At War Blog: Ending a Life, and a Part of Yourself, For the First Time

Two hundred meters was all that separated me from an insurgent carrying an AK-47. I sat in a dilapidated brown leather chair, recessed in the shadows of a second-story room in the government complex of Falluja, Iraq. My sights were perfectly centered as I perched my elbows on the desk in front of me. The clear tip traced the center of his chest. He crept around a corner of a mud wall and slowly moved toward our position. Fear built inside me. I hesitantly began to pull the trigger of my M-16.

I was scared, to say the least. It was the first time my training would be tested. I heard my rifle crack as I fired. The weapon’s recoil nudged my shoulder, and he crumpled to the ground. The aroma of gunpowder filled the room. I fired two more rounds into his motionless body, then stared in amazement as his body lay lifeless, his black and red scarf astray. The sun rose across the city’s skyline. I was 19.

For me, the 10th of November is special. It is the Marine Corps’s birthday, a day for celebrating camaraderie. But it is also the day, eight years ago, when I was pinned down in the relentless firefights of Operation Phantom Fury. It is the day when I took a person’s life for the first time.

These two drastically different events make for mixed emotions at that time of year. In 2004, fighting in a large-scale attack on the corps’s birthday was thrilling. I’d be lying if I said that I am not still motivated by the memory. What better way to celebrate 229 years of decorated service than to take part in writing the corps’s next chapter? But I also feel as though I lost a part of myself that day.

Taking someone’s life brings you to the darkest side of yourself. There are nights when I see the faces of people I killed. There are days when I get lost in vivid memories of violent combat for minutes at a time. But it also leaves you emotionally numb. In the last eight years, I have not been able to cry unless I am reminiscing about Falluja. It is as if my brain created a space where feelings were lost or delayed. And when I did feel emotions after killing, it was often the sense of relief that I was not on the receiving end – an emotion that might readily, but incorrectly, be interpreted as satisfaction.

It was easy then to fall back on the powerful logic that it was either me or them, or worse yet, one of my fellow Marines. But that logic leaves questions with no easy answers. Did I in some ways come to enjoy killing? Was the loss of a life, and my innocence, worth it?

Pulling the trigger for the first time was beyond difficult. But the more I had to do it, the easier it became. With each passing trigger pull I lost more and more of my innocence. In fact, I actually started to get used to “slaying bodies,” as we called killing the enemy back then. And as more and more of my comrades were injured or killed, the sweeter the revenge began to taste. Looking back on it now, I feel bad that I did not feel bad.

Taking someone’s life changes you whether you like to admit it or not. It took me a long time to notice and admit the changes in me. It is something most people will never have to do. I am envious of those people. I look back on taking an insurgent’s life and can’t help but think I went a little crazy from doing so. I wonder from time to time what I was like before that day many years ago. But I also realize I will never be that person again.

I cannot be alone. In the wake of a suicide epidemic among veterans and active-duty troops, there must be others dealing with these demons. There must be other combat veterans caught in a moral struggle over their wartime actions.

Despite pondering these thoughts for many years, I chose to re-enlist in 2006 knowing for sure that I would go to Afghanistan. Part of me wanted the rush that combat gave me. After being so close to death, things that once excited you have a way of losing their thrill when you return home. I wanted to feel alive again. Strangely, that involved surrounding myself with the threat of death.

Afghanistan was very different from Iraq. The Taliban were very persistent in recovering their wounded. My squad fired thousands of rounds, but the most we ever saw was blood spatter and entrails. No dead bodies. No proof that we killed anyone.

The firefights were intense. Some of them lasted hours. The enemy mastered complex ambushes and attacked us from multiple locations at once, which truly tested my leadership. The fear was real. The bullets were real. I loved it, and with time, my men did too.

At the beginning of our deployment to Afghanistan, I was the only one in my squad with combat experience. The first time we took fire, my men briefly froze, just as I did years earlier. Looking at their faces I could see the fear as they struggled to accept our reality. But within seconds of the first rounds’ hitting our position, their training kicked in and we not only suppressed but also maneuvered on the enemy. The pride I felt watching my men execute their training was immeasurable.

After our first encounter with the enemy I knew they had felt what I had felt, and wanted to feel again. It was all they talked about. And when we went for days without enemy contact, my men would talk about how they missed the rush.

I was lucky enough to bring all of my men home from Afghanistan. Even now, two years later, we still joke about missing the firefights. Though I left the Marine Corps last month after nearly 10 years of service, I will still share with my men the memories of being pinned down in alleyways, the sound of bullets whizzing past our heads and the stench of death.

And so I am left with a raging conflict of emotions and memories. I wonder what life will be like without the thrill of combat or the agony of taking a human life. I’m sure I will become nostalgic watching videos and reminiscing over old photos. But more than anything, I worry about the part of me that I lost and whether I will find it somewhere down the line.

Thomas James Brennan is a reporter for The Robesonian in Lumberton, N.C. Before being medically retired this fall, he was a sergeant in the Marine Corps stationed at Camp Lejeune, N.C. He served in Iraq and Afghanistan with the First Battalion, Eighth Marines, and is a member of the Military Order of the Purple Heart. Follow him on Twitter at @thomasjbrennan.

