U.S. Is Weighing Stronger Action in Syrian Conflict

Francisco Leong/Agence France-Presse — Getty Images

Rebels in northern Syria celebrated on Wednesday next to what was reported to be a government fighter jet.

WASHINGTON — The Obama administration, hoping that the conflict in Syria has reached a turning point, is considering deeper intervention to help push President Bashar al-Assad from power, according to government officials involved in the discussions.

While no decisions have been made, the administration is considering several alternatives, including directly providing arms to some opposition fighters.

The most urgent decision, likely to come next week, is whether NATO should deploy surface-to-air missiles in Turkey, ostensibly to protect that country from Syrian missiles that could carry chemical weapons. The State Department spokeswoman, Victoria Nuland, said Wednesday that the Patriot missile system would not be “for use beyond the Turkish border.”

But some strategists and administration officials believe that Syrian Air Force pilots might fear how else the missile batteries could be used. If so, they could be intimidated from bombing the northern Syrian border towns where the rebels control considerable territory. A NATO survey team is in Turkey, examining possible sites for the batteries.

Other, more distant options include directly providing arms to opposition fighters rather than only continuing to use other countries, especially Qatar, to do so. A riskier course would be to insert C.I.A. officers or allied intelligence services on the ground in Syria, to work more closely with opposition fighters in areas that they now largely control.

Administration officials discussed all of these steps before the presidential election. But the combination of President Obama’s re-election, which has made the White House more willing to take risks, and a series of recent tactical successes by rebel forces, one senior administration official said, “has given this debate a new urgency, and a new focus.”

The outcome of the broader debate about how heavily America should intervene in another Middle Eastern conflict remains uncertain. Mr. Obama’s record in intervening in the Arab Spring has been cautious: While he joined in what began as a humanitarian effort in Libya, he refused to put American military forces on the ground and, with the exception of a C.I.A. and diplomatic presence, ended the American role as soon as Col. Muammar el-Qaddafi was toppled.

In the case of Syria, a far more complex conflict than Libya’s, some officials continue to worry that the risks of intervention — both in American lives and in setting off a broader conflict, potentially involving Turkey — are too great to justify action. Others argue that more aggressive steps are justified in Syria by the loss in life there, the risks that its chemical weapons could get loose, and the opportunity to deal a blow to Iran’s only ally in the region. The debate now coursing through the White House, the Pentagon, the State Department and the C.I.A. resembles a similar one among America’s main allies.

“Look, let’s be frank, what we’ve done over the last 18 months hasn’t been enough,” Britain’s prime minister, David Cameron, said three weeks ago after visiting a Syrian refugee camp in Jordan. “The slaughter continues, the bloodshed is appalling, the bad effects it’s having on the region, the radicalization, but also the humanitarian crisis that is engulfing Syria. So let’s work together on really pushing what more we can do.” Mr. Cameron has discussed those options directly with Mr. Obama, White House officials say.

France and Britain have recognized a newly formed coalition of opposition groups, which the United States helped piece together. So far, Washington has not done so.

American officials and independent specialists on Syria said that the administration was reviewing its Syria policy in part to gain credibility and sway with opposition fighters, who have seized key Syrian military bases in recent weeks.

“The administration has figured out that if they don’t start doing something, the war will be over and they won’t have any influence over the combat forces on the ground,” said Jeffrey White, a former Defense Intelligence Agency intelligence officer and specialist on the Syria military. “They may have some influence with various political groups and factions, but they won’t have influence with the fighters, and the fighters will control the territory.”

Jessica Brandt contributed reporting from Cambridge, Mass.

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Facebook Gift Store Urges Users to Shop While They Share

SAN FRANCISCO — Facebook is already privy to its users’ e-mail addresses, wedding pictures and political beliefs. Now the company is nudging them to share a bit more: credit card numbers and offline addresses.

James Best Jr./The New York Times

Facebook Gifts is a service that prompts users to buy things for friends on the social network.

Sharing Even More

What do you think about Facebook’s plan to have users buy gifts for their friends through the site using their credit cards?

A screenshot of Facebook Gifts.

The nudge comes from a new Facebook service called Gifts. It allows Facebook users — only in the United States for now — to buy presents for their friends on the social network. On offer are items as varied as spices from Dean & DeLuca, pajamas from BabyGap and subscriptions to Hulu Plus, the video service. This week Facebook added iTunes gift cards.

The gift service is part of an aggressive moneymaking push aimed at pleasing Facebook’s investors after the company’s dismal stock market debut. Facebook has stepped up mobile advertising and is starting to customize the marketing messages it shows to users based on their Web browsing outside Facebook.

Those efforts seem to have brought some relief to Wall Street. Analysts issued more bullish projections for the company in recent days, and the stock was up 49 percent from its lowest point, closing Tuesday at $26.15, although that is still well below the initial offering price of $38. The share price has been buoyed in part by the fact that a wave of insider lockup periods expired without a flood of shares hitting the market.

