Gadgetwise Blog: Tip of the Week: Screen Savers That Educate

Screen saver programs, originally intended to help prevent damage to older computer monitors, are often used now for security or entertainment purposes when the computer is idle. Most operating systems include a few built-in screen savers that display animated geometric patterns or photos, but you do not have to go too far to find screen savers that educate as well.

Windows users still trying to get the hang of Microsoft Office 2010, for example, can grab a free screen saver that shows tips for using the software. A trial version of the Universal Tutor screen saver from Cool Educational Software is available; an annual subscription costs $30.

Recent versions of Mac OS X have included screen savers that display the Word of the Day from the New Oxford American Dictionary, or an RSS Visualizer that pulls down headlines from online news sources. To see what is available in your version of Mac OS X, click the System Preferences icon in the Dock, click on the Desktop and Screen Saver icon and click the Screen Saver tab in the box.

Plenty of shareware sites offer free screen savers, but be careful when installing any third-party program, as malicious software may also be along for the ride. Screen savers can also sap resources from the computer, so go to your computer’s settings and just set your monitor to turn off after a short period of inactivity if you would rather not lose processing power. But if your computer has power to spare, donating its idle time to a group-computing effort like SETI@Home or one from the Boinc project usually gets you an interesting screen saver — while helping scientific causes.

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The New Old Age Blog: Doctor's Orders? Another Test

It is no longer news that Americans, and older Americans in particular, get more routine screening tests than they need, more than are useful. Prostate tests for men over 75, annual Pap smears for women over 65 and colonoscopies for anyone over 75 — all are overused, large-scale studies have shown.

Now it appears that many older patients are also subjected to too-frequent use of the other kind of testing, diagnostic tests.

The difference, in brief: Screening tests are performed on people who are asymptomatic, who aren’t complaining of a health problem, as a way to detect incipient disease. We have heard for years that it is best to “catch it early” — “it” frequently being cancer — and though that turns out to be only sometimes true, we and our doctors often ignore medical guidelines and ongoing campaigns to limit and target screening tests.

Diagnostic tests, on the other hand, are meant to help doctors evaluate some symptom or problem. “You’re trying to figure out what’s wrong,” explained Gilbert Welch, a veteran researcher at the Dartmouth Institute for Health Policy and Clinical Practice.

For these tests, medical groups and task forces offer many fewer guidelines on who should get them and how often — there is not much evidence to go on — but there is general agreement that they are not intended for routine surveillance.

But a study using a random 5 percent sample of Medicare beneficiaries — nearly 750,000 of them — suggests that often, that is what’s happening.

“It begins to look like some of these tests are being routinely repeated, and it’s worrisome,” said Dr. Welch, lead author of the study just published in The Archives of Internal Medicine. “Some physicians are just doing them every year.”

He is talking about tests like echocardiography, or a sonogram of the heart. More than a quarter of the sample (28.5 percent) underwent this test between 2004 and 2006, and more than half of those patients (55 percent) had a repeat echocardiogram within three years, most commonly within a year of the first.

Other common tests were frequently repeated as well. Of patients who underwent an imaging stress test, using a treadmill or stationery bike (or receiving a drug) to make the heart work harder, nearly 44 percent had a repeat test within three years. So did about half of those undergoing pulmonary function tests and chest tomography, a CAT scan of the chest.

Cytoscopy (a procedure in which a viewing tube is inserted into the bladder) was repeated for about 41 percent of the patients, and endoscopy (a swallowed tube enters the esophagus and stomach) for more than a third.

Is this too much testing? Without evidence of how much it harms or helps patients, it is hard to say — but the researchers were startled by the extent of repetition. “It’s inconceivable that it’s all important,” Dr. Welch said. “Unfortunately, it looks like it’s important for doctors.”

The evidence for that? The study revealed big geographic differences in diagnostic testing. Looking at the country’s 50 largest metropolitan areas, it found that nearly half the sample’s patients in Miami had an echocardiogram between 2004 and 2006, and two thirds of them had another echocardiogram within three years — the highest rate in the nation.

In fact, for the six tests the study included, five were performed and repeated most often in Florida cities: Miami, Jacksonville and Orlando. “They’re heavily populated by physicians and they have a long history of being at the top of the list” of areas that do a lot of medical procedures and hospitalizations, Dr. Welch said.

But in Portland, Ore., where “the physician culture is very different,” only 17.5 percent of patients had an echocardiogram. The places most prone to testing were also the places with high rates of repeat testing. Portland, San Francisco and Sacramento had the lowest rates.

We often don’t think of tests as having a downside, but they do. “This is the way whole cascades can start that are hard to stop,” Dr. Welch said. “The more we subject ourselves, the more likely some abnormality shows up that may require more testing, some of which has unwanted consequences.”

Properly used, of course, diagnostic tests can provide crucial information for sick people. “But used without a good indication, they can stir up a hornet’s nest,” he said. And of course they cost Medicare a bundle.

An accompanying commentary, sounding distinctly exasperated, pointed out that efforts to restrain overtesting and overtreatment have continued for decades. The commentary called it “discouraging to contemplate fresh evidence by Welch et al of our failure to curb waste of health care resources.”

