Conversion disorder

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Conversion_disorder 

 

Conversion disorder
Jean-Martin Charcot demonstrating hypnosis in a hysterical patient to his students. Hysteria as a clinical diagnosis was later replaced by conversion disorder.
Specialty	Psychiatry, Neurology
Symptoms	Numbness, weakness, paralysis, seizures, tremor, fainting, impaired hearing, swallowing and vision
Causes	Long term stress
Treatment	Cognitive behavioral therapy, antidepressants, physical/occupational therapy

Conversion disorder (CD), or functional neurologic symptom disorder, is a diagnostic category used in some psychiatric classification systems. It is sometimes applied to patients who present with neurological symptoms, such as numbness, blindness, paralysis, or fits, which are not consistent with a well-established organic cause, which cause significant distress, and can be traced back to a psychological trigger. It is thought that these symptoms arise in response to stressful situations affecting a patient's mental health or an ongoing mental health condition such as depression. Conversion disorder was retained in DSM-5, but given the subtitle functional neurological symptom disorder. The new criteria cover the same range of symptoms, but remove the requirements for a psychological stressor to be present and for feigning to be disproved. The ICD-10 classifies conversion disorder as a dissociative disorder, and the ICD-11 as a dissociative disorder with unspecified neurological symptoms.However, the DSM-IV classifies conversion disorder as a somatoform disorder.

Signs and symptoms

Conversion disorder begins with some stressor, trauma, or psychological distress. Usually the physical symptoms of the syndrome affect the senses or movement. Common symptoms include blindness, partial or total paralysis, inability to speak, deafness, numbness, difficulty swallowing, incontinence, balance problems, seizures, tremors, and difficulty walking. The symptom of feeling unable to breathe, but where the lips are not turning blue, can indicate conversion disorder or sleep paralysis. Sleep paralysis and narcolepsy can be ruled out with sleep tests. These symptoms are attributed to conversion disorder when a medical explanation for the conditions cannot be found. Symptoms of conversion disorder usually occur suddenly. Conversion disorder is typically seen in people aged 10 to 35, and affects between 0.011% and 0.5% of the general population.

Conversion disorder can present with motor or sensory symptoms including any of the following:

Motor symptoms or deficits:

• Impaired coordination or balance
• Weakness/paralysis of a limb or the entire body (hysterical paralysis or motor conversion disorders)
• Impairment or loss of speech (hysterical aphonia)
• Difficulty swallowing (dysphagia) or a sensation of a lump in the throat
• Urinary retention
• Psychogenic non-epileptic seizures or convulsions
• Persistent dystonia
• Tremor, myoclonus or other movement disorders
• Gait problems (astasia-abasia)
• Loss of consciousness (fainting)

Sensory symptoms or deficits:

• Impaired vision (hysterical blindness), double vision
• Impaired hearing (deafness)
• Loss or disturbance of touch or pain sensation

Conversion symptoms typically do not conform to known anatomical pathways and physiological mechanisms. It has sometimes been stated that the presenting symptoms tend to reflect the patient's own understanding of anatomy and that the less medical knowledge a person has, the more implausible are the presenting symptoms. However, no systematic studies have yet been performed to substantiate this statement.

Diagnosis

Definition

Conversion disorder is now contained under the umbrella term functional neurological symptom disorder. In cases of conversion disorder, there is a psychological stressor.

The diagnostic criteria for functional neurological symptom disorder, as set out in DSM-5, are:

1. The patient has at least one symptom of altered voluntary motor or sensory function.
2. Clinical findings provide evidence of incompatibility between the symptom and recognised neurological or medical conditions.
3. The symptom or deficit is not better explained by another medical or mental disorder.
4. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.

Specify type of symptom or deficit as:

• With weakness or paralysis
• With abnormal movement (e.g. tremor, dystonic movement, myoclonus, gait disorder)
• With swallowing symptoms
• With speech symptoms (e.g. dysphonia, slurred speech)
• With attacks or seizures
• With amnesia or memory loss
• With special sensory loss symptoms (e.g. visual blindness, olfactory loss, or hearing disturbance)
• With mixed symptoms.

Specify if:

• Acute episode: symptoms present for less than six months
• Persistent: symptoms present for six months or more.

Specify if:

• Psychological stressor (conversion disorder)
• No psychological stressor (functional neurological symptom disorder)

Exclusion of neurological disease

Conversion disorder presents with symptoms that typically resemble a neurological disorder such as stroke, multiple sclerosis, epilepsy, hypokalemic periodic paralysis or narcolepsy. The neurologist must carefully exclude neurological disease, through examination and appropriate investigations. However, it is not uncommon for patients with neurological disease to also have conversion disorder.

In excluding neurological disease, the neurologist has traditionally relied partly on the presence of positive signs of conversion disorder, i.e. certain aspects of the presentation that were thought to be rare in neurological disease but common in conversion. The validity of many of these signs has been questioned, however, by a study showing they also occur in neurological disease. One such symptom, for example, is la belle indifférence, described in DSM-IV as "a relative lack of concern about the nature or implications of the symptoms". In a later study, no evidence was found that patients with functional symptoms are any more likely to exhibit this than patients with a confirmed organic disease. In DSM-V, la belle indifférence was removed as a diagnostic criterion.

Another feature thought to be important was that symptoms tended to be more severe on the non-dominant (usually left) side of the body. There have been a number of theories about this, such as the relative involvement of cerebral hemispheres in emotional processing, or more simply, that it was "easier" to live with a functional deficit on the non-dominant side. However, a literature review of 121 studies established that this was not true, with publication bias the most likely explanation for this commonly held view. Although agitation is often assumed to be a positive sign of conversion disorder, release of epinephrine is a well-demonstrated cause of paralysis from hypokalemic periodic paralysis.

Misdiagnosis does sometimes occur. In a highly influential study from the 1960s, Eliot Slater demonstrated that misdiagnoses had occurred in one third of his 112 patients with conversion disorder. Later authors have argued that the paper was flawed, however, and a meta-analysis has shown that misdiagnosis rates since that paper was published are around four percent, the same as for other neurological diseases.

Deliberate feigning

Conversion disorder, by its nature, is more prone to deliberate feigning. One neuroimaging study suggested that feigning may be distinguished from conversion by the pattern of frontal lobe activation.

Psychological mechanism

The psychological mechanism of conversion can be the most difficult aspect of a conversion diagnosis. Even if there is a clear antecedent trauma or other possible psychological trigger, it is still not clear exactly how this gives rise to the symptoms observed. Patients with medically unexplained neurological symptoms may not have any psychological stressor, hence the use of the term "functional neurological symptom disorder" in DSM-5 as opposed to "conversion disorder", and DSM-5's removal of the need for a psychological trigger.

Treatment

There are a number of different treatments available to treat and manage conversion syndrome. Treatments for conversion syndrome include hypnosis, psychotherapy, physical therapy, stress management, and transcranial magnetic stimulation. Treatment plans will consider duration and presentation of symptoms and may include one or multiple of the above treatments. This may include the following:

1. Occupational therapy to maintain autonomy in activities of daily living;
2. Physiotherapy where appropriate.
3. Treatment of comorbid depression or anxiety if present.
4. Educating patients on the causes of their symptoms might help them learn to manage both the psychiatric and physical aspects of their condition. Psychological counseling is often warranted given the known relationship between conversion disorder and emotional trauma. This approach ideally takes place alongside other types of treatment.

