Noteworthy News Articles on Mental Health Topics, July 8-15, 2007



The Gregarious Brain
David Dobbs, New York Times Magazine- 7/8/2007

If a person suffers the small genetic accident that creates Williams syndrome, he’ll live with not only some fairly conventional cognitive deficits, like trouble with space and numbers, but also a strange set of traits that researchers call the Williams social phenotype or, less formally, the “Williams personality”: a love of company and conversation combined, often awkwardly, with a poor understanding of social dynamics and a lack of social inhibition. The combination creates some memorable encounters. Oliver Sacks, the neurologist and author, once watched as a particularly charming 8-year-old Williams girl, who was visiting Sacks at his hotel, took a garrulous detour into a wedding ceremony. “I’m afraid she disrupted the flow of this wedding,” Sacks told me. “She also mistook the bride’s mother for the bride. That was an awkward moment. But it very much pleased the mother.”
      Another Williams encounter: The mother of twin Williams boys in their late teens opened her door to find on her stoop a leather-clad biker, motorcycle parked at the curb, asking for her sons. The boys had made the biker’s acquaintance via C.B. radio and invited him to come by, but they forgot to tell Mom. The biker visited for a spell. Fascinated with how the twins talked about their condition, the biker asked them to speak at his motorcycle club’s next meeting. They did. They told the group of the genetic accident underlying Williams, the heart and vascular problems that eventually kill many who have it, their intense enjoyment of talk, music and story, their frustration in trying to make friends, the slights and cruelties they suffered growing up, their difficulty understanding the world. When they finished, most of the bikers were in tears.
     These stories are typical of those who have Williams syndrome. (Some people with the disorder as well as many who work with them simply call it Williams.) Williams syndrome rises from a genetic accident during meiosis, when DNA’s double helix is divided into two separate strands, each strand then becoming the genetic material in egg or sperm. Normally the two strands part cleanly, like a zipper’s two halves. But in Williams, about 25 teeth in one of the zippers — 25 genes out of 30,000 in egg or sperm — are torn loose during this parting. When that strand joins another from the other parent to eventually form an embryo, the segment of the DNA missing those 25 genes can’t do its work.
     The resulting cognitive deficits lie mainly in the realm of abstract thought. Many with Williams have so vague a concept of space, for instance, that even as adults they will fail at six-piece jigsaw puzzles, easily get lost, draw like a preschooler and struggle to replicate a simple T or X shape built with a half-dozen building blocks. Few can balance a checkbook. These deficits generally erase about 35 points from whatever I.Q. the person would have inherited without the deletion. Since the average I.Q. is 100, this leaves most people with Williams with I.Q.’s in the 60s. Though some can hold simple jobs, they require assistance managing their lives.
     The low I.Q., however, ignores two traits that define Williams more distinctly than do its deficits: an exuberant gregariousness and near-normal language skills. Williams people talk a lot, and they talk with pretty much anyone. They appear to truly lack social fear. Indeed, functional brain scans have shown that the brain’s main fear processor, the amygdala, which in most of us shows heightened activity when we see angry or worried faces, shows no reaction when a person with Williams views such faces. It’s as if they see all faces as friendly.
     People with Williams tend to lack not just social fear but also social savvy. Lost on them are many meanings, machinations, ideas and intentions that most of us infer from facial expression, body language, context and stock phrasings. If you’re talking with someone with Williams syndrome and look at your watch and say: “Oh, my, look at the time! Well it’s been awfully nice talking with you . . . ,” your conversational partner may well smile brightly, agree that “this is nice” and ask if you’ve ever gone to Disney World. Because of this — and because many of us feel uneasy with people with cognitive disorders, or for that matter with anyone profoundly unlike us — people with Williams can have trouble deepening relationships. This saddens and frustrates them. They know no strangers but can claim few friends.
     This paradox — the urge to connect, the inability to fully do so — sits at the center of the Williams puzzle, whether considered as a picture of human need (who hasn’t been shut out of a circle he’d like to join?) or, as a growing number of researchers are finding, a clue to the fundamental drives and tensions that shape social behavior. After being ignored for almost three decades, Williams has recently become one of the most energetically researched neurodevelopmental disability after autism, and it is producing more compelling insights. Autism, for starters, is a highly diverse “spectrum disorder” with ill-defined borders, no identified mechanism and no clearly delineated genetic basis. Williams, in contrast, arises from a known genetic cause and produces a predictable set of traits and behaviors. It is “an experiment of nature,” as the title of one paper puts it, perfect for studying not just how genes create intelligence and sociability but also how our powers of thought combine with our desire to bond to create complex social behavior — a huge arena of interaction that largely determines our fates.
     Julie R. Korenberg, a neurogeneticist at Cedars-Sinai Medical Center and at the University of California, Los Angeles, who has helped define the Williams deletion and explore its effects, believes the value of Williams syndrome in examining such questions is almost impossible to overstate. “We’ve long figured that major behavioral traits rose in indirect fashion from a wide array of genes,” Korenberg says. “But here we have this really tiny genetic deletion — of the 20-some-odd genes missing, probably just 3 to 6 create the cognitive and social effects — that reliably creates a distinctive behavioral profile. Williams isn’t just a fascinating mix of traits. It is the most compelling model available for studying the genetic bases of human behavior.”
     Korenberg’s work is part of a diverse research effort on Williams that is illuminating a central dilemma of human existence: to survive we must relate and work with others, but we must also compete against them, lest we get left behind. It’s like the TV show “Survivor”: we want to keep a place in the group — we must — and doing so requires not only charming others but also showing we can contribute to their success. This requires a finely calibrated display of smarts, savvy, grit and hustle. Show too little, and you’re voted off the island for being subpar. Show too much, and you’re ousted as a conniving threat. Where is the right balance? A partial answer lies in the mix of skills, charms and deficiencies that is Williams syndrome.
     Williams syndrome was first identified in 1961 by Dr. J. C. P. Williams of New Zealand. Williams, a cardiologist at Greenlane Hospital in Auckland, noticed that a number of the hospital’s young cardiac patients were small in stature, had elfin facial features and seemed friendly but in some ways were mentally slow. His published delineation of this syndrome put Dr. Williams on the map — off which he promptly and mysteriously fell. Twice offered a position at the prestigious Mayo Clinic in Rochester, Minn., he twice failed to show, disappearing the second time, in the late ’60s, from London, his last known location, with the only trace an unclaimed suitcase later found in a luggage office.
