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J Neurol Neurosurg : first published as 10.1136/jnnp.49.8.867 on 1 August 1986. Downloaded from

Journal ofNeurology, Neurosurgery, and Psychiatry 1986;49:867-873

Hypersexuality or altered sexual preference following brain injury

BRUCE L MILLER,* JEFFREY L CUMMINGS,t HUGH McINTYRE,* GEORGE EBERS,J MARSHALL GRODE§ From the Department ofNeurology, Harbor-UCLA Medical Center,* Los Angeles, CA, Departments of Neurology, UCLA Medical Center and Brentwood VA Medical Center,t Los Angeles CA, Department of Neurology, University of Western Ontario, London, Ontario, ,$ Department ofNeurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA,§ USA

SUMMARY Eight patients are described in whom either (four cases) or change in sexual preference (four cases) occurred following brain injury. In this series disinhibition of sexual activity and hypersexuality followed medial basal-frontal or diencephalic injury. This contrasted with the patients demonstrating altered sexual preference whose injuries involved limbic system structures. In some patients altered sexual behaviour may be the presenting or dominant feature of brain injury. his three Hypersexual behaviour and alteration in sexual roommates. Mental status examination on admis- Protected by copyright. preference has been produced by experimental brain sion revealed a withdrawn and apathetic male. He answered injury in animals' but appear to be unusual con- many questions with curses but had normal digit span, con- sequences of focal brain injuries in humans.24 When structions and language. He did not know the date and such alterations offer remembered none of three words after 3 minutes. Fun- occur, they meaningful insights duscopic examination revealed papilloedema and both legs into the anatomy and physiology underlying normal were weak and spastic with bilateral Babinski signs. sexual behaviour and provide important evidence A computed tomographic scan (CT) showed a basal- regarding the neurological basis of aberrant sexual frontal haemorrhage and angiography revealed an aneurysm behaviour. This study describes eight patients in of the anterior communicating artery. He became extremely whom sexual activity was either increased or changed drowsy within 24 hours and slowly slipped into coma. following a focal brain injury. The relevant literature Despite aggressive medical and surgical management he died is briefly reviewed and clinico-pathologic correlations 2 weeks after admission to hospital. Necropsy showed hae- made. morrhage in the basal frontal areas bilaterally with involvement of the septal region. Case histories Case 2 A 59-year-old right-handed man was admitted to a psychiatric hospital in a floridly hypersexual state. Two Hypersexuality years previously he had a grand mal seizure and at that time Case 1 A 39-year-old right-handed businessman was CT scan revealed a subfrontal meningioma. The tumour was http://jnnp.bmj.com/ admitted to the hospital following sudden collapse. Two removed transcallosally without complication. After surgery weeks prior to admission he had the acute onset of a frontal his desire for sexual activity increased from once per week to headache associated with nuchal rigidity. The evening of his at least once and sometimes 3 to 4 times per day. Intercourse hospital admission he walked to the bathroom in his home frequently lasted longer than 1 hour and he had some and fell to the floor. Seconds later his wife found him repet- difficulty achieving . Over the next 9 months his itively saying his own name. He was brought to hospital excessive sexual demands led to the end of a close awake and alert but his verbal output was sparse. In the relationship with a girlfriend of many years. hospital, he publicly masturbated and attempted to have Two years after his surgery he became increasingly preoc- intercourse with his wife and with female nurses in cupied with sex and developed a manic syndrome. He was on September 26, 2021 by guest. front of admitted to hospital where he publicly masturbated and sex- ually propositioned both male and female patienis and staff Address for reprint requests: Dr Bruce L Miller, Department of (he had a past history of previous homosexual contacts). In Neurology, Harbor-UCLA Medical Center, 1000 W Carson Street, hospital his behaviour was ameliorated with thiothixene and Torrance, California 90509, USA. benztropine. Mental status examination revealed decreased generation of word lists (eight animals named in 1 minute) Received 5 November 19E 5 and mild difficulty with verbal memory (one of three words Accepted 15 December 1985 remembered after 3 minutes). The basic neurological exam- 8i167 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.49.8.867 on 1 August 1986. Downloaded from

