Les ��tats anxieux dans l��histoire de la m��decine Deuxi��me partie: de la neurasth��nie au trouble anxi��t�� g��n��ralis��e

The last ??great neurosis,?? described by general practitioners before the Freudian classification, the neurasthenia (Beard, 1869, 1880; Charcot, 1887) originated between 1870 and 1900 in the USA and in Europe. It was then dismembered and annexed by the psychiatrists, through psychasthenia (Janet, 1903) and mild depressive states. It declined slowly at the beginning of the 20th century, but is still alive in the textbook of P. Guiraud (1956) and in the ICD-10 (1992). Helped by the works of E. Brissaud (1890) and E. Hecker (1892), Freud??s ??anxiety neurosis?? (1895) remains, however, the most famous clinical entity resulting from the dismemberment of neurasthenia. It includes anxious expectation, anxiety attacks, and somatic equivalents. Diffused in France by Hartenberg, Lalanne (1902), and then Heckel (1917), it was contested by G. Ballet, Pitres and Regis (1902) and F. Raymond (1911) ?? successor of Charcot at the Salpêtrière Hospital. After 1910, the hereditary ??emotive constitution?? of E. Dupré tended to gather the manifestations of anxiety neurosis, several hysterical symptoms, some depressive disorders, and post-traumatic disorders resulting from the lst World War (Devaux and Logre, 1917; De Fleury, 1924). But many French authors separated psychical anxiety and somatic anguish ?? later named panic disorder, (Brissaud, 1902; Claude and Lévy-Va1ensi, 1938; Ey, 1950). After 1945, the emergence of several somatic entities such as stress, vagotonia, and spasmophilia can be seen as new attempts by general practitioners for the annexation of anxiety disorders. After 1960, two opposite clinical orientations can be described: those inspired by psychoanalysis maintain the autonomy of anxiety neurosis; others separate, from psychopharmacological criteria, generalized anxiety and acute anguish. This last, named ??panic attack?? (D. Klein, 1962), gathers in fact the symptoms of paroxysmal anxiety (Brissaud), anxiety attack (Freud), emotive attack (Dupré), emotive or anxious crisis (Devaux and Logre), and the mental paroxysmal form of anxiety (Heckel). Though the clinical dichotomy between generalized anxiety and panic disorder has been emphasized by DSM-IV and ICD-10, a dimensiona1 approach of mental disorders would include most anxious and ??neurotic?? symptoms, beyond anxiety neurosis.     

International Migration of Doctors,and Its Impact on Availability of Psychiatrists in Low and Middle Income Countries

Background

Migration of health professionals from low and middle income countries to rich countries is a large scale and long-standing phenomenon, which is detrimental to the health systems in the donor countries. We sought to explore the extent of psychiatric migration.

Methods

In our study, we use the respective professional databases in each country to establish the numbers of psychiatrists currently registered in the UK, US, New Zealand, and Australia who originate from other countries. We also estimate the impact of this migration on the psychiatrist population ratios in the donor countries.

Findings

We document large numbers of psychiatrists currently registered in the UK, US, New Zealand and Australia originating from India (4687 psychiatrists), Pakistan (1158), Bangladesh (149) , Nigeria (384) , Egypt (484), Sri Lanka (142), Philippines (1593). For some countries of origin, the numbers of psychiatrists currently registered within high-income countries'' professional databases are very small (e.g., 5 psychiatrists of Tanzanian origin registered in the 4 high-income countries we studied), but this number is very significant compared to the 15 psychiatrists currently registered in Tanzania). Without such emigration, many countries would have more than double the number of psychiatrists per 100, 000 population (e.g. Bangladesh, Myanmar, Afghanistan, Egypt, Syria, Lebanon); and some countries would have had five to eight times more psychiatrists per 100,000 (e.g. Philippines, Pakistan, Sri Lanka, Liberia, Nigeria and Zambia).

Conclusions

Large numbers of psychiatrists originating from key low and middle income countries are currently registered in the UK, US, New Zealand and Australia, with concomitant impact on the psychiatrist/population ratio n the originating countries. We suggest that creative international policy approaches are needed to ensure the individual migration rights of health professionals do not compromise societal population rights to health, and that there are public and fair agreements between countries within an internationally agreed framework.     

