Ronald J. Kulich, PhD

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Sexual Sadism and Masochism Disorders the focus of desire in sexual sadism disorder is on inflicting pain or psychological suffering (such as humiliation) on another hiv infection stages purchase prograf online from canada, and the focus of desire in sexual masochism disorder is on being subjected to pain or humiliation stage 1 hiv infection timeline cheap prograf online american express. Examples include physical bondage symptomatic hiv infection symptoms order prograf canada, blindfolding hiv infection symptoms in mouth order prograf line, spanking acute hiv infection timeline order prograf now, whipping hiv infection and diarrhea discount 5 mg prograf otc, electric shocks, cutting, Clinical Descriptions of the Paraphilic Disorders 379 humiliation. Most sadists establish relationships with masochists to derive mutual sexual gratification. Although many people are able to take both dominant and submissive roles, masochists outnumber sadists. Most people who engage in sadomasochistic behaviors are relatively comfortable with their sexual practices and would not meet the diagnostic criteria requiring that the desires lead to distress or impairment. These diagnostic labels were retained because some sadistic and masochistic practices can be dangerous. One particularly dangerous form of masochism, called asphyxiophilia, can result in death or brain damage; it involves sexual arousal by restricting breathing, which can be achieved using a noose, a plastic bag, or chest compression. More commonly, the diagnosis is applicable when the sadomasochistic urges and preferences lead to either personal or relationship distress. There is some concern that the diagnosis of sexual sadism disorder is rarely applied in clinical settings. In an unpublished review of over 500 million visits to psychiatrists, gynecologists, urologists, and other physicians, no doctor recorded a diagnosis of sexual sadism disorder (Narrow, 2008, cited in Krueger, 2010a). Doctors in clinical settings may not use the diagnosis even when symptoms are present because of worries over stigma. The diagnosis, then, is applied almost entirely within forensic settings (Krueger, 2010a). Paraphilias are not diagnosed unless the sexual interests cause marked distress or impairment. Few major studies are available on the etiology of paraphilic disorders, and the available studies largely focus on sexual offenders. He has worked out a set of rituals to engage in this behavior; he knows which bus routes and times will be most crowded, chooses a bus that tends to have many women, and times his attacks so that he can leave the bus at a stop along with many other people. Occasionally, Terry likes to be tied down before sex, but she is able to enjoy sex without bondage as well. Matt feels aroused only when he is able to cause pain to someone as part of engaging in sex. He has not been able to sustain a relationship with any of the women he has met in clubs. Barry is a 40-year-old single man who has never had a sustained dating relationship or sexual partnership. Several times a week, Barry parks his car at the beach, masturbates, and then finds a way to lure a woman to his car, usually by asking for directions. Etiology of the Paraphilic Disorders Given that many people have interests in sexual sadism, masochism, or exhibitionism, why do some of these interests become difficult to control for some people, such that they reach a diagnosable level As we consider possible causes of the paraphilic disorders, including neurobiological factors, early abuse, and psychological variables, keep in mind that there are many gaps in knowledge. Such work does not tell us, though, why some people become unable to control their paraphilic interests and develop a paraphilic disorder. Because many people do not want to talk about their paraphilic disorders, researchers have few opportunities to understand their causes. Indeed, the vast majority of studies rely on samples of less than 25 persons (Kafka, 2010). Beyond the lack of research and the small sample sizes, most of the research focuses on men who are arrested for their sexual behavior; little is known about those whose sexual behavior does not lead to arrest. Hence, much of this literature is most relevant for understanding sexual offenders, who represent a more severe subset of those with paraphilic disorders. Neurobiological Factors Because the overwhelming majority of people with paraphilic disorders are men, there has been speculation that androgens (hormones like testosterone) play a role. Androgens regulate sexual desire, and sexual desire appears atypically high among some sexual offenders with paraphilic disorders. Nonetheless, men with paraphilic disorders do not appear to have high levels of testosterone or other androgens (Thibaut, De La Barra, et al. Childhood Sexual Abuse Childhood sexual abuse is relevant in understanding the most severe forms of paraphilic disorder. That is, across multiple studies, about 40 to 66 percent of adult sexual offenders reported a history of sexual