Finding Gold In the Jumble Of Dreams
Anna Fels, M.D., New York Times- 4/1/2003

Often, my psychiatric patients bring carefully recorded dreams to their sessions. They are sophisticated people who have been taught that dream interpretation is part of the therapy drill. After all, Freud singled out dreams as the royal road to the unconscious. A hundred years later, scientists are still unsure what dreams are about, but their very inscrutability suggests that they guard deep truths, that they are the magic keys to the psychic kingdom.
    When I first started practice, I dreaded listening to patients' dreams. Typically, a patient would stare down at scribbled notes and begin: "I was in this place that was sort of like my bedroom, but it was also a cave I saw in a TV program yesterday, and there was a guy swinging from a perch who I thought was going to hit me, but then I was in this swimming pool... " I, meanwhile, would suddenly feel disoriented and queasy. It was a sensation I remembered from childhood holidays when my great-aunt would sit the family down and project carousels of travel slides accompanied by a patter of incomprehensible anecdotes. With the slides, as with listening to dreams, I felt lost and excluded: you had to have been there.
    After several years, however, I began to think about dreams differently. A patient with a mood disorder brought in his first dream, an event notable in itself, after seeing me for several months. It was not like any dream I had ever heard It began with the patient on a train, which stopped by the ocean. He climbed off the train onto the beach and saw a huge, curved disk of sea under a gray sky. And that was the dream. He seemed untroubled by this static, unpeopled vision. Before I could even reflect on the image, I felt the hairs on my neck stand up. "Have you been feeling suicidal?" I asked. The brief hesitation before his reply told me all I needed to know.
    After that session, I asked my patient to bring in dreams on a regular basis. It was not that I had any illusion that I could figure out what specific dream events or figures meant. As I began to see, it was more like taking core samples of the patient's emotional life. The textures of the dreams, like those of geologic specimens, gave a broad overview of the landscape. In the patient's dreams, I could evaluate the richness or paucity of events, the use or lack of color, the presence of characters, the range of feelings available. As my patient's depression gradually abated with treatment, his dreams evolved in their emotional breadth and complexity. I began to notice that the dreams of other patients, far from uncovering deeply hidden motives and desires, often openly replayed the dominant sensations of their daily lives, despite the distractingly jumbled and fractured plots. Anxious people had anxious dreams; exuberant extroverts had expansive, buoyant dreams with characters miraculously flying away from danger; inhibited people dreamed of being shamefully exposed. The gist of their dream stories often had a deep familiarity -- after all, it was the same brain, with the same organization and repertoire of feelings, they used each day.
    Scientifically, this rather plebeian notion of dreams made a certain amount of sense. At this juncture, neurophysiologists' best guess is that dreams are byproducts of the mind's system of classifying and storing information. New experiences are fitted into the loose clusters of associations that the person's mind deems relevant to specific events. And, as the lacework of neural connections is reshaped or strengthened, images and sensations are generated. The mind, confronted with these disparate pictures and emotions, scrambles to arrange them into plausible narratives, confabulating wildly as it goes. But the plotlines used by each of us are limited; as the novelist Saul Bellow once wrote, "Each man has his own batch of poems." In some ways our poems are the very definition of who we are, and it is this private anthology that we read in our dreams.
    Several months after the terrifyingly empty ocean dream, my patient brought in another one. The new dream was dense, lively and populated with people from all different parts of his life. He was in the countryside, driving a convertible he had owned years before. His long dead parents were with him, but his wife was also there. At a stoplight they were suddenly attacked by a man he recognized from his job. The car careered into an alley, but they somehow ended up in an open field. It sounded good to me.

Self-Protection or Delusion? The Many Varieties of Paranoia
Richard A. Friedman, M.D., New York Times- 4/1/2003

"I am being harassed by the guy next door and I want him to stop," the woman In my office said with firm conviction. The man would leer at her in the elevator just to make her squirm, she said. But when I inquired further, she described a lingering feeling of being mistreated by people she said were jealous of her. She was even sure that someone had once tried to poison her. Then I asked a question that gave me a direct taste of her problem. Is it possible that you are mistaken? Her pleasant manner instantly shifted to icy contempt before she denounced me for implying that she was paranoid. Of course, she was right. And the unshakable nature of her belief was the clincher. Certainly none of her ideas were bizarre or impossible. People are harassed and envied all the time. But her absolute absence of doubt was what made her psychotic. She could not imagine being wrong.
    Probably no psychiatric term is bandied about as loosely as paranoia. But paranoia covers a broad terrain, from a stable personality trait to a symptom of severe mental illness. Paranoia may even confer an adaptive advantage in some instances. After all, someone who is always watching his back and is mindful that his peers are driven by self-interest is more likely to have a competitive edge when one is needed. In politics, mild paranoia is probably an asset; no politician could survive for long with a rosy and trusting view of the world. But there is a world of difference between having a paranoid streak and harboring a delusion. Some people, like my patient, develop a delusional disorder in middle or late life, having had no trace of paranoid thinking before. Their disorder is fairly rare but striking. These patients falsely believe that they are the objects of persecution, envy or even love. Yet they often function effectively at work and can superficially pass for normal in social settings.
    Ian McEwan's "Enduring Love" describes a man in the grip of a mistaken but unyielding belief that he is loved by a complete stranger whom be meets by chance. Celebrity stalkers often fall into this category. They insist that they are secretly loved by a powerful or famous figure. Clearly, there is more than a little self-importance at the heart of these delusions. Whether it is being persecuted or loved, it is all about being the center of attention. And all attempts to convince them that their beliefs are mistaken fail. Because they have no doubt about their delusions, they are immune to reason.
    The most common cause of paranoia is also the least understood by the public, schizophrenia. A chronic mental illness that is generally believed to affect 1 percent of Americans, schizophrenia is characterized by delusions, often paranoid in nature; hallucinations; and so-called negative symptoms that include social withdrawal and apathy. Contrary to popular notion, schizophrenia has nothing to do with split or multiple personality. It is thinking and perception, not personality, that are so disordered in schizophrenia.
    What is intriguing is that drugs can produce symptoms that mimic schizophrenia, and they have yielded clues about the neurobiology of psychosis. Cocaine and amphetamines, for example, flood the brain with the neurotransmitter dopamine, producing psychosis in vulnerable people. And the cocaine-induced delusions are easy to confuse with those of schizophrenia. Antipsychotic drugs alleviate psychosis by blocking dopamine receptors in important brain areas. In doing so, they normalize the excess dopamine activity in schizophrenia and stimulant-induced psychosis. Curiously, antipsychotic drugs, which are so effective in treating the paranoia of schizophrenia, are of limited use in delusional disorder. That suggests that the neurobiology of paranoia is diverse, just as the illnesses that produce it are.
    An intriguing clue to the origin of psychotic thinking comes from recent brain imaging studies. Dr. David Silbersweig and Dr. Jane Epstein at the New York Weill Cornell Center used PET scans to study schizophrenic patients who were having delusions and auditory hallucinations while their brains were being imaged. The paranoid subjects showed increased activity in the amygdala, a part of the brain involved in the emotional processing of fear and danger, not only in response to threatening words, but also to neutral words. Healthy people respond like this only in threatening situations.
    The implication is that the brain is responding to a nonexistent threat, at least in these paranoid schizophrenic subjects. It's like a faulty burglar alarm set off in the absence of an intruder. The paranoid patient is correctly responding to real brain activity that indicates danger, but those neural circuits have no good reason to be firing in the first place. To make matters worse, the schizophrenic subjects also showed decreased activity in the prefrontal cortex compared with healthy people. The prefrontal cortex serves an executive function, critically evaluating signals from brain regions and shaping responses to them. So in addition to having an overactive fear circuit, these paranoid subjects have an impaired ability to judge whether their fears are rational. Sure, paranoid people, like the rest of us, do occasionally have enemies. But if these imaging studies are replicated, the results will mean that the real enemies of paranoid people are their own brains.

