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Research article | Open | Open Peer Review | Published: 26 September 2012
Meeting the needs of women who use drugs and alcohol in North-east India – a challenge for HIV prevention services
Michelle Kermode1,
Chinzaning Hangzo Songput2,
Collins Z Sono2,
Temjen Nungsang Jamir2 &
Alex Devine1
BMC Public Healthvolume 12, Article number: 825 (2012) | Download Citation
The North-east Indian states of Manipur and Nagaland consistently report relatively high HIV prevalence. The targeted HIV prevention interventions in these two states are mostly delivered by non-government organizations (NGOs), and prevention of HIV transmission by injecting drug use is their main focus. Most injecting drug users (IDUs) are male, and the services are primarily tailored to meet their needs, which are not necessarily the same as those for women. This qualitative study describes the health service needs of women who use drugs and alcohol in Manipur and Nagaland, with the goal of identifying strategies and activities that can be implemented by NGOs wanting to improve their reach among vulnerable women.
In 2009-10, semi-structured in-depth interviews were conducted with 27 key informants and nine focus group discussions (FGDs) with women who use drugs and alcohol, and two FGDs with male IDUs. The thematic areas covered included: the context of female drug and alcohol use; drug and alcohol use patterns; HIV risk behaviours; barriers and facilitators of service use; perceived health needs; and expressed health service needs. The data were recorded, transcribed, translated and thematically analysed.
The most problematic substance for women from Nagaland was alcohol, and for women from Manipur it was heroin. The most commonly identified health problems were primarily related to the women's drug and alcohol use, reproductive health and mental health. Other problems of major concern included social exclusion, violence, children's welfare, and financial difficulties. The expressed service needs of these women were women-only integrated health services, women-only detoxification and rehabilitation services, mental health services, desensitization of mainstream health workers, free access to medicines, assistance to meet basic needs, and a safe place for engaging in sex work.
The expressed health and other service needs of women who use drugs and alcohol in Manipur and Nagaland do not match the services currently provided by HIV prevention NGOs, and this may, in part, account for the relatively poor uptake of these services by women. Strategies and activities that can be implemented by NGOs to strengthen their reach to vulnerable women are identified. However, many of these women's needs are beyond the scope of services typically offered by HIV prevention NGOs, and require a coordinated multi-sectoral response.
Research and program responses to the dual public health problems of HIV and drug use primarily focus on men and injecting drug use, with the result that there is a substantial body of evidence regarding HIV risks for male injectors. Much less is known about the nexus between non-injecting drug and alcohol use and HIV risk behaviours. This bias is partially understandable given the epidemiology of injecting drug use, which is predominantly engaged in by men, and a relatively efficient route of HIV transmission. However, between 10-40% of injecting drug users (IDUs) are women, most of whom are more vulnerable to HIV infection compared to males for a number of reasons, in particular their participation in sex work [1–3]. HIV prevention programs targeting IDUs tend to be male dominated and not very accessible for female IDUs, whose needs are not the same as their male counterparts [1, 2]. Similarly, these services do not cover women who use non-injecting drugs and alcohol, unless they identify as female sex workers (FSWs), even though there is a growing awareness of the association between alcohol use and HIV risks [4–6].
Amplification of the risk of HIV infection due to the overlap between female injecting drug use and sex work is well documented both in India and elsewhere [7]. Female IDUs have riskier and more sex due to the need to earn sufficient income to procure drugs and support their basic needs, and they are sometimes expected to earn enough to support the drug use of their male partners as well [2, 3, 7–12]. Female IDUs' engagement in sex work is associated with higher rates of sexually transmitted infections (STIs) that in turn increase their risk of HIV infection [10]. Women who are dependent on non-injecting drugs and alcohol are also likely to have increased vulnerability to STIs including HIV [8, 13, 14], but unless they are injecting or engaging in sex work, are unlikely to come to the attention of HIV prevention programs.
Women substance users are more stigmatised than their male counterparts, and this directly affects their ability to access services. They delay seeking health care because they fear judgement, and when they do attend services, the quality of the care they receive is often sub-optimal due to the negative attitudes of the health care workers and their lack of knowledge and understanding about the health and social issues linked with female substance use [1, 2, 7, 14–17]. Women dependent on substances are less likely, over their lifetime, to enter treatment compared to men. However, gender does not predict treatment retention, completion, or outcome [1, 18]. Women are more vulnerable to the adverse social and mental health consequences of substance use including depression, insomnia, anxiety, post-traumatic stress disorder, suicidal tendencies, poor self-image, reduced family support, family rejection, and guilt for neglecting children [1, 7, 8, 15, 17, 18].
The goal of the present study is to assess the health service needs and HIV risks of female (injecting and non-injecting) drug and alcohol users in two North-east Indian states (Manipur and Nagaland) in order to promote improved access to services. The specific study objectives were to: 1. Understand the local context of female drug and alcohol use in Manipur and Nagaland; 2. Describe the HIV risks among the female drug and alcohol users; 3. Identify the health and other problems experienced by these women; 4. Elucidate their health service needs; 5. Document the barriers to health service access; and 6. Recommend strategies for current health services in Manipur and Nagaland to improve access for female drug and alcohol users. This paper reports on the findings related to objectives 3-6.
The context of Manipur and Nagaland
Manipur and Nagaland are two North-east Indian states that consistently report a high HIV prevalence, and in the case of Manipur, the highest in the country (adult HIV prevalence in 2009 was 1.4% in Manipur and 0.8% in Nagaland) [19]. The North-east region is characterised by various long-standing civil insurgent movements, deeply felt social conservatism, and substantial under-development. The Christian church is powerful in the public and private spheres in both states (especially in Nagaland), and as such, gives shape to socio-cultural values, as well as individual world views [20].
The sale and consumption of alcohol is illicit in both states, but relatively commonplace nevertheless. An estimated 1-2% of the adult population has injected drugs, mostly heroin and Spasmoproxyvon (SP, a pharmaceutical agent containing dextropropoxyphene that is designed to be taken orally, but also misused by injection) [21], with the result that IDUs have been the primary focus of HIV prevention interventions to date, and most IDUs are male. However, there is increasing recognition of the important contribution that sexual transmission is making to the spread of HIV in the region, especially in Nagaland, where the prevalence of HIV in 2008 was only 3.2% among IDUs but 14.6% among FSWs. The HIV prevalence among IDUs in the neighbouring state of Manipur is much higher at 28.6% (Personal communication from National AIDS Control Organisation, Northeast India). This major difference in HIV prevalence is explained by the very different patterns of drug use (type of drugs used and methods of use) in the two states.
Initially we planned a study of the health service needs of female injecting drug users, but were urged by local NGO staff to broaden the investigation to also cover non-injecting and alcohol users as their vulnerability was an area of concern for field staff that had not been well documented. The HIV prevention response in these states is being led by the National AIDS Control Organization (NACO) and the respective State AIDS Control Societies (SACS). Working alongside these government agencies since 2004 is Project ORCHID, which is funded by Avahan (Bill & Melinda Gates Foundation in India) to contribute to HIV prevention in selected districts of Manipur and Nagaland [22].
This qualitative study involved semi-structured, in-depth interviews with key informants (KIs) and focus group discussions (FGDs) with female and male drug and alcohol users in Manipur and Nagaland. The data collection took place in late 2009 and early 2010. The study was facilitated by partnerships with local Project ORCHID NGOs working in both urban and rural settings. These NGOs have existing relationships with female drug and alcohol users through their networks of outreach workers and peer educators, and the drug and alcohol using participants were generally recruited by these workers. Local research officers (ROs) were trained and supervised by the study investigators to coordinate and conduct the data collection in each state.
A female drug or alcohol user was defined as a woman who judged herself to be a regular (injecting or non-injecting) user of one or more of the following drugs in the past six months: alcohol, heroin/brown sugar, propoxyphene/Spasmo-proxyvon (SP), cannabis or amphetamine type substances (ATS). All participants were aged ≥ 18 years.
In-depth interviews with key informants (KIs)
A total of 27 KIs were purposively recruited and interviewed (15 in Manipur and 12 in Nagaland). The KIs were from a range of government, private and NGO services, and included: directors, program managers and field workers from organizations that work with sex workers, drug users, and vulnerable women; workers from drug detoxification and rehabilitation centres; HIV testing counselors; nurses working with HIV patients; a journalist; and a 'booze joint' owner (booze joints are illicit bars). Each interview took approximately one hour.
FGDs with drug and alcohol users
Five focus groups discussions (FGDs) were conducted with women alcohol and drug users in Manipur (2 in Imphal, 3 in Churachandpur), and four in Nagaland (3 in Dimapur, 1 in Wokha). There were 7-8 participants in each group, with a total of 39 participants in Manipur and 32 in Nagaland. Some groups included alcohol users exclusively, while others were a mixture of alcohol users, opiate users and those who used both substances. One FGD was conducted with male drug users in Imphal, Manipur (n = 11) and one in Dimapur, Nagaland (n = 12). Male drug users were considered to be another type of key informant regarding female drug and alcohol use. All FGDs were conducted by the local ROs, and each FGD lasted approximately two hours. FGD participants were identified through snowball sampling. The outreach workers approached potential participants in the field through their own networks, and in venues such as 'booze joints' and hotspots for drug use. The initially recruited participants were invited to bring along some of their peers. This resulted in a mixture of participants i.e. some were NGO service users and others were not, and while some were engaged in sex work, the majority were not. FGD participants were provided with payment to compensate for child care and travel costs.
Both the KI interviews and FGDs were conducted in the local language by the ROs using semi-structured interview guides. The thematic areas covered by the guides included: the local context of female drug and alcohol use; drug and alcohol use patterns and risk behaviours; current patterns of service usage; barriers and facilitators to service usage; perceived health needs; and expressed service needs. The interview guides were developed with the literature and the study objectives in mind, then refined and piloted in collaboration with the Indian partner NGOs and local research team members. They were translated into the local languages (Paite, Manipuri and Nagamese) after detailed discussion of the intended meanings and appropriate language for each thematic area. All interviews and FGDs were digitally recorded, transcribed, and translated into English for subsequent analysis.
The data were analysed thematically [23]. A step-wise description of this process is provided below:
The interview and FGD transcripts were transcribed and translated by the field-based research officers under the supervision of two of the authors (CHS, CZS).
