Masturbation prohibition in sex offenders: a crossover study.

Some self-help groups for individuals with aberrant sexual interests (e.g., Sexaholics Anonymous and Sex and Love Addicts Anonymous) maintain that a period of "sexual sobriety" is necessary for treatment. The hypothesis was tested that sexual urges during a 30-day period of voluntary abstinence from masturbation would be less frequent and intense than during a period when masturbation was not avoided. Outpatient pedophiles were randomly assigned to either refrain from masturbating or make no attempt to alter their masturbation frequency for a period of 30 days. All participants were crossed over to the other treatment condition at the start of the 2nd month. Sexual urges and behavior were measured using weekly self-reports. A repeated measures ANOVA failed to show a difference in reported intensity of sexual urges, F(7, 91) = 1.15, p = 0.34; masturbation urges, F(7, 91) = 1.73, p = 0.11; adult sex urges, F(7, 91) = 1.82, p = 0.09; or child sex urges, F(7, 91) = 1.58, p = 0.15, in Masturbation Allowed vs. Masturbation Not Allowed conditions. Of 17 participants, 3 (18%) were able to retain completely from masturbating for 1 month, 4 participants (25%) thought it was helpful not to masturbate; 1 participant (7%) thought therapists should recommend avoidance of masturbation. This study suggests that sexual sobriety from masturbation does not aid in the control of pedophilic fantasies. This may be because the technique is ineffective, or because so few participants are willing to engage in it.

Prediction of dangerous behaviour in male erotomania.

BACKGROUND: New cases of erotomania in men, plus cases from the literature, were analysed to explore any association between erotomania and dangerousness, and to identify possible predictors. METHOD: Files at two in-patient facilities were examined to determine the presence of DSM-III-R delusional disorder, erotomanic type. The sample (13 cases) was divided into dangerous and benign groups on the basis of serious antisocial behaviour directly related to erotomanic delusions. These cases were combined with all reports of erotomania in men (16 cases), found in the English language psychiatric literature, to allow for statistical analysis. RESULTS: Two factors, multiple delusional objects (P < 0.0005) and serious antisocial behaviour unrelated to the delusions (P < 0.05), were found to be significantly associated with dangerousness. Using a combination of these two variables it was possible to predict dangerousness with an accuracy of 88.9% (weighted prediction accuracy or 'hit rate'). We identified no false negatives but three false positives. CONCLUSIONS: The presence of multiple objects, and a history of serious antisocial behaviour unrelated to the erotomanic delusions, are useful predictors of dangerous behaviour in men with erotomania.

Sexual disorders in Huntington's disease.

This study assessed the frequency and type of sexual disorders associated with Huntington's disease (HD) in an unbiased sample. Of 39 HD patients and 32 of their partners, 82% and 66%, respectively, had one or more sexual disorders by DSM-III-R criteria. The most frequent for both groups was hypoactive sexual disorder. Significantly more patients who had both inhibited orgasm and increased sexual interest also had paraphilic disorders. Findings support the hypotheses that sexual disorders are frequent among HD patients and their partners and that sexual disorders among HD patients may take the form of increased sexual interest or paraphilias. The association between inhibited orgasm, increased sexual interest, and paraphilic disorders will require further investigation but suggests a possible etiology for some paraphilias.

Apathy following cerebrovascular lesions.

BACKGROUND AND PURPOSE: Although apathy has been reported to constitute a frequent sequela of stroke lesions, there have been no prospective studies on the frequency and correlates of apathy after stroke lesions. In the present study, we examined the frequency and correlates of apathy in a consecutive series of 80 patients with cerebrovascular lesions. METHODS: We included patients within the first 10 days after a stroke lesion. Patients were examined with a comprehensive neuropsychiatric battery that included the Apathy Scale. RESULTS: Eighteen patients (22.5%) showed apathy, nine of whom were also depressed. On the other hand, 18 patients (22.5%) showed depression in the absence of apathy. Although depression and apathy may exist independent of one another, major depression (but not minor depression) was associated with an increased frequency of apathy. Apathy was also significantly associated with older age, cognitive impairments, and deficits in activities of daily living. Finally, apathy was significantly associated with lesions in the posterior limb of the internal capsule. CONCLUSIONS: These findings demonstrate that apathy is a frequent finding among patients with acute stroke lesions and may coexist with important emotional and cognitive poststroke disturbances.

