by the pines

Definition

Person-centered therapy, which is also known as client-centered, non-directive, or Rogerian therapy, is an approach to counseling and psychotherapy that places much of the responsibility for the treatment process on the client, with the therapist taking a nondirective role.

Purpose

Two primary goals of person-centered therapy are increased self-esteem and greater openness to experience. Some of the related changes that this form of therapy seeks to foster in clients include closer agreement between the client’s idealized and actual selves; better self-understanding; lower levels of defensiveness, guilt, and insecurity; more positive and comfortable relationships with others; and an increased capacity to experience and express feelings at the moment they occur.

Description

Background

Developed in the 1930s by the American psychologist Carl Rogers, client-centered therapy departed from the typically formal, detached role of the therapist emphasized in psychoanalysis and other forms of treatment. Rogers believed that therapy should take place in a supportive environment created by a close personal relationship between client and therapist. Rogers’s introduction of the term “client” rather than “patient” expresses his rejection of the traditionally hierarchical relationship between therapist and client and his view of them as equals. In person-centered therapy, the client determines the general direction of therapy, while the therapist seeks to increase the client’s insight and self-understanding through informal clarifying questions.

Beginning in the 1960s, person-centered therapy became associated with the human potential movement. This movement, dating back to the beginning of the 1900s, reflected an altered perspective of human nature. Previous psychological theories viewed human beings as inherently selfish and corrupt. For example, Freud’s theory focused on sexual and aggressive tendencies as the primary forces driving human behavior. The human potential movement, by contrast, defined human nature as inherently good. From its perspective, human behavior is motivated by a drive to achieve one’s fullest potential.

Self-actualization, a term derived from the human potential movement, is an important concept underlying person-centered therapy. It refers to the tendency of all human beings to move forward, grow, and reach their fullest potential. When humans move toward self-actualization, they are also pro-social; that is, they tend to be concerned for others and behave in honest, dependable, and constructive ways. The concept of self-actualization focuses on human strengths rather than human deficiencies. According to Rogers, self-actualization can be blocked by an unhealthy self-concept (negative or unrealistic attitudes about oneself).

Rogers adopted terms such as “person-centered approach” and “way of being” and began to focus on personal growth and self-actualization. He also pioneered the use of encounter groups, adapting the sensitivity training (T-group) methods developed by Kurt Lewin (1890-1947) and other researchers at the National Training Laboratories in the 1950s. More recently, two major variations of person-centered therapy have developed: experiential therapy, developed by Eugene Gendlin in 1979; and process-experiential therapy, developed by Leslie Greenberg and colleagues in 1993.

While person-centered therapy is considered one of the major therapeutic approaches, along with psychoanalytic and cognitive-behavioral therapy, Rogers’s influence is felt in schools of therapy other than his own. The concepts and methods he developed are used in an eclectic fashion by many different types of counselors and therapists.

Process

Rogers believed that the most important factor in successful therapy was not the therapist’s skill or training, but rather his or her attitude. Three interrelated attitudes on the part of the therapist are central to the success of person-centered therapy: congruence; unconditional positive regard; and empathy. Congruence refers to the therapist’s openness and genuineness—the willingness to relate to clients without hiding behind a professional facade. Therapists who function in this way have all their feelings available to them in therapy sessions and may share significant emotional reactions with their clients. Congruence does not mean, however, that therapists disclose their own personal problems to clients in therapy sessions or shift the focus of therapy to themselves in any other way.

Unconditional positive regard means that the therapist accepts the client totally for who he or she is without evaluating or censoring, and without disapproving of particular feelings, actions, or characteristics. The therapist communicates this attitude to the client by a willingness to listen without interrupting, judging, or giving advice. This attitude of positive regard creates a nonthreatening context in which the client feels free to explore and share painful, hostile, defensive, or abnormal feelings without worrying about personal rejection by the therapist.

The third necessary component of a therapist’s attitude is empathy (“accurate empathetic understanding”). The therapist tries to appreciate the client’s situation from the client’s point of view, showing an emotional understanding of and sensitivity to the client’s feelings throughout the therapy session. In other systems of therapy, empathy with the client would be considered a preliminary step to enabling the therapeutic work to proceed; but in person-centered therapy, it actually constitutes a major portion of the therapeutic work itself. A primary way of conveying this empathy is by active listening that shows careful and perceptive attention to what the client is saying. In addition to standard techniques, such as eye contact, that are common to any good listener, person-centered therapists employ a special method called reflection, which consists of paraphrasing and/or summarizing what a client has just said. This technique shows that the therapist is listening carefully and accurately, and gives clients an added opportunity to examine their own thoughts and feelings as they hear them repeated by another person. Generally, clients respond by elaborating further on the thoughts they have just expressed.

According to Rogers, when these three attitudes (congruence, unconditional positive regard, and empathy) are conveyed by a therapist, clients can freely express themselves without having to worry about what the therapist thinks of them. The therapist does not attempt to change the client’s thinking in any way. Even negative expressions are validated as legitimate experiences. Because of this nondirective approach, clients can explore the issues that are most important to them—not those considered important by the therapist. Based on the principle of self-actualization, this undirected, uncensored self-exploration allows clients to eventually recognize alternative ways of thinking that will promote personal growth. The therapist merely facilitates self-actualization by providing a climate in which clients can freely engage in focused, in-depth self-exploration.

Applications

Rogers originally developed person-centered therapy in a children’s clinic while he was working there; however, person-centered therapy was not intended for a specific age group or subpopulation but has been used to treat a broad range of people. Rogers worked extensively with people with schizophrenia later in his career. His therapy has also been applied to persons suffering from depression, anxiety, alcohol disorders, cognitive dysfunction, and personality disorders. Some therapists argue that person-centered therapy is not effective with non-verbal or poorly educated individuals; others maintain that it can be successfully adapted to any type of person. The person-centered approach can be used in individual, group, or family therapy. With young children, it is frequently employed as play therapy.

There are no strict guidelines regarding the length or frequency of person-centered therapy. Generally, therapists adhere to a one-hour session once per week. True to the spirit of person-centered therapy, however, scheduling may be adjusted according to the client’s expressed needs. The client also decides when to terminate therapy. Termination usually occurs when he or she feels able to better cope with life’s difficulties.

