Archive for the ‘Love And Sex’ Category

How To Take Wellbutrin (Bupropion)

WELLBUTRIN SR and XL (Bupropion)

Wellbutrin SR comes in two strengths: 100mg blue tablets and 150mg purple tablets. Wellbutrin XL comes in 150mg and 300mg tablets.

Wellbutrin enhances the brain’s natural stimulants, dopamine and norepinephrine. These help increase mental energy and motivation/interest. Wellbutrin also helps to control addictions, increase sexual functioning (especially libido and orgasm), and aids in weight reduction.  Wellbutrin works just as effectively as the Serotonin Reuptake Inhibitors (SSRI’S) for anxiety symptoms associated with depression. 

HOW TO TAKE FOR DEPRESSION

WELLBUTRIN XL

Do not break tablets.


Starting dose
150mg in the morning for one week
After one week Increase dose to 300 mg in morning.
Sometimes dose needs to be increased to 450mg, and rarely to 600mg.

WELLBUTRIN SR

Starting dose One 150 mg tablet in the morning. 

If any significant side effects, decrease dose by cutting the tablet in half or switch to 100mg tablet. (Only about 10% of the slow release action is lost when the tablet is cut.)


After 3 – 7 days
Add a 2nd tablet at lunch

After 1 week on 2 tablets per day
Take both tablets in the morning if tolerated
After 3 – 4 weeks of 2 tablets per day If dose is not strong enough, add a 3rd tablet per day and take in divided doses of 2 in the morning and 1 at lunch.
(A total of four tablets per day can be used in divided doses but this is rarely needed by most people.)

OTHER TREATMENTS

SMOKING

300mg of Wellbutrin SR is usually the most effective dose to help quit or decrease smoking. It’s is even more effective when combined with nicotine replacement. (Nicotrol inhaler is best-tolerated form) 

A smoker does not have to be motivated to decrease or discontinue smoking. They just need to try the drug along with the smoking. Most people find that after taking the medication they no longer crave nicotine, and the need to smoke decreases.

SEXUAL DYSFUNCTION

Wellbutrin is effective for treatment of low sexual interest. It can also help primary orgasmic dysfunction or secondary orgasmic problems caused by other medications, especially SSRI’s. Treatment success is usually 40-50% for orgasmic dysfunction on an “as needed” basis.

WEIGHT REDUCTION

Wellbutrin has recently been found in studies to improve weight loss in obese patients. It is also an effective treatment for sluggishness and weight gain secondary to medications.

ADD and BOREDOM

Often respond well to Wellbutrin.

ANTIDEPRESSANT AUGMENTATION

Wellbutrin works well as a complementary drug with other antidepressants to achieve a more effective response in some patients.

SIDE EFFECTS

Side effects are usually mild and controllable with a dose adjustment or by adding a second medication to control side effects until they subside.

Most common side effects are:

  • Insomnia
  • Dry Mouth
  • Nervousness
  • Irritability

For full information, see package insert or prescribing information.

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Crazy But Not Insane

I saw an interview last week on the Today Show with the lawyer for Debra Lafave, the 23 school teacher in Florida accused of sexual assault of a 14 year old male student.  Her lawyer is seeking an insanity defense because what she did is obviously insane. He felt that because she’s so attractive, putting her in prison (a hell hole) would be like throwing raw meat to lions and he was not sure she would survive.
My first reaction was to agree with him. But then I thought that approach is mainly going to piss people off. When you look at her picture and hear the facts you immediately think, “That’s crazy”.

Then you see another teacher in Tennessee, Pamela Turner, is accused of sexual assault of a 13 year old.

What could possibly cause these two women to show such poor judgment? Do they have a legitimate insanity defense? Recently Mary Kay Letourneau, the Washington teacher who was charged for sexual assault of a 13 year old student, got out of prison after 7 years and married her ex-student. They have 2 kids together, 7 and 8 years old. He’s now 22 and she’s 43. Can these relationships really work out?

