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Treatment of Anxiety Disorders: A Systematic Review

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Treatment of Anxiety Disorders: A Systematic Review

Book. 2005 11

Authors: Swedish Council on Health Technology Assessment

Abstract
Background
The assignment was to examine various methods of treating the established anxiety disorders. Intervention to alleviate non-specific symptoms of worry, apprehension and anxiety were not part of the assignment. The assessment included the treatment of children, adolescents and adults with:Panic disorder (PD). Obsessive-compulsive disorder (OCD). Post-traumatic stress disorder (PTSD). Generalized anxiety disorder (GAD). Specific phobias.
Because the course of anxiety disorders is often protracted, a special focus was placed on identifying studies that evaluate the long-term effects of treatment. For each anxiety disorder, one or more treatments have proven to be effective (strong scientific evidence). With the exception of specific phobias, both pharmacological treatment and psychotherapy are moderately effective. The symptoms are alleviated, but full remission is rarely achieved. With a few exceptions, the symptoms recur once treatment has been completed. The socioeconomic costs – primarily in terms of lower productivity, as well as greater ill-health, death rates and the need for somatic care (treatment for physical symptoms) – are high. The cost effectiveness of various treatment options has not been determined. There is insufficient scientific evidence for comparing either the efficacy or cost effectiveness of different treatments. Studies of psychodynamic therapies are almost totally lacking. Some benzodiazepines have been shown to be effective in treating certain anxiety disorders. However, it has been well established that the drugs cause significant problems in terms of side effects, dependence or an exacerbation of symptoms after treatment has proceeded for a certain period of time. No study has unequivocally explained why anxiety disorders are associated with raised death rates. Long-term studies on how to reduce raised death rates through some form of intervention are lacking. Panic disorder (PD), with or without agoraphobia (fear of having a panic attack in a place from which escape would be difficult): The antidepressants sertraline, paroxetine, imipramine and clomipramine (strong scientific evidence), as well as most likely citalopram and moclobemide (limited scientific evidence), reduce the frequency of panic attacks. Agoraphobia is only slightly affected by antidepressants (moderately strong scientific evidence). Exposure to the situations that cause panic alleviates the symptoms of agoraphobia with PD (moderately strong scientific evidence). Cognitive behavioral therapy (CBT) that includes exposure alleviates the symptoms of PD without agoraphobia or with mild to moderate agoraphobia (strong scientific evidence). Its effectiveness for PD with severe agoraphobia has not been established. Exposure as a monotherapy alleviates the symptoms of agoraphobia (moderately strong scientific evidence). Psychotherapy has a more long lasting effect than psychotropic drugs (moderately strong scientific evidence). Antidepressants and CBT or exposure have proven to be more effective in combination than as monotherapies (moderately strong scientific evidence). Specific Phobias: Exposure, modeling and participant modeling, in which the patient learns to handle whatever triggers the fear, has a substantial, long-term impact on specific phobias (strong scientific evidence). There is no proven pharmacological treatment for specific phobias. Social Anxiety Disorder (SAD): Fluvoxamine, sertraline, paroxetine, venlafaxine and escitalopram alleviate the symptoms of SAD (strong scientific evidence). CBT, particularly in a group setting, alleviates the symptoms of SAD (strong scientific evidence). Antidepressants and psychological therapies have not proven more effective in combination than when administered separately (moderately strong scientific evidence). Obsessive-Compulsive Disorder (OCD): Clomipramine, sertraline, paroxetine, fluoxetine, fluvoxamine (strong scientific evidence) and citalopram (moderately strong scientific evidence) alleviate the symptoms of both obsessions and compulsions. The drugs are effective as long as they are being administered, but most patients relapse once the treatment has been terminated (moderately strong scientific evidence). Behavioral therapy (exposure / response prevention) reduces the symptoms in approximately half of all patients with compulsions (strong scientific evidence). The effect remains at two-year follow-up (moderately strong scientific evidence). Post-Traumatic Stress Disorder (PTSD): Fluoxetine, sertraline and paroxetine alleviate the symptoms of PTSD (strong scientific evidence). Sertraline remains effective at one-year follow up (strong scientific evidence). Various kinds of repeated exposure to that which is reminiscent of the traumatic event (strong scientific evidence) and CBT (moderately strong scientific evidence) alleviate the symptoms of PTSD. Eye Movement Desensitization and Reprocessing (EMDR), which combines eye movements with behavioral therapy, is effective for PTSD (moderately strong scientific evidence), but the eye movements lack specific therapeutic value (strong scientific evidence). Generalized Anxiety Disorder (GAD): Paroxetine, venlafaxine (strong scientific evidence), sertraline and escitalopram (moderately strong scientific evidence) alleviate the symptoms of GAD. CBT is effective for GAD (moderately strong scientific evidence). Treating Children and Adolescents: CBT alleviates the symptoms of separation anxiety disorder, overanxious disorder, GAD and SAD (strong scientific evidence). The effect remains at two-year follow-up (moderately strong scientific evidence). Fluoxetine, paroxetine, sertraline and fluvoxamine have proven to alleviate the symptoms, but none of them has been approved for these disorders in children and adolescents. Exposure to the feared object or situation is effective for patients with specific phobias (strong scientific evidence). Clomipramine, sertraline, fluoxetine (strong scientific evidence), paroxetine and fluvoxamine (moderately strong scientific evidence) alleviate the symptoms of OCD. Clomipramine, sertraline and fluvoxamine have been approved for treatment in children and adolescents. Behavioral therapy, whether CBT or not, is equally effective as antidepressants for treating OCD (strong scientific evidence). Combination treatment is somewhat more effective (strong scientific evidence). CBT alleviates the symptoms of PTSD (moderately strong scientific evidence).