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State of the Art: Google Maps App for iPhone Goes in the Right Direction - Review

It was one of the biggest tech headlines of the year: in September, Apple dropped its contract with Google, which had always supplied the data for the iPhone’s Maps app. For various strategic reasons, Apple preferred to write a new app, based on a new database of the world that Apple intended to assemble itself.

As everybody knows by now, Apple got lost along the way. It was like a 22-car pileup. Timothy Cook, Apple’s chief executive, made a quick turn, publicly apologizing, firing the executive responsible and vowing to fix Maps. For a company that prides itself on flawless execution, it was quite a detour.

Rumors swirled that Google would create an iPhone app of its own, one that would use its seven-year-old, far more polished database of the world.

That was true. Today, Google Maps for the iPhone has arrived. It’s free, fast and fantastic.

Now, there are two parts to a great maps app. There’s the app itself — how it looks, how it works, what the features are. In this regard, few people complain about Apple’s Maps app; it’s beautiful, and its navigation mode for drivers is clear, uncluttered and distraction-free.

But then there’s the hard part: the underlying data. Apple and Google have each constructed staggeringly complex databases of the world and its roads.

The recipe for both companies includes map data from TomTom, satellite photography from a different source, real-time traffic data from others, restaurant and store listings from still more sources, and so on. In the end, Apple says that it incorporated data from at least 24 different sources.

Those sources always include errors, if only because the world constantly changes. Worse, those sources sometimes disagree with one another. It takes years to fix the problems and mesh these data sources together.

So the first great thing about Google’s new Maps is the underlying data. Hundreds of Google employees have spent years hand-editing the maps, fixing the thousands of errors that people report every day. (In the new app, you report a mistake just by shaking the phone.) And since 2006, Google’s Street View vehicles have trawled 3,000 cities, photographing and confirming the cartographical accuracy of five million miles of roads.

You can sense the new app’s polish and intelligence the minute you enter your first address; it’s infinitely more understanding. When I type “200 W 79, NYC,” Google Maps drops a pin right where it belongs: on the Upper West Side of Manhattan.

Apple’s Maps app, on the other hand, acts positively drunk. It asks me to clarify: “Did you mean 200 Durham Road, Madison, CT? Or 200 Madison Road, Durham, CT?”

Um, what?

And then there’s the navigation. Lots of iPhone owners report that they’ve had no problem with Apple’s driving instructions, and that’s great. But I’ve been idiotically misdirected a few times — and the trouble is, you never know in advance. You wind up with a deep mistrust of the app that’s hard to shake. Google’s directions weren’t great in the app’s early days either, and they’re still not always perfect. But after years of polishing and corrections, they’re right a lot more often.

The must-have features are all here: spoken driving directions, color-coded real-time traffic conditions, vector-based maps (smooth at any size). But the new app also offers some incredibly powerful, useful features that Apple’s app lacks.

Street View, of course, lets you see a photograph of a place, and even “walk” down the street in any direction. Great for checking out a neighborhood before you go, scoping out the parking situation or playing “you are there” when you read a news article.

Along with driving directions, Google Maps gives equal emphasis to walking directions and public transportation options.

This feature is brilliantly done. Google Maps displays a clean, step-by-step timeline of your entire public transportation adventure. If you ask for a route from Westport, Conn., to the Empire State Building, the timeline says: “4:27 pm, Board New Haven train toward Grand Central Terminal.” Then it shows you the names of the actual train stops you’ll pass. Then, “5:47 pm, Grand Central. Get off and walk 2 min.” Then, “5:57 pm, 33rd St: Board the #6 Lexington Avenue Local towards Brooklyn Bridge.” And so on.

Even if public transportation were all it did, Google Maps would be one of the best apps ever. (Apple kicks you over to other companies’ apps for this information.)

E-mail: pogue@nytimes.com

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Another Look at a Drink Ingredient, Brominated Vegetable Oil

James Edward Bates for The New York Times

Sarah Kavanagh, 15, of Hattiesburg, Miss., started an online petition asking PepsiCo to change Gatorade’s formula.

Sarah Kavanagh and her little brother were looking forward to the bottles of Gatorade they had put in the refrigerator after playing outdoors one hot, humid afternoon last month in Hattiesburg, Miss.

But before she took a sip, Sarah, a dedicated vegetarian, did what she often does and checked the label to make sure no animal products were in the drink. One ingredient, brominated vegetable oil, caught her eye.

“I knew it probably wasn’t from an animal because it had vegetable in the name, but I still wanted to know what it was, so I Googled it,” Ms. Kavanagh said. “A page popped up with a long list of possible side effects, including neurological disorders and altered thyroid hormones. I didn’t expect that.”

She threw the product away and started a petition on Change.org, a nonprofit Web site, that has almost 200,000 signatures. Ms. Kavanagh, 15, hopes her campaign will persuade PepsiCo, Gatorade’s maker, to consider changing the drink’s formulation.

Jeff Dahncke, a spokesman for PepsiCo, noted that brominated vegetable oil had been deemed safe for consumption by federal regulators. “As standard practice, we constantly evaluate our formulas and ingredients to ensure they comply with federal regulations and meet the high quality standards our consumers and athletes expect — from functionality to great taste,” he said in an e-mail.

In fact, about 10 percent of drinks sold in the United States contain brominated vegetable oil, including Mountain Dew, also made by PepsiCo; Powerade, Fanta Orange and Fresca from Coca-Cola; and Squirt and Sunkist Peach Soda, made by the Dr Pepper Snapple Group.

