Psychiatric Disorders

Personality Disorders
Personality disorders: Pervasive, inflexible, and stable personality traits that deviate
from cultural norms and cause distress or functional impairment.
(See also Dissociative Identity Disorder in Ch. 188.)
Personality traits are patterns of thinking, perceiving, reacting, and relating that are
relatively stable over time and in various situations. Personality disorders occur when
these traits are so rigid and maladaptive that they impair interpersonal or vocational
functioning. Personality traits and their potential maladaptive significance are usually
evident from early adulthood and persist throughout much of life.
Mental coping mechanisms (defenses) are used unconsciously at times by everyone. But
in persons with personality disorders, coping mechanisms tend to be immature and
maladaptive (see Table 191-1). Repetitious confrontation in prolonged psychotherapy or
by peer encounters is usually required to make such persons aware of these mechanisms.
Without environmental frustration, persons with personality disorders may or may not be
dissatisfied with themselves. They may seek help because of symptoms (eg, anxiety,
depression) or maladaptive behavior (eg, substance abuse, vengefulness) that results from
their personality disorder. Often they do not see a need for therapy, and they are referred
by their peers, their families, or a social agency because their maladaptive behavior
causes difficulties for others. Because these patients usually view their difficulties as
discrete and outside of themselves, mental health professionals have difficulty getting
them to see that the problem is really based on who they are.
Persons with severe personality disorders are at high risk of hypochondriasis, alcohol or
drug abuse, and violent or self-destructive behaviors. They may have inconsistent,
detached, overemotional, abusive, or irresponsible styles of parenting, leading to medical
and psychiatric problems for their children. Persons with a personality disorder are less
likely to comply with a prescribed treatment regimen. Even when they do, their
symptoms--whether psychotic, depressive, or anxious--are far less responsive to drugs.
Persons with personality disorders are often very frustrating to those around them,
including physicians--who have to deal with their unrealistic fears, excessive demands,
sense of entitlement, unpaid bills, noncompliance, and angry vilification. Such persons
can also cause stress for other patients who are exposed to their dramatic or demanding
behaviors.

Diagnosis and Classification

Diagnosis is based on observing repetitive patterns of behavior or perception that cause
distress and impair social functioning, even when the patient lacks insight about these
patterns and despite the fact that the patient often resists change.
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV),
divides personality disorders into three clusters: A) odd/eccentric, B) dramatic/erratic,
and C) anxious/inhibited.

Cluster A
Paranoid personality: Persons with this personality disorder are generally cold and
distant in interpersonal relationships or are controlling and jealous if they become
attached. They tend to react with suspicion to changes in situations and to find hostile and
malevolent motives behind other people's trivial, innocent, or even positive acts. Often
these hostile motives represent projections of their own hostilities onto others (see also
Ch. 193). When they believe they have confirmed their suspicions, they sometimes react
in ways that surprise or scare others. They then use the resulting anger of or rejection by
others (ie, projective identification) to justify their original feelings. Paranoid persons
tend to take legal action against others, especially when they feel a sense of righteous
indignation. However, they cannot see their role in a conflict. In their occupations, these
persons may be highly efficient and conscientious, although they usually need to work in
relative isolation.
Paranoid tendencies may develop among persons who feel particularly alienated because
of a defect or handicap. For example, a person with chronic deafness may mistakenly
think he is being talked about or laughed at.
Schizoid personality: Persons with this personality disorder are introverted,
withdrawn, solitary, emotionally cold, and distant. They are most often absorbed in their
own thoughts and feelings and fear closeness and intimacy with others. They are reticent,
are given to daydreaming, and prefer theoretic speculation to practical action.
Schizotypal personality: Like schizoid persons, persons with this personality
disorder are socially isolated and emotionally detached, but in addition, they express
oddities of thinking, perception, and communication, such as magical thinking,
clairvoyance, ideas of reference, or paranoid ideation. These oddities suggest
schizophrenia but are never severe enough to meet its criteria (see Ch. 193). Nonetheless,
persons with this personality disorder are believed to have a muted phenotypic expression
(spectrum variant) of the genes that cause schizophrenia.

