But how much do you know about the people behind the Internet? Who were the founding fathers and mothers of computer science? Do you know who coined the term ‘computer bug’ or who said “We don’t have the option of turning away from the future. No one gets to vote on whether technology is going to change our lives”?

Take our computing quiz, compiled from resources in Who’s Who, the Oxford Dictionary of National Biography, Oxford Reference, and the American National Biography, to see if you’re a computer genius or if you need an upgrade!

Who’s Who, published annually by A & C Black since 1897, and online exclusively by Oxford University Press since 2008, is the leading source of up-to-date information about over 35,000 influential people from all walks of life, worldwide, who have left their mark on British public life. Written by specialist authors, the Oxford DNB biographies will introduce you to the people behind British history’s great events as well as its literature, science, art, music, and ideas. Oxford Reference is the home of Oxford’s quality reference publishing bringing together over 2 million entries, and more than 16,000 illustrations, into a single cross-searchable resource. Discover the lives of more than 18,700 men and women — from all eras and walks of life — who have influenced American history and culture in the acclaimed American National Biography Online.

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Spring 2013 marks two significant anniversaries for Alexander Pope, perhaps the most representative and alien English poet of the 18th century. Pope is memorialized both for the 325th anniversary of his birth, on 21 May 1688, and for the 300th anniversary of two significant literary acts: one a publication, the other a proposal to publish.

On the 7 March 1713, Pope published one of his most important poems. Windsor Forest was published the same month as the signing of the multi-stage Treaty of Utrecht, with which, in part, the poem deals: “Hail, sacred Peace! hail long-expected days” (Windsor Forest, line 353). The redistribution of territories determined by that treaty created various, continuing friction points between Protestant Britain and its Catholic adversaries: France ceded vast North American territories to Great Britain leaving French Canada surrounded by English lands, while Spain ceded Gibraltar to Britain and acquired the Falkland islands (Islas Malvinas). It was a period of global, territorial conflicts, but passions were inflamed by the Protestant/Catholic schism.

Later that same year, Pope made public, and sought subscriptions for, a proposal for the first major English translation of Homer’s Iliad and Odyssey since that of Shakespeare’s contemporary George Chapman (1559–1634). Pope’s Homeric effort became one of the major cultural accomplishments of the period. In a letter of 4 October 1726, Voltaire praised Pope’s fingers, “which have dressed Homer so becomingly in an english coat”.

As a man, Pope himself has at least two claims on our attention, though his anniversary will undoubtedly rank lower in public attention than would that of many other poets of these Isles. A Google search on English poets by forename and surname lets us plot a rough graph of Internet popularity:

However, there are other digital measures of a poet’s popularity. Pope’s epigrammatic style and his rhyming couplets, which suffered critically at the hands of the Romantics and later generations, now proves to be remarkably popular among the choruses of Twitter, where there are a number of “Pope” persona:

— and endless Pope Tweets, quoting (or misquoting) lines from his verse. Pope’s epigrammatic couplets were crafted to place a succinct thought within a limited number of words:

One of the things that continues to intrigue about Pope, is his extraordinary confidence and ability to focus on his vision of what he should do and be in life. Two years before the date marked by this anniversary, Pope published one of his two great “epigrammatic essays” — An Essay on Criticism (first published anonymously, 15 May 1711). Pope was only 23, and the work does more than mark him out as a singular and singularly memorable essayist on the human condition. It presents us with the noteworthy instance of a young man, still at the beginning of his literary career, publicly admonishing and correcting the established critical community. It reminds me of the equally confident, if often less accessible, manifestoes of the Modernist movement.

For Pope was no social or cultural insider, but what might be thought of as a “corporeal and incorporeal outsider.” Pope was twice marginalized in his world. Marginalized once for his beliefs — as a Catholic, then barred from teaching, attending university, voting, or holding public office on pain of imprisonment. The anti-Catholic sentiment was aggravated by the War of the Spanish Succession (1701–1714), which led to a statute preventing Catholics from living within 10 miles (16 km) of either London or Westminster.

These constraints would have pinched especially hard on the ambitions of Pope’s essentially middle class family. They were prosperous enough, however, to be able to escape to the country, moving to a small estate in Binfield (or Bynfield), Berkshire, when Alexander was twelve. Binfield was only a dozen kilometres west of Great Windsor Park, though remains of the ancient royal hunting grounds of Windsor Forest undoubtedly “crown’d with tufted trees” (Windsor Forest, line 27) various plots between the two. On the verges of these forests, you could pretend to be anyone, and one’s beliefs could be recast in the poetic imagery of patriotism and Classical analogy we find in Windsor Forest.

Estates at Windsor, Berkshire — British Library, “The unveiling of Britain”. © The British Library Board Royal Ms. 18.D.III, f.32

Pope could never escape his second marginalization, however, for he literally carried it with him on his back. From the age of twelve, exactly at the time of the family move from London, Pope suffered from a form of tuberculosis that affected the bone, deforming his body, stunting his growth. Pope grew to a height of only 4 feet 6 inches (1.37 m), and was left with a severe hunchback.

The disease received its formal medical description in Pope’s lifetime, though too late to help the poet. A decade before Pope’s death in 1744, a Liverpool surgeon, H. Park, wrote an epistolary volume in which characteristics and (painful) treatments of the disease were described: An Account of a new method of treating diseases of the joints of the knee and elbow, in a letter to Mr. Percival Pott. (London: J. Johnson, 1733). The recipient of the “letter”, the remarkable English surgeon Sir Percivall Pott (1714–1788) was one of the founders of orthopedy, and the first scientist to demonstrate that cancer may be caused by an environmental carcinogen. He published a volume on Some few general remarks on fractures and dislocations (London: Hawes, Clarke and Collins, 1768), providing the first clinical description of extrapulmonary tuberculosis (tuberculous spondylitis), the disease with which Pope suffered, subsequently known as Pott’s disease.

I recommend a re-reading of Windsor Forest with some sense of the twice-excluded author in mind. All good poems can be read in many ways, but one of the things this re-reading proposes is the struggle of an outsider to create a re-vision of the world that contains and excludes him.

Dr. Robert V. McNamee is the Director of the Electronic Enlightenment Project, Bodleian Libraries, University of Oxford.

Electronic Enlightenment is a scholarly research project of the Bodleian Libraries, University of Oxford, and is available exclusively from Oxford University Press. It is the most wide-ranging online collection of edited correspondence of the early modern period, linking people across Europe, the Americas, and Asia from the early 17th to the mid-19th century — reconstructing one of the world’s great historical “conversations”.

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Image credits: (1) Alexander Pope portrait. NYPL Digital Gallery. (2) Google searches for poets. Copyright Dr. Robert V. McNamee. Used with permission. (3) Screengrab from Twitter by Dr. Robert V. McNamee. (4) Screengrab from Twitter by Dr. Robert V. McNamee. (5) Estates at Windsor, Berkshire — British Library, “The unveiling of Britain.” © The British Library Board Royal Ms. 18.D.III, f.32. Used with permission. (6) From a mid-19th century text book. Out of copyright.

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Notwithstanding the many privacy concerns it raises, the role of video surveillance footage in cracking the Boston terror attack case in a matter of days is well known. Such footage played an equally critical role in tracking down the bombers of the 2005 London attacks. However, in 2005 investigators took weeks to manually sift through about two thousand hours of video footage. This time around, thousands of hours of video were analyzed in barely 48 hours.

The city of Boston is smaller than London; still, it has thousands of surveillance cameras, very similar to the London of 2005. What has changed is technology: video analysis has become significantly more sophisticated in the years since 2005. For example, pre-processing tools are able to filter hours of video footage in, say, an empty subway station at night. Investigators are able to focus only on periods of activity rather than patiently watch footage of an empty platform for hours on end.

Of course, more crowded scenes, especially those as packed as the sidewalks alongside the marathon route require far more sophisticated technology, much of which is still in its infancy. Today there are many commercial video analytics tools that claim to be able to detect a person leaving a bag or backpack and walking away. Such tools are certainly very useful in narrowing down portions of video footage to be analyzed manually during post-incident investigations. But can they reliably alert us in real-time without generating too many false positives? For example, you lay down a brief case and move behind a pillar to find a quiet place to make a phone call. A video surveillance system might well conclude that you have left the scene and your bag is a potential threat. Hundreds of such warnings might be generated every minute — who is to monitor and decide which ones to follow up on?

Another technique that has seen significant advances in recent years is tracking moving objects in videos, especially human beings. Further, it is now possible (only barely though), to track the same person as he moves across large distances as he moves in and out of the field of view of multiple cameras. So, in principle, a hypothetical `big brother’ central server that processes feeds from multiple cameras should be able to track anyone suspected in a ‘left bag’ event and verify whether they rapidly walk away from the scene or not. Of course, bandwidth remains a limitation, which is why many video analytics solutions rely on local ‘event detection’ at the camera level so as to minimize transferring too much data across a network. Further, in such situations, different cameras need to be ‘told’ to track a ‘particular’ person seen by another camera, and that too in a bandwidth efficient manner. So much work remains to be done for efficient large-scale multi-camera tracking.

But there is more: Many recent terror attacks, especially in India, share a similar modus operendi — the terrorist leaves his dangerous cargo on a bicycle that he parks in a crowded market and walks away, seemingly on an innocent shopping errand. Should our central server raise an alarm? After all, many people genuinely shop while their two-wheeled vehicle, bicycle or motorbike, lies parked nearby, perhaps also loaded with their recent purchases. Do we warn citizens of dire consequences if they leave packets on their bikes?

Clearly our central server needs to work harder, track more people, for longer. Most importantly, it needs to reason. However ubiquitous video cameras might be, they still cannot be everywhere — certainly not in every store, restaurant, or loo! The central server would need to explain away the actions of most of the people it tracked, and narrow down on only a few, such as someone entering a subway station, leaving a bag and then boarding a train. (Such ‘explaining away’ to home in on the right answer is an example of ‘abductive reasoning’. If it appears difficult for a machine to mimic, take note that just such reasoning has in fact already been used by IBM’s Watson program that won the 2009 Jeopardy! competition.)

Moreover, how might the video surveillance servers of the future come to know what is normal behavior and what is not? Certainly it would be impossible to catalogue every instance of normalness for the machine to ‘look up’ and compare against. Instead, the machine would need to learn, using massive amounts of ‘normal’ video footage. Difficult, but by no means impossible any more. Consider this: each year over 15 million hours of video is uploaded onto YouTube. In contrast, a human being is exposed to barely half a million hours of ‘video experience’ over a lifetime (90 years × 365 days × 16 hours/day). Yet we learn, and rather early on, the difference between normal and abnormal, be it suspicious or merely eccentric. Granted that eccentricity is not entirely absent from YouTube videos, still, there is more than enough ‘normal’ video available today for machines to learn from, if only they knew how.

Intelligent systems such as our hypothetical central video-surveillance server need to go beyond merely looking at the world while watching us. They also need to continuously learn from the data they experience, so as to see and focus on what is actually important. Only then can they connect the dots and make reasonably accurate predictions, so corrective action can be taken in time, and not only after a tragedy has occurred.

Finally, the cycle we just described above: Look, Listen, and Learn, so as to Connect, Predict and finally Correct, will be a common feature of the highly connected ‘web-intelligent’ systems of the not too distant future, be they for video surveillance, self-driving cars, or even the smart-grid.

Gautam Shroff is Vice President & Chief Scientist, Tata Consultancy Services and head of the TCS Innovation Lab in Delhi, India. He occasionally teaches in an adjunct capacity at the IIT Delhi and IIIT Delhi, as well as online via Coursera. He is the author of The Intelligent Web: Search, smart algorithms, and big data.

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Image credit: High tech overhead security camera at a government owned building. Photo © trekandshoot via iStockphoto.

