Noteworthy News Articles on Mental Health Topics, December 9-13, 2003



Mental Health Experts Can Often Tell Defendant's Tale
Henri E. Cauvin, Washington Post- 12/9/2003

CHESAPEAKE, Va., -- Lee Boyd Malvo told his story Monday without having to take the witness stand. From the racially charged speeches he was directed to study to the violent video games that he was encouraged to play, Malvo's world after he met John Allen Muhammad came to life -- albeit as told by the court-appointed psychologist who examined the teenager. Unlike other witnesses, the mental health experts who examined Malvo can testify about what he said to them. Known as hearsay, such secondhand testimony generally is inadmissible because the other side cannot cross-examine the source of the information. But Malvo's attorneys have argued that he was brainwashed by Muhammad, and many of the experts they have lined up to bolster their insanity argument are not bound by the limitations that constrain other witnesses. Not only can mental health experts offer opinions and conclusions, they can also explain the basis for those opinions and conclusions.
    Indeed, on his first full day on the stand, the psychologist, Dewey G. Cornell, a University of Virginia professor and an authority on juvenile crime, took the court on a riveting journey into the mind of Malvo that could prove pivotal. Juries, especially in a case as emotional as this, want answers -- ideally, from the defendant. But criminal defendants rarely take the stand. So, unless the defense attorneys decide at the eleventh hour to allow Malvo, 18, to testify, the answers, if they come at all, will have to come from elsewhere.
    With Cornell's testimony on Monday, the defense began providing the most detailed answers yet. Some of them, such as the abuse they say Malvo suffered at the hands of his mother, might elicit sympathy from jurors. Others, such as the revelation that, as a child in Jamaica, he attacked and sometimes killed cats, could disturb or frighten the people deciding his fate. Ultimately, they hope the testimony can provide the context for what happened during the October 2002 sniper shootings.
    So not only could Cornell provide such information as the influence of the movie "The Matrix" on Malvo, but he also could show a clip, playing four especially violent minutes from the science fiction film that stars Keanu Reaves and Laurence Fishburne. And when Cornell wanted to explain to the jury the types of combat-oriented video games that Malvo learned to play under Muhammad's influence, he did more than talk. On the big screen mounted on the wall across from the jurors, he let them see for themselves just how graphic and violent the games can be.
    After objecting heatedly and repeatedly to many of the attempts to introduce hearsay evidence last week, Fairfax Commonwealth's Attorney Robert F. Horan Jr. objected less frequently Monday. When he did, he tried to remind the jury that Cornell was simply relating Malvo's account of events, which might not be the truth. "It's very hard to keep stuff out when you're a prosecutor and there's a mental health defense," said David I. Bruck, the South Carolina defense lawyer who used a mental health defense to persuade a jury to spare the life of Susan Smith after she admitted killing her two children.
    The psychologist's testimony was perhaps the most compelling evidence in the trial so far, and it underscored the importance of the insanity defense. Without it, the defense case would have been dramatically different, shorn of the stories about Malvo's rocky childhood and encounters with Muhammad. Many defense attorneys say that in arguing insanity, the defense team does not actually expect Malvo to be found not guilty. But such a defense allows the lawyers to present evidence that would otherwise be admissible only during a sentencing phase -- after a jury had reached a guilty verdict. "A death penalty defense attorney who waits for the penalty phase to begin to explain what led to those acts may have waited too long," Bruck said. "A jury's view of the defendant can harden like concrete, long before the defense gets to present mitigation."
    On the stand, Cornell told the jury that he had been appointed by the court as a mitigation expert, to examine Malvo and to testify during the penalty phase. But that changed when the defense said in October it would argue that Malvo was not guilty by reason of insanity.
    As favorable as the evidence might have been to the defense on Monday, the expert exception cuts both ways: When the prosecution presents its own mental health experts, they, too, will have examined Malvo and they, too, will be similarly unconstrained by the hearsay rule. "That's certainly the flip side," said Todd E. Edelman, who teaches criminal law at Georgetown University Law Center. "All the contradictory things that Malvo said. All kinds of things that reveal unsavory attitudes."
    Whether Malvo will take the stand, either during the defense case or during the penalty phase, is unknown. Until they were barred last week from speaking to the media, Malvo's attorneys said any such decision would not be made until the end of the defense case. Many defense lawyers say that an argument can be made for Malvo taking the stand, but they would nevertheless be stunned if it happened. "There's so much at risk," said Steven D. Benjamin, a Richmond defense lawyer. "There's so much they stand to lose if they put Malvo on the stand."