I have spent the last few days researching the laws relating to age of consent for sex and the use of the insanity defense. I have also thought about the possible psychiatric disorders that could be involved and tried to understand how the biology of love could go so awry as it appears to have done. In the case of the 2 current teachers, their behavior is clearly crazy but not legally insane. They’re both toast. What a waste.

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Teachers Having Sex With Students!

Two attractive young school teachers have come to national attention this year because they had sexual relationships with 13 and 14 year old boys in their classes. What is even crazier is that both of these women were married and neither would have any trouble finding sexual partners if they wanted to have sex outside their marriage. In both instances they knew that what they were doing constituted a felony offense and could easily result in prison time if caught. Neither of them was particularly careful. Both must have heard of the notorious case of Mary Kay Letourneau who served seven years in a Washington state prison (1998-2005) for having sex with an under aged male student.

The insanity defense

But were they insane? Unfortunately, no. Insanity is not a medical or even psychiatric term. It is a legal term meaning not sane or not rational. The concept of legal insanity was first introduced in England in 1843 when the courts decided that Daniel M’Naghten was not guilty of murder because he thought he was acting in self defense. He had paranoid delusions which if true would have put him in danger. More specifically insanity was defined as: because of a mental illness at the time of the criminal act the individual didn’t understand what they were doing or they didn’t understand that it was wrong.

Since Federal courts do not have jurisdiction over criminal behavior except in special instances, e.g., national defense or interstate commerce, almost all of these cases are handled according to the laws of their state. The age of consent for sex varies from 14 in Nevada to 18 in California. Many states also have age difference stipulations, in an attempt to prevent exploitation by adults.

In 1962 the American Law Institute expanded the definition of insanity. The first standard was basically the same – due to a mental defect the individual did not know that the act was wrong. They added that legal insanity could also be the inability to adhere to the right. This latter standard was interpreted as an “irresistible impulse” but was sometimes limited to acts that would have occurred even if a policeman was standing there. Now four states have completely eliminated the insanity defense. Most states don’t include “irresistible impulse” as a legal defense.

There has always been a public skepticism about the use of the insanity defense. It has been seen as a loophole for sociopaths to escape responsibility or a mechanism where psychiatrists could get people off because they had some mental problems or a difficult childhood.

In 1982 there was a national uproar when the insanity defense was used by John Hinckley after he attempted to assassinate President Reagan. He was found not guilty by reason of insanity. Since that time it has generally been more difficult to successfully use the insanity defense. There is a perception that the insanity defense is used frequently but the fact is that it is rarely used, maybe 1 in 2000 cases. When used it is usually not successful. When successful it is usually so obvious that the prosecutor agrees and it doesn’t even go to trial.

So, the legal question is easy to answer in the two prominent current cases involving teachers. They were both continuing to function in their teaching jobs. They undoubtedly knew that what they were doing was wrong. In fact Debra LaFave in Florida was quoted as saying that, “part of the arousal was because it was not allowed”. They couldn’t even use the defense of “irresistible impulse” since there were multiple separate instances. Both of these women may have bipolar symptoms with seriously impaired judgment and impulse control. Both may be genetically addiction prone and both may have Attention Deficit Hyperactivity Disorder with impulsivity. Is it possible that they both have an Adderall or Concerta deficiency? As Dennis the Menace said, “by the time I realized the consequences of my action I had already done it”. But these psychiatric/emotional factors would only apply as possible mitigating factors in the determination of punishment – not the establishment of guilt.

The cases of Debra LaFave (Florida) and Pamela Turner (Tennessee) are dramatic if not shocking but not unusual. According to the U.S. Department of Education, between 6-10% of public school children have been sexually abused or harassed by school employees and teachers.

It’s in our genes

We are still left with the question “why”?

Remember, to understand any behavior you have to look at the immediate causality (motivation, dynamics, brain chemistry, etc.) but also the ultimate causality. Why does this behavior exist in the world?

