Excerpts from Must Read Books & Articles
on Mental Health Topics
Articles- Part XXXIII
What's Normal?: Bipolar Diagnosis and Children
Jerome Groopman, The New Yorker- 4/9/2007
In April, 2000, Steven Hyman, a psychiatrist who at the time was the director of the National Institute of Mental Health, convened a meeting of nineteen prominent psychiatrists and psychologists in order to discuss bipolar-disorder in children. The disorder has long been recognized as a serious psychiatric illness in adults, characterized by recurring episodes of mania and depression. (It is sometimes called manic depression.) People with bipolar disorder are often unable to hold down jobs; require lifelong treatment with powerful medications, many of which have severe side effects; and have high suicide rates. The disorder is thought to afflict between one and four per cent of Americans and tends to run in families, although no genes for it have been identified. At the time of the meeting, few children had been given a diagnosis of the illness, and it was considered to begin, typically, in adolescence or early adulthood.
In the late nineteen-nineties, however, there was an increase in awareness of bipolar disorder in children, first in medical journals and then in places like BPParents, a Listserv founded by the mother of an eight-year-old boy who had been diagnosed with the disorder. Hyman himself had been consulted by parents of children who, he told me, were "really suffering and extremely disruptive, having violent outbursts at school and at home, and hard to contain under any circumstances." Many of the parents told Hyman that they believed their child had bipolar disorder, and they cited a book called "The Bipolar Child: The Definitive and Reassuring Guide to Childhood's Most Misunderstood Disorder." The book, which was written by Demitri Papolos, a psychiatrist affiliated with the Albert Einstein College of Medicine, in New York City, and his wife, Janice, the author of several how-to manuals, had been published in 1999. (It has sold more than 200,+!00 copies, and a third edition came out last summer.) "The first parents who visited me came with the Papolos book in hand," Hyman said.
The Papoloses argued that bipolar disorder was often overlooked in children. In 1998, according to "The Bipolar Child," nearly four million children were given Ritalin or other stimulants for hyperactivity, of that number, the Papoloses contended, more than a million would eventually receive a bipolar diagnosis. They also cited researchers' estimates that anywhere from a third to half of the 3.4 million children thought to suffer from depression were actually experiencing the early onset of bipolar disorder. The book detailed the negative effects of bipolar disorder on patients (disruptive behavior, drug abuse, suicide attempts) but also prominently featured what might be described as its paradoxical benefits:
This illness is as old as humankind, and has probably been conserved in the human genome because it confers great energy and originality of thought. People who have had it have literally changed the course of human history: Manic-depression has afflicted (and probably fueled the brilliance of) people like Isaac Newton, Abraham Lincoln, Winston Churchill, Theodore Roosevelt, Johann Goethe, Honore de Balzac, George Frederic Handel, Ludwig von Beethoven, Robert Schumann, Leo Tolstoy, Charles Dickens, Virginia Woolf, Ernest Hemingway, Robert Lowell, and Anne Sexton.
(These claims are similar to those made about other serious psychiatric disorders, particularly depression.)
The Papoloses' research was based on responses to questionnaires that they distributed through BPParents, whose several hundred members are parents who suspect that their children have the disorder. "These children seem to burst into life and are on a different time schedule from the rest of the world right from the beginning," the Papoloses wrote. "Many are extremely precocious and bright-doing everything early and with gusto. They seem like magical children, their creativity can be astounding, and the parents speak about them with real respect, and sometimes even awe." The book included some parents' observations:
She was always ahead of her time. She started talking at eight months with the words "kitty cat." She walked at nine months and was speaking in complete sentences by a year. She was writing small novels in the second grade. She acted and danced
During the meeting at the N.I.M.H., the psychiatrists and psychologists argued about whether bipolar disorder existed in children, and, if it did, how it could be distinguished from other syndromes affecting mood and behavior, such as attention-deficit hyperactivity disorder (A.D.H.D.) and autism. One psychiatrist, Barbara Geller, a professor at Washington University, in St. Louis, had published articles about children whose moods often fluctuated rapidly. In the course of a single day, the children were extremely sad, even suicidal, and then, suddenly, they became elated and "grandiose"-a term that psychiatrists use to mean an inflated sense of one's abilities. Geller believed that some of these children who matched several specific and narrow criteria had bipolar disorder. Joseph Biederman, a child psychiatrist at Massachusetts General Hospital, in Boston, who also attended the meeting, had treated children suffering from extreme symptoms of irritability and aggressive behavior and, often with a colleague, Janet Wozniak, had published several articles in medical journals asserting that these children met the criteria for bipolar disorder described in the Diagnostic and Statistical Manual of Mental Disorders (D.S.M-IV), the reference book for psychiatric illnesses. Hyman encouraged the group to arrive at a consensus, in part to create a uniform set of criteria that could be used to enroll children in studies of the disorder.
