The Brain in Love Part 7

Falling in love can be so powerful that we ignore the potential pitfalls. Use your head and your heart when you fall in love. When emerging from the desert, be sure to take care of yourself. Pack your own canteen full of water so that you are less dependent on the oasis. Pay attention and take your time before drinking the water.

Lesson #6: Notice the warning signs in a potential new relationship-use your brain and your heart when you fall in love.

THE BRAIN IS A SNEAKY ORGAN.

Addictions, Weird s.e.x, Fiends, and Fetishes "The brain is a sneaky organ."

-JERRY SINFELD Does your brain play tricks on you? Surprise you? Torture you? Appall you? Mine does. Even at the most inappropriate times. I can be sitting in church, trying my best to be thoughtful, prayerful, spiritual, and close to G.o.d, and then the next moment my brain notices the rear end of the young woman in front of me.

"Stop it," my superego yells.

"Oh, please, just one more quick look?" My brain pleads.

"No, you are in church."

Or, I can be out to dinner with my sweetheart, having spent the day planning to make it a special evening for us, and then ruin it all by noticing for a half second too long the young, bouncy waitress with the ample cleavage walking by the table. Poof, the evening is ruined. "What's the matter with me?" I think, "I did not want the waitress, I wanted my sweetheart." Also, I can be driving in traffic and wonder what it would be like to drive into oncoming traffic or slam into the car next to me. Ouch! Or, I can be walking in a grocery store, notice someone carrying an armload of boxes, and wonder what it would be like to tickle the person. Yuk? The list goes on and on from suicidal thoughts ("What would they think if I jumped off the balcony and splattered myself on the ground?"), to homicidal thoughts ("How would it feel to shoot that person in the face?"), to strange thoughts ("I wonder if it would be erotic to watch anteaters having s.e.x?"). Before you think I am abnormal or just plain sick, I have been listening to these "sneaky thoughts" from my patients for more than twenty-five years. We all have them. They just sneak up on us without planning. I was walking recently with a friend, one of the sweetest, most thoughtful women I know. She told me about a time when one of her daughter's friends was being irritating and she had the thought of pouring a jug of milk over her head. Of course, she didn't do it, but the thought ran through her brain nonetheless.

What causes our brain to have these bizarre, silly, or unhelpful thoughts? What causes our brain to be sneaky? The limbic or emotional brain is always generating possibilities, novelties, and interesting hypotheses. Like dream states while awake, the brain is constantly churning, imagining, and playing. Thankfully, we have an area of the brain called the prefrontal cortex (PFC), which inhibits these sneaky thoughts and prevents us from saying them or acting upon them. When this part of the brain works right, it can laugh at or dismiss these sneaky thoughts. When there is damage or disease to this part of the brain, these hurtful, embarra.s.sing thoughts surface in our behavior.

I was once at a conference with a close friend of mine, Jillian. She had experienced a car accident several years earlier that hurt her PFC. She had a reputation for saying exactly what was on her mind without filtering its content. Two obese women sitting in front of us at the conference were engaged in a spirited conversation about their weight. One woman said to the other, "I don't know why I am so fat, I eat like a bird."

Jillian looked at me and said loud enough for everyone around us to hear, "Yeah, like a condor."

I looked at her in total embarra.s.sment. Horrified, Jillian put her hand to her mouth and said, "Oh my G.o.d, did that thought get out of my mouth?"

Yes, I nodded.

"I'm so sorry," she said as the women moved away from us.

The brain is a sneaky organ. From minor gaffs, to embarra.s.sing moments, to a lifetime of trouble, the brain is in the center of our behavior.

PFC Damage Damage to the PFC can happen in a number of different ways, such as through a head injury, some form of toxic exposure, or later in life through diseases of aging, such as dementia. The most common cause of dementia that is a.s.sociated with difficult behavior is called frontal temporal lobe dementia (FTD). People with this type of dementia are more likely to act like Jillian. In a study from UCLA, researchers examined patients with FTD and Alzheimer's disease (AD). Typically, early in the illness FTD affects the front parts of the brain, while AD affects the back parts of the brain. When damaged, the front parts of the brain are more involved in poor judgment and a decreased control over one's actions. Researchers studied both groups for sociopathic behavior, evaluated the characteristics surrounding their acts, and compared the groups on neuropsychological tests and brain-imaging studies. There were twenty-eight patients in each group. Sixteen (57 percent) of the FTD patients had sociopathic behavior compared to two (7 percent) of the AD patients. Sociopathic acts among FTD patients included such things as unsolicited s.e.xual acts, traffic violations, and physical a.s.saults. When interviewed, the FTD patients with sociopathic acts were aware of their behavior and knew that it was wrong but could not prevent themselves from acting impulsively. They claimed remorse, but they did not act on it or show concern for the consequences. Among FTD patients with sociopathy, brain-imaging studies showed right prefrontal cortex involvement. The PFC helps us supervise our behavior and control the sneaky thoughts most of us have.