The WPA-WHO Global Survey of Psychiatrists�� Attitudes Towards Mental Disorders Classification

This article describes the results of the WPA-WHO Global Survey of 4,887 psychiatrists in 44 countries regarding their use of diagnostic classification systems in clinical practice, and the desirable characteristics of a classification of mental disorders. The WHO will use these results to improve the clinical utility of the ICD classification of mental disorders through the current ICD-10 revision process. Participants indicated that the most important purposes of a classification are to facilitate communication among clinicians and to inform treatment and management. They overwhelmingly preferred a simpler system with 100 or fewer categories, and over two-thirds preferred flexible guidance to a strict criteria-based approach. Opinions were divided about how to incorporate severity and functional status, while most respondents were receptive to a system that incorporates a dimensional component. Significant minorities of psychiatrists in Latin America and Asia reported problems with the cross-cultural applicability of existing classifications. Overall, ratings of ease of use and goodness of fit for specific ICD-10 categories were fairly high, but several categories were described as having poor utility in clinical practice. This represents an important focus for the ICD revision, as does ensuring that the ICD-11 classification of mental disorders is acceptable to psychiatrists throughout the world.     

Psychiatry and ethics: The problematics of respect for religious meanings

Over the past two decades American psychiatrists have had to address the emergence of an increasingly fervent religious pluralism. Particularly in cases of socially controversial new religious movements (NRMs), distressed families have pressured psychiatrists to assess the mental state of recruits to such sects, often labeled cults. At this inevitably acrimonious interface between family values and religious liberties, psychiatrists have for the most part resisted pressures to medicalize religious conversions. This article provides an historical review of American psychiatric response to NRMs with respect to nosology and practice. It introduces this response in the more general context of ethics and the problematics of respect for religious meanings.     

Melanocortin-4 receptor mRNA is expressed in sympathetic nervous system outflow neurons to white adipose tissue

Energy balance results from the coordination of multiple pathways affecting energy expenditure and food intake. Candidate neuropeptides involved in energy balance are the melanocortins. Several species, including Siberian hamsters studied here, decrease and increase food intake in response to stimulation and blockade of the melanocortin 4-receptor (MC4-R). In addition, central application of the MC3/4-R agonist melanotan-II decreases body fat (increases lipolysis) beyond that accounted for by its ability to decrease food intake. Because an increase in the sympathetic nervous system drive to white adipose tissue (WAT) is the principal initiator of lipolysis, we tested whether the sympathetic outflow circuitry from brain to WAT contained MC4-R mRNA expressing cells. This was accomplished by labeling the sympathetic outflow to inguinal WAT using the pseudorabies virus (PRV), a transneuronal retrograde viral tract tracer, and then processing the brain for colocalization of PRV immunoreactivity with MC4-R mRNA, the latter assessed by in situ hybridization. MC4-R mRNA was impressively colocalized in PRV-labeled cells (approximately greater than 60%) in many brain areas across the neuroaxis, including those typically implicated in lipid mobilization (e.g., hypothalamic paraventricular, suprachiasmatic, arcuate and dorsomedial nuclei, lateral hypothalamic area), as well as those not traditionally identified with lipolysis (e.g., preoptic area, subzona incerta of the lateral hypothalamus, periaqueductal gray, solitary nucleus). These data provide compelling neuroanatomical evidence that could underlie a direct central modulation of the sympathetic outflow to WAT by the melanocortins through the MC4-Rs resulting in changes in lipid mobilization and adiposity.     

Bridged bicyclic vasopressin receptor antagonists with V(2)-selective or dual V(1a)/V(2) activity

The synthesis and biological testing of a novel series of nonpeptide vasopressin receptor antagonists, containing a bridged bicyclic nucleus, are reported. Variation of substituents (R(1)-R(3)) in general formula 3, and the configuration of the stereocenter, resulted in potent V(2)-selective (e.g., 5) and balanced dual V(1a)/V(2) (e.g., 10) compounds. Data from receptor binding, cell-based functional, and in vivo assays are presented [corrected]     

