Nancy C. Raymond

Psychiatric comorbidity and compulsive/impulsive traits in compulsive sexual behavior.

In recent years there has been an increase in identifying and treating a clinical syndrome that has been given many different names, including compulsive sexual behavior (CSB). The purpose of this study was to determine the prevalence of psychiatric disorders in a sample of individuals with CSB, as evaluated by a structured psychiatric interview. A secondary focus of this research was to determine if individuals with CSB exhibit obsessive-compulsive characteristics or exhibit impulse control problems. Participants were 23 men and two women who responded to newspaper advertisements and met criteria for CSB according to diagnostic criteria established and assessed by expert clinicians. The Structured Clinical Interview for DSM-III, patient version (SCID-P) and the Structured Clinical Interview for Axis II Disorders (SCID-II) were used to interview all participants. To study compulsive or impulsive traits the authors developed a semistructured interview. Standardized rating scales were also administered. Eighty-eight percent of the sample met diagnostic criteria for an axis I disorder at the time of the interview, and 100% of the sample met criteria for an axis I disorder at some time in their lives. The most common diagnoses were mood and anxiety disorders. The sample exhibited more traits of impulsivity than compulsivity. The data are consistent with the suggestion proposed by others that argues for conceptualizing these disorders as impulsive/compulsive spectrum disorders. Attention must be given to addressing these traits, as well as to the treatment of other axis I and axis II disorders, when treating CSB.

Psychopathology in subgroups of obese women with and without binge eating disorder

The examination of psychopathology in subgroups of obese patients is a new area of research in psychiatry. This project studied rates and types of psychopathology among obese subjects meeting the proposed DSM-IV criteria of binge eating disorder (BED) and obese subjects without BED. One hundred obese women with a mean age of 39.2 years and a mean body mass index (BMI) of 35.9 kg/m2 were evaluated using the Structured Clinical Interview for DSM-III-R (SCID-Modified Version) and a self-rating personality inventory, Personality Diagnostic Questionnaire-Revised (PDQ-R), before entering a treatment study for weight reduction. Those subjects meeting proposed DSM-IV criteria for BED had significantly higher lifetime rates for an axis I diagnosis compared with those that did not meet criteria for BED. Subjects with BED showed higher rates of lifetime affective disorder and bulimia nervosa, but did not differ on any other axis I diagnoses. Axis II cluster B and cluster C diagnoses were found more frequently among BED subjects. The specific diagnoses of histrionic, borderline, and avoidant personality disorders were found significantly more often among BED subjects. The results support the idea that binge eating may identify a distinct subgroup among the obese population who have significantly higher rates of certain forms of psychopathology on both Axis I and Axis II. The findings of increased rates of depression are consistent with other studies and suggest that our treatment modalities need to address this problem.

Compulsive Sexual Behavior Inventory: A Preliminary Study of Reliability and Validity

This preliminary study was designed to develop empirically a scale of compulsive sexual behavior (CSB) and to test its reliability and validity in a sample of individuals with nonparaphilic CSB ( N = 15), in a sample of pedophiles ( N = 35) in treatment for sexual offending, and in a sample of normal controls ( N = 42). Following a factor analysis and a varimax rotation, those items with factor loadings on the rotated factors of greater than .60 were retained. Three factors were identified, which appeared to measure control, abuse, and violence. Cronbachs alphas indicated that the subscales have good reliability. The 28-item scale was then tested for validity by a linear discriminant function analysis. The scale successfully discriminated the nonparaphilic CSB sample and the pedophiles from controls. Further analysis indicated that this scale is a valid measure of CSB in that there were significant differences between the three groups on the control subscale. Pedophiles scored significantly lower than the other two groups on the abuse subscale, with the other two groups not scoring significantly differently from one another. This indicated that pedophiles were more abusive than the nonparaphilic CSB individuals or the controls. Pedophiles scored significantly lower than controls on the violence subscale. Nonparaphilic individuals with compulsive sexual behavior scored slightly lower on the violence subscale, although not significantly different. As a preliminary study, there are several limitations to this study, which should be addressed, in further studies with larger sample sizes.This preliminary study was designed to develop empirically a scale of compulsive sexual behavior (CSB) and to test its reliability and validity in a sample of individuals with nonparaphilic CSB (N = 15), in a sample of pedophiles (N = 35) in treatment for sexual offending, and in a sample of normal controls (N = 42). Following a factor analysis and a varimax rotation, those items with factor loadings on the rotated factors of greater than .60 were retained. Three factors were identified, which appeared to measure control, abuse, and violence. Cronbachs alphas indicated that the subscales have good reliability. The 28-item scale was then tested for validity by a linear discriminant function analysis. The scale successfully discriminated the nonparaphilic CSB sample and the pedophiles from controls. Further analysis indicated that this scale is a valid measure of CSB in that there were significant differences between the three groups on the control subscale. Pedophiles scored significantly lower than the other two groups on the abuse subscale, with the other two groups not scoring significantly differently from one another. This indicated that pedophiles were more abusive than the nonparaphilic CSB individuals or the controls. Pedophiles scored significantly lower than controls on the violence subscale. Nonparaphilic individuals with compulsive sexual behavior scored slightly lower on the violence subscale, although not significantly different. As a preliminary study, there are several limitations to this study, which should be addressed, in further studies with larger sample sizes.

