Schizophrenia and Other Psychotic Disorders

Schizophrenia and Other Psychotic Disorders
Chapter Eleven Schizophrenia and Other Psychotic Disorders

In Class Exercise https://www.youtube.com/watch?v=afbKXWCQMvE
Take out a piece of paper and write your to do list for this week.

The Symptoms of Schizophrenia
A group of disorders characterized by severely impaired cognitive processes, personality disintegration, mood disturbances, and social withdrawal Psychosis: condition involving loss of contact with or distorted view of reality Lifetime prevalence: 1% of U.S. population Involve unusual thoughts or perceptions, such as: Delusions Hallucinations Disordered thinking Bizarre behavior

Positive Symptoms Delusions:
False beliefs that are firmly and consistently held despite disconfirming evidence or logic Individuals are unable to distinguish between private thoughts and external reality Most individuals are either unaware or only moderately aware of the illogical nature of hallucinations or delusions Poor insight

Positive Symptoms (cont’d.)
Figure 11-1 Awareness of Psychotic Symptoms in Individuals with Schizophrenia Most individuals with schizophrenia are unaware or only modestly aware that they have symptoms of the disorder. The symptoms they are most unaware of include delusion, disordered thinking and blunt affect. Source: Amador (2003). Used by permission of Dr. Xavier Amador.

Delusional themes: Delusions of grandeur Delusions of control Delusions of thought broadcasting Delusions of persecution Delusions of reference Delusions of thought withdrawal Most common delusion involves paranoid ideation

Hallucinations: Sensory perceptions not directly attributable to environmental stimuli: Auditory (hearing) Visual (seeing) Olfactory (smelling) Tactile (feelings) Gustatory (tasting)

Auditory hallucinations are most common and can range from malevolent to benevolent Greatest distress: When voices are dominant and insulting, and individual lacks communication with the voices Auditory hallucinations appear to be real to the individual

Disorganized thought and speech: Common characteristic of schizophrenia Loosening of associations (cognitive slippage) Continual shifting from topic to topic without any apparent logical or meaningful connection between thoughts Incoherent speech or bizarre, idiosyncratic responses

Grossly abnormal psychomotor behavior: Extremes in activity levels Catatonia: characterized by marked disturbances in motor activity Excited catatonia Withdrawn catatonia Peculiar body movements or postures Strange gestures or grimaces Combination

Negative Symptoms Associated with inability or decreased ability to initiate actions or speech, express emotions, or feel pleasure Avolition: inability to take action or focus on goals Alogia: lack of meaningful speech Asociality: minimal interest in social relationships Restricted affect: severe or limited emotionality in situations in which emotional reactions are expected

Cognitive Symptoms Associated with problems with attention, memory, and difficulty in developing a plan of action Moderately severe to severe impairments Poor executive functioning Inability to sustain attention Difficulty retaining and using recently learned information

Other Psychotic Disorders
Involve psychotic symptoms, but do not meet the diagnosis for schizophrenia Include: Brief psychotic disorder Schizophreniform disorder Delusional disorder Schizoaffective disorder Attenuated psychosis syndrome Other specified psychotic disorder

Brief Psychotic Disorder and Schizophreniform Disorder
Psychotic episodes that last at least one day but less than one month Can be caused by psychological trauma Relatively uncommon Schizophreniform disorder: Psychotic episodes that last at least one month but less than six months Shares anatomical and neural deficits of schizophrenia

Brief Psychotic Disorder and Schizophreniform Disorder (cont’d.)
Neither require impairment in social or occupational functioning Diagnoses are often considered provisional diagnoses Initial diagnoses based on currently available information

Brief Psychotic Disorder and Schizophreniform Disorder (cont’d.)