868 Miller, Cummings, McIntyre, Ebers, Grode ination was normal except for absence of olfaction. CT scan had increased appetite, disturbed sleep, and a verbal output (fig 1) revealed bilateral basal medial frontal lucencies con- that approached flight of ideas. sistent with old infarctions. He was discharged after one Mental status examination revealed normal attention with month and was lost to follow-up. intact language, memory, and calculation. Her writing was Case 3 At age 30 years a previously healthy right-handed very small and she had difficulty copying 3-dimensional man contracted a viral encephalitis. After recovery he devel- drawings. She had a left homonymous hemianopsia, a mild oped complex partial seizures with occasional secondary left hemiparesis, and a dense left hemisensory deficit includ- generalisation. He had a variety of seizure auras, often hear- ing diminished sensitivity to pain and temperature. CT scan ing the sound of sweet, unrecognisable music. Multiple elec- (fig2) demonstrated a lucency in the right thalamic and troencephalograms (EEG) showed frequent right and rare hypothalamic regions. She gradually recovered and the left temporal sharp waves. After his recovery from encepha- heightened sexual sensation disappeared after 1 month. litis he became profoundly hyposexual. His wife complained that he never approached her sexually, and their frequency Change in of intercourse dropped from 2 to 3 times per week to 1 or 2 Case 5 A 50-year-old man was hospitalised in 1981 by his times per year. In the postictal period, however, the patient wife in an effort to control his pathological sexual behav- became sexually aroused. His wife became aware of his post- iour. They had been married for 30 years. For the first 15 ictal behavioural change and sought sexual relations with years of the they had a mutually satisfying him during these periods. The arousal lasted less than 10 relationship with approximately 5 times minutes and the patient was amnesic for the encounters. Fol- per week. At the age of 34 the patient developed subtle lowing one prolonged complex partial seizure the patient felt changes in personality and displayed poor financial judge- intense lasting 12 hours. ment. During the same year he lost his business, developed Case 4 A 31-year-old woman developed a severe headache increasing difficulty with and , began to and was admitted to hospital where a CT scan revealed make sexual proposals toward his 7-year-old daughter and blood in the basilar cisterns and angiography showed a right her friends, and also began collecting . After superior cerebellar artery aneurysm. The aneurysm was sur- losing his business in 1968, he worked for approximately 7 gically clipped but 5 days after operation she had a more years at a job far below the level of his previous leaving a left-sided motor and sensory deficit, and a behav- employment. He eventually developed urinary incontinence ioural change. and in 1975 a diagnosis of "idiopathic" hydrocephalus was Protected by copyright. Previously a shy person, she began to talk incessantly made. A ventriculo-atrial shunt was inserted, and the incon- about sexual matters and propositioned her physicians. She tinence disappeared. At the same time it was noted that he developed a sexual preoccupation with her internist and dis- was hypothyroid and he was treated for this condition. cussed openly in explicit sexual language with him, and He maintained an aberrant interest in sexual matters. He others, her desires for him. She propositioned only males, made frequent and increasingly more public sexual advances and on one occasion she requested intercourse with a towards young children and his conversation was filled with cachectic 70-year-old patient dying of cancer. While in hos- sexual innuendo. He frequently embarrassed his wife by pital, she described intense sexual excitement, and in retro- showing pornographic pictures to visitors at their home. IQ spect she remembers feeling "warm" and "aroused" almost testing in 1977 revealed a verbal IQ of 105 and a per- the entire month. In addition to the sexual excitement, she formance IQ of 106. Endocrine testing suggested hypo- http://jnnp.bmj.com/

Fig 1 CTscan (Case 2) demonstrates bilateral basal-frontal infarction in a patient with a hypersexual syndrome following removal ofa subfrontal meningioma. on September 26, 2021 by guest. J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.49.8.867 on 1 August 1986. Downloaded from

