LET TERS TO THE ED I TOR

LET TERS TO THE ED I TOR
Re: The Neurobiology,
Neuropharmacology, and Phar ma co -
logic Treat ment of Paraphilias and
Com pul sive Sex ual Be hav iour
Dear Ed i tor:
Dr Brad ford re cently re viewed the phar -
ma co logic treat ment of the paraphilias
and com pul sive sex ual be hav iour (1).
As a rec og nized ex pert in fo ren sic psy -
chi a try and an opin ion leader he is po -
ten tially an im por tant agent in chang ing
phy si cian prac tices and pa tient out -
comes (2). There fore, we be lieve it is
im per a tive that Dr Brad ford’s rec om -
men da tions be based on the best avail -
able em pir i cal ev i dence, if they are to do
more good than harm.
To sup port his al go rithm for the treat -
ment of paraphilias Dr Brad ford re -
viewed se lected clin i cal stud ies, briefly
de scrib ing some of them (1). There is a
rel a tively high risk that nar ra tive re -
views of this type will be ten u ous, in -
com plete, or, worse still, based on
bi ased study se lec tion and ci ta tion. As
well, they may ad vo cate ther apy even af -
ter it has been shown to be use less or
harm ful (3–6).
To al low cli ni cians to em ploy them con -
fi dently treat ment rec om men da tions
should, when ever pos si ble, be based on
3 el e ments: em pir i cal ev i dence from a
sys tem atic re view, an ex am i na tion of
the ev i dence’s strength, and ex plicit
spec i fi ca tion of val ues or pref er ences as -
so ci ated with out comes (7). Dr Brad -
ford’s re view ful filled none of these
meth od olog i cal re quire ments.
Cli ni cian con fi dence in Dr Brad ford’s
rec om men da tions must be un der mined
by the fact that his re view does not in -
clude the meth od olog i cally ro bust
metaanalysis by White and oth ers (8).
The ob jec tive of this metaanalysis was
to de ter mine the ef fec tive ness of ther a -
pies to as sist peo ple who have sex ual
pref er ence dis or ders and those who have
been con victed of sex ual of fences. A
com pre hen sive search of the world lit er -
a ture in Au gust 1998 iden ti fied only a
sin gle ran dom ized con trolled trial of
antilibidinal med i ca tion that met meth -
od olog i cal cri te ria in tended to min i mize
bias. This trial found that
medroxyprogesterone (MPA) to gether
with imaginal de sen si ti za tion was no
better than imaginal de sen si ti za tion
alone for prob lem atic or anom a lous sex -
ual be hav iour and de sire (9).Yet, Dr
Brad ford did not cite this trial or any
orig i nal study pub lished af ter 1998.
White and col leagues re ported, “At
pres ent there are so few data to ei ther
sup port or re fute the use of antilibidinal
drugs, such as medroxyprogesterone,
that it is dif fi cult to jus tify their use out -
side of a well-con ducted trial.” This
state ment con trasts with Dr Brad ford’s
sug ges tion that “clin i cal stud ies show
that MPA has a sig nif i cant im pact on de -
vi ant sex ual fan ta sies and de vi ant sex ual
urges and be hav iour.”
Cli ni cians are left with less con fi dence
in Dr Brad ford’s rec om men da tions than
might have been the case had they been
de rived from a re view pro cess that was
less prone to bias. We think cli ni cians
should use antilibidinal drug treat ments
with cau tion.
Sex of fend ers are of ten un der in tense
pres sure to com ply with clin i cal treat -
ment rec om men da tions, re gard less of
the weight of ev i dence (or lack thereof)
sup port ing the rec om mended treat ment.
As such, we be lieve re search ers must be
meth od olog i cally rig or ous in study ing
their treat ment. Cli ni cians carry a heavy
eth i cal re spon si bil ity to eval u ate care -
fully the ev i dence sup port ing any treat -
ment they rec om mend to these pa tients.
False con fi dence in treat ments for sex
of fend ers can re sult in harm, not only to
the pa tients but also to those whom we
would most wish to pro tect.
Can J Psy chia try, Vol 46, August 2001 559
Ref er ences
1. Brad ford JMW. The neurobiology,
neuropharmacology, and phar ma co log i cal treat ment
of paraphilias and com pul sive sex ual be hav iour. Can
J Psy chi a try 2001;46:26–34.
2. Thomson O’Brien MA, Oxman AD, Haynes RB, Da -
vis DA, Freemantle N, Harvey EL. Lo cal opin ion
lead ers: ef fects on pro fes sional prac tice and health
care out comes. (Cochrane Re view). Cochrane Da ta -
base Syst Rev 2000; (2): CD000125.
3. Ravnskov U. Cho les terol low er ing tri als in cor o nary
heart dis ease: fre quency of ci ta tion and out come.
