What’s Wrong With a Child? Psychiatrists Often Disagree
 Attention deficit  with or without hyperactivity (ADD, ADHD), Oppositional Defiant , Impulse Disorder, Bipolar?

Paul Williams, 13, has had almost as many psychiatric diagnoses as birthdays.

The first psychiatrist he saw, at age 7, decided after a 20-minute visit that the boy was suffering from depression.

A grave looking child, quiet and instinctively suspicious of others, he looked depressed, said his mother, Kasan Williams. Yet it soon became clear that the boy was too restless, too explosive, to be suffering from chronic depression.

Paul was a gifted reader, curious, independent. But in fourth grade, after a screaming match with a school counselor, he walked out of the building and disappeared, riding the F train for most of the night through Brooklyn, alone, while his family searched frantically.

It was the second time in two years that he had disappeared for the night, and his mother was determined to find some answers, some guidance.

What followed was a string of office visits with psychologists, social workers and psychiatrists. Each had an idea about what was wrong, and a specific diagnosis: “Compulsive tendencies,” one said. “Oppositional defiant disorder,” another concluded. Others said “pervasive developmental disorder,” or some combination.

Each diagnosis was accompanied by a different regimen of drug treatments.

By the time the boy turned 11, Ms. Williams said, the medical record had taken still another turn — to bipolar disorder — and with it a whole new set of drug prescriptions.

“Basically, they keep throwing things at us,” she said, “and nothing is really sticking.”

At a time when increasing numbers of children are being treated for psychiatric problems, naming those problems remains more an art than a science. Doctors often disagree about what is wrong.

A child’s problems are now routinely given two or more diagnoses at the same time, like attention deficit and bipolar disorders. And parents of disruptive children in particular — those who once might have been called delinquents, or simply “problem children” — say they hear an alphabet soup of labels that seem to change as often as a child’s shoe size.

The confusion is due in part to the patchwork nature of the health care system, experts say. Child psychiatrists are in desperately short supply, and family doctors, pediatricians, psychologists and social workers, each with their own biases, routinely hand out diagnoses.

But there are also deep uncertainties in the field itself. Psychiatrists have no blood tests or brain scans to diagnose mental disorders. They have to make judgments, based on interviews and checklists of symptoms. And unlike most adults, young children are often unable or unwilling to talk about their symptoms, leaving doctors to rely on observation and information from parents and teachers.

Children can develop so fast that what looks like attention deficit disorder in the fall may look like anxiety or nothing at all in the summer. And the field is fiercely divided over some fundamental questions, most notably about bipolar disorder, a disease classically defined by moods that zigzag between periods of exuberance or increased energy and despair. Some experts say that bipolar disorder is being overdiagnosed, but others say it is too often missed.

“Psychiatry has made great strides in helping kids manage mental illness, particularly moderate conditions, but the system of diagnosis is still 200 to 300 years behind other branches of medicine,” said Dr. E. Jane Costello, a professor of psychiatry and behavioral sciences at Duke University. “On an individual level, for many parents and families, the experience can be a disaster; we must say that.”

For these families, Dr. Costello and other experts say, the search for a diagnosis is best seen as a process of trial and error that may not end with a definitive answer.

If a family can find some combination of treatments that help a child improve, she said, “then the diagnosis may not matter much at all.”

A Kaleidoscope of Diagnoses
The most commonly diagnosed mental disorders in younger children include attention deficit hyperactivity disorder, or A.D.H.D., depression and anxiety, and oppositional defiant disorder.

All these labels are based primarily on symptom checklists. According to the American Psychiatric Association’s diagnostic manual, for instance, childhood problems qualify as oppositional defiant disorder if the child exhibits at least four of eight behavior patterns, including “often loses temper,” “often argues with adults,” “is often touchy or easily annoyed by others” and “is often spiteful or vindictive.”

At least six million American children have difficulties that are diagnosed as serious mental disorders, according to government surveys — a number that has tripled since the early 1990s. But there is little convincing evidence that the rates of illness have increased in the past few decades. Rather, many experts say it is the frequency of diagnosis that is going up, in part because doctors are more willing to attribute behavior problems to mental illness, and in part because the public is more aware of childhood mental disorders.

At the playground, in the gym, standing in line at the grocery store, parents swap horror stories about diagnoses, medications or special education classes. Their children are often as fluent in psychiatric jargon as their mothers and fathers are.