One of the main functions of the highest level of functioning of the human brain is to control deeper primitive instinctual behavior. In certain conditions such as Attention Deficit Hyperactivity Disorder and hypomania there is a deficit in higher level functions and behavior is more at the mercy of our emotions and instincts.

So, the first answer to why is that “it’s in our genes”. The single most important reason we exist is to reproduce. The more we reproduce the greater the chance that we will be able to adapt to the ever changing world.

Age of consent

What about the question of age. At what age is it appropriate to begin having sex? According to Mother Nature it is when we are capable of producing offspring. That means in many cases younger then 13. In four states the legal age of consent for sex is 14 and all but Nevada have an age difference specification. As a medical student in 1966 working in the obstetrics department of Parkland Hospital it was not unusual to deliver 12 year old girls having their second baby. They were usually from very poor families and because of the financial aid provided for dependent children program this was a way for children to help support for their families.

What makes people act crazy?

So if it’s so natural why is it crazy? It’s crazy when it’s against the law and in fact a felony. The potential consequences are so severe that there must be powerful forces at work other than basic instinct. Is it hormones or pheromones? Is it brain chemistry? Is it a society where we hear a lot about sex but especially in the case of married couples we?re not having a lot of sex? Is it cultural with a lot of emphasis on doing what feels good? Yes to all of the above.

Personality determines some behavior. Personality is character plus temperament. Character includes maturity, self-sufficiency, lack of self-centeredness, and respect for others. Perpetrators of inappropriate sexual behavior usually have some deficits of character.

Temperament is mainly genetics and includes persistence, harm avoidance, need for approval, and novelty seeking. Risk taking is one of the traits for which specific genetic polymorphism has been identified. Risk takers have been found to have lower amounts of a particular enzyme in the brain (monoamine oxidase inhibitor, or MAO). Some risk takers are sky divers, some are pathological gamblers and some break rules or the law as a form of excitement. Personality traits tend to be fairly stable. To know the degree to which pathologic personality traits would explain the behavior of the two recent teachers in the news would require detailed personal history.

Is it a personality disorder?

Two particular personality disorders are commonly associated with sexually deviant behavior. They are borderline personality and narcissistic personality. (These do not include antisocial personality which is cool calculating manipulators without conscience that can be perpetrators.) The borderline personality lacks a clear sense of identity and is impulsive and engages in self-destructive behavior. They often but not always have a history of being abused. The borderline personality usually has elements of bipolar disorder and ADHD.

There are two types of narcissistic personality. One is a person who was treated as being better than other people and deep down truly believes it. They may be from wealthy families or be particularly attractive or gifted in sports, art, or music. Because they feel better than others they don’t believe the rules or laws should apply to them. They have a sense of entitlement – they should be able to have what they want. The more common type of narcissistic personality is a person who deep down feels inferior, inadequate, unlovable, but works hard to avoid these feelings by trying to convince themselves and others of their superiority. They may end up acting the same way as type one.

It is certainly possible that the two teachers recently in the news fit into one of these personality categories.

Could it be love?

Is it possible that a 13 or 14 year old boy could be “in love” with a 25-35 year old teacher? And if so, could it be morally wrong for them to engage in sexual intercourse? This is a harder question than the legal one. The fact that what’s legal depends on what state you live in reflects the subjectivity and arbitrariness of the issue. No matter how bizarre it may seem, Mary Kay Letourneau at age 35 began an intense emotional relationship with her 12 year old student. Their relationship became sexual shortly after he turned 13. Recently they were married. Their relationship survived unbelievable media scrutiny and her spending 7 years in prison. Along the way they have had 2 children. It certainly seems crazy but it’s hard to deny that their love for each other is real.

What is love?