It is hard for laypeople to know when tests make sense, but clearly we need to keep track of those we and our family members have. That way, if the cardiologist suggests another echocardiogram, we can at least ask a few pointed questions:

“My father just had one six months ago. Is it necessary to have another so soon? What information do you hope to gain that you didn’t have last time? Will the results change the way we manage his condition?”

Questions are always a good idea. Especially in Florida.

Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

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The New Old Age Blog: Doctor's Orders? Another Test

It is no longer news that Americans, and older Americans in particular, get more routine screening tests than they need, more than are useful. Prostate tests for men over 75, annual Pap smears for women over 65 and colonoscopies for anyone over 75 — all are overused, large-scale studies have shown.

Now it appears that many older patients are also subjected to too-frequent use of the other kind of testing, diagnostic tests.

The difference, in brief: Screening tests are performed on people who are asymptomatic, who aren’t complaining of a health problem, as a way to detect incipient disease. We have heard for years that it is best to “catch it early” — “it” frequently being cancer — and though that turns out to be only sometimes true, we and our doctors often ignore medical guidelines and ongoing campaigns to limit and target screening tests.

Diagnostic tests, on the other hand, are meant to help doctors evaluate some symptom or problem. “You’re trying to figure out what’s wrong,” explained Gilbert Welch, a veteran researcher at the Dartmouth Institute for Health Policy and Clinical Practice.

For these tests, medical groups and task forces offer many fewer guidelines on who should get them and how often — there is not much evidence to go on — but there is general agreement that they are not intended for routine surveillance.

But a study using a random 5 percent sample of Medicare beneficiaries — nearly 750,000 of them — suggests that often, that is what’s happening.

“It begins to look like some of these tests are being routinely repeated, and it’s worrisome,” said Dr. Welch, lead author of the study just published in The Archives of Internal Medicine. “Some physicians are just doing them every year.”

He is talking about tests like echocardiography, or a sonogram of the heart. More than a quarter of the sample (28.5 percent) underwent this test between 2004 and 2006, and more than half of those patients (55 percent) had a repeat echocardiogram within three years, most commonly within a year of the first.

Other common tests were frequently repeated as well. Of patients who underwent an imaging stress test, using a treadmill or stationery bike (or receiving a drug) to make the heart work harder, nearly 44 percent had a repeat test within three years. So did about half of those undergoing pulmonary function tests and chest tomography, a CAT scan of the chest.

Cytoscopy (a procedure in which a viewing tube is inserted into the bladder) was repeated for about 41 percent of the patients, and endoscopy (a swallowed tube enters the esophagus and stomach) for more than a third.

Is this too much testing? Without evidence of how much it harms or helps patients, it is hard to say — but the researchers were startled by the extent of repetition. “It’s inconceivable that it’s all important,” Dr. Welch said. “Unfortunately, it looks like it’s important for doctors.”

The evidence for that? The study revealed big geographic differences in diagnostic testing. Looking at the country’s 50 largest metropolitan areas, it found that nearly half the sample’s patients in Miami had an echocardiogram between 2004 and 2006, and two thirds of them had another echocardiogram within three years — the highest rate in the nation.

In fact, for the six tests the study included, five were performed and repeated most often in Florida cities: Miami, Jacksonville and Orlando. “They’re heavily populated by physicians and they have a long history of being at the top of the list” of areas that do a lot of medical procedures and hospitalizations, Dr. Welch said.

But in Portland, Ore., where “the physician culture is very different,” only 17.5 percent of patients had an echocardiogram. The places most prone to testing were also the places with high rates of repeat testing. Portland, San Francisco and Sacramento had the lowest rates.

We often don’t think of tests as having a downside, but they do. “This is the way whole cascades can start that are hard to stop,” Dr. Welch said. “The more we subject ourselves, the more likely some abnormality shows up that may require more testing, some of which has unwanted consequences.”

Properly used, of course, diagnostic tests can provide crucial information for sick people. “But used without a good indication, they can stir up a hornet’s nest,” he said. And of course they cost Medicare a bundle.

An accompanying commentary, sounding distinctly exasperated, pointed out that efforts to restrain overtesting and overtreatment have continued for decades. The commentary called it “discouraging to contemplate fresh evidence by Welch et al of our failure to curb waste of health care resources.”

It is hard for laypeople to know when tests make sense, but clearly we need to keep track of those we and our family members have. That way, if the cardiologist suggests another echocardiogram, we can at least ask a few pointed questions:

“My father just had one six months ago. Is it necessary to have another so soon? What information do you hope to gain that you didn’t have last time? Will the results change the way we manage his condition?”

Questions are always a good idea. Especially in Florida.

Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

Read More..

Facebook Gift Store Urges Users to Shop While They Share





SAN FRANCISCO — Facebook is already privy to its users’ e-mail addresses, wedding pictures and political beliefs. Now the company is nudging them to share a bit more: credit card numbers and offline addresses.