PMID: 28876726

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Treatment for Binge Eating Disorder

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Treatment for Binge Eating Disorder

Book. 2016 04

Authors: Swedish Council on Health Technology Assessment

Abstract
Aim
The aim of this systematic review was to evaluate the efficacy of treatments for Binge Eating Disorder (BED). Conclusions: Several different treatments for BED result in remission (defined as cessation of binge episodes) or decreased frequency of binge eating episodes. Both Cognitive Behavioral Therapy (CBT) and Interpersonal Psychotherapy (IPT) result in remission, or decreased frequency of binge eating episodes up to one year after end of treatment. No conclusions are presented for follow ups beyond one year due to few studies. At end of treatment, guided self-help, based on CBT, results in remission and decreased frequency of binge eating episodes. SSRI and lisdexamfetamine result in remission and decreased frequency of binge eating episodes at end of treatment. The effect of psycho­pharmacology beyond the end of treatment is unknown. Future research should investigate the long term and adverse effects, cost-effectiveness, the effect of treatments for children and adolescents, and the effect of treatments on quality of life.

PMID: 28876759

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Depression Treatment for the Elderly

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Depression Treatment for the Elderly

Book. 2015 01

Authors: Swedish Council on Health Technology Assessment

Abstract
Conclusions: Many elderly with depression do not benefit sufficiently from the use of antidepressants. In short-term studies, selective serotonin reuptake inhibitors (SSRIs) are not significantly more effective than placebo for elderly with depression. But for those who improved during treatment with SSRI, maintenance treatment up to one year can prevent relapse. The selective serotonin and norepinephrine reuptake inhibitor duloxetine has been evaluated specifically for recurrent depression in elderly and has a slightly better effect than placebo in the short term, but often causes adverse effects that may be problematic for the elderly. Psychotherapy in the form of problem-solving therapy may decrease depression symptoms for patients with poor health aged 65 years and over, but access to such treatment is lim­ited. More and larger studies on the effects of other psychotherapies and on the effects of physical activity, is warranted to elucidate their benefit and risk balance in depression of the elderly. Treatments that are effective, according to this evaluation, have not yet been evaluated in health economic studies. However, since the treatment cost per individual is often relatively low, it is likely that effective treatment is also cost-effective. The benefits and risks of depression treatment are insufficiently studied for the frail elderly aged 65 years and over. More knowledge is warranted to determine how treatment for depression can be individualized. Due to the lack of knowledge about effective depression treatment for the elderly, it is particularly important to monitor treatment outcome carefully and to reconsider treatment strategy when the patient do not recover.

