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Mestre-Bach G, Potenza MN. Current Understanding of Compulsive Sexual Behavior Disorder and Co-occurring Conditions: What Clinicians Should Know about Pharmacological Options. CNS Drugs 2024; 38:255-265. [PMID: 38485889 DOI: 10.1007/s40263-024-01075-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/15/2024] [Indexed: 04/02/2024]
Abstract
Compulsive sexual behavior disorder (CSBD) has recently been recognized as a psychiatric disorder. Pharmacological treatments for CSBD have received little study and thus have limited empirical support. The main objective of the present work is to review existing literature on the efficacy of different drugs on the symptomatology of CSBD, including the subtype of problematic pornography use (PPU). The main pharmacological approaches to treating CSBD have included opioid antagonists (naltrexone and nalmefene), selective serotonin reuptake inhibitors (paroxetine, citalopram, fluoxetine, and sertraline), mood stabilizers (topiramate), tricyclic antidepressants (clomipramine), serotonin antagonist and reuptake inhibitors (nefazodone), and N-acetylcysteine. Since people with CSBD may experience different co-occurring disorders, these should be considered when choosing the best pharmacological treatment. Pharmacological therapy for CSBD/PPU has been suggested as an adjunct to psychological therapies, which, for the moment, have the most empirical evidence. However, to evaluate the efficacy of most of the drugs presented in this narrative review, data to date have only been available from case studies. Thus, empirical support is scant and generalizability of results is limited, highlighting the need for more research in this area.
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Affiliation(s)
- Gemma Mestre-Bach
- Instituto de Investigación, Transferencia e Innovación, Universidad Internacional de La Rioja, La Rioja, Spain
| | - Marc N Potenza
- Department of Psychiatry, Yale University School of Medicine, One Church Street, Rm 726, New Haven, CT, 06510, USA.
- Connecticut Mental Health Center, New Haven, CT, USA.
- Connecticut Council on Problem Gambling, Wethersfield, CT, USA.
- Wu Tsai Institute, Yale University, New Haven, CT, USA.
- Yale Child Study Center, Yale University School of Medicine, New Haven, CT, USA.
- Department of Neuroscience, Yale University School of Medicine, New Haven, CT, USA.
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Pharmacological Treatments for Compulsive Sexual Behaviors Among Offending Individuals. CURRENT ADDICTION REPORTS 2022. [DOI: 10.1007/s40429-022-00460-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Turner D, Briken P, Grubbs J, Malandain L, Mestre-Bach G, Potenza MN, Thibaut F. The World Federation of Societies of Biological Psychiatry guidelines on the assessment and pharmacological treatment of compulsive sexual behaviour disorder. DIALOGUES IN CLINICAL NEUROSCIENCE 2022; 24:10-69. [PMID: 37522807 PMCID: PMC10408697 DOI: 10.1080/19585969.2022.2134739] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 09/18/2022] [Accepted: 10/03/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The current guidelines aim to evaluate the role of pharmacological agents in the treatment of patients with compulsive sexual behaviour disorder (CSBD). They are intended for use in clinical practice by clinicians who treat patients with CSBD. METHODS An extensive literature search was conducted using the English-language-literature indexed on PubMed and Google Scholar without time limit, supplemented by other sources, including published reviews. RESULTS Each treatment recommendation was evaluated with respect to the strength of evidence for its efficacy, safety, tolerability, and feasibility. Psychoeducation and psychotherapy are first-choice treatments and should always be conducted. The type of medication recommended depended mainly on the intensity of CSBD and comorbid sexual and psychiatric disorders. There are few randomised controlled trials. Although no medications carry formal indications for CSBD, selective-serotonin-reuptake-inhibitors and naltrexone currently constitute the most relevant pharmacological treatments for the treatment of CSBD. In cases of CSBD with comorbid paraphilic disorders, hormonal agents may be indicated, and one should refer to previously published guidelines on the treatment of adults with paraphilic disorders. Specific recommendations are also proposed in case of chemsex behaviour associated with CSBD. CONCLUSIONS An algorithm is proposed with different levels of treatment for different categories of patients with CSBD.
