Advances in Psychosomatic Medicine最新文献

The field of sexual trauma is one of the most controversial and value-laden in mental health. The three factors which most affect adult sexual desire and function are the type of sexual trauma, how the sexual incidents were dealt with at the time and, most important, whether the person views her/himself as a survivor or victim. The assessment and treatment program described focuses on couple sex therapy with a special focus on processing the sexual trauma, honoring the person's veto and being 'partners in healing'. The core therapeutic theme is valuing intimate, erotic sexuality, which reinforces being a proud survivor rather than a shameful, anxious or angry victim. It is crucial to create a relapse prevention program to ensure that the person with the sexual trauma history continues to experience the positive roles of adult couple sexuality.

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

Gonadotropin-releasing hormone agonists are underutilized in patients seeking diminution of problematic sexual drives. This chapter reviews the literature on surgical castration of sex offenders, anti-androgen use and the rationale for providing androgen deprivation therapy, rather than selective serotonin reuptake inhibitors or more conservative interventions, for patients with paraphilias and excessive sexual drive. Discussions of informed consent, side effects, contraindications and case examples are provided.

The influences of culture are present in different areas of human health, as is the case with reproductive behaviors. To have a child means to have made a responsible decision. If conception takes longer to happen, these patients require the help of doctors to stimulate the refractory body. In light of data suggesting that psychosexual symptoms may interfere with fertility, successful infertility treatment and the ability to tolerate ongoing treatment rely on paying attention to these symptoms. Infertility is not only a fault of nature, but it is also something that does not respect the established order, a fact that casts doubt on the truth of the femininity and masculinity representations prevailing in a culture. Infertility is always a disease of the couple, and it is the couple that must be treated. The same is true when it comes to addressing sexual dysfunction. The dominant values and cultural practices indelibly affect the sexuality of infertile couples. In order to be credible, humanization of the treatment protocols for infertile couples must take into account the problems of intimacy as well as the sexual health of these couples.

Patients with both chronic pain and substance use disorders offer special challenges and opportunities. They represent a large number of patients with significant costs to themselves and society that translate into poor outcome. The challenges in defining addiction in patients with chronic pain, particularly in those treated with chronic opioid therapy, have distracted the healthcare community from designing effective treatment programs. Traditional treatment programs for chronic pain disorders or substance use disorders are incapable of addressing the issues of the patients' 'other' problem. Treatment devolves to prescribing opioid medications with the belief that both disorders will be treated at least in part, which is deemed better than receiving no treatment at all. Patients are actually concerned about the risks of this type of treatment, and even if it did offer significant benefits, physicians demonstrate a lack of knowledge and skill in administering opioids to these patients. The inadequate treatment of either chronic pain or addiction interferes with the treatment of the other condition and necessitates the design of new treatment paradigms. A new approach to patients with both chronic pain and addiction should start with an evaluation and formulation of these patients to determine the different domains that contribute to their disability (diseases, dimensions, behaviors, life stories). A comprehensive formulation provides the appropriate platform for the implementation of an integrated program of therapy for both conditions that can be intensified to provide more, rather than less, care for the patient that does not meet the goals of functional rehabilitation.

Cannabinoids have been used for thousands of years to provide relief from suffering, but only recently have they been critically evaluated in clinical trials. This review provides an in-depth examination of the evidence supporting cannabinoids in various pain states, along with an overview of potential adverse effects. In summary, there is strong evidence for a moderate analgesic effect in peripheral neuropathic and central pain conditions, and conflicting evidence for their use in nociceptive pain. For spasticity, most controlled studies demonstrate significant improvement. Adverse effects are not uncommon with cannabinoids, though most are not serious and self-limiting. In view of the limited effect size and low but not inconsequential risk of serious adverse events, cannabinoids should be employed as analgesics only when safer and more effective medication trials have failed, or as part of a multimodal treatment regimen.

Evaluations of the nature of an individual's sexual functioning are done with relative frequency in today's clinical healthcare environment, often prompted by sequelae of a medical disorder (e.g. diabetes, breast cancer), surgical procedure (e.g. bilateral oophorectomy), or prescribed medications (SSRI antidepressant, antihypertensive). In addition, an increasingly large number of evaluations of sexual functioning are done in association with clinical trials research in the rapidly emerging field of sexual medicine. Although clinical and research assessments of sexual functioning share many similarities, they can also be quite different, with distinct perspectives and goals regarding the assessment process. Research evaluations tend to be narrowly focused on an index condition, with highly defined patient characteristics, and long lists of inclusion/exclusion criteria. Treatment regimens are defined by research protocol a priori, and assigned through randomization, with few options for alternatives. The process results in a rigorously defined sample of patients, but one that may be hard to generalize from to real world clinical reality. Clinical sexual evaluations, on the other hand, tend to arise in a much broader health context. There are no exclusionary patient characteristics; medical, psychological, and relationship complexities all form the context in which the patient's sexual functioning occurs, and must be factored in to the clinical evaluation and treatment recommendations. Regardless of which context gives rise to the evaluation, there are three basic sources of data that we draw from: psychometric assessment, clinical interview and laboratory assays. The clinician doing a sexual evaluation must assimilate and integrate the data from these three sources in an iterative process and arrive at a cogent diagnosis and treatment plan.

Premature ejaculation (PE) is distinguished as a 'complaint' versus a 'syndrome'. Complaints of PE in men with normal ejaculation time durations are highly prevalent among the general male population. However, PE syndromes characterized by a rigid pattern of very short ejaculation times have a much lower prevalence. A major insufficiency of the DSM-IV-TR definition of PE is the absence of a cut-off point of its short ejaculation time criterion. Recently, a new classification of PE has been proposed for the pending DSM-V. It has been proposed to distinguish four PE categories; lifelong PE, acquired PE, natural variable PE and premature-like ejaculatory dysfunction. The syndromes differ in ejaculation time duration, frequency and pattern of PE complaints, and its course in life. The difference in underlying pathophysiology and etiology of the different syndromes determines the first choice of treatment. Lifelong PE need to be treated by medication, acquired PE by treatment of its medical cause, medication or psychotherapy. Psychoeducation and reassurance is indicated for men with natural variable PE. Finally, psychotherapy and/or counselling is the first choice of treatment of men with premature-like ejaculatory dysfunction.

Epidemiological studies have found that problems with sexual desire are one of the most common sexual complaints in females. Such complaints are far less common in males. In women, problems with sexual desire have been found to be associated with age, relationship duration, relationship distress, and complaints of anxiety and depression. Evidence-based interventions include cognitive behavioral therapy and androgen therapy. Endocrinopathies are common causes of male problems with libido. There is minimal evidence available concerning the treatment of psychological etiologies of low sexual desire in men.

The use of mind-altering substances can be found in very different cultures and traced back thousands of years; the same is true for the searching of drugs that could increase sexual functioning. In this text, we explore the relation between drugs of abuse and sexuality in three domains: drugs and sexual dysfunctions, drugs and risky sexual behavior and drugs used as sexual aids. Although some drugs can increase sexual response in the early stages of the addiction career, particularly in those with a previous sexual dysfunction, the chronic use of substances tends to deteriorate all stages of sexual response in both male and female abusers. There is sufficient evidence for considering that drug use before or during sexual intercourse can, in certain circumstances, elevate the risk of unwanted pregnancy or sexually transmitted diseases. Specific prevention strategies should be addressed to this population. Some psychotropic drugs are sometimes used as sexual aids. This can have some risks and should alert the therapist to a possible underlying and undiagnosed sexual problem.