abuse, rates that are substantially higher than the rates among those charged with nonsexual offenses or among those in the general population (Jespersen, Lalumiere, & Seto, 2009; Levenson & Grady, 2016). Nonetheless, sexual abuse cannot be the whole story-large-scale follow-up studies of boys with confirmed sexual abuse have shown that fewer than 5 percent were charged with any type of sexual offense as adults (Ogloff, Cutajar, et al. Psychological Factors For some of the paraphilias, succumbing to the sexual urge can be thought of as an impulsive act, in which the person loses control over his behavior. Alcohol decreases the ability to Treatments and Community Prevention for the Paraphilic Disorders 381 inhibit impulses, and accordingly, many incidents of pedophilic disorder, voyeuristic disorder, and exhibitionistic disorder occur in the context of alcohol use. Others report that their sexual behaviors are more likely to happen in the context of negative moods, suggesting that sexual activity is being used to escape from negative affect. People with paraphilic disorders tend to show heightened impulsivity and poor emotion regulation (Ward & Beech, 2006). Men who engage in paraphilias that involve nonconsenting women or children may have hostile attitudes and a lack of empathy toward their sexual targets (Babchishin, Hanson, et al. A separate line of work focuses on pedophilia, and more specifically neurocognitive problems associated with pedophilia. Men with pedophilia also show minor physical anomalies related to atypical prenatal development more than those with other paraphilic sexual behaviors do (Dyshniku, Murray, et al. Beyond the cognitive deficits related to pedophilia, there may be more than one psychological pathway to pedophilia (Knight & King, 2012). Some pedophiles show an intense preoccupation with sex, a sense of emotional compatibility with children, and a specific sexual preference for children. Other pedophiles demonstrate more general tendencies toward elevated impulsivity and psychopathy compared to the general population (Mann, Hanson, & Thornton, 2010). Quick Summary Neurobiological theory of paraphilic disorders has focused on excessively high levels of male hormones (testosterone), but the theory has not received strong support. Sexual offenders report higher rates of being sexually abused than do other offenders, but very few children who are abused grow up to engage in sexual offenses against others. Alcohol use and negative affect are often immediate triggers of inappropriate sexual behaviors. Psychological theories focus on impulsivity, poor emotion regulation, and when paraphilic behavior is directed at nonconsenting others, hostility and lack of empathy. For pedophilia, there may be more than one pathway: some men are sexually preoccupied with children and experience a sense of emotional compatibility with children; other men have a profile of more general impulsive, psychopathic traits. Describe the major problems with the research literature on causes of paraphilic disorders. What types of factors might contribute to the loss of control over sexual urges for those with paraphilic disorders After we discuss treatment approaches, we will turn to a discussion of issues in addressing the legal and public ramifications of sexual offending. We know very little about the effectiveness of these treatments of paraphilic disorders. Strategies to Enhance Motivation Sex offenders often lack the motivation to change their illegal behavior. Many refuse to take part in treatment, and even among those who begin treatment, many will drop out. The therapist can help the client focus on reasons for change, including the potential legal and other consequences of continued engagement in the same sexual behavior (Miller & Rollnick, 1991). Cognitive Behavioral Treatment In the earliest years of behavioral treatment, paraphilic disorders were narrowly viewed as attractions to inappropriate objects and activities. Looking to behavioral psychology for ways to reduce these attractions, researchers fixed on aversion therapy. Thus, a person with a boot fetish would be given a shock on the hands or a drug that produces nausea when looking at a boot, a person with pedophilic disorder when gazing at a photograph of a nude child, and so on. In the form of aversion therapy called satiation, men are coached to pair their paraphilic fantasies with another aversive stimulus: masturbating for 55 minutes after orgasm (Kaplan & Krueger, 2012). Cognitive interventions are often used to counter the distorted thinking of people with paraphilic disorders. For example, an exhibitionist might claim that the girls he exposes himself to are too young to be harmed by it. The therapist would counter this distortion by pointing out that the younger the victim, the worse the harm will be (Kaplan & Krueger, 2012). Therapists often offer social skills training, and teach sexual impulse control strategies such as distraction. Training in empathy toward others is another common technique; teaching the sex offender to consider how his or her behavior would affect