To power the Gifts service, Facebook rented a warehouse in South Dakota and created its own software to track inventory and shipping. It will not say how much it earns from each purchase made through Gifts, though merchants that have a similar arrangement with Amazon.com give it a roughly 15 percent cut of sales.

If it catches on, the service would give Facebook a toehold in the more than $200 billion e-commerce market. Much more important, it would let the company accumulate a new stream of valuable personal data and use it to refine targeted advertisements, its bread and butter. The company said it did not now use data collected through Gifts for advertising purposes, but could not rule it out in the future.

“The hard part for Facebook was aggregating a billion users. Now it’s more about how to monetize those users without scaring them away,” said Colin Sebastian, an analyst with Robert W. Baird.

He added: “Gifts should also contribute more to Facebook’s treasure trove of user data, which has the benefit of a virtuous cycle, driving more personalization of the site, leading to better and more targeted ads, which improves overall monetization.”

Facebook already collects credit card information from users who play social games on its site. But they are a limited constituency, and a wider audience may be persuaded to buy a gift when Facebook reminds them that a friend is expecting a baby or a cousin is approaching her 40th birthday.

The Gifts service, which grew out of Facebook’s acquisition of a mobile application called Karma, was introduced in September and expanded earlier this month on the eve of the holiday shopping season.

Magnolia Bakery, based in New York, was among Facebook’s early partners for Gifts. Its vice president for public relations, Sara Gramling, said the company had sold roughly 200 packages of treats since then. She counted it as a marketing success. The bakery, which gained fame thanks to “Sex and the City,” had only recently begun shipping its goods. “It was a great opportunity to expand our network,” she said.

Magnolia Bakery isn’t exactly catering to the masses. A half-dozen cupcakes cost $35, plus about $12 for shipping. Facebook, Ms. Gramling said, takes care of the billing. The bakery is eyeing Facebook’s global reach, too, as it opens outlets internationally, especially in the Middle East.

One of the appeals of Facebook Gifts is the ease of making a purchase. Facebook users are nudged to buy a gift (a gift-box icon pops up) for Facebook friends on their birthdays. They are offered a vast menu to choose from: beer glasses, cake pops, quilts, marshmallows, magazine subscriptions and donations to charity. They are asked to choose a greeting card. Then they are asked for credit card details. Facebook says it stores that credit card information, unless users remove it after making a purchase.

Facebook has declined to say how many users have bought gifts, only that among those who have, the average purchase is $25.

David Streitfeld contributed reporting.

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The New Old Age Blog: Doctor's Orders? Another Test

It is no longer news that Americans, and older Americans in particular, get more routine screening tests than they need, more than are useful. Prostate tests for men over 75, annual Pap smears for women over 65 and colonoscopies for anyone over 75 — all are overused, large-scale studies have shown.

Now it appears that many older patients are also subjected to too-frequent use of the other kind of testing, diagnostic tests.

The difference, in brief: Screening tests are performed on people who are asymptomatic, who aren’t complaining of a health problem, as a way to detect incipient disease. We have heard for years that it is best to “catch it early” — “it” frequently being cancer — and though that turns out to be only sometimes true, we and our doctors often ignore medical guidelines and ongoing campaigns to limit and target screening tests.

Diagnostic tests, on the other hand, are meant to help doctors evaluate some symptom or problem. “You’re trying to figure out what’s wrong,” explained Gilbert Welch, a veteran researcher at the Dartmouth Institute for Health Policy and Clinical Practice.

For these tests, medical groups and task forces offer many fewer guidelines on who should get them and how often — there is not much evidence to go on — but there is general agreement that they are not intended for routine surveillance.

But a study using a random 5 percent sample of Medicare beneficiaries — nearly 750,000 of them — suggests that often, that is what’s happening.

“It begins to look like some of these tests are being routinely repeated, and it’s worrisome,” said Dr. Welch, lead author of the study just published in The Archives of Internal Medicine. “Some physicians are just doing them every year.”

He is talking about tests like echocardiography, or a sonogram of the heart. More than a quarter of the sample (28.5 percent) underwent this test between 2004 and 2006, and more than half of those patients (55 percent) had a repeat echocardiogram within three years, most commonly within a year of the first.

Other common tests were frequently repeated as well. Of patients who underwent an imaging stress test, using a treadmill or stationery bike (or receiving a drug) to make the heart work harder, nearly 44 percent had a repeat test within three years. So did about half of those undergoing pulmonary function tests and chest tomography, a CAT scan of the chest.

Cytoscopy (a procedure in which a viewing tube is inserted into the bladder) was repeated for about 41 percent of the patients, and endoscopy (a swallowed tube enters the esophagus and stomach) for more than a third.

Is this too much testing? Without evidence of how much it harms or helps patients, it is hard to say — but the researchers were startled by the extent of repetition. “It’s inconceivable that it’s all important,” Dr. Welch said. “Unfortunately, it looks like it’s important for doctors.”

The evidence for that? The study revealed big geographic differences in diagnostic testing. Looking at the country’s 50 largest metropolitan areas, it found that nearly half the sample’s patients in Miami had an echocardiogram between 2004 and 2006, and two thirds of them had another echocardiogram within three years — the highest rate in the nation.

