Iranian Journal of Psychiatry and Behavioral Sciences
Volume:15 Issue: 4, Dec 2021

The fact that substance use may result in dependence and severe harm to the user and the community has led to serious and extensive endeavors to design and implement preventive interventions. Prevention programs, however, have been shown to have different effects, and that should not be taken for granted. Systematic reviews and meta-analyses in the field have tried to reveal the effects of different types of substance use prevention programs and to identify the influencing factors.

The purpose of the current review was to more accurately identify factors associated with the effectiveness of interventions or reversal of desired effects. Evidence Acquisition: We systematically reviewed systematic review and meta-analyses studies within the period of 2009 - 2019 that reported the effectiveness of substance use prevention programs. After the systematic screening of 1586 articles, 43 articles were finally reviewed.

In preparation for extracting our data, we designed a structural model for analyzing the results of research on the effectiveness of substance use prevention programs. In general, universal types of prevention programs were reported as more effective than the two other types of selective and indicated programs. Regarding the context of programs, the school setting was more effective than others. In the case of interventions performed in the family setting, selective programs were more effective. Interventions provided by specialists were more effective than those provided by laypeople and / or peers. Interventions provided by more than one person and from more than one discipline showed higher effectiveness.

Based on our structural design, we feel that further studies are needed to extend our knowledge regarding the effectiveness of substance use prevention programs.

Resilience is a dynamic system for successful adjustment with various circumstances, particularly adverse living conditions. In this respect, the Child and Youth Resilience Measure (CYRM-12) can simultaneously assess the individual, relational, contextual, and cultural resources of resilience.

The present study aimed to investigate the psychometric properties of the Persian version of CYRM-12 in Iranian youth.

In this cross-sectional study, a total number of 440 students aged 14 - 18 years were enrolled. The students were studying in middle and high schools (the academic year of 2019 - 2020) in the city of Islamshahr, Iran, and were selected using random cluster sampling. Data collection questionnaires included the CYRM-12, CYRM-28, Warwick-Edinburgh Mental Well-Being Scale (WEMWBS), and Depression, Anxiety, and Stress Scale (DASS-21).

Our results supported the one-factor structure and showed that the given measure had a good fit (χ 2 /DF = 2.63, RMSEA = 0.06, CFI = 0.95, and GFI = 0.95). The internal consistency measured by Cronbach’s alpha coefficient was also satisfactory (0.79). As well, the test-retest reliability determined by Pearson’s correlation coefficient (with a two-week interval) was obtained 0.70. Moreover, this scale had acceptable convergent and divergent validities.

The Persian version of the CYRM-12 delivered good reliability and validity to assess resilience in Iranian youth.

Resilience is a dynamic system for successful adjustment with various circumstances, particularly adverse living conditions. In this respect, the Child and Youth Resilience Measure (CYRM-12) can simultaneously assess the individual, relational, contextual, and cultural resources of resilience.

The present study aimed to investigate the psychometric properties of the Persian version of CYRM-12 in Iranian youth.

In this cross-sectional study, a total number of 440 students aged 14 - 18 years were enrolled. The students were studying in middle and high schools (the academic year of 2019 - 2020) in the city of Islamshahr, Iran, and were selected using random cluster sampling. Data collection questionnaires included the CYRM-12, CYRM-28, Warwick-Edinburgh Mental Well-Being Scale (WEMWBS), and Depression, Anxiety, and Stress Scale (DASS-21).

Our results supported the one-factor structure and showed that the given measure had a good fit (χ 2 /DF = 2.63, RMSEA = 0.06, CFI = 0.95, and GFI = 0.95). The internal consistency measured by Cronbach’s alpha coefficient was also satisfactory (0.79). As well, the test-retest reliability determined by Pearson’s correlation coefficient (with a two-week interval) was obtained 0.70. Moreover, this scale had acceptable convergent and divergent validities.

The Persian version of the CYRM-12 delivered good reliability and validity to assess resilience in Iranian youth.

In every culture, different criteria are considered for choosing a spouse, and some psychological factors predict spouse selection in people on the verge of marriage.

This study aimed to investigate the role of attitudes toward love, emotional maturity, and early maladaptive schemas in predicting spouse selection in a sample of people on the verge of marriage.