Normal results

The expected results of person-centered therapy include improved self-esteem; trust in one’s inner feelings and experiences as valuable sources of information for making decisions; increased ability to learn from (rather than repeating) mistakes; decreased defensiveness, guilt, and insecurity; more positive and comfortable relationships with others; an increased capacity to experience and express feelings at the moment they occur; and openness to new experiences and new ways of thinking about life.

Outcome studies of humanistic therapies in general and person-centered therapy in particular indicate that people who have been treated with these approaches maintain stable changes over extended periods of time; that they change substantially compared to untreated persons; and that the changes are roughly comparable to the changes in clients who have been treated by other types of therapy. Humanistic therapies appear to be particularly effective in clients with depression or relationship issues. Person-centered therapy, however, appears to be slightly less effective than other forms of humanistic therapy in which therapists offer more advice to clients and suggest topics to explore.

Abnormal results

If therapy has been unsuccessful, the client will not move in the direction of self-growth and self-acceptance. Instead, he or she may continue to display behaviors that reflect self-defeating attitudes or rigid patterns of thinking.

Several factors may affect the success of person-centered therapy. If an individual is not interested in therapy (for example, if he or she was forced to attend therapy), that person may not work well together with the therapist. The skill of the therapist may be another factor. In general, clients tend to overlook occasional therapist failures if a satisfactory relationship has been established. A therapist who continually fails to demonstrate unconditional positive regard, congruence, or empathy cannot effectively use this type of therapy. A third factor is the client’s comfort level with nondirective therapy. Some studies have suggested that certain clients may get bored, frustrated, or annoyed with a Rogerian style of therapeutic interaction.

Definition

Long-standing, deeply ingrained patterns of social behavior that are detrimental to those who display them or to others.

Description

Personality disorders constitute a separate diagnostic category (Axis II) in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders(DSM). Unlike the major mental disorders (Axis I), which are characterized by periods of illness and remission, personality disorders are generally ongoing. Often, they first appear in childhood or adolescence and persist throughout a person’s lifetime. Aside from their persistence, the other major characteristic of personality disorders is inflexibility. Persons affected by these disorders have rigid personality traits and coping styles, are unable to adapt to changing situations, and experience impaired social and/or occupational functioning. A further difference between personality disorders and the major clinical syndromes listed in Axis I of DSM-IV-TR(DSM, fourth edition, text revised) is that people with personality disorders may not perceive that there is anything wrong with their behavior and are not motivated to change it. Although the DSM-IV-TRlists specific descriptions of 10 personality disorders, these conditions are often difficult to diagnose. Some characteristics of the various disorders overlap. In other cases, the complexity of human behavior makes it difficult to pinpoint a clear dividing line between pathology and normality in the assessment of personality. In still other cases, persons may have more than one personality disorder, complicating the diagnosis. There also has been relatively little research done on some of the personality disorders listed in DSM-IV-TR.

The 10 personality disorders listed in DSM-IV-TRinclude:

• Paranoid personality disorder. The individual affected with this disorder believes in general that people will exploit, harm, or deceive him or her, even if there is no evidence to support this belief.
• Schizoid personality disorder. The individual with this disorder seems to lack desire for intimacy or belonging in a social group, and often chooses being alone to being with others. This individual also tends not to show a full range of emotions.
• Schizotypal personality disorder. With this disorder, the affected person is uncomfortable with (and may be unable to sustain) close relationships, and also has odd behaviors and thoughts that would typically be viewed by others as eccentric, erratic, and bizarre.
• Antisocial personality disorder. Individuals with this disorder have no regard for the rights of others. Other, recent names associated with this personality type are psychopath and sociopath. Unable to base their actions on anything except their own immediate desires, persons with this disorder demonstrate a pattern of impulsive, irresponsible, thoughtless, and sometimes criminal behavior. They are often intelligent, articulate individuals with an ability to charm and manipulate others; at their most dangerous, they can become violent criminals who are particularly dangerous to society because of their ability to gain the trust of others combined with their lack of conscience or remorse.
• Borderline personality disorder. People with this disorder are unstable in their relationships, decisions, moods, and self-perceptions. These individuals are often impulsive and insecure.
• Histrionic personality disorder. The behavior of individuals of this personality type is characterized by persistent attention-seeking, exaggerated emotional displays (such as tantrums), and overreaction to trivial problems and events.
• Narcissistic personality disorder. This disorder consists primarily of an inflated sense of self-importance coupled with a lack of empathy for others. Individuals with this disorder display an exaggerated sense of their own importance and abilities and tend to fantasize about them. Such persons also have a sense of entitlement, expecting (and taking for granted) special treatment and concessions from others. Paradoxically, individuals with narcissistic personality disorder are generally very insecure and suffer from low self-esteem.
• Avoidant personality disorder. This disorder has characteristics that resemble those of social phobia, including hypersensitivity to possible rejection and the resulting social withdrawal in spite of a strong need for love and acceptance. Individuals with this disorder are inhibited and feel inadequate in social situations.
• Dependent personality disorder. Persons with dependent personality disorder are extremely passive and tend to subordinate their own needs to those of others. Due to their lack of self-confidence, they avoid asserting themselves and allow others to take responsibility for their lives.
• Obsessive-compulsive personality disorder. This disorder is characterized by a preoccupation with orderliness, perfectionism, and control.

An additional category for personality disorders exists—personality disorder not otherwise specified. This category is reserved for clinicians’ use when they encounter a patient with symptoms similar to one of the above disorders, but the exact criteria for a specific disorder are not met.

Definition

Perphenazine is a phenothiazine antipsychotic used to treat serious mental disorders. It has also been used to treat severe nausea and vomiting. It is sold in the United States under the brand name Trilafon and is also available under its generic name.

Purpose

Perphenazine is used to treat psychotic disorders and severe nausea and vomiting.

Description

Perphenazine is one of many drugs in the class called phenothiazine derivatives. Phenothiazines work by inhibiting the actions of the brain chemicals, dopamine and norepinephrine, which are overproduced in individuals with psychosis.

Recommended dosage

For the treatment of psychosis, adults usually receive a total of 4 mg to 16 mg taken as tablets in three or four doses daily, up to a maximum of 64 mg each day. Injections of perphenazine are also available and are typically given in 5 mg doses every six hours, up to 15 mg per day. Hospitalized patients can receive up to 30 mg per day in the injectable form of perphenazine.