“The change in attitude is enormous,” said Christina Hoven, a psychiatric epidemiologist at Columbia University. “Not long ago people did all they could to hide problems like these.” Attention deficit disorder is perhaps the most straightforward diagnosis. Elementary school teachers are often the ones who first mention it as a possibility, and soon parents are answering questions from a standard checklist: Does the child have difficulty sustaining attention, following instructions, listening, organizing tasks? Does he or she fidget, squirm, impulsively interrupt, leave the classroom?

These behaviors are so common, particularly in boys, that critics question whether attention disorder is a label too often given to boys being boys. But most psychiatrists agree that while many youngsters are labeled unnecessarily, most children identified with attention problems could benefit from some form of therapy or extra help.

They are less certain about the children — perhaps a quarter of those seen for mental problems, some experts estimate — who do not fit any one diagnosis, and who often go for years before receiving a satisfactory label, if they receive one at all.

These youngsters collect labels like passport stamps, and an increasing number end up with the label Paul Williams received: bipolar disorder.

An Illness Under Dispute: Bipolar Disorder in Children
Until recently, psychiatrists considered bipolar disorder to be all but nonexistent in children under 18. Today, it is the fastest growing mood disorder diagnosed in children, featured on the cover of news magazines and on daytime talk shows like “The Oprah Winfrey Show.”

The explosion of interest in bipolar disorder came after the approval of several drugs, called antipsychotics, or major tranquilizers, for the short-term treatment of mania in adults.

Beginning in the 1990s some researchers began to argue that bipolar disorder was underdiagnosed in adults. Soon, several child psychiatrists were arguing that the illness was more common than previously thought in children too.

Some experts who made those arguments had ties to manufacturers of antipsychotic drugs, financial interests disclosed in professional journals. But the message struck a chord, particularly with doctors and parents trying to manage difficult children.

Parents whose children have been given the label tend to adopt the psychiatric jargon, using terms like “cycling” and “mania” to describe their children’s behavior. Dozens of them have published books, CDs, or manuals on how to cope with children who have bipolar disorder.

A recent Yale University analysis of 1.7 million private insurance claims found that diagnosis rates for bipolar disorder more than doubled among boys ages 7 to 12 from 1995 to 2000, and experts say the rates have only gone up since then.

Katherine Finn, a 14-year-old who lives in Grand Rapids, Mich., said she was grateful for the growing awareness of the disease. Possessed by feelings of worthlessness as early as the fourth grade, Katherine said that by the sixth grade she “threw my sanity out the window.”

She became impulsive, loud, and abrasive, she said, adding, “I would blurt things out in class, I would moo like a cow, act like a little kid, just say the most random stuff.”

A psychiatrist promptly diagnosed the problem as bipolar disorder, after learning that there was a history of the disease on her mother’s side of the family. Katherine began taking drugs that blunted the extremes in her mood, and she now is doing well at a new school.

“It hit me like a Mack truck when I heard the diagnosis, but I knew right away it was correct,” said her mother, Kristen Finn, who is writing a book about her experience.

Still, many psychiatrists believe that, although childhood bipolar disorder may be real in families like the Finns, it is being wildly overdiagnosed. One of the largest continuing surveys of mental illness in children, tracking 4,500 children ages 9 to 13, found no cases of full-blown bipolar disorder and only a few children with the mild flights of excessive energy that could be considered nascent bipolar disorder — a small fraction of the 1 percent or so some psychiatrists say may suffer from the disease.

Moreover, the symptoms diagnosed as bipolar disorder in children often bear little resemblance to those in adults. Instead, the children’s moods seem to flip on and off like a stoplight throughout the day, and their upswings often look to some psychiatrists more like extreme agitation than euphoria.

“The question with these kids is whether what we’re seeing is a form of mania, or whether it’s extreme anger due to something else,” said Dr. Gregory Fritz, medical director of the Bradley Hospital, a psychiatric clinic for children in Providence, R.I.

Dr. Ellen Leibenluft, a research psychiatrist at the National Institute of Mental Health, argues that children who are receiving a diagnosis of bipolar disorder fall into two broad groups. The children in one group, a minority, have mood cycles similar to those of adults with bipolar disorder, complete with grandiose moods, and a high likelihood of having a family history of the illness. Those in the other group have severe problems regulating their moods and little family history, and may have some other psychiatric disorder instead.

“It is a mistake to lump them all together and assume they are all the same,” Dr. Leibenluft said. “It may be that the disorder has different dimensions and looks different in different kids.”

For parents with a child who is frantic and possibly dangerous, these distinctions may be academic. The medications may blunt their child’s extreme behavior, which may be all the confirmation they need.

For others, though, the uncertainties about childhood bipolar disorder loom larger. They wonder whether mania really explains what their child is going through, and if not, what it is that is being treated.

Evelyn Chase of Richmond, Va., said that a neurologist drove home his diagnosis of bipolar disorder in her 10-year-old son by pulling out “a copy of Time magazine and slamming the article in front of me.”

Ms. Chase said her son seemed to react most strongly to abrupt changes in the environment and to certain dyes and chemicals. “I used the bipolar diagnosis for school and getting services, but I don’t think it covers his behaviors,” she said.

For Paul Williams, the diagnosis simply feels like a temporary stop. In his short life, Paul has taken antidepressants like Prozac, antipsychotic drugs used to treat schizophrenia, sleeping pills and so-called mood stabilizers for bipolar disorder, in so many combinations that he has become nonchalant about them.

“Sometimes they help, sometimes they don’t,” he said. “Sometimes they make me feel like another person, like not normal.”

In recent months, his mother said, Paul seems to have improved: he visibly tries to control himself when he is upset and usually succeeds. He is an eager Mets fan who loves reading Harry Potter and the Goosebumps series. He gets out and plays baseball and football, like any 13-year-old boy.

But he has grown tired of telling his story to doctors, and neither he nor his mother expect that bipolar disorder will be the last diagnosis they hear.

In Search of Clarity
The specialists who manage children’s psychiatric disorders are trying to bring more standards and clarity to the field. Harvard researchers are completing the most comprehensive nationwide survey of mental illness in minors and hope to publish a report next year. And a recent issue of the journal Child and Adolescent Psychology was entirely devoted to the subject of basing diagnoses in hard evidence.

Given the controversies, one of the articles concludes, “we acknowledge that tackling the issue may be tantamount to taking on a 900-pound gorilla while still wrestling with a very large alligator.”

Dr. Darrel Regier of the American Psychiatric Association, who is coordinating work on the next edition of the association’s diagnostic manual for mental disorders, due out in 2011, said that researchers would focus on drawing distinctions among several childhood disorders, including bipolar disorder and attention deficit disorder.

“We wouldn’t disagree that criteria for these disorders currently overlap to some degree,” Dr. Regier wrote in an e-mail message, “and that a significant amount of research is under way to disentangle the disorders in order to support more specific treatment indications.”

Until that happens, parents with very difficult children are left to read the often conflicting signals given by doctors and other mental health professionals. If they are lucky, they may find a specialist who listens carefully and has the sensitivity to understand their child and their family.

In dozens of interviews, parents of troubled children said that they had searched for months and sometimes years to find the right therapist.

“The point is that not everything is A.D.H.D., not everything is bipolar, and it doesn’t happen like you see in the movies,” said Dr. Carolyn King, who treats children in community clinics around Detroit, and has a private practice in the nearby suburb of Grosse Pointe Farms.

“Kids often have very subtle symptoms they can mask for short periods of time,” Dr. King said, “and the most important thing is to observe them closely, and get a complete history, starting from birth and straight through every single developmental milestone.”

She added, “A speech delay can look like anxiety,” an obsessive private ritual like mania.

Or struggling children, in the end, may look only like themselves, with a unique combination of behaviors that defy any single label. Camille Evans, a mother in Brooklyn whose son’s illness was tagged with a half-dozen different diagnoses in the last several years, said she concluded, after seeing several psychiatrists, that the boy’s silences and learning difficulties were best understood as a mild form of autism.

“That’s the diagnosis that I think fits him best, and I’ve just about heard them all,” Ms. Evans said.

The label is not perfect, she said, but it is more specific than “developmental delay” — one diagnosis they heard — and does not prime him for aggressive treatment with drugs like attention deficit disorder or bipolar disorder would. He has not responded well to the drugs he has tried.

“Most important for me,” Ms. Evans said, “the diagnosis gives him access to other things, like speech therapy, occupational therapy and attention from a neurologist. And for now it seems to be moving him in the right direction.”

Benedict Carey
NY Times
November 11, 2006

I MET her in 2011, during my first few weeks as an intern in internal medicine. She was not the kind of patient who had appeared in my textbooks. She had been admitted from rehab after expressing an intent to take her own life, and I soon learned that her body was as troubled as her mind.

She had heart failure from a condition called hypertrophic obstructive cardiomyopathy, in which an overgrown muscular wall keeps blood from properly flowing out of the heart. She might have been born with it, or acquired it from years of neglected high blood pressure. Her blood pooled in her swelling legs and seeped into her lungs, causing her to wheeze constantly. She was in her late 50s, but seemed much older.

While learning her medical history, I also got to know her. A former artist, derailed by addiction, she had become alienated from her career and her family. She had let the problems in her heart fester and had never received consistent treatment.

At this point, she wasn’t a suitable candidate for heart surgery. But I felt there was still hope. A procedure called alcohol septal ablation could potentially reduce her symptoms. It involved injecting alcohol into a blood vessel to strangle the blood supply to the muscular part of the heart obstructing blood flow. The patient was desperate to have the procedure performed; she hoped to experience a life outside of hospitals, to reconnect with her family, to start painting again. With my sense of righteous optimism intact from my medical school days, I convinced the other doctors that, in spite of the risks, we should try it.

The procedure was uneventful, but when I was updated on the patient’s condition the next morning, I was stunned. Overnight, she had gone into complete heart block: a failure of the electrical transmissions that cause the heart to beat, a rare but known complication of the procedure. She temporarily lost her pulse, underwent CPR and electrical defibrillation. A pacemaker had to be inserted. She was transferred to the intensive care unit.

Later in the day, the complications cascaded, and she found herself buried again under the flexed wrists of medical residents and nurses, pushing her sternum into a doughy pulp. After half an hour of frenzied CPR, infusions, electrical shocks and other assorted hail marys, resuscitation was called off. As the silhouettes in scrubs withdrew from her bed, she lay there limp, frothing from the mouth, dead.

This was not the way this story was supposed to end. Certainly not how I had imagined it would.

Since then, I have come to believe that I was a victim of irrational optimism, a condition running rampant in both doctors and patients, particularly in end-of-life care.

Physicians are thought to be the harbingers of bad tidings, the people who use cold words like “prognosis.” But studies show that they are just as capable of emotions as their patients are. According to a study published in 2000 in the British medical journal BMJ, about two-thirds of doctors overestimate the survival of terminally ill patients.

A study of cancer patients and their doctors in the Annals of Internal Medicine a year later found that many doctors didn’t quite tell patients the truth about their prognosis. Doctors were up front about their patients’ estimated survival 37 percent of the time; refused to give any estimate 23 percent of the time; and told patients something else 40 percent of the time. Around 70 percent of the discrepant estimates were overly optimistic.

This optimism is far from harmless. It drives doctors to endorse treatments that most likely won’t save patients’ lives, but may cause them unnecessary suffering and inch their families toward medical bankruptcy.

One source of this optimism is pop culture, which frequently depicts heroic recoveries from seemingly life-threatening situations. Another is the medical school experience. What motivates weary medical students is the hope that one day interventions they perform will save lives, heal families and enact cosmic good.

Later, our judgment becomes clouded as we build relationships with patients, share their fears and anxieties, cherish their small victories and celebrations and hope that there may still be a way, however unlikely, they can make it to their grandson’s bar mitzvah.

And yet studies have shown that patients almost universally prefer to be told the truth. If physicians cannot deliver the hard facts, not only do they deprive their patients of crucial information, but they also delay the conversation about introducing palliative care.

Modern palliative care originated in response to the proliferation of new treatments and resuscitation technologies. Keeping a patient “alive” became easier. And yet the definition of “alive” suffered — with quality of life frequently being usurped by length of life.

Palliative care was the first alternative approach that allopathic medicine offered patients and has now gained wide acceptance. One of the greatest milestones for palliative care was a study published in 2010 in The New England Journal of Medicine that showed that patients with lung cancer who early on had palliative care integrated with standard cancer care not only had a better quality of life, but lived a few months longer than those who received standard care alone. Yet we use this strategy far less than we should and insist on more invasive treatments, even when there is little chance that they will work.

It’s not just the doctors who are guilty of false hope — it’s the patients, too.

When I became a resident, one of my patients was an elderly woman with a tumor that continued growing despite the most powerful (read: toxic) chemotherapies. She had come down with an infection, but was almost completely depleted of white blood cells, the body’s sentient guardians against such invasions. And yet, she wanted more of the same, more chemotherapy, more radiation, more intubations and more resuscitations.

I wanted to do everything I could to save her, but I remembered the patient from my internship, the one with heart failure, and I didn’t want to make the same mistake. I knew there were only a few things we could do to provide real comfort. So I emptied out a waiting room to create a safe place for the patient’s daughter, her appointed health care proxy. This was not the first time she had found herself in a room of worried physicians, all of whom knew all too well the magnitude of her mother’s illness and the futility of carrying on.

AND yet she maintained that her mother would want everything, from intubation and mechanical breathing to cardiac resuscitation and CPR. I implored her that the chances of her mother’s being revived by those maneuvers and her having a life beyond the blunt end of a breathing machine were maybe just 1 percent. And yet the allure of that sliver of a chance kept her going.

The patient’s condition got worse. The tumor grew to the point that we had to put in a tube to deflate her intestines. She developed clots in her lungs, but we couldn’t treat them with blood thinners because she was already bleeding internally. She had to get all of her medications and nutrition through an I.V. It was clear to the team that the more humane thing to do would be to focus on her symptoms and keep her comfortable rather than trying to extend her life.

But there was nothing we could do to uproot the horror of irrational optimism that had spread through her body like a cancer uncontrollable.

Haider Javed Warraich is a resident in internal medicine at the Beth Israel Deaconess Medical Center and the author of the novel “Auras of the Jinn.”
NY Times, 3/5/2013

The context of this article relate to images, the Abbild, I use the German because the English "image" almost always evokes the idea of picture. So from a psychological standpoint any dream or visual image in one's mind while engaging life or others, is an Abbild, a representation of what goes on always beneath the surface of consciousness.

That being said, my experience is that it is a sad fact that this rich under-surface of Abbild / representations / images / etc. which we all have goes largely unappreciated. The most regular forms of it, of course, are the dreams we have each night. I say "each night" because the "problem" is that for most Westerners the dream is forgotten almost as quickly as it comes in the morning. So to "capture" the dream requires an intentionality -- the desire and determination to write it down, for without this these Abbild of the "underneath" of life go unheeded.

Now back to my statements (which, BTW, occurred in order):

1. Isn't it a wonderful grace that each problem in life, symptom, tension, restlessness, aimlessness, is at the the same time an evocazione?

So this morning, I was struck by what a wonderful thing it is that we, as human beings, have the possibility to "listen," what some have called in-hearing, or to "see," what some have called in-sighting or seeing through to these Abbild.

And furthermore, as one, who "takes care", in the sense of therapeia of many who suffer greatly in life, I do feel it as "grace" in the sense of "unmerited favor" that the "problem(s)in life, symptom, tension, restlessness, [and the] aimlessness" that many who come to me might feel are at the same time Abbild. So for me, every one of these "so-called" problems are evocations -- a calling out from the depths. And it goes without saying that as a physician and therapist, I feel these as helpful, perhaps essential for the suffering souls that "grace" has brought to my door.

2. A possibility to "find" the image, perhaps in a dream or expressed in the plasticità of the arts or in movements made by the hands or feet.

Here, I was reaching out to the suffering souls to perhaps "believe" (not sure that's the right word) that the Abbild is there all the time. The challenge is to find it, among all the noise of life, to get quiet to listen, to see. And then my thoughts shifted to all the wonderful ways in which these images come. To me, they came first in dreams. I began to have a series of complex and impenetrable dreams in my late 30's. Inside myself, I knew they were significant, but didn't know how to approach them. Here I was a neurologist and psychopharmacologist, a lapsed Freudian (never did completely track with Freud as a young psychiatrist-in-training nor did I do a Freudian analysis), who despite years of training didn't know how to work with my own dreams. So I grappled in the dark for many years.

Yet through my experience, and then from my experience in medical / psychological practice, first a Jungian-oriented practitioner and then as an Jungian Analyst (after I finished my training in Switzerland) I slowly became aware that these images came to people in many different ways. This is what I meant in my words "plasticità of the arts or in movements made by the hands or feet."