Mental Health Advocates: Program Being Cut Saves Money
Stephen Frothingham, Associated Press, 4/1/2003 15:24

CONCORD, N.H. -- Three times a week, a van picks up Patricia Powanda at her apartment in Derry and takes her to a place where she gets help from professionals and from her peers, others who have mental health illnesses. ''It keeps me out of the hospital,'' Powanda said Tuesday before a Statehouse rally. Powanda was one of about 60 people protesting a proposed 55 percent budget cut for the peer support centers, which serve about 4,000 adults at 15 locations.
    The proposed cut would reduce funding for the program from $2.2 million to $1 million a year. Advocates said the cuts will cost money because the centers keep recovering mental health patients out of hospitals and community mental health centers, which are more costly to operate. The benefits are more than financial, they say. Helping and being helped by peers restores self-esteem and hope.
    The centers are staffed by recovering mental health patients. They offer job training, transportation, vocational and nutritional counseling and 24-hour telephone support. ''I've never found a place that felt more comfortable and secure,'' said Janine Vance, who is on the staff at the Alternative Life Center, a peer support agency in Wolfeboro.  Richard Cummings, director of the Corner Bridge Peer Support Center in Laconia, said the centers provide services for about $20 an hour. Service at state funded community mental health centers costs about $100 an hour, he said. Cummings said the proposed cuts will cause about half the centers to close.
    Geoffrey Souther, the acting director of the Department of Behavioral Health, said there has been no decision yet on closures. He said the division was hoping to keep at least one peer support agency open in each of the state's 10 regions. Souther's division chose to cut the program to comply with overall budget cuts proposed by Gov. Craig Benson, he said. The Legislature is still discussing Benson's proposals; some lawmakers and state officials are proposing ways to reduce the effect of the cuts by bringing in more federal Medicaid money. Those solutions may indirectly help restore funding to the peer support program. Souther said he had no doubt that the program is effective in empowering participants he said the Statehouse rally demonstrated that. ''Five or ten years ago, that never would have happened,'' Souther said.
    At the close of the rally, the crowd surrounded Ken Braiterman, a recovering mental health patient and chairman of the state Mental Health Consumer Council. Braiterman told them that the peer support program was being cut because decision makers believed its clients were powerless. ''We're not just some people who were released from the hospital 25 years ago,'' Braiterman told the cheering crowd. ''We have a voice and we have each other. And they are going to hear from us.''

Justices Hear Debate on Extending Statute of Limitations
Linda Greenhouse, New York Times- 4/1/2003

WASHINGTON-- Until the mid-1990's, sex crimes were like most other criminal offenses under California law and could not be prosecuted after three years had elapsed. But concerned that the inability of young victims of sex crimes to come forward promptly was permitting their tormentors to escape prosecution, the California Legislature extended the statute of limitations for sex crimes against children. Now a prosecution can be brought at any time, as long as less than a year has passed since an adult has given evidence to the authorities of having been the victim of a serious sexual offense before the age of 18.  The Legislature's decision to make the amendment retroactive made people vulnerable to prosecution for offenses decades old. Hearing arguments in an appeal brought by a man charged with molesting his daughters as long ago as 47 years ago, the Supreme Court today wrestled with the constitutional implications of such a sharp retroactive change in the law.
    It was evident that this was not an easy case for the justices. They appeared concerned with considerations of basic fairness as well as with the broad arguments that California and the Bush administration made in support of the statute. Although framed as a response to the problems of child victims, "your argument is across-the-board," Justice Ruth Bader 'Ginsburg told Janet Gaard, an assistant state attorney general arguing for California. "It would also apply to pickpocketing," Justice Ginsburg said. In answer to questions, Ms. Gaard said that the same constitutional principles that supported a retroactive change in the statute of limitations would also support revoking an executive pardon or a legislative grant of amnesty. While consistent with her position, these answers appeared to trouble some justices.
    On the other hand, the court's precedents for invalidating retroactive legislation are rather strict, establishing various tests for determining constitutionality that at least on their face do not quite fit the California law. The Constitution prohibits Congress and the states from enacting ex post facto laws, a prohibition that the court interpreted in a 1798 decision that the modern Supreme Court still regards as definitive. In that decision, Calder v. Bull, the court declared that legislators could not do any of the following: criminalize an act that was not a crime when it was committed; "aggravate" a crime, making it more serious than it was when committed; make the punishment greater than it was when the crime was committed; or alter the legal rules of evidence to make it easier for the government to obtain a conviction. The court has subsequently indicated that these four categories are the only types of legislative action that the Constitution's ex post facto clause prohibits. Until the case today, Stogner v. California, No. 011757, the court had not considered how reviving an expired statute of limitations fits into that. analysis. Undisputed in this case was a legislature's ability simply to extend a statute of limitations that had not yet expired for crimes committed in the past.
    Representing Marion R. Stogner, the defendant in this case, Roberto Najera argued that reviving a statute of limitations once it has expired was a breach of a fundamental promise that a government makes with its citizens. The action should be considered in the same prohibited category as a change in the rules of evidence, he said. Some justices were skeptical. "Your claim doesn't fit very comfortably under any of the four categories in Calder v. Bull," Justice Sandra Day O'Connor told Mr. Najera, adding that he was "trying to shoehorn" his argument into the evidence category.
    Arguing for the federal government on California's behalf, Irving L. Gornstein, an assistant solicitor general, said Mr. Najera misunderstood the type of evidence rule to which the ex post facto prohibition applies. Mr. Gornstein said that while the state might not reduce the amount of evidence sufficient to show that a person committed a crime, that was not what California did. California simply made it easier for prosecutors to show they had brought a case in a timely manner, he said.
    Justice Stephen G. Breyer offered an alternative route to ruling for the defendant. He said that reviving the statute of limitations appeared to be an "aggravation" of the seriousness of a crime that would fit under the second of the categories in the 1798 precedent. "It seems to aggravate the crime," he said, "to say that once we could have prosecuted within 3 years and now we can prosecute within 50 years."
    Mr. Stogner, who is in failing health, was charged in 1998 with having molested his two daughters from 1955 to 1973. The women made the accusation in 1998 to police officers who were investigating accusations of child sexual abuse elsewhere in the extended family. Mr. Stogner raised constitutional objections to the prosecution, which the California state courts rejected on the basis of a 1999 California Supreme Court decision that had upheld the retroactive amendment. He then appealed to the United States Supreme Court. The case has not yet gone to trial. Several other state legislatures tried to make similar changes to their statutes of limitations in the 1980's and 90's, but all were rejected in the state courts.
    Mr. Stogner's appeal drew the attention of the National Association of Criminal Defense Lawyers,, which filed a brief on his behalf, and of the American Psychological Association, which said the law was an appropriate response to the demonstrated problem of young children's inability to recognize and report sexual abuse.
    The Bush administration told the court that new and pending federal legislation gave the government a stake in the outcome of this case. Congress has already enacted a law permitting terrorism prosecutions for crimes for which the statute of limitations had already expired. The administration is seeking legislation to eliminate the federal statute of limitations retroactively for child abduction and for sexual offenses against children and to modify it for some cases involving DNA evidence.
    Last year California passed a separate law lifting the statute of limitations, for a one-year period that began Jan. 1, on civil lawsuits against churches, schools and other institutions that knowingly permitted sexual abusers to have access to children. The law has caused great alarm among the state's Roman Catholic churches. It may not be affected by the outcome of the case today, because the Supreme Court is analyzing that case under a precedent that applies only to criminal prosecutions, not civil suits for damages.

New California Law Gives Child Sex Abuse Prosecutors More Time
Jim Wasserman, Associated Press, 4/3/2003

SACRAMENTO, Calif. -- Gov. Gray Davis signed a bill on Thursday giving prosecutors more time to press charges in potential child sex abuse cases. The law could help authorities investigating 19 potential sex abuse cases involving Los Angeles priests where time limits were set to expire beginning Monday. But the law's future is uncertain the Supreme Court is hearing a case that challenges whether California can legally prosecute decades-old molestation charges. A decision is expected in July.
    California prosecutors used to have one year to press charges after receiving accusations of child sexual abuse. But the law was changed after prosecutors claimed defenders of suspected Los Angeles priests were running out the clock on the time limit by challenging their attempts to gather evidence.
    The Archdiocese of Los Angeles says the documents prosecutors want are confidential. The new law would stop the one-year clock from running while judges consider the merits of defense challenges. A spokesman for the archdiocese declined comment Thursday. The Sacramento-based California Catholic Conference, which speaks on church public policy, reported no position on the bill.
    Before 1994, authorities had to bring charges within three to six years of the crimes being committed. In 1994, California lawmakers said prosecutors could bring charges at any time, so long as they were brought within a year of a victim informing police, no matter how long ago the abuses took place. The bill signed on Thursday eliminates that one-year requirement if a suspect is challenging a grand jury subpoena for evidence.
    On the Net: Read AB949 at www.assembly.ca.gov

Funding Cuts May End Sex Assault Crisis Center
Amalie Nash, Ann Arbor News- 4/4/2003

