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Introduction Recently the guidelines for the diagnosis of paraphilic disorders in the International Classification of Diseases and Related Health Problems, Eleventh Revision (ICD-11), have been published. Aim This article analyzes legal, regulatory, and policy issues relevant to the potential effects of the changes for the classification of paraphilic disorders in the ICD-11 in Germany. Methods A forensic and a legal expert in Germany worked with other international experts to conduct this evaluation using an assessment guide provided by the World Health Organization. Main Outcome Measures Possible effects of the changes for the classification of paraphilic disorders in the ICD-11 on forensic practice, health systems, adjudication of individuals who have committed a sexual offense, and the provision of treatment in Germany. Results Results highlight the special situation of medical confidentiality in the German health system that facilitates the establishment of preventive networks for the treatment of pedophilic patients. The ICD-11 guidelines will help to clarify the boundary between pedophilic disorder and crimes of child sexual abuse. These will also establish a boundary with other paraphilic diagnostic concepts. We describe the central construct of criminal responsibility in the German legal system in relation to paraphilic disorders, the prominent role of expert witnesses, and the differences in the conceptualization of medical confidentiality within the health care system and within the legal system. Clinical Implications The ICD-11 proposals for paraphilic disorders provide a clearer differentiation, as compared with ICD-10, between variants of normal sexual behavior and sexual behavior that involves a non-consenting person or entity. Particular patterns of sexual preference that are not of relevance to public health, the health care system, or the legal system, such as masochism and fetishism, will no longer be named psychiatric entities and will, therefore, be regarded as private behaviors and destigmatized. Strengths & Limitations The assessment shows the specific legal situation in Germany for the treatment of paraphilic patients in a sexual medicine, psychiatric, and legal discourse. However, it was done only by a small number of experts. Conclusion A conclusion of the analysis was that the more specific and narrower definitions in the ICD-11 diagnostic guidelines, compared with those in ICD-10, particularly for pedophilic disorder and coercive sexual sadism disorder, will result in a reduction in false-positive diagnoses. It is unlikely that significant unintended and negative consequences will occur as a result of implementing the ICD-11 guidelines for paraphilic disorders.

Background The diagnosis of paraphilic disorder is a complicated clinical judgment based on the integration of information from multiple dimensions to arrive at a categorical (present/absent) conclusion. The recent update of the guidelines for paraphilic disorders in ICD-11 presents an opportunity to investigate how mental health professionals use the diagnostic guidelines to arrive at a diagnosis which thereby can optimize the guidelines for clinical use. Aim This study examined clinicians’ ability to use the ICD-11 diagnostic guidelines for paraphilic disorders which contain multiple dimensions that must be simultaneously assessed to arrive at a diagnosis. Methods The study investigated the ability of 1,263 international clinicians to identify the dimensions of paraphilic disorder in the context of written case vignettes that varied on a single dimension only. Outcomes Participants provided diagnoses for the case vignettes along with dimensional ratings of the degree of presence of five dimensions of paraphilic disorder (arousal, consent, action, distress, and risk). RESULTS Across a series of analyses, clinicians demonstrated a clear ability to recognize and appropriately integrate the dimensions of paraphilic disorders; however, there was some evidence that clinicians may over-diagnose non-pathological cases. Clinical Translation Clinicians would likely benefit from targeted training on the ICD-11 definition of paraphilic disorder and should be cautious of over-diagnosing. Strengths and Limitations This study represents a large international sample of health professionals and is the first to examine clinicians’ ability to apply the ICD-11 diagnostic guidelines for paraphilic disorders. Important limitations include not generalizing to all clinicians and acknowledging that results may be different in direct clinical interactions vs written case vignettes. CONCLUSION These results indicate that clinicians appear capable of interpreting and implementing the diagnostic guidelines for paraphilic disorders in ICD-11.