someone else may lessen the tendency to engage in such activities. Relapse prevention, modeled after the work on substance abuse described in Chapter 10, is also an important component of many broader treatment programs. A therapist who uses relapse prevention techniques would help a person identify situations and emotions that might trigger symptomatic behavior. Biological Treatments A variety of biological interventions have been tried on sex offenders. Castration, or removal of the testes, was used a great deal until hormonal treatments (described next) became available (Balon, 2016). Surgical castration is not a common treatment today due to major ethical concerns. Treatments and Community Prevention for the Paraphilic Disorders 383 On the other hand, several medications have been used to treat paraphilic disorders, particularly among sex offenders. Among men, sexual drive and functioning are regulated by androgens (such as testosterone). Long-term use of hormonal agents is associated with several negative side effects, including feminization, infertility, liver problems, osteoporosis, diabetes, and depression. Informed consent concerning these risks must be obtained, and many patients will not agree to use these drugs long term (Balon, 2016). Balancing Efforts to Protect the Public Against Civil Liberties for Those with Paraphilias Most people are frightened by sexual offenses, so balancing the protection of the public against the civil liberties of sexual offenders is not easy. In the United States, it is generally unconstitutional to detain a person on the basis of his or her potential for future crimes. The diagnosis of paraphilia, then, has significant implications for civil liberties: receipt of this diagnosis can lead to placement in a psychiatric facility after a prison term is completed. In this context, it has been argued that particular care should be taken to ensure the validity of these diagnoses (Wakefield, 2011). Citizens can then use computerized police records to determine whether sex offenders are living in their neighborhoods. The hope behind these laws is that they will protect against repeat offenses; to date, findings have been mixed about whether these programs are successful in reducing sexual crimes. One unintended consequence of these laws is that some have committed violent crimes toward sex offenders in their neighborhoods (Younglove & Vitello, 2003). Navigating the tension between protecting the public and civil liberties for offenders is an ongoing process. The most commonly used biological treatments to reduce sexual desire and paraphilic behaviors are: a. Name four cognitive behavioral strategies used in the treatment of paraphilic disorders. Describe the evidence base for the psychological and biological treatments of paraphilic disorders. Hostility and lack of empathy appear relevant when sexual behaviors are directed toward nonconsenting others. Some men with pedophilia are obsessed with sex and strongly attracted to children both emotionally and sexually; other men with pedophilia act out of a more general cluster of impulsive and antisocial traits. Treatment approaches must begin by engaging and motivating the client, which is often difficult to do. Early cognitive behavioral approaches focused on aversion therapy and cognitive techniques to challenge distorted beliefs about the consequences of sexual behaviors. Over time, cognitive behavioral therapists have also begun to use techniques to improve social skills, help people control impulses, increase empathy for potential victims, identify potential high-risk situations for the return of symptoms, and where relevant, address childhood experiences of sexual abuse. Research suggests that psychological treatments do not significantly reduce rates of legal offenses. Drugs that reduce testosterone levels have been found to reduce both sex drive and deviant sexual behaviors, but because of the side effects, there are ethical issues involved in the long-term use of these drugs. Laws were passed that allowed the public to access information about where sexual offenders live, but some offenders have been victimized when such information became public. Many people experience brief sexual symptoms, but these are not diagnosable unless they are recurrent, cause either distress or impairment, and are not explained by medical conditions. Researchers have identified many different variables that contribute to sexual dysfunctions, including biological variables, previous sexual experiences, relationship issues, psychopathology, low arousal, and cognitions (for example, self-blame). Desire does not consistently precede the excitement phase for women, and although Kaplan relied on biological changes to define the excitement phase, biological changes do not closely mirror subjective arousal for women. F (unless the problem is recurrent and leads to distress or impairment, it cannot be diagnosed); 2. The spectator role refers to a problem in which a person becomes immersed in considering how they look and seem Key Terms during a sexual encounter rather than enjoying the moment.