This cross-sectional study was conducted from June to September 2018. After applying inclusion and exclusion criteria, participants were selected using the convenience sampling method and evaluated by the Love Attitudes Scale, the Emotional Maturity Scale, the Young Early Maladaptive Schema Scale-short form, and the preference criteria of spouse selection inventory.

The results showed that Pragma love, lack of independence, and disconnection and rejection were the best predictors of the spouse selection process (R2 = 0.50; F = 11.62; P < 0.001). Also, Eros love, lack of independence, and impaired autonomy and performance were the best predictors of content spouse selection (R2 = 0.66; F = 15.38; P < 0.001).

Young people have criteria for selecting a spouse. Pragma love, which is rational love, predicts the spouse selection process, and if content spouse selection is used, Eros love, which is hedonic, is the best predictor. Thus, all family therapists and counselors need to know about this criterion in each area they work.

Because of the long duration of the coronavirus disease 2019 (COVID-19) pandemic, people may suffer greatly from the common burnout caused by this virus.

Considering the psychological consequences of COVID-19, this study investigated the validity and reliability of the Persian version of the COVID-19 Burnout Scale (COVID-19-BS).

The Persian version of the COVID-19-BS was prepared through forward translation, reconciliation, and back-translation. The method of the study was descriptive (psychometric). The statistical population included all students of Ahvaz Jundishapur University of Medical Sciences, Iran, from October 2020 to November 2020. Using the convenience sampling method, 251 students were selected. All participants completed the COVID-19 Anxiety Syndrome Scale (C-19ASS), the Compassion Scale (CS), and the COVID19-BS. Convergent validity, divergent validity, and confirmatory factor analysis (CFA) were used to evaluate the validity. Data analysis was performed using SPSS version 25 and LISREL 8.5 software.

The findings supported the single-factor structure of COVID-19-BS and a good internal consistency of the scale. Internal consistency obtained by Cronbach’s alpha method for the total score of C-19ASS was 0.72, indicating a good internal consistency. The COVID-19-BS had a positive and significant correlation with the C-19ASS (P = 0.01, r = 0.37) and a negative and significant correlation with the CS (P = 0.01, r = -0.41), indicating the convergent and divergent validity of this scale (P <0.01).

The present psychometric study complements the cross-cultural literature of this instrument. The COVID-19-BS showed good validity and reliability, and it can be useful in assessing the burnout caused by COVID-19 in the Iranian population. This scale seems to be a useful and practical tool for assessing COVID-19 burnout in research and clinical settings.

Addiction is one of the most prominent problems and the fourth leading crisis worldwide. In Iran, this issue is more complicated because of increasing young population in this country.

This study aimed to predict addiction susceptibility regarding students’ personality traits at Qazvin universities.

In this cross-sectional study, 227 students from Qazvin universities were selected using the multistage random stratified sampling method. Data collection tools were demographic information form, Addiction Susceptibility questionnaire (ASQ), and NEO personality inventory. After collecting the required data, SPSS software version 21 was used to analyze the data by running variance analysis and paired sample t-test.

In this study, neuroticism (P = 0.031) and openness (P = 0.043) with regression coefficients of 0.584 and 0.586 had positive and significant effects on addiction susceptibility, respectively. In contrast, extraversion (P = 0.023), agreeableness (P = 0.038), and consciousness (P < 0.001) with regression coefficients of -0.639, -0.186, and -1.342 had negative and significant effects on addiction susceptibility, respectively.

The findings revealed a significant relationship between personality traits and addiction susceptibility. Accordingly, the aforementioned psychological traits must be empathized in educational, preventive, and therapeutic programs so that the vulnerable groups, including students, would receive some help.

The mental state of the mother is one of the factors influencing the development of infants. Besides, the quality of the child’s relationship with her/his parent is very important in childhood development.

This study aimed at investigating the relationship between the mother’s depression and developmental disorders in infants.

This cross-sectional study utilized a sample size of 311 subjects. The study population included all infants and their mothers who were referred to health centers of the city of Hamadan, Iran, to receive the usual one-year care. Mothers’ depression was assessed with the second edition of the Beck Depression Inventory, and children’s developmental disabilities were assessed with one-year Ages and Stages Questionnaire.