Generalized anxiety disorder after stroke.

A series of 309 admissions to a stroke unit was examined for anxiety symptoms. Patients were diagnosed with DSM-III-R generalized anxiety disorder (GAD) symptom criteria. They were divided into groups of no anxiety (59.2%), worried but not fulfilling GAD criteria (13.9%), and GAD (26.9%). Patients were then divided into depressed and nondepressed groups based on the existence of DSM-III major or minor (dysthymic) depression. These groups were not significantly different in their background characteristics, family or personal psychiatric history, social support or the severity of physical impairment. Anxiety plus depression was associated with left cortical lesions, whereas anxiety alone was associated with right hemisphere lesions. Patients with worry had anterior and patients with GAD had posterior right hemisphere lesions. These findings suggest that anxiety disorder (independent of depression) is not related to background characteristics or to severity of impairment but is, in part, influenced by the brain structures that are injured.

Catastrophic reaction after cerebrovascular lesions: frequency, correlates, and validation of a scale.

The frequency and correlates of the catastrophic reaction (CR) were examined in 52 consecutive patients with an acute stroke lesion. A new scale proved reliable for measuring the severity of CR. The CR was significantly associated with depression, a personal and family history of psychiatric disorder, and subcortical lesions, which were mostly located in the basal ganglia. Patients with and without a CR, when matched for the presence and type of depression, differed only in that CR patients had significantly more anterior lesions and a significantly higher frequency of subcortical damage. Results demonstrate that the CR is significantly associated with poststroke depression and may be a specific manifestation of certain types of poststroke depression.

Anosognosia in patients with cerebrovascular lesions. A study of causative factors.

BACKGROUND AND PURPOSE: Psychological and biological hypotheses have been proposed to explain anosognosia. We correlated the presence of anosognosia with the presence and severity of psychiatric disturbances, neglect, intellectual impairments, and computed tomographic evidence of lesion size, location, and measurements of brain atrophy. METHODS: A series of 80 patients with acute stroke were assessed using a battery of psychiatric and neuropsychological tests and computed tomography. RESULTS: There were five main findings. First, 27 (28%) of the 96 patients originally screened showed anosognosia. Second, patients with anosognosia had significantly higher frequencies of hemispatial neglect and related phenomena, as well as deficits in recognizing facial emotions and in receptive prosody. Third, depression was equally frequent among patients with and without anosognosia. Fourth, patients with anosognosia had a significantly higher frequency of right hemisphere lesions, primarily involving the temporoparietal junction, thalamus, and basal ganglia. Fifth, patients with anosognosia showed significantly more subcortical brain atrophy, primarily involving the frontal white matter and diencephalic areas. CONCLUSIONS: The present study demonstrates that anosognosia does not "protect" stroke patients from depressive feelings; rather, it represents arousal-attentional disorders after lesions in specific areas of the right hemisphere in nonaphasic patients with preexisting subcortical atrophy.

Buspirone hydrochloride in the treatment of an atypical paraphilia.

A case report involving buspirone hydrochloride in the successful treatment of a patient with an atypical paraphilia and transvestic fetishism is presented. Treatment outcome was assessed by the patient's self-report as well as by retrospective examination of detailed notes about paraphilia fantasies which unknown to the therapists, had been kept by the patient. Preliminary evidence indicates that buspirone appears to effectively treat some paraphilias.

Depression in patients with acute traumatic brain injury.