The Washtenaw County-sponsored Sexual Assault Crisis Center may be forced to close this fall as a result of budget woes that have already slashed services to rape victims and other clients, officials said. Officials say disbanding the center is the worst-case scenario -- but a distinct possibility -- if additional funds or partnerships can't be found before the fiscal year ends Sept. 30.
    The center, the only Washtenaw County program offering support services to sexual assault victims from the general public, has already begun feeling the effects of funding cuts that have slashed 60 percent from its budget since last August. Advocates stopped responding to local hospitals this week when sexual assault victims show up, although they plan to continue following up with those victims at a later time, said Elizabeth Lindsey, volunteer services coordinator at the center. Since August, they've met with 70 victims at the hospital - including five last weekend - guiding them through the medical examination and the police inquiry, she said.
    Other service cuts include:
* A reduction in staff members from seven last October to three currently;
* No individual counseling for victims whose sexual assaults occurred more than six months ago;
* No plans for future support groups after the current one finishes in July;
* No volunteer training sessions after the session scheduled for May, and no internship opportunities for students;
* A reduction in professional consultations and training.
    The next likely step is to eliminate the court advocacy service in which staff members attend hearings with victims, Lindsey said. Since court cases take six months to more than a year, advocates can't promise they'll be available until the end, she said. "We'll hang on as long as we can," Lindsey said. "We've been here 27 years, and this is really sad. Right now, we're going with the punches and doing the best we can. We were unique because we're one of the only standalone sexual assault programs in the area."
    There were 123 rapes reported in Washtenaw County in 2001 and 115 the year before that, according to Michigan State Police statistics. Last year's figures are not yet available.The Sexual Assault Crisis Center provides counseling to about 250 people a year and answers an average of 2,000 to 3,000 calls on its 24-hour crisis line, Lindsey said.
    The center had a budget of $491,106 in the 2001-02 fiscal year, consisting of $252,680 in grant funds and $238,426 in local funds from the Washtenaw Community Health Organization. The budget fell to $303,643 this fiscal year as a result of a loss of $124,292 in county funds and $73,495 in grants, according to county figures. The county agreed to add $12,500 from its general funds to the current budget as a one-time allotment simply to keep the operation going, said Ellen Clement, administrative health officer for the Washtenaw County Public Health Department. The budget is expected to dip to $173,633 in the upcoming fiscal year since county funding has disappeared, and one grant fell by $5,700.
    State budget cuts have forced many counties to disband what are considered non-mandated services. Other local public health programs, such as the Maternal-Infant Health Advocacy Service, also have suffered as a result of budget cuts, Clement said. "We're desperately working to find a way to replace local funding or work in a collaboration or partnership to sustain the services," Clement said. "A number of important initiatives have begun recently, and it's heart-breaking to have cuts on the heels of developing excellent programming."
    Dana Walker is a rape survivor who now facilitates a support group at the Assault Crisis Center. The 25-year-old Eastern Michigan University student said the program, which she attended four years ago, was essential to her recovery process. "I had seen counselors before, but I never really had anyone understand the things that were going through my head before I went there," Walker said. "Finally there were others who felt the same way I did. I felt like they really cared." Walker returned to the center for one-on-one counseling when she felt she needed someone to talk with after she finished the initial program. In January, she decided to volunteer. "I wanted to be able to help someone else get through it sooner if I could," she said. "It's been a little hard because you hate to hear people going through that, but when you see someone starting to get it, it's worth it."
    Walker said she and others who benefited from the program were angered to learn that funding cuts threatened its existence. "I'm angry because the way I see it, it's taken years upon years for the government to look at women's issues as important," Walker said. "Domestic violence and sexualized violence are two things we need to focus on. It feels like they're not paying attention to these problems, which is in a sense condoning it."
    Local police officials say they also turn to the Assault Crisis Center after sexual assaults are reported. "It's an important service that we're able to refer victims to," Ann Arbor Detective Sgt. Richard Kinsey said. "It will be a real detriment to see something happen to the program." The clients who will be hardest hit are those with no insurance or low incomes who can't afford private therapy, Lindsey said. She's been sending letters to local therapists, hoping someone can step in and offer help or a solution.
    County officials have been talking with other local agencies about the possibility of combining services or becoming partners, and are considering turning the Assault Crisis Center into a nonprofit agency if new funding sources could be found, said Mike Murphy, coordinator for prevention for the Washtenaw County Public Health and Mental Health Department. "Sept. 30 is a critical date for us, and we hope we won't have to close but can make some kind of a transition," Murphy said. "There are a lot of unknowns right now, and everyone is scrambling for money." Supporters of the center are encouraging people to write the Washtenaw Community Health Organization Board or appear in person at a county board meeting. The board meets again April 16 at the Library Learning Resource Center.

Play Offers Clues to Preschoolers' Depression
Dianne Partie Lange, Los Angeles Times- 4/4/2003

Preschoolers are often believed to "mask" their depression with behavior problems, stomach aches or other physical complaints because they can't express themselves verbally. But a new study has found that young children exhibit the same symptoms as depressed adults and older children.
    As part of a five-year study of depression in preschoolers sponsored by the National Institutes of Mental Health, researchers interviewed the parents of 174 children between the ages of 3 and 5 1/2. The depressed children were much more likely to have anhedonia (lack of pleasure in activities), sadness, irritability and low energy than children who had no psychiatric problems or who had attention-deficit/hyperactivity disorder or oppositional defiant disorder.
    "They don't enjoy playing. They look sad and are irritable," says principal investigator Dr. Joan Luby, assistant professor of child psychiatry at Washington University School of Medicine in St. Louis. Some also engaged in play around negative or death themes and had disturbed sleep or appetite.
    "Preschoolers are inherently joyful beings," says Luby, "so if your preschooler begins to not enjoy activities or a favorite food and it lasts for many days, it's a matter of concern." The study was published in the March issue of the Journal of the American Academy of Child and Adolescent Psychiatry.

Shaping the Connection: Parent/Child Bonding
Benedict Carey, Los Angeles Times- 4/5/2003

Children aren't the only ones showing off at the playground. Parents are on display too: There are the playful moms and dads, swinging on the monkey bars; the bookworms and cell phone gossips, their minds elsewhere; the anxiety-prone, shadowing their child's every step as if it could be the last; and those who continually bark instructions ("William, now what do we call that? William, what do we say to that boy? William!").
    As natural as it comes to some, parenting is for others a work in progress. In part, psychiatrists say, this is because mothers and fathers often repeat some of the same gestures, patterns and habits of their own parents. These habits are more than mere quirks. As several years-long research studies now show, children who grow up with a warm, stable connection to their parents (or other caregivers) are primed to form the same kind of connection later on, whereas those who start with uncertain or anxious bonds often struggle to forge close relationships as adults, even with their own children.
    The study of these parent-child bonds and their consequences is known as attachment theory, a field of psychology that over the years has inspired both scientifically rigorous research and a stream of unsubstantiated, quick-fix parenting therapies, from simple advice to touch and hug children more often to more forceful "rebirthing" techniques to induce attachment. Yet recent studies underscoring the lasting effect of a loving, attentive caregiver have generated a surge of renewed interest among family researchers and therapists about the notion of attachment. More than a dozen new books based on attachment have landed in bookstores over the last year, from parenting guides to scholarly works. A wide range of attachment-based research is underway, from studies of mothers in the San Francisco Bay Area to female prison inmates in Baltimore to low-income families in New York.
    "The revolution has happened," said Victoria Levin, a behavioral research specialist at the National Institutes of Health in Bethesda, Md. "Attachment theory is now the background and backbone of a lot of the work that's going on in families with young children. This is because researchers who started out studying infants have followed these kids into adolescence. They find that the quality of their original attachment still predicts a child's competence, the way they interact with other people, how they do in school, whether they have behavior problems, and on and on."
    Current studies attempt to teach parents the theory, in effect, so that they can apply it themselves. At UC San Francisco, Dr. Alicia Lieberman has worked with immigrant families and victims of domestic abuse, showing them how stress and painful memories can interfere with attentive parenting. Jude Cassidy, a psychologist at the University of Maryland, is running a program for about 100 inmates at a Baltimore prison, teaching them how to see their young children's behavior and body language as attachment students would. And at the Marycliff Institute, a family counseling center in Spokane, Wash., psychologists are significantly improving relations between parents and preschool children in an experiment called the Circle of Security.
    Cammy Latimer, an elder-care worker in Spokane, had her hands full with two young children when she heard about this study. Her youngest child, Alyxandria, then 2, was prone to tantrums and defiance. "Once I had a stranger come up to me and actually say something about it," she said. "It wasn't much different from what I see other kids do, but at that point I was interested to try anything that could help me with her."
    Latimer liked the fact that the program used a single image -- a circle -- to help explain how attachment worked. From a very early age, the theory goes, children move away from their parents to explore but continually circle back, using their parents as a "secure base." An infant crawling around a new room continually looks to her parent, for reassurance or attention, and periodically reaches out to be held. Children repeat the same loops -- moving away to explore, reaching or looking back to touch base -- as they get older, whether investigating a playground as a toddler, playing in the backyard with a new friend or phoning from a party.
    In theory, the ideal parent does several things: encourages exploration, remains alert for the child's cues and signals for reassurance or shared emotion, and then responds to those cues by offering comfort. "It's a dance between the child and parent, with rhythm and timing, and it's going on all the time, from a very early age," said Kent Hoffman, a psychologist at Marycliff who designed the program with two colleagues, Bert Powell and Glen Cooper.
    To picture this circle, counselors asked Latimer and Alyxandria to participate in a classic attachment experiment called the Strange Situation. . As observers watch through two-way mirrors, a mother and young child are led into a small waiting room where a box of toys is in plain view. . The mother then leaves the room, so that the child is alone with the stranger. Infants and toddlers who become upset when their mother leaves and then reunite warmly when she returns are thought to be securely attached. "All sorts of things go on during this interaction, but you're watching the reunion very closely," said Dr. Robert Marvin, a researcher at the University of Virginia who is working with the Marycliff group. "What you want to see is for the child to show need openly and for that need to be filled," by a quick glance, a gesture, a smile, a touch -- any intimate signal. .
    However trivial they might seem, these small exchanges are physically shaping a child's brain and body as he or she grows, new research shows. A mother's caress or comfort not only lowers the amount of stress hormones circulating in the child's blood, for instance, it also helps teach the child's body to regulate its own response to upsetting events in the future.
    "The idea is that we are born to form attachments, that our brains are physically wired to develop in tandem with another's, through emotional communication, beginning before words are spoken," said Allan Schore, a UCLA behavior specialist and leading attachment expert. "If these things go awry, you're going to have seeds of psychological problems, of difficulty coping, stress in human relations, substance abuse, those sorts of problems later on."
    The video of the Latimers' Strange Situation revealed a complex interplay. As her mother stepped out of the room, Alyxandria, though unsettled, continued playing, and she remained absorbed in the toys when her mother came back. At the end of the session, mother and daughter played out a scene familiar to any parent: Asked to put away the toys, Alyxandria resisted and haggled until her mother did the job.
    Watching the replay later, Latimer smiled at the sight of Alyxandria's manipulations and defiance. "Especially when I was in public places, I was very reluctant to have an argument with her, so I let many things slide," she said. The video suggested that, like many loving parents, Latimer relates to her young daughter in a variety of guises. Sometimes she was the wise, engaged mother, as when reading to her child. Other times she came across more as a friendly partner, a kind of big sister.
    In counseling sessions that followed, Latimer was encouraged to expand on the role of wise, strong mother and to reflect on the origins of the mother as friend. "Our belief is that all parents have an inner gyroscope, a North Star" of parenting to guide them, said Hoffman. "The issue is that there are often experiences in our own past that create dissonance when we start to trust that sense of balance."
    Often treated as a friend by her own mother, Latimer recalled taking control of situations when she was very young, even though she wasn't ready to do so. "I'm still very close to my mother -- we talk every day -- but I could see that with Aly she wanted me to take control and let her know what to do." At the end of the Marycliff program, the Latimers visited the Strange Situation again, also on videotape. This time the little girl gets visibly upset when her mother leaves. When mom gets back, she jumps in her lap, and the two read a book together for a few minutes. Alyxandria then cleans up all the toys. "I do still get frustrated sometimes, but now it's like I stand back and remind myself I'm the bigger, stronger, wiser person here," Latimer said. "I don't end up screaming at anyone anymore."
    In two years, Hoffman, Cooper and Powell have guided more than 70 parents and their children through the program. Some parents are too reluctant to allow their children to explore, perhaps because their own overprotectiveness is contributing to their toddler's neediness and reluctance to explore. Others discover they are often too busy multi-tasking on the phone or doing other chores to notice when their children circle back for a comforting smile or remark. The researchers say they have documented significant improvements in attachment in 3 of 4 families.
    Those results, while encouraging, are preliminary, the researchers say. It is too soon to know whether the improvements will endure or how well similar attachment programs will work among different groups of parents. L. Alan Sroufe, a child development researcher at the University of Minnesota, says only time will tell. "I do not doubt that people can change -- of course they can. But usually it doesn't happen quickly."

