Was Snow White a transsexual?

The Rorschach Ink Blot test is considered to be an essential analytical instrument when studying the personalities of individuals presenting identity disorders, in particular, in the context of a sex change request. Nevertheless, there exist less than 20 studies of transsexualism utilising the Rorschach since the creation of this diagnostic category in 1953. This research has mostly concerned itself with relations between psychopathology and transsexualism. Practically non-existent are studies investigating the psychological conditions that permit, shape or induce sex change requests in individuals. Transsexuals request the removal of their genitals through mutilation surgery, which can be seen as subjects literally crying out to be castrated. This request is all the more surprising given that castration, in psychoanalytic terms, is considered to be the most severe punishment that an individual (woman or man) can be threatened with. Therefore, we asked ourselves which psychic conditions could motivate such as request. Based on any earlier study where answers (some explicit, others symbolic) given by sex-change applicants tested on the Rorschach were analysed, results seemed to suggest a counter-phobic attitude underlying sex-reassignment requests (28). According to these hypotheses, the fear of castration (banal as such) can only be overcome through the active search for castration itself. In opting for castration, the transsexual puts an end to the states of anxious waiting that are dominated by feelings of the incertitude and unpredictability of an eventual castration. Once obtained, the threat it constituted disappears, and with it so does the fear. Thus, by taking this active and voluntary step, the subject is no longer exposed to an imminent danger in a passive manner. This in itself creates a great feeling of relief, if not of actual pleasure in the subject (28). In this article, we postulated in a purely speculative manner, the existence of one or several modalities in the transsexual dynamics. Nevertheless, one can ask oneself about the possibility of a request based on a desire rather than on a defense, or even on the existence of a defensive process diametrically opposed to the counter-phobic attitude and which, instead of actively provoking the dreaded reality, would privilege its avoidance and the search of passivity. This latter hypothesis has the advantage of being rather easy to explore with the Rorschach because, according to Exner, the predominance of passive compared to active human movement responses (which he terms the Snow White Syndrome) indicates the propensity to escape into passive fantasies and the tendency to avoid the initiative for behaviour or decision-making, if other people can do it in the subject's place (12). Our results largely confirmed the hypothesis of the existence of an opposite mechanism, as a third of subjects (n = 26) presented Snow White Syndrome. According to Exner, these transsexuals are typically characterized by hiding into a world of make believe, avoiding all responsibility, as well as any decision-making. This passivity in our Snow White Syndrome group was all the more remarkable in that, on the whole, it infiltrated into all the movement responses and seemed to define a rigid style of thinking and mental elaboration, in addition to a suggestive content of passivity. However, this condition cannot be associated with a general lack of dynamism or energy. In fact, the treatment of information, which provides data concerning the motivation to treat a stimulus field of the stimulus--whether this concerns the capture (L) of the stimulus or the elaboration (DQ+) of the response--displayed a sufficient amount of motivation. Furthermore, internal resources (EA) were considerable and were brought into play whenever it was necessary to adopt a behaviour or make a decision. Furthermore, based on these Rorschach findings, we note that in transsexuals with Snow White Syndrome, there is a stereotyped tendency to shy away from difficulties by seeking refuge in realistic representations (but that lack in variety), which could be materialized by actions, but where the initiative is delegated to others. These transsexuals appear to shy away from the difficulties of life by seeking refuge into a world of fantasy, which they fill with the representations borrowed from reality (rather than fantasy) and consequently that are liable to be transposed, if necessary, back into reality. Therefore, one can better understand why they shun away from the deceiving reality that their physical sex represents, into the satisfying dream where they possess the genitals of the opposite sex, that is, a perfectly real organ, no longer the result of the subject's fantasy world.     

What is a psychosis and where is it located?

Kraepelin's dichotomy, manic-depressive insanity and dementia praecox, are contrasting and true endogenous disease entities which affect excitability, the fundamental property of the CNS. Kraepelin wanted to establish a valid classification and hit the extremes in brain structure and function at a time when we had no knowledge of brain dysfunction in "functional" psychoses. The aetiology is now known: the psychoses are part of human growth and maturation and might be classified according to their brain dysfunction, which is exactly what Kraepelin wanted. However, presumably to reduce the stigma attached to the word "psychosis", there is currently a strong initiative to eliminate the concept. But knowledge of what is happening in the brain in a psychosis might be more helpful in reducing stigma. It is suggested that psychosis is due to an affection of the supplementary motor area (SMA), located at the centre of the Medial Frontal Lobe network. The SMA is one of the rare universally connected areas of the brain, as should be the case for such a key structure that makes decisions as to the right moment for action. This important network, which partly has continuous neurogenesis, has sufficiently widespread connections. The SMA, a premotor area located on the medial side of the frontal lobes, is one of the last regions to reach a concurrence of synaptogenesis. An affection of the SMA, a deficient or abolished Delayed Response Task, seriously disturbs our relation and adaptation to the surroundings. We usually master the Delayed Response Task around the age of 7 months, a time at which the second CNS regressive event takes place, which proceeds from the posterior to the anterior of the brain. In very late maturation, a persistent affection of the SMA might occur. We experience a chronic psychosis: infantile autism (IA), a chronic inability to act consciously, which contrasts with the episodic SMA affection post-puberty, when excitation is reduced due to excessive pruning of excitatory synapses. Silent spots are the result of insufficient fill-in mechanisms following a breakdown of circuitry. They may affect the SMA in the case of very late puberty. An acute reduction in excitation and concomitantly a marked increase in silent spots might lead to an acute psychosis. A frontal preference is likely, given that a reduction might occur anywhere in the cortex, but particularly in the areas maturing latest. The varying localisations probably explain the difficulty in accepting schizophrenia as a disease entity. The multifactorial inheritance of the dichotomy implies that the genetics are not fate, a psychotic development might be prevented given enough epigenetic factors: brain food (omega 3). Might the present dietary adversity, with its lack of brain food, be responsible for a rising incidence in psychosis? A psychosis is an understandable and preventable dysfunction of the brain, and its mechanisms are known. Primarily a disorder of reduced excitation in an attenuated CNS, this explains why all the neuroleptics are convulsants, raising excitation, in contrast to all antidepressives, which are anti-epileptic.     