In 2013, the American Psychiatric Association (APA) published the 5th edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5). In 2019, the World Health Assembly approved the 11th revision of the International Classification of Diseases (ICD-11). It has often been suggested that the field would benefit from a single, unified classification of mental disorders, although the priorities and constituencies of the two sponsoring organizations are quite different. During the development of the ICD-11 and DSM-5, the World Health Organization (WHO) and the APA made efforts toward harmonizing the two systems, including the appointment of an ICD-DSM Harmonization Group. This paper evaluates the success of these harmonization efforts and provides a guide for practitioners, researchers and policy makers describing the differences between the two systems at both the organizational and the disorder level. The organization of the two classifications of mental disorders is substantially similar. There are nineteen ICD-11 disorder categories that do not appear in DSM-5, and seven DSM-5 disorder categories that do not appear in the ICD-11. We compared the Essential Features section of the ICD-11 Clinical Descriptions and Diagnostic Guidelines (CDDG) with the DSM-5 criteria sets for 103 diagnostic entities that appear in both systems. We rated 20 disorders (19.4%) as having major differences, 42 disorders (40.8%) as having minor definitional differences, 10 disorders (9.7%) as having minor differences due to greater degree of specification in DSM-5, and 31 disorders (30.1%) as essentially identical. Detailed descriptions of the major differences and some of the most important minor differences, with their rationale and related evidence, are provided. The ICD and DSM are now closer than at any time since the ICD-8 and DSM-II. Differences are largely based on the differing priorities and uses of the two diagnostic systems and on differing interpretations of the evidence. Substantively divergent approaches allow for empirical comparisons of validity and utility and can contribute to advances in the field.

Objectives: The present study aims to evaluate existing policy and practice relating to the use of pharmacological treatments with patients suffering from paraphilic disorders who are at risk of committing further sexual offences. Methods: A systematic literature search was conducted to document current legal policies across 26 different countries. In addition, a questionnaire assessing the practice of pharmacological treatment was sent to practitioners involved in the treatment of patients with paraphilic disorders. Results: Legal policies concerning the preconditions of using pharmacological treatments differ considerably between countries, and for most jurisdictions do not exist. Drawing on the responses of 178 practitioners, pharmacological agents are a useful addition to psychotherapeutic interventions, especially with those patients classified as medium or high risk for sexually violent behaviours. It would appear that most patients are medically examined, are informed of the risks and possible side effects before treatment commences and are also obliged to sign a consent form. Conclusions: Although pharmacological agents can be seen as an intrusion into a patients’ sexual self determination, results indicate that ethical and clinical standards are being met in the majority of cases. However, further promotion of current WFSBP treatment guidelines would help to standardise practice across North American and European countries.

The World Health Organization is currently developing the 11th revision of the International Classifications of Diseases and Related Health Problems (ICD-11), with approval of the ICD-11 by the World Health Assembly anticipated in 2018. The Working Group on the Classification of Sexual Disorders and Sexual Health (WGSDSH) was created and charged with reviewing and making recommendations for categories related to sexuality that are contained in the chapter of Mental and Behavioural Disorders in ICD-10 (World Health Organization 1992a). Among these categories was the ICD-10 grouping F65, Disorders of sexual preference, which describes conditions now widely referred to as Paraphilic Disorders. This article reviews the evidence base, rationale, and recommendations for the proposed revisions in this area for ICD-11 and compares them with DSM-5. The WGSDSH recommended that the grouping, Disorders of sexual preference, be renamed to Paraphilic Disorders and be limited to disorders that involve sexual arousal patterns that focus on non-consenting others or are associated with substantial distress or direct risk of injury or death. Consistent with this framework, the WGSDSH also recommended that the ICD-10 categories of Fetishism, Fetishistic Transvestism, and Sadomasochism be removed from the classification and new categories of Coercive Sexual Sadism Disorder, Frotteuristic Disorder, Other Paraphilic Disorder Involving Non-Consenting Individuals, and Other Paraphilic Disorder Involving Solitary Behaviour or Consenting Individuals be added. The WGSDSH’s proposals for Paraphilic Disorders in ICD-11 are based on the WHO’s role as a global public health agency and the ICD’s function as a public health reporting tool. Electronic supplementary material The online version of this article (doi:10.1007/s10508-017-0944-2) contains supplementary material, which is available to authorized users.

The letter by Kraus et al. (2018) published recently in World Psychiatry presents diagnostic criteria for compulsive sexual behaviors (CSBs). Here, we discuss the potential impact of including CSB disorder in ICD-11 for four areas: educational efforts related to CSB (for both clinicians and patients), investigation of underlying mechanisms and subtypes, development of personalized treatment frameworks, and answering socially important questions and advancing important prevention efforts and effective policies. Each of these four areas has their own challenges that should be addressed, and we briefly describe and discuss them. We hope that this information will help continue a dialog and provide a framework for moving forward in this area.