Therapy for Soldiers on the Iraqi Battlefield
Bernard Weinraub, New York Times- 4/6/2003

WITH V CORPS HEADQUARTERS, near the Kuwait border, -- The other day, the buddy of a frightened soldier took him to see Maj. Graham Hoffman, a psychiatrist from Pueblo, Colo., and a reservist who has been called up to serve in the war against Iraq. "He was frightened of going to Iraq and afraid of chemical attacks, couldn't get it out of his mind," Major Hoffman said. "It seemed like a pretty normal amount of fear."
    Major Hoffman, who serves with the 883rd Combat Stress Control Detachment, a unit run by psychiatrists, said he tried to "reframe" the fears of the soldier in order to calm him. The doctor told the soldier that it was perfectly natural to be scared, and that, even though a chemical attack would be dreadful, it would probably not prove fatal to many soldiers because of their training and the masks and outfits they wear to protect against such an assault. "We talked about ways to relax," said Major Hoffman, a quiet-spoken, 46-year-old doctor who joined the Army reserves after the Sept. 11 attacks. "This was a guy who was really keyed up. We taught him simple things -- holding your breath, letting it out after five seconds, feeling the tension leave your body. Semi-hypnotic stuff. Self-massage. He seemed much more reassured when he left."
    There are two combat stress units in V Corps, the Army force in the Iraq war, teams of doctors who treat soldiers struggling with fears and anxieties. (In addition, each division has a psychiatrist, psychologist and social worker assigned to it.) Many medical personnel in the Army are reservists. Civilian psychiatrists like Major Hoffman serve a minimum of three months in a theater of war, like Iraq, but may serve much longer at the government's request. In contrast to their work in civilian life, psychiatrists in the Army are less engaged in resolving the personal problems of soldiers than getting them back into the field as quickly as possible.
    Antidepressants and antianxiety medications, commonplace in civilian life, are not prescribed for soldiers, for example, at least in the early stages of their treatment. "Our job is not to get into prescriptions because we don't see battle stress as an abnormal response situation," said Maj. Timothy Patterson, a psychiatrist and reservist from Mansfield, Ohio, who runs a combat stress unit.
    "To start using medicines gives soldiers the impression that they're patients, and they're not," Major Patterson said. "We see them as soldiers having a normal amount of stress in an abnormal situation." Combat stress symptoms include "feelings of anxiety, upset stomachs, somatic complaints -- anxieties that are converted to body illness -- twitching, as well as emotional and maybe even spiritual problems."
    Major Patterson said that initially, several days of rest, fluids, hot food and sleep left most soldiers ready to return to their combat units. Often sleep deprivation -- and commanders' not realizing that soldiers need plenty of sleep -- leaves troops unable to function properly. Major Patterson said that about 80 percent of soldiers treated by the combat stress unit returned to their units after several days of rest and relaxation.
    Major Hoffman said that combat stress units in the Army go back to World War I, when recuperation areas were created to help anxious soldiers. In recent years, he said, the Army had' studied the Israeli Defense Force's methods of dealing with combat stress. The Israeli military was more. or less in a permanent state of war, he said, with a defense force comprised of reservists and others. The Army had created several channels to deal with combat stress, Major Hoffman said. If a soldier, he said, "is not able to normalize the emotions they're experiencing, not able to maintain cognitive control," the Army often places them in a headquarters unit for 7 to 10 days. The soldiers are assigned low-pressure jobs like kitchen duty and given further rest. Unlike Vietnam, the officers said, when troubled soldiers were often flown out of the country to hospitals or stateside units, the Army makes deliberate efforts to keep soldiers near their units. "Keep them close to their tribe," Major Patterson said. "It sometimes hurts the individual in the long term to send them away. They carry a sense of failure, take it home with them. It's a horrible scar to bear."
    The combat stress units here have started relatively late, in part because their Humvee vehicles and .communication equipment were delayed. In the past, Army commanders have sometimes given lip service to psychiatrists, viewing soldiers who visit them as slackers. But a certain urgency in V Corps has given psychiatrists some importance after the recent arrest of a soldier in the 101st Airborne Division who is accused of throwing a hand grenade into a tent, killing two officers and wounding 13.
    Major Patterson, who is 48, and whose practice in Ohio includes steel mill and factory workers who have been laid off or are unemployed, said the soldiers he meets in the mess hall sometimes question the reason they are in the Iraq war. "That's why its important for officers to remind them why they're here," Major Patterson said. "We lose sight of our goals. Soldiers want assurance. They have to be kept focused on their mission."
    Sitting outdoors in the pulsing desert heat in mid-afternoon, Major Patterson and Major Hoffman said it was normal for soldiers facing combat to also face fear and stress. "Out here, we lose all the normal structures as to who we are," Major Patterson said., "You're in a foreign situation. Look around. You're in the biggest sandbox in the world. With no toys, except guns. People get frightened. They have no control over their daily life. And they have to be reminded of the token skills that allowed them to succeed so far."