In fact, for the six tests the study included, five were performed and repeated most often in Florida cities: Miami, Jacksonville and Orlando. “They’re heavily populated by physicians and they have a long history of being at the top of the list” of areas that do a lot of medical procedures and hospitalizations, Dr. Welch said.

But in Portland, Ore., where “the physician culture is very different,” only 17.5 percent of patients had an echocardiogram. The places most prone to testing were also the places with high rates of repeat testing. Portland, San Francisco and Sacramento had the lowest rates.

We often don’t think of tests as having a downside, but they do. “This is the way whole cascades can start that are hard to stop,” Dr. Welch said. “The more we subject ourselves, the more likely some abnormality shows up that may require more testing, some of which has unwanted consequences.”

Properly used, of course, diagnostic tests can provide crucial information for sick people. “But used without a good indication, they can stir up a hornet’s nest,” he said. And of course they cost Medicare a bundle.

An accompanying commentary, sounding distinctly exasperated, pointed out that efforts to restrain overtesting and overtreatment have continued for decades. The commentary called it “discouraging to contemplate fresh evidence by Welch et al of our failure to curb waste of health care resources.”

It is hard for laypeople to know when tests make sense, but clearly we need to keep track of those we and our family members have. That way, if the cardiologist suggests another echocardiogram, we can at least ask a few pointed questions:

“My father just had one six months ago. Is it necessary to have another so soon? What information do you hope to gain that you didn’t have last time? Will the results change the way we manage his condition?”

Questions are always a good idea. Especially in Florida.

Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

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The New Old Age Blog: Doctor's Orders? Another Test

It is no longer news that Americans, and older Americans in particular, get more routine screening tests than they need, more than are useful. Prostate tests for men over 75, annual Pap smears for women over 65 and colonoscopies for anyone over 75 — all are overused, large-scale studies have shown.

Now it appears that many older patients are also subjected to too-frequent use of the other kind of testing, diagnostic tests.

The difference, in brief: Screening tests are performed on people who are asymptomatic, who aren’t complaining of a health problem, as a way to detect incipient disease. We have heard for years that it is best to “catch it early” — “it” frequently being cancer — and though that turns out to be only sometimes true, we and our doctors often ignore medical guidelines and ongoing campaigns to limit and target screening tests.

Diagnostic tests, on the other hand, are meant to help doctors evaluate some symptom or problem. “You’re trying to figure out what’s wrong,” explained Gilbert Welch, a veteran researcher at the Dartmouth Institute for Health Policy and Clinical Practice.

For these tests, medical groups and task forces offer many fewer guidelines on who should get them and how often — there is not much evidence to go on — but there is general agreement that they are not intended for routine surveillance.

But a study using a random 5 percent sample of Medicare beneficiaries — nearly 750,000 of them — suggests that often, that is what’s happening.

“It begins to look like some of these tests are being routinely repeated, and it’s worrisome,” said Dr. Welch, lead author of the study just published in The Archives of Internal Medicine. “Some physicians are just doing them every year.”

He is talking about tests like echocardiography, or a sonogram of the heart. More than a quarter of the sample (28.5 percent) underwent this test between 2004 and 2006, and more than half of those patients (55 percent) had a repeat echocardiogram within three years, most commonly within a year of the first.

Other common tests were frequently repeated as well. Of patients who underwent an imaging stress test, using a treadmill or stationery bike (or receiving a drug) to make the heart work harder, nearly 44 percent had a repeat test within three years. So did about half of those undergoing pulmonary function tests and chest tomography, a CAT scan of the chest.

Cytoscopy (a procedure in which a viewing tube is inserted into the bladder) was repeated for about 41 percent of the patients, and endoscopy (a swallowed tube enters the esophagus and stomach) for more than a third.

Is this too much testing? Without evidence of how much it harms or helps patients, it is hard to say — but the researchers were startled by the extent of repetition. “It’s inconceivable that it’s all important,” Dr. Welch said. “Unfortunately, it looks like it’s important for doctors.”

The evidence for that? The study revealed big geographic differences in diagnostic testing. Looking at the country’s 50 largest metropolitan areas, it found that nearly half the sample’s patients in Miami had an echocardiogram between 2004 and 2006, and two thirds of them had another echocardiogram within three years — the highest rate in the nation.

In fact, for the six tests the study included, five were performed and repeated most often in Florida cities: Miami, Jacksonville and Orlando. “They’re heavily populated by physicians and they have a long history of being at the top of the list” of areas that do a lot of medical procedures and hospitalizations, Dr. Welch said.

But in Portland, Ore., where “the physician culture is very different,” only 17.5 percent of patients had an echocardiogram. The places most prone to testing were also the places with high rates of repeat testing. Portland, San Francisco and Sacramento had the lowest rates.

We often don’t think of tests as having a downside, but they do. “This is the way whole cascades can start that are hard to stop,” Dr. Welch said. “The more we subject ourselves, the more likely some abnormality shows up that may require more testing, some of which has unwanted consequences.”