Emperor Napoleon Bonaparte: did he have seizures? Psychogenic or epileptic or both?

Napoleon Bonaparte was a general in the French army at 24 years of age, later conquering most of Europe. He was one of the greatest military geniuses the world has ever known, but also an extremely intelligent individual. Did he have seizures? The evidence shows that he had both psychogenic and epileptic attacks. The psychogenic attacks were likely related to the tremendous stress in his life, and the epileptic seizures were the result of chronic uremia from a severe urethral stricture caused by gonorrhea that was transmitted from his wife, Empress Josephine.     

Was Silas Weir Mitchell really a psychiatrist?

Silas Weir Mitchell was held by many of his contemporaries in the United States, Great Britain and on the continent of Europe to be the greatest medical scientist in the Western Hemisphere. He is considered the founding father of American neurology and made important contributions in the fields of basic science and the delineation of diseases. He was also a best-selling novelist and a public figure of stature. According to Wilder Penfield, the eminent Canadian neurosurgeon, Mitchell was, for the last three decades of the 19th century, the outstanding psychiatrist in the United States. We examine some aspects of this claim by reviewing briefly what psychiatrists did in Mitchell's day, the role played by neurologists in the treatment of the neuroses and his own particular psychiatric interests. We conclude that, contrary to Penfield's contention, Mitchell never really practiced psychiatry beyond what any generalist of today would consider as being within his or her scope. He was, however, a mentor to the psychiatrists of his time.     

Review: Autophagy and neurodegeneration: survival at a cost?

S. J. Cherra III, R. K. Dagda and C. T. Chu (2010) Neuropathology and Applied Neurobiology 36, 125–132
Autophagy and neurodegeneration: survival at a cost? Protein aggregation, mitochondrial impairment and oxidative stress are common to multiple neurodegenerative diseases. Homeostasis is regulated by a balanced set of anabolic and catabolic responses, which govern removal and repair of damaged proteins and organelles. Macroautophagy is an evolutionarily conserved pathway for the degradation of long‐lived proteins, effete organelles and protein aggregates. Aberrations in macroautophagy have been observed in Alzheimer, Huntington, Parkinson, motor neuron and prion diseases. In this review, we will discuss the divergent roles of macroautophagy in neurodegenerative diseases and suggest a potential regulatory mechanism that could determine cell death or survival outcomes. We also highlight emerging data on neurite morphology and synaptic remodelling that indicate the possibility of detrimental functional trade‐offs in the face of neuronal cell survival, particularly if the need for elevated macroautophagy is sustained.     

Clinical trials in ALS: what did we learn from recent trials in humans?

Amyotrophic lateral sclerosis (ALS) is a devastating neurodegenerative disease. No treatment is currently able to stop the disease process. In the absence of new active compounds there is an urgent need to develop new strategies based on the neuroprotective activity of available drugs. ALS is a heterogeneous disease. To build up these therapeutic trials, we need to have a better understanding of the prognostic factors in this disease. During the Phase IV Rilutek Trial in France, we developed in a large population of patients a prognostic score based on clinical parameters available at the bedside. The most significant variables are vital capacity, spasticity, fasciculations, swallowing, cough and creatininemia. This score proved to be very useful in daily use in the clinic and for planning disease management in ALS as in the design of therapeutic trials. In ALS clinical trials, efficacy can be evaluated using survival or functional parameters. In phase II trials, function remains the most commonly used. In phase III trials, the gold standard endpoint remains the survival rate at month 18. We analyzed the most recent ALS trials published in the literature. This review suggests that in these trials there is a discrepancy between drug effects on survival versus function. These results suggest that a reappraisal of strategies to identify therapeutic targets for ALS is required.     

Endogenous versus exogenous cell replacement for Parkinson’s disease: where are we at and where are we going?