Adult patients with serious nausea and vomiting receive 8 mg to 16 mg per day as tablets in divided into several doses up to a maximum of 24 mg per day. Injections are typically given in 5 mg to 10 mg doses every six hours, up to 15 mg per day in patients who are not confined to bed. Hospitalized patients can receive up to a maximum of 30 mg per day. Intravenous perphenazine can be given to nausea and vomiting patients up to 1 mg every one to two minutes to a maximum of 5 mg.

The correct dosage of perphenazine must be carefully determined for each patient. Physicians try to find a dose that controls symptoms of the disease without causing intolerable side effects. Dosage guidelines for the treatment of psychosis have not been established for children under the age of 12 years. In children over age 12, the lowest adult dosage is generally used to treat psychosis. Children with severe nausea and vomiting are usually given 5 mg injections every six hours.

Precautions

Persons who take perphenazine should not stop taking the drug abruptly. Instead, the dose should be decreased gradually, then stopped. People who take perphenazine often have develop sunburn more easily than Sunscreen should be used by people, especially fair-skinned individuals, taking perphenazine.

People who are known to have severe central nervous system depression should not take perphenazine or any other drug in its class. In addition, those with a prior history of brain damage, coma, or bone marrow depression should not receive perphenazine without a thorough evaluation by a doctor.

Children under the age of 12 years, the elderly (over age 65), those with a history of epilepsy, glaucoma, prostate problems, severe asthma, and other severe breathing problems should receive perphenazine only with great caution and under close supervision of a physician. In addition, persons with a history of heart or blood vessel disease and those with a history of liver or kidney disease should take perphenazine only after a thorough evaluation. Perphenazine should also be used cautiously when taken over a long period. Rarely should perphenazine be taken by pregnant or nursing women.

Side effects

Serious or life-threatening side effects due to perphenazine are rare. However, if any of these occur, patients should contact their doctors or get immediate medical attention: seizures, irregular heartbeat, significant changes in blood pressure, muscle stiffness, weakness, pale skin color, and increased sweating. The treating doctor should be contacted immediately if any of these common side effects develop: rapid movements of the tongue, uncontrolled chewing movement, unusual amounts of lip smacking, and frequent movement of the arms or legs. The treating doctor should be contacted relatively soon if any of the following common side effects develop: reduced balance control, muscle spasms, restlessness, trembling, weakness in the limbs, blurred vision, and decreased night vision.

Less common side effects that need to be reported to the doctor include severe sunburn, skin rashes, and urination problems. Rare side effects that should be reported to the doctor include abdominal pain, muscle aches, joint aches, fever, chills, muscle weakness, and vomiting. Common and not serious side effects include constipation, drowsiness, decreased sweating, mouth dryness, and nasal congestion. Uncommon and not typically serious side effects include decreased sexual desire, increased susceptibility to sunburn, menstrual cycle changes, swelling or pain in the breasts, and weight gain.

Interactions

Combining perphenazine with drugs such as the anti-mallarials amodiaquine, chloroquine, and sulfadoxine-pyrimethamine (Fansidar) can increase the concentrations within the body of these three latter drugs.

Perphenazine combined with barbiturates tends to lower the concentrations of perphenazine in the body. Combining perphenazine with clonidine (Catapres), guanadrel (Hylorel), and guanethidine (Ismelin) can produce dangerously low blood pressure.

Perphenazine should not be combined with alcohol, because alcohol increases the drug’s depressive effect on the central nervous system. Perphenazine inhibits the effects of levodopa in Parkinson patients when the two are combined. Lithium combined with perphenazine lowers the levels of both drugs.

Perphenazine should not be combined with analgesics (pain killers) containing narcotics because of the combination increases depressive effects on the central nervous system. Orphenadrine (Norflex) combined with perphenazine can reduce the beneficial effects of perphenazine.

Definition

Pemoline is classified as a central nervous system (CNS) stimulant. It is sold in the United States under the brand names Cylert and PemADD and is also available under its generic name.

Purpose

Pemoline is used in combination with psychological, educational, and social support for the treatment of attention-deficit/hyperactivity disorder (ADHD).

Description

Pemoline is a central nervous system stimulant that derives at least some of its effects by increasing levels of dopamine in the brain. Dopamine is one of several neurotransmitters in the brain. Neurotransmitters are naturally occurring chemicals that regulate the transmission of nerve impulses from one cell to another. Mental and physical well-being are partially dependent on maintaining the proper balance among the various neurotransmitters in the brain.

Pemoline is similar in its effects to dextroamphetamine and methylphenidate, two other drugs used to treat ADHD, although it is not chemically related to these drugs. The mechanism of action of CNS stimulants in the treatment of ADHD is not totally clear, but probably includes increased mental alertness, decreased mental fatigue, and an increased sense of well-being.

Pemoline should not be used as a substitute for psychological, educational, and social support in treating ADHD. Because pemoline may be associated with liver toxicity (poisoning causing liver damage), it should be used only after other drugs to treat ADHD have been tried. Patients should try dextroamphetamine or methylphenidate first.

Pemoline is available in 18.75-mg, 37.5-mg, and 75-mg oral tablets and in 37.5-mg chewable tablets.

Recommended dosage

The dose of pemoline should be carefully adjusted to patient need. The initial dose of pemoline in children six years of age or older is 37.5 mg each morning. The dose may be increased by 18.75 mg each week to as much as 75 mg daily. Most people respond to doses ranging from 56.25 mg to 75 mg daily, although some people may require as much as 112.5 mg daily.

There is no need to continue pemoline indefinitely. Rather, patients should be evaluated both during therapy and during periods in which the medication is voluntarily stopped. In many situations, the drug may be safely discontinued altogether when the child reaches adolescence.

Precautions

Pemoline is associated with liver toxicity. Symptoms range from mild reversible changes in liver function tests to acute liver failure. The risk of liver damage should be weighed against any therapeutic benefit derived from treatment with pemoline. Therefore, if no therapeutic benefit is observed within three to four weeks of starting the drug, pemoline should be discontinued. In order to detect the early signs of liver damage, liver function tests should be performed before starting the drug and every two weeks while taking pemoline.

Because pemoline is a central nervous stimulant, physical or psychological addiction is possible in people who are emotionally unstable.