Properly used, of course, diagnostic tests can provide crucial information for sick people. “But used without a good indication, they can stir up a hornet’s nest,” he said. And of course they cost Medicare a bundle.

An accompanying commentary, sounding distinctly exasperated, pointed out that efforts to restrain overtesting and overtreatment have continued for decades. The commentary called it “discouraging to contemplate fresh evidence by Welch et al of our failure to curb waste of health care resources.”

It is hard for laypeople to know when tests make sense, but clearly we need to keep track of those we and our family members have. That way, if the cardiologist suggests another echocardiogram, we can at least ask a few pointed questions:

“My father just had one six months ago. Is it necessary to have another so soon? What information do you hope to gain that you didn’t have last time? Will the results change the way we manage his condition?”

Questions are always a good idea. Especially in Florida.

Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

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Gadgetwise Blog: Tip of the Week: Screen Savers That Educate

Screen saver programs, originally intended to help prevent damage to older computer monitors, are often used now for security or entertainment purposes when the computer is idle. Most operating systems include a few built-in screen savers that display animated geometric patterns or photos, but you do not have to go too far to find screen savers that educate as well.

Windows users still trying to get the hang of Microsoft Office 2010, for example, can grab a free screen saver that shows tips for using the software. A trial version of the Universal Tutor screen saver from Cool Educational Software is available; an annual subscription costs $30.

Recent versions of Mac OS X have included screen savers that display the Word of the Day from the New Oxford American Dictionary, or an RSS Visualizer that pulls down headlines from online news sources. To see what is available in your version of Mac OS X, click the System Preferences icon in the Dock, click on the Desktop and Screen Saver icon and click the Screen Saver tab in the box.

Plenty of shareware sites offer free screen savers, but be careful when installing any third-party program, as malicious software may also be along for the ride. Screen savers can also sap resources from the computer, so go to your computer’s settings and just set your monitor to turn off after a short period of inactivity if you would rather not lose processing power. But if your computer has power to spare, donating its idle time to a group-computing effort like SETI@Home or one from the Boinc project usually gets you an interesting screen saver — while helping scientific causes.

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News Analysis: Sunni Leaders Gaining Clout in Mideast

Mohammed Saber/European Pressphoto Agency

A Palestinian woman in Gaza City on Tuesday walked amid the rubble left from eight days of fighting that ended in a cease-fire.

RAMALLAH, West Bank — For years, the United States and its Middle East allies were challenged by the rising might of the so-called Shiite crescent, a political and ideological alliance backed by Iran that linked regional actors deeply hostile to Israel and the West.

But uprising, wars and economics have altered the landscape of the region, paving the way for a new axis to emerge, one led by a Sunni Muslim alliance of Egypt, Qatar and Turkey. That triumvirate played a leading role in helping end the eight-day conflict between Israel and Gaza, in large part by embracing Hamas and luring it further away from the Iran-Syria-Hezbollah fold, offering diplomatic clout and promises of hefty aid.

For the United States and Israel, the shifting dynamics offer a chance to isolate a resurgent Iran, limit its access to the Arab world and make it harder for Tehran to arm its agents on Israel’s border. But the gains are also tempered, because while these Sunni leaders are willing to work with Washington, unlike the mullahs in Tehran, they also promote a radical religious-based ideology that has fueled anti-Western sentiment around the region.

Hamas — which received missiles from Iran that reached Israel’s northern cities — broke with the Iranian axis last winter, openly backing the rebellion against the Syrian president, Bashar al-Assad. But its affinity with the Egypt-Qatar-Turkey axis came to fruition this fall.

“That camp has more assets that it can share than Iran — politically, diplomatically, materially,” said Robert Malley, the Middle East program director for the International Crisis Group. “The Muslim Brotherhood is their world much more so than Iran.”

The Gaza conflict helps illustrate how Middle Eastern alliances have evolved since the Islamist wave that toppled one government after another beginning in January 2011. Iran had no interest in a cease-fire, while Egypt, Qatar and Turkey did.

But it is the fight for Syria that is the defining struggle in this revived Sunni-Shiite duel. The winner gains a prized strategic crossroads.

For now, it appears that that tide is shifting against Iran, there too, and that it might well lose its main Arab partner, Syria. The Sunni-led opposition appears in recent days to have made significant inroads against the government, threatening the Assad family’s dynastic rule of 40 years and its long alliance with Iran. If Mr. Assad falls, that would render Iran and Hezbollah, which is based in Lebanon, isolated as a Shiite Muslim alliance in an ever more sectarian Middle East, no longer enjoying a special street credibility as what Damascus always tried to sell as “the beating heart of Arab resistance.”

If the shifts seem to leave the United States somewhat dazed, it is because what will emerge from all the ferment remains obscure.

Clearly the old leaders Washington relied on to enforce its will, like President Hosni Mubarak of Egypt, are gone or at least eclipsed. But otherwise confusion reigns in terms of knowing how to deal with this new paradigm, one that could well create societies infused with religious ideology that Americans find difficult to accept. The new reality could be a weaker Iran, but a far more religiously conservative Middle East that is less beholden to the United States.