The mean age of mothers in this study was 29.7 ± 5.6. The prevalence of developmental disorders in infants was 3.5%. This study showed that mothers’ depression had no significant relationship with any of the developmental domains in infants. None of the developmental domains in infants were related to the mother’s occupation and education. However, the gross motor skills (Pvalue: 0.007) and problem-solving skills (P-value: 0.031) were significantly related to the socioeconomic level, and communication (P-value: 0.034), and personal-social skills (P-value: 0.026) of the infant were directly related to the mother’s age.

Mother’s depression is not related to the infant’s developmental disorders. There is a relationship between the socioeconomic level of the family and gross motor and problem-solving skills of the infant. The mother’s age is directly related to communication and personal-social skills of the infant.

Dentophobia can reduce the number of regular visits to dentists and endanger the oral health of people. New technologies such as virtual reality (VR) can be used in the treatment of psychological problems such as dentophobia.

The present study aimed to investigate the effectiveness of virtual reality exposure therapy (VRET) on dentophobia in clients of dental offices in the cities of Isfahan, Tehran, and Shahrekord in 2020.

The research method was quasi-experimental with a pre-test, post-test, and follow-up design and a control group. The statistical population of this study consisted of all clients with dentophobia visiting private dental clinics of Isfahan, Tehran, and Shahrekord in 2020. Thirty clients with dentophobia who were willing to participate in the research were selected as the sample using convenience sampling and randomly divided into experimental and control groups (n = 15 per group). The experimental group underwent eight sessions (15-minutes sessions per week) of virtual reality exposure therapy, while the control group received no intervention. The follow-up was performed after 45 days. The research instruments included the Modified Dental Anxiety Scale (MDAS), Samsung Gear 360 (2017 Edition), and HTC VIVE Pro Virtual Reality Headset. Data were analyzed using repeated-measures ANOVA.

The results showed that virtual reality exposure therapy effectively decreased dentophobia in clients of dental offices in the experimental group (P = 0.0001).

According to research findings, virtual reality exposure therapy was an efficient therapy for improving dentophobia and reducing phobia symptoms in clients of dental offices.

Spiritual care (SC) is an appropriate source for adaptation and coping with disease and life stressors. Although SC contributes to the quality of life and mental health of clients, there are barriers to the provision of such care.

This study aimed to explore barriers to the provision of SC in mental health care centers from the viewpoints of mental health care provider (MHCP) experts.

This qualitative study was conducted based on conventional content analysis on 19 participants who were selected from different groups of MHCPs. The participants were selected by purposive sampling method from December 2019 to December 2020 in Karaj and Tehran, Iran, by considering the maximum diversity. Data were collected through semi-structured interviews with participants during an average time of 60 min per interview until data saturation. The transcripts of the interviews were analyzed by qualitative content analysis.

Barriers to SC were obtained in four categories and 10 subcategories. The categories included “SC concept-related barriers”, “barriers related to MHCPs”, “organizational barriers”, and “barriers related to SC recipients.”

This study demonstrated various barriers to the provision of SC to the clients of health care centers that should be removed to promote the level and quality of SC.

The global spread of COVID-19, due to its pathogenesis and high mortality rate, has caused high levels of stress among various levels of societies. Hence, it is necessary to investigate social support interventions concerning their effectiveness and accessibility.

The study aimed to determine the association between coping strategies and social support in survivors of COVID-19.

Following a descriptive-correlational design, using the census method, 158 discharged cases with a definitive diagnosis of COVID-19 in 2020 were recruited. Data collection tools included the demographic characteristics questionnaire, CISS-48 stresscoping methods, and Wax’s social support questionnaire. Data were analyzed using descriptive and inferential statistics of Pearson correlation coefficient and multivariate regression in SPSS version 22.

The most and least frequent stress coping strategies used by patients were problem-oriented (48.49±9.99) and avoidanceoriented stress strategies (24.48 ± 4.11), respectively. Family support (39.02 ± 4.20) was the major source of support. There was a significant correlation between the score of social support and the total score of stress, problem-oriented, and avoidance-oriented stress. According to the regression analysis, there was a significant association between the score of coping strategies and educational level.

By increasing the awareness of COVID-19 patients about problem-based coping strategies, their stress can be reduced. Also, due to the high level of social support provided by the family, planning for family-centered nursing interventions and engaging family members in the care of COVID-19 patients are important.

There is increasing attention toward the recognition of psychotic disorders with autoimmune etiologies, especially among first-episode psychosis patients. These patients may be underdiagnosed before they develop a full range of neurological symptoms.