Molekulare Charakterisierung der Ichthyosen

Ichthyoses comprise an etiologically heterogeneous group of Mendelian disorders of cornification (MEDOC) that affect the entire integument and are characterized by hyperkeratosis and/or visible scaling. In recent years basic research has elucidated the genetic basis of almost all ichthyosis forms and enormously improved diagnostic facilities. The Network for Ichthyoses and Related Keratinization Disorders (NIRK; www.netzwerk-ichthyose.de) and the patient support organization Selbsthilfe Ichthyose e. V. (www.ichthyose.de) provide helpful contact points for physicians and patients in Germany. The first worldwide Ichthyosis Consensus Classification was approved in August 2009. Its nosology is based on clinical presentation but also reflects pathogenic aspects. The major criterion is the distinction between syndromic and non-syndromic forms. Controversial disease names have been re-defined: Ichthyoses due to keratin mutations are referred to under the new umbrella term keratinopathic ichthyosis (KPI), which comprises epidermolytic ichthyosis (mutation in keratin 1 or 10) and superficial epidermolytic ichthyosis (keratin 2). The term autosomal recessive congenital ichthyosis (ARCI) represents the umbrella for harlequin ichthyosis and for the group of lamellar ichthyosis and congenital ichthyosiform erythroderma. The international classification should serve as a reference for future research into these diseases, including further genotype-phenotype correlation studies.     

Cultural niche construction in a metapopulation

Cultural niche construction is the process by which certain evolving cultural traits form a cultural niche that affects the evolution of other genetic and cultural traits [Laland, K., et al., 2001. Cultural niche construction and human evolution. J. Evol. Biol. 14, 22-33; Ihara, Y., Feldman, M., 2004. Cultural niche construction and the evolution of small family size. Theor. Popul. Biol. 65, 105-111]. In this study we focus on cultural niche construction in a metapopulation (a population of populations), where the frequency of one cultural trait (e.g. the level of education) determines the transmission rate of a second trait (e.g. the adoption of fertility reduction preferences) within and between populations. We formulate the Metapopulation Cultural Niche Construction (MPCNC) model by defining the cultural niche induced by the first trait as the construction of a social interaction network on which the second trait may percolate. Analysis of the model reveals dynamics that are markedly different from those observed in a single population, allowing, for example, different (or even opposing) dynamics in each population. In particular, this model can account for the puzzling phenomenon reported in previous studies [Bongaarts, J., Watkins, S., 1996. Social interactions and contemporary fertility transitions. Popul. Dev. Rev. 22 (4), 639-682] that the onset of the demographic transition in different countries occurred at ever lower levels of development.     

Attention to Eye Contact in the West and East: Autonomic Responses and Evaluative Ratings

Eye contact has a fundamental role in human social interaction. The special appearance of the human eye (i.e., white sclera contrasted with a coloured iris) implies the importance of detecting another person''s face through eye contact. Empirical studies have demonstrated that faces making eye contact are detected quickly and processed preferentially (i.e., the eye contact effect). Such sensitivity to eye contact seems to be innate and universal among humans; however, several studies suggest that cultural norms affect eye contact behaviours. For example, Japanese individuals exhibit less eye contact than do individuals from Western European or North American cultures. However, how culture modulates eye contact behaviour is unclear. The present study investigated cultural differences in autonomic correlates of attentional orienting (i.e., heart rate) and looking time. Additionally, we examined evaluative ratings of eye contact with another real person, displaying an emotionally neutral expression, between participants from Western European (Finnish) and East Asian (Japanese) cultures. Our results showed that eye contact elicited stronger heart rate deceleration responses (i.e., attentional orienting), shorter looking times, and higher ratings of subjective feelings of arousal as compared to averted gaze in both cultures. Instead, cultural differences in the eye contact effect were observed in various evaluative responses regarding the stimulus faces (e.g., facial emotion, approachability etc.). The rating results suggest that individuals from an East Asian culture perceive another''s face as being angrier, unapproachable, and unpleasant when making eye contact as compared to individuals from a Western European culture. The rating results also revealed that gaze direction (direct vs. averted) could influence perceptions about another person''s facial affect and disposition. These results suggest that cultural differences in eye contact behaviour emerge from differential display rules and cultural norms, as opposed to culture affecting eye contact behaviour directly at the physiological level.     