Use of the Internet has been increasingly associated with sexual behaviors. Referred to as online sexual activity, these sexual behaviors include cybersexual behavior and pornography usage. Child custody evaluators are increasingly being asked to assess the impact of these behaviors on child custody and visitation determinations. In this article, we review the Internet-related sexual behaviors of cybersex and pornography usage, which have been associated with an increased risk of compulsive sexual behavior. Gender differences, general effects of pornography, and the effects of cybersex on the family are reviewed. Healthy sexuality and normative sexual behaviors in children are described. Legal issues and case law are comprehensively reviewed.

In the World Health Organization's forthcoming eleventh revision of the International Classification of Diseases and Related Health Problems (ICD-11), substantial changes have been proposed to the ICD-10 classification of mental and behavioural disorders related to sexuality and gender identity. These concern the following ICD-10 disorder groupings: F52 Sexual dysfunctions, not caused by organic disorder or disease; F64 Gender identity disorders; F65 Disorders of sexual preference; and F66 Psychological and behavioural disorders associated with sexual development and orientation. Changes have been proposed based on advances in research and clinical practice, and major shifts in social attitudes and in relevant policies, laws, and human rights standards. This paper describes the main recommended changes, the rationale and evidence considered, and important differences from the DSM-5. An integrated classification of sexual dysfunctions has been proposed for a new chapter on Conditions Related to Sexual Health, overcoming the mind/body separation that is inherent in ICD-10. Gender identity disorders in ICD-10 have been reconceptualized as Gender incongruence, and also proposed to be moved to the new chapter on sexual health. The proposed classification of Paraphilic disorders distinguishes between conditions that are relevant to public health and clinical psychopathology and those that merely reflect private behaviour. ICD-10 categories related to sexual orientation have been recommended for deletion from the ICD-11.

This chapter will review the noncontact crimes of exhibitionism, voyeurism, possession of child pornography, and interacting with children over the Internet. Epidemiology, comorbidity, offender characteristics, risk of recidivism, relevant diagnoses according to DSM-IV-TR and NB-DSM-5 including methods for making them, and relevant treatment modalities will be discussed. Diagnostic methods and issues are relevant to all of these disorders; so a brief discussion of methods and limitations of diagnosis relevant to all of these disorders will be made initially. Finally, conclusions and future directions will be given. It should be noted that while an attempt will be made to be thorough in literature selection, the broad scope of this chapter makes an exhaustive review, particularly of the psychometric properties of assessment and actuarial instruments, impossible. Literature will be confined to those aspects most salient to these noncontact offenses.

I reviewed the empirical literature for 1900-2008 on the paraphilia of Sexual Masochism for the Sexual and Gender Identity Disorders Work Group for the forthcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. The results of this review were tabulated into a general summary of the criticisms relevant to the DSM diagnosis of Sexual Masochism, the assessment of Sexual Masochism utilizing the DSM in samples drawn from forensic populations, and the assessment of Sexual Masochism using the DSM in non-forensic populations. I concluded that the diagnosis of Sexual Masochism should be retained, that minimal modifications of the wording of this diagnosis were warranted, and that there was a need for the development of dimensional and structured diagnostic instruments. It should be noted that this summary reflects my original literature review. Subsequently, interactions with other members of the workgroup and advisors have resulted in modification of these initial suggestions.

Objective: This study was conducted to describe Axis I sexual diagnoses of 60 males arrested for possession of child pornography obtained via the Internet and/or attempting to meet children via the Internet.Methods: Data was obtained from a chart review of evaluations conducted on 60 males referred for a psychosexual evaluation following an arrest for possession of child pornography and/or attempting to meet children. All crimes involved use of the Internet. Information obtained from the chart review was entered into SAS. All diagnoses were made according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Simple descriptive statistics were computed and cross tabulations were tested for significance using χ2 or Fisher's Exact test.Results: Of the total sample, 40% had at least one paraphilia. Thirty-one percent had a diagnosis of pedophilia and 18% of a paraphilia not otherwise specified (NOS). Thirty-three percent had a sexual disorder NOS, characterized by hypersexuality. Seventy percent of the total sample had an Axis I disorder that antedated and was judged to be contributory to the behavior leading to their arrest.Conclusions: This sample of men arrested for committing crimes against children and adolescents via the Internet has a high incidence of lifetime sexual and other psychopathology.