We aimed to characterize the rate and clinical presentations of first-episode autoimmune psychosis patients.

All patients with first-episode psychosis (FEP) with the onset of symptoms over a maximum course of three months were recruited and underwent a comprehensive examination and serum and cerebrospinal fluid autoimmune tests.

Seven out of 15 patients with FEP were under 20 years, and four were Afghans. Twelve patients developed prodromal symptoms, all had at least one type of delusion, and 11 patients had experience of hallucinations. Formal thought disorders were detected in seven patients. Five patients had catatonic symptoms.

Certain sample features made our cases unique, including young age, high rate of prodromal symptoms, catatonic features, and formal thought disorders. Lack of specific criteria to arrive at the diagnosis of autoimmune psychosis would be a major milestone to achieve in future studies.

Violence is a critical phenomenon in clinical settings, which negatively affects the nurses’ quality of working life (QoWL).

The aim of this study was to determine occupational violence and its association with nurses’ QoWL in intensive care units.

This was a descriptive, analytical, correlational study, the participants of which were 220 nurses working in the intensive care units of Mazandaran educational-medical centers. The participants were selected by using the stratified random sampling method in 2019. Data collection instruments were three questionnaires, namely Dumont Occupational Violence, Walton QoWL, and Demographic Information. The data were analyzed using SPSS, version 24, and descriptive and inferential statistics.

Overall, 63.2% of the participants rated their QoWL as average, and 68.3% of the nurses stated that they had experienced violent behaviors from their nursing colleagues. Also, people with higher incomes had significantly higher QoWL (P = 0.003). In general, there was a significant negative correlation between occupational violence and QoWL (P = 0.01, r = -0.173).

By taking into account the various aspects of QoWL, nurse managers should adopt effective strategies to create favorable working conditions to improve the QoWL of nurses and reduce the incidence of violent behaviors.

According to the spread and popularity of social networks and easy access to them through smartphones, the impact of these networks’ long-term application and consequences, including psychological vulnerability, could not be ignored.

The present study investigated the mediating role of using smartphone social networks considering personality traits and psychological vulnerability.

The research population included all users (over 18 years of age) of social networks in Isfahan, Iran, from which 250 individuals (i.e. 96 male and 154 female subjects) were selected. The research method was descriptive and causal-correlational. For data collection, the short-form five-factor personality questionnaire neuroticism-extraversion-openness (NEO), the smartphone social media addiction questionnaire, and a psychological vulnerability questionnaire were used. The Pearson correlation coefficient and the path analysis of structural equation modeling were employed to analyze the data.

The findings revealed that among personality factors, neuroticism and low extraversion could explain the use of social networks in a significant and desirable way. Moreover, using social networks could explain psychological vulnerability in the form of causal-structural relationships.

The findings indicated a relatively good fit of the measurement model. Accordingly, the variable of social network usage plays a mediating role in the relationship between psychological vulnerability and some personality traits.

According to Contrast Avoidance Model, those suffering from generalized anxiety disorder (GAD) are afraid of severe emotional changes such as the transition from a good or neutral position to sudden unhappiness following a negative event. Also, the model shows that persistent worrying can be used to maintain negative emotions as a means of preventing a sudden change to negative in people with GAD.

This study aimed to evaluate the psychometric properties of the Persian version of the General Emotion QuestionnaireContrast Avoidance Model (GEQ-CAM).

Early, the GEQ was translated into Persian according to the translation instructions and using multistage cluster sampling. Initially, five universities located in Tehran were randomly selected, then from each of them, three different colleges were selected for the academic year of 2020. Afterward, 50 cases with GAD were selected using the convenience sampling method, yielding a total sample size of 576 (526 students and 50 cases with GAD).

General Emotion Questionnaire has an excellent level of internal consistency (α = 0.973) and test-retest reliability (0.986). This questionnaire indicated a positive and significant correlation with Penn State Worry Questionnaire (r = 0.804) and GAD-7 (r = 0.727), which indicates its appropriate convergent validity. Also, confirmatory factor analysis supported its 2-factor structure.

In accordance with previous studies, the findings suggested that psychometric properties of the Persian version of the General Emotion Questionnaire-Contrast Avoidance Model are acceptable; hence, this questionnaire can be used for research, diagnostic, and therapeutic purposes.

