(:title A Summary and Data to Think About:) (:description A quick overview of why one cannot readily blame so-called homophobia for the elevated mental disorders among homosexuals.:) (:keywords homosexual, bipolar disorder, serotonin, BPD, OCD, obsessive compulsive disorder, paraphilias, eating disorders, mood disorders, axis I disorders, axis II disorders, schizophrenics:) Whether one looks for mental illness among homosexuals or homosexual interests among the mentally ill, the evidence clearly associates homosexuality with mental illness, a find not accounted for in terms of stigma, prejudice, and victimization of homosexuals. Recall that homosexuals are much more likely than heterosexuals to manifest multiple mental disorders in lifetime. Judging by the profile of nonheterosexuals among adolescents, especially school dropouts, and the relative overrepresentation of nonheterosexuals among delinquents/criminals and mentally ill individuals, comparisons between nonheterosexual college students and heterosexual college students almost certainly underestimate the prevalence of abnormal traits among nonheterosexuals. This is important in that studies on nonheterosexuals that have used college student samples have likely portrayed nonheterosexuals in a better light. Recall the association between homosexuality and borderline personality disorder (BPD). Recall that one manifestation of BPD is repeated suicide attempts. Compared to heterosexual men, homosexual men are more likely to attempt suicide but the same cannot be said of successful suicides. Although from a clinical standpoint, one either has BPD or not, some people fail to meet the full diagnostic criteria of BPD but are close and are not mentally normal, as is true of various abnormal mental conditions that do not meet full mental disorder diagnostic criteria.[^A. Angold, E. J. Costello, E. M. Farmer, B. J. Burns, A. Erkanli, J Am Acad Child Adolesc Psychiatry 38, 129 (Feb, 1999).^] In this regard, it is noteworthy that BPD represents an extreme along a continuum.[^N. Haslam, Aust N Z J Psychiatry 37, 696 (Dec, 2003).^]'^,^' [^L. Rothschild, C. Cleland, N. Haslam, M. Zimmerman, J Abnorm Psychol 112, 657 (Nov, 2003).^] Therefore, repeated suicide attempts among male homosexuals are almost certainly a manifestation of mental illness. Besides, personality disorders, especially BPD, and worsening Axis I disorders, especially depression and substance use, predict suicide attempts.[^S. Yen et al., J Abnorm Psychol 112, 375 (Aug, 2003).^] Several aspects of brain-drug interaction suggest that elevated substance use among homosexuals reflects disturbed brain functioning: >>bquote<< Some data: * Data from 14 placebo-controlled drug cross-over studies show that left-handers manifest greater EEG responses (indicative of electrical activity of the brain) to a wide variety of psychoactive drugs compared to right-handers and the differences are not brain hemisphere-specific.[^P. Irwin, Neuropsychologia 23, 61 (1985).^] * Schizophrenics with more minor physical anomalies experience greater side-effects of anti-psychotic drugs.[^J. L. Waddington, Br J Psychiatry 167, 41 (1995).^] * Individuals with elevated fluctuating asymmetry and minor physical anomalies experience greater verbal memory deficits following caffeine ingestion.[^R. E. Jung, R. A. Yeo, S. W. Gangestad, Neuropsychiatry Neuropsychol Behav Neurol 13, 195 (Jul, 2000).