Wash Away Bad Hair Days
In the Lab as Procter & Gamble Tries to Figure Out Pantene, Fickle Shampoo Shoppers and Other Marketing Mysteries
Believing better data leads to happier shoppers, Procter & Gamble Co. recently mobilized its market researchers to scientifically define those infinitely varied unhappy days when a woman’s hair has gone rogue.
They are the dreaded bad hair days, and P&G has put them at the center of a massive research and advertising effort aimed at winning back women to Pantene shampoos and conditioners. At stake are millions of dollars in sales lost during the recession, when consumers cut back discretionary spending and economized on things like hair products.
Scientists at the consumer-products giant surveyed women and found they felt less “hostile,” “ashamed,” “nervous,” “guilty” or “jittery,” depending on the hair products they used, while at other times they said they felt more “excited,” “proud” and “interested.”
Users of a new version of Pantene, one researcher concluded, “reported more joy than those in the control group.”
Understanding the Hair-Mood Connection
P&G researchers had
women take a psychological survey to get insights into their hair-related emotions. Using neuroscience equipment, they measured brainwaves as women watched ads to make sure they were paying attention.
Bad hair days are one focus of the latest Pantene ad. Which one is the bad hair? This is advertising, so they both look pretty good. The bad hair is on the left.
P&G changed the product and packaging to make it easier to shop the ‘wall of white’ bottles in drugstore aisles.
P&G’s ad shows how bad hair makes women feel. In its research, consumers said they felt less ‘hostile’ and ‘nervous,’ depending on the hair products they used.
With an estimated $3 billion in world-wide sales, Pantene is one of P&G’s blockbusters and the longtime top-selling drugstore brand. But it is still hurting from the economic downturn, when women traded down to low-priced rivals like Suave and trendy Tresemmé. Those brands made gains in market share while Pantene’s slipped, according to estimates from data firm Euromonitor International Inc. In 2009, Pantene’s U.S. sales dropped 9% to $812 million, far steeper than the 3% decline for shampoos, conditioners and styling products overall, Euromonitor says.
Bad hair is a touchy subject, and companies step cautiously around the topic. Women blame weather, a bad haircut or a bad night’s sleep—but damaged, unhealthy hair is a big factor in bad hair, too, says David Rubin, director of U.S. hair-care marketing at rival Unilever. New ads for Unilever’s Dove line find humor in the damaging ways women style their hair. “We don’t talk bad hair days very much,” Mr. Rubin says.
Some 25% of women say they feel they don’t want to leave the house on a bad hair day, says Bob Gorman, Alberto-Culver Co.’s U.S. marketing director for Tresemmé. Yet because bad hair is so subjective, it’s difficult to sell a “bad hair” solution.
“Someone with curly hair might want it straight, and someone with straight hair could want it curly,” Mr. Gorman says. “Somebody’s bad hair day could be a good one for you.”
Women are fickle when it comes to shampoo. Only about a third of hair-care users say they stick to a single brand, according to market-research firm Mintel International, and about half say they switch between a couple of brands; the rest say they change “constantly.”
Shampoo tends to be bought on impulse—meaning many women keep some personal inventory at home. “During the recession, people used up what they already had, and then they consolidated to just one or two products instead of three or four,” says Thom Blischok, president of global innovation and strategy for SymphonyIRI Group, a market-research firm.
In spring 2009, scientists at P&G undertook research that was extreme even by the company’s standards, making a deep dive into women’s feelings about their hair. The effort capped years of work at P&G to reformulate Pantene products, redesign the packages and pare the line down from 14 “collections” to eight. Finally, P&G created ads scientifically proven to command attention.
“A ‘good hair day’ is the ultimate goal of our work,” says Jeni Thomas, a senior scientist at P&G, shaking her own thick, smoothly coiffed hair. “If you get it right, it’s a huge emotional lift. If you get it wrong, it’s not.”
P&G is famous for the lengths it will go to get insights into its customers’ needs—measuring toothbrush strokes or counting mascara coats and then devising products that make users feel good.
History of Pantene: The Highlights
Pantene, named for the ingredient panthenol, was launched in 1947 by Swiss drug company Hoffman-LaRoche. The high-end line featured glass bottles.
1960s: Pantene arrives in the U.S. It is sold in luxury settings like the Waldorf Astoria Hotel and Saks Fifth Avenue.
1970s: Gold caps, introduced around 1975, would become an iconic feature of the brand’s packaging.
1985: P&G buys Pantene, with annual sales of about $40 million, as part of the acquisition of consumer-products maker Richardson-Vicks.
1990s: P&G’s global expansion of Pantene begins; sales hit $1 billion in 1995.
2007: Simplified packaging was meant to make selecting Pantene products easier—but sales would drop sharply in the recession.
Pantene, P&G figured, could do more than wash your hair: It could erase your negative feelings about having unattractive hair.
“We wanted to go beyond just talking to consumers about a specific benefit, like smoothness or volume,” Dr. Thomas says. “To gauge the performance of Pantene’s reinvention, it was important to look deeper at these overall feelings about hair.”
The researchers administered the Positive Affect Negative Affect Schedule—a questionnaire psychology researchers employ to measure mood. P&G surveyed almost 3,400 women, who rated how intensely they felt 20 specific emotions in relation to their hair. Then, about 1,300 women went on to use Pantene hair products for one week and afterward completed the questionnaire a second time. About 900 of these women used new Pantene formulas and packaging, and about 400 used the old version.
Both before and after using Pantene, subjects rated how strongly they experienced moods ranging from “enthusiastic,” “determined” and “inspired” to “hostile,” “ashamed” and “irritable.”
“This allows us to understand what people mean when they talk about ‘bad hair,’ ” says Marianne LaFrance, a Yale University professor of psychology who analyzed the P&G test data.
In a separate earlier study of the hair-mood connection conducted in 2000, Dr. LaFrance concluded that “bad hair negatively influences self-esteem, brings out social insecurities and causes people to concentrate on the negative aspects of themselves.”
Comparing the new-Pantene and old-Pantene groups, researchers got insight into how the shampoo and conditioner formulas might affect someone’s emotional state. Dr. LaFrance says overall she found a “statistically significant difference” in the positive emotion scores between the new versus old product users.
New-Pantene users gave especially high scores to four emotions—”excited,” “proud,” “interested” and “attentive.” Test administrators classify the feelings “excited” and “proud” as components of “joy.”
But there were variations among this group. Women using products for “fine hair” reported feeling less “hostile,” “ashamed” and “nervous.” Users of products for color-treated hair reported feeling less “guilty” and “jittery.”
“Jittery might not be the first emotion that comes to mind,” says Dr. LaFrance. “It’s the non-direct link that we’re interested in.”
P&G took a closer look at some of the emotions a number of individuals reported feeling—especially “attentive.” “If people are having a good hair day, do they focus more on what they’re doing?” says Dr. Thomas. “It raised a lot of interesting questions we need to consider on the power of a good hair day.”
As part of the relaunch, P&G simplified the product lineup. Before the relaunch there were 14 Pantene collections spanning 165 individual items—a number that P&G executives concede probably confused shoppers. In fact, people inside P&G sometimes called their brand’s section of the shampoo aisle “the wall of white,” referring to the vast array of Pantene packages.
“It was a tough shopping experience,” says Craig Bahner, P&G’s vice president of North American hair care. “We learned that the brand had become too complex.”
The new formulas are grouped into four main categories—curly, fine, medium/thick and color-treated—and packages are accented with bright colors. P&G also retained the “Classic Care,” “Nature Fusion” and “Relaxed & Natural” lines, and upgraded a fourth line now called “Restore Beautiful Lengths.” In all, they pared the Pantene line down to 120 items.