Cluster B
Borderline personality: Persons with this personality disorder--predominantly
women--are unstable in their self-image, mood, behavior, and interpersonal relationships.
This personality disorder becomes evident in early adult years, but it tends to become
milder or to stabilize with age. Such persons believe they were deprived of adequate care
during their childhood and consequently feel empty, angry, and entitled to nurturance. As
a result, they are relentless seekers of care. This personality disorder is by far the most
common type seen in psychiatric and all other types of health care services.
When persons with a borderline personality feel cared for, they appear like lonely waifs,
who seek help for depression, substance abuse, eating disorders, and past mistreatments.
However, when they fear the loss of the caring person, their mood shifts dramatically and
is frequently expressed as inappropriate and intense anger. The shift in mood is
accompanied by extreme changes in their view of the world, themselves, and others--
from black to white, from hated to loved, or vice versa (see splitting in Table 191-1).
Their view is never neutral. When they feel abandoned (ie, all alone), they dissociate or
become desperately impulsive. At times, their concept of reality is so poor that they have
brief episodes of psychotic thinking, such as paranoid ideas and hallucinations.
Such persons have far more dramatic and intense interpersonal relationships than those
with cluster A personality disorders. Their thought processes are disturbed more than
those of persons with an antisocial personality, and aggression is more often turned
against the self. They are more angry, more impulsive, and more confused about identity
than those with a histrionic personality. They tend to evoke intense, initially nurturant
responses in caretakers. But after repeated crises, vague unfounded complaints, and
failures to comply with therapeutic recommendations, caretakers--including the
physician--often become very frustrated with them and view them as help-rejecting
complainers. Splitting, acting out, hypochondriasis, and projection are common coping
mechanisms (see Table 191-1).
Antisocial personality (previously called psychopathic or sociopathic): Persons with
this personality disorder callously disregard the rights and feelings of others. They exploit
others for materialistic gain or personal gratification (unlike narcissistic persons, who
exploit others because they think their superiority justifies it). Characteristically, they act
out their conflicts in impulsive and irresponsible ways, sometimes with hostility and
serious violence. They tolerate frustration poorly. Often they do not anticipate the
negative consequences of their antisocial behaviors and typically do not feel remorse or
guilt afterward. Many of them have a well-developed capacity for glibly rationalizing
their behavior or for blaming it on others. Dishonesty and deceit permeate their
relationships. Punishment rarely modifies their behavior or improves their judgment and
foresight; it usually confirms their harshly unsentimental view of the world.
Antisocial personality disorder is often associated with alcoholism, drug addiction,
infidelity, promiscuity, failure in one's occupation, frequent relocation, and
imprisonment. In Western culture, more men have this personality disorder than women,
and more women have a borderline personality; these two disorders have much in
common. In the families of patients with both personality patterns, the prevalence of
antisocial relatives, substance abuse, divorces, and childhood abuse is high. Often, the
patient's parents have a poor relationship, and the patient was severely emotionally
deprived in his formative years. Life expectancy is decreased, but among survivors, the
disorder tends to diminish or stabilize with age.
Narcissistic personality: Persons with this personality disorder are grandiose; ie, they
have an exaggerated sense of superiority. Their relationships with others are
characterized by their need to be admired, and they are extremely sensitive to criticism,
failure, or defeat. When confronted with a failure to fulfill their high opinion of
themselves, they can become enraged or seriously depressed. Because they believe
themselves to be superior, they often believe others envy them and feel entitled to have
their needs attended to without waiting. Thus they can justify exploiting others whose
needs or beliefs they consider less important. Such characteristics often offend persons
they encounter, including their physicians. This personality disorder occurs in high
achievers but may also occur in persons with few achievements.
Histrionic (hysterical) personality: Persons with this personality disorder
conspicuously seek attention, are conscious of appearance, and are dramatic. Their
expression of emotions often seems exaggerated, childish, and superficial and, like other
dramatic behaviors, often evokes sympathetic or erotic attention from others. Thus
relationships are often easily established but tend to be superficial and transient. These
persons may combine sexual provocativeness or sexualization of nonsexual relationships
with unexpected sexual inhibitions and dissatisfactions. Behind their sexually seductive
behaviors and their tendency to exaggerate somatic problems (ie, hypochondriasis) often
lie more basic wishes for dependency and protection.

Cluster C
Dependent personality: Persons with this disorder surrender responsibility for major
areas of their lives to others and allow the needs of those they depend on to supersede
their own needs. They lack self-confidence and feel intensely insecure about their ability
to take care of themselves. They often protest that they cannot make decisions and do not
know how or what to do. This behavior is due partly to a belief that others are more
capable and partly to a reluctance to express their views for fear of offending persons
they need with their aggressiveness (ie, a form of aggression against self). Dependency
occurs in other personality disorders where it may be hidden by obvious behavioral
problems; eg, histrionic or borderline behaviors mask underlying dependency.
Avoidant personality: Persons with this personality disorder are hypersensitive to
rejection and fear starting relationships or anything new because they may fail or be
disappointed. This personality disorder is a spectrum variant of generalized social phobia
(see Ch. 187). Because of their strong conscious desire for affection and acceptance,
persons with an avoidant personality disorder, unlike those with a schizoid personality
disorder, are openly distressed by their isolation and inability to relate comfortably to
others. Unlike those with a borderline personality disorder, they respond to rejection with
withdrawal, not temper tantrums. Persons with an avoidant personality disorder tend to
have an incomplete or a weak response to anxiolytic drugs.
Obsessive-compulsive personality: Persons with this personality disorder are
conscientious, orderly, and reliable, but their inflexibility often makes them unable to
adapt to change. Because they are cautious and weigh all aspects of a problem, they may
have difficulty making decisions. They take responsibilities seriously, but because they
hate mistakes and incompleteness, they can become entangled with details and forget the
purpose of or have trouble completing their tasks. As a result, their responsibilities cause
them anxiety, and they rarely enjoy much satisfaction from their achievements.
Most obsessive-compulsive traits are adaptive, and as long as they are not too marked,
persons who have them often achieve much, especially in the sciences and other
academic fields in which order, perfectionism, and perseverance are desirable. However,
they can feel uncomfortable with feelings, interpersonal relationships, and situations in
which they lack control or must rely on others or in which events are unpredictable.

Other Personality Types

Passive-aggressive, cyclothymic, and depressive types of personality disorders are not
classified in the DSM-IV. Yet, they can be useful diagnoses.
Passive-aggressive (negativistic) personality: Persons with this personality
disorder typically appear inept or passive, but these behaviors are covertly designed to
avoid responsibility or to control or punish others. Passive-aggressive behavior is often
evident in procrastination, inefficiency, or unrealistic protests of disability. Frequently,
such persons agree to perform tasks they do not want to perform and then subtly
undermine completion of the tasks. Such behavior usually serves to deny or conceal
hostility or disagreements.
Cyclothymic personality (see also Ch. 189)
In persons with this personality disorder, high-spirited buoyancy alternates with gloom
and pessimism; each mood lasts weeks or longer. Characteristically, the rhythmic mood
changes are regular and occur without justifiable external cause. This personality disorder
is a spectrum variant of manic-depressive illness (bipolar disorder), but most cyclothymic
persons do not develop bipolar disorder. Cyclothymic personality is considered a
temperament, present in many gifted and creative people.
Depressive (masochistic) personality: Persons with depressive personality
disorder are chronically morose, worried, and self-conscious. Their pessimistic outlook
impairs their initiative and disheartens persons who spend much time with them. To
them, self-satisfaction is undeserved and sinful. They unconsciously believe their
suffering is a badge of merit needed to earn the love or admiration of others. This
personality disorder is considered a temperament that usually does not result in social
dysfunction.