BMJ 1992;305:15–9.
4. Neihouse PF, Priske SC. Quo ta tion ac cu racy in re -
view ar ti cles. An nals of Pharamacotherapy
1989;1989:594–6.
5. Antman EM, Lau J, Kupelnick B, Mosteller F,
Chalmers TC. A com par i son of re sults of meta-anal -
y ses of ran dom ized con trol tri als and rec om men da -
tions of clin i cal ex perts. Treat ments for myo car dial
in farc tion. JAMA 1992;268:240–8.
6. Coo per HM, Rosenthal R. Sta tis ti cal ver sus tra di -
tional pro ce dures for sum ma riz ing re search find ings.
Psychol Bull 1980;87:442–9.
7. Guyatt GH, Sinclair J, Cook DJ, Glasziou P. Users’
guides to the med i cal lit er a ture: XVI. How to use a
treat ment rec om men da tion. Ev i dence-based Med i -
cine Working Group and the Cochrane Ap pli ca bil ity
Methods Working Group. JAMA 1999;
281:1836–43.
8. White P, Bradley C, Ferriter M, Hatzipetrou L. Man -
age ments for peo ple with dis or ders of sex ual pref er -
ence and for con victed sex ual of fend ers (Cochrane
Re view). Cochrane Da ta base Syst Rev 2000; (2):
CD000251. Re view.
9. McConaghy N, Armstrong MS, Blaszcynski A. Ex -
pec tancy, co vert sen si ti za tion and imaginal de sen si -
ti za tion in com pul sive sex u al ity. Acta Psychiatr
Scand 1985;72:176–87.
David Haslam, MD, MSc, FRCPC
Susan Adams, MB, FRCPC
Toba Oloruntoba, MB, FRCPC
North Bay, Ontario
Open-Label Risperidone Treatment
of 6 Children and Adolescents With
Autism
Dear Ed i tor:
Au tis tic dis or der is a per va sive de vel op -
men tal dis or der char ac ter ized by im -
paired re cip ro cal so cial in ter ac tion,
com mu ni ca tion skills, and imag i na tive
ac tiv ity. No ef fec tive phar ma co logic
strat e gies have been de vel oped for treat -
ment of its core symp toms. Nev er the -
less, pharmacotherapy is an im por tant
treat ment mo dal ity and of ten part of a
com pre hen sive ther a peu tic pro gram.

560 The Ca na dian Jour nal of Psy chia try Vol 46, No 6
An im bal ance in the serotonergic neu ro -
trans mit ter sys tem may un der lie as pects
of the pa thol ogy ob served in au tis tic pa -
tients (1). Risperidone, an atyp i cal
antipsychotic that is both a se ro to nin and
do pa mine an tag o nist, has been shown to
treat adults with au tism ef fec tively (2).
Studies have shown that risperidone also
im proves symp toms in sev eral psy chi at -
ric dis or ders of older chil dren and ad o -
les cents (3–5). In this let ter, we de scribe
its use for treat ing chil dren with au tism.
Our sam ple con sisted of 9 sub jects with
a DSM-IV di ag no sis of au tis tic dis or der
(7 males and 2 fe males; me dian age 7.1
yrs, range 3.4 to 13.4 yrs). Screening
pro ce dures in cluded med i cal his tory,
phys i cal and neu ro log i cal ex am i na tions,
com plete blood count, elec tro lytes, glu -
cose, se rum urea ni tro gen, creatinine,
liver func tion, uri nal y sis, ECG, EEG,
and au di tory evoked po ten tials. Pa tients
were drug-free for at least 4 weeks be -
fore the be gin ning of the trial. No other
psy cho ac tive med i ca tion was given dur -
ing the study.
The sub jects un der went a 12-month
trial. Risperidone was started at 0.5 mg
daily and ti trated up ward to a max i mum
of 3 mg daily.
Be hav ioural rat ings were car ried out at
base line and at fixed in ter vals (3, 6, and
12 months). The fol low ing in stru ments
were em ployed: Clin i cal Global Im pres -
sion (CGI) (6), Be hav ioural Sum ma -
rized Eval u a tion Scale (BSE) (7), and
Vineland So cial Ma tu rity Scale (VSMS)
(8).
Most of the screen ing tests, in clud ing
com plete blood count, liver func tion,
elec tro lytes, glu cose, se rum urea ni tro -
gen, creatinine, uri nal y sis, and EEG,
were also per formed 3 times dur ing the
study (at 3, 6, and 12 months). Blood
pres sure was mon i tored dur ing the first
days of the trial. Side ef fects were eval u -
ated us ing the Extrapyramidal Symp -
toms Rat ing Scale (ESRS) (9).
Three pa tients were with drawn from the
study due to fam ily non com pli ance, and
6 sub jects com pleted the whole trial.