Mike Wallace Speaks About His Depression
Krista Larson, Associated Press- 4/7/2003 20:04

SOUTH BURLINGTON, Vt. -- Journalist Mike Wallace says it began with trouble sleeping and eating. After being named in a $120-million libel suit against CBS News, Wallace was having trouble coping. And as the 1984 trial continued, Wallace descended into what was later diagnosed as clinical depression. ''Little by little, I would go out reporting on jobs and I didn't know the questions to ask,'' recalled Wallace, who has been co-editor of ''60 Minutes'' since its 1968 premiere. ''I couldn't, I didn't hear the answers. I couldn't follow up. And suddenly I began to spiral down.''
    Wallace, 74, detailed his personal experiences with mental illness Monday at the third annual Governor's Summit on the Employment of People with Disabilities, also attended by Sen. James Jeffords. ''The stigma associated with mental illness is lessening, but we have a long, long way to go,'' said Jeffords, who personally invited Wallace to speak at the event. ''I look forward to the day when we view mental illness no differently than physical illness.''
    Wallace emphasized Monday that depression is an illness that can be effectively treated. ''With talk and with medication, it is something that can be treated and can be cured, which is exactly what happened to me,'' he said. ''I was simply ashamed of the fact. I didn't want to tell the people that I had worked with that I was depressed.''
    The libel lawsuit against CBS News was later dropped. And in 1985, Wallace appeared as a guest on Bob Costas' ''Later,'' an early morning program with an audience full of listeners still awake. ''And I said, 'those are my people, the people who can't get to sleep' and that's the first time I began to talk about this publicly,'' he said. ''And I'm so glad that I did.''
    Wallace also detailed his experiences in the 1998 HBO documentary, ''Dead Blue: Surviving Depression.'' He says he doesn't like to consider himself ''a professional depressant,'' but explained Monday how sharing his experiences has been beneficial to him and to others. ''First of all, you feel so much better when you go public,'' he said. ''It's good for you to go public, and then after you've gone public, people come up to you on the street.''
    Those attending the governor's summit spent Monday drafting recommendations to give Gov. James Douglas on ways to reduce barriers to employment for people with mental illness. However, Wallace said he did not come across any stigma in disclosing his illness to co-workers. ''I think everyone breathed a sigh of relief that it was finally out in the open,'' he said. Wallace also never felt any pressure to change careers. ''I never heard that they were worried about it because by the time they learned the truth about it, I was over it,'' he said. ''I don't think the stress of the job was what it was; I really do believe it was that libel suit and you do lose your way. ... You really begin to believe some of the nasty things that are said about you.''
    The experiences of an accomplished professional like Wallace can do much to dispel stereotypes about mental illnesses, Douglas said. ''Speaking out about it as Mr. Wallace has done for us this morning, I believe is a very important step to overcoming the stigma,'' Douglas said. Previous speakers at the governor's summit have included actors Michael J. Fox, who has Parkinson's disease, and Christopher Reeve, who became paralyzed from the neck down in a horseback riding accident in 1995.

Toilet Training by the Clock
New York Times, 4/8/2003

Starting toilet training early is a good way to have it last longer, a study released yesterday said. When parents began intensive toilet training --directing the child to use the toilet more than three times a day -- before the child reached 27 months, it took 10 to 16 months and ended, on average, when the child was 35 months old. Children who began the process from 27 months old to 33 months old were toilet trained, on average, by their 36th month, according to the study, which was published in the journal Pediatrics. On the other hand, the two groups showed no difference in the amount of constipation or stool withholding, which have been described as side effects of starting toilet training too early, said the study's lead researcher, Dr. Nathan J. Blum of the Children's Hospital of Philadelphia.
    The study was based on a series of interviews with the parents of 378 children. The children, patients at a large suburban pediatric practice, were almost all white, the study said; other research has found that children in minority communities tend to be toilet trained earlier. The data show that parents are not especially good at judging when their children are ready to begin toilet training, Dr. Blum said. The finding, he added, is not surprising, given the vague nature of advice that experts offer on what to look for.

Mothers' Minds and Babies' Bellies
New York Times, 4/8/2003

Mothers who are depressed or anxious are more likely to take their children to doctors for stomachaches and abdominal pains, a new study has concluded. The study found that mothers with the highest levels of depression were twice as likely as mothers with the lowest levels to seek medical help for abdominal pain reported by their children. The gap persisted even when the figures were adjusted to account for different levels of pain. Dr. Rona L. Levy, a psychologist at the University of Washington School of Social Work, presented the findings to a conference of the Society of Behavioral Medicine in Salt Lake City late last month.
    The study made use of survey data from patients enrolled in a large health maintenance organization. It had been collected for a broader study examining the ways that pain and coping mechanisms are transferred from mothers to their children. The researchers focused on 326 children who had suffered a stomachache or abdominal pain in the two weeks before the survey, according to the mothers' responses. The researchers then examined the H.M.O.'s records to see which of the mothers had brought the children to see pediatricians for similar complaints in the previous three months. The data were then compared with the mothers' mental states.
    "We are not advocating that parents ignore physical symptoms in their children," Dr. Levy said. But it is important, she said, for pediatricians and parents to realize that the decision to seek medical treatment can be influenced by a mother's psychological state. Children learn how to deal with life's aches and pains by watching how their parents respond to them, she said.

Group Blames Medication
Ellen Barry, Boston Globe- 4/11/2003

As friends, family, and investigators searched for a possible motive in Tuesday's slaying of a Massachusetts General Hospital cardiologist, an antipsychiatry ''watchdog group'' said that Colleen Mitchell's psychiatric medication had spurred her to shoot Dr. Brian McGovern and then turn the gun on herself. Members of the Citizens Commission on Human Rights, which is affiliated with the Church of Scientology, planned a protest at the hospital today against the use of antidepressants such as Zoloft, which Mitchell had apparently been taking.
    There is a long history of allegations that selective seratonin reuptake inhibitors (a tremendously popular category of antidepressants that includes Prozac and Paxil) drive people to violence or suicide. In 2001, a Wyoming jury made a $6.4 million judgment against GlaxoSmithKline, which makes Paxil, after an oil field worker taking the drug shot his wife, daughter, and granddaughter and then committed suicide. The company appealed the decision and ultimately settled out of court. The following year, the Food and Drug Administration filed a brief supporting the drug maker's position.
    A Harvard Medical School psychiatrist said yesterday that it is ''preposterous'' to assign blame for a crime to an antidepressant like Zoloft. The drugs increase buildup of a naturally occurring chemical, seratonin, around nerve endings in the brain. Although ''edgy'' people may sometimes see an exaggeration of that quality, he said, the effects are transient. ''These medicines are not that powerful, frankly, for good or for ill,'' said Dr. J. Alexander Bodkin, chief of the Clinical Psychopharmacology Research Program at McLean Hospital. ''It is not a cause for misbehavior, not an excuse for misbehavior, and it doesn't help us understand the misbehavior.''
    But a Utah activist who has testified as an expert witness against drug manufacturers said a high level of seratonin in the brain can cause people to ''act out their nightmares,'' leading them to commit violent crimes. Ann Blake Tracy, director of the International Coalition for Drug Awareness, said she had become increasingly suspicious of SSRI antidepressants as she watched more and more friends in Utah begin taking them, ''doing violent things completely out of character for them.''
    The debate over the drugs has emerged in Boston several times since 1990, when a McLean researcher, Dr. Martin Teicher, published a study showing that 3.5 percent of patients taking Prozac attempt or commit suicide due to severe agitation. Eight years later, Teicher helped to patent a reformulation of the drug, whose application states that the new version reduces side effects such as ''intense, violent suicidal thoughts.''

California Center Combats Terror's Psychological Effects
Lisa Krieger, Houston Chronicle- 4/12/2003

SAN JOSE, Calif. -- Americans have a lot of practice coping with earthquakes, floods, hurricanes and other natural disasters. But threats of terrorism? As evidenced by the recent run on duct tape after yet another "orange alert" from the federal government, many people feel pretty helpless. Now, a new Palo Alto-based team of therapists has set out to help Americans build a sense of emotional resiliency not provided by emergency supplies, extra vigilance or official warnings -- over time, they hope, taking the terror out of terrorism. The group, called the National Center on Disaster Psychology and Terrorism, seeks to create a "National Mental Health Corps" to work with communities to prevent and prepare for mass casualty assaults -- then act as "rapid responders" in the awful event of an attack.
    Terrorism is destructive because it creates a feeling that psychologists have nicknamed "Pre-Traumatic Stress Disorder," that jumpy, anxious premonition that sometime, somewhere, someone you don't know will assault you. Even worse, many are left feeling there's nothing they can do to protect themselves, said Larry Beutler, professor of psychology at the Pacific Graduate School of Psychology and a co-founder of the center.
    The strategy of modern terrorists is to create huge numbers of psychological, not just physical, casualties. "In this country, we know a lot about natural disaster, but not a lot about terrorism," Beutler said. "Terrorism is different because it is a malevolent act, something aimed at you specifically -- not because of anything about you, but because you are an American." "What is frightening is the idea that somebody else out there, not just fate, is plotting against your life," he said. "You haven't just lost control -- you've lost control to another person." "If you're afraid of earthquakes, you can move away. If you're afraid of heights, you can stay out of tall buildings," Beutler said. "But there are few things you can do to get away from all other people."
    National authorities such as Dr. Leon Moores of the Walter Reed Army Medical Center in Washington have calculated that use of a weapon of mass destruction could cause thousands of casualties -- but that the psychological consequences of such an attack would have an affect on millions. That projection is based on the legacy of attacks in other countries. Israeli officials have calculated that for one death directly caused by an Iraqi Scud missile attack on Israel during the Gulf War, there were 272 hospital admissions resulting from psychological emergencies. In Tokyo, the 1995 sarin attack in the city subway killed 12 people -- but caused more than 4,000 non-affected individuals to run to local hospitals with psychogenic symptoms of chemical injury.
    The Sept. 11 tragedies forced military, medical and psychological experts to re-evaluate their approach to mass casualty terrorism, said center psychologist and co-founder Bruce Bongar. There was an urgent need for highly trained clinical psychologists to treat the thousands of victims, rescuers and their families, he said. But the effort to deliver mental health care was scattered, disorganized and understaffed, involving well-intentioned but inadequately trained mental health professionals. And because they were volunteers, most from out of town, they couldn't make a long-term commitment to troubled patients.
    The droves of "trauma tourists" who descended upon New York and Washington actually might have compounded the suffering of victims and their families, Bongar said. The Red Cross spent a lot of energy turning away volunteers who rushed down to help but lacked credentials. The inadequate training of those who rushed to help was not entirely their own fault; there is little training available in disaster mental health services, Bongar and Beutler said. And there is scant knowledge about which kinds of treatments actually work. Better training will be a focus of the center's work. The center has its origins in a small grant from Oxford University Press, which sponsored a two-day, invitation-only conference last October for experts in disaster response. It is a collaboration between the Pacific Graduate School of Psychology and the Palo Alto Veterans Health Care System, with funding anticipated from the federal government.
    Running the center are four prominent psychologists -- American Psychological Association President Philip Zimbardo, Palo Alto VA Health System psychology service chief James Breckenridge, as well as Beutler and Bongar. Center psychologists also hope to find a scientific way to identify the small but significant number of people who are most emotionally vulnerable. "There is a natural resiliency in Americans," said Beutler. "After Sept. 11, the great majority of people were angry and upset and horrified, but did not have major psychological illness. Everybody didn't need treatment." "But if we deal with terrorism by preparing solely for physical damage, and not psychological, we're in serious trouble."

