Bay County Has Michigan's Highest Drinking Rate
Associated Press, 11/28/2004

BAY CITY, Mich.-- It's 5 p.m. on a weeknight, and Clinton Blade is on his eighth beer at the Lighthouse Lounge. He says he might down eight more before retiring to his apartment above the bar. Blade is one of more than 9,000 Bay County residents -- about 11 percent of the adult population -- who are heavy drinkers, according to the Michigan Department of Community Health. The county has the state's highest percentage of heavy drinkers, defined as those who consume more than 60 drinks a month, The Bay City Times reported in a Sunday story.
      More than 22,000 residents -- about a quarter of the adult population -- are binge drinkers, which means they have at least five drinks in a row at least once a month. Only Marquette County has a higher rate of binge drinkers in the state. "I drink every day. It's not a problem," said Blade, a 33-year-old construction worker. "It's the American way. When I get off work, I want to mellow out."
      Margo A. Charlebois, executive director of Bay Area Social Intervention Services, Inc., an alcohol prevention and treatment agency in Bay City, says the statistics are evidence of a major problem. "It really speaks to the culture in Bay County," she said. In the past five years, two inpatient alcohol-treatment centers closed in Bay City because insurance coverage and public funding declined. The only inpatient program left in Bay County is Bridgewater, an eight-bed facility in Bay City that is often full.
      Alcoholics also won't find detoxification services in Bay County. The closest one is in Saginaw. "Where are the people who couldn't get help?" Charlebois asked. "My guess is they're in jail or on the streets."
      Health and law enforcement leaders are finding creative ways to combat problem drinking without sinking their budgets. Next year, the District Court will test a program that offers reduced jail time for third-time drunken driving offenders in exchange for treatment, alcohol education classes and finding a job. The Bay County Jail is offering a new substance-abuse program for adolescents.

Law, Psychiatry Clash When a Mother Kills
Thomas Korosec, Houston Chronicle- 11/28/2004

DALLAS - The shocking list of Texas women accused of killing their children, brutally, by hand, grew by one last week. Dena Schlosser, police say, cut off the arms of her infant daughter, then sat holding the knife, listening to hymns in her apartment in Plano, a Dallas suburb. A day earlier, the 35-year-old homemaker allegedly told her husband she wanted to send the child to God. The case immediately drew comparisons with those of Andrea Yates, the Houston mother who drowned her five children in a bathtub in 2001, and Deanna Laney, who killed two of her three sons in East Texas last year by bashing their skulls with rocks.
      In those and at least two other headline Texas cases in recent years, the worlds of criminal justice and psychiatry collided, and with little agreement about what should happen to the women involved. "There are people who feel a price must be paid and those who are willing to concede there is something called mental illness," said Dr. Jaye Crowder, a forensic psychiatrist in Dallas. The idea that someone can become so ill that they do not know what they're doing "is something terribly difficult for some people to understand."
      Although legal and psychiatric experts caution it is too early to say how Schlosser's case will develop, it appears likely to center on mental illness and the question of sanity in the eyes of the law. She has been charged with capital murder and is being held in custody without bail. Child Protective Services officials say Schlosser was treated in a psychiatric hospital for postpartum depression after the child's birth in January. By August, the mother of three was taken off psychiatric medication and child welfare officials closed their case. But then came Monday. After going to the child's crib in a back bedroom and cutting off the child's arms at the shoulders, Schlosser called her husband, who was at work in Arlington, to tell him what she had done, according to court papers and a 911 call.

Defining psychosis
"These cases present the courts with problems because of the vast differences between legal and psychological definitions," said Dr. Sherwood Brown, assistant professor of psychiatry at the University of Texas Southwestern Medical School in Dallas. "You can be psychotic and suffer from delusions and hear voices, and still know the difference between right and wrong, which is the legal definition of sanity."
      The jury that found Laney not guilty by reason of insanity earlier this year, and the jury that convicted Yates of capital murder in 2002, were both criticized in reaching their verdicts, he said. Psychological experts in both cases agreed that the women were suffering from psychosis, but in Yates' case, the state's expert testified she knew what she was doing when she killed her children.

Researching a disorder
Leslie Hunt, executive director of the Austin-based Postpartum Resource Center of Texas, said research into postpartum psychosis has not advanced to the point that experts can say with certainty whether women suffering from the disorder abandon free will and an ability to choose. "It's a truly baffling disorder that needs more attention," Hunt said. "Until more is understood, women who commit these heinous crimes will be judged in the courts, where they've been judged harshly."
      Experts say postpartum depression affects about 10 percent of women after giving birth. Symptoms include emotional numbness, withdrawal, lack of joy and loss of concentration severe enough to interfere with one's ability to function. The more extreme postpartum psychosis affects about one in 1,000 and can be accompanied by thoughts of suicide, delusions, hallucinations, paranoia, and, in about 4 percent of cases, the act of harming one's children.
      Lisa Ann Diaz, a Plano mother who was found not guilty of capital murder by reason of insanity in August, said a prayer — "Dear God, please take care of my precious angel" — before drowning her two daughters last fall. She told authorities she knew it was time to kill them when she spotted a pair of crows in her yard.
      It comes as little surprise to experts in the field that religion has played a role in the Texas cases, including both Yates' and Laney's. Yates said she believed she was saving her children from eternal damnation. She thought Satan lived within her and the state would execute her for her children's murders and rid the world of evil. "The content of delusions is strongly related to your culture," Brown said. Street people often clash with authorities, he explained, so their delusions tend to include police, the CIA or the FBI. "These are women with religion in their lives," Brown said. "You also see strong themes of good and evil, which grows out of that."