Syndromes

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Some therapists focus on nonsexual issues antiviral vitamins purchase prograf 5mg visa, such as difficulties with in-laws or with child rearing-either in addition to or instead of interventions directly focused on sex hiv infection rates los angeles buy prograf 1 mg without prescription. For some couples stories of hiv infection symptoms order prograf 0.5mg, planning romantic events together is recommended to restore closeness and intimacy (Wincze & Weisberg hiv transmission statistics canada buy prograf overnight delivery, 2015) antiviral serum discount prograf 0.5 mg line. Encouraging partners to communicate their sexual likes and dislikes to each other can help a range of sexual dysfunctions (Wincze & Weisberg hiv infection from kissing buy prograf 1 mg without a prescription, 2015). Skills and communication training is particularly warranted when sexual dysfunction is specific to a given relationship and was not a concern with previous partners. A therapist might try to reduce the pressure a man with erectile dysfunction feels by challenging his belief that intercourse is the only true form of sexual activity. Therapists might coach women who are hypercritical of their appearance to consider more positive ways of viewing their bodies and their sexuality. Sensate Focus To help couples refocus on the sensual pleasure of their intimacy, many therapists prescribe sensate focus, a technique introduced by Masters and Johnson (1970). Therapists appoint one partner to do the first pleasuring; the partner who is "getting" is simply to enjoy being touched. The one being touched is not required to feel a sexual response and is responsible for immediately telling the partner if something becomes uncomfortable. The sensate-focus assignment usually promotes contact, constituting a first step toward reestablishing sexual intimacy. Most of the time, partners begin to realize that their physical encounters could be intimate and pleasurable without necessarily being a prelude to sexual intercourse. Treatments for Specific Sexual Dysfunctions Therapists often use more specific techniques for female orgasmic disorder, genito-pelvic pain/ penetration disorder, premature ejaculation, and erectile disorder, and we discuss these next. Many of these specific techniques are combined with the general treatments we already discussed. The first step is for the woman to carefully examine her nude body, including her genitals, and to identify various areas with the aid of diagrams. Next, she is instructed to touch her genitals and to find areas that produce pleasure. Finally, her partner enters the picture, first watching her masturbate, then doing for her what she has been doing for herself, and finally having intercourse in a position that allows him to stimulate her genitals manually or with a vibrator. As illustrated in the Clinical Case of Anne in the beginning of this chapter, directed masturbation has been shown to help treat female orgasmic disorder, particularly when women have a lifelong inability to experience orgasm, with 60 to 90 percent of that subgroup achieving orgasm post-treatment (ter Kuile, Both, & van Lankveld, 2012). Genito-Pelvic Pain/Penetration Disorder A woman with genito-pelvic pain/ penetration disorder might be trained in relaxation, and then practice inserting her fingers or dilators into her vagina, starting with inserting smaller dilators and working up to larger ones. Such programs have been shown to help many women with sexual pain disorder (ter Kuile & Reissing, 2014). Clinical Descriptions of the Paraphilic Disorders 373 As a behavioral treatment of premature ejaculation, the squeeze technique is often used, in which a partner is trained to squeeze the penis in the area where the head and shaft meet to rapidly reduce arousal. This technique is practiced without insertion, and then during insertion, the penis is withdrawn and the squeeze is repeated as needed. In a similar approach, men are taught to withdraw their penis as needed during intercourse to reduce arousal. Behavioral techniques are not as powerful as antidepressant medication for premature ejaculation, but they are helpful as a supplement to medication (Cooper, Martyn-St James, et al. Psychotherapy can also help men regain confidence after experiences of these symptoms (Althof, 2014). Although some men stop taking these medications due to side effects such as headaches and indigestion, most men will tolerate the side effects to gain relief from their sexual symptoms. Across 27 treatment studies, about 83 percent of men who took sildenafil were able to successfully have intercourse compared with about 45 percent of men who took a placebo (Fink, Mac Donald, et al. Quick Summary Key cognitive behavioral treatments for sexual dysfunction include psychoeducation, couples therapy, cognitive interventions, and sensate focus. Sex therapists may recommend that a woman who does not achieve orgasm practice masturbation without her partner present. Large surveys have shown that many people occasionally fantasize about some of the activities we will be describing, and some engage in these behaviors. Voyeuristic attractions may be particularly common: More than 40 percent of people report fantasies of watching