Humanity? Maybe It's in the Wiring
Sandra Blakeslee, New York Times- 12/9/2003

Neuroscientists have given up looking for the seat of the soul, but they are still seeking what may be special about human brains, what it is that provides the basis for a level of self-awareness and complex emotions unlike those of other animals. Most recently they have been investigating circuitry rather than specific locations, looking at pathways and connections that are central in creating social emotions, a moral sense, even the feeling of free will. There are specialized neurons at work, as well — large, cigar-shaped cells called spindle cells. The only other animals known to have such cells are the great apes. These neurons are exceptionally rich in filaments. And they appear to broadcast socially relevant signals all over the brain.
    The body, it turns out, is as important as the brain. Dr. Antonio Damasio, a neurologist at the University of Iowa Medical Center and the author of the book "Looking for Spinoza: Joy, Sorrow and the Feeling Brain," has pioneered the argument that emotions and feelings are linked to brain structures that map the body. From human social emotions, he said, both morality and reason have grown. Similar ideas were advanced in simpler form more than a century ago. Now, researchers can point to specific aspects of brain structure that suggest how our forebears came to develop complex social emotions, culture and other quintessential human behaviors.
    The search for brain differences has not been easy. Mammalian brains are extraordinarily similar. All contain an outer rind, or cortex. The human cortex, where intelligence lies, is simply a lot bigger than that of other creatures given the human body's size. But the size of the brain is not everything. One important feature of more complex brains is that they are rich in circuits — linked cells from various parts of the brain that become active at the same time.
    Imagine a Christmas tree with millions of lights, each representing a cell group. The thought of dogs would activate a small set of lights. The thought of a beloved dog that died last year would activate some of the same lights plus others. The thought of a cat would activate yet another set with some overlap because animals are involved. Thinking about a sunset would activate whole new sets of lights with no overlap. Once a thought is complete, all the lights or neurons fall silent, waiting to be called into play in different combinations when new thoughts arise.
    Some sets of lights are found in structures that serve as major hubs for thinking and feeling. For example, a brain region called the anterior cingulate — a hub from which many circuits branch out — is almost always active when human subjects are experiencing emotions or need to think about things that are difficult. Any conflict of any sort, any reward, and the anterior cingulate starts buzzing. At least that is the judgment of the researchers who track increased blood flow with brain scans called functional magnetic resonance imaging.
    One of the first circuits studied in the 1940's involved the sense of touch. Sensations from the skin, including pain and temperature, were found to be carried by nerve fibers to a part of the brain devoted to bodily sensation. Less distinct sensations from viscera and internal organs went to a small region called the insula. Or so the thinking of the time went. But Dr. Arthur Craig, a functional neuroanatomist at the Barrow Neurological Institute in Phoenix, says this classic view is incorrect for most sensations.
    In a series of recent articles published in leading neuroscience journals, Dr. Craig has laid out a new wiring diagram for how the body talks to the brain. Tissues from all over the body, from skin surface to muscles, contain nerve endings or sensors that relay information, via long nerves, to the upper spinal cord. From this information come sensations including sharp pain, burning pain, cool or warm temperature, itching, muscle contraction, muscle burn because of lactic acid, joint movements, soft touch, mechanical stress, tickling, flushing, hunger and thirst.
The target cells, called Lamina 1 neurons, together make up a map of the state of the body. They are the first of several steps in the sorting and transmitting of sensory information, through structures in the brain stem and midbrain to the cortex. The line ends at two thumb-size parts of the cortex called the insula, one on the left and one on the right side of the brain. But the crucial stop along the way may be a nucleus of cells in the back of the thalamus with the intimidating name of the posterior ventromedial nucleus, VMpo for short.
    This structure hardly exists in most mammals. It is the size of a grain of sand in the macaque monkey, but relatively enormous in humans — the size of a pistachio nut. It collects information on bodily states like temperature or the need for water, that need to be monitored to keep the body stable, in equilibrium. A nearby structure, another similar nucleus, also collects sensory news from internal organs. Each sends the information on to the pair of insulae.
    In brain imaging studies the insulae show increased blood flow when people are exposed to disgusting odors, bad tastes, light touch or feel itching, muscle fatigue, stomach pain, thirst and most other body sensations. Because of this, scientists think that this collection of neurons contains a richer and more detailed map of the state of the body. Just as a map on the computer screen can grow more complex as cities, roads, even buildings are added, the brain seems to be making ever more complex constructions of feelings to represent what is going on in the body. How this happens is still a mystery. But the insula, Dr. Craig said, is "a system that represents the material me." In each insula information becomes feelings. Self-awareness emerges, Dr. Craig said. Other animals have basic emotions, but the consensus is that most lack self-awareness and complex emotions because they lack brain structures like the VMpo and have insulae that are much less complex.
    There is a final step. Information from the left and right insula is rerouted to the front part of the right insula where a new map is created, with yet another level of feeling, yet another sense of what is going on internally and in the world. This, say some neuroscientists, is where body states are translated into social emotions, which are the sorts of feelings that poets and novelists concentrate on — love and hate, lust and disgust, cold calculation, hot tempers, sadness and happiness. If one feels heavy, or light, in the metaphorical sense, one is feeling it in the right anterior insula.
    In scores of brain studies, this part of the insula is activated when we recall sadness or anger, anticipate pain, feel panic or become sexually aroused or have an emotional response to music. It lights up when people view or imitate emotional expressions in others. And in one study it showed activity when people experienced the pain of being socially excluded. A number of experiments show that the anterior insula is the main area that is active when people experience self-awareness, the realization that "it is my body that is moving," my physical self moving through time.
    In a separate line of research, Dr. John M. Allman, a neuroscientist at the California Institute of Technology, and his colleagues have delved below the level of brain structure to identify a special class of neuron — spindle cells — that are relatively enormous cells that collect information from one region of the brain and send it on to other regions. They function like air traffic controllers for emotions. They seem to lie at the heart of the human social emotion circuitry, including a moral sense. At a Society for Neuroscience meeting in New Orleans last month, Dr. Allman reported finding spindle cells in an area called the frontoinsular cortex in only two species — humans and African apes. This is a region closely connected to the insula and part of the same elaborate circuitry in which emotions are generated and experienced. An adult human had 82,855 such cells, a gorilla had 16,710, a bonobo had 2,159 and a chimp had 1,853. All had more spindle cells in the right hemisphere than in the left.
    This particular part of the cortex is a somewhat mysterious region, Dr. Allman said. In brain imaging studies, it lights up when people look at romantic partners; perceive unfairness, deception or uncertainty about rewards; experience embarrassment; or, if they are mothers, hear infants cry. The area is part of the orbitofrontal cortex, a part of the brain that seems to have undergone an evolutionary leap forward as recently as 100,000 years ago. It is where autobiographical memories are retrieved and choices are made for governing future behavior. It is activated with moral quandaries and economic decision making.
    Four years ago, Dr. Allman and his colleagues identified spindle cells in the anterior cingulate of humans, African apes and orangutans but not in any other species. The anterior cingulate is an older part of the brain that participates in autonomic functions like heart rate and blood pressure, generation of vocalizations and the production and recognition of facial expressions. In humans, the experience of any intense emotion — love, anger, lust — activates the anterior cingulate. It is active during demanding tasks and when people make errors. The harder the task, the more activation.
    Spindle cells probably first appeared 10 million to 15 million years ago in a common ancestor of apes, hominids and humans, Dr. Allman said. Today these rare neurons are 5 to 40 times as abundant in humans as in apes. Spindle cells may help people register the general appropriateness of transactions or events, he said. They are a teaching system that takes output from social emotion circuits — I feel good about this, I don't feel good about that — and sends it all over the cortex for further action to occur. Spindle cells are not present at birth. They appear around age 4 months and gradually increase during the second and third year of life, the same time that guilt and embarrassment appear. As children develop a sense of moral judgment, the frontal lobes and spindle cell system continue to expand. No neuroscientist would make a leap to say that this is where the conscience or sense of free will is lodged. But if one imagined a single location for these fundamental aspects of human nature, this would be the place.