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Historically, law was not generally considered an important part of gerontological science. As noted by Doron & Hofman in 2005, the law was, at best, considered part of gerontology in that it played a part in the shaping of public policy towards the older population, or was incidental to ethical discussions connected with old age. At worst, gerontology has simply ignored those aspects of the law connected with the old, and kept lawyers out of its province.

Yet in recent years there have been winds of change. Lawyers and gerontologist have started to work together and have slowly but surely developed what is becoming  known as “Jurisprudential Gerontology” (or “Geriatric Jurisprudence“): a true inter, multi, and trans-disciplinary project that looks into the fascinating interactions between law, society, and aging, in all its different aspects. These changes have become much more relevant as the UN has started to engage in the process to establish a new convention for the rights of older persons.

As part of this attempt to “connect” law, human rights, and gerontology, I have recently conducted a study on the European Court of Justice. The European Court of Justice (ECJ) is considered by many to be the most important judicial institution of the European Union today. Nevertheless, despite the potential importance and relevance of the ECJ rulings to the lives and rights of older Europeans, no research has attempted to analyze or study the ECJ rulings in a gerontological context.

Using a mixed, quantitative method (measuring and testing through statistical tools) and qualitative method (understanding the content through textual analysis), a sample of ECJ cases involving older persons were collected and descriptively analyzed. In establishing the sample, an internet-based computerized keyword search was conducted within the ECJ official website. The preliminary search identified 1,325 cases, out of which 123 “direct cases” were found (i.e. cases that included issues directly relevant to rights of older persons).

Analyzing these results found that the 123 cases were spread throughout the period of 1994 to 2009 in the following way:

Number of cases per year

As seen above, there is no clear pattern of either increase of decrease in the number of cases throughout the years, and on average, in most of the time period, each year between 5–10 cases were filed. This equals to 1%-2% of the general annual new case load of the ECJ.

From a legal issue perspective, almost half the cases (58/47.2%) were categorized by the ECJ as “Social Policy” issues, while the two other major legal issues were Free Movement of Persons (29/23.6%) and Social Security for Migrant Workers (26/21.1%). Only very few elder rights cases involved issues like Competition (3 cases), or Principles of Community Law (1 case). Attempting to move beyond the ECJ’s own categorization, and analyzing the actual legal issues, it was found that the vast majority of the cases involved issues of pensions: either state funded pensions (61/49.6%) or employer-based occupational pensions (36/29.3%). The rest of the cases were mostly age discrimination, mandatory retirement, or attendance/home care (all of them 6 cases each).

In conclusion, it could be said on the one hand that the number of elder rights cases brought before the ECJ is very low, and their overall quantitative weight is minor at best.  Yet on the other hand, within these limited numbers of cases and narrow scope of legal decisions, the outcomes are encouraging. In the majority of the cases the court rules in favor of the elderly. Overall then, the findings of this study suggest that the ECJ can potentially serve as an important protector of rights of older Europeans, if, and to the extent that, these cases reach its jurisdiction.

Prof. Israel (Issi) Doron is the Head of the Department of Gerontology at the University of Haifa, Israel, and the Past President of the Israeli Gerontological Society. His research focuses on the relationships between law, aging and human rights, with specific interest in international human rights of older persons. His paper ‘Older Europeans and the European Courts of Justice’ appears in the journal Age and Ageing and can be read in full and for free for a limited time.

Age and Ageing is an international journal publishing refereed original articles and commissioned reviews on geriatric medicine and gerontology. Its range includes research on ageing and clinical, epidemiological, and psychological aspects of later life.

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Image credit: Symbol of law and justice in the empty courtroom, law and justice concept. Photo by VladimirCetinski, iStockphoto.

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I’ve spent decades in magnetic resonance research and since 1980 my colleagues and I have been studying the human brain. Like many fields of science, it is astounding to reflect on the progress made in the uses of magnetic resonance which has gone from being a physicist’s means of studying the nucleus to an omnipresent tool for clinical medicine and biological research, especially in neuroscience. Our society holds great hopes for brain research. The Obama administration recently announced a “Brain Activity Map” project that would seek “to advance the knowledge of the brain’s billions of neurons and gain greater insights into perception, actions, and ultimately, consciousness.” However, the work that my colleagues and I have done to understand brain metabolism and function argues that some of the enthusiasm shown for these methods needs a fundamental re-examination.

In essence, I have seen too much scientific work that starts with assumptions that we know and have a solid and consensus-driven understanding of concepts like memory or consciousness when in fact we do not and cannot. Countless tests of “memory” that track activated areas of the brain via fMRI have abandoned scientific observation and induction in favor of a priori assumptions about words or ideas that have value during common usage but are not empirical concepts. What we now know about consciousness from brain imaging is that certain measurable brain properties, such as the total neuronal energy consumption, are necessary for the person to be in the state of consciousness as defined by the anesthesiologist during surgery. As more properties, including brain activities, necessary for a person to be in the state of consciousness are uncovered, the better we will understand it, but we will not get there by trying to define that elusive intangible called consciousness.

Image Credit: Brain MRI, 60M. Photo by © Nevit Dilmen, Creative Commons via Wikimedia Commons.

While there are marvelous results to be gained from careful research on brain metabolism and blood flow as measured by fMRI, there is little to be gained by making assumptions about the human mind. We shouldn’t leap from early but exciting understanding of brain activities necessary for a person’s behavior to assumptions about mental processes presumed to underlie those behaviors. Once we are trained to do things reproducibly — like recognizing a face or avoiding a moving automobile — brain activity supports our response. While we (as scientists) know a lot about how the muscle receives electrical impulses, we would never assert that the biceps, triceps, and deltoids lift a bride over the threshold after a wedding — the groom does. Even as we learn, with astounding precision, about which areas of the visual cortex are activated when the person learns to differentiate between cars and vases, we should not assume that the brain makes this distinction. It is the person who decides and acts; it is the organ — the muscle or brain — that supports her behavior.

One can postulate many reasons for society’s enthusiasm to translate basic research into useful applications in health and control. Nevertheless, it is dangerous for a subtle collective willingness among research scientists to replace traditional scientific methods that are producing wonderful descriptions of the brain’s support of observable behaviors with claims of having found a physical basis for mental concepts like working memory or attention.

Thomas Nagel’s recent book offers a very clear lens for this approach. He proposes that science has failed as an epistemological method because material science cannot explain the mind. Nagel argues that the mind obviously exists, and since chemistry and physics can’t explain it then science has failed and we must look for alternate epistemologies. I certainly agree that physical science cannot explain mind but I would depart from Nagel’s solution for two important reasons. While he defines physical science as proposing to explain everything, the more realistic and generally held view is that science is capable of understanding some aspects of the world but not necessarily all. We can’t combine the subjective views of the mind held by literature, psychology, philosophy, and everyday life with measurements of neuronal activities to give us a scientific, objective, or complete description of mind. However this is a failing of material science only if one holds a nineteenth century view that material science can explain everything in the world, a view discarded when the limits of classical physics were revealed by quantum mechanics and relativity.

As Neils Bohr succinctly observed “Physics does not tell us what nature is but rather tells us what we can say about nature.”

Robert G. Shulman is a biophysicist who has pioneered the use of nuclear magnetic resonance (NMR) and other spectroscopic techniques in physics, biochemistry, and brain imaging. He is the author of Brain Imaging: What it Can (and Cannot) Tell Us About Consciousness. His original studies created active fields of investigation in all these disciplines. He is the Sterling Professor (Emeritus) of Molecular Biophysics and Biochemistry at Yale University where he formed the Magnetic Resonance Center, taught Biochemistry, Biophysics, and Literature, and was Director of the Division of Biological Sciences. He is a member of the National Academy of Sciences and of the Institute of Medicine.

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There is currently extensive use of complementary and alternative medicine (CAM) — also known as integrative or mind-body medicine — in the United States to sustain well-being in both aging baby boomers and in children and adolescents. The National Center for Complementary and Alternative Medicine (NCCAM) defines CAM therapies as “a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine,” with “conventional” medicine being defined as the approaches used by clinicians in the routine daily practice of Western or allopathic medicine that are within the currently accepted standard of care.

The most recent comprehensive assessment of CAM use in the United States found that roughly 40% of US adults had used at least one CAM therapy within the past year. In addition, Americans make more visits to CAM providers each year than to primary care physicians and spend at least as much money on out-of-pocket expenses for CAM services as they do for all conventional physician services combined. Patients with mental disorders turn to CAM for relief of symptoms of anxiety, mood, insomnia, impaired cognition, and perceived stress. The most commonly used CAM techniques include prayer for health and the use of multivitamin supplementation. Given widespread use of CAM services among patients, there is an urgent need for greater awareness and familiarity with its applications and outcomes.

As baby boomers age and increase use of CAM, mental health professionals require a working knowledge of CAM techniques intended to address late life mood disorders. An estimated 33-88% of older adults will use CAM therapies, including those with late-life depression and bipolar disorder. CAM treatments of mood and anxiety disorders include acupuncture, deep breathing exercises, massage therapy, meditation, naturopathy, and yoga.

Complementary and alternative medicine encompasses a number of techniques collectively known as mindful exercise (e.g. yoga, Qigong, and Tai Chi), or meditation. This ‘physical exercise executed with a profound inwardly directed contemplative focus’ is increasingly utilized for improving psychological well-being. In general, mindful physical exercise contains the following key elements:

1. a non-competitive, non-judgmental meditative component,
2. mental focus on muscular movement and movement awareness combined with a low to moderate level of muscular activity,
3. centered breathing,
4. a focus on anatomic alignment (i.e., spine, trunk, and pelvis) and proper physical form,
5. energy centric awareness of individual flow of intrinsic body energy, otherwise known as prana, life force, qi, or Kundalini.

Mindful exercise has been shown to provide an immediate source of relaxation and mental quiescence. Scientific evidence has shown that medical conditions such as hypertension, cardiovascular disease, insulin resistance, depression, and anxiety disorders respond favorably to mindful exercises.

There is a growing database of the physiological effects of mindful exercise and meditation. Tai Chi and Qi Gong have been shown to promote relaxation and decrease sympathetic output, and to benefit anxiety, depression, blood pressure, and recovery from immune-mediated diseases. Tai Chi and Qi Gong have been shown to improve immune function and vaccine-response. These practices have also been shown to increase blood levels of endorphins and baroreflex sensitivity, and to reduce levels of inflammatory markers (CRP), adrenocorticotrophic hormone (ACTH), and cortisol, implicating the hypothalamic-pituitary-adrenal (HPA) axis as a mediator of stress and anxiety reduction. Brain wave or electroencephalopathy (EEG) studies of participants undergoing Tai Chi and Qi Gong exercise have found increased frontal EEG alpha, beta, and theta wave activity, suggesting increased relaxation and attentiveness. These changes have not been found in aerobic exercise controls.

Yogic meditation (Kirtan Kriya) for stressed family dementia caregivers resulted in lower levels of depressive symptoms, and improvements in mental health and cognitive functioning. Participants in the yogic meditation group showed a 43% improvement in telomerase activity after 12 minutes of daily practice for 8 weeks, compared with 3.7% in relaxation music control participants. This suggests that brief daily meditation practices can benefit stress-induced cellular aging. Kirtan Kriya reversed the pattern of increased NF-κB-related transcription of pro-inflammatory cytokines, and decreased IRF1-related transcription of innate antiviral response genes in distressed dementia caregivers. This reinforces the relationship between stress reduction and beneficial immune response. In the same study, nine caregivers received brain FDG-PET scans at baseline and post-intervention. When comparing the regional cerebral metabolism between groups, significant differences over time were found in different patterns of regional cerebral metabolism suggesting brain-fitness effect different from passive relaxation.

Studies of meditation also report decreased sympathetic nervous activity and increased parasympathetic activity associated with decreased heart rate and blood pressure, decreased respiratory rate, and decreased oxygen metabolism. Functional neuroimaging studies have been able to corroborate these subjective experiences by demonstrating the up-regulation in brain regions of internalized attention and emotion processing with meditation.