All par ents re ported some be hav ioural
im prove ment, such as in creased aware -
ness and so cial in ter ac tion, as well as de -
creased self-abuse, ir ri ta bil ity,
hy per ac tiv ity, and sleep dis tur bance.
Five of the 6 risperidone-treated pa tients
were cat e go rized as re spond ers on the
ba sis of the CGI Scale. The Wilcoxon
signed-rank test showed that the de -
crease in the to tal BSE score be tween
base line and month 12 was sta tis ti cally
sig nif i cant (P = 0.03). No sig nif i cant
changes were noted us ing the VSMS.
Un to ward ef fects in cluded mild se da -
tion (2 cases) and weight gain (1 case).
One of the pa tients ex pe ri enced an ep i -
lep tic sei zure 6 months af ter start ing
risperidone ther apy. Liver func tion
tests, EEG, and other lab o ra tory stud ies
re mained within nor mal lim its. Blood
pres sure did not vary from nor mal
val ues.
Our study showed that risperidone was
able to re duce self-abuse, ag gres sion,
and hy per ac tiv ity in au tis tic chil dren.
The ob vi ous fac tors ham per ing its gen -
er al iza tion in clude the small num ber of
pa tients, the unblind na ture, and the lack
of con trol groups. Con trolled re search is
needed to fur ther eval u ate the ef fi cacy of
risperidone in treat ing au tism.
Ref er ences
1. Cham ber lain RS and Herman BH. A novel bio chem i -
cal model link ing dysfunctions in brain melatonin,
proopiomelanocortin pep tides, and se ro to nin in au -
tism. Biol Psy chi a try 1990;28:773–93.
2. Purdon SE, Lit W, Labelle A, Jones BDW.
Risperidone in the treat ment of per va sive de vel op -
men tal dis or der. Can J Psy chi a try 1994;39:400–5.
3. McDougle CJ, Holmes JP, Bronson MR, An der son
GM, Volkmar FR, Price LH, and oth ers. Risperidone
treat ment of chil dren and ad o les cents with per va sive
de vel op men tal dis or ders: a pro spec tive open-la bel
study. J Am Acad Child Adolesc Psy chi a try
1997;36:685–93.
4. Demb HB. Risperidone in young chil dren with per va -
sive de vel op men tal dis or ders and other de vel op men -
tal dis abil i ties. J Child Adolesc Psychopharmacol
1996;6:79–80.
5. Nicolson R, Awad G, Sloman L. An open trial of
risperidone in young au tis tic chil dren. J Am Acad
Child Adolesc Psy chi a try 1998;37:372–6.
6. Na tional In sti tute of Men tal Health: clin i cal global
im pres sions. Psychopharmacol Bull
1985;21:839–43.
7. Barthélemy C, Adrien JL, Tanguay P, Garreau B,
Fermanian J, Roux S, and oth ers. The be hav ioural
sum ma rized eval u a tion: va lid ity and re li abil ity of a
scale for the as sess ment of au tis tic be hav iours. J Au -
tism Dev Disord 1990;20:189–203.
8. Doll EA. Vineland so cial ma tu rity scale. Rev ed.
Prince ton (NJ): Ed u ca tional Testing Ser vice; 1952.
9. Chouinard G, Ross-Chouinard A, Annable L, Jones
BD. The extrapyramidal symp tom rat ing scale. Can J
Neurol Sci 1980;7:233.
Fabiana Vercellino, MD
Elisabetta Zanotto, MD
Giambattista Ravera, MD
Edvige Veneselli, MD
Genoa, Italy
Bupropion and Drug-Induced
Parkinsonism
Dear Ed i tor:
I re port the case of a 48-year-old male
phy si cian who pre sented with a ma jor
de pres sive ep i sode (MDE). He had suf -
fered with sea sonal af fec tive dis or der
(SAD) for sev eral years. He de scribed
him self as al ways hav ing been ob ses -
sional and perfectionistic.
Ini tially, he had re sponded pos i tively to
citalopram at a dos age of 20 mg daily, al -
though he had ex pe ri enced sig nif i cant
sex ual side ef fects and a with drawal syn -
drome when he dis con tin ued it. There is
a pos i tive fam ily his tory of de pres sive
ill ness in his mother postmenopause, re -
quir ing hos pi tal iza tion and re spon sive
to med i ca tion man age ment. His
18-year-old son also pre sented with de -
pres sive ill ness at the same time as the
fa ther and ini tially re sponded pos i tively
to bupropion (Wellbutrin).
Ma jor de pres sion was ev i dent in clin i cal
in ter view, with self-re port, Beck De -
pres sion In ven tory (BDI), and the Hos -
pi tal Anx i ety and De pres sion and
(HAD) Scale show ing mod er ately se -
vere de pres sion with as so ci ated anx i ety.