Dyslexia Myths Dispelled
John Langone, New York Times- 12/9/2003

Overcoming Dyslexia," by Dr. Sally Shaywitz. Knopf, $25.95.
Early in this book about a disorder that may afflict one child in every five in America, the author dispels two widely held beliefs: that children with dyslexia are prone to seeing letters or words backward, and that the problem is linked to intelligence. "The problem is a linguistic one, not a visual one," writes Dr. Shaywitz, a professor of pediatrics at Yale. Dyslexia represents a difficulty with reading, she says, not with thinking skills, one that "does not reflect an overall defect in language," but rather a weakness in a part of the language system. She refers to this component as the "phonologic module, the language factory, the functional part of the brain where the sounds of language are put together to form words, and where words are broken down into their elemental sounds." The "phonologic model" explains clearly why some smart people have difficulty learning to read, the author writes.
    Dr. Shaywitz provides valuable advice and exercises intended to teach children and adults to read. "At the very beginning stage of reading," she writes, "the initial goal is to draw the child's attention to the sounds of language." Another step she suggests is getting a child to develop an awareness that words can rhyme. "Tuning into rhymes sensitizes very young children to the fact that words come apart," she says.

Killer's 'Abnormal Brain' Described
Shelley Murphy, Boston Globe- 12/10/2003

Admitted killer Gary Lee Sampson was born with a malfunctioning brain and has difficulty reasoning, problem solving, and controlling his impulses, according to a neuropsychologist who testified yesterday at Sampson's federal death penalty trial. "He had an abnormal brain virtually from the beginning of life," said Thomas Deters, who is director of neuropsychology at the Spaulding Rehabilitation Hospital in Boston and was hired by the defense team to assess Sampson's brain function.
    After interviewing Sampson and administering a battery of tests during two jailhouse visits last year, Deters told jurors in US District Court in Boston yesterday that Sampson has an IQ of 91, which is considered average, but scored poorly on tests that focused on his ability to make decisions and control his behavior. Deters cited one test that showed there was a 70 percent chance of Sampson "falling into the brain damaged category."
    Sampson, 44, who grew up in Abington, pleaded guilty in September to carjacking and killing Philip McCloskey, 69, of Taunton, and Jonathan Rizzo, 19, of Kingston, after they picked him up hitchhiking on separate days in July 2001. He faces additional charges in New Hampshire for the slaying of Robert "Eli" Whitney, 59, of Penacook, N.H.
    The jury, which has heard 13 days of testimony and will return to court today, will decide whether Sampson should be executed or sentenced to life in prison for the slayings of McCloskey and Rizzo. Defense lawyers, who could finish presenting their evidence as early as today, are trying to convince jurors that Sampson suffers from bipolar disorder and his life should be spared.
    While acknowledging that CAT scans and an MRI of Sampson's brain came back normal, Deters testified that such tests assess the structure of the brain and don't always reveal functional abnormalities. Deters also told jurors that he believed Sampson's brain condition was exacerbated by drug and alcohol abuse and head trauma which Sampson had claimed to suffer over the years, including a car accident and up to a dozen fights. But during cross-examination, Deters acknowledged that Sampson had a motive to lie to him during their meetings and acknowledged that hospital records differ from Sampson's account of a Sept. 22, 1979, car accident that he said left him with head trauma. Deters testified that Sampson said he was driving at 60 miles per hour when he struck a tree, climbed out of the wreckage, and passed out. Yet, Assistant US Attorney Frank Gaziano presented records that indicated Sampson was in good condition when he arrived at South Shore Hospital in Weymouth, where he was treated for a scalp laceration.
    Gaziano presented prison records indicating that Sampson lied in April 1986, when he sought treatment for headaches. At the time, Sampson falsely claimed that the 1979 car accident caused a blood clot "the size of a golf ball" to form inside his head. He claimed he underwent surgery at the hospital to remove it. Challenging Deters's conclusion that Sampson had difficulty with problem solving, Gaziano recounted portions of Sampson's confession that showed how he methodically planned and carried out each slaying.



British Warning on Antidepressant Use for Youth
Erica Goode, New York Times- 12/11/2003


British drug regulators yesterday recommended against the use of all but one of a new generation of antidepressants in the treatment of depressed children under 18. In a letter sent to doctors and other health professionals, the government regulators said a review of data on the safety and effectiveness of the drugs, known as S.S.R.I.'s, indicated that their benefits did not outweigh their potential risks.

Their effectiveness in treating depression in children, they said, has not been sufficiently demonstrated, and some drugs have been linked with suicidal thoughts and self-harm in children and adolescents. A summary of the findings was published on the Web site of the British Medicines and Healthcare Products Regulatory Agency (www.mhra.gov.uk). The agency, the equivalent of the Food and Drug Administration in the United States, said it was issuing a strong signal to doctors but was not barring the drugs completely because there were cases when their use might still be warranted. The agency exempted Prozac, from Eli Lilly, but recommended against the use of six drugs: Paxil, from GlaxoSmithKline; Zoloft, from Pfizer; Effexor, from Wyeth; Celexa and Lexapro, from Forest Laboratories Inc., and Luvox, from Solvay.

The F.D.A. is investigating whether the data support a link between suicide and the S.S.R.I.'s — selective serotonin reuptake inhibitors —in children and adolescents. On Feb. 2, an advisory committee for the agency will hold public hearings on the issue. But Dr. Russell Katz, director of the division of neuropharmacological drug products, said that for many reasons, finding whether such a link exists was no easy task. "Our view at the moment is that the risk is not particularly well-understood or defined," Dr. Katz said. "It is not at all a straightforward matter to figure this out." He said there was no indication that the British regulators had access to any studies beyond those already under review by the F.D.A.

In June, the American agency warned doctors that they should not prescribe Paxil for depressed children and adolescents until it had sorted out the issue. In October it issued a health advisory noting that doctors should use caution in prescribing S.S.R.I.'s to young patients and should closely monitor those taking the drugs.

Only a few of the drugs — including Prozac, Paxil and Zoloft — have been tested in large trials as a treatment for depression in young people. One big problem for outside researchers, and for the public, is that the data that seems to show a link between the drugs and suicide is privately held by drug companies, though it has been provided to the government agencies. Even for those who have the data, determining if a link exists is complicated, Dr. Katz and other experts said, because it is not always clear that the patients described as suicidal actually are. For example, experts say, some teenagers may cut or harm themselves but do not intend to commit suicide.