and sang way beyond her years.
At eighteen months he climbed out of the baby bed in the middle of the night, opened the fridge, got out three dozen eggs (it was Easter time), and proceeded to sit in his booster chair and crack three dozen eggs onto our hardwood floors. (He wanted to bake a real cake--he didn't like the toy mixing bowl I had given him to play with.) After the insurance company quit laughing they did pay to refinish our floors.
In August, 2001, the results of the meeting were published in the Journal of the American Academy of Child and Adolescent Psychiatry, and it was concluded that "bipolar disorder exists and can be diagnosed in prepubertal children," though the article went on to say that not all children who appeared to have the disorder satisfied the DAM criteria. The vagueness of the definition offered few guidelines for practical diagnosis.
Meanwhile, articles inspired by the Papoloses' book had begun appearing in newspapers and magazines, promoting the idea that there was a new diagnosis for troubled children. In August, 2002, Time published a cover story titled "Young and Bipolar," with the tagline "Once Called Manic Depression, the Disorder Afflicted Adults. Now It's Striking Kids. Why?" The article featured a list of behaviors--adapted from the Papoloses' book--that was intended to help parents "recognize some warning signs" of the disorder. Among those were "poor hand writing," "complains of being bored," "is very intuitive or very creative," "excessively distressed when separated from family," "has difficulty arising in the A.M..," "elated or silly, giddy mood states," "curses viciously in anger," and "intolerant of delays." The magazine also published a sidebar listing prominent writers and musicians who may have suffered from bipolar disorder, including Lord Byron, Edgar Allan Poe, and Kurt Cobain. Although the article cited external factors such as stress and drug use, it also noted that the disorder is "hugely familial," as one doctor put it. (One mother, who was afflicted with bipolar disorder, claimed that she knew before her son was born that he would be bipolar, because he was restless even in the womb.)
Not long after the article came out, a research team at Massachusetts General Hospital, led by Biederman and Wozniak, began an eight-week comparative study of the antipsychotic drugs olanzipine (marketed under the name Zyprexa) and risperidone (Risperdal) for thirty-one children between the ages of four and six who had been given a diagnosis of bipolar disorder based on
D.S.M. criteria. During the trial, the children gained an average of six pounds and experienced sharp increases in prolactin, a pituitary hormone, which, when elevated, might interfere with sexual development. But their symptoms of severe irritability and aggression were markedly muted by the treatment, and the researchers, while noting the adverse effects, concluded that the drugs could be beneficial to bipolar children.