Preliminary investigation of the impulsive and neuroanatomical characteristics of compulsive sexual behavior

In recent years, there has been increased interest in a clinical syndrome characterized by excessive sexual thoughts, sexual urges, and/or sexual behaviors that has many aspects in common with impulse control disorders. This study provides a preliminary examination of the impulsive aspects of this syndrome, compulsive sexual behavior (CSB). Sixteen male subjects, eight CSB patients and eight non-patient controls, completed psychometric measures of impulsivity and compulsive sexual behavior, performed a behavioral task designed to assess impulse control (Go-No Go task), and underwent diffusion tensor imaging (DTI) procedures. The results indicated that CSB patients were significantly more impulsive; whether measured by psychometric testing or the Go-No Go procedure, than controls. The results also indicate that CSB patients showed significantly higher superior frontal region mean diffusivity (MD) than controls. A correlational analysis indicated significant associations between impulsivity measures and inferior frontal region fractional anisotropy (FA) and MD, but no associations with superior frontal region measures. Similar analyses indicated a significant negative association between superior frontal lobe MD and the Compulsive Sexual Behavior Inventory. Thus, while CSB patients were more impulsive than controls, the DTI results were not consistent with impulse control disorders.

Onset of binge eating and dieting in overweight women: implications for etiology, associated features and treatment

This study investigated differences between overweight binge eating women who reported the onset of binge eating prior to or following the onset of dieting (binged first [BF], or dieted first [DF]). Of overweight binge eating subjects enrolled in a treatment study, 38.7% indicated binge eating first, and 48.1% dieting first. The mean age of onset of binge eating differed significantly between the two groups (11.8 years vs. 25.7 years). More of the BF group (82.5%) satisfied proposed binge eating disorder (BED) criteria than did the DF group (52.0%), although short of significantly. The results suggest that: (a) the leading hypothesis concerning dieting as a cause of binge eating does not apply to a substantial number of individuals who binge eat; (b) there may be an early pattern and a late pattern in the development of binge eating among overweight individuals; and (c) the early or binge first pattern may be more likely to result in BED.

Treatment of compulsive sexual behaviour with naltrexone and serotonin reuptake inhibitors: two case studies.

Although there is no universally accepted definition of compulsive sexual behaviour (CSB), the term is generally used to indicate excessive sexual behaviour or sexual cognitions that lead to subjective distress, social or occupational impairment, or legal and financial consequences. Similar to impulse control disorders, CSB is characterized by a failure to resist the impulse for sex. Opioid antagonists have been effective in treating urge-driven disorders, such as pathological gambling disorder, alcoholism, borderline personality disorder with self-injurious behaviour, cocaine abuse, mental retardation with self-injurious behaviour and eating disorders. Based upon the efficacy of opioid antagonists in treating disorders associated with urges, we hypothesized that naltrexone would reduce both the urges associated with CSB and therefore reduce the sexual behaviour. We present two case reports of individuals with CSB treated successfully with naltrexone, a novel treatment for CSB. In both cases, symptoms dramatically decreased and psychosocial functioning improved with the use of naltrexone. Although more research is needed to determine the mechanism that leads to the excessive sexual behaviour in individuals with CSB, the present case reports suggest that naltrexone may be effective in treating some cases of CSB.