Delusional Disorder Persistent, nonbizarre delusions without other odd behaviors Common themes: Erotomania Grandiosity Jealousy Persecution Somatic complaints

Schizoaffective Disorder
Existence of both symptoms of schizophrenia and major depressive or manic symptoms Diagnosis is difficult as individual may have two separate mental disorders Relatively rare

Psychotic Disorder Not Elsewhere Classified
Psychotic symptoms that are not significant enough to meet criteria for specific psychotic disorder Postpartum psychosis without a mood component Persistent auditory hallucination without other symptoms Nonbizarre hallucinations with mood symptoms Psychotic symptoms of unknown etiology

The Course of Schizophrenia
Prodromal phase: Onset and buildup of symptoms: Social withdrawal and isolation Peculiar behavior and inappropriate affect Poor communication patterns Neglect of personal grooming Active phase: Full-blown symptoms: Severe disturbances in thinking Deterioration in social relationships Restricted or inappropriate affect

The Course of Schizophrenia (cont’d.)
Residual phase: Symptoms no longer prominent Symptom severity declines and individual shows mild impairment Complete recovery is rare, but schizophrenics can lead productive lives

The Course of Schizophrenia (cont’d.)
Figure 11-3 Varying Outcomes with Schizophrenia This figure shows five of the many outcomes possible with schizophrenia in individuals during a 15-year follow-up study. Source: Wiersma et al., 1998.

Etiology of Schizophrenia
Figure 11-4 Multipath Model of Schizophrenia The dimensions interact with one another and combine in different ways to result in schizophrenia.

Biological Dimension Genetics and heredity play important role
Disorder is understood to result from as many as 20 genes and their interactions Schizophrenia is found among close relatives of people diagnosed with disorder 16% chance for close relatives (e.g. mother/son) 4% chance for distant relatives (e.g. aunt/niece) 1% for general population

Biological Dimension (cont’d.)
Figure 11-6 Risk of Schizophrenia Among Blood Relatives of Individuals Diagnosed with Schizophrenia This figure reflects the estimate of the lifetime risk of developing schizophrenia- a risk that is strongly correlated with the degree of genetic influence. Source: Data from Gottesman (1978, 1991).

Neurostructures: Schizophrenics have smaller cortical volumes (also found in healthy individuals) and ventricular enlargement Loss of brain cells in cortex over six-year period Differences in brain structure between individuals with and without schizophrenia is relatively small Abnormalities may result from antipsychotic medication

Neurotransmitters: Dopamine hypothesis: Schizophrenia results from excess dopamine activity at certain synaptic sites Support from research with three drugs: Phenothiazines: block dopamine receptor sites L-dopa: sometimes produces schizophrenic-like symptoms Amphetamines: symptoms similar to acute paranoid schizophrenia in non-schizophrenics

Psychological Dimension
Use of cocaine, amphetamines, alcohol, and especially cannabis increase chances of developing psychotic disorder

Social Dimension Family influence is controversial
Certain social conditions have influence: Severe physical abuse from mothers prior to 12 years of age Positive remarks and warmth expressed by caregivers improved symptoms Maltreatment by adult or bullying High-risk children are more sensitive to effects of adverse and healthy child-rearing practices Other social risk factors: Lower educational level of parents Lower occupational status of fathers Living in poorer residential areas at birth Migration among 1st and 2nd generation immigrants to U.K. Culture affects the way disorder is viewed Indigenous belief systems influence views of etiology and treatment

Social Dimension (cont’d.)
Figure 11-7 Risk of Psychotic Symptoms at Age 11 Associated With Cumulative Childhood Trauma Youth exposed to both bullying and childhood maltreatment demonstrate a significantly increased risk of developing psychotic symptoms Source: Arsenault et al. (2011)

Social Dimension (cont’d.)
Expressed emotion (EE): Negative communication pattern found among some relatives of individuals with schizophrenia; associated with higher relapse rates Interpretations of findings: High-EE environment may lead directly to relapse Severely ill individual may cause high-EE patterns

Treatment of Schizophrenia
Antipsychotic medication: Can reduce intensity of symptoms Dosage levels must be monitored Can produce side effects Reduce severity of positive symptoms of schizophrenia (e.g., hallucinations and delusions) Offer little relief for negative symptoms (e.g., social withdrawal, apathy, impaired personal hygiene)