There are few reliable statistics on the incidence of pediatric bipolar disorder, but according to a national study of community-hospital discharge records, led by Brady Case, a research assistant professor of psychiatry at New York University and a child-psychiatry fellow at Bradley Hospital, in Providence, the percentage of mentally ill children under eighteen who have been given a diagnosis of the disorder increased more than fourfold between 1990 and 2000. Many doctors fear that the media, in drawing attention to bipolar disorder, may have exaggerated its prevalence in children and presented a misleading picture of the disorder. The situation has some similarities to the over-diagnosis of attention-deficit disorder in the first half of the nineteen-nineties, during which the prescription of stimulants such as Ritalin tripled for children between the ages of two and four, according to a study published in February, 2000, in the Journal of the American Medical Association. Some children do, of course, suffer from bipolar disorder, but it is important to recognize that the consequences of its treatment can be dire, particularly when parents are unaware of or ignore the dangerous side effects of the medications. In December, 2006, a four-year-old girl in Massachusetts, who had received a bipolar diagnosis at the age of two and a half, died from an apparent overdose of Clonidine, a blood-pressure medicine used to sedate hyperactive children. She was also taking Seroquel, an antipsychotic, and Depakote, an anti-seizure medication that helps regulate mood. (Her parents have been charged with murder and have pleaded not guilty.) The diagnosis has spread too broadly, so that powerful drugs are prescribed too widely," Hyman told me. "We are going to have hell to pay in terms of side effects."
The above text covers the first two pages of this six page article. For the remainder, visit the archives of the New Yorker Magazine at www.newyorker.com/archive.
A Lifetime of Restless Isolation Explained
Tim Page, The New Yorker- 8/20/07
My second-grade teacher never liked me much, and one assignment I turned in annoyed her so extravagantly that the red pencil with which she scrawled "See me!" broke through the lined paper. Our class had been asked to write about a recent field trip, and, as was so often the case in those days, I had noticed the wrong things:
Well, we went to Boston, Massachusetts through the town of Warrenville, Connecticut on Route 44A. It was very pretty and there was a church that reminded me of pictures of Russia from our book that is published by Time-Life. We arrived in Boston at 9:17. At 11 we went on a big tour of Boston on Gray Line 43, made by the Superior Bus Company like School Bus Six, which goes down Hunting Lodge Road where Maria lives and then on to Separatist Road and then to South Eagleville before it comes to our school. We saw lots of good things like the Boston Massacre site. The tour ended at 1:05. Before I knew it we were going home. We went through Warrenville again but it was too dark to see much. A few days later it was Easter. We got a cuckoo clock.
It is an unconventional but hardly unobservant report. In truth, I didn't care one bit about Boston on that spring day in 1963. Instead, I wanted to learn about Warrenville, a village a few miles northeast of the town of Mansfield, Connecticut, where we were then living. I had memorized the map of Mansfield, and knew all the school bus routes by heart—a litany I would sing out to anybody I could corner. But Warrenville was in the town of Ashford, for which I had no guide, and I remember the blissful sense of resolution I felt when I certified that Route 44A crossed Route 89 in the town center, for I had long hypothesized that they might meet there. Of such joys and pains was my childhood composed.
I received a grade of "Unsatisfactory" in Social Development from the Mansfield Public Schools that year. I did not work to the best of my ability, did not show neatness and care in assignments, did not cooperate with the group, and did not exercise self-control. About the only positive assessment was that I worked well independently. Of course: then as now, it was all that I could do.
In the years since the phrase became a cliché, I have received any number of compliments for my supposed ability to "think outside the box." Actually, it has been a struggle for me to perceive just what these "boxes were—why they were there, why other people regarded them as important, where their borderlines might be, how to live safely within and without them. My efforts have been only partly successful: after fifty-two years, I am left with the melancholy sensation that my life has been spent in a perpetual state of parallel play, alongside, but distinctly apart from, the rest of humanity.
From early childhood, my memory was so acute and my wit so bleak that I was described as a genius—by my parents, by our neighbors, and even, on occasion, by the same teachers who gave me failing marks. I wrapped myself in this mantle, of course, as a poetic justification for behavior that might otherwise have been judged unhinged, and I did my best to believe in it. But the explanation made no sense. A genius at what? Were other "geniuses" so oblivious that they couldn't easily tell right from left and idly wet their pants into adolescence? What accounted for my rages and frustrations, for the imperious contempt I showed to people who were in a position to do me harm? Although I delighted in younger children, whom I could instruct and gently dominate, and I was thrilled when I ran across an adult willing to discuss my pet subjects, I could establish no connection with most of my classmates. My pervasive childhood memory is an excruciating awareness of my own strangeness.