There are no reliable estimates of how many American children and teenagers are on antidepressants, but studies indicate the number has risen sharply over the past decade. Experts on the British agency's advisory committee estimated that 40,000 Britons under 18 were taking such drugs, with about half taking Prozac. The British agency exempted Prozac, the regulators said, because studies have shown it to be effective for treating depression in children and adolescents.

Some experts said the British action was extreme. "I think they're really overreacting," said Dr. Jeffrey A. Lieberman, a professor of psychiatry and pharmacology at the University of North Carolina. "This is really going way too far, and in the process doing more harm than good." Dr. David Shaffer, a professor of psychiatry and pediatrics at Columbia University who sent a letter on the issue at Pfizer's request to the British drug agency, said he had concluded that there was insufficient data to restrict the use of the drugs in adolescents. "The bottom line is that suicidal ideation and suicide attempts are very common in depressed kids," he said.
Dr. David Healy, of the University of Wales College of Medicine, who has been outspoken about the need for more unbiased testing of antidepressants, said the British agency had not addressed larger questions about the drugs. "The issue isn't necessarily that these drugs should be banned for children," he said. "The question is, `What is the safest way they can be used?' "

Other researchers said the British action was helpful in calling attention to the unanswered questions about the effectiveness and safety of antidepressants for children. "Right now there is a large question of whether the standard of treatment for children diagnosed with depression" should be the inhibitors, said Dr. Julie Magno Zito, associate professor of pharmacy and medicine at the University of Maryland. Alison Langley, a spokeswoman for the British agency, said the recommendation was issued because the drugs "don't work in the majority of cases for children under 18 with depressive illnesses."

Although the regulators cautioned doctors that the S.S.R.I.'s should not be prescribed "as new therapy," they added that if a child was already taking one of the drugs and doing well, "the normal completion of the planned treatment course should be considered as an option in the management of the illness." They also said that the drugs might still be appropriate for some children — those who cannot tolerate Prozac, for example — and cautioned only that in such cases the medication should be prescribed and supervised by a specialist rather than by a general practitioner.

In addition, the regulators noted that their recommendation did not apply to the use of Luvox and Zoloft for children and adolescents who suffered from obsessive-compulsive disorder, citing research that demonstrated the effectiveness of the two drugs for the condition. Children and adolescents who are currently taking the drugs, the regulators cautioned, should not stop taking them abruptly or change their treatment without medical supervision.



Worm Researchers Find `Drunk' Gene
Paul Elias, Associated Press, 12/12/2003

SAN FRANCISCO -- Researchers found a gene responsible for drunkenness in worms after plying thousands of the tiny creatures with booze, a discovery that could boost the fight against alcoholism. The experiment was conducted by researchers at the University of California at San Francisco and appears today in the science journal Cell.

Because it is believed that alcohol affects all animals similarly, humans, like worms, may also possess a single gene responsible for drunkenness. "Our end goal is to find a way to cure alcoholism and drug abuse," Dr. Steven McIntire said. "We hope to develop effective therapeutics to improve the ability of people to stop drinking."

After six years of work on the project, McIntire can now spot a soused worm about as well as a highway patrol trooper can spot a drunken driver. He and the other scientists dosed hundreds of thousands of worms with enough alcohol that they would be too drunk to drive legally -- if they were human with the same blood-to-alcohol levels. The drunken worms moved slower and more awkwardly than sober ones, and laid fewer eggs. Teetotaler worms form a neat S shape to power propulsion while the bodies of drunken worms were straighter and less active.

Researchers found that the sober worms had the same mutated gene that appears to make them immune to alcohol's intoxicating effects. The natural job of the gene they found is to help slow brain transmissions. Alcohol increases the gene's activity, which slows down brain activity even more. But if the gene is disabled, as it was in the mutant worms, the brain never gets the chance to slow down.

Still, McIntire and other addiction experts caution there's much research left to do before the leap to people can be made. "Humans are a lot more complicated than the worm," said neurobiology professor Steven Treistman of the University of Massachusetts Medical School. Treistman said many other genes are probably involved in helping people get drunk and that McIntire's work with worms couldn't measure other human intoxicating effects such as slurred speech and loss of inhibition.


Support Group Helps Chronic Shoplifters
Dan Shine, Detroit Free Press- 12/12/2003

It is similar to placing a gambling addict in Las Vegas or sending an alcoholic to a bar on St. Patrick's Day. To a chronic shoplifter, the malls and stores during the holidays are just as tempting. The stores teem with desirable merchandise, and display tables spill over with the newest gadgets and the latest must-haves. Customers crowd the aisles, making theft detection by security guards more difficult. Shoppers are dressed in bulky winter coats that can conceal stolen goods, and they tote multiple shopping bags that can be filled with contraband.

"The holidays are going to be rough," Helen, a 57-year-old woman who has served jail time for shoplifting, tells a group of fellow problem shoplifters meeting in Southfield recently. "I can't wait for the holidays to be over." They all nod their heads in agreement. The support group -- Cleptomaniacs and Shoplifters Anonymous, or CASA -- meets weekly at Clean House, a holistic treatment center that recently opened in a former Southfield printing facility near Telegraph and I-696.

The group is believed to be the only one of its kind in Michigan and only one of a handful of similar groups in the country. Its meeting draws young and old, black, white, Asian and Hispanic men and women from all over the Detroit area. A city mother of two sits next to a suburban grandmother who sits next to a white collar worker. Most attending the meeting are required to attend the sessions as part of a court order following a shoplifting arrest. Some continue to come even after the courts say they don't have to, feeling the support of the group keeps them on the straight and narrow. They sit in a tight circle of folding chairs, going around the room one by one and telling their stories of addiction. Like an alcoholic or problem gambler, most in this group believe what they have is an addiction. They all would like to stop, but feel powerless to do so.

Season of worry
As the meeting starts, a small table in the center of the room holds flickering candles, a basket of dollar donations and a bowl of small rocks. The discussion on a recent Wednesday in November centered on the upcoming holiday shopping season. All in attendance said they didn't want to shoplift during the holidays, but wondered how they would provide gifts for all of their family and friends. In the past, many had shoplifted them.