Already, Islamists have been empowered in Egypt, Libya and Tunisia, while Syria’s opposition is being led by Sunni insurgents, including a growing number identified as jihadists, some identified as sympathizing with Al Qaeda. Qatar, which hosts a major United States military base, also helps finance Islamists all around the region.

In Egypt, President Mohamed Morsi resigned as a member of the Muslim Brotherhood only when he became head of state, but he still remains closely linked with the movement. Turkey, the model for many of them, has kept strong relations with Washington while diminishing the authority of generals who were longstanding American allies.

“The United States is part of a landscape that has shifted so dramatically,” said Mr. Malley of the International Crisis Group. “It is caught between the displacement of the old moderate-radical divide by one that is defined by confessional and sectarian loyalty.”

The emerging Sunni axis has put not only Shiites at a disadvantage, but also the old school leaders who once allied themselves with Washington.

The old guard members in the Palestinian Authority are struggling to remain relevant at a time when their failed 20-year quest to end the Israeli occupation of Palestinian lands makes them seem both anachronistic and obsolete.

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Puerto Rico Races to Rescue Its Pension Fund

Puerto Rico is fighting to stay afloat in a rising sea of debt.

Its economy is sputtering. Its population is shrinking. Its recent election is disputed. Its public pension fund is perilously low on cash. The American territory has just been through a brutal five-year recession, something not experienced in the United States as a whole since the 1930s.

Desperate to raise cash, Puerto Rican officials have been selling off anything they can: two toll roads and the main airport so far.

To bring in tax revenue, they are trying to lure people out of the underground economy. Coffee shops, hairdressers, even outdoor market stalls are being required to issue printed receipts with every sale. The receipts carry a lottery number, with a chance to win cars or cash, as an incentive to get shoppers to pay the island’s 7 percent sales tax.

Though many of Puerto Rico’s problems are reminiscent of Greece’s — tax noncompliance, a stagnant economy, years of issuing long-term debt to cover short-term payments — investors have had a nearly insatiable appetite for its bonds.

But now their support is dwindling. Some big investors are pruning their holdings. That is beginning to widen the cost of borrowing for Puerto Rico relative to other states and municipalities, which are benefiting from a big decline in borrowing costs. The interest rate its 30-year bonds now pay is about 2.5 percentage points higher than other municipal borrowers’, up from a difference of just 1.5 percentage points at the beginning of 2012, according to Municipal Market Data.

The possibility of a credit downgrade also hangs in the air, something that could lead to more selling.

“There is no specific event looming on the horizon,” said Alan Schankel, a managing director at Janney Capital Markets in Philadelphia. “But it’s a problem of immense magnitude, and it’s very challenging to sit here and see how they work their way out of it.”

Puerto Rico needs to be able to issue bonds at attractive rates to cover its short-term financing needs. Perhaps more important, it has to figure out how to salvage its retirement funds. After shortchanging them for years, it now has the weakest major public pension system in America.

The main fund, which serves about 250,000 government workers, past and present, is only 6 percent funded — a small percentage of what is considered the minimum needed for a marginally healthy pension plan — and could run out of money as soon as 2014. Another fund, for about 80,000 teachers, which is 20 percent funded, will last just a few years longer if nothing is done. Police officers and teachers in Puerto Rico have opted out of Social Security and rely entirely on their pensions.

“For now, I’m not totally shaken about the possibility of the fund going broke,” said Jorge Ramón Román, a 78-year-old retired instructor for the island’s Civil Air Patrol. “But I do fear for the future, when I’ll be an even older person, more infirm and with less of a pension.”

Héctor M. Mayol Kauffman, the executive director of the pension system, said it would be impossible to cut the benefits of people who are already retired, citing court precedent.

Puerto Rican officials were racing this fall to put together a rescue plan for the pension fund. Voters, though, pushed out Gov. Luis Fortuño, who had tried austerity measures that included cutting tens of thousands of government workers along with a revamping of the fund.

They elected Alejandro García Padilla, who promised to create 50,000 new jobs in the next 18 months. But the margin was razor-thin and Mr. Fortuño has requested a recount. Mr. García Padilla’s party had dropped out of the retirement overhaul effort, but the governor-elect says he will deal with the looming pension crisis with “diligence and promptness” and has put together a task force of economists and financial advisers.

“We will not leave retired government workers stranded at a bus stop in their older years,” he said.

Since the election, yields on the island’s 30-year bonds have continued to widen.

“I don’t think that there’s a default that’s about to happen, but a default isn’t the only bad thing that can happen when you’ve got bonds,” Mr. Schankel said. Puerto Rico’s bonds are just a notch or two above junk status. If they fall to that level, at least some institutions would be forced to sell, potentially setting off a chain reaction. And individual investors could get a jolt if they saw the value of their holdings fall. Many people own Puerto Rican debt without knowing it, through their mutual funds.

“The concern is that Puerto Rico is a systemic risk to the municipal bond market because it’s so widely held,” said Robert Donahue, a managing director with Municipal Market Advisors.