^] * In an investigation of alcoholics compared to normal controls, alcoholic adults did not have a greater number of minor physical anomalies than normal adults, but the distribution among alcoholics appeared to be bimodal (having two peaks), suggesting heterogeneity within this group.[^C. T. Gualtieri, A. Adams, C. D. Shen, D. Loiselle, Am J Psychiatry 139, 640 (May, 1982).^] It is likely that a number of alcoholics have experienced a disruptive uterine environment . Many studies have revealed elevated left-handedness among alcoholics,[^W. Sperling et al., Alcohol Alcohol 35, 394 (Jul-Aug, 2000).^] although some have not, which likely results from inadequate sample size. One study even reported atypical asymmetrical usage of eyes, ears, and feet among alcoholics compared to normal controls and heroin users.[^M. K. Mandal, B. Bhushan, A. Kumar, P. Gupta, Alcohol Alcohol 35, 381 (Jul-Aug, 2000).^] * 40-50% of schizophrenics abuse recreational drugs, and among them substance use disorders are associated with incarceration, homelessness, violence and suicide, but more interestingly, there is little evidence “that schizophrenic symptoms lead to substance use (self-medication), that substance use leads to schizophrenia, or that there is a genetic relationship between schizophrenia and substance use.”[^J. J. Blanchard, S. A. Brown, W. P. Horan, A. R. Sherwood, Clin Psychol Rev 20, 207 (Mar, 2000).^] * Inducing lesions in various parts of the brain in rats increases the liability toward rapid dependence on drugs such as cocaine and stimulants.[^J. M. Deminiere, P. V. Piazza, M. Le Moal, H. Simon, Neurosci Biobehav Rev 13, 141 (Summer-Fall, 1989).^]'^,^' [^S. Schenk, B. A. Horger, R. Peltier, K. Shelton, Brain Res 543, 227 (Mar 15, 1991).^] * As a general rule, substance use disorders are elevated among mentally ill individuals, and notably so for prisoners, schizophrenics and individuals with antisocial personality disorder or bipolar disorder.[^D. A. Regier et al., Jama 264, 2511 (Nov 21, 1990).^] >><< Homosexuals manifest elevated paraphilias. Paraphilias result from developmental disturbances: >>bquote<< Some evidence: * Paraphiles manifest elevated Axis I and Axis II mental disorders.[^N. C. Raymond, E. Coleman, M. H. Miner, Compr Psychiatry 44, 370 (Sep-Oct, 2003).^]'^,^' [^D. W. Black, L. L. Kehrberg, D. L. Flumerfelt, S. S. Schlosser, Am J Psychiatry 154, 243 (Feb, 1997).^] * Pedophilia[^R. Blanchard et al., Arch Sex Behav 28, 111 (Apr, 1999).^] and zoophilia[^G. Duffield, A. Hassiotis, E. Vizard, J Forensic Psychiatry 9, 294–304 (1998).^] are more likely to accompany mental retardation . In a comparison of mental patients with two control groups (medical in-patients and psychiatric staff), the prevalence of bestiality (both actual sexual contacts and sexual fantasy) was 55% in the psychiatrically ill group but much lower in the control groups (10% and 15%, respectively).[^W. A. Alvarez, J. P. Freinhar, Int J Psychosom 38, 45 (1991).^] Recall that homosexual behavior is elevated among both mentally ill individuals and zoophiles. * Homosexual and paraphilic behaviors are more common among individuals with outcomes resulting from developmental disturbances such as [[Psychiatry/Patients|schizophrenia]] and ADHD.[^M. P. Kafka, R. A. Prentky, J Clin Psychiatry 59, 388 (Jul, 1998).^], [^M. P. Kafka, J. Hennen, Sex Abuse 14, 349 (Oct, 2002).^] * Furthermore, pedophiles manifest elevated anomalies: ** A less dense right frontal area of the brain.