"It puts a lot of pressure on everybody," says Brenda, a middle-age suburban mother. "I wonder what will happen if I don't give my children all they want. Will they still love me? Janet, who served four years in prison for shoplifting, feels the pressure, too. "I don't know how to tell my 9-year-old that he's not going to have any toys unless his mom is going to steal," she says. Nevina, a 22-year-old Detroiter who owns a beauty salon, said the holidays are "supposed to be a happy time of year, but I find it very stressful. I'm used to getting my nieces and nephews an abundance of gifts," she says. "This year will be different."

There are an estimated 23 million shoplifters in the United States, nearly 1 in 11 people, according to the Web site, www.shopliftersalternative.org. U.S. retailers lose $25 million each day to shoplifting, or about $10 billion annually. In Michigan, shoplifting costs retailers about $500 million each year, according to the Michigan Retailers Association. The cost of protecting merchandise from shoplifters -- security systems and guards -- adds from 2 percent to 5 percent to the price of an item, the association says.

Men tend to shoplift as often as women, and most shoplifters are adults. A small percentage of shoplifters may be those who steal out of need or for profit, but most shoplifters are people who have emotional problems and repressed anger. These people use shoplifting as a way to act out or to "make life even." As one woman in the group put it: "I steal when I don't get what I deserve in life or what I feel I deserve in life."

Terry Shulman, a 38-year-old Southfield lawyer, author and recovering shoplifter, founded CASA in 1992 when he went looking for a support group and found none. Shulman, who wrote the book "Something for Nothing: Shoplifting Addiction and Recovery" (Infinity Publishing, $24.95), first shoplifted a gumball at age 10 while his parents were divorcing. As a teenager, Shulman, who was upset with his father, began shoplifting comic books and then art supplies. The shoplifting helped relieve him of the stress he felt in his life, he says. He also got a high from getting away with a theft. His shoplifting continued into college until he was caught twice. He had a strong desire to stop, but ended up attending other 12-step programs when he couldn't find a support group for shoplifters. "I didn't know anyone else who was a shoplifter, so I felt like an oddball," he says. One of the biggest benefits his support group provides is the reduction of shame. "You realize you're not alone," Shulman says.

Although he has amassed a decade of wisdom from running the group, Shulman usually keeps quiet during the meetings except to maintain the discussion or to probe deeper into what someone in the group has said. On this particular night, 14 people -- 12 women and two men -- are at the meeting. Jessica, who is 18, volunteers to go first. She was caught shoplifting in February and has since tried to stay away from stores "to be cautious." She has been shoplifting since she was 14, when her mother's boyfriend got her into it. Her family thought that when she was arrested, it was her first time. "I didn't want them to know the truth," she says.

Seated next to her, Helen, who at 57 is old enough to be Jessica's grandmother, knows how she feels. Although she has been tempted to shoplift again, she says having to face her grandchildren and the members of the group would be too much guilt for her to bear. She says she doesn't want her grandchildren to tell their friends their grandmother is in jail for shoplifting, so she stays away from stores and sends her daughter to buy things instead. "I've been busted when I've had money in my pocket," Helen says. "It's like an addiction. I try to control it, but just can't."

Shulman interjects to remind the group of the phone list where members of the group can call others when they feel tempted to shoplift. He also encourages them to make their own gifts, give gift certificates or order presents over the Internet to avoid going shopping.

'I got caught up in it'
Janet, who is in her 30s, says she first shoplifted when she was 7, but didn't know it. Her aunt sent her out of the store with some merchandise. " 'Go take this to the car,' she would tell me," Janet says. She stole candy when she was 10, and by the time she was in her early 30s, she was shoplifting with her sisters-in-law. "We stole socks, undies, panties for our daughters," Janet says. "I thought, 'If I can do that, I can do more.' " She says she stole for her children, herself and for her husband, who she thought would stop selling drugs if she stole enough merchandise. "I got caught up in it," she says. "I loved to shoplift. I would go in a store and say 'I'm going to get one thing' and instead come out with $8,000-$9,000" in merchandise.

She did four years in jail for shoplifting and was paroled in April. "I'm trusting in God that I'm not going to shoplift anymore," Janet says. "I can't go in a store without taking something. I stay out of stores. I trust in God that I'll stop dreaming about shoplifting." But whenever she has money problems, "the first thing that comes to mind is to go make some money shoplifting," Janet says. "I can get up and say I want to change, but I go into a store and no matter what, I'm coming out with something," she says. "In my head, I know it's wrong, but like I said, it likes calling my name."

Brenda, who is in her 50s, says she shoplifted a year ago -- the only time she has done it. "I felt I was a bad person because I had a good job and money," she says. She still is at a loss to explain why she did it. "I stole men's underwear, and I'm not married," Brenda says with a laugh. "There was no urge; it just happened."

Lending support
As people talk, group members come and go. Some stay for the whole meeting, while others arrive late or leave early. They make sure that Shulman signs a slip of paper to show their probation officer they were there. Members often get up to grab a cookie from a table in the front of the room and a cup of hot cider. Some have small, short discussions outside the room to offer support to someone who is leaving before rejoining the group. Sometimes the discussion strays to the judicial system and which cities, courts and judges to avoid. At other times, the group's tales have a boastful ring to them. How much they stole, how much fun it was, how easy it was. But inevitably, each story ends with them being caught and the bragging ends. "This is really hard on me," one says. "Again, my life is in the hands of the courts."

Jerry, who is 58, has been shoplifting for 10 years. She has been arrested four times. "I needed to know why I was doing it because I can't stop doing it," Jerry says. She says she felt a sense of loss with her mother's death and shoplifting was a way for her to cope with her loss. She had never shoplifted before her mother died. "I don't know what to do," Jerry says. "I'm confused. I'm in a frenzy. I try not to think about it. I go in a store not thinking about it, but end up doing it. "It's out of control," she says. "I can't stop." She says she has a better understanding of the anger and emptiness she felt after her mother's death and has not shoplifted since May -- a long time for her, she says. "I never thought of it as an addiction," Jerry says. "My husband is a recovering alcoholic. He was the one with the problem. Now I realize I'm in the same boat. "It's the hardest thing to stop doing." She says the "demons are there" every day, but that "you can't let them control you."