Finally, to test television ads for new Pantene, P&G, working with a firm it declines to name, hooked viewers up for a high-resolution electroencephalogram, placing caps on subjects’ heads to measure their brainwaves as they watched commercials.
“We know based on what’s firing in the brain whether or not we were tapping into her emotions, whether there is potential she will remember it, and whether she is paying attention to it,” says Catherine Grzymajlo, a senior manager in P&G’s consumer-market knowledge group.
Brainwave activity,or the lack of it,guided changes in Pantene’s commercials, which began airing in May. In one ad, P&G noticed viewers were distracted when a model, with a look of frustration, was trying to deal with her unruly hair; they were wondering why she was upset and stopped focusing on the rest of the ad, Ms. Grzymajlo says. P&G re-edited the spot to focus less on the model’s expression and more on her hair.
Pleased with the insights they gained, P&G researchers say they expect to do similar tests measuring brainwave responses to ads in the future.
“The sky’s the limit in terms of what we can do with it,” says Ms. Grzymajlo.
Write to Ellen Byron at firstname.lastname@example.org
Everyone warns parents about the drama of the teen years—the self-righteous tears, slamming doors, inexplicable fashion choices, appalling romances.
But what happens when typical teen angst starts to look like something much darker and more troubling? How can parents tell if a moody teenager is simply normal—or is spinning out of control? This may be one of the most difficult dilemmas parents will ever face.
Signs of Depression
Physicians often use the mnemonic “SIGECAPS” for the checklist of symptoms, says Mark Goldstein, chief of adolescent and young adult medicine at Massachusetts General Hospital in Boston. He cautions that parents should not try to diagnose their children, but bring the child to a pediatrician. A teen may have a problem if four or more of these signs persist for two weeks or longer.
Is your teen’s sleep impaired? Is he or she sleeping too much? Not enough? Trouble falling asleep or staying asleep?
Has your teen lost interest in once-enjoyable activities? These could include school, sports or extracurriculars, friends, even eating.
Does your teen have excessive guilt? Or, is the child feeling worthless or devalued?
Does your teen feel a loss of energy? Is he or she unusually tired or exhausted?
Does your teen have a diminished ability to think and concentrate? An increased indecisiveness?
Has your teen’s appetite changed? Either decreased or increased? Some teens lose weight with depression. Others gain it.
Are your teen’s physical movements speeding up or slowing down? This one may be hard for parents to determine. But look for sluggishness—or, alternately, restlessness or the jitters.
Is your teen thinking about death? Doctors ask teens: Have you had thoughts about death repeatedly? Have you thought about suicide? Do you have a plan?
Studies show that about 20% of teenagers have a psychiatric illness with depression, anxiety and attention-deficit hyperactivity disorder being among the most prevalent. Yet parents of teens are often blind-sided by a child’s mental illness. Some are unaware that mental illnesses typically appear for the first time during adolescence. Or they may confuse the symptoms of an actual disorder with more normal teen moodiness or anxiety.
Eric Beasley, a 49-year-old project manager for a software company in Cary, N.C., has been there. He says that his daughter always seemed like a typical child. She was a good student and a great soccer player with many friends. But three years ago, when she turned 14, she began to throw temper tantrums when her team lost—stomping her feet and yelling at her teammates. She even asked her dad for help managing her anger, and he talked to her about ways to cope.
“I thought it was typical teen behavior,” says Mr. Beasley, who also has two sons. “We’d never had girls before. And I’d heard they were very moody and emotional.”
But his daughter’s behavior declined. She snuck out of the house one evening to meet her boyfriend and stayed out all night. When they confronted her about some of her actions, she became alarmingly depressed, weeping in bed for days and refusing to eat. She took a handful of her father’s heart medicine and was committed to a psychiatric hospital for 10 days.
Mr. Beasley says he expected his daughter’s problems to be solved by the hospital stay. “We had no idea that was only the beginning,” he says.
His daughter did feel better for about a week, he says. But even with therapy and medication, she sank further into depression, throwing tantrums over little things, “like whether she was given a fork instead of a spoon at the dinner table,” Mr. Beasley says. She started swearing, lying and leaving the house in anger.
Her parents took away her cellphone, monitored her email accounts and put an alarm system on the house to keep her from sneaking out. After she told her parents that she was running away to live with a boyfriend, Mr. Beasley had her hospitalized again for six days. Several months later, she tried to overdose using her own medication.
Experts say that many parents fail to recognize the signs of a child’s mental illness. Some don’t know what to look for. Others don’t want to admit that there is a problem. After all, everyone wants a perfect child: 10 fingers and 10 toes, looks, brains, charm—and hopefully a Harvard degree.
A mental illness can threaten to derail much of that. And a psychiatric disorder—unlike, say, cancer—can come with a stigma attached, which can fuel a parent’s feeling of denial.
Making matters worse: It can be genuinely difficult for parents to tell the difference between early signs of a mental illness and typical teen behavior.
But the risks of missing the more serious problems are huge. Untreated depression and other mental disorders can derail a child’s developmental progress or, in the worse-case scenario, lead to suicide. For this reason, experts say, parents must be vigilant.
“All we want parents to do is notice there is a problem and to bring their child to the doctor,” says Mark Goldstein, chief of adolescent and young adult medicine at Massachusetts General Hospital. He recommends parents first take their concerns to a pediatrician as that doctor has the longest relationship with the family and will be easier to get an appointment with than a psychiatrist.
The American Academy of Pediatrics has been making a push in the past few years to better train its members in how to identify and manage mental illnesses in children and teens. This month, they issued a 160-page guide to help doctors screen early, intervene and determine when to refer to a mental-health specialist. And today the group is publishing a new CD-Rom for doctors that includes tools to help pediatricians screen and assess for psychiatric disorders, develop care plans and educate parents.
“It’s one of those things, an ounce of prevention kind of deal,” says Evelyn Gerber, 37, a chemist in Salt Lake City. She says she has become “hyper vigilant” about watching for signs of troubling behavior in her 16-year-old son, who was diagnosed with attention-deficit hyperactivity disorder in second grade.
Ms. Gerber says her son was an emotional child who sometimes got pushed around by bullies on the school bus and once stabbed a kid with a pencil in an attempt to fight back. After that incident, in 4th grade, she got counseling for him.
These days, he functions well in school and has good friends. But he also sometimes pouts or cries in frustration after he has a fight with his dad and locks himself in his room. Other times, he turns red-faced or yells when he doesn’t get his way or he is frustrated with the computer.
But Ms. Gerber says she never lets him brood in his room for more than a few minutes before going in to talk to him. And she uses the 15-minute drive to school each day to chat with him about everything from peer pressure to drugs and alcohol. “If you can see the problems coming and ward them off, your child won’t sink so deep,” she says.
Parents who are worried that their teen is showing signs of mental illness should first put their child’s behavior into perspective, experts say. Occasional outbursts of anger, irritability or crying are normal for teens. So is dressing weird, rebelling against rules and even experimenting with drugs and alcohol.
Periodic tension is typical, too. “It’s when the conflict rises to the level of hostility and real animosity, and doesn’t recover easily, that I become concerned,” says Guy Diamond, a psychologist and director of the Center for Family Intervention Science at the Children’s Hospital of Philadelphia.
Dr. Diamond says sulks or doldrums that persist for two or more weeks could be a sign of depression and should be taken seriously.