The pa tient was tak ing beta blockers for
es sen tial hy per ten sion, which was well
con trolled. He had self-med i cated with
nefazodone at doses up to 200 mg daily,
with lit tle ev i dent ben e fit apart from im -
proved sleep pat tern. When he was next
as sessed, the de pres sive af fect was more
sig nif i cant. Bupropion SR was added at
a dos age of 150 mg daily, with some
clonazepam as needed for break through
panic. Clin i cal im prove ment in

August 2001 Let ters to the Editor 561
de pres sion was ev i dent within 8 weeks,
as re ported by the pa tient and his fam ily
and as ob served in in ter view.
At 12 weeks, the pa tient com plained of
tremor, nau sea, micrographia, and shuf -
fling gait. These symp toms had emerged
within 10 weeks of the ini tial bupropion
pre scrip tion. He dis con tin ued the
bupropion and the symp toms re solved
over 10 days. The de pres sion wors ened,
how ever, as the extrapyramidal symp -
toms re solved. At tempts at re in tro duc -
ing the bupropion at lower doses were
un suc cess ful, and the pa tient now con -
tin ues on nefazodone plus fluoxetine,
with the ad di tion of light treat ment, with
sig nif i cant clin i cal im prove ment.
A re view of the lit er a ture from the Drug
In for ma tion Ser vice showed 2 case re -
ports of re vers ible orofacial dyskinesia
af fect ing the eyes and tongue in a
70-year-old woman re ceiv ing
bupropion at doses from 75 to 225 mg
daily. Other symp toms in cluded hand
tremor, nau sea, and diz zi ness. Af ter dis -
con tinu a tion, the dyskinesia re ceded,
and other side ef fects dis ap peared.
Two other ge ri at ric pa tients (aged 85
and 72 years) were treated with
bupropion for ma jor de pres sion and ex -
pe ri enced a “fall ing back ward” re ac tion.
Max i mum dos ages in each pa tient were
up to 400 mg and 350 mg daily, re spec -
tively. Nei ther pa tient had a his tory of
orthostatic hypotension or ver tigo. Both
did man i fest other symp toms con sis tent
with parkinsonian syn drome (for ex am -
ple, akinesia and shuf fling gait). Af ter
bupropion was dis con tin ued, these ad -
verse ef fects re solved within 1 to 2
weeks.
The lit er a ture sug gests that at ther a peu -
tic doses bupropion ex hib its do pa -
mine-ag o nist ef fects, and at high doses it
may have a do pa mine-an tag o nist ef fect.
The man u fac turer does have some case
re ports pre- and postmarketing of
parkinsonian-type side ef fects, but no
causal re la tion has yet been es tab lished.
There was 1 re port of a 53-year-old pa -
tient who had a dystonic re ac tion with
nefazadone 2 hours af ter the first dose.
This pa tient’s chief com plaint was lip
smack ing, with hand and arm ges tur ing.
The symp toms re solved within 1 hour in
re sponse to diphenhydramine and
benztropine. The Drug In for ma tion
search did not yield any ki netic in ter ac -
tions be tween nefazadone and
bupropion that might have re sulted in a
fur ther in crease in bupropion se rum lev -
els. There was no fam ily his tory of neu -
ro log i cal dis or der or Par kin son’s
dis ease in this pa tient.
Ref er ences
1. Cardoni AA, Raasch RH. Buproprion drug eval u a -
tion. In: Hutchison TA, Shahan DR, An der son ML,
ed i tors. DRUGDEX Sys tem. Green wood Vil lage
(CO): Micromedix, Inc (Edi tion ex pires June 2001.
Ac cessed Jan u ary 18, 2001.
2. Burda A, Web ster K, Leikin JB, Chan SB, Stokes
KA. “Nefazodone-in duced acute dystonic re ac tion.”
Vet Hum Toxicol 1999;41(5):321–2.
Laurence Jerome, MBChB, MSc, MRC PSYCH,
FRCPC
London, Ontario
Re: Training Residents for
Community Psychiatric
Practice—The Resident Perspective
Dear Ed i tor:
It is en cour ag ing to see fur ther study of
com mu nity psy chi at ric prac tice (1). Dr
Freeland and oth ers state, “it would
seem un likely that com mu nity psy chi a -
try elec tives would be pop u lar at the
PGY5 stage of train ing,” but I would like
to pro vide a dif fer ent ex pe ri ence.
