Sunday, April 11, 2010

"Sleeping Beauty Paraphilia" and Body Image Disturbance After Brain Injury

Brain injuries caused by strokes, tumors or head trauma can, on occasion, result in Unusual Changes in Sexuality, as discussed in an earlier blog post. A new case report by Bianchi-Demicheli et al. (2010) describes a unique paraphilia1 in a married 34 year old man. The authors called it Sleeping Beauty paraphilia:
This [man] felt sexually aroused from seeing sleeping women as well as from taking care of their hands and nails while they were asleep.
The patient came to the attention of the authors when he was brought to the emergency psychiatric unit after assaulting his wife with pepper spray while wearing a latex mask.2 More details of the case are as follows:
His marriage had been in crisis for several years because over the time the patient developed a particular and progressive sexual deviant behaviour. He felt sexually aroused from seeing sleeping women as well as from taking care of their hands and nails while they were asleep, beginning mostly with the right hand.

In the first time of his marriage he could control these fantasies, but over the years he lost the control of his sexual urges and he must irresistibly act his deviant behaviour. In order to realize his uncontrollable impulse, he was used to provide his wife sleeping pills to satisfy his paraphilia. In the first time his wife used to agree to take sleeping pills, but later she refused to bend to man’s freakish will. The man began secretly to administer benzodiazepines since the dosage of 23 mg of Bromazepam.

In September 2006, his wife discovered this practice and refused to take sleeping pills and the couple entered in a very strong conflict.
The assault occurred because the woman refused to comply with her husband's "freakish will":
Because of the extremely powerful obsession with sleeping women and painting their nails, the patient disguised himself with a latex mask an attacked his wife, as she returned from work, with an Olerosin Capsicum (OC) spray, to anaesthetize her. During this episode, his wife succeeded in taking off his mask, escaped and called the police who brought him to the psychiatric emergencies.
The psychiatric exam and laboratory tests all came out as normal. The patient reported no family history of mental illness. However, he sustained a head injury at the age of 10 which resulted in a four day coma.3 He was given a neurological exam, including an MRI, which showed "moderate atrophy in the fronto-parietal region with a diffuse and severe white matter injury compatible with his previous head trauma (Figure 1)." I don't know that I would characterize the white matter damage as severe, but then again I'm not a neuroradiologist.

Figure 1 (Bianchi-Demicheli et al., 2010). On the T2 images (A–C) one notes atrophy in the parietal and frontal lobes as well as subcortical lesions in the frontal white matter (arrows B,C); FLAIR also shows multiple subcortical white matter lesions (arrows: D); DTI [dffusion tensor imaging] demonstrates a decrease of the fractional anisotropy in the areas seen on the right (E: arrow) and on the left (F: arrow).

Bianchi-Demicheli et al. (2010) linked the fronto-parietal damage to behavioral disinhibition and a specific disturbance in body image, which was revealed by neuropsychological testing:
The patient was diagnosed with a moderate dysexecutive syndrome and a very specific body image disorder characterized by an incomplete mental image of his hands, mostly the right (i.e., personal representational hemineglect), as ascertained by his graphical representation of his body parts.

The clinical hypothesis was that the paraphilia might be related to his post-traumatic disturbed body image and more specifically to the incomplete hands representation.
One puzzling aspect of this case is why the "Sleeping beauty paraphilia" became uncontrollable only in adulthood, showing a progressive escalation during his marriage. This might be suggestive of a neurodegenerative disorder, but that was not part of his diagnosis. And I'm not sure why an old traumatic brain injury would have lead to "moderate" atrophy in the fronto-parietal region. I might have expected more involvement of the orbitofrontal cortex (e.g. Burns & Swerdlow, 2003), given the nature of the patient's behavioral changes. However, many other examples of impulsive sexual offenses (Langevin, 2006) are even less obviously related to neurological status (e.g. after head injuries when the damage might not be visible on an MRI scan, and of course the population of offenders who have never sustained a TBI). Since the lesions were distributed and not focal, a final mystery is why the body image disturbance was confined to the right hand (implying a left hemisphere origin). This type of personal representational hemineglect (neglect for a mental representation of one side of the body) is most often associated with lesions in the right hemisphere (Ortigue et al., 2006).

A final comment concerns the sort of urges or behaviors that are categorized as paraphilias. What is considered acceptable can vary widely across cultures and subcultures (Bhugra et al., 2010) and across individuals. If the patient of Bianchi-Demicheli et al. found a partner willing to have her fingernails done while sedated with sleeping pills, perhaps the classification would change from paraphilic disorder (see Footnote 1 below) to something that might be considered strange and paraphilic to most people, but causing no distress to the two willing participants.

Footnotes

1 According to DSM-IV, paraphilias are defined as recurrent, and intense sexual urges, fantasies, or behaviors that involve unusual objects, activities, or situations and cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Changes in this set of diagnoses are being discussed for the new DSM-5 (currently under development):
The Paraphilias Subworkgroup is proposing two broad changes that affect all or several of the paraphilia diagnoses, in addition to various amendments to specific diagnoses. The first broad change follows from our consensus that paraphilias are not ipso facto psychiatric disorders. We are proposing that the DSM-V make a distinction between paraphilias and paraphilic disorders. A paraphilia by itself would not automatically justify or require psychiatric intervention. A paraphilic disorder is a paraphilia that causes distress or impairment to the individual or harm to others. One would ascertain a paraphilia (according to the nature of the urges, fantasies, or behaviors) but diagnose a paraphilic disorder (on the basis of distress and impairment). In this conception, having a paraphilia would be a necessary but not a sufficient condition for having a paraphilic disorder.
2 No mention of whether or not it was a Prince Charming mask.

3 The authors did not speculate too much on the Freudian implications of juvenile coma and adult arousal by sleeping women:
Presumably, the occurrence of head trauma leading to catatonia in [adolescence] might have played a critical role [in] the development of his sexual self and body image.
References

Bianchi-Demicheli F, Rollini C, Lovblad K, & Ortigue S (2010). "Sleeping Beauty paraphilia": deviant desire in the context of bodily self-image disturbance in a patient with a fronto-parietal traumatic brain injury. Medical science monitor : international medical journal of experimental and clinical research, 16 (2) PMID: 20110923

Bhugra D, Popelyuk D, McMullen I. (2010). Paraphilias across cultures: contexts and controversies. J Sex Res. 47:242-56.

Burns JM, Swerdlow RH. (2003). Right orbitofrontal tumor with pedophilia symptom and constructional apraxia sign. Arch Neurol. 60:437-40.

Langevin R. (2006). Sexual offenses and traumatic brain injury. Brain Cogn. 60:206-7.

Ortigue S, Mégevand P, Perren F, Landis T, Blanke O. (2006). Double dissociation between representational personal and extrapersonal neglect. Neurology 66: 1414–17.

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