Neuroeconomics of suicide

Suicidal behavior is a leading cause of injury and death worldwide. Suicide has been associated with psychiatric illnesses such as depression and schizophrenia, as well as economic uncertainty, and social/cultural factors. This study proposes a neuroeconomic framework of suicide. Neuroeconomic parameters (e.g., risk-attitude, probability weighting, time discounting in intertemporal choice, and loss aversion) are predicted to be related to suicidal behavior. Neurobiological and neuroendocrinological substrates such as serotonin, dopamine, cortisol (HPA axis), nitric oxide, serum cholesterol, epinephrine, norepinephrine, gonadal hormones (e.g., estradiol and progesterone), dehydroepiandrosterone (DHEA) in brain regiouns such as the orbitofrontal/dorsolateral prefrontal cortex and limbic regions (e.g., the amygdala) may supposedly be related to the neuroeconomic parameters modulating the risk of suicide. The present framework puts foundations for "molecular neuroeconomics" of decision-making processes underlying suicidal behavior.     

Role of corticotropin releasing factor in anxiety disorders: a translational research perspective

Anxiety disorders are a group of mental disorders that include generalized anxiety disorder (GAD), panic disorder, phobic disorders (e.g., specific phobias, agoraphobia, social phobia) and posttraumatic stress disorder (PTSD). Anxiety disorders are among the most common of all mental disorders and, when coupled with an awareness of the disability and reduced quality of life they convey, they must be recognized as a serious public health problem. Over 20 years of preclinical studies point to a role for the CRF system in anxiety and stress responses. Clinical studies have supported a model of CRF dysfunction in depression and more recently a potential contribution to specific anxiety disorders (i.e., panic disorder and PTSD). Much work remains in both the clinical and preclinical fields to inform models of CRF function and its contribution to anxiety. First, we will review the current findings of CRF and HPA axis abnormalities in anxiety disorders. Second, we will discuss startle reflex measures as a tool for translational research to determine the role of the CRF system in development and maintenance of clinical anxiety.     

Drivers and socioeconomic impacts of tourism participation in protected areas

Nature-based tourism has the potential to enhance global biodiversity conservation by providing alternative livelihood strategies for local people, which may alleviate poverty in and around protected areas. Despite the popularity of the concept of nature-based tourism as an integrated conservation and development tool, empirical research on its actual socioeconomic benefits, on the distributional pattern of these benefits, and on its direct driving factors is lacking, because relevant long-term data are rarely available. In a multi-year study in Wolong Nature Reserve, China, we followed a representative sample of 220 local households from 1999 to 2007 to investigate the diverse benefits that these households received from recent development of nature-based tourism in the area. Within eight years, the number of households directly participating in tourism activities increased from nine to sixty. In addition, about two-thirds of the other households received indirect financial benefits from tourism. We constructed an empirical household economic model to identify the factors that led to household-level participation in tourism. The results reveal the effects of local households' livelihood assets (i.e., financial, human, natural, physical, and social capitals) on the likelihood to participate directly in tourism. In general, households with greater financial (e.g., income), physical (e.g., access to key tourism sites), human (e.g., education), and social (e.g., kinship with local government officials) capitals and less natural capital (e.g., cropland) were more likely to participate in tourism activities. We found that residents in households participating in tourism tended to perceive more non-financial benefits in addition to more negative environmental impacts of tourism compared with households not participating in tourism. These findings suggest that socioeconomic impact analysis and change monitoring should be included in nature-based tourism management systems for long-term sustainability of protected areas.     

Examining Physical Activity Service Provision to Culturally and Linguistically Diverse (CALD) Communities in Australia: A Qualitative Evaluation

Strong evidence exists for the role of physical activity in preventing and managing a range of chronic health conditions. A particular challenge in promoting physical activity as a health strategy exists in culturally and linguistically diverse (CALD) groups, as such groups demonstrate high risk for a range of non-communicable diseases. The aim of this research was to examine the perspective of multicultural health service providers for CALD groups with respect to the physical activity services/initiatives on offer, access barriers to these services, and ideas for future service delivery in this area. Semi-structured interviews were conducted with 15 multicultural health service providers across the capital cities of the three most populous states in Australia (New South Wales, Queensland, and Victoria), and thematic content analysis was used to examine the data. Findings indicated that the majority of physical activity initiatives were associated with organizations offering other social services for CALD communities but were greatly restrained by resources. As well, it was found that most services were not designed by taking into account specific cultural requirements for CALD communities or their cultural expectations. Common barriers identified to service uptake were classified as socio-cultural (e.g., gender, language, context of health) and environmental (e.g., transportation) in nature. These findings should be utilized when planning future physical activity and health promotion initiatives for increasing CALD participation. In particular, programs need to be culturally tailored to the specific expectations of CALD groups, addressing cultural safety and sensitivity, and should be in partnership with other organizations to extend the reach and capacity.     