For the last 3 years, the multispeciality
com mu nity train ing net work at the Uni -
ver sity of West ern On tario has, un der
the di rec tor ship of Dr James Rourke, of -
fered elec tive com mu nity psy chi at ric
ex pe ri ence in ru ral prac tice. The elec tive
is of fered in all years of train ing. To date,
3 res i dents, all at the PGY5 level, have
used this op por tu nity to com plete a 3- to
6-month ro ta tion. In fol low-up, all res i -
dents in di cated that this train ing ex pe ri -
ence was most ap pro pri ate for PGY4
and PGY5 res i dents. One res i dent has
sub se quently gone on to prac tise in ru ral
com mu nity psy chi a try, de spite no prior
ca reer pref er ence. All res i dents in di -
cated a pos i tive ex pe ri ence with the
elec tive.
These data, al though ob vi ously lim ited,
sup port of fer ing com mu nity psy chi at ric
elec tives to all stages of train ing in an ef -
fort to en cour age a ca reer choice in this
needed area.
Ref er ences
1. Freeland A, Le vine S, Johnston M, Busby K.
Training res i dents for com mu nity psy chi at ric prac -
tice: the res i dent per spec tive. Can J Psy chi a try
2000;45:655–9.
Patrick Conlon, MD, FRCPC
Goderich, Ontario
Metamorphosis of Delusion of
Pregnancy
Dear Ed i tor:
De lu sion of preg nancy has been de -
scribed in a wide range of psy chi at ric
con di tions. It has been con fused with,
and, for ap pro pri ate treat ment, needs to
be dif fer en ti ated from, pseudocyesis,
sim u lated preg nancy, pseudopregnancy,
and couvade syn drome (1). While
pseudocyesis is a somatoform symp tom,
de lu sion of preg nancy is a psy chotic
symp tom, ne ces si tat ing antipsychotic
med i ca tion with re sult ing side ef fects
(such as amenorrhoea and galactorrhea)
that make this dis tinc tion dif fi cult. The
fol low ing case re port dis cusses many
per ti nent is sues re gard ing the evo lu tion
of de lu sion of preg nancy.
Case Report
Ms A, aged 33 years, sin gle, ed u cated,
and with a fam ily his tory of chronic
men tal ill ness, pre sented to our psy chi -
at ric hos pi tal with com plaints of ab nor -
mal be hav iour and 3 gen er al ized
sei zures. Her his tory in cluded a psy -
chotic ep i sode that had re mit ted par tially
with treat ment. Dur ing this past

562 The Ca na dian Jour nal of Psy chia try Vol 46, No 6
psy chotic ep i sode, she had can cel led her
en gage ment, cast ing as per sions on her
fi ance’s in ten tions, and was ir ri ta ble and
abu sive. She har boured persecutory and
ref er en tial de lu sions, in clud ing the de lu -
sion of be ing con trolled and the de lu sion
of love with a film ac tor. She be lieved
that she was preg nant and al ready had 2
chil dren. On treat ment with haloperidol
(20 mg daily) com bined with
carbamazepine (600 mg daily) she im -
proved, ex cept for neg a tive symp toms.
She later dis con tin ued haloperidol, ex -
pe ri enced a re cur rence, and was
rehospitalized. She had a de lu sion that,
in her pre vi ous birth, she was the wife of
the Hindu god Lord Rama, as well as a
de lu sion of 7 years’ preg nancy. She be -
lieved she had had Rama’s child, and she
had au di tory hal lu ci na tions from the
womb. She also had de lu sions that she
was be ing con trolled through hyp no -
tism, that her hair was be ing trans -
planted with an other per son’s hair, and
that her brother wanted to have a sex ual
re la tion ship with her. She had au di tory
hal lu ci na tions about la dies com ment ing
about her and abus ing her. Her sleep and
ap pe tite were dis turbed. She was di ag -
nosed as suf fer ing with para noid
schizo phre nia.
Her brain scan, EEG, and rou tine bio -
chem i cal pa ram e ters were nor mal. The
re sponse to risperidone (6 to 8 mg daily),
electroconvulsive ther apy (ECT), and
flupenthixol (40 mg fort nightly) for ad e -
quate du ra tion was poor. Hence, she was
given pimozide (up to 8 mg daily).
Within 1 week of start ing pimozide, the
du ra tion of her “preg nancy” grad u ally
less ened from 7 years to 5, 4, and 3
years. Finally, 2 months later, she had
only an over val ued idea re lated to preg -
nancy. She was re ported to be slightly
with drawn, oc ca sion ally ir ri ta ble, and to
be help ing with house hold work.
The in ter est ing as pects of this case are
its meta mor pho sis in terms of the evo lu -
tion, de vel op ment, maintainance, and
grad ual re mis sion of the de lu sion of
preg nancy in re sponse to pimozide
treat ment (2). The role of cul tural fac tors
in psychopathology also be come clear,
con sid er ing that Lord Rama’s wife gave
birth to her sons af ter he de serted her.
