Advances in Psychosomatic Medicine最新文献

The diagnosis of sexual dysfunction(s) or disorder(s) is paramount to the development of the field of sexual medicine. Historically, the diagnoses of these disorders have been considered reliable. The validity of diagnoses of sexual disorders (and the rest of our classification systems) has recently been questioned, especially from the point of clinical utility and homogeneity. This review discusses the issues involved in the development of valid and useful diagnoses of sexual disorders, reviews the proposed changes in the upcoming Diagnostic and Statistical Manual of Mental Disorders, 5th edition, as well as the problems inherent in the revision of this (and any) diagnostic system, and suggests some possible remedies to this process.

Recent developments and trends in sex therapy are reviewed and assessed. Major trends identified are: (1) multidisciplinarity in the treatment of sexual problems, whereby psychological interventions are combined with medical and other types of treatment (e.g. physical therapy); (2) systemic and theoretical integration, as evidenced by an emphasis on contextual influences on sexual responses and an openness to different theoretical perspectives; (3) a shift in focus from sexual function to sexual satisfaction and eroticism; (4) an emphasis on age and the aligning of expectations to reality; (5) the impact and applications of new technologies, and (6) progress toward the recognition of diversity in the human sexual experience. The overall challenge to sex therapy is to address the complexity of sexual problems in ways that are considered feasible to a public with limited time and resources.

Chronic pain and substance abuse are common problems. Each entity represents a significant and independent burden to the patients affected by them, the healthcare system caring for them, and society at large supporting them. If the two problems occur together, all of these burdens and their consequences are magnified. Traditional treatments fail a substantial percentage of even the most straightforward cases. Clearly, new approaches are required for the most complex of cases. Success is possible only if multiple disciplines provide integrated care that incorporates all of the principles of substance abuse and chronic pain rehabilitation treatment into one package. While experience provides the foundation for implementing these programs, research that documents the methods behind successful outcomes will be needed to sustain support for them.

Chronic pain is a sensory experience that produces suffering and functional impairment and is the result of both sensory input as well as secondary adaptation of the nervous system. The sensitization of the nervous system to pain is influenced by physical activity (or inactivity) and medication exposure. Medication taking and physical activity are behaviors that are increased or decreased by positive and negative reinforcement. Patients often have comorbid psychiatric conditions at presentation, including addictions, mood disorders, personality vulnerabilities and life circumstances that amplify their disability and impede their recovery. Behavioral conditioning contributes to chronic pain disorders in the form of both classical (Pavlov) and operant (Skinner) conditioning that increases the experience of pain, the liability to ongoing injury, the central amplification of pain, the use of reinforcing medications such as opiates and benzodiazepines, and behaviors associated with disability. The term 'abnormal illness behavior' has been used to describe behaviors that are associated with illness but are not explained physiologically. Behavioral conditioning often amplifies these abnormal behaviors in patients with chronic pain. Addiction can also be seen as a behavior that is reinforced and conditioned. The same factors that amplify abnormal illness behaviors also increase the liability to addiction. Psychiatric comorbidities also complicate and amplify abnormal illness behaviors and addictive behaviors and further contribute to the disability of chronic pain patients. Model interventions that reinforce healthy behaviors and extinguish illness behaviors are effective in patients with addictions and chronic pain. Maladaptive behaviors including addictive behaviors can be used as targets for classical and operant conditioning techniques, and these techniques are demonstrably effective in patients with chronic pain and addictions.

As opioid prescribing has dramatically expanded over the past decade, so too has the problem of prescription drug abuse. In response to these now two major public health problems - the problem of poorly treated chronic pain and the problem of opioid abuse - a new paradigm has arisen in pain management, namely risk stratification. Once a prescriber has determined that opioids will be used (a medical decision based on how intense the pain is, what has been tried and failed and, to some extent, what type of pain the patient has), he/she must then decide how opioid therapy is to be delivered. Different models of delivery of opioid therapy can be utilized, beginning the process with a risk assessment that is highly individualized to each patient. Recently, researchers have produced a wide variety of literature regarding assessment tools to be used for this purpose. And while there remains a need for larger prospective studies to examine the ability of each tool to predict aberrant drug-taking behaviors, clinicians can and should utilize one or more of these screening tools and understand their benefits and limitations. This chapter will describe the nature of current screening assessments, their potential for use in the pain population in various settings, past clinical observations and suggestions for moving forward.

Our understanding of the sexual pain disorders vaginismus and dyspareunia has been fundamentally altered over the past two decades due to increased attention and empirically sound research in this domain. This increased knowledge base has included a shift from a dualistic view of the etiology of painful and/or difficult vaginal penetration being due to either psychological or physiological causes, to a multifactorial perspective. The present chapter reviews current classification and prevalence rates, including ongoing definitional debates. Research regarding the etiology, assessment and management of sexual pain disorders is discussed from a biopsychosocial perspective. Cyclical theories of the development and maintenance of sexual pain disorders, which highlight the complex interplay among physiological, psychological and social factors, are described. Medical/surgical treatment options, pelvic floor rehabilitation and psychological approaches are reviewed, as well as future directions in treatment research.