Treatment
Treating a personality disorder takes a long time. Personality traits such as coping
mechanisms, beliefs, and behavior patterns take many years to develop, and they change
slowly. Changes usually occur in a predictable sequence, and different treatment
modalities are needed to facilitate them. Reducing environmental stress can quickly
relieve symptoms such as anxiety or depression. Behaviors, such as recklessness, social
isolation, lack of assertiveness, or temper outbursts, can be changed in months. Group
therapy and behavior modification, sometimes within day care or designed residential
settings, are effective. Participation in self-help groups or family therapy can also help
change socially undesirable behaviors. Behavioral change is most important for patients
with borderline, antisocial, or avoidant personality disorder.
Interpersonal problems, such as dependency, distrust, arrogance, or manipulativeness,
usually take > 1 yr to change. The cornerstone for effecting interpersonal changes is
individual psychotherapy that helps the patient understand the sources of his
interpersonal problems in the context of an intimate, cooperative, nonexploitative
physician-patient relationship. A therapist must repeatedly point out the undesirable
consequences of the patient's thought and behavior patterns and must sometimes set
limits on his behavior. Such therapy is essential for patients with histrionic, dependent, or
passive-aggressive personality disorder. For some patients with personality disorders that
involve how attitudes, expectations, and beliefs are mentally organized (eg, narcissistic or
obsessive-compulsive types), psychoanalysis is recommended, usually for >= 3 years.
General principles: Although treatment differs according to the type of personality
disorder, some general principles apply to all. Family members can act in ways that either
reinforce or diminish the patient's problematic behavior or thoughts, so their involvement
is helpful and often essential.
Drugs have limited effects. They can be misused or used in suicide attempts. When
anxiety and depression result from a personality disorder, drugs are only moderately
effective. For persons with personality disorders, anxiety and depression may have
positive significance, ie, that the person is experiencing unwanted consequences of his
disorder or is undertaking some needed self-examination.
Because personality disorders are particularly difficult to treat, therapists with experience,
enthusiasm, and an understanding of the patient's expected areas of emotional sensitivity
and usual ways of coping are important. Kindness and direction alone do not change
personality disorders.
Psychosexual Disorders

[General]
Psychosexual disorders include sexual dysfunctions, the most common form of
psychosexual disorder seen by the practicing physician; gender identity disorders; and
paraphilias.
Accepted norms of sexual behavior and attitudes vary greatly within and among different
cultures. Masturbation, once widely regarded as a perversion and a cause of mental
disorders, is now recognized as normal sexual activity throughout life; it is considered a
symptom only when it inhibits partner-oriented behavior, is performed in public, or is
sufficiently compulsive to cause distress. Its incidence is about 97% in males and 80% in
females. Although masturbation is harmless, guilt created by the disapproval and punitive
attitudes of others may cause considerable distress and impair sexual performance.
About 4 to 5% of the population are preferentially homosexual for their entire lives.
Since 1973, the American Psychiatric Association has not considered homosexuality a
disorder. Like heterosexuality, homosexuality results from complex biologic and
environmental factors leading to an almost inevitable preference in the selection of a
sexual partner. For most, it is not a matter of choice. Nevertheless, many people,
including physicians, regard homosexuality as immoral and sinful, and a physician's
intense aversion to homosexuality (homophobia) may interfere with appropriate care of
homosexuals.
Frequent sexual activity with many partners, often one-time-only encounters, indicates
a diminished capacity for pair-bonding. The fear of AIDS has resulted in a decrease in
casual sex. Most cultures discourage extramarital sexuality but accept premarital coitus as
normal. In the USA, most people have intercourse before marriage, as part of the trend
toward more sexual freedom in developed countries.
Well-informed physicians can offer sensitive, disciplined advice on sexual matters and
should not miss opportunities for helpful intervention, remembering that sexual practices
differ by culture and that the strength of the sexual drive, individual needs, and the
frequency of sexual contact vary greatly.