The de lu sion in this case might be
restitutive in the face of the pa tient’s ex -
treme in se cu rity as a spin ster and fol -
low ing loss of a love ob ject. Sim i larly, it
might have a met a phor i cal wish-ful fill -
ment func tion or sat isfy the “pro cre ative
im per a tive” for women from her so cio -
eco nomic back ground in the In dian
so ci ety.
Ref er ences
1. Mi chael A, Jo seph A, Pallen A. De lu sions of preg -
nancy. Br J Psy chi a try 1994;164;244–6.
2. de Pauw K W. Three thou sand days of preg nancy: a
case of monosymptomatic de lu sional pseudocyesis
re spond ing to pimozide. Br J Psy chi a try
1990;157:924–8.
Dr Sagnik Bhattacharyya, DPM
Dr Santosh K Chaturvedi, MD
Bangalore, India
Home Visits From an Outpatient
Psychiatric Clinic
Dear Ed i tor:
State psy chi at ric clin ics in Is rael are
open to the pub lic, en abling di rect ac cess
to men tal health care. Pa tients and their
fam i lies, gen eral prac ti tio ners, and
nonmedical agen cies can re quest an in -
ter ven tion from a men tal health team.
Home vis its are pro vided as part of
everyday care, usu ally in emer gen cies.
We re port an eval u a tion of 89 home vis -
its per formed by our staff in re sponse to
emer gency calls. We re corded from pa -
tients’ files the chief com plaint, source
of re quest, di ag no sis, visit out come, and
pro fes sion als in volved. Ages ranged
from 18 to 87 years (mean 50.9, SD
18.61). Fifty (56%) pa tients were
women, and 39 (44%) were men. The
chief com plaint was ag gres sive be hav -
iour (52% of cases), with psy chotic
symp toms in 25%, sui cidal threats in
13%, and “other” in 11%. Forty-five
per cent of calls came from fam ily
mem bers, 26% from wel fare de part -
ments, and 19% from gen eral prac ti tio -
ners. Only 5% of calls came from
pa tients. These rates con trasted with
other re ports (1).
Di ag no ses were pri mary psy chotic ill -
ness in 49% of the vis its, or ganic men tal
dis or ders in 24%, per son al ity dis or ders
in 16%, and pri mary mood dis or ders in
11%. Phy si cians (ei ther res i dents or spe -
cial ists in psy chi a try) and nurses car ried
out most of the vis its. In 55% of the vis -
its, sub jects agreed to come vol un tarily
to the clinic for fur ther as sess ment and
treat ment. In 45%, the sub jects’ judg -
ment was im paired or they posed a dan -
ger to them selves or oth ers, and a
com pul sory in ter ven tion ac cord ing to
the Is raeli Men tal Health Act was re -
quested from ju di cial au thor i ties. An in -
ter est ing find ing is that when a spe cial ist
in psy chi a try was in charge of the visit
(n = 33, 37%) only 25% of the vis its
ended with a re quest for a com pul sory
in ter ven tion. This con trasted with cases
eval u ated by res i dents in psy chi a try and
other pro fes sion als, in which there was
an in creased trend for re quest ing com -
pul sory in ter ven tions. Al though it is not
clear ex actly why there were fewer re -
quests for com pul sory in ter ven tions
when vis its were per formed by spe cial -
ists, we think that this out come de serves
more at ten tion and fur ther re -
search.With com mu nity-based treat -
ments, a del i cate equi lib rium ex ists
be tween over crowded clin ics (with the
con se quent need for spe cial ists in psy -
chi a try to be avail able for con sul ta tion
and treat ment) and the need for less re -
stric tive in ter ven tions that may, in turn,
add to the de mands made on usu ally
over bur dened cli ni cians.
Al tered be hav iour is a rea son for emer -
gency psy chi at ric as sess ment (2). Of
course, what is of in ter est is the ex tent to
which al tered be hav iour is a man i fes ta -
tion of a treat able men tal ill ness. In this
re port, al tered be hav iour was re corded
as the chief com plaint in about one-half
of the cases, and psy chotic com plaints in

August 2001 Let ters to the Editor 563
one-quar ter of them. Actually, how ever,
at least three-quar ters of the sub jects suf -
fered from a psy chi at ric dis or der, and it
seems that in-home vis its were jus ti fied.
Al lowing di rect ac cess by com mu nity
agen cies and the pub lic may im pose a
great strain on com mu nity men tal health
cen tres. Nev er the less, this ap proach al -
lows prac ti tio ners to reach more pa -
tients. We call for more re search in this
area of com mu nity psy chi a try, com bin -
ing quan ti ta tive and qual i ta tive
meth od ol o gies.
Ref er ences
1. Stoffels R. The home visit—a study of am bu la tory
man age ment of psy chi at ric pa tients within the scope
of two mo bile out pa tient ser vices. Psychiatr Prax
1988;15(3):90–5.