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Affiliation(s)
- Daniel Turner
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany
| | - Peer Briken
- Institute for Sex Research, Sexual Medicine, and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Joshua Grubbs
- Department of Psychology, Bowling Green State University, Bowling Green, OH, USA
| | - Leo Malandain
- Department of Psychiatry and Addictive Disorders, University Hospital Cochin (site Tarnier) AP-HP, Paris, France
| | - Gemma Mestre-Bach
- Facultad de Ciencias de la Salud, Universidad Internacional de La Rioja, La Rioja, Spain
| | - Marc N. Potenza
- Departments of Psychiatry and Neuroscience and Child Study Center, Yale School of Medicine, New Haven, CT, USA
- Connecticut Mental Health Center, New Haven, CT, USA
- Connecticut Council on Problem Gambling, Wethersfield, CT, USA
- Wu Tsai Institute, Yale University, New Haven, CT, USA
| | - Florence Thibaut
- Department of Psychiatry and Addictive Disorders, University Hospital Cochin (site Tarnier) AP-HP, Paris, France
- INSERM U1266, Institute of Psychiatry and Neurosciences, University of Paris Cité, Paris, France
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Savard J, Görts Öberg K, Dhejne C, Jokinen J. A randomised controlled trial of fluoxetine versus naltrexone in compulsive sexual behaviour disorder: presentation of the study protocol. BMJ Open 2022; 12:e051756. [PMID: 36691245 PMCID: PMC9171192 DOI: 10.1136/bmjopen-2021-051756] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 05/19/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Compulsive sexual behaviour disorder is a new disorder in the International Classification of Diseases (ICD-11), and is associated with negative consequences in different areas of life. Evidence for pharmacological treatment of compulsive sexual behaviour disorder is weak and treatment options are limited. This proposed study will be the largest and the first randomised controlled trial comparing the efficacy and tolerability of two active drugs in compulsive sexual behaviour disorder. METHODS AND ANALYSIS Eighty adult participants with compulsive sexual behaviour disorder according to ICD-11 will be randomised to receive either naltrexone 25-50 mg or fluoxetine 20-40 mg for 8 weeks, followed by 6 weeks without treatment. The study will be conducted in a subspecialised outpatient sexual medicine unit at Karolinska University Hospital, Stockholm, Sweden. The study is financed by grants and entirely independent of the manufacturers.Exclusion criteria include severe psychiatric or psychical illness, changes to concurrent medication and non-compatible factors contraindicating the use of either drug. The primary outcome measure is the Hypersexual Disorder: Current Assessment Scale (HD: CAS), and tolerability will be assessed by the Udvalg for Kliniske Undersogelser side effect rating scale (UKU), drug accountability, adherence to treatment and drop-out rate. Participants will complete questionnaires at regular intervals, with the main endpoint for efficacy after 8 weeks (end of treatment) and after 14 weeks (follow-up). Blood chemistry will be repeatedly collected as a safety precaution and for research purposes. The results will be analysed using an appropriate analysis of variance model or a mixed model, depending on the distribution of HD: CAS and the extent of missing data. ETHICS AND DISSEMINATION The Swedish Ethical Review Authority and the Swedish Medical Products Agency have approved the study on 27 May 2020 and 4 June 2020, respectively (ref. no. 2020-02069 and ref. no. 5.1-2020-48282). Findings will be published in peer-reviewed journals and presented at relevant conferences. TRIAL REGISTRATION NUMBER 2019-004255-36.
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Affiliation(s)
- Josephine Savard
- Department of Clinical Sciences/Psychiatry, Umea University, Umea, Sweden
- ANOVA clinic, Karolinska University Hospital, Stockholm, Sweden
| | - Katarina Görts Öberg
- ANOVA clinic, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Cecilia Dhejne
- ANOVA clinic, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Jussi Jokinen
- Department of Clinical Sciences/Psychiatry, Umea University, Umea, Sweden
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Sultana T, Sahib Din J. Compulsive Sexual Behavior and Alcohol Use Disorder Treated With Naltrexone: A Case Report and Literature Review. Cureus 2022; 14:e25804. [PMID: 35836443 PMCID: PMC9273192 DOI: 10.7759/cureus.25804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2022] [Indexed: 11/09/2022] Open
Abstract
Compulsive sexual behavior (CSB) or sexual addiction is a term that generally indicates excessive and uncontrolled sexual behavior. This may lead to subjective distress, social and occupational impairment, or legal and financial consequences. Often, this condition is underreported and untreated. Until now there are no FDA-approved medications for sexual addiction or compulsive sexual behaviors. However, the therapeutic benefits of selective serotonin reuptake inhibitors (SSRIs) and naltrexone are known. This is a case of a 53-year-old male with a history of extensive alcohol use, alcohol withdrawal seizure, and delirium tremens. The patient was treated with naltrexone 50 mg/day for alcohol use disorder. The patient reported that his “sexual compulsion” also reduced after the medication and there was an improvement in both alcohol addiction and self-reported compulsive sexual behavior. This case report also includes a literature review of pharmacotherapy, especially naltrexone, for the treatment of sexual addiction/compulsive sexual behavior. The literature review has shown that patients’ symptoms were improved in different doses without side effects, and based on this and our experience, it can be said that naltrexone is effective in the reduction and remission of the symptoms of CSB or sexual addiction.
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Affiliation(s)
- Tania Sultana
- Psychopharmacology Research Program, The Manhattan Psychiatric Center, New York City, USA
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Stancil SL, Abdel-Rahman S, Wagner J. Developmental Considerations for the Use of Naltrexone in Children and Adolescents. J Pediatr Pharmacol Ther 2021; 26:675-695. [PMID: 34588931 DOI: 10.5863/1551-6776-26.7.675] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/27/2021] [Indexed: 11/11/2022]
Abstract
Naltrexone (NTX) is a well-tolerated drug with a wide safety margin and mechanism of action that affords use across a wide variety of indications in adults and children. By antagonizing the opioid reward system, NTX can modulate behaviors that involve compulsivity or impulsivity, such as substance use, obesity, and eating disorders. Evidence regarding the disposition and efficacy of NTX is mainly derived from adult studies of substance use disorders and considerable variability exists. Developmental changes, plausible disease-specific alterations and genetic polymorphisms in NTX disposition, and pharmacodynamic pathways should be taken into consideration when optimizing the use of NTX in the pediatric population. This review highlights the current state of the evidence and gaps in knowledge regarding NTX to facilitate evidence-based pharmacotherapy of mental health conditions, for which few pharmacologic options exist.