Juries deciding sanity
Houston defense attorney George Secrest successfully defended Evonne Rodriquez, who was found not guilty by reason of insanity for the 1997 killing of her 4-month-old child. He said Texas, with its elected prosecutors and judges, has a long tradition of letting juries, not medical professionals, decide whether someone is insane. "It's safer politically to say, 'We'll just let the jury decide,' " he said.
      But legal rules in the state set a high bar for defendants pleading insanity, Secrest said. Prosecutors can use any action before or after the crime that hints that a person was cognizant of his or her wrongdoing, and that evidence often exists. "Experts will tell you people can drift in an out of sanity from moment to moment," said Secrest, whose client told police she killed her child to rid him of demons. "They may know what they did was wrong a half-hour later, but not the moment they did it." He said prosecutors in Houston pressed their capital murder case against Rodriquez even though their own psychological expert agreed she was insane. "It was fortunate for us they videotaped her confession," Secrest said. "You could see how wigged out she was. She was just in a different world."

Looking into their minds
George Parnham, Yates' attorney in Houston, said the law requires sane, rational jurors to interpret what a psychotic person "knew" when the crime occurred. "It's difficult for most people to comprehend what is going on in the mind of someone so terribly ill," he said.
      Dr. Phillip Resnick, professor of psychiatry at Case Western Reserve University School of Medicine in Cleveland, testified as a defense expert in both the Yates and Laney trials. He noted that jurors are likely to accept an insanity defense only in cases where experts hired by prosecutors agree with those hired by the defense team. In Laney's trial last spring, he noted, all five psychological experts agreed she was unaware of her actions, and still her eventual acquittal was not assured. The first vote by the jury was eight to four for conviction. The Tyler jury heard a forensic pathologist testify that bruises on the victims' tongues showed they died screaming. "That kind of testimony makes jurors not want to excuse anyone," Resnick said.

New Court Aims to Aid Mentally Ill
Jeff Coen, Chicago Tribune- 11/28/2004

After six months funneling troubled defendants into specialized mental health courts, planners say the new effort at the Criminal Courts Building is showing signs of success. Just 18 recognizably mentally ill offenders have been moved out of the Cook County Jail so far. But none of them has had new arrests after they were placed on felony probation, officials said.
     That statistic is impressive considering that the 11 male participants had averaged 2.5 arrests in the year prior to being moved into the mental health court, organizers said. The seven female participants averaged more than five. Most have extensive histories of arrests for crimes including retail theft and prostitution. "We're talking people who on average have about 40 arrests in their backgrounds," said Mark Kammerer, who has led the effort for the Cook County state's attorney's office.
      Launched in May after years of planning, the pilot program seeks to locate the mentally ill in the Cook County Jail and link them to treatment centers. Non-violent felony offenders suffering from schizophrenia, bipolar disorder or severe depression are given the option to plead guilty in their new cases and be sent directly to treatment as a condition of their probation. The hope is that with the proper counseling and medication, such defendants can readjust to society on some level and commit fewer crimes. In addition to helping the individuals, planners said keeping them out of the local criminal justice system could ease overcrowding in the jail, where about 1,000 inmates are on some kind of psychotropic medication.
      The plan works by identifying candidates already in the jail on new cases. Specialists at the jail's Cermak Hospital compare a list of open files from the Illinois Division of Mental Health Services to the daily list of jail inmates. When they locate matching names--typically those who at one point were in treatment at a community center--the candidates' criminal records and other factors are considered. Once a candidate voluntarily agrees to be part of the program, he or she is placed on probation and met outside the jail by caseworkers from the social service agency Treatment Alternatives for Safe Communities, or TASC.
      The 18 current participants had averaged 108 days in the jail during the last year, said Maureen McDonnell, director of justice operations for TASC and its project leader for the mental health court. The lack of new arrests shows the model can work, McDonnell said. "That stands out for us as a very positive thing so far," she said.
      If a program participant misses a treatment or a court date, it is considered a technical violation, planners said. A warrant is sent directly to a crisis intervention team at the Chicago Police Department, which attempts to locate the missing probationer. In the past, such offenders might only have been located a year or more later and by then have completely regressed into their illness.
      There have been a few disappointments. Organizers say such heavy work to keep the offenders on track has pressed resources and would limit the number of people who can participate in the program. First envisioned as a pilot program for up to 50 offenders, the program may now be capped by the end of the year at 25. Judge Lawrence Fox, who sees the female offenders, says he also believes the screening process for candidates needs to be refined. "What I have found is we are getting the most seriously mentally ill and those with the most serious histories," the judge said. "Those are tough cases to work with and tough cases to get through."
      Fox said he might like staff members in the mental health unit of the Cook County Probation Department to select some candidates who are less ill, instead of relying on computer matching, and possibly locate better candidates for long-term success. McDonnell said she agrees with Fox that wider and better screening ultimately will make the program more viable. "There absolutely is a range of needs out there," McDonnell said, acknowledging that the level and intensity of the need for services among those now involved in the program has been greater than expected. McDonnell said she hopes more funding will be found to expand the mental health court in the coming years. "That definitely is one of the things we'll be looking for," McDonnell said. "The early outcomes so far have been promising, but we are still learning."