Research has shown men and women of all ages and sexual orientations to use the Internet for sexual purposes. For example, the Internet is used to access pornography, to find sex-related information, to purchase sexual merchandise, and to find partners for romance and sex. The specific characteristics of the medium have made it attractive for engaging in sexual behaviors that are regulated by societal and cultural norms offline. Thus, the Internet has made it easier to explore and express one's sexuality at less risk of negative personal sanctions. In this regard, the technological innovation has meant a sexual revolution, particularly for disenfranchised groups. While generally being perceived as positive, concerns have been raised about potential risks associated with the Internet. The purpose of this chapter is to provide the reader with an empirical and theoretical overview of the first 15 years of research in the field of Internet sexuality.

Autogynephilia is defined as a male's propensity to be sexually aroused by the thought of himself as a female. It is the paraphilia that is theorized to underlie transvestism and some forms of male-to-female (MtF) transsexualism. Autogynephilia encompasses sexual arousal with cross-dressing and cross-gender expression that does not involve women's clothing per se. The concept of autogynephilia defines a typology of MtF transsexualism and offers a theory of motivation for one type of MtF transsexualism. Autogynephilia resembles a sexual orientation in that it involves elements of idealization and attachment as well as erotic desire. Nearly 3% of men in Western countries may experience autogynephilia; its most severe manifestation, MtF transsexualism, is rare but increasing in prevalence. Some theorists and clinicians reject the transsexual typology and theory of motivation derived from autogynephilia; their objections suggest a need for additional research. The concept of autogynephilia can assist clinicians in understanding some otherwise puzzling manifestations of nonhomosexual MtF transsexualism. Autogynephilia exemplifies an unusual paraphilic category called 'erotic target identity inversions', in which men desire to impersonate or turn their bodies into facsimiles of the persons or things to which they are sexually attracted.

Addictive drugs have in common that they are voluntarily self-administered by laboratory animals (usually avidly), and that they enhance the functioning of the reward circuitry of the brain (producing the 'high' that the drug user seeks). The core reward circuitry consists of an 'in-series' circuit linking the ventral tegmental area, nucleus accumbens and ventral pallidum via the medial forebrain bundle. Although originally believed to simply encode the set point of hedonic tone, these circuits are now believed to be functionally far more complex, also encoding attention, expectancy of reward, disconfirmation of reward expectancy, and incentive motivation. 'Hedonic dysregulation' within these circuits may lead to addiction. The 'second-stage' dopaminergic component in this reward circuitry is the crucial addictive-drug-sensitive component. All addictive drugs have in common that they enhance (directly or indirectly or even transsynaptically) dop-aminergic reward synaptic function in the nucleus accumbens. Drug self-administration is regulated by nucleus accumbens dopamine levels, and is done to keep nucleus accumbens dopamine within a specific elevated range (to maintain a desired hedonic level). For some classes of addictive drugs (e.g. opiates), tolerance to the euphoric effects develops with chronic use. Postuse dysphoria then comes to dominate reward circuit hedonic tone, and addicts no longer use drugs to get high, but simply to get back to normal ('get straight'). The brain circuits mediating the pleasurable effects of addictive drugs are anatomically, neurophysiologically and neurochemically different from those mediating physical dependence, and from those mediating craving and relapse. There are important genetic variations in vulnerability to drug addiction, yet environmental factors such as stress and social defeat also alter brain-reward mechanisms in such a manner as to impart vulnerability to addiction. In short, the 'bio-psycho-social' model of etiology holds very well for addiction. Addiction appears to correlate with a hypodopaminergic dysfunctional state within the reward circuitry of the brain. Neuroimaging studies in humans add credence to this hypothesis. Credible evidence also implicates serotonergic, opioid, endocannabinoid, GABAergic and glutamatergic mechanisms in addiction. Critically, drug addiction progresses from occasional recreational use to impulsive use to habitual compulsive use. This correlates with a progression from reward-driven to habit-driven drug-seeking behavior. This behavioral progression correlates with a neuroanatomical progression from ventral striatal (nucleus accumbens) to dorsal striatal control over drug-seeking behavior. The three classical sets of craving and relapse triggers are (a) reexposure to addictive drugs, (b) stress, and (c) reexposure to environmental cues (people, places, things) previously associated with drug-taking behavior. Drug-triggered relapse involves the nucleus accumb

Almost any diagnosis of cancer, but particularly those primarily affecting areas related to sexual function, can lead to sexual impairment. Multiple phases of sexuality are impacted, and various dysfunctions result. Both biological and psychosocial mechanisms are involved in sexual difficulties after cancer. This chapter principally focuses on the detrimental effects of breast, cervical, vulvar, ovarian, prostate and testicular cancer on the sexual health of survivors. When applicable, pharmacologic and psychosocial treatment for sexual dysfunction is discussed.