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Use of Anticraving Agents in the Treatment of Exhibitionism and Frotteuristic Disorder. J Clin Psychopharmacol 2021; 41:611-612. [PMID: 34519457 DOI: 10.1097/jcp.0000000000001441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Naltrexone in Compulsive Sexual Behavior Disorder: A Feasibility Study of Twenty Men. J Sex Med 2020; 17:1544-1552. [DOI: 10.1016/j.jsxm.2020.04.318] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 04/13/2020] [Accepted: 04/14/2020] [Indexed: 11/18/2022]
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Thibaut F, Cosyns P, Fedoroff JP, Briken P, Goethals K, Bradford JMW. The World Federation of Societies of Biological Psychiatry (WFSBP) 2020 guidelines for the pharmacological treatment of paraphilic disorders. World J Biol Psychiatry 2020; 21:412-490. [PMID: 32452729 DOI: 10.1080/15622975.2020.1744723] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Objectives: The primary aim of these guidelines is to evaluate the role of pharmacological agents in the treatment and management of patients with paraphilic disorders, with a focus on the treatment of adult males. Because such treatments are not delivered in isolation, the role of specific psychotherapeutic interventions is also briefly covered. These guidelines are intended for use in clinical practice by clinicians who diagnose and treat patients, including sexual offenders, with paraphilic disorders. The aim of these guidelines is to bring together different views on the appropriate treatment of paraphilic disorders from experts representing different countries in order to aid physicians in clinical decisions and to improve the quality of care.Methods: An extensive literature search was conducted using the English-language-literature indexed on MEDLINE/PubMed (1990-2018 for SSRIs) (1969-2018 for hormonal treatments), supplemented by other sources, including published reviews.Results: Each treatment recommendation was evaluated and discussed with respect to the strength of evidence for its efficacy, safety, tolerability, and feasibility. The type of medication used depends on the severity of the paraphilic disorder and the respective risk of behaviour endangering others. GnRH analogue treatment constitutes the most relevant treatment for patients with severe paraphilic disorders.Conclusions: An algorithm is proposed with different levels of treatment for different categories of paraphilic disorders accompanied by different risk levels.
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Affiliation(s)
- Florence Thibaut
- Department of Psychiatry and Addictive Disorders, University Hospital Cochin, University of Paris, INSERM U1266, Institute of Psychiatry and Neurosciences, Paris, France
| | - Paul Cosyns
- Collaborative Antwerp Psychiatric Research Institute (CAPRI), University of Antwerp, Antwerp, Belgium
| | - John Paul Fedoroff
- Division of Forensic Psychiatry, The Royal Institute of Mental Health Research, University of Ottawa, Ottawa, ON, Canada
| | - Peer Briken
- Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Kris Goethals
- Collaborative Antwerp Psychiatric Research Institute (CAPRI), University of Antwerp and University Forensic Centre, Antwerp University Hospital, Antwerp, Belgium
| | - John M W Bradford
- The Royal Institute of Mental Health Research, University of Ottawa, McMaster University, Ottawa & Hamilton, ON, Canada
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Abstract
PURPOSE OF REVIEW We reviewed recent data on sexual addiction and its treatment. We examined the different definitions of this disorder, related to the pathophysiological mechanisms. We addressed the pharmacological treatment of sexual addiction. RECENT FINDINGS Hypersexual behavior can be considered an addictive disorder. Sexual addiction is accompanied by significant psychiatric and addictive comorbidities and is responsible for life impairment. A comprehensive and efficient treatment must be proposed. Selective serotonin reuptake inhibitors seem the first-line pharmacological treatment for sexual addiction. Naltrexone could be another therapeutic option. Psychotherapy and preferentially cognitive-behavioral therapy should be used in association with pharmacotherapy and treatments of comorbidities.
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Affiliation(s)
- Leo Malandain
- Department of Adult Psychiatry and Medical Psychology, Saint-Antoine Hospital, Sorbonne Université, AP-HP, Paris, France.
| | - Jean-Victor Blanc
- Department of Adult Psychiatry and Medical Psychology, Saint-Antoine Hospital, Sorbonne Université, AP-HP, Paris, France
| | - Florian Ferreri
- Department of Adult Psychiatry and Medical Psychology, Saint-Antoine Hospital, Sorbonne Université, AP-HP, Paris, France
| | - Florence Thibaut
- University Hospital Cochin (site Tarnier), Paris University, AP-HP, Paris, France
- INSERM U1266, Institute of Psychiatry and Neurosciences, Paris, France
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Buchel C, Miedl S, Sprenger C. Hedonic processing in humans is mediated by an opioidergic mechanism in a mesocorticolimbic system. eLife 2018; 7:39648. [PMID: 30444488 PMCID: PMC6239433 DOI: 10.7554/elife.39648] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 10/17/2018] [Indexed: 01/01/2023] Open
Abstract
It has been hypothesized that the pleasure of a reward in humans is mediated by an opioidergic system involving the hypothalamus, nucleus accumbens and the amygdala. Importantly, enjoying the pleasure of a reward is distinct from incentive salience induced by cues predicting the reward. We investigated this issue using a within subject, pharmacological challenge design with the opioid receptor antagonist naloxone and fMRI. Our data show that blocking opioid receptors reduced pleasure associated with viewing erotic pictures more than viewing symbols of reward such as money. This was paralleled by a reduction of activation in the ventral striatum, lateral orbitofrontal cortex, amygdala, hypothalamus and medial prefrontal cortex. Crucially, the naloxone induced activation decrease was observed at reward delivery, but not during reward anticipation, indicating that blocking opioid receptors decreases the pleasure of rewards in humans. Editorial note: This article has been through an editorial process in which the authors decide how to respond to the issues raised during peer review. The Reviewing Editor's assessment is that all the issues have been addressed (see decision letter).