Sensory integration is a necessary skill for acquiring reading skills because it strongly depends on the rapid and strong relation between written and verbal symbols. There is no standardized test for Iranian children with dyslexia to investigate their sensory processing problems. Therefore, understanding the validity and reliability of the child sensory profile 2 (CSP2) would be essential for a detailed assessment of sensory impairments in dyslexic children.

The current research aimed to establish the internal consistency, factor analysis, and convergent validity of the Persian version of CSP2 in children with dyslexia.

The sample of this study included 200 dyslexic children aged 6 to 12 years who were referred to learning disabilities centers in Qom from September 2019 to February 2020 by using the multistage sampling method. To collect data, the CSP2 questionnaire and the dyslexia test (NEMA) were used. The factor structure was assessed by confirmatory factor analysis. The internal consistency of the CSP2 was examined by using Cronbach’s alpha. Convergent validity was assessed by examining the relationship between CSP2 and NEMA.

Internal consistency was obtained as 0.89, 0.92, 0.77, and 0.94 for the four subscales of sensory processing, namely registration, seeking, sensitivity, and avoiding, respectively. The result of confirmatory factor analysis gained support for Dunn’s four-factor model. Total scores of NEMA were correlated with the scores of CSP2 subscales (seeking, avoiding, sensitivity, and registration).

The Persian version of the Child Sensory Profile 2 is a valid (via confirmatory factor analysis and convergent validity) and reliable (via internal consistency) tool for assessing sensory processing in children with dyslexia.

Binge eating is a public health problem associated with reduced physical health (ie, being overweight and obese) and mental health. Binge eating symptoms are so prevalent that many people who struggle with the symptoms have never been diagnosed with the binge eating disorder (BED). Examining the underlying emotional mechanisms of this behavior and the gender differences in these mechanisms remains largely unexplored.

The present study aimed to investigate the association between internal and external body-image shame and binge eating symptoms in men and women mediated by self-criticism.

This correlation study was based on structural equation modeling. The statistical population of the study included all students of Shahid Beheshti University of Medical Sciences, Tehran, Iran. Finally, using multi-stage cluster random sampling, a total of 313 participants were included in the study. Instruments including Body-Image Shame Scale (BISS), Forms of Self-criticizing/Selfreassuring Scale (FSCRS), and Binge Eating Scale (BES) were used in the study.

According to the results, the severity of binge eating symptoms had a positive and significant relationship with external and internal body-image shame, hated-self, and inadequate-self, while it had a negative and significant relationship with reassuredself. The results also indicated that in men, inadequate-self, and reassured-self, and in women, hated-self, inadequate-self, and reassured-self mediated the association between internal and external body-image shame and the severity of binge eating symptoms.

Our results indicated that forms of self-criticism could differently mediate the relationship between external and internal body-image shame and the severity of binge eating symptoms in Iranian men and women. This gender difference in the mediation model can be considered in clinical practice, and appropriate treatment methods can be used accordingly

One of the most common mental health-related issues related to the COVID-19 pandemic is high levels of distress and anxiety due to the COVID-19 pandemic. Psychological well being and conservation of the general population are utterly significant components of facing COVID-19 pandemic. It seems that despite the availability of highly standardized tools to investigate COVID19-related anxiety, the Coronavirus Anxiety Scale (CAS) can be helpful in different populations due to its short design.

The present study aimed to assess the psychometric properties of the Persian (Iranian) version of the Coronavirus Anxiety Scale (P-CAS).

In this web-based cross-sectional study, 305 individuals (184 females vs. 121 males) participated. All participants were evaluated by five questionnaires, including the P-CAS, COVID Stress Scales (CSS), the Depression, Anxiety and Stress Scale-21 (DASS-21), Whiteley Index (WI), and Difficulties in Emotion Regulation Scale (DERS). Cronbach’s alpha, confirmatory factor analysis (CFA), and correlation coefficient were used for data analysis using SPSS 23 and AMOS-23 software.

The results of CFA demonstrated that the factor structure of the P-CAS was good, and the scale had an appropriate internal consistency (α= 0.80). A satisfactory convergent validity was shown due to positive correlations of the P-CAS with the related scales. Test-retest reliability of P-CAS was also satisfactory (ICC = 0.95).