The printed transcripts were read over completely by the first author (MK) without any active coding at that stage.
All data were initially manually coded by the first author (MK) according to themes deductively derived from the interview guides. Initial themes were: patterns of drug and alcohol use; reasons for drug and alcohol use; HIV risk behaviours; health problems experienced by the women; other problems experienced by the women; differences between male and female drug and alcohol users; barriers to service access; and health and other service needs.
Subthemes were subsequently inductively identified for each theme through recognition of consistent patterns inherent in the data. Some sub-themes were further open-coded where appropriate. The sub-themes relevant to this paper are summarized below:
drug & alcohol withdrawal; mental health; sexual & reproductive health; gastrointestinal problems; drug overdose; other.
Other problems
social exclusion; care of children; financial problems; lack of basic needs; violence.
Barriers to access
stigma & discrimination; financial constraints; poor/absent health infrastructure; limited geographical access; fear of identification as a high-risk group member.
Health and other service needs
women only health services; detoxification & rehabilitation; mental health care; sensitization of health care workers; access to medicines; assistance to meet basic needs; other.
The findings were then synthesized, interpreted and reported following the structure provided by the study objectives.
Finally, the findings were presented to stakeholders in the two states in the context of dissemination meetings that included those who had participated in data collection, and feedback on the findings was actively sought.
When undertaking the data analysis and reporting the findings, the subjective perspectives of the female drug and alcohol users were privileged over those of the KIs. However, the perspectives of the KIs tended to support and augment what the FGD participants had to say, and are also presented here. We indicate when the views of the KIs are different from the women's.
All potential participants were informed about the nature and purpose of the study when they were invited to participate. Those who volunteered to participate gave informed consent, and were assured of confidentiality. The staff who recruited the participants used a written plain language statement to guide the information they shared verbally with the women when inviting them to participate in the study. The women who agreed to participate were subsequently consented verbally using a format approved by the two ethics committee's that reviewed the application – this involved the research officer signing that she had shared the required information with each of the women, and that they had agreed to participate – this process was witnessed whenever possible. Ethics approval was obtained from the University of Melbourne Human Research Ethics Committee and the Institutional Review Board of the Emmanuel Hospital Association, New Delhi, India.
Background information on participants
The demographic information of all FGD participants are summarized in Table 1. The proportion of widowed and divorced women was very high considering the relatively young age of the participants.
Table 1 Demographic information for all FGD participants
Physical health problems
The most pressing health problems identified by these women were explicitly and implicitly associated with their dependence on drug and alcohol use. Many of the women spontaneously mentioned the symptoms of withdrawal from drugs and alcohol as their major health concern, and consequently associated the use of drugs or alcohol with feeling better.
"P1: People who use drugs are okay. They experience sickness only when they don't have their daily dose. Without it we can't even move, when people talk nicely to us, we take it very negatively. We face no health problems when we are on drugs. When we are high on drugs, we become smarter."
"P2: We are sick only when we don't do drugs. Without our daily dose, we experience body aches… and start fighting with our husbands and children… but when we are on drugs, we are relieved of all the body aches and when we are not on drugs, the sickness increases. (FGD1 Dimapur, Nagaland)"
"P: Rice beer users also experience shaking of hands if they don't drink. We feel scared when not drinking. (FGD2 Dimapur)"
For these women their health problems were associated with the absence of drugs or alcohol, rather than the presence of them. This is a different construct from that of the KIs who mostly perceived the presence of drugs and alcohol as the source of poor health for users.
A number of reproductive health problems were reported including unwanted pregnancy leading to both abortion and birth of children, white vaginal discharge, irregular or absent menstruation, and STIs – syphilis and gonorrhoea were named in particular. When the women suspected they had an STI, they often tried to self-treat rather than suffer the embarrassment of seeking diagnosis and treatment from a health professional. Long periods of amenorrhea were identified by the women using heroin in particular, and irregular menstruation contributed to late detection of pregnancy. In some cases of pregnancy, the identity of the father was difficult to ascertain, or the father refused to acknowledge paternity, with the result that some women were single parents to their children.
A lot of the participants, both FGD participants and KIs, identified a range of gastro-intestinal complaints as problematic for female alcohol users in particular, especially gastritis, stomach problems, liver problems, hepatitis, lack of appetite, weight loss due to poor food intake, diarrhoea, constipation, and nausea and vomiting. Drug overdose was mentioned as a health risk by many participants and some of the FGD participants provided graphic descriptions of their friend's and their own experiences of overdose. Much less commonly mentioned were HIV, TB, and HCV.
Depression, stress and tension were frequently mentioned as a problem for women who use drugs and alcohol. Loss of hope was clearly expressed by some participants – many were resigned to their situation and could see no means of escape, and therefore, no viable future for themselves.
"P: No women who drink and do drugs are happy with their lives. (FGD2 Dimapur, Nagaland)"
"KI: If we look at their mental status, their motivation towards life and hope is very low. They are living for the sake of living. Once they die, then it is over, this is what they think. They don't have any hope for the future. Being women, they also want to be a part of family where there are children, a husband and all. But it is only a dream to them. Sometimes we ask them "What is your wish for your life?" They answer "To live a life in a family like before" - this is their wish in life… They don't have any hope for living a normal life. I think it might be the reason why they don't want to go for health treatment or anything else. They think that even if they were free from drugs, they don't have any place to go for a living. (KI3 NGO Project Manager, Manipur)"
Social and economic problems
The women drug and alcohol users in this study experienced a number of social and economic problems including social exclusion, violence, concerns about children, and financial difficulties resulting in lack of basic needs such as food, health care and medicines. These problems were often of much greater concern to them than their physical health problems.
Social judgment and consequent exclusion, including rejection by families were commonplace features of these women's lives, and clearly a major source of distress for them. Family abandonment preceded drug and alcohol use for some of the women, and was therefore perceived to be a cause of it, while for other women, family abandonment was a direct consequence of their drug and alcohol use. Sometimes the women deliberately stayed away from their families because they felt ashamed of their situation. Exclusion from the church was also frequently mentioned, and feelings of self-stigmatization and guilt were evident.
"P: Due to our No. 4 [heroin] use we have guilty feelings and are scared of our family. Even if we go home our family doesn't want us to be at home, due to our drug habit. (FGD4 Churanchandpur, Manipur)"
"P: Due to alcohol use we do not want to participate in church or social gatherings. We prefer to be with our friends – we often drink together and we are scared to enter the church building. There is the feeling that they are staring only at us, so we are keeping aloof from the society and church. (FGD5 Churachandpur)"
Several of the women in this study provided vivid descriptions of being subject to emotional and physical violence, including rape. The source of violence included families, husbands, army, police, pressure groups (women's and youth groups as well as underground groups) clients, and chiltus (local gangsters). The violence sometimes took the form of social humiliation e.g. the women were tonsured and publically scolded for the perceived immorality of their lifestyle.
"P: I have faced many hardships as I need money for No. 4 [heroin]. Male customers invite us and say they will pay the money at the place, and when we go to the place they have lied to us, and they rape us and will not give even 25 paise, and then they will run away. (FGD4 Churanchandpur, Manipur)"
"KI: They are facing a lot of violence. They get caught by some strange men in the hot spots and are having sex forcibly - they don't get any money but get beaten up by these men. Very recently one incident happened where they were caught by some men who inserted a stick inside their private parts. It is very hard to hear about such inhuman behaviour, but it is common among the women who are chronically dependent on drugs and doing sex work. Who will complain to police for their sake? No one complains. If it happened to an ordinary housewife people would come out in support. Community people don't like them. (KI8 NGO Project Manager, Manipur)"
According to participants, the women who use drugs and alcohol could themselves be perpetrators of violence when under the influence of alcohol in particular, and sometimes children were the target of their violence. The situation for some children of women who are drug and alcohol dependant was described as precarious, especially if the father is also a substance user or is absent. Several participants related instances of child neglect and mistreatment when children remained with their mother. This neglect took the form of poor supervision, inadequate provision of food, and limited access to education.
"P: Sometimes, when I take my daily dose and am high on drugs, I can teach my children very well. But sometimes when I don't take my dose and experience turkey [drug withdrawal] I get mad and put that frustration onto my child and instead of taking care, I hit the child. When my thoughts are not much on getting my drugs I can teach the child, but when my thoughts are all focused on where and how to get my dose, I forget about my child. (FGD3 Dimapur, Nagaland)"
Some children were being cared for away from their mothers by family members or in orphanages, and this was described as a major source of guilt and pain for their mothers. The women's inevitable financial difficulties led to many other problems such as lack of shelter, lack of food, and inability to provide not only for themselves but also for their children.
Barriers to accessing health care
A number of barriers to accessing health services were identified by both the KIs and the women drug and alcohol users. The women's own sense of shame, which was often deeply felt, or their reluctance to self-identify as a drug or alcohol user coupled with actual and anticipated discrimination from health care providers meant that they did not generally attend health care services. When the women experienced a health problem that could not be ignored, they mostly consulted with a pharmacist or a health worker from an NGO clinic. They generally avoided the government services because they feared being treated poorly, and the private services because they could not afford to pay.
Even attending the NGO services was sometimes problematic, as to do so could result in the woman being identified as HIV positive, a drug user or a sex worker (whether or not she was). The women understood that the NGO services were only available for women who were HIV positive, injecting drug users, or sex workers, and thus precluded non-injecting drug users and alcohol users.
"P: Injecting users are availing the services but oral users who are hidden do not want to avail the services because they do not want others to know they are taking drugs."
"F: What would be the reason that prevents them from accessing the services and programs they need?"