Rafael Matos contributed reporting from San Juan, P.R.

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Clearing the Fog Around Personality Disorders

For years they have lived as orphans and outliers, a colony of misfit characters on their own island: the bizarre one and the needy one, the untrusting and the crooked, the grandiose and the cowardly.

Their customs and rituals are as captivating as any tribe’s, and at least as mystifying. Every mental anthropologist who has visited their world seems to walk away with a different story, a new model to explain those strange behaviors.

This weekend the Board of Trustees of the American Psychiatric Association will vote on whether to adopt a new diagnostic system for some of the most serious, and striking, syndromes in medicine: personality disorders.

Personality disorders occupy a troublesome niche in psychiatry. The 10 recognized syndromes are fairly well represented on the self-help shelves of bookstores and include such well-known types as narcissistic personality disorder, avoidant personality disorder, as well as dependent and histrionic personalities.

But when full-blown, the disorders are difficult to characterize and treat, and doctors seldom do careful evaluations, missing or downplaying behavior patterns that underlie problems like depression and anxiety in millions of people.

The new proposal — part of the psychiatric association’s effort of many years to update its influential diagnostic manual — is intended to clarify these diagnoses and better integrate them into clinical practice, to extend and improve treatment. But the effort has run into so much opposition that it will probably be relegated to the back of the manual, if it’s allowed in at all.

Dr. David J. Kupfer, a professor of psychiatry at the University of Pittsburgh and chairman of the task force updating the manual, would not speculate on which way the vote might go: “All I can say is that personality disorders were one of the first things we tackled, but that doesn’t make it the easiest.”

The entire exercise has forced psychiatrists to confront one of the field’s most elementary, yet still unresolved, questions: What, exactly, is a personality problem?

Habits of Thought

It wasn’t supposed to be this difficult.

Personality problems aren’t exactly new or hidden. They play out in Greek mythology, from Narcissus to the sadistic Ares. They percolate through biblical stories of madmen, compulsives and charismatics. They are writ large across the 20th century, with its rogues’ gallery of vainglorious, murderous dictators.

Yet it turns out that producing precise, lasting definitions of extreme behavior patterns is exhausting work. It took more than a decade of observing patients before the German psychiatrist Emil Kraepelin could draw a clear line between psychotic disorders, like schizophrenia, and mood problems, like depression or bipolar disorder.

Likewise, Freud spent years formulating his theories on the origins of neurotic syndromes. And Freudian analysts were largely the ones who, in the early decades of the last century, described people with the sort of “confounded identities” that are now considered personality disorders.

Their problems were not periodic symptoms, like moodiness or panic attacks, but issues rooted in longstanding habits of thought and feeling — in who they were.

“These therapists saw people coming into treatment who looked well put-together on the surface but on the couch became very disorganized, very impaired,” said Mark F. Lenzenweger, a professor of psychology at the State University of New York at Binghamton. “They had problems that were neither psychotic nor neurotic. They represented something else altogether.”

Several prototypes soon began to emerge. “A pedantic sense of order is typical of the compulsive character,” wrote the Freudian analyst Wilhelm Reich in his 1933 book, “Character Analysis,” a groundbreaking text. “In both big and small things, he lives his life according to a preconceived, irrevocable pattern.”

Others coalesced too, most recognizable as extreme forms of everyday types: the narcissist, with his fragile, grandiose self-approval; the dependent, with her smothering clinginess; the histrionic, always in the thick of some drama, desperate to be the center of attention.

In the late 1970s, Ted Millon, scientific director of the Institute for Advanced Studies in Personology and Psychopathology, pulled together the bulk of the work on personality disorders, most of it descriptive, and turned it into a set of 10 standardized types for the American Psychiatric Association’s third diagnostic manual. Published in 1980, it is a best seller among mental health workers worldwide.

These diagnostic criteria held up well for years and led to improved treatments for some people, like those with borderline personality disorder. Borderline is characterized by an extreme neediness and urges to harm oneself, often including thoughts of suicide. Many who seek help for depression also turn out to have borderline patterns, making their mood problems resistant to the usual therapies, like antidepressant drugs.

Today there are several approaches that can relieve borderline symptoms and one that, in numerous studies, has reduced hospitalizations and helped aid recovery: dialectical behavior therapy.

This progress notwithstanding, many in the field began to argue that the diagnostic catalog needed a rewrite. For one thing, some of the categories overlapped, and troubled people often got two or more personality diagnoses. “Personality Disorder-Not Otherwise Specified,” a catchall label meaning little more than “this person has problems” became the most common of the diagnoses.

It’s a murky area, and in recent years many therapists didn’t have the time or training to evaluate personality on top of everything else. The assessment interviews can last hours, and treatments for most of the disorders involve longer-term, specialized talk therapy.

Psychiatry was failing the sort of patients that no other field could possibly help, many experts said.

“The diagnoses simply weren’t being used very much, and there was a real need to make the whole system much more accessible,” Dr. Lenzenweger said.

Resisting Simplification 

It was easier said than done.

The most central, memorable, and knowable element of any person — personality — still defies any consensus.