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Affiliation(s)
- Christian Buchel
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stephan Miedl
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Sprenger
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Coffin PO, Santos GM, Hern J, Vittinghoff E, Santos D, Matheson T, Colfax G, Batki SL. Extended-release naltrexone for methamphetamine dependence among men who have sex with men: a randomized placebo-controlled trial. Addiction 2018; 113:268-278. [PMID: 28734107 PMCID: PMC5760469 DOI: 10.1111/add.13950] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 04/04/2017] [Accepted: 07/18/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIMS Methamphetamine use is increasingly prevalent and associated with HIV transmission. Early-phase human studies suggested naltrexone reduced amphetamine use among dependent individuals. We tested if extended-release naltrexone (XRNTX) reduces methamphetamine use and associated sexual risk behaviors among high-risk methamphetamine-dependent men who have sex with men (MSM). DESIGN Double-blind, placebo-controlled, randomized trial of XRTNX versus placebo over 12 weeks from 2012 to 2015. SETTING San Francisco Department of Public Health, California, USA. PARTICIPANTS One hundred community-recruited, sexually-active, actively-using methamphetamine-dependent MSM. Mean age was 43.2 years; 96% were male, 3% transfemale, and 1% transmale; 55.0% were white, 19.0% African American, and 18.0% Latino. INTERVENTIONS XRNTX 380 mg (n = 50) or matched placebo (n = 50) administered by gluteal injection at 4-week intervals. MEASUREMENTS Regression estimated average level and change in level of positive urines during the period 2-12 weeks (primary outcomes) and sexual risk behaviors (secondary outcome). FINDINGS Ninety per cent of visits were completed. By intent-to-treat, participants assigned to XRNTX had similar differences during 2-12 weeks in methamphetamine-positive urines as participants assigned to placebo [incidence rate ratio (IRR) = 0.95, 95% confidence interval (CI) = 0.76-1.20; Bayes factor < 0.3]. Observed urine positivity declined from 78 to 70% in the XRNTX arm and 74 to 64% in the placebo arm. Adherence to injections was 96.7% in the XRNTX arm and 91.3% in the placebo arm. Sexual risk behaviors declined similarly among participants in both arms (all P > 0.05). There were no serious adverse events related to study drug and no differences in frequency of adverse events by treatment arm. CONCLUSIONS Notwithstanding very high medication adherence for this study, extended-release naltrexone does not appear to reduce methamphetamine use or sexual risk behaviors among methamphetamine-dependent men who have sex with men compared with placebo.
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Affiliation(s)
- Phillip O. Coffin
- San Francisco Department of Public Health, 25 Van Ness Avenue, Ste. 500, San Francisco CA 94102,University of California San Francisco, 500 Parnassus Ave, San Francisco CA 94143
| | - Glenn-Milo Santos
- San Francisco Department of Public Health, 25 Van Ness Avenue, Ste. 500, San Francisco CA 94102,University of California San Francisco, 500 Parnassus Ave, San Francisco CA 94143
| | - Jaclyn Hern
- San Francisco Department of Public Health, 25 Van Ness Avenue, Ste. 500, San Francisco CA 94102
| | - Eric Vittinghoff
- University of California San Francisco, 500 Parnassus Ave, San Francisco CA 94143
| | - Deirdre Santos
- San Francisco Department of Public Health, 25 Van Ness Avenue, Ste. 500, San Francisco CA 94102
| | - Tim Matheson
- San Francisco Department of Public Health, 25 Van Ness Avenue, Ste. 500, San Francisco CA 94102
| | - Grant Colfax
- Health and Human Services, Marin County, 20 North San Pedro Road, San Rafael, CA 94903
| | - Steven L. Batki
- University of California San Francisco, 500 Parnassus Ave, San Francisco CA 94143
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Should Sexual Offending Be Considered an Addiction? Implications for Prevention and Treatment Approaches. CURRENT ADDICTION REPORTS 2016. [DOI: 10.1007/s40429-016-0120-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Feasibility, Acceptability, and Tolerability of Targeted Naltrexone for Nondependent Methamphetamine-Using and Binge-Drinking Men Who Have Sex with Men. J Acquir Immune Defic Syndr 2016; 72:21-30. [PMID: 26674372 DOI: 10.1097/qai.0000000000000922] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND There are no effective pharmacologic strategies for nondependent methamphetamine (meth)-using and binge-drinking men who have sex with men (MSM) at high-risk for HIV. We sought to determine the feasibility of enrolling and retaining this population in a pharmacologic trial; the acceptability of pharmacotherapy study procedures; and the tolerability of targeted naltrexone versus placebo. METHODS Thirty meth-using and binge-drinking MSM were randomly assigned 1:1 to 50 mg naltrexone or placebo for 8 weeks for targeted administration (ie, during craving or in anticipation of meth or alcohol use). Substance use counseling and behavioral assessments were conducted every 2 weeks. Medication use was measured using WisePill dispensers. RESULTS Trial completion was 93%; visit completion rate was 95%. Mean weekly number of medication pills taken was 2.1 and was similar between arms. Participant satisfaction rate was 96%. There were neither serious adverse events nor differences in adverse event rates between arms. In exploratory intention-to-treat analyses, there were no differences in meth use and drinking. Naltrexone participants had greater reductions in serodiscordant receptive anal intercourse [incident rate ratio (IRR) = 0.15; 95% CI = 0.05 to 0.42] and serodiscordant condomless receptive anal intercourse (IRR = 0.11; 95% CI = 0.03 to 0.37), compared with placebo. In subgroup analyses among frequent meth users, naltrexone participants had greater reductions in meth-using days (IRR = 0.78; 95% CI = 0.62 to 0.99). In as-treated analyses, frequent study medication users in the naltrexone arm had greater reductions in binge drinking days (IRR = 0.72; 95% CI = 0.54 to 0.97). CONCLUSIONS Targeted naltrexone is a feasible, acceptable, and tolerable intervention strategy for nondependent meth-using and binge-drinking MSM. Naltrexone was associated with significant sexual risk reductions; and for some individuals, naltrexone was associated with meth and binge-drinking reductions.