The Next Step: Treatment
A family therapy designed for teens with elevated depression and suicidal thoughts is showing good results. Attachment-Based Family Therapy, or ABFT, was developed by researchers at the Children’s Hospital of Philadelphia. A study reported last February in the Journal of the American Academy of Child and Adolescent Psychiatry included 66 children, ages 12 to 17. Patients with severe suicidal thinking were at least four times more likely to have no suicidal thinking at the end of the treatment—three months later than patients who had other treatments.
Some hallmarks of the therapy:
- Family involvement. Most treatment models mainly work with the adolescents alone, says study leader Guy Diamond, director of the Center for Family Intervention Science at Children’s Hospital of Philadelphia. Yet a family’s influence is very important to teens, he says. “We try to help parents understand the challenges that these kids are struggling with and give them the parenting tools that allow them to reach out and support a depressed and suicidal adolescent.”
- A specific time frame. Unlike many other forms of therapy, ABFT is a rapid process, lasting just six to 12 weeks. Therapists first meet with the teen to identify the issues that are causing the child to be distant from his or her family and discuss the importance of addressing these problems directly. Then they meet separately with the parents to help them understand what is going on with their child, discuss ways to improve trust and work on emotional-based parenting skills.
- A no-blame atmosphere. “We are not interested in blaming the parents,” says Dr. Diamond. “We say, ‘If the kid could get some of this off his chest, it could open up communication.'” In the final stage, the therapists meet with the teen and parents together, to facilitate the dialogue between them.
Source: Children’s Hospital of Philadelphia
Parents should pay attention to how a teen is functioning in school, sports, favorite activities, a job and with friends. A temperamental child who throws a fit, even for a few days, but continues to get good grades, enjoy friends and participate in sports is likely OK. But one whose grades fall, who shuns friends or refuses to participate in a team or activity he or she once loved may have a more serious problem.
Other signs to watch out for, experts say: Teens who are excessively angry, abuse alcohol or drugs, or run into trouble with the law may be depressed. Also, changes in eating habits—eating more or less—or sleeping (ditto) may signal a problem.
“The most important thing parents can do is stay connected to their kids and keep open communication,” says Dr. Diamond. “Let them know that they can talk to you about anything serious and know that you will listen and hear them.” He often encourages parents to consult a therapist on how to talk to their children about these difficult issues.
A 48-year-old writer from Asheville, N.C., says she spends much of her time these days trying to monitor and help her teenage son. A handsome, outgoing kid who excels at golf, he was diagnosed with obsessive-compulsive disorder when he was in middle school, after teachers suggested she have him evaluated by a doctor because he was getting up from his desk every few minutes during class to sharpen his pencil.
Then, after she divorced his father two years ago, the boy became increasingly angry. He started yelling at his mother if he didn’t get his way. Then he began throwing things: rocks and apples at cars and eggs at houses.
Last year, he watched as his friends stripped his mom’s Christmas tree and threw all the ornaments in the road. Then he got arrested twice—first for using a paintball gun to disfigure all the mailboxes in an entire neighborhood and then for possessing marijuana at school.
His mother has taken him to five different psychologists—he often refuses to go back—who gave him an additional diagnosis of ADHD.
“If your eyes aren’t open, if you’re in denial, the problems escalate,” she says.
Mr. Beasley believes that his daughter’s life was saved by a company called Behavioral Link that provides peer support, intensive in-home counseling and therapists who are available around the clock for parents and children to call in a crisis. Now she has a psychologist she likes and takes her medication. Her grades are getting better, Mr. Beasley says, and her depression appears to be in check.
“We were naïve,” says Mr. Beasley in retrospect. “Someone needed to sit us down and say, ‘Here are things you should be looking for.’ ”
Don’t say “mental retardation” – the new term is “intellectual disability.” No more diagnoses of Asperger’s syndrome – call it a mild version of autism instead. And while “behavioural addictions” will be new to doctors’ dictionaries, “Internet addiction” didn’t make the cut.
The American Psychiatric Association is proposing major changes Wednesday to its diagnostic bible, the manual that doctors, insurers and scientists use in deciding what’s officially a mental disorder and what symptoms to treat. In a new twist, it is seeking feedback via the Internet from both psychiatrists and the general public about whether the changes will be helpful before finalizing them.
The manual suggests some new diagnoses. Gambling so far is the lone identified behavioural addiction, but in the new category of learning disabilities are problems with both reading and math. Also new is binge eating, distinct from bulimia because the binge eaters don’t purge.
Sure to generate debate, the draft also proposes diagnosing people as being at high risk of developing some serious mental disorders – such as dementia or schizophrenia – based on early symptoms, even though there’s no way to know who will worsen into full-blown illness. It’s a category the psychiatrist group’s own leaders say must be used with caution, as scientists don’t yet have treatments to lower that risk but also don’t want to miss people on the cusp of needing care.
Another change: The draft sets scales to estimate both adults and teens most at risk of suicide, stressing that suicide occurs with numerous mental illnesses, not just depression.
But overall the manual’s biggest changes eliminate diagnoses that it contends are essentially subtypes of broader illnesses – and urge doctors to concentrate more on the severity of their patients’ symptoms. Thus the draft sets “autism spectrum disorders” as the diagnosis that encompasses a full range of autistic brain conditions – from mild social impairment to more severe autism’s lack of eye contact, repetitive behaviour and poor communication – instead of differentiating between the terms autism, Asperger’s or “pervasive developmental disorder” as doctors do today.
The psychiatric group expects that overarching change could actually lower the numbers of people thought to suffer from mental disorders.
“Is someone really a patient, or just meets some criteria like trouble sleeping?” APA President Dr. Alan Schatzberg, a Stanford University psychiatry professor, told The Associated Press. “It’s really important for us as a field to try not to overdiagnose.”
Psychiatry has been accused of overdiagnosis in recent years as prescriptions for antidepressants, stimulants and other medications have soared. So the update of this manual called the DSM-5 – the Diagnostic and Statistical Manual of Mental Disorders, fifth edition – has been anxiously awaited. It’s the first update since 1994, and brain research during that time period has soared. That work is key to give scientists new insight into mental disorders with underlying causes that often are a mystery and that cannot be diagnosed with, say, a blood test or X-ray.
“The field is still trying to organize valid diagnostic categories. It’s honest to re-look at what the science says and doesn’t say periodically,” said Ken Duckworth, medical director for the National Alliance for the Mentally Ill, which was gearing up to evaluate the draft.
The draft manual, posted at http://www.DSM5.org, is up for public debate through April, and it’s expected to be lively. Among the autism community especially, terminology is considered key to describing a set of poorly understood conditions. People with Asperger’s syndrome, for instance, tend to function poorly socially but be high-achieving academically and verbally, while verbal problems are often a feature of other forms of autism.
“It’s really important to recognize that diagnostic labels very much can be a part of one’s identity,” said Geri Dawson of the advocacy group Autism Speaks, which plans to take no stand on the autism revisions. “People will have an emotional reaction to this.”
Liane Holliday Willey, an author of books about Asperger’s who also has the condition, said in an email that school autism services often are geared to help lower-functioning children.
“I cannot fathom how anyone could even imagine they are one and the same,” she wrote. “If I had put my daughter who has a high IQ and solid verbal skills in the autism program, her self-esteem, intelligence and academic progress would have shut down.”