There is little evidence-based treatment of conversion disorder. Other treatments such as cognitive behavioral therapy, hypnosis, EMDR, and psychodynamic psychotherapy, EEG brain biofeedback need further trials. Psychoanalytic treatment may possibly be helpful. However, most studies assessing the efficacy of these treatments are of poor quality and larger, better controlled studies are urgently needed. Cognitive Behavioural Therapy is the most common treatment, however boasts a mere 13% improvement rate.

Prognosis

Empirical studies have found that the prognosis for conversion disorder varies widely, with some cases resolving in weeks, and others enduring for years or decades. There is also evidence that there is no cure for conversion disorder, and that although patients may go into remission they can relapse at any point. Furthermore, many patients can get rid of their symptoms with time, treatments and reassurance.

Epidemiology

Frequency

Information on the frequency of conversion disorder in the West is limited, in part due to the complexities of the diagnostic process. In neurology clinics, the reported prevalence of unexplained symptoms among new patients is very high (between 30 and 60%). However, diagnosis of conversion typically requires an additional psychiatric evaluation, and since few patients will see a psychiatrist it is unclear what proportion of the unexplained symptoms are actually due to conversion. Large scale psychiatric registers in the US and Iceland found incidence rates of 22 and 11 newly diagnosed cases per 100,000 person-years, respectively. Some estimates claim that in the general population, between 0.011% and 0.5% of the population have conversion disorder.

Culture

Although it is often thought that the frequency of conversion may be higher outside of the West, perhaps in relation to cultural and medical attitudes, evidence of this is limited. A community survey of urban Turkey found a prevalence of 5.6%. Many authors have found occurrence of conversion to be more frequent in rural, lower socio-economic groups, where technological investigation of patients is limited and people may know less about medical and psychological concepts.

Gender

Historically, the concept of 'hysteria' was originally understood to be a condition exclusively affecting women, though the concept was eventually extended to men. In recent surveys of conversion disorder (formerly classified as "hysterical neurosis, conversion type"), females predominate, with between two and six female patients for every male but some research suggests this gender disparity may be confounded by higher rates of violence against women.

Age

Conversion disorder may present at any age but is rare in children younger than ten or in the elderly. Studies suggest a peak onset in the mid-to-late 30s.

History

The first evidence of functional neurological symptom disorder dates back to 1900 BC, when the symptoms were blamed on the uterus moving within the female body. The treatment varied "depending on the position of the uterus, which must be forced to return to its natural position. If the uterus had moved upwards, this could be done by placing malodorous and acrid substances near the woman's mouth and nostrils, while scented ones were placed near her vagina; on the contrary, if the uterus had lowered, the document recommends placing the acrid substances near her vagina and the perfumed ones near her mouth and nostrils."

In Greek mythology, hysteria, the original name for functional neurological symptom disorder, was thought to be caused by a lack of orgasms, uterine melancholy and not procreating. Plato, Aristotle and Hippocrates believed a lack of sex upsets the uterus. The Greeks believed it could be prevented and cured with wine and orgies. Hippocrates argued that a lack of regular sexual intercourse led to the uterus producing toxic fumes and caused it to move in the body, and that this meant all women should be married and enjoy a satisfactory sexual life.

From the 13th century, women with hysteria were exorcised, as it was believed that they were possessed by the devil. It was believed that if doctors could not find the cause of a disease or illness, it must be caused by the devil.

At the beginning of the 16th century, women were sexually stimulated by midwives in order to relieve their symptoms. Gerolamo Cardano and Giambattista della Porta believed polluted water and fumes caused the symptoms of hysteria. Towards the end of the century, however, the role of the uterus was no longer thought central to the disorder, with Thomas Willis discovering that the brain and central nervous system were the cause of the symptoms. Thomas Sydenham argued that the symptoms of hysteria may have an organic cause. He also proved the uterus is not the cause of symptom.

In 1692, in the US town of Salem, Massachusetts, there was an outbreak of hysteria. This led to the Salem witch trials, where the women accused of being witches had symptoms such as sudden movements, staring eyes and uncontrollable jumping.

During the 18th century, there was a move from the idea of hysteria being caused by the uterus to it being caused by the brain. This led to an understanding that it could affect both sexes. Jean-Martin Charcot argued that hysteria was caused by "a hereditary degeneration of the nervous system, namely a neurological disorder".

In the 19th century, hysteria moved from being considered a neurological disorder to being considered a psychological disorder, when Pierre Janet argued that "dissociation appears autonomously for neurotic reasons, and in such a way as to adversely disturb the individual's everyday life". However, as early as 1874, doctors including W. B. Carpenter and J. A. Omerod began to speak out against the hysteria phenomenon as there was no evidence to prove its existence.

Sigmund Freud referred to the condition as both hysteria and conversion disorder throughout his career. He believed those with the condition could not live in a mature relationship, and that those with the condition were unwell in order to achieve a "secondary gain", in that they are able to manipulate their situation to fit their needs or desires. He also found that both men and women could have the disorder.

Freud's model suggested the emotional charge deriving from painful experiences would be consciously repressed as a way of managing the pain, but that the emotional charge would be somehow "converted" into neurological symptoms. Freud later argued that the repressed experiences were of a sexual nature. As Peter Halligan comments, conversion has "the doubtful distinction among psychiatric diagnoses of still invoking Freudian mechanisms".

Pierre Janet, the other great theoretician of hysteria, argued that symptoms arose through the power of suggestion, acting on a personality vulnerable to dissociation. In this hypothetical process, the subject's experience of their leg, for example, is split off from the rest of their consciousness, resulting in paralysis or numbness in that leg.

Later authors have attempted to combine elements of these various models, but none of them has a firm empirical basis. In 1908, Steyerthal predicted that: "Within a few years the concept of hysteria will belong to history ... there is no such disease and there never has been. What Charcot called hysteria is a tissue woven of a thousand threads, a cohort of the most varied diseases, with nothing in common but the so-called stigmata, which in fact may accompany any disease." However, the term "hysteria" was still being used well into the 20th century.

Some support for the Freudian model comes from findings of high rates of childhood sexual abuse in conversion patients. Support for the dissociation model comes from studies showing heightened suggestibility in conversion patients. However, critics argue that it can be challenging to find organic pathologies for all symptoms, and so the practice of diagnosing patients with such symptoms as having hysteria led to the disorder being meaningless, vague and a sham diagnosis, as it does not refer to any definable disease. Furthermore, throughout its history, many patients have been misdiagnosed with hysteria or conversion disorder when they had organic disorders such as tumours or epilepsy or vascular diseases. This has led to patient deaths, a lack of appropriate care and suffering for the patients. Eliot Slater, after studying the condition in the 1950s, stated: "The diagnosis of 'hysteria' is all too often a way of avoiding a confrontation with our own ignorance. This is especially dangerous when there is an underlying organic pathology, not yet recognised. In this penumbra we find patients who know themselves to be ill but, coming up against the blank faces of doctors who refuse to believe in the reality of their illness, proceed by way of emotional lability, overstatement and demands for attention ... Here is an area where catastrophic errors can be made. In fact it is often possible to recognise the presence though not the nature of the unrecognisable, to know that a man must be ill or in pain when all the tests are negative. But it is only possible to those who come to their task in a spirit of humility. In the main the diagnosis of 'hysteria' applies to a disorder of the doctor–patient relationship. It is evidence of non-communication, of a mutual misunderstanding ... We are, often, unwilling to tell the full truth or to admit to ignorance ... Evasions, even untruths, on the doctor's side are among the most powerful and frequently used methods he has for bringing about an efflorescence of 'hysteria'".