In a recent systematic review of neurobiological and clinical features of mindfulness meditations, Chiesa and Serretti (2010) provided evidence on the neurobiological changes related to Mindfulness Meditation (MM) practice in psychiatric disorders. Meditation practices that focus on concentration of an object or mantra seem to elicit the activation of fronto-parietal networks of internalized attention; meditation techniques that focus on breathing may elicit additional activation of paralimbic regions of insula and anterior cingulate; and meditation techniques that focus on emotion may elicit fronto-limbic activation. Future studies will be needed to disentangle the brain activation patterns related to different meditation traditions.

Given the noninvasive nature of mindful exercise and meditation, these exercises are an appropriate option for consumers and clinicians, particularly for conditions that have been examined in controlled studies. Significant evidence supports the assertion that Tai Chi and Qi Gong and yoga and meditation can improve physical and mental health, and quality of life. Ethical considerations should be taken into account when practicing or recommending spiritual interventions by healthcare professionals to respect patients’ beliefs in choosing mind-body interventions.

Dr. Helen Lavretsky is a Professor of Psychiatry at the Semel Institute for Neuroscience and Human Behavior at UCLA, a geriatric psychiatrist with the research interest in geriatric depression and caregiver stress, as well as complementary and alternative medicine and mind-body approaches to treatment and prevention of disorders in older adults. She is co-editor of Late-Life Mood Disorders with Martha Sajatovic and Charles Reynolds. She is a recipient of the two Career Development awards from NIMH and other prestigious research awards. Her current research include clinical and translational studies of geriatric depression and caregiver stress, as well as complementary and alternative interventions for stress reduction in older adults.

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The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a classification of all diagnoses given to patients by mental health professionals. Since the publication of the third edition in 1980, each edition has been a subject of intense interest to the general public. The current manual, DSM-5, is the first major revision since 1994.

DSM-5 is not, as sometimes claimed, “the bible of psychiatry”. It is not based on a thorough understanding of the causes of mental disorder, which remain largely unknown. Nor does it provide guidance concerning treatment. What DSM does is to allow mental health professionals to communicate with each other by listing criteria by which diagnoses can be made reliable.

When DSM-5 was in the planning stage, there was talk of radical changes, leading to a “paradigm shift”. This did not happen, as the scientific reviewers of proposals for revision insisted that major changes could not be made without very strong scientific evidence. A few changes attracted attention in the media (such as allowing a diagnosis of depression in people suffering from grief). By and large, the manual is not that different from its predecessors.

The problems with DSM-5 are the same as those affecting all earlier editions. If we do not understand what causes mental illness, it is very difficult to classify it. Unfortunately, the use of certain diagnoses is so widespread that people get the impression that categories in psychiatry are as real as hepatitis or multiple sclerosis. They are not. They are simply convenient ways of describing what clinicians see in practice. None of them have a correlation with biomarkers such as blood tests, genes, or brain imaging. They remain entirely dependent on signs and symptoms, which is all that mental health practitioners can currently observe.

The DSM system has led to an inflated prevalence of certain disorders, sometimes producing diagnostic epidemics. These problems affect some of the most common disorders in practice. Thus “major depression” is a very disparate collection of signs and symptoms that cannot be used to determine the correct treatment. Bipolar disorder is being diagnosed in patients who do not have its classical features, and has even been applied to young children. Attention deficit hyperactivity disorder (ADHD) has no definite boundaries, and is being greatly over-diagnosed, both in children and adults. Autism spectrum disorders, once considered rare, are now being seen as among the most common of all conditions that professionals see.

The real problem behind diagnostic epidemics is the failure of the DSM system to distinguish between mental disorder and normality. There is no agreed on definition of mental illness, whose scope has been steadily expanded. This trend is associated with a dangerous over-prescription of drugs that were originally developed for patients with severe and clearcut illnesses.

The DSM system can be described as flawed but necessary. Clinicians need to communicate to each other, and even a wrong diagnosis allows them to do so. However it will require many decades before we know enough about mental illness to produce a truly scientific classification.

Joel Paris is a professor of psychiatry at McGill University (Montreal, Canada), and a research associate at the SMBD-Jewish General Hospital, Montreal. He is the author of 15 books, most recently The Intelligent Clinician’s Guide to the DSM-5®, and 183 peer-reviewed scientific articles.

The OUPblog is running a series of articles on the DSM-5 in anticipation of its launch today, 18 May 2013. Read previous posts: “DSM-5 will be the last” by Edward Shorter, “The classification of mental illness” by Daniel Freeman and Jason Freeman, “Personality disorders in DSM-5″ by Donald W. Black, and “American psychiatry is morally challenged” by Michael A. Taylor.

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The fundamental problem with American psychiatry is American psychiatrists. It seems every few months there’s fresh news about some well-known academic psychiatrist paid boatloads to endorse a new treatment that doesn’t work—or worse—causes harm. Among the 394 US physicians in 2010 who received over $100,000 from the pharmaceutical industry, 116 were psychiatrists, well out of proportion of the percentage of psychiatrists in medical practice. The American Psychiatric Association is also heavily supported by the drug industry. Its annual meetings, once efforts to educate members, are now basically week-long infomercials for Big Pharma. This influence has seeped into clinical trials as well, where study design is carefully manipulated by industry representatives to favor their new product. In turn, companies analyze their data out of view of academics, sequestering data unfavorable to their product, and ghostwriting journal articles for academics.

In similar fashion, fancy devices have been introduced with claims of wondrous benefits, none of which have materialized. Light-emitting boxes, for example, were supposed to be the next great psychiatric advent to prevent winter depressions, but the evidence for this claim is still weak. Similarly, vagal nerve stimulation (an implanted electronic pacer in the chest with electrodes attached to a nerve in the neck) was supposed to relieve treatment-resistant depressions. Yet it offers no demonstrated benefit and costs the poor soul subjected to it about $20,000 out of pocket. Transcranial magnetic stimulation, a ring-shaped magnet that delivers a magnetic pulse to the head, was going to replace electroconvulsive therapy. At best it has a placebo effect. And yet, these treatments continue because of their support by psychiatrists, many of whom have a vested interest in the success of the products. Integrity, it seems, is the only thing in short supply for psychiatry these days.

Just like the new antidepressant and antipsychotic drugs that have been introduced in the past three decades, the idea behind these new treatments was simply to make money. In 2006, US sales alone for these new gadgets topped 289 billion, and continue to rise. Between 1998 and 2006, the industry spent 855 million dollars on lobbying—a total which exceeds that of all other lobbies—to keep that momentum rolling.

You can’t fault the desire to make money; it’s the American way. But when treatments are equated to widgets, profits will always trump concerns of efficacy and safety. Can you think of an industry in which that has not been the case? Sadly, this was not always the situation with psychiatry. The early psychiatric drugs were developed by industry and psychopharmacologists working in concert, striving toward the production of effective and reasonably safe agents. And they succeeded. The older and less expensive antidepressants and antipsychotics are still just as good as or better than the new agents. In fact, the cost to patients drops from 18% to 6% of their medical dollar when they switch from patented to generic medications.

The new psychiatric drugs and novel treatments are frauds. The evidence that they work is weak and is often distorted to the point of fabrication. Studies show that the new antidepressants (e.g., Prozac, Paxil, and Citalopram) achieve remissions at only slightly better rates than a placebo. The widely prescribed anticonvulsant valproic acid (Depakote) outpaces lithium in prescriptions as a mood stabilizer, and yet it’s not as effective. That’s because the guidelines for psychiatric drug treatments are written by academics paid out of the pocket of Big Pharma. These guidelines are required reading in residency training and dictate the diagnostic and treatment decision-making of most psychiatrists, but really they’re just cookbooks, following the bottom line not the data. The most recent version of the DSM, for example, was drafted by academics, many of whom continue to receive substantial financial support from the industry. This clear conflict of interest in part accounts for why the thresholds for illnesses in the manual continue to get lower and lower: if more people are “ill,” it justifies the prescription of more psychotropic medication. Thus perpetuating the whole corrupt cycle.

Over the past half-dozen years, academic psychiatry has started to wean itself from the pharmaceutical milk-cow. Drug “reps” are restricted at most medical centers now, and direct payments to departmental activities are increasingly limited. These are good first steps, but financial support to departments still occurs. Multisite clinical trials are still industry affairs. The well-known psychiatrists and experts crafting treatment guidelines and new versions of the DSM are still industry supported. Despite the financial pain that might ensue, the only solution is to end the relationship. No academic responsible for the training and mentoring of medical students and young physicians should accept any industry money. They already receive adequate financial support from their institutions. If the industry wants its products tested, unrestricted grants can be given to the institution, which can then monitor the use of the funds for a small overhead fee as is done in the case of other funding sources. No more industry-designed and analyzed research. No more hidden unfavorable data. No more industry-supported lectures. No more direct industry support of any kind. This way, even if we make mistakes, our medicine will at least have integrity.

Michael A. Taylor, MD, is the author of Hippocrates Cried: The Decline of American Psychiatry. He works as an adjunct clinical professor of psychiatry at the University of Michigan Medical School. He was founding editor of the peer-reviewed journal, Cognitive and Behavioral Neurology, and also worked as professor, chairman, and director at the Department of Psychiatry and Behavioral Sciences at the Chicago Medical School. He established and directed the psychiatry residency-training program at the State University of New York at Stony Brook.

Oxford University Press is running a series of articles on psychiatry and the DSM-5 in anticipation of the launch of the DSM-5 at the American Psychiatry Association meeting on 18 May 2013.

The OUPblog is running a series of articles on the DSM-5 in anticipation of its launch on 18 May 2013. Stay tuned for a view from Joel Paris. Read previous posts: “DSM-5 will be the last” by Edward Shorter, “The classification of mental illness” by Daniel Freeman and Jason Freeman, and “Personality disorders in DSM-5″ by Donald W. Black.

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Those of us in the mental health professions anxiously await the release of the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Others may wonder what the fuss is about, and may even wonder what the DSM-5 is. In short, it is psychiatry’s diagnostic Bible. While some imbue it with the reverence given a religious tract, it is not inerrant and only reflects the collective wisdom of those entrusted with the charge of revising it. The current manual, DSM-IV, came out in 1994 with a text revision in 2000, so in some ways the march to DSM-5 has been a 19 year journey.

As a psychiatrist, I am interested in classification, but I am particularly interested in how antisocial personality disorder, or ASP, has been classified over time. Over the past 200 years, ASP has been consistently recognized as one of the most identifiable and important of the psychiatric disorders, whether called manie sans délire, moral insanity, or even psychopathic personality. These terms all describe, at their most fundamental, bad behavior unconnected to medical illness or psychosis. During the DSM-5 deliberations, I and others became concerned that the committee dedicated to discussing personality disorders (the Personality and Personality Disorders Work Group) might decide to ditch the current diagnostic criteria and replace them with a combination of new diagnostic criteria and a “dimensional,” rather than categorical, evaluation of various personality traits.

The DSM-5 deliberations, for the most part, took place quietly and behind closed doors by clinicians and researchers who devoted many hours to their deliberations. They were tasked with considering the literature, research advances, and the users and patients’ needs when recommending changes to a diagnosis. Having watched the process as an interested observer, I can say that it was — for the most part — open, transparent, and free of conflicts of interest, despite loud and strident complaints from some quarters. Yet the Personality and Personality Disorders Work Group still produced a plan deemed by many as unworkable and overly complicated. This new plan was rejected by the leadership of the American Psychiatric Association in December 2012. The Personality and Personality Disorders Work Group was the only committee involved with the DSM-5 revision process in which two members openly and publicly resigned. No other work group had its many years of work rebuked.