Side effects

Loss of appetite accompanied by weight loss generally occurs during the first few weeks after starting pemoline. With continued treatment, appetite and body weight usually stabilize.

,

Because it is a central nervous system stimulant, insomnia is a common side effect of pemoline.

The most serious side effect is liver toxicity. Liver toxicity is usually characterized by changes in liver function tests without obvious liver damage, but in rare cases, liver failure resulting in death or requiring a liver transplant has occurred.

Interactions

There are no scientific data concerning drugs that negatively interact with pemoline. However, because pemoline is considered a stimulant, other drugs with stimulant properties (caffeine, over-the-counter decongestants, amphetamines, antidepressants) may theoretically and inappropriately increase CNS stimulation.

Definition

Peer groups are an important influence throughout one’s life, but they are more critical during the developmental years of childhood and adolescence. There is often controversy about the influence of a peer group versus parental influence, particularly during adolescence. Recent studies show that parents continue to have significant influence, even during adolescence, a reassuring finding for many parents. It appears that the power of the peer group becomes more important when the family relationships are not close or supportive. For example, if the parents work extra jobs and are largely unavailable, their children may turn to their peer group for emotional support. This also occurs when the conflict between parents and children during adolescence, or at any time during a child’s development, becomes so great that the child feels pushed away and seeks closeness elsewhere. Most children and adolescents in this situation are not discriminating about the kind of group they join. They will often turn to a group simply because that group accepts them, even if the group is involved in illegal or negative activities. Gang involvement, for example, is a common form of organized—often antisocial—peer interaction. Gangs may be based on ethnicity, sex, and/or common activity. Most youths who join gangs come from families where drug and alcohol use, financial burdens, and broken relationships are common. The need for affiliation or closeness is often greater than the need to “do the right thing” for some adolescents who feel isolated and abandoned by members of their own family. Being part of a gang provides such individuals with acceptance and security not available at home or in other peer groups.

Membership in peer groups

Despite significant gains in diversity training, current studies continue to show that children are less likely to accept those who are different from themselves. The differences can be as obvious as physical impairments, or as subtle as differences in academic motivation. These rigid standards may create an atmosphere of exclusion for some children and adolescents that pushes them toward peer acceptance of any type.

Peer groups offer children and adults alike the opportunity to develop various social skills, such as leadership, sharing or teamwork, and empathy. Peer groups also offer the opportunity to experiment with new roles and interactions, similar to treatment groups, although they are less structured. It is for this reason that many children and adolescents drift from one group to another as they “find themselves,” or work toward formation of their relatively permanent identity.

Aggression in peer groups

Although bullying and teasing have long been part of peer group interactions, these negative behaviors have increased over the last decade, resulting in school violence in many instances. As children and adolescents feel marginalized from their peers, anger builds to a point of rage at times. It is at those times that violence erupts within the school or community setting.

Negative peer interactions also occur more frequently following friendships or romantic relationships that have gone sour. The level of harassment that many of these children—often young women—experience is great enough for parents to become involved. In some cases, it may be necessary to move the child to another school district. A potential remediation for these negative interactions includes more active teacher involvement when negative social interactions are observed.

Definition

Pedophilia is a paraphilia that involves an abnormal interest in children. A paraphilia is a disorder that is characterized by recurrent intense sexual urges and sexually arousing fantasies generally involving: nonhuman objects; the suffering or humiliation of oneself or one’s partner (not merely simulated); or animals, children, or other nonconsenting persons. Pedophilia is also a psychosexual disorder in which the fantasy or actual act of engaging in sexual activity with prepubertal children is the preferred or exclusive means of achieving sexual excitement and gratification. It may be directed toward children of the same sex or children of the other sex. Some pedophiles are attracted to both boys and girls. Some are attracted only to children, while others are attracted to adults as well as to children.

Pedophilia is defined by mental health professionals as a mental disorder, but the American legal system defines acting on a pedophilic urge as a criminal act.

Description

The focus of pedophilia is sexual activity with a child. Many courts interpret this reference to age to mean children under the age of 18. Most mental health professionals, however, confine the definition of pedophilia to sexual activity with prepubescent children, who are generally age 13 or younger. The term ephebophilia, derived from the Greek word for “youth,” is sometimes used to describe sexual interest in young people in the first stages of puberty.

The sexual behaviors involved in pedophilia cover a range of activities and may or may not involve the use of force. Some pedophiles limit their behaviors to exposing themselves or masturbating in front of the child, or fondling or undressing the child, but without genital contact. Others, however, compel the child to participate in oral sex or full genital intercourse.

The most common overt aspect of pedophilia is an intense interest in children. There is no typical pedophile. Pedophiles may be young or old, male or female, although the great majority are males. Unfortunately, some pedophiles are professionals who are entrusted with educating or maintaining the health and well-being of young persons, while others are entrusted with children to whom they are related by blood or marriage.

Causes and symptoms

Causes

A variety of different theories exist as to the causes of pedophilia. A few researchers attribute pedophilia along with the other paraphilias to biology. They hold that testosterone, one of the male sex hormones, predisposes men to develop deviant sexual behaviors. As far as genetic factors are concerned, as of 2002 no researchers have claimed to have discovered or mapped a gene for pedophilia.

Most experts regard pedophilia as resulting from psychosocial factors rather than biological characteristics. Some think that pedophilia is the result of having been sexually abused as a child. Still others think that it derives from the person’s interactions with parents during their early years of life. Some researchers attribute pedophilia to arrested emotional development; that is, the pedophile is attracted to children because he or she has never matured psychologically. Some regard pedophilia as the result of a distorted need to dominate a sexual partner. Since children are smaller and usually weaker than adults, they may be regarded as nonthreatening potential partners. This drive for domination is sometimes thought to explain why most pedophiles are males.

Symptoms

A pedophile is often very attractive to the children who are potential victims. Potential pedophiles may volunteer their services to athletic teams, Scout troops, or religious or civic organizations that serve youth. In some cases, pedophiles who are attracted to children within their extended family may offer to baby-sit for their relatives. They often have good interpersonal skills with children and can easily gain the children’s trust.

Some pedophiles offer rationalizations or excuses that enable them to avoid assuming responsibility for their actions. They may blame the children for being too attractive or sexually provocative. They may also maintain that they are “teaching” the child about “the facts of life” or “love”; this rationalization is frequently offered by pedophiles who have molested children related to them. All these rationalizations may be found in pornography with pedophilic themes.