2. Steer RA, Di a mond H, Litwork E, Henry M. Pre dic -
tion of mul ti ple vis its by a com mu nity men tal health
cen ter’s psy chi at ric emer gency home vis it ing team.
Com mu nity Ment Health J 1979;15(3):214–8.
Daniel Moldavsky, MD
Henri Szor, MD
Yuval Melamed, MD
Daniel Levi, MD
Avner Elizur, MD
Tel-Aviv, Israel
Clinical Characteristics of
Delusional Disorder
Dear Ed i tor:
Some pa tients with psy cho sis oc cur ring
in later years, but with out psy cho genic
psy cho ses or brain dis eases such as Alz -
hei mer’s dis ease and vas cu lar de men tia,
have sys tem atized de lu sions but are still
able to main tain a good qual ity of life.
These pa tients have a dis ease de scribed
as a de lu sional dis or der or late-on set
paraphrenia.
We re port a study in ves ti gat ing the clin i -
cal char ac ter is tics and the CT brain scan
find ings in 13 pa tients over age 65 years
suf fer ing from de lu sional dis or der.
Di ag no sis was based on the ICD-10
clas si fi ca tion. The 13 age-matched sub -
jects who vis ited the hos pi tals for phys i -
cal ex am i na tion com plained of
head ache and in som nia. They were still
able to main tain a good qual ity of life
and had no ex og e nous dis eases.
We eval u ated the de tails of the pa tients’
hal lu ci na tions and de lu sions, their vi -
sual or hear ing im pair ments, and their
prog no ses. To eval u ate the rate of at ro -
phy or en large ment in the 2 sides of the
brain, the re gions of in ter est were di -
vided into left and right frontoparietal
lobe, in ter nal ar eas of the tem po ral lobe,
the an te rior horn of the lat eral ven tri cles,
the fron tal lobe, and Sylvian fis sures.
They were mea sured by NIH Im age
com puter soft ware (W Rasband, Na -
tional In sti tutes of Health, Bethesda
[MD]. Ver sion 1.58).
Clin i cal char ac ter is tics were as fol lows:
5 pa tients had vi sual or tac tile hal lu ci na -
tions, 11 pa tients had de lu sions of in -
jury, 2 had de lu sions of ob ser va tion, and
1 had de scent de lu sion. Ten pa tients had
vi sual or hear ing im pair ments. Dur ing
mon i tor ing, it was found that 2 pa tients
pro gressed to de men tia within 4 years, 2
pa tients could not be fol lowed up, 1 pa -
tient died of pneu mo nia, and con tin u ous
de lu sional dis or der per sisted in 8
pa tients.
There were sig nif i cant dif fer ences in the
de gree of at ro phy of both sides of the
frontoparietal lobe There were, how -
ever, no sig nif i cant dif fer ences be tween
the 2 groups rel a tive to the other brain
ar eas.
In pre vi ous stud ies of late-on set
paraphrenia, var i ous risk fac tors, such as
fe male sex, deaf ness, loss of vi sion, and
liv ing alone were iden ti fied (1). In this
study, all pa tients were women and
many pa tients (76.92%) had vi sual or
hear ing im pair ments. Con cern ing the
lit er a ture on CT find ings on de lu sional
dis or der, Flint (2) found that the
paraphrenia group had sig nif i cantly
more clin i cally un sus pected (si lent) ce -
re bral infarctions, and all af fected pa -
tients had subcortical or fron tal-lobe
infarctions, with 1 pa tient also hav ing a
pa ri etal-oc cip i tal in farct (2). Our CT
data, how ever, show that de lu sional dis -
or der is as so ci ated with frontoparietal
at ro phy.
From the above re sults, we sug gest that
de lu sional dis or der is as so ci ated with
such fac tors as sex, au dio vi sual
dysfunctions, and frontoparietal
im pair ment.
Ref er ences
1. Prager S, Jeste DV. Sen sory im pair ment in late-life
schizo phre nia. Schizophr Bull 1993;19:755–72.
2. Flint AJ, Rifat SL, East wood MR. Late-on set para -
noia; dis tinct from paraphrenia? In ter na tional Jour -
nal of Ge ri at ric Psy chi a try 1991;6:103–9.
Atsushi Hamuro, MD
Yuichi Sugai, MD
Hiroshi Isono, MD PhD
Shigeo Torii, MD, PhD
Tokyo, Japan
Sexual Aversion Disorder Treated
With Behavioural Desensitization
Dear Ed i tor:
Sex ual aver sion dis or der is a sex ual dys -
func tion char ac ter ized by an aver sion to
gen i tal con tact (1,2), un will ing ness to
have sex, and avoid ance of com mu ni ca -
tion or touch ing that may lead to sex (3).