Vincent Gigante, Not Crazy After All
Andy Newman, New York Times, 4/13/2003

An enduring urban mystery was solved last week when Vincent (The Chin) Gigante, the Mafia leader who spent decades slobbering, muttering and wandering Manhattan in his bedclothes, admitted in a Brooklyn federal court that he had deceived the teams of psychiatrists who had evaluated his mental competency from 1990 to 1997 and found him to be suffering from various forms of dementia. Mr. Gigante, 75, was sentenced to three years in prison, to be served, if he lives, after he completes his current racketeering sentence in 2007. He pleaded guilty on the eve of a trial at which prosecutors were prepared to play audiotapes of numerous phone calls he has made to family and friends since being imprisoned in 1997.
    Another mystery remains: How did some of the most respected minds in forensic psychiatry and neuropsychology -- including a prominent Harvard psychiatrist, five past presidents of the American Academy of Psychiatry and Law, and the man who invented the standard test for malingering, get it wrong? For Mr. Gigante's 1997 trial and. sentencing, at least six doctors declared him mentally incompetent. A juxtaposition of some of their 1997 findings and excerpts from a phone call Mr. Gigante made to his wife, Olympia, in December 2000, shows how far apart diagnosis can be from behavior:
"Mr. Gigante currently has moderate to severe dementia which reflects significant underlying central nervous system dysfunction." -- Dr. Wilfred G. van Gorp, director of neuropsychology at Columbia University Medical School
"He is suffering from schizophrenia. Schizophrenia is a disease of the mind which is manifested by delusions, hallucinations, a thought disorder, and what we call negative symptoms. Negative symptoms include a flattening of affect or a constriction of emotional tone, psychomotor retardation, a slowing down of his thinking processes and of his muscular motor coordinate movements."-- Dr. Louis D'Adamo, who had been Mr. Gigante's personal psychiatrist for 17 years.
"I do not believe that Mr. Gigante's overall level of dementia can reasonably be attributed to the type or dose of his current medications.... None of the likely causes will change in the future, with or without treatment, and thus the dementia will either continue at about its present level or, more likely, worsen over time." -- Dr. William H. Reid, professor of Forensic Psychiatry at the University of Texas medical school and past president of the American Academy of Psychiatry and Law.
"I don't think he has a sense of time passing in the sense of knowing when things occur, or at least I didn't see that in the interview. But he might have some idea of, you know, past versus present." -- Dr. Thomas G.Gutheil, co-director of the Law and Psychiatry Resource Health Center at Harvard Medical School
He does not speak in sentences. He just speaks in words. Very often I would ask him a question and he would give a short answer which is not related to my question at all .... In all the years I've known him I have never been able have a cogent conversation with him….If I would say to him, "Vincent, how are you feeling, are you feeling better than last time?" He would say, "My mother cooks." "Did you sleep last night?" "I ain't sick no more."' -- Dr. D'Adamo
"Mr. Gigante revealed impairments of memory (recalling only one out of three objects in five minutes), orientation (knew only the year), fund of information (impoverished)….He was unable to discuss meaningfully any aspect of his case….this examination is consistent with other data and with substantial incapacity to understand sentencing….In anything that requires organized thought or thinking at any level of abstraction, his basic deficit is revealed by his inability to really do that and , in fact, thee is no clinical evidence in the entire data base that affirmatively indicates that he can manipulate abstract information." -- Dr. Gutheil
"He manifests organic brain damage by his inability to, for example, subtract 7 from 100. His memory is impaired. He sometimes is very con fused and doesn't know where he is or the time of day, the year. His recall is very poor. If you would give him two or three objects to recall, he would have difficulty doing it immediately after you tell him and certainly after a period of three or four minutes." -- Dr. D'Adamo
   During the recorded conversation in 2000 with his wife, Olympia, Mr. Gigante reconstructs both sides of a lengthy discussion with a prison doctor:
GIGANTE-- I went to the doctor today.
OLYMPIA-- You did? What'd he say?
GIGANTE-- He says, "You haven't got a rupture." He says, "What's this about ruptures?" I says, "You were supposed to call me." He says, "Well, how long you got the pain?" I says, "It's about 2 months" Ain't it about two months?
OLYMPIA-- Maybe.
GIGANTE-- On and off. He says, "six months?" I says, "Doc;" I says, " [tssk], almost two months." He says, "All right, I'm gonna give you the same medicine you're taking."
GIGANTE-- Then he put a glove on and he went and he examined me down there and he said, well, he says "You ain't got a rupture. Cough." I coughed. You know something? It didn't hurt. Every time I sneeze or cough, it hurts. Today it didn't hurt. "Does that hurt?" I says, "No here's the pain." I showed him where the pain is and I showed him where the scar is. I said, "That scar hurts too ....
OLYMPIA-- So if it's not a rupture, what did he say it is?
GIGANTE-- He says it could be a torn ligament. 'What do I know? He's a D.O. [doctor of osteopathy.] He ain't a doctor. You understand?
    The subject shifts from Mr. Gigante's possible hernia to his heart condition:
GIGANTE-- Then he told me that the heart doctor is a fine doctor. I says, "I didn't say he ain't."
GIGANTE-- He says, "Well, I'm going to give you all, all the same medicines and this and that. You pick it up today." I says, "Doctor, I can't pick up the medicine today because I still got all that medicine, I gotta finish that first."
GIGANTE-- He says, "You know, your ejection, when we done the echocardiogram, your ejection fraction is down to 35." Normal is 60.
OLYMPIA-- So?
GIGANTE-- So I says, "What do you want me to do?" He says, "Well, I'm just telling you." I says, "Then I'm in trouble." "Oh no," he says, "don't worry," He says, `You'll be all right. You're doing fine." I says, "Thank you." I Says, "but the pains in the chest don't mean nothing, doc?" "All right, take your Nitro." I says, "I do but it gives me headaches." He, he was nice. I ain't saying he wasn't bad, but he does the best he could.
    All the doctors who examined Mr. Gigante were asked if there was any chance he was malingering. Most of them said no, noting that in addition to his behavior, scans of his brain showed abnormalities in blood flow consistent with vascular dementia.
"Mr. Gigante's responses appeared to reflect cognitive processing difficulties and were very atypical of malingering." -- Richard Rogers, a malingering expert and professor of psychology at the University of North Texas in Denton.
   The reports of the psychiatric experts are broadly in agreement as to Mr. Gigante's assessment as not competent or unfit to proceed with sentencing. Note that these individuals are senior people in the profession of forensic psychiatry and very familiar with the issue of real versus malingered mental illness. All raised or addressed the question of malingering; all found the evidence not supportive of that diagnosis. Beside dementia, additional diagnoses offered included various forms of schizophrenia (Dr. Portnow notes that 34 different doctors made this diagnosis over the years), personality disorders and serious medical conditions.
"Although he could have certainly fooled me, and I will readily concede that possibility, and some of the other doctors recently, the evidence in all of the database, the clinical evidence in all the database, comes down the other way." -- Dr. Gutheil
   Many of the doctors were played brief excerpts from the tapes by the prosecutors:
"[Mr. Gigante] sounded like a guy talking to his family -- the technical term in forensic psychiatry is schmoozing." -- Dr. Gutheil said that nothing he heard established that Mr. Gigante was legally competent.
"The guy on the tapes is not the one I examined. I hear the tapes and I hear a quasi-normal person talking. The question is how do you explain it." -- Dr. van Gorp said Mr. Gigante might be both mentally ill and a malingerer.
"It should make all of us humble that we can indeed be had, because we don't get inside somebody's brain." -- Jonathan D. Brodie, a psychiatry professor at New York University School of Medicine who testified for the prosecution in 1997, called on his the prosecution in 1997 called to admit that they had blown the call.