So what went wrong? My own belief is that the work group overreached. In response to researchers on the committee whose life’s work was to understand and test dimensional schemes for describing personality traits, the committee wed itself to developing a scheme to replace the existing criteria for personality disorders. They came up against considerable pushback. I believe they never fully grasped that psychiatrists and many other clinicians tend to think categorically (is trait ‘x’ present or not?), rather than dimensionally (how much of trait ‘x’ is present?), and are very concerned with insurance reimbursement (would an insurer pay for the care of someone with some, but not all, of these traits?). The scheme itself appeared overly time consuming to busy practitioners; instead of simply deciding on a diagnosis, they might have to rate up to 5 personality ‘domains’ and 25 trait ‘facets’. Many clinicians, too, were concerned that some of the personality disorders that are well-researched and whose criteria were known to be valid (antisocial and borderline personality disorders, for example) would be changed for no good reason. In my view, the committee members have only themselves to blame for what proved to be an embarrassing turn of events. To preserve comity, the American Psychiatric Association leadership agreed to place the new scheme in the appendix of DSM-5 so as to be available to researchers and clinicians.

So, to those who wonder what has happened with antisocial personality disorder in DSM-5: the answer is nothing. After all those hours of deliberation and discussion, the criteria set for ASP, and all the other personality disorders, in the DSM-5 is exactly the same as it was in DSM-IV.

Donald W. Black, MD, is the author of Bad Boys, Bad Men: Confronting Antisocial Personality Disorder (Sociopathy), Revised and Updated Edition. He is a Professor of Psychiatry at the University of Iowa Roy J. and Lucille A. Carver College of Medicine in Iowa City. A graduate of Stanford University and the University of Utah School of Medicine, he has received numerous awards for teaching, research, and patient care, and is listed in “Best Doctors in America.” He serves as a consultant to the Iowa Department of Corrections. He writes extensively for professional audiences and his work has been featured in television and print media worldwide. Read his previous blog posts.

The OUPblog is running a series of articles on the DSM-5 in anticipation of its launch on 18 May 2013. Stay tuned for views from Michael A. Taylor and Joel Paris. Read previous posts: “DSM-5 will be the last” by Edward Shorter and “The classification of mental illness” by Daniel Freeman and Jason Freeman.

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According to the UK Centre for Economic Performance, mental illness accounts for nearly half of all ill health in the under 65s. But this begs the question: what is mental illness? How can we judge whether our thoughts and feelings are healthy or harmful? What criteria should we use?

This month sees the publication of the latest version of the psychiatrist’s bible: the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM is arguably the definitive reference work on mental illness, used by health services worldwide (though the World Health Organisation’s International Classification of Diseases and Health Related Problems is widely used in the UK). Sales of the previous edition, DSM-IV, are estimated at about a million copies — not bad for a book that runs to almost 1000 densely packed pages and retails for around £80.

What’s changed in DSM-5 — apart from the move from Roman to Arabic numerals in the title? Well, terms have been revised (“mental retardation” has become “intellectual disability”, for example). New disorders have been introduced. For instance, “premenstrual dysphoric disorder” has been added to the list of depressive disorders. And, perhaps most controversially, some professionals have worried that the threshold for diagnosis of certain disorders appears to have been lowered — meaning that more people may be classified as mentally ill. Indeed there is organised opposition to the new edition, exemplified by the International DSM-5 Response Committee.

The DSM’s basic approach, on the other hand, has remained consistent for more than 30 years: a painstaking enumeration of symptoms, designed to make the clinician’s task of diagnosis easier and more consistent. This is an objective that it has undoubtedly achieved. But are those diagnoses scientifically valid?

Take clinical depression, for example. Nine possible symptoms are listed in DSM-IV, and you’d need to report at least five of them to warrant a diagnosis. These symptoms must be sufficiently intense to really interfere with a person’s life and they must have lasted for a while.

One effect of this approach is to emphasize the severe end of a spectrum that also includes relatively mild psychological problems. So the DSM criteria won’t capture everyday fluctuations in mental health. And they won’t pick up people with, say, four symptoms rather than five.

Implicit here is a debate about the nature of mental illness. The DSM uses a medical model of psychiatric illness. It thinks in terms of separate, discrete disorders, just like physical medicine. The approach is binary: either you meet the criteria for a particular condition, or you don’t.

Many would argue that this kind of all-or-nothing attitude, with hundreds of separate conditions, doesn’t fit well with people’s real-life experience of psychological problems. Better instead to think of psychological experience as being dimensional — that is, encompassing a wide variety of experiences, from the unproblematic to the severely distressing. The further along that dimension, the more symptoms a person is likely to have and the more upsetting and disruptive those symptoms will be.

This is the psychological model of mental illness. It argues that there’s no binary opposition between disorder and ‘normality’. Psychological disorders are simply the extreme manifestation of traits that we all possess to varying degrees. For example, almost everyone experiences occasional feelings of anxiety. People who develop what the DSM classes as an anxiety disorder aren’t experiencing something qualitatively different. They’re simply undergoing a more intense version of the same thing.

There is a third approach to understanding mental illness: the sociological model. Proponents argue that psychological disorders aren’t illnesses at all. They’re a label used to stigmatize and control behaviour society deems objectionable — such as homosexuality, which featured in the DSM until 1980.

Our view is that psychological problems aren’t illusory. They are real expressions of distress, for which most people — understandably — want help. However there is variability in the validity of individual diagnoses. Therefore it is often wisest not to focus on particular diagnoses. Better instead to adopt a dimensional approach, and to concentrate on the key problems and day-to-day symptoms that lead people to seek assistance. To help us understand these problems, we can look at epidemiological information to see which experiences occur together, and therefore may share common causes. Psychologists call this a data-driven approach.

We can also be guided by our knowledge of how the brain works. For example, basic emotions such as fear or unhappiness are powered by relatively distinct circuits in the brain. So we can understand certain psychological problems as what follow when these emotional circuits don’t function properly. We can match up the emotion and the problem: sadness and depression, fear and anxiety disorders, for example. This is what we might call a theory-driven approach, though given the complexity of brain activity it may – at least at present — be a little optimistic.

Importantly, even such a psychological, evidence-based approach doesn’t get around the need to classify problems. Mental health professionals must still make decisions about how to label the problems people describe to them. Without some kind of classificatory system, we can’t communicate, research, and evaluate treatments.

But the problems inherent in the current systems arguably constitute the greatest obstacle to that work. Given the extent of the burden on society and individuals alike, improving the scientific understanding of psychological disorders remains a priority. And that means DSM-5 certainly won’t be the last word on the classification of mental illness.

Daniel Freeman is a Professor of Clinical Psychology in the Psychiatry Department at the University of Oxford. Jason Freeman is a writer and editor. Their latest book is The Stressed Sex: Uncovering the Truth about Men, Women, and Mental Health (Oxford University Press).

The OUPblog is running a series of articles on the DSM-5 in anticipation of its launch on 18 May 2013. Stay tuned for views from Donald W. Black, Michael A. Taylor, and Joel Paris. Read yesterday’s post “DSM-5 will be the last” by Edward Shorter.

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In assessing DSM-5, the fog of battle has covered the field. To go by media coverage, everything is wrong with the new DSM, from the way it classifies children with autism to its unremitting expansion of psychiatry into the reach of “normal.” What aspects should we really be concerned about?

Think of a bowl of spaghetti. There are the central swirls of spaghetti in the middle of the bowl and the strands of spaghetti hanging over the side. Most of the controversy has been about the strands dangling down, how we classify marginal disorders of various kinds. It’s not that people with these disorders, such as the hyperactive and the autistic, aren’t important, but they aren’t the meat and drink of psychiatry.

The problem that the DSM-5 doesn’t address lies at the center of the bowl. It concerns psychiatry’s main diagnoses, not its marginal outliers, and those main diagnoses are major depression, bipolar disorder, and schizophrenia. The new edition hasn’t really touched any of them; the way they were defined and classified, and the way they continue to be recognized, ignores major differences within each diagnosis.

Keep in mind how easy it has been to get funny-sounding new diagnoses into psychiatry. Some, such as bipolar disorder, come in as a result of fad. A German psychiatrist named Karl Leonhard created bipolar disorder in 1957 when he said that there are two kinds of depression, unipolar depression (no mania) and the depression that alternates with mania (later called, in DSM-3 in 1980, bipolar disorder). Leonhard’s European and American disciples — a small but influential band — saw to it that separating depressions by “polarity” was widely accepted. Yet there was no new science here; it was the whim of one man.

Some of the diagnoses at the heart of the bowl came in by fiat. Robert Spitzer, the architect of DSM-3, simply decided in 1980 to collapse psychiatry’s various depressions — which had been as diverse as chalk and cheese — into a single disorder: major depression. There were howls of protest, but, hey, the thing was already in print. Set in stone. Even though it makes no scientific sense to classify depressions on the basis of polarity, that’s what we have ended up doing.

Serious depression — or melancholia — remains serious depression whether an episode of mania complicates it or not. Sooner or later, many patients with serious depression will experience some manic features, without that changing their basic diagnosis.

Related to schizophrenia, psychosis (loss of contact with reality via hallucinations or delusions) certainly exists. And there are many forms of it: some come out of the blue, others begin insidiously and seem to grow out of the patient’s personality; some involve loss of brain tissue, others don’t; some end very badly, others stabilize at the ability to lead a more or less normal life: you may not become a neurosurgeon, but you get married, have kids, keep a job, the whole ball of wax. These are different diseases.

St. Elizabeth’s Hospital. Wall of room in Ward Retreat 1. Reproductions made by a patient with dementia praecox…Pictures symbolize events in patient’s past life and represent a mild state of mental regression. Undated, but likely early 20th century. Washington, DC. Selected by Kathleen.

Yet we now give all these forms of psychosis a single diagnosis: schizophrenia. That’s without a plural “s.” If you’ve got chronic psychosis you’ll be called schizophrenic, even though you may not have any symptoms in common with others who have that diagnosis. You may have quite different family (genetic) backgrounds; you may not have a common response to treatment; and you may not have a common course and outcome. Those are all the ways we delineate separate diseases and “schizophrenia” demonstrates none of those hallmarks. It’s an artifact that Emil Kraepelin, the great German disease classifier, inserted into the literature in the 1890s, calling it dementia praecox. So powerful was his concept — that all the different “subtypes” of schizophrenia went remorselessly downhill — that the term has survived the relentless scientific plucking that all other diagnoses in medicine continually experience.

But conceptual power is not the same thing as verification. There is no marker telling us that everybody with “schizophrenia” has the same disease. (There are, by the way, such markers for some other major diseases; I don’t have space to go into it here, but google “dexamethasone suppression test”.)

So, are there problems with DSM-5? Yes, but they aren’t the problems most critics pick at. Criticisms of DSM-5 seem to be rising in a crescendo, as though a gaggle of high-school teachers were called to assess the work of a very naughty schoolboy. The drafters of the current edition were mightily concerned with maintaining stability; they didn’t want to hack great changes into previous editions. So there is not a chance in the world they would have looked critically at these central problems.

But out there in the real world, there are growing numbers of nosological rebels, or skeptics about the DSM version of disease classification. They have mainly stayed off the airwaves up to now. But you can feel the dubiety rising. There probably will not be a DSM-6.

Edward Shorter is Jason A. Hannah Professor in the History of Medicine and Professor of Psychiatry in the Faculty of Medicine, University of Toronto. He is an internationally-recognized historian of psychiatry and the author of numerous books, including How Everyone Became Depressed: The Rise and Fall of the Nervous Breakdown,  A Historical Dictionary of Psychiatry and Before Prozac: The Troubled History of Mood Disorders in Psychiatry. Read his previous blog posts.

The OUPblog is running a series of articles on the DSM-5 in anticipation of its launch on 18 May 2013. Stay tuned for views from Daniel and Jason Freeman, Donald W. Black, Michael A. Taylor, and Joel Paris.

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How common is insomnia in older adults, and what are the repercussions of chronic sleep problems?