PMID: 28876804

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Autism-spectrum disorders in adolescence and adulthood: focus on sexuality.

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Autism-spectrum disorders in adolescence and adulthood: focus on sexuality.

Curr Opin Psychiatry. 2017 Sep 04;:

Authors: Turner D, Briken P, Schöttle D

Abstract
PURPOSE OF REVIEW: The combination of the core symptoms, characterizing individuals with autism-spectrum disorder (ASD), can lead to problems in romantic relationships and sexual functioning. The purpose of this article is to review studies on sexuality in individuals with ASD published since January 2016.
RECENT FINDINGS: Individuals with ASD and especially women show a higher diversity in sexual orientation in comparison with the non-ASD population. Furthermore, ASD women are more frequently in a relationship and usually report more previous sexual experiences. Up to now, sexual education programs specifically addressing the needs of the ASD population were scarce, which was criticized by patients, their parents, and caregivers. With the development of the Tackling Teenage Training program, a psychoeducational intervention designed specifically for ASD individuals was introduced, leading to significant improvements in psychosexual functioning and knowledge. Such programs are needed because a considerable rate of problematic sexual behaviors, including public masturbation and paraphilic sexual interests were found in the ASD population.
SUMMARY: Just like their typically developing counterparts, individuals with ASD show the whole range of normal-to-problematic sexual behaviors. Improving sexual knowledge could lead to less inappropriate sexual behaviors and could improve sexual health as part of a healthy and satisfying life.

PMID: 28877047 [PubMed – as supplied by publisher]

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Explainer: what is Dance Movement Psychotherapy?

EugeneTitov/Shutterstock

Dance Movement Psychotherapy (DMP) uses the body, movement and dance as a way of expressing oneself and findings ways of exploring and addressing psychological problems or difficulties. It is an approach to psychological treatment that does not rely on talking about problems as the only way of finding solutions.

According to the Association of Dance Movement Psychotherapy UK:

DMP recognises body movement as an implicit and expressive instrument of communication and expression. DMP is a relational process in which client and therapist engage in an empathic creative process using body movement and dance to assist integration of emotional, cognitive, physical, social and spiritual aspects of self.

It is often regarded as one of the arts therapies, which also includes music therapy and dramatherapy, and a type of embodied psychotherapy, and also a relatively new profession, founded in the 1940s in the US and only in the 1980s in Britain. It is also practised in Australia and Germany. In all cases, therapists receive specific training and licence to practise in the discipline and offer their services to a wide range of vulnerable people, working in private practice, hospitals, schools, social services, charities, care homes or prisons offering one-to-one or group work.

In these different settings, practitioners may follow different approaches but they all adopt a specific direction based on the needs of the clients. Our early research outlined some of the common features of this therapy across settings and client populations.

• Dance: a range of different practices including breath, posture, gesture, pedestrian movement, rhythmical movement and – less often – a more technical or style-specific form of dancing. Skill is not a requirement for people to begin this therapy and learning steps isn’t what takes place within sessions.

• Embodiment: the connection one may have with your own physical self is of high value because it can support a “body-mind” integration.

• Creativity: the process that enables patients to find new solutions to problems.

• Imagery, symbolism and metaphor: important tools used to access unconscious or difficult feelings such as anger, shame or fear. Using these tools allows the patient to work through problematic issues indirectly.

• Non-verbal communication: people don’t always have the words to express what they are feeling. Sometimes it is easier to reach and communicate emotions to other people non-verbally.

Does it work?

Our research suggests that DMP can contribute to a person’s overall well-being. But, to confidently answer the question of whether it is effective as a treatment, there is a need to improve the number, size and quality of the studies in this area. Both practitioners and researchers are still exploring what are the important components of this psychological intervention that contribute towards positive change.