Parkinson’s disease is the second most common neurodegenerative disease and has currently no effective treatment, one that would be able to stop or reverse the loss of dopaminergic neurons in the substantia nigra pars compacta. In addition, Parkinson’s disease diagnosis is typically done when a significant percentage of the dopaminergic neurons is already lost. In neurodegenerative disorders, some therapeutic strategies could be effective only at inhibiting further degeneration; on the other hand, cell replacement therapies aim at replacing lost neurons, an approach that would be ideal for the treatment of Parkinson’s disease. Many cell replacement therapies have been tested since the 1970s in the field of Parkinson’s disease; however, there are still significant limitations prohibiting a successful clinical application. From the first fetal midbrain intrastriatal graft to the most recent conversion of astrocytes into dopaminergic neurons, we have gained equally, significant insights and questions still looking for an answer. This review aims to summarize the main milestones in cell replacement approaches against Parkinson’s disease. By focusing on achievements and failures, as well as on the additional research steps needed, we aim to provide perspective on how future cell replacement therapies treats Parkinson’s disease.Key Words: endogenous, neurodegenerative disease, neurogenesis, neurotrophic factors, Parkinson’s disease, stem cells, transdifferentiation, transplantations     

Who did what? Authorship and contribution in 2001

Numerous examples of irresponsible authorship are associated with the rise in the number of authors per article and with the documented rise in authorship disputes. Multiple co-investigators have become the norm, and a result is that old concepts of authorship-which, when there was but one author, automatically linked credit with accountability-have eroded. The answer, in the tradition of scientific transparency, is for authors to decide together their individual contributions and disclose these to their readers. This disclosure is now required by many major general medical journals and has been adopted by the International Committee of Medical Journal Editors as the standard.     

Alexander of Macedon, the greatest warrior of all times: did he have seizures?

Alexander the Great (356-323 BC) was likely "the most incomparable general the world has ever seen." His name is often listed among the famous individuals in history who have had seizures. Examination of his illnesses reveals that in 333 BC he entered Tarsus, hot and exhausted, and plunged himself into the River Cydnus, ice-cold from melting mountain snows. His cramps were so severe that he was rescued half-conscious and ashen white, and quickly developed acute pneumonia. Only one doctor dared give him a medication, known for producing powerful and immediate effects. Immediately after drinking this medicine "he lost his speech and falling into a swoon, he had scarcely any sense or pulse left" (Plutarch, ad 75). His reactions were the direct effect of the medication, and this and only this phrase represents the "evidence" for epilepsy. None of his other illnesses involved seizures. Clearly, Alexander the Great did not have epilepsy and his name should be removed from the list of famous individuals who have had seizures.     

Can patients with Alzheimer's disease learn a category implicitly?

Can a person with a damaged medial-temporal lobe learn a category implicitly? To address this question, we compared the performance of participants with mild Alzheimer's disease (AD) to that of age-matched controls in a standard implicit learning task. In this task, participants were first presented a series of objects, then told the objects formed a category, and then had to categorize a long sequence of test items [Knowlton B. J., Squire L. R. (1993). The learning of categories: parallel brain systems for item memory and category knowledge. Science, 262, 1747-1749]. We tested the hypotheses that: (1) both Control and AD participants would show evidence for implicit learning after the unwanted contribution of learning during test is removed; (2) the degree of implicit learning is the same for AD and Control participants; (3) training with exemplars that are highly similar to an unseen prototype will lead to better implicit category learning than training with exemplars that are less similar to a prototype. With respect to the first hypothesis, we found that both AD and Control participants performed better on tests of implicit learning than could be attributed to just learning on test trials. We found no clear means for evaluating our second hypothesis, and argue that comparisons of the degree of implicit learning between patient and control groups in this paradigm are confounded by the contribution of other memory systems. In line with the third hypothesis, only training with similar exemplars resulted in significant implicit category learning for AD participants.     

Who comes from where and who goes where? Treatment methods for psychiatric inpatients

Based on data of the psychiatric basic documentation of 4066 patients, predictors of type of referral as well as outpatient aftercare were analyzed by means of logistic regression analyses. Of the patients, 25.7% were admitted without any referral, 18.4% were referred by a general practitioner, and 9.8% by a psychiatrist in private practice. Patients referred by a general practitioner suffered more frequently from an affective disorder or schizophrenia and were residents of senior citizen homes. Inpatients sent by a psychiatrist were more often residents of sheltered homes, showed a present episode lasting more than 3 months, and had undergone psychopharmacological pretreatment with an atypical antipsychotic or SSRI. Outpatient aftercare was recommended to 83.1% of inpatients: 49.4% by a general practitioner and 32.1% by a psychiatrist in private practice. Outpatient aftercare by a general practitioner was more frequent in the elderly and patients with addiction disorders. Referral by a psychiatrist in private practice as well as schizophrenia or an affective disorder led more often to outpatient aftercare by a psychiatrist. The small number of patients referred by general practitioners and psychiatrists in private practice has to become the focus of quality management.