I have treated patients with FTD who started s.e.xually abusing children. These men had no prior history of bad behavior. I have treated others with late-onset PFC disorders who developed unusual s.e.xual behaviors. One case was particularly sad. A pastor of thirty years underwent brain surgery for a tumor to his PFC. He took time off from his position in the church. At first the operation seemed a success and the pastor went back to work. Then gradually over the next year, his behavior started to become bizarre. He had temper issues at church and was less reliable than before. Through his church he developed a friendship with a seven-year-old boy. Over time the relationship turned s.e.xual. When he was caught, the whole community was stunned. The investigator for the case said there was absolutely no evidence of this type of behavior prior to the surgery. Yet, because of his position of trust, the judge gave this pastor thirty years in prison.

Tourette's Syndrome Other areas of the brain besides the PFC can also be involved in sneaky behavior. The PFC helps us think about and supervise our odd behaviors. The basal ganglia and anterior cingulate gyrus can also fire abnormally and wreak havoc. Tourette's syndrome is an example that involves both of these systems. People who have Tourette's syndrome (TS) have uncontrollable urges to move their muscles (tics) or say exactly what is on their mind. They can control the urges for a while, but like tension on a rubber band that needs to be released, the urge builds until it has to be set free. TS is cla.s.sified as a tic disorder where people have both motor (involuntary muscle movements) and vocal tics (involuntary vocalizations). Examples of motor tics include shoulder shrugging, leg movements, hip thrusts, excessive blinking, eyebrow raising, facial grimaces, head jerking, punching, and even s.e.xual gestures. Examples of vocal tics include puffing, blowing, throat clearing, whistling, animal noises (barking, mooing, crowing), and swearing (termed corprolalia). Several years ago I spoke for the Tourette Syndrome Foundation of Canada on the island of Victoria. I spoke in front of four hundred people who had TS. It was more than interesting to speak in front of that many with tic disorders. In the audience there were people who were barking, whistling, and jerking. It taxed my ability to stay focused on my talk.

During the middle of the lecture someone blurted out, "f.u.c.k you."

Taken aback, I just ignored him.

A few minutes later, it happened again: "f.u.c.k you" came from the audience.

Now, I started to sweat. What should I do?

One more time, "f.u.c.k you," came even louder.

I couldn't stand it anymore and said, "Is that a tic? Or don't you like the lecture?"

The man blushed and said it was a tic. But how is a speaker really to know?

TS is a treatable disorder, with medication and behavioral therapy. Without therapy it can ruin lives. David Comings, MD, a researcher at the City of Hope in Los Angeles, writes in his book Tourette Syndrome and Human Behavior, that families of Tourette's sufferers tend to have other unusual behaviors. These have included unusual s.e.xual behavior, violence and abuse (especially within the family unit), obsessive compulsive tendencies, anxiety disorders, manic depression, and even psychotic symptoms. TS highlights that there are underlying mechanisms in the brain that correlate with impulse control disorders.

Obsessive-Compulsive Disorder Obsessive-compulsive disorder (OCD) is similar to TS. In fact, about half the people with TS also have OCD. Obsessive-compulsive disorder affects somewhere between two to four million people in the United States. This disorder can impair a person's functioning and often affects a person's s.e.xuality. OCD is often a disorder secretive to the outside world, but not to those who live with the person. The hallmarks of this disorder are obsessions (recurrent disgusting or frightening thoughts) or compulsions (behaviors that a person knows make no sense but feels compelled to do anyway). The obsessive thoughts are usually senseless, repugnant, and invasive; they are sneaky and may involve repet.i.tive thoughts of violence (such as killing one's child), contamination (such as becoming infected by shaking hands), doubt (such as having hurt someone in a traffic accident, even though no such accident occurred), or s.e.xuality (such as unusual acts with children or animals). Many efforts are made to suppress or resist these thoughts, but the more a person tries to control them, the more powerful they become.

The most common compulsions involve hand-washing, counting, checking, touching, and masturbating. These behaviors are often performed according to certain rules in a very strict or rigid manner. For example, a person with a counting compulsion may feel the need to count every crack on the pavement on their way to work or school. What would be a five-minute walk for most people could turn into a three- or four-hour trip for the person with obsessive-compulsive disorder. They have an urgent, insistent sense inside of "I have to do it." A part of the individual generally recognizes the senselessness of the behavior and doesn't get pleasure from carrying it out, although doing it often provides a release of tension.

The intensity of OCD varies widely. Some people have mild versions, where, for example, they have to have the house perfect before they go on vacation or they spend the vacation worrying about the condition of the house. The more serious forms can cause a person to be housebound for years. I once treated an eighty-three-year-old woman who had obsessive, s.e.xual thoughts that made her feel dirty inside. It got to the point where she would lock all her doors, draw all the window shades, turn off the lights, take the phone off the hook, and sit in the middle of a dark room trying to catch the abhorrent s.e.xual thoughts as they came into her mind. Her life became paralyzed by this behavior and she needed to be hospitalized.

New research has shown a biological pattern a.s.sociated with OCD. Brain-SPECT studies have shown increased blood flow in the basal ganglia and anterior cingulate gyrus (ACG). The ACG is involved in allowing a person to shift his or her attention from subject to subject. When this area is overactive, a person gets "stuck" on the same thought or behavior.

