you could get anything you wanted off this guy,'' said Lowell Police Superintendent Edward F. Davis III. Police say shutting down Mavroidis's private medical practice, on Merrimack Street in downtown Lowell, will make a significant dent in prescription drug abuse in the area. Local treatment facilities in Lowell are prepared to deal with a spike in patients suffering from withdrawal symptoms, said Davis.
    Mavroidis, a board-certified psychiatrist and neurologist, was released on his own recognizance. Through his lawyer, Robert M. Walsh of Manchester, N.H., he issued a statement saying he expected to be vindicated.  ''For many years I have provided medical services to psychiatric patients in Lowell and the surrounding communities,'' he stated. ''Many of these patients have long-term and severe psychiatric illnesses. The charges that have been brought against me are based on a report by a patient with such a long-term illness and a history of encounters with law enforcement.''
    Though the current criminal charges are based on a single incident, medical regulators alleged a broader pattern of abuse when they summarily suspended Mavroidis's license Wednesday, based on the account of a young man addicted to Xanax and heroin, whom they called Patient A. The patient began seeing Mavroidis, the board's complaint says, ''specifically because he had heard on the street that [the doctor] freely issued narcotics prescriptions.'' During their visits, the complaint states, the two would ''talk informally,'' and Mavroidis would provide the patient with Xanax, Ambien, Neurotin, Zyprexa, and other prescriptions, without discussing how they might interact with each other or with heroin. On one visit, according to the complaint, Mavroidis taunted the patient with a bottle of Xanax, making gestures that showed he wanted oral sex. The patient complied and Mavroidis gave him some loose Xanax pills, an exchange that became routine until the visits ended in August, the complaint says.
    In addition, the board accused Mavroidis of living with another patient, itself an apparent violation of medical ethics, since psychiatrists are not supposed to have close personal relationships with patients. ''Patient B'' received many prescriptions between Oct. 2, 1997 and Aug. 31. Last December, police raided the house the two shared and charged Patient B with possession of heroin and a hypodermic needle. The patient pleaded guilty and was sentenced to six months in prison.
    Nancy Achin Sullivan, executive director of the Board of Registration in Medicine, said the case was of particular concern to the board because of the allegation that Mavroidis preyed on addicts, who are vulnerable both because of their dependency and because they fear authorities will not believe them. ''Instead of being held hostage and having their addiction fed, people who have substance abuse problems should be able to go to a doctor and get help,'' she said.

Texas Attorney General Takes on HMO Giants
Polly Ross Hughes, Houston Chronicle- 9/28/2001

AUSTIN -- Texas Attorney General John Cornyn launched an investigation Thursday into payment practices of the state's largest HMOs, saying insurance company disputes with health providers are threatening the health of patients.  Cornyn noted a flood of complaints to his office from doctors and hospitals this year, including health providers saying they have terminated contracts with specific HMOs over allegedly improper payment schemes. "These payment problems may affect patients' access to doctors of their choice and, ultimately, affect patient care," Cornyn said. "No doctor should be forced to choose between practicing medicine and dealing with an unfair payment scheme."
    The Texas Association of Health Plans accused Cornyn of duplicating efforts already under way by Texas Insurance Commissioner Jose Montemayor's office and said it has been "diligently working" with the state insurance department on all issues related to claims and payments. "This investigation further appears to ignore any abuses and problems on the claims side, including physician, hospital and other provider claims fraud ... which are said to account for tens of billions of dollars nationally each year -- dollars that are ultimately paid by consumers," the association's statement read.
    Also on Thursday, a group of lawyers announced they are on the verge of filing a class action lawsuit -- also alleging improper payment schemes -- against one of the largest managed care health insurance companies in Texas.  "When the physician provides service to the members, they have all these difficulties getting paid. There are all these gambits and strategies that the plans use to slow down and deny payment to physicians," said plaintiff attorney Robert J. Provan.
    Gov. Rick Perry earlier this year vetoed a bill that required health plans to make prompt payments to doctors and hospitals. Perry said he preferred solving the problem administratively through new rules and strict enforcement efforts at the insurance department. The governor had no immediate comment on Cornyn's investigation. Montemayor's office earlier this month adopted prompt payment rules to address complaints of health care providers who say their ability to treat patients has been jeopardized by financial woes. The new probe by the attorney general will look into related issues that slow down payments.
    Doctors complain that health plans often "bundle" several services provided into one category, effectively paying for only one service provided. They also are accused of "downcoding," paying for a less expensive procedure than what was provided. Cornyn, a candidate for the U.S. Senate, said if the investigation reveals violations of Texas law, he could seek penalties up to $10,000 per violation, plus attorneys fees and costs.

