psycho weeks 9-13

• Complexity

  • Can cause distress/impairment in many areas of daily functioning

  • Chronic, relatively intense, associated with role impairment, cause stress on self or others

  • Prone to perceiving threat

  • concerned/worried when there is no threat/situation is ambiguous

• Causes 

  • Biological 

    • Genetics: tense, uptight, anxious - inherited, some predisposed to experience anxiety/panic more than others

    • neuroanatomy/neurotransmitters: CRF system; limbic system, behavioural inhibition system, fight/flight system, GABA/serotonin etc.

  • Psychological 

    • Behaviour factors: anxiety learned through classical conditioning, operant condition, modeling 

    • Cognitive factors: Beck’s Triad

    • Interpersonal factors: parenting style/attachment, sense of control/uncontrollability

    • Anxiety sensitivity

  • Social

    • biological/psychological predispositions for anxiety/panic triggered by stressful events (stress, trauma, environment etc.)

  • Integrated approach (triple vulnerability)

    • Combines biological, psychological, sociological factors explain development of anxiety disorders

• Summary

  • Generalized anxiety disorder: uncontrollable worrying about minor things

  • Panic disorders/agoraphobia: unexpected recurrent panic attacks with physiological symptoms (dizziness, rapid heart etc.)

  • Social anxiety disorder: irrational fear/avoidance of social situations 

  • Specific phobia: fear/avoidance of objects that are not real dangers 

  • Separation anxiety disorder: unrealistic worry something will happen to important people when they leave 

• Generalized anxiety disorder

  • intense/unfocused worry about minor events

  • Feeling a catastrophe after event is over

  • Cannot stop worry-anxiety style 

    • Ongoing more days/period of at least six months 

  • Symptoms: muscle tensions, irritability, sleep disturbance, fatigue

• Causes 

  • Biological

    • Runs in family

    • Kendler (1992) found risk of GAD is greater for identical female twins than fraternal female twins 

    • Heritability of anxiety sensitivity (AS) rather than GAD

      • AS: fear of anxiety symptoms (dizziness, shakiness) due to belief that these are signs of harmful outcomes

  • Psychological

    • Dugas and Ladouceur (1998) developed model containing 4 distinct cognitive characteristics of GAD:

1. Intolerance of uncertainty

2. Positive beliefs about worry

3. Poor problem orientation

4. Cognitive avoidance 

• Treatment for anxiety attacks 

  • Drugs: benzodiazepines for short term, antidepressants/antipsychotics 

  • Psychological

    • CBT

      • Patients confront worry-evoking images/thoughts; goal is for patient to obtain coping mechanisms 

      • Training in relaxation skills

      • learning to substitute calming/adaptive thoughts for intrusive ones

      • Learning skills of de-catastrophizing 

      • Mindfulness-based therapy 

• Panic attacks

  • Panic: abrupt experiencer of fear/acute discomfort-associated with sympathetic nervous system 

    • Two types:

1. cued/expected-always occurring in specific situation

2. uncued/unexpected-without warning

• Panic disorder: repeated episodes of unexpected attacks 

• Agoraphobia

  • Intense fear/avoidance of situations that may be difficult to escape

  • Agora derives from Greek word “fear of the marketplace”

  • Interoceptive avoidance: removing self from activities that produce physiological arousal-similar to panic attacks

  • Marked fear/anxiety for ⅖ of the following

1. Using public transport

2. Being in open spaces

3. Being in enclosed spaces

4. Standing in line/crowd

5. Being outside of home alone 

• Panic disorder causes

  • Biological 

    • Some are genetically predisposed 

  • Psychological

    • Conditioning Theory of Panic Attacks 

      • Attacks = classical conditioning response 

• Treatment for panic attacks

  • Medication

    • Prozac and Paxil (SSRIs) 

    • 60% patients are free of panic if drug use continues 

    • Relapse rates high post-medication (50%)

  • Psychological intervention

    • Panic control treatment (PCT)

      • Form of CBT - patients exposed to cluster of bodily sensations

      • Cog therapy/relax techniques are practiced

  • Integrated approach

    • More effective to use sequential strategy than combining treatments 

• Phobic disorders

  • Phobia: irrational/exaggerated fear of specific object that is inconsistent to real dangers/threats

• Specific phobias 

  • Irritations fear of particular object/situation

  • Phobic item usually provokes fear/anxiety

  • Impact of specific phobia depends on person's ability to avoid

  • Prevalence varies from one culture to another 

• Specific types of phobias

  • Forming phobia name comes from Greek word phobia meaning “fear of”