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Piquet-Pessôa M, Fontenelle LF. Opioid antagonists in broadly defined behavioral addictions: a narrative review. Expert Opin Pharmacother 2016; 17:835-44. [PMID: 26798982 DOI: 10.1517/14656566.2016.1145660] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Naltrexone (NTX), a mu-opioid receptor antagonist, has been approved for the treatment of alcoholism and opioid dependence. More recently, however, NTX and a related drug, nalmefene (NMF), have also shown positive results for the treatment of gambling disorders. AREAS COVERED In this study, we reviewed the trials testing the effect of opioid antagonists (OA) in gambling disorders and in other broadly defined behavioral addictions, including selected DSM-5 disruptive, impulse-control, and conduct disorders, obsessive-compulsive and related disorders, eating disorders, and other conditions not currently recognized by official classification schemes. We found six randomized controlled trials (RCTs) of OA in gambling disorder, two RCTs of OA in trichotillomania (hair pulling disorder), two RCTs of OA in binge eating disorder, and one RCT of OA for kleptomania. We also reviewed case reports on hypersexual disorder, compulsive buying and skin picking disorders. EXPERT OPINION The reviewed data supported the use of OA, namely NTX and NMF, in gambling disorder (both) and kleptomania (NTX). We did not find enough evidence to support the use of NTX or NMF in trichotillomania (hair pulling disorder), excoriation (skin-picking) disorder, compulsive buying disorder, hypersexual disorder, or binge eating disorder.
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Affiliation(s)
- Marcelo Piquet-Pessôa
- a Obsessive, Compulsive, and Anxiety Spectrum Disorders Research Program, Institute of Psychiatry , Federal University of Rio de Janeiro (UFRJ) , Rio de Janeiro , Brasil
| | - Leonardo F Fontenelle
- a Obsessive, Compulsive, and Anxiety Spectrum Disorders Research Program, Institute of Psychiatry , Federal University of Rio de Janeiro (UFRJ) , Rio de Janeiro , Brasil.,b D'Or Institute for Research and Education (IDOR) , Rio de Janeiro , Brasil.,c Monash Institute of Cognitive and Clinical Neurosciences (MICCN), School of Psychological Sciences & Monash Biomedical Imaging (MBI) Facility , Monash University , Victoria , Australia
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Thibaut F, Bradford JMW, Briken P, De La Barra F, Häßler F, Cosyns P. The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the treatment of adolescent sexual offenders with paraphilic disorders. World J Biol Psychiatry 2015; 17:2-38. [PMID: 26595752 PMCID: PMC4743592 DOI: 10.3109/15622975.2015.1085598] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 08/18/2015] [Indexed: 01/12/2023]
Abstract
The primary aim of these guidelines was to evaluate the role of pharmacological agents in the treatment of adolescents with paraphilic disorders who are also sexual offenders or at-risk of sexual offending. Psychotherapeutic and psychosocial treatments were also reviewed. Adolescents with paraphilic disorders specifically present a different therapeutic challenge as compared to adults. In part, the challenge relates to adolescents being in various stages of puberty and development, which may limit the use of certain pharmacological agents due to their potential side effects. In addition, most of the published treatment programmes have used cognitive behavioural interventions, family therapies and psychoeducational interventions. Psychological treatment is predicated in adolescents on the notion that sexually deviant behaviour can be controlled by the offender, and that more adaptive behaviours can be learned. The main purposes of these guidelines are to improve the quality of care and to aid physicians in their clinical decisions. These guidelines brought together different expert views and involved an extensive literature research. Each treatment recommendation was evaluated and discussed with respect to the strength of evidence for efficacy, safety, tolerability and feasibility. An algorithm is proposed for the treatment of paraphilic disorders in adolescent sexual offenders or those who are at risk.