Like most forms of psychiatric illness, OCD has a biological basis, and part of effective treatment often involves medication. At this writing there are eight "antiobsessive medications" and there are more on the way. Before 1987 there were no good medications to treat OCD. The current medications that have shown effectiveness with OCD are Anafranil (clomipramine), Prozac (fluoxetine), Zoloft (sertraline), Paxil (paroxetine), Effexor (venlafaxine), Luvox (fluvoxamine), Celexa (citalopram), and Lexapro (escitalopram oxalate). These medications have provided many patients with profound relief from OCD symptoms.

In addition, behavior therapy is often helpful for these patients. This is where a patient is gradually exposed to the situations most likely to bring out the rituals and habits. Behavior therapy also includes thought-stopping techniques and strong urging by the therapist for the patient to face his or her worst fear (for example, having a patient with a dirt or contamination fear play in the mud).

There is a group of disorders that have been labeled as Obsessive Compulsive Spectrum Disorders. It is based on the premise that these disorders occur because the person experiences repet.i.tive unwanted thoughts or behaviors. They tend to get stuck on thoughts and cannot get them out of their minds unless they act in a specific manner. OCD spectrum disorders include trichotillomania (pulling out one's own hair), onychophagia (nail biting), Tourette's syndrome, kleptomania (compulsive stealing), body dysmorphic disorder (unreasonably feeling a part of the body is excessively ugly), compulsive shopping, pathological gambling, fetishes, and s.e.xual addictions.

In the past decade the Internet has brought a whole new meaning to pathological gambling and s.e.xual addictions. Both are on the rise with younger and younger people. The term addiction used to be used exclusive to chemicals such as alcohol, drugs, or nicotine. With recent research on the brain, we now understand that many behaviors can become as chemically addictive as a substance. Gambling and p.o.r.nography can be such an addiction.

Pathological gambling includes all betting behaviors that interfere or hurt personal, family, or work-related activities. The essential features of a gambling addiction include: increased preoccupation with gambling a need to bet more money more frequently restlessness or irritability when attempting to stop "chasing" losses loss of control, manifested by continuation of the gambling behavior in spite of increasingly serious negative consequences in extreme cases, financial ruin, legal problems, loss of career and family, and even suicide.

According to the National Gambling Impact Study Commission, the national lifetime prevalence of gambling is no less than 1.2 percent of the total population (2.5 million). In longstanding gambling markets such as Nevada, more than 5 percent of the population will develop some problem with gambling, a prevalence rate about five times that of schizophrenia and more than twice that of cocaine addiction.

Youth are more troubled and addicted than adults. The pre-frontal cortex (PFC) is not fully developed until age twenty-five, making it much more likely that teens and young adults will have problems controlling their impulses. According to the National Coalition Against Legalized Gambling, the following are the prevalence rates among youth groups: 16 to 24-year-old males, 4 percent; 11 to 18-year-old males, 4 to 7 percent; national average, all ages, 1.2 percent.

s.e.xual Addictions s.e.xual addiction can encompa.s.s a wide variety of activities. Sometimes a s.e.x addict has problems with just one undesirable behavior, sometimes with many. According to s.e.x Addicts Anonymous, a high percentage of s.e.x addicts think that their unhealthy use of s.e.x has been a progressive process. It may have started with excessive masturbation, the use of p.o.r.nography, or a s.e.xual relationship, but over the years it progressed to increasingly risky behaviors. The core problem with s.e.xual addictions, like all addictions, is the feeling of powerlessness or helplessness over a compulsive behavior, resulting in a person's life becoming unmanageable or out of control. Addicts typically experience shame, guilt, and self-loathing. The addict tries to stop, but is unable to do so. The consequences are often severe, including terminated relationships, problems at work, arrests, financial troubles, a loss of s.e.xual interest in anything not a.s.sociated with the addiction, low self-esteem, and feelings of hopelessness.

The preoccupation with s.e.x takes up tremendous amounts of energy, draining time from other activities and responsibilities; as this intensifies, behaviors or rituals follow, which usually leads to more troubled behavior, such as searching the net for p.o.r.nography, lying about s.e.x, or secretive flirting. There is usually guilt over the behaviors, followed by shame, despair, and confusion.

Here are six questions to consider if you think you may have a s.e.xual addiction: Do you keep dark secrets about your s.e.xual activities from those who should know? Do you lead a double life?

Do you frequently feel remorse, shame, or guilt after a s.e.xual encounter?

Is it taking more variety and frequency of s.e.xual activities than previously to bring the same levels of excitement and relief ?

Have you ever been arrested or are you in danger of being arrested because of your practices of voyeurism, exhibitionism, prost.i.tution, s.e.x with minors, indecent phone calls, etc.?

Do your s.e.xual activities include the risk, threat, or reality of disease, pregnancy, coercion, or violence?

Has your s.e.xual behavior ever left you feeling hopeless, alienated from others, or suicidal?

If the answer to any of these questions is yes, professional help may be in order. See an expert in s.e.xual addiction.

In a study performed by my colleagues Mark Laaser and Richard Blankenship on s.e.x addicts, the PFC was clearly involved. The researchers used the Amen Clinic Brain System Checklist, a questionnaire I developed based on our brain-imaging work, with seventy patients who met the diagnostic criteria for a s.e.xual addiction. In addition, I performed brain-SPECT studies on eleven of the patients. The results of the survey were that 67 percent of the partic.i.p.ants showed prefrontal cortex problems. Fifty percent of the partic.i.p.ants had anterior cingulate gyrus issues (a tendency to get stuck on negative thoughts or behaviors, like addictions). There was also a high a.s.sociation between limbic (mood issues) and basal ganglia problems (anxiety issues). On the SPECT scans, eleven out of eleven patients with s.e.xual addictions showed low activity in the PFC.