James Best Jr./The New York Times

Facebook Gifts is a service that prompts users to buy things for friends on the social network.






Sharing Even More




What do you think about Facebook’s plan to have users buy gifts for their friends through the site using their credit cards?







A screenshot of Facebook Gifts.






The nudge comes from a new Facebook service called Gifts. It allows Facebook users — only in the United States for now — to buy presents for their friends on the social network. On offer are items as varied as spices from Dean & DeLuca, pajamas from BabyGap and subscriptions to Hulu Plus, the video service. This week Facebook added iTunes gift cards.


The gift service is part of an aggressive moneymaking push aimed at pleasing Facebook’s investors after the company’s dismal stock market debut. Facebook has stepped up mobile advertising and is starting to customize the marketing messages it shows to users based on their Web browsing outside Facebook.


Those efforts seem to have brought some relief to Wall Street. Analysts issued more bullish projections for the company in recent days, and the stock was up 49 percent from its lowest point, closing Tuesday at $26.15, although that is still well below the initial offering price of $38. The share price has been buoyed in part by the fact that a wave of insider lockup periods expired without a flood of shares hitting the market.


To power the Gifts service, Facebook rented a warehouse in South Dakota and created its own software to track inventory and shipping. It will not say how much it earns from each purchase made through Gifts, though merchants that have a similar arrangement with Amazon.com give it a roughly 15 percent cut of sales.


If it catches on, the service would give Facebook a toehold in the more than $200 billion e-commerce market. Much more important, it would let the company accumulate a new stream of valuable personal data and use it to refine targeted advertisements, its bread and butter. The company said it did not now use data collected through Gifts for advertising purposes, but could not rule it out in the future.


“The hard part for Facebook was aggregating a billion users. Now it’s more about how to monetize those users without scaring them away,” said Colin Sebastian, an analyst with Robert W. Baird.


He added: “Gifts should also contribute more to Facebook’s treasure trove of user data, which has the benefit of a virtuous cycle, driving more personalization of the site, leading to better and more targeted ads, which improves overall monetization.”


Facebook already collects credit card information from users who play social games on its site. But they are a limited constituency, and a wider audience may be persuaded to buy a gift when Facebook reminds them that a friend is expecting a baby or a cousin is approaching her 40th birthday.


The Gifts service, which grew out of Facebook’s acquisition of a mobile application called Karma, was introduced in September and expanded earlier this month on the eve of the holiday shopping season.


Magnolia Bakery, based in New York, was among Facebook’s early partners for Gifts. Its vice president for public relations, Sara Gramling, said the company had sold roughly 200 packages of treats since then. She counted it as a marketing success. The bakery, which gained fame thanks to “Sex and the City,” had only recently begun shipping its goods. “It was a great opportunity to expand our network,” she said.


Magnolia Bakery isn’t exactly catering to the masses. A half-dozen cupcakes cost $35, plus about $12 for shipping. Facebook, Ms. Gramling said, takes care of the billing. The bakery is eyeing Facebook’s global reach, too, as it opens outlets internationally, especially in the Middle East.


One of the appeals of Facebook Gifts is the ease of making a purchase. Facebook users are nudged to buy a gift (a gift-box icon pops up) for Facebook friends on their birthdays. They are offered a vast menu to choose from: beer glasses, cake pops, quilts, marshmallows, magazine subscriptions and donations to charity. They are asked to choose a greeting card. Then they are asked for credit card details. Facebook says it stores that credit card information, unless users remove it after making a purchase.


Facebook has declined to say how many users have bought gifts, only that among those who have, the average purchase is $25.


David Streitfeld contributed reporting.



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Egypt’s President Said to Limit Scope of Judicial Decree


Tara Todras-Whitehill for The New York Times


Egyptians at a burned-out school in Cairo on Monday before the funeral of an activist who was injured in a clash and died Sunday.







CAIRO — With public pressure mounting, President Mohamed Morsi appeared to pull back Monday from his attempt to assert an authority beyond the reach of any court. His allies in the Muslim Brotherhood canceled plans for a large demonstration in his support, signaling a chance to calm an escalating battle that has paralyzed a divided nation.




After Mr. Morsi met for hours with the judges of Egypt’s Supreme Judicial Council, his spokesman read an “explanation” on television that appeared to backtrack from a presidential decree placing Mr. Morsi’s official edicts above judicial scrutiny — even while saying the president had not actually changed a word of the statement.


Though details of the talks remained hazy, and it was not clear whether the opposition or the court would accept his position, Mr. Morsi’s gesture was another demonstration that Egyptians would no longer allow their rulers to operate above the law. But there appeared little chance that the gesture alone would be enough to quell the crisis set off by his perceived power grab.


Hundreds of opponents of Mr. Morsi protested in Tahrir Square on Tuesday, Reuters reported, with the crowd expected to grow in the late afternoon.


The presidential spokesman, Yasser Ali, said for the first time that Mr. Morsi had sought only to assert pre-existing powers already approved by the courts under previous precedents, not to free himself from judicial oversight.