Anxiety: the Only Certainty
Terrence Monmaney, Los Angeles Times- 9/29/2001

Bridal shops say the weddings are on, but real estate agents say their phones aren't ringing. Thousands of workers nationwide are being laid off, but Mercedes-Benz dealers in Southern California report strong sales. People with no history of depression are feeling low, therapists say, while some patients with diagnosed anxiety disorders are actually doing better than before. More than two weeks after the terrorist attacks, Americans are responding in a spectrum of ways, some seemingly paradoxical, to the uncertainty now settling on the land like an autumn mist.
    Recovering from the shock of this previously unthinkable devastation, the nation faces wide-open questions as U.S. troops mass overseas and the prospect of further terror at home sinks in: What's next? And when will it happen? "There's a real sense of, 'When is the other shoe going to drop?' " said Jerilyn Ross, president of the Anxiety Disorders Association of America and a therapist in Washington. "It's very unsettling."
    Generally, the disaster's effects on Americans' personal plans might be described as partial, with big commitments going forward while major decisions are being put off. That view was summed up by Valerie Largin, relocation coordinator for the Transition Connection in Sacramento. None of the firm's clients has backed out of a planned move, she said, though inquiries about future moves have dropped off. "People who had planned to come are coming, and people who needed to go are going," she said.
    Of all catastrophes, a terrorist strike is perhaps the most difficult to put into perspective, tougher to absorb than conventional war or natural disaster or disease, according to experts in risk analysis, which attempts to explain how people make choices in the face of uncertainty. And the nagging worry about future terrorist killings, which military authorities have said are possible, is not easy to shake. "This is the kind of hazard that's hard to get a handle on because it comes from the intentions of other people, and those are hard to understand," said Paul Slovic, director of the Eugene, Ore., firm Decision Research and a pioneering risk scholar.
    Many researchers and therapists have emphasized that the frustration, fear and sadness that many Americans still feel are healthy emotions. As Boston University psychologist Curtis Hsia put it: "Don't be worried just because you're worried."
    To be sure, people whose loved ones died aboard the hijacked planes or in the World Trade Center or Pentagon have only entered grief's long tunnel. And notwithstanding the outbreak of red, white and blue, a black mourning pall continues to hang over much of the nation. In New York City, poles and walls remain covered with the impossibly poignant wallpaper of fliers bearing the faces of loved ones lost on Sept. 11.
    "People are saying the world is different now," said Harold Pass, director of the outpatient psychiatry clinic at the Stony Brook campus of the State University of New York. There, only 55 miles from the attack site, people are "postponing major decisions like buying houses and cars and traveling," he said. "They want to be with their families. They're hunkering down." One family he knows had been planning a trip to Florida but canceled "because they're frightened about what might happen in the next few weeks."
    Patients he's seeing are experiencing serious anxiety, he said, with disturbed sleep, stomachaches and difficulty concentrating. Yet many who did not lose a loved one don't feel entitled to their grief, he said. But the "worried well are hurting," he said, and their pain is just as real as anyone's. "You don't have to be embarrassed or ashamed you didn't lose someone." Around Washington, the great charred section of the supposedly unassailable headquarters of the U.S. military is only the most obvious wound. The mood in the capital is somber, Ross said, with otherwise well-adjusted people dogged by "a sort of low-level depression and malaise."
    Hsia, at Boston's Center for Anxiety and Related Disorders, said people around the city, where the two flights that were crashed into the World Trade Center towers originated, "are more anxious, really nervous, and they're unsure of what happens next." Several therapists said they have observed a phenomenon that may surprise the nonexpert: Some patients long disturbed by free-floating anxiety or self-doubt say they are less troubled.
    Gary Emery, a Los Angeles-based cognitive therapist who espouses swift treatments of depression and other disorders, said some of his clients have suddenly improved. "It put everything into perspective and their own problems seemed less serious," he said. "The cause of many emotional problems is patients turning inward, and these events forced people to turn outward." Also, the devastation and terrible losses have probably awakened in many people an often dormant appreciation for life. "People may actually have some gratitude that they didn't have before," he said.
    Ross, in Washington, said she has had fewer new patients in the last two weeks, presumably because "people who are fearful now feel it's normal to be afraid." But among some clients in their 20s and 30s, she's observed for the first time signs of a despair that once marked an earlier generation worried about nuclear annihilation. "I'm seeing some existential anxiety among my younger patients, who are asking themselves, 'What kind of a world am I bringing my children into?' " She said a woman she counsels has begun wondering if she should back out of her engagement to be married. "I said, 'This is not the time to decide.' People who are worn down mentally and physically shouldn't be making a decision now that will affect them permanently."