"P: They do not admit to themselves that they are an addict – they are hidden. Some do not want others to know about their drug use. Saying it is a way of self-disclosing our identity… In spite of telling our friends about the available services they do not listen to us. People have an idea that the services are only for positive people. (FGD3 Churachandpur, Manipur)"
"Another perceived short-coming of the NGO services was that the range of services offered was limited mainly to the provision of condoms, needles and syringes, whereas the women's most pressing problems were unrelated to HIV prevention, and often beyond the scope of services offered by the HIV prevention NGOs. These problems included family conflict, social exclusion, mental health problems, drug and alcohol dependence, and financial difficulties."
"P1:They conduct group discussions with us. As part of the program, syringes and condoms are also available. No other programs except group discussions [ they all laugh ]."
"F: Can anyone tell about other services?"
"P2: Nothing, except syringes and condom distribution."
"F: Excluding syringes and condoms, any other program you access?"
"P1: No. With four to five participants they often conduct group discussions where they talk on the topic of prevention [ laughs ]. We are fed up of hearing and listening to the same topic which we have known, we already know [ all of them laugh ]."
"P2: We hesitate to attend the meeting assuming that the same message will be given."
"P3: We know about STIs and HIV. (FGD3 Churachandpur, Manipur)"
Other barriers included the cost of services and medicines, the inability of the women to travel away from their own locality, and poorly functioning or absent health services.
"KI: Some of the women say 'We go to the hospitals but the doctor was not there, nurse was not there, and there was no medicine'. So if at the first shot, first time they go, if they don't meet the doctor they don't want to go the second time, they feel very discouraged, so lots of motivation is required. We tell them to go and they say 'We'll go, we'll go', but they don't go. Yeah, access is one thing, plus facility availability in the hospital is also another thing. If everything is always available I'm sure they will be motivated to go, but many times they don't get what they need and they are asked to buy [medicines], and they don't have money to buy. (KI2 NGO Director, Nagaland)"
Women-only health services
An integrated health service for women, staffed by women, was seen by the majority of participants as an important strategy for increasing access to care for female drug and alcohol users.
"KI: And there should be more women specific health centres – I don't know whether it would be possible or not, but if there could be more health centres specifically for women irrespective of whether they are drug or alcohol users, for women in general. Any women can just walk into the centre and can get services. If something like that can be tried out I am sure it will go a long way in improving the health status of our women in general and maybe even the drug users in particular. (KI2 NGO Director, Nagaland)"
Related to the concept of women-only health services was that of women-only drop-in-centres (DICs) at the NGOs, as the current DICs are very male-dominated, and this actively deters the participation of women.
"KI: The women often say they feel uneasy to pass through the DIC and go for treatment as the males often tease them, and even if they did not tease them, they still feel uncomfortable because it is male dominated. (KI13 Outreach Worker, Manipur)"
The participants envisioned a women-only DIC as a place to rest, have tea and snacks, with make-up and other toiletries as well as bathing and clothes washing facilities. Another suggestion was the appointment of more female outreach workers and peer educators as part of the targeted HIV prevention programs. Legal advice services, children's services, nutrition programs, and community mobilization programs were also mentioned as desirable services by the KIs in particular.
Detoxification and rehabilitation services for women
The women frequently emphasized the desperate need for women-only and women-friendly drug and alcohol detoxification and rehabilitation centres that are low cost and can accommodate children. They were also adamant that some sort of short-stay home/half-way house accommodation was necessary following completion of the rehabilitation program to reduce the very real risk of relapse, especially as women are not so easily reconciled with their family compared to men, even when recovered. The transition from rehabilitation to social reintegration was seen as a very vulnerable time for these women. Another important component of rehabilitation mentioned by many participants was meaningful vocational training, and access to micro-finance opportunities to start up small businesses.
"P: A short stay home [is needed] if the course in the rehab centre is short. After the detox period, vocational training would be very helpful for us. After completing the rehab course there should be something that can fully occupy our minds, this way it will be easier to forget what we desire. If not, after the course of rehab, if we stay the same way, it is very easy to use it again. A rehab centre is what we need in Churachandpur. (FGD3 Churachandpur, Manipur)"
It may not be necessary to admit all women seeking detoxification to a residential program, as community based programs were an alternative model of care mentioned by some KIs.
The need for mental health care and counselling for women drug and alcohol users was particularly emphasized by many participants, both the women themselves and the KIs.
"P: A good doctor, a psychiatric doctor – most of us are using alcohol and drugs due to depression and negative thinking – to provide quality counselling. If counselling and medical treatment are provided I believe this may be more helpful than syringes and condom distribution. Due to depression we are half-hearted. A doctor to be available in the NGOs to help us psychologically. (FGD5 Churachandpur, Manipur)"
Sensitization of health care workers and the general community
The need to raise awareness of the health and other problems faced by women drug and alcohol users among health care workers and the general community was frequently mentioned. The women anticipated and sometimes received poor treatment when seeking health care, and this was a major barrier to access.
"KI: Particularly in the health set up, whether in the government sector or the private sector, or the NGO sector, I think the sensitivity towards women, the issues of women – gender sensitivity – I think that is one area we are very much lagging behind. A woman should be made comfortable even if she is into drugs or alcohol. I think there has to be a lot of education and sensitization on gender sensitivity – that is one area that can be improved upon. (KI2 NGO Director, Nagaland)"
Free access to medicines and general health check-ups
Several FGD participants were of the view that general health services, integrated with STI testing and treatment services, should be made available to the women for free. Some were quite strident about their need for free medicines to treat the symptoms they were experiencing, especially treatments for gastritis and liver problems, a range of vitamins and minerals, and 'glucose drips'. Frequently the drugs and vitamins were identified individually by name, and at times even by trade names e.g. 'Liv 52'. They complained that they were repeatedly given the same medicines when attending the NGO clinics and wanted a range of medicines to be available for them free of cost. Some identified the restricted access to medicines as a factor that deterred women from returning to the clinics.
"P1: What I want is, as most of us have a gastritis problem, we need medicine for liver, stomach. And there are some who are dying when they skip food for two to three days – for such persons, they need vitamin and glucose."
"P2: Mostly drug and alcohol users have gastritis problems. I am not criticizing the existing services, but when we access free medical check-ups, free medicine is not available for us. So a place where free medicine for liver, stomach, and glucose should be available. When I start drinking alcohol I can stay without food even for three months, and if I stop drinking I am dying, and after four to five glucose drips, I will be alright again. (FGD5 Churachandpur, Manipur)"
Assistance to meet basic needs
The need to help women drug and alcohol users find employment or livelihood opportunities was also mentioned. As many of the women had been rejected by their families, they often lacked a safe and secure place to sleep.
"P: We need a place to sleep as we drug user are busy hunting for money for our drug use, and most of the time we are not allowed to enter our own house. We need a proper place with food as we cannot sleep in the street, and this will also help us mentally with our trouble in finding a place to sleep. (FGD3 Churachandpur, Manipur)"
A place for engaging in sex work
Some of the FGD participants who were sex workers identified the need for a safe place where they can both live and sell sex.
"P: We need a house where we can also sleep and for sex work. Where one of the staff will play the role of manager, and with a clinic attached."
"P: A place to sell sex and earn money for IDU sex workers."
"P: The pimps are taking advantages of us, they disregard us and often cheat us, and they never pay the exact amount of our share."
"P: What you said is true. We have to share the money with the pimp fifty-fifty. So if we could have a place where we can sell sex and earn money. We can share fifty to the pimp manager. Fifty from the manager's share should include house rent and food."
"P: If three or four or up to seven of us can stay in a place in such a way we could earn and live properly."
"P: This way we can stand as a strong self help group."
"(FGD 3 Churachandpur, Manipur)"
Health, social and economic problems
The women drug and alcohol users in this study experienced a range of health problems including drug and alcohol dependence/withdrawal, a number of reproductive health complaints, and poor mental health. They also described many social and economic problems that clearly have the potential to impact negatively on their health and well-being, and on their capacity to access services, including financial difficulties, social exclusion, violence, and concerns about the well-being of their children. From the women's perspective, their health problems were mostly over-shadowed by their social and economic problems.
The main health problems experienced by these women related to symptoms associated with withdrawal from drugs or alcohol, and as these symptoms were alleviated by the use of drugs or alcohol, the use of these substances made them feel 'well'. This construct contrasts with that of most health care providers who are likely to perceive drugs and alcohol as a source of illness rather than wellness. However, even though the women frequently articulated this bodily experience of drugs and alcohol making them feel 'better', there was also a lot of discussion regarding the need for detoxification and rehabilitation services, clearly indicating that drugs and alcohol are also perceived, at least at some level, to be problematic in their lives.
Poor mental health is both a cause and a product of drug and alcohol dependence. Social exclusion and violence, instances of which were vividly described by the women in the FGDs, are also likely to have a negative impact on their mental health, as does rejection by and separation from families. A large study of women and drug use in India identified 75% of female substance users as having a possible underlying psychiatric disorder such as depression or anxiety, and one-third reported at least one suicide attempt during the previous year [8].
Considering the relatively young age of these women, a large proportion were widowed or divorced (almost two-thirds in Manipur and one-third in Nagaland). As in other parts of India, divorcees and widows are socially and economically vulnerable, and if young, sexually vulnerable as well. Young widowhood in Manipur in particular is likely to be associated with the death of a drug-using spouse from drug overdose or HIV. It is possible that for some of these women, divorce has been a consequence of their drug or alcohol use. However, it is also likely that the precarious situation of widows and divorcees is contributing to both drug and alcohol use and engagement in sex work.