  • 5 major subtypes

1. Blood-injury-injection ie. needles

2. Animal ie. spiders

3. Natural environment ie. thunderstorms

4. Situational ie. flying

5. other types ie. vomiting 

• Phobia causes

  • Two-factor model of phobia development based on classical/operant conditioning

    • Develops from classical: neutral objects/situations gain ability to evoke fear-pairs with noxious/aversive stimuli

    • Person learns to reduce conditions fear by avoiding CS (operant)

      • Negative reinforcement 

  • Observational learning - modeling and receiving negative info

  • Prepared learning (non-associative model) - some fears reflect classical conditioning but only stimuli where organism is physiologically prepared for sensitivity

• Treating Phobias (learning/exposure based)

  • Gradual exposure: patient exposed gradually to increase fearful stimuli 

  • Systematic desensitization: similar to gradual, patient exposed to more progressively fearful stimuli and being taught relaxation techniques 

  • Modeling therapy: patient exposed to others filmed/lived demonstrations of others interacting

  • Virtual reality therapy: exposed to computer-simulated fear situation, can be gradual

• Social anxiety disorder (social phobia)

  • Is excessive fear/anxiety of social situations due to possibility of being scrutinized by others 

  • Individual fears acting in away that causes negative reactions from peers

  • Thoughts of being judged/embarrassed/humiliated/rejected 

  • Social anxiety is a mental health disorder, shyness is a personality trait

• Causes of social anxiety 

  • Biological

    • Genetic heritability 

    • Behavioural inhibition

    • People with SAD react to angry faces-activation of amygdala

    • Neurotransmitters 

  • Psychological

    • Conditioning theory of panic attacks can be applied to explain SAD

• Treating social anxiety 

  • Drug therapies

    • Antidepressants (SSRIs) - Paxil and Zoloft

    • Some suggest combining psychological and drug treatments

  • Cognitive behavioural group therapy (CBGT)

    • Involves group role play of feared situation

  • Social mishap exposures

    • Patients encouraged to confront social phobic situations 

    • Patients try to become aware of irrational thoughts 

Trauma-Related and OCD-week 9

• Acute stress disorder

  • Traumatic event - person exposed to actual/threatened death, serious injury, sexual violence

  • Most who encounter trauma experience stress-this is normal

    • If stress causes impairment to social functioning and lasts for less than a month, Acute Stress Disorder is diagnosed

    • Longer than a month is PTSD diagnosed

      • Symptoms start shortly after, or a month-year

    • Nearly half acute stress disorder cases become PTSD

• Post-Traumatic Stress Disorder (PTSD)

  • Extreme response to stress-increases anxiety, stimuli avoidance, numbing of emotional responses

    • Fear of re-experiencing

    • nightmares/flashbacks 

    • Avoidance of feelings of event

  • Often experienced by first responders

  • Chronic or delayed-onset

• Clusters of symptoms in ASD and PTSD

  • Re-experiencing 

  • Avoidance of stimuli 

  • Reduction of responsiveness 

  • Symptoms increase arousal

• PTSD causes/risks

  • Direct exposure; intensity; severity 

  • Gender (more in females)

  • Perceived life threat

  • Family history

  • Dissociative symptoms 

  • Coping with stress-focus on emotions 

  • Anxiety sensitivity 

• Causal theories 

  • Psychological-learning theories

    • PTSD comes from classical conditioning

    • Avoidance builds up

  • Cognitive-biological theories 

    • Constant involuntary recollection of event

    • Abnormal activity of cortisol and norepinephrine

    • Constant biochemical arousal can damage key brain areas (hippocampus, amygdala)

  • Social and cultural factors

    • No to little support system

    • Coping skills

• PTSD treatments 

  • Exposure therapy - prolonged exposure 

    • Combined CBT: involved step-by-step process of being exposed to imagery reflecting trauma 

    • Exposure accompanied by changing thoughts

  • Virtual exposure therapy

  • MDMA

• OCD/related disorders 

  • Characterized by patterns of repetitive behaviours associated with significant personal distress

  • Disorders include

1. Obsessive-compulsive 

2. Body dysmorphic

3. Hoarding 

4. Trichotillomania (hair pulling)

5. Excoriation (skin picking)

• OCD

  • Uncontrollable thoughts to repeat certain acts over and over

  • Obsessions

    • Persistent thoughts/ideas that invade consciousness

    • Fears contamination; expressing sexual impulse; hypochondriac fears of bodily dysfunction

  • Compulsions 

    • Repetitive behaviour a person feels need to perform 

    • Often occurs in response to obsessive thoughts, frequent, interfere with daily life

    • Two categories: checking rituals & cleaning rituals 

• OCD causes 

  • Biological: low levels of serotonin activity; brain regions (orbitofrontal cortex, caudate nuclei) these convert sensory info to thoughts and actions 

