Behavioural problems: are drugs really the answer?
For almost every behavioural issue, these days there's a medicine to treat it
Tuesday 03 June 2008
Spending too much time on the internet? Worried about a low sex drive, shyness or lack of social skills? Or do you lose your temper too easily, blush too readily or spend too much time and money shopping?
Time was when such behaviours might have been regarded as individual differences, or put down to lack of self control and restraint. But not any more. Increasing numbers of behavioural conditions are being treated with drug therapy. Bereavement issues, blushing, low sex drive, high sex drive, sex addiction, lack of orgasm, gambling, fear of public speaking, stealing, domestic violence and phobias are all being targeted with drugs that are either in clinical trials or already available.
For drug companies, this market is potentially huge. It's claimed, for example, that almost half of women have a sexual problem. Nearly 8 per cent of adults, it seems, have intermittent explosive disorder, while another 8 per cent are compulsive shoppers. Thirteen to 15 per cent – around 10 million of us in Britain – are said to be social phobics, and up to 10 per cent have a fear of public speaking. On top of that are the gamblers, the phobics and the depressed – all suitable cases for treatment.
But critics argue that some of these treatments amount to medicalisation of individual differences and traits. Unlike physiological diseases such as cancer, behaviour disorders are a grey area, with no clear boundary between normality and illness. While there is no doubt that people at the extreme end do need treatment, others who may have symptoms may not.
Another problem is defining symptoms of some conditions. Take intermittent explosive disorder, the definition of which seems to defy even people in the field. "It is a vaguely defined condition for which effective treatments have not been identified,'' say researchers at Chicago University who have been involved in one drug trial.
One of the major areas for trials of new drugs is sexual problems. Reports have suggested that one in three women have low sex drive – and one drug trial has involved women whose symptoms include failure to achieve orgasm in half of their sexual encounters.
Professor Graham Hart, of the University of Glasgow, co-author of a paper on this issue in the British Medical Journal, says that the imperative now is for more and better sexual gratification. "Celibacy is the new deviance,'' he says. "The problem with such an overly medical approach to sexual behaviour is that social and interpersonal dynamics may be ignored.
"People choose one another for their uniqueness. The last century saw a considerable increase in acceptance of diversity of sexual expression – it would be a shame if this century saw diversity replaced by uniform expectations of performance and desire.''
At the University of East Anglia, Dr Ray Crozier, an expert on shyness, makes a similar case about the medicalisation of blushing. He argues that, in many cases, there is nothing inherently wrong, painful or unhealthy about blushing, yet it is treated both with surgery and drugs. More often than not, he says, the problem is in the eye of the perceiver.
"Shame and embarrassment are powerful experiences that lead people to find a way to escape from them. But anxiety about blushing is not caused by inherent properties of the blush, and something important would be lost if blushing were eradicated.''
An eight-week drug treatment for newly bereaved people is about to start a clinical trial. Researchers carrying out the trial hope that at least half of those taking part, all of whom must have lost a first-degree relative, will show improvement after taking the drug, duloxetine. One of the aims is to assess the effect of treatment in patients with bereavement-associated depression. A second is to look at its effects on health status, pain and other symptoms. "We expect substantial reductions in measures of grief and bereavement, with improvements in measures of pain, symptom burden and functional status,'' according to researchers at Cooper Green Mercy Hospital and the Jefferson Clinic in the US.
There have been some reports of success in treating this problem, which is defined as time spent on the internet at the expense of occupational, relationship and social activities. Research at Mount Sinai School of Medicine, New York, showed after treatment with an antidepressant called escitalopram, internet use dropped from an average of 36.8 hours a week to 16.5 hours. But in a second part of the research, the same results were achieved with a placebo.
Losing your temper could lead to a diagnosis of intermittent explosive disorder (IED), a condition that is acquiring its own family of drug and other therapies. Just what IED includes, and excludes, is not clear, but Mayo Clinic doctors say: "Road rage. Domestic abuse. Angry outbursts or temper tantrums that involve throwing or breaking objects. Sometimes such erratic eruptions can be caused by a condition known as intermittent explosive disorder.'' Some 8 per cent of adults suffer from IED, and doctors at Chicago University are using divalproex sodium, a drug used for epilepsy and bipolar disorder, to treat it.