Treatment of Schizophrenia (cont’d.)
Antipsychotic medication: Extrapyramidal side effects include: Parkinsonism (muscle tremors, shakiness) Dystonia (slow, involuntary movement) Akathesis (motor restlessness) Neuroleptic malignant syndrome (muscle rigidity) Metabolic syndrome: Medical condition associated with obesity, diabetes, high cholesterol, and hypertension

Psychosocial therapy: Most beneficial is combination of antipsychotic medication and psychotherapy Tailored to address: Social communication Deficits in emotional perception and in understanding beliefs and attitudes of others Difficulties with employment Lack of social networks

Cognitive-behavioral therapy: Teaching coping skills to: Manage positive and negative symptoms Address cognitive deficits Show improvements in normal functioning Mindfulness training: Accept symptoms in nonjudgmental manner Enhances feelings of self-control, reducing negative symptoms

Cognitive-behavioral therapy steps: Engagement Assessment Identification of negative beliefs Normalization Collaborative analysis of symptoms Developing alternative explanations

Family communication and education: Normalize family experience Demonstrate concern, empathy, sympathy Educate family members about schizophrenia Avoid blame Identify strengths and competencies Develop stress management skills Teach family to cope with symptoms Strengthen communication

Meet Wendy Wendy is in her mid twenties and has become less and less able to perform her work at a local bank. She complains that her thoughts are unconnected and uncontrollable. She hears things that other people do not hear. She looks confused. list questions or observations that, when answered, would support a diagnosis for each of the three psychotic disorders.

I almost forgot… She believes her parents are trying to poison her and that she is Christ She has come to your mental hospital. Please write down a treatment plan for Wendy on the handout. Think of a treatment plan involving several components—medication, cognitive therapy, social skills training, family therapy, and so forth.

Sexual Dysfunction, Gender Dysphoria, and Paraphilic Disorders
Chapter Thirteen Sexual Dysfunction, Gender Dysphoria, and Paraphilic Disorders

Disorders of Sex and Gender
Experts recognize two general categories of SEXUAL DISORDERS SEXUAL DYSFUNCTIONS Problems with sexual responses PARAPHILIC DISORDERS Repeated and intense sexual urges and fantasies in response to socially inappropriate objects or situations DSM-5 also includes a category called GENDER DYSPHORIA Pattern in which people feel that they have been born to the wrong sex and identify with the other gender Sexual behavior is a major focus of both our private thoughts and public discussions. Relatively little is known about racial and other cultural differences in sexuality. Sex therapists and sex researchers have only recently begun to attend systematically to the importance of culture and race.

Sexual Dysfunctions SEXUAL DYSFUNCTIONS
Are disorders in which people cannot respond normally in key areas of sexual functioning Involve as many as 30 percent of men and 45 percent of women in the United States, who suffer from such a dysfunction during their lives Are often interrelated to other dysfunctions Sexual dysfunctions are typically very distressing, and often lead to sexual frustration, guilt, loss of self-esteem, and interpersonal problems.

Sexual Dysfunctions The human sexual response has a cycle with four phases Desire Excitement Orgasm Resolution Four stages: Appetitive phase: Characterized by person’s interest in sexual activity Arousal phase: May follow or precede the appetitive phase Is heightened and intensified when specific and direct sexual stimulation occurs Orgasm phase: Characterized by involuntary muscular contractions throughout the body and eventual release of sexual tension Females are capable of multiple orgasms Resolution phase: Characterized by relaxation of the body after orgasm Heart rate, blood pressure, and respiration return to normal

The Normal Sexual Response Cycle
Figure 11-1 Researchers have found a similar sequence of phases in both males and females. Sometimes, however, women do not experience orgasm; in that case, the resolution phase is less sudden. And sometimes women experience two or more orgasms in succession before the resolution phase. (Adapted from Kaplan, 1974; Masters & Johnson, 1970, 1966.)