Hypersexuality or altered sexual preference following brain injury 869

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Fig 3 Pathologyfrom Case S demonstrates an infiltrating hypothalamic glioma in a patient with a change in sexual preferencefrom to .

increase in sexually motivated activity was apparent after he regained consciousness from his encephalitis. He made sex- ual comments toward females he encountered in the hospital Protected by copyright. and attempted to fondle the nurses. He masturbated pub- licly. After discovery of the hydrocephalus and shunt place- Fig 2 CTscan (Case 4) demonstrates a right thalamic ment, his sexual behaviour became "disgusting" according infarction with possible hypothalamic involvement in a patient to his wife. He became "the man with a thousand hands" with a secondary and a hypersexual state. attempting to fondle her each time she came within reach. He requested intercourse with her frequently and also asked that she have sex with other men while he watched, an inter- thalamic dysfunction and a repeat CT scan was normal. est never previously expressed. By 1979 he discussed sex almost continuously. He was On examination he was alert and language, memory and arrested for propositioning children in his neighbourhood. calculation were intact. He could name only six animals in I He also developed a Weber's syndrome (left third nerve minute and he could not abstractly interpret proverbs or palsy and a right hemiparesis). CT scan demonstrated a neo- copy complex constructions. Neurological examination was plasm involving the left brainstem from the pons to the mid- normal except for mild . A CT scan brain. Soon afterwards he developed Benedikt's syndrome revealed hydrocephalus with the tip of the shunt inserted (left third nerve palsy, right hemiparesis and hemiataxia). into midline anterior hypothalamic-inferior septal struc- Although the hypothalamus was not visibly involved on CT, tures. Cisternography was consistent with normal pressure the patient's endocrine testing suggested hypothalamic dys- hydrocephalus but the patient refused shunt revision. function. Case 7 A right-handed woman was well until age 31 years http://jnnp.bmj.com/ The patient gradually deteriorated and died in 1984. Nec- when she developed progressive lethargy, somnolence and ropsy revealed a brainstem glioma involving the thalamus, confusion followed by a generalised seizure. She became hypothalamus, ventral midbrain and pons with greater comatose and had frequent generalised seizures. Cere- involvement on the left side (fig 3). Histological studies brospinal fluid (CSF) examination revealed lymphocytosis, demonstrated a hypercellular grade 3 astrocytoma. normal glucose and an elevated CSF protein. Fungal and Case 6 A 75-year-old man developed herpes zoster oph- bacteriologic studies of serum and CSF were normal and an thalmicus followed by encephalitis that quickly lead to EEG showed generalised slowing with left-sided focal spike coma. He improved slowly over 3 weeks but required nurs- and slow wave activity. A presumptive diagnosis of herpes ing home care due to disinhibited behaviour and poor judge- simplex encephalitis was made. on September 26, 2021 by guest. ment. Two years later a CT scan showed hydrocephalus and She gradually improved but manifested an aphasia with a ventriculo-peritoneal shunt was inserted, but he deterio- incoherent repetitive and irrelevant verbal output consisting rated necessitating hospitalisation. mainly ofneologistic jargon. Learning was severely impaired Prior to the encephalitis the patient and his wife had and she could not remember recent or remote events. She, weekly sexual relations. In earlier years he had rarely sug- was emotionally indifferent. Sexual behaviour changed: she gested that they participate in "" but had not insis- showed no interest in intercourse with her husband although ted when she declined, and their relationship had been she complied with his advances. She made both oral and otherwise considered normal and satisfactory to his wife. An manual sexual advances to female attendants in the hospital. J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.49.8.867 on 1 August 1986. Downloaded from