unsuspecting people undress, have sex, or be naked (Joyal & Carpentier, 2017). Fifty Shades of Gray, a book describing a sadomasochistic relationship, became one of the best-selling books of all time, with 125 million copies sold in the United States by 2015. Although many people are interested in or have tried these sexual activities, many fewer people report that these interests are sustained, uncontrollable, or distressing (Joyal & Carpentier, 2017). As some of these behaviors and interests appear relatively common, considerable debate has emerged about whether it is appropriate to diagnose some of the paraphilias. In 2009, the Swedish National Board of Health and Welfare decided to remove some of the paraphilic diagnoses. The board reasoned that many people practice variant sexual behaviors safely with consenting adult partners and do not experience any distress or impairment as a result (Richters, De Visser, et al. Impairment and engagement of nonconsenting others are important boundaries between normative and problematic sexual behavior. For example, transvestic disorder does not typically involve nonconsenting others and rarely leads to impairment; the diagnosis of this disorder typically rests on the presence of distress. Diagnostic criteria that rely on distress about sexual desires and behaviors are somewhat illogical. In contrast, the person who feels guilty and ashamed because he or she has internalized stigma about this behavior is diagnosable. Clinical Descriptions of the Paraphilic Disorders 375 Clinical Case William William and Nancy sought marital therapy after Nancy learned that William had a long history of voyeurism. Nancy had been startled to walk into their guest room and find him viewing the neighbor with binoculars while masturbating. Upon confrontation, William shared with his wife that he had felt intense and uncontrollable urges to watch strangers undress since his early adolescence. William and Nancy reported that they had been married for 20 years, and that throughout the duration of their relationship, neither had found their sexual life very satisfying. Nancy was concerned that he rarely initiated sexual contact with her, and indeed, in an individual session, William reported that he preferred watching strangers to having sex with his wife. William had tried different strategies to gain control over his voyeuristic urges, including reading self-help books and attending a support group, with no success. He reported that he came from an extremely strict family and had been teased relentlessly by his father. Although his desire to watch strangers haunted him, he had felt too ashamed to discuss his sexual preferences with anyone in the past. His sexual detachment was part of a broader pattern of emotional distance and lack of disclosure with others in his life. In therapy, William began to explore the sense of social rejection that he had experienced since early childhood. As his wife learned of his past, they achieved a stronger emotional bond, which freed them to discuss their sexuality more openly. As their sex life improved, William reported that his desire to watch others undress faded. Because transvestic behavior so rarely leads to impairment or involves nonconsenting others, we do not discuss transvestic disorder further here. Research is limited by the lack of structured diagnostic interviews to reliably assess paraphilic disorders (Krueger, 2010b) and even more by the reluctance of many people with paraphilias to reveal their proclivities. But statistics on arrests underestimate prevalence because so many crimes go unreported and some paraphilias. The data do indicate, however, that most people with paraphilic disorders are male and heterosexual; even with sexual masochism and voyeurism disorders, which occur in noticeable numbers of women, men vastly outnumber women (Richters, De Visser, et al. Onset for many of the paraphilic disorders, including fetishistic, voyeuristic, exhibitionistic, and pedophilic disorders, typically occurs during adolescence. The onset of sexual sadism disorder and sexual masochism disorder tends to occur by early adulthood (Balon, 2016; Grundmann, Krupp, et al. A person with one form of paraphilic interests is often aroused by other paraphilic stimuli-that is, tendencies to engage in exhibitionism, sexual sadism, sexual masochism, and voyeurism are correlated (Baur, Forsman, et al. The person with fetishistic disorder has recurrent and intense sexual urges toward these fetishes, and the presence of the fetish is strongly preferred or even necessary for sexual arousal. Beyond nonliving objects, some people focus on nonsexual body parts, such as hair, nails, hands, or feet, for sexual arousal. At age 13 he reached orgasm by masturbating while imagining women in their underwear. He began to have intercourse at age 18, and his preferred partner was a prostitute whom he asked to wear underwear with the crotch removed while they had sex. He found that he preferred masturbating into stolen underwear more than sexual intercourse. He avoided dating because he feared the scorn that his focus on underwear might provoke. He had begun to experience significant depression over the ways in which his sexual behavior was limiting his social life. Like Ruben in the clinical case, the person with