Much recent work has been done to identify the underlying causes of conversion and related disorders and to better understand why conversion disorder and hysteria appear more commonly in women. Current theoreticians tend to believe there is no single cause for these disorders. Instead, the emphasis tends to be on the patient's understanding and a variety of psychotherapeutic techniques. In some cases, the onset of conversion disorder correlates to a traumatic or stressful event. There are also certain populations that are considered at risk for conversion disorder, including people with a medical illness or condition, people with personality disorders or dissociative identity disorder. However, no biomarkers have yet been found to support the idea that conversion disorder is caused by a psychiatric condition.

There has been much recent interest in using functional neuroimaging to study conversion. As researchers identify the mechanisms which underlie conversion symptoms, it is hoped they will enable the development of a neuropsychological model. A number of such studies have been performed, including some which suggest the blood-flow in patients' brains may be abnormal while they are unwell. However, the studies have all been too small to be confident of the generalisability of their findings, so no neuropsychological model has been clearly established.

An evolutionary psychology explanation for conversion disorder is that the symptoms may have been evolutionarily advantageous during warfare. A non-combatant with these symptoms signals non-verbally, possibly to someone speaking a different language, that she or he is not dangerous as a combatant and also may be carrying some form of dangerous infectious disease. This can explain that conversion disorder may develop following a threatening situation, that there may be a group effect with many people simultaneously developing similar symptoms (as in mass psychogenic illness), and the gender difference in prevalence.

The Lacanian model accepts conversion disorder as a common phenomenon inherent in specific psychical structures. The higher prevalence of it among women is based on somewhat different intrapsychic relations to the body from those of typical males, which allows the formation of conversion symptoms.

A Beautiful Mind (film)

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/A_Beautiful_Mind_(film) 

 

A Beautiful Mind
Theatrical release poster
Directed by	Ron Howard
Written by	Akiva Goldsman
Based on	A Beautiful Mind by Sylvia Nasar
Produced by	Brian Grazer Ron Howard
Starring	Russell Crowe Ed Harris Jennifer Connelly Paul Bettany Adam Goldberg Judd Hirsch Josh Lucas Anthony Rapp Christopher Plummer
Cinematography	Roger Deakins
Edited by	Daniel P. Hanley Mike Hill
Music by	James Horner
Production companies	Universal Pictures DreamWorks Pictures Imagine Entertainment
Distributed by	Universal Pictures (North America) DreamWorks Pictures (International)
Release dates	December 13, 2001 (Beverly Hills premiere) December 21, 2001 (United States)
Running time	135 minutes
Country	United States
Language	English
Budget	$58 million
Box office	$316.8 million

A Beautiful Mind is a 2001 American biographical drama film directed by Ron Howard. Written by Akiva Goldsman, its screenplay was inspired by Sylvia Nasar's 1998 biography of the mathematician John Nash, a Nobel Laureate in Economics. A Beautiful Mind stars Russell Crowe as Nash, along with Ed Harris, Jennifer Connelly, Paul Bettany, Adam Goldberg, Judd Hirsch, Josh Lucas, Anthony Rapp, and Christopher Plummer in supporting roles. The story begins in Nash's days as a brilliant but asocial mathematics graduate student at Princeton University. After Nash accepts secret work in cryptography, his life takes a turn for the nightmarish.

A Beautiful Mind was released theatrically in the United States on December 21, 2001. It went on to gross over $313 million worldwide and won four Academy Awards, for Best Picture, Best Director, Best Adapted Screenplay and Best Supporting Actress for Connelly. It was also nominated for Best Actor, Best Film Editing, Best Makeup, and Best Original Score.

Plot

In 1947, John Nash arrives at Princeton University as a co-recipient, with Martin Hansen, of the Carnegie Scholarship for Mathematics. He meets fellow math and science graduate students Sol, Ainsley, and Bender, as well as his roommate Charles Herman, a literature student.

Determined to publish his own original idea, Nash is inspired when he and his classmates discuss how to approach a group of women at a bar. Hansen quotes Adam Smith advocating "every man for himself", but Nash argues that a cooperative approach would lead to better chances of success in developing a new concept of governing dynamics. Publishing an article on his theory, he earns an appointment at MIT where he chooses Sol and Bender over Hansen to join him.

In 1953, Nash is invited to the Pentagon to study encrypted enemy telecommunications, which he deciphers mentally. Bored with his regular duties at MIT, including teaching, he is recruited by the mysterious William Parcher of the United States Department of Defense with a classified assignment: to look for hidden patterns in magazines and newspapers to thwart a Soviet plot. Nash becomes increasingly obsessive in his search for these patterns, delivering his results to a secret mailbox, and comes to believe he is being followed.

One of his students, Alicia Larde, asks him to dinner, and they fall in love. On a return visit to Princeton, Nash runs into Charles and his niece, Marcee. With Charles' encouragement, he proposes to Alicia and they marry. Nash fears for his life after surviving a shootout between Parcher and Soviet agents, and learns Alicia is pregnant, but he is forced to continue his assignment. While delivering a guest lecture at Harvard University, Nash tries to flee from people he thinks are Soviet agents, led by a psychiatrist named Dr. Rosen, but is forcibly sedated and committed to a psychiatric facility.

Dr. Rosen tells Alicia that Nash has schizophrenia and that Charles, Marcee, and Parcher exist only in his imagination. Alicia backs up the doctor, telling Nash that no "William Parcher" is in the Defense Department and takes out the unopened documents he delivered to the secret mailbox. Nash is given a course of insulin shock therapy and eventually released. Frustrated with the side effects of his antipsychotic medication, he secretly stops taking it and starts seeing Parcher and Charles again.

In 1956, Alicia discovers Nash has resumed his "assignment" in a shed near their home. Realizing he has relapsed, Alicia rushes to the house to find Nash had left their infant son in the running bathtub, believing "Charles" was watching the baby. Alicia calls Dr. Rosen, but Nash accidentally knocks her and the baby to the ground, believing he's fighting Parcher.

As Alicia flees with the baby, Nash fights with his visions and realizes that all of them have looked the same ever since he first saw them. He stops Alicia's car and tells her he realizes that "Marcee" isn't real because she doesn't age, finally accepting that Parcher and other figures are hallucinations. Against Dr. Rosen's advice, Nash chooses not to restart his medication, believing he can deal with his symptoms himself, and Alicia decides to stay and support him.

Nash returns to Princeton, approaching his old rival Hansen, now head of the mathematics department, who allows him to work out of the library and audit classes. Over the next two decades, Nash learns to ignore his hallucinations and, by the late 1970s, is allowed to teach again.

In 1994, Nash is awarded the Nobel Memorial Prize in Economic Sciences for his revolutionary work on game theory, and is honored by his fellow professors. At the ceremony, he dedicates the prize to his wife. As Nash, Alicia, and their son leave the auditorium in Stockholm, Nash sees Charles, Marcee, and Parcher watching him, but merely glances at them before departing.