Despite their roseate talk, my parents and my school put a good deal of effort into finding out precisely what was wrong with me. It was obvious that I was not "normal," especially by the straitened standards of the early nineteen-sixties. I have sometimes wondered whether the I.Q. scores with which I was credited were nudged upward by my father, who was both a professional educator with a keen interest in gifted children and the person who administered my most triumphant examinations. Whatever the case, while my younger brother and sister soared through school, academically and socially, I was consistently at or near the bottom of the class, and decidedly out of control—half asleep or aggressively assertive—much of the time.
And so, between the ages of seven and fifteen, I was given glucose-tolerance tests, anti-seizure medications, electroencephalograms, and an occasional Mogadon to shut me down at night. I suffered through a summer of Bible camp; exercise regimens were begun and abandoned; and the school even brought in a psychiatrist to grill me once a week Somehow, every June, I was promoted to the next grade, having accomplished little to deserve it. Meanwhile, the more kindly homeroom teachers, knowing that I would be tormented on the playground, permitted me to spend recess periods indoors, where I memorized vast portions of the 1961 edition of the World Book Encyclopedia.
A brown carton in my basement contains most of the surviving documents of my childhood, and they present a pretty fair portrait of my pre-teen obsessions. There are meandering and implausible stories, none with happy endings; intricately detailed street maps of make-believe cities on which I worked silently for hours; and countless crayon drawings of grinning girls with shoulder-length hair and U-shaped smiles, their stick figures fleshed out only by exaggerated biceps. Other children collected coins or baseball cards; I tore obituaries of Sophie Tucker and David O. Selznick from the Hartford Courant and pasted them sloppily into a scrapbook
In my darker moods, I think that the rest of my life can be encapsulated in a single sentence: I grew up and grew into other preoccupations, some of which have served me well. I became a music critic and culture writer, first for the SoHo News, and then for the Times, Newsday, and the Washington Post. In the middle of all this, I became enamored of the American author Dawn Powell, whose life and works I absorbed in much the same manner I had the World Book, and I spent five years editing her novels, short stories, plays, diaries, and letters and writing her first biography. I look back on these projects with a certain mystified satisfaction; I'm glad they were done, but it is as though they had been accomplished by somebody else, for the particular furies and fevers that impelled them have long since evaporated.
In the fall of 2000, in the course of what had become a protracted effort to identify—and, if possible, alleviate—my lifelong unease, I was told that I had Asperger's syndrome. I had never heard of the condition, which had been recognized by the American Psychiatric Association only six years earlier. Nevertheless, the diagnosis was one of those rare clinical confirmations which are met mostly with relief. Here, finally, was an objective explanation for some of my strengths and weaknesses, the simultaneous capacity for unbroken work and all-encompassing recall, linked inextricably to a driven, uncomfortable personality. And I learned that there were others like me—people who yearned for steady routines, repeated patterns, and a few cherished subjects, the driftwood that keeps us afloat.
The syndrome was identified, in 1944, by Hans Asperger, a Viennese pediatrician, who wrote, "For success in science or art, a dash of autism is essential." Yet Oliver Sacks makes a clear distinction between full-fledged autism and Asperger's syndrome. In The New Yorker some years ago, Sacks wrote that "people with Asperger's syndrome can tell us of their experiences, their inner feelings and states, whereas those with classical autism cannot. With classical autism there is no `window,' and we can only infer. With Asperger's syndrome there is self-consciousness and at least some power to introspect and report."
In his 1998 book "Asperger's Syndrome: A Guide for Parents and Professionals," Tony Attwood observed, "The person with Asperger's syndrome has no distinguishing physical features but is primarily viewed by other people as different because of their unusual quality of social behavior and conversation skills. For example, a woman with Asperger's Syndrome described how as a child she saw people moving into the house up the street, ran up to one of the new kids and, instead of the conventional greeting and request of 'Hi, you want to play?,' proclaimed, 'Nine times nine is equal to 81.'"