He said that the president meant all along to follow an established Egyptian legal doctrine suspending judicial scrutiny of presidential “acts of sovereignty” that work “to protect the main institutions of the state.” The judicial council had said Sunday that it could bless aspects of the decree deemed to qualify under the doctrine.


Mr. Morsi had maintained from the start that his purpose was to empower himself to prevent judges appointed by former President Hosni Mubarak from dissolving the constituent assembly, which is led by his fellow Islamists of the Muslim Brotherhood’s Freedom and Justice Party. The courts have already dissolved the Islamist-led Parliament and an earlier constituent assembly, and the Supreme Constitutional Court was widely expected to rule against this one next week.


But the text of the original decree had exempted all presidential edicts from judicial review until the ratification of a constitution, not just those edicts related to the assembly or justified as “acts of sovereignty.”


Legal experts said that the spokesman’s explanations of the president’s intentions, if put into effect, would amount to a revision of the decree Mr. Morsi issued last Thursday. But lawyers said that the verbal statements alone carried little legal weight.


How the courts would apply the doctrine remained hard to predict. And Mr. Morsi’s opposition indicated it was holding out for far greater concessions, including the breakup of the whole constituent assembly.


Speaking at a news conference while Mr. Morsi was meeting with the judges, the opposition activist and intellectual Abdel Haleem Qandeil called for “a long-term battle,” declaring that withdrawal of Mr. Morsi’s new powers was only the first step toward the opposition’s goal of “the withdrawal of the legitimacy of Morsi’s presence in the presidential palace.” Completely withdrawing the edict would be “a minimum,” he said.


Khaled Ali, a human rights lawyer and former presidential candidate, pointed to the growing crowd of protesters camped out in Tahrir Square for a fourth night. “The one who did the action has to take it back,” Mr. Ali said.


Moataz Abdel Fattah, a political scientist at Cairo University, said Mr. Morsi was saving face during a strategic retreat. “He is trying to simply say, ‘I am not a new pharaoh; I am just trying to stabilize the institutions that we already have,’ ” he said. “But for the liberals, this is now their moment, and for sure they are not going to waste it, because he has given them an excellent opportunity to score.”


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The Hard Road Back: Prosthetic Arms a Complex Test for Amputees




A Future Reset:
After losing his arm in an I.E.D. explosion in Afghanistan, Cpl. Sebastian Gallegos has adjusted to his prosthetic limb.







SAN ANTONIO — After the explosion, Cpl. Sebastian Gallegos awoke to see the October sun glinting through the water, an image so lovely he thought he was dreaming. Then something caught his eye, yanking him back to grim awareness: an arm, bobbing near the surface, a black hair tie wrapped around its wrist.




The elastic tie was a memento of his wife, a dime-store amulet that he wore on every patrol in Afghanistan. Now, from the depths of his mental fog, he watched it float by like driftwood on a lazy current, attached to an arm that was no longer quite attached to him.


He had been blown up, and was drowning at the bottom of an irrigation ditch.


Two years later, the corporal finds himself tethered to a different kind of limb, a $110,000 robotic device with an electronic motor and sensors able to read signals from his brain. He is in the office of his occupational therapist, lifting and lowering a sponge while monitoring a computer screen as it tracks nerve signals in his shoulder.


Close hand, raise elbow, he says to himself. The mechanical arm rises, but the claw-like hand opens, dropping the sponge. Try again, the therapist instructs. Same result. Again. Tiny gears whir, and his brow wrinkles with the mental effort. The elbow rises, and this time the hand remains closed. He breathes.


Success.


“As a baby, you can hold onto a finger,” the corporal said. “I have to relearn.”


It is no small task. Of the more than 1,570 American service members who have had arms, legs, feet or hands amputated because of injuries in Afghanistan or Iraq, fewer than 280 have lost upper limbs. Their struggles to use prosthetic limbs are in many ways far greater than for their lower-limb brethren.


Among orthopedists, there is a saying: legs may be stronger, but arms and hands are smarter. With myriad bones, joints and ranges of motion, the upper limbs are among the body’s most complex tools. Replicating their actions with robotic arms can be excruciatingly difficult, requiring amputees to understand the distinct muscle contractions involved in movements they once did without thinking.


To bend the elbow, for instance, requires thinking about contracting a biceps, though the muscle no longer exists. But the thought still sends a nerve signal that can tell a prosthetic arm to flex. Every action, from grabbing a cup to turning the pages of a book, requires some such exercise in the brain.


“There are a lot of mental gymnastics with upper limb prostheses,” said Lisa Smurr Walters, an occupational therapist who works with Corporal Gallegos at the Center for the Intrepid at Brooke Army Medical Center in San Antonio.


The complexity of the upper limbs, though, is just part of the problem. While prosthetic leg technology has advanced rapidly in the past decade, prosthetic arms have been slow to catch up. Many amputees still use body-powered hooks. And the most common electronic arms, pioneered by the Soviet Union in the 1950s, have improved with lighter materials and microprocessors but are still difficult to control.


Upper limb amputees must also cope with the critical loss of sensation. Touch — the ability to differentiate baby skin from sandpaper or to calibrate between gripping a hammer and clasping a hand — no longer exists.