Mental Illness Sends Many to Foster Care
Chris L. Jenkins, Washington Post- 11/29/2004

RICHMOND -- Almost one of every four children in Virginia's foster care system is there because parents want the child to have mental health treatment, a report commissioned by the General Assembly states. The study -- the result of a months-long examination of the state's foster care and mental health services -- chronicles the difficult decisions that thousands of Virginia parents have made to relinquish custody of their children to the foster care system so they can get mental health services that are otherwise unavailable or unaffordable.
     Many of these parents have children who suffer from schizophrenia, severe depression or bipolar disorder. The cost of caring for these severe conditions is so high that private insurers and HMOs don't fully cover it, and in many cases, the families make too much money to be eligible for Medicaid. But because children can get those services if they are in foster care or in special education programs, parents turn to the child welfare system, which can provide day treatment, residential care and other expensive services. "The main problem is that there is inadequate access to mental health treatment . . . and it tends to be extremely expensive if parents are able to receive it," said Raymond R. Ratke, deputy commissioner of the state's Department of Mental Health, Mental Retardation and Substance Abuse Services, who led the work group that published the report.
      State and local officials have known about the problem for years, but the report is the first time Virginia has tried to determine its extent. In the 2004 legislative session, lawmakers passed a resolution impelling state officials to study the issue. A work group was established, and it met seven times during the summer and fall. The report, published this month, is based on an analysis of the Department of Social Services database, which offers partial information on how children come into foster care. It found that of the 8,702 children in foster care as of June 1, "2,008 . . . appear to be in custody to obtain treatment."
      In many cases, the report says, parents develop "a sense of having failed, and feelings of losing control over their own and their children's lives." The report's recommendations to the General Assembly include increasing funding for the Comprehensive Services Act, which is designed to provide money for mental health services for children, and helping families access private insurance for mental health services. The state estimates that 62,000 young people suffering from mental illness, behavioral disorders and emotional problems are not being served adequately by the commonwealth.
      State lawmakers who have studied the issue say they will push for an immediate infusion of funding for the Comprehensive Services Act, which spent $235.5 million in fiscal 2003 for mental health services. "This indicates a tragedy for many families," said Sen. William C. Mims (R-Loudoun), who is considering legislation that would add money to the state's mental health system. "It's the law of unintended consequences," Mims added. "But the state has fallen short. These parents don't do it for convenience. They do it out of necessity . . . and it's unacceptable."
      Advocates for the mentally ill say that other states and the District also struggle with funding mental health services for children and wonder how to stem the tide of children placed into foster care solely to get help. Last year, the federal government found that at least 12,700 children were placed in foster care or juvenile jails only because they needed mental health treatment. The study called it a significant problem in every state.
      A bill before Congress, known as the Family Opportunity Act, would let families of disabled children purchase coverage under the Medicaid program. Some states have also utilized federal programs that help states pay for residential treatment. Virginia officials said they will look more closely at those alternatives.
      Parents who have placed young people in foster care said it was the only alternative after years of arrests, psychiatric ward visits and violent behavior by their children. "We tried so much, but there seemed like there was nothing out there for him," said Fairfax County resident Marnie Merriam, mother of a 16-year-old with bipolar disorder. She said her son, Anthony, had started to lash out at her younger children, in one instance needing the police to calm him. "Giving him to the system was really the last thing I ever wanted to do. "But it came to this, and it robs you of the natural feelings of being a parent," she said. "Almost like you're giving up. . . . But I knew it was for the best."
      Advocates for the mentally ill said the chief problem is a "fragmented system" that doesn't get services to children fast enough because of long waiting lists and expensive treatments. "We are not very good at intervening early," said Margaret Crowe, policy director of Voices for Virginia's Children, a nonprofit advocacy organization in Richmond. "Children often have signs of problems, but all too often these issues are just not addressed."

Remedies: This Is Your Brain on Beer
John O'Neil, New York Times- 11/30/2004

This is the picture a new study paints of how different levels of alcohol affect a driver's brain: The first drink makes it harder to stay in your lane, while the second makes it easier to ignore the fact that you're headed for the ditch. The study was published in the current issue of the journal Neuropsychopharmacology.
      Nine test subjects made a series of simulated drives in a brain-scanning device after consuming drinks intended to raise their blood alcohol level to 0.04 or 0.08, which in recent years has become the legal limit in most states. For some runs they were given a placebo, a drink containing only a trace of alcohol served in a glass that reeked of it.
      The researchers, Dr. Vince D. Calhoun and Dr. Godfrey D. Pearlson of Yale, found that the first drink appeared to produce a slight impairment of gross motor activities. But in that condition, the subjects actually drove a little better, and a little slower, apparently aware of their possible impairment, than they did when they were completely sober, Dr. Pearlson said.
      The second drink was followed by a significant decline in gross motor functioning. But perhaps its most striking effect was on a region of the brain known as the orbitofrontal cortex, which plays an important role in what Dr. Pearlson described as error monitoring and inhibition -- reviewing what other brain regions are proposing and squelching bad ideas. "People were less aware of the consequences of their actions" after the second drink, Dr. Pearlson said. "They were poor judges of their deteriorating skills." As a result, they drove faster, left their lanes more often and were involved in more simulated collisions, leading Dr. Pearlson to conclude that the decision by some states to lower the blood-alcohol limit had been a good one.



Addiction: A Gene for Getting Hooked
John O'Neil, New York Times- 11/30/2004

Teenagers whose bodies clear nicotine unusually slowly from their systems became addicted to cigarettes at more than twice the rate of their peers, a study has concluded. In recent years, researchers have come to believe that genetic factors make some people more susceptible to addiction to tobacco, alcohol and other drugs, along with well-established social and environmental factors, said the study's lead researcher, Dr. Jennifer Lee O'Loughlin of McGill University in Montreal. The study, released last week, focused on genetic defects that have moderate or severe effects on the liver's ability to metabolize nicotine, the addictive stimulant in tobacco.
      The study, published in Tobacco Control, a British journal, involved 281 seventh graders who had begun to smoke but were not yet considered addicted. Thirteen percent had one of the defective versions of the gene. Over five years, 25 percent of the teenagers who were the slowest to process nicotine increased their smoking to the point of dependence, compared with 9 percent of those with normal nicotine metabolism and 10 percent who were slightly impaired, the study found. Having nicotine remain in the brain longer appeared to speed the habit-forming process, Dr. O'Loughlin said. On the other hand, it apparently meant that the teenagers with the severe genetic defect went longer between nicotine cravings - they smoked half as many cigarettes as tobacco-addicted teenagers with normal genes.
      Dr. O'Loughlin said it was possible that more research could identify those at high risk for addiction. In the meantime, she said, her researchers had concluded that findings like this helped convince young teenagers that they were taking a drug that might alter their brains.