Results from systematic reviews of studies with all client groups suggest that DMP can have a relatively large impact on a wide range of symptoms. The authors conclude that the degree to which DMP can achieve therapeutic change can be compared to other forms of psychotherapy. A more recent study also suggested that this form of therapy can increase quality of life, well-being, mood, body-image and can offer substantial decrease in levels of depression.

Other reviews look at work with different client populations. For example, we found that DMP is a promising intervention in the treatment of depression when compared to standard care, especially with adults.

Studies on effectiveness of DMP on people with schizophrenia suggest that it can reduce symptoms such as apathy, lethargy, blunted emotional responses and social withdrawal. Improved quality of life was the main finding from the review of studies on DMP in cancer care. A review on the treatment of dementia and a study on autism suggest that further research is needed. But in all cases the results seem positive, making this form of therapy a very attractive alternative to conventional psychotherapies.

The Conversation

Vicky Karkou is a Professor of Dance, Arts and Wellbeing at Edge Hill University. She has received funding from ESRC,
the European Union and charities for conducting research in this area. She is a registered member of the Association of Dance Movement Psychotherapy UK and a practiting dance movement psychotherapist and supervisor.

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Monitoring outcomes is key to improving mental health treatment in South Africa

Precision medicine matches patients with interventions, rather than just matching treatments to illnesses. Shutterstock

The traditional way of understanding medical treatment is that a doctor matches a particular treatment to a particular illness. The problem is that people with the same illness can respond differently to the same treatment.

Precision medicine – or personalised medicine – is a relatively new approach that takes account of individual differences when planning treatments. Here, doctors individualise interventions by matching patients with appropriate treatments. This entails using evidence to select the most effective intervention for a patient based on their genetic makeup, circumstances, lifestyle and collection of symptoms.

To do this doctors need to collect detailed information about how different patients respond to different treatments.

Many health related disciplines are moving towards the practice of precision medicine. For example, research suggests that about 55% of people who are diagnosed with depression will respond well to antidepressant medication. In precision medicine, doctors try to understand what individual factors predict these different treatment responses. This enables doctors to make evidence based decisions about which patients with depression should be prescribed medication and which should receive other kinds of treatment. Using this approach could help patients recover quicker and can save time and resources

But this approach to collecting and using evidence to plan interventions is not being widely used when it comes to psychological treatments. This is particularly true in developing countries like South Africa where psychologists aren’t routinely monitoring their treatment outcomes and using evidence to improve their practice.

This is a serious problem. A precision approach would enable psychologists to use scarce mental health resources more efficiently, select the most appropriate treatments, and provide better care to the high number of South Africans suffering from mental health problems.

It was in this context that we embarked on a project to implement a routine outcome monitoring system in a community psychology clinic in the Western Cape Province of South Africa. Our results showed that it’s possible to monitor treatment outcomes as part of routine psychological care, although the tools used to achieve this need to be refined.

Giving evidence-based approaches a chance

So why has psychology been so slow to move towards precision medicine?

Research published recently in the South African Journal of Psychology highlights the fact that many psychologists are reluctant to use empirical evidence when treating individual patients. It seems that many psychologists also resist objectively monitoring how their patients respond to psychological interventions and measuring treatment outcomes.

Part of the problem is that many psychologists don’t believe that psychological functioning can be quantified.

It’s true that it can be difficult to measure psychological change and it’s impossible to use a single measure of treatment outcome for all patients. But there are a number of tools that have been developed that can provide useful information about how patients respond to psychotherapy. These tools are more widely used in developed countries and their use is advocated by the American Psychiatric Association as a way of improving standards of care. But this isn’t the case in most developing countries.

We believe that it’s not enough for psychologists to rely heavily on theories which are unsupported by evidence or subjective accounts of recovery. Psychologists in South Africa have a duty to begin thinking about how they can adapt and apply tools that have been developed elsewhere to collect information about treatment outcomes. This will move the practice of psychology in South Africa closer to an evidence-based approach.

Based on this understanding, we implemented a treatment monitoring system at a community psychology clinic. We asked all patients at the clinic to give us regular feedback about their level of emotional and social functioning. Patients were asked to complete short questionnaires about changes in their symptoms, perceptions of their emotional well-being and changes in the quality of their relationships. We encouraged the clinicians working in the clinic to use this patient feedback to monitor patient responses and refine their treatments.