Insomnia is very common among older adults, and is associated with adverse health outcomes, including cognitive and functional decline. It has been estimated that approximately 40-70% of older adults age 65 and older experience sleep problems, with about 20% experiencing severe sleep problems. Insomnia has multiple causes, but chronic health conditions such as diabetes, hypertension, cancer, and osteoarthritis are among the most common health problems associated with poor sleep. Another common cause of insomnia is depression. Furthermore, insomnia in older adults may exacerbate the severity of pre-existing health conditions, perhaps leading to costly health service use.

Who were your participants in this study?

The sample of our study consisted of middle-aged and older adults aged 50 years or older who participated in the longitudinal Health and Retirement Study. Individuals in our sample were assessed for insomnia symptoms in 2006, and their health service utilization was assessed two years later. At baseline, 55% of participants were women, 88% were non-Hispanic white, 59% had a diagnosis of hypertension, 38% had osteoarthritis, and 21 percent had diabetes. Twenty-four percent reported one insomnia symptom, and 18% reported two or more insomnia symptoms at baseline.

According to your research, what is the link between insomnia and the use of health care services in older adults?

We found that individuals reporting one insomnia symptom, as well as two or more insomnia symptoms at baseline, were more likely to use a number of health services two years later compared to those reporting no insomnia symptoms. This health service utilization included hospitalization, use of home healthcare services, and use of a nursing home. Surprisingly, we found this association was still statistically significant for hospitalization and use of any of the three health services after accounting for a number of common health conditions, and depression.

Image courtesy of the authors.

What do your results suggest?

Our results suggest that insomnia is associated with greater use of costly health services, and that perhaps preventing, or at least clinically addressing insomnia symptoms, might minimize healthcare costs for middle-aged and older adults. Our results also suggest that the assessment and recognition of insomnia by clinicians might help identify individuals at greater risk of hospitalization and other costly services. Medical professionals might be able to target and provide more intensive preventive care to individuals reporting insomnia symptoms. Our study found that if the association between the experience of insomnia symptoms and health service use were in fact causal, we would expect to see a six to fourteen percent decrease in health service use. It should be noted that our findings are based on self-reported insomnia symptoms and health service utilization, which is subject to reporting and recall bias.  Furthermore, we only examined any use of health services, and we did not assess the duration and frequency of use. Our findings need to be confirmed in other population-based studies of older adults, and more research is needed to examine this association using objective measures of sleep quality and measures that capture the intensity of health service use.

What are some ways to prevent and treat insomnia?

Very often, simple sleep hygiene measures such as reducing environmental stimuli at night, establishing bedtime routines, or avoiding day-time naps would be sufficient to address insomnia. Adequately addressing and managing chronic health conditions can also prevent the development of insomnia. If these measures do not improve sleep, behavioral therapy can be effective. In some cases, sleep medications may be used on a short-term basis. However, the use of sleep medications in older adults, if taken for a longer period of time, has been shown to lead to numerous adverse health outcomes, such as falls, hip fractures, and cognitive and functional impairment.

Mr. Christopher Kaufmann is a doctoral student in the Department of Mental Health at the Johns Hopkins Bloomberg School of Public Health. His research interests are in the utilization of health services related to psychiatric disorders, as well as the use of prescription medications among older adults. Dr. Adam Spira is an Assistant Professor in the Department of Mental Health at the Johns Hopkins Bloomberg School of Public Health. He studies the link between sleep disturbance and both cognitive and functional decline in older people. Together they are the authors of “Insomnia and Health Services Utilization in Middle-Aged and Older Adults: Results From the Health and Retirement Study” in The Journals of Gerontology Series A, which is available to read for free for a limited time.

The Journals of Gerontology were the first journals on aging published in the United States. The tradition of excellence in these peer-reviewed scientific journals, established in 1946, continues today. The Journals of Gerontology, Series A publishes within its covers the Journal of Gerontology: Biological Sciences and the Journal of Gerontology: Medical Sciences.

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In 1913, Allgemeine Psychopathologie (General Psychopathology) was published. A guide for young students, doctors and psychologists, it had been completed two years earlier by a 28-year-old German psychiatrist: Karl Jaspers. He aimed to overcome scientific reductionism and establish psychopathology as a new comprehensive science during a period of significant advances in neuroscience. The work had an immediate, dramatic impact and is now a classic in psychiatric literature. Moreover, he established psychopathology as a discipline in its own right — to carefully describe, define, differentiate, and bring order to the chaos of anomalous mental phenomena.The relevance of psychopathology for psychiatry is threefold: it is the common language that allows specialists, belonging to different schools, each one speaking its own jargon, to understand each other; it is the ground for diagnosis and classification in a field where all major conditions are not aetiologically defined disease entities, but exclusively clinically defined syndromes; it makes an indispensable contribution to understanding, a special kind of intelligibility based on the meanings and conditions of possibility of personal experiences.

Department of Psychosis Studies, Institute of Psychiatry, King’s College London and OASIS Team, South London and the Maudsley NHS Foundation Trust, London, UK. Used with permission.

Psychiatrists need both the personal cultivation and thorough scientific education that psychopathology provides. Its emphasis on human experience, meaningfulness, and valid and reliable methodology to approximate human subjectivity makes it the organon of the humanities in psychiatry, and perhaps in medicine in general. When evidence-based guidelines are still scarce (as is the case, for instance, with early psychoses), psychopathological formation seems to be an indispensable resource for the psychiatrist. For example, it provides the ability to feel an atmosphere and attune to situations that are not yet plainly and unambiguously defined. Moreover, Jaspers drew attention to the active role of the patient. As a self-interpreting agent engaged in a world, the patient interacts with his or her basic disorder and contributes to the shaping of the clinical syndromes.

Jaspers was also active in other fields, such as philosophy, which deeply influenced his work as a psychopathologist. General Psychopathology tried to bring the direct investigation and description of clinical phenomena as subjectively experienced by the patients into the field of clinical psychiatry. Specifically, it changed our understanding of psychosis and schizophrenia. Jaspers’ phenomenological analyses of the pre-delusional atmosphere are still considered an outstanding example of “what it is like” to be a person who is undergoing puzzling and ineffable experiential changes which pave the way to full-blown schizophrenic delusions.

Today, Jaspers work continues to reward and inform psychiatrists. His phenomenological method can help solve ongoing diagnostic concerns by improving the validity of present clinical phenotypes and his approach can be integrated with current neurobiological hypotheses. His person-centered approach in clinical practice is very useful to contemporary psychiatry. In fact, patients are seen as meaning-making, participating in their own healing as empowered agents, and their behaviors not necessarily pathological but potentially adaptive. One hundred years on, we’re still learning from Karl Jaspers.

Paolo Fusar-Poli, MD, PhD, RCPsych is Clinical Senior Lecturer at the Department of Psychosis Studies at the Institute of Psychiatry, London and consultant at the OASIS prodromal team, South London and the Maudsley Foundation NHS Trust. Giovanni Stanghellini, MD and Dr. Phil. honoris causa is full professor of Dynamic Psychology and Psychopathology at Chieti University (Italy) and Associate Professor at Diego Portales University in Santiago (Chile). Schizophrenia Bulletin has a special issue on the 100th anniversary of General Psychopathology.

Schizophrenia Bulletin seeks to review recent developments and empirically based hypotheses regarding the etiology and treatment of schizophrenia. They have published a special issue devoted to the centenary of its publication (1913-2013), as well as other publications including the volume One Century of Karl Jaspers General Psychopathology to be published by Oxford University Press.

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Over millions of years, evolution by natural selection has produced adaptations in humans: biological and psychological traits that improved human survival and reproduction in ancestral environments. For example, ripe fruit was an infrequent but calorically rich part of the human ancestral diet. We therefore have a sweet tooth that rewards us when we eat ripe fruit.

But evolution works slowly and gradually, over many generations. Sometimes, the environment changes so quickly that our adaptations can’t evolve quickly enough in response to these changes. This is called an “adaptive mismatch.” Today, modern society presents us with many sweet-tasting goodies, like candy, that aren’t healthy for us. And yet, we continue to crave these unhealthy treats because they “parasitize” our sweet preference—an adaption that was designed to reward ripe fruit-eating.

But, what do adaptive mismatches have to do with pornography? A lot.

Heterosexual men become sexually aroused from seeing naked, fertile women. This sexual arousal is an adaptation that motivates men to prepare for the possibility of sex.

Like candy, pornography creates an adaptive mismatch. For a moment, try to see the world not from “human eyes” but from the eyes of an animal biologist. You might think that men’s enjoyment of pornography is bizarre: men are sexually aroused by the sight of ink that’s splattered on magazine pages, or computer pixels that display light. Nobody would argue that men evolved to have sex with magazines or computers. Adaptive mismatch? Quite.

Pornography is a formidable industry, with men as the primary consumers. And because pornography exploits slow-to-change adaptations, investigating men’s preferences in pornography can inform us about those adaptations.

A previous study documented that pornography depicting two men having sex with one woman (MMF) was more prevalent than pornography depicting two women having sex with one man (FFM). However, a different study documented that men report viewing FFM pornography preferentially over MMF pornography. To reconcile these contradictory findings, we recently published in Behavioral Ecology a paper documenting that adult DVDs containing more depictions of MMF on the DVD cover achieve better sales rankings than DVDs containing more depictions of FFM. Our results indicate two important things about men’s sexual psychology: (1) The type of pornography men say they view may differ from what they actually view, and (2) men’s greater sexual arousal from viewing MMF pornography may be a consequence of another adaptive mismatch: adaptations to sperm competition.

Sperm competition occurs when a woman has sex with two or more men within a sufficiently brief period of time, and the different men’s sperm compete to fertilize the ova. Men have evolved adaptations to increase their chances of success in sperm competition. Some adaptations to sperm competition involve increasing sexual arousal. For example, when men estimate a greater likelihood that their romantic partner recently had sex with another man, they ejaculate more sperm the next time they have sex with her, report greater interest in having sex with her, and sometimes, sexually coerce her.

To tie this all together, men’s preference for MMF pornography is evidence of adaptations to sperm competition. Men who see MMF scenes are “witnessing” sperm competition unfold between the two men in that scene. And as sperm competition theory predicts, men have adaptations that cause them to become sexually aroused by the risk of sperm competition, motivating them to purchase adult DVDs that contain depictions of it.

Sperm competition theory may help solve other puzzles about male sexuality. Notably, it may inform the question of why men become jealous—yet simultaneously, sexually aroused—by the thought of their romantic partner having sex with another man.

Michael N. Pham is a graduate student in evolutionary psychology at Oakland University. William F. McKibbin is an assistant professor of psychology at the University of Michigan—Flint. Todd K. Shackelford is chair and professor of psychology at Oakland University. They are the co-authors of the paper ‘Human sperm competition in postindustrial ecologies: sperm competition cues predict adult DVD sales’, published in the journal Behavioural Ecology.

Bringing together significant work on all aspects of the subject, Behavioral Ecology is broad-based and covers both empirical and theoretical approaches. Studies on the whole range of behaving organisms, including plants, invertebrates, vertebrates, and humans, are welcomed.

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A diagnosis of heart failure can be overwhelming. Here are ten things you can learn to cope with this condition.

(1) Learn how the heart and heart failure works. This series of informative animations can take you on a journey through heart failure and its management.

(2) Learn to navigate an enormous amount of information. You’ll receive advice from cardiologists, nurses, and GPs — not to mention family, friends, and everyone who wants to help.

(3) Learn about the causes, symptoms, and developmentof heart failure.

(4) Learn the warning signs of heart failure, their level of severity, and who to consult and when.

(5) Learn to adjust your lifestyle to get the most out of life when you have heart failure. This condition will have an impact on every aspect of your life including travel, work, and relationships.