Sorry. Your Eating Disorder Doesn't Meet Our Criteria.
Robin Marantz Henig, New York Times- 11/30/2004

Imagine a 20-year-old woman who refuses to eat anything except carrots and toast because she is afraid of gaining weight, even though she is 5-foot-8 and weighs only 99 pounds. She exercises to the point of exhaustion five mornings a week because, though she is bone-thin, she thinks her thighs are too flabby. Her periods are irregular, but she has never gone more than three months without menstruating. Another woman, who is also 20 and also 5-foot-8, has an opposite eating pattern. She goes without eating all day, and starting at 6 p.m. she eats nonstop, whatever she can get her hands on. Her favorite pastime is to sit in front of the television with a gallon of mocha-chip ice cream. She maintains a normal weight of 130 by occasionally forcing herself to vomit. But purging is not always easy in her college dormitory, with four young women sharing a single bathroom, so she ends up vomiting, on average, about once a week.
      Everyone can agree that these women have some sort of disordered eating. But psychiatrists would say that neither one falls into the strict definition of anorexia nervosa, the most severe eating disorder, or its relative, bulimia nervosa. According to the bible of psychiatric diagnosis, the American Psychiatric Association's Diagnostic and Statistical Manual, anorexia must be accompanied by cessation of menstrual periods for at least three months in a row, and bulimia must involve vomiting or other forms of purging at least two times a week, on average. Instead these women, and thousands like them, would fall into a category that doctors have been relying on for years, a vague nondiagnosis known by the acronym Ednos: eating disorder not otherwise specified.
      Diagnosing psychiatric conditions is more of an art than a science, and the Not Otherwise Specified label reflects the imprecision of that art. The American Psychiatric Association's manual has a Not Otherwise Specified category for many disorders, whenever symptoms are so vague, so mild or so untreatable that it doesn't seem to warrant the full-fledged diagnosis. With the manual continually under revision, the Not Otherwise Specified grab bag is the place where new diagnoses emerge. For instance, the diagnosis of Asperger's syndrome, a variant of autism, was pulled from a collection of disorders previously labeled Pervasive Personality Disorder Not Otherwise Specified.
      Much is at stake in whether a condition is elevated to the status of a full-fledged diagnosis. Because no laboratory tests or other objective criteria exist for making psychiatric diagnoses, the American Psychiatric Association's manual is the definitive arbiter of the line between normal and abnormal. Its definitions help determine such practical matters as insurance reimbursement, competence and eligibility for disability. But they also help determine something more elusive, and probably more important: whether someone's behavior should be considered a personality quirk or a symptom of mental illness.
      Now, in the diagnostic category of eating disorders, the search for greater specificity in the Not Otherwise Specified grab bag is generating much attention. "The Future of Ednos" was a topic at an international meeting on eating disorders in Amsterdam last month, and it is the title of a book expected to be released in Europe next year. To some observers, this new attention comes not a moment too soon. "Ednos right now is a real hodgepodge," said Dr. B. Timothy Walsh, professor of pediatric psychopharmacology at Columbia. "We have people in that category with anorexia nervosa," but they still menstruate so they don't meet all the criteria for a formal diagnosis.
      Similarly, Dr. Walsh said, "we have people who are obese and binge but don't vomit," so they don't fit into the strict definition of bulimia nervosa, which requires both binging and purging. Or they might binge and vomit once a week, but to qualify as bulimic they would have to vomit at least twice a week. "What we really need to do is collect data," Dr. Walsh said. "All the knowledge base we currently have relates to people who vomit twice a week. But if it turns out that the characteristics of those who binge and vomit once a week are similar to those who do so twice a week, then we can loosen the criteria for bulimia nervosa."
      The history of eating disorders has been a gradual one as the Diagnostic and Statistical Manual has been revised through the years. Anorexia nervosa first appeared in the version of the manual known published in 1980, and bulimia appeared for the first time in the same edition. Bulimia was renamed bulimia nervosa in the next edition, which came out in 1987. Anorexia nervosa affects 0.5 to 3.7 percent - or about 1.5 million to 11 million American women -- at some point in life, according to the National Institute of Mental Health. Rates are lower among men and teenage boys. The lifetime prevalence of bulimia is higher -- from 1.1 to 4.2 percent of women -- with a similar age and sex distribution.
      In the current version of the diagnostic manual, published in 1994, one condition -- binge eating disorder -- was pulled out of Ednos and listed as a "provisional diagnostic category," the first step in the process of achieving its own diagnosis. The disorder is much like bulimia nervosa, but without the purging.
      The "provisional" designation highlights the need for more research into a condition's prevalence and treatment, and highlighting binge eating disorder in this way was a prelude to its being named as a separate diagnosis in the manual that is to appear in 2012. "That's one of most compelling reasons to get something out of the Not Otherwise Specified category," said Dr. Michael First, associate professor of clinical psychiatry at Columbia. Dr. First is a member of the planning group that is directing the enormous undertaking of revising the manual for its fifth edition. "If you feel that there's a homogeneous group of patients in there for which there's a treatment, the fact that it's called Not Otherwise Specified really obscures it, hindering treatment, hindering research," he said.
      Another candidate for a new eating disorder in the fifth edition of the manual can be thought of as the flip side of binge eating, a condition that has been labeled "purging disorder" by Dr. Pamela Keel, an associate professor of psychology at the University of Iowa. Just as binge eating disorder has many of the characteristics of bulimia, so does purging disorder. But neither meets the strict criteria for bulimia nervosa. People with purging disorder, Dr. Keel said, are of normal weight, and they purge after eating normal or even small amounts of food.
      Right now, purging disorder is relatively hidden, buried in the Ednos category. And until the Diagnostic and Statistical Manual panelists ask for more data, as they have for binge eating disorder, not much more will be known, Dr. Keel said. "Within widely used diagnostic interviews, if a person has never had a low weight and denies a history of binge eating, the interviewer skips all questions regarding the use of vomiting, laxatives or diuretics to control weight," Dr. Keel wrote in an e-mail message. "It's very difficult to learn more about a problem if you never ask any questions about it."
      As Dr. First sees it, several criteria must be met before a diagnosis is pulled out of the Not Otherwise Specified category and into a stand-alone diagnosis. These criteria have to be met before binge eating disorder, purging disorder or any other condition emerges out of the Ednos grab bag. The first requirement is that a significant number of patients must be affected, he said. Second, there has to be evidence of an existing and effective treatment.
      The criterion of an effective treatment has prevented many conditions from being entered in the Diagnostic and Statistical Manual. In the 1980's, there was an effort to include "sadistic personality disorder." But it failed, said Dr. First, because no treatment existed. "We could have decided to call something sadistic personality disorder," he said, "but if there's no treatment, what would be the point?"
      The third criterion for removing a condition from the Not Otherwise Specified category is the trickiest to meet. It relates to a kind of diagnosis-creep. Experts working on Diagnostic and Statistical Manual panels must ask how close the condition is to behavior that could be considered normal. For binge eating disorder, for instance, they must ask: When is such behavior a true psychiatric condition, and when is it the kind of thing that almost everyone engages in every Thanksgiving? "This is the matter of what we call false positives," Dr. First said. "It's the danger of defining as a psychiatric syndrome a set of symptoms that normal people have." When a new category is created in the manual, he said, "you're trying to identify a category that will help patients get treatment." "But," he continued, "you're worried that this category is going to be applied to normal people as well."
      Some psychiatrists want to create a different label for Ednos, calling it instead "mixed eating disorder" or "atypical eating disorder." But Dr. Walsh of Columbia said that would be merely a cosmetic change. "If I'm a clinician and I get a call from a school saying, 'Hey, I've got a person with mixed eating disorder coming over,' I don't know if I'm going to be seeing someone who weighs 80 pounds or 280 pounds," he said. "The whole belief that diagnoses are useful things rests on their ability to put together under one umbrella a relatively homogeneous set of syndromes, which gives the clinician the ability to shortcut a full assessment." Diagnostic labels, said Dr. Walsh, "allow big shortcuts."
      Dr. Keel, on the other hand, prefers the term "mixed eating disorder" over Ednos. She said the mixed eating disorder label "may have the benefit of eliminating the false impression that Ednos is somehow less severe or less clinically significant than so-called full-threshold eating disorders." But she expressed concern that the term would limit the enthusiasm for teasing out what other identifiable conditions lie within the Ednos category.
      As experts debate what to do about Ednos - pull out distinct disorders from the grab bag category, change the diagnostic criteria for the existing disorder, give the grab bag a more scientific-sounding name - people with disordered eating are left in a kind of therapeutic limbo. Eventually, the hope is, the uncertainties will be resolved, and the woman with anorexia who still menstruates and the woman with bulimia who only purges once a week, will be able to get the diagnosis and treatment that they need.