Cast

• Russell Crowe as John Nash
• Jennifer Connelly as Alicia Nash
• Ed Harris as William Parcher
• Christopher Plummer as Dr. Rosen
• Paul Bettany as Charles Herman
• Adam Goldberg as Richard Sol
• Josh Lucas as Martin Hansen
• Anthony Rapp as Bender
• Jason Gray-Stanford as Ainsley Neilson
• Judd Hirsch as Hellinger
• Austin Pendleton as Thomas King
• Vivien Cardone as Marcee Herman
• Killian, Christian, and Daniel Coffinet-Crean as Baby

Production

Development

A Beautiful Mind was the second schizophrenia-themed film that Ron Howard had planned to direct. The first, Laws of Madness, would have been based on the true story of schizophrenic Michael Laudor, who overcame difficult odds to successfully graduate from Yale Law School. Howard purchased the rights to Laudor's life story for $1.5 million in 1995 and had Brad Pitt slated to play the lead role. However, after Laudor killed his fiancée in 1998 in the midst of a psychotic episode, plans for the movie were cancelled.

After producer Brian Grazer first read an excerpt of Sylvia Nasar's 1998 book A Beautiful Mind in Vanity Fair magazine, he immediately purchased the rights to the film. Grazer later said that many A-list directors were calling with their point of view on the project. He eventually brought the project to Ron Howard, his long time partner.

Grazer met with a number of screenwriters, mostly consisting of "serious dramatists", but he chose Akiva Goldsman because of his strong passion and desire for the project. Goldsman's creative take on the project was to avoid having viewers understand they are viewing an alternative reality until a specific point in the film. This was done to rob the viewers of their understanding, to mimic how Nash comprehended his experiences. Howard agreed to direct the film based on the first draft. He asked Goldsman to emphasize the love story of Nash and his wife; she was critical to his being able to continue living at home.

Dave Bayer, a professor of mathematics at Barnard College, Columbia University, was consulted on the mathematical equations that appear in the film. For the scene where Nash has to teach a calculus class and gives them a complicated problem to keep them busy, Bayer chose a problem physically unrealistic but mathematically very rich, in keeping with Nash as "someone who really doesn't want to teach the mundane details, who will home in on what's really interesting". Bayer received a cameo role in the film as a professor who lays his pen down for Nash in the pen ceremony near the end of the film.

Greg Cannom was chosen to create the makeup effects for A Beautiful Mind, specifically the age progression of the characters. Crowe had previously worked with Cannom on The Insider. Howard had also worked with Cannom on Cocoon. Each character's stages of makeup were broken down by the number of years that would pass between levels. Cannom stressed subtlety between the stages, but worked toward the ultimate stage of "Older Nash". The production team originally decided that the makeup department would age Russell Crowe throughout the film; however, at Crowe's request, the makeup was used to push his look to resemble the facial features of John Nash. Cannom developed a new silicone-type makeup that could simulate skin and be used for overlapping applications; this shortened make-up application time from eight to four hours. Crowe was also fitted with a number of dentures to give him a slight overbite in the film.

Howard and Grazer chose frequent collaborator James Horner to score the film because they knew of his ability to communicate. Howard said, regarding Horner, "it's like having a conversation with a writer or an actor or another director". A running discussion between the director and the composer was the concept of high-level mathematics being less about numbers and solutions, and more akin to a kaleidoscope, in that the ideas evolve and change. After the first screening of the film, Horner told Howard: "I see changes occurring like fast-moving weather systems". He chose it as another theme to connect to Nash's ever-changing character. Horner chose Welsh singer Charlotte Church to sing the soprano vocals after deciding that he needed a balance between a child and adult singing voice. He wanted a "purity, clarity and brightness of an instrument" but also a vibrato to maintain the humanity of the voice.

The film was shot 90% chronologically. Three separate trips were made to the Princeton University campus. During filming, Howard decided that Nash's delusions should always be introduced first audibly and then visually. This provides a clue for the audience and establishes the delusions from Nash's point of view. The historic John Nash had only auditory delusions. The filmmakers developed a technique to represent Nash's mental epiphanies. Mathematicians described to them such moments as a sense of "the smoke clearing", "flashes of light" and "everything coming together", so the filmmakers used a flash of light appearing over an object or person to signify Nash's creativity at work. Two night shots were done at Fairleigh Dickinson University's campus in Florham Park, New Jersey, in the Vanderbilt Mansion ballroom. Portions of the film set at Harvard were filmed at Manhattan College. (Harvard has turned down most requests for on-location filming ever since the filming of Love Story (1970), which caused significant physical damage to trees on campus.)

Tom Cruise was considered for the lead role. Howard ultimately cast Russell Crowe. For the role of Alicia Nash, Rachel Weisz was offered the role but turned it down. Charlize Theron and Julia Ormond auditioned for the role. According to Ron Howard, the four finalists for the role of Alicia were Ashley Judd, Claire Forlani, Mary McCormack and Jennifer Connelly, with Connelly winning the role. Before the casting of Connelly, Hilary Swank and Salma Hayek were also candidates for the part.

Writing

The narrative of the film differs considerably from the events of Nash's life, as filmmakers made choices for the sense of the story. The film has been criticized for this aspect, but the filmmakers said they never intended a literal representation of his life.

One difficulty was the portrayal of his mental illness and trying to find a visual film language for this. As a matter of fact, Nash never had visual hallucinations: Charles Herman (the "roommate"), Marcee Herman and William Parcher (the Defense agent) are a scriptwriter's invention. Sylvia Nasar said that the filmmakers "invented a narrative that, while far from a literal telling, is true to the spirit of Nash's story". Nash spent his years between Princeton and MIT as a consultant for the RAND Corporation in California, but in the film he is portrayed as having worked for the Department of Defense at the Pentagon instead. His handlers, both from faculty and administration, had to introduce him to assistants and strangers. The PBS documentary A Brilliant Madness tried to portray his life more accurately.

Few of the characters in the film, besides John and Alicia Nash, correspond directly to actual people. The discussion of the Nash equilibrium was criticized as over-simplified. In the film, Nash has schizophrenic hallucinations while he is in graduate school, but in his life he did not have this experience until some years later. No mention is made of Nash's homosexual experiences at RAND, which are noted in the biography, though both Nash and his wife deny this occurred. Nash fathered a son, John David Stier (born June 19, 1953), by Eleanor Agnes Stier (1921–2005), a nurse whom he abandoned when she told him of her pregnancy. The film did not include Alicia's divorce of John in 1963. It was not until after Nash won the Nobel Memorial Prize in 1994 that they renewed their relationship. Beginning in 1970, Alicia allowed him to live with her as a boarder. They remarried in 2001.

Nash is shown to join Wheeler Laboratory at MIT, but there is no such lab. Instead, he was appointed as C. L. E. Moore instructor at MIT, and later as a professor. The film furthermore does not touch on the revolutionary work of John Nash in differential geometry and partial differential equations, such as the Nash embedding theorem or his proof of Hilbert's nineteenth problem, work which he did in his time at MIT and for which he was given the Abel Prize in 2015. The so-called pen ceremony tradition at Princeton shown in the film is completely fictitious. The film has Nash saying in 1994: "I take the newer medications", but in fact, he did not take any medication from 1970 onwards, something highlighted in Nasar's biography. Howard later stated that they added the line of dialogue because they worried that the film would be criticized for suggesting that all people with schizophrenia can overcome their illness without medication. In addition, Nash never gave an acceptance speech for his Nobel prize.

Release and response

A Beautiful Mind received a limited release on December 21, 2001, receiving positive reviews, with Crowe receiving wide acclaim for his performance. It was later released in the United States on January 4, 2002.