Sexual Dysfunctions Some people struggle with sexual dysfunction their whole lives For others, normal sexual functioning preceded the disorder In some cases the dysfunction is present during all sexual situations In others it is tied to particular situations

Disorders of Desire Desire phase of the sexual response cycle
Dx Checklist Male Hypoactive Sexual Desire Disorder For at least 6 months, individual repeatedly experiences few or no sexual thoughts, fantasies, or desires. Individual experiences significant distress about this. Female Sexual Interest/Arousal Disorder For at least 6 months, individual usually displays reduced or no sexual interest and arousal, characterized by the reduction or absence of at least three of the following: Sexual interest Sexual thoughts or fantasies Sexual initiation or receptiveness Excitement or pleasure during sex Responsiveness to sexual cues Genital or nongenital sensations during sex. Individual experiences significant distress. Desire phase of the sexual response cycle Consists of an interest in or urge to have sex, sexual fantasies, and sexual attraction to others Two dysfunctions affect this phase MALE HYPOACTIVE SEXUAL DESIRE DISORDER FEMALE SEXUAL INTEREST/AROUSAL DISORDER MALE HYPOACTIVE SEXUAL DESIRE DISORDER Characterized by a lack of interest in sex and little sexual activity: physical responses may be normal. Prevalent in about 16 percent of men. While most cultures portray men as wanting all the sex they can get, as many as 18 percent of men worldwide have this disorder, and the number seeking therapy has increased during the past decade. FEMALE SEXUAL INTEREST/AROUSAL DISORDER Characterized by a lack of normal interest in sexual activity; rare initiation of or little excitement during sexual activity. Reduced sexual interest and desire may be found in as many as 33 percenty of women. It is important to note that many sex researchers and therapists believe it is inaccurate to combine desire and excitement symptoms into a single female disorder.

Disorders of Desire: Causes
Most cases of low sexual desire or sexual aversion are caused primarily by sociocultural and psychological factors, but biological conditions can also lower sex drive Biological causes Hormone abnormalities: Prolactin, testosterone, and estrogen for both men and women Medications, drugs, and chronic illness Psychological causes General increase in anxiety, depression, or anger may reduce sexual desire Fears, attitudes, and memories may contribute to sexual dysfunction Certain psychological disorders Sociocultural causes Attitudes, fears, and psychological disorders Situational pressures Molestation or assault Cultural standards Sex drive is determined by a combination of biological, psychological, and sociocultural factors, and any of these may reduce sexual desire. Biological causes A number of hormones interact to produce sexual desire and behavior. Abnormalities in their activity can lower sex drive. These hormones include prolactin, testosterone, and estrogen for both men and women. Sex drive can also be lowered by some medications (including birth control pills and pain medications), some psychotropic drugs, a number of illegal drugs, and chronic illness. Psychological causes A general increase in anxiety, depression, or anger may reduce sexual desire in both men and women. Fears, attitudes, and memories may contribute to sexual dysfunction. Certain psychological disorders, including depression and obsessive-compulsive disorder, may lead to sexual desire disorders. Sociocultural causes Many sufferers of desire disorders are feeling situational pressures. Examples: divorce, death, job stress, infertility, and/or relationship difficulties Cultural standards can set the stage for development of these disorders. The trauma of sexual molestation or assault is especially likely to produce sexual dysfunction.

What Techniques Are Applied to Particular Dysfunctions?
Disorders of desire These disorders are among the most difficult to treat because of the many issues that feed into them Therapists typically apply a combination of techniques Affectual awareness, self-instruction training, behavioral approaches, and biological interventions In addition to the general components of sex therapy, specific techniques can help in each of the sexual dysfunctions.