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Affiliation(s)
- Florence Thibaut
- University Hospital Cochin, Faculty of Medicine Paris Descartes, INSERM U 894 CPN,
Paris,
France
| | - John M. W. Bradford
- University of Ottawa, Institute of Mental Health Research, Division of Forensic Psychiatry, Queen’s University, Clinical Director, Forensic Treatment Unit, Brockville Mental Health Centre, Royal Ottawa Health Care Group,
Brockville,
Ontario,
Canada
| | - Peer Briken
- Institute for Sex Research and Forensic Psychiatry, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf,
Hamburg,
Germany
| | - Flora De La Barra
- East Psychiatry and Mental Health Department, University of Chile,
Clinica Las Condes,
Chile
| | - Frank Häßler
- Clinic for Child and Adolescent Psychiatry, University of Medicine of Rostock,
Rostock,
Germany
| | - Paul Cosyns
- University Forensic Centre (University Hospital of Antwerp),
Belgium
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19
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Bandelow B, Wedekind D. Possible role of a dysregulation of the endogenous opioid system in antisocial personality disorder. Hum Psychopharmacol 2015; 30:393-415. [PMID: 26250442 DOI: 10.1002/hup.2497] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 04/29/2015] [Accepted: 06/23/2015] [Indexed: 11/09/2022]
Abstract
Around half the inmates in prison institutions have antisocial personality disorder (ASPD). A recent theory has proposed that a dysfunction of the endogenous opioid system (EOS) underlies the neurobiology of borderline personality disorder (BPD). In the present theoretical paper, based on a comprehensive database and hand search of the relevant literature, this hypothesis is extended to ASPD, which may be the predominant expression of EOS dysfunction in men, while the same pathology underlies BPD in women. According to evidence from human and animal studies, the problematic behaviours of persons with antisocial, callous, or psychopathic traits may be seen as desperate, unconscious attempts to stimulate their deficient EOS, which plays a key role in brain reward circuits. If the needs of this system are not being met, the affected persons experience dysphoric mood, discomfort, or irritability, and strive to increase binding of endogenous opioids to receptors by using the rewarding effects of aggression by exertion of physical or manipulative power on others, by abusing alcohol or substances that have the reward system as target, by creating an "endorphin rush" by self-harm, by increasing the frequency of their sexual contacts, or by impulsive actions and sensation seeking. Symptoms associated with ASPD can be treated with opioid antagonists like naltrexone, naloxone, or nalmefene.
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Affiliation(s)
- Borwin Bandelow
- Department of Psychiatry and Psychotherapy, University of Göttingen, Germany
| | - Dirk Wedekind
- Department of Psychiatry and Psychotherapy, University of Göttingen, Germany
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20
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Firoz K, Nidheesh Sankar V, Rajmohan V, Manoj Kumar G, Raghuram TM. Treatment of fetishism with naltrexone: a case report. Asian J Psychiatr 2014; 8:67-8. [PMID: 24655631 DOI: 10.1016/j.ajp.2013.11.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Revised: 10/31/2013] [Accepted: 11/18/2013] [Indexed: 10/25/2022]
Abstract
Fetishism is a paraphilic sexual disorder characterized by recurrent, intense sexually arousing fantasies, sexual urges or behaviors involving the use of nonliving objects. We describe a case of fetishism with comorbid alcohol and cannabis dependence. A 40-year-old man was presented with sexual fantasies and urges toward women's undergarments since the age of 25 years. He had fetish behavior even during prolonged period of abstinence from substance use. Our case remitted from fetishism and cannabis and alcohol use on treatment with naltrexone and maintains remission for the last 11 months. Experience with our patient suggests that naltrexone may be effective to treat fetishism with comorbid substance use. Our case is reported as it is the first reported case of successful use of naltrexone in fetishism comorbid with cannabis and alcohol dependence.
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Affiliation(s)
- K Firoz
- Department of Psychiatry, MES Medical College, Perinthalmanna, Kerala, India.
| | - V Nidheesh Sankar
- Department of Psychiatry, MES Medical College, Perinthalmanna, Kerala, India
| | - V Rajmohan
- Department of Psychiatry, MES Medical College, Perinthalmanna, Kerala, India
| | - G Manoj Kumar
- Department of Psychiatry, MES Medical College, Perinthalmanna, Kerala, India
| | - T M Raghuram
- Department of Psychiatry, MES Medical College, Perinthalmanna, Kerala, India
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21
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Bresin K, Gordon KH. Endogenous opioids and nonsuicidal self-injury: A mechanism of affect regulation. Neurosci Biobehav Rev 2013; 37:374-83. [DOI: 10.1016/j.neubiorev.2013.01.020] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2012] [Revised: 12/20/2012] [Accepted: 01/11/2013] [Indexed: 01/02/2023]
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22
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Turner D, Basdekis‐Jozsa R, Briken P. Prescription of Testosterone‐Lowering Medications for Sex Offender Treatment in German Forensic‐Psychiatric Institutions. J Sex Med 2013; 10:570-8. [DOI: 10.1111/j.1743-6109.2012.02958.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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23
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Cohen S, Kühn KU, Sträter B, Scherbaum N, Weig W. [Adverse side-effect on sexual function caused by psychotropic drugs and psychotropic substances]. DER NERVENARZT 2011; 81:1129-37; quiz 1138. [PMID: 20628721 DOI: 10.1007/s00115-010-3074-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Unhindered sexuality plays an important role in the quality of life and this also holds true for patients with psychiatric illnesses. Knowledge concerning the complex neuronal and endocrine control mechanisms of sexual function reveals areas of possible dysfunction caused by the interactions between the control system, psychiatric drugs and addictive psychoactive substances. The differentiation of the cause of the dysfunction between being caused by the underlying illness and caused by other factors is difficult in practice. Both classical tri-cyclic antidepressants and selective serotonin uptake inhibitors can frequently cause adverse effects in multiple dimensions of sexual function. This same is true for neuroleptics, whereby the differentiation between symptoms of schizophrenia and side-effects from the medication can make an evaluation difficult. The medication-based strategy used to treat opiate dependency by administration of methadone causes sexual dysfunction in many cases. The consideration of medication-induced sexual dysfunction has a great importance with regard to compliance. Possible solutions can be modification of the medication regime, additional medication, e.g. partial antagonists and PD5 inhibitors, as well as dysfunction-specific psychotherapy and psychoeducation.