Demographics

Pedophilia is one of the more common paraphilias; the large worldwide market for child pornography suggests that it is more frequent in the general population than prison statistics would indicate. Together with voyeurism and exhibitionism, pedophilia is one of the three paraphilias most commonly leading to arrest by the police.

The onset of pedophilia usually occurs during adolescence. Occasional pedophiles begin their activities during middle age but this late onset is uncommon. In the United States, about 50% of men arrested for pedophilia are married.

The frequency of behavior associated with pedophilia varies with psychosocial stress. As the pedophile’s stress levels increase, the frequency of his or her acting out generally rises also.

Pedophilia is more common among males than among females. In addition, the rate of recidivism for persons with a pedophilic preference for males is approximately twice that of pedophiles who prefer females.

Little is known about the incidence of pedophilia in different racial or ethnic groups.

Diagnosis

According to the Diagnostic and Statistical Manual of Mental Disorders,fourth edition text revised, the following criteria must be met to establish a diagnosis of pedophilia.

• Over a period of at least six months, the affected person experiences recurrent, intense and sexually arousing fantasies, sexual urges or actual behaviors involving sexual activity with a prepubescent child or children aged 13 or younger.
• The fantasies, sexual urges or behaviors cause clinically significant distress or impairment in social, occupational or other important areas of daily functioning.
• The affected person must be at least age sixteen and be at least five years older than the child or children who are the objects or targets of attention or sexual activity.

A diagnosis of pedophilia cannot be assigned to an individual in late adolescence (age 17 to 19) who is involved in an ongoing sexual relationship with a 12- or 13-year-old person.

In establishing a diagnosis of pedophilia, it is important for a mental health professional to determine if the patient is attracted to males, females or both. It is also important to determine whether incest is a factor in the relationship. Finally, the doctor must determine whether the pedophilia is exclusive or nonexclusive; that is, whether the patient is attracted only to children (exclusive pedophilia) or to adults as well as to children (nonexclusive pedophilia).

One difficulty with the diagnosis of the disorder is that persons with pedophilia rarely seek help voluntarily from mental health professionals. Instead, counseling and treatment is often the result of a court order. An interview that establishes the criteria for diagnosis listed above may be enough to diagnose the condition, or surveillance or Internet records obtained through the criminal investigation may also be used.

An additional complication in diagnosis is that the paraphilias as a group have a high rate of comorbidity with one another and an equally high rate of comorbidity with major depression, anxiety disorders, and substance abuse disorders. A person diagnosed with pedophilia may also meet the criteria for exhibitionism or for a substance abuse or mood disorder.

Treatments

In the earliest stages of behavior modification therapy, pedophiles may be narrowly viewed as being attracted to inappropriate persons. Such aversive stimuli as electric shocks have been administered to persons undergoing therapy for pedophilia. This approach has not been very successful.

In 2002, the most common form of treatment for pedophilia is psychotherapy, often of many years’ duration. It does not have a high rate of success in inducing pedophiles to change their behavior.

Pedophilia may also be treated with medications. The three classes of medications most often used to treat pedophilia (and other paraphilias) are: female hormones, particularly medroxyprogesterone acetate, or MPA; luteinizing hormone-releasing hormone (LHRH) agonists, which include such drugs as triptorelin (Trelstar), leuprolide acetate, and goserelin acetate; and anti-androgens, which block the uptake and metabolism of testosterone as well as reducing blood levels of this hormone. Most clinical studies of these drugs have been done in Germany, where the legal system has allowed their use in treating repeat sexual offenders since the 1970s. The anti-androgens in particular have been shown to be effective in reducing the rate of recidivism.

Surgical castration is sometimes offered as a treatment to pedophiles who are repeat offenders or who have pleaded guilty to violent rape.

Increasingly, pedophiles are being prosecuted under criminal statutes and being sentenced to prison terms. Imprisonment removes them from society for a period of time but does not usually remove their pedophilic tendencies. In 2002, many states have begun to publish the names of persons being released from prison after serving time for pedophilia. Legal challenges to this practice are pending in various jurisdictions.

Prognosis

The prognosis of successfully ending pedophilic habits among persons who practice pedophilia is not favorable. Pedophiles have a high rate of recidivism; that is, they tend to repeat their acts often over time.

The rate of prosecution for pedophiles through the criminal justice system has increased in recent years. Pedophiles are at high risk of being beaten or killed by other prison inmates. For this reason, they must often be kept isolated from other members of a prison population. Knowledge of the likelihood of abuse by prison personnel and inmates is not, however, an effective deterrent for most pedophiles.

Prevention

The main method for preventing pedophilia is avoiding situations that may promote pedophilic acts. Children should never be allowed to in one-on-one situations with any adult other than their parents or trustworthy family members. Having another youth or adult as an observer provides some security for all concerned. Conferences and other activities can be conducted so as to provide privacy while still within sight of others.

Children should be taught to yell or run if they are faced with an uncomfortable situation. They should also be taught that it is acceptable to scream or call for help in such situations.

Another basis of preventing pedophilia is education. Children must be taught to avoid situations that make them vulnerable to pedophiles. Adults who work with youth must be taught to avoid situations that may be construed as promoting pedophilia.

Many states have adopted legislation that requires periodic background investigations of any adult who works with children. These persons may be paid, such as teachers, or they may be volunteers in a youth-serving organization.

The Boy Scouts of America has tried to address the problem of pedophilia by creating a training program that is required for all adults in the organization. All applications for volunteers are reviewed and approved by several persons. Adults and youth are required to use separate facilities on all activities. Secret meetings and one-on-one interactions between adults and youth are prohibited. This program has received several national awards.

Definition

Pathological gambling disorder occurs when a person gambles compulsively to such an extent that the wagering has a severe negative effect on his or her job, relationships, mental health, or other important aspects of life. The person may continue to gamble even after they have developed social, economic, interpersonal, or legal problems as a result of the gambling.

Description

Pathological gambling disorder is characterized by uncontrollable gambling well beyond the point of a social or recreational activity, such that the gambling has a major disruptive effect on the gambler’s life. People who are pathological gamblers may lose their life savings, and may even commit crimes (stealing, embezzling, or forging checks) to get money for their “habit.” Relationships and jobs may also be lost as a result of the disorder.