The ingredient is added often to citrus drinks to help keep the fruit flavoring evenly distributed; without it, the flavoring would separate.

Use of the substance in the United States has been debated for more than three decades, so Ms. Kavanagh’s campaign most likely is quixotic. But the European Union has long banned the substance from foods, requiring use of other ingredients. Japan recently moved to do the same.

“B.V.O. is banned other places in the world, so these companies already have a replacement for it,” Ms. Kavanagh said. “I don’t see why they don’t just make the switch.” To that, companies say the switch would be too costly.

The renewed debate, which has brought attention to the arcane world of additive regulation, comes as consumers show increasing interest in food ingredients and have new tools to learn about them. Walmart’s app, for instance, allows access to lists of ingredients in foods in its stores.

Brominated vegetable oil contains bromine, the element found in brominated flame retardants, used in things like upholstered furniture and children’s products. Research has found brominate flame retardants building up in the body and breast milk, and animal and some human studies have linked them to neurological impairment, reduced fertility, changes in thyroid hormones and puberty at an earlier age.

Limited studies of the effects of brominated vegetable oil in animals and in humans found buildups of bromine in fatty tissues. Rats that ingested large quantities of the substance in their diets developed heart lesions.

Its use in foods dates to the 1930s, well before Congress amended the Food, Drug and Cosmetic Act to add regulation of new food additives to the responsibilities of the Food and Drug Administration. But Congress exempted two groups of additives, those already sanctioned by the F.D.A. or the Department of Agriculture, or those experts deemed “generally recognized as safe.”

The second exemption created what Tom Neltner, director of the Pew Charitable Trusts’ food additives project, a three-year investigation into how food additives are regulated, calls “the loophole that swallowed the law.” A company can create a new additive, publish safety data about it on its Web site and pay a law firm or consulting firm to vet it to establish it as “generally recognized as safe” — without ever notifying the F.D.A., Mr. Neltner said.

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Another Look at a Drink Ingredient, Brominated Vegetable Oil

James Edward Bates for The New York Times

Sarah Kavanagh, 15, of Hattiesburg, Miss., started an online petition asking PepsiCo to change Gatorade’s formula.

Sarah Kavanagh and her little brother were looking forward to the bottles of Gatorade they had put in the refrigerator after playing outdoors one hot, humid afternoon last month in Hattiesburg, Miss.

But before she took a sip, Sarah, a dedicated vegetarian, did what she often does and checked the label to make sure no animal products were in the drink. One ingredient, brominated vegetable oil, caught her eye.

“I knew it probably wasn’t from an animal because it had vegetable in the name, but I still wanted to know what it was, so I Googled it,” Ms. Kavanagh said. “A page popped up with a long list of possible side effects, including neurological disorders and altered thyroid hormones. I didn’t expect that.”

She threw the product away and started a petition on Change.org, a nonprofit Web site, that has almost 200,000 signatures. Ms. Kavanagh, 15, hopes her campaign will persuade PepsiCo, Gatorade’s maker, to consider changing the drink’s formulation.

Jeff Dahncke, a spokesman for PepsiCo, noted that brominated vegetable oil had been deemed safe for consumption by federal regulators. “As standard practice, we constantly evaluate our formulas and ingredients to ensure they comply with federal regulations and meet the high quality standards our consumers and athletes expect — from functionality to great taste,” he said in an e-mail.

In fact, about 10 percent of drinks sold in the United States contain brominated vegetable oil, including Mountain Dew, also made by PepsiCo; Powerade, Fanta Orange and Fresca from Coca-Cola; and Squirt and Sunkist Peach Soda, made by the Dr Pepper Snapple Group.

The ingredient is added often to citrus drinks to help keep the fruit flavoring evenly distributed; without it, the flavoring would separate.

Use of the substance in the United States has been debated for more than three decades, so Ms. Kavanagh’s campaign most likely is quixotic. But the European Union has long banned the substance from foods, requiring use of other ingredients. Japan recently moved to do the same.

“B.V.O. is banned other places in the world, so these companies already have a replacement for it,” Ms. Kavanagh said. “I don’t see why they don’t just make the switch.” To that, companies say the switch would be too costly.

The renewed debate, which has brought attention to the arcane world of additive regulation, comes as consumers show increasing interest in food ingredients and have new tools to learn about them. Walmart’s app, for instance, allows access to lists of ingredients in foods in its stores.

Brominated vegetable oil contains bromine, the element found in brominated flame retardants, used in things like upholstered furniture and children’s products. Research has found brominate flame retardants building up in the body and breast milk, and animal and some human studies have linked them to neurological impairment, reduced fertility, changes in thyroid hormones and puberty at an earlier age.

Limited studies of the effects of brominated vegetable oil in animals and in humans found buildups of bromine in fatty tissues. Rats that ingested large quantities of the substance in their diets developed heart lesions.

Its use in foods dates to the 1930s, well before Congress amended the Food, Drug and Cosmetic Act to add regulation of new food additives to the responsibilities of the Food and Drug Administration. But Congress exempted two groups of additives, those already sanctioned by the F.D.A. or the Department of Agriculture, or those experts deemed “generally recognized as safe.”