Critical response

On Rotten Tomatoes, A Beautiful Mind holds an approval rating of 74% based on 213 reviews and an average score of 7.20/10. The website's critical consensus states: "The well-acted A Beautiful Mind is both a moving love story and a revealing look at mental illness." On Metacritic, the film has a weighted average score of 72 out of 100 based on 33 reviews, indicating "generally favorable reviews". Audiences polled by CinemaScore gave the film an average grade of "A-" on an A+ to F scale.

Roger Ebert of Chicago Sun-Times gave the film four out of four stars. Mike Clark of USA Today gave three-and-a-half out of four stars and also praised Crowe's performance, calling it a welcome follow-up to Howard's previous film, 2001's How the Grinch Stole Christmas. Desson Thomson of The Washington Post found the film to be "one of those formulaically rendered Important Subject movies". The portrayal of mathematics in the film was praised by the mathematics community, including John Nash himself.

John Sutherland of The Guardian noted the film's biopic distortions, but said:

Howard pulls off an extraordinary trick in A Beautiful Mind by seducing the audience into Nash's paranoid world. We may not leave the cinema with A-level competence in game theory, but we do get a glimpse into what it feels like to be mad - and not know it.

Some writers such as Shailee Koranne argue that the film presents an unrealistic or inappropriate depiction of the disorder schizophrenia, which the protagonist John Nash suffers from, stating that places too much emphasis on “fixing” the disorder.

Writing in the Los Angeles Times, Lisa Navarrette criticized the casting of Jennifer Connelly as Alicia Nash as an example of whitewashing. Alicia Nash was born in El Salvador and had an accent not portrayed in the film.

Box office

During the five-day weekend of the limited release, A Beautiful Mind opened at the #12 spot at the box office, peaking at the #2 spot following the wide release. The film went on to gross $170,742,341 in the United States and Canada and $313,542,341 worldwide.

Insulin shock therapy

From Wikipedia, the free encyclopedia

 

Insulin shock therapy
Insulin shock therapy administered in Långbro Hospital, Stockholm in the 1930s
ICD-9-CM	94.24
MeSH	D003295

Insulin shock therapy or insulin coma therapy was a form of psychiatric treatment in which patients were repeatedly injected with large doses of insulin in order to produce daily comas over several weeks. It was introduced in 1927 by Austrian-American psychiatrist Manfred Sakel and used extensively in the 1940s and 1950s, mainly for schizophrenia, before falling out of favour and being replaced by neuroleptic drugs in the 1960s.

It was one of a number of physical treatments introduced into psychiatry in the first four decades of the 20th century. These included the convulsive therapies (cardiazol/metrazol therapy and electroconvulsive therapy), deep sleep therapy, and psychosurgery. Insulin coma therapy and the convulsive therapies are collectively known as the shock therapies.

Origins

In 1927, Sakel, who had recently qualified as a medical doctor in Vienna and was working in a psychiatric clinic in Berlin, began to use low (sub-coma) doses of insulin to treat drug addicts and psychopaths, and after one of the patients experienced improved mental clarity after having slipped into an accidental coma, Sakel reasoned the treatment might work for mentally ill patients. Having returned to Vienna, he treated schizophrenic patients with larger doses of insulin in order to deliberately produce coma and sometimes convulsions. Sakel made his results public in 1933, and his methods were soon taken up by other psychiatrists.

Joseph Wortis, after seeing Sakel practice it in 1935, introduced it to the US. British psychiatrists from the Board of Control visited Vienna in 1935 and 1936, and by 1938, 31 hospitals in England and Wales had insulin treatment units. In 1936, Sakel moved to New York and promoted the use of insulin coma treatment in US psychiatric hospitals. By the late 1940s, the majority of psychiatric hospitals in the US were using insulin coma treatment.

Technique

An insulin treatment ward, circa 1951, Roundway Hospital, Devizes, England

Insulin coma therapy was a labour-intensive treatment that required trained staff and a special unit. Patients, who were almost invariably diagnosed with schizophrenia, were selected on the basis of having a good prognosis and the physical strength to withstand an arduous treatment. There were no standard guidelines for treatment. Different hospitals and psychiatrists developed their own protocols. Typically, injections were administered six days a week for about two months.

The daily insulin dose was gradually increased to 100–150 units (1 unit = 34.7 μg) until comas were produced, at which point the dose would be levelled out. Occasionally doses of up to 450 units were used. After about 50 or 60 comas, or earlier if the psychiatrist thought that maximum benefit had been achieved, the dose of insulin was rapidly reduced before treatment was stopped. Courses of up to 2 years have been documented.

After the insulin injection patients would experience various symptoms of decreased blood glucose: flushing, pallor, perspiration, salivation, drowsiness or restlessness. Sopor and coma—if the dose was high enough—would follow. Each coma would last for up to an hour and be terminated by intravenous glucose or via naso-gastric tube. Seizures occurred before or during the coma. Many would be tossing, rolling, moaning, twitching, spasming or thrashing around.

Some psychiatrists regarded seizures as therapeutic and patients were sometimes also given electroconvulsive therapy or cardiazol/metrazol convulsive therapy during the coma, or on the day of the week when they didn't have insulin treatment. When they were not in a coma, insulin coma patients were kept together in a group and given special treatment and attention. One handbook for psychiatric nurses, written by British psychiatrist Eric Cunningham Dax, instructs nurses to take their insulin patients out walking and occupy them with games and competitions, flower-picking and map-reading, etc. Patients required continuous supervision as there was a danger of hypoglycemic aftershocks after the coma.

In "modified insulin therapy", used in the treatment of neurosis, patients were given lower (sub-coma) doses of insulin.

Effects

A patient subjected to the practice in Lapinlahti Hospital, Helsinki in the 1950s

A few psychiatrists (including Sakel) claimed success rates for insulin coma therapy of over 80% in the treatment of schizophrenia. A few others argued that it merely accelerated remission in those patients who would undergo remission anyway. The consensus at the time was somewhere in between, claiming a success rate of about 50% in patients who had been ill for less than a year (about double the spontaneous remission rate) with no influence on relapse.

Sakel suggested the therapy worked by "causing an intensification of the tonus of the parasympathetic end of the autonomic nervous system, by blockading the nerve cell, and by strengthening the anabolic force which induces the restoration of the normal function of the nerve cell and the recovery of the patient." The shock therapies in general had developed on the erroneous premise that epilepsy and schizophrenia rarely occurred in the same patient. The premise was supported by neuropathologic studies that found a dearth of glia in the brains of schizophrenic patients and a surplus of glia in epileptic brains. These observations led the Hungarian neuropsychiatrist Ladislas Meduna to induce seizures in schizophrenic patients with injections of camphor, soon replaced by pentylenetetrazol (Metrazole). Another theory was that patients were somehow "jolted" out of their mental illness.

The hypoglycemia (pathologically low glucose levels) that resulted from insulin coma therapy made patients extremely restless, sweaty, and liable to further convulsions and "after-shocks". In addition, patients invariably emerged from the long course of treatment "grossly obese", probably due to glucose rescue-induced glycogen storage disease. The most severe risks of insulin coma therapy were death and brain damage, resulting from irreversible or prolonged coma respectively. A study at the time claimed that many of the cases of brain damage were actually therapeutic improvement because they showed "loss of tension and hostility". Mortality risk estimates varied from about one percent to 4.9 percent.