870 Miller, Cummings, McIntyre, Ebers, Grode She gained 50 pounds and ate food and nonfood items, in- jury to the brain although the lesions seen with this cluding toilet paper and faeces. There was little im- condition are sufficiently variable that it is difficult to provement or change in her behaviour over 13 years. identify one specific area in the brain responsible for Case 8 A 71-year-old man developed Parkinson's disease the diminished sexual interest.5 Hypersexual at age 61 manifested initially by micrographia. Slowness, behaviour2 and change in sexual preference6 are less rigidity, and tremor were apparent within 2 years. He worked as a clerk until age 66 when disability lead to retire- common following brain injury and study of hyper- ment. On levodopa-carbidopa his extrapyramidal symptoms sexuality in humans after focal brain injury gives abated but he became preoccupied with intrusive sexual fan- important clues about areas of the brain involved in tasies and ruminations concerning sexual topics. He began the normal sexual response. Likewise alterations in to insert objects into his and on one occasion a pencil sexual preference associated with brain lesions may had to be surgically removed. His medication was reduced suggest which areas of the brain influence sexual and the aberrant sexual behaviour abated. He had no history orientation in humans. The cases presented here ofpsychiatric disturbances or previous or contribute to this evolving and complex field. paraphilic behaviour. He had been married for over 30 years The patients described in this paper fall into two and his wife also denied that he had ever shown an interest in atypical sexual practices. overlapping categories. All the patients developed a Mental status was normal and general neurological exam- change in sexual behaviour (table). Cases I to 4 dem- ination demonstrated findings consistent with idiopathic onstrated an increase in sexual activity and Cases 5 to Parkinson's disease. CT scan of the head was normal and 8 exhibited an alteration in sexual preference with or EEG showed mild slowing. During a 6 year follow up without a heightened sexual drive. The first group of period, the patient has had no recurrence of unusual sexual patients manifested a disinhibited public expression behaviour. of their increased drive. This sexual disinhibition was often associated with a general disinhibition of Discussion behaviour, and in some cases the patients exhibited elements of secondary mania. Sexual disinhibition

The normal human sexual response has multiple com- and public have been described with Protected by copyright. ponents including arousal, copulation and orgasm. dysfunction of the basal frontal lobe,6 and two of our The stimulus leading to sexual arousal varies from patients with the syndrome (patients I and 2) had CT person to person and is determined by a combination scan evidence of injury in this region. In case 1 the of experiential, genetic, and neurological factors. The injury was due to the rupture of an anterior commu- organisation of the human sexual response and the nicating aneurysm, and in case 2 a subfrontal menin- neural basis for sexual preference is an area of neu- gioma had been present. Exhibitionism has also been rology that is poorly understood and much of our described in patients with Huntington's disease,7 information comes from lesion studies in animals. epilepsy, mutiple sclerosis, and Gilles de la Tourette Animal studies are not completely applicable to hu- syndrome.8 9 Between 5 and 35% of those arrested mans, however, and even non-human primates have for exhibitionism are found to be suffering from sexual behaviours that differ markedly from those of organic disorders to which the behaviour can be at men and women. Hyposexuality is common with in- least partially attributed.10 l

Table http://jnnp.bmj.com/ Case Gender Age (yr) Sexual behaviour Lesion site Cause 1 Male 39 Public with sexual Basal frontal Anterior communicating advances toward female nurses aneurysm 2 Male 59 Increased sexual drive with Basal frontal Meningioma manic behaviour 3 Female 31 Verbal preoccupation with sex Right thalamic- Infarction following and "erotic" feeling lasting hypothalamic subarachnoid I month. "Secondary mania" haemorrhage

4 Male 30 Sexual arousal post seizures. Right temporal Post-encephalitic on September 26, 2021 by guest. Interictal hyposexuality seizure disorder 5 Male 50 Pedophilia with impotence Left midbrain- Glioma hypothalamic 6 Male 75 and sexual Hydrocephalus Post-encephalitic disinhibition 7 Female 31 Change from hetero- Bitemporal Post herpes encephalitis to homosexual preference 8 Male 71 Penile mutilation Basal ganglia Parkinsonism. Lcvodopa precipitated behaviour J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.49.8.867 on 1 August 1986. Downloaded from