PURPOSE OF REVIEW: Traumatic brain injury (TBI) is one of the leading causes of permanent disability in young adults and is frequently accompanied by changes in sexual behaviors. Satisfying sexuality is an important factor for overall quality of life in people with disabilities. The purpose of this article is to review the studies evaluating the assessment, correlates and management of sexuality following TBI. RECENT FINDINGS: The Brain Injury Questionnaire of Sexuality is the first validated questionnaire specifically developed for adults with TBI. A considerable amount of individuals with TBI show inappropriate sexual behaviors and sexual dysfunctions. Whereas inappropriate sexual behaviors are related to younger age, less social participation and more severe injuries, sexual dysfunctions show an association with higher fatigue, higher depression scores, less self-esteem and female sex. Healthcare professionals have suggested that because of discomfort at the individual or institutional level, sexual problems are often not sufficiently addressed and have suggested that a specialist should treat sexual problems. SUMMARY: Although some important correlates of sexual problems could be identified, methodological differences across studies limit their comparability. Furthermore, there is an absence of evidence-based treatment strategies for addressing sexual problems. Therapeutic efforts should take into account the identified correlates of sexual problems following TBI. Language: en

In this article, the second of a two-part series, the authors present information on the clinical assessment of individuals with paraphilias and hypersexual disorders. They review ethical considerations in the assessment and treatment of individuals with paraphilias. The role of interview and subjective and objective instruments in the assessment of individuals with paraphilias and hypersexual disorders is discussed. The authors discuss the use of penile plethysmography or phallometry, polygraphy, and viewing time assessments. Risk assessment of sexual offenders is reviewed. The authors then discuss behavioral, environmental, and psychopharmacological treatments for paraphilias and hypersexual disorders. Cognitive-behavioral therapy appears to be the most effective nonpharmacological strategy. The authors describe cognitive-behavioral techniques for decreasing and/or controlling sexual urges (e.g., satiation, covert sensitization, fading, cognitive restructuring, victim empathy therapy) as well as methods for enhancing appropriate sexual interest and arousal (e.g., social skills training, assertiveness skills training, sex education, couples therapy). The authors also discuss the role of relapse prevention therapy and 12-step programs, as well as other nonbiological therapies such as surveillance networks. The importance of providing appropriate treatment for comorbid conditions (e.g., depression, substance abuse or dependence) is stressed. The authors then review psychopharmacological treatments, including serotonin reuptake inhibitors (SRIs) and antiandrogens, in particular, the use of gonadotropin-releasing hormone (GNRH) agonists. SRIs have been studied in these disorders in an uncontrolled way and appear promising. Earlier antiandrogens (e.g., estrogen, progesterone, and cyproterone acetate) have demonstrated efficacy in the treatment of paraphilias. The newer GNRH agonists have the advantage over the earlier treatments of being available in long-acting depot formulations and having fewer side effects. Preliminary studies and case reports with these agents appear promising. Further study of both the SRIs and GNRH agonists in these disorders is needed. The article concludes with a treatment algorithm, in which the authors suggest beginning with less restrictive treatments (e.g., behavioral or verbal therapies), if possible, and moving to more restrictive alternatives (e.g., biological therapies, institutionalization) as needed. A guide for clinicians and patients about where and how to find appropriate clinicians and treatment resources in the United States is provided.

In this article, the first of a two-part series, the authors present reasons for considering the paraphilic and hypersexual disorders together and provide an overview of these disorders. The DSM-IV diagnostic criteria for paraphilias are reviewed, and proposed criteria for hypersexual disorders are presented. The question of whether the paraphilic and hypersexual disorders should be considered within the spectrum of obsessive-compulsive disorders is considered. The authors then review the epidemiology of these disorders, and discuss some implications of recent sexual predator legislation. The authors discuss the etiology of the paraphilias and hypersexual disorders, and consider the role of endocrinological function, findings from brain imaging and neuropsychological testing, findings from primate research, the monoamine hypothesis, the imprinting hypothesis, social learning theory, the concept of courtship disorder, the role of obsessive-compulsive elements, psychodynamic theories, and genetic factors. The phenomenology of the paraphilias and hypersexual disorders is discussed, including the tendency for multiple paraphilias to co-occur, the lack of a specific offender profile, the predominance of males among those with paraphilias, the incidence of a history of victimization in individuals with paraphilias and compulsive sexual disorders, the onset and course of both types of disorders, and the lack of internal motivation for change in individuals with paraphilias and hypersexual disorders. The authors then discuss disorders that commonly co-occur with paraphilias and compulsive sexual disorders, including mood disorders, substance abuse and dependence disorders, attention-deficit/hyperactivity disorder, anxiety and impulse control disorders, and personality disorders. The second article in the series will discuss the clinical assessment and the behavioral and psychopharmacological treatment of these disorders. A guide for clinicians and patients on where and how to find specialized clinicians and treatment resources in the United States will also be provided. (Journal of Psychiatric Practice 2001;7:391–403)