Make It a Fair Fight
Hilary Stout, Wall Street Journal- 11/30/2004

A growing body of research suggests there is no such thing as a compatible couple. This may come as no surprise to all those who have endured years of thermostat wars, objectionable spending habits and maddening tendencies at the wheel. But it flies smack in the face of Hollywood, most people's core fantasies, and all those dating Websites touting sceintific screening to find a perfect match.
      Years of relationship studies by some leading figures in the field make it increasingly clear that most couples, whether they're happy or unhappy, have a similar number of irreconcilable differences. What is more, all couples -- happy or not -- tend to argue about the same things. Top of the list -- whether you are rich or poor -- is money.
     "Compatibility is misunderstood and overrated," says Ted Huston, a professor of psychology and human ecology. Huston and his colleagues have been following 168 couples since they married as twentysomethings during the 1980s. They interviewed them two months after their wedding, then again 14 months, 26 months and 13 years later about two potential marriage minefields: leisure interests; and the expectations about who should do what around the house. After 13.5 years, 105 of the couples still were married and 56 were divorced. (The others were widowed or couldn't be located.) The researchers found that the couples who divorced "were not less similar" in either category

The never-ending argument
This study and others like it also make clear that most disagreements that arise in a marriage -- 69 percent of them, according to work by John Gottman, a relationship researcher at the University of Washington -- are never resolved. The result has been a gradual shift in marriage therapy toward helping spouses manage, accept, and even "honor" their discord, rather than trying to resolve the unresolvable. "If I were to characterize the way programs have changed in last half-decade that would be the major thing," Huston says.
     Of course some conflicts do matter deeply.-- she wants children, he doesn't, to name a big one; alcoholism and infidelity to name a couple more. Differing religions and cultural attitudes also are problematic, especially after the couple has children, says Scott Stanley, co-director of the Center for Marital and Family Studies at the University of Denver. He and co-director Howard Markman have done extensive studies tracking couples from courtship through years of marriage.
     But the bottom line, Markman says, is that "virtually all couples, happy and unhappy, are going to argue, particularly in the early stages" of marriage. "What tends to predict the future of a relationship is not what you argue about, but when you do argue, how you handle your negative emotions."
     Growing consensus around that notion has led some in the profession to develop rules of engagement that can make arguing less destructive:
* Don't escalate an argument by blurting out generalizations: "You always ... " Stay on the specific subject. Don't drag out past events, behavior and lingering grudges into the discussion.
* Don't interrupt -- let your spouse finish making a point before you jump in.
* Take a little time to cool down after a heated argument. But within an hour, Gottman recommends having a "reconciliatory. conversation," which will should result in a more level-headed, productive discussion.
     While airing differences is important, make sure to set aside some time where discussing areas of discord is off limits, Stanley and Markman say. A walk by the river on a beautiful autumn day isn't the time to bring up problems; it is a time to enjoy each other and remember what attracted you to each other in the first place. Instead -- and this may seem weird -- set aside a time to talk about the things that are bothering you.
     Like many married couples, Jim and Kathryn Lewis have a Saturday "date" built into their weekly schedules. The purpose isn't to catch a movie or linger over a romantic dinner. Essentially, it is to argue. On the recommendation of Stanley a few years ago, the couple started going out to breakfast every Saturday morning to discuss problems and issues. At first it felt a little weird.
Once they settled into the routine, it proved enormously helpful. Before, discord could erupt at any moment and tempers would flare. Now, knowing they have a set time to discuss difficult issues is comforting and leaves them the rest of the week to relax, Lewis says. In fact, they rarely argue during the sessions anymore. The simply work through issues. "Now we really look forward to it,: he says.



If Your Teen Starts Smoking, Get Tough
Gregory Ramey, Cox News Service- 11/30/2004

DAYTON, OHIO - While vacuuming her 14-year-old son's bedroom, Patti discovered a pack of Marlboro cigarettes under his bed. She slumped in a beanbag chair and cried. Patti was overwhelmed with feelings of anger, betrayal and confusion. Patti is a devoted single parent. She made her own baby food when her son was an infant. She took him to the doctor if there was ever a concern about a cough or rash. All her caring and concern seemed so worthless to her right now. Despite her best efforts, her son was intentionally engaging in a behavior. that would likely cause him severe health problems and premature death. How should Patti handle this situation?
• Enforce the rules. Parents need to enforce a simple rule of "nothing illegal in my house." This includes teens buying or possessing, alcohol, cigarettes or illegal drugs. Parents need to be strong on
this one. Get angry. Yell and scream. Communicate to your child that smoking isn't allowed in your house. Make certain your teen experiences strong and consistent consequences for this life-threatening behavior.
     There are times when a parent needs to be calm, understanding and sympathetic. You need to listen and truly try to appreciate the world from your child's point of vies. This is not one of those times. We are legitimately concerned about the death of 1,000. Americans: in Iraq, and 3,000 citizens from the events of 9-11. However, 440,000 die yearly from cigarette smoking in America. Your child's health is at stake, and you need to stress in the strongest terms that this behavior will not be tolerated.
• Forget about education. Education usually is of little value. You can direct your teen to an Internet site about the dangers of smoking, but don't expect it to have much effect.
• Increase surveillance. Your teen's privacy should be respected. Except under extraordinary circumstances, you should never read your teen's journal or email, or listen to their phone conversations. But there is no right to possession of illegal substances, alcohol or cigarettes. You have every right to look through their room to see if they are obeying these rules.
• Stop smoking. If you smoke, how can ytou tell your teen not to smoke?

What We Do Defines Us, Therapist Says
Susan Reimer, Baltimore Sun- 11/30/2004

The people who come to see psychiatrist Gordon Livingston at his office in Columbia, Md., are not whiners. That's a common misunderstanding about people who enter talk therapy--that they want someone who will listen to them complain. But the paradox of psychiatry is that it often takes real courage, and sometimes real effort, to crawl out of bed and. find help.. Just the act of opening the Yellow Pages and picking up the phone may seem impossible to someone in the depths of depression or in terrible turmoil.
     It is another paradox of his profession that those patients, who have come to him for advice, have taught Livingston enough to fill a book He has just published "Too Soon Old, Too Late Smart" (Marlowe & Company, $18.) Its subtitle is "Thirty True Things You Need to Know Now" "I have some sense of how certain things work," said Livingston, who has been practicing psychiatry for more than 30 years. "And in the end, there are things that we can change and things we can't... Qualities like courage and determination are brought into play.
     Livingston, who writes regularly for The Baltimore Sun, has collected 30 original essays that cover quite a range. If there is a central theme, it is summed up in the title of the second essay, "We are what we do," and the sixth, "Feelings follow behavior." Livingston is talking simply about acting, getting up out of the chair, about putting one foot in front of the other, about doing what works, about faking it until it feels right.
"We are not what we think, or what we say, or how we feel. We are what we do," he says. "We are drowning in words, many of which turn out to be lies we tell ourselves or others." Many of us are waiting to feel better before we pursue the things that we know will make us feel better, he writes. Things such as exercise, hobbies or reaching out to be with people we care about, things that require effort, energy and a determination. that sometimes can be courageous.
     "Only bad things happen quickly" is another of the 30 things Livingston wants you to know. Real change and healing take time. Becoming the people we wish to be is hard work, and transformation is not sudden. But it is the act of trying that defines who we are, he says.