Disorders of Excitement
ERECTILE DISORDER (ED) Characterized by persistent inability to attain or maintain an erection during sexual activity Occurs in as much as 25 percent of the general male population Found in half of all adult men, who have erectile difficulty during intercourse at least some of the time Dx Checklist Erectile Disorder For at least 6 months, individual usually finds it very difficult to obtain an erection, maintain an erection, and/or achieve past levels of erectile rigidity during sex. Individual experiences significant distress. Figure 11-2 Most cases of erectile disorder result from an interaction of biological, psychological, and sociocultural processes.

Disorders of Orgasm Orgasm phase of the sexual response cycle
Sexual pleasure peaks and sexual tension is released as the muscles in the pelvic region contract rhythmically Three disorders of this phase PREMATURE EJACULATION DELAYED EJACULATION FEMALE ORGASMIC DISORDER Dx Checklist Premature Ejaculation For at least 6 months, individual usually ejaculates within 1 minute of beginning sex with a partner and earlier than he wants to. Individual experiences significant distress. Delayed Ejaculation For at least 6 months, individual usually displays a significant delay, infrequency, or absence of ejaculation during sexual activity with a partner. Female Orgasmic Disorder For at least 6 months, individual usually displays a significant delay, infrequency, or absence of orgasm, and/or is unable to achieve past orgasmic intensity. For men: Semen is ejaculated. For women: Outer third of the vaginal walls contract.

What Techniques Are Applied to Particular Dysfunctions?
Erectile disorder Treatments Focus on reducing a performance anxiety and/or increasing stimulation May include sensate-focus exercises such as the “TEASE TECHNIQUE” Biological approaches Improved with development of sildenafil (Viagra) and other erectile dysfunction drugs Biological approaches have gained great momentum with the development of sildenafil (Viagra) and other erectile dysfunction drugs. Most other biological approaches have been around for decades and include gels, suppositories, penile injections, and a vacuum erection device (VED). These procedures are now viewed as “second-line” treatment.

Disorders of Orgasm PREMATURE EJACULATION (EARLY or RAPID) Causes
Characterized by persistent reaching of orgasm and ejaculation within 1 minute of beginning sexual activity with a partner Causes Psychological Biological As many as 30 percent of men experience premature ejaculation at some time. Psychological causes Psychological, particularly behavioral, explanations of this disorder have received more research support than other explanations. The dysfunction seems to be typical of young, sexually inexperienced men. It may also be related to anxiety, hurried masturbation experiences, or poor recognition of arousal. Biological factors Genetic predisposition Overactive and underactive serotonin receptors Greater sensitivity or nerve conduction in the area of their penis There is a growing belief among many clinical theorists that biological factors may also play a key role in many cases of this disorder. One theory states that some men are born with a genetic predisposition. A second theory argues that the brains of men with early ejaculation contain certain serotonin receptors that are overactive and others that are underactive. A third explanation holds that men with this dysfunction experience greater sensitivity or nerve conduction in the area of their penis.

Disorders of Orgasm FEMALE ORGASMIC DISORDER Causes Biological causes
Characterized by persistent failure to reach orgasm, experiencing orgasms of very low intensity, or delay in orgasm Causes Biological Psychological Sociocultural Affects almost 25 percent of women; 10 percent or more have never reached orgasm; 9 percent reach orgasm only rarely Women who are more sexually assertive and more comfortable with masturbation tend to have orgasms more regularly. Female orgasmic disorder is more common in single women than in married or cohabiting women. Most clinicians agree that orgasm during intercourse is not mandatory for normal sexual functioning. Once again, biological, psychological, and sociocultural factors may combine to produce these disorders. Because arousal plays a key role in orgasms, arousal difficulties often are featured in explanations of female orgasmic disorder. Early psychoanalytic theory used to consider lack of orgasm during intercourse to be pathological; current evidence suggests that this is untrue. Biological causes A variety of physiological conditions: include diabetes and multiple sclerosis Medications and illegal substances Postmenopausal changes Psychological causes The psychological causes of female sexual interest/arousal disorder, including depression Memories of childhood trauma and relationship distress Postmenopausal changes may also be responsible Sociocultural causes Theory of female orgasmic problems resulting from sexually restrictive cultural messages challenged Sexually restrictive histories are equally common in women with and without disorders Cultural messages about female sexuality have been changing while the rate of female sexual dysfunction stays constant For years, the leading sociocultural theory of female orgasmic problems was that they resulted from sexually restrictive cultural messages. This theory has been challenged because: Sexually restrictive histories are equally common in women with and without disorders. Cultural messages about female sexuality have been changing while the rate of female sexual dysfunction stays constant. Researchers suggest that unusually stressful events, traumas, or relationships may produce the fears, memories, and attitudes that characterize these dysfunctions. Research has also linked orgasmic behavior to certain qualities in a woman’s intimate relationships (such as emotional intimacy).