According to our results, the P-CAS is a valid and reliable instrument to evaluate the severity of dysfunctional anxiety due to COVID-19 pandemic.

Social appearance anxiety refers to the fear of negative evaluation and judgment about appearance in social situations. Previous scales have focused more on body dysmorphic, and a tool that can measure this anxiety in social situations has not been previously introduced.

This study aimed to investigate the factor structure and psychometric properties of the Social Appearance Anxiety Scale (SAAS) in the student community.

This psychometric study was conducted on a sample of 415 Iranian students in 2020 using the convenience sampling method. The participants completed the Social Physique Anxiety Scale, Body Dysmorphic Scale, and Body Shape Scale. Cronbach’s alpha, confirmatory factor analysis (CFA), exploratory factor analysis (EFA), and convergent validity were used to examine internal consistency. The data were analyzed using SPSS software (version 24) and AMOS software (version 21).

Cronbach’s alpha for total score was 0.95. The relationship between the SAAS and Body Dysmorphic Scale (r = 0.73; P < 0.01), Body Shape Scale (r = 0.46; P < 0.01), and Social Physique Anxiety Scale (r = 0.79; P < 0.01) showed good convergent validity. The EFA extracted one factor that explained 0.60 of the total variance. After testing the one-factor model in CFA, the analysis showed good fitness indexes (comparative fit index = 0.95; goodness of fit index = 0.91). The item-total correlation of the Iranian SAAS was within a range of 0.51 - 0.84.

The present scale has a high internal consistency and reliability and can be used for research and evaluation objectives in clinical settings in Iranian society

Despite effective treatments are available for depressive disorders, less than half of patients utilize them and the treatment gap is large.

This study aimed to investigate factors associated with adherence to follow-up in patients diagnosed with a depressive disorder in the collaborative care program in Tehran between May 2017 to October 2017.

A retrospective cross-sectional study was performed in three community mental health centers (CMHCs) in Tehran.

A total of 435 cases were recruited, and their adherence to follow-up rate was 41.6%. According to multivariate regression, being visited in a particular center, having a high school or higher level of education, having a positive family history with effective treatment, taking selective serotonin reuptake inhibitors (SSRIs), experiencing a lower level of perceived mental health before the first visit, and referral to a psychiatrist could predict adherence to follow-up. Patients who had a chief complaint of typical depressive symptoms and those who were employed were less likely to be adherent to follow-up.

More population-based studies in various settings and cultures are needed to enhance our knowledge regarding interventions necessary to deliver quality care to depressed patients.

Postpartum depression (PPD) affects various dimensions of women’s lives. The present study aimed to compare infant care behavior and maternal self-efficacy between depressed and non-depressed mothers.

This case-control study was conducted among 80 (n = 40 per group) postpartum women.

A socio-demographic characteristics form, Edinburgh Postnatal Depression Scale (EPDS), Maternal Self-efficacy Questionnaire (MSQ), and Infant Care Behavior questionnaire were used for data collection. Independentt-test was run for data analysis. The mean score of maternal self-efficacy in the depressed group was 29.3 (3.6), and it was 33.0 (3.3) in the non-depressed group, which was significantly higher in the non-depressed group compared to the depressed group based on independentt-test results (adjusted mean difference: -3.7; 95% Confidence Interval: -2.2 to 5.3; P < 0.001).

The mean score of infant care behavior was 72.2 (5.2) in the depressed group and 73.0 (9.0) in the non-depressed group, indicating no significant differences between the two groups according to independent t-test (P = 0.627).

Depressed women were less self-efficient; thus, given the central role of mothers, some strategies should be adopted to minimize mothers’ postpartum physical and mental problems and promote their self-efficacy and infant care behaviors.

Testosterone is a fundamental biological drive for human survival. Evidence documents an association between the evolutionary suppression of testosterone and the civilization processes, especially their socialization and family colonization abilities, among early humans. Interestingly, opiates suppress testosterone as a side effect. However, in clinical practice, clients undergoing opioid substitution therapy have subnormal, normal, or even above-normal testosterone. This paper discusses a possibility indicating that opiates promoted civilization processes among early humans. We further suggest that modern humans might have inherited the positive impact of opiates on early humans as a biological propensity for using opioids. Some users may use opioids for selfmedication to decrease their extraordinarily high testosterone levels.