OBJECTIVE: This study was undertaken to examine patients with closed head injuries for the presence of depressive disorders. METHOD: A consecutive series of 66 patients with closed head injuries but no significant spinal cord or other organ system injury were examined by means of a semistructured psychiatric interview. The Hamilton Rating Scale for Depression as well as scales measuring impairment in activities of daily living, intellectual functioning, and social functioning were administered. The patients' CT scans were also examined. RESULTS: Seventeen patients had major depression and two had minor depression. The presence of left dorsolateral frontal lesions and/or left basal ganglia lesions and, to a lesser extent, parietal-occipital and right hemisphere lesions was associated with an increased probability of developing major depression. Compared to the nondepressed group, the group with major depression had a higher frequency of previous psychiatric disorder and showed evidence of poorer social functioning. CONCLUSIONS: Major depression occurs in about one-quarter of patients after traumatic brain injury. This is the same frequency as in other major disorders such as stroke. Major depression appears to be provoked by one or more factors that include poor premorbid social functioning and previous psychiatric disorder or injury to certain critical brain locations.

Misidentification of self and the Riel Phenomenon.

Misidentification syndromes or phenomena are found in a number of psychiatric situations that may become the subject of forensic science review. One of the most curious is misidentification of self in which the individual perceives himself or herself as another being while able to explain the loss of the original identity. Recognizing these phenomena may be helpful in accurate diagnosis, in considering such conditions as psychosis of whatever type, multiple personality disorder, and other amnesia and fugue states, and in understanding the person's psychopathology. Two cases are presented to illustrate a process that the authors have named the Riel Phenomenon, after the person who was a party to what is often recognized as the most famous case in Canadian history.

Simulated paraphilias: a preliminary study of patients who imitate or exaggerate paraphilic symptoms and behaviors.

In a consecutive series of admissions to the Johns Hopkins Sexual Disorders Unit, 4 out of 20 patients appeared to have simulated paraphilic symptoms that further assessment indicated were either exaggerated or not present. The paper presents case histories of these 4 patients. A descriptive comparison is made between these patients and control groups of patients who admitted having paraphilic symptoms and a group of patients accused of having paraphilic symptoms but who denied them. Patients who simulated paraphilias tended to be self-referred (75%) and without current legal charges (100%). None of these patients was referred or sought treatment for pedophilia, in contrast to the other two patient groups, in which pedophilia accounted for 75% of the referrals. Several possible explanations for why patients might simulate paraphilias and implications for therapists who evaluate or treat sex offenders are discussed.

Are depressive symptoms nonspecific in patients with acute stroke?

OBJECTIVE: Some investigators have suggested that major depression might be overdiagnosed in stroke patients because of changes in appetite, sleep, or sexual interest caused by their medical illness; others have suggested that depression may be underdiagnosed in stroke patients who deny symptoms of depression because of anosognosia, neglect, or aprosody. The authors' goal was to determine how frequently depressive symptoms occur in acute stroke patients with and without depressed mood to estimate how often diagnostic errors of inclusion or exclusion may be made. METHOD: They examined the rate of autonomic and psychological symptoms of depression in 205 patients who were consecutively hospitalized for acute stroke. Eighty-five (41%) of these patients had depressed mood, and 120 (59%) had no mood disturbance. Forty-six (54%) of the 85 patients with depressed mood (22% of all patients) were assigned the DSM-III diagnosis of major depression. RESULTS: The 120 patients without mood disturbance had a mean of one autonomic symptom, but the 85 patients with depressed mood had a mean of almost four. Tightening the diagnostic criteria to account for one more nonspecific autonomic symptom decreased the number of patients with major depression by only three; adding two more criteria decreased the number by only five. Thus, the rate of DSM-III major depression was 1% higher than the rate with one extra nonspecific autonomic symptom and 2% higher than the rate with two extra criteria. Conversely, loosening diagnostic criteria to account for denial of depressive illness increased the rate of major depression by only 5%. CONCLUSIONS: Both autonomic and psychological depressive symptoms are strongly associated with depressed mood in acute stroke patients.

Phenomenological comparisons of major depression following stroke, myocardial infarction or spinal cord lesions.

