Sexual & Sexuality

Whether or not sexual offending behavior-or the predisposition to such-is a mental illness, there are patients with traditional mental illnesses who also present with sexually inappropriate and even sexual offending behavior.

Sexual dysfunctions as distinct syndromes were first identified in DSM-III in 1980. At that time, sets of criteria were specified for inhibited sexual desire, inhibited sexual excitement, inhibited female orgasm, inhibited male orgasm, premature ejaculation, dyspareunia, and functional vaginismus.

In this article we discuss psychoneuroendocrine influences on sexual orientation and the psychodynamics of internalized homophobia. Because of space limitations, we focus on homosexual orientation, although research in this area sheds light on heterosexual and bisexual orientation as well.

Among 25 to 30 million Americans in whom depression is diagnosed annually, 18 to 25 million are treated with antidepressants, of which 90% are SSRI or non-selective serotonin reuptake inhibitor (SRI) antidepressants, the most frequently prescribed medications for all outpatients aged 18 to 65 years.

In this article, we examine the relationship between anxiety disorders and SDs, using DSM-IV-TR categories, although we are conscious of the limits of this approach. In doing so, we will consider not only the dichotomy between normal and pathological functioning but also the issue of sexual satisfaction as part of wellness.

It is a widely known fact that Fyodor Dostoevsky, the famous 19th-century Russian novelist, suffered from epilepsy for most of his life. However, not too many persons are aware that Dostoevsky also had a sleep disorder called delayed sleep phase syndrome, which may have contributed to his seizures.1 Although no one knows for certain, it is quite conceivable that Dostoevsky's sleep disorder worsened his epilepsy, according to Carl Bazil, MD, PhD, director of Clinical Anticonvulsant Drug Trials and director of the Neurology Division, Columbia Comprehensive Sleep Center, Columbia University, New York.

"There must be some way out of here," said the joker to the thief."There's too much confusion, I can't get no relief. . . .""No reason to get excited," the thief, he kindly spoke,"There are many here among us who feel that life is but a joke.But you and I, we've been through that, and this is not our fate,So let us not talk falsely now, the hour is getting late."From "All Along the Watchtower," Bob Dylan

Paraphilias are defined by DSM-IV-TR as sexual disorders characterized by "recurrent, intense sexually arousing fantasies, sexual urges or behaviors generally involving (1) nonhuman objects, (2) the suffering or humiliation of oneself or one's partner, or (3) children or other nonconsenting persons that occur over a period of 6 months" (Criterion A), which "cause clinically significant distress or impairment in social, occupational, or other important areas of functioning" (Criterion B). DSM-IV-TR describes 8 specific disorders of this type (exhibitionism, fetishism, frotteurism, pedophilia, sexual masochism, sexual sadism, voyeurism, and transvestic fetishism) along with a ninth residual category, paraphilia not otherwise specified (NOS).

Emergency department (ED) visits have increased from 89 million in 1992 to more than 110 million in 2002, while the number of EDs decreased by about 15% during the same period. One suspected consequence of ED overcrowding is an increased tendency to disregard a psychiatric problem, especially if it is not the chief complaint.

Sleep disorders are very common and are often underrecognized and underreported in children. If left untreated, these disorders can cause serious developmental and physiologic problems.

Paraphilias as defined by DSM-IV, are sexual impulse disorders characterized by intensely arousing, recurrent sexual fantasies, urges and behaviors (of at least six months' duration) that are considered deviant with respect to cultural norms and that produce clinically significant distress or impairment in social, occupational or other important areas of psychosocial functioning. The common paraphilias described include exhibitionism (exposure of genitals to a stranger), pedophilia (sexual activity with a prepubescent child, generally 13 years of age or younger), voyeurism (observing others' sexual activities), fetishism (use of inert objects, such as female undergarments), transvestic fetishism (cross-dressing), sexual sadism (inflicting suffering or humiliation), sexual masochism (being humiliated, beaten, bound or made to suffer) and frotteurism (touching, rubbing against a nonconsenting person).

When assessing a sleep-related problem in a psychiatric patient, investigating all possible causes may be more helpful than assuming the complaint is a result of medication or the underlying condition.

Sleep-associated movement disorders are common in the general population. When patients complain of sleep disturbance, psychiatrists should consider,and question for, features of nocturnal movement disorder.