Violence against these women was commonplace and not limited only to those who were engaging in sex work. Similarly, in the large Indian study mentioned above, 73% of female substance users had experienced violence, and of these, 91% reported physical violence, 53% sexual violence, and more than 75% had sustained physical injury as a result of the violence [8]. In South India, violence against sex workers was associated with economic insecurity, more adverse reproductive health outcomes, and greater risk of HIV and STIs [24, 25]. It is clear that interventions to reduce the level of violence experienced by these women are greatly needed. However, while successful community empowerment of sex workers in South India has been able to reduce the amount of violence perpetrated against them by the police in particular [26], effective collectivization of FSWs in Manipur and Nagaland has not been very successful to date [12], and interventions targeting only sex workers will not help all of these women.
The situation for the children of women who use drugs and alcohol is concerning. These children can develop emotional, behavioural and learning problems, witness and be subject to violence, and become involved in substance use at a young age [8]. In Manipur and Nagaland, having children outside of wedlock is socially unacceptable and there are few support structures in place to assist women and children in this situation. Both the mother and the children are likely to suffer poverty and social exclusion as a consequence of single parenthood. Arguably, one of the best ways to support the children of women who are drug and alcohol users is to support their mothers, and one of the best ways to support their mothers is to help with their children. Programs that are trying to attract women drug and alcohol users should also consider the needs of their children, as has happened at the Sonagachi Project in the neighbouring state of West Bengal [27], and with the Ambar project in Venezuela [28].
According to the participants in this study, the establishment of a comprehensive, integrated women's health centre is more likely to attract women drug and alcohol users than the current HIV prevention services or existing government health services. Not only would this model provide a 'one-stop shop', it would also offer some protection from identification as a member of a high risk group. These centres are more likely to meet the needs of women if they are low-cost, strategically but discretely located, open at times that suited the clients, and staffed by a range of female staff, including female doctors. The range of health services could potentially encompass general health care, family planning, antenatal care, mental health, counseling, HIV testing, STI management, opioid substitution therapy, TB treatment, ART, overdose management, and condom and needle & syringe distribution.
One of the most pressing service needs from the perspective of the women was detoxification and rehabilitation. Services for women requiring detoxification and rehabilitation for alcohol addiction are currently not available, and the options for women drug users who want assistance to reduce their drug use are very limited. To the best of our knowledge, there are no Alcoholics Anonymous or Narcotics Anonymous type programs for women in either state. In the absence of women-friendly detoxification and rehabilitation services it is difficult to imagine how women who are dependent on drugs and alcohol can gain a measure of control over their lives.
Interventions that aim to promote the mental health and well-being of these women are potentially available, affordable, and effective [29], and may reduce risk-taking behaviours, and increase participation in HIV testing and adherence to treatments. Such interventions also have the potential to assist these women with anger management, and thereby reduce their own acts of violence [29].
Health care workers located at services that are likely to be patronized by female drug and alcohol users need to be sensitized to the health services needs of these women, and equipped to provide non-discriminatory treatment and care. This is especially the case for specialist obstetrician and gynaecologists, primary health care centres, mental health services, and hospital staff.
Awareness raising and sensitization of church leaders and groups are also important in the context of Manipur and Nagaland. The Church has a powerful influence over societal attitudes to these vulnerable women [20], as well as huge potential to promote social inclusion and provide them with much needed supports. A similar program among women's and youth groups and police could also be beneficial.
The suggestion that FSWs be provided with a safe place where they can both live and work is a tantalizing one. However, there are obvious challenges to the establishment of such a venue in a very conservative setting where organised anti-sex worker campaigns are a reality and the legal status of sex workers is precarious. Nevertheless, it must be acknowledged that this type of arrangement has the potential to reduce the risks of HIV and STI infection and exposure to violence, as well as making it easier to target FSWs with health and other services. Many of these women are homeless, so it would also provide them with shelter.
Limited overlap between the felt needs of the women and the services provided by HIV prevention programs
As women who use drugs and alcohol are reluctant to attend mainstream health services because they anticipate and often encounter discriminatory attitudes on the part of the health care workers, and they are unable to afford the service and the associated costs of tests and medicines, another point of entry into the health care system for these women is through the HIV prevention and care services provided by NGOs (funded mostly by government and large donor agencies), which were viewed as more sympathetic to their situation. Health care for HIV positive women, and HIV prevention services for women who inject drugs, FSWs and female sexual partners of IDUs are predominantly provided by NGOs in Manipur and Nagaland. The content of these services is determined by policy makers and program planners with an HIV prevention and care agenda firmly in mind e.g. ART treatment, HIV testing, STI treatment, IEC, needle/syringe and condom distribution. However, these services as currently structured are unlikely to meet the needs of the women participating in this study. This lack of congruence between the services the women say they want and the services actually provided probably, at least in part, accounts for the relatively poor uptake of these services by vulnerable women.
Women drug and alcohol users' most pressing needs were often not directly related to health, and certainly HIV and STIs were not high on the list of issues that concerned them most. Financial insecurity, inability to adequately feed and shelter themselves and their children, family and social rejection, violence, and related to all of these, poor mental health, were the main concerns of the study participants. These findings resonate with those from the larger Indian study on women and substance use that ranked the top ten services that female substance users had not accessed but would like to as: mental health services, vocational training, housing/shelter, legal/advocacy services, nutritional programs for children, microfinance, female condoms, OST, de-addiction services for women, and STI services [8]. Additionally, these women perceived NGOs as the place to which they were most likely to turn for support [8]. Consequently, if NGOs who currently implement HIV prevention programs are able to expand their services so that they more effectively respond to the stated needs of these women, more women may attend. However, a major challenge for any NGO wanting to offer a more integrated service is the struggle to mobilise and coordinate sufficient funds from multiple agencies and government sectors in order to do so.
This study has a number of limitations that should be considered when interpreting the findings. There could be some selection bias because the FGD participants were recruited through the NGO networks, but this is somewhat offset by the fact that we deliberately recruited both NGO service-users and non-users. Given the sensitive nature of the questions about socially taboo behaviours of women, some participants may have been inclined to provide more socially acceptable responses, at the expense of valid responses, resulting in bias. We were unable to identify those participants engaged in sex work from the majority who were not, and it is probable that the health service and other needs of women engaging in sex work are somewhat different from those who do not. It is a qualitative investigation so findings cannot be generalized, although there is no compelling reason to assume that the situation is very different for other groups of female drug and alcohol users in Manipur and Nagaland. A follow-up survey with a representatively sampled group of women would strengthen the findings.
This qualitative study aimed to describe the health needs of women who use drugs and alcohol in Manipur and Nagaland in order to identify strategies for strengthening services so that they can more effectively reach and meet the needs of these extremely vulnerable women. The study findings highlight a range of factors that have direct implications for the provision of health and other services, including HIV prevention programs, and raise a number of key questions that need to be answered if the situation of women drug and alcohol users in Manipur and Nagaland is to be improved: How can HIV prevention programs attract vulnerable women, including women who inject drugs and engage in sex work, when the range of services they are funded to offer do not meet the expressed needs of the women? How can women who are dependent on drugs and alcohol gain access to effective and affordable detoxification and rehabilitation services in the absence of such services? Below are some suggested strategies and activities that NGOs providing HIV prevention programs can initiate in order to promote greater participation of women in their programs. A few NGOs in Manipur and Nagaland have already implemented some of these activities, often with very limited funding.
Active recruitment of female staff members, especially among the cadre of peer educators.
Provision of the following:
Safe spaces for women that are welcoming and that encourage informal interaction between the women and the staff
Basic needs such as food and shelter
Programs for the children of vulnerable women
Women-friendly OST services
Basic health care and family planning services alongside STI services
Mental health literacy training for all NGO clinic and field staff.
Liaison with and sensitization of the following:
Existing detoxification and rehabilitation services to promote the development of women-friendly services
Health care workers in mainstream services including maternal and child health services
Church and women's groups interested in supporting vulnerable women
Law enforcement services.
Sustained advocacy with relevant government ministries, departments and agencies regarding the health and other needs of women drug and alcohol users.
In the long-term, the optimal model for addressing the questions raised above is probably the provision of integrated women-only services, but achieving this requires collaboration across sectors of government involving those responsible for health, HIV prevention, children's welfare, drug and alcohol treatment, justice, employment and education.
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Kermode M, Devine A, Chandra P, Dzuvichu B, Gilbert T, Herrman H: Some peace of mind: assessing a pilot intervention to promote mental health among widows of injecting drug users in north-east India. BMC Publ Health. 2008, 8: 294-10.1186/1471-2458-8-294.
We would like to acknowledge the contributions of Neiphrulou Lasuh, Purnima Devi and Biak Lun who so ably assisted with the data collection, and the following NGOs who facilitated the FGDs: Community Awareness Development (CAD) Foundation, Guardian Angel, Prodigal's Home, Akimbo Society, and Agape Youth Welfare Organization in Nagaland; and Social Awareness Service Organization (SASO), Society for HIV/AIDS and Lifeline Operation (SHALOM), and Lamka Rehabilitation and Research Centre (LRRC) in Manipur. We are especially grateful to all the key informants and FGD participants.
Nossal Institute for Global Health, University of Melbourne, 161 Barry St Carlton, Melbourne, Victoria, 3010, Australia
Michelle Kermode
& Alex Devine
Project ORCHID, CBCNEI Mission Compound, Panbazar, Guwahati, Assam, 781001, India
Chinzaning Hangzo Songput
, Collins Z Sono
& Temjen Nungsang Jamir
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Correspondence to Michelle Kermode.
All authors contributed to study conception and all have read and approved the final manuscript. MK and AD were responsible for study design, analysis and interpretation, and drafting the manuscript. CHS, CZS and TNJ contributed to acquisition of the data and interpretation of the findings.
Injecting drug use
Health service needs