The goal was to see whether a system that has been used to monitor treatment outcomes in other countries, such as the US and Australia, could be usefully incorporated into routine care in a South African context. We found that it is possible to monitor treatment responses as part of routine psychological care and that the tools that currently exist could be used in South Africa. But we may still need to do some work to make sure that these tools are easily understood by patients and correctly used by psychologists.

More work to be done

Monitoring systems like the one we implemented normally rely on patients to self-report their symptoms and level of functioning. One of the challenges we experienced is that patients didn’t always understand what they were being asked. This meant that their responses could not always be accurately interpreted.

More work is clearly needed to refine the system to make it more user-friendly for patients. This will entail more than just directly translating the instruments into local languages. We need to make sure that the words and ideas used are culturally appropriate and meaningful in different South African contexts.

But even if the system is perfected, this will be of little value if psychologists don’t use it. In our research we found that some clinicians did not use the system consistently or correctly, even when they were trained to do so.

More work with practising psychologists is needed to understand their reluctance to monitor treatment outcomes as part of routine patient care. Maybe there are good reasons for their resistance. But it might also simply be that some psychologists need to make an ideological shift in the way they think about their work and the way they understand the importance of evidence-based practice.

The Conversation

Jason Bantjes receives funding from South African Medical Research Foundation.

Mark Tomlinson and Xanthe Hunt do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond the academic appointment above.

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The Goldwater rule prevents psychiatrists diagnosing Trump from afar but some say there’s too much at stake

In the late 19th century, Sigmund Freud’s colleague Wilhelm Fleiss successfully diagnosed an illness in one of Freud’s relatives, without even having met them. Freud was so impressed by Fleiss’s “diagnostic acumen” that he went on to advocate the method in certain circumstances.

Freud would write that diagnosing someone without personally examining them was acceptable where the features of certain disorders, such as paranoid schizophrenia (then known as dementia paranoides), made the interview process counterproductive. Here, Freud noted that “a written report or a printed case history can take the place of personal acquaintance with the patient”.

Now, a controversial debate about the ethics of diagnosis at a distance or long-distance diagnosis has arisen in the US. It has come about as commentators have proposed that President Donald Trump suffers from narcissistic personality disorder (NPD) and attention deficit hyperactivity disorder (ADHD), among other conditions.


Read more: The appeal of narcissistic leaders is also their downfall


Sigmund Freud believed diagnosing people without examining them was appropriate in some circumstances.
Wikimedia Commons

Health professionals have weighed in as well. Psychotherapist and former assistant professor of psychiatry John D. Gartner has been particularly vehement in his assessment of the President. Gartner asserts that Trump suffers from malignant narcissism, a specific manifestation of NPD.

According to the DSM-5 — the authoritative psychiatric manual — this condition is characterised by various “traits of antagonism”, including “manipulativeness, deceitfulness, [and] callousness”.

Notably, the DSM-5 names the condition only once throughout its hundreds of pages; and some academic psychiatrists say the disorder is understudied and its features largely unsettled, with no treatment yet established.

Despite this, Gartner is convinced that the president’s conduct fulfils the criteria of malignant narcissism — even without having interviewed him:

We’ve seen enough public behaviour by Donald Trump now that we can make this diagnosis indisputably.

Recently, the American Psychoanalytic Association (APsaA) issued a memo to its more than 3,500 members, advising they were “free to comment about political figures as individuals”, and that the APsaA did not regard “political commentary by its individual members an ethical matter”.

By contrast, the American Psychiatric Association (APA) has long maintained a strict ethical stance on the open discussion of public figures’ mental states. Enshrined in the so-called Goldwater rule, the APA’s prescription cautions psychiatrists against diagnosis at a distance.

As former APA President Herbert Sacks put it, psychiatrists should avoid engaging in “psychobabble”, especially when it comes to politicians. He said that, when “reported by the media”, such diagnostic speculation only “undermines psychiatry as a science”.