(6) Learn to work with your doctors, nurses, and other medical professionals. They help patients understand what is wrong: take patients through their medicines, introduce them to the people they need to work with, and describe heart failure clinics. Ask for tools, such as medicine charts or a symptoms and events diary, to help you stay oragnized.

(7) Learn your treatment options and what to ask your doctor. You’ll feel more reassured.

(8) Learn how this will affect your caretakers, who face many problems including depression. They need as much support as you.

(9) Learn how other patients overcome their difficulties. You can gain knowledge from their experiences.

(10) Learn to network with other people who have heart failure. Meeting fellow sufferers can help you feel less alone and more able to cope.

Professor Kenneth Dickstein is the creator and full-time enthusiast of the patient centred website Heart Failure Matters! Designed to meet a global educational need by helping patients understand their complex medical condition, it is available in in English, French, German, Spanish, Dutch and Russian (with the translation to Arabic happening this year).

The European Journal of Heart Failure, edited by Professor Dirk van Veldhuisen, is the International Journal of the European Society of Cardiology dedicated to the advancement of knowledge in the field of heart failure.

Oxford University Press is supporting Heart Failure Awareness Day with resources from across the press. Read our previous blog posts: “The five big lifestyle changes for heart health” ; “Why do we have a Heart Failure Awareness Day?” ; “Seven things you never knew about heart failure” ; and “More malignant than cancer?”

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By Sebastian Amyes

 
Bacteria have achieved many firsts; they were the first cellular life-forms on the planet, they are the primary biomass on the planet; they are the most prevalent cell type in and on the human body outnumbering our own cells; they are responsible for more human deaths than any other infectious agents; and, in some parts of the world, they are the premier cause of all deaths. How did these small, single-cell organisms, that are invisible to the naked eye become so successful? Essentially this has been through rapid evolution leading to adaptability. All living organisms evolve. The speed at which they can do this is dependent on the generation time; for humans this is about 25 years whereas for bacteria it is often measured in minutes, sometimes as little as 20 minutes. It is believed that 99% of the species that have lived on the planet are now extinct; this is often because their generation time was too long for the necessary evolutionary adjustments needed to survive changes in their environment. Every year yet more species of animals and plants become extinct because they have been too specialised to adapt.

The rapid division of bacteria means that they can adapt overnight to changes in their surroundings. A prime example has been the development of antibiotic resistance in clinical bacteria. It has often been reported that the US Surgeon General indicated in the 1960s that the discovery, first of penicillin, and then of the rest of antibiotics heralded the end of clinical bacterial infections. It is now common knowledge that such a view was fatally flawed. Simple mutations in key genes during cell division provided the bacteria with a means of escaping the action of the antibiotic (resistance). Once learned and part of the bacterial DNA, these genes could then be passed on to other bacteria by the process known as conjugation (bacterial sex) so that these new bacteria benefited from the resistance “learnt” in earlier bacteria. Seventy years ago, almost all clinical bacteria were sensitive to all antibiotics; now many bacteria are resistant to some, some bacteria are resistant to most, and a few bacteria are resistant to all antibiotics. Within one human lifetime, clinical bacteria have evolved the means of overcoming all the antibiotics we can produce.

electron micrograph of Vibrio cholerae

Witnessing this remarkable adaptive ability, it is hardly surprising that bacteria have been able to inhabit all parts of the planet, from hot springs to the Antarctic, from mountain tops to the bottom of the ocean. The demise of any species is often dependent on the loss of its food supply. Bacteria evolve so quickly that they can adapt to use different nutritional sources. They have evolved so that they can live off virtually any organic matter, they can even adapt to use crude oil. Like some insect populations, bacteria form colonies. Many bacterial colonies comprise one billion individual cells or more. Total eradication of that number of bacteria is difficult and often impossible. Unlike bees, ants, and wasps, for example, the survival of that colony is more egalitarian and is not dependent on a single individual, the queen. If there is a catastrophe, any one of the individual bacterial cells in a bacterial colony can go on to form a new colony if it can survive the eradication of the previous colony. When it has formed a new colony and the next threat comes, the same survival tactic is engaged.

Bacteria preceded mammals by nearly four billion years. It is almost certain that they will be predominant long after humans and other mammals are extinct. There have been suggestions that bacteria arrived on Earth on meteorites; this may be true but it is more likely that they evolved here. However, we have already sent our bacteria into space on satellites and these may, at some time, colonise other planets. Here on Earth, our own bacteria will continue to thrive. As we have unearthed the fossil record, we have classified different eras in geological time, which are often colloquially rephrased as epochs such as the “Age of the Dinosaurs” or the “Age of the Fish”. As they have always been the largest biomass, the truth is that from the Precambrian era, four billion years ago, the Earth has always been in the “Age of the Bacteria” and probably will be forever.

Sebastian Amyes is Professor of Microbial Chemotherapy at the University of Edinburgh. He has specialised on the development of antibiotic resistance in bacteria. He has published more than 500 papers on bacteria and written a number of books on the subject, including Bacteria: A Very Short Introduction.

The Very Short Introductions (VSI) series combines a small format with authoritative analysis and big ideas for hundreds of topic areas. Written by our expert authors, these books can change the way you think about the things that interest you and are the perfect introduction to subjects you previously knew nothing about. Grow your knowledge with OUPblog and the VSI series every Friday and like Very Short Introductions on Facebook.

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Image credit: electron micrograph of Vibrio cholerae [Public Domain] via Dartmouth College

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Today’s problem for the health-conscious person is information overload; new health studies pour out daily from newspapers, radio stations, and television networks. Just how true are the studies? How compelling are the facts they claim? After reading countless scientific articles, listening to hundreds of international experts, and keeping an ear open when patients tell me about their experiences, I’ve identified the only five lifestyle changes with compelling evidence behind them. Taken together, these steps provide about 80% protection from heart attacks, as well as stroke and cancer, and this message comes from three major studies organized by the Harvard Medical School and published in highly rated journals.

(1) Unfortunately, the image of smoking as ‘sexy’, which was promoted for years in the USA and elsewhere, still lingers; young women remain the group least likely to give up smoking. But giving up smoking (or not starting in the first place) it essential. It confers just over one-third of the lifestyle benefits associated with healthy living.

(2) “Exercise is the elixir of life,” says Richard Verrier, from the Harvard School of Public Health. You need at least thirty minutes of moderate to vigorous exercise daily — ideally every day, but five days per week will do. How much effort should you put into it? A simple criterion: you should be sweating by the end of it.

(3) We know that the Western diet (with its high intake of fat, sugars, and calories) damages the arterial endothelium and promotes obesity, diabetes, and heart attacks. There are several validated, health promoting diets which counteract this, including the Prudent diet (which emphasises a high intake of vegetables, fruit, legumes, whole grains, fish and poultry), the DASH BP-reducing diet (similar, but with the addition of salt restriction; ideal for the many people with hypertension) and the Healthy Eating diet (again similar, but using a numerical index to score components). The Mediterranean diet may be the best of all of these, being immortalised by the declaration that it now belongs to the Intangible Cultural Heritage of Europe. Furthermore, in April 2013 in probably the largest and longest diet study ever undertaken, five years of the Mediterranean diet with high olive oil and nuts reduced heart attacks, strokes and (of note) total mortality in 7447 persons , all versus a standard low fat diet.

(4) Consistent studies show that fat around the middle — abdominal fat — is closely linked to increased heart disease and diabetes. Therefore a health body weight, indicated by a body mass index (BMI) of 25 or below, is vital for keeping the heart healthy. Fat tissue is not only cosmetically undesirable, but produces a variety of hormones, each of which is capable of adverse effects. For example, release of these hormones from fat tissue into the blood can trigger a series of chemical changes that eventually produce more fat. In brief, fat produces fat.

(5) Moderate alcohol, the fifth protective factor (and part of the Mediterranean diet) is a two-faced friend. A little helps, but more than that harms substantially. The ‘red wine’ hypothesis, which states that the beverage has benefits extending beyond its alcohol content, may also have some truth in it; deep red grape juice has the same effect of inhibiting blood clots, but only in higher doses. A fine Pinot Noir — the author’s favourite — may therefore be safely considered as one of the ‘big five’, but only in small doses.

Lionel Opie qualified as a medical doctor at the University of Cape Town, before winning a Rhodes Scholarship to Oxford University where he trained in heart research and later worked with leaders of thought at Harvard University. After the world’s first heart transplant in Cape Town, he was invited back to South Africa to develop heart research at Groote Schuur Hospital, where he still works. His book Living Better, Living Longer guides the reader through this morass of information with the message that just five key steps taken now will promote long-term health benefits for heart and mind and give protection from future heart disease and brain deterioration.

Oxford University Press is supporting Heart Failure Awareness Day with resources from across the press.

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Gooey chocolate and scoops of mouth-watering chocolate ice cream. Steaming hot golden French fries. Children see thousands of commercials each year designed to increase their desire for foods high in sugar, fat, and salt like those mentioned above. Yet, we know almost nothing about how this advertising onslaught might be affecting the brain.

A recent study in Social Cognitive and Affective Neuroscience conducted by researchers from the University of Michigan, Oregon Research Institute, and Yale University starts to uncover how the brain responds to food commercials in teens. Thirty adolescents visited a lab to watch a typical television show that included commercial breaks composed of frequently advertised food (e.g., McDonald’s, Wendy’s) and non-food commercials (e.g., AT&T, Ford). But unlike a typical TV viewing experience, these participants had their brain response measured in a functional magnetic resonance imaging (fMRI) scanner.

While watching the food commercials, regions of the brain linked with reward, attention, and cognition were more active for all participants. After completing the fMRI scan, teens also remembered the food commercials better than the non-food commercials. Why does this matter? It appears that food advertisements (by far the most frequently marketed product to this age group) are better at getting into the mind and memory of kids. This makes sense because our brains are hard-wired to get excited in response to delicious foods. When these calorie-laden products are combined with $1 billion dollars’ worth of marketing by the food and beverage industry, it creates a potent combination.

Surprisingly, healthy-weight teens had greater brain activity in regions associated with reward and attention than obese adolescents. Why might this be? The study suggests that obese adolescents may have been trying to control their response to the food commercials, which might have altered the way their brain responded.

Yet, what happens after obese teens come into contact with more and more food cues later that day? Their self-control might decline in the face of an environment that pushes consumption of high-calorie foods. If a teen is stressed, hungry, or depressed, his or her willpower might be even more likely to falter. The healthy-weight adolescents might also be impacted by how their brain responds to food commercials, but the consequences might not be apparent immediately. A number of brain regions that were more responsive in the lean adolescents during the food commercials have been linked with future weight gain. It will be important to explore how brain responses to food marketing might be related to increased risk of obesity in the future.

This research highlights the possible ways that food advertising may affect younger generations. How do we prevent food advertisers from being the major driver of what our kids eat? We can rely solely on parents to police what teenagers buy or attempt to educate children about how advertising might impact them. We also may need to set guidelines that prevent marketers from aggressively targeting kids with commercials for unhealthy foods. The road ahead is not without challenges, but action must be taken to turn back the tide of childhood obesity.

Dr. Ashley N. Gearhardt is an assistant professor of psychology at the University of Michigan. Her work focuses on the overlap between addictive and eating behaviors, as well as the role of the environment in obesity. Gearhardt is a co-author of the study ‘Relation of Obesity to Neural Activation in Response to Food Commercials‘, which is published by the journal Social Cognitive and Affective Neuroscience.

Social Cognitive and Affective Neuroscience (SCAN) provides a home for the best human and animal research that uses neuroscience techniques to understand the social and emotional aspects of the human mind and human behavior.

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Avian influenza. H7N9. Bird flu. If you are planning a trip to China, these phrases might have you concerned. There are still many uncertainties regarding the new influenza A (H7N9) virus: it isn’t clear where the virus started or how people are getting sick, and a vaccine is not yet available. Amid these unanswered questions, it’s not surprising that many travelers are doubting their plans. You may find yourself wondering if travel to China is still safe, or if you should cancel your trip.