Here is an example of a s.e.x addict. Joseph had been married eighteen years when he came to see me. During his marriage he had many affairs and spent excessive money in strip clubs and on Internet p.o.r.nography sites. Even though he did not want to be divorced, and his wife was threatening to leave him if he didn't stop, he felt he had little control over his s.e.xual behavior. Joseph had a family history of substance abuse and addiction, common among s.e.x addicts. When he was arrested for soliciting s.e.x from an undercover vice police officer, he sought treatment for his s.e.xual addiction. Traditional psychotherapy was ineffective. Attention-deficit/hyperactivity disorder (ADHD), a neurological disorder that often affects the PFC and that is highly responsive to certain medical treatments, was suspected and he was sent to my clinic for an evaluation. His scans showed marked decreased prefrontal cortex activity. He was prescribed stimulant medication and placed on a brain healthy program (healthy diet, exercise, fish oil, and vitamins). With his medical treatment in place, he sought the help of an expert in s.e.xual addiction. Joseph is now ten years sober from his s.e.xual addiction. He and his wife have renewed their wedding vows and continue to do well.

Like Joseph, people with ADHD are likely to engage in some form of addiction. According to ADHD expert Wendy Richardson, "It is common for people with ADHD to turn to addictive substances such as alcohol, marijuana, heroin, prescription tranquilizers, pain medication, nicotine, caffeine, sugar, s.e.x, cocaine, and street amphetamines in attempts to soothe their restless brains and bodies. Using substances to improve our abilities, help us feel better, or decrease and numb our feelings is called self-medicating." Treatment of ADHD and other underlying disorders affecting the PFC substantially increase the efficacy of treating addictive disorders.

Unusual s.e.x In the movie There's Something About Mary, the main character, Mary, was stalked by Dom when she attended Princeton University. Dom's obsessive behaviors led to restraining orders. In addition, Mary had to change her name and buy all new shoes. Dom had taken all of her footwear. At the end of the movie Dom finds Mary once again. He is seen pa.s.sionately clutching several pairs of her shoes as Mary's friends are pulling him off her. Dom is clearly over-attached to her shoes.

Can neuroscience help us understand these deviations, paraphilias, and fetishes? Unusual s.e.x can have elements of both obsessive-compulsive disorder (repet.i.tive thoughts or behaviors that feel as though they are out of control), and attention-deficit/hyperactivity disorder (a.s.sociated with impulse control problems). Obviously, there is more to the story, as most people with OCD or ADHD do not engage in these behaviors. Imaging and brain chemistry findings can help uncover some the reasons behind these behaviors.

s.e.xual excitement is an individual experience; things that some people find stimulating are not the least bit interesting to others. Within a culture there are s.e.xual norms that most individuals and couples incorporate into their own lives. Outside the range of these norms lies an area of more unusual s.e.xual acts termed paraphilias or perversions: sneaky thoughts that get played out in actions. The word paraphilia, coined by Sigmund Freud, has Greek origins. "Para" meaning along the side and "philia" meaning love. It has been estimated that men outnumber women with a paraphilia 20:1, indicating that brain s.e.x differences and hormonal factors are likely involved. The medical definition of a paraphilia connotes s.e.xual deviance, perversion, or abnormality. It is seen as a medical problem only if the behavior interferes with relationships, health, work, or legal status or causes significant emotional distress. Culturally bound limits distinguish between normal and deviant s.e.xual practices. Here is a list of common paraphilias and fetishes.

COMMON PARAPHILIAS.

Exhibitionism: exposure of genitals to a stranger Fetishism: use of nonliving objects, such as Mary's shoes Frotteurism: rubbing against a stranger Hyphephilia: fabrics Klismaphilia: enema Masochism: pain, humiliation, or punishment of self Narratophilia: erotic talk Pedophilia: children Sadism: psychological or physical suffering of another Stigmatophilia: body piercing or tattooing Voyeurism: observation of others undressed or in the act of s.e.xual activity Transvestic fetishism: cross-dressing OTHER TYPES of PARAPHILIAS Acrotomophilia: amputee partner Asphyxiophilia: self-strangulation Autonepiophilia: diaperism Coprophilia: feces or defecating Mysophilia: filth Urophilia: urine or urinating Zoophilia: animals Fetishes A fetish, defined as "an excessive or irrational devotion to some object or activity," such as Dom's attachment to Mary's shoes, becomes a problem when people become dependent on the object or practice. It can be an inanimate object, such as shoes, or an animate object, such as feet or b.r.e.a.s.t.s. People use various things to achieve s.e.xual excitement. A fetish is when that object becomes the preferred or exclusive method of achieving excitement.

TYPES OF FETISHES.