text:
Tokutarō is a masculine Japanese given name.

Possible writings
Tokutarō can be written using different combinations of kanji characters. Some examples:

The characters used for "taro" (太郎) literally means "thick (big) son" and usually used as a suffix to a masculine name, especially for the first son. The "toku" part of the name can use a variety of characters, each of which will change the meaning of the name ("徳" for benevolence, "得" for gain, "啄" and so on).

徳太郎, "benevolence, big son"
得太郎, "gain, big son"
啄太郎, "peck, big son"
篤太郎, "sincere, big son"
竺太郎, "bamboo, big son"

Other combinations...

徳太朗, "benevolence, thick, bright"
徳多朗, "benevolence, many, bright"
徳汰朗, "benevolence, excessive, bright"
得太朗, "gain, thick, bright"
得多朗, "gain, many, bright"
登久太郎, "climb up, long time, big son"

The name can also be written in hiragana とくたろう or katakana トクタロウ.

Notable people with the name
, Japanese general
, Japanese politician
, Japanese Yakuza member
, Japanese photographer
, Japanese footballer
Tokutarō Watanabe, Japanese businessman

Japanese masculine given names

redpajama_set_name: RedPajamaWikipedia


According to Chef Boy Logro always check the meat for marbling and firmness.
which should be compact to deliver great tasting cuisines.
Marinate shredded beef tenderloin in oyster sauce, Japanese soy sauce, dark mushroom soy sauce, salt, white pepper, Chinese wine and cornstarch.
Blanch into fat-heated cooking oil and set aside.
Blanch the swamp cabbage into boiling water with baking soda for 3 seconds then soak into ice cold water.
Stir-fry with ginger puree and garlic puree the blanching kangkong, and flambé with Chinese wine. Season with salt, pepper and chicken powder.
Place on plate over the top with stir-fried shredded beef, ang garnish! with kinchay.


text:
Le délire d'illusion des sosies de Capgras  (parfois appelé illusion des sosies ou délire d'illusion des sosies ou encore syndrome de Capgras) est un trouble psychiatrique dans lequel le patient, tout en étant parfaitement capable d'identifier la physionomie des visages, affirme envers et contre tout que les personnes de son entourage ont été remplacées par des sosies qui leur ressemblent parfaitement.