A team of experts appointed by the psychiatric association has worked for more than five years to find some unifying system of diagnosis for personality problems.

The panel proposed a system based in part on a failure to “develop a coherent sense of self or identity.” Not good enough, some psychiatric theorists said.

Later, the experts tied elements of the disorders to distortions in basic traits.

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Clearing the Fog Around Personality Disorders

For years they have lived as orphans and outliers, a colony of misfit characters on their own island: the bizarre one and the needy one, the untrusting and the crooked, the grandiose and the cowardly.

Their customs and rituals are as captivating as any tribe’s, and at least as mystifying. Every mental anthropologist who has visited their world seems to walk away with a different story, a new model to explain those strange behaviors.

This weekend the Board of Trustees of the American Psychiatric Association will vote on whether to adopt a new diagnostic system for some of the most serious, and striking, syndromes in medicine: personality disorders.

Personality disorders occupy a troublesome niche in psychiatry. The 10 recognized syndromes are fairly well represented on the self-help shelves of bookstores and include such well-known types as narcissistic personality disorder, avoidant personality disorder, as well as dependent and histrionic personalities.

But when full-blown, the disorders are difficult to characterize and treat, and doctors seldom do careful evaluations, missing or downplaying behavior patterns that underlie problems like depression and anxiety in millions of people.

The new proposal — part of the psychiatric association’s effort of many years to update its influential diagnostic manual — is intended to clarify these diagnoses and better integrate them into clinical practice, to extend and improve treatment. But the effort has run into so much opposition that it will probably be relegated to the back of the manual, if it’s allowed in at all.

Dr. David J. Kupfer, a professor of psychiatry at the University of Pittsburgh and chairman of the task force updating the manual, would not speculate on which way the vote might go: “All I can say is that personality disorders were one of the first things we tackled, but that doesn’t make it the easiest.”

The entire exercise has forced psychiatrists to confront one of the field’s most elementary, yet still unresolved, questions: What, exactly, is a personality problem?

Habits of Thought

It wasn’t supposed to be this difficult.

Personality problems aren’t exactly new or hidden. They play out in Greek mythology, from Narcissus to the sadistic Ares. They percolate through biblical stories of madmen, compulsives and charismatics. They are writ large across the 20th century, with its rogues’ gallery of vainglorious, murderous dictators.

Yet it turns out that producing precise, lasting definitions of extreme behavior patterns is exhausting work. It took more than a decade of observing patients before the German psychiatrist Emil Kraepelin could draw a clear line between psychotic disorders, like schizophrenia, and mood problems, like depression or bipolar disorder.

Likewise, Freud spent years formulating his theories on the origins of neurotic syndromes. And Freudian analysts were largely the ones who, in the early decades of the last century, described people with the sort of “confounded identities” that are now considered personality disorders.

Their problems were not periodic symptoms, like moodiness or panic attacks, but issues rooted in longstanding habits of thought and feeling — in who they were.

“These therapists saw people coming into treatment who looked well put-together on the surface but on the couch became very disorganized, very impaired,” said Mark F. Lenzenweger, a professor of psychology at the State University of New York at Binghamton. “They had problems that were neither psychotic nor neurotic. They represented something else altogether.”

Several prototypes soon began to emerge. “A pedantic sense of order is typical of the compulsive character,” wrote the Freudian analyst Wilhelm Reich in his 1933 book, “Character Analysis,” a groundbreaking text. “In both big and small things, he lives his life according to a preconceived, irrevocable pattern.”

Others coalesced too, most recognizable as extreme forms of everyday types: the narcissist, with his fragile, grandiose self-approval; the dependent, with her smothering clinginess; the histrionic, always in the thick of some drama, desperate to be the center of attention.

In the late 1970s, Ted Millon, scientific director of the Institute for Advanced Studies in Personology and Psychopathology, pulled together the bulk of the work on personality disorders, most of it descriptive, and turned it into a set of 10 standardized types for the American Psychiatric Association’s third diagnostic manual. Published in 1980, it is a best seller among mental health workers worldwide.

These diagnostic criteria held up well for years and led to improved treatments for some people, like those with borderline personality disorder. Borderline is characterized by an extreme neediness and urges to harm oneself, often including thoughts of suicide. Many who seek help for depression also turn out to have borderline patterns, making their mood problems resistant to the usual therapies, like antidepressant drugs.

Today there are several approaches that can relieve borderline symptoms and one that, in numerous studies, has reduced hospitalizations and helped aid recovery: dialectical behavior therapy.

This progress notwithstanding, many in the field began to argue that the diagnostic catalog needed a rewrite. For one thing, some of the categories overlapped, and troubled people often got two or more personality diagnoses. “Personality Disorder-Not Otherwise Specified,” a catchall label meaning little more than “this person has problems” became the most common of the diagnoses.

It’s a murky area, and in recent years many therapists didn’t have the time or training to evaluate personality on top of everything else. The assessment interviews can last hours, and treatments for most of the disorders involve longer-term, specialized talk therapy.