Shoes: boots, high heels Clothes: leather, jackets or pants, suspenders, underwear, bras, raincoats, lace, silk, and nylon Body parts: b.u.t.tocks, b.r.e.a.s.t.s, legs, elbows, ears, feet Profiles in Fetishes I Like to Watch Watching unsuspecting people engaged in s.e.xual activity or getting undressed holds an air of appeal to voyeurs because they are aroused by the chance of getting caught watching. They seek excitement, often as a way to stimulate an underactive brain. Exhibitionists find excitement in revealing their genitals to strangers, also considered an impulse-control disorder. A sixty-five-year-old man with dementia displayed this kind of behavior and was arrested five times, within one year, because of complaints regarding indecent exposure. Dementia often results in a disinhibition due to frontal-lobe deficits.

Vacuuming to Death The tools of masturbation are as varied as people's imaginations. I have heard and read stories about vibrators, ice cream scoopers, b.u.t.ter knives, an old-fashion whisk, serving spoon, hairbrush, toothbrush, pillows, stuffed animals, pens, candles, d.i.l.d.os, tampons, towels, bedding, bottles, cell phones, curling irons, hot dogs, salami, Popsicles, and fruit. The list goes on and on. One case, however, stands above the rest in weirdness. A seventy-seven-year-old man was found dead in his bathroom due to a heart attack. Next to his body was found a vacuum cleaner and hair dryer. Both these electrical devices were still on and the man's underpants were actually found lodged in the hose of the vacuum! More than likely, these appliances were used autoerotically during masturbation.

Don't Try This at Home People will go to almost any means to get s.e.xual pleasure, even strangling or asphyxiating themselves to near death, or in some cases, death itself. For some, inducing a lack of oxygen to the brain while masturbating enhances s.e.xual experience. The ways to choke off one's air supply are innumerable. For this purpose people have used hanging or choking devices, such as ropes, electrical cords, ties, belts; constricting devices around the chest or abdomen; plastic bags covering the face; toxic gases or chemicals that are inhaled; or partial or total submersion in water, known as aquaerotic asphyxiation. The problem with this sort of excitement is that hundreds of deaths each year result from this behavior. Sometimes the release mechanisms fail, sometimes people do not know when to quit. This paraphilia can affect people of all ages. In one study of 132 people, 6 were in their fifties, 2 in their sixties, and 1 in his seventies. This practice may continue throughout life; frequency may lessen with age, but the motivation behind the behavior may never be completely gone.

Stop Being a Baby Paraphilic infantilism or autonepiophilia, also called diaperism, is the desire to be a baby and to talk and act the way an infant does. One thirty-five-year-old man employed in law enforcement was affected with this disorder his whole life. While at his job he did not feel like a baby and none of his colleagues knew about his desires, he dressed like a child when going out into public. His desire to become a baby began around the age of twelve. It can be postulated that the threat of s.e.xual maturity caused regression. His infantlike behavior involved wearing diapers, eating baby food, sleeping in a custom-sized crib, and sucking on a pacifier. While wearing diapers he would urinate and defecate in them as a child would and, at other times, he would m.a.s.t.u.r.b.a.t.e while wearing them. This case is an extreme side of a disorder that can be looked at as a spectrum ranging from infantile obsession to sadom.a.s.o.c.h.i.s.tic behaviors involving domination and discipline.

Unusual Places Like other orifices in the body, many objects have been used to stimulate the a.n.u.s and r.e.c.t.u.m. The oldest reported case dates to the sixteenth century when a foreign object that was inserted into the r.e.c.t.u.m became lodged, and at that time removal of the object was not possible. To this day, physicians find themselves extracting objects from the r.e.c.t.u.m, sometimes requiring surgery. Such was the case of a sixty-three-year-old man who inserted a salami into his r.e.c.t.u.m. Twenty-six percent of those admitted to the hospital for foreign bodies in their r.e.c.t.u.ms required surgery. Reports of patients seen in an emergency room for this problem vary and do not occur only in young people. In a large study of these patients seen at USC and UCLA Medical Centers between 1993 and 2002, the mean age was 40.5 years old. Other reports include an elderly woman at a nursing home who reportedly inserted utensils into her r.e.c.t.u.m. She said she was "digging herself out" and had been doing so for years, which caused her long-term constipation and stool incontinence. A sixty-five-year-old man who described abdominal pain had an inverted gla.s.s jar lodged in his r.e.c.t.u.m, which eventually required surgical removal.

Can You Say Mooo ...

Zoophilia, or b.e.s.t.i.a.lity, is usually condemned as animal abuse and outlawed as a crime against nature. Scientific surveys, however, have shown that it is more frequent than most people would think. One to two percent, and perhaps as many as eight to ten percent, of s.e.xually active adults have had significant s.e.xual experience with an animal at some point in their lives. In the past, b.e.s.t.i.a.lity was particularly hated for the fear that it would produce monsters. Just over half of U.S. states explicitly outlaw s.e.x with animals. In some countries laws existed against single males living with female animals. For example, an old Peruvian law prohibited single males from having a female llama. The Bible clearly prohibits b.e.s.t.i.a.lity. Leviticus 18:23 says, "And you shall not lie with any beast and defile yourself with it, neither shall any woman give herself to a beast to lie with it: it is a perversion." And 20:1516 continues, "If a man lies with a beast, he shall be put to death; and you shall kill the beast. If a woman approaches any beast and lies with it, you shall kill the woman and the beast; they shall be put to death, their blood is upon them."