The Goldwater rule is named after former Republican presidential nominee Barry Goldwater, who was defeated in the 1964 election.
Wikimedia Commons

Although the Goldwater rule is not enshrined in Australian law, a code of ethics provides guidance to Australian psychiatrists about their conduct in the media.

What is the Goldwater rule?

The Goldwater rule is named after an incident involving Republican presidential nominee Barry Goldwater. Having been defeated in the 1964 US election, Goldwater sued the editor of the short-lived political magazine “Fact” for defamation.

Just one month before the election, Fact’s front page had printed a controversial declaration:

1,189 psychiatrists say Goldwater is psychologically unfit to be president!

Fact had conducted a broad but clinically invalid survey, providing questionnaires to more than 12,000 psychiatrists whose details the magazine had obtained from the American Medical Association’s membership list. Of the 2,417 responses it received, some 1,189 psychiatrists asserted Goldwater was unfit for office.

In the feature article, Fact purported to quote many of the psychiatrists it had surveyed, and used their words to suggest that Goldwater was a “megalomaniac, paranoid, and grossly psychotic”, and even suffering from “schizophrenia”.

In the trial that followed, Goldwater was awarded some US$75,000 in punitive damages — enough to ensure that Fact never published another issue.

Fact magazine’s last issue, and the headline for which Goldwater sued.
Courtesy FLAT File magazine at the Herb Lubalin Study Center, New York.

The ruling raised disturbing questions for the APA, threatening not only the reputation of the psychiatric profession, but the future livelihoods of practitioners. In slightly different circumstances, a psychiatrist might face similar civil action, whether “for invasion of privacy or defamation of character”.

In 1973, some four years after the trial, the Goldwater rule was first published in the APA’s professional ethical code. In the most recent 2013 edition, the rule reads as follows:

On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general.

However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.

The rule in dispute

Many academic psychiatrists disagree with the rule. Some have suggested that breaking the Goldwater rule is ethical when it’s necessary to diagnose “mass murderers” from afar, or when “the importance of the diagnosis of an individual … rise[s] to the level of a national threat”.

Others have criticised the rule more generally, calling it “an excessive organisational response” to “an inflammatory and embarrassing moment for American psychiatry”. And one psychiatrist has recently described the prescription as “American society’s gag rule”.

In February this year, the New York Times published a letter signed by some 33 psychiatrists who blamed the rule for silencing them at this “critical time”. They wrote that “too much [was] at stake to be silent any longer”, and that Donald Trump’s “emotional instability” had made him “incapable of serving safely as president”.

The tension between the APA and its members, and between the APA and the APsaA, partly reflects the history of the two disciplines. Since the 1940s, psychiatry has increasingly focused on medical interventions, while tending to neglect the “in-depth talk therapies” which, despite their general decline, remain central to the psychoanalytic method.

But the situation is still more complicated than this. After all, the methods of psychiatrists and psychoanalysts often overlap. In many practices, for instance, psychiatrists employ intuitive reasoning in the diagnostic process.

For some diagnosticians, the so-called “Praecox-Gefühl” or “praecox feeling” remains at the “clinical core” of diagnosing schizophrenia, despite the method’s varied reliability. First described in the 1940s, the praecox feeling is a complex, emotionally charged intuitive sense that a psychiatrist sometimes gets when detecting the subtle symptoms of an emergent psychosis.

What now for the Goldwater rule?

That psychoanalysts may wish to distinguish themselves from psychiatrists on the Goldwater rule, and vice versa, is unsurprising. In countless ways — more than can be named here — psychoanalysts and psychiatrists adopt different views of their roles in the diagnostic process. This is the result of their different training backgrounds, histories, and professional cultures.

Less expected, however, is the growing feeling among psychoanalysts and psychiatrists alike, that today, more than ever, the Goldwater rule should be set aside. While neither group may wish to admit it, the Trump era may have brought psychiatrists and psychoanalysts closer together — at least on this point.

The Conversation

Chris Rudge receives funding from the Australian Research Centre of Excellence for the History of Emotions.

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