     The rarity of Williams syndrome — about 1 in 7,500 people have it, compared with about 1 in 150 for autism or 1 in 800 for Down syndrome — rendered it obscure. Unless they had the syndrome’s distinctive cardiovascular problems (which stem from the absence of the gene that makes blood vessels, heart valves and other tissue elastic and which even today limit the average lifespan of a person with Williams to around 50), most people with Williams were simply considered “mentally retarded.”
     This ended in the late 1980s, when a few researchers in the emerging field of cognitive neuroscience began to explore Williams. Among the most earnest was Ursula Bellugi, the director of the Laboratory for Cognitive Neuroscience at the Salk Institute for Biological Studies in La Jolla, Calif. Bellugi, who specializes in the neurobiology of language, was drawn to the linguistic strength that many Williamses displayed in the face of serious cognitive problems. The first person with Williams she met, in fact, came by referral from the linguist Noam Chomsky. “The mother of that Williams teenager later connected me with two more, both in their teens,” Bellugi said. “I didn’t have to talk to them long to realize something special was going on. Here they had these great cognitive deficits. Yet they spoke with the most ardent and delightful animation and color.”
     To understand this uneven cognitive profile, Bellugi gave an array of language and cognitive tests to three groups: Williams children and teenagers, Down syndrome kids with similar I.Q.’s and developmentally average peers. “We would do these warm-up interviews to get to know them, ask about their families,” said Bellugi, who, less than five feet tall and with a ready smile and an animated manner, is somewhat elfin and engagingly gregarious herself. “Only, the Williams kids would turn the tables. They’d tell you how pretty you look or ask, ‘Do you like opera?’ They would ornament their answers in a way other kids didn’t. For instance, you’d ask an adolescent, ‘What if you were a bird?’ The Down kids said things like: ‘I’m not a bird. I don’t fly.’ The Williams teens would say: ‘Good question! I’d fly through the air being free. If I saw a boy I’d land on his head and chirp.’ ”
     Bellugi found that this fanciful verbosity was accompanied by infectious affability. To measure it she developed a questionnaire and gave it to parents of Williams, Down and normal children. It asked about things like friendliness toward strangers, connections to familiar people, different social scenarios. At every age level, those with Williams scored significantly higher in sociability than those in the other groups. Having long studied the human capacity for language and its biological basis, Bellugi assumed that some extraordinary urge to use language drove this hypersociability: “The language just seemed to be erupting out of them.”
     Then she attended a meeting of Williams families that included infants and toddlers. “That was about a year into my research project,” she says. “The room was full of little ones — babies, toddlers who weren’t speaking yet. And when I came in the room all the young children old enough to walk ran to the door to greet me. No clinging to Mom; they just broke away. And when I would talk to mothers holding infants — literally babes in arms — some of these babies would almost dive out of their mothers’ arms to meet me. “I knew then I was wrong. The language wasn’t driving the sociability. If anything, it was the other way around.”
     Developmental psychologists sometimes call the social urge the “drive to affiliate.” It seemed clear early on that the Williams deletion, which was definitively identified in the mid-1990s, either strengthened this drive or left it unfettered. But how do missing genes steer behavior toward gregariousness and engagement? How can a deletion heighten a trait rather than diminish it? I got a hint when I met Nicki Hornbaker, who is 19, at Bellugi’s office in La Jolla. Nicki, whose Williams was diagnosed when she was 2, has been participating as a subject in Bellugi’s research for 15 years. She and her mother, Verna, drove down from Fresno that day to continue testing and to talk with me about living with Williams syndrome. Like most people with Williams, Nicki loves to talk but has trouble getting past a cocktail-party-level chatter. Nicki, however, has fashioned at least a partial solution.
     “Ever since she was tiny,” Verna Hornbaker told me, “Nicki has always especially loved to talk to men. And in the last few years, by chance, she figured out how to do it. She reads the sports section in the paper, and she watches baseball and football on TV, and she has learned enough about this stuff that she can talk to any man about what the 49ers or the Giants are up to. My husband gets annoyed when I say this, but I don’t mean it badly: men typically have that superficial kind of conversation, you know — weather and sports. And Nicki can do it. She knows what team won last night and where the standings are. It’s only so deep. But she can do it. And she can talk a good long while with most men about it.”
     In the view of two of Bellugi’s frequent collaborators, Albert Galaburda, a Harvard Medical School professor of neurology and neuroscience, and Allan Reiss, a neuroscientist at the Stanford School of Medicine, Nicki’s learned facility at sports talk illustrates a central lesson of Williams and, for that matter, modern genetics: genes (or their absence) do not hard-wire people for certain behaviors. There is no gene for understanding calculus. But genes do shape behavior and personality, and they do so by creating brain structures and functions that favor certain abilities and appetites more than others.
     Reiss and Galaburda’s imaging and autopsy work on Williamses’ brains, for instance, has shown distinct imbalances in structure and synaptic connectivity. This work has led Galaburda to suspect that some of the genes missing in the Williams deletion are “patterning genes,” which direct embryonic development and which in this case dictate brain formation. Work in lab animals has shown that at least one patterning gene choreographs the developmental balance between the brain’s dorsal areas (along the back and the top of the brain) and ventral areas (at the front and bottom). The dorsal areas play a strong role in vision and space and help us recognize other peoples’ intentions; ventral areas figure heavily in language, processing sounds, facial recognition, emotion, music enjoyment and social drive. In an embryo’s first weeks, Galaburda says, patterning genes normally moderate “a sort of turf war going on between these two areas,” with each trying to expand. The results help determine our relative strengths in these areas. We see them in our S.A.T. scores, for example: few of us score the same in math (which draws mostly on dorsal areas) as in language (ventral), and the discrepancy varies widely. The turf war is rarely a draw.
     In Williams the imbalance is profound. The brains of people with Williams are on average 15 percent smaller than normal, and almost all this size reduction comes from underdeveloped dorsal regions. Ventral regions, meanwhile, are close to normal and in some areas — auditory processing, for example — are unusually rich in synaptic connections. The genetic deletion predisposes a person not just to weakness in some functions but also to relative (and possibly absolute) strengths in others. The Williams newborn thus arrives facing distinct challenges regarding space and other abstractions but primed to process emotion, sound and language. This doesn’t mean that specific behaviors are hard-wired. M.I.T. math majors aren’t born doing calculus, and people with Williams don’t enter life telling stories. As Allan Reiss put it: “It’s not just ‘genes make brain make behavior.’ You have environment and experience too.”
     By environment, Reiss means less the atmosphere of a home or a school than the endless string of challenges and opportunities that life presents any person starting at birth. In Williams, he says, these are faced by someone who struggles to understand space and abstraction but readily finds reward listening to speech and looking at faces. As the infant and toddler seeks and prolongs the more rewarding experiences, already-strong neural circuits get stronger while those in weaker areas may atrophy. Patterns of learning and behavior follow accordingly.