  • Cognitive: exaggerate risk of unfortunate events to prevent them; comes from trying too hard to control thinking

• Treatment - exposure and response (ritual) preventing (ERP)

  • Therapists achieve results in treating OCD with ERP

  • Exposure involves patients placing themselves in situations that start compulsive rituals 

  • People with OCD learn to tolerate anxiety triggered of obsessive thoughts while prevents from performing rituals

• Obsessive-compulsive-related disorders

  • Body dysmorphic 

    • Imagined physical defect in appearance causing some to feel ugly/disfigure 

    • Become obsessed with perceived defect/engage in fixing

    • Co-occurs with OCD

    • Exposure therapy 

  • Hoarding disorder

    • Need to retain useless possessions causing distress or making it difficult to maintain safe living space

    • Starts early and gets worse

    • CBT often given

  • Trichotillomania (hair-pulling)

    • Has severe social consequences 

    • 1-5% college students-more so females 

  • Excoriation (skin-picking)

    • 1-5% of general population

    • Scabs, scars, open wounds

    • Treatment: habit reversal training 

schizophrenia-week 11

• Other psychotic disorders

• Schizophreniform: people experiencing symptoms of schizophrenia for less than 6 months

• Schizoaffective: people who have schizophrenia symptoms/characteristics of mood disorders

• Delusional disorder: people with persistent belief contrary to reality without other schizo characteristics

• Brief psychotic disorder: people with 1 or more positive symptoms (delusions, hallucinations etc.) in less than a month

• Attenuated psychosis syndrome: one or more schizo symptoms but person is aware 

• Schizotypal personality: characteristics similar to those who experience schizo but less severe

• Schizophrenia

  • Psychotic disorder with major disturbances of thought, emotion, behaviour

  • Characterized by: disordered thinking-not logically related, faulty perception/attention, flat/inappropriate affect, bizarre disturbances in motor activity

• Prevalence and comorbidity

  • In canada: 1% general population lives with schizophrenia

    • Half treated in community

    • 10% commit suicide 

    • Mortality rate 3x higher than canadians w/o schizo

    • 50% suffer from comorbid disorder 

      • Substance abuse (37%)

      • Depression (40%)

  • Higher in Canada, worldwide prevalence levels declining 

    • Most given to immigration rates/high latitude

  • Greater prevalence found:

    • Among those who immigrate 

    • Countries with high latitudes with less sunlight and reduced vit. D

• Course of schizophrenia 

  • Sometimes begins childhood; appears late adolescence or early childhood

  • Have number of acute episodes of symptoms

  • Often less severe but debilitating symptoms between episodes 

  • Most treated in community; hospitalization sometimes necessary

  • Common phases:

1. Prodromal - period of gradual deterioration

2. Acute - characterized by delusions, hallucinations, illogical thinking

3. Residual - follows acute phase; characterized by return to prodromal level

Children with Schizophrenia-week 11

• Clinical description

  • Schizophrenia spectrum disorders: recognized by those in field of schizophrenia

• DSM-5-TR includes dimensional assessment of symptoms on 0-4 scale

  • 0 = no symptoms

  • 1 = equivocal evidence

  • 2 = present but mild

  • 3 = present and moderate 

  • 4 = present and severe 

• Symptoms

1. Positive symptoms: active presentation of problematic symptoms

   1. excesses/bizarre distortions to one's thoughts, emotions, behaviours 

   2. 60-80% experience hallucinations; 70% experience delusions 

2. Negative symptoms: absence/insufficiency of behaviours

   1. Alogia: negative thought disorder; absence of speech; poverty of speech

   2. Avolition: inability to initiate activities; apathy; loss of motivation; ambivalence 

   3. blunted/flat affect: show less outward emotions (blunted); show almost no outward emotions (flat); immobile/expressionless

   4. Anhedonia: inability to experience pleasure 

   5. Asociality: lack of interest in socializing; social withdrawal; attend to own ideas; breakdown of social skills 

3. Disorganized symptoms - rare

   1. Inappropriate affect: emotional responses out of context; shift rapidly from one emotion to another for no reason

   2. Disorganized behaviour: awkward movements; repealed grimaces; odd gestures

   3. Catatonia: rigidity; posturing; excitement 

• Delusions 

  • Beliefs held but not contrary to reality

  • Common delusions 

    • Persecution 

    • Reference 

    • Grandeur 

    • Control

  • Cotard’s syndrome

  • Capgras syndrome 

  • Found in more than half with schizo 

• Hallucinations and heightened perceptions

  • Perception intensifies

    • Can develop years before actual onset

  • Hallucinations 

    • Sensory perception absent of stimulation from environment 

    • Distortions 

    • Types: auditory; visual; tactile (sensations not happening); somatic (things in body); gustatory (tasting things); