Providentia

December 1 Is World AIDS Day

This December 1, spare a thought for the estimated 33.2 million people around the world living with HIV/AIDS (95 per cent of them in the developing world). This year alone, some 2.5 million people will become newly infected with HIV (including countless children). The World AIDS Campaign's slogan in marking World AIDS Day is "Stop AIDS: Keep the Promise". Leadership is the theme for this year as a special plea towards governments and non-governmental organizations to provide the leadership needed to overcome ingrained resistance to strategies that have proven effective in preventing the spread of AIDS including condom distribution and providing retroviral drugs to prevent the transfer of HIV from mothers to their unborn children.

Despite numerous promises from industrialized nations to provide low-cost generic medications to combat AIDS, tuberculosis and malaria, they have routinely failed to deliver. Sadly, it does not appear to be a political priority as new causes crowd out old ones. In the meantime, people are dying and the resources in many Third World countries are strained to the breaking point trying to deal the patients and their families (this includes an estimated 14 million AIDS orphans). This problem isn't going away.

Click here for more information on how you can get involved.

After Disaster Strikes

While the 11 September 2001 terrorist attacks resulted in thousands of deaths and injuries, some injuries remain undiagnosed. The May 2008 issue of Prehospital and Disaster Medicine presents a research study examining incidence of traumatic brain injuries among persons hospitalized in New York City following the 11 September 2001 attacks. Using medical records of persons admitted to 36 hospitals in New York City with injuries or illnesses related to the attacks, individuals diagnosed with traumatic brain injuries (TBI) were identified using diagnosis codes from the International Classification of Diseases (9th Revision). Undiagnosed TBIs were identified by an adjudication team of TBI experts that reviewed the abstracted medical record information. Persons suspected of having an undiagnosed TBI were subsequently contacted and informed of the diagnosis of potential undetected injury.

The results indicate that, of the 282 records that were examined, fourteen cases of diagnosed TBIs and 21 cases of undiagnosed TBIs were identified for a total of 35 TBI cases (12% of all of the total). The leading cause of TBI was being hit by falling debris (22 cases) and one-third of the TBIs (13 cases) occurred among rescue workers. More than three years after the event, four out of six persons (66.67%) with an undiagnosed TBI who were contacted reported they were currently experiencing symptoms consistent with a TBI. The researchers conclude that not all cases of traumatic brain injury among hospitalized survivors of the 2001 attacks were identified at the time of acute injury care. Many individuals with undiagnosed cases were found to experience problems due to lack of effective diagnosis and treatment. The authors recommend additional clinical surveys be provided in-hospital for hospitalized survivors of mass-casualty incidents to help improve pre-discharge TBI diagnosis and refer patients to appropriate outpatient services. The use and adequacy of head protection for rescue workers also needs to be re-evaluated.

Click here for the abstract.

Car Fetishist Sentenced

A 45-year old Alberta man was sentenced to time served and two years probation for indecent exposure charges arising from an apparent sexual fetish for classic cars. The defendant (not named in the original news story) pleaded guilty to three counts of indecent exposure for repeatedly climbing on top of classic cars and masturbating in public. On March 22 of this year, he was caught masturbating on top of a $50,000 BMW Sedan at a Home and Garden show at the Northlands Agri Com. He was observed on two other occasions pleasuring himself on other cars in the Edmonton area.

A psychiatric evaluation report submitted at the time of his sentencing indicated that the man was sexually aroused by classic cars and also had a longstanding history of minor mental retardation due to a thyroid condition. While deemed to be a high risk for committing similar sexual offenses in future, he was not considered to pose an active risk to the public at large. In the submitted report, psychiatrist Curtis Woods indicated that the offender "announced that he is specifically sexually attracted to 'the roof top ... it's curved like a woman's body, the sex appeal, it felt good". He also reported a sexual attraction to motorcycles

Click here for more information.

Casting Out The Djinn

Visitors to the countries of Western Africa (including Morocco, Algeria, and Senegal) can take in the exotic sights, sounds and smells associated with that part of the world but, for a real understanding of the religious life of the people, you need to learn about the marabouts. Meaning "saints" in the Berber language spoken in Morocco and Algeria, the marabouts act as spiritual leaders of the particular brand of Islam practiced throughout the West African nations. While the marabout tradition appears to predate Islam (and Islamic leaders often denounce the veneration attached to them), marabout worship can take many forms. The term marabout extends to the living spiritual leaders, known for their virtuous living and ability to act as agents between humans and divine forces, but also to the tombs where they are buried. Long after a marabout's death, the tomb can be a site for pilgrimages with each saint being judged by the miracles attached to his name and stories surrounding his life. Of all the marabouts who continue to attract pilgrims long after their death, there are few who are more revered than Bouya Omar.

Believed to have been born in 16th century Morocco, Bouya (Father) Omar developed a reputation for his ability to heal those suffering from mental illness. Much as in other parts of the world, mental illness was believed to be due to being possessed by evil spirits, in this case malign djinoun (djinn is the singular form). Although they are familiar figures in Western culture these days, djinoun (more commonly known as genies) are often perceived in West Africa as mischievous or vindictive spirits able to possess humans and cause illness. They were originally part of Arabian folklore but traditions concerning djinoun have been adopted in many countries in Western Africa, especially with respect to symptoms of mental illness. Bouya Omar's reputation stemmed from his ability to communicate with djinoun, learn what grievance they had against the one possessed, and persuading the djinn to leave. Long after his death, the tomb of Bouya Omar (near Marrakesh) continues to be the centre of veneration with families taking their mentally ill loved ones to the tomb to seek Bouya Omar's help. Physical restraints (including chains) are often used and ailing supplicants are kept near the tomb for months (if not years) to participate in complex rituals of prayer, animal sacrifice, or ritual fumigation with herbs administered by traditional healers (known as fquih or feki).

While modern psychiatry is slowly gaining acceptance in the larger cities, there is no real relationship between mainstream psychiatry and the traditional healers. Fquih have been known to recommend patients to psychiatrists when their rituals fail to help their patients but psychiatrists often view them as being little more than charlatans. Patients admitted to the few psychiatric hospitals available in the region tend to find themselves caught between medical and traditional views of healing with no real middle ground. Tempting as it is to consign the traditional healers to the fringes of African society, that is far from the case and they show no signs of going away, especially when psychiatric medication remains unaffordable for many Africans.

Is there a real solution? If so, feel free to share it with the ones at the tomb, waiting to be healed.

Remembering Washoe

There has been surprisingly little publicity concerning the recent death of Washoe, the first signing chimpanzee on October 30, 2007.  Washoe, matriarch of a research colony at Central Washington University's Chimpanzee and Human Interaction Institute, died of age-related causes at the ripe age of 42, far longer than she likely would have lived in the wild. Captured from her home in Africa in 1965, Washoe was originally sold to the United States Air Force are part of a group of "astrochimps". The ending of the space program led to Washoe being sent to live with Beatrix and Allen Gardner when she was 10 months old. They incorporated Washoe into their project on cross-species communication and began teaching her American Sign Language. Through careful work, Washoe was taught over 200 signs and observers at Central Washington University have reported the use of signing among the various members in the chimpanzee colony to which Washoe belonged.

The Washoe project came under criticism by Herbert Terrace, a psychologist at Colombia University, who began a series of experiments with a signing chimp affectionately named Nim Chimpsky. Although Nim learned 125 signs, Terrace concluded that he did not show any signs of the sequential use of signing that reflected human use of grammar. Nim simply used signs to obtain a desired end, not unlike what has been observed with other animals trained though operant conditioning. Terrace's conclusions, which he published in his 1979 Book Nim, placed him at odds with the Gardners who challenged his findings on methodological grounds. They considered the conditions under which Nim was taught to be too artificial and that the naturalistic setting in which Washoe and other signing chimps were raised was better suited to learning to communicate. Washoe also became notorious for biting off the middle finger of cognitive researcher, Karl Pribram, and essentially ending his career as a neurosurgeon.

Plans to assess whether Washoe passed on signing to her children were terminated when both of her offspring died as infants. Her death leaves only three other signing chimps in the small colony. It is uncertain whether additional chimpanzees will be added later.

Click here for the link.

Breaking the Cycle

The November 2007 issue of the Journal of the American College of Surgeons provides the results of a study evaluating whether, "Caught in the Crossfire," a hospital-based, peer intervention program for young victims of violence can be a cost-effective tool for reducing the impact of violence on later behaviour. The study used a retrospective design to examine patients admitted to a university-based urban trauma centre between January 1998 and June 2003 with an 18 month follow-up. The patients in the study were 12 to 20 years of age and were hospitalized for intentional violent trauma. The treatment group had a minimum of five interactions with an intervention specialist while a control group was selected from the hospital database. All patients were matched for age, socioeconomic status and ethnic background. The total sample size was 154 patients .

The results indicated that participating in the hospital-based program lowered the risk of later criminal justice involvement (relative risk=0.67; 95% CI, 0.45, 0.99; p=0.04) but there was no effect on risks of reinjury and death. Later violent criminal offending was reduced by 7% (p=0.15). Statistical analysis showed that age had a confounding effect on the association between program participation and criminal justice involvement (relative risk=0.71; p=0.043). When compared with juvenile detention center costs, the total cost reduction from the intervention program annually was $750,000 to $1.5 million. The researchers concluded that hospital-based peer intervention programming can meaningfully reduce the risk of criminal justice system involvement, is more effective with younger patients, and is cost effective. The potential of such programs for breaking the cycle of violence found in inner cities is self-evident.

Click here for the abstract.

Love Hurts

The publication of Richard Krafft-Ebbing's masterwork Psychopathia Sexualis in 1886 represented a landmark in thinking about human sexuality and the bizarre forms that it can take. In addition to describing different types of sexual expression that the author regarded as "perverse" (usually any form of sex that didn't lead to procreation), it quickly became one of the most influential books on human sexuality ever written and introduced numerous new terms into common usage. One of these terms, "masochism" which Krafft-Ebbing defined as "the opposite of sadism (which he also coined). While the later is the desire to cause pain and use force, the former is the wish to suffer pain and be subjected to force". For all that he had given a name to a shadowy sexual practice that had never before been described in the scientific literature, one person in particular who was less than pleased with the new term was the Austrian author, Leopold von Sacher-Masoch. Krafft-Ebbing justified naming this new sexual anomaly after the prominent author whom he described as "the poet of Masochism" due to his erotic writings and because of his own eccentric personal life (to which we now turn).

Born in 1836 in what is now the Ukraine (but then part of the Austrian empire), Leopold von Sacher-Masoch was part of a fairly upper-middle class family (his father was a police director), he studied law, history and mathematics at Graz University and then returned to his home town to begin a quiet academic life. He wrote fiction and non-fiction alike although it was his fiction, often concerning historical themes, that quickly won out. He gave up lecturing to become a full-time author and "man of letters". His short stories marked him as a brilliant author known for his humanist and utopian ideas but he largely supported himself as a journalist. Although Sacher-Masoch was well-regarded in literary circles, it was the sexual themes that came out of his later works that have made him so well-known. His plan for a grandiose short story cycle that he called The Legacy of Cain was never completed but the short stories and novels that he did finish revealed his fascination for being physically dominated and abused by women (especially ones that wore fur). The short novel for which he is best known, Venus in Furs was published in 1870, and has become an erotic classic in its own right. In this book, the hero Severin asks to be treated as a slave and to be abused by Wanda (the "Venus in furs" of the story). The fact that Sacher-Masoch often acted out these fantasies in real-life with his wives and mistresses was not well-known since he preferred to keep his private life as private as he could.

Sacher-Masoch was, to put it mildly, displeased when Krafft-Ebbing made him an apostle of sexual perversion. He had gone to great lengths to maintain his public persona as a man of letters and he found this new fame humiliating. Doubly galling was the fact that the word "masochism" took on a life of its own and quickly became an established medical term. It may be a coincidence that his health went into a decline shortly after Psychopathia Sexualis came out but by March of 1895, he was delusional and violent. After attempting to kill his then-wife Hulda, she arranged for him to be discreetly moved to an asylum in Lindheim, Hesse. Although his official obituary states that he died that year, there are claims that Sacher-Masoch lived on as an anonymous asylum inmate and actually died years later.

Despite his name being a byword for kinky sexuality, the full-extent of Sacher-Masoch's private life only became known in 1906 when his first wife, Aurora, published her memoirs (under the pseudonym of Wanda von Sacher-Masoch). The lurid details generated tremendous controversy and kept his books in the public eye. Despite moral outrage and attempts at censorship over the years, Leopold von Sacher-Masoch has attained a not-so-quiet immortality (but perhaps not the kind that he would have wanted).

When Victims Seek Help

For women who have been victimized by domestic violence, visiting a hospital emergency department can be an agonizing experience due to the problems in opening up to emergency staff. A study published in the November 2007 issue of Annals of Internal Medicine examining how female patients interact with emergency providers focuses on this issue. The study is based on an analysis of audio taped conversations made during a randomized, controlled trial of computerized screening for domestic violence in two emergency department (one urban and one sub-urban). Using a sample of 1281 English-speaking women age 16 to 69 years and 80 providers (30 attending physicians, 46 residents, and 4 nurse practitioners), 871 audiotapes, including 293 that included provider screening for domestic violence, were analyzed. Results indicated that providers typically asked about domestic violence in a routine manner during questioning concerning patient social history. Communication strategies that encouraged women to disclose abuse more openly included probing (defined as asking one or more additional topically related question), providing open-ended opportunities to talk, and being generally responsive to patient clues (any mention of a psychosocial issue). Chart documentation of domestic violence was present in one third of cases. While non-verbal communication was not directly examined, the results indicated that hectic and crowded clinical settings may obstruct candid reporting of domestic violence. Specific strategies designed to encourage meaningful discussion helped victims to open up about abuse. The researchers also identified common pitfalls and good practices in screening for domestic violence.

Click here for the abstract.

Does Child Abuse Affect Brain Development?

I was just attending the annual conference of the Association for the Treatment of Sexual Abusers that was held in San Diego this year. It was a stimulating experience with talks and workshops by some of the leading clinicians and researchers in the field. One of the high points of the conference was a presentation by Dr. Martin Teicher, Associate Professor at Harvard Medical School and director of the Clinical Biopsychiatry Research Program at McLean Hospital in Belmont, Massachusetts. The focus of Dr. Teicher's presentation was on the neurobiological affects of different types of stress on the developing brain, especially in terms of the short and long-term impact of child physical and sexual abuse on brain development. In particular, that early childhood maltreatment acts as a severe stressor that can produce various physiogical and hormonal reactions that leads to lasting alterations in patterns of brain development which, in turn, can manifest as different psychiatric disorders. Early stress can program the body's "fight or flight" systems to react more adversely to later stressors. There is also evidence for different periods during development when different regions of the brain are especially affected by early stress. Therefore, it isn't just the nature of the abuse but at when the abuse happens that can affect later development. Early neglect can also be as debilitating as physical or sexual abuse (a point that I have discussed before).

There also appear to be different abuse-related syndromes associated with particular ages of abuse and specific regional brain changes. Posttraumatic Stress Disorder, Major Depression, Borderline Personality Disorder, Impulse Disorders and aggression may be the result of abuse that only emerges at a much later stage of brain development (or even in adulthood). Even verbal abuse can impact later emotional and social development. Dr. Teicher concluded the presentation by arguing that society reaps what it sows in how children are nurtured. Early abuse can mold the brain to be more irritable, impulsive, and hypervigilant. He states that "maltreatment is a chisel that shapes a brain to contend with anticipated strife but at the cost of deep, enduring wounds. Early childhood stress isn't something you "get over". It is an evil that we must acknowledge and confront if we aim to do anything about the unchecked cycle of violence which often leads victims of abuse to become abusers".

Click here for the complete presentation.

Dadd the Painter

Of all the prominent English artists who came to international attention during the reign of Queen Victoria, Richard Dadd definitely is in a class by himself. Born in 1817, as the fourth of seven children, Dadd showed early promise as an artist and began sketching at an early age. After his family moved to London, he entered the Royal Academy of Arts at the age of twenty. Along with other artists with whom he studied, Dadd formed an important group that became known as the Clique although he remained the foremost artist among them. Their meetings throughout the 1830s and into the 1840s inspired a new style of painting that rejected academic high art and favoured more personal art that they felt should be judged by the public rather than academics. Given Dadd's developing prominence in the art world, it was only natural that he was chosen to go with his patron, Sir Thomas Phillips, as a draftsman on a planned expedition through Greece, Turkey and Egypt. The expedition that began in 1842 was seen as an excellent opportunity for Dadd to expand his artistic horizons. Absolutely nobody could have foreseen the profound change that would come on him over the course of the journey. There were gruelling hardships along the way but the alteration in Dadd's personality as they traveled up the Nile by boat caught everyone by surprise. He became increasingly violent towards the other expedition members and developed delusions that he was under the influence of the Egyptian god, Osiris. He left his patron and returned to England in 1843 but Dadd did not show notable improvement. His writings during this time suggested that he was hearing voices calling on him to do battle with the Devil in various forms. A prominent alienist assessed him at the request of his family and declared Dadd to be "non compos mentis" but he was not hospitalized. It remains unclear why Dadd began to fixate on his father as being the Devil in disguise but, on August 28 of that year, while they were both traveling to Cobham, Kent, he murdered and dismembered his father with a knife and razor and then fled the country. At his brother's suggestion, police searched Dadd's rooms in London where they found sketches of other friends and acquaintances, each with a slashed throat.

After unsuccessfully attempting to kill another tourist with a razor, Richard was arrested by French police and confessed to killing his father. When he was searched, a list of names was found of people who "must die" including his father. Upon being returned to England, he was found guilty and committed to Bethlem Royal Hospital (more commonly known as Bedlam). The actual diagnosis is open to question with schizophrenia or bipolar disorder being the most likely candidates (some of his other siblings also developed psychiatric problems). Dadd would spend the rest of his life as a psychiatric patient but, ironically, it was during his time in hospital that he produced his most famous works. Although the idea of art therapy was still unknown, he was given access to paints and canvasses and produced a series of paintings that were individual and unique. He became known as a artist of "fairy lore", although he chose numerous themes for his paintings (all from memory, he had no models). His most famous painting, The Fairy Feller's Master Stroke, was commissioned by the head steward at Bethlem and took nine years to complete. It still hangs in the Tate Gallery and needs to be displayed with special lighting to show the full three-dimensional quality of the painting. In 1864, Dadd was moved to Broadmoor Psychiatric Hospital where he spent the rest of his life. Until his death from lung disease in 1886, he painted regularly with only infrequent visitors to interrupt him. News of the "mad painter" and his paintings generated considerable interest and there were numerous showings of his artwork during his lifetime.

Richard Dadd continues to attract a cult following long after his death and his work has been the subject of countless showings and retrospectives. His works are on display at galleries around the world. Visitors to Bethlem Royal Hospital where Dadd spent most of his life can still see many of his works there. The Bethlem Gallery continues to maintain one of the most extensive collections of art on the theme of mental illness and includes works by Dadd and numerous other historical and contemporary artists. Check out their online gallery and plan a visit if your're ever in that part of Great Britain It's an ongoing monument to human creativity and a fitting memorial for a truly great artist.