Etiology
The etiology of psychosexual disorders is complex and varies greatly. Inherited or subtle
constitutional factors probably play a part. Fetal androgens help prepare the brain for later
sexual activity; interference with this process may not be damaging in itself, but it may
make a person vulnerable to damaging environmental influences during childhood
psychosexual development.
Parental attitudes toward sexual behavior are important (see also Gender Identity
Disorders, below). A forbidding, puritanical rejection of physical sexuality, including
touching, by a parent engenders guilt and shame in a child and inhibits his capacity for
enjoying sex and developing healthy relationships as an adult. Relations with parents may
be damaged by excessive emotional distance, by punitive behaviors, or by seductiveness
and exploitation. Children exposed to hostility, rejection, and cruelty are likely to become
sexually maladjusted. Children need to feel accepted and lovable. (Enabling a person to
have confidence that he is capable and worthy of being loved for himself is a goal of
therapy.)
Problems with parent-child relationships can contribute to sexual dysfunctions, gender
identity disorders (eg, transsexualism, transvestism), or paraphilias (see below). Love and
lust may become dissociated, so that emotional bonds can be formed with persons from
the same social class or intellectual circle, but physical sexual relationships can be
formed only with those considered inferiors, such as prostitutes, with whom there is no
affinity or emotional ties. Sexual intercourse with one's spouse is associated with guilt
and anxiety, and sexual release occurs only in relationships or practices in which tender,
caring feelings are not aroused.
The pattern of erotic arousal is fairly well developed before puberty; therefore, if a
gender identity disorder or paraphilia develops, causes should be sought in the
prepubertal years. Three processes are involved: Anxiety interferes with normal
psychosexual development; the standard pattern of arousal is replaced by another, which
allows the person to experience sexual pleasure; and the pattern of sexual arousal often
acquires symbolic and conditioning facets (eg, a fetish symbolizes the object of arousal
but may have been chosen because the fetish was accidently associated with sexual
curiosity, desire, and excitement). Whether all transsexual or paraphilic development
results from these psychodynamic processes is controversial.
Sexual Dysfunctions
Disturbances in the sexual response cycle or pain associated with sexual arousal or
intercourse.
(See also Chs. 220and 243.)
Proper sexual functioning in men and women depends on the sexual response cycle,
which consists of an anticipatory mental set (sexual motive state or state of desire),
effective vasocongestive arousal (erection in men; swelling and lubrication in women),
orgasm, and resolution. In men, the sensation of orgasm includes emission followed by
ejaculation. Emission, mediated by contractions of the prostate, seminal vesicles, and
urethra, produces a sensation of ejaculatory inevitability. In women, orgasm is
accompanied by contractions (not always subjectively experienced as such) of the
muscles of the outer third of the vagina. In both sexes, generalized muscular tension,
perineal contractions, and involuntary pelvic thrusting (every 0.8 sec) usually occur.
Orgasm is followed by resolution--a sense of general pleasure, well-being, and muscular
relaxation. During this phase, men are physiologically refractory to erection and orgasm
for a variable period of time, but women may be able to respond to additional stimulation
almost immediately.
The sexual response cycle is mediated by a delicate, balanced interplay between the
sympathetic and parasympathetic nervous systems. Vasocongestion is largely mediated
by parasympathetic (cholinergic) outflow; orgasm is predominantly sympathetic
(adrenergic). Ejaculation is almost entirely sympathetic; emission involves sympathetic
and parasympathetic stimulation. These responses are easily inhibited by cortical
influences or by impaired hormonal, neural, or vascular mechanisms. - and -adrenergic
blockers may desynchronize emission, ejaculation, and perineal muscle contractions
during orgasm, and serotonin agonists frequently interfere with desire and orgasm.
Disorders of sexual response may involve one or more of the cycle's phases. Generally,
both the subjective components of desire, arousal, and pleasure and the objective
components of performance, vasocongestion, and orgasm are disturbed, although any
may be affected independently.
Sexual dysfunctions may be lifelong (no effective performance ever, generally due to
intrapsychic conflicts) or acquired (after a period of normal function); generalized or
limited to certain situations or certain partners; and total or partial.
Most patients complain of anxiety, guilt, shame, and frustration, and many develop
physical symptoms. Although dysfunction usually occurs during sexual activity with a
partner, inquiry about function during masturbation is useful. If it is unaffected, the cause
may be interpersonal factors.

Etiology
Lifelong and acquired dysfunction can have similar causes. Poor communication with the
partner is usually present.
Psychologic factors include anger directed toward the partner; fear of the partner's
genitals, of intimacy, of losing control, of dependency, or of pregnancy; guilt after a
pleasurable experience; depression; anxiety due to marital discord, stressful life
situations, aging, ignorance of sexual norms (eg, frequency and duration of intercourse,
oral-genital sex, or sexual practices); and belief in sexual myths (eg, the supposed
deleterious effects of masturbation, hysterectomy, or menopause). Immediate causes of
anxiety include fear of failure, demand for performance, spectatoring (observing one's
physical responses), an excessive wish to please the partner, and avoidance of sex or of
talking about sexual concerns. These factors further impair performance and satisfaction,
and continued avoidance of sexual activity with impaired communication creates a
vicious circle.
Related inhibitory factors include ignorance of the sex organs and their function (often
because anxiety, shame, or guilt has inhibited learning), traumatic events in childhood or
adolescence (eg, incest, rape), feelings of inadequacy, inappropriate religious training,
excessive modesty, and puritanical aversion to intercourse.
Situational factors, including marital discord, boredom, or negative emotions (eg, anger,
fear, shame, guilt), may be related to place, time, or a particular partner.
Physical factors may involve a physical disorder or use of illicit or prescribed drugs.
Even when physical factors are identified, secondary psychogenic elements are almost
always present, complicating the problem.
HYPOACTIVE SEXUAL DESIRE DISORDER
A disorder in which sexual fantasies and desire for sexual activity are persistently or
recurrently diminished or absent, causing marked distress or interpersonal difficulties.
Hypoactive sexual desire disorder may be lifelong or acquired, generalized (global) or
situational (partner-specific). It occurs in 20% of women and in 10% of men.

Etiology
Sexual desire is a complex psychosomatic process based on brain activity (the
"generator" or "motor" running in a rheostatic cyclic fashion), a poorly defined hormonal
milieu, and cognitive scripting that includes sexual aspiration and motivation.
Desynchronization of these components results in hypoactive sexual desire disorder.
The acquired form is commonly caused by boredom or unhappiness in a long-standing
relationship, depression (which leads more often to decreased interest in sex than it does
to impotence in the male or to inhibited excitement in the female), dependence on alcohol
or psychoactive drugs, side effects from prescription drugs (eg, antihypertensives,
antidepressants), and hormonal deficiencies. This disorder can be secondary to impaired
sexual functioning in the arousal or orgasm phase of the sexual response cycle.
The lifelong generalized form is sometimes related to traumatic events in childhood or
adolescence, the suppression of sexual fantasies, a dysfunctional family, or, occasionally,
deficient levels of androgens. Generally, testosterone levels < 300 ng/dL in the male and
< 10 ng/dL in the female are considered potential causes. Although testosterone is
necessary for intact desire in males and females, it alone is not sufficient, and correcting
low levels may not correct generalized hypoactive sexual desire disorder.