     “Take the gaze,” Reiss told me. Everyone who has worked with Williams children knows the Williams gaze, which in toddlers is often an intense, penetrating eye contact of the sort described as “boring right through you.” The gaze can seem like a hard-wired expression of a Williams’s desire to connect. Yet the gaze can also be seen as a skill learned at the end of the horrible colic that many Williams infants suffer during their first year and before they start to talk well. This window is longer than that for most infants, as Williams children, oddly, start talking a year or so later than most children. It’s during this window that the gaze is at its most intense. Until she was 9 months old, for instance, Nicki Hornbaker rarely slept more than an hour at a time, and when she was quiet she tended to look vaguely at her mother’s hairline. Then her colic stopped, she started sleeping and “almost overnight,” her mother told me, “she became a happy, delightful, extremely social child, and she couldn’t get enough eye contact.” Later, when talk gave Nicki a more effective way to connect, the intensity of the eye contact eased. Nicki’s eyes now meet yours, warm and engaging, but they don’t bore through you.
     To Reiss, the gaze is one of several things Williams people learn in order to pursue social connections. “They want that connection,” he said, “and they learn all these things to get it: the gaze and the gregariousness, the smiles and language and narrative skills, in succession as they’re able to. What they learn is shaped by the inclinations and abilities their genes create.
     “Look at the difference between Williams kids and fragile X.” Fragile X, another developmental syndrome, produces similar cognitive defects but a pronounced social reticence or aversion to looking at faces. If a Williams wants to lock eyes, a fragile X child will literally twist himself sideways to avoid eye contact. “Nothing could be more different from a Williams,” Reiss continued. “But the thing is, fragile X kids don’t do that when they’re a year old. They’ll still look at you at that age. And Williams kids don’t have that intense gaze yet at that age. It’s only over the next year or two that they take this incredible divergence. In both cases you have a genetically inclined pattern of behavior that is reinforced.”
     This is a genetic version of Bellugi’s observation that sociability drives language. The child gravitates toward the pathways that offer smoother going or more interesting experiences — at least until she finds other pathways more rewarding (sports talk, for example). In fragile X, those pathways tend to keep a child close to himself. In Williams they lead headlong toward others.
     As an experiment of nature, Williams syndrome makes clear that while we are innately driven to connect with others, this affiliative drive alone will not win this connection. People with Williams rarely win full acceptance into groups other than their own. To bond with others we must show not just charm but sophisticated cognitive skills. But why? For vital relationships like those with spouses or business partners, the answer seems obvious: people want to know you can contribute. But why should casual friendships and group membership depend on smarts?
     One possible answer a comes from the rich literature of nonhuman primate studies. For 40 years or so, primatologists like Jane Goodall, Frans de Waal and Robert Sapolsky have been studying social behavior in chimps, gorillas, macaques, bonobos and baboons. Over the past decade that work has led to a unifying theory that explains not only a huge range of behavior but also why our brains are so big and what their most essential work is. The theory, called the Machiavellian-intelligence or social-brain theory, holds that we rise from a lineage in which both individual and group success hinge on balancing the need to work with others with the need to hold our own — or better — amid the nested groups and subgroups we are part of.
     It started with fruit. About 15 or 20 million years ago, the theory goes, certain forest monkeys in Africa and Asia developed the ability to digest unripe fruit. This left some of their forest-dwelling cousins — the ancestors of chimps, gorillas and humans — at a sharp disadvantage. Suddenly a lot of fruit was going missing before it ripened.
     To find food, some of the newly hungry primate species moved to the forest edge. Their new habitat put more food in reach, but it also placed the primates within reach of big cats, canines and other savanna predators. This predation spurred two key evolutionary changes. The primates became bigger, giving individuals more of a fighting chance, and they started living in bigger groups, which provided more eyes to keep watch and a strength of numbers in defense.
     But the bigger groups imposed a new brain load: the members had to be smart enough to balance their individual needs with those of the pack. This meant cooperating and exercising some individual restraint. It also required understanding the behavior of other group members striving not only for safety and food but also access to mates. And it called for comprehending and managing one’s place in an ever-shifting array of alliances that members formed in order not to be isolated within the bigger group.
     How did primates form and manage these alliances? They groomed one another. Monkeys and great apes spend up to a fifth of their time grooming, mostly with regular partners in pairs and small groups. This quality time (grooming generates a pleasing release of endorphins and oxytocin) builds strong bonds. Experiments in which a recording of macaques screaming in alarm is played, for instance, have shown a macaque will respond much more strongly to a grooming partner’s cries than to cries from other members of the group. The large time investment involved seems to make a grooming relationship worth defending.
     In this and other ways a group’s members would create, test and declare their alliances. But as the animals and groups grew, tracking and understanding all those relationships required more intelligence. According to the social-brain theory, it was this need to understand social dynamics — not the need to find food or navigate terrain — that spurred and rewarded the evolution of bigger and bigger primate brains.
     This isn’t idle speculation; Robin Dunbar, an evolutionary psychologist and social-brain theorist, and others have documented correlations between brain size and social-group size in many primate species. The bigger an animal’s typical group size (20 or so for macaques, for instance, 50 or so for chimps), the larger the percentage of brain devoted to neocortex, the thin but critical outer layer that accounts for most of a primate’s cognitive abilities. In most mammals the neocortex accounts for 30 percent to 40 percent of brain volume. In the highly social primates it occupies about 50 percent to 65 percent. In humans, it’s 80 percent.
     According to Dunbar, no such strong correlation exists between neocortex size and tasks like hunting, navigating or creating shelter. Understanding one another, it seems, is our greatest cognitive challenge. And the only way humans could handle groups of more than 50, Dunbar suggests, was to learn how to talk. “The conventional view,” Dunbar notes in his book “Grooming, Gossip and the Evolution of Language,” “is that language evolved to enable males to do things like coordinate hunts more effectively. . . . I am suggesting that language evolved to allow us to gossip.”