Hypersexuality or altered sexual preference following brain injury 871 Patient 3 developed hyposexuality and post-ictal may lead to pedophilia, and conversely, careful sexual arousal associated with temporal lobe seizures assessment of pedophilic patients may lead to the after recovering from limbic encephalitis. Hypo- discovery of associated neurological abnormalities. sexuality in patients with temporal lobe seizures In Cases 6 and 7, viral encephalitis leading to limbic is well known'2 and ictal sexual auras have been area damage was the predisposing neurological fac- described but have occurred almost exclusively in tor. Patient 6 was sexually disinhibited and developed women.13 Hypersexual behaviour has most com- voyeurism, a new sexual interest for him. In addition monly been associated with the abrupt cessation of to the encephalitis, this patient had a malpositioned seizures either in the post-ictal period or following shunt inserted into the septal region and obstructive temporal lobectomy."4 It is possible that the sexual hydrocephalus. No other patients with voyeurism behaviour following the seizures was due to associated with focal brain lesions were found in continued limbic electrical discharge, or that the the literature, but Berlin'8 reported one voyeuristic increased sexual activity was due to post-ictal patient with an elevated leutinising (LH) disinhibition of structures in the septum and/or level and a second with elevations of both LH and hypothalamus (an equivalent of post-ictal paralysis). . These endocrine studies were not done Patient 4 had a profound verbal preoccupation in the cases reported here. Case 7 developed the with sexual matters and exhibited a manic syndrome. Kluver-Bucy syndrome and changed from a hetero- Secondary mania has been described following brain sexual to a homosexual orientation following herpes injury and is more common in patients, like case 4, encephalitis. Similar alterations in gender preference with lesions in the thalamic and periventricular in association with the Kluver-Bucy syndrome have regions of the right hemisphere."5 Increased sexual previously been reported,'9-21 and a few patients drive is common in patients with mania although were reported to have become disinhibited and this patient's sexual preoccupation was unusually publicly demonstrative. extreme. She described after recovery that she had Patient 8 developed genital mutilation when

experienced an erotic-orgiastic sensation throughout initially started on levodopa-carbidopa. Altered Protected by copyright. the period of her increased interest in sex. sexual behaviour was common in post-encephalitic The second group of patients (Cases 5 to 8) devel- Parkinsonism' and approximately half of oped a change from what was previously a stable and Parkinsonism patients receiving levodopa experience established pattern of sexual behaviour. Like the first an activation of sexual behaviour.22 -24 group, most of the patients (Cases 5, 6, and 7) also Investigations of experimental animals and pre- developed disinhibited public expression of their vious observations of humans with altered sexual altered sexual behaviour. No single common anatom- behaviour establish three phases of sexual response: ical area was involved in this second group of patients arousal, copulation, and orgasm. Sexual arousal and but in all cases the lesions were in or near the limbic object choice depend primarily on limbic system system. The patients in this group with the most structures including hypothalamus and temporal dramatic change in sexual preference had lesions in lobe. The preoptic nucleus of the hypothalamus is the temporal lobe and/or midbrain adjacent to the sexually dimorphic and in utero hormonal manipu- hypothalamus, and those with most marked sexual lations can reverse the gender preference of male and disinhibition also had frontal lobe damage. female rats.25 26 Electrical stimulation of the nucleus Patient 5 manifested impotence and pedophilia also leads to copulatory behaviour and ablation pro-

associated with an infiltrating glioma of the midbrain- duced permanent loss of sexual activity. In humans, http://jnnp.bmj.com/ hypothalamic region (fig 3). This patient had a hypothalamic lesions reduce sexual drive27 and may profound change in sexual orientation from a hetero- have contributed to the altered object choice of sexual pattern to an almost single-minded preoccu- Case 5. pation with children. Early in the course of his long Temporal lobe structures also play an important illness he was secretive about his interest in children. role in sexual preference and activity. Lilly et al'9 After he developed hydrocephalus he became observed that in the human Kluver-Bucy syndrome, increasingly more disinhibited about his new sexual the bilateral temporal lobe dysfunction was associ-