Brain Scan Helps Diagnose Bipolar Disorder, Study Says
Reuters News Service, 11/30/2004

CHICAGO - Bipolar disorder, a sometimes misdiagnosed mental illness characterized by wide emotional swings, may be identifiable by chemical abnormalities visible in victims' brains, researchers said Tuesday. Detailed brain scans performed on 42 adults, half of whom had been previously diagnosed as bipolar, showed consistently different levels of five chemicals in areas of the brain that control behavior, movement, vision, reading and sensory information, they said. The Mayo Clinic study used a high-power magnetic resonance imaging scanner that had twice the magnetic field strength of scanners previously used to examine the brains of bipolar patients.
      "Bipolar disorder is challenging to diagnose because individuals can cover up the symptoms of the illness or may recognize only their depression, not the manic phase of the disorder," Mayo Clinic radiologist John Port said in a report delivered to the annual meeting of the Radiological Society of North America. "The psychiatric community clearly needs a tool to help diagnose bipolar disorder," he said.
      The types of therapy used with bipolar disorder differ from those employed to fight depression, so a correct diagnosis is important, Port said. Most diagnoses are made based on conversations with the patient. Roughly 2.3 million Americans suffer from bipolar disorder, according to the National Institute of Mental Health.

Child Obesity: They Can't Do It Alone
Jeannine Stein, Los Angeles Times- 11/30/2004