     Dunbar’s assertion about the origin of language is controversial. But you needn’t agree with it to see that talk provides a far more powerful and efficient way to exchange social information than grooming does. In the social-brain theory’s broad definition, gossip means any conversation about social relationships: who did what to whom, who is what to whom, at every level, from family to work or school group to global politics. Defined this way, gossip accounts for about two-thirds of our conversation. All this yakking — murmured asides in the kitchen, gripefests in the office coffee room — yields vital data about changing alliances; shocking machinations; new, wished-for and missed opportunities; falling kings and rising stars; dangerous rivals and potential friends. These conversations tell us too what our gossipmates think about it all, and about us, all of which is crucial to maintaining our own alliances.
     For we are all gossiped about, constantly evaluated by two criteria: Whether we can contribute, and whether we can be trusted. This reflects what Ralph Adolphs, a social neuroscientist at the California Institute of Technology, calls the “complex and dynamic interplay between two opposing factors: on the one hand, groups can provide better security from predators, better mate choice and more reliable food; on the other hand, mates and food are available also to competitors from within the group.” You’re part of a team, but you’re competing with team members. Your teammates hope you’ll contribute skills and intergroup competitive spirit — without, however, offering too much competition within the group, or at least not cheating when you do. So, even if they like you, they constantly assess your trustworthiness. They know you can’t afford not to compete, and they worry you might do it sneakily.
     Deception runs deep. In his book, “Our Inner Ape,” Frans de Waal, a primatologist at Emory University, describes a simple but cruel deception perpetrated by a female chimp named Puist. One day, Puist chases but cannot catch a younger, faster female rival. Some minutes later, writes de Waal, “Puist makes a friendly gesture from a distance, stretching out an open hand. The young female hesitates at first, then approaches Puist with classic signs of mistrust, like frequent stopping, looking around at others and a nervous grin on her face. Puist persists, adding soft pants when the younger female comes closer. Soft pants have a particularly friendly meaning; they are often followed by a kiss, the chimpanzee’s chief conciliatory gesture. Then, suddenly, Puist lunges and grabs the younger female, biting her fiercely before she manages to free herself.”
     This “deceptive reconciliation offer,” as de Waal calls it, is classic schoolyard stuff. Adult humans generally do a better job veiling a coming assault. The bigger the neocortex, the higher the rate of deceptive behavior. Our extra-big brains allow us to balance bonding and maneuvering in more subtle and complicated ways.
     People with Williams, however, don’t do this so well. Generating and detecting deception and veiled meaning requires not just the recognition that people can be bad but a certain level of cognitive power that people with Williams typically lack. In particular it requires what psychologists call “theory of mind,” which is a clear concept of what another person is thinking and the recognition that the other person a) may see the world differently than you do and b) may actually be thinking something different from what he’s saying.
     Cognitive scientists argue over whether people with Williams have theory of mind. Williams people pass some theory-of-mind tests and fail others. They get many jokes, for instance, but don’t understand irony. They make small talk but tend not to discuss the subtler dynamics of interpersonal relationships. Theory of mind is a slippery, multilayered concept, so the debate becomes arcane. But it’s clear that Williamses do not generally sniff out the sorts of hidden meanings and intentions that lie behind so much human behavior. They would reach for Puist’s outstretched hand without hesitation.
     To inquire into human behavior’s genetic underpinnings is to ask what most essentially defines us. One of the most vexing questions raised by both Williams research and the social-brain thesis is whether our social behavior is ultimately driven more by the urge to connect or the urge to manipulate the connection.
     The traditional inclination, of course, is to distinguish essential human behavior by our “higher” skills and cognitive powers. We dominate the planet because we can think abstractly, accumulate and relay knowledge and manipulate the environment and one another. By this light our social behavior rises more from big brains than from big hearts.
     Andreas Meyer-Lindenberg, a psychiatrist and neurologist, sees it differently. Meyer-Lindenberg spent the last several years at the National Institute of Mental Health exploring neural roots of mood, cognitive and behavioral disorders — including Williams syndrome, which he has investigated as part of a team led by Karen Berman, a N.I.M.H. psychiatrist, clinical neurobiologist and imaging specialist. Working with Berman and Carolyn Mervis, a developmental psychologist at the University of Louisville, Meyer-Lindenberg became convinced that we may be overvaluing the cerebral. “Cognitive social neuroscience tends to be very top-down,” Meyer-Lindenberg says. “It looks at lofty things like triadic intentionality — I’m conscious of you being conscious of me being conscious of you, things like that. Things that presuppose consciousness and elaborate intellectual procedures.” The Berman group’s work, however, was focused on brain networks operating, as Meyer-Lindenberg puts it, “at a lower hierarchical level.” “And the most important abnormalities in Williams,” he says, “are circuits that have to do with basic regulation of emotions.”
     The most significant such finding is a dead connection between the orbitofrontal cortex, an area above the eye sockets and the amygdala, the brain’s fear center. The orbitofrontal cortex (or OFC) is associated with (among other things) prioritizing behavior in social contexts, and earlier studies found that damage to the OFC reduces inhibitions and makes it harder to detect faux pas. The Berman team detected a new contribution to social behavior: They found that while in most people the OFC communicated with the amygdala when viewing threatening faces, the OFC in people with Williams did not. This OFC-amygdala connection worked normally, however, when people with Williams viewed nonsocial threats, like pictures of snakes, sharks or car crashes.
     This appears to explain the amygdala’s failure in Williams to fire at the sight of frightening faces and suggests a circuit responsible for Williamses’ lack of social caution. If the results hold up, the researchers will have cleanly defined a circuit evolved specifically to warn of threats from other people. This could account not just for the lack of social fear in Williams, but with it the wariness that can motivate deeper understanding. It is possible, in short, that people with Williams miss social subtleties not just because they lack cognitive tools but because they also lack a motivation — a fear of others — that the rest of us carry to every encounter. To Meyer-Lindenberg, the primacy of such circuits suggests that human sociability rises from evolutionarily reinforced mechanisms — a raw yearning to connect; fearfulness — that are so basic they’re easy to undervalue.
     The disassociation of so many elements in Williams — the cognitive from the connective, social fear from nonsocial fear, the tension between the drive to affiliate and the drive to manipulate — highlights how vital these elements are and, in most of us, how delicately, critically entwined. Yet these splits in Williams also clarify which, of caring and comprehension, offers the more vital contribution. For if Williams confers disadvantage by granting more care than comprehension, reversing this imbalance creates a far more problematic phenotype.
     As Robert Sapolsky of the Stanford School of Medicine puts it: “Williams have great interest but little competence. But what about a person who has competence but no warmth, desire or empathy? That’s a sociopath. Sociopaths have great theory of mind. But they couldn’t care less.”