    A crude measure of the atrocity's inroads into the American psyche is how people think about big decisions such as getting married or buying a house. The evidence on that front is mixed. Though an uncounted number of weddings were postponed because of travel restrictions immediately after the attacks, future brides appear to be on track. "Nobody's changed their plans," said an assistant at Cinderella's Bridal Salon in Topeka, Kan. "Nothing's changed so far," said the Condon Bridal Boutique in Charleston, S.C.
    Contrary to predictions that the attacks and the slumping economy might steer consumers away from substantial purchases, some Mercedes dealers, for instance, are thriving. "We're having a good month," said sales manager Sam Haidar at Calstar Motors in Glendale. At Fletcher Jones Motor Cars in Newport Beach, sales manager Chriz Lanza also said business was very good last weekend. "Life goes on," he said when asked why.
    In real estate circles, brokers say deals in escrow aren't falling through, but few customers are starting a housing search. "We haven't lost any transactions," said Stanley Shapiro, president of the Century 21 office in Beverlywood, "but we haven't opened any new ones either." A more sober view was expressed by Fred Saenz, manager of a Remax office in the mid-Wilshire district. "Nobody wants to purchase a big-ticket item during this situation," he said.
    Making major decisions in this tumultuous time is greatly complicated by the difficulty of evaluating current dangers and predicting trends, experts agree. "Risk assessment doesn't do that well when the hazard is new and we don't have much information to go on," Slovic said. In the best of times, people aren't necessarily good at evaluating hazards, researchers say. Studies by Slovic and others have shown that Americans consistently underestimate the risk of some dangerous activities, such as smoking cigarettes, and dramatically overestimate others, such as living near a nuclear power plant. Among the reasons for such skewed perceptions, researchers say, is that people tend to go easy on serious risks that are known, voluntary and optional. By contrast, they have strong emotional reactions against involuntary risks with possibly serious consequences even if the odds of harm are exceedingly small.
    In that context, researchers say, the new risk that the public is now concerned about--hijacked aircraft used as missiles--is off the charts. That may help explain why many people are avoiding airline travel, even though analysts suggest that the overall odds of dying in an airline crash remain at roughly 1 in several million.
    Similarly, psychotherapists and decision researchers caution against dwelling on news coverage of the attacks, especially images of the fiery crashes into the World Trade Center towers. Mentally replaying those images may make a recurrence of the atrocity seem more likely than it really is because of the so-called exemplar effect, said decision researcher Jay Koehler of the University of Texas. That is like first-year medical students suddenly fearing that they will contract the exotic diseases they are studying, even though their chances of doing so are negligible.
    Another factor adding to anxiety, Koehler said, is embedded in the notion that trusted airline security systems failed, triggering sensations that researchers say are part of feeling betrayed. To Koehler, that helps explain why Americans appear to be driving more, even though driving is more hazardous than flying. Studies by Koehler and others have found that people willingly take on an added risk from the environment if they believe that the device supposedly protecting them won't backfire.
    In one recent study, researchers gave people a hypothetical choice of a vaccine that was perfectly safe but offered less protection or another one that offered maximum protection but also carried an extremely small risk of causing injury. They found that people overwhelmingly favored the safer vaccine, even though the choice meant that they were more likely to become ill from the targeted disease.
    Koehler is optimistic that as memories of the attacks fade, anxieties will dissipate and behavior will become more rational. "We're all thinking now about terrorists and hijacking," he said, "but in a few years this will recede into the background and we'll go back to something closely resembling our regular lives." He spoke not only as a researcher but as a witness to the earthquake that devastated the Bay Area in 1989, when he was a Stanford graduate student. He recalls being afraid to drive across the Bay Bridge--a common fear at the time. "I was obsessed by that," he said. "But nobody worries about driving across the bridge now."
    Others are not as sanguine about the future--or remain wary of making predictions in the turmoil of the moment. For them, the attacks are too fresh for them to be comfortable with old routines or plans made before Sept. 11. Hilaire Dallo, controller of the Mayflower moving company's Los Angeles office, said he just canceled a mid-October vacation in France--and lost his $250 deposit. "It's just too unstable for me," he said. "We don't know what the government is going to be doing. Everything is in limbo right now. It's too uncertain for me to get on a plane for 12 hours."