Pathological gambling disorder is an example of a process, or behavioral, addiction, as distinct from an addiction to such substances as food, drugs, tobacco, or alcohol. In process addictions, the characteristic “rush” or “high” comes from the series of steps or actions that are involved in the addictive behavior. With gambling, the “high” may be stimulated by the social atmosphere or group setting of the casino, race track, or bingo hall as well as by the excitement of risk-taking. Some gamblers have a “lucky” outfit, item of clothing, or accessory that they wear or take along when gambling; sometimes putting on the outfit or item in question is enough to start the “rush.”

People with pathological gambling disorder may engage in many different types of gambling activities. These may include games of chance that are found in casinos, such as slot machines, card games, and roulette. Many of these games are now available on the Internet, the chief difference being that the bettor uses a credit card instead of cash or chips. Other gambling activities may include the state lottery, horse or dog racing, or even bingo. The person may place bets on the outcome of an election, baseball or football games, or even the weather on a particular day. Pathological gambling usually develops slowly over time; people tend to begin with acceptable levels of social or recreational gambling and slowly progress to pathological gambling. In most cases the disorder develops slowly over a period of years; however, there are cases of patients who gambled socially for decades and then began to gamble compulsively under the impact of a major life stressor, such as divorce or being laid off from work.

Causes and symptoms

Causes

There are no known biological causes of pathological gambling disorder. Some studies have found interesting differences between compulsive gamblers and the general population on the biological level, but none that are thought to be an actual cause of pathological gambling. Many people, however, have significant psychological causes for excessive gambling. They may use gambling as an emotional escape from depression; this pattern appears more often in females with the disorder than in males. Some people who are pathologic gamblers are seeking the mood alteration associated with gambling— specifically the excitement and energy that they find in the activity— more than the money involved. In other words, the person with the disorder is reinforced by an emotional “high” rather than by the money itself. Some researchers have found that males diagnosed with pathological gambling disorder were more likely to have been diagnosed with attention-deficit/hyperactivity disorder as children than males in the general population. Other researchers have described compulsive gamblers in general as highly competitive people who are restless and easily bored.

Other theories about the causes of pathological gambling emphasize cognitive distortions rather than mood problems. Pathological gambling has been associated with dysfunctional thinking patterns; many people with this disorder are highly superstitious or believe that they can control the outcome of events when they are gambling. Many people diagnosed with the disorder also have distorted beliefs about money, tending to see it at the same time as the source of all their problems and the answer to all their problems. Patients diagnosed with pathological gambling disorder have an increased risk of either having or developing histrionic, narcissistic, or borderline personality disorder.

One social change that has been linked with the rise in the number of adults diagnosed with pathological gambling disorder in the United States is the increased availability of legalized gambling.

Definition

Passionflower (Passiflora incarnata) is a vine whose leaves and flowers are widely used in Europe to make a herbal remedy for anxiety and insomnia. The plant, which is native to the tropical regions of North America, was first used by the Aztecs of Mexico as a folk remedy for these conditions. Passionflower is also known as maypop, apricot vine, passion vine, and granadilla. It grows as much as 30 ft (10 m) tall, with a thick, woody stem.

Passionflower received its name from the sixteenth-century conquistadors who claimed Mexico for the Spanish Empire. The priests and soldiers who accompanied Hernando Cortez thought that the whitish-purple flowers of the vine symbolized certain features of the passion of Christ. The corona in the center of the flower reminded them of Christ’s crown of thorns, the five stamens of the number of Christ’s wounds, and the tendrils of the whips that were used to scourge Christ.

Purpose

Passionflower is still used as a sedative and anxiolytic, although far more frequently in Great Britain and Europe than in the United States. In Britain, passionflower is the single most common ingredient in herbal sedatives, and the German Commission E approved it for use as a tranquilizer. It is also used in homeopathic remedies. In addition to its long-standing uses as a remedy for anxiety and insomnia, passionflower has also been recommended for the treatment of gastrointestinal disorders related to anxiety; asthma; tachycardia (an abnormally rapid heartbeat); menstrual cramps; seizures; attention-deficit/hyperactivity disorder; and hysteria. A topical preparation made from passionflower has been used to treat hemorrhoids.

The parts of the plant that grow above the ground are gathered to make passionflower preparations. They may be used either fresh or dried. The most common sources of the passionflower that is used today are India, the West Indies, and the southern United States, even though the vine can also be grown in Mexico and Latin America.

Description

Passionflower preparations may be made from the flowers, leaves, or shoots of the plant. After the first fruits of the plant have matured, younger shoots growing 12.7–17.8 cm. above the ground are harvested and air-dried. The plant material is then used to prepare infusions, teas, liquid extracts, and tinctures of passionflower. In Europe, passionflower is often combined with lemon balm or valerian to make a sedative tea. The standardized formula approved by the German Commission E contains 30% passionflower, 40% valerian root, and 30% lemon balm. Passionflower is also used to make a special sedative tea for children, which typically includes 30% passionflower, 30% lemon balm, 30% lavender flower, and 10% St. John’s wort. Passionflower is sometimes combined with hawthorn to make a remedy for stomach cramps associated with gastritis.

Although passionflower has been shown in animal studies to have sedative and antispasmodic effects, researchers are not yet certain which compounds in the plant have these properties. Passionflower is known to contain flavonoids and a group of alkaloid compounds that include harman, harmine, harmaline, and harmalol. Some researchers have hypothesized that the medicinal effects of passionflower derive from a combination of these substances rather than from any of them in isolation. A recent Swiss study, however, appears to indicate that a flavonoid called chrysin may be the source of passionflower’s anxiolytic properties.

Recommended dosage

As the German recipe indicates, passionflower is considered safe for children. Dosages for children should be calculated on the basis of the child’s weight. Since most adult dosages of herbal remedies assume an average adult weight of 150 lb (70 kg), a child weighing 50 lb (23 kg) can be given 1/3 of the adult dose.

Recommended adult doses of passionflower are as follows:

• • Infusion: 2–5 g of dried herb, up to three times daily
• • Fluid extract (1:1 ratio in a solution of 25% alcohol):0.5–1.0 mL up to three times daily
• • Tincture (1:5 ratio in a solution of 45% alcohol):0.5–2.0 mL up to three times daily.