Anti - Smoking Pill May Help Curb Drinking
Associated Press, 7/9/2007

WASHINGTON -- A single pill appears to hold promise in curbing the urges to both smoke and drink, according to researchers trying to help people overcome addiction by targeting a pleasure center in the brain.

The drug, called varenicline, already is sold to help smokers kick the habit. New but preliminary research suggests it could gain a second use in helping heavy drinkers quit, too.

Much further down the line, the tablets might be considered as a treatment for addictions to everything from gambling to painkillers, researchers said.

Several experts not involved in the study cautioned that there is no such thing as a magic cure-all for addiction and that varenicline and similar drugs may find more immediate use in treating diseases like Alzheimer's and Parkinson's.

Pfizer Inc. developed the drug specifically as a stop-smoking aid and has sold it in the United States since August under the brand name Chantix. Varenicline works by latching onto the same receptors in the brain that nicotine binds to when inhaled in cigarette smoke, an action that leads to the release of dopamine in the brain's pleasure centers. Taking the drug blocks any inhaled nicotine from reinforcing that effect.

A study published Monday suggests not just nicotine but alcohol also acts on the same locations in the brain. That means a drug like varenicline, which makes smoking less rewarding, could do the same for drinking. Preliminary work, done in rats, suggests that is the case.

''The biggest thrill is that this drug, which has already proved safe for people trying to stop smoking, is now a potential drug to fight alcohol dependence,'' said Selena Bartlett, a neuroscientist with the Ernest Gallo Clinic and Research Center at the University of California, San Francisco who led the study. Details appear this week in the journal Proceedings of the National Academy of Sciences.

Pfizer provided the drug for the study, but was not otherwise involved in the research.

More often than not, smoking and drinking go together -- an observation pub-goers have made for hundreds of years. That a single drug could work to curb both addictions isn't a given -- nor is it surprising, said Christopher de Fiebre, an associate professor of pharmacology and neuroscience at the University of North Texas Health Science Center at Fort Worth.

''This is an extremely important paper and hopefully it will convince the major funding agencies that they need to examine the interactions between nicotine and alcohol to a greater extent than they have done to date,'' said de Fiebre, who was not connected with the study.

In fact, the California researchers, together with the National Institute on Alcohol Abuse and Alcoholism, are now planning the first studies in humans of the drug's effectiveness in curbing alcohol cravings and dependence, Bartlett said. That the drug is already Food and Drug Administration-approved should speed things along.

''This is a drug that people are actually using. That's not trivial -- not at all,'' said Mark Egli, co-leader of the medications development program at the NIAAA, part of the National Institutes of Health. ''There is plenty of animal research that looks pretty cool but there is no way those drugs are ever going to be used by human beings.''

In the new study, researchers trained rats to drink alcohol and measured the effect of varenicline once the animals became the laboratory equivalent of heavy drinkers. They found the drug curbed their drinking. Even when stopped, the animals resumed drinking but didn't binge.

Just as varenicline doesn't work for all smokers, it's highly unlikely it would for all drinkers.

''Is this going to be a cure-all? No, not for smoking or alcoholism because both diseases are more complicated than a single target or single genetic issue,'' said Allan Collins, a professor of pharmacology at the University of Colorado who was not connected to the study.

Still, Collins, who's worked on the topic for decades, called the drug's potential use in treating alcoholism a ''no-brainer.'' And Egli said it supports the emerging view that there is a common biological basis for addictions to both alcohol and tobacco.

As for Pfizer, the New York company has yet to decide whether to seek broader FDA approval for the drug, a spokesman said.