There is lit tle writ ten about sex ual aver -
sion dis or der (4), and it is gen er ally con -
sid ered to be dif fi cult to treat (3). I re port
here the case of a pa tient with a global,
life long sex ual aver sion dis or der that re -
sponded sur pris ingly well to a be hav -
ioural ap proach.
Case Report
When I first met Ms G, a 30-year-old
white woman, she had been mar ried for
5 years. She and her hus band had never
con sum mated their mar riage. Both part -
ners de scribed a lov ing re la tion ship and
de scribed them selves as “shy and con -
ser va tive.” They both were vir gins, and
she stated she was not fear ful of sex u al -
ity or a sex ual re la tion ship. There was no
his tory of sex ual abuse, as sault, or rape,
and no is sues around sex ual ori en ta tion.

564 The Ca na dian Jour nal of Psy chia try Vol 46, No 6
Ms G had never ex pe ri enced or gasm,
even dur ing sleep, and had never mas tur -
bated. She en joyed kiss ing and cud dling,
but was un able to, or al low her hus band
to, pro ceed fur ther. She suf fered from
re cur rent ma jor de pres sive dis or der. At
the time of as sess ment, she was suf fer -
ing from a de pres sive ep i sode of 1½
years du ra tion only par tially treated with
nefazaodone (Serzone 200) mg twice
daily.
Of note was a his tory of food aver sion as
a young child, with on go ing dif fi cul ties
with new foods, which had to be in tro -
duced very slowly in com bi na tion with
es tab lished foods. She had seen a sex ual
coun sel lor on 15 oc ca sions in the past,
which had helped her and her hus band
de velop com fort with nu dity and
hold ing.
Ms G de sired a preg nancy and so was
very mo ti vated for treat ment. The treat -
ment plan in cluded switch ing to
Paroxetine (Paxil), which more ef fec -
tively treated her de pres sion. Si mul ta -
neously, 2 be hav ioural de sen si ti za tion
hi er ar chies were drawn up, with
prac ti cal steps lead ing to in creased sex -
ual in ti macy. One hi er ar chy dealt with
in creas ing her com fort in ex plor ing her
own body, and the other dealt with part -
ner re la tions. Over the next 5½ months, I
saw Ms G for a to tal of 8 ses sions, sev -
eral of which in cluded her hus band. She
made steady prog ress, and within that
time she was able to ob tain or gasm by
mas tur ba tion, con sum mate her mar -
riage, and be come preg nant. The cou ple
were able to main tain sex ual in ti macy
through out the preg nancy and
postpartum.
This case il lus trates a very good out -
come us ing a be hav ioural ther apy ap -
proach that was rel a tively quick and had
re quired in fre quent sin gle-ther a pist con -
tacts (about ev ery 2 to 4 weeks). The lit -
er a ture fa vours a be hav ioural ther apy
ap proach (4–6), but with 1 or 2 ther a -
pists, and fre quent ses sions of daily to
twice-weekly meet ings (5). More over,
the lit er a ture sug gests a poor prog no sis
for sex ual aver sion dis or der es pe cially,
as in this case, when it is global, life long,
as so ci ated with de pres sion, and as so ci -
ated with anorgasmia (3). Fac tors
con trib ut ing to a fa vour able out come in
this case in clude a pos i tive spousal re la -
tion ship, high mo ti va tion, lack of a his -
tory of sex ual trauma, and di rect
in volve ment of the pa tient in cre at ing
and re vis ing the hi er ar chies.
Per haps fur ther stud ies on sex ual aver -
sion dis or der would bear out some of the
ob ser va tions made here. There may be a
sub group of pa tients with pri mary sex -
ual aver sion dis or der who re spond very
well to rel a tively lit tle in ter ven tion.
Ref er ences
1. Katz RC, Jar dine D. The re la tion ship be tween worry,
sex ual aver sion and low sex ual de sire. J Sex Mar i tal
Ther 1999;25:293–6.
2. Schover LR, LoPiccolo J. Treat ment ef fec tive ness
for dysfunctions of sex ual de sire. J Sex Mar i tal Ther
1982;8: 179–97.
3. Crenshaw TL. The sex ual aver sion syn drome. J Sex
Mar i tal Ther 1985;11:285–92.
4. Ponticas Y. Sex ual aver sion ver sus hypoactive sex ual
de sire: a di ag nos tic chal lenge. Psychiatr Med
1992;10:273–81.
5. Marks IM. Re view of be hav ioural psy cho ther apy, II:
sex ual dis or ders. Am J Psy chi a try 1981;138:750–6.
6. Crenshaw TL, Goldberg JP, Stern WC. Phar ma co -
log i cal mod i fi ca tion of psychosexual dys func tion. J
Sex Mar i tal Ther 1987;13:239–52.
Susan Finch, MD, CM, FRCPC
Duncan, British Columbia