Travelers should be aware that the Centers for Disease Control and Prevention (CDC) is not recommending against travel to China at this time. Currently no sustained person-to-person spread of the H7N9 virus has been found. So, while public health officials will continue closely monitoring the situation and working to determine how the virus is spreading, travelers don’t need to cancel their trips at this time.

However, travelers and their physicians should take this opportunity to remember that healthy behaviors are always important, especially while traveling. CDC is repeating its standard advice to travelers and Americans living in China to follow good hand hygiene and food safety practices and to avoid contact with animals. Simple actions like staying away from animals, eating food that is fully cooked, and washing your hands often can go a long way toward preventing illness (including H7N9). Travelers should also see a doctor right away if they become sick with fever, coughing, or shortness of breath during or after travel to China.

It’s important for travelers to remember that, although new illnesses like H7N9 make it into the news, any international travel can pose a health risk if you aren’t prepared. If you are planning an international trip, you should visit your doctor at least 4-6 weeks before your trip. You may need vaccines or medicine to stay healthy while traveling and your doctor can advise you on actions you can take while you are overseas to make sure your trip is safe and healthy.

For the most up-to-date information for travelers from the CDC regarding H7N9, see the CDC Travel Notice. CDC will also provide updated information on the H7N9 situation as it becomes available. For more information on healthy travel, please visit the CDC travel website and follow them on Twitter @CDCtravel.

Megan Crawley O’Sullivan, MPH is a Health Communications Specialist in the Travelers’ Health Branch, Division of Global Migration and Quarantine, National Center for Emerging and Zoonotic Infectious Diseases at the Centers for Disease Control and Prevention.

The new 2014 edition of CDC Health Information for International Travel (commonly known as The Yellow Book) will be released later this year by Oxford University Press.

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There is a saying in ethics: you can’t get an “ought” from an “is.” Descriptions of the world as it is do not reveal truths about the world as it ought to be. Even when descriptions of real-world conditions suggest that something is seriously wrong — that our actions are causing unintended and avoidable harms to ourselves, to others, to our common environment — reaching agreement on how we ought to change our thinking and our behavior, and then putting these changes into practice, is hard. Efforts at reform may fail again and again, but we need “is” to understand how to get to “ought.” In health care work, describing and reflecting on current conditions can shed light on persistent ethical challenges. Palliative care workers who focus on the relief of suffering and other goals central to the care of the sick observe and experience many such challenges daily.

In the United States each year, 2.5 million people die. Because cause of death is often a condition typically associated with age, Medicare billing-code data offers a reliable way to understand where older people were, day by day, as they approached the end of their lives. A recent article by Joan M. Teno, health services researcher at Brown University, and her team, published in JAMA in February 2013 and subsequently picked up by the media, compared samples of Medicare patients who died in 2000, 2005, and 2009. Each sample included nearly 300,000 patients, all of whom had a medical diagnosis of cancer, chronic obstructive pulmonary disease, or dementia for the final six months prior to death. This data suggests that these patients were hospice-eligible and their deaths were not unexpected.

Digging into the data, the researchers found that over the course of this nine-year period the percentage of patients who died in hospice increased. However, these hospice referrals tended to come only after dying patients had spent time in the intensive care unit. That is, the intensity of treatment near the very end of life first spiked sharply upward. As Teno and her co-authors explain, “Site of death, as noted on a death certificate, only provides information on where a person was at the moment of death,” while understanding the end of life as an “experience” involves looking at all places of care, the transitions between these places, and when and why these transitions occurred. They conclude that, even with more frequent referrals to hospice and the expansion of palliative care programs in hospitals over the period they studied, “the notion that there is a trend toward less aggressive care” may be unfounded.

Reading Joan Teno’s careful research and analysis in this article and others, I am reminded of the technique of Jan van Eyck, the 15th century northern European painter who was the first master of the new medium of oil painting. Analysis of van Eyck’s works reveal that he applied layer upon layer of translucent paint to create the impression of light that shapes space and reveals surface and texture. (The Getty Museum has created this public website of images from its recent documentation of van Eyck’s “Ghent Altarpiece.”) It was not a quick or simple way to work, but it built up the light. So, too, does the science that describes, day by day, layer by layer, the complexity of the end of life in our society, and that suggests the complexity of the work needed to change this experience. If the picture that emerges from this study — of the ICU as the route to hospice — troubles us, are we willing to think and act differently? And how much earlier in the journey?

Nancy Berlinger is a research scholar at The Hastings Center. With Bruce Jennings and Susan M. Wolf, she is the author of The Hastings Center Guidelines for Decisions on Life-Sustaining Treatment and Care Near the End of Life: Revised and Expanded Second Edition (Oxford University Press, 2013). Learn more at HastingsCenterGuidelines.org.

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A respected cardiologist of our acquaintance recently confessed that he often tells his patients to lose weight. This may sound like good advice, but he knows better. Scores of clinical studies show that heavier patients with heart disease are, on average, less likely to die than thinner ones. Furthermore, weight loss efforts are typically counterproductive. Our cardiologist friend knows the studies but can’t quite bring himself to let go of the association between weight and health. He is not alone. In fact, the pervasive clinical and cultural bias against fat and fat people distorts medical practice, despite mounting evidence that human metabolic function is far more complex than previously understood.

Weight Loss Advertisement from Woman Beautiful Magazine, November 1908 via Library of Congress

It is true that heavier individuals are more likely to develop heart disease on average than are thinner patients, although it is not clear that being heavier causes heart disease. It may be that some related factor or factors — such as diet, exercise, stress, socio-economic status or a combination of these — causes both increased weight and makes one susceptible to heart disease.

That said, a growing body of evidence has shown that, among people who already have heart disease, heavier patients are less likely to die. This is so counter-intuitive that medical researchers refer to this burgeoning body of research as “reverse epidemiology” or the “obesity paradox.”

A recent study has shown that this “obesity paradox” holds for Type II Diabetes as well. Granted, people in the general population are more likely to develop Type II Diabetes in the first place if they are heavier, although the causal pathways remain unknown. However, among those who develop Type II Diabetes, many are in the “normal weight” category. Furthermore, among Type II Diabetes patients, the heavier ones are less likely to die than their thinner counterparts.

In the general population, heavier body mass is indeed associated with cardiometabolic abnormalities (i.e., high blood pressure, triglycerides, cholesterol, glucose, insulin resistance and inflammation). However, even here, the association is far from perfect. Specifically, almost one quarter of “normal weight” people — or 16 million Americans — have metabolic abnormalities, whereas more than half of “overweight” and almost one third of “obese” people — or 56 million Americans — have normal profiles, according to a 2008 study. We are beginning to understand that it is not the quantity but rather the quality of fat in our bodies that predicts cardiovascular risk; the unseen fat deeply embedded in our internal organs, known as visceral adipose tissue, is the type of fat most likely to lead to cardiometabolic abnormalities while visible fat beneath our skin may be more metabolically benign.

These studies belie the idea that heavier or bigger bodies are automatically diseased bodies and that weight loss is a panacea. When we further consider that 90-95% of dieters end up regaining what they lose, and that use of diet drugs or supplements may be particularly dangerous in patients with heart disease, the insistence on weight loss is more puzzling.

Rubber Reducing Garment advertising, Woman Beautiful Magazine, November 1908. via Library of Congress

“It took a lot of self-discipline, but I finally gave up dieting,” quips a popular Facebook posting. This post is funny because it inverts the common assumption that dieting requires discipline and is a virtuous endeavor. Indeed, being fat is still widely regarded as evidence of the sins of sloth and gluttony, despite — or perhaps because — of growing talk of “obesity” as a medical problem and public health crisis. It is this conviction that being fat is morally wrong that makes it hard for doctors, as well as ordinary people, to give up dieting and dieting advice. This is all the more true in times and places, like the contemporary United States, where the socially and economically privileged tend to be thin and the disadvantaged are more likely to be heavy.

Especially distressing are studies showing that many medical professionals regard their heavy patients as lazy and non-compliant. A recent study showed that doctors treat their heavy patients with less empathy and compassion than their thinner peers. In extreme cases, convinced that excess weight is responsible for ill health and that weight loss is the solution, doctors may not conduct necessary diagnostic exams that would have pointed to the underlying cause of illness.

It is time that medical professionals give up the focus on fat. This won’t be easy; the belief that if overweight and obese patients lost weight they would be healthier is deeply embedded in both our popular and our medical culture. Yet, there is a better way. Rather than focusing on outward appearance, it would be infinitely more productive and accurate to talk about cardiometabolic risk and to recognize that there are both metabolically-healthy and metabolically-unhealthy individuals in all categories of weight. Instead of promoting weight loss, doctors should emphasize that patients of all sizes incorporate physical activity and a balanced diet into their lives. Several studies have shown that physically fit “obese” individuals have lower incidence of heart disease and mortality from all causes than do sedentary people of “normal” weight. Similarly, a recent clinical trial published in the New England Journal of Medicine showed that adopting a Mediterranean diet reduced cardiovascular risk without inducing weight loss. The sixth of May is International No-Diet Day and a good time for doctors and patients alike to give up their unhealthy focus on weight loss.

Abigail C. Saguy, PhD is Associate Professor and Vice Chair of Sociology at UCLA and author of What’s Wrong with Fat? (Oxford, 2013).Tamara B. Horwich, MD, MS is a UCLA cardiologist who has published research on the link between body mass and mortality among heart disease patients.

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How would you feel if you were told you had heart failure? Once you had recovered from the shock, what are the questions you’d ask? European Heart Failure Awareness Days aim to combat all those blank looks in doctors’ offices.

So you have heart failure and now you have to live with it. But you’re not alone; millions of people out there have heart failure. That’s millions of people who struggle to make their daily lives just a bit better every day. And it’s possible. That’s another aim of the Awareness Days — making people’s lives better every day.

Anybody can get heart failure in many different circumstances, though it is most common in older people. Heart failure is a serious medical condition but it doesn’t mean that your heart is going to stop; it means that your heart is finding it difficult to pump your blood round your body to meet the needs of your daily activities. This means that you can have heart failure for a long time and live with it to the best of your ability.

It is with this in mind that the Heart Failure Association of the European Society of Cardiology initiated the first Heart Failure Awareness Day in 2010. The lack of knowledge among doctors as well as the general public concerned heart failure specialists who were looking for a way to access potential sufferers, help those already with the condition as well as their families, and inform local doctors and nurses. As a result, they turned to local heart failure organisations which are usually linked to national cardiac societies. Read the report from the very first Awareness Day.

Since then, the event has grown dramatically. Where at first a hospital in one country held an open house and a newspaper in another country published an article, now the Awareness Days have a huge variety of events from experienced organisers who plan countrywide to newcomers who start small but with big ambitions.

This year, countries all over Europe will hold their events on one or more days over the weekend of 10-12 May. The Heart Failure Association offers a basic structure for events and has created a poster and comprehensive leaflets that can be translated and tailored for each country. Organisers can also download a web banner for their local websites. In order to reach the maximum of people, the Association has created an exhaustive patient information website, translated into six languages.

Some countries organise walks, others hold public events where blood pressure readings are done. Informational leaflets are given out and medical staff give talks on heart failure. Most organisations contact local newspapers and television and radio stations to reach a wider audience.

Alongside newcomers Cyprus, the former Yugoslav republic of Macedonia, and Belarus — all enthusiastically preparing their events and media campaigns — the Russian Federation organisers have extended the dates of their Awareness Days so that they can cover their vast territory. In one month, they will go to 30 cities and try to reach over 20,000 patients. Germany has spread its awareness day programme over 16 hospitals, introduced a public cooking programme on The Mediterranean Kitchen, arranged an art competition in regional schools on the subject “My heart – A technical miracle,” and created a walk-through artery for their visitor health screenings. In the UK, the Awareness Day events are very much nurse-run. Read what is happening around Europe on 10-12 May 2013.