[^S. E. Hendricks et al., J Clin Psychiatry 49, 108 (Mar, 1988).^] ** A higher incidence of left hemisphere (brain) impairment.[^S. Hucker et al., Canadian J Behav Sci 18, 440 (1986).^] ** Smaller left frontal and temporal areas (portions of the brain) and increased brain asymmetry.[^P. Wright, J. Nobrega, R. Langevin, G. Wortzman, Ann Sex Res3, 319 (1990).^] ** Elevated non-right-handedness.[^A. F. Bogaert, Neuropsychologia 39, 465 (2001).^]'^,^' [^J. M. Cantor, B. K. Christensen, P. E. Klassen, R. Dickey, R. Blanchard, paper presented at the International Academy of Sex Research conference, Montreal 2001.^]'^,^' [^J. M. Cantor et al., Neuropsychology 18, 3 (Jan, 2004).^] ** Low baseline plasma cortisol and prolactin (cortisol and prolactin are hormones); and increased body temperature and multiple serotonergic abnormalities (serotonin is, among other things, a neurotransmitter, i.e., a substance that allows adjacent neurons to communicate with each other).[^M. Maes et al., Neuropsychopharmacology 24, 37 (Jan, 2001).^] ** An overactive sympathoadrenal system (referring to the innervation of the adrenal gland by the sympathetic nervous system).[^M. Maes et al., Psychiatry Res 103, 43 (Aug 5, 2001).^] ** A study associated pedophilia with 1) childhood head injuries before age 6 years that resulted in unconsciousness and 2) psychiatric morbidity among the mothers of pedophiles.[^R. Blanchard et al., Arch Sex Behav 31, 511 (Dec, 2002).^] These injuries were also associated with attentional problems and left-handedness and head injuries after age 13 years in pedophiles were associated with drug abuse and promiscuity.[^R. Blanchard et al., Arch Sex Behav 32, 573 (Dec, 2003).^] Therefore, it cannot be necessarily assumed that the injuries contributed to the pedophilia because it is likely that prenatal disruptive factors increased the likelihood of both pedophilia and proneness to injury. Left-handed individuals appear more likely to experience injuries, a find not readily explicable in terms of their living in a world numerically dominated by right-handed individuals.[^Luetters CM, Kelsey JL, Keegan TH, et al. Left-handedness as a risk factor for fractures. Osteoporos Int 2003.^]'^,^' [^Canakci V, Akgul HM, Akgul N, et al. Prevalence and handedness correlates of traumatic injuries to the permanent incisors in 13-17-year-old adolescents in Erzurum, Turkey. Dent Traumatol 2003;19(5):248-54.^] Traumatic head injuries in childhood or adolescence are associated with an elevated likelihood of various mental disorders in adulthood, especially mental illness co-existing with criminality.[^M. Timonen et al., Psychiatry Res 113, 217 (Dec 30, 2002).^] The above finds are not based on probability samples of pedophiles or other paraphiles, but then it is very difficult to obtain a probability sample of paraphiles. On the other hand, since many independent investigations of paraphiles reveal a high incidence of comorbid disorders or anomalies among them, it would be remarkable if all the above finds turn out to be an artifact of nonrepresentative samples. >><< The tendency for multiple paraphilias to co-occur associates paraphilias with poor canalization of development. Not only do [[Sexuality/Paraphilias|homosexuals manifest elevated paraphilias]], but the majority of self-identified homosexuals behave in a heterosexual manner at some point of their lives and also display a high variability of sexual behavior, i.e., compared