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Affiliation(s)
- S Cohen
- LVR-Klinikum, Kliniken der Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland
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24
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Thibaut F, De La Barra F, Gordon H, Cosyns P, Bradford JMW. The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the biological treatment of paraphilias. World J Biol Psychiatry 2010; 11:604-55. [PMID: 20459370 DOI: 10.3109/15622971003671628] [Citation(s) in RCA: 124] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES The primary aim of these guidelines was to evaluate the role of pharmacological agents in the treatment and management of paraphilia, with a focus on the treatment of adults males. Because such treatments are not delivered in isolation, the role of specific psychosocial and psychotherapeutic interventions was also briefly covered. These guidelines are intended for use in clinical practice by clinicians who diagnose and treat patients with paraphilia. The aim of these guidelines is to improve the quality of care and to aid physicians in clinical decisions. METHODS The aim of these guidelines was to bring together different views on the appropriate treatment of paraphilias from experts representing different continents. To achieve this aim, an extensive literature search was conducted using the English language literature indexed on MEDLINE/PubMed (1990-2009 for SSRIs) (1969-2009 for antiandrogen treatments), supplemented by other sources, including published reviews. RESULTS Each treatment recommendation was evaluated and discussed with respect to the strength of evidence for its efficacy, safety, tolerability and feasibility. CONCLUSIONS An algorithm was proposed with six levels of treatment for different categories of paraphilias.
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Affiliation(s)
- Florence Thibaut
- Faculty of Medicine, Rouen University Hospital Ch. Nicolle, University of Rouen, Rouen, France.
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Abstract
In the DSM-IV-TR, specific impulse control disorders not elsewhere classified (ICD) have been designated following four principles: (1) through the addition of an adjective that emphasizes the aberrant character of an otherwise normal behaviour (e.g., pathological gambling); (2) by means of metaphors (such as in intermittent explosive disorder); (3) according to the presumably quintessential nature of their main signs and symptoms, such as impulsive (e.g., impulse control disorders not elsewhere classified), compulsive (e.g., compulsive shopping), or addictive (e.g., internet addiction); or (4) using Greek suffix mania (e.g., kleptomania, pyromania, and trichotillomania). Given this flagrant inconsistency, we argue that time has come to adopt a less arbitrary way of describing these disorders, at least until it becomes clearer whether they are really impulsive, compulsive or addictive or if the preoccupation with this distinction is valid. In keeping with DSM's emphasis on descriptive phenomenology rather than on unsupported theory, a less biased terminology is in order. Therefore, we would like to suggest: (1) the substitution of the term ICD by the more neutral expression 'volitional disorders not elsewhere classified'; (2) the use of the classical Greek suffix mania, already present in some DSM-IV-TR ICDs, as the main naming principle to be adopted in the DSM-V; and (3) the creation of compulsive, impulsive, and mixed subtypes of the 'volitional disorders not elsewhere classified', since they are beginning to be validated by treatment trials.
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Affiliation(s)
- Leonardo F Fontenelle
- Anxiety and Depression Research Program, Institute of Psychiatry, Universidade Federal do Rio de Janeiro (IPUB/UFRJ), Rio de Janeiro, RJ, Brazil.
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27
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Guay DR. Drug treatment of paraphilic and nonparaphilic sexual disorders. Clin Ther 2009; 31:1-31. [DOI: 10.1016/j.clinthera.2009.01.009] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2008] [Indexed: 10/21/2022]
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28
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Sajith SG, Morgan C, Clarke D. Pharmacological management of inappropriate sexual behaviours: a review of its evidence, rationale and scope in relation to men with intellectual disabilities. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2008; 52:1078-1090. [PMID: 18557968 DOI: 10.1111/j.1365-2788.2008.01097.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
BACKGROUND The management of inappropriate sexual behaviours (ISB) including sexual offending is difficult, especially when the person treated has intellectual disabilities (ID). Psychological therapies are the accepted first line of treatment. Pharmacological treatments have also been advocated, particularly for people who have committed serious sexual offences. There is limited information on available drugs and evidence of their efficacy in the treatment of ISBs, in particular for people with ID. METHODS A literature search of electronic databases was undertaken. Pharmaceutical companies were contacted for unpublished information. Trials that included people with ID were systematically reviewed for the benefits and outcome in that population. RESULTS Androgen depleting drugs (cyproterone acetate, medroxyprogesterone acetate and luteinising hormone releasing hormone agonists) and psychotropic drugs (serotonin specific reuptake inhibitors and antipsychotics) are the two major categories of medications used in the treatment of ISBs. The majority of studies identified were open trials and most relied on self-report measures. Trials that included people with ID were few in number. Most trials indicated beneficial effects including reduction in sexually deviant fantasies and behaviours. CONCLUSION The quality of evidence base for the use of pharmacological agents in the treatment of ISBs is inadequate to justify their use in routine clinical practice. If used, they should only be a part of a comprehensive treatment programme and closely monitored. In addition, there are several clinical, ethical and legal issues to be addressed before considering pharmacological treatment of ISBs in people with ID.