David Mamet, in his recent book "Bambi vs. Godzilla," discerned redeeming qualities in the condition. Considering filmmakers past and present, he stated that "it is not impossible that Asperger's syndrome helped make the movies. The symptoms of this developmental disorder include early precocity, a great ability to maintain masses of information, a lack of ability to mix with groups in age-appropriate ways, ignorance of or indifference to social norms, high intelligence, and difficulty with transitions, married to a preternatural ability to concentrate on the minutia of the task at hand."
The Asperger's spectrum ranges from people barely more abstracted than a stereotypical "absent-minded professor" to the full-blown, albeit highly functioning, autistic. Symptoms of Asperger's have been attributed ex post facto to successful figures, but these are the fortunate ones—persons able to invent outlets for their ever-welling monomanias. Many are not so lucky, and some end up institutionalized or homeless. (In the late nineteen-seventies, I saw a ragged, haunted man who spent urgent hours dodging the New York transit police to trace the dates and lineage of the Hapsburg nobility on the walls of subway stations.) For some—record collectors with every catalogue number at hand, theatre buffs with first-night casts memorized, children who draw precise architectural blueprints of nineteenth-century silk mills—a duster of facts can be both luminous and lyric, something around which to construct a life.
We are informally referred to as "Aspies," and if we are not very, very good at something we tend to do it very poorly. Little in life comes naturally—except for our random, inexplicable, and often uncontrollable gifts—and, even more than most children, we assemble our personalities unevenly, piece by piece, almost robotically, from models we admire. (I remember the deliberate decision to appropriate one teacher's mischievous grin and darting eyes, which I found so charming that I thought they might work for me, too.)
So preoccupied are we with our inner imperatives that the outer world may overwhelm and confuse. What anguished pity I used to feel for pinatas at birthday parties, those papier-mâché donkeys with their amiable smiles about to be shattered by little brutes with bats. On at least one occasion, I begged for a stay of execution and eventually had to be taken home, weeping, convinced that I had just witnessed the braining of a new and sympathetic acquaintance.
Caring for inanimate objects came easily. Learning to make genuine connections with people—much as I desperately wanted them—was a bewildering process. I felt like an alien, always about to be exposed. Or, to adapt another hoary but useful analogy, not only did I not see the forest for the trees; I was so intensely distracted that I missed the trees for the species of lichen on their bark.
My first and most powerful obsession was music—the same records played again and again while I watched them spin, astonished at their evocation of aural worlds that I not only instinctively understood even as a toddler but in which I actually felt comfortable. I was both terrified of and tantalized by death (which was absolutely real to me from earliest childhood), and by the way recordings restored Enrico Caruso and Nellie Melba to life for a few minutes, ghostly visitors who had returned to sing for me at 78 r.p.m., through a hiss of shellac and antiquity.
When I was ten, I became fascinated by silent films, the visual complement to my old records. I spent hours at the library of the University of Connecticut, a few minutes' walk from home, researching the lives of actors and actresses on microfilm, and recall the genuine sense of mourning that came over me when I saw Barbara La Marr's sad, youthful face on an obituary page from 1926. Not surprisingly, "Sunset Boulevard" was my favorite "talkie" (I actually called them that—in 1965!), and I'd regularly set the alarm and wake in the middle of the night to watch Chester Conklin or Louise Dresser take on minor roles in some B movie that the Worcester, Massachusetts, UHF station put on when nobody else was watching.
“I despise the Beatles and their ilk," this remarkably Blimpish young man proclaimed in a school paper shortly after the first Ed Sullivan show, when other boys my age were growing their hair long and learning to play the guitar. My favorite pop musician then was the Scottish comedian Harry Lauder, a star in vaudeville and music halls at the beginning of the last century, who told obscure jokes in brogue and sang through exaggerated hiccups in a state of pretend intoxication. The depth of my admiration for Lauder now baffles me as much as the steady diet of horehound drops I adopted as snack food, or my insistence, much of one autumn, that I wear a rabbit's foot in each buttonhole of my shirt, which I kept tightly fastened up to the neck. But nobody could have persuaded me to abandon these quirks, and any attempt to do so would have been taken as a physical threat and reduced me to hysteria.