Symptoms and Signs

The patient complains of a lack of interest in sex, even in ordinarily erotic situations. The
disorder is usually associated with infrequent sexual activity, often causing serious
marital conflict. Some patients have sexual encounters fairly often to please their partners
and may have no difficulty with performance but continue to have sexual apathy. When
boredom is the cause, frequency of sex with the usual partner decreases, but sexual desire
may be normal or even intense with others (the situational form).

Diagnosis and Treatment

A thorough history must be obtained, because the problem may be secondary to marital
difficulties, which may include sexual satiation outside of the marriage. The disorder is
not diagnosed when the symptoms are better accounted for by another psychiatric
disorder (eg, depression) or a physical disorder (eg, terminal illness, endocrinopathies). If
the patient also has sexual dysfunction, the clinician must determine which came first,
because sexual dysfunction can lead to loss of desire and vice versa.
Treatment is directed at removing or alleviating the underlying cause--eg, marital
conflict, depression, other sexual dysfunction (especially arousal or orgasm difficulties).
Changing drugs and, in the occasional case of androgen deficiency, administering IM
testosterone may be required.
SEXUAL AVERSION DISORDER
Persistent or recurrent aversion to and avoidance of all or almost all genital sexual
contact with a sexual partner, causing marked distress or interpersonal difficulties.
Sexual aversion disorder occurs occasionally in males and much more often in females.
Patients report anxiety, fear, or disgust in sexual situations. The disorder may be lifelong
(primary) or acquired (secondary), generalized (global) or situational (partner-specific).

Etiology and Diagnosis

If lifelong, aversion to sexual contact, especially to intercourse, may result from sexual
trauma, such as incest, sexual abuse, or rape; from a very repressive atmosphere in the
family, sometimes enhanced by orthodox and rigid religious training; or from initial
attempts at intercourse that resulted in moderate to severe dyspareunia. Even after the
dyspareunia disappeared, painful memories may persist. If the disorder is acquired after a
period of normal functioning, the cause may be partner-related (situational or
interpersonal) or due to trauma or dyspareunia. If aversion produces a phobic response
(even panic), less conscious and unrealistic fears of domination or of bodily damage may
also be present. Situational sexual aversion may occur in persons who attempt to or are
expected to have sexual relations incongruent with their sexual orientation.

Treatment
Treatment is aimed at removing the underlying cause when possible. The choice of
behavioral or psychodynamic psychotherapy depends on the diagnostic understanding.
Marital therapy is indicated if the cause is interpersonal. Panic states can be treated with
tricyclic antidepressants, selective serotonin reuptake inhibitors, monoamine oxidase
inhibitors, or benzodiazepines.
SEXUAL DYSFUNCTION DUE TO A PHYSICAL DISORDER
Clinically significant sexual dysfunction that causes personal distress or interpersonal
problems and is most likely fully explained by direct physiologic effects of a physical
disorder.
Any specific sexual dysfunction (eg, erectile dysfunction, hypoactive sexual desire
disorder, dyspareunia) may have a psychologic, physiologic, or combined etiology. The
distinction between "physiologic" and "psychologic" is blurred in many disorders. For
example, diabetes mellitus may cause erectile dysfunction without psychologic
contributions, but psychologic factors often also contribute. A variety of physical
disorders can cause sexual dysfunction (See Table 192-1).
Sexual dysfunction due to a physical disorder is usually generalized (not specific to a
given partner or situation). It is diagnosed when evidence from a patient's history,
physical examination, or laboratory assessment can explain the dysfunction
physiologically and when mental disorders that may better explain it can be ruled out.
Resolution of the underlying physical disorders often results in resolution or amelioration
of the sexual dysfunction. When the cause of sexual dysfunction is a combination of
psychologic and physical factors, the appropriate diagnosis is sexual dysfunction due to
combined factors.
SUBSTANCE-INDUCED SEXUAL DYSFUNCTION
Sexual dysfunction that causes personal distress or interpersonal problems and is fully
explained by substance abuse or develops during or within a month of substance
intoxication.
In this disorder, any phase of the sexual response cycle, except resolution, may be
impaired. Substances that commonly cause sexual dysfunction are listed in Table 192-1.
Substance-induced sexual dysfunction may occur only or predominantly during substance
intoxication. For example, alcohol intoxication may cause erectile dysfunction or
orgasmic disorders that resolve when the patient is not intoxicated.
Clinicians must determine that the patient's sexual dysfunction is not better explained by
another psychiatric disorder or a concomitant physical disorder. Because patients often do
not associate their sexual dysfunction with use of substances, especially prescribed drugs,
direct questioning by a clinician may be necessary to establish the etiologic link.
MALE ORGASMIC DISORDERS
A persistent or recurrent delay in or absence of orgasm after normal sexual arousal.
Mitigating factors include age and adequacy of the stimulation (in focus, intensity, and
duration). Orgasmic disorders may be due to a physical disorder or use of a substance
(eg, alcohol, opioids, antihypertensives, antidepressants, antipsychotics). Depression is a
common cause of orgasmic difficulty as well as decreased desire and arousal. Problems
with achieving orgasm are usually linked to difficulty in developing sufficient arousal.
The man's emotional state (eg, anger, anxiety, guilt, boredom) can inhibit arousal and
orgasm. However, arousal may be sufficient to achieve partial or full erection but not to
produce orgasm. Erectile failure (see Ch. 220) may cause more distress than orgasmic
difficulty.
Premature Ejaculation
Orgasm and ejaculation with minimal sexual stimulation that persistently or recurrently
occurs before, during, or shortly after penetration and before the man desires.
Premature ejaculation is usually partner-related; most men can delay orgasm during
masturbation for much longer than they can during coitus. The disorder is probably due
to a combination of psychologic and physiologic factors. Regardless of cause, treatment
with small doses of a selective serotonin reuptake inhibitor is usually successful. The
drug is taken either daily or 1 to 2 h before a sexual encounter.
Sexual Pain Disorders
Sexual pain (dyspareunia) in men, when present, usually occurs during coitus and rarely
during arousal. The leading causes are prostatitis and neurologic damage. Occasionally,
in the absence of a definite physical cause, guilt is a factor. Dyspareunia in women is
discussed in Ch. 243.