New Drug-Offender Program Drawing Unexpected Clients
Fox Butterfield, New York Times- 9/29/2001

LOS ANGELES--Christine Tello, her hair dyed flamboyant pink, mumbled as she tried to explain to Judge Stephen Marcus why she had not obeyed his order to report to a residential drug treatment center. She was supposed to have been one of the lucky first drug addicts sentenced under Proposition 36, a voter-backed initiative that mandates treatment instead of prison for first- and second-time offenders who use or possess drugs. But Ms. Tello told the judge, "I forgot, I lost the paper," and then added, "I didn't like the place."
    It has been less than three months since the law took effect on July 1, and there are no statewide statistics on its effectiveness. But cases like Ms. Tello's concern many judges, prosecutors and drug treatment providers. Some of the problems that critics of Proposition 36 predicted have not arisen. California's treatment centers have not been overwhelmed, because far fewer drug offenders than anticipated have pleaded guilty under the new law. But among those who have sought treatment, there have been far more severe addicts than anyone expected, with the added complications of mental illness, homelessness and unemployment.
    "One of the lessons we are learning is that we are getting a lot of people who are so addicted they just aren't ready for treatment," Judge Marcus said in his courtroom in the vast downtown Los Angeles County criminal courts building. "Their addiction is so powerful it controls everything in their lives." In Los Angeles County, which accounts for one-fourth of all California drug arrests, about 30 percent of offenders who pleaded guilty under Proposition 36 have since had bench warrants issued for their arrests because they failed to show up at treatment centers or did not return to court for a review of their progress, Judge Marcus said. "That is an ominous sign in such a short time," he said.|
    Similarly in Sacramento County, planners projected that 7 out of 10 offenders under Proposition 36 would need minimal treatment because they were casual drug users with supportive families or jobs. Instead, county officials say, more than half have turned out to be hard-core addicts needing maximum treatment.
    Supporters of Proposition 36, which won 61 percent of the vote, contend that the law is working well. "The basic goals are being met," said Bill Zimmerman, executive director of the Campaign for New Drug Policies, the advocacy group in Santa Monica that sponsored Proposition 36. "The key thing is, people who formerly were being incarcerated are now getting treatment," Mr. Zimmerman said, so the criminal justice system is being forced to change. And Mr. Zimmerman insisted that the high numbers of arrest warrants did not bother him. "The doctors tell us that we can't expect more than one-third of these serious addicts to recover," he said. "That's a very low number, but it is a lot higher than the number who were being cured in jail or prison without treatment. And there are the other not-so-serious addicts we can really help."
    The success of Proposition 36 is important beyond California, the nation's most populous state. Mr. Zimmerman's group has been trying to get similar initiatives on the ballot for the November 2002 elections in Florida, Michigan, Missouri and Ohio. Supporters of such measures think the political winds are shifting their way after a 20-year trend toward ever-tougher criminal laws. This year more than half a dozen states have quietly rolled back some of their strictest anticrime measures, including those imposing mandatory minimum sentences and forbidding early parole. The new laws reflect an era of falling crime, budget crunches and the skyrocketing cost of running prisons. Among the states that have changed their laws as the prison population nationwide has quadrupled over the last two decades are Connecticut, Indiana, Louisiana, Mississippi and North Dakota.
    One of the main selling points of Proposition 36 was that it promised to reduce the number of inmates in California's costly prison system, the nation's largest, and it may be succeeding. As of mid-September, the number of inmates in California has fallen since July 1 by 1,900 to 159,000 said Dan Carson, an analyst for the nonpartisan Legislative Analysts Office. Not all the decline is attributable to Proposition 36, Mr. Carson said, but the drop is still significant in a state that in 1994 passed the nation's toughest three-strikes law, mandating sentences of 25 years to life for third-time felony offenders.
    In Los Angeles, county officials had originally projected that an average of 80 people a day would accept sentencing under Proposition 36 and then be sent to treatment. But only about 45 defendants a day have done so, said David Davies, the chief of adult field services for the Los Angeles Probation Department. Mr. Davies believes the main reason for the low number is that many defendants eligible for the new law--those charged only with drug use or possession and no related crime like assault or robbery--are choosing to plead guilty under the old law, where the sentence may be simple probation or a few weeks in jail. This is especially true for those charged with a misdemeanor, Mr. Davies said.
    If they plead guilty under Proposition 36, they will be given treatment, but it could last for months and they would be on probation for three years. If they violate that probation by skipping treatment more than twice or failing a drug test twice, they could be sent to prison for years, said Mike Demby, the deputy head Los Angeles public defender. "We are now concerned they could have more exposure under Proposition 36," Mr. Demby said. "So there are cases where we would advise our clients not to plead under Proposition 36 and stay with the old law, even though we want people to get into treatment."
    The unexpectedly high proportion of severe addicts accepting Proposition 36 comes in part from a decline in the numbers of people charged with lesser crimes, officials say. But it also represents the reality of drugs and the streets, said Mr. Davies, the probation official. The average person pleading guilty under the new law has had 16 previous arrests, Mr. Davies said. "this is a tough group," he said. "They are not teenagers who just experimented with drugs for the first time."
    One of the biggest concerns for everyone involved is whether there is enough money for treatment. Proposition 36 appropriated $120 million a year for the entire state, which under a complex formula translates to only $2,000 per defendant in Los Angeles, Mr. Davies said. Because the cheapest residential treatment costs $75 a day in Los Angeles, that amounts to less than a month of treatment.
    Studies have shown great success even for hard-core addicts in residential treatment if they stay for at least 12 to 18 months, said Liz Stanley Salazar, regional director for Phoenix Houses of California, a major drug treatment program. But the immediate problem, Ms. Salazar and others like Judge Marcus say, is that there is no enforcement mechanism to guarantee the defendants like Ms. Tello, whom the judge ordered temporarily held in the county jail, will go from the courtroom to assessment centers to treatment and then back to court for review. The county is huge, and many defendants lack cars to get them to their treatment center, Judge Marcus said. In the end, the judge said, treatment that is not well financed, and not backed by legal sanctions, may be nor more effective in curing addiction than prison itself.