A commonly reported starting age for b.e.s.t.i.a.lity is at p.u.b.erty, which is consistent for both males and females. Those who discover an interest at an older age often trace it back to memories or feelings that developed during this earlier period. As with human attraction, zoophiles may be attracted to only particular species, appearances, personalities, or individuals, and both these and other aspects of their feelings vary over time.

A colleague of mine from North Dakota once treated a man who had an obsession with heifers (young cows). It started when he was nine years old. While milking a cow, the scent and feel aroused him. Later that day he m.a.s.t.u.r.b.a.t.ed to the experience. Thirty years later he had had s.e.x with more than five hundred heifers, but no human females. He had the cows perform oral s.e.x on him by placing peanut b.u.t.ter or honey on his p.e.n.i.s.

In October 2005, a Bangladeshi man was sentenced to three months in jail after pleading guilty to charges of b.e.s.t.i.a.lity in the United Arab Emerites. The camel involved in the case was put down in accordance with Islamic law. A court official said the man, who worked as a driver, had been spotted going into his employer's barn on a regular basis. His employer became suspicious as his duties did not involve him dealing with animals. The employer followed his driver into the barn one day and saw him starting to have s.e.x with a female camel. The owner lost his temper and started beating him. He then took him to the police station to press charges. The driver confessed to police that he had fallen in love with the camel and had s.e.x with the animal.

Anatomy of a Fetish and the Arousal Template According to s.e.x addictionologist Mark Laaser, PhD, "the arousal template" underlies many s.e.xual fetishes and paraphilias. The theory of the arousal template says that it is important to understand where you were and how old you were when you experienced your first s.e.xually arousing experience. This often lays the neural tracts for later excitement, even if the experience happened as early as age two or three. The first experience gets locked into the brain, and when you get older, you seek to repeat the experience because it was the way you had the initial arousal, like the first time you fell in love, used cocaine, or had to cope with pain. Here are several examples, Adam, a forty-five-year-old stockbroker, grew up with an incredibly demeaning, shaming mother who gave him no love and acceptance. Four little girls lived next door to him when he was growing up. The little girls often came over to his house to play. They usually wore white socks and black patent leather shoes. When Adam got married, his fetish was that he wanted his wife to wear lacey dresses, patent leather shoes, and look like a little girl. It took him back to the arousal template of playing with the neighbors. His wife was initially okay with the s.e.xual play, then not, as he wanted it every time to get an o.r.g.a.s.m.

Gary also had a harsh and critical mother, plus an alcoholic dad. He grew up in Texas playing rodeo with a neighboring girl. They tied each other up as part of their play. It gave him a sense of control and pleasure, control he did not have over his erratically behaving mother or father. When he became s.e.xually active as an adult, he wanted to tie women up, which eventually turned into an S&M fetish.

Lucy was an adult woman whose fetish was being spanked, slapped, and tied up. When she was five years old her father s.e.xually molested her, including digital penetration. When she told her mother about the abuse, she was slapped because she didn't want to hear about it. The arousal template got mixed up with messages of pleasure and pain.

When Fred was a little boy, he was molested by an uncle. He felt ashamed and furious. As an adult he got married and loved his wife deeply, but also went to adult bookstores that had video booths. He would invite strange men into the booth and offer to do oral s.e.x on them. When they dropped their pants, he would go into a rage and beat them up. His behavior was attempting to right a past wrong.

For children raised in the 1950s, there were some mothers who were overconcerned with their children's bowel regularity and gave them frequent enemas. If it was arousing to them, they would later insert objects into their r.e.c.t.u.m. I once treated a patient whose mother subjected him to frequent enemas. He was also a coffee addict. Twice a day he would brew coffee, put it in an enema bag, insert it into his r.e.c.t.u.m, and then m.a.s.t.u.r.b.a.t.e.

At age thirteen, a boy was coming out of the shower naked and looked out the window toward next door. In the window he saw a woman washing the dinner dishes. She saw him and smiled at him. Subsequently, he would shower at the same time each night hoping to get a smile from the woman next door. As an adult he became a male exotic dancer and would also pose nude for art cla.s.ses.

Chuck was a church pastor who got caught looking at p.o.r.n, exclusively of Asian women. He had served in Vietnam in 1965 and 1966 as a medical corpsman. It was common for him to deal with death and disfigurement. For R&R he went to the ma.s.sage parlors in Tokyo where he wanted only local women. He was emotionally locked into these women from dealing with the trauma and stress of wartime. Part of the arousal template occurs when you go through a stress, such as something that happened at an earlier point in life. Subsequent stress can trigger how the s.e.xual arousal helped you escape the earlier turmoil.

The arousal template can happen later in life. For example, when a young college couple was driving home from a concert and the woman was masturbating her boyfriend with her feet; he e.j.a.c.u.l.a.t.ed in front of a woman for the first time. Subsequently he became obsessed with feet. He collected woman's running shoes and took pictures of female marathons, but only of the women's shoes. He had a collection of two hundred pairs of female running shoes and wanted his wife to wear them as a part of s.e.x. They came into treatment because she discovered him looking at Internet foot p.o.r.nography sites.