A friend published a sweet autobiography entitled "Thank You, Everyone," in which she expressed gratitude to everybody who had influenced her, ranging from Woody Allen to my sister Betsy. If I were to create a similar book, I would call it "Sorry, Everyone," and apologize for my youthful cluelessness: To the girl in seventh grade with the protruding jawbone (it never occurred to me that she would not share my enthusiasm for her unusually simian features). To the boy who came over to my house in the middle of my Caruso phase and endured a precious weekend afternoon comparing recordings of "Celeste Aida." To the perplexed young women from early adolescence who might have become lovers had I understood that their sudden friendship and proximity had any sort of physical impetus. Instead, I chattered on about this and that, rarely making eye contact, and soon they vanished, in search of more game and grounded potential partners. Sorry, everyone. I didn't understand.
It was hard for me to be touched. I froze when I was hugged by anybody who was not a relative, and I made love like the Tin Man until I was well into adulthood. Like many children before and since, I recoiled when fundamental facts about the reproduction of the species were explained to me (there was, typically for the time and the place, no suggestion that new pleasures might be involved, and the physical act, examined through an anxious, pre-sexual eye, sounded bizarre). Shortly after this enlightenment, my parents threw a party, attended by their closest friends. I watched their athletic, fortyish bodies, properly clothed, in mortified amazement, and then took a recount of their children. Oh, my God, I thought. They did that three times!
Anything related to the human body seemed to me bad news. In the fourth grade, when my affliction was most intense, I would be herded out to play kickball during our physical-education classes. Teams were chosen, and I was embedded among the strongest kids, to provide some chance of even battle. In memory, it is forever bases loaded with two outs when my turn at the plate comes, and I am as well suited as a giraffe to meet the big red ball that rolls toward me with frightening speed.
The above text covers the first three pages of this eleven page article. For the remainder, visit the archives of the New Yorker Magazine at www.newyorker.com/archive..
Sue Halpern, New Yorker- 5/19/2008
In November, 2004, when he was nineteen years old, a marine I'll call Travis Boyd found himself about to rush the roof of the tallest building in the northern end of Falluja in the midst of a firelight. Boyd, whose first assignment in Iraq was to the security detail at Abu Ghraib prison, had been patrolling the city with his thirteen-man infantry squad, rooting out insurgents and sleeping on the floors of abandoned houses, where they'd often have to remove dead bodies in order to lay out their bedrolls.
With Boyd in the lead, the marines ran up the building's four flights of stairs. When they reached the top, "the enemy cut loose at us with everything they had," he recalled. "Bullets were exploding like firecrackers all around us." Boyd paused and his team leader, whom he thought of as an older brother, ran past him to the far side of the building. Moments after he got there, he was shot dead. Within minutes, everyone else on the roof was wounded. "We had to crawl out of there," said Boyd, who was hit with shrapnel and suffered a concussion, earning a Purple Heart. "That was my worst day."
It is in the nature of soldiers to put emotions aside, and that is what Boyd did for three years. He "stayed on the line" with his squad and finished his tour of duty the following June, married his high school girlfriend, and soon afterward began training for his second Iraq deployment, not thinking much about what he had seen or done during the first. Haditha, where he was sent in the fall of 2005, was calmer than Falluja. There were roadside bombs, but no direct attacks. Boyd was now a team leader, and he and his men patrolled the streets like police. When drivers did not respond to the soldiers' efforts to get them to stop, he said, "we'd have to light them up." He was there for seven months.
With one more year of service left on his commitment, and not enough time for a third deployment, Boyd was separated from his unit and assigned to fold towels and dean equipment at the fitness center of his Stateside base. It was a quiet, undemanding job, intended to allow him to decompress from combat. Instead, he was haunted by memories of Iraq. He couldn't sleep. His mind raced. He was edgy, guilt-racked, depressed. He could barely do his job.