''Without having considerable more data on this it would be very difficult for us to say we might pursue it or not. It's almost a wait-and-see,'' said Pfizer's Stephen Lederer.

Suicide Findings Question Link to Antidepressants
Nicholas Bakalar, New York Times- 7/10/2007

Two large new studies in The American Journal of Psychiatry suggest that treatment of depression, either with psychotherapy or drugs, reduces the risk of suicide attempts in all age groups, especially during the first months of treatment. The findings raise further questions about possible links between antidepressant drugs and suicide.

In 2005, the Food and Drug Administration, faced with evidence from controlled studies, mandated a “black box” notification on all antidepressant drugs, warning that their use in children and adolescents could increase the risk of suicide. In May, after reviewing controlled data from all age groups, the F.D.A. required an updated version to include a warning about suicide risk in young adults 18 to 24.

The studies the F.D.A. analyzed, in which patients were followed closely and matched to controls, are considered the most direct way to analyze results. The two new studies were based on retrospective reviews of medical records.

In one, researchers led by Dr. Gregory E. Simon, a psychiatrist with the Center for Health Studies in Seattle, reviewed the records of 109,356 people being treated for depression in a large prepaid health plan serving 500,000 people in Washington State and northern Idaho. They found that suicide attempts were most common in the month before treatment began, declined sharply in the month after it began, and tapered off in the following six months. All treatments — psychotherapy, medication or both — showed the same pattern, suggesting that treating depression reduced suicide risk regardless of technique.

The authors acknowledged that they had no way to assess the severity of illness either before or after starting treatment, and that about a third of patients dropped out of treatment within a few weeks, two factors that may have influenced the results. Dr. Simon has received research grants and consulting fees from pharmaceutical companies.

Dr. David Shaffer, a professor of pediatrics and psychiatry at Columbia who was not involved in the study, said the results should prove reassuring to people taking antidepressants. “The study provided no evidence that starting an antidepressant increases the likelihood of a suicide attempt,” he said. “Starting treatment, regardless of which kind, seems to reduce suicide attempts.”

The second study was led by Robert D. Gibbons, director of the Center for Health Statistics at the University of Illinois at Chicago. Using medical data from the Veterans Health Administration, researchers found that among 226,866 adults with depression, the overall rate of suicide attempts after beginning treatment with a selective serotonin reuptake inhibitor, or S.S.R.I., was about one-third the rate of those who received no antidepressant at all. This was true for men 18 to 25 as well as for older adults.

“The V.A. has a very good electronic medical record system, so this is likely to be reliable data,” said Dr. Nada Stotland, a professor of psychiatry at Rush Medical College in Chicago. “That makes these results even more powerful.” Dr. Stotland had no part in the study.

The risk of suicide attempt was significantly higher before S.S.R.I. treatment than immediately after starting it, a finding that coincides with that of the Simon study. The scientists acknowledged that their patients were almost all men, and that they did not include any suicide attempts that did not result in contact with the Veterans Health Administration medical records system. One of the six authors has been a paid adviser to pharmaceutical companies.

The authors of both papers worried that extending the boxed warning to young adults might discourage people from seeking effective treatment. “The F.D.A. didn’t say anything wrong in the warning,” Dr. Simon said. “I am 100 percent in support of the message that we need better follow-up care. But my concern is that the warning may scare people away from treatment.”

Dr. Gibbons expressed similar concerns. “These two studies clearly show that the greatest risk for suicide is depression,” he said. “Failure to treat depression, either using pharmacotherapy or psychotherapy, will lead to dramatic increases in the rate of serious suicide attempts and completions in the U.S. and in the world.”

''We've been working on this for so long, it finally seems to be in reach,'' said Carter, who has championed mental health causes for more than 35 years.

David Wellstone hopes to carry out the legacy of his father, a Minnesota Democrat who died in a plane crash in 2002. ''Although he was passionate on many issues, there was not another issue that surpassed this in terms of his passion,'' David Wellstone said.

Carter and Wellstone hope to win passage for the ''Paul Wellstone Mental Health and Addiction Equity Act,'' that would require equal health insurance coverage for mental and physical illnesses when policies include both. The two advocates, along with Rep. Patrick Kennedy, D-R.I., discussed the bill over lunch with The Associated Press on Tuesday, before testifying at a House subcommittee hearing on the bill. ''It's a moral issue,'' Carter said.

David Wellstone recalled his father talking about his own brother's battle with mental illness, and said the experience motivated him to seek to better mental health coverage laws when he got to the Senate. In 1996, Wellstone and Sen. Pete Domenici, R-N.M., won passage of a law banning plans that offer mental health coverage from setting lower annual and lifetime spending limits for mental treatments than for physical ailments.

The legislation in Congress would build on that by adding things like co-payments, deductibles and treatment limitations, a longtime goal of Paul Wellstone's.

Patrick Kennedy said the bill's prospects have brightened not only because of a Democratic Congress, but also with more people getting sensitized to mental illness because of soldiers returning from Iraq with post-traumatic stress disorder. ''It's a much different environment now,'' said Kennedy, who has battled depression, alcoholism and drug abuse.

But the legislation faces a competing bill in the Senate championed by Kennedy's father, Sen. Ted Kennedy, D-Mass. House advocates say it doesn't go far enough. The Senate bill came from a compromise following negotiations with businesses, the insurance industry and mental health advocates. Business and insurance groups fought previous versions, contending the legislation would drive up insurance costs.

The House version says that if a plan provides mental health benefits, it must cover conditions provided by the health plan with the highest average enrollment of federal employees. The Senate bill lacks similar language.

Another difference is that the Senate bill calls for pre-emption of state parity laws in treatment limitations and financial requirements.

Rep. John Kline of Minnesota, the subcommittee's top Republican, said the House bill would drive up costs of health insurance.

But Stephen Melek, an actuary with the firm Milliman, said his firm's analysis of the House bill estimated it would cause an increase of health insurance premiums of just 0.6 percent -- or $2.40 per member per month.