fetishistic disorder feels a compulsive attraction to the object; the attraction is experienced as involuntary and irresistible. The exclusive and very special status the object occupies as a sexual stimulant distinguishes fetishistic disorder from the ordinary attraction that, for example, high heels may hold for heterosexual men in Western cultures. The person with a boot fetish must see or touch a boot to become aroused, and the arousal is overwhelmingly strong when a boot is present. Some carry on their fetishism alone and in secret by fondling, kissing, smelling, gazing at the adored object, or using the fetish as they masturbate. People with pedophilic disorder generally molest children whom they know, such as neighbors or friends of the family. Most with pedophilic disorder do not engage in violence other than the sexual act, although when they do become violent, it is often a focus of lurid stories in the media. Because overt physical force is seldom used in pedophilic disorder, the child molester often denies that he is forcing himself on his victim. What are the demographic characteristics of people who meet the criteria for pedophilic disorder People with pedophilic disorder can be straight or gay, though most are heterosexual. Among those convicted of pedophilic offenses, about half have never been married (Seto & Eke, 2017). Sexual arousal in response to pictures of young children can be measured by the penile plethysmograph. In large-scale studies, arousal as measured in this way discriminates those who have committed sexual offenses with children (Cantor & McPhail, 2015), and is one of the strongest predictors of repeated sexual offenses (Hanson & Bussiere, 1998). Nonetheless, arousal in response to pictures of children is not a perfect predictor of pedophilic disorder. It is also likely that there are different subgroups of rapists: some show more sadistic traits, some show more hypersexuality, and others show more impulsive traits (Krstic, Neumann, et al. That is, rapists are more likely than nonrapists to have been the victim of sexual and physical abuse (Knight & Sims-Knight, 2011). Even watching violence against women in films can lead men to view violence as more acceptable. At least eight experiments have been conducted in which men are asked to watch videos that contain sexual activities either with or without violence. This research suggests that rape may be encouraged by pornography that depicts violent sexual relations and more broadly highlights the importance of social factors. It is typically defined as "attempted or completed vaginal, anal, or oral sexual intercourse obtained through force, through the threat of force, or when the victim is incapacitated and unable to give consent" (Abbey & McAuslan, 2004). For three-quarters of women who are raped, the rape occurs before the age of 25 (Zinzow & Thompson, 2015). Rates of coercive sexual behavior, in which the person is pressured to engage in sexual contact, are even more common than rape. About 8 percent of male college students in the United States report that they have used force or the threat of force to engage in intercourse, anal sex, or oral sex (White & Smith, Treatment for Rapists 2004). The high rates of Treatment programs for rape and coercive sexual rapists rely on the general behavior have led many approaches we describe for to suggest that sexual vioparaphilic disorders: motilence reflects a social and vational strategies, cognicultural problem (Gavey & this famous scene from Gone With the Wind illustrates one of the myths tive behavioral techniques, Senn, 2014). This has led about rape-that despite initial resistance, women like to be "taken. As with the research education about the negaon treatment for paraphilic disorders, the evidence regarding the tive outcomes of rape and coercive sexual behavior, and to strengthen effectiveness of these approaches is remarkably slim-only 24 raplaws and response systems (DeMatteo, Galloway, et al. Outcomes of that study suggested that in a social context, it is only natural to ask questions about rapists. Can treatment reduce committed an offense during the 5-year follow-up period, compared the risk of recidivism Although this may seem Understanding the Etiology of Rape like a small gain from treatment, any gain is important with such a Sexually aggressive men tend to show antisocial and impulsive difficult problem. In a study using both self-report and penile plethysmography, one-quarter of men drawn from a community sample showed or reported arousal when viewing sexually provocative pictures of children (Hall, Hirschman, & Oliver, 1995). Pedophiles show more arousal to sexual stimuli involving children than to stimuli involving adults; nonpedophiles tend to show relatively more arousal to stimuli involving adults (Blanchard, Kuban, et al. Pedophilic disorder is diagnosed only when adults act on their sexual urges toward children, or when the urges reach the frequency or intensity to be distressing to the person or those close to them. Incest refers to sexual relations between close relatives for whom marriage is forbidden. The next most common form, which is considered more pathological, is between father and daughter. Fathers who abuse their daughters tend to do so after the daughter achieves puberty.