A new class of antiandrogen medications, gonadotropin-releasing hormone agonists, offers promise in the treatment of the paraphilias, with substantially less side effects than medroxyprogesterone acetate or cyproterone acetate. This paper reports the results of treatment using a depot suspension of leuprolide acetate on 12 patients with paraphilic disorders or with sexual disorders not otherwise specified to suppress or help these individuals control their deviant sexual behavior or impulses. The method involved uncontrolled observations of individuals treated with depot-leuprolide acetate for various lengths of time, from 6 months to 5 years, with the follow-up intervals ranging from 6 months to 6 years. Leuprolide acetate resulted in a significant suppression of deviant sexual interests and behavior as measured by self-report and was well tolerated. However, the three patients who were on long-term therapy developed bone demineralization, suggesting that this is a significant side effect of prolonged therapy. Leuprolide acetate shows promise as a treatment for the paraphilias.

This article reviews hypersexuality in individuals with neuropsychiatric disorders and its psychopharmacologic treatment. A brief review of the neurology, neuroendocrinology, and neuropharmacology of sexual behavior is presented. Literature describing the occurrence and treatment of hypersexuality in individuals with neuropsychiatric disorders is reviewed along with literature which discusses the pharmacologic treatment of individuals with hypersexual disorders in nonneuropsychiatric populations. Finally, a clinical algorithm for approaching and treating such disorders in a neuropsychiatric population is presented.

Clinical Management of Sex Addiction is divided into four sections: one discussing the early stages of the “addiction” process, one discussing treatment and therapy, one discussing special populati...

The DSM-5 has been under revision since 1999 and is scheduled for publication in 2013. This article will review the major proposed modifications of the Paraphilias.The information reviewed was obtained from PubMed, PsychInfo, the DSM-5.org website and other sources and reviewed.Pedohebephilia, Hypersexual Disorder and Paraphilic Coercive Disorder are new proposed diagnoses. Paraphilias have been assigned their own chapter in DSM- 5 and a distinction has been made between Paraphilias and Paraphilic Disorders. Victim numbers have been included in diagnosis of paraphilias that involve victims and remission and severity measures have been added to all paraphilias. Transvestic Disorder can apply to males or females, Fetishistic Disorder now includes partialism, and Sexual Masochism Disorder has Asphyxiophilia as a specifier.This study is based on a literature review and influenced by the knowledge and biases of the authors.The Paraphilic Disorders Section of the DSM-5 represents a significant departure from DSMIV-TR.

Sexual offenders continue to occupy the public's attention; a significant proportion of this population is diagnosed with paraphilias. Cognitivebehavioral treatment has been the mainstay of treatment for sex offenders and for the paraphilias for the past three decades. This article will review the history of cognitivebehavioral therapy, its techniques, and its efficacy.A literature review was conducted of PubMed and PsychInfo Databases.A significant literature exists describing cognitive-behavioral therapy and presenting outcome studies and meta-analyses evaluating its efficacy.This study is based on a literature review and influenced by the knowledge and biases of the authors.Cognitive-behavioral therapy is the most prominent therapy for sexual offenders. Although reports from individual programs and meta-analyses support its efficacy, overall, the strength of the evidence base supporting this therapy is weak and much more empirical research is needed.

This article reviews the current evidence base for the diagnosis, assessment, and treatment of hypersexual conditions. Controversy concerning this diagnosis is discussed. Terminology and diagnostic criteria, as well as psychological, psychopharmacological, and other treatment approaches, are presented.

I reviewed the empirical literature for 1900-2008 on the paraphilia of Sexual Sadism for the Sexual and Gender Identity Disorders Workgroup for the forthcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The results of this review were tabulated into a general summary of the criticisms relevant to the DSM diagnosis of Sexual Sadism, the assessment of Sexual Sadism utilizing the DSM in samples drawn from forensic populations, and the assessment of Sexual Sadism using the DSM in non-forensic populations. I conclude that the diagnosis of Sexual Sadism should be retained, that minimal modifications of the wording of this diagnosis are warranted, and that there is a need for the development of dimensional and structured diagnostic instruments.