Disorders of Sexual Pain
GENITO-PELVIC PAIN/PENETRATION DISORDER Occurs when enormous physical discomfort during intercourse are experienced by women much more often than men May involve learned fear response, relationship difficulties, infection, disease Dx Checklist Genito-Pelvic Pain/ Penetration Disorder For at least 6 months, individual repeatedly experiences at least one of the following problems: Difficulty having vaginal penetration during intercourse Significant vaginal or pelvic pain when trying to have intercourse or penetration Significant fear that vaginal penetration will cause vaginal or pelvic pain Significant tensing of the pelvic muscles during vaginal penetration. Individual experiences significant distress from this. Most clinicians agree with the cognitive-behavioral theory that this form of genito-pelvic pain/penetration disorder is a learned fear response. A variety of factors can set the stage for this fear, including anxiety and ignorance about intercourse, exaggerated stories, trauma caused by an unskilled partner, and the trauma of childhood sexual abuse or adult rape. Some women experience painful intercourse because of infection or disease. Although psychological factors or relationship difficulties may contribute to this problem, psychosocial factors alone are rarely responsible.

What Are the General Features of Sex Therapy?
Modern sex therapy principles and techniques Assessing and conceptualizing the problem Mutual responsibility Education about sexuality Emotion identification Attitude change Elimination of performance anxiety and the spectator role Increasing sexual and general communication skills Changing destructive lifestyles and marital interactions Addressing physical and medical factors

Paraphilic Disorders Dx Checklist Paraphilic Disorder For at least 6 months, individual experiences recurrent and intense sexually arousing fantasies, urges, or behaviors involving objects or situations outside the usual sexual norms (nonhuman objects; nongenital body parts; the suffering or humiliation of oneself or one’s partner; or children or other nonconsenting persons). Individual experiences significant distress or impairment over the fantasies, urges, or behaviors. (In some paraphilic disorders—pedophilic disorder, exhibitionistic disorder, voyeuristic disorder, frotteuristic disorder, and sexual sadism disorder—the performance of the paraphilic behaviors indicates a disorder, even in the absence of distress or impairment.) Table 11-5

Paraphilic Disorders PARAPHILIC DISORDER
Diagnosis applied only when the urges, fantasies, or behaviors cause significant distress or impairment OR When satisfaction of the disorder places the individual or others at risk of harm – either currently or in the past (DSM-5) For example, people who initiate sexual contact with children warrant a diagnosis of pedophilic disorder regardless of how troubled the individuals may or may not be over their behavior.

Types Telephone Scatologia- Necrophilia- Zoophilia-
making obscene phone calls, such as describing one’s masturbatory activity, threatening to rape the victim, or trying to find out the victim’s sexual activities. Necrophilia- deriving sexual gratification from viewing or having sexual contact with a corpse. Zoophilia- having sex with animals or having recurrent fantasies of sex with animals.

Types Coprophilia- Klismaphilia- Urophilia- Autagonistophilia-
deriving sexual pleasure from contact with feces. Klismaphilia- deriving sexual pleasure from the use of enemas. Urophilia- deriving sexual pleasure from contact with urine. Autagonistophilia- having sex in front of others. Somnaphilia- having sex with a sleeping person. Stigmatophilia- deriving sexual pleasure from skin piercing or a tattoo.