Maria Cruz bustles around her kitchen preparing dinner, keeping one eye on a simmering pot of salsa verde and the other on her 8-year-old son, Abel. He's an energetic kid prone to bursts of song and dance — and to occasionally sneaking food when his mother's back is turned. "Ay, junior!" cries Maria as she spies him slinking off with a just-cooked chicken leg. Any mother would be annoyed, but Cruz's concern goes deeper. At 4 feet 7, Abel weighs just under 200 pounds, making him morbidly obese. Concerned about a family history of diabetes and fearing his weight will continue to rise, Cruz recently enrolled her son in an eight-week nutrition and exercise program that involves the entire family, not just the child. After a couple of weeks, Abel already has lost 5 pounds, an accomplishment that makes Cruz beam. She stands in the kitchen smoothing her son's T-shirt over his stomach and smiles. "See?" she says. "It used to stick out."
      Cruz and her husband, Abel Sr., are among millions of parents of overweight or obese children who are trying to help their children lose weight safely. Some, like Cruz, have been lucky enough to enroll their children in special programs that, while temporary, offer useful information. But there are far too few programs to fill the need, and many families have no idea where to turn. Some struggle to devise a nutrition and workout plan with little or no guidance. The process — however it's done — is seldom easy and can take years of commitment. Experts agree that parents are a crucial element in their children's weight loss. Kids need strong role models and a support system to provide proper nutrition, exercise and motivation to stick to a plan. That may mean that parents, many of whom are themselves battling weight problems along with their kids, can no longer live in denial about their own health.
      Obesity rates in the U.S. continue to rise: More than 15% of kids between ages 6 and 19 are considered obese, according to the federal Centers for Disease Control and Prevention. And those extra pounds put these children at heightened risk of diabetes, high cholesterol and high blood pressure. Obesity in youth is also a strong predictor of obesity in adulthood.
      While the obesity problem touches every demographic, ethnicity and culture, health experts cite the same culprits for all: television, computers and video games; junk food and unhealthful school lunches; inadequate school physical education programs and a scarcity of safe playgrounds and parks; busy moms and dads who don't emphasize the importance of physical activity to their children. Doctors may diagnose the condition, but might lack the time or knowledge to counsel families on nutrition, exercise and the psychological aspects of weight loss.
      Considering the mighty flow of information — much of it conflicting — about issues as varied as portion size and protein, it's not surprising that parents need help getting their kids started. Parents willing to make changes find the process both rewarding and frustrating. Cruz has been successful in changing some of her son's eating habits — he now eats more vegetables and fruit — but it can be a tug of war weaning him off the soda and sweets he loves.
      But Cruz, 27, is determined to help her son. She's trying to rearrange her work schedule at the downtown Los Angeles McDonald's restaurant where she's employed so she can take Abel to more exercise classes. Abel Sr., 34, works as a roofer, and the parents' busy work schedules make it difficult to keep tabs on whether their son is getting daily exercise. The family has taken long walks in their neighborhood. Cruz's parents and husband are diabetic, so meals are generally healthy and include a good mix of protein and healthy carbs such as vegetables. Since Abel started his program, however, she cooks with far more prudence. "I add only a tiny bit of this," she says, carefully measuring the vegetable oil she's putting into a pot. Lean meats are usually boiled or roasted without any added fat. Abel turns his nose up at numerous vegetables, but broccoli, cabbage and spinach are still offered.
      Adapting meals and exercising more have been good for her too, says Cruz. Having battled a weight problem most of her life, she doesn't want her only child to go through what she has. But there's another fear that hovers in Cruz's mind. She recalls hearing of an incident in New Mexico four years ago when a 3-year-old girl who weighed 120 pounds was temporarily removed from her family by authorities because of feared health risks. "I don't want that to happen to us," she says, "because we love Abel so much."
      However unfounded her worries might be, it's partly what motivated the family to heed the suggestion of Abel's pediatrician to enroll him in PowerPlay MD, a privately funded weight-loss program started by Los Angeles pediatrician Lydia Hazan that provides instruction in nutrition and offers exercise and some counseling on how to modify behavior and deal with such issues as teasing. The program, which follows up with families after the eight weeks, is held at a few health centers in the Los Angeles area. "They kept telling me I needed to do something, but I didn't pay attention," she says, when her son, who weighed 7 pounds, 12 ounces at birth, began to gain a great deal of weight around age 5. Abel underwent a battery of tests at Childrens Hospital Los Angeles to see if there was an underlying medical cause, but results were negative.
      Some families welcome an intervention, says Abel's pediatrician, Dr. Luis Lopez, while others ignore repeated warnings until the situation becomes critical. In the Latino community, he adds, there is often the belief that a chubby baby is a healthy baby. "It's hard to break through that wall," he says. "You cannot wait for these kids to be above the 95th percentile of BMI," Lopez says, referring to the body mass index charts that use height and weight to determine overweight and obesity. "Once they're obese, it's extremely difficult to get them to lose weight and maintain it."