to heterosexuals, the incidence of disparate erotic targets in the same individual is elevated among homosexuals. In the past homosexuality was initially classified as a sociopathic personality disorder in the DSM because of the assumed defective conscience of homosexuals, but soon thereafter, it was classified as a paraphilia and remained a paraphilia till it was declassified as a mental disorder. There is a strong association between hypersexual desire and paraphilias or non-paraphilic sexual compulsion disorders; besides, paraphilias and non-paraphilic sexual compulsion disorders (NPSCDs) often co-occur. Other than being relatively overrepresented among paraphiles, homosexuals are also relatively overrepresented among individuals with NPSCDs. The incidence of Axis I disorders such as mood disorders, anxiety disorders, and substance use disorders as well as Axis II disorders (personality disorders)is especially elevated among individuals with paraphilias or NPSCDs,[^N. C. Raymond, E. Coleman, M. H. Miner, Compr Psychiatry 44, 370 (Sep-Oct, 2003).^]'^,^' [^D. W. Black, L. L. Kehrberg, D. L. Flumerfelt, S. S. Schlosser, Am J Psychiatry 154, 243 (Feb, 1997).^]'^,^' [^M. P. Kafka, R. A. Prentky, J Clin Psychiatry 55, 481 (Nov, 1994).^]'^,^' [^E. Coleman, Psychiatr Ann 22, 320 (1992).^]'^,^' [^E. Coleman, N. Raymond, A. McBean, Minn Med 86, 42 (Jul, 2003).^] as is also true of homosexuals. Axis I and Axis II disorders are also elevated among various disorders listed in Table 1[^S. L. McElroy, K. A. Phillips, P. E. Keck, Jr., J Clin Psychiatry 55 Suppl, 33 (Oct, 1994).^] below such as bulimia nervosa,[^T. D. Brewerton et al., J Clin Psychiatry 56, 77 (Feb, 1995).^] binge eating disorder,[^S. Specker, M. de Zwaan, N. Raymond, J. Mitchell, Compr Psychiatry 35, 185 (May-Jun, 1994).^] pathological gambling,[^S. M. Specker, G. A. Carlson, G. A. Christenson, M. Marcotte, Ann Clin Psychiatry 7, 175 (Dec, 1995).^]'^,^' [^S. M. Specker, G. M. Carlson, K. M. Edmonson, P. E. Johnson, M. Marcotte, J Gambling Studies 12, 67–81 (1996).^] compulsive buying,[^G. A. Christenson et al., J Clin Psychiatry 55, 5 (Jan, 1994).^] and trichotillomania.[^G. A. Christenson, T. B. Mackenzie, J. E. Mitchell, Am J Psychiatry 148, 365 (Mar, 1991).^] (:html:)
Table 1: Similarity Between OCD* and Some Disorders (published, 1994)
Disorder Phenomenology Male/Female Sex Course Occurs with OCD Comorbid mood disorders Family history Physiology Treatment response
Body dysmorphic disorder 3 3 3 3 3 2 - 3
Hypochondriasis 3 3 1 3 3 - - 2
Anorexia 3 0 2 3 3 2 2 2
Bulimia 2 0 2 2 3 2 2 2
Binge eating disorder 2 2 2 - 2 - - 2
Delusional disorder 2 1 3 2 1 - - 1
Impulse control Disorders IED** 2 0 1 - 1 2 2 1
Kleptomania 2 0 1 2 3 - - 1
Pathological gambling 2 0 1 1 3 1 1 1
Pyromania 2 0 - - - 2 2 -
Trichotillomania 2 0 2 1 3 - - 2
Paraphilias 2 0 2 -*** 1**** - - 2
NPSCDs***** 2 0 2 -*** 2 - - 1
Tourette's syndrome 3 0 2 3 2 2 2 1
Notes: *Obsessive-Compulsive disorder; **Intermittent explosive disorder; ***both paraphilias and [obviously] NPSCDs border on obsession-compulsion, see text for further details that associate these disorders with OCD (the data were not in at the time this table was published by McElroy et al.); ****an underestimate based on inadequate data available at the time, see text for details; *****Non-paraphilic sexual compulsion disorders. Scale: 0–3, 0 = no or minimal similarity, 3 = strong similarity, blank = insufficient data.