Patients with major depression admitted to hospital with acute stroke (n = 44), acute myocardial infarction (n = 25), or acute spinal cord injury (n = 12) were examined for differences in their phenomenological presentation of major depression. Depressed stroke patients were found to have significantly higher scores on the syndrome clusters for generalized anxiety and ideas of reference than depressed cardiac or spinal cord injury patients. In addition, significantly more stroke patients met diagnostic criteria for generalized anxiety disorder compared with the other two groups. Although spinal cord injury patients were younger, more likely to be treated with benzodiazepines, and less likely to be treated with beta-blockers, none of these factors distinguished stroke patients with anxious depression from stroke patients with depression only. These findings are consistent with the hypothesis that the etiology of depression following stroke may be different from that associated with myocardial infarction or spinal cord injury.

Depression and cerebrovascular disease.

Depressive disorder is a common complication of stroke. Although somatic symptoms of stroke may be mistaken for depression, DSM-III criteria for major depression are appropriate for use in this clinical setting. The etiology of poststroke depression can be viewed from a number of perspectives. Evidence from examining lesion characteristics and depression suggests that a disease model is suitable for some cases of poststroke depression. Alternatively, adequacy of social support and gender differences influence the occurrence of poststroke depression. Poststroke depression can be effectively treated with tricyclic antidepressants, and the use of these agents may also enhance physical and cognitive recovery.

The impact of poststroke depression on recovery in activities of daily living over a 2-year follow-up.

The impact of clinically diagnosed depression on recovery in activities of daily living over a 2-year follow-up was examined in a prospective study of 63 stroke patients. Although impairment in activities of daily living, neurologic diagnoses and findings, lesion location and volume as measured on computed tomographic scan, demographic variables, cognitive impairment, and social functioning were comparable between depressed (n = 25) and nondepressed (n = 38) patients during their acute hospitalization, the two groups had different patterns of recovery in activities of daily living. At 2 years after suffering a stroke, patients with an in-hospital diagnosis of depression (either major or minor depression) were significantly more impaired in both physical activities and language functioning than were non-depressed patients. Among patients with major depression, this disparity in the recovery profile was present even after the depression had remitted. This study emphasizes the need for early recognition and treatment of poststroke depression.

Tricyclic antidepressants in the treatment of poststroke depression.

Depression is a serious complication of stroke. Although tricyclic antidepressants have well-established efficacy in the treatment of functional depression, they are not often used to treat depression following stroke. Studies have identified two types of depression in patients following stroke: major depression and minor depression. Longitudinal studies indicate that untreated major depression may last about 1 year, whereas untreated minor depression may last more than 2 years. Patients with depression who are not treated with antidepressant medication have been found to do more poorly on several measures of physical and cognitive rehabilitation than depressed patients who are treated. Two double-blind drug treatment studies of depression following stroke have been done. Although adverse side effects were reported in both studies, serious side effects were no more common in the active drug group than in the placebo group. Both studies, however, reported significantly better outcome, measured by depression scores or activities of daily living, in patients treated with nortriptyline or trazodone than in placebo-treated controls. Thus, although the use of antidepressant medication requires caution, the recognition and treatment of depression in patients who have had a stroke may result in a significant enhancement of both physical and cognitive recovery as well as emotional state.

Characteristics of patients referred to psychiatrists for competency evaluations.

Requests for inpatient psychiatric consultations at a general hospital over a three-year period were reviewed. Of 2,423 referrals, 79 (3.3%) were specifically for evaluation of competency, and 78.5% of those cases resulted in a diagnosis of an organic mental disorder. The proportion of referrals with organic mental disorder was significantly greater than it was in a control population of patients referred for consultation for any reason. Patients with organic mental disorder who were referred for competency evaluation had greater cognitive impairment than did control subjects.

Buspirone hydrochloride in the treatment of transvestic fetishism.

The author presents a case report of a 46-year-old man with generalized anxiety disorder and transvestic fetishism who responded to treatment with buspirone. The patient stopped cross-dressing while taking buspirone, but alprazolam had no effect on the frequency of cross-dressing. The author discusses the implications of using buspirone in the treatment of both inhibited sexual desire and transvestic fetishism.