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 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 expert in fo ren sic psy - chi a try and an opin ion leader he is po - ten tially an im por tant agent in changing 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 recom - 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 liter - 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 either sup port or re fute the use of antilibidinal drugs, such as medroxyprogesterone, that it is dif fi cult to justify 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 studies show that MPA has a sig nif i cant im pact on de - viant sex ual fan ta sies and deviant sex ual urges and behaviour. 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 patients. 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. 1. Brad ford JMW. The neurobiology, neuropharmacology, and phar ma co log i cal treatment 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 opinion 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 citation 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 Medi - 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 prefer - 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 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 often part of a com pre hen sive ther a peu tic pro gram. Can J Psychiatry, Vol 46, August 2001 559

560 The Canadian Journal of Psychiatry Vol 46, No 6 An im bal ance in the serotonergic neuro - 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 ado - 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 maximum of 3 mg daily. Be hav ioural rat ings were carried 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 Impres - 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, including com plete blood count, liver func tion, elec tro lytes, glu cose, se rum urea nitro - gen, creatinine, uri nal y sis, and EEG, were also per formed 3 times during the study (at 3, 6, and 12 months). Blood pres sure was mon i tored during the first days of the trial. Side ef fects were evalu - ated using 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 basis of the CGI Scale. The Wilcoxon signed-rank test showed that the de - crease in the total 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 using the VSMS. Un to ward ef fects in cluded mild seda - tion (2 cases) and weight gain (1 case). One of the pa tients ex pe ri enced an epi - lep tic sei zure 6 months af ter starting risperidone ther apy. Liver func tion tests, EEG, and other lab o ra tory studies re mained within nor mal limits. Blood pres sure did not vary from nor mal val ues. Our study showed that risperidone was able to re duce self-abuse, aggression, and hy per ac tiv ity in au tis tic children. 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 further eval u ate the ef fi cacy of risperidone in treat ing au tism. 1. Cham ber lain RS and Herman BH. A novel bio chem i - cal model linking dysfunctions in brain melatonin, proopiomelanocortin peptides, 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 others. 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. National 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 others. 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 symptom 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 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 having been ob ses - sional and perfectionistic. Ini tially, he had re sponded pos i tively to citalopram at a dosage 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 depressive ill ness in his mother postmenopause, re - quir ing hos pi tal iza tion and responsive 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 evident 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 anxiety. The pa tient was taking 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 Letters to the Editor 561 de pres sion was ev i dent within 8 weeks, as re ported by the pa tient and his family 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 initial bupropion pre scrip tion. He dis con tin ued the bupropion and the symp toms re solved over 10 days. The de pres sion worsened, 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 exam - 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 suggests 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 interac - 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. 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 January 18, 2001. 2. Burda A, Web ster K, Leikin JB, Chan SB, Stokes KA. Nefazodone-in duced acute dystonic reaction. 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 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 psychia - 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 resi - dents in di cated that this training experi - 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 limited, sup port of fer ing com mu nity psy chi at ric elec tives to all stages of training in an ef - fort to en cour age a ca reer choice in this needed area. 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 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, educated, 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 Canadian Journal of Psychiatry 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 delu - sion of being 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 treatment with haloperidol (20 mg daily) com bined with carbamazepine (600 mg daily) she im - proved, ex cept for neg a tive symptoms. 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 hypno - 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 auditory hal lu ci na tions about la dies commenting about her and abus ing her. Her sleep and ap pe tite were dis turbed. She was diag - 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 gradually 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 helping with house hold work. The in ter est ing as pects of this case are its meta mor pho sis in terms of the evolu - 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 socio - eco nomic back ground in the In dian so ci ety. 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 State psy chi at ric clin ics in Is rael are open to the pub lic, en abling di rect ac cess to mental health care. Pa tients and their fam i lies, gen eral prac ti tio ners, and nonmedical agencies can re quest an in - ter ven tion from a mental 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 general prac ti tio - ners. Only 5% of calls came from pa tients. These rates con trasted with other reports (1). Di ag no ses were pri mary psy chotic ill - ness in 49% of the visits, or ganic mental 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 visits 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 visits 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 clinics (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 Letters to the Editor 563 one-quar ter of them. Actually, however, 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 community agen cies and the public may impose a great strain on com mu nity mental 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, combin - ing quan ti ta tive and qual i ta tive meth od ol o gies. 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 mobile 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 multiple vis its by a com mu nity mental 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 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-onset paraphrenia. We re port a study in ves ti gat ing the clini - 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 physi - 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 patients hal lu ci na tions and de lu sions, their vi - sual or hear ing im pair ments, and their prog no ses. To evaluate the rate of atro - 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 fissures. 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 hearing 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 areas. 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 (silent) ce - re bral infarctions, and all af fected pa - tients had subcortical or fron tal-lobe infarctions, with 1 pa tient also having 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 atrophy. 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. 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; distinct 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 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 touching 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 married for 5 years. She and her hus band had never con sum mated their mar riage. Both part - ners de scribed a loving 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 orientation.

564 The Canadian Journal of Psychiatry Vol 46, No 6 Ms G had never ex pe ri enced or gasm, even during sleep, and had never mastur - bated. She en joyed kiss ing and cud dling, but was un able to, or al low her husband to, proceed fur ther. She suf fered from re cur rent major de pres sive dis or der. At the time of as sess ment, she was suffer - 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 intro - 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 husband de velop com fort with nu dity and holding. 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 effec - tively treated her de pres sion. Simulta - 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 total 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 sexual 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). Moreover, the lit er a ture suggests a poor prog no sis for sex ual aver sion disorder especially, 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 studies 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 little in ter ven tion. 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 Marital 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 Marital 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