Psychiatry was failing the sort of patients that no other field could possibly help, many experts said.

“The diagnoses simply weren’t being used very much, and there was a real need to make the whole system much more accessible,” Dr. Lenzenweger said.

Resisting Simplification 

It was easier said than done.

The most central, memorable, and knowable element of any person — personality — still defies any consensus.

A team of experts appointed by the psychiatric association has worked for more than five years to find some unifying system of diagnosis for personality problems.

The panel proposed a system based in part on a failure to “develop a coherent sense of self or identity.” Not good enough, some psychiatric theorists said.

Later, the experts tied elements of the disorders to distortions in basic traits.

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The Hard Road Back: Prosthetic Arms a Complex Test for Amputees

A Future Reset:
After losing his arm in an I.E.D. explosion in Afghanistan, Cpl. Sebastian Gallegos has adjusted to his prosthetic limb.

SAN ANTONIO — After the explosion, Cpl. Sebastian Gallegos awoke to see the October sun glinting through the water, an image so lovely he thought he was dreaming. Then something caught his eye, yanking him back to grim awareness: an arm, bobbing near the surface, a black hair tie wrapped around its wrist.

The elastic tie was a memento of his wife, a dime-store amulet that he wore on every patrol in Afghanistan. Now, from the depths of his mental fog, he watched it float by like driftwood on a lazy current, attached to an arm that was no longer quite attached to him.

He had been blown up, and was drowning at the bottom of an irrigation ditch.

Two years later, the corporal finds himself tethered to a different kind of limb, a $110,000 robotic device with an electronic motor and sensors able to read signals from his brain. He is in the office of his occupational therapist, lifting and lowering a sponge while monitoring a computer screen as it tracks nerve signals in his shoulder.

Close hand, raise elbow, he says to himself. The mechanical arm rises, but the claw-like hand opens, dropping the sponge. Try again, the therapist instructs. Same result. Again. Tiny gears whir, and his brow wrinkles with the mental effort. The elbow rises, and this time the hand remains closed. He breathes.

Success.

“As a baby, you can hold onto a finger,” the corporal said. “I have to relearn.”

It is no small task. Of the more than 1,570 American service members who have had arms, legs, feet or hands amputated because of injuries in Afghanistan or Iraq, fewer than 280 have lost upper limbs. Their struggles to use prosthetic limbs are in many ways far greater than for their lower-limb brethren.

Among orthopedists, there is a saying: legs may be stronger, but arms and hands are smarter. With myriad bones, joints and ranges of motion, the upper limbs are among the body’s most complex tools. Replicating their actions with robotic arms can be excruciatingly difficult, requiring amputees to understand the distinct muscle contractions involved in movements they once did without thinking.

To bend the elbow, for instance, requires thinking about contracting a biceps, though the muscle no longer exists. But the thought still sends a nerve signal that can tell a prosthetic arm to flex. Every action, from grabbing a cup to turning the pages of a book, requires some such exercise in the brain.

“There are a lot of mental gymnastics with upper limb prostheses,” said Lisa Smurr Walters, an occupational therapist who works with Corporal Gallegos at the Center for the Intrepid at Brooke Army Medical Center in San Antonio.

The complexity of the upper limbs, though, is just part of the problem. While prosthetic leg technology has advanced rapidly in the past decade, prosthetic arms have been slow to catch up. Many amputees still use body-powered hooks. And the most common electronic arms, pioneered by the Soviet Union in the 1950s, have improved with lighter materials and microprocessors but are still difficult to control.

Upper limb amputees must also cope with the critical loss of sensation. Touch — the ability to differentiate baby skin from sandpaper or to calibrate between gripping a hammer and clasping a hand — no longer exists.

For all those reasons, nearly half of upper limb amputees choose not to use prostheses, functioning instead with one good arm. By contrast, almost all lower limb amputees use prosthetic legs.

But Corporal Gallegos, 23, is part of a small vanguard of military amputees who are benefiting from new advances in upper limb technology. Earlier this year, he received a pioneering surgery known as targeted muscle reinnervation that amplifies the tiny nerve signals that control the arm. In effect, the surgery creates additional “sockets” into which electrodes from a prosthetic limb can connect.

More sockets reading stronger signals will make controlling his prosthesis more intuitive, said Dr. Todd Kuiken of the Rehabilitation Institute of Chicago, who developed the procedure. Rather than having to think about contracting both the triceps and biceps just to make a fist, the corporal will be able to simply think, close hand, and the proper nerves should fire automatically.

In the coming years, new technology will allow amputees to feel with their prostheses or use pattern-recognition software to move their devices even more intuitively, Dr. Kuiken said. And a new arm under development by the Pentagon, the DEKA Arm, is far more dexterous than any currently available.

But for Corporal Gallegos, becoming proficient on his prosthesis after reinnervation surgery remains a challenge, likely to take months more of tedious practice. For that reason, only the most motivated amputees — super users, they are called — are allowed to undergo the surgery.

Corporal Gallegos was not always that person.

His father, an Army veteran, did not want him to join the infantry, but it was like him to ignore the advice.

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