Anxiety Over Attacks Causing Children to Conjure 'Revenge Fantasies'
Martha Irvine, Associated Press- 9/29/2001

A few days after planes strike the World Trade Center and the Pentagon, a 3-year-old girl on Long Island begins sleepwalking and muttering. Her parents listen to her muddled words: ''My don't like the bad people. I will hit the bad people with a hammer,'' she says. Anger and anxiety brought on by the Sept. 11 terror attacks have put revenge on the minds of many young people, even those who've been told little about the devastation but still sense something's very wrong.
    For those who know more, the revenge fantasies can get quite graphic. Nicholas Sands, a 6-year-old from Los Angeles, is still so angry that he wants to track down terrorists and ''cut off their arms and legs so they die.'' ''That would be really cool,'' says Nicholas, whose father's cousin was among those killed when American Airlines Flight 11 hit the World Trade Center. A 10-year-old boy from Swartz Creek, Mich., says he wants to ''shoot Osama bin Laden in the head with a 20-gauge shotgun and then drop him from a plane into the Pacific Ocean so he does a belly flop.''
    Hearing such talk can be disconcerting to parents, and even to the children themselves. But experts say revenge fantasies are generally a normal response. ''Let's face it. Half of the adult population is walking around spouting off this kind of thing in diners and living rooms across the country,'' says James Feldman, national director of public education for KidsPeace, a nonprofit organization that deals with children in emotional crisis. He and others say young people may be even more likely than adults to come up with revenge fantasies because they feel particularly powerless, not to mention scared and insecure. The contents of those fantasies tend to come from the children's surroundings, or sometimes TV and movies.
    Some young people are just venting. That's what 15-year-old Wesley Tolson says he was doing when he sent his mother an e-mail suggesting the U.S. military ''nuke'' all Middle East countries that don't support the United States and then seize their oil assets. ''But I was just joking around,'' says Tolson, who lives in Houston. In reality, he says, any plan for retaliating ''is a tricky situation, and a lot of kids see that.''
    Robert Billingham, a professor of human development and family studies at Indiana University, says spouting off, especially for boys, is a primal response. He compares it to the ''banging on the chest and hooting and hollering'' that apes do when they feel threatened. ''The danger is that if you do it in a peer group, it's kind of like throwing gasoline on a fire,'' Billingham says. He says fear of that ''mob mentality'' prompted officials on his Bloomington, Ind., campus to take swift action after hearing that Middle Eastern students were being verbally harassed after the attacks.  ''We went into our classrooms and just lambasted the stupidity of this behavior and said 'You will not do this,''' Billingham says. ''I think the students were surprised, but it also seemed to work.''
    When it comes to younger children, he and Feldman say it's first important to assure them their feelings are normal and then to calmly discuss the underlying anxiety and anger. They say it's also important to talk through alternatives to the fantasies, and to remind them that the government and the adults around them are working to keep them safe.  ''We've been lauded by the world for staying calm, thinking things through, looking at options, trying to reason with people,'' Feldman says of the government response. ''That's a great example for kids.''
    Still, as the military prepares, experts say children are only likely to have more questions. Carol Gifford, a mother in Lansdale, Pa., says that's true of her 7-year-old daughter, Elizabeth Bloom. Nearly three weeks after the attacks, Elizabeth still fears that her school will be bombed. She's also worried about her 18-year-old brother, who's a freshman at American University in Washington. But Elizabeth is also mad and has her own ideas about punishing those responsible for starters, taking away their ''guns and stuff and all their bombs,'' she says. ''And then we should put them someplace so they can't destroy anything for a really long time for like a year or two because that would keep them out of trouble for a while.''
    On the Net: KidsPeace sites: http://www.kidspeace.org   and  http://www.teencentral.net

For Haunted Survivors, the Towers Fall Again and Again
Andrew Jacobs, New York Times- 9/30/2001