The second exemption created what Tom Neltner, director of the Pew Charitable Trusts’ food additives project, a three-year investigation into how food additives are regulated, calls “the loophole that swallowed the law.” A company can create a new additive, publish safety data about it on its Web site and pay a law firm or consulting firm to vet it to establish it as “generally recognized as safe” — without ever notifying the F.D.A., Mr. Neltner said.

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Google Releases Maps App for iPhone as Apple Regroups

The return of a Google-powered maps application to the iPhone may make it easier for Apple’s customers to find their way. But it will not relieve Apple of the pressure to bring its own maps service up to snuff.

The release of the new Google Maps app for the iPhone, expected in Apple’s App Store on Thursday, does put to rest most of the conspiracy theorizing that began when Apple stopped bundling Google’s mapping service with the latest operating system for the iPhone and iPad, released in September. Apple did that because it was determined to own an increasingly critical feature of its devices, but the move seemed premature, as flaws in the company’s new service led to unusual public embarrassment.

Mobile analysts wondered whether Google would create an app for the iPhone or allow Apple, its rival, to flail around without a service on its devices that so many people rely on. After all, any long-term fallout for the iPhone could, in theory, benefit Google by making its own Android mobile operating system, which includes Google Maps, more attractive to customers.

Analysts also questioned whether Apple would approve the distribution of a Google Maps app through its App Store or hold it up, as it has some previous Google apps, to help Apple Maps.

That speculation is over. By making a high-quality maps app for the iPhone, it appears Google has put creating the biggest possible audience for its maps service above trying to undermine Apple’s product. “They’re more interested in owning the relationship with customers in any way they can,” said Carolina Milanesi, an analyst at Gartner.

Apple and Google representatives declined to discuss the app.

Marc Prioleau, a consultant on strategy, mergers and acquisitions in the maps and location services fields, said the release of the Google Maps app did not lessen the daunting challenge for Apple of making a maps service that is competitive with Google’s, a process that could take years.

“I don’t think it helps them, except in the sense that the iPhone stops having the thorn in its side of lacking the best mobile map app out there,” he said. “The fact that it’s Google means they’re back to the same position.”

Because of the sheer volume of data contained in Apple Maps, it is hard to judge how much Apple has improved the service since releasing it, Mr. Prioleau said.

But the bar is very high. “You can get 98 percent of stuff on maps right, and people who use it will remember the 2 percent you got wrong until they die,” he said.

Ms. Milanesi, the Gartner analyst, said she did not think Apple had lost a significant number of sales as a result of the deficiencies in Apple Maps, because its customers had shown a willingness in the past to overlook shortcomings in maps. When Apple used to bundle the Google Maps service with the built-in maps app on the iPhone, for instance, the service lacked turn-by-turn navigation, a feature that was available on other mobile devices, including Google’s.

“People were putting up with something that wasn’t as good as Android,” Ms. Milanesi said.

While Google is often criticized by reviewers for producing software and devices that are less polished than Apple’s, the Apple Maps fiasco illustrated how Google has the upper hand in some Internet services. The company has a multiyear head start on Apple in maps, and a huge team of employees dedicated to correcting the errors that can plague location data for businesses and other points of interest.

When Apple Maps came out, iPhone users quickly began identifying misplaced landmarks, incorrect addresses and other problems. The problems led to an unusual public apology by Timothy D. Cook, Apple’s chief executive, in which he recommended that people use competing maps services while the company improved Apple Maps.

This week, local police in Australia issued a warning about Apple Maps after assisting several motorists who were led astray in hot, desolate areas without water. Apple corrected the error on its Australian map, and the police reportedly issued a separate warning about incorrect directions from Google Maps.

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OPEC Leaves Production Quotas in Place

Members of the Organization of Petroleum Exporting Countries left their 30 million-barrel-per-day quota for oil production intact Wednesday, indicating the cartel’s satisfaction with current crude prices and its reluctance to do anything to further weaken the world economy.

But even as it stuck with the status quo, OPEC may face serious tests in the near future, as rising production in the United States and elsewhere threatens the cartel’s market share and influence in the world.

So far, though, OPEC has had an easy year. Crude prices have been stable and within the range the organization favors. Although oil prices for U.S.-produced oil have fallen into the range of $80 to $90 a barrel, the price of a global benchmark, Brent crude, remains well above $100 per barrel.

The OPEC basket price, which members consider representative of what they receive for their oil, was $104.80 a barrel on Tuesday.

“At these prices no one wants to rock the boat,” said Bhushan Bahree, an OPEC analyst at IHS Cera , who was in the meeting, held in Vienna.

But the global oil market is undergoing significant change, led by the surge in U.S. oil production, which reached 6.5 million barrels a day in September. That was the highest since 1998 and a 900,000 barrels-per-day increase from a year earlier, according to the U.S. Energy Information Administration.

Meanwhile, Iraq, an OPEC member not subject to the organization’s quotas because the country is recovering from the ravages of war, is also rapidly increasing production, reaching levels last seen in the late 1990s.

OPEC probably cannot avoid being buffeted by these shifts and their impact on market share.

“More production in the U.S. means there is less available for OPEC,” said Jamie Webster, an analyst for Washington-based consultants PFCEnergy, who was in Vienna observing the meeting.

Approximately a third of global oil output is produced by the cartel’s 12 members: Algeria, Angola, Ecuador, Iran, Iraq, Kuwait, Libya, Nigeria, Qatar, Saudi Arabia, the United Arab Emirates and Venezuela.