For all those reasons, nearly half of upper limb amputees choose not to use prostheses, functioning instead with one good arm. By contrast, almost all lower limb amputees use prosthetic legs.


But Corporal Gallegos, 23, is part of a small vanguard of military amputees who are benefiting from new advances in upper limb technology. Earlier this year, he received a pioneering surgery known as targeted muscle reinnervation that amplifies the tiny nerve signals that control the arm. In effect, the surgery creates additional “sockets” into which electrodes from a prosthetic limb can connect.


More sockets reading stronger signals will make controlling his prosthesis more intuitive, said Dr. Todd Kuiken of the Rehabilitation Institute of Chicago, who developed the procedure. Rather than having to think about contracting both the triceps and biceps just to make a fist, the corporal will be able to simply think, close hand, and the proper nerves should fire automatically.


In the coming years, new technology will allow amputees to feel with their prostheses or use pattern-recognition software to move their devices even more intuitively, Dr. Kuiken said. And a new arm under development by the Pentagon, the DEKA Arm, is far more dexterous than any currently available.


But for Corporal Gallegos, becoming proficient on his prosthesis after reinnervation surgery remains a challenge, likely to take months more of tedious practice. For that reason, only the most motivated amputees — super users, they are called — are allowed to undergo the surgery.


Corporal Gallegos was not always that person.


His father, an Army veteran, did not want him to join the infantry, but it was like him to ignore the advice.


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Clearing the Fog Around Personality Disorders





For years they have lived as orphans and outliers, a colony of misfit characters on their own island: the bizarre one and the needy one, the untrusting and the crooked, the grandiose and the cowardly.




Their customs and rituals are as captivating as any tribe’s, and at least as mystifying. Every mental anthropologist who has visited their world seems to walk away with a different story, a new model to explain those strange behaviors.


This weekend the Board of Trustees of the American Psychiatric Association will vote on whether to adopt a new diagnostic system for some of the most serious, and striking, syndromes in medicine: personality disorders.


Personality disorders occupy a troublesome niche in psychiatry. The 10 recognized syndromes are fairly well represented on the self-help shelves of bookstores and include such well-known types as narcissistic personality disorder, avoidant personality disorder, as well as dependent and histrionic personalities.


But when full-blown, the disorders are difficult to characterize and treat, and doctors seldom do careful evaluations, missing or downplaying behavior patterns that underlie problems like depression and anxiety in millions of people.


The new proposal — part of the psychiatric association’s effort of many years to update its influential diagnostic manual — is intended to clarify these diagnoses and better integrate them into clinical practice, to extend and improve treatment. But the effort has run into so much opposition that it will probably be relegated to the back of the manual, if it’s allowed in at all.


Dr. David J. Kupfer, a professor of psychiatry at the University of Pittsburgh and chairman of the task force updating the manual, would not speculate on which way the vote might go: “All I can say is that personality disorders were one of the first things we tackled, but that doesn’t make it the easiest.”


The entire exercise has forced psychiatrists to confront one of the field’s most elementary, yet still unresolved, questions: What, exactly, is a personality problem?


Habits of Thought


It wasn’t supposed to be this difficult.


Personality problems aren’t exactly new or hidden. They play out in Greek mythology, from Narcissus to the sadistic Ares. They percolate through biblical stories of madmen, compulsives and charismatics. They are writ large across the 20th century, with its rogues’ gallery of vainglorious, murderous dictators.


Yet it turns out that producing precise, lasting definitions of extreme behavior patterns is exhausting work. It took more than a decade of observing patients before the German psychiatrist Emil Kraepelin could draw a clear line between psychotic disorders, like schizophrenia, and mood problems, like depression or bipolar disorder.


Likewise, Freud spent years formulating his theories on the origins of neurotic syndromes. And Freudian analysts were largely the ones who, in the early decades of the last century, described people with the sort of “confounded identities” that are now considered personality disorders.


Their problems were not periodic symptoms, like moodiness or panic attacks, but issues rooted in longstanding habits of thought and feeling — in who they were.


“These therapists saw people coming into treatment who looked well put-together on the surface but on the couch became very disorganized, very impaired,” said Mark F. Lenzenweger, a professor of psychology at the State University of New York at Binghamton. “They had problems that were neither psychotic nor neurotic. They represented something else altogether.”


Several prototypes soon began to emerge. “A pedantic sense of order is typical of the compulsive character,” wrote the Freudian analyst Wilhelm Reich in his 1933 book, “Character Analysis,” a groundbreaking text. “In both big and small things, he lives his life according to a preconceived, irrevocable pattern.”


Others coalesced too, most recognizable as extreme forms of everyday types: the narcissist, with his fragile, grandiose self-approval; the dependent, with her smothering clinginess; the histrionic, always in the thick of some drama, desperate to be the center of attention.


In the late 1970s, Ted Millon, scientific director of the Institute for Advanced Studies in Personology and Psychopathology, pulled together the bulk of the work on personality disorders, most of it descriptive, and turned it into a set of 10 standardized types for the American Psychiatric Association’s third diagnostic manual. Published in 1980, it is a best seller among mental health workers worldwide.