preference. Pedophilia has previously been reported ated more commonly with changes in sexual prefer- on September 26, 2021 by guest. in association with post-encephalitic Parkinsonism, ence than with frank hypersexuality. Similarly a suprasellar meningiomas, post-anoxic encephalo- patient with fetishism and cross-dressing changed to a pathy, and epilepsy.3416 Henn and co-workers'7 heterosexual pattern of sexual behaviour after tempo- found that of 111 offenders arrested for child molesta- ral lobectomy for seizures.28 In two patients reported tion 14 4% had acquired organic psychosyndromes here (Cases 6 and 7), change in sexual orientation was and an additional 13 5% were mentally retarded. more prominent than increased sexual behaviour. Together these observations suggest that brain injury Patient 3 had interictal hyposexuality combined with J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.49.8.867 on 1 August 1986. Downloaded from

872 Miller, Cummings, McIntyre, Ebers, Grode postictal hypersexuality in association with temporal described here with dysfunction of the hypothalamus lobe epilepsy. Patient 6 manifested post-encephalitic and temporal lobe. Change in sexual behaviour voyeurism and patient 7 changed gender preference should suggest the possibility of a brain lesion. from heterosexual to homosexual after herpes encephalitis. This work was supported by the Veterans Adminis- Arousal, the pleasure associated with sexual activ- tration. The authors thank Harry Vinters MD for ity, and orgasm may, in part, be mediated by mono- providing the pathology report and figures on Case 5. aminergic compounds.29 Yohimbine elevates central References norepinephrine levels and increases mounting behav- iour in male rats even when associated with genital 1 Lisk R. Increased sexual behavior in the male rat following anaesthesia.30 compounds have also lesions in the mamillary region. J Exp Zool 1966; been associated with increased sexual drive2' and 161:129-36. Case 9 suggests that dopamine may play a role in 2Poeck K, Pilleri G. Release of hypersexual behavior due to Acta Neurol 1965; as well as drive. lesion in the limbic system. Scand sexual preference 41:233-44. Sexual arousal leads to increased copulatory activ- 3Fairweather DS. Psychiatric aspects of the post- ity. Although peripheral somatosensory inputs are encephalitic syndrome. J Ment Sci 1947;391:200-54. important for this aspect of reproductive activity, hu- 4Regestein QR, Reich P. Pedophilia occurring after onset man patients with paraplegia may experience arousal of cognitive impairment. J Nerv Ment Dis 1978; and even orgasm without peripheral sensory input, 166:794-8. suggesting that central structures are sufficient for this sBoller F, Frank E. Clinical syndromes. In: Boller F, Frank experience.3' Copulatory behaviour may be induced E, eds. Sexual Dysfunction in Neurological Disorders. by stimulating the septal region in primates,32 and Diagnosis, Management and Rehabilitation. New York: orgiastic sensations in patients Raven Press, 1982:48-50. Heath33 described 6Blumer D, Benson DF. Personality changes with frontal during stimulation of this region. The patients in this and temporal lobe lesions. In: Benson DF, Blumer D, series with true hypersexuality (Nos 1, 2, and 3) had eds. Psychiatric Aspects of Neurologic Disease. New Protected by copyright. lesions involving or adjacent to the medial septal area. York: Grune and Stratton, 1975:151-70. All these aspects of reproductive behaviour are 7Rosenbaum D. with Huntington's chorea. mediated by structures with extensive frontal and lim- Psychiatr Q 1941;15:93-9. bic connections. The basal frontal area has multiple 8Cummings JL. Sexual behavior. In: Cummings J, ed. Clin- connections with the thalamus, hypothalamus and ical Neuropsychiatry. New York: Grune and Stratton, other elements of the limbic system.34 Prominent 1985:242-6. ex- connect the frontal lobe to the pre- 9Comings DE, Comings