The high oil prices of recent years have led oil companies to invest heavily in exploration and in techniques to extract hydrocarbons that until recently were off limits, including the shale formations in North Dakota in the United States. As a result, supply is increasing faster than just about anyone expected, while demand remains sluggish as a result of the tepid world economy.

IHS Cera, a market analysis firm, expects the global supply of oil from non-OPEC producers like the United States, Kazakhstan and Brazil to grow by 1.2 million barrels per day next year. That would be well ahead of world demand, which the firm expects to increase by only 800,000 barrels a day in 2013.

Should this prediction, which is in line with the cartel’s own forecast, prove to be on the mark, OPEC will probably need to trim its output, giving up market share, to buffer falling prices.

The signs are that — quota notwithstanding — it is already cutting back. An OPEC report published Tuesday showed that Saudi Arabia, the key decision maker in the group, had already reduced output by 200,000 barrels a day in November, to 9.5 million barrels per day, its lowest level since October 2011.

“If the world ends up with a lot more capacity to produce oil than appetite to consume it, then either OPEC countries have to figure out a way to cut back production or prices will crash,” said Michael Levi, an energy fellow at the Council on Foreign Relations. “Sometimes OPEC doesn’t make decisions, but individual countries do and then others follow.”

Abdalla Salem el-Badri, the OPEC secretary general, acknowledged the possibility of production cuts in Vienna on Wednesday. “Maybe in the coming months we will produce less,” he said.

Recently, OPEC has not revealed specific quotas for members. But the whole organization was supposed to observe a 30 million barrel-per-day ceiling, which it is now being exceeded by around 1 million barrels per day. This lack of specific targets allows the Saudis to try keeping the global system balanced by adjusting the amount of oil they sell, without the need to haggle over changes.

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Daily Stock Market Activity

Wall Street opened higher on Tuesday after unexpectedly cheery data out of Europe and as the Federal Reserve was set to begin its two-day policy meeting.

The Standard & Poor’s 500-stock index added 0.9 percent, the Dow Jones industrial average rose 0.7 percent and the Nasdaq composite index was up 1.3 percent in early trading.

The stock market has entered a traditionally quiet period heading into the end of the year, with thinner trading volumes and fewer large fluctuations likely.

Though the pace of talks quickened in Washington to avert impending tax increases and spending cuts, senior politicians on both sides cautioned that an agreement on all the outstanding issues remained uncertain.

The lack of progress in negotiations about the “fiscal cliff” has kept investors from making aggressive bets in recent weeks, though most expect a deal will eventually be reached.

In Germany, analyst and investor sentiment rose sharply in December, entering positive territory for the first time since May, a leading survey showed. The data helped drive European shares higher. The DAX in Frankfurt was up 0.6 percent in afternoon trading, while the FTSE 100 in London gained 0.2 percent.

“We’ve been getting a lot of the beginning of our day from seeing what Europe has been doing, and I think that’s going to hold true today,” said Kim Caughey Forrest, senior equity research analyst at Fort Pitt Capital Group in Pittsburgh.

The Fed begins its two-day Federal Open Market Committee meeting on Tuesday. The central bank was expected to announce a new round of Treasury securities purchases on Wednesday, according to a Reuters survey of analysts. The program would replace its so-called Operation Twist stimulus effort, which expires at the end of the year.

The Treasury Department sold its remaining stake in the American International Group, bringing an end to a government ownership role about four years after a $182 billion bailout. A.I.G.'s shares were up 4 percent in morning trading.

Two firms raised their price targets for Urban Outfitters, sending the retailer’s shares up 6 percent.

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Mind: A Compromise on Defining and Diagnosing Mental Disorders

They plotted a revolution, fell to debating among themselves, and in the end overturned very little except their own expectations.

But the effort itself was a valuable guide for anyone who has received a psychiatric diagnosis, or anyone who might get one.

This month, the American Psychiatric Association announced that its board of trustees had approved the fifth edition of the association’s influential diagnostic manual — the so-called bible of mental disorders — ending more than five years of sometimes acrimonious, and often very public, controversy.

The committee of doctors appointed by the psychiatric association had attempted to execute a paradigm shift, changing how mental disorders are conceived and posting its proposals online for the public to comment. And comment it did: Patient advocacy groups sounded off, objecting to proposed changes in the definitions of depression and Asperger syndrome, among other diagnoses. Outside academic researchers did, too. A few committee members quit in protest.

The final text, which won’t be fully available until publication this spring, has already gotten predictably mixed reviews. “Given the challenges in a field where objective lines are hard to draw, they did a solid job,” said Dr. Michael First, a psychiatrist at Columbia who edited a previous version of the manual and was a consultant on this one.

Others disagreed. “This is the saddest moment in my 45-year career of practicing, studying and teaching psychiatry,” wrote Dr. Allen Frances, the chairman of a previous committee who has been one of the most vocal critics, in a blog post about the new manual, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM5.

Yet many experts inside and outside the process said the final document was not radically different from the previous version, and its lessons more mundane than the rhetoric implied. The status quo is hard to budge, for one. And when changes do happen, they are not necessarily the ones that were intended.