Ce syndrome délirant a été décrit par le psychiatre Joseph Capgras en 1923. Il appartient au groupe des psychoses chroniques non dissociatives qui surviennent chez l'adulte. Le délire consiste à méconnaître l'identité d'un familier alors que sa reconnaissance formelle paraît préservée. Par exemple le patient, se retrouvant face à un proche, déclare que ce dernier a été remplacé par quelqu'un qui lui ressemble, un sosie, un double ou un imposteur mais que ce n'est pas la personne qu'il connaît : « il lui ressemble mais ce n'est pas lui ». L'examen des détails (couleur de cheveux, yeux) le renforce dans son idée : ce n'est pas vraiment la bonne personne. Le patient vit très mal la proximité avec ces sosies qui n'ont pas d'individualité, pas de nom. Des réactions agressives sont possibles.

Cette affection est plus fréquente chez les patients ayant des troubles neurologiques ou psychiatriques comme dans la schizophrénie, les traumatismes cérébraux ou les démences. Il est plus fréquent chez les patients qui ont une maladie neurodégénérative que chez ceux qui n'en ont pas. Il a aussi été rapporté une association avec le diabète, l'hypothyroïdie et les crises de migraine. Il est plus fréquent chez les femmes avec un ratio femme-homme de 3-2. Ce syndrome est également plus fréquent chez les personnes ayant des troubles cognitifs importants.

Diagnostic
Les objets du délire sont les proches comme le conjoint, les parents, les enfants,  (Capgras). La  peut aussi toucher toutes les personnes connues du patient. Le sosie de soi est plus rare. Les sosies sont en général considérés comme des imposteurs malveillants.

Le diagnostic différentiel peut induire : hallucinations (une perception sans objet), puisque c'est en présence d'un proche que le patient dit voir son sosie ; illusions, c'est-à-dire une dysperception, mais bien une construction délirante ; prosopagnosie : la difficulté des patients Capgras pourrait concerner la reconnaissance visuelle puisque pour un certain nombre d'entre eux, leurs proches sont des imposteurs uniquement quand ils les regardent en face mais pas quand ils leur téléphonent.

Les causes peuvent inclure des lésions organiques (accident vasculaire cérébral, démence, troubles métaboliques, intoxication), des troubles fonctionnels (troubles psychiques). Le principal diagnostic psychiatrique associé au syndrome de Capgras est celui de schizophrénie (54 %). Les troubles de l'humeur (dépression, manie, trouble bipolaire) sont moins fréquemment associés. Puis viennent les troubles schizoaffectifs ;  un trouble fonctionnel isolé, dans le cas de . Il existe aussi des cas de Capgras isolés .  est une patiente de 59 ans, adressée pour des idées délirantes à thème de persécution et de faux-semblant (F22 dans le DSM-). Elle soutient que son mari et sa fille ont été remplacés par des doubles malfaisants.

Recherche

Mécanismes constatés
Les explorations fonctionnelles mettent en évidence une atteinte lésionnelle préférentielle de la région temporo-pariétale, surtout de l'hémisphère droit (pour les droitiers).

Modèles explicatifs

Modèle neuropsychologique à deux voies

Dans les , Ellis et Young ont proposé un modèle de reconnaissance des visages suivant deux voies parallèles :
 Une voie accédant consciemment aux informations sémantiques sur l'identité de la personne ;
 Une voie affective et inconsciente, donnant une réponse affective à des stimulus familiers mis en évidence par une activation du système nerveux autonome (augmentation du rythme cardiaque, sudation, mydriase).
Ces deux voies sont ensuite réunies dans un module d'intégration.

Les patients prosopagnosiques, incapables de reconnaître les visages familiers, manifesteraient une atteinte spécifique de la  explicite, les patients atteint du syndrome de Capgras une atteinte de la  affective et implicite, en miroir de la prosopagnosie. Les prosopagnosiques manifestent une réaction du système nerveux autonome (par une sudation) en présence de visages de proches, alors que les patients Capgras n'en manifestent aucune (même conductance cutanée que pour les personnes inconnues). Une autre différence est que les patients Capgras refusent d'admettre leur erreur d'identification même en face de preuves convaincantes alors que les prosopagnosiques sont tout à fait convaincus de leur déficit.

En d'autres termes, ce syndrome serait lié à une dissociation dans la perception des visages entre la reconnaissance des caractéristiques affectives et celles des traits physionomiques. En effet, ces patients ne sont pas du tout prosopagnosiques : ils reconnaissent parfaitement les traits des visages mais leur cerveau serait incapable d'accéder à l'information affective associée au visage d'un proche. N'éprouvant pas d'émotion ni de sensation de familiarité, ils interpréteraient leur sensation de façon délirante comme une situation où un sosie a remplacé leur être cher.

Le délire de faux-semblant n'intervient qu'en tant qu'élaboration à visée explicative pour le sujet. Le patient reconnaît bien physiquement le visage de son proche mais il ne ressent aucun lien affectif avec lui. Il doit, pour se sortir de cette contradiction, recourir à une élaboration délirante secondaire. Henriet  proposent la séquence suivante :

Perturbation des communications neuronales

Pour Hirstein et Ramachandran (1997) la cause principale du syndrome de Capgras vient de la défaillance de la communication entre le centre de reconnaissance visuelle du lobe temporal inférieur et le complexe limbique et en particulier l'amygdale. Cette perturbation de la communication conduit à un dysfonctionnement de la mémoire épisodique. Quand le patient Capgras rencontre une personne familière, au lieu de compléter l'information épisodique sur cette personne stockée dans un « fichier » dédié, il va ouvrir un nouveau « fichier » comme si c'était une personne inconnue.

Dans un ouvrage publié en 2011, Ramachandran reprend son schéma de connexions mais sans faire intervenir la mémoire épisodique. Il rajoute à la voie du « quoi » qui va de l'aire  au gyrus temporal, la voie qu'il nomme du « et alors ? » qui part du . La voie du Quoi est liée à la reconnaissance des objets et à leur signification, celle du Et alors ? concerne les réponses émotionnelles suscitées par les stimuli biologiquement importants comme les yeux, la nourriture, les expressions faciales et les mouvements. David, le patient Capgras étudié par Ramachandran, a été victime d'un accident de voiture qui, à son avis, a partiellement endommagé les fibres de la voie du Et alors ? qui relie son gyrus fusiforme, en partie via le STS, à son amygdale, laissant cependant ces deux structures, ainsi que la voie du Quoi, parfaitement intactes.

L'étude d'un patient présentant des hallucinations visuelles et des troubles de l'identification dans le cadre d'un syndrome de Capgras ont amené Antérion et ses collègues (2008) à s'interroger sur le rôle des jugements de familiarité dans le syndrome. Le patient, un ancien artisan de , lors d'un séjour à l'hôpital, prit plusieurs femmes devant lui pour sa femme bien qu'elles ne lui ressemblaient pas (syndrome de Fregoli). Plus tard, il développa un syndrome de Capgras : sa femme était un imposteur. Cependant quelque chose de spécial  le caractérisait :
Ce phénomène de perte de familiarité concernant non seulement le visage, mais également tous les aspects de la vie intime suggère une déconnexion entre les voies visuelles ventrales d'identification des visages et le système limbique impliqué dans le souvenir de leur contenu émotionnel et de leur association à des épisodes antérieurs de la vie. Plusieurs études d'imagerie ont montré que le cortex cingulaire postérieur (dont le rétrosplenial) était impliqué dans le jugement de familiarité. Il est donc possible qu'une déconnexion entre l'amygdale et le cortex rétrosplenial puisse expliquer en partie les symptômes.