Inez Graham is at war with her memory. She spends her days sobbing and afraid, battling images of flames and falling debris and trying to quell the soundtrack of screams in her head. A ringing phone, a plane overhead or a passing truck make her hunker down in fear. She refuses to go outside. She tells friends not to visit and says the smell of smoke, like some unseen phantom, lingers around her home in Newark. She tries to stave off sleep, but when she dozes off, the nightmares are always the same. She is back at the World Trade Center, barefoot and breathless, trying to outrun the tidal wave of concrete and glass. But in this version, her daughters are with her, and she cannot save them. "I want the old Inez back, she said, giving in to another round of tears. "But I just can't get that day out of my head."
    Those who escaped from the World Trade Center will never get that day entirely out of their heads. But two and half weeks after the unfathomable happened, there is little uniformity in the ways that survivors are coping. Many, like Mrs. Graham, 40, are utterly traumatized, unable to imagine anything resembling their lives before the disaster. Others, like Lynn Simpson, a 50-year-old who worked for a public relations company, find themselves rattled, but spiritually intact in a way even they do not entirely understand. Ms. Simpson, who made her way through the wreckage of the 83rd floor of 1 World Trade Center and then was enveloped by the storm of falling rubble, says she feels remarkably whole, although the bruises on her arms and legs have yet to fade. "I was in a state of shock for a few days, but I'm very happy to be alive," she said. "Right now, I'm overwhelmed by the feeling that life is precious."
    Those who specialize in trauma-related disorders say symptoms can sometimes take weeks or even months to emerge. "Just because someone isn't feeling stressed right now doesn't necessarily mean they won't have trauma symptoms two months from now," said George Bonanno, a clinical psychologist at Columbia University who studies grief and trauma. But experts say they have no way of knowing who will heal and who will be plagued by chronic unease, although studies suggest that fewer than 25 percent of those who escaped will experience symptoms of traumatic stress three months from now. There is, however, a wild card: the continuing threat of further attacks, some psychologists say, may exacerbate and prolong the distress. "This is uncharted territory," said Dr. Russell J. Kormann, a post-traumatic stress specialist at Rutgers University's Anxiety Disorders Clinic. "We don't have an idea who is going to be affected and to what degree. It's something thousands of people will be dealing with for years to come."
    Mrs. Graham cheated death without physical injury. She and her best friend, Dee Howard, both employees of the Port Authority of New York and New Jersey, made it down 61 flights of stairs just minutes before the first building cascaded down around them. At a time when thousands of people are mourning their dead, friends tell them to be thankful they are alive. But being survivors has brought them little comfort. "People say, 'Don't given in to the fear, don't let evil win,' all these cliches, but they don't know what I'm going through," said Ms. Howard, 37. She had lived with her fiancé in Irvington, N.J., but lately she has been staying with her parents in East Orange, too petrified even to venture out on their terrace. "I'm trying to get better, but I just can't."
    Others are coping with similar feelings of distress. Robin Seaberry, 38, one of a handful of people who escaped from the 101st floor of the south tower, cannot step into elevators or venture into the subway. "I'm afraid of everything, even my own kids," she said. "I can't eat, I can't sleep. And when I close my eyes, I see faces on fire. I feel like I'm going crazy." Some, like Toshiko Homma, have yet to speak about September 11th. Mrs. Homma, who was badly burned on her face, legs and hands as she tried to escape from 1 World Trade Center, said watching news footage from that day makes her physically ill. "I'm sorry, I can't talk about this anymore," she said from her home in Queens before abruptly hanging up the phone.
    Ash Mead Pollard, 45, an asset manager for Deutsche Bank who helped rescue Mrs. Homma, describes himself as a "tough guy." But in the past two weeks he has been confronting an aspect of himself he never knew. He jumps out of bed when he hears an airplane, the rumble of the subway makes him shudder and he can no longer listen to the music he once adored. He is so jarred by noise that he disassembled all the telephones in his temporary office and used tape to muffle their rings. Last week, as he drove over the Whitestone Bridge, he panicked when the cars in front of him came to a sudden halt. Imagining a bomb on the bridge, he turned his car around and took a lengthy detour to get to his home in the Bronx. "I usually handle stress well, but I feel like I'm losing control," Mr. Pollard said. He escaped the collapse of the first tower by ducking inside a nearby firehouse, only to be enveloped by debris from the second tower the moment he emerged.
    Others say they are coping well. Many of those who have regained their footing say they never imagined their lives were in danger. Adam Mayblum, 35, who worked for a small investment firm in 1 World Trade Center, said that throughout his descent from the 87th floor he assumed the worst was over. Since then, he has cried a few times (he lost a close colleague) and he is still unnerved by abrupt noises, but Mr. Mayblum said he was ready to move on. "It's been much harder on my family than it's been on me," he said, though he alter questioned whether his psyche had escaped unharmed. "Maybe it hasn't dawned on me yet. Maybe I haven't absorbed the calamity of it yet."
    For many survivors, the anxieties and troubling flashbacks are mixed with guilt. Teresa Veliz, 31, an office manager for a software company, is haunted by the memory of an elderly man, too exhausted to move, who sat down in the stairwell as she hustled by. "I feel bad because I don't know if he made it out," she said. Many of those who escaped the buildings cannot shake the image of firefighters ascending the stairs to their deaths. Others feel guilty for not helping friends and co-workers, less nimble or less lucky, who perished. Nearly everyone is grappling with enormous grief.
    For some, the losses are too much to process. Richard Fern, 39, a technical support manager for Euro Brokers, started working again at the company's New Jersey office, but he cannot ignore the absence of 60 colleagues who didn't make it out of 2 World Trade Center. A cousin who worked at the trade center died as well. "I've been really busy, to the point where I can't really dwell on what happened," said Mr. Fern, one of only three people who escaped from the 84th floor. "I guess that's a good thing. Anyway, I'm not very good at showing my emotions."
    Grief counselors have been telling survivors to talk about their experiences, but Dee Howard and Inez Graham say each retelling brings on an unbearable rush of panic. "Everyone wants to hear the tragic details, but they don't really care how I feel," said Ms. Howard, who like Mrs. Graham is taking anti-anxiety medication. "They just want me to get on with my life." Still, both women have come a long way since September 11th, when they emerged from a thick cloud of dust, holding hands, barefoot and clearly in shock. A head-to-toe coating of ash made them look like Kabuki actors, their intricately woven braids cemented in place. Ms. Howard was mute. The only thing Mrs. Graham could say was she needed to get home to Newark, though the two of them were walking toward Brooklyn.
    Ten minutes earlier they and a third woman had been sitting in an ambulance at the edge of the World Trade Center, terrified, soaking wet and gasping for air, their lungs assaulted by smoke and soot. But just as a paramedic prepared to give them oxygen, the building began to topple. "Nez! Run! Ms. Howard shouted, and the two stumbled onto Church Street. Ms. Howard still regrets not dragging along the other woman, a stranger who remained inside the ambulance, which they later learned was destroyed by falling debris.
    The two made it a few yards before being overcome by the suffocating blackness. After briefly losing one another in the pandemonium, they vowed not to let go of each other's hands. On Wednesday, the two held hands again for the first time since that day. Until a reporter brought them together, they had been too fearful to travel the three miles that separated them. They hugged each other tightly, Mrs. Graham trying to comfort her friend, who could not stop crying. "It's going to be all right," Mrs. Graham said. "It's going to be all right." After a few minutes, Ms. Howard let go, stepped back and dried her eyes. The two women looked at each other, and for the first time in two weeks, they laughed.