Autism: Nudging Toward Normal
Jane Gross, New York Times- 4/13/2003

PARAMUS, N.J. It is lunchtime at the Alpine Learning Group here, and four preschool children assemble at a small round table and unwrap their sandwiches and juice boxes. The teacher prompts a sweet-faced 4-year-old named Ben to initiate a conversation with his classmate, Emily. "Ask Emily- 'Do you need a napkin?"' suggests the teacher, Deirdre Moon. Ben dutifully repeats question "Say 'Here, Emily,"' Ms. Moon continues, showing Ben how to pass the napkin to the little girl. He imitates the gesture.
    Now Ms. Moon turns to Emily. "Say `Thank you, Ben."' Emily thanks him. Again, it is Ben's turn. "Say `You're welcome,"' the teacher tells him. Ben is muttering to himself, staring into the middle distance. "Ben, look at me," Ms. Moon says. His eyes flicker toward her face. She repeats her instruction. This time Ben complies. This lunchtime chitchat would be effortless for most children. But for Ben and Emily it is an achievement, since both are autistic.
    Autism is the mysterious neurological disorder that strands children is a private world, oblivious to others, without the curiosity and instinct to imitate, which makes learning possible. Many have no meaningful language, are prone to tantrums that disrupt schooling and cling to ritualistic behavior like hand-flapping or twirling that take the place of play. Thus a simple social interaction between Ben and Emily deserves extravagant praise. "Good job, you guys," Ms. Moon says buoyantly. "Awesome."
    The number of children like Ben and Emily seems to be rising steeply, as documented in a new study in California that found an increase of 273 per cent in the number of children with profound autism from 1987 to 1998, a number that continues to increase. Some experts attribute this in part to improved diagnosis. Once children like these were considered lost causes, destined for an institution. But along with a growing caseload is new confidence in one form of treatment, applied behavior analysis.
    A.B.A. is the only intervention that has proved successful in controlled experiments, although small and unreplicated. The method has its roots in the research of B. F. Skinner, who developed a system of modifying behavior with rewards and punishments. His early techniques have been refined through the decades and found to be helpful with autistic children. Then came news that recovery was possible for some children: a 1987 study by O. Ivar Lovaas at the University of California at Los Angeles followed 19 autistic children under age 4 through a regime of 40 hours a week of one-on-one behavioral therapy. Nine of 19 children, generally those with higher I.Q.'s, achieved normal cognitive functioning. Followed into adolescence, these children were found, as well, to be socially indistinguishable from peers, shy in some cases but not outside the normal range. This early, intensive behavioral intervention is now recommended by an array of experts, including the National Academy of Sciences, which issued a report in 2001 urging at least 25 hours a week. But fewer than 10 percent of autistic children receive it, the academy says, because of long waiting lists at special schools, shortages of trained therapists and difficulty persuading districts to pay for this particular treatment when more generic special education, while less effective, would be much cheaper.
    Many parents, Ben's among them, initially react with horror at seemingly robotic techniques. How can a 2-or 3-year-old -- the typical age at diagnosis -- sit still for hours and hours, bombarded with commands and rewarded for compliance with bits of food, special toys or squeals of praise? Ben's mother recalls her initiation to the treatment. Ben was 2 at the time, newly diagnosed. He had no speech and spent most of his time at the window ledge pushing a toy train back and forth, stroking his own cheek and ignoring his parents and twin brother, Oliver. Heeding the advice of a network of parents with autistic children and unwilling to experiment with unproven treatments like milk and wheat-free diets, swimming with dolphins or mercury cleansing, the family reluctantly agreed to try an A.B.A. home program, supervised by AP pine's outreach staff.
    The first goal was to get Ben to sit is a chair, make eye contact and follow simple instructions, all prerequisites for language and learning. "Without basic attending behaviors, a child will just run around the room and flap," says Ben's father, Adam. (Adam and Yvonne, both tax lawyers, asked that their surname and hometown not be published.) Reinforcing Ben's efforts with M&M's, a chance to turn the pages of "Cat in the Hat" and constant praise for "Good sitting!" and "Good looking!," the little boy gradually accepted the chair and the eye contact, the tools of engagement. But for the first two weeks, or so it seemed to Ben's distraught mother, Yvonne, the house in northern New Jersey rang with anguished howling. "Many times I thought to myself, `You're out of here,"' Yvonne recalls about the therapists. "It was heartbreaking to hear him so upset. He's a little boy. I wanted him playing in the park. Then I remembered he didn't know how to play in the park"
    Ben's progress was swift. He mastered simple things like pointing when he wanted something or playing peekaboo. Slowly and methodically, the therapist's physical and verbal prompting was "faded," in the jargon of behavior analysis, and reinforcements for success made less tangible and immediate. The skills were generalized to natural situations, like a family celebration or a trip to the store. Tantrums were discouraged by ignoring them or redirecting Ben's attention elsewhere. These outbursts usually have a reason, therapists say, like avoiding a task. Ben was taught to seek relief in a less stigmatizing way, like asking for a break. Anytime he was tantrum-free for five minutes, calculated on a kitchen timer there were special rewards.
    By summer, just before his third birthday, Ben was speaking, the most promising of signs. "Some children respond more readily and rapidly," says Bridget Taylor, co-founder of the Alpine Learning Group and a leading researcher in the field. "We just don't know in advance who those kids are." (I.Q. may be an indicator of success, although the test is less reliable in children without speech.) The four variables, Dr. Taylor says, are the age when treatment begins, the quantity of therapy, the quality of therapy and the neurological potential of the child--whether, for instance, autism is coupled with mental retardation. "We have control over the first three," Dr. Taylor says. "No. 4 becomes apparent over time," generally between age 5 and 8. Until last fall, Ben continued his therapy at home -- up to 30 hours a week, one on one. His parents were similarly trained, so they could consistently reinforce what Ben was learning. "You have to keep on top of it every waking minute," Yvonne says. "And when you're tired, the temptation is to say, `Just this one time.'"
    Ben's family has been luckier than most in finding and paying for this kind of care, which became wildly popular after the 1993 publication of "Let Me Hear Your Voice," an account by a mother of her two children's recovery from autism, with Dr. Taylor, then a graduate student, as their teacher. With interest at a new high, skilled A.B.A. teachers, who charge $40 to $100 an hour, were scarce. The family's goal was 30 hours of treatment a week but they could rarely find qualified therapists for that many hours.
    At first, Ben's family paid thousands of dollars out-of-pocket for his teachers. The state of New Jersey expects school districts to pay for a disabled child's education after age 3, but itself supports only two hours of treatment a week before then. Months of exhausting back and forth with their insurance company eventually produced some reimbursement. The next hurdle was finding a preschool spot and getting the state to agree to pay for it. Again, Adam and Yvonne were blessed. Already familiar to Alpine directors from the outreach program, they were offered a coveted slot when another preschooler made the transition to a mainstream kindergarten. And their home school district approved the placement without protest, agreeing to pay the $60,307 for a 12-month school year, including case management, home visits, the training of family and staff and gradual mainstreaming for children ready for it. Some districts might have insisted that a public :special education classroom was sufficient, leading to costly litigation if a family had the conviction, stamina and money for the fight.
    Like many such schools, the Alpine Learning Group was founded by parents; the first classes were held in 1988, with four children in a church basement. It now ranks among the most respected programs, along with the Princeton Child Development Institute and the Douglass Developmental Disabilities Center of Rutgers University. Its outreach program serves 14 children up to age 5. The school itself has 27 students, ages 3 to 21. Some of the younger children, like Ben, are candidates for mainstreaming, although others never master the necessary language, social and behavioral skills to get by in a regular classroom. The older students at Alpine are more impaired, being readied for jobs and some degree of self-sufficiency in group homes. Obviously, that is not what their parents hoped at the beginning. But untreated they might have been institutionalized, which over a lifetime is far more expensive than even this costly form of education.
    Last fall, Ben began at Alpine, working one on one from 9 a.m. to 2:45 p.m. with either Ms. Moon or another teacher, Danielle Spinnato. Formal lessons are interspersed with so-called incidental learning, like the scene at lunch. Four times a week; after school, Ben has two hours of therapy at home. Often, Oliver is included and he helps guide Ben through make-believe birthday parties and board games.
    Applied behavioral analysis is a way of life, lived 24/7. Immersion is essential because learning to clap, wave or point can require hundreds of repetitions for an autistic child. Hand-washing and similar self-help skills are taught one step at a time: Pull up sleeves, turn on water, wet hands, get soap, rub hands together, rinse off soap, get paper towel, dry hands, throw towel away. Tantrums and other idiosyncratic behavior must be all but eradicated if a child is to attend a regular school, go to church or take a family vacation.
    This winter, Ben has worked on more than 40 academic, social and self-help programs, each with a defined objective, step-by-step teaching method and measurable goal. His programs, filed in a fat black binder, include "requests preferred items from a peer," "puts on a shirt," "follows instructions from a distance," "answers questions about the calendar," "cuts using scissors" and "tolerates the presence of dogs." The give-and-take of natural conversation can be a struggle. When Ben drops a piece of paper on the way to the recycling bin, Ms. Moon prompts him to say "oops." At lunch, she takes his straw away so he will have to ask for it. In the gym, she asks, "Who wants to go on the trampoline?" Ben says nothing but climbs aboard. She insists he come down and say "me" before taking his turn.
    By January, Ben had met Alpine's criteria to spend a few hours a week in a normal preschool:. he responds to his name, follows simple one-step instructions like "Hang up your coat," takes turns with other children and rarely throws tantrums. Ms. Spinnato accompanies him to the Friends Neighborhood Nursery School in nearby Ridgewood. She reminds him to look at the teacher or stop touching his face, but less conspicuously than in his Alpine classroom -- a silent thumbs up, for example, instead of an audible "Awesome!" as she nudges him toward normal. Ben easily learns a song about bluebirds. But he does not join the others making bird feeders with crumpled bread, peanuts, raisins and seed. He cleans up nicely when it is time to go and says "Bye" to his friends. A little girl named Molly asks Ben to make her a Valentine card. The next week he does. Adjustments -- improvisations, really-- are necessary as Ben's life unfolds. In preparation for Friends, Dr. Taylor asked Yvonne to replace his sweatpants with jeans, like his new. classmates wore. Some autistic children find certain clothes uncomfortable or make a ritual of wearing the same thing. Everyone at Alpine told Ben how cool he looked. The praise made the scratchy denims bearable.
    Ben poses different challenges at home, where it is difficult to maintain the rigorous consistency of school. One afternoon, cranky from the flu, he refuses cough medicine, wrests himself from the nanny's hold and begins singing "Old McDonald Had a Farm" at the top of his lungs. Yvonne tries to calm him without success. Both have trouble prodding Ben from a favorite hiding place behind the couch. During frequent home visits Dr. Taylor guides their way. She does not want Ben behind the couch since it encourages his natural isolation. Nor does she want him confused by two adults telling him what to do at the same time. Yvonne should take the lead, Dr. Taylor advises.
    It is always two steps forward and one step back. For several days running, Yvonne says, Ben will be a model 4-year-old, taking his cereal bowl to the sink without being asked and greeting company. Then, for no apparent reason, she wakes to find her son "the poster child for autism," moving from one peculiar behavior to the next so the family can't go anywhere without strangers staring. But good days outnumber the bad by a widening margin. One recent evening, Adam was on his knees by the side of the model railroad tracks. He is an affectionate father, shaping Ben's behavior with the sort of praise that would not have registered on the child's radar screen awhile back. "How many cars are there?" Adam asks Ben. The who-what-why-where-when-and-how questions were part of the boy's curriculum that week. "Four," Ben answers smartly. Adam disagrees, touching the little cars -- one -two-three-four -- all the way to six. Yvonne turns her attention to the counting. Her husband insists there are six cars. Ben holds firm on four. Yvonne sees immediately that the front two were engines, thus Ben is right. Adam is thrilled by the subtlety of Ben reasoning and explodes with high fives. Then he bombards his son with addition problems. 6 + 6? 12; 3 + 7? 10; 7 + 6? Both are confident now, grinning. And Ben looks squarely into his father's eyes.