Psychologists to Review Stance on Gays
Associated Press, 7/10/2007

NEW YORK -- The American Psychological Association is embarking on the first review of its 10-year-old policy on counseling gays and lesbians, a step that gay-rights activists hope will end with a denunciation of any attempt by therapists to change sexual orientation.

Such efforts -- often called reparative therapy or conversion therapy -- are considered futile and harmful by many gay-rights activists. Conservative groups defend the right to offer such treatment, and say people with their viewpoint have been excluded from the review panel. A six-member task force set up by the APA has its first meeting beginning next Tuesday.

Already, scores of conservative religious leaders and counselors, representing such groups as the Southern Baptist Convention and Focus on the Family, have written a joint letter to the APA, expressing concern that the task force's proposals would not properly accommodate gays and lesbians whose religious beliefs condemn gay sex.

''We believe that psychologists should assist clients to develop lives that they value, even if that means they decline to identify as homosexual,'' said the letter, which requested a meeting between APA leaders and some of the signatories.

APA spokeswoman Rhea Farberman said a decision on when and how to reply to the letter had not yet been made.

The current APA policy, adopted in 1997, opposes any counseling that treats homosexuality as a mental illness, but does not explicitly denounce reparative therapy. The APA has decided to review the policy at a time when gay-rights groups are increasingly critical of such treatment and groups that support it.

Conservatives contend that the review's outcome is preordained because the task force is dominated by gay-rights supporters.

''We're concerned,'' said Carrie Gordon Earll of Focus on the Family. ''The APA does not have a good track record of listening to other views.''

Joseph Nicolosi, a leading proponent of reparative therapy, predicted the task force would propose a ban of the practice -- and he vowed to resist such a move. Nicolosi, who was rejected as a task force nominee, is president of the National Association for Research and Therapy of Homosexuality.

Clinton Anderson, director of the APA's Lesbian, Gay and Bisexual Concerns Office, insisted the panel would base its findings on scientific research, not ideology. He defended the decision to reject certain conservative applicants to the task force.

''We cannot take into account what are fundamentally negative religious perceptions of homosexuality -- they don't fit into our world view,'' Anderson said.

One of the counselors denied a seat on the task force was Warren Throckmorton, a psychology professor at Grove City College near Pittsburgh. Though Throckmorton doesn't advocate a specific form of reparative therapy, he argues that psychologists should respect gay clients' religious beliefs in cases where the faith teaches that homosexual behavior is wrong.

''We work with clients to pursue their chosen values,'' he said. ''If they are core, unwavering commitments to their religious belief, therapists should not try to persuade them differently under the guise of science.''

However, one of the task force members, New York City psychiatrist Jack Drescher, said the conservatives don't acknowledge the harm that might be caused when a gay patient -- even voluntarily -- undergoes therapy to suppress or change sexual orientation.

''They want a rubber stamp of approval for a form of therapy that's questionable in its efficacy and they don't want to deal with the issue of harmful side effects,'' said Drescher, who is editor of the Journal of Gay and Lesbian Psychotherapy.

As the APA planned the policy review, it received input from gay-rights groups, including Parents, Families and Friends of Lesbians and Gays.

PFLAG's executive director, Jody Huckaby, said reparative therapy had been particularly harmful for young gays whose parents insisted on trying to change their sexual orientation. His group contends these efforts can cause depression and suicidal behavior.

Current APA policy stipulates that no therapy should occur without ''informed consent'' of a gay or lesbian client. Jason Cianciotto of the National Gay and Lesbian Task Force said he hoped the APA would declare that no young person could ever be deemed to have given informed consent, and thus no reparative therapy would be approved for minors.

The largest ministry that does counsel gays to change their sexual orientation is Exodus International. Its president, Alan Chambers -- who says prayer and therapy enabled him to move away from homosexuality -- is among those apprehensive of the APA review.

''I had hoped for more diversity on that panel,'' Chambers said. ''I see a lot of people who represent the other side -- who don't believe that people like me have a right to self-determination.''

The task force may submit a preliminary report to the APA's directors in December. Anderson said a final report might be completed by next March.

On the Net: American Psychological Association: http://www.apa.org/

Mass. Psychiatric Patients Feel Strain
Liz Kowalczyk, Boston Globe- 7/15/2007

The state investigated at least 21 complaints over the last 18 months that emergency departments mistreated psychiatric patients, and officials cited hospitals in half those cases for problems that included wrongly forcing patients to undress, punching or hitting patients, and restraining others for hours without proper monitoring. One patient died while in restraints, and a patient's arm was broken as a nurse forcibly removed his pants.

These cases are a sign of the growing strain on the state's overcrowded emergency rooms, doctors, nurses, patients and state officials said, and also reflect a shortage of services for the mentally ill, the challenge of caring for sometimes-aggressive psychiatric patients, and inconsistent training of harried ER staff.

Emergency rooms can be battlegrounds. They often are the last resort for psychiatric patients in crisis -- some patients are so out of control and aggressive that mental health facilities will not take them -- and ERs have responded by creating "safe rooms" to handle such patients and on occasion calling in police for help, according to inter views with 20 doctors, nurses, patients, and hospital administrators.

ER staff give psychiatric medications but are not trained to provide comprehensive psychiatric care, they said. And many of these patients stay in ERs for days without proper treatment because of backlogs in psychiatric facilities, creating potentially volatile situations for those patients, staff, and other patients. Hospital officials said nurses, too, have been injured in confrontations, and patients contend that they are humiliated by policies like the one requiring them to undress.

Patients "will be in the ER from hours to days and they get absolutely no care," said Linda Condon, an emergency room nurse who has worked at four hospitals in Southeastern Massachusetts. "You put a person with psychiatric problems in a room with four walls and nothing to do, and there are going to be problems."