An age-matched comparison of subjects with binge eating disorder and bulimia nervosa

The purpose of this study was to compare data from a group of obese subjects with binge eating disorder (BED) with data from a group of normal weight bulimia nervosa (BN) subjects. Subjects were compared using the Eating Disorder Questionnaire (EDQ), the Eating Disorder Inventory (EDI), the Personality Disorders Questionnaire for DSM-III-R (PDQ-R), the Hamilton Anxiety and Depression Rating Scales, and the Beck Depression Inventory. A group of 35 age-matched subjects were selected retrospectively from treatment study subjects. The EDQ findings indicated that members of the BN group desired a lower body mass index, were more afraid of becoming fat, and more uncomfortable with their binge eating behavior than the BED group members. The BED subjects had a younger age of onset of binge eating behavior (14.3) than the BN subjects (19.8), even though both groups started dieting at a similar age (BED = 15.0, BN = 16.2). The EDI results showed BN subjects had more eating and weight-related pathology, with significantly higher scores on five of the eight subscales. On the PDQ-R more BN subjects endorsed Axis II impairment (BN = 69%, BED = 40%). While demonstrating greater eating pathology in the BN group, this study also found significant pathology and distress in BED subjects.

Cytokine production in patients with anorexia nervosa, bulimia nervosa, and obesity.

OBJECTIVE We previously reported elevated serum levels of the cytokines interleukin-6 (IL-6) and transforming growth factor-beta (TGF-beta) in patients with anorexia nervosa (AN). We investigated the cellular production of these two cytokines and of interferon-gamma (IFN-gamma), interleukin-1alpha (IL-1alpha), and tumor necrosis factor-alpha (TNF-alpha) in subjects with AN, bulimia nervosa (BN), and obesity as well as in normal-weight control subjects. METHODS Supernatant fluids from isolated peripheral blood mononuclear cells (PBMC) incubated with and without concanavalin A (ConA) were assayed for cytokine concentrations by enzyme-linked immunosorbent assay (ELISA). RESULTS Significant differences across the four groups were found in the stimulated cellular production of IFN-gamma and IL-6. Stimulated IFN-gamma production was elevated in the AN group compared to controls. IL-6 production was significantly elevated in obese subjects relative to the two normal-weight groups, BN and controls, and tended to be higher in the AN group than in the controls, but not significantly so. IL-1alpha production was greater in obese subjects. CONCLUSION The findings of increased IFN-gamma production and a tendency toward increased IL-6 production (both of which suppress food intake in animals) in individuals who severely restrict food intake suggest a potential role for these cytokines in the pathogenesis of AN. Elevated IL-6 and IL-1alpha production by PBMC in obese individuals requires further investigation to determine if these cytokines contribute to the development or perpetuation of obesity.

Nociceptive, but not tactile, thresholds are elevated in bulimia nervosa

A reduction in the satiating properties of food has been postulated to be a factor responsible for the prolonged eating episodes its bulimia nerrosa (e.g., Pyle et al 1981; Geracioti and Liddle 1988; Smith 1989). With remarkably few exceptions, satiety-related information is relayed to the central nervous system via the vagus nerve (Giduck et al 1987; Kim et al 1989; Robinson et al 1988). Therefore, abnormalities in vagal function may possibly underlie the absence of the nomtal satiety response present in bulimia nervosa. Recent findings suggest that the vagus may serve as a common substrate in the peripheral control of both satiety and anti-nociception. Electrical stimulation of the vagus, including subdiaphragmatic branches, inhibits ~esponsivity to a noxious somatosensory stimulus (e.g., Pen et al 1088) and vagotomy reduces the analgesic response to peripherally administered opiates in the rat (Randich and Maixner 1984; Aicher and Randich 1988; Steinman et al 1986). Thus, we hypothesized that if bulimia nervosa

Binge eating disorder: Clinical features and treatment of a new diagnosis

&NA; This review will describe the diagnostic criteria for the recently proposed diagnosis of binge eating disorder and provide an overview of its prevalence, clinical characteristics, and treatment approaches. Studies indicate that binge eaters represent a substantial proportion (18‐46%) of the obese in weight control programs. Normal‐weight patients with bulimia nervosa, obese binge eaters, and obese nonbinge eaters appear to represent three distinct populations, with obese nonbinge eaters showing the least psychological disturbance and patients with bulimia nervosa exhibiting the most. Preliminary findings indicate that obese binge eaters may be more likely than nonbinge eaters to drop out of treatment when treated by conventional weight loss programs, although weight losses achieved by binge eaters and nonbinge eaters who finish treatment do not differ significantly. Treatment programs that focus on the disturbed eating behavior appear to be effective to some degree in reducing binge eating frequency and related pathology, but patients tend to relapse after completion of treatment. Operationalized criteria such as the proposed DSM‐IV criteria for binge eating disorder could facilitate coordinated research on binge eaters who do not meet criteria for bulimia nervosa.