The new manual does extend the reach of psychiatry in some areas, as many critics feared it might. Hoarding is now a mental disorder (previously it was considered a symptom of obsessive-compulsive behavior). “Premenstrual dysphoric disorder,” a severe form of premenstrual syndrome, is also new (it was previously in the appendix).

And binge-eating disorder (also formerly in the appendix), a kind of severe, highly distressing gluttony, is now a full-blown diagnosis. This one by itself could tag millions of people considered healthy, if often overindulgent, with a psychiatric label, some experts said.

But the deeper story is one of compromise. It is most evident in how the committee handled three of the thorniest diagnoses in psychiatry: autism, depression and pediatric bipolar disorder.

The group working on depression declared early on that it wanted to eliminate the so-called bereavement exclusion, which stated that grieving the loss of a loved one should not be considered a clinical disorder, though it shares many of the same outward signs. Grief has always been a normal reaction to death, not a kind of depression.

Advocacy and support groups, such as those representing people who have lost a child, objected furiously to the idea that the bereaved might be given a diagnosis of depression.

“This was just astonishing, that they would eliminate the exclusion, and a distortion of the research on the subject,” said Jerome Wakefield, a professor of social work and psychiatry at New York University, who did not work on the manual.

In the end the committee cut a deal. It eliminated the grief exclusion but added a note in the text, reminding doctors that any significant loss — of a job, a relationship, a home — could cause depressive symptoms and should be carefully investigated.

“It’s like they took it all back,” Dr. Wakefield said. “I don’t like the way it was done — in a footnote — but it’s there.”

The debate over autism was even more furious, and it resulted in a similar rapprochement.

From the outset, the committee intended to tighten the definition of autism and simplify it, eliminating related labels like Asperger syndrome and “pervasive developmental disorder not otherwise specified,” or PDD-NOS. The rate of diagnosis of such conditions has exploded over the past decade, in part due to the vagueness of the definitions, and the committee wanted to draw clearer boundaries.

It proposed a single “autism spectrum disorder” category, with stricter requirements.

Some outside researchers raised concerns. In January one of them, Dr. Fred Volkmar of the Yale School of Medicine, who had quit the committee in protest, presented research suggesting that 45 percent or more of people who currently had an autism or related diagnosis would not have one under the proposed revision.

Autism groups reacted immediately, fearing that the change in the diagnosis would deny services to children and families who need them.

The committee countered with its own study, suggesting that the new definition would exclude about 10 percent of people currently with a diagnosis. And again, the experts took a half step back.

The new, streamlined definition was approved, but with language that took into account a person’s diagnostic history. “It’s explicit that anyone who’s had an Asperger’s or autism or PDD-NOS diagnosis before is now included,” said Catherine Lord, a committee member who worked on the new definition and who is director of the Center for Autism and the Developing Brain in New York. “Essentially everyone gets in.”

Pediatric bipolar disorder posed a different challenge.

In the 1990s and 2000s, psychiatrists began giving aggressive, explosive children a diagnosis of bipolar disorder in increasing numbers. The trend appalled many patient advocates and doctors.

Bipolar disorder, which is characterized by episodes of depression and mania, had previously been an adult problem; now the diagnosis is given to children as young as 2 — along with powerful psychiatric drugs and tranquilizers that also cause rapid weight gain. The committee wanted to stop the trend in its tracks, said experts who were involved.

Most of the children treated for bipolar disorder did not have it, recent research found. The committee settled on an alternative label: “disruptive mood dysregulation disorder,” or D.M.D.D., which describes extreme hostility and outbursts beyond normal tantrums.

“They essentially wanted to have some place for these kids, and D.M.D.D. was all they had in their kit,” said Dr. Gabrielle Carlson, a child psychiatrist at Stony Brook University Medical Center, who provided some outside consultation. “These are mostly kids who have A.D.H.D. or what we would call oppositional defiant disorder, but with this explosive feature. They need help; you can’t wait forever. The question was what to call it, without pretending we know enough to saddle them with a lifelong diagnosis” like bipolar disorder.

D.M.D.D. has its own problems, as many experts were quick to point out. It could be a symptom of an underlying condition, as Dr. Carlson argues. It could “medicalize” frequent temper tantrums. It’s brand new, and no one knows how it will play out in practice.

But it is now in the book — because it was the best solution available, experts inside and outside of the revision process said.

From beginning to end, many experts said, the process of defining psychiatric diagnoses is very much like finding the right one for an individual: it’s a process of negotiation, in many cases.

“That’s one of the take-aways from all this, and I think it’s a good one,” Dr. Carlson said. “A diagnosis is a hypothesis. It’s a start, and you have to start somewhere. But that’s all it is.”

One of the committee’s most ambitious proposals was perhaps the least noticed: a commitment to update the book continually, when there’s good reason to, rather than once every decade or so in a giant heave. That was approved without much fanfare.

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Mind: A Compromise on Defining and Diagnosing Mental Disorders

They plotted a revolution, fell to debating among themselves, and in the end overturned very little except their own expectations.

But the effort itself was a valuable guide for anyone who has received a psychiatric diagnosis, or anyone who might get one.

This month, the American Psychiatric Association announced that its board of trustees had approved the fifth edition of the association’s influential diagnostic manual — the so-called bible of mental disorders — ending more than five years of sometimes acrimonious, and often very public, controversy.