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Further reading National Institute for Health and Care Excellence (2014) Pneumonia in adults: diagnosis and management hiv transmission facts statistics cheapest generic prograf uk. Pseudomonas aeruginosa hiv infection rates baltimore order prograf 0.5mg without prescription, Escherichia coli hiv infection woman to man discount prograf 5mg visa, Klebsiella pneumoniae hiv infection time frame order 0.5 mg prograf fast delivery, Staphylococcus aureus) and rarely by viral or fungal pathogens antiviral drugs for shingles generic prograf 1mg without a prescription. While doing this hiv infection kissing prograf 1mg otc, collect information about the patient, the current problem, the context and comorbidities. Establish what has been decided regarding the ceiling of care and resuscitation status of the patient. If the working diagnosis is hospital-acquired pneumonia, start antibiotic therapy (Table 63. Consider switching to oral therapy after 48 h if there is clinical improvement and plasma C-reactive protein level is falling. Further reading Infectious Diseases Society of America and the American Thoracic Society (2016) Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Pneumothorax is diagnosed by the presence of a white visceral pleural line on the chest X-ray, with no pulmonary vessels visible beyond this. Contralateral shift of the trachea and mediastinum with depression of the hemi-diaphragm are typical features of tension pneumothorax although may not always be evident. Priorities 1 If the patient is unconscious, initial resuscitation is as for coma from any cause (Chapter 3). The acute onset (or presence on waking from sleep) of asymmetric face, arm or leg weakness, speech disturbance or visual field defect support a diagnosis of stroke. Fever at presentation, prominent headache, or neck stiffness should make you consider alternative diagnoses. This should be completed on all patients with stroke to ensure that the stroke deficits are collected in a systematic way and the less obvious signs of stroke are not missed. Classically presents with sudden onset headache with or without focal neurological signs. Often progressive symptoms with or without symptoms of raised intracranial pressure. More often global signs such as clouding of consciousness, confusion, headache together with symptoms and signs of sepsis. Usually generalized rather than focal symptoms such as headache, vomiting, clouding consciousness and seizures. Presents with focal neurological signs, sometimes in patients with known systemic vasculitis. Diagnosis on brain imaging, inflammatory and autoimmune markers and may need brain biopsy. Patients with ischaemic stroke should have their blood pressure kept below 185/110 mmHg. This should be done using a standardized screening protocol such as one that first checks the ability of the patient to cough and then goes on to test the ability to swallow teaspoons of water, followed by a glass of water. If a patient is unable to swallow safely, start feeding with a nasogastric tube within 24 h of admission. If intravenous fluids are required (and enteral hydration is preferred) then avoid the use of glucose solutions as hyperglycaemia may worsen outcomes. This requires monitoring of temperature, pulse, blood pressure and oxygen saturation, at least daily examination of the chest, and monitoring for urinary tract infection. Manage initially by early mobilization, good hydration, a diet rich in complex polysaccharides, and the use of commodes or toilets rather than bedpans. Establishing the cause of the stroke Investigations needed are summarized in Table 65. Probably the lower the blood pressure the better, so most patients will benefit from antihypertensive treatment. If the patient is in known atrial fibrillation, then may not need echocardiography as patient will be anticoagulated anyway. Intracerebral haemorrhage Intracranial arteriography: if suspected vasculitis, aneurysm, arteriovenous malformation, cavernoma Subarachnoid haemorrhage See Chapter 67. Intercollegiate Stroke Working Party (2016) National clinical guideline for stroke 5th edn. Cause Migraine aura (with or without headache) Partial epileptic seizure Transient global amnesia Comment Stereotypical positive symptoms such tingling and visual symptoms, spreading over several minutes and typically resolving within 60 min. Symptom Dysphasia Monocular visual loss Unilateral weakness Unilateral sensory loss Dysarthria Homonymous hemianopia Ataxia/unsteadiness Dysphagia Diplopia Vertigo Carotid territory Yes Yes Yes Yes Yes Yes Yes Yes No No Vertebrobasilar territory No No Yes Yes Yes Yes Yes Yes Yes Yes Transient ischaemic attack Box 66. Consider dual antiplatelet therapy short term for at least seven days (aspirin and clopidogrel). Patients in atrial fibrillation should be anticoagulated with rapid-onset anticoagulants (Chapter 103) once brain imaging has excluded intracerebral haemorrhage and there are no contraindications to anticoagulation. Some will present in an acute confusional state and a collateral history is essential. In others, there may be objective neck stiffness, mild disorientation, or subtle deficits such as dysphasia or pronator drift. Uncommonly, the presence of subhyaloid or vitreous haemorrhage