Documents from the Department of Public Health -- which conducts investigations when patients or relatives complain or hospitals themselves report problems -- show that investigators cited 11 hospitals for a range of problems. Those cases include:

A blind, disabled patient who went to Lawrence General Hospital in April because he was suicidal. Hospital policy then required psychiatric patients to undress so that staff could look for hidden drugs or weapons, but the patient wanted to keep on his jeans. A male nurse "used excessive force" to remove them, the health department found, breaking the patient's arm. The patient required surgery and a three-week hospital stay.

In April 2006, a 49-year-old former nurse who arrived in the emergency room at Melrose-Wakefield Hospital at 10:30 p.m., intoxicated and uncooperative. Staff strapped down his arms and legs, gave him sedatives, and assigned a security guard to watch him. After a nurse called the security guard away to help with another violent patient, the first patient had a fatal cardiac arrest. The hospital's internal investigation determined that the patient was not properly monitored. Staff told state investigators that the ER was "very, very busy."In June 2006, a male teen in the Merrimack Valley Hospital ER in Haverhill began pulling medical equipment out of a wall, kicking furniture, and biting staff. While he was biting a nurse, a staff member repeatedly punched him in the face. State investigators said the hospital did not properly train staff on how to restrain patients. Hospital staff said punching was a last resort because the patient was severely injuring the nurse.

State documents released to the Globe omitted the names of patients and staff for privacy reasons. When health officials find problems during investigations, hospitals must implement plans to correct them.

The state public health and mental health departments have been so concerned about the pattern of complaints that they sent a memo to hospital executives in September, detailing 21 steps they should take to improve care of psychiatric patients in ERs, including reducing waiting times, using trained mediators, and further training staff in techniques to calm patients.

But patients and advocates for people with mental illness say problems remain rampant. They are pushing legislators to increase the mental health department's role in regulating ER care and to require the public health department to develop "best practices" for treating psychiatric patients.

"When we get upset and don't want to take our clothes off, they think we're going to flip out," said Constance Surette, 57, of Plymouth, who has bipolar disorder and works with a group pushing for legislation. "But the way they treat us, of course they're going to get that reaction. The ERs should use peer mediators to talk to [psychiatric patients] because they are frightened of the authority figures."

Surette filed a complaint with the health department last month, alleging that city police officers at Quincy Medical Center sprayed one psychiatric patient with mace and handcuffed another to a bench while she was in the ER. Hospital spokeswoman Janice Sullivan said that she could not confirm Surette's account but that the actions taken were appropriate "for the safety of everyone involved."

Doctors and nurses say they have made improvements but are doing the best they can in an impossible situation. They said the number of complaints statewide is small considering the thousands of psychiatric patients who seek care in Massachusetts ERs each year.

In 2005, ERs reported 168,000 visits by psychiatric patients, 10 percent more than in 2003, according to the Massachusetts Health Data Consortium. And they usually have to wait longer for care. The average ER stay for patients who are eventually sent home or to another hospital is nearly three hours; it's nearly six hours for psychiatric patients. And many of these patients wait two to three days in the ER for an inpatient bed in a psychiatric facility to open."The emergency departments are overwhelmed," said Dr. Paul Bulat, medical director of the emergency room at St. Luke's Hospital in New Bedford. "We are seeing more violent patients and out-of-control patients. We're seeing mental health problems much worse than we should be."

ER directors are reluctant to acknowledge that overcrowding hurts patient care. But staff told the state health department that busyness was a factor in several of the cases investigated, especially those that involved inadequate monitoring of patients.

In the case of the former nurse who died at Melrose-Wakefield Hospital, not only did the security guard leave the patient alone for about 20 minutes, but the patient's condition was not checked every 15 minutes while he was restrained, as required by hospital policy. Monitoring is especially crucial for intoxicated patients who receive sedatives.

Hospital spokesman Richard Pozniak said he could not comment on the case because of regulations requiring patient information to be kept confidential. State investigators said in their report that 13 patients were in the ER when the man arrived, and 20 other patients arrived before he died 4 1/2 hours later.

Public health investigators also found that lack of training is an issue, including in cases where staff used excessive force. Better training in techniques to calm patients is especially important as frustrated psychiatric patients with no where else to go spend hours in the ER .

In the case of the patient whose arm was broken at Lawrence General Hospital, investigators found a range of problems, including that the hospital's internal investigation of the complaint did not include interviewing the patient. Investigators also found no evidence that staff and security had been trained in patient's rights. And they said the nurse should have explored the patient's reasons for wanting to keep on his jeans before resorting to force.

Hospital spokeswoman Ellen Murphy Meehan said the hospital "expressed deep regret to the patient" for what it considers an accident. She said Lawrence General has since changed its policy to allow some psychiatric patients to keep on their clothes and instead be frisked and scanned with a hand-held metal detector.

Paul Dreyer, director of the state Division of Health Care Quality, said "a culture change" is needed; he is organizing an educational summit for ER staff in the fall, hoping hospitals will improve on their own, making legislation unnecessary. Legislators expect to hold hearings this summer or in the fall.

We want "people to realize they don't have to call in security the first time someone looks at them cross-eyed," Dreyer said. "The ERs are in a production mode. Their aim is to process the patients as quickly as possible to get on to the next patient. These patients may not take well to being treated that way. They may act out."

A number of hospitals said they have improved care after serious encounters. UMass Memorial Medical Center -- where campus police beat a psychiatric patient with a baton in 2004, injuring him, and, several months later, threw a patient against a wall and called her a "bitch," according to state reports -- said it has made significant changes. These include creating a secured, quiet area for psychiatric patients and training police to use calming techniques. Dr. Patrick Smallwood, medical director for emergency mental health services, also joined the hiring panel for campus police officers last year.

Dr. Bruce Auerbach, chief for emergency and ambulatory services at Sturdy Memorial Hospital in Attleboro, said hospitals need more resources, not more regulation. "When a patient who is having a behavioral health crisis is in my ER for four days not getting the intervention he needs -- it's a travesty in our healthcare system," he said.