Respected singer-songwriter Townes Van Zandt was said to have lost much of his long-term memory from this treatment, performed on him for bipolar disorder, preceding a life of substance abuse and depression.

Decline

Insulin coma therapy was used in most hospitals in the US and the UK during the 1940s and 1950s. The numbers of patients were restricted by the requirement for intensive medical and nursing supervision and the length of time it took to complete a course of treatment. For example, at one typical large British psychiatric hospital, Severalls Hospital in Essex, insulin coma treatment was given to 39 patients in 1956. In the same year, 18 patients received modified insulin treatment, while 432 patients were given electroconvulsive treatment.

In 1953, British psychiatrist Harold Bourne published a paper entitled "The insulin myth" in the Lancet, in which he argued that there was no sound basis for believing that insulin coma therapy counteracted the schizophrenic process in a specific way. If treatment worked, he said, it was because patients were chosen for their good prognosis and were given special treatment: "insulin patients tend to be an elite group sharing common privileges and perils". Prior to publishing "The insulin myth" in The Lancet, Bourne had tried to submit the article to the Journal of Mental Science; after a 12-month delay, the Journal informed Bourne they had rejected the article, telling him to "get more experience".

In 1957, when insulin coma treatment use was declining, The Lancet published the results of a randomized, controlled trial where patients were either given insulin coma treatment or identical treatment but with unconsciousness produced by barbiturates. There was no difference in outcome between the groups and the authors concluded that, whatever the benefits of the coma regimen, insulin was not the specific therapeutic agent.

In 1958, American neuropsychiatrist Max Fink published in the Journal of the American Medical Association the results of a random controlled comparison in 60 patients treated with 50 iatrogenic insulin-induced comas or chlorpromazine in doses from 300 mg to 2000 mg/day. The results were essentially the same in relief and discharge ratings but chlorpromazine was safer with fewer side-effects, easier to administer, and better suited to long-term care.

In 1958, Bourne published a paper on increasing disillusionment in the psychiatric literature about insulin coma therapy for schizophrenia. He suggested there were several reasons it had received almost universal uncritical acceptance by reviews and textbooks for several decades despite the occasional disquieting negative finding, including that, by the 1930s when it all started, schizophrenics were considered inherently unable to engage in psychotherapy, and insulin coma therapy "provided a personal approach to the schizophrenic, suitably disguised as a physical treatment so as to slip past the prejudices of the age."

Although coma therapy had largely fallen out of use in the US by the 1970s, it was still being practiced and researched in some hospitals, and may have continued for longer in countries such as China and the Soviet Union.

Recent writing

Recent articles about insulin coma treatment have attempted to explain why it was given such uncritical acceptance. In the US, Deborah Doroshow wrote that insulin coma therapy secured its foothold in psychiatry not because of scientific evidence or knowledge of any mechanism of therapeutic action, but due to the impressions it made on the minds of the medical practitioners within the local world in which it was administered and the dramatic recoveries observed in some patients. Today, she writes, those who were involved are often ashamed, recalling it as unscientific and inhumane. Administering insulin coma therapy made psychiatry seem a more legitimate medical field. Harold Bourne, who questioned the treatment at the time, said: "It meant that psychiatrists had something to do. It made them feel like real doctors instead of just institutional attendants".

One retired psychiatrist who was interviewed by Doroshow "described being won over because his patients were so sick and alternative treatments did not exist". Doroshow argues that "psychiatrists used complications to exert their practical and intellectual expertise in a hospital setting" and that collective risk-taking established "especially tight bonds among unit staff members". She finds it ironic that psychiatrists "who were willing to take large therapeutic risks were extremely careful in their handling of adverse effects". Psychiatrists interviewed by Doroshow recalled how insulin coma patients were provided with various routines and recreational and group-therapeutic activities, to a much greater extent than most psychiatric patients. Insulin coma specialists often chose patients whose problems were the most recent and who had the best prognosis; in one case discussed by Doroshow a patient had already started to show improvement before insulin coma treatment, and after the treatment denied that it had helped, but the psychiatrists nevertheless argued that it had.

A Beautiful Mind

The 1994 Nobel Prize winner in Economics John Nash became psychotic and was first treated at McLean Hospital. When he relapsed he was admitted to Trenton NJ State hospital. His associates at Princeton University pleaded with the hospital director to have Nash treated in the insulin coma unit, recognizing that it was better staffed than other hospital units. He responded to treatment and treatment was continued with neuroleptics.

Nash's life story was presented in the film A Beautiful Mind, which accurately portrayed the seizures associated with his treatments. In a review of the Nash history, Fink ascribed the success of coma treatments to the 10% of associated seizures, noting that physicians often augmented the comas by convulsions induced by ECT. He envisioned insulin coma treatment as a weak form of convulsive therapy.

Other explanations

In the UK, psychiatrist Kingsley Jones sees the support of the Board of Control as important in persuading psychiatrists to use insulin coma therapy. The treatment then acquired the privileged status of a standard procedure, protected by professional organizational interests. He also notes that it has been suggested that the Mental Treatment Act 1930 encouraged psychiatrists to experiment with physical treatments.

British lawyer Phil Fennell notes that patients "must have been terrified" by the insulin coma therapy procedures and the effects of the massive overdoses of insulin, and were often rendered more compliant and easier to manage after a course.

Leonard Roy Frank, an American activist from the psychiatric survivors movement who underwent 50 forced insulin coma treatments combined with ECT, described the treatment as "the most devastating, painful and humiliating experience of my life", a "flat-out atrocity" glossed over by psychiatric euphemism, and a violation of basic human rights.

In 2013, French physician-and-novelist Laurent Seksik wrote an historical novel about the tragic life of Eduard Einstein: Le cas Eduard Einstein. He related the encounter between Dr Sakel and Mileva Maric, Albert Einstein's first wife (and Eduard's mother), and the way Sakel's therapy had been given to Eduard, who had schizophrenia.

Representation in media

Like many new medical treatments for diseases previously considered incurable, depictions of insulin coma therapy in the media were initially favorable. In the 1940 film Dr. Kildare's Strange Case, young Kildare uses the new "insulin shock cure for schizophrenia" to bring a man back from insanity. The film dramatically shows a five-hour treatment that ends with a patient eating jelly sandwiches and reconnecting with his wife. Other films of the era began to show a more sinister approach, beginning with the 1946 film Shock, in which actor Vincent Price plays a doctor who plots to murder a patient using an overdose of insulin in order to keep the fact that he was a murderer a secret. More recent films include Frances (1982) in which actress Frances Farmer undergoes insulin coma treatment, and A Beautiful Mind, which depicted genius John Nash undergoing insulin treatment. In an episode of the medical drama House M.D., House puts himself in an insulin shock to try to make his hallucinations disappear. Sylvia Plath's The Bell Jar refers to insulin coma therapy in chapter 15.

Anti-homelessness legislation

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Anti-homelessness_legislation 

 

Man sleeps on the street.

Anti-homelessness legislation can take two forms: legislation that aims to help and re-house homeless people; and legislation that is intended to send homeless people to homeless shelters compulsorily, or to criminalize homelessness and begging.