"I'd avoid crowds, I'd avoid driving, Pd avoid going out at night," he told me the first time we spoke. "I'd avoid people who weren't infantry, the ones who hadn't been bleeding and dying and going weeks and months without showers and eating M.R.E.s. I'd have my wife drive me if I had to go off the base. A few times, I thought I saw a mortar in the road and reached for the steering wheel. I was always on alert, ready for anything to happen at any time."
Eventually, as part of a standard medical screening, Boyd was diagnosed as having chronic post-traumatic stress disorder. P.T.S.D., which in earlier conflicts was known as battle fatigue or shell shock but is not exclusively war-related, has been an officially recognized medical condition since 1980, when it entered the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders. (In an earlier edition, it was called "gross stress reaction.") P.T.S.D. is precipitated by a terrifying event or situation—war, a car accident, rape, planes crashing into the World Trade Center and is characterized by nightmares, flashbacks, and intrusive and uncontrollable thoughts, as well as by emotional detachment, numbness, jumpiness, anger, and avoidance. Boyd's doctor prescribed medicine for his insomnia and encouraged him to seek out psychotherapy, telling him about an experimental treatment option called Virtual Iraq, in which patients worked through their combat trauma in a computer-simulated environment. The portal was a head-mounted display (a helmet with a pair of video goggles), earphones, a scent-producing machine, and a modified version of Full Spectrum Warrior, a popular video game.
When Travis Boyd agreed to become a subject in the Virtual Iraq clinical trial, in the spring of 2007, he became one of about thirty-five active-duty and former members of the military to use the program to treat their psychological wounds. Currently, the Department of Defense is testing Virtual Iraq—one of three virtual-reality programs it has funded for P.T.S.D. treatment, and the only one aimed at "ground pounders" like Boyd—in six locations, including the Naval Medical Center San Diego, Walter Reed Army Medical Center, in Washington, D.C., and Weill Cornell Medical College, in New York. According to a recent study by the RAND Corporation, nearly twenty per cent of Iraq and Afghanistan war veterans are suffering from P.T.S.D. or major depression. Almost half won't seek treatment. If virtual-reality exposure therapy proves to be clinically validated—only preliminary results are available so far—it may be more than another tool in the therapists' kit, it may encourage those in need to seek help.
"Most P.T.S.D. therapies that we've seen don't seem to be working, so what's the harm in dedicating some money to R. & D. that might prove valuable?" Paul Rieckhoff, the executive director of Iraq and Afghanistan Veterans of America, said last November. In January, his group issued a lengthy report called "Mental Health Injuries: The Invisible Wounds of War," which cited research suggesting that "multiple tours and inadequate time at home between deployments increase rates of combat stress by 50%." Rieckhoff went on, "I'm not someone who responds to sitting with some guy, talking about my whole life. I'm going to go in and talk to some dude who doesn't understand my shit and talk about my mom? I'm the worst of that kind of guy. So V.R. therapy, maybe it will work. We're a video-game generation. It's what we grew up on: So maybe we'll respond to it."
Strictly speaking, using virtual reality to treat combat-related P.T.S.D. is not new. In 1997, more than twenty years after the Vietnam War ended, researchers in Atlanta unveiled Virtual Vietnam. It dropped viewers into one of two scenarios: a jungle clearing with a "hot" landing zone, or a Huey helicopter, its rotors whirring, its body casting a running shadow over rice paddies, a dense tropical forest, and a river. The graphics were fairly crude, and the therapist had a limited number of sights and sounds to manipulate, but Virtual Vietnam had the effect of putting old soldiers back in the thick of war. Ten combat veterans with long-term P.T.S.D. who had not responded to multiple interventions participated in a clinical trial of Virtual Vietnam, typically lasting a month or two. All of them showed significant signs of improvement, both directly after treatment and in a follow-up half a year later. (P.T.S.D. is assessed on a number of scales, some subjective and others based on the observation of the clinician.) As successful as it was, though, Virtual Vietnam didn't catch on. It was an experiment, and when the experiment was over the researchers moved on.