is detected on fundoscopy; in the context of a suggestive history these findings are usually pathognomonic. Identification and obliteration of such aneurysms is needed to reduce the risk of rebleeding. Subarachnoid haemor rhage is often seen in trauma, but is a completely different clinical entity and is not considered here. It occurs more commonly in women, and is strikingly more common in Finland and Japan. Three main modifiable risk factors have been identified: smoking, hypertension and heavy alcohol consumption. As a general rule, this should be performed as an emergency including when out of hours. Samples should be analysed immediately on receipt; if analysis is delayed, false positives may occur. Regional neuroradiology consultation may be required to offer a specialist opinion on such imaging. In severe hypertension, active pharmacological blood pressure control (Chapter 55) may be required: discuss with neurosurgery. Patients presenting in an acute confusional state may give no history of headache and careful witness accounts must be sought. It is important to separate the cardiac sequelae from the neurological presentation, as these events usually require no specific treatment, and antiplatelet or anticoagulant therapy may be disastrous. One option is to immediately repeat a lumbar puncture, if this can be done less than 6 h since the first attempt; otherwise such patients should be discussed with neurosurgery. Hydrocephalus presenting in a delayed fashion is often picked up once the patient is in the rehabilitation phase, and may simply present with a plateau or regression in rehab progress. The patient may be clinically dry; have biochemical features such as a high haemoglobin/haematocrit, high urea, or high serum urate. Urine output is relatively high; urinary sodium levels are elevated; plasma osmolality is low (due to salt loss). Most cases in the developed world are caused by Neisseria meningitidis or Streptococcus pneumoniae. In the context of immunosuppression, alcohol-use disorder or age >60 years, Listeria monocytogenes should also be considered. Disorders which can mimic meningitis include subarachnoid haemorrhage (Chapter 67), viral encephalitis (Chapter 69), brain abscess, subdural empyema and cerebral malaria. Priorities 1 Review the physiological observations, make a focused clinical assessment (Table 68. Consider requesting microscopy and culture for acid-fast bacilli if tuberculosis is suspected (Appendix 68. The cell count will usually be high, with a polymorphonuclear leucocytosis, but may be low in overwhelming infection or immuno suppression. High polymorph count: this is typical of pyogenic bacterial meningitis, although may occur early in the course of viral meningitis. Ask advice from a microbiologist or infectious diseases physician on the best antibiotic regimen and duration of treatment. Distinguishing between viral and partially treated pyogenic bacterial meningitis can be difficult. If tuberculous or cryptococcal meningitis is possible on clinical grounds (see Table 68. Jarrin I, Sellier P, Lopes A (2016) Etiologies and management of aseptic meningitis in patients admitted to an internal medicine department. Intracranial infection Viral encephalitis Other infectious causes of encephalitis Bacterial meningitis (Chapter 68) Tuberculous meningitis (Appendix 68. Current major symptoms and their time course (confirm with family or friends) Recent foreign travel (Chapter 33) Insect or animal exposure (occupational/recreational) Contact with infectious disease Sexual history Immunization history Immunosuppression If meningism is present, or there are other reasons to suspect bacterial meningitis, take blood cultures and start appropriate antibiotic therapy (Chapter 68). The thoracic region (70%) is the most common site of compression, followed by the lumbar (20%) and cervical (10%) spine. With the exception of cauda equina syndrome secondary to acute lumbar disc prolapse, definitive management of this subgroup is rarely as urgent as in malignant disease, but investigation and referral should still occur promptly. In the presence of neurological signs and symptoms, investigation and management must be rapid. Priorities 1 Clinical assessment Examine the spine and perform a full neurological examination, including assessment of perineal and perianal sensation, and anal tone (Box 70. However, infection and impaired tissue healing is a major concern in the latter group. Clinical feature Spinal pain Site of compression Comment Almost all patients with cord compression due to malignant disease will have spinal pain, and pain is typically the first symptom. The vast majority (>90%) are extradural; intramedullary (within the spinal cord) metastases are very rare. Thoracic pain following mild trauma may distract from the underlying diagnosis: trauma can precipitate a pathological fracture in pre-existing disease. Around 75% of patients have limb weakness at the time of diagnosis Spasticity and hyperreflexia take time to develop, and may be absent in the acute setting.

Diseases

• Chromosome 20, trisomy
• Thies Reis syndrome
• Boylan Dew Greco syndrome
• Inborn metabolic disorder
• Glycogenosis type IV
• Amnesia, drug-induced
• Silver Russell syndrome
• Brachymesophalangy mesomelic short limbs osseous anomalies