Sustained personal autonomy: a measure of successful aging.

OBJECTIVES: This study addresses the following question: What characteristics of urban, noninstitutionalized elders predict which individuals are most likely to remain independent of personal assistance during a 2-year observation period? METHODS: A population-based sample of 602 noninstitutionalized urban residents aged 70 and older was followed for 2 years. RESULTS: Ninety-eight of the 487 survivors remained independent. Factors associated with sustained independence were relatively younger age, male gender, fewer medical conditions, good physical function, and nonsmoking. The attitudes "favors family or self over agency assistance" and "does not expect filial obligation" were also independently associated. DISCUSSION: The results are consistent with previous studies of successful aging and show that attitudes expressed at baseline favoring personal independence are associated with sustained autonomy during a period of at least 2 years.

Aging and immigration: Who are the elderly?

"The present article joins two generally separate streams of research, gerontologic and immigration research in the United States. The paper considers data from several studies of seniors in Cleveland, Ohio in the 1990s; the 'Black and White Caregivers' and the 'Use of Services of Black and White Elderly'. These are considered not in terms of their original research goals, but rather in terms of a reflective examination of assumptions regarding the identity of the elders and caregivers that framed the two studies." The authors conclude that identifying elderly people by race tends to conceal rather than clarify ethnic and cultural differences among this population.

Harmony and consensus: cultural aspects of organization in international science.

This article is the beginning of an analysis of cultural processes involved in scientific social organization and change which focuses on the International Working Group for the Harmonization of Dementia Drug Testing Guidelines (IWG). We provide some background for the IWG and for the study of its processes and focus on the construction of consensus and consensus statements of the constituent working groups of the IWG. We delineate a cultural ethos of cooperation that pushes scientists to agree even when they do not and to conceal disagreements. Our observations suggest that the consensus process may serve to inhibit or block the development of new ideas and solutions to problems by keeping conflicts hidden and different viewpoints masked. The masked ideas, although minority ideas, may contain much of importance for subsequent paradigm shifts in approaches to Alzheimer disease and other dementias. In subsequent reports, we will chronicle other aspects of the work of the IWG, including the nature of cross-cultural differences in the drug research structures and processes, governmental regulatory bodies, and the relationship of the pharmaceutical industry to clinical trials research. The present article adds some understanding of the IWG and its mission and contributes to the literature on the cultural construction and social organization of science.

The clinical introduction of genetic testing for Alzheimer disease. An ethical perspective.

OBJECTIVE: Primary caregivers should be aware of recent progress in the genetics of Alzheimer disease (AD) and of the clinical and ethical considerations raised regarding the introduction of genetic testing for purposes of disease prediction and susceptibility (risk) analysis in asymptomatic individuals and diagnosis in patients who present clinically with dementia. This statement addresses arguments for and against clinical genetic testing. PARTICIPANTS: The 20 participants were selected by the investigators (S.G.P., T.H.M., A.B.Z., and P.J.W.) to achieve balance in the areas of genetics, counseling, ethics, and public policy, and to include leadership from related consensus projects. The consensus group met twice in closed meetings and carried on extensive correspondence over 2 years (1995-1997). The project was supported by the National Human Genome Research Institute of the National Institutes of Health. EVIDENCE: All 4 involved chromosomes were discussed in group meetings against a background of information from several focus group sessions with AD-affected families. The focus groups comprised volunteers identified by the Cleveland Area Chapter of the Alzheimer's Disease and Related Disorders Association and represented a variety of ethnic populations. CONSENSUS PROCESS: The first draft was written in April 1996 by the principal investigator (S.G.P.) after the consensus group had met twice. The draft was mailed to all consensus group members 3 times over 6 months for extensive response and redrafting by the principal investigator until all members were satisfied. CONCLUSIONS: Except for autosomal dominant early-onset families, genetic testing in asymptomatic individuals is unwarranted. Use of APOE genetic testing as a diagnostic adjunct in patients already presenting with dementia may prove useful but it remains under investigation. The premature introduction of genetic testing and possible adverse consequences are to be avoided.

Culture-specific delusions. Sense and nonsense in cultural context.

It can be said that a definition of delusions requires the invocation of cultural understandings, standards of acceptability, as well as conceptions of reality and the forces that animate it. For these reasons, the determination of delusional or normative ideation can only be effected properly within particular cultural contexts. The cross-cultural record suggests that it is difficult to separate the delusional from the cultural; a belief that is patterened and culturally specific is, by definition a cultural, not a delusional belief. One must rely upon particular, relevant local cultural understandings to ascertain when the bounds of culture have been transgressed and meaning has given way to unshareable nonsense.

From DSM-I to III-R; voices of self, mastery and the other: a cultural constructivist reading of U.S. psychiatric classification.