While most in the group say they bring someone with them when they shop so they won't shoplift, Nevina, the salon owner, said someone always accompanies her to the mall. "There's a devil on my shoulder all the time saying, 'Steal it; don't buy it.' " David, a bookish-looking man in his late 40s or early 50s, says he is a long-term shoplifter. He has been doing it for 42 years and has been caught twice. "I beat the odds, but getting caught twice is not worth it," he says. "I'd give everything back to have peace of mind." He says his children have a hard time getting a "picture of who their father is. It's hard for a father to gain the trust of their kids," he says. David says most of the items he has shoplifted were things he didn't want or need.

Elizabeth, who is in her 60s, pulls up her pant leg to show everyone her electronic tether. She says she hasn't been to a store this week. "Otherwise, believe me, I would have shoplifted," she says matter-of-factly. "I don't like it anymore. It's like, nasty. I used to not let it bother me. "But I feel lower than anybody else. You can't feel like you have integrity if you're doing this."

After a little more than two hours, the meeting is over. But before they adjourn, David picks a smooth rock from the bowl. He silently hands it to each person in the group. Each caresses it and gives it back. David then gives it to Janet, who is attending her first meeting. He tells her the rock was once a mountain, but was worn down by the hardships of wind and rain. It endured to come out as a strong survivor. She is told to think of the group whenever she holds the rock. With it in her hand, she is told, it will make it more difficult -- both physically and emotionally -- to shoplift. They all then join hands, close their eyes and take deep breaths as they listen to Shulman dispense inspirational messages. As the group breaks up, the solemnity is broken momentarily when one of the members accuses Shulman of theft as he signs copies of his book. "Hey, you stole my pen," the member says as they all laugh.

FOR HELP
CASA: Cleptomaniacs and Shoplifters Anonymous meets 7-9 p.m. each Wed. at the Clean House Holistic Counseling Clinic, 24750 Swanson Rd., Southfield. Call 248-358-8508 anytime.



The Basis for Sexual Orientation
Los Angeles Times, 12/12/2003

The controversy swirling around gay marriage has put the choice-versus-genetics debate front and center. With gay marriage now supported by Massachusetts' highest court and gay rights likely to be an issue in the presidential campaign, the question of whether sexual orientation is an innate or acquired trait is an increasingly urgent one.

Since at least 1991, some scientific research has suggested a biological basis to homosexuality — meaning sexual orientation is probably at least partly natural destiny, not simply choice. But that point is open to political and scientific debate, and our understanding of how biology may drive sexual orientation is still fuzzy.

Understanding homosexuality or heterosexuality involves, among other things, figuring out how the brain, the seat of all complex behavior, becomes male or female in the first place. Until recently, researchers thought that a surge in the male hormone testosterone sets the brain on a male track. Without testosterone, the brain continues developing on a female track. But in October, California researchers studying fetal development identified 54 genes that play a role in the expression of sex — before hormones are ever released. "This refutes the idea that hormones are the only story in sexual differentiation of the brain," said Dr. Eric Vilain, an assistant professor of human genetics and urology at the David Geffen School of Medicine at UCLA, who led the research.

The findings' implications are many. An estimated one in 4,000 babies worldwide is born with "ambiguous genitalia," making it difficult to tell whether the baby is a boy or a girl. By analyzing chromosomes and looking for internal sexual organs such as ovaries or a prostate gland, doctors make their best guess as to the true sex of the child and sometimes perform surgery to make the anatomy conform to that. DNA analysis of the variations in these 54 genes and other genes that interact with them may help doctors figure out to which gender the child belongs, Vilain says. The 54 genes may also help explain transgenderism, in which a person feels he or she was born the "wrong" sex. The situation is found in about one in every 50,000 people. The UCLA study does not address homosexuality directly. But other data suggest that 75% of boys who were confused about their gender identity as children grow up to be gay, said Vilain. The new study, he said, may help "pave the way to find out about gender identity" in such children.

Other studies on the genetic roots of homosexuality are mixed. Dr. Richard C. Pillard, a professor of psychiatry at Boston University School of Medicine, has studied male and female homosexuals, believed to make up at least 3% to 4% of the population. Pillard holds that men's sexual orientation is often inherited while in women, "sexuality is not as rigidly set." In identical male twins, his research shows, if one is gay, there's a 50% chance that the other one is too. Granted, if homosexuality were totally genetically determined, that figure should be 100%. On the other hand, in male fraternal twins, his studies show there's a 20% chance that if one is homosexual, the other will be.

In 1991, an autopsy study by Simon LeVay at the Salk Institute for Biological Studies in San Diego found that part of the brain called the anterior hypothalamus was twice as large in heterosexual men as in homosexual men, suggesting a biological basis for homosexuality. Because the gay men all had AIDS, it is possible that the disease, rather than their homosexuality, transformed their brains.

Other studies that have tried to draw a biological link to homosexuality have faced problems as well. In 1993, Dean Hamer, a molecular biologist at the National Cancer Institute, studied 40 pairs of gay brothers and published his results in Science. Hamer identified a region called Xq28 on the X chromosome (inherited from the mother) that was statistically correlated to homosexuality. In 1995, a second study by Hamer and others confirmed that finding. In 1999, researchers led by George Rice at the University of Western Ontario in Canada studied the same brain region in 52 gay male sibling pairs and reported contradictory findings. Clearly, more research is needed to determine whether homosexuality is inherited.




Drinking Could Be Learned Behavior
Carol Ann Campbell, Newhouse News Service- 12/12/2003

Seeing double: Who was tested?
The study on the genetic risks of alcoholism targeted a sample of about 600 pairs of male twins, some identical and some fraternal, who had been enrolled in the Vietnam Era Twin Registry. The twins sampled in the study were born from 1939 to 1957 and had served in the U.S. military. Parents were also part of the study.

Researchers placed the twins in several categories, such as identical twins who were both alcoholics and fraternal twins where one was an alcoholic. Family environment goes a long way toward moderating the influence of genes in alcoholism, according to a new study. Researchers looked at sets of identical male twins in which one twin was an alcoholic and one was not.

The study found that children raised by the alcoholic father were twice as likely to develop alcoholism as the children raised by the genetically identical twin who was not an alcoholic. The results, published in this month's Archives of General Psychiatry, reinforce the view of some experts who say too much alcoholism research in recent years has focused on genetics while ignoring family environment or upbringing. Researchers obtained information through lengthy telephone interviews with mothers, fathers and children.