Precautions

Passionflower should not be used in doses higher than the recommended levels. Because it has a sedative effect, it should not be combined with alcoholic beverages or prescription sedatives. Passionflower should not be used by pregnant or lactating women, or for children under six months old.

Side effects

As of 2002, passionflower has not been reported to cause any significant side effects when taken at recommended dosage levels.

Interactions

The alkaloids found in passionflower, especially harman and harmaline, may increase the effects of a class of prescription antidepressants called monoamine oxidase inhibitors (MAOIs). These drugs are most often prescribed for depression, panic attacks, and eating disorders. Passionflower may also increase the effects of over-the-counter sedatives as well as prescription sedatives.

Definition

Paroxetine is an antidepressant of the type known as selective serotonin reuptake inhibitors (SSRI). It is sold in the United States under the brand name Paxil.

Purpose

Paroxetine is approved by the United States Food and Drug Administration (FDA) for treatment of depression and for the following anxiety disorders: obsessive-compulsive disorder, panic disorder, generalized anxiety disorder, post-traumatic stress disorder, and social anxiety disorder.

Description

Paroxetine increases the amount of serotonin (also called 5-HT) available in the brain. Serotonin is a neurotransmitter, or chemical in the brain that carries nerve impulses from a sending neuron (nerve cell) to a receiving neuron. The sending neuron releases serotonin into a little gap between neurons, called the synapse. The receiving neuron picks up the serotonin from the synapse, allowing the nerve impulse to continue on its way.

Researchers think that depression and certain other disorders may be caused, in part, because there is not enough available serotonin in the brain. Normally, once a nerve impulse has crossed the synapse, serotonin is reabsorbed by the sending neuron that released it. Once reabsorbed, this serotonin is no longer available and cannot interact with a receiving neuron. Paroxetine blocks the reabsorption, or re-uptake, of serotonin, leaving it available to stimulate receiving neurons. Therefore, paroxetine facilitates the transmission of nerve impulses by increasing available serotonin in the brain and thus increasing its effectiveness.

Paroxetine is an antidepressant that is virtually completely absorbed via oral administration. Food does not reduce its absorption.

The benefits of paroxetine develop slowly over a period of up to four weeks. Patients should be aware of this and continue to take the drug as directed, even if they feel no immediate improvement.

Recommended dosage

The recommended dosage of paroxetine is 20–50 mg per day. The drug should be taken only once per day. An appropriate initial dosage is 20 mg. Dosage changes should not be made more frequently than once per week.

The recommended dosage for older persons or individuals with liver or kidney disease is 10 mg per day. The total dosage for such persons should not exceed 40 mg per day.

Precautions

Paroxetine should never be taken with monoamine oxidase inhibitors (MAOIs)(see interactions below).

Paroxetine may lower the threshold for a manic episode among people with bipolar (manic-depressive) disorders. For this reason, the drug should be used only with caution and under close supervision in these patients. It may also increase the change of having a seizure in people with a history of seizure disorders.

The possibility of suicide is a component of depression. The minimum number of doses of paroxetine should be dispensed at any one time to minimize the potential for use as a suicide agent.

Hyponatremia (abnormally low concentration of sodium in the blood) has been associated with the use of paroxetine. In all cases, this condition resolved when the drug was discontinued. Most of these instances occurred among older individuals who were also taking diuretics (water pills).

Side effects

Common side effects associated with paroxetine include headache, weakness, chills, malaise, nausea, and sleepiness. Other complaints included dry mouth, dizziness, tremors, constipation, diarrhea, and problems with ejaculation. Adverse reactions to paroxetine have been reported for all organ systems of the body, but all of these side effects are uncommon.

In general, the incidence of side effects increases as the dosage of paroxetine increases.

Interactions

There is the potential for a fatal interaction with another class of antidepressant drugs called monoamine-oxidase (MAO) inhibitors. There have been reports of dangerously elevated body temperature, muscle rigidity, and rapid changes in vital signs such as heart rate and blood pressure. Mental changes ranging from extreme agitation to delirium and coma have also been reported. Because of this, paroxetine should never be taken in combination with MAO inhibitors. Patient taking any MAO inhibitors, for example Nardil (phenelzine sulfate) or Parmate (tranylcypromine sulfate), should stop the MAO inhibitor then wait at least 14 days before starting paroxetine or any other antidepressant. The same holds true when discontinuing paroxetine and starting an MAO inhibitor.

The combination of paroxetine with the antipsychotic drug thioridazine has the potential to cause fatal cardiac arrhythmias (irregular heartbeat). The use of paroxetine in combination with tryptophan may result in unwanted reactions including agitation, restlessness, and gastrointestinal distress. Paroxetine may also increase the change of having a seizure in people with a history of seizure disorders. People taking anticonvulsants to control seizures should be closely monitored and a physician may need to adjust the dosage of their seizure medication.

People with bipolar disorder are commonly treated with lithium. No interactions between paroxetine and lithium have been reported, nor have are there any reported interactions with the common anti-anxiety drug diazepam (Valium).

Phenobarbital at dosages greater than 100 mg per day decreases the bioavailability of paroxetine in some persons. Paroxetine has been reported to increase the systemic bioavailability of procyclidine.

Definition

Parent management training (PMT) is an adjunct to treatment that involves educating and coaching parents to change their child’s problem behaviors using principles of learning theory and behavior modification.

Purpose

The aim of PMT is to decrease or eliminate a child’s disruptive or inappropriate behaviors at home or school and to replace problematic ways of acting with positive interactions with peers, parents and such authority figures as teachers. In order to accomplish this goal, PMT focuses on enhancing parenting skills. The PMT therapist coaches parents in applying such strategies as rewarding positive behavior, and responding to negative behavior by removing rewards or enforcing undesirable consequences (punishments). Although PMT focuses on specific targeted behaviors rather than on the child’s diagnosis as such, it has come to be associated with the treatment of certain disorders. PMT is used in treating oppositional defiant disorder, conduct disorder, intermittent explosive disorder (age-inappropriate tantrums), and attention deficit disorder with hyperactivity (attention-deficit/hyperactivity disorder). Such antisocial behaviors as firesetting and truancy can also be addressed through PMT.