Terminology also reflects cultural sensitivities. Most patient- advocacy groups already have adopted the term “intellectual disability” in place of “mental retardation.” Just this month, the White House chief of staff, Rahm Emanuel…
Terminology also reflects cultural sensitivities. Most patient- advocacy groups already have adopted the term “intellectual disability” in place of “mental retardation.” Just this month, the White House chief of staff, Rahm Emanuel, drew criticism from former Republican vice-presidential nominee Sarah Palin and others for using the word “retarded” to describe some activists whose tactics he questioned. He later apologized.
JUDY WOODRUFF: Now: rethinking mental illness.
For the first time in 16 years, the American Psychiatric Association is revising its essential dictionary, formally titled “The Diagnostic and Statistical Manual of Mental Disorders.” The book is used widely by mental health professionals to classify and diagnose illnesses. The proposed revisions have been a decade in the making, among them: a single category called autism spectrum disorders that would incorporate Asperger’s syndrome; a category called behavioral addictions, in which gambling would be the sole disorder; a risk syndromes category to help identify earlier stages of disorders like dementia and psychosis; and a recognition of binge eating disorder.
The draft has been posted online and will be reviewed and refined over the next two years.
For some perspective on the proposals and their implications, I’m joined by Dr. Alan Schatzberg. He’s president of the American Psychiatric Association. He is also chair of psychiatry at Stanford University. And Dr. Allen Frances, he’s former chief of psychiatry at the Duke University Medical Center. He led the last effort to revise the manual.
Gentlemen, thank you both for being with us.
And, Dr. Schatzberg, to you first. Why is this manual so important?
DR. ALAN SCHATZBERG, president, American Psychiatric Association: Well, it is used by — as you pointed out, Judy, by practitioners around the world to diagnose potential patients, people who come in for treatment with specific complaints, and to classify them as having one or another disorder.
It becomes the common language that mental health practitioners use to describe patients, so that we can agree on a diagnosis, very similar to cardiologists talking to an internist, saying the patient has had a myocardial infarction, or what we call a heart attack. We need to have agreed-upon diagnoses and criteria for making those diagnoses if we’re going to be able to take care of patients.
JUDY WOODRUFF: So, it’s important for doctors, obviously for the patients. Insurance companies?
DR. ALAN SCHATZBERG: Absolutely, because insurance companies will in fact pay for benefits for treatment, whether they be psychosocial, or pharmacologic, or somatic, or other forms of treatment, for specific conditions. And those conditions have to be specified somewhere.
So, just as we have the international classification of disorders for medical disorders that are used commonly by — and promulgated by the WHO, the APA, the American Psychiatric Association, has promulgated criteria and classification for mental disorder, and it started doing it in 1952.
JUDY WOODRUFF: And, just quickly, why does it need to be redone?
DR. ALAN SCHATZBERG: Because, as we study patients with particular disorders, as we understand more about genetics, about epidemiology, about brain imaging, about treatment response, about risk factors, about groupings of patients, we start to see that there are patterns that emerge, that there are disorders that are more similar to one another than we thought.
There are some disorders that we thought would be very different that we find out are really one or another variation of a common disorder. And, so, the nomenclature needs to be refined periodically.
JUDY WOODRUFF: And, Dr. Frances, now, we understand you have some concerns with what the Psychiatric Association is recommending. Tell us what those are, your main concerns.
DR. ALLEN FRANCES, former chief of psychiatry, Duke University Medical Center: Well, we learned some very, very painful lessons in doing “DSM-IV.”
We thought we were being extra careful and very conservative.
JUDY WOODRUFF: This is the last manual.
DR. ALLEN FRANCES: That’s correct.
And we thought we were being really careful about everything we did, and we wanted to discourage changes. But, inadvertently, I think we helped to trigger three false epidemics, one for autistic disorder that you mentioned, another for the childhood diagnosis of bipolar disorder, and the third for the wild overdiagnosis of attention deficit disorder.
And my concern has been that the ambitions expressed by those working on “DSM-V” would lead to unintended consequences, with many patients being created through new categories or the lowering of thresholds of existing categories, people who probably don’t need the treatment that they might receive, but would probably receive if they get a diagnosis.
JUDY WOODRUFF: So, what’s an example of something that you think may be diagnosed that shouldn’t be diagnosed?
DR. ALLEN FRANCES: Well, I think you mentioned some. Binge eating disorder is, I think, a classic example.
In order to meet the criteria for this proposed diagnosis, a person would need to binge just once a week for three months. I would certainly qualify for that. I think the estimates, the low estimates, are that this would include 6 percent of the general population.
Once a diagnosis becomes official, there’s a kind of wildfire effect, and it becomes more and more popular, especially if this is marketed as an important indication for the pharmaceutical industry. And my guess is that, before very long, maybe 10 percent of the population would qualify for this diagnosis of binge eating disorder.
That means 20 million people. And there’s no proven treatment for the condition. And, undoubtedly, lots of people would be getting unnecessary, expensive, and often harmful treatments for conditions that really are made up by the people doing the manual, without very strong support or need.
JUDY WOODRUFF: Dr. Schatzberg, how do you respond to that concern, that things are going to be diagnosed that shouldn’t be?
DR. ALAN SCHATZBERG: They’re — in fact, I think “DSM-V” has been assiduous, very careful…
JUDY WOODRUFF: And, again, this is the new — this is the acronym for this new manual.
DR. ALAN SCHATZBERG: This is the — yes, this is — the proposed criteria has been — have been very careful to define the threshold for patients being in distress, being impaired, and being able to obtain or receive a diagnosis. We try to be — refine on those criteria from “DSM-IV” to make it tighter. In fact, I think “DSM-V” will reduce the number of patients who receive diagnoses.
Now, for bulimia, I think it’s very important to point out that these patients or subjects are highly distressed. It’s not just a matter of someone overeating and having a bad meal or a bad day on Thanksgiving. In fact, these — this disorder is seen commonly in young women. It tends to be associated very commonly with obesity.
And, the last I looked, obesity is a major epidemic in this country. And if we are to in fact address and help the society deal with their obesity problems, we have to have a way of defining this pathological overeating.
JUDY WOODRUFF: Dr. Frances, you want to come back on that point?
DR. ALLEN FRANCES: Well, just quickly, obesity is certainly the largest public health problem facing Americans, but that doesn’t mean it’s a mental disorder.
JUDY WOODRUFF: And, Dr. Frances, broaden this out. I mean, clearly, there are specific concerns you have. But — but, more broadly, why should we be concerned, whether it’s young people, attention deficit, which is what you said happened with the previous manual, or any of these diagnoses going forward? What’s the real concern here?
DR. ALLEN FRANCES: Well, with attention deficit disorder as an example, the prescription of stimulants has exploded.
And what’s happened is that, often, these are given, not for a mental disorder, but for performance enhancement. And getting a diagnosis of attention deficit disorder allows you to get that stimulant treatment, which, for many people, may not be for a mental disorder, but may just be so that they can do better in their everyday lives.
Thirty percent of college students use stimulants to do better at school.
JUDY WOODRUFF: You want to re…
DR. ALLEN FRANCES: And this also creates — it also creates a secondary, illegal market that the prescription drugs are sold on, so that there is a huge public health, I think, significance in this, as well as a societal problem that’s been caused by it.
JUDY WOODRUFF: A huge public health concern, Dr. Schatzberg?
DR. ALAN SCHATZBERG: Well, certainly, they’re — we don’t want to have overuse of stimulants or performance-enhancing drugs. But just having a diagnosis doesn’t mean that, in fact, that leads to it.
In fact, that is a whole social kind of question about how best to treat individuals with attention deficit disorder. But those individuals who are using stimulants, potentially illegally or illicitly, are not doing it because they have a psychiatric diagnosis. They’re using it for their own performance enhancement. And it’s just as — having a diagnosis of attention deficit disorder doesn’t lead to potential necessarily performance enhancement.