These diagnostic criteria held up well for years and led to improved treatments for some people, like those with borderline personality disorder. Borderline is characterized by an extreme neediness and urges to harm oneself, often including thoughts of suicide. Many who seek help for depression also turn out to have borderline patterns, making their mood problems resistant to the usual therapies, like antidepressant drugs.


Today there are several approaches that can relieve borderline symptoms and one that, in numerous studies, has reduced hospitalizations and helped aid recovery: dialectical behavior therapy.


This progress notwithstanding, many in the field began to argue that the diagnostic catalog needed a rewrite. For one thing, some of the categories overlapped, and troubled people often got two or more personality diagnoses. “Personality Disorder-Not Otherwise Specified,” a catchall label meaning little more than “this person has problems” became the most common of the diagnoses.


It’s a murky area, and in recent years many therapists didn’t have the time or training to evaluate personality on top of everything else. The assessment interviews can last hours, and treatments for most of the disorders involve longer-term, specialized talk therapy.


Psychiatry was failing the sort of patients that no other field could possibly help, many experts said.


“The diagnoses simply weren’t being used very much, and there was a real need to make the whole system much more accessible,” Dr. Lenzenweger said.


Resisting Simplification 


It was easier said than done.


The most central, memorable, and knowable element of any person — personality — still defies any consensus.


A team of experts appointed by the psychiatric association has worked for more than five years to find some unifying system of diagnosis for personality problems.


The panel proposed a system based in part on a failure to “develop a coherent sense of self or identity.” Not good enough, some psychiatric theorists said.


Later, the experts tied elements of the disorders to distortions in basic traits.


Read More..

Clearing the Fog Around Personality Disorders





For years they have lived as orphans and outliers, a colony of misfit characters on their own island: the bizarre one and the needy one, the untrusting and the crooked, the grandiose and the cowardly.




Their customs and rituals are as captivating as any tribe’s, and at least as mystifying. Every mental anthropologist who has visited their world seems to walk away with a different story, a new model to explain those strange behaviors.


This weekend the Board of Trustees of the American Psychiatric Association will vote on whether to adopt a new diagnostic system for some of the most serious, and striking, syndromes in medicine: personality disorders.


Personality disorders occupy a troublesome niche in psychiatry. The 10 recognized syndromes are fairly well represented on the self-help shelves of bookstores and include such well-known types as narcissistic personality disorder, avoidant personality disorder, as well as dependent and histrionic personalities.


But when full-blown, the disorders are difficult to characterize and treat, and doctors seldom do careful evaluations, missing or downplaying behavior patterns that underlie problems like depression and anxiety in millions of people.


The new proposal — part of the psychiatric association’s effort of many years to update its influential diagnostic manual — is intended to clarify these diagnoses and better integrate them into clinical practice, to extend and improve treatment. But the effort has run into so much opposition that it will probably be relegated to the back of the manual, if it’s allowed in at all.


Dr. David J. Kupfer, a professor of psychiatry at the University of Pittsburgh and chairman of the task force updating the manual, would not speculate on which way the vote might go: “All I can say is that personality disorders were one of the first things we tackled, but that doesn’t make it the easiest.”


The entire exercise has forced psychiatrists to confront one of the field’s most elementary, yet still unresolved, questions: What, exactly, is a personality problem?


Habits of Thought


It wasn’t supposed to be this difficult.


Personality problems aren’t exactly new or hidden. They play out in Greek mythology, from Narcissus to the sadistic Ares. They percolate through biblical stories of madmen, compulsives and charismatics. They are writ large across the 20th century, with its rogues’ gallery of vainglorious, murderous dictators.


Yet it turns out that producing precise, lasting definitions of extreme behavior patterns is exhausting work. It took more than a decade of observing patients before the German psychiatrist Emil Kraepelin could draw a clear line between psychotic disorders, like schizophrenia, and mood problems, like depression or bipolar disorder.


Likewise, Freud spent years formulating his theories on the origins of neurotic syndromes. And Freudian analysts were largely the ones who, in the early decades of the last century, described people with the sort of “confounded identities” that are now considered personality disorders.


Their problems were not periodic symptoms, like moodiness or panic attacks, but issues rooted in longstanding habits of thought and feeling — in who they were.


“These therapists saw people coming into treatment who looked well put-together on the surface but on the couch became very disorganized, very impaired,” said Mark F. Lenzenweger, a professor of psychology at the State University of New York at Binghamton. “They had problems that were neither psychotic nor neurotic. They represented something else altogether.”


Several prototypes soon began to emerge. “A pedantic sense of order is typical of the compulsive character,” wrote the Freudian analyst Wilhelm Reich in his 1933 book, “Character Analysis,” a groundbreaking text. “In both big and small things, he lives his life according to a preconceived, irrevocable pattern.”


Others coalesced too, most recognizable as extreme forms of everyday types: the narcissist, with his fragile, grandiose self-approval; the dependent, with her smothering clinginess; the histrionic, always in the thick of some drama, desperate to be the center of attention.