Gender Identity Disorders

Disorders characterized by a strong, persistent cross-gender identification and by
continuous discomfort about one's anatomic (assigned) sex or by a sense of
inappropriateness in the gender role of that sex.
Core gender identity is a subjective sense of knowing to which gender one belongs, ie,
the awareness that "I am a male" or "I am a female." Gender identity is the inner sense
of masculinity or femininity. Gender role is the objective, public expression of being
male, female, or androgynous (blended). It is everything that one says and does to
indicate to others or to oneself the degree to which one is male or female. For most
persons, gender identity and role are congruous. Those with gender identity disorders,
however, experience a severe incongruity between their anatomic sex and their gender
identity.
Although biologic factors, such as gender complement and the prenatal hormonal milieu,
largely determine gender identity, the formation of a secure, unconflicted gender identity
and gender role is influenced by social factors, such as the character of the parents'
emotional bond and the relationship that each of them has with the child.
When sex labeling and rearing are confusing, children may become uncertain about their
gender identity or role. However, when sex labeling and rearing are clear, even the
presence of ambiguous genitalia usually does not affect a child's gender identity.
Transsexuals usually have had gender identity problems in early childhood (see below).
However, the majority of children with gender identity conflicts do not develop into
adults with a gender identity disorder.
Childhood gender identity disorders are usually present by 2 yr of age. A child with the
disorder prefers cross-dressing, insists that he is of the other sex, intensely and
persistently desires to participate in the stereotypical games and activities of the other
sex, and has negative feelings toward his genitalia. For example, a young girl may insist
she will grow a penis and become a boy; she may stand to urinate. A boy may sit to
urinate and wish to be rid of his penis and testes. Most children with these disorders are
not evaluated until they are 6 to 9 yr old.

Diagnosis
The diagnosis requires the presence of both cross-gender identification (the desire to be
or insistence that one is the other sex) and a sense of discomfort about one's sex or of
inappropriateness in one's gender role. Cross-gender identification must not be merely a
desire for perceived cultural advantages of being the other sex. For example, a boy who
says he wants to be a girl so that he will receive the same special treatment his younger
sister receives is not likely to have gender identity disorder. The diagnosis also requires
the presence of significant distress or obvious impairment in social, occupational, or other
important areas of functioning. Gender identity disorder is not diagnosed if a person
engages in cross-dressing or other cross-gender activities without concurrent psychologic
distress or functional impairment or if a person has a physical intersex condition (eg,
congenital adrenal hyperplasia, ambiguous genitalia, androgen insensitivity syndrome).
Gender role behaviors fall on a continuum of traditional masculinity or femininity.
Western cultures are more tolerant of tomboyish behaviors in young girls (generally not
associated with a gender identity disorder) than feminine or sissy behaviors in boys.
Many boys role-play as girls or mothers, including trying on their sister's or mother's
clothes. Usually, this behavior is part of normative development. Only in extreme cases
does this behavior and an associated expressed wish to be the other sex persist. In such
cases, a diagnosis of gender identity disorder of childhood should be considered.
TRANSSEXUALISM
A gender identity disorder in which the person believes he is the victim of a biologic
accident, cruelly imprisoned in a body incompatible with his subjective gender identity.
Estimated incidence is about 1 in 30,000 male births and 1 in 100,000 female births.
Rarely, transsexualism is associated with genital ambiguity or genetic abnormality. Most
transsexuals who request treatment are males who claim a feminine gender identity and
regard their genitalia and masculine features with repugnance. Their primary objective in
seeking help is not to obtain psychologic treatment but to obtain hormones and genital
surgery that will make their physical appearance approximate their gender identity.
The diagnosis is made only if the disturbance has been continuous (not limited to periods
of stress) for at least 2 yr. Differential diagnosis, often difficult to make, must distinguish
transsexuals from distressed transvestites, cross-dressing homosexuals, schizophrenics
with gender identity conflicts, and persons with primary borderline personality disorder.
Primary male transsexualism begins in early childhood with participation in girls'
games, fantasies of being female, avoidance of rough-and-tumble play and competitive
games, and distress at the physical changes of puberty, often followed by a quest for
feminizing somatic treatments. Many transsexuals adopt a convincing public feminine
gender role. Some are satisfied with acquiring a more feminine appearance and an
identity card (eg, driver's license) that allow them to work and live in society as women.
Others are not; they can achieve a more stable adjustment by using moderate doses of
feminizing hormones (eg, ethinyl estradiol 0.10 mg/day). Many transsexuals request sex
reassignment surgery despite the sacrifices involved. The decision for surgery often raises
important social problems for the patient and ethical problems for some physicians. In
follow-up studies, genital surgery has helped selected transsexuals live happier and more
productive lives and so is justified in highly motivated, properly diagnosed transsexuals
who have stable social and work records and have completed a 1- to 2-yr real-life test in
the opposite gender role. Before surgery, patients often need assistance with "passing" in
public, including gestures and voice modulation. Participation in gender support groups,
available in most large cities, is usually helpful. A few homosexual men, schizophrenics,
and patients with serious personality problems request this surgery; results in these
patients may be unsatisfactory medically, psychiatrically, and socially.
Female transsexualism is increasingly seen in medical and psychiatric practice. The
patient asks for mastectomy, hysterectomy, oophorectomy, and androgenic hormones (eg,
IM testosterone ester preparations 300 to 400 mg q 3 wk) to permanently alter her voice
and induce a more masculine muscle and fat distribution. She may ask for an artificial
phallus (neophallus) to be fashioned via plastic surgery. Surgery may help certain
patients achieve greater adaptation and life satisfaction. As with male-to-female
transsexuals, such patients should meet the criteria established by the Harry Benjamin
International Gender Dysphoria Association and have lived in the male gender role at
least 1 yr. Anatomic results of neophallus surgical procedures are often less satisfactory
than neovaginal procedures for male-to-female transsexuals. Complications are common,
especially in procedures that involve extending the urethra into the neophallus.