(:htmlend:) There is a molecular basis to the comorbidity in the above examples: >>bquote<< Some examples: * Body dysmorphic disorder, anorexia, trichotillomania, and onychophagia respond to drugs known as selective serotonin reuptake inhibitors (SSRIs).[^S. L. McElroy, K. A. Phillips, P. E. Keck, Jr., J Clin Psychiatry 55 Suppl, 33 (Oct, 1994).^] Speaking of serotonin, serotonin is involved in feeding, sexual behavior, and aggression across widely varying species.[^N. K. Popova, T. G. Amstislavskaya, Neuroendocrinology 76, 28 (Jul, 2002).^]'^,^' [^N. K. Popova, T. G. Amstislavskaya, Psychoneuroendocrinology 27, 609 (Jul, 2002).^]'^,^' [^W. A. Weiger, Biol Rev Camb Philos Soc 72, 61 (Feb, 1997).^] Serotonergic abnormalities are often found among paraphilias such as pedophilia,[^M. Maes et al., Neuropsychopharmacology 24, 37 (Jan, 2001).^]'^,^' [^M. P. Kafka, Arch Sex Behav 26, 343 (Aug, 1997).^]'^,^' [^M. P. Kafka, Ann N Y Acad Sci 989, 86 (Jun, 2003).^] aggression and violent criminality in humans and non-human primates,[^A. C. Swann, J Clin Psychiatry 64 Suppl 4, 26 (2003).^]'^,^' [^G. C. Westergaard et al., Neuropsychopharmacology Apr 2 (Apr 2, 2003).^]'^,^' [^G. C. Westergaard, S. J. Suomi, J. D. Higley, P. T. Mehlman, Psychopharmacology (Berl) 146, 440 (Oct, 1999).^] and a variety of mental disorders including depression,[^R. J. Donati, M. M. Rasenick, Life Sci 73, 1 (May 23, 2003).^]'^,^' [^M. El Yacoubi et al., Proc Natl Acad Sci U S A 100, 6227 (May 13, 2003).^]'^,^' [^C. J. Harmer, S. A. Hill, M. J. Taylor, P. J. Cowen, G. M. Goodwin, Am J Psychiatry 160, 990 (May, 2003).^]'^,^' [^K. J. Ressler, C. B. Nemeroff, Depress Anxiety 12 Suppl 1, 2 (2000).^] borderline personality disorder,[^T. Rinne, W. van den Brink, L. Wouters, R. van Dyck, Am J Psychiatry 159, 2048 (Dec, 2002).^] bulimia, anorexia, panic attacks, and obsessive-compulsive disorder.[^A. F. Schatzberg, J. O. Cole, Manual of clinical psychopharmacology (American Psychiatric Press, Washington, DC, ed. 2nd, 1991), pp. xvi, 372 p.^] * Bulimia, binge eating disorder, kleptomania, intermittent explosive disorder, paraphilias, and non-paraphilic sexual compulsion disorders respond to a broad range of drugs such as antidepressants and mood stabilizing agents.[^S. L. McElroy, K. A. Phillips, P. E. Keck, Jr., J Clin Psychiatry 55 Suppl, 33 (Oct, 1994).^]'^,^' [^E. Coleman, T. Gratzer, L. Nesvacil, N. C. Raymond, J Clin Psychiatry 61, 282 (Apr, 2000).^] There exist reports of the remission of transsexualism, exhibitionism, fetishistic transvestism, and even homosexuality as a result of antidepressant use (see here). Antidepressant treatment that increases serotonin levels in the brain cures or diminishes paraphilias and non-paraphilic sexual compulsion disorders in several individuals.[^M. P. Kafka, E. Coleman, J Clin Psychopharmacol 11, 223 (Jun, 1991).^]'^,^' [^D. M. Greenberg, J. M. Bradford, S. Curry, A. O'Rourke, Bull Am Acad Psychiatry Law 24, 525 (1996).^]'^,^' [^J. M. Bradford, T. G. Gratzer, Can J Psychiatry 40, 4 (Feb, 1995).^]'^,^' [^M. P. Kafka, J. Hennen, J Clin Psychiatry 61, 664 (Sep, 2000).^]'^,^' [^A. Abouesh, A. Clayton, Arch Sex Behav 28, 23 (Feb, 1999).^]'^,^' [^A. M. Levitsky, N. J. Owens, J Am Geriatr Soc 47, 231 (Feb, 1999).^]'^,^' [^68. V. B. Galli, N. J. Raute, B. J. McConville, S. L. McElroy, J Child Adolesc Psychopharmacol 8, 195 (1998).^]'^,^' [^J. Zohar, Z. Kaplan, J. Benjamin, J Clin Psychiatry 55, 86 (Mar, 1994).^]'^,^' [^M. J. Kruesi, S. Fine, L. Valladares, R. A. Phillips, Jr., J. L. Rapoport, Arch Sex Behav 21, 587 (Dec, 1992).^]'^,^' [^M. P. Kafka, Br J Psychiatry 158, 844 (Jun, 1991).^]'^,^' [^M. P. Kafka, J Clin Psychiatry 52, 60 (Feb, 1991).^]'^,^' [^M. P. Kafka, Ann Clin Psychiatry 6, 189 (Sep, 1994).