Fetishistic Disorder FETISHISTIC DISORDER
Includes recurrent intense sexual urges, sexually arousing fantasies, or behaviors involving use of a nonliving object or nongenital part, often to the exclusion of all other stimuli, accompanied by clinically significant distress or impairment. Women’s underwear, shoes, and boots are especially common; more prevalent in men than women, usually begins in adolescence Researchers have been unable to pinpoint the causes of fetishistic disorder. Behaviorists propose that fetishes are learned through classical conditioning. Behavioral treatment Aversion therapy Masturbatory satiation Orgasmic reorientation People with this disorder are sometimes treated with aversion therapy. Another behavioral treatment is masturbatory satiation, in which clients masturbate to boredom while imagining the fetish object. An additional behavioral treatment is orgasmic reorientation, a process that teaches individuals to respond to more appropriate sources of sexual stimulation.

Transvestic Disorder TRANSVESTIC DISORDER (TRANSVESTISM or CROSS-DRESSING) Characterized by fantasies, urges, or behaviors involving dressing in the clothes of the opposite sex in order to achieve sexual arousal

Exhibitionistic Disorder
Characterized by arousal from the exposure of genitals in a public setting EXHIBITIONISTIC DISORDER Characterized by arousal from the exposure of genitals in a public setting Includes a desire to provoke shock or surprise, rather than initiate sexual contact Usually begins before age 18 and is most common in males Treatment Generally includes aversion therapy and masturbatory satiation May be combined with orgasmic reorientation, social skills training, or cognitive-behavioral therapy

Voyeuristic Disorder VOYEURISTIC DISORDER
Characterized by repeated and intense sexual urges to observe people as they undress or engage in sexual activity Many psychodynamic theorists propose that those with voyeuristic disorder are seeking power. Behaviorists explain the disorder as a learned behavior that can be traced to a chance and secret observation of a sexually arousing scene. May involve masturbation during the act of observing or while remembering it later. Vulnerability of discovery often adds to the excitement,.

Frotteuristic Disorder
Includes repeated and intense fantasies, urges, or behaviors involving touching and rubbing against a nonconsenting person Usually begins in the teen years or earlier Almost always male, the person fantasizes during the act that he is having a caring relationship with the victim. Acts generally decrease and disappear after age 25.

Pedophilic Disorder Cause
Characterized by repeated and intense sexual urges or fantasies about watching, touching, or engaging in sexual acts with children; person either acts on these urges or experiences clinically significant distress or impairment Some people are satisfied with child pornography. Includes watching, fondling, or engaging in sexual intercourse typically with female children Others are driven to watching, fondling, or engaging in sexual intercourse with children. Evidence suggests that two-thirds of victims are female. People with this disorder usually develop it in adolescence. Some were sexually abused as children; many were neglected, excessively punished, or deprived of close relationships in childhood. Most are immature, display distorted thinking, and have an additional psychological disorder. Cause Some theorists have proposed a related biochemical or brain structure abnormality but clear biological factors have yet to emerge in research. Treatment Most people with this disorder are imprisoned or forced into treatment. Treatments include aversion therapy, masturbatory satiation, orgasmic reorientation, and treatment with antiandrogen drugs. Cognitive-behavioral treatment involves relapse-prevention training, modeled after programs used for substance dependence.

Sexual Masochism Disorder
Characterized by fantasies, urges, or behaviors involving the act or the thought of being humiliated, beaten, bound, or otherwise made to suffer; most fantasies begin in childhood Information for image A celebration of S/M Sexual sadism and sexual masochism have been viewed by the public with either bemusement or horror, depending on the circumstances and events that surround particular acts of these paraphilias. On the light side, the annual Folsom Street Fair in San Francisco is a very large event that celebrates S/M and invites people (like this participant) to go on stage, display their trademark outfits and, in some cases, participate in whippings or spankings. Only those who are very distressed or impaired by such fantasies receive the diagnosis. Most masochistic fantasies begin in childhood and seem to develop through the behavioral process of classical conditioning.