      At a recent PowerPlay session, Cruz and Abel join a group of other moms and their young kids in a room at the downtown Eisner Pediatric & Family Medical Center. Today there is good news: Abel has lost almost 2 pounds, his weight dipping just below 200. Abel gets a high-five from Judith Mercado, who leads the hourlong nutrition session. "How many calories do we look for in a snack?" she asks the group, which chimes back, "One hundred!" She offers tips such as perusing school lunch menus to pick out healthy foods, and she encourages the kids to try new fruits and vegetables. For parents, having overweight children isn't "a sign of ill will — parents are just confused," says PowerPlay's Hazan. "I'm bringing it back to basics and common sense. Kids want to discuss diet; they want to learn. Why not be open about it?"
      Habits about food and diet are formed by the family, says Dr. Naomi Neufeld, founder and medical director of KidShape, a 17-year-old program with some 30 locations that, like PowerPlay, educates families about nutrition and provides exercise. "In the beginning," says Neufeld, "it's hard to convince someone that simply reducing the amount of soda or juice the child drinks can make an effective change, but even after two weeks they see changes. The family's even fighting less, so we're addressing the family dynamic. They're seeing results, and that's quite powerful."
      Cruz gives PowerPlay high marks for helping her and Abel understand things such as portion size, food groups and the importance of daily exercise. When he wants a snack before meals, she takes a cue from the program's workbook and, instead of giving him food, asks him first if he's tired, bored or thirsty — usually it's one of the three. "I'm going to start doing that with myself too," she says. After dinner she sits at the dining room table while Abel clears the dishes, then sits down next to his mother. "Look, Mom," he says, "my eyes are bigger." She laughs and strokes his cheek. "Yeah, when he was fatter his eyes were closed more," she says. "But now he's losing weight."
      "My mom was happy that I lost weight," Abel says. But was he? "Yes, because I'm a little fat and I need to lose weight," he says, adding that he feels tired after exercising, but more energetic during the day. "I want all the kids to see that I'm losing weight." In second grade a classmate called him fat, but otherwise teasing, Cruz says, hasn't been a big issue since Abel started school. Cruz, who recalls being teased in school about her own weight, told her son not to be ashamed of his size, that "if we can do something about it, we'll fix it. You're overweight, but you care for other people, and you have parents who love you." After a talk with the boy and Abel's teacher, the teasing stopped, and the boys are now friends.
      One research study found that the stigmatization of overweight children may be getting worse. In 1960 children were shown illustrations of a healthy child, an obese child and of kids with various disabilities, such as being in a wheelchair or on crutches, and were asked with whom they'd most want to be friends. The obese child was chosen least. When that study was duplicated in 2003, the number of children who put the obese kid at the bottom of the list increased by 40%.
      It was difficult for Elsa Sweasey to hear about the teasing her 10-year-old daughter, Jacqueline, endured at school. "A lot of kids would call her names like 'Miss Piggy' and 'jack-o'-lantern,' " says Sweasey, as tears well up in her eyes. "She didn't tell me, another child did. She said that Jacqueline was crying. I told Jacqueline that I don't want people hurting her. I told her we were going to do something about it, that being chubby doesn't mean you're dumb or ugly."
      Sweasey, 45, sits on a bench behind Our Mother of Good Counsel, a Roman Catholic church and school in L.A., while Jacqueline plays volleyball just yards away. Over the shouts and laughter of the children, Sweasey talks about the changes the family has made since a visit to the pediatrician a few months ago. The doctor told Jacqueline that if she didn't start paying attention to her weight now, the situation could be far worse by the time she was a teenager. Since then the family has kicked into high gear. Jacqueline has stopped drinking soda and eating chips, and she no longer snacks after dinner while watching TV — habits that, Sweasey says, pushed Jacqueline's weight up to 140, despite the fact that she was fairly active.
      Sweasey takes her daughter to the Hollywood YMCA several days a week for karate, swimming or hip-hop dance classes, or to work out on the cardio equipment, which they do side by side. She works a night shift job in maintenance at Cal State L.A. and is attending school to get her high school equivalency diploma. After picking up Jacqueline and brother Eric, 8, after school, she sits through volleyball practice or takes the kids to the Y. On weekends, Sweasey, her husband, John, 47, and their kids all trek to the Y. Sleep these days is minimal, but her determination to help her daughter is far stronger than her desire to nap. Jacqueline has already lost about 11 pounds, and her delight shows. At home she reaches into her closet and retrieves a pretty floral dress that used to be too tight. It's still a little snug, but she can get into it. "When I see my mom work out, I want to do it," she says.
      But can Jacqueline keep such a hectic schedule for long? "She has her own mind and her own will, which is pretty strong for a 10-year-old," says her father, adding that he doesn't believe Jacqueline will burn out on exercise. "I don't worry about that," he says. "She loves a lot of different sports." Not every child is as motivated as Jacqueline, says her pediatrician, Dr. Ameeta Ganju. "She was very honest with me, saying she often ate in front of the TV. The family gets full credit for being receptive to the discussion and helping me brainstorm ideas, and making those changes happen."
      Sweasey and Cruz, like other parents, want the simplest things for their kids — being able to shop in the children's department instead of the adult's, or running the length of the schoolyard. Cruz would like to get Abel started in soccer; the exercise and camaraderie would be good for him, she thinks. "There's nothing that's impossible," she says. "Sometimes it's a little hard and you get tired, but we can make it. We want our son to be healthy. So it's worth it."