Those who are aware of the problem and closest to their patients are working hard to see that the message gets out to those with the condition and those who live with sufferers: find out all you can about heart failure; you’ll feel better, prolong your life, and enjoy it more. This is the essence of the Awareness Day campaigns. Europe has woken up and is taking up the challenge by spreading the word.

Anya Creaser works for the Heart Failure Association, a registered branch of the European Society of Cardiology. With Prof Petar Seferovic, Coordinator of the HFA Committee for National Heart Failure Societies, she has coordinated the Awareness Days since the inception in 2010.

Oxford University Press is supporting Heart Failure Awareness Day with resources from across the press and blog posts on the subject.

The European Journal of Heart Failure, edited by Professor Dirk van Veldhuisen, is the International Journal of the European Society of Cardiology dedicated to the advancement of knowledge in the field of heart failure.

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The high-profile marking of John Snow’s bicentenary on the fifteenth of March would have surprised the great man. The London School of Hygiene and Tropical Medicine, the WellcomeTrust, and The Lancet were among the august UK organisations to honour him with events including an exhibition, three days of seminars, and a gala dinner. The physician was also celebrated in the United States where he has a large fan base.

By the time of his death, on 16 June 1858 at the age of 45, Snow was convinced beyond doubt that his theory on the mode of transmission of epidemic cholera was correct but had little expectation that any credit would accrue to him. His friend, the Soho curate Henry Whitehead, said Snow predicted that he might not live to see the day when great cholera outbreaks were in the past — which was true — and also that his name would be forgotten when that day came, which was not. On the contrary, he is now widely regarded as the father of the science of epidemiology, with his life and work the subject of countless books, articles and web pages, while 200 years after his birth his legacy remains the focus of lively academic debate.

But it’s an unfair world. Achievement alone isn’t always enough to ensure that an individual, however deserving, secures a place in history and in Snow’s case, myth had a role to play. Not that Snow appeared at all interested in fame, posthumous or contemporary. Another friend, Josuah Parsons from his student days, remarked: “The naked truth for its own sake was what he sought and loved. No consideration of honour or profit seemed to have the power to buy his opinions on any subject.” That was just as well, for both honour and profit were in short supply, at least where his groundbreaking work on epidemic disease was concerned.

By the mid-1850s when Snow published his seminal work on cholera he was enjoying some success in the fast-developing specialism of anaesthesia, even attending Queen Victoria at the birth of two of her children. His thinking on disease was largely ignored, however, mainly because he rejected the then widely accepted belief that foul air, or miasma, was to blame. He reasoned, correctly, that cholera was spread when some of the matter thrown off by a victim — the vomit or the massive cloudy discharges from the bowels — found its way into a healthy person’s mouth. He also explained the disease’s frightening habit of striking hundreds of people simultaneously without warning: the cause was infected sewage leaking into the water supply, a common occurrence in the first half of the 19th century. He was not believed.

In the summer of 1854 in order to test his theory Snow carried out what become known as the Grand Experiment, tramping the streets of South London while the country was in the grip of its third cholera epidemic, knocking on doors and asking which of two water companies the householder used. He discovered that customers of the company that took its supplies untreated from the Thames, right next to where the sewers of London were discharged, were between eight and nine times more likely to die of cholera than those whose supplier had recently moved its source upriver, out of reach of the filth.

It was as Snow was putting the finishing touches to this work that he became involved in the Broad Street episode. His serious academic reputation is largely based on the South London research, but it is Broad Street that has contributed most to his enduring reputation, linking as it does a compelling story with two icons — a “death map” and the image of a street pump — with the addition of a little fiction along the way.

Overnight on Thursday, 31 August 1854, 200 people in a tiny part of Soho around Broad Street and Golden Square were struck down by a massive explosion of cholera, the fastest and most deadly ever seen in Britain. Whole families were carried off together. The epidemic continued for 10 days, still confined to a few streets, before petering out. The eventual death toll was over 600.

When Snow heard what was happening, he first looked at the addresses where the fatal cases had occurred and then went on to pioneer what is now a vital tool in epidemiology, disease-mapping, marking the deaths, house by house, on a street plan. The map showed just how local the outbreak was; all the deaths clustered in and around Broad Street. What interested Snow, however, was that those deaths either plummeted or stopped altogether at every point where it was easier to go to another pump than the one in Broad Street.

On the night of 7 September then, a week into the epidemic, Snow gate-crashed a parish meeting at St. James’s church, Piccadilly, where the Board of Guardians responsibly locally for public health were discussing the outbreak. Polluted water from the Broad Street well was to blame, he told the Guardians. They must put the pump out of action.

So far, all true. At this point in some accounts though a little creative licence creeps in. After a bitter row with the recalcitrant authorities, we are told, Dr Snow then storms off, either to chain up the pump handle himself or wrench it off with his own hands. In fact while the authorities were far from convinced, they did take Snow’s advice and the pump was disabled.

The next piece of fiction is that the deaths then stopped in their tracks and, hey presto, overnight John Snow was vindicated. Truth was, the epidemic had already peaked of its own accord; putting the pump out of action proved nothing. The longer, more complex story of how John Snow was proved right is actually more interesting but it’s easy to see why such a satisfying ending to the tale has evolved. And if myth has proved helpful in ensuring that a brilliant man who was dismissed and reviled during his lifetime is now so rightly celebrated, it’s no bad thing.

Sandra Hempel is a writer and editor who specialises in health and social issues. Her book The Medical Detective – John Snow, Cholera and the Mystery of the Broad Street Pump won the British Medical Association book award for the public understanding of science and the Medical Journalists’ Association book award. Her next book The Inheritor’s Powder, which looks at arsenic poisoning and forensic toxicology, is published by Weidenfeld and Nicolson on 13 June 2013. She recently gave a talk at the London School of Hygiene and Tropical Medicine about John Snow.

Throughout the year, the International Journal of Epidemiology will be publishing special reprints marking John Snow’s bicentenary, including The Siege of Krishnapur by J. G. Farrell and Cholera, with reference to the geological theory: A proximate cause – a law by which it is governed – a prophylactic by John Lea. The IJE is an essential requirement for anyone who needs to keep up to date with epidemiological advances and new developments throughout the world. It encourages communication among those engaged in the research, teaching, and application of epidemiology of both communicable and non-communicable disease, including research into health services and medical care. OUP publishes the journal on behalf of the International Epidemiological Association.

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Image credits: (i) John Snow, seated, resting right arm on table, anon. (ii) ‘A cholera patient’, caricature of a cholera patient experimenting with remedies (Robert Cruikshank’s random shots No. 2) (iii) Street Map of Soho, around Golden Square, illustrating incidences of cholera deaths during the period of the Cholera Epidemic, 1853. All three images are used with permission from the Wellcome Trust. Do not reproduce without express permission.

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Bird Day began in 1894 as part of the wildlife conservation movement that sprang up in response to the slaughter of the bison and the Passenger Pigeon. Birds always had a large role, for they were threatened but also familiar and fascinating. More than any other form of life they drew and held people, becoming for many a lifelong interest, passion, and even obsession. This generation made identifying birds by sight or (less frequently) song a popular hobby, and with it a new kind of book: the field guide. Birding now draws more people than any other outdoor recreation, from every part of the country and ranging from those who want to see every bird on earth to the much greater number who keep a field guide on the windowsill and a casual eye on the bird feeder in the backyard. They buy guides of every kind and check websites with up-to-date information on migration, rarities, and oddities. Some birds become celebrities. “Pale Male,” one of a pair of red-tailed hawks nesting in New York City, attracted a local, then a national following, and their courtship and nesting led to a book, Red-tails in Love.

Birders always went with bird conservation for Audubon’s founders saw the hobby as a way to get women outdoors and interested in nature so they would support bird conservation. Their political work began with campaigns against market hunting and for the protection of songbirds, went on through work for nature reserves, then the banning of pesticides like DDT, and saving the ecosystems on which birds—and all of us–depend. Birders’ cooperation with science goes back as far and has a rich a history. In 1900 amateurs sent their observations to ornithological journals; in the 1920s they joined the national bird-banding program organized by the Bureau of Biological Survey; in the 1980s signed up for the US Fish and Wildlife Service’s Breeding Bird Survey; and now they contribute to citizen science programs gathering data to analyze changes in bird populations across the continent. In a world of climate change and growing human populations, birds provide one of our best windows on we affect nature, and birders serve as the eyes and ears and the interested hearts of that effort.

Reed’s sparrows Reed’s shirt pocket-sized books were easy to carry. From Chester A. Reed, Bird Guide: Part Two, Land Birds East of the Rockies from Parrots to Bluebirds (1906; reprint, New York: Doubleday, Page, 1912).

Because the world keeps changing research never stops, but what keeps the scientist active also makes birding a continuing adventure, as much an exploration of nature as a matter of checking off species. Even on their home grounds birders see annual variation as birds expand their ranges or move out of their area, and occasionally the spectacular irruptions of new species or the occasional collapse of established ones. In the 1950s the self-introduced cattle egret spread through the country, and now the introduced Eurasian collared dove is doing the same. Cave swallows began nesting in the square drainage pipes under large highways, and ornithologists and birders remade their range maps. Recently West Nile virus devastated birds in many parts of the United States. As residues of the banned pesticide DDT leached out of the environment, bald eagles and peregrine falcons returned to parts of their old ranges, and now we can hope to see a eagle soaring over Minneapolis or an urban falcon taking a pigeon over Fifth Avenue.

Birders support conservation and work for it, but they go to the field because birds fascinate them, and here we come back to Bird Day’s original purpose — celebrating birds and inviting us to learn more. Those who want to learn about birds have many more resources than their ancestors. The few field guides available in 1894 treated a small selection of birds, had poor illustrations, and gave only hints about how to tell one bird from another—not surprising when even experts could not reliably distinguish all species in the field. Now every bookstore has shelves of guides with the latest tips on field identification, illustrated with digital photographs or expert paintings even more expertly reproduced, arranged to guide the reader to the right name, and catering to every interest and level of expertise. Roger Tory Peterson’s books, written for people with some experience but not a great deal, sit on bookstore shelves next to David Sibley’s guide, the National Geographic guide, and a dozen more for those who have outgrown “Peterson.” Further along we find volumes on identifying hawks at a distance or sorting out immature gulls, and a new form that offers on one page a dozen or more views of the species sitting, standing, and soaring — a miniature library of images. Audio guides make learning bird songs as easy as sorting out their distinctive plumages, and software puts field guides on our phones. Those tired of identification or just interested in birds in other ways can consult handbooks about birds’ lives, their evolution, and their development.

Seton’s raptors, Auk 14 (Oct. 1897): 395-396

Birders can pursue their passion as far and in as many directions as they wish, for the hobby, though identified with listing, gives us a way to pay attention to the natural world. We can wander, study, and marvel in whatever ways attract us. It has never been a better or more important time to be involved with birds and never a better time to celebrate Bird Day.

Thomas R. Dunlap is Professor of History at Texas A&M University, He is the author of In the Field, Among the Feathered: A History of Birders and Their Guides and Faith in Nature: Environmentalism As Religious Quest.

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Image credit: Both images in the public domain and courtesy of the author.

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Find out more about how to prevent heart failure and keep your heart healthy.

Oxford University Press in conjunction with the European Society of Cardiology and the Heart Failure Association is offering 20% off all our books in cardiology for the month of May, including the authoritative Oxford Textbook of Heart Failure, the practical and concise Oxford Specialist Handbooks on the topic of Heart Failure, and three titles in cardiology published in conjunction with the European Society of Cardiology. In addition we will be offering one month’s free access to the Oxford Textbook of Heart Failure on Oxford Medicine Online, as well as free articles from the European Journal of Heart Failure. We are also publishing a series of special, related articles on the OUPblog.

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