The committee of doctors appointed by the psychiatric association had attempted to execute a paradigm shift, changing how mental disorders are conceived and posting its proposals online for the public to comment. And comment it did: Patient advocacy groups sounded off, objecting to proposed changes in the definitions of depression and Asperger syndrome, among other diagnoses. Outside academic researchers did, too. A few committee members quit in protest.

The final text, which won’t be fully available until publication this spring, has already gotten predictably mixed reviews. “Given the challenges in a field where objective lines are hard to draw, they did a solid job,” said Dr. Michael First, a psychiatrist at Columbia who edited a previous version of the manual and was a consultant on this one.

Others disagreed. “This is the saddest moment in my 45-year career of practicing, studying and teaching psychiatry,” wrote Dr. Allen Frances, the chairman of a previous committee who has been one of the most vocal critics, in a blog post about the new manual, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM5.

Yet many experts inside and outside the process said the final document was not radically different from the previous version, and its lessons more mundane than the rhetoric implied. The status quo is hard to budge, for one. And when changes do happen, they are not necessarily the ones that were intended.

The new manual does extend the reach of psychiatry in some areas, as many critics feared it might. Hoarding is now a mental disorder (previously it was considered a symptom of obsessive-compulsive behavior). “Premenstrual dysphoric disorder,” a severe form of premenstrual syndrome, is also new (it was previously in the appendix).

And binge-eating disorder (also formerly in the appendix), a kind of severe, highly distressing gluttony, is now a full-blown diagnosis. This one by itself could tag millions of people considered healthy, if often overindulgent, with a psychiatric label, some experts said.

But the deeper story is one of compromise. It is most evident in how the committee handled three of the thorniest diagnoses in psychiatry: autism, depression and pediatric bipolar disorder.

The group working on depression declared early on that it wanted to eliminate the so-called bereavement exclusion, which stated that grieving the loss of a loved one should not be considered a clinical disorder, though it shares many of the same outward signs. Grief has always been a normal reaction to death, not a kind of depression.

Advocacy and support groups, such as those representing people who have lost a child, objected furiously to the idea that the bereaved might be given a diagnosis of depression.

“This was just astonishing, that they would eliminate the exclusion, and a distortion of the research on the subject,” said Jerome Wakefield, a professor of social work and psychiatry at New York University, who did not work on the manual.

In the end the committee cut a deal. It eliminated the grief exclusion but added a note in the text, reminding doctors that any significant loss — of a job, a relationship, a home — could cause depressive symptoms and should be carefully investigated.

“It’s like they took it all back,” Dr. Wakefield said. “I don’t like the way it was done — in a footnote — but it’s there.”

The debate over autism was even more furious, and it resulted in a similar rapprochement.

From the outset, the committee intended to tighten the definition of autism and simplify it, eliminating related labels like Asperger syndrome and “pervasive developmental disorder not otherwise specified,” or PDD-NOS. The rate of diagnosis of such conditions has exploded over the past decade, in part due to the vagueness of the definitions, and the committee wanted to draw clearer boundaries.

It proposed a single “autism spectrum disorder” category, with stricter requirements.

Some outside researchers raised concerns. In January one of them, Dr. Fred Volkmar of the Yale School of Medicine, who had quit the committee in protest, presented research suggesting that 45 percent or more of people who currently had an autism or related diagnosis would not have one under the proposed revision.

Autism groups reacted immediately, fearing that the change in the diagnosis would deny services to children and families who need them.

The committee countered with its own study, suggesting that the new definition would exclude about 10 percent of people currently with a diagnosis. And again, the experts took a half step back.

The new, streamlined definition was approved, but with language that took into account a person’s diagnostic history. “It’s explicit that anyone who’s had an Asperger’s or autism or PDD-NOS diagnosis before is now included,” said Catherine Lord, a committee member who worked on the new definition and who is director of the Center for Autism and the Developing Brain in New York. “Essentially everyone gets in.”

Pediatric bipolar disorder posed a different challenge.

In the 1990s and 2000s, psychiatrists began giving aggressive, explosive children a diagnosis of bipolar disorder in increasing numbers. The trend appalled many patient advocates and doctors.

Bipolar disorder, which is characterized by episodes of depression and mania, had previously been an adult problem; now the diagnosis is given to children as young as 2 — along with powerful psychiatric drugs and tranquilizers that also cause rapid weight gain. The committee wanted to stop the trend in its tracks, said experts who were involved.

Most of the children treated for bipolar disorder did not have it, recent research found. The committee settled on an alternative label: “disruptive mood dysregulation disorder,” or D.M.D.D., which describes extreme hostility and outbursts beyond normal tantrums.

“They essentially wanted to have some place for these kids, and D.M.D.D. was all they had in their kit,” said Dr. Gabrielle Carlson, a child psychiatrist at Stony Brook University Medical Center, who provided some outside consultation. “These are mostly kids who have A.D.H.D. or what we would call oppositional defiant disorder, but with this explosive feature. They need help; you can’t wait forever. The question was what to call it, without pretending we know enough to saddle them with a lifelong diagnosis” like bipolar disorder.

D.M.D.D. has its own problems, as many experts were quick to point out. It could be a symptom of an underlying condition, as Dr. Carlson argues. It could “medicalize” frequent temper tantrums. It’s brand new, and no one knows how it will play out in practice.

But it is now in the book — because it was the best solution available, experts inside and outside of the revision process said.