Further Dynamics One of the doctors in my clinic, Leonti Thompson, has extensive forensic experience. He was the former chief of psychiatry for the Department of Corrections in the State of California. In his role with prisoners he examined and treated many s.e.x offenders. Often his work involved trying to explain seemingly bizarre and/or offensive behavior in a way that could help to provide a basis for more objective dispositions of the inmates. He found that explaining these unusual behaviors from a developmental point of view was helpful. In this explanation he explained that libidinal/s.e.xual drives-not yet given a definitive s.e.xual categorization in the immature brain-could be attached to a variety of activities based on co-occurring emotionally laden experiences. These involved the tying together in the brain patterns that were out of the ordinary. An example comes from Victorian schools in which (probably s.a.d.i.s.tic) teachers would emphasize caning problem boys on their b.u.t.tocks. As adults a number of these men would go to receive their "discipline" from the ladies in the leather boots and whips. He explained that the s.e.xual receptive areas in the brain overlap the areas receiving stimuli from the rectal areas and with punishment an a.s.sociation was set up between those two areas. There was confusion then between pleasure and relief from pain. As the individual matured, the previously undifferentiated libidinal valences became more clearly defined as erotic. Pain and s.e.x became conjoined in the mind and relief from pain and pleasure also became conjoined and confused. In this way one could understand how m.a.s.o.c.h.i.s.tic experiences might be related to s.e.x.

Dr. Thompson has seen a number of patients at our clinics who have s.e.xual problems involving legal considerations, and explanations to the families are helpful. He uses brain-SPECT imaging findings to explain relevant brain dynamics as the obsessive aspects represented by the anterior cingulate gyrus hyperactivity, for example. He recently had a patient who had a diaper fetish in a small town. Both he and his wife held visible positions and the public revelation was painful. The couple was severely traumatized. He had anterior cingulate behavior that was getting him into potentially serious consequences with the court. He was also very depressed. An important part of helping to bring a more therapeutic slant into the process was trying to have the couple see his behavior in a more logical way.

The Brain and Paraphilias Three different areas of the brain are involved in paraphilias: pre-frontal cortex (PFC), anterior cingulate gyrus (ACG) and basal ganglia (BG), and limbic or emotional structures. Each of these areas contributes in a different way and they may, in fact, act together in a circuit or system that reinforces the reoccurrence of the s.e.xual behavior. Hormonal issues are important as well. Paraphilias are what I term an impulsive-compulsive disorder. They have features of both a lack of impulse control, that involves the PFC, and compulsion, that involves the ACG and BG.

The PFC, as we have seen, is critical to executive function. Damage to this area causes disinhibition and a lowering of impulse control. Therefore, people are more likely to behave in ways that are not acceptable and feel no qualms about their behavior. An article in the Archives of Neurology from University of Virginia researchers described a case of a man with a right pre-frontal cortex tumor who developed pedophilia and was unable to inhibit his s.e.xual urges despite knowing his behavior was wrong. The behavior resolved following tumor removal.

In a study from McLean Hospital in Boston, researchers evaluated 120 men with paraphilias, including 60 s.e.x offenders. As a group, they were more likely to report a higher incidence of physical abuse (often a.s.sociated with brain injuries), fewer years of completed education, a higher prevalence of learning and behavioral problems, more psychiatric/substance-abuse hospitalizations, increased work-related problems, as well as more lifetime contact with the criminal justice system. All of these issues are a.s.sociated with low PFC function.

Overactivity in the ACG and BG are a.s.sociated with compulsive behaviors and cause people to get stuck on negative thoughts and behaviors. In addition, a part of the BG called the nucleus acc.u.mbens is a.s.sociated with pleasure sensations. When it is triggered by something perceived as pleasurable, it reinforces or encourages the behavior to happen again and again.

The limbic or emotional structures in the brain, including the hippocampus in the temporal lobe, add the spice or emotional charge to the paraphilia. The brain's memory centers work through a.s.sociation. One memory can trigger off a series of emotions, such as how hearing a song can trigger a happy memory of your lover, or the same song may trigger the sorrow of a failed relationship or deceased spouse. Likewise, certain paraphilias can trigger pleasure. There is a reported case of a sixty-five-year-old man who became obsessed with the desire for a peg leg. His fascination with peg legs began when he was young after seeing people with false legs. He thought they were fascinating (pleasure) and the prosthetics devices became more and more important over the years. It got to the point where he was aroused by them. He related the peg leg with positive feelings, generated from the brain's limbic system, so that whenever he would see or think about peg legs he would experience very positive feelings. He was unhappy at the time of his evaluation and believed that if he had a peg leg, he would be happy.

As we saw in Lesson Four, men and women have a number of important anatomical differences in the brain; one important area is called the hippocampus, part of the limbic system, on the inside aspects of the temporal lobes. Most paraphiliacs are men. In men, the hippocampus is known to be involved in the control of erection. There is evidence from animal studies that a larger hippocampus is related to polygamous behaviors. The hippocampus is involved in both mating strategies of these animals and their "geographic range." Paraphilacs are often diagnosed with antisocial personality disorder, have a larger number of s.e.xual partners, and show greater geographic range than most men. Sociobiologists even distinguish their polygamous mating strategies than those of other people. Essentially, they are in a cla.s.s of their own and the size of the hippocampus may have something to do with it.