BG. A case of familial efferent pathways hibitionism in Tourette's syndrome successfully treated optic region of the hypothalamus and may control with haloperidol. Am J Psychiatry 1982;139:913. sexual drive. Behavioural changes may be the only '0Blair C, Lanyon RI. Exhibitionism: etiology and treat- manifestation of damage to the basal frontal area and ment. Psychol Bull 1981;89:439-63. this region is vulnerable to both trauma and hydro- Arieff AJ, Rotman DB. 100 cases of . J cephalus. The disinhibited behaviour seen with injury Nerv Ment Dis 1942;96:523-8. to this region may include inappropriate discussion of 12Herzog A, Russell V, Vaitukaitis JL, Geschwind N. Neu- sex6 but increased sexual drive is less common. Two roendocrine dysfunction in temporal lobe epilepsy. patients in this series with increased drive and actual Arch Neurol 1982;39:133-5. Sexual 1 13Remillard GM, Andermann F, Testa GF, etal. increased sexual activity (Cases and 2) had demon- http://jnnp.bmj.com/ In ictal manifestations predominate in women with tem- strable lesions of the basal frontal lobe. addition, poral lobe epilepsy: a finding suggesting sexual dimor- several of the patients in this series had basal frontal phism in the human brain. Neurology 1983;33:323-30. injury in addition to other pathology that may have Blumer D. Hypersexual episodes in temporal lobe epi- led to a mixed pattern with both alteration in sexual lepsy. Am J Psychiatry 1970;126:1099-106. preference and disinhibited sexual activity. "Cummings JL,, Mendez M. Secondary Mania with focal These observations emphasise that specific sexual cerebrovascular lesions. Am J Psychiatry 1984; changes may occur following brain injury and in some 141:1084-7. 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Hypersexuality or altered sexual preference following brain injury 873 9Lilly R, Cummings JL, Benson DF, Frankel M. The 27Bauer HG. Endocrine and metabolic conditions related to human Kluver-Bucy syndTome. Neurology 1983;33: pathology in the hypothalamus: a review. J Nerv Ment 1141-5. Dis 1958;128:323-38. 20Terzian H, Dalle Ore G. Syndrome of Kluver and Bucy 28Mitchell W, Falconer MA. Epilepsy with fetishism re- reproduced in man by bilateral removal of the temporal lieved by temporal lobectomy. Lancet 1954;2:626-30. lobes. Neurology 1955;5:373-86. 29Everitt BJ. Editorial: Monoamines and the control of sex- 21 Shraberg D, Weisberg L. The Kluver-Bucy syndrome in ual behavior. Psychol Med 1983;13:715-20. man. J Nerv Ment Dis 1978;166:130-4. 30 Clark JT, Smith ER, Davidson JM. Enhancement of sex- "Bowers MB, Van Woert M, Davis L. Sexual behavior ual motivation in male rats by Yohimbine. Science during L-dopa treatment for parkinsonism. Am J 1984;225:847-9. Psychiatry 1971;127:1091-3. 31 Money J. Phantom orgasm in the dreams of paraplegic 23 Brown E, Brown GM, Kofman 0, Quarrington B. Sexual men and women. Arch Gen Psychiatry 1960;3:373-82. function and affect in parkinsonian men treated with 32 MacLean PD, Denniston RH, Dua S, Ploog DW. Further L-dopa. Am J Psychiatry 1978;135:1552-5. studies on cerebral representation of penile erection: 24Shapiro SK. Hypersexual behavior complicating levo- caudal thalamus, midbrain, and pons. J Neurophysiol dopa (L-dopa) therapy. Minn Med 1973;56:58-9. 1963;26:273-93. 2S Gorski RA, Gordon JH, Shryne JE, Southam AM. Evi- 33 Heath RG. Pleasure response of human subjects to direct dence for a morphological sex difference within the stimulation of the brain: physiologic and psycho- medial preoptic area of the rat brain. Brain Res dynamic considerations In: Heath RG, ed. The Role of 1978;148:333-46. Pleasure in Behavior. New York: Harper and Row, 26Pardridge WM, Gorski R, Lippe BM, Green R. An- 1964:219-43. drogens and sexual behavior. Ann Int Med 1982; 34Nauta WJH. Neurol associations of the frontal cortex. 96:488-501. Acta Neurobiol Exp 1972;32:125-40. Protected by copyright. http://jnnp.bmj.com/ on September 26, 2021 by guest.