From beginning to end, many experts said, the process of defining psychiatric diagnoses is very much like finding the right one for an individual: it’s a process of negotiation, in many cases.

“That’s one of the take-aways from all this, and I think it’s a good one,” Dr. Carlson said. “A diagnosis is a hypothesis. It’s a start, and you have to start somewhere. But that’s all it is.”

One of the committee’s most ambitious proposals was perhaps the least noticed: a commitment to update the book continually, when there’s good reason to, rather than once every decade or so in a giant heave. That was approved without much fanfare.

Read More..

Euro Watch: Italian Political Turmoil Weighs on Markets

ROME — Italian bond yields rose Monday, and stocks in Milan led major European indexes lower, after a weekend of political turmoil in Italy gave rise to fears that the country was headed for renewed instability.

The former prime minister, Silvio Berlusconi, said he would again seek Italy’s highest office after pulling his party’s support from Mario Monti, the unelected official who currently holds the office. Mr. Monti decided over the weekend to step down.

Mr. Berlusconi, a four-time prime minister, left office a year ago as markets pushed Italy to the brink of financial collapse. Mr. Monti has restored Italy’s credibility with investors, who have given the country a break on its borrowing costs. But those gains have come at the cost of painful austerity measures that have worsened the country’s economic situation and given Mr. Berlusconi an opening to attack.

Mr. Monti will leave after Parliament passes a budget this month and may contest national elections against Mr. Berlusconi, with the vote — previously scheduled for April — now possible as early as February or March.

The Milan benchmark MIB index fell as much 2.7 percent in afternoon trading Monday, having fallen as much as 3.6 percent. Italian banks — which as big holders of government bonds remain sensitive to declines in the prices of those bonds — were the big losers. Intesa Sanpaolo, the most active stock, fell 6.2 percent and Unicredit declined 5.9 percent.

The yield gap, or spread, between interest rates on Italian 10-year sovereign bonds and equivalent German securities, the European benchmark for safety, grew to 3.5 percentage points Monday from 3.25 points late Friday, suggesting that investors were growing more wary of holding Italian debt. The Italian 10-year bonds, for which the yield peaked this year at more than 7 percent, were trading to yield 4.8 percent, up 29 basis points. A basis point is one-hundredth of a percent.

A barometer of euro zone blue-chip stocks, the Euro Stoxx 50 index, fell 0.5 percent late in afternoon trading. The euro was little changed from its levels in New York on Friday, at $1.2932.

“It’s as if a tank moved through” the market, said Mario Sechi, editor in chief of the Rome daily newspaper Il Tempo, speaking on Radio 24 on Monday morning. Like many Italian commentators, Mr. Sechi expressed reservations about Mr. Berlusconi’s decision to return to politics.

A dismal economic report Monday served as a reminder that despite Mr. Monti’s success with investors, the real economy continues to suffer. Italian industrial production fell a seasonally adjusted 1.1 percent in October from September, and by 6.2 percent from a year earlier, Istat, the national statistics agency, reported from Rome.

The coming Italian election “remains high on our list of tail risks for 2013,” Holger Schmieding, an economist in London with Berenberg Bank, wrote in a research note. “A Berlusconi campaign against ‘German austerity’ could potentially unsettle markets,” he wrote, and possibly push Spain or Italy into the need for a bailout or require additional bond purchases by the European Central Bank to hold down borrowing costs.

Chancellor Angela Merkel of Germany was to meet Monday with Mr. Monti on the sidelines of the Nobel peace prize ceremony in Oslo, said Georg Streiter, a spokesman for the chancellor.

Ms. Merkel pushed to have Mr. Monti replace Mr. Berlusconi, but found herself on the receiving end of the Italian technocrat’s own campaign for a course of European reform focused more on growth and creating jobs than the restructuring and austerity championed by the German leader.

As a rule, the German government does not comment on its partners’ domestic politics, but Foreign Minister Guido Westerwelle warned that an attempt to scale back Italy’s reform push could result in further destabilization in the euro zone.

“Italy can not remain stagnant on two-thirds of its reform process,” Mr. Westerwelle said through a spokesman. “This would throw not only Italy, but the rest of Europe, into turbulence.”

Spanish bonds also came under renewed pressure following Mr. Monti’s announcement, with the interest rate spread of Spanish 10-year bonds over equivalent German bonds rising to 4.27 percentage points from 4.16 points on Friday. The yield on the benchmark Spanish 10-year rose 10 basis points to 5.5 percent; it reached 7.1 percent in July, amid concerns that Spain would be forced into a full bailout after having to negotiate a €100 billion rescue package for its banks in June.

Luís de Guindos, the Spanish economy minister, warned that Italy’s political turmoil would have an impact on his country. “When doubts emerge over the stability of a neighboring country like Italy, which is also seen as vulnerable, there’s an immediate contagion for us,” he said Monday morning on Spanish national radio.

Asked whether Spain would itself seek further European rescue funding, the economy minister instead said that “the help that Spain needs is that the doubts over the future of the euro be removed.”

Speaking ahead of the Nobel ceremony on Monday, the European Commission president, José Manuel Barroso, said that Italy had to “continue on the road of structural reforms.” The elections, Mr. Barroso said on Sky News, “must not be used to postpone reforms.”

David Jolly reported from Paris. Raphael Minder contributed reporting from Madrid and Melissa Eddy from Berlin.

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