JUDY WOODRUFF: Just…
DR. ALAN SCHATZBERG: That’s kind of a silly argument, from my end.
JUDY WOODRUFF: Just — well, just quickly, what — where do we go from here, Dr. Frances? This — we — as we said, there are two years now before this is finalized. What would you look to see happen, Dr. Frances, in just a few words?
DR. ALLEN FRANCES: Well, I think the process to date has been way too secretive and closed to external influence. It should be opened up.
I think there needs to be a very, very careful forensic review, because unintended consequences in forensics can be a huge problem. I think there needs to be a risk-benefit analysis of each of the new suggestions to make sure they do, indeed, make sense.
And I think the field trials that will be coming up soon need to be exposed to public review before they begin.
JUDY WOODRUFF: And, Dr. Schatzberg, in a few words, will all those things happen?
R. ALAN SCHATZBERG: Well, you know, the task force will take in the comments on the public posting. I think this is an incredible example of openness and transparency.
The field trials will, in fact, test out whether these proposed kinds of categories make sense, and they make — and whether they make sense from a diagnostic end, as well as from a sociologic end. So, we will try to address some of these issues.
JUDY WOODRUFF: It’s “The Diagnostic and Statistical Manual of Mental Disorders.”
And, gentlemen, we thank you both for being with us, Dr. Alan Schatzberg, Dr. Allen Frances. Thank you.
DR. ALAN SCHATZBERG: Thank you, Judy.
DR. ALLEN FRANCES: Thank you.
Some people are usually cheerful. Others are more likely to have sad, depressing thoughts. Such traits help make up our personalities.
But could such traits actually be related to measurable differences in brain structure?
In a new study in Psychological Science, neuroscientists report that extraverts tend to have a larger-than-average orbitofrontal cortex, a region that sits behind the eyes and is especially active when the brain registers rewards.
“They tend to be more cheerful and assertive and have a tendency to want awards,” said Colin G. DeYoung, the study’s lead author and a psychologist at the University of Minnesota. “It makes sense that they would have more of the machinery to keep track of winning.” The findings said nothing about how volume is linked to behavior, or which preceded which.
The scientists relied on M.R.I. scans of more than 100 adults, after establishing each subject’s personality type using a model known as the Big Five.
Any person, the model purports, can be described by their level of five traits: extraversion, agreeableness, conscientiousness, neuroticism, and openness/intellect.
Those that exhibit high conscientiousness are hard working and self-disciplined. They tend to have a larger-than-average lateral prefrontal cortex, enabling them to plan ahead, parse through complex thoughts and make decisions, the scientists found.
Neurotics, or those who often have negative, depressing thoughts, tend to have a smaller medial prefrontal cortex, a part of the brain known to regulate emotion.
Similarly, being agreeable corresponds to larger size in certain regions.
People who exhibited openness, a personality type that is creative and enjoys new ways of thinking, did not display noticeably different sizes in any regions.
It is important to remember that all such links between brain biology and personality are highly suggestive, and poorly understood. And although personalities are generally stable, they can be affected by experience over a lifetime, Dr. DeYoung said.
In other words, for those with a small medial prefrontal cortex, there is hope that it may grow.
Is there a part of you that you hate to look at and perhaps try to hide from others? Do you glance at your image in distress whenever you pass a reflective surface?
Many of us are embarrassed by or dissatisfied with some body part or other. I recall that from about age 11 through my early teens I sat in class with my hand over what I thought was an ugly bump on my nose. And I know a young woman of normal weight who refuses to sit down in a subway car because she thinks it makes her thighs look huge.
But what if such self-consciousness about a perceived facial or body defect becomes all consuming, an obsession or paranoia that keeps the person from focusing on school or work, pursuing normal social activities, even leaving the house to shop or see a doctor? What if it leads to attempted suicide?
Such are the challenges facing tens of thousands of Americans who suffer from body dysmorphic disorder, or B.D.D., a syndrome known for more than a century but recognized only recently by the official psychiatric diagnostic manual. Even more recently, effective treatments have been developed for the disorder, and its emotional and neurological underpinnings have begun to yield to research.
A pioneering researcher, Dr. Jamie D. Feusner, and his colleagues at the David Geffen School of Medicine at the University of California, Los Angeles, recently found patterns of brain activity in people with B.D.D. that appeared to differ from those of others. The differences showed up in areas involved in visual processing. The more severe the symptoms, the more the person’s brain activity on imaging scans differed, on average, from normal levels, the researchers reported in the February issue of The Archives of General Psychiatry.
These brain changes may help explain how people can become overly focused on a perceived defect of their face, hair, skin or facial or body shape that others may not notice — indeed, that may not even exist. Some turn to alcohol and drugs to try to cope with the extreme distress. Others seek cosmetic surgery — which fails to relieve anxiety and can even make the problem worse, leaving scars where nothing was apparent before.
Some men have a form of B.D.D. called muscular dysmorphic disorder, thinking they look puny and weak when in fact their muscles are highly developed through compulsive weight training.
Dr. Katharine A. Phillips, a professor of psychiatry at Brown Medical School, is perhaps the best known authority on B.D.D. and the author, most recently, of “Understanding Body Dysmorphic Disorder: An Essential Guide” (Oxford University Press, 2009).
In an interview, Dr. Phillips described how crippling the disorder can become for those who spend hours in front of a mirror trying to “fix” their “ugly hair” or disguise a facial blemish only they can see. Some pick at an unnoticeable mark on their skin until they do indeed have a visible lesion. Some won’t leave the house unless they can totally cover their face and hair. Those who do go out without masking the area of concern sometimes suddenly flee and hide when they think someone has noticed it or is staring at them.
Many trace their problem to a childhood emotional trauma, like being teased about their looks, parental neglect, distress over parents’ divorce, or emotional, sexual or physical abuse. But Dr. Phillips says most people survive such traumas without developing B.D.D., especially if other factors in their lives lift their self-esteem.
Rather, she explained, the disorder seems to have a combination of genetic, emotional and neurobiological underpinnings.
“It’s likely that the genes a person is born with provide an essential foundation for B.D.D. to develop,” Dr. Phillips wrote. She noted that in about 20 percent of cases, a parent, a sibling or a child also had the disorder. Imaging studies done by Dr. Feusner, Dr. Phillips and others suggest that some brain circuits may be overactive in people with the disorder.
One presumed factor — societal emphasis on looks — is far less important than you might think. Dr. Phillips said the incidence of B.D.D. was nearly the same all over the world, regardless of cultural influences. Also, unlike eating disorders, which mainly affect women seeking supermodel thinness, nearly as many men as women have body dysmorphic disorder.
Which Treatments Work?
The good news is that even though research into the causes of the disorder is in its relative infancy, treatments have been found to help a large percentage of those affected, as long as their problem is recognized and they manage to overcome their embarrassment long enough to get to a qualified therapist.
The two most effective approaches are cognitive behavioral therapy and treatment with serotonin-enhancing drugs, either alone or in combination. In cognitive therapy, patients gradually learn to reorder their thinking, expose their “defect” to others and view themselves more realistically as whole individuals rather than seeing only the presumed defect.
In studies using serotonin-enhancing drugs, half to three-quarters of people with B.D.D. have improved, although Dr. Phillips warned that it can take as long as three months to see the benefit of a proper dose. (Moreover, there is still controversy about how many people achieve long-lasting benefits from the serotonin drugs.)