International law

Since the publication of the Universal Declaration of Human Rights (Charter of the United Nations — UN) in 1948, the public perception has been increasingly changing to a focus on the human right to housing, travel and migration as a part of individual self-determination rather than the human condition. The Declaration, an international law reinforcement of the Nuremberg Trial Judgements, upholds the rights of one nation to intervene in the affairs of another if said nation is abusing its citizens, and rose out of a 1939–1945 World War II Atlantic environment of extreme split between "haves" and "have nots." Article 6 of the 1998 Declaration of Human Duties and Responsibilities declares that members of the global community have individual and collective duties and responsibilities to take appropriate action to prevent the commission of gross or systematic human rights abuses. The modern study of homeless phenomena is most frequently seen in this historical context.

Laws supporting homeless people

Laws supporting homeless people generally place obligations on the state to support or house homeless people.

United Kingdom

The 1834 Poor Law Amendment Act required parish unions to supply houses for workers but these unions purposely made these work houses unattractive in order to discourage workers from applying for housing. This Act also made casual wards known as "spikes" available for those who needed temporary housing in return for their labor. It was estimated that approximately 30,000 to 80,000 people used the spikes in the early 1900s in Great Britain.

Under the Homeless Reduction Act 2017 unhoused persons should be able to access assistance from their council. Councils also must work to prevent people from becoming unhoused, and families with children will still be housed by councils.

Part 7 of the Housing Act 1996 provides action to prevent homelessness and also to provide assistance to those who are threatened with homelessness.

Wales

In 2014, a law was implicated which means that the councils must attempt to stop people becoming homeless in the first place. Prior to this law, councils only had to assist unhoused persons labelled under 'priority', which included mostly families with young children.

According to the charity Crisis, this law has increased council efficiency via more proficient services, including fewer families being placed into expensive emergency accommodation.

Scotland

See also: Scottish homelessness

The Homelessness etc. (Scotland) Act 2003 was legislation passed by the Scottish Parliament that set the goal of providing permanent residence to those deemed unintentionally homeless. Following, the Homeless Persons (Unsuitable Accommodation) (Scotland) Order 2004 was passed in 2004. This order made it so that, unless exceptional circumstances were present, any familial unit including children or an expectant mother was not placed in "unsuitable temporary housing". Scotland's most recent anti-homelessness legislation is entitled The Housing Support Services (Homelessness)(Scotland) Regulations 2012, and it came into full effect on June 1, 2013. These regulations require local authorities to assist homeless people in a variety of ways, including help in adjusting to a new living situation, debt counseling and managing a personal budget.

Since 2012, Scotland have gained some of the strongest homelessness rights in the world. This is as a result of the insertion of having no distinction between the idea of 'priority' and 'non-priority' homeless, this creates an opportunity for anyone houseless to be entitled to at least temporary, and usually permanent accommodation.

United States

The 1987 McKinney–Vento Homeless Assistance Act: A change created by the amendments of 1992 was the creation of the Access to Community Care and Effective Services and Support program (or ACCESS); this program was created in order to assist the homeless people who had both serious mental illness issues, as well as substance abuse problems and lasted a total of 5 years.

The Fair Housing Act passed in 1968 was designed to protect those who were traditionally discriminated against by housing agencies because of their race, gender, religion, familial status, and disability. Some states and cities also gave homeless people equal access to housing accommodations regardless of their income. Although this Act did not specifically refer to the homeless population, the main beneficiaries of this law were homeless individuals.

The Americans with Disabilities Act of 1990, also known as the ADA states that people with disabilities must be given appropriate housing accommodations that meet their special needs. Additionally, people with disabilities should be given the chance to interact with people who do not have disability.

Laws criminalizing behaviors engaged in by homeless people

Laws that criminalize homeless people generally take on one of five forms:

• Restricting the public areas in which sitting or sleeping are allowed
• Removing homeless people from particular areas
• Prohibiting begging
• Selective enforcement of laws
• Selective creation of laws (The French novelist Anatole France noted this phenomenon as long ago as 1894, famously observing that "the law, in its majestic equality, forbids the rich as well as the poor to sleep under bridges".)

England and Wales

The 1977 Housing (Homeless Persons) Act greatly restricted requirements for housing homeless people so that only individuals who were affected by natural disasters could receive housing accommodations from the local authorities. This led to the rejection of the majority of homeless applications received by the local government. This Act also made it difficult for homeless individuals without children to receive accommodations provided by local authorities.

Rough sleeping is viewed as a criminal offence under Vagrancy Act 1824. Nowadays, this law is primarily used to move individuals without formal caution or arrest.

United States

Further information: Homelessness in the United States § Criminalization of homelessness

Homeless people find it harder to secure employment, housing, or federal benefits with a criminal record, and therefore penalizing the act of being homeless makes exiting such a situation much more difficult. Although the court's opinion in Jones v. City of Los Angeles (see above) was vacated, the result suggests that criminalizing homelessness may be unconstitutional. Similarly, in response to growing reports of hate crimes, some state governments have proposed the addition of "people experiencing homelessness" to their hate-crimes statutes.

One study in Colorado examined a common justification for anti-homelessness laws – that a "tough love" approach ultimately improved the lives of homeless people – and found that the homeless reported worse quality of life due to the laws. Another study in California found that people experiencing extreme poverty face apathy, disrespect, and discrimination from police enforcing anti-homelessness laws, resulting in a reluctance to seek services and to engage with outreach when offered.

Europe

The European Court of Human Rights ruled that an anti-begging ordinance in Geneva violated human rights in the 2021 Lăcătuș v. Switzerland case. The plaintiff was from the Romani people in Romania and had been fined more than 400 euros for begging.

Hungary

Hungary is the only country where criminalization of homelessness is addressed in its constitution, which is seen as part of a broader illiberal governance in the country. Sleeping in a public space is illegal and violators can be fined or jailed. One study found that the criminalization of homelessness increased tolerance for extralegal violence against homeless individuals.

Anti-homeless architecture

Anti-homeless architecture is an urban design strategy that is intended to discourage loitering, camping, and sleeping in public. While this policy does not explicitly target homeless people, it restricts the ways in which people can use public spaces, which affects the homeless population.

Anti-homeless spikes on a shop ledge.

This strategy can take many forms, including:

• Reducing the number of sitting areas in public spaces
• Installing bolts and spikes in flat surfaces in order to make sleeping on them uncomfortable
• Installing dividers on metal benches to prevent sleeping
• Metal teeth and bars on ledges to prevent sitting
• Boulders placed in parks to prevent homeless encampments

These forms of architecture are also referred to as hostile architecture. They can make life for the unhoused persons more difficult as they modify public spaces that would otherwise be accessible. Arguments are put forward that the resources spent on the upkeep and design of hostile architecture should instead spent on addressing the root causes of homelessness.

The Oregon Department of Transportation placed large boulders in several locations to discourage illegal camping near freeways. Anti-homeless spikes were installed in London, England, and New York City in order to make homeless activity more difficult. Anti-homeless architecture is a common tactic in major cities. Local governments often employ anti-homeless architecture practices following complaints from local business owners as the presence of homeless individuals lowers property prices and discourages business traffic.

Critics of anti-homeless architecture claim that it targets an already vulnerable population, and that it hides the effects of homelessness, rather than meaningfully addressing it.

Perception of homelessness and policy implications

United States

The authors of a 2017 study on homelessness stated that homeless people have a higher incidence of sickness, with their most common health problem being skin problems. Homeless people also have a lack of access to sanitation, leading to poor hygiene. These characteristics are noticeable and may trigger reactions of disgust from onlookers who are inclined, at an evolutionary level, to be pathogen-averse. This leads the general public to keep their physical distance from homeless people, and promotes exclusionary policies. As an example, these authors state that while the majority of the general public support subsidized housing for homeless individuals, they do not want that housing in their own neighborhood.