Like Virtual Vietnam, Virtual Iraq is a tool for doing what's known as prolonged exposure therapy, which is sometimes called immersion therapy. It is a kind of cognitive-behavioral therapy, derived from Pavlov's classic work with dogs. Prolonged-exposure therapy, which falls under the rubric of C.B.T., is at once intuitively obvious and counterintuitive: it requires the patient to revisit and retell the story of the trauma over and over again and, through a psychological process called "habituation,"and rid it of its overwhelming power. The idea is to disconnect the memory from the reactions to the memory, so that although the memory of the traumatic event remains, the everyday things that can trigger fear and panic, such as trash blowing across the interstate or a car backfiring—what psychologists refer to as cues—are restored to insignificance. The trauma thus becomes a discrete event, not a constant, self-replicating, encompassing condition.
This process was explained to me by JoAnn Difede, the director of the Program for Anxiety and Traumatic Stress Studies at Weill Cornell, when I visited her in her office, last fall. Difede, a tough-minded New Yorker, began using virtual-reality exposure therapy with patients from the hospital's burn unit in the nineteen-nineties. She treated victims of September 11th with a program called Virtual W.T.C., which she designed with the creators of Virtual Vietnam, and is currently running a Virtual Iraq clinical trial as well as supervising therapists at other study sites.
Difede says that therapists have been slow to adopt exposure therapy, because they worry that it might be cruel to immerse a patient in a drowning pool of painful memories. It's a worry that, she believes, misses the point of the therapy. "If you suddenly become afraid of the staircase because you had to walk down twenty-five flights of stairs to get out of the World Trade Center, the stairs went from being neutral to being negative," Difede explained. "What we should be doing is extinguishing the cues associated with the stimuli, which should allow for a more complete remission, as well as mastery of the experience. It also should allow for greater emotional engagement. Because numbing and avoidance are symptoms of P.T.S.D., you're asking the person to do in treatment the very thing their mind is avoiding doing. That's quite a dilemma."
Its this dilemma that makes virtual reality especially attractive to clinical psychologists like Difede. Because the traumatic environment is produced in a computer graphics lab, and its elements are controlled by the therapist, virtual reality can nudge an imagination that is at once overactive and repressed. "Voila, you're there!" Difede said. "You don't have to do any work. You don't have to engage in any mental effort. We'll do it for you. We'll bring you there and then, gradually, we'll let you get involved in the experience in sensory detail."
When Travis Boyd was first asked to consider enrolling in the Virtual Iraq clinical trial, he was hesitant. He had already decided not to talk to his division therapist, because "I didn't want to have it on my military record that I was crazy," he said. And he was a marine. "Infantry is supposed to be the toughest of the tough. Even though there was no punishment for going to therapy, it was looked down upon and seen as weak. But V.R sounded pretty cool. They hook you up to a machine and you play around like a video game." Telling his buddies that he was going off to do V.R. was a lot easier than telling them he was seeing a shrink.
Before he was introduced to Virtual Iraq, the therapist asked him to close his eyes and talk about his wartime experiences. Without much prompting, he was back on the roof in Falluja, under fire, stalled at the top of the stairs, watching his friend and team leader run past him and die, and then he was dragging out his friend's body, looking at his messed-up face. When Boyd was finished, the doctor asked him to tell the story again. And, when he was finished that time, to tell it again. As he did, she asked him what he was smelling, and if the enemy was on the roof opposite or on the roof next door, and if there were planes overhead. She wanted to learn the details of his narrative and determine which moments were most troubling to him—she called them "hot spots"—and to figure out how she was going to use the sensory variables embedded in Virtual Iraq.
The above text covers the first two pages of this six page article. For the remainder, visit the archives of the New Yorker Magazine at www.newyorker.com/archive.