What does not work is plastic surgery and other cosmetic treatments. Even if the treatments modify one presumed defect, the person is likely to come up with another, and another, and another, leading to a vicious cycle of costly and often deforming as well as ineffective remedies.
Most important, Dr. Phillips said, is not to give up. Effective treatment is out there and it can make a tremendous difference — even a lifesaving difference. Her new book lists centers around the country that specialize in treating B.D.D.
The proposed new edition of Diagnostic and Statistical Manual of Mental Disorders could place large swaths of the population under the umbrella of pathology.
Last week, the American Psychiatric Association unveiled the much-awaited blueprint for the next edition of its official handbook of diagnoses, the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, or DSM V. Outlets from the New York Times to the Hindustan Times heralded its arrival. ABC News announced, “Big changes for DSM, the psychiatrists’ bible.”
Such fanfare makes sense. The DSM is as much a cultural institution as a clinical one. As an arbiter of what is normal and what is not, the manual also plays an important role in insurance and disability determinations. In the courtroom it can bear on criminal culpability.
Scores of revisions have been proposed by nearly 200 experts under the supervision of the DSM V task force, which will release a final version of DSM V in 2013—19 years after the publication of the DSM IV.
The problem is that the changes don’t really advance psychiatry. Worse, some are prescriptions for trouble. One of the most controversial is the creation of a diagnosis called “psychosis risk syndrome.” Granted, the motivation is laudable: to identify adolescents or young adults at risk for developing serious mental illnesses marked by hallucinations and delusions. What doctor wouldn’t want to intervene early to ward off an affliction like schizophrenia? But a diagnosis believed to foreshadow a full-blown psychotic illness has the potential to be highly stigmatizing. That is especially unfortunate if the labeled individual does not even go on to develop such an illness—and the chances of that are estimated at about 70%, according to a 2009 Journal of Clinical Psychiatry review paper, “Intervention in Individuals at Ultra-High Risk For Psychosis.”
To complicate matters further, treatment is not especially effective in forestalling psychotic illness in the minority destined to develop it. And since we don’t know who those people will be, otherwise healthy kids will be exposed to potent antipsychotic medications and their side effects, such as diabetes and weight gain.
Thus, until the science of prevention becomes more advanced, it is better to keep psychotic risk syndrome out of the main DSM, placing it in an Appendix for Further Research.
This is just a suggestion from one person—me. By the time the public comment period ends on April 20, the APA’s inbox will be overflowing. Indeed, within moments of the task force’s posting its draft on the Internet, psychiatry-watchers sprang into action.
Some with Asperger’s Disorder (“Aspies,” as they often call themselves) decried the proposed elimination of their category, which would be subsumed under a new diagnosis called Autism Spectrum Disorder. They resist being lumped with individuals who have lower IQs and language delays. Among the “transgendered,” one camp urged that the existing diagnosis of Gender Identity Disorder be removed because it implies they are mentally ill. The other camp wanted it left in so that insurers will pay for sex-change surgeries.
Psychiatrists weighed in, too, on various aspects of the blueprint. “The DSM V would dramatically raise the rates of mental disorder in the general population,” said Allen Frances, head of the team that revised the fourth edition of the manual. “Some of the new diagnoses would be extremely common and pharmaceutical marketing would amplify the risk of their being found. This means, of course, that a lot of otherwise normal people will be medicated.”
But the larger question raised by the proposed revisions is whether these changes help us to better understand mental disorders.
For perspective, let’s go back to 1980 when the revolutionary third edition of the handbook, the DSM III, was published. In a radical break from earlier editions, which were based largely on Freudian concepts of unconscious conflict and stunted sexual development, the DSM III categorized illnesses based on symptoms. A patient was said to have a condition if he or she had a certain number of the classic symptoms. Such an approach increased the odds that two examiners would agree on what diagnosis to assign a patient. This enabled clinicians to communicate better. Different research teams could work on new treatments for the same problems as well as compare, and confirm, one another’s work.
Yet just because two examiners concur that a person qualifies for a particular diagnosis does not mean that he has an authentic mental illness. How do we know, for example, that a person diagnosed with major depressive disorder (the formal designation for pathological depression) is not actually suffering from a bout of natural if intense sadness brought on by a shattering loss, a grave disappointment or a scathing betrayal?
The manual will not help us here. In fact, a number of changes proposed for the DSM V (e.g., new diagnoses for binge eating, hoarding and hypersexuality) are likely to inadvertently place large swaths of normal human variation under the umbrella of pathology.
The other problem that confounds psychiatry is how to draw boundaries around diagnostic categories, given that we rarely know the cause of mental illness at the neural level. Mental illnesses are the product of numerous genes that interact with one another, with the environment and also with experience. (A recent study by the National Institute of Mental Health found that 80 genes could be associated with bipolar disorder.) Add to this the miasma of social and personal encounters that impinge upon the genetically vulnerable individual—stress, poverty, family instability, drug or alcohol use, and so forth—and the causal mechanisms of any mental illness become staggeringly complex and elusive. Moreover, the “psychopathological pie,” as a colleague calls it, is rarely divided up as tidily as the manual implies. Patients often have symptoms that sprawl across several diagnostic categories. For example, half of kids who receive the diagnosis of bipolar disorder also have ADHD.
The upshot is that, with some important exceptions, drug treatment is often guided more by symptoms than by diagnosis. In fact, good psychiatrists do not rely too heavily on the DSM when they care for patients. There is simply no substitute for observing the patient, listening to his story, and fine-tuning his treatments—psychological and pharmacological—as needed.
The framers of the DSM III knew this well. They cautioned against manual users taking too literally the sharp boundaries drawn between disorders and between disorder and mental health. “This version,” they wrote in the preface, “is only one still frame in the ongoing process of attempting to better understand mental disorders.” Thirty years later, despite undeniable progress in brain science, we are saying much the same thing.
Dr. Satel, a psychiatrist, is a resident scholar at the American Enterprise Institute and a lecturer at Yale University School of Medicine.
RARE INFLUENCE “Avatar” is reflected in collections by Jean Paul Gaultier and Valentino (center).
JEN KAO has seen “Avatar” — twice. Ms. Kao, a New York designer known for filmy knits and aggressive black leather, plans to infuse her next collection, in September, with some of that movie’s violent colors and savage frills.
Well, Ms. Kao, get in line. Jean Paul Gaultier was feeling an “Avatar” moment way back in January. Just a month after the release of the James Cameron blockbuster, he injected strains of its Edenic imagery into his couture collection.
Nor did the editors of Vogue waste time paying homage to that movie’s blue-skinned tribes. A 10-page fashion feature in its March issue is photographed in a mossy forest, the models stamped with fierce tattoos. “Avatar,” prompts the accompanying text. “You can’t miss the sci-fi angle.”
Few films in recent memory have had such a vivid and instantaneous impact on the world of style. So it seems perverse that last month, when the Academy of Motion Picture Arts and Sciences announced the nominees for best costume design, Mayes C. Rubeo and Deborah Lynn Scott’s luridly exotic designs for the film were not in the running. Come Sunday, when Oscars are bestowed, the award will go to one in a lineup of more reliably conventional period fare, films that include “Bright Star,” “Nine” and “Coco Before Chanel.”
In earlier eras, such a slight would have stung. Film and fashion, after all, once enjoyed a relationship so intertwined as to border on incestuous. Today, among style-world insiders at least, the insult scarcely registers. Clearly a long and fabled love affair has lost its heat.