Description

In PMT, the therapist conducts initial teaching sessions with the parent(s), giving a short summary of foundational concepts in behavior modification; demonstrating interventions for the parents; and coaching parents in carrying out the techniques of PMT. Early meetings with the therapist focus on training in the principles of behavior modification, response-contingent learning, and ways to apply the techniques. Parents are instructed to define the behavior(s) to be changed concretely and specifically. In addition, they learn how to observe and identify relevant behavior and situational factors, and how to chart or otherwise record the child’s behavior. Defining, observing and recording behavior are essential to the success of this method, because when such behaviors as fighting or tantrums are highlighted in concrete, specific ways, techniques of reinforcement and punishment can be put to use. Progress or its absence is easier to identify when the description of the behavior is defined with enough clarity to be measurable, and when responses to the PMT interventions are tracked on a chart. After the child’s parents grasp the basic interventions as well as when and how to apply them, the techniques that the parents practiced with the therapist can be carried out at home.

Learning theory, which is the conceptual foundation of PMT, deals with the ways in which organisms learn to respond to their environment, and the factors that affect the frequency of a specific behavior. The core of learning theory is the notion that actions increase or decrease in frequency in response to the consequences that occur immediately after the action. Research in parent-child interactions in families with disruptive, difficult or defiant children shows that parental responses are unintentionally reinforcing the unwanted behavior. PMT trains parents to become more careful in their reactions to a child’s behavior. The parents learn to be more discerning: to provide attention, praise and increased affection in reaction to the child’s behaving in desired ways; and to withdraw attention, to suspend displays of affection, or to withdraw privileges in instances of less desirable behavior.

The most critical element of PMT is offering positive reinforcement for socially appropriate (or at least nondeviant) behaviors. An additional component involves responding to any undesired behaviors by removing rewards or applying punishment. These two types of response to the child must be carried out with great consistency. Consistent responding is important because erratic responses to unwanted behavior can actually cause the behavior to increase in frequency. For instance, if a child consistently throws tantrums in stores, hoping to be given something to end the tantrum, inconsistent parent responses can worsen the situation. If a parent is occasionally determined not to give in, but provides a candy bar or a toy to end the tantrum on other occasions, the child learns either to have more tantrums, or to have more dramatic tantrums. The rise in the number or intensity of tantrums occurs because the child is trying to increase the number of opportunities to obtain that infrequent parental reward for the behavior. Planning responses ahead of time to predefined target behaviors by rewarding desired actions and by withdrawing rewards or applying punishment for undesirable behavior is a fundamental principle of PMT. Consistent consequences, which are contingent on (in response to) the child’s behavior, result in behavior change. Parents practice therapeutic ways of responding to their child’s behavior in the PMT sessions with the therapist.

Through PMT, parents learn that positive rewards for appropriate behaviors can be offered in a variety of ways. Giving praise, providing extra attention, earning points toward obtaining a reward desired by the child, earning stickers or other small indicators of positive behavior, earning additional privileges, hugging (and other affectionate gestures) are all forms of reward. The technical term for the rewarding of desired behavior is positive reinforcement. Positive reinforcement refers to consequences that cause the desired target behavior to increase.

PMT instructs parents to cancel rewards or give punishments when the child behaves in undesirable ways. The removal of rewards usually entails time away from the circumstances and situations in which the child can do desired activities or receive attention. The concept of a “time out” is based on this notion of removal of rewards. Time out from rewards customarily means that the child is removed from people and stimulation for a certain period of time; it can also include deprivation of privileges.

Punishment in PMT is not necessarily what parents typically refer to as punishment; it most emphatically is not the use of physical punishment. A punishment in PMT involves a response to the child’s negative behavior by exposing the child to something he or she regards as unpleasant. Examples of punishments might include having to redo the correct behavior so many times that it becomes annoying; verbal reproaches; or the military standby—”drop and give me fifty”—having to do pushups or situps or laps around a playing field to the point of discomfort.

The least challenging problems, which have the greatest likelihood of successful change, are tackled first, in hope of giving the family a “success experience.” The success experience is a positive reinforcement for the family, increasing the likelihood that they will continue using PMT in efforts to bring about change. In addition, lower-level behavioral problems provide opportunities for parents to become skilled in intervening and to learn consistency in their responses. After the parents have practiced using the skills learned in PMT on the less important problems, more severe issues can be tackled.

In addition to face-to-face sessions with the parents, some PMT therapists make frequent telephone calls to the parents between sessions. The purposes of the calls are to remind parents to continue to be consistent in applying the techniques; to answer questions about the work at home; and to praise the parents’ attempts to correct the child’s behavior. In addition, ongoing support in sessions and on the telephone helps parents feel less isolated and thus more likely to continue trying to use learning principles in managing their child. Troubleshooting any problems that arise regarding the application of the behavioral techniques is handled over the telephone and in the office sessions.

An additional aspect of learning theory is that rewarding subunits of the ultimately desired behavior can lead to developing more complex new actions. The subunits are finally linked together by changing the ways in which the rewards are given. This process is called “chaining.” Sometimes, if the child shows no elements of the desired response, then the desired behavior is demonstrated for the child and subsequent “near hits” or approximations are rewarded. To refine “close but not quite” into the targeted response, rewards are given in a slightly “pickier” manner. Rewarding successive approximations of the desired behavior is also called “shaping.”

Risks

The best way to learn to alter parental responses to child behaviors is with the support and assistance of a behavioral health professional (psychologist, psychiatrist, clinical social worker). As noted earlier, parents often inadvertently reinforce the problem behaviors, and it is difficult for a parent to see objectively the ways in which he or she is unintentionally supporting the defiant or difficult behavior. Furthermore, inappropriate application of such behavioral techniques as those used in PMT can actually make the problem situation worse. Families should seek therapists with valid credentials, skills, training and experience in PMT.

Normal results

Typically, the parents should notice a decrease in the unwanted behaviors after they implement the techniques learned in PMT at home. Of the various therapies used to treat childhood disorders, PMT is among those most frequently researched. PMT has shown effectiveness in changing children’s behavior in very well-designed and rigorous studies. PMT has a greater effect on behavior than many other treatments, including family therapy or play therapy. Furthermore, the results— improved child behavior and reduction or elimination of undesirable behavior— are sustained over the long term. When a group of children whose families had used PMT were examined one to fourteen years later, they had maintained higher rates of positive behavior and lower levels of problem behavior.