Paraphilias have been reported with multiple sclerosis (MS). Multiple sclerosis is a disorder of the central nervous system where neurons lose their coverings and plaques become deposited into nerve-cell fields causing short circuits. MS affects multiple areas of the brain, including the prefrontal cortex. A wide variety of symptoms are a.s.sociated with this disease, and usually it affects mood or cognition. There is a case report in the medical literature of a man recently diagnosed with MS who began displaying paraphilic behavior. He had no previous history of s.e.xual abuse or dysfunction and was in a long-term relationship. As the MS worsened, he began to m.a.s.t.u.r.b.a.t.e incessantly and s.e.xually accosted strangers on the street. His behavior became so out of control that it eventually led to his incarceration. In his case, the changes in his brain precipitated the s.e.xual behaviors. Paraphilic symptoms have also been a.s.sociated with other brain diseases such as epilepsy, Parkinson's disease, dementia, and tumors.

Hormones play a significant role in s.e.xual behavior. In the pursuit of treatments for paraphilias, research has shown that a common birth control method in women, Depo Provera, can help. This synthetic hormone decreases s.e.xual desire and helps to tranquilize the brain. It has also been found to act in the temporal lobes and been used to treat epilepsy and rage attacks in men. It does not just lower plasma testosterone levels, implicated in hypers.e.xual behavior; it also acts as a method of calming seizure like activity in the brain. In one case a thirty-eight-year-old man suffered brain damage after falling off his bike. He had no history of mental illness or s.e.xual dysfunction and his wife thought he had been a good problem solver. After the accident, his behavior changed drastically and he began displaying hypers.e.xual tendencies. He hara.s.sed his seventeen-year-old stepdaughter and she became the target of his s.e.xual advances. His s.e.xual behavior was related to his epileptic seizures and would occur simultaneous with them. After he received the hormone treatment, he stopped seizing and his s.e.xual problems ceased as well.

Are s.e.x Offenders Treatable?

The treatment of s.e.x offenders has changed radically in the last decade. What was once considered a hopeless disorder is now thought by some professionals to be treatable in many cases. The goal is to preserve normal s.e.xual interests and behaviors while reducing deviant or paraphilic ones. According to Canadian psychiatrist John Bradford, pharmacological treatments have been shown to decrease the main problem in pedophilia, the preference of children for s.e.xual gratification. Biological treatments, specifically castration and neurosurgery, have been used to treat s.e.xual offenders to reduce their s.e.xual drive and to prevent relapse. The studies of these treatments have reported markedly low recidivism rates, of about 5 percent following long periods of time. These outcome studies help us understand these disorders, which involve excessive response to male hormones, and what to do about it. The biological effects of surgical castration and male hormone suppression by antiandrogens and hormonal agents have the same effect on s.e.xual behavior. In addition, Dr. Bradford has found antiobsessive medications, called SSRIs, which enhance serotonin, to be also helpful in this population.

Dwayne McCallum, a past medical director of a prison in Colorado, has used ideas from my brain-imaging research with s.e.x offenders. He noticed that many of them had ADHD, and treating the disorder decreased their impulsivity and subsequently their recidivistic behavior. He also noted another group of s.e.x offenders who had anterior cingulate gyrus issues (rigid, worried, inflexible, repet.i.tive negative thoughts) that responded better to serotonin-enhancing medications, such as Lexapro. When it comes to s.e.x offenders, most people think like my father, "You should kill all the b.a.s.t.a.r.ds." My imaging work and the pioneering work of John Bradford, however, suggests a much more radical approach to them. By scanning and treating the abnormal brain function that many possess, we are likely to decrease subsequent crimes.

Getting Sneaky Thoughts out of Your Mind As mentioned in the beginning of this chapter, we all get sneaky thoughts. Sometimes they turn into trouble. One way to rid yourself of the pesky or irritating thoughts is to play them out to their worst conclusion. Here is a case below from my Men's Health column. One man wrote in with the following question. "I walked in on my sister-in-law while she was changing. Now I can't stop thinking about her. What do I do?"

I wrote, "If you're thinking about what might happen the next time you're alone with your sister-in-law, let that fantasy play out in your mind. But when you do, give it a negative ending. Getting caught by your wife or sister-in-law's husband is generally a good start, but take the nightmare a step further by imagining the effect this would have on your relationships with other family members as well. It'll make the whole fantasy less appealing-and allow it to die a natural death. If the thoughts, or even paraphilias and fetishes, cause you distress, use this technique to decrease their frequency."

Lesson #7: We all get unusual or sneaky thoughts; that is normal. When they get out of control, it may be a sign that the brain needs help.

THE "OH G.o.d!" FACTOR

s.e.x As a Religious Experience "If we accept the postulate given to me by Teresa during my Freshman year that, 'it will be a cold day in h.e.l.l before I sleep with you,' and take into account the fact that I slept with her last night, then I am sure that h.e.l.l ... has already frozen over. The corollary of this theory is that since h.e.l.l has frozen over, it follows that it is not accepting any more souls and is therefore, extinct ... leaving only Heaven thereby proving the existence of a divine being which explains why, last night, Teresa kept shouting 'Oh my G.o.d.'"