^] Depression is a common correlate of various disorders listed in Table 1 above. However, even non-depressed bulimics benefit from antidepressants.[^B. T. Walsh, J. W. Stewart, S. P. Roose, M. Gladis, A. H. Glassman, J Psychiatr Res 19, 485 (1985).^] * Urge-driven disorders such as pathological gambling disorder, alcoholism, borderline personality disorder with self-injurious behavior, cocaine abuse, mental retardation with self-injurious behavior, eating disorders, and sexual compulsion disorders have been successfully treated by opioid antagonists.[^N. C. Raymond, J. E. Grant, S. W. Kim, E. Coleman, Int Clin Psychopharmacol 17, 201 (Jul, 2002).^] * The experience of pleasure and a sense of relief from stress correspond to the release of the neurotransmitter dopamine at several sites in the brain. Dopamine metabolism and dopamine-neurons are modified by serotonin-, opiod-, cannabinoid-, norepinephrine-, and GABA-neurons. Genetic or structural anomalies (including those resulting from developmental disturbances) involving such neurons or their relatedness can compromise adequate release of dopamine, prompting individuals to engage in behaviors that maintain appropriate dopamine levels in various brain regions. Examples of such behaviors include drug abuse (alcohol, cocaine, methamphetamine, heroin, nicotine, marijuana, and others), compulsive gambling, overeating, compulsive sexual behaviors, and risky behaviors. Specifically, inadequate levels of the dopamine D2 receptor increase the liability for multiple addictive, impulsive, and compulsive behaviors such as severe alcoholism or other drug dependence, binge eating of sugary foods, pathological gambling, compulsive sexual behaviors, ADHD, Tourette 's syndrome, autism, chronic violence, posttraumatic stress disorder, schizoid/avoidant cluster disorders, conduct disorder, and antisocial behavior.[^K. Blum et al., J Psychoactive Drugs 32 Suppl, i (Nov, 2000).^]'^,^' [^D. E. Comings, K. Blum, Prog Brain Res 126, 325 (2000).^] A low level of dopamine D2 receptor binding in the left caudate nucleus has been reported in patients with obsessive-compulsive disorder.[^D. Denys, N. Van Der Wee, J. Janssen, F. De Geus, H. G. Westenberg, Biol Psychiatry 55, 1041 (May 15, 2004).^] >><< It should not be assumed that chemical imbalances alone are solely responsible for the problems described above because although some chemical imbalances are readily corrected by drugs, amelioration or remission of the associated disorders takes a long time. When several mental disorders co-occur, someone may be prompted to argue that one or more mental disorders are specific manifestations of another mental disorder, but this is not always correct.[^N. C. Raymond, E. Coleman, M. H. Miner, Compr Psychiatry 44, 370 (Sep-Oct, 2003).^] For instance, some have argued that bulimia is a symptom of a mood disorder;[^B. T. Walsh, S. P. Roose, A. H. Glassman, M. Gladis, C. Sadik, Psychosom Med 47, 123 (Mar-Apr, 1985).^] however, a taxometric analysis revealed that bulimia is a disorder on its own.[^D. H. Gleaves, M. R. Lowe, A. C. Snow, B. A. Green, K. P. Murphy-Eberenz, J Abnorm Psychol 109, 56 (Feb, 2000).^] Let us address a system-level explanation of comorbidity. Depression is a common correlate of obsessive-compulsive disorder[^V. H. LaSalle et al., Depress Anxiety 19, 163 (2004).^] and the disorders listed in Table 1 above. Note that these disorders are characterized by a difficulty in maintaining stable brain functioning. Therefore, increased odds of depression in these disorders can be loosely understood in terms of resource depletion or exhaustion as a result of greater effort on the part of the brain to stabilize mental functioning. It should be obvious by now that nonheterosexuals find it more difficult to maintain stable mental functioning compared to heterosexuals, on average. !!References [^#^]