Theodore Jacob, lead researcher of the study and a scientist with the Palo Alto Veterans Affairs Health Care System in Menlo Park, Calif., said the most significant parts of the study focused on sets of identical twins in which one father was an alcoholic and the other was not. It turned out that the children who were at high genetic risk of alcoholism, but who were raised by the non-alcoholic twin father, had only about the same risk of developing the disease as the control group did.

"This strongly suggests that environmental influences can be brought to bear in the prevention of alcoholism," said Kathy K. Bucholz, a researcher at Washington University School of Medicine in St. Louis who also worked on the study. "It might be good for people in genetic research who seem to ignore the psychological and social factors that contribute to the development of alcoholism," said Helene White, professor of sociology at Rutgers University's Center of Alcohol Studies in Piscataway, N.J. Many children of alcoholics imitate their parents' drinking and grow up in tension-filled environments, she said.



Insurer Pressure Cited as Psychiatric Stays Shortened
Liz Kowalczyk, Boston Globe- 12/13/2003

During his stay in MetroWest Medical Center's psychiatric unit, Darlene James's 11-year-old son often exploded in anger. He would punch and kick the nurses until they restrained him or sent him to the quiet room, where he would pound the walls, she said. Even Paul's psychiatrist wrote in his case summary that Paul was unstable and would need extensive outpatient treatment. So James was surprised when, 12 days after the boy's admission, doctors discharged him from the hospital.
"Was I scared to take him home?" James said in an interview, recalling that anxious day in September 2001. "Boy, was I ever. He was still raging." Although doctors said Paul no longer required hospital care, James worries another factor was at work: Her insurance company had agreed to pay for just three hospital days and MetroWest was swallowing the rest of the cost for Paul's stay, $10,000 and growing.

While MetroWest executives deny insurance coverage influenced her son's discharge, James's family felt the impact of a revolution in hospital care. Once considered treatment, hospitalization for psychiatric patients now is viewed more as an emergency stopover, a chance to stabilize suicidal or violent patients so they can be discharged to less-expensive outpatient treatment. The shorter hospital stays are due partly to more effective antidepressant and antipsychotic drugs that allow patients to work and live on their own, a positive development for 54 million Americans with mental illness.

But pressure to shorten hospital stays also has come from managed care insurers, which have refused to pay for extensive hospital care. They have helped force down the average stay for psychiatric patients from 25.6 days in 1990 to 9.3 days in 2001, according to the most recent data from the National Association of Psychiatric Health Systems. At McLean Hospital in Belmont, a Harvard Medical School teaching hospital, patients now stay 10 days on average, compared with 16 days 10 years ago. Hospital executives, who are coping with huge patient demand, a shortage of beds, and limited insurance payments, feel they are caught in the middle -- and often are stuck providing free care when insurers won't pay.

Insurers have intensified the pressure this year in Massachusetts, executives say, and it is raising concerns among doctors and state regulators that early discharges may be hurting patients. And this fall Massachusetts regulators warned one insurer, Blue Cross & Blue Shield of Massachusetts, and the company it works with, Magellan Health Services, that they are denying hospital days to some patients who are not well enough to leave. Through September 2003, patients and hospitals appealed 132 Magellan denials of care. After a review, state health officials reversed most of those denials and urged the company to change its policies.

Deborah Nelson, vice president for quality management and clinical services at Beacon Health Strategies in Woburn, a mental health managed-care company, said people should not ignore the positive impact of shorter hospital stays. Managed care companies, she said, have pushed for more focused and effective evidence-based treatment and a rich web of intensive outpatient services. "That's a win-win for everyone," she said. "The members I talk to don't want to be in the hospital; they want to be home with their families."

But doctors said that these services can be spotty, particularly given state budget cuts, and that not all families are capable of caring for suicidal or aggressive loved ones. "Once the patient's condition improves, the insurer wants them moved out," said Dr. Paul Barreira, chief of community clinical services at McLean. "But what if their family is incapable of watching them? Or, conversely, private insurers say they're no longer covering the patient because he's not improving and they're not responsible for chronic care. It's not sane, it's not rational."

Krissie Burnham, of Rockport, could not understand why North Shore Medical Center's Hunt Center in Danvers discharged her 14-year-old son, who is bipolar or manic-depressive, after about a week in February. She argued against his discharge, saying he had angrily locked himself in his room on a recent visit home, but staff insisted. As he went to gather his belongings, she said, he punched a hole in a hospital wall. Burnham was afraid he'd attack his 9-year-old twin brothers, so she had him stay with his grandparents until his new medication began working. "The hospital said the medication was going to take two weeks to work, and he couldn't stay there that long," she said.

Hospital executives would not comment on the case because of patient confidentiality. But like executives at MetroWest, a North Shore Medical Center spokeswoman said doctors discharge patients only when they're ready to go home, never because an insurance company refuses to pay. In fact, they said, they often keep patients and write off the cost. McLean, for example, provided $1 million in free care last year to patients whose insurance companies refused to pay. And MetroWest absorbed the cost of the nine days Cigna would not cover for James's son -- more than $10,000.

Cigna executives would not comment on the case because of patient confidentiality. But a spokeswoman said that the company's standards for care match those developed by the American Psychiatric Association and that company psychiatrists review all coverage decisions. But James said what happened after her son's discharge led her to believe she was right. Three days after he was sent home, she said, Paul tried to stab himself in the thigh with a sharp tool, and she took him back to MetroWest for six more days. Paul was admitted to the hospital again earlier this year, but is now living at a residential school, where his mother said he is doing very well.

The state review of Maryland-based Magellan, which Blue Cross pays to manage mental health care for 1 million of its members, is a window into the reasoning insurers use when they press for shorter hospital stays. During the first nine months of this year, patients, families, and hospitals appealed to the state 183 times to overturn insurance company denials of mental health care -- by far the most common type of appeal. More than 70 percent of these appeals were about Magellan, which had denied treatment for patients who were depressed, psychotic, or in alcohol or drug detoxification programs. A similar pattern existed in 2002. State health officials said they are particularly concerned because in 60 percent to 75 percent of the cases, state reviewers agreed with patients and hospitals, overturning Magellan's denial of care and ordering the company to pay for extra hospital days.