Plasticità is Italian and roughly translated "plasticity or suppleness." In Italian, nouns have gender and plasticità is a feminine noun. However, in America, we only have the word "plastic" which, at least to me, feels cold, hard, mechanical -- the manufacturing plastic products for the masses. While this, in itself, is neither good nor bad, the Western association to it, in my opinion, is somewhat fixed. One could say that "plastic" is "hard" and plasticità is "soft" -- of course, this is an oversimplification, but somewhat touches on my point here. So another way to express the living Abbild is to to draw, to sculpt, to create and express an artistic plasticità.

Any finally, my last statement, "in movements made by the hands or feet." This is perhaps a reaction to the persistent Western focus upon achievement. What I mean is that in America we tend to make everything a project or a goal or something we must get proficient in. And my experience is that this is so even in creative activity, such as in the arts (as mentioned in the above paragraph) regardless of whether one regards themselves an artist or more often, one who "plays" with art for fun or because they feel it inside themselves and express it on the canvas or the form that holds that expression. So, this statement appeals to the possibility to regard movements of all kinds, such as gardening (e.g., as something down with the hands) and walking (e.g. as something done with the feet) as creative expressions. And sometimes these Abbild are ones not expressed in dreams or not remembered from the dreams, or perhaps not understood from the dreams.

Anyway this is a very involved topic that I could write pages on.

3. The image or dream, a risonare, a "once again," a shout, a whisper, a sense upon the skin, can you hear it? Can you feel it?

Here, I was playing with the language, particularly our English words that begin with "re-" such as: re-verbation, re-sound, re-play (I add the hypen to help you see the "re-" in each one). By this I mean the "calling" back of an echo, that is the concrete expression of hearing a sound once again. So, this use of the Italian risonare, a verb that captures (at least I suppose it captures for Italians, all that I explained: the reverbation, the echo, the effort to replay a tape, a record, an MP3 file) is my feeble way to express something new, "can you risonare for a moment ... to the Abbild that lay within yourself? These are the "words, sound, voices" within a dream and the physical feelings, both in dreams and our dayworld, that are part and parcel of all emotions. I do understand that this is the difficult thing to accept for the more rationally-thinking-oriented people.

First a word of explanation, as a Jungian, I accept his distinction between feelings and emotions that a  feeling is a value (at least that's how it is expressed as a concept, by the thinkers) and a tapestry / texture / mélange (French for a kalidescope of colors and shapes, which from a more Germanic conceptual framework are a mixture often of incongruous elements). The latter perhaps captures a bit what the feelers might experience of what the thinkers call "feeling values". I find that very few people can grasp the perception of a feeler's feelings, yet we must try. The mélange for the visual and the tapestry for its quality of inter-weaving and completeness. All terribly inadequate metaphors.

So this lame "can you hear it? Can you feel it?" is my way of caring for the suffering, the thinkers and the feelers, who may experience "emotion" in the bodily (the rapid heart beat, the sweating, the skin reaction, the difficulty breathing). These experiences are Abbild too and to allow this frame gives one imaginal possibilities that may help.

4. Can you allow in the “festina lentamente”? The lentaggine of Petrarch’s re-spect, or ispirare rispetto, a looking back? or a looking ahead?

This is my last statement and feels like the end of a flow of ideas and Abbild. I love the Latin statement "festina lente" -- the paradox of "hastening slowly". What a metaphor? So beautiful, so poignant, yet so true, at least in Western life. And here I was playing with that antiquated Latin phrase. So it felt right to allow the "lente" the verb to change into another word. First, to the Italian "lentamente" which is an adverb meaning "slowly," but then this continued to evolve, "wanting to be a noun" (now I do know that this experience may sound strange, a word evolving or moving. But this is what happens inside when one allows the Abbild some room to move on their own. One cannot pick where they go.). So that is the origin of the lentaggine, the Italian feminine noun, meaning "slow-ness", like, I imagine, the lentaggine of a turtle (Please, my Italian friends chime in here to express how you might use the word). 

So my experience continues, and here it becomes girded in history, in Petrarch, Francesco Petrarch (July 20, 1304 – July 19, 1374), an Italian scholar and poet. So to look back with respect, the "rispetto" of Petrarch, means to be in awe of what we see from the inside. This is the wonderful reverence of being a human being, of being alive to experience the richness of the inner life and that this inner life is the religious life, the holy and wholly present life.