Vermont Statistics Show More Young People Seeking Treatment for Heroin
Associated Press, 9/30/2001

BURLINGTON, Vt. -- More young Vermonters are seeking treatment for heroin addiction, according to a state survey. Statistics compiled by the Department of Health show people between the ages of 18 and 24 are the fastest growing group of people seeking clinical treatment for heroin use in Vermont. The state also has a higher than average number of young people who have tried the drug. Three percent of Vermont students in grades 8 through 12 said they have tried heroin, while an average of 2 percent of students across the country acknowledged they've used the drug.
    ''Unfortunately, that is the age group that is getting involved with this drug,'' said Dr. Michael Zacharias, the clinical director at Maple Leaf Farm, an alcohol and drug treatment center in Underhill. ''This is an age group that, psychologically and emotionally, is very into the moment. And heroin is a drug that takes so much care of the moment.'' The number of young people in treatment for heroin use increased from 22 in fiscal year 1997 to 128 in the last fiscal year, according to the Department of Health. In six months between July and December 2000 111 people between ages 18 and 24 were admitted to treatment for heroin use.
    ''It's remarkable,'' said Dr. Lisa Marsch, a psychiatrist and professor at the University of Vermont. ''The number of young kids using this drug has been steadily climbing.'' In the last 10 years at the UVM's substance abuse treatment clinic, the number of young people seeking treatment for heroin addiction has increased dramatically. In 1990, no one under age 25 was treated at UVM for heroin use, she said. Now 60 percent of the 40 or so people being treated there are younger than 25.
    Tom Perras, director of the state's alcohol and drug abuse programs, said young people who try heroin often come from families with a history of alcohol or drug abuse. They likely drink alcohol and have tried drugs, he said.  Marsch, who heads a new adolescent treatment program, said teen-agers likely to use heroin have typically been drinking alcohol or smoking cigarettes since age 9 or 10. Most are males and are white, she said.

Late-Onset Alcoholism: Older People Who Are Isolated, Clinically Depressed Face Risk
Irene S. Levine, New York Times- 9/30/2001

Although the stereotype of an alcoholic generally is one of an unkempt, down-and-out street person, researchers and clinicians are discovering an "invisible epidemic" of drinking problems among older men and women. Some older people have been drinking excessively for most of their lives; others use relatively small amounts of alcohol but mix alcohol with prescribed medications in harmful ways; still others develop alcohol problems late in life.
    The U.S. Department of Health and Human Services defines late-onset alcoholism as a drinking problem that begins after age 60. This can develop for a variety of reasons. Listings in their address books may be dwindling as friends and family move or pass away. Certain health problems may interfere with their ability to get around. Little by little, almost without realizing it, a person can easily become isolated and lonely and seek comfort from a bottle.
    "Older persons who live alone appear to be at greater risk for alcoholism," said Dr. Barnett Meyers, professor of psychiatry and clinical epidemiology at Weill Medical College of Cornell University in White Plains, N.Y. A glass of wine at lunch and then again at dinner, or a few bottles of beer in front of the television, may seem like a "quick fix" -- to relax, to get comfortable, to numb the pain of loneliness, to get a good night's sleep or to re-create warm memories of times once spent with a spouse or good friend.