The most common club drugs or party drugs are MDMA, ketamine and GHB. How dangerous is continued use of these substances? Can they cause real damage to the brain?

There is growing epidemiologic and clinical data that confirm progressive hypothalamic-pituitary-gonadal hypofunctioning in aging men. What role does the HPG axis play in the complex psychobiology of male sexual and affective disorders? The treatment rationale, clinical indications and risks in using exogenous testosterone for late-life depression are explored.

restless legs syndrome, Parkinson disease, ADHD

The infamous trial of People v Schmidt, presided over by Justice Benjamin Cardozo, provides a cautionary tale for forensic psychiatrists. In his commentary on a biography of the celebrated judge, Stone assesses the quest to clarify the meaning and scope of the insanity defense.

Can a common cough medicine contribute to effective treatment of symptoms in persons with neurologic disorders? The evidence is mounting in its favor. At the recent American Academy of Neurology annual meeting, research results were presented from a phase 3, double-blind, placebo-controlled, multicenter study into the safety and efficacy of a dextromethorphan/quinidine capsule in

Little attention has been paid to the prevalence of sexual assault and its sequelae among military men. The past-year prevalence of sexual assault among enlisted men ranges from 0.4% to 3.7%, a figure equal to or exceeding the lifetime prevalence among civilian men in some studies. Increased awareness and understanding of male sexual assault as well as routine screening of all patients, regardless of gender, for exposure to sexual victimization will enhance their recovery.

Since the 1990s there has been an increase in research on sexual harassment and its mental health consequences. These researchers discuss the use of alcohol to self-medicate harassment-engendered distress and the need for greater attention to potential alcohol-related consequences of harassment experiences.

Despite the fact that awareness of HIV and AIDS transmission is pervasive, risky sexual behavior has been increasing in many parts of the world in recent years, with a concomitant rise in new cases of HIV and other sexually transmitted diseases.

Underdiagnosis of sexual dysfunction occurs frequently, even though more than two out of five adult women and one out of five adult men experience it in their lifetime. To increase recognition and care of sexual dysfunction, multidisciplinary teams of medical experts recently published diagnostic algorithms and treatment guidelines that include comprehensive psychosocial assessments, sexual histories, and discussions of selected psychotherapies and pharmacotherapies.

Despite the image presented in films, books and television, prostitution places women and children at high risk for PTSD and other comorbid disorders. What experiences lead to this life?

Hollywood has had a long-standing love affair with psychiatry and its portrayals of electroconvulsive therapy reflect and influence public attitudes toward the treatment. One-third of medical students decreased their support for the treatment after being shown ECT scenes from movies, and the proportion of students who would dissuade a family member or friend from having ECT rose from less than 10% prior to viewing to almost 25% afterward. So what is the legacy of portrayals that have been so abhorrent, and are there any exceptions to the rule?

For various reasons, up to half of patients stop taking their prescribed antidepressant within three months. Side effects are often the biggest obstacle in maintaining treatment adherence. How can clinicians help patients deal with the sexual dysfunction and weight gain that often accompany psychotropic treatment?

Stephen R. Shuchter, M.D., professor of clinical psychiatry and associate director of residency training at University of California, San Diego, spends his "down" time performing as Elvis and other rock 'n' roll legends. In these efforts, he expresses his creativity and brings delight to those he entertains. Lessons from each "career" have helped his success in the other.

The SSRIs have become the most widely prescribed antidepressants in the United States. With this increased use has come more information on adverse events associated with their use, such as sexual dysfunction. However, movement disturbances associated with SSRI use can adversely impact treatment. This article explains the pathology of movement disorders and describes confounding variables such as other medications, pre-existing neurological insults and the nature of case reviews. Those at risk include the elderly, patients taking neuroleptics and those exposed to high levels of SSRIs.

Men's Reactions to Female Sexual Coercion

This is the second of two articles regarding herbal medicines as discussed at the American Psychiatric Association's annual meeting in Toronto. Potential benefits and risks of kava, St. John's wort and hoasca were considered at the recent American Psychiatric Association's symposium on herbal medicine.

The diagnostic criteria for sexual addiction are derived from the behaviorally nonspecific criteria for addictive disorder that were presented in Part 1 (Goodman, 1998b), by replacing "behavior" with "sexual behavior".