Desk Reference to the Diagnostic Criteria From DSM-5®
These are the notes of all psychopathology lectures. Case studies and practice questions included. Also, different illustrations to remember the fabric better. The DSM-V criteria are included in all disorders. Each lecture titles includes the DSM-V number, so you can easily find the disorder in the...
Psychopathology symptoms, classification and diagnosis notes
15-09-2021: Introduction, Sexual Dysfunction (201)
What are sexual dysfunctions
Sexual dysfunction is anything outside of the mainstream so to say. It can be sexual pain, inability to
have intercourse, premature ejaculation, difficult to get or keep an erection, difficulty with
orgasming.
When you have a client in front of you (or a case in the exam), you need to start thinking
immediately do I have sufficient information to conduct the conceptualisation of this case, or do I
need to know more. Am I convinced with the criteria that this person or this couple is telling me is it
sufficient to come up with a diagnosis? And what do I need to reach the criteria that the DSM-5 gives
us.
Overview of the lecture
- Presentation of sexual problems and assessment.
- Aetiologies (prognosis) and theories of sexual dysfunction.
1. Dominant models.
- DSM: relevance and changes since the last version.
- Types of sexual psychopathologies according to the DSM-5.
1. Women sexual dysfunctions.
2. Men’s sexual dysfunctions.
3. … other sexual dysfunctions.
- Current topical issues (“female viagra” and myths
- General treatment/interventions
1. Psycho-sexual education
2. Sensate focudes
3. CBT
Changes from DSM-IV to DSM-V → not in exam
- (For females) sexual desire and arousal disorders are combined. Female sexual
interest/arousal disorder.
- Sexual dysfunctions (except substance-/medication-induced sexual dysfunction) now require
a duration of approximately 6 months.
- Vaginismus and dyspareunia are now combined: genito-pelvic pain/penetration disorder
(GPPPD).
- Subtypes for all disorders: lifelong versus acquired, generalized versus situational.
- Removed from DSM-5 due to lack of evidence-based data: sexual aversion disorder. Sexual
aversion is when you almost have a phobic response to sexual stimuli. These people don’t
want anything to do with sex, not with doctor, not gynaecologists, and also not with the
studies of sex, so investigators can never reach these people.
In women, when they have a physical arousal/genital stimulated, they don’t have to be subjectively
aroused, it is not in concordance. With men this is not the case, with men it is more in concordance,
, PSYCHOPATHOLOGY NOTES
so when a man’s genital is stimulated, they’re almost always subjectively aroused. With men they
measure the size of the penis and with women they measure the blood flow to the vaginal walls. But
now, when they actually measure the clitoris (which is much more like a penis then the vaginal walls,
female penis) in combination with the subjective arousal, then there is more concordance, and it
looks more similar to men.
What can cause/maintain SD?
Changes (with age, phase, state etc…)
Coordinated by: neurologic, vascular, endocrine. You need the right hormones, to be able to make
the erotic organs more sensitive, for sexual touch and pleasure. Then you need a good blood flow to
have an erection and to have the vaginal walls engulfing. And you also need a neurological system to
have the autonomic responses making the organs sensitive, for the sexual touch.
Individual sexuality incorporates: family, societal, religious (beliefs, experiences). An example: for
many men and women masturbation is normal, you do it to relax, you do it by yourself or with/by
you partner. It’s a common thing. For some people with different backgrounds touching yourself
might be considered as wrongdoing. Pleasurable touch for women is not normal in some cultures.
When we talk about anal sex, some find it exciting and stimulating, but for others it can elicit a lot of
disgust and negative feelings. So, when those people get asked by their partner to try anal, they
might feel pressured to do something ‘dirty’.
Sexual activity incorporates: inter-personal relationships, each partner (attitude, needs, responses,…)
Causal factors in sexual dysfunction
Predisposing factors:
- Restrictive upbringing.
- Disturbed family relations.
- Traumatic early sexual experiences.
- Poor sex education.
- Performance anxiety.
- Partner demands.
- Poor communication.
- Guilt.
- Loss of attraction.
- Psychological problems.
, PSYCHOPATHOLOGY NOTES
How can we break this cycle?
The bio-psycho-social assessment
You want to know the cardiovascular profile of the
person. For example, testosterones levels. The same for
women, for a lot of conditions, you need a physiological
profile, in addition to the societal factors and
inter/intra-personal factors.
Phases of sexual activity
There is the excitement phase when you have the
fantasies, the wanting, the excitement of having
sex. The body is preparing, the blood flow is going
to your vagina and nipples or penis. Your body is
preparing for intercourse. There is the plateau
phase. The peak of sexual arousal but it is a bit on
hold, there is some control there. The orgasm is
the peak of sexual arousal with the emotional
peak. And the resolution when it’s done.
The main critique on this model is that in general our human sexual response is not really this linear.
For some people they don’t need the excitement phase, it can just be a single touch and they go to
plateau and orgasm. You can also skip orgasm. It doesn’t have to be sexual disorder when for
example the excitement phase is skipped. The distinction between phases might be artificial, because
sexual response is not linear & uniform process.
The sexual tipping point
Excitation factors:
1. You might feel very excited to have sex, but
2. You might really want to be with this person and have sex, but
3. You want to have sex, but
Inhibition factors:
1. You don’t have a condom.
2. You feel very insecure about your body.
3. You’re afraid you’re coming to fast.
Excitation factors mostly exceed the inhibition factors.
- Male hypoactive sexual desire disorder.
- Premature (early) ejaculation.
- Substance/medication-induced sexual dysfunction.
- Other specified sexual dysfunction.
- Unspecified sexual dysfunction.
Men’s sexual dysfunctions
Delayed Ejaculation (DE)
A marked inability to achieve desired ejaculation. More common in men over 50 (visual vs. tactile:
older men need more tactile information than visual information). With age there is decreasing
distress, but increasing difficulty with erection and blood flow / and pelvic muscularity and elasticity.
Only 75% of men report always ejaculation during sexual activity. Many theories regarding the
aetiology of DE but with little empirical data to support any particular theory.
3 common factors associated with DE:
- Higher frequency of masturbation.
- Idiosyncratic masturbatory style.
- Disparity between the reality of sex with his partner compared to preferred sexual fantasy
during masturbation.
In the clinical setting:
- DE is often mistakenly diagnosed as ED. Because with DE men often try and try to try and
reach an orgasm, but eventually the penis will go to sleep. This may look like ED, but because
it literally just takes too long to reach an orgasm it is actually DE.
- Focus on pleasure instead of function.
- Learn to focus attention on sexual stimuli.
- Cognitive restructuring.
- Suspend masturbatory activity temporarily.
- Use condoms during masturbation?
- Check relationship.
Erectile Disorder (ED)
Failure to obtain or maintain erection during partnered sexual activities. Marked decrease in erectile
rigidity. More common in men over 50. Most problems remit without professional intervention.
Viagra helps a lot of men with ED.
There was a study that showed that erectile disfunction often appears before cardiac arteriosclerosis.
Around 25 months before the actual heart attack occurs. It’s easy to understand because in the penis
we have the smallest capillaries, so what happens if these veins are excluded first, you get erectile
disfunction. You should see this as a red flag, that if you’re a young person and you never had any
problems with you erection and suddenly you do, you should get check-up at a cardiologist or a
doctor. This made ED more of a medical disorder.
Medication and relational drugs with a negative impact on erectile function (e.g., antihypertensives,
antidepressants, recreation substances, etc.)
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