Dr. Jeffrey Simmons of the Department of Mental Health said Magellan doctors rightly consider whether a patient is suicidal or homicidal when deciding whether to pay for hospital care. But, he said, they sometimes ignored warnings from doctors that certain patients will deteriorate as soon as they leave. Simmons said that he didn't know whether patients harmed themselves or others after discharge but that state officials may study that issue. In one case, according to state records, a woman who was bipolar was swinging so rapidly between mania and depression that her mood changed almost daily. Magellan reviewers wanted to discharge her on a day when she was between symptoms, but the next day her mania was full-blown again. The state overturned Magellan's denial, ordering the insurer to pay for 27 more hospital days for the patient.

Part of the problem, said a Blue Cross senior vice president, Dr. James Fanale, is that mental health treatment is far more subjective than treatment for physical problems. "You come in to the hospital for pneumonia, and on the fifth day you still have a fever, you need an intravenous antibiotic, you stay another day," he said. "Medical care is much more refined. Mental health care is just not as concrete. There's more judgment to it. There's a little more art." Still, Blue Cross and Magellan executives said that they've taken steps to reduce disputes with hospitals and patients, including hiring more Massachusetts physicians to review cases, and that the number of appeals has dropped dramatically since September. Later this month, state health officials will review these steps to see whether they're sufficient.


Annals of Homosexuality: From Greek to Grim to Gay
Edward Rothstein, New York Times- 12/13/2003

I n Tony Kushner's "Angels in America," which concludes tomorrow night on HBO, homosexuality is associated with religious martyrdom; salvation is found in the embrace of sexual identity. In American courts, homosexuality is being associated with bourgeois family life; salvation is being sought in social routine. And in Louis Crompton's sober, searching and somber new history, "Homosexuality and Civilization," homosexuality is associated with the inner workings of civilization itself. The book provides the background to the resentments and passions that erupt in Mr. Kushner's play and haunt debates about gay marriage, and it, too, offers a promise of salvation.

It begins in the gladness of early Greece, where homosexuality had an "honored place" for more than a millennium and concludes with the madness of 19th-century Europe. In between is what Mr. Crompton calls a "kaleidoscope of horrors" lasting more than 1,500 years. In the 13th century, a French law stated: "Whoever is proved to be a sodomite shall lose his testicles. And if he does it a second time, he shall lose his member. And if he does it a third time, he shall be burned." Beginning in 1730 in the Netherlands, 250 trials of "sodomites" took place, followed by at least 75 executions. Between 1806 and 1835, 60 homosexuals were hanged in England.

Mr. Crompton, an emeritus professor of English at the University of Nebraska and the author of "Byron and Greek Love," a much-praised study of Byron's sexuality, was one of the first American professors some 30 years ago to teach the history of homosexuality, a project that was at the time both daring and inherently polemical. But this is a restrained, careful, clear book of scholarly exposition; it is no martyrology. It also hopes to be a post-mortem. Mr. Crompton ends the book "at the moment when executions finally cease in Europe," promising both the fading of homosexuality's stigma and the slow healing of its stigmata.

But what led to this "kaleidoscope of horrors"? In ancient Greece, homosexuality was philosophically praised and institutionally sanctioned, associated with virtues of courage and mentorship. In ancient Rome, it was primarily cultivated in relationships between masters and slaves, but homosexual behavior was common to Pompey, Caesar, Mark Antony and Octavius. "Of the first 15 emperors," Gibbon pointed out, "Claudius was the only one whose taste in love was entirely correct."

Why did such indulgence, tolerance and even sanction disappear? Mr. Crompton offers a very different interpretation from the influential theory outlined by the French philosopher Michel Foucault. In Mr. Crompton's view, the concept of homosexuality was not something created in 19th-century Europe when it was first considered a medical condition, nor was it, despite cultural variations, so drastically different in other times and places. Mr. Crompton argues that Christianity created the most radical change in attitudes toward homosexuality. "The debt owed by civilization to Christianity is enormous," he writes; but so, he believes, have been Christianity's sins. In Japan, for example, before the mid-19th-century Western influence, homosexuality was "an honored way of life among the country's religious and military leaders so that its acceptance paralleled, and in some respects even surpassed, ancient Athens." It was common among Buddhist sages, part of samurai culture and an accepted aspect of the Kabuki theater world.

Christianity attacked such customs when it gained access, Mr. Crompton argues, but its assault began in the West as early as the 4th century (not the 12th century, he says, as the historian John Boswell believed). Mr. Crompton traces Christian hostility to Leviticus, which may have been written around 550 B.C., at the very time that homoerotic poetry was thriving in Greece. It mandated death for homosexual acts. Mr. Crompton suggests that this law was an attempt to differentiate the Jews from Mediterranean cults in which transvestite priests, eunuchs and sexual activity played a central role in ritual and worship. As filtered through the severity of the writings of the Apostle Paul, though, that condemnation became central to Christianity, strictly distinguishing it from Roman and pagan cultures. In Mr. Crompton's view, it also ended up influencing the later criminal codes of France, Spain, England, the Holy Roman Empire, the Italian states and Scandinavia.

Judging from this history, though, prohibition seems to have been unable to quash the practice in any social class; in the European aristocracy, at any rate, it flourished. In 1610, when Louis XIII came to the French throne, Mr. Crompton notes, "one `sodomite,' James I, ruled England, Scotland, and Ireland; another, Rudolph II, presided over the Holy Roman Empire; and France had its second homosexual king within a generation."

The relationship between homosexuality and political liberty is also marked by peculiarities. Mr. Crompton points out that by the Enlightenment, in Roman Catholic countries anticlerical feeling swept ancient antisodomy laws away, along with the church's authority. But countries already affected by the Reformation had no need to rebel; their antisodomy legislation remained intact. So by the 19th century, homosexuality was tolerated far more in countries like France, Spain and Italy than in England, the Netherlands or the United States.

What, then, does contemporary salvation consist of? For Mr. Crompton, it is heralded by figures like Jeremy Bentham, who argued for reform of antisodomy laws in the late 18th century. But history, while it provides context for contemporary debates, offers no clear guidance. Homosexuality in ancient Greece and Rome, for example, involved pederasty, and in Rome, slavery. Liberal democracy has recognized that neither is compatible with human autonomy; both take advantage of those unable to exercise their will and reason fully. So whatever evolves in coming years will not be based on past models but on ones yet to evolve, models in which martyrdom, at the very least, should become superfluous.