Movies and fashion? “I don’t think there’s a connection,” said Simon Doonan, the creative director of Barneys New York. Despite the cultural frenzy surrounding fashion in the last decades, “it’s very rare,” Mr. Doonan said, to find real fashion in the movies or, more tellingly, to see current films that “create much of an impact on the world of style.”
A generation ago, Mr. Doonan would have had to acknowledge an influence so powerful it drove merchants and garment makers to rush line-for-line knockoffs into production. As recently as the 1970s and ’80s, stores and catwalks teemed with adaptations, mostly literal, of Hollywood’s greatest wardrobe hits.
Faye Dunaway’s Depression-era glamour girl in “Bonnie and Clyde” (1967) spawned a raft of slinky midi-skirts, twin sets and jaunty berets like those that lent her character a vixenish appeal. Diane Keaton’s tomboy regalia in “Annie Hall” (1977) prompted legions of fans to adopt Ms. Keaton’s signature tweeds, khaki trousers and slouchy fedoras. Since the release of “Out of Africa” in 1985, the ivory-tone hacking jacket and khaki safari looks that Meryl Streep wore on the savannah have been a recurrent theme on Ralph Lauren’s runway.
Not to leave out John Travolta. In his white disco suit and open-to-the-navel black shirt in “Saturday Night Fever” (1977), Mr. Travolta inspired scores of would-be hipsters to scour stores across the country for sexy facsimiles, the better to show off a slab of bare chest.
But in the ’60s and ’70s, only a handful of trendsetting stars — the likes of Audrey Hepburn, Ms. Dunaway and Ali MacGraw — were idolized by moviegoers. “We didn’t have tweeters, bloggers and legions of minor celebrities to challenge their influence,” said André Leon Talley, Vogue’s editor at large. Had “Coco Before Chanel” been released in those heady days, he said, “it would have inspired fashion in a great way.”
Today the impact of Ms. MacGraw’s sophisticated preppie in “Love Story” (1970) would likely be lost in the flurry of outsize personalities flaunting their wardrobes on the concert stage and television, and on popular blog sites like The Sartorialist, which routinely anoints raffishly garbed, anonymous young urbanites as the latest arbiters of taste.
“These days the inspiration of film on fashion is never very apparent,” Mr. Doonan said. “You might tell yourself, I want a leather jacket like Marlon Brando wore in ‘The Wild One’ or a woolly hat like Ali MacGraw’s in ‘Love Story.’ ” Films retain their emotional impact on viewers, he acknowledged. “But what those viewers take away is often a single wardrobe item, a talisman. It’s like they’re getting a holy relic.”
The influence that film wields now is often oblique, registering as no more than an impression, a color or mood. In his spring 2007 collection, Marc Jacobs acknowledged “Marie Antoinette” and his friend, its director Sofia Coppola. But the feeling of that giddy costume extravaganza came through only in an airy cream and ivory palette and in shapes suggesting trim court breeches and dainty fichu collars.
Obscure vintage films and art house flicks — or those that failed to find a mass audience — also fuel imaginations. Cynthia Rowley alluded, albeit subtly, to the intricately interwoven textures of the costumes for “The Fantastic Mr. Fox” in a fall 2010 collection that was partly constructed from feathers and fringe. Films move her emotionally and aesthetically, Ms. Rowley said, but like many of her confederates on Seventh Avenue, she turns her back on crowd pleasers in favor of movies “whose costumes are part of a self-contained universe, one that looks as if it sprang full-blown from the director’s imagination.”
In previous decades the symbiotic relationship between Hollywood and Seventh Avenue was largely the product of strenuous marketing. Stores rushed to reproduce memorable costumes like the pouf-shouldered organdy gown Gilbert Adrian designed for Joan Crawford in “Letty Lynton” (1932) or the breezy white sundress Edith Head confected for Elizabeth Taylor in “A Place in the Sun” (1951).
“Fashion and film used to feed off each other,” said Eugenia Paulicelli, the curator of “Fashion + Film: The 1960s Revisited,” which opens at the CUNY Graduate Center on March 12. “Paris in that period may have been the center of chic,” Ms. Paulicelli said, “but Hollywood, too, became a fashion capital.”
In the mid ’70s, films like “The Great Gatsby” were hungrily exploited by the garment trade. No less a retail force than Bloomingdale’s swiftly adapted Theoni Aldredge’s Oscar-winning Gatsby costumes in a clothing line exclusive to the store. Years later, film-fueled promotions — among them “Dick Tracy” (1990) and “Phantom of the Opera” (2004) — misfired as often as they hit their mark.
But the prospect of failure hasn’t deterred a youth-oriented chain like Hot Topic from issuing hoodies with wolf ears, and bangles engraved “I cannot be without you … Edward C,” in time for the release last year of “Twilight: New Moon.” Nor has it discouraged the makers of “Alice in Wonderland,” which opens on Friday, from forging alliances with swarms of marketers.
Even Barneys, which has long turned up its nose at such commercial ploys, has done windows promoting celluloid spectacles like “The Last Samurai.” As Mr. Doonan recalled, that film’s elaborate costumes served as a backdrop for a smattering of Dries Van Noten and Balenciaga designs that bore no relation to the film. An effort to mirror the samurai costumes “would have been corny,” he offered with mock disdain, “and corniness is something that terrifies fashion people.”
In the last decade, the once-unchallenged role of movies in shaping public tastes has been largely usurped by television and the concert stage. The costumes for Carrie Bradshaw and her style-besotted pals in “Sex and the City” famously sparked a run on Manolo Blahnik stilettos, Fendi baguettes and garish nameplate necklaces. Variations of the crested blazers, mini-kilts and headbands worn by the private school divas of “Gossip Girl,” were instant best sellers. And today a merchant might be well advised to seek inspiration instead from the cyborg-like bodysuits worn on stage by the Black Eyed Peas at Madison Square Garden last week.
As an engine that drives fashion, film may have lost steam. But to fashion insiders it remains a rich and constant reference point. “What film can do better than almost anything else,” said Ms. Paulicelli, the curator, “is establish a powerful intimacy with viewers’ gaze.”
Wittingly or not, those viewers take in colors, subtle tactile impressions or an overall atmosphere that can linger in the mind for years, part of a vast store of images that may surface at any time.
While visiting a fashion showroom late last month, Jeffrey Kalinsky, the director of designer merchandising for Nordstrom, glimpsed a crisp dress that transported him to a more formally elegant time. “I thought of Catherine Deneuve in her Saint Laurent dresses and pilgrim pumps,” he said wistfully. “It was a ‘Belle de Jour’ moment.”
California’s yearly budget cycles and cuts are a huge threat to seniors and those with disabilities.
As a result those with disabilities and their allies are camping on the traffic island at Adeline Street at Russell [Berkeley, CA] for an indefinite period under what they term CUIDO (Communities United in Defense of Olmstead). According to literature handed out, they “are a new group organised to fight the proposed budget cuts that threaten to institutionalise people with disabilities and seniors against their will, in violation of Olmstead, a Supreme Court ruling on the Americans with Disabilities Act (ADA) stating that unnecessary segregation of individuals with disabilities in institutions constitutes discrimination based on disability.”
Governor of California, Arnold Schwarznegger is proposing draconian cuts to some vital services which otherwise would allow those with disabilities to remain in their homes and communities. These cuts are pointed toward In-Home support services (IHSS) through a 40% cut in State funding. This will affect more than 490,000 disabled and elderly Californians and over 385,000 caregivers. Medi-CAL has a proposed cut of $750 million with a cap on some services which will put it out of reach for many with no health care alternative whilst increasing emergency room use. The elimination of Adult Day Health Care (ADHC) which would cut $109 from day care services that currently provides a variety of services to 37,000 people at risk of nursing home placement. Also in the proposals are the forced drugging of people with mental disabilities and the elimination of spending for mental health rehabilitation programs.