Moser (2001) has long been a consistent critic of the empirical basisof the inclusionofparaphilicdisorders in the APA’s diagnostic manuals and has, to date, already published two Letters to the Editor of this Journal critical of the Paraphilias Subworkgroup’s DSM-5 proposals (Moser, 2009, 2010b). InMoser’s (2010a)current lettercriticizingourproposal for Hypersexual Disorder as ‘‘just more muddled thinking,’’he restates many of the general criticisms that he has previously raised about paraphilic disorders. Interestingly, he agrees that ‘‘there are people who have difficulty controlling their sexual fantasies, urges, and behaviors’’and that‘‘these individuals may benefit frompsychiatric intervention’’butonlyasserts‘‘Thepresent formulationofHypersexualDisorderdoesnotdescribe these individuals.’’He offers no counter proposal as to how to better define such a condition. Many of his specific criticisms of Hypersexual Disorder reflect a combination of misunderstanding, omissions, dichotomous reductionism or an incomplete reading of the review which identifies the sources for the specific criteria for this proposed condition (Kafka, 2010). In addition, Moser applies an interpretation of each suggested criterion in a manner that overlooks the greater context of the forest for its trees. Moser asserts that‘‘Kafka’s proposed diagnostic criteria do not indicate that the sexual interest must be either non-paraphilic or have an impulsivity component.’’ In fact, all of the required behavioral specifiers (Kafka, 2010, Table 1, p. 379) associated with the operational definition of Hypersexual Disorder were deliberately chosen as non-paraphilic behaviors. Despite these specifiers being intrinsic to the diagnosis, he did not acknowledge them. In addition, when an enduring sexual behavior repetitively occurs in response to dysphoric affects (A2), stressful events (A3), include repetitive volitional impairment (A4), and persistent risk-taking behavior (A5), aren’t these characteristicsasufficient representationofan impulsivitycomponent? Pathological Gambling, a prototypical impulse control disorder in DSM-IV-TR, includes these same impulsivity-associated components (and others) as well (American Psychiatric Association, 2000). By isolating and criticizing the wording of each A criterion item, Moser completely misses the broader context required by the proposed diagnosis: it is not merely any single specific behavioral criterion that defines this syndrome, but that it is a polythetic mixture of four or more of these five behavioral descriptors of sexual behavior, a minimum persistence of at least6 months,and,most importantly, clinically significantdistress and/or role impairment (B criterion). It is the composite that constitutes a psychiatric disorder, not an isolated criterion item. Each selected criterion item has been selected from multiple published rating scales (Kafka, 2010, pp. 380–386). By analogy, isolating and then criticizing the relativity or inexactness of a single behavioral criterion, such as‘‘often has difficulty organizing tasks and activities,’’would misconstrue the polythetic contextuality and required degree of impairment requiredassociatedwiththediagnosisofAttentionDeficitHyperactivity Disorder, Inattentive Subtype. When discussing the B criterion for Hypersexual Disorder (significant distress and social role impairment), Moser’s M. P. Kafka (&) Harvard Medical School, Boston, MA, USA e-mail: mpkafka@rcn.com

This article provides a case report of a patient with pedophilia who was treated over a 4-year period with medroxyprogesterone acetate (MPA) at a dose of 300 mg/day and as a consequence developed Cushing's Syndrome and adrenal insufficiency, for which he was treated and from which he recovered. He also reported a hypersexual reaction to his own past cessation of MPA. Gonadotropin-releasing hormone agonists, which have a more benign side-effect profile than MPA, are suggested as an alternative to MPA.

Recent research has raised the possibility that electroconvulsive therapy (ECT) results in a persistent elevation of seizure threshold among males. In this study, seizure threshold, quantified by the method of limits procedure, was assessed at the first and last treatments of 148 consecutive depressed patients. Patients with and without a prior history of ECT did not differ in seizure threshold at the first treatment, seizure duration at the first treatment or averaged across all treatments, or in the magnitude of the seizure threshold increase over the ECT course. No evidence was obtained that history of ECT was associated with alterations of seizure threshold or seizure duration.