Sexual Sadism Disorder
Characterized by repeated and intense arousal by the physical or psychological suffering of another individual; usually male SEXUAL SADISM DISORDER Arousal may be expressed through fantasies, urges, or behaviors. Involves imagined total control over a sexual victim Named for the infamous Marquis de Sade Causes Sadistic fantasies may first appear in childhood or adolescence; pattern is long-term. Theoretical explanations Behavioral: Appears to be related to classical conditioning Psychodynamic and cognitive: Underlying feelings of sexual inadequacy Biological: Possible brain and hormonal abnormalities Aversion therapy is primary treatment.

But remember… The definitions of various paraphilic disorders are strongly influenced by the norms of the particular society in which they occur Some clinicians argue that these behaviors should be considered disorders only when other individuals are hurt by them

Gender Dysphoria People with this disorder persistently feel that they have been born to the wrong biological sex, and gender changes would be desirable Gender dysphoria is more than a variant lifestyle and is not a clearly defined medical problem (DSM-5)

Gender Dysphoria Dx Checklist
Gender Dysphoria in Adolescents and Adults For 6 months or more, individual’s gender-related feelings and/or behaviors are at odds with those of his or her assigned gender, as indicated by two or more of the following symptoms: Gender-related feelings and/or behaviors clearly contradict the individual’s primary or secondary sex characteristics Powerful wish to eliminate one’s sex characteristics Yearning for the sex characteristics of another gender Powerful wish to be a member of another gender Yearning to be treated as a member of another gender Firm belief that one’s feelings and reactions are those that characterize another gender. Individual experiences significant distress or impairment.

Hero to a New Audience When he won the gold medal for the decathlon at the 1976 Olympics, Bruce Jenner became a national hero and was widely viewed as the personification of masculinity—the world’s best male athlete—leading to lucrative contracts as the spokesperson for the popular cereal Wheaties (left), among other products. When in 2015 Jenner appeared in Vanity Fair magazine (right) as a transgender woman, Caitlyn, she became a hero to thousands of transgender persons who hoped that this high-profile revelation would reduce the public’s misunderstanding of and prejudice against transgender individuals.

Etiology of Sexual Dysfunctions
Figure 13-4 Multipath Model of Sexual Dysfunctions The dimensions interact with one another and combine in different ways to result in a specific sexual dysfunction.

Biological Dimension Levels of testosterone (low) or estrogens (high) linked to lower sexual interest in men and women, and erectile difficulties in men Medications used to treat medical conditions affect sex drive Some believe alcohol is leading cause of disorders Illnesses and other physiological factors Amount of blood flow into genital area

Psychological Dimension
Predisposing or historical factors Current problems and concerns Traditional psychoanalysts focus on the role of unconscious conflicts Cognitive theorists focus on performance anxiety and spectator role Role of early psychosexual experiences Situational or coital anxiety for women

Social Dimension Social upbringing and current relationships
Being raised in strict religious environment Traumatic sexual experiences Relationship issues often forefront of sexual disorders among and between men and women

Sociocultural Dimension
Sexual behavior and functioning influenced by gender, age, cultural scripts, education level, country of origin For example, women: Are capable of multiple orgasms Entertain different sexual fantasies Have a broader arousal pattern to sexual stimuli Are more attuned to relationships in sex encounter Take longer than men to become aroused Gender role expectations

Treatment of Sexual Dysfunctions (cont’d.)
Psychological treatment approaches: Include following components: Education Replace myths and misconceptions with facts Anxiety reduction Desensitization or graded approaches Structured behavioral exercises Graded tasks that gradually increase amount of sexual interaction Communication training Teaching appropriate ways of communicating sexual wishes

Video Maintaining desire in a long term relationship

Schizophrenia and Other Psychotic Disorders

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