According to researchers at the Mayo Clinic in the US, naltrexone, a drug prescribed for alcoholism, interferes with the brain chemical dopamine. They say the drug has been successfully used for "suppressing a euphorically compulsive and interpersonally devastating addiction to internet pornography".
A number of drugs have been in trials for the treatment of compulsive gambling. In one pilot study, nine out of 15 patients who took topiramate, a drug used for the treatment of seizure disorders, achieved full remission of gambling behaviour. The drug is thought to work by reducing the arousal that comes with gambling. Yale University has a trial of memantine ongoing for the same purpose.
As many as one in 12 of us have this disorder, according to psychiatrists at the University of Iowa, although it is mainly found in developed countries with market-based economies. They say some antidepressants help to ease the compulsion, and doctors at the Clinical Hospital Centre Zagreb-Croatia have successfully used fluvoxamine.
Speaking in public is an effort for many, but could taking a drug used for schizophrenia, psychosis and similar conditions help those with severe cases? A pilot study has been under way at the University of Minnesota, where quetiapine is being given to individuals with reported fear of public speaking. "We hypothesise that individuals will react with less self-reported anxiety,'' say researchers.
Low sex drive
Also know as hypoactive sexual disorder, it involves a distressing absence of sexual fantasies, thoughts and desire for sexual activity, and it affects up to 30 per cent of women and 10 per cent of men. Around 900 women aged over 18 are taking parts in a trial of the drug flibanserin, a compound that has an effect on brain chemicals related to mood. Sponsored by Boehringer Ingelheim Pharmaceuticals, trial inclusion criteria say that women who take part must be willing to try to have sexual activity at least once a month.
Female orgasmic disorder
Also known as inhibited female orgasm, it is claimed to be a disorder that affects one in three women at some time in their lives. Symptoms are said to include persistent delay in, or absence of, orgasm following sex. A study at King's College found that introverted women were 2.5 times more likely to have this problem. A trial has been under way in the States, sponsored by GlaxoSmithKline, where the drug bupropion is being used. One study found that it increased the incidence of orgasm as soon as 28 days after starting treatment. Exactly who might benefit is not clear, but one clue is that the trial inclusion criteria say women wishing to take part should have had an orgasm in less than half of sexual encounters.
People diagnosed with kleptomania have been taking part in an eight-week treatment programme with the drug naltrexone. "The hypothesis is that naltrexone will be effective in reducing the urges to steal in patients with kleptomania. The proposed study will provide needed data on the treatment of a disabling disorder that currently lacks a clearly effective treatment,'' say the Minnesota University researchers.
More than 60 clinical trials and more than a dozen drugs are currently being tested for a condition that interferes with the lives of up to 13 per cent of people, according to the Institute of Psychiatry. Anxiety disorder is characterised by a fear of social or performance situations, and sufferers are often concerned that they will do or say something embarrassing. One of the trials involves children aged eight and over.
But therapy has its critics: "Shyness has become an unhealthy state of mind for individuals living in contemporary Western societies,'' according to a University of Sussex report. "Insofar as its behavioural symptoms imply a failure to achieve certain cultural values, such as assertiveness, self-expression and loquacious vocality, shyness is increasingly defined as a problem for which people can, and should, be treated.''
Poor social skills
Have difficulty understanding social cues? Can't read facial expressions? Fear not – help may soon be at hand. Researchers at Zurich University have shown that they can improve the ability of healthy people to read social cues in the eyes of others by giving them oxytocin, a hormone that plays a major role in establishing maternal behaviour. One treatment session was enough to improve the recognition of social cues in pairs of eyes on a computer screen.
Self-control used to be a key message for violent partners, but a pill may be more effective. Men and women who have been violent to their partners, with or without the involvement of alcohol, are being prescribed Prozac in a clinical trial sponsored by the US National Institutes of Health. While treatments have concentrated on anger management, there's some evidence that the drug can reduce acts of aggression.
"We will evaluate whether fluoxetine (Prozac), used together with traditional psychotherapy, can reduce aggression in people who are physically violent towards their spouses or significant others,'' they say.
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