A lot of times I’ll ask a patient, “are you in love with??” The answer I often get is “well I do love them”. I often push for a more definite commitment. I say something like, “you love your dog. You love chocolate”. What I’m asking is, “are you IN love with them, committed to them? Do you want to/like to have sex with them?” One of the most telling questions is “how would you feel if they had sex with someone else?” If you are in love with someone the idea of them having sex with someone else is devastating. But what is love? In the context of relationships there are 3 components, each with a unique biology and psychology.

They are:

  • Sex
  • Romance
  • Attachment

Sexual attraction and arousal is most highly correlated with the hormone testosterone in men and women. Men are more aroused visually. Youthfulness, beauty, and cleavage are thought to be arousing because they are associated with fitness to reproduce. Men are competitive and hierarchical. Mother Nature wants the men with the best genes to have the most offspring. A man can impregnate many women during the same time period. This is not something women like to hear, but they need to understand that a man’s biology and physiology is different than theirs. When a man makes an exclusive commitment to a woman he will still notice other attractive women, but that will not take away from his committed love relationship.

Women are less sexually aroused visually. A woman can only be pregnant by one man at any given time. She will be more physically vulnerable during her pregnancy and it will be hard for her to attend to an infant and also provide for all her own and the babies needs. Women are more attracted to men who can be providers/protectors. They are more impressed by maturity and stability.

Since the availability of birth control men and women have more freedom to have sex for fun, but the underlying biology and instincts still play a major role. But one of the risks of sex for “fun” is that you may fall in love or get “attached”. This is a warning that Helen Fisher, PhD gives her students in her college classes. She has done years of research into the “biology of love” that she describes in her recent book, Why We Love: The Nature and Chemistry of Romantic Love.

When Dr. Fisher did functional MRI’s to measure brain activity she found dramatic differences in those who were “in love”. Their brains looked similar to people with major addictions. The reward area of the brain and the brain transmitter dopamine increase with romantic love. Norepinephrine also goes up and serotonin goes down. Does this mean that raising our serotonin levels with some antidepressants could interfere with our romantic feelings? Maybe. Does this mean that “being in love” with someone is like being hooked on them or addicted to them? Yes. Sorry if that seems unromantic. When you read how Mary Kay Letourneau after spending time in jail, going through a humiliating trial, sentenced to seven years of prison probated still sought out her under age lover does that not sound like addictive behavior? She was clearly out of control.

Probably the most important part of a relationship is attachment. Sex is great but it’s only a small percent of the time a couple spends together. Romantic feelings can come and go depending on many factors especially stress but the attachment can grow steadily for a lifetime. The biology of attachment is most related to the hormones oxytocin in women and vasopressin in men. Women who don’t bond to their babies have been found to have low oxytocin. Estrogen increases oxytocin. Studies using voles (rodents) show the importance of oxytocin to attachment. Mountain voles have low oxytocin and are polygamous but prairie voles have higher oxytocin and are monogamous. Orgasm causes the release of oxytocin (women) and vasopressin (men) and dopamine. Sex can increase attachment and romantic feelings. This is great in a committed relationship. It may not be so great in a forbidden relationship such as is usually the case between a teacher and student.

Self-control

So are we mainly at the mercy of our genes, brain transmitters, and hormones? Obviously not. But we are certainly under their influence. No testosterone, no libido. No dopamine, no interest. In mature adults control is in the highest level in the front of the brain – the prefrontal cortex. There are numerous cases of individuals who were high functioning, moral, responsible adults who after suffering damage to the front of their brain began acting impulsively and more under the influence of their primitive instincts. We know that certain psychiatric disorders are associated with reduced functioning of the highest brain levels.

Where does this leave us with our two school teachers accused of sexually assaulting their young male students? To understand their behavior is not to excuse it. In each of their cases we need a lot more information. They will be held responsible and will be punished. Hopefully, the punishment will fit the crime but with so much media attention and so much emotion involved there is no telling how it will turn out. The real issue is that this is a complex, common problem that deserves a lot of study and hopefully new national standards and programs to protect kids from determining their life course before they are mature enough to fully understand their options.

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