Transcultural Psychiatry: Cultural Difference,Universalism and Social Psychiatry in the Age of Decolonisation

In the mid-twentieth century, in the aftermath of WWII and the Nazi atrocities and in the midst of decolonisation, a new discipline of transcultural psychiatry was being established and institutionalised. This was part and parcel of a global political project in the course of which Western psychiatry attempted to leave behind its colonial legacies and entanglements, and lay the foundation for a more inclusive, egalitarian communication between Western and non-Western concepts of mental illness and healing. In this period, the infrastructure of post-colonial global and transcultural psychiatry was set up, and leading psychiatric figures across the world embarked on identifying, debating and sometimes critiquing the universal psychological characteristics and psychopathological mechanisms supposedly shared among all cultures and civilisations. The article will explore how this psychiatric, social and cultural search for a new definition of ‘common humanity’ was influenced and shaped by the concurrent global rise of social psychiatry. In the early phases of transcultural psychiatry, a large number of psychiatrists were very keen to determine how cultural and social environments shaped the basic traits of human psychology, and ‘psy’ practitioners and anthropologist from all over the world sought to re-define the relationship between culture, race and individual psyche. Most of them worked within the universalist framework, which posited that cultural differences merely formed a veneer of symptoms and expressions while the universal core of mental illness remained the same across all cultures. The article will argue that, even in this context, which explicitly challenged the hierarchical and racist paradigms of colonial psychiatry, the founding generations of transcultural psychiatrists from Western Europe and North America tended to conceive of broader environmental determinants of mental health and pathology in the decolonising world in fairly reductionist terms—focusing almost exclusively on ‘cultural difference’ and cultural, racial and ethnic ‘traditions’, essentialising and reifying them in the process, and failing to establish some common sociological or economic categories of analysis of Western and non-Western ‘mentalities’. On the other hand, it was African and Asian psychiatrists as well as Marxist psychiatrists from Eastern Europe who insisted on applying those broader social psychiatry concepts—such as social class, occupation, socio-economic change, political and group pressures and relations etc.—which were quickly becoming central to mental health research in the West but were largely missing from Western psychiatrists’ engagement with the decolonising world. In this way, some of the leading non-Western psychiatrists relied on social psychiatry to establish the limits of psychiatric universalism, and challenge some of its Eurocentric and essentialising tendencies. Even though they still subscribed to the predominant universalist framework, these practitioners invoked social psychiatry to draw attention to universalism’s internal incoherence, and sought to revise the lingering evolutionary thinking in transcultural psychiatry. They also contributed to re-imagining cross-cultural encounters and exchanges as potentially creative and progressive (whereas early Western transcultural psychiatry primarily viewed the cross-cultural through the prism of pathogenic and traumatic ‘cultural clash’). Therefore, the article will explore the complex politics of the shifting and overlapping definitions of ‘social’ and ‘cultural’ factors in mid-twentieth century transcultural psychiatry, and aims to recover the revolutionary voices of non-Western psychiatrists and their contributions to the global re-drawing of the boundaries of humanity in the second half of the twentieth century.

     

Menopausal syndrome: Illness or social role — A transcultural analysis

In recent years the medical diagnosis and treatment of menopausal syndrome has come under a barrage of criticism. Critics of the conventional clinical approach claim that menopausal syndrome is largely a social role foisted on middle-aged women in this society. The physician plays a very active part (albeit an inadvertent one) in recruiting women into this role. This paper examines the evidence for this thesis, including cross-cultural and intracultural variation. The evidence examined suggests that the more psychological and psychosomatic symptoms do seem to vary with cultural role expectations. Research paradigms for further testing of this thesis are adapted from the study of mental disorders and described.In contrast, those organic changes directly associated with estrogen insufficiency do lead in some women to definite pathologies, e.g., osteoporosis and an increased rate of bone fractures. Whether these organic concomitants of aging in women should be viewed and treated medically is a moot question, and one which involves values and politics more than medical facts.Syracuse University