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Affiliation(s)
- S G Sajith
- Olive Mount Mansion, Merseycare NHS Trust, Liverpool, UK.
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Lim SY, Evans AH, Miyasaki JM. Impulse Control and Related Disorders in Parkinson's Disease. Ann N Y Acad Sci 2008; 1142:85-107. [DOI: 10.1196/annals.1444.006] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Abstract
Malfunctioning of the brain's reward center is increasingly understood to underlie all addictive behavior. Composed of mesolimbic incentive salience circuitry, the reward center governs all behavior in which motivation has a central role, including acquiring food, nurturing young, and having sex. To the detriment of normal functioning, basic survival activities can pale in importance when challenged by the allure of addictive substances or behaviors. Dopamine is the neurotransmitter driving both normal and addictive behavior. Other neurotransmitters modulate the amount of dopamine released in response to a stimulus, with the salience determined by the intensity of the dopamine pulse. Opiates (either endogenous or exogenous) exemplify such modulators. Prescribed for treating alcoholism, naltrexone blocks opiates' capacity to augment dopamine release. This article reviews naltrexone's mechanism of action in the reward center and describes a novel use for naltrexone in suppressing a euphorically compulsive and interpersonally devastating addiction to Internet pornography.
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Affiliation(s)
- J Michael Bostwick
- Department of Psychiatry and Psychology, 200 First St SW, Rochester, MN 55905, USA.
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Abstract
PURPOSE OF REVIEW This review addresses testosterone-lowering and other psychotropic medications for the treatment of paraphilic patients or sexual offenders. RECENT FINDINGS Randomized controlled studies are still lacking, and only a few new studies were reported during the past year. On the other hand, there is substantial scientific knowledge about the wide range of psychiatric comorbidity associated with paraphilias and in sexual offenders. Empirically based treatment of these patients, especially of impulsivity, anxiety and mood disorders, may also ameliorate sexual impulsivity. SUMMARY Medication interventions, either substantially lowering serum testosterone or treating axis I comorbidities, show definite promise as a significant component of the management of sexual offenders. Pharmacotherapy should be combined with other therapeutic treatment modalities, most commonly cognitive-behaviour based psychotherapy and intensive community supervision.
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Brewer JA, Potenza MN. The neurobiology and genetics of impulse control disorders: relationships to drug addictions. Biochem Pharmacol 2007; 75:63-75. [PMID: 17719013 PMCID: PMC2222549 DOI: 10.1016/j.bcp.2007.06.043] [Citation(s) in RCA: 267] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2007] [Revised: 06/27/2007] [Accepted: 06/28/2007] [Indexed: 01/28/2023]
Abstract
Impulse control disorders (ICDs), including pathological gambling, trichotillomania, kleptomania and others, have been conceptualized to lie along an impulsive-compulsive spectrum. Recent data have suggested that these disorders may be considered addictions. Here, we review the genetic and neuropathological bases of the impulse control disorders and consider the disorders within these non-mutually exclusive frameworks.
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Affiliation(s)
- Judson A Brewer
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
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Berner W, Briken P. [Paraphilia, sexual preference disorders. Diagnosis, etiology, epidemiology, treatment and prevention]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2007; 50:33-43. [PMID: 17177100 DOI: 10.1007/s00103-007-0108-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Hostility towards relationships is one prominent characteristic symptom for disorders of sexual preference (ICD-10) and paraphilias (DSM-IV). Paraphilic symptoms sometimes progress to obsessive or addictive- like forms leading to a loss of self-control but can occur also as single incidents or as episodic events. Besides constitutional aspects, problems in the development of close relationships to primary caregivers (attachment) play an important role in the development of these disorders. Actual relationship- and self-confidence problems often trigger the severity of disturbance, especially in the episodic forms of paraphilia. For patients who are in conflict with the law, cognitive-behavioral therapeutic approaches with the aim to minimize self-deception regarding the effects of the paraphilic behavior have become more and more relevant. Regarding the medical treatment, anti-hormonal therapy plays an important role, but also treatment with serotonergic agents and naltrexone are used. Only little can be advised in terms of prevention; general psycho-hygiene (regarding the parent-child relationship) is recommended. Beside these general measures, institutions which offer special treatment for people in danger to become delinquents may be able to prevent serious harm for possible victims of abuse.
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Affiliation(s)
- Wolfgang Berner
- Universitätsklinikum Hamburg-Eppendorf, Hamburg-Eppendorf, BRD.
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Abstract
This paper is the 27th consecutive installment of the annual review of research concerning the endogenous opioid system, now spanning over 30 years of research. It summarizes papers published during 2004 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia; stress and social status; tolerance and dependence; learning and memory; eating and drinking; alcohol and drugs of abuse; sexual activity and hormones, pregnancy, development and endocrinology; mental illness and mood; seizures and neurologic disorders; electrical-related activity and neurophysiology; general activity and locomotion; gastrointestinal, renal and hepatic functions; cardiovascular responses; respiration and thermoregulation; and immunological responses.
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY 11367, USA.
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