Paraphilias
Disorders characterized by long-standing, intense, sexually arousing fantasies, urges, or
behaviors that involve inanimate objects, actual or imagined suffering or humiliation of
oneself or one's partner, or nonconsenting partners and that are associated with
clinically important distress or disability.
These arousal patterns are considered deviant because they are often obligatory for sexual
functioning (ie, erection or orgasm cannot occur without the stimulus), may involve
inappropriate partners (eg, children), and cause significant distress or impairment in
social, occupational, or other important areas of functioning. In persons with a paraphilia
(those whose sexual drive is absorbed almost entirely in performing or submitting to
flagellation or similar practices, is directed toward articles of clothing, or is largely
expressed in exhibitionism or voyeurism), the capacity for affectionate, reciprocal
emotional and sexual intimacy with a partner is generally impaired or nonexistent, and
other aspects of personal and emotional adjustment are impaired.
Paraphilias are far more common among males than among females in most cultures.
Biologic reasons for the unequal distribution may exist, although they are poorly defined
at present. Developmentally, males must transfer their infantile identification with their
mothers to their fathers during the preschool or oedipal period, from about age 3 to 6 yr,
whereas females do not have to transfer their identification. The need to disidentify
during a critical period of psychosexual development makes the male more vulnerable,
possibly leading to the much higher incidence of paraphilias in males.
Many of the paraphilias are rare. The most common paraphilias are pedophilia,
voyeurism, and exhibitionism. Sex offenders may have multiple paraphilias.