Online Training
As pediatric autism rates rise, so does the need for training and information. In response, Mark Durand, a psychologist at the State University of New York at Albany, has set up a distance-learning curriculum about the origins of the disorder and ways to treat it. The three-course program, which awards a certificate, covers diagnosis, philosophical and legal issues, basic principles of behavior analysis and teaching techniques. Professor Durand holds weekly online chats, and his campus lectures are taped for viewing online or via CD. Most students are teachers or health care providers, but about l0 percent are parents of autistic children. Tuition is $411 to $630 for credit, and $200 to audit. New classes begin in September. For information: http://www.albany.edu/psy/autism/aden_courses.html

Transgenders Fighting for Same Protections as Gays
Alicia Chang, Associated Press- 4/14/2003

ALBANY, N.Y.-- Four months after New York became the 13th state in the nation to outlaw discrimination against homosexuals, transgender-rights advocates continue to seek the same protections. A law prohibiting anti-gay bias in employment, housing, education and public services took effect in January, but many transgender people felt betrayed that they are not included under the new statute. ''Transgender'' describes a range of gender identities, including cross-dressers, transvestites, transsexuals and those born with the physical characteristics of both sexes.
    On Monday, dozens of transgender activists holding signs like ''Gender Rights Now'' joined lawmakers to introduce an anti-discrimination bill. ''This is about basic human rights,'' said Sen. Thomas Duane, the Senate sponsor of the bill and the chamber's only openly gay member. Currently, three states and 53 cities and counties in the United States, including New York City, Buffalo, Rochester, and Suffolk County, have passed laws protecting transgender rights.
    Last December, Republican Gov. George Pataki signed into law the Sexual Orientation Non-Discrimination Act, which was supported by Empire State Pride Agenda. The Pride Agenda, the state's largest gay and lesbian group, had endorsed Pataki in his 2002 re-election bid after the Republican-controlled state Senate said it would take up the gay rights bill. It was a resounding victory for gay-rights activists, who lobbied for the civil rights protections for more than three decades. However, many transgender people were stung that the new law left them out. Duane, a Manhattan Democrat, introduced an amendment last year to add protections for transgender residents, but the measure failed in the Senate.
    Tanya Walker, 39, of New York City, who considers herself a ''pre-operative transsexual,'' said she was often assaulted and faced verbal abuse from strangers who disapproved of her taking female hormones and dressing as a woman. ''I've been brutalized and beaten on the street because people notice that you're not wearing the clothes assigned to your gender,'' said Walker, who has scars on her temples and cheeks.
    Assemblyman Richard Gottfried, a Manhattan Democrat and co-sponsor of the transgender rights bill in the Assembly, said many people mistakenly assumed that the gay rights' measure applied to transgenders as well. Gottfried said a law safeguarding transgender rights was ''long overdue.'' A spokeswoman for Assembly Speaker Sheldon Silver, Sisa Moyo, said the speaker was opposed to discrimination and would take a look at a transgender rights bill.

To Fight Meth Labs, Missouri Targets Cold Pills
Stephanie Simon, Los Angeles Times-4/14/2003

ST. LOUIS -- Desperate to halt a soaring drug problem in rural Missouri, state lawmakers are weighing severe restrictions on sales of common over-the-counter cold medications, such as Sudafed, that can be used to make methamphetamine. The House last week passed the toughest legislation in the nation regulating pseudoephedrine, the active ingredient in most nasal decongestants. The bill, now under consideration by the Senate, would limit customers to two boxes of medication per transaction. More controversial still, the bill would require stores to keep nasal decongestants behind the counter or within 6 feet of the cash register, or to tag each box with an anti-theft device.
    Several other states have banned consumers from buying more than three boxes of cold pills at one time. But no other state regulates where decongestants can be sold, said Nancy Bukar, a lobbyist for the Consumer Healthcare Products Assn., which represents manufacturers and distributors of over-the-counter medicines. "This is a ridiculous solution," said Ronald Leone, executive vice president of a trade group representing convenience stores. Most stores, he said, already stash cigarettes, adult magazines, liquor and condoms behind the counter. There's no room, he argued, for decongestants. "This law is draconian," he said, "and it's not going to solve the problem."
    The problem is that pseudoephedrine can be combined with other ingredients -- such as anhydrous ammonia from farm fertilizer or red phosphorus from matches -- to produce methamphetamine, a highly addictive, illegal stimulant that is also known as meth, ice, crystal and crank. Missouri law enforcement officers raided 2,725 meth labs last year -- an average of more than seven a day. California's illicit labs tend to produce a higher volume of the drug, but for two years running, Missouri has led the nation in the sheer number of meth seizures. The makeshift labs -- which involve highly volatile chemicals and are prone to explosions -- have been found all over the state, including wealthy suburbs. They are most common in sparsely populated rural areas, where meth addicts convert abandoned barns into miniature factories, using everyday products such as cold pills, propane tanks and coffee filters to brew the stimulant.
    "Methamphetamine represents the fastest-growing drug threat in Missouri," said Sen. Anita Yeckel, a Republican who is sponsoring the pseudoephedrine bill. "We want to take the most aggressive way we can to fight the problem.... Tighter control of meth ingredients seems to be one of the most promising approaches." Critics argue that although the bill might slow down theft of cold pills, it would not prevent a meth addict from buying as much as he needed to make the drug. Although customers would be limited to two boxes per transaction, they could get back in line again and again, buying two additional boxes every time. Or they could buy two at each of a dozen stores. Still, Capt. Chris Ricks of the Missouri State Highway Patrol said law enforcement would welcome any restrictions that make it even a bit harder for meth cooks to get their hands on pseudoephedrine. "There is a methamphetamine epidemic in this state," Ricks said. "We're looking for any tool we can get that might help us fight it."