An invisible epidemic
A recent article in the journal American Family Physician estimates that as many as 17 percent of adults age 60 or older may have a drinking problem. One study of seniors ages 60 through 94 found that 62 percent consumed alcohol and that 6 percent had more than two drinks per day. Reports from the National Institute on Alcoholism and Alcohol Abuse suggest that the prevalence of drinking problems in nursing homes also is high. These figures compare with an alcohol-abuse rate of 7.41 percent in the general population, according to the institute.
    But the problem of alcohol abuse by the elderly is largely hidden, because it occurs behind closed doors. As opposed to the club and bar settings that attract youth, drinking among seniors takes place in private homes and apartments and at retirement communities, where drinking at social gatherings often is the norm. Because many seniors don't have to get to work at a specified time and do not have the same number of social ties as younger people, it is a problem that often goes unnoticed by family members, close friends and even professionals.
    Although older people generally visit their family practitioners several times a year, physicians often fail to look for or recognize drinking problems. Some doctors simply aren't attuned to the symptoms of problem drinking and may erroneously attribute falls, mental confusion, traffic accidents and other problems resulting from alcohol use to illness or to the aging process itself. Even when physicians suspect that an older person has a drinking problem, doctors may be too embarrassed or too busy to do anything about it. In some cases, they are simply too forgiving.

Hiding the problem
Some seniors hide their alcohol use from their doctors. "Just as in younger people, denial is a factor that makes it hard for physicians and family members to engage an older person with a drinking problem into treatment," said Dr. Michael Finkelstein, an internist and senior vice president of medical affairs at Northern Westchester Hospital in Mt. Kisco, N.Y. "And even when they are asked directly, patients may not realize that their drinking is truly a problem."
    Clearly, the combination of age, alcohol use, medical problems and prescribed medications can result in serious trouble. For this reason, the same standards used to assess "problem drinking" in younger individuals cannot be used for individuals over age 60 who are more likely to have chronic health problems. For example, alcohol can exacerbate existing hypertension, heart problems, diabetes and memory lapses. Heavy drinking exacts an even worse toll. It can permanently damage the brain and central nervous system as well as the liver, heart, kidneys and stomach. When mixed with prescribed and over-the-counter medications, alcohol greatly increases the potential for adverse effects that may even prove deadly.

What is too much?
To determine whether an older person's drinking is really a problem, Meyers suggests that physicians, family members and patients themselves question whether the drinking behavior is atypical for that individual. If it is, it may be symptomatic of attempts to "self-medicate" an untreated medical or psychiatric condition, as is often the case with people who are depressed.
    Meyers described recent visits from bright, independent and accomplished patients who spontaneously asked whether their own alcohol use was problematic. One 70-year-old widower became depressed and had difficulty falling asleep. This occurred soon after his only daughter, with whom he had been quite close, got married and moved to another part of the country. The patient told Meyers, "When I get lonely, I can't get to sleep without having a glass of wine or two before going to bed." Another 75-year-old patient reported having trouble falling asleep. She began to drink within months after the loss of her husband and asked, "Doctor, is this a problem?" A 70-year-old retiree admitted that he was having "a drink or two during the day" for the first time in his life while his younger and more socially active wife was away from home. This was a new pattern for him, and he volunteered the information with some concern that he might be "turning into an alcoholic."

Talking with doctors
"Although this self-confessional attitude may be more common in the office of a psychiatrist," Meyers said, "all physicians who treat seniors should communicate an open and inquisitive attitude that allows for a discussion of drinking behavior. "Answers to such questions, however, are not always clear-cut," Meyers said. He believes that drinking should not be discouraged based on age alone. "It isn't appropriate to infantilize older people," Meyers said. "When a patient suddenly begins drinking late in life, we need to work together and view the drinking as a signal. "In addition to the potential for alcohol abuse, there may be other underlying problems such as depression. The establishment of an open relationship with a physician--that allows for monitoring alcohol consumption, providing guidelines and using additional interventions that may be needed--is a critical step in the management of these patients."
    The Department of Health and Human Services recommends that all 60-year-olds be screened for alcohol and/or prescription drug abuse by their primary-care doctors as part of a routine physical. Rescreening should occur as the individual undergoes key life transitions. Doctors and patients need to keep in mind that regardless of age, when recognized and detected, alcoholism is a treatable illness. People who are socially isolated or clinically depressed are particularly vulnerable and in greatest need of such vigilance by their doctors.

Warning signs
The National Institute of Aging has identified several signs to help determine if someone has a drinking problem:
- Drinking to calm nerves.
- Losing interest in food.
- Lying about or trying to hide drinking habits.
- Drinking alone more often.
- Getting drunk more than three of four times per year.
- Needing more alcohol to get "high"; feeling irritable when not drinking.
- Having medical, social or financial problems as a result of drinking.

Cocaine's Effect on Brain Brings Nearly Instant Addiction
Ronald Kotulak & Jon Van, Chicago Tribune- 9/30/2001

The reason some people become addicted to cocaine after a brief exposure is that the narcotic has an uncanny ability to alter brain-cell connections, according to researchers at the University of California at San Francisco. The pattern of activity produced by a single injection of cocaine lasts 5 to 10 days and is similar to the kinds of changes involved in learning and memory, Dr. Antonello Bonci reported in the British journal Nature. The experiments were conducted in rodents. "The significance of this finding is that a single dose of cocaine usurped a cellular mechanism involved in a normally adaptive learning process, which may help to explain cocaine's ability to take control of incentive-motivational systems in the brain and produce compulsive drug-seeking behavior," he said.