Le syndrome de Capgras a aussi été associé à la paramnésie réduplicative, autre syndrome délirant de trouble de l'identification. Cette association est fréquente. Il a donc été proposé que des aires cérébrales similaires sont touchées. La paramnésie réduplicative apparaît dans des lésions du lobe frontal. On pense que le syndrome de Capgras est aussi lié à une atteinte de régions frontales. Cependant, cette hypothèse n'est pas tranchée. On évoque des atteintes des lobes temporaux et pariétaux par ailleurs.

Histoire et société

Cas princeps de J. Capgras (1923)
Avec son assistant, Jean Reboul-Lachaux, Joseph Capgras (1873-1950), un psychiatre français, a décrit dans une étude appelée L'illusion des sosies dans un délire systématisé chronique en 1923 le cas de , âgée de , qui affirmait que tous ses proches et elle-même avaient plusieurs sosies. Ce terme de « sosie » était utilisé par la patiente elle-même.  (Capgras 1923).

L'« illusion des sosies » de Capgras deviendra sous l'impulsion de Lévy-Valensi le « syndrome de Capgras » en 1929.

Dans la culture
Ce syndrome, quoique jamais explicitement défini comme tel, sert de trame générale à l'intrigue de Le Double, nouvelle de l'écrivain russe Fiodor Dostoïevski publiée le  (adaptée au cinéma par Richard Ayoade en 2013), ainsi qu'au roman de science-fiction de Jack Finney, L'Invasion des Profanateurs, paru en 1955 (adapté au cinéma). Ce syndrome est au centre de l'intrigue d'un roman de Richard Powers : La Chambre aux Échos, édition Le Cherche midi, . Dans le roman Les Yeux de Slimane-Baptiste Berhoun, le personnage de Capgras souffre du syndrome du même nom.

Il apparaît également dans plusieurs séries télévisées :
 dans Scrubs (, ), l'un des patients refuse d'aider les médecins à le soigner car il pense qu'ils ont été remplacés par des sosies maléfiques ;
 dans Esprits criminels (, ), le tueur est atteint du syndrome de Capgras ;
 dans Perception (, ), une femme est atteinte de syndrome de Capgras ;
 dans Profilage (, ), un ancien militaire tue des promeneurs et des membres d'un cabinet médical ;
 dans  (, ), une étude est lancée sur ce syndrome par Catherine Black ;
 dans New York unité spéciale (, ), la mère de l'enfant maltraitée est atteinte du syndrome de Capgras.
 dans la série New Amsterdam, (saison 3 épisode 4), un ado est mis dehors par sa mère qui ne le reconnait pas. C'est le Docteur Froome qui s'occupe de lui.
 dans la série littéraire Le Destin des Jedi ( de l'univers littéraire étendu de la saga Star Wars ), un mal similaire frappe les Jedi de l'Ordre reconstitué par Luke Skywalker, qui se mettent soudainement à prendre leur entourage pour des clones parfaits de leurs amis, maîtres et membres de leur famille. L'origine de ce syndrome n'est en revanche pas neurologique, mais magique.

Il est également au centre du film  de Veronika Franz et Severin Fiala, où deux jumeaux sont persuadés que leur mère, qui rentre d'une opération de chirurgie esthétique, a été remplacée par un sosie, et feront alors tout pour faire parler le supposé sosie quant à ce qui est arrivé à leur bien-aimée mère.

Il est évoqué dans le film fantastique The Broken de Sean Ellis.

Dans le thriller argentin  () de  sorti en 2019, le syndrome de Capgras du héros, Lorenzo, est un des ressorts de l'action.

Dans le manga Time Shadows de Tanaka Yasuki, la maladie des Ombres est inspirée de ce syndrome.

Notes et références

Voir aussi

Articles connexes
 Prosopagnosie
 Syndrome de Fregoli
 Changeling (folklore)
 Délire monothématique

Bibliographie
 Délires d'identité et troubles d'identification.
 Armin Schneider « Syndrome de Capgras » in Neurologie du comportement, Masson, 2008.

Liens externes
 Marc Gozlan, « L'homme qui croyait que son chat en était un autre »,

Trouble délirant
Délire d'illusion des sosies de Capgras
Sémiologie psychiatrique


CalPERS issued a memorandum to public agencies on 03/30/2017 detailing their policies with respect to Industrial Disability Retirements, and announcing audits that would soon take place. They have since conducted an unprecedented 60 audits of member public agencies. For some agencies the policy does not represent a change in their existing practices, but for many, the announced policies are significant and will dramatically impact how they handle future IDR Applications.


When our clients come to Cabo San Lucas to plan their wedding we arrange all kinds of appointments for them! From wedding venue site inspections to ceremony location scouting, to event design meetings and wedding menu tastings, to hair and makeup trials, and many others details, if feasible. We know planning a destination wedding requires such jam-packed, in-person coordination and so we strive to make the trip productive for all. It can be overwhelming, but that's why we work ahead of the planning visit to narrow choices and focus the schedule on the essential elements.
Just this past week we welcomed Jennifer and her mother Charlene to Los Cabos. Elena, Carlos, and our wedding planner, Elsa Dilasser, are working with Jennifer on the bride's 2019 wedding. The first order of business? Choosing where to host the wedding. After several site inspections to some of Cabo's most fabulous resorts, Jennifer decided Esperanza, an Auberge Resort, was where her dream wedding would take place!
At the heart of every wedding? Food.
We can't blame Jennifer for choosing Esperanza, especially after the hotel treated the bride and her mom to an incredible wedding menu tasting! So much delicious food and beverage was offered to tempt Jennifer and her mom, right down to the pretty pearlized mini wedding cake they served for dessert! It was a two-tier, stacked wedding cake with the first tier a vanilla cake with white chocolate filling, and the second tier a butter almond cake with vanilla buttercream filling. A sweet ending to a productive site inspection!
Once again, we thank our event partners at Esperanza Resort for taking such elegant, thoughtful care of our clients Jennifer and Charlene. It was an experience they won't forget, and we can only imagine how fabulous the wedding itself will be! Cheers!


News: Google to launch its own retail stores this year?
Rumors are high on the fact that search giant Google, will be about to launch its own version of retail outlets in 2013, just like its counterparts, Apple. Although Google already do have some 'stalls' in airports in the UK and abroad, this will be the first retail outlets for the search giant.
The iPhone is a cool device. You'll happily store all your contacts and other details, and if your like me, sometimes forget were you've left it. Not a good idea. A recently discovered bug (yes, another one!) found in iOS 6.1 apparently allows any iPhone model, including the latest iPhone 5 running the iOS 6.1 operating system to by-pass the password lock!
Apple have now acknowledged the bug, so if you are running iOS 6.1, especially if you have sensitive data, you'll be advised to keep checking the Apple website for a posted update that Apple will sure put forward to all of you. To see how easy the button combination is on your iPhone in allowing a hacker to by-pass the password screen, read on..
Astro special: Earth Asteroid is at its closest today. Watch it online here!
Last week I posted a blog on the soon to arrive Asteroid 2012 DA14. Well, today, Friday 15th February 2013 it's finally here, or shall I say, its closest approach to our Earth. It's now nearer to us than many communications satellites in Earth orbit and tumbling around at a mind-blowing 20,000 mph.
If it's a clear night you might just spot a glimpse of the huge rock, around 150 feet wide and will approach Earth at a 'tiny' 17,000 miles, in astronomical terms this is right up close. And if you want to get up close and personal to Asteroid 2012 DA14 check out the this blog for a live video feed of the rock, coming to its closest approach 19:24 hrs GMT or 2.24pm EST today..
News: Apple iWatch, fact or fiction?
The big news this week from close sources at Apple sight that designs have been made and pre-production models produced of a so-called iWatch (or whatever, if anything, Apple decide to call it). Its a logical, but certainly not unique concept from the californian based company and in my my humble opinion Apple need something new to help prevent the recent slide in its share price.
According to various (trusted) sources including The Wall Street Journal, long time Apple product maker, Foxconn, have been in talks with Apple on various 'wearable' devices including the iWatch. But what can we expect of this wrist-based technology and what sort of competition will Apple be up against?
Astro: Gamma Ray Burst nearly wiped out Earth in 8th century!
Gamma Ray Bursts (GRBs) are the most powerful explosions in the universe, fact. They are caused when a massive Star (much bigger than our own Sun) explodes by collapsing in on itself, probably producing a Neutron Star or a massive Black Hole. The result is that a huge amount of energy, in the form of Gamma Rays, X-Rays etc are produced, killing everything in its path for many light-years.
If a GRB does hit Earth, the chances it will cause everything living thing death, a bit like a mass extinction which caused the demise of the Dinosaurs. Now researchers have found the probability of a GRB did indeed hit our Earth way back in the 8th century, and here's how they know this..
WTF: Heat exchanger cup holder to charge your batteries!
There are a lot of gadgets on the market, especially for USB novelty stuff that users might use once, maybe twice, then relegate them to the bottom draw. However this new concept might just be what desk users have been looking for. It's a 'heat exchanger' that converts heat from your favorite brew and chargers a device connected to it.
The project called the One Puck offers to provide around 1 amp of current to any connected device, be it an iPhone, Android Tablet or just about anything else. Just think of the applications. At present its a Kickstarter project, however the innovative team behind the One Puck, Epiphany Labs, says it will cost around $150.00 once it gets launched.
Cambridge, UK-based Raspberry, the makers of the top-selling credit card sized bare bones computer, the PI, are about to launch another, cheap-as-chips attachment for it, an HD quality camera.
According to Engaget, the 'eye pi' camera will set users back around $25 (about £19) and for the price it seems pretty high spec with a 1080p HD camera at 30fps on a small PCB measuring around 25 x 20 x 9mm, connected to the standard PI ribbon cable to be connected to your PI computer.
Astro: Asteroid on closest Earth fly-by next week!
It's widely know that Asteroids and Comets played a part in wiping out living things on Earth in the distant past, including the Dinosaurs. And next week our Earth gets skimmed (astronomically speaking) by a huge boulder from the depths of our solar system. But according to NASA, the 'half-the-size' of a football field rock will miss Earth by 'just' 17,200 miles give or take.
If the nights are clear you might just be able to glimpse the boulder as a spec of light, or if NASA (we all hope) are wrong then it might just be the final Friday on Earth as we know it! If you want to know more, get an idea of how close it will pass Earth then read on!