In the late 1970s, Ted Millon, scientific director of the Institute for Advanced Studies in Personology and Psychopathology, pulled together the bulk of the work on personality disorders, most of it descriptive, and turned it into a set of 10 standardized types for the American Psychiatric Association’s third diagnostic manual. Published in 1980, it is a best seller among mental health workers worldwide.


These diagnostic criteria held up well for years and led to improved treatments for some people, like those with borderline personality disorder. Borderline is characterized by an extreme neediness and urges to harm oneself, often including thoughts of suicide. Many who seek help for depression also turn out to have borderline patterns, making their mood problems resistant to the usual therapies, like antidepressant drugs.


Today there are several approaches that can relieve borderline symptoms and one that, in numerous studies, has reduced hospitalizations and helped aid recovery: dialectical behavior therapy.


This progress notwithstanding, many in the field began to argue that the diagnostic catalog needed a rewrite. For one thing, some of the categories overlapped, and troubled people often got two or more personality diagnoses. “Personality Disorder-Not Otherwise Specified,” a catchall label meaning little more than “this person has problems” became the most common of the diagnoses.


It’s a murky area, and in recent years many therapists didn’t have the time or training to evaluate personality on top of everything else. The assessment interviews can last hours, and treatments for most of the disorders involve longer-term, specialized talk therapy.


Psychiatry was failing the sort of patients that no other field could possibly help, many experts said.


“The diagnoses simply weren’t being used very much, and there was a real need to make the whole system much more accessible,” Dr. Lenzenweger said.


Resisting Simplification 


It was easier said than done.


The most central, memorable, and knowable element of any person — personality — still defies any consensus.


A team of experts appointed by the psychiatric association has worked for more than five years to find some unifying system of diagnosis for personality problems.


The panel proposed a system based in part on a failure to “develop a coherent sense of self or identity.” Not good enough, some psychiatric theorists said.


Later, the experts tied elements of the disorders to distortions in basic traits.


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As Rebels Gain, Congo Again Slips Into Chaos





GOMA, Democratic Republic of Congo — The lights are out in most of Goma. There is little water. The prison is an empty, garbage-strewn wasteland with its rusty front gate swinging wide open and a three-foot hole punched through the back wall, letting loose 1,200 killers, rapists, rogue soldiers and other criminals.




Now, rebel fighters are going house to house arresting people, many of whom have not been seen again by their families.


“You say the littlest thing and they disappear you,” said an unemployed man named Luke.


In the past week, the rebels have been unstoppable, steamrolling through one town after another, seizing this provincial capital, and eviscerating a dysfunctional Congolese Army whose drunken soldiers stumble around with rocket-propelled grenades and whose chief of staff was suspended for selling crates of ammunition to elephant poachers.


Riots are exploding across the country — in Bukavu, Butembo, Bunia, Kisangani and Kinshasa, the capital, a thousand miles away. Mobs are pouring into streets, burning down government buildings and demanding the ouster of Congo’s weak and widely despised president, Joseph Kabila.


Once again, chaos is courting Congo. And one pressing question is, why — after all the billions of dollars spent on peacekeepers, the recent legislation passed on Capitol Hill to cut the link between the illicit mineral trade and insurrection, and all the aid money and diplomatic capital — is this vast nation in the heart of Africa descending to where it was more than 10 years ago when foreign armies and marauding rebels carved it into fiefs?


“We haven’t really touched the root cause,” said Aloys Tegera, a director for the Pole Institute, a research institute in Goma.


He said Congo’s chronic instability is rooted in very local tensions over land, power and identity, especially along the Rwandan and Ugandan borders. “But no one wants to touch this because it’s too complicated,” he added.


The most realistic solution, said another Congo analyst, is not a formal peace process driven by diplomats but “a peace among all the dons, like Don Corleone imposed in New York.”


Congo’s problems have been festering for years, wounds that never quite scabbed over.


But last week there was new urgency after hundreds of rebel fighters, wearing rubber swamp boots and with belt-fed machine guns slung across their backs, marched into Goma, the capital of North Kivu Province and one of the country’s most important cities.


The rebels, called the M23, are a heavily armed paradox. On one hand, they are ruthless. Human rights groups have documented how they have slaughtered civilians, pulling confused villagers out of their huts in the middle of the night and shooting them in the head.


On the other hand, the M23 are able administrators — seemingly far better than the Congolese government, evidenced by a visit in recent days to their stronghold, Rutshuru, a small town about 45 miles from Goma.


In Rutshuru, there are none of those ubiquitous plastic bags twisted in the trees, like in so many other parts of Congo. The gravel roads have been swept clean and the government offices are spotless. Hand-painted signs read: “M23 Stop Corruption.” The rebels even have green thumbs, planting thousands of trees in recent months to fight soil erosion.


“We are not a rebellion,” said Benjamin Mbonimpa, an electrical engineer, a bush fighter and now a top rebel administrator. “We are a revolution.”