Treatment
Long-term individual or group psychotherapy is usually necessary and may be especially
helpful when it is part of multimodal treatment that includes social skills training,
treatment of comorbid physical and psychiatric disorders (eg, seizure disorders, attention
deficit disorder, depression), and hormonal treatment. Treatment has been considered less
effective when court ordered, although many adjudicated sex offenders have benefited
from treatments, such as group psychotherapy and antiandrogen drugs. In the USA, IM
medroxyprogesterone acetate is the treatment of choice; cyproterone acetate is used in
Europe. Typically, a male with a moderate to severe paraphilia is given
medroxyprogesterone 200 mg IM 2 to 3 times/wk for 2 wk, followed by 200 mg 1 to 2
times/wk for 4 wk, then 200 mg q 2 to 4 wk. Serum testosterone should be monitored and
maintained in the normal female range. Treatment is usually long-term, because deviant
sexual arousal patterns usually recur shortly after testosterone levels return to normal. In
addition to antiandrogens, selective serotonin reuptake inhibitors (eg, high-dose
fluoxetine 60 to 80 mg/day or fluvoxamine 200 to 300 mg/day) may be useful. Drugs are
most effective when used as part of multimodal treatment programs.
FETISHISM
Use of an inanimate object (the fetish) as the preferred method of producing sexual
excitement, usually beginning in adolescence.
Common fetishes include aprons, shoes, leather or latex items, and women's
underclothing. The fetish may replace sexual activity with a partner or may be integrated
into sexual behavior with a willing partner, usually as a requirement for erotic arousal.
Minor fetishistic behavior as an adjunct to consensual sexual behavior is not considered a
psychiatric disorder because distress, disability, and clinically significant dysfunction are
absent. More intense, obligatory fetishistic arousal patterns may cause serious problems
in a relationship. When the fetish becomes the sole object of sexual desire, sexual
relationships are often avoided. (Transvestic fetishism rather than fetishism may be
diagnosed when a male is sexually stimulated and gratified by wearing, rather than
simply fondling, women's garments, usually underclothing.)
Transvestic Fetishism
Dressing in women's clothing by heterosexual males, generally beginning in late
childhood and at least initially associated with sexual arousal.
Transvestic fetishism (transvestism) is diagnosed as a psychiatric disorder only if the
fantasies, urges, or cross-dressing behaviors are associated with clinically significant
distress or recognizable dysfunction. Transvestites often say mood-regulating properties
and cross-gender expression are important motivations for cross-dressing.
Cross-dressing per se is not a disorder. Personality profiles of cross-dressing men are
generally similar to age- and race-matched norms. When partners are cooperative, these
men have intercourse in partial or full feminine attire. When their partners are not
cooperative, they may feel anxiety, depression, guilt, and shame associated with the
desire to cross-dress. Cross-dressing men who are conflicted about their behavior may
purge all of their women's clothes, accessories, and makeup, but they generally resume
their activities after days to months, hence the clinical dictum, "Once a cross-dresser,
always a cross-dresser."
Most transvestites do not present for treatment. Those who do are brought in by unhappy
spouses, are referred by courts, or are self-referred out of concern about being
apprehended and experiencing negative social and employment consequences. Some
present for treatment of comorbid gender dysphoria, substance abuse, or depression.
Social and support groups for cross-dressers are generally helpful.
PEDOPHILIA
A preference for repetitive sexual activity with prepubertal children.
(See also Ch. 264.)
Arbitrarily, the age of a person with this disorder is set at >= 16 yr, with the age
difference between him and the child victim set at >= 5 yr. The age of the child is
generally <= 13 yr. For older adolescents with pedophilia, no precise age difference is
specified; clinical judgment is relied on. When the victim is postpubertal, the disorder is
frequently labeled child molestation or ephebophilia (attraction to youths) rather than
pedophilia.
Pedophiles prefer opposite-sex to same-sex children 2:1. Heterosexually oriented males
tend to prefer girls aged 8 to 10 yr; in most cases, the adult is known to the child.
Looking or touching seems more prevalent than genital contact. Homosexually oriented
males prefer boys aged 10 to 13 yr, and their acquaintanceship with the child is more
casual than that of heterosexually oriented males. Bisexual adult pedophiles usually
choose children < 8 yr. Exclusive pedophiles are attracted only to children; nonexclusive
types may also be attracted to adults.
Pedophiles may limit their sexual activities to their own children or close relatives
(incest) or may also victimize other children. Predatory pedophiles may use force and
threaten to physically harm the children or their pets if they disclose the sexual abuse.
The course of pedophilia is chronic and may be complicated by substance abuse or
dependence, depression, marital conflict, or antisocial personality disorder.
Sexual offenses against children constitute a significant proportion of reported criminal
sexual acts. The recidivism rate for homosexual pedophilia is second only to
exhibitionism, ranging from 13 to 28% of those apprehended--roughly twice the rate of
heterosexual pedophilia.
EXHIBITIONISM
Achieving sexual excitement via repetitive acts of genital exposure to an unsuspecting
stranger.
The exhibitionist (usually male) may masturbate while exposing himself or while
fantasizing about exposing himself. He may be aware of his need to surprise, shock, or
impress the unwilling observer. The victim is almost always a female adult or child.
Actual sexual contact is almost never sought. Age at onset is usually the mid 20s; rarely,
the first act occurs during preadolescence or middle age. About 30% of apprehended
male sex offenders are exhibitionists. They have the highest recidivism rate of all sex
offenders; about 20 to 50% are rearrested. Most exhibitionists are married, but the
marriage is often troubled by poor social and sexual adjustment, including frequent
sexual dysfunction. Very few females have exhibitionism, although society sanctions
some exhibitionistic tendencies in females (through media and entertainment venues).
Folklore says that "women exhibit everything but the genitals; men, nothing but."
VOYEURISM
Achieving sexual arousal by observing unsuspecting persons who are naked, disrobing,
or engaging in sexual activity.
Voyeurism usually begins in adolescence or early adulthood. Adolescent voyeurism is
generally viewed more leniently; few teenagers are arrested. The essential feature is
spending considerable time repetitively seeking out viewing opportunities. All sexual
activity is related to voyeurism for a person with the most severe form. Orgasm is usually
achieved by masturbating during or after the voyeuristic activity (peeping). The voyeur
does not seek sexual contact with those he is observing. The disorder must be
differentiated from normal sexual curiosity between persons who know each other.
SEXUAL MASOCHISM
Intentional participation in an activity in which one is humiliated, beaten, bound, or
otherwise abused to experience sexual excitement.
Masochistic fantasies tend to begin in childhood; involvement with partners, by early
adulthood. Sadomasochistic fantasies and sexual behavior between consenting adults is
very common. Masochistic activity tends to be ritualized and chronic. For most
practitioners, the humiliation and beating are simply acted out in fantasy, with
participants knowing that it is a game and carefully avoiding actual humiliation or injury.
However, some masochists increase the severity of their activity as time goes on,
potentially leading to serious injury or death.
Masochistic activities may be the preferred or exclusive mode of producing sexual
excitement. Persons may act on their masochistic fantasies themselves (eg, binding
themselves, piercing their skin, applying electrical shocks, burning themselves) or seek
out a partner who may be a sexual sadist. Activities with a partner include bondage,
blindfolding, spanking, flagellation, humiliation by means of urination or defecation on
the person, forced cross-dressing, or simulated rape. A potentially dangerous form
involves autoerotic partial asphyxiation (hypoxyphilia), in which a person uses ligatures,
nooses, or plastic bags to induce a state of relative cerebral hypoxia at the point of
orgasm. Volatile nitrites ("poppers") may be inhaled to enhance cerebral hypoxia. The
intent is to enhance orgasm, but accidental deaths occasionally result from this activity.
SEXUAL SADISM
Infliction of physical or psychologic suffering (humiliation, terror) on the sexual partner
to stimulate sexual excitement and orgasm.
The disorder commonly begins in early adulthood, although sadistic fantasies often occur
during childhood. Generally, the person has insistent, persistent fantasies in which sexual
excitement results from suffering inflicted on the partner. The diagnosis is warranted
whether the partner consents or not. Sadism is different from minor manifestations of
aggression in normative sexual activity. At the extreme end of the spectrum, sexual
sadism involves brutal rape or torture of victims. Even more extreme is lust murder, in
which death of the victim produces sexual excitement.
Sexual sadism must sometimes be differentiated from rape, a complex amalgam of sex
and power over the victim. Sexual sadism is diagnosed in < 10% of rapists, although for
many, forcing an unwilling person to engage in intercourse increases sexual excitement.
However, inflicting suffering is not the motive for most rapists, and the victim's suffering
usually does not increase the rapist's sexual excitement.
Sexual sadism is usually chronic. When practiced with nonconsenting partners, this
criminal activity is likely to continue until the sadist is apprehended. Sexual sadism is
particularly dangerous when associated with antisocial personality disorder (see Ch. 191).

By;Aloyce Ambokile,
+255(748)620-248