The protesters believe that society should provide for its people and the group also highlight that they are against cuts in the K-12 and higher education programs, childcare, Calworks and “all the programs that a civilised society should provide for its people.”
In May Arnieville was set up on the traffic island at Adeline and Russell in South Berkeley for four days. The resurrection of the tent city was to draw more attention to the issues and likened by protester Jean Stewart as a ‘Hooverville’. These were shanty towns that popped up during the Great Depression and were named after President at the time Herbert Hoover as he reportedly let the nation slide into depression.
Different events will be held at the camp such as live music, spoken word and poetry amongst teach-ins and many more.
No one who knows Justin Kaplan would ever have expected this. A Pulitzer Prize-winning historian with a razor intellect, Mr. Kaplan, 84, became profoundly delirious while hospitalized for pneumonia last year. For hours in the hospital, he said, he imagined despotic aliens, and he struck a nurse and threatened to kill his wife and daughter.
“Thousands of tiny little creatures,” he said, “some on horseback, waving arms, carrying weapons like some grand Renaissance battle,” were trying to turn people “into zombies.” Their leader was a woman “with no mouth but a very precisely cut hole in her throat.”
Attacking the group’s “television production studio,” Mr. Kaplan fell from his hospital bed, cutting himself and “sliding across the floor on my own blood,” he said. The hospital called security because “a nurse was trying to restrain me and I repaid her with a kick.”
Mr. Kaplan’s hallucinations lifted as doctors treated his pneumonia. But hospitals say many patients are experiencing such inexplicable disorienting episodes. Doctors call it “hospital delirium,” and are increasingly trying to prevent or treat it.
Disproportionately affecting older people, a rapidly growing share of patients, hospital delirium affects about one-third of patients over 70, and a greater percentage of intensive-care or postsurgical patients, the American Geriatrics Society estimates.
“A delirious patient happens almost every day,” said Dr. Manuel N. Pacheco, director of consultation and emergency services at Mount Auburn Hospital in Cambridge, Mass. He treated Mr. Kaplan, whom he described as “a very learned, acclaimed person,” for whom “this is not the kind of behavior that’s normal.” “People don’t talk about it, because it’s embarrassing,” Dr. Pacheco said. “They’re having sheer terror, like their worst nightmare.”
The cause of delirium is unclear, but there are many apparent triggers: infections, surgery, pneumonia, and procedures like catheter insertions, all of which can spur anxiety in frail, vulnerable patients. Some medications, difficult for older people to metabolize, seem associated with delirium.
Doctors once dismissed it as a “reversible transient phenomenon,” thinking “it’s O.K. for someone, if they’re elderly, to become confused in the hospital,” said Dr. Sharon Inouye, a Harvard Medical School professor. But new research shows significant negative effects.
Even short episodes can hinder recovery from patients’ initial conditions, extending hospitalizations, delaying scheduled procedures like surgery, requiring more time and attention from staff members and escalating health care costs. Afterward, patients are more often placed, whether temporarily or permanently, in nursing homes or rehabilitation centers. Older delirium sufferers are more likely to develop dementia later. And, Dr. Inouye found, 35 percent to 40 percent die within a year.
“It’s terrible, more dangerous than a fall,” said Dr. Malaz A. Boustani, a professor at the Indiana University Center for Aging Research, who found that elderly patients experiencing delirium were hospitalized six days longer, and placed in nursing homes 75 percent of the time, five times as often as those without delirium. Nearly one-tenth died within a month. Experts say delirium can contribute to death by weakening patients or leading to complications like pneumonia or blood clots.
Ethel Reynolds, 75, entered a Virginia hospital last July to have fluid drained that had been causing her feet to swell. She wound up hospitalized for weeks, sometimes so delirious that “she screamed constantly, writhed,” said her daughter, Susan Byrd. “I had to get in bed with her because she thought someone was coming and they were going to hurt us,” Ms. Byrd said.
Ms. Reynolds ended up needing dialysis and surgery after an infection, and she died in September.
“We got her death certificate, and the No. 1 cause of death was delirium,” said Ms. Byrd, an ophthalmology nurse. “I was just blown away. As a nurse, I was expecting a quote-unquote medical reason: kidneys, heart, lung, an organ that I could understand had failed, and it wasn’t. It was delirium.”
Other triggers involve disorienting changes: sleep interrupted for tests, isolation, changing rooms, being without eyeglasses or dentures. Medication triggers can include some antihistamines, sleeping pills, antidepressants and drugs for nausea and ulcers. Dr. Inouye said that many “doctors don’t know how to appropriately use meds in older people, in terms of dosing” and compatibility with other medications.
Earle Helton, 80, a retired chemist hospitalized after a stroke, ordered his family to “throw a rope over the hedge so he could escape,” said his daughter, Amanda. He tried removing his hospital gown, loudly sang “Lullaby and Goodnight,” and doctors had to tie down his hands to prevent him from leaving, said his wife, Ginnie. Only when Dr. Inouye stopped some medications that other doctors had prescribed did he become lucid.
Delirium is sometimes treated with antipsychotics, but doctors urge caution using such drugs.
Delirium can wax and wane, not always causing aggressive agitation.
“It is often the person quietly in bed,” and the condition can linger for weeks or months, landing patients back in the hospital, said Dr. Julie Moran, a geriatrician at Beth Israel Deaconess Medical Center in Boston. “We would have to build 100 more floors to keep everybody until they cleared their delirium. There are times when we could be working round the clock seeing patients with delirium.”
Frequently, geriatricians say, delirium is misdiagnosed, or described on patient charts as agitation, confusion or inappropriate behavior, so subsequent doctors might not realize the problem. One study found “delirium” used in only 7 percent of cases; “confusion” was most common. Another study of delirious older emergency-room patients found that the condition was missed in three-quarters of them.
People with dementia seem at greater risk for delirium, but many delirious patients have no dementia. For some of them, delirium increases the risk of later dementia. In such cases, it is unclear if delirium caused the dementia, or was simply a signal that the person would develop it later.
Some hospitals are adopting delirium-prevention programs, including one developed by Dr. Inouye, which adjusts schedules, light and noise to help patients sleep, ensures that patients have their eyeglasses and hearing aids, and has them walk, exercise and do cognitive activities like word games.
Dr. Moran’s hospital removes catheters, intravenous lines and other equipment whenever possible because they can make patients feel trapped, leading to delirium. She said nurses repeatedly assess cognitive function so patients “don’t have smoldering symptoms of delirium for days before they end up yelling and screaming.”
Mr. Kaplan, a biographer of Mark Twain and Walt Whitman, later jotted notes about his hallucinations, including being in a police helicopter “tracking fugitives with enormous light.”
“Exhilarating until I become one of the fugitives,” he wrote. “End up cold and naked in some sort of subway passage.”
His fall bruised his elbow, leg and wrist, said his wife, the writer Anne Bernays. The next day, “he was gaga till about noon,” and even “looked me in the eye and said ‘I’m going to kill you,’ ” she said. “He didn’t know where he was and didn’t recognize me.”
Fortunately, his delirium was discovered very quickly and he made a very good recovery, Dr. Pacheco said. “But,” he said, “delirium is very disruptive for the patient, family, hospital caregivers.”
As Mr. Kaplan understated later, “It was a lot of unpleasantness.”