Their aims, he said, were to overthrow the government and set up a more equitable, decentralized political system. This is why the rebels have balked at negotiating with Mr. Kabila, though this weekend several rebels said that the pressure was increasing on them to compromise, especially coming from Western countries.


On Sunday, rebel forces and government troops were still squared off, just a few miles apart, down the road from Goma.


The M23 rebels are widely believed to be covertly supported by Rwanda, which has a long history of meddling in Congo, its neighbor blessed with gold, diamonds and other glittering mineral riches. The Rwandan government strenuously denies supplying weapons to the M23 or trying to annex eastern Congo. Rwanda has often denied any clandestine involvement in this country, only to have the denials later exposed as lies.


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Libel Case That Snared BBC Widens to Twitter


PARIS — The Internet, it is sometimes said, turns every citizen into a journalist. If that is the case, some Twitter users in Britain are discovering one of the downsides of the business.


As many as 10,000 Twitter users reportedly face the threat of legal action because of comments posted on the Internet or forwarded to others in which they referred to a BBC report wrongly linking a former Conservative Party official to the sexual abuse of a child. The official, Alistair McAlpine, was not named in the Nov. 2 BBC report, but enough clues were provided that Twitter users were able to identify him — which they did, in great numbers.


The BBC quickly settled a libel claim, paying Mr. McAlpine £185,000, or nearly $300,000, and apologized for the error as a case of mistaken identity. Another British television broadcaster, ITV, agreed on Thursday to pay Mr. McAlpine £125,000 to settle another claim, this one over a subsequent broadcast in which a list purporting to show Conservative figures linked to sex abuse accusations had been visible to viewers.


Mr. McAlpine did not stop with the mainstream media. On Friday, a spokeswoman for the politician told The Guardian newspaper that his lawyers had identified 20 “high-profile tweeters” from whom they were seeking libel damages. Among them were a comedian, Alan Davies; Sally Bercow, the wife of John Bercow, the speaker of the House of Commons; and George Monbiot, a Guardian columnist.


There have been previous libel suits over comments posted on Twitter, a site that lets users write short messages to their followers. In March, a New Zealand cricket player, Chris Cairns, was awarded £90,000 by the High Court in London over a Twitter post by an Indian cricket official in which he falsely accused Mr. Cairns of match-fixing.


But the campaign by Mr. McAlpine appears to be the broadest yet, and it employs some novel tactics.


“Many people have had their reputations trashed on Twitter before, but nobody has decided to take action on this scale,” said Tim Lowles, a media lawyer at Collyer Bristow in London.


In addition to the prominent figures, Mr. McAlpine is reportedly pursuing action against thousands of other Twitter users, including people who had merely repeated to their own followers comments made by others.


Twitter users with fewer than 500 online followers who are “wishing to apologize and make contact” can use a Web site created by Mr. McAlpine’s law firm, R.M.P.I., to try to settle their cases.


“It is not this firm or Lord McAlpine’s intention to create any hardship,” a letter posted on the site states.


All that Twitter users who think they might have libeled Mr. McAlpine have to do is read the letter, fill out a downloadable form asking them for details of the postings in question, make an apology and send the form back via e-mail. Those who respond are reportedly asked to make donations to charity, and the firm warns that there will also be a “small administrative charge.”


British libel and defamation laws are notoriously friendly to claimants. While a planned overhaul would give publishers a bit more protection, the rise of social media like Twitter has vastly expanded the possibilities for libeling someone.


Some of the Twitter posts in question do not directly mention the offense to which Mr. McAlpine was falsely linked. The posting by Ms. Bercow asked, “Why is Lord McAlpine trending? *innocent face*” She insisted in a subsequent post that her initial comment had not been libelous.


Mr. Lowles said that under British law it was possible to libel someone indirectly or by innuendo, even if the incorrect accusations were not mentioned directly, as long as they were clear from the context.


It is not clear how far Mr. McAlpine intends to go in pursuing Twitter users who commented on the BBC accusations. R.M.P.I. did not return calls.


Some people register on Twitter anonymously or under fake names. British courts have ruled in previous cases that Internet companies like Twitter can be ordered to turn over the personal details of users, but this can be time-consuming and costly. A Twitter spokeswoman in Britain declined to comment on whether the company had received any such requests.


Like other social media companies, Twitter considers itself a conduit for its users but disavows responsibility for the content of the 400 million comments posted daily. The site’s guidelines state that users bear this burden.


“Most people still don’t think when they write something on Twitter that they are actually publishing,” Mr. Lowles said. “Whether or not this will act as a deterrent, I don’t know. People should think before they tweet.”


Could the threat of libel action dissuade Britons from posting on Twitter? By Friday, at least one prominent Twitter account had disappeared — that of Ms. Bercow, who had more than 50,000 followers, and who had followed up her comments on Mr. McAlpine with an apparent mistake in a different case: she appeared to have violated a court order by naming a British teenager who had been abducted by one of her teachers.


“This could have a chilling effect,” Paul Bernal, a lecturer in media law at the University of East Anglia, said of the McAlpine case. “I know people who have said that they are not going to post as much because of this.”


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