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text:
Seven Arrested For Fleecing StubHub For $1.6 Million In Tickets
Kate Vinton Forbes Staff
Seven alleged cyber criminals have been arrested as part of an international cybercrime ring that hacked StubHub and laundered upwards of $1.6 million dollars, the New York D.A.'s Office announced Tuesday. Two of the alleged criminals were arraigned in New York today, with bail set at $2 million and $500,000.
Six of the arrests were made on Tuesday across three countries—three in London, one in Toronto, and two in New York—highlighting the international scope of cybercrime. A seventh criminal was arrested in Spain earlier this month. One American is expected to turn himself in this week, and two cybercriminals are still beyond reach in Russia, according to Manhattan D.A. Cyrus R. Vance at a press conference on Tuesday.
This case originally began over a year ago in March 2013, when StubHub discovered a cyber breach and reported it to authorities, Vance said. This led to a case being opened with the New York City District Attorney's Office, according to a StubHub statement. The investigation uncovered that cybercriminals had gained access to StubHub accounts and used customers pre-existing card information to purchase tickets for resale, in what is known as an "Account Take-Over Fraud."
StubHub, the subsidiary of eBay (which had its own cyber breach) that allows people to buy and sell tickets online to games, concerts, and theater shows, notified affected customers after the breach and refunded them for the tickets in addition to increasing security, according to a statement.
At the press conference, Vance said the D.A.'s office didn't yet know how the hackers had gained access to the StubHub accounts. According to StubHub's statement, there were "no intrusions into StubHub's technical or financial systems," meaning that the hackers must have accessed customer logins either through information from other data breaches or through the use of key-loggers or malware on the customers' computers.
The case originated with two Russian hackers --Vadim Polyakov, 30, and Nikolay Matveyehuk, 21. The two allegedly hacked 1,600 StubHub accounts, purchasing at least 3,500 e-tickets. These tickets were then emailed to three Americans in New York and New Jersey—Daniel Petryszyn, 28, Laurence Brinkmeyer, 29, and Bryan Caputo, 29. The three Americans were allegedly responsible for reselling the stolen tickets and then laundering the money into various accounts, including PayPal accounts belonging to Polyakov and Matveyehuk and bank accounts in the UK, Canada, and Germany. One of the bank accounts belonged to Russian Sergei Kirin, 37, who advertised money laundering on the internet and took a percentage of the money as his fee.
According to Vance, the three Americans clearly knew they were involved in an international hacking and money laundering scheme. In a series of texts from Petryszyn to Brinkmeyer, Petryszyn allegedly said "…this guy [Polyakov] is pretty much admitting he is a hacker," and "…I want to be the USA rep for these guys" and "…I don't give a f*** I will launder all the money they want."
On July 1, 2014, the DA's Office discovered via Facebook that Polyakov and a friend were leaving Russia to travel in Spain. Interpol then issued an international Red Notice for his arrest. On July 3, Spanish authorities arrested Polyakov outside his hotel near Barcelona in coordination with U.S. Secret Service. The other six arrests occurred in coordination on Tuesday.
"Fighting cyber crime today requires international cooperation," said Vance at a press conference on Tuesday alongside the members of the City of London Police and Royal Canadian Mounted Police. "It allowed us to bring down cyber crime rings on both sides of the Atlantic at the same time."
In contrast the narrative of an international cybercrime and conspiracy presented at the press conference and by the prosecution, Petryszyn and Caputo's attorneys attempted to paint the defendants as average young men with college degrees and no criminal records.
Attorney Liam Malanaphy described Petryszyn, who showed up in court in jeans, a t-shirt and handcuffs, as a "kid from New Jersey" who is "nervous as hell." Malanaphy went on to say that he didn't live the lifestyle of a person with millions of dollars, sharing an Upper East Side apartment with friends and driving his father's car. Similarly, Attorney Reginald Sharpe described how Caputo, who showed up in court in shorts, lives with his mother and brother in Kearny, New Jersey, and graduated with honors from Montclair State University.
Despite this, Judge Melissa Jackson placed Petryszyn's bail at $2 million and Caputo's bail at $500,000 in keeping with the prosecution's request, which had noted the defendants' access to money and the international scope of the crime. Both plead not guilty to their charges.
These two arraignments are just the start of what will be a long process of bringing down this international cyber crime ring, including the pending arrests of Kirin and Matveyehuk who are still in Russia. At the press conference, Vance highlighted StubHub's role in the case, as awareness and reporting are the first steps to bringing these cybercriminals to justice.
A year ago Vance's office announced the convictions of 15 individuals connected to the Western Express cybercrime ring which stretched from Brooklyn to Ukraine, Vance said. In that case, the defendants were convicted of trafficking more than 95,000 stolen credit card numbers, which resulted in more than $5 million in credit card fraud, according to a press release.
At the press conference, Vance urged people to be on alert. "Cybercrime is everywhere, unfortunately," Vance said. "We are all capable of being victims."
A flow chart presented at the D.A. Office's Press Conference, highlighting the connections between the indicted individuals.
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Kate Vinton
I track the world's wealthiest people as part of the Forbes wealth team. Before joining the wealth team, I was the producer for the Forbes technology channel and reporte...

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Project Type: Alumni
Alumni – 2012 Emily Stover Emily Stover \ Franconia Minneapolis / St. Paul MLA: University of Minnesota, Landscape Architecture, 2012 BFA: University of Illinois Urbana-Champaign, 1999 Emily Stover is an architect and public artist working in alternative landscapes and new media, and is currently developing temporary architecture as interactive community space. Recently, she has collaborated… Continue reading Emily Stover
Ben Garthus
Ben Garthus is a Brooklyn-based artist that makes work which stretches the boundaries of sculpture to include the unexpected discoveries that are possible when human interaction merges with systems, objects and structures
Peter McLarnan
Peter McLarnan, Writer/Director/Producer of Independent feature film The Sound of Small Things. The Sound of Small Things premiered at Slamdance Film Festival in 2012 and went on to play at festivals across the country. The Sound of Small Things is distributed online by Seed and Spark.
K. Valentine Cadieux
Valentine Cadieux, My Ten Chances project is called: Cultivating table conversations: How to listen to food system stories
My intent for these three weeks is to develop a practice of line drawings to braid together more integratively three strands of my work that should obviously be related but that haven't to date worked together very smoothly…