The continual process of mental disease classification in U.S. psychiatry is assumed to reflect advancing professional knowledge of these disorders. To date, the American Psychiatric Association has developed four standard classifications, or nosologies, called Diagnostic and Statistical Manuals ('DSMs'). DSM-I, the earliest, appeared in 1952 while the most recent, DSM-III-R, appeared in 1987. This paper employs a cultural constructivist perspective to deconstruct these nosologies and the classificatory process itself. Constructivism's premises, which emphasize culture, history, meaning and the constructed nature of medical phenomena, serve as the framework for the analysis. The paper shows that professional psychiatric classification expresses an underlying cultural psychology which encompasses four phenomenological domains and one of three Western person conceptions. Classifications are found to be explorations of culturally meaningful etiologies that explain the absence of 'self control', a central ethnopsychological aspect of the idealized self. Consideration of the vantage point of the voice of classification indicates that the ideal self is gender- (male), ethnic- (German Protestant) and age-specific (adult). The ethnic self's essence, and that of the Other, is believed to be biological, itself assumed to be natural and beyond culture or bias. Consequently, the ethnopsychology constructs as biologically caused the real and imagined differences in the gender, age or culturally Other. This invidious ethnobiological essentialism acts to create and maintain self-worth through a radical differentiation of self from those represented as Other.

Donor type natural killer cells after haploidentical T cell-depleted bone marrow stem cell transplantation in a patient with adenosine deaminase-deficient severe combined immunodeficiency.

T cell-depleted haploidentical (parental) bone marrow stem cell transplants are given to most infants with the syndrome of severe combined immunodeficiency (SCID) because they have no available HLA-identical sibling potential donors. Since they usually do not undergo cytoreduction prior to transplantation, these children later demonstrate mixed hematopoietic chimerism. Most often, T cells (but usually not B lymphocytes, macrophages, or other hematopoietic cells) can be shown to be of donor type. The origin of natural killer (NK) cells in such chimeras has not been reported. Two lymphocyte lines derived from the CD16+ fraction of an adenosine deaminase (ADA)-deficient male SCID's blood mononuclear cells (MNC) 13 months following maternal marrow stem cell transplantation demonstrated typical phenotypic and functional characteristics of NK cells after expansion. Karyotyping showed both lines to be XX. Thus, NK cell engraftment can occur in SCID infants who have not been conditioned, even when significant NK cell function is present before transplantation.

Alzheimer's disease in the context of black (Southern) culture.

Medical and lay interest in Alzheimer's disease has increased dramatically in recent years. A newly developing aspect of this overall interest centers on assessing the nature and impact of Alzheimer's in the context of minority populations. This article seeks to add to the scant literature on culture, ethnicity, and Alzheimer's disease. The paper considers clarification of some key terms "culture," "ethnicity," and "race" as an important initial step in placing Alzheimer's within any cultural context. The focus of the present article is southern (American) culture and its most common northern representative, black culture. The paper shows that the meanings and signification of symptoms associated with alzheimer's are likely to be interpreted in terms of a folk medical system's models of illness, which is described, and not in terms of biomedical models. The cultural contextual basis of symptom assessment, the cultural meaning of symptoms and their implications for help-seeking are discussed as are features of family social organization in black southern culture which have implications for care-giving and care-burdens.

Visible saints: social cynosures and dysphoria in the Mediterranean tradition.

"Visible saints" are individuals in the Mediterranean culture area who lead lives of heroic, exemplary and public suffering. This paper offers an analysis of visible saints as social cynosures as a means of exploring critical cultural psychiatric issues. We examine the changing nature of saintly suffering in the culture area and look at the media through which familiarity with the saints and their passions is developed and maintained. A detailed clinical case study is presented of "Madame Lorca," identified by her peers as a "saint." We focus on a particular illness episode which proved to be an amplification of symptoms of long standing. Psychiatric diagnostic instruments were administered and indicated the presence of severe clinical depression. However, our research suggests that Mme. Lorca's symptomatology reflects culturally specific methods of coping with dysphoric affects and chronic illness. The paper concludes with an exploration of the nature of personal illness as it relates to a wider cultural system of meaning. The findings demonstrate that the visible saint and her symptomatology are part of a cultural system which generates, promotes, patterns and frames the experience of dysphoric affect in a cultural complex quite distinct from that of clinical depression.

The twice-born: 'Christian psychiatry' and Christian psychiatrists.

This essay introduces Christian psychiatrists into the growing literature on Western psychiatry and biomedicine. It seeks to describe specific beliefs and practices of Christian psychiatrists as a means of examining the reality of an ascribed corporate existence, i.e., 'Christian Psychiatry'. Beliefs and practices examined here include conceptions of therapeutic relationships and processes, conceptions of Divinity, Explanatory Models, notions of the nature and sources of healing, self identity, and role relationships of Christian psychiatrists vis-à-vis patients and the wider society. The data suggest that there is no 'Christian Psychiatry', but only Christian psychiatrists. Implications for patient care and the cultural basis of ideology and practice in psychiatry are also discussed.

Definitions and diagnoses: cultural implications of psychiatric help-seeking and psychiatrists' definitions of the situation in psychiatric emergencies.

This paper explores lay and psychiatric actors' definitions of mental illness by focusing on several aspects of emergency psychiatric diagnosis. First, it considers psychiatric diagnosis as a social and cultural process in which mental illnesses are defined with increasing specificity as individuals move from lay to psychiatric contexts. Second, the paper considers variation in psychiatric residents' conceptions of mental illness, their role in emergency contexts, and lastly, their diagnostic styles. Diagnostic styles are shown to exist and to be grounded in residents' definitions of the situation. It is suggested that the variation in psychiatrists' definitions of the psychiatric situation, especially as regards etiology, plays a prominent, but as yet unnoted, role in producing variability in psychiatric diagnosis. It is also argued that actors' definitions are cultural, grounded in non-professional lay ideology, and are not products of secondary professional socialization.