But the public also maintains concern for homeless people, supporting increases in federal spending on homelessness programs. In fact, when surveyed, the public supports spending on homelessness over other social problems by consistently putting homeless people in the top third of their spending priorities.

Respondents to surveys also feel that 55% of homeless people are addicted to drugs or alcohol, and that 45% of homeless people have been to jail before. The majority of U.S. residents surveyed also think that homeless people make neighborhood worse, and that their presence brings down the profitability of local businesses.

Discrimination against homeless people

From Wikipedia, the free encyclopedia
https://en.wikipedia.org/wiki/Discrimination_against_homeless_people

 

Anti-homeless architecture

Discrimination against homeless people is the act of treating homeless people or people perceived to be homeless unfavorably. As with most types of discrimination, it can manifest in numerous forms.

Discriminatory legislation regarding homelessness

Main article: Criminalization of homelessness

Use of the law to discriminate against homeless people takes on disparate forms: restricting the public areas in which sitting or sleeping are allowed, ordinances restricting aggressive panhandling, actions intended to divert homeless people from particular areas, penalizing loitering, asocial, or, or unequally enforcing laws on homeless people and not on those who are not homeless. An American Civil Liberties Union report claimed that the government of LA discriminated against the homeless residents. The report lays out the ways such as “harassment, segregation, issuing citations,” by which the government discriminates against the homeless people and holds back essential services that could save their lives.

There is also potential for individuals experiencing homelessness to face employment discrimination. Many employers require applicants to list home addresses on job applications, which creates potential for an employer to recognize an applicant's address as a homeless shelter. Sarah Golabek-Goldman writes about BAN THE ADDRESS, a campaign that proposes that employers delay asking about an applicant's address until after the applicant is given a job offer. The BAN THE ADDRESS campaign seeks to protect individuals experiencing homelessness from discrimination in the hiring process by attempting to eliminate one source of potential employment discrimination.

There are at least 5 states which consider crimes against homeless people with the reason being due to their homelessness to be a hate crime, which include Florida, Maine, Washington and Rhode Island. It is also a hate crime stature in Washington, DC.

History of Discrimination

Within the US, homeless individuals have faced discriminatory action for decades. American Colonists in the 17th Century believed unhoused individuals to be homeless because of their moral inadequacies. Early views of homeless individuals revolved around a dehumanizing view, and that they were not in good religious standing.

The term "Homeless" was first recorded in the US in the 1870s. This was first used towards individual's that would travel around throughout the country in search of work. This term was created and used towards those that were perceived to be a threat towards the traditional home style life. Stigma and prejudicial view towards these individuals came from the idea that they had strayed from the domestic lifestyle.

In the 1820s less than 7% of Americans lived in cities. The rapid growth of industrialization increased the population sizes in these cities rapidly. The population of Boston, MA between the years of 1820 and 1860 grew 134,551.

In the 1870s the issue of homelessness became a national issue. Words such as "vagrant" and "bums" began to be used at this time. Veterans of the civil war, displaced persons from the civil war, and immigrant families made up large portions of the homeless population in this era. In 1874 the homeless or "vagrant" population in Boston was reported to be 98,263 individuals.

Anti Vagrancy Laws existed in the US in various forms since the 17th century. These laws often targeted unhoused women and African-Americans. Up until the 1970s, Anti Vagrancy laws punished innumerable amounts of Americans. In 1972 the Supreme Court invalidated and undermined these Anti Vagrancy. The Deinstitutionalization Movement of the 1960s and 1970s released thousands of individuals from Mental Hospitals and Institutions. Many of these individuals became homeless because of this releasing. These individuals suffering from mental illness struggled to survive unhoused.

The modern issue of homelessness in the US has grown exponentially in recent years in part due to housing crises, the COVID Pandemic, and increased cost of living.

Anti-camping legislation and policy

The French novelist Anatole France noted this phenomenon as long ago as 1894, famously observing that "the law, in its majestic equality, forbids the rich as well as the poor to sleep under bridges".

In July 2022, The Los Angeles City Council voted 10-1 in favor of expanding Municipal Code 41.18, the anti-camping law banning sitting, sleeping and storing property within 500 feet of several parks, recreation centers and other facilities. Following the council's vote, Councilman Hugo-Martínez, who opposed 41.18, wrote in a Twitter post, "LA's Municipal Code 41.18 criminalizes unhoused people, preventing them from existing in large portions of the city, even as we don't have nearly enough housing or shelter beds to accommodate everyone forced to live on our streets."

Coercive Psycho-pharmaceutical Treatment

For example, see Homelessness in California § Forced mental-health and addiction treatment

Criminal victimization

See also: Homelessness in the United States § Crimes against homeless people

Precise factors associated with victimization and injury to homeless people are not clearly understood. Nearly one-half of homeless people are victims of violence. There have been many violent crimes committed against homeless people due to their being homeless. A study in 2007 found that this number is increasing. This can be further understood as to why this happens, and supported by another study that found that people do not even perceive homeless people as fully human, neither competent or warm.

Lack of access to public restrooms

Per the National Alliance to End Homelessness, in January 2017, there were a total of 553,742 homeless people accounted for across the United States, including territories. Of those accounted for, 192,875 of them were unsheltered and "lived in a place not meant for human habitation, such as the street or an abandoned building". Many unsheltered homeless camps are located in industrial districts and along highways, far away from public parks facilities where traditional public bathrooms are located. If local municipalities do not provide bathroom access, homeless people are left to urinate and defecate in the streets and waterways near their camps.

Robinson and Sickels with the University of Colorado Denver released a report highlighting the criminalization of homelessness across the State of Colorado. During their research, they found that 83% of the people they interviewed said they were denied bathroom access because they were homeless. Without access to bathrooms, unsheltered homeless populations across the country are living in third-world conditions. This, in turn, leads to public health concerns such as the hepatitis A outbreak seen in California. As reported by Kushel with The New England Journal of Medicine, in 2017 alone 649 people in California were infected with hepatitis A; this outbreak began in the homeless population.

Anti-homeless architecture

"Anti-homeless spikes" in front of a window

City and town plans may incorporate hostile architecture, also known as anti-homeless or defensive architecture, to deter homeless people from camping or sleeping in problematic areas. Research conducted by Crisis (based in the UK) recorded that 35% said they were unable to find a free place to sleep as a result of the designs. The named hostile architectures include; anti-homeless spikes, segregated benches and gated doorways.

Due to the politicization of the homelessness problem, the funds to help people with mental illness have been diverted to other areas leaving the mentally ill without any help. Mental health is considered one of the most significant contributing factors to homelessness.

Resources to Help

People who are homeless struggle with social inclusion. Some are scared to reach out because they fear the discrimination that may come with it. Reconstructing past relationships into something positive can make all the difference.

Another substantial factor is employment. Employment can help these people to feel wanted as well as assist them to get back on their feet. There are some facilities that offer shelter and employment, one being in Los Angeles. “Skid Row,” conducted a study to see what kind of impact this help gives. Homeless people granted the shelter were likelier to want to work. 

There are many actions to take when it comes to helping homeless people. Some simple ones are donating clothing, household items, books, and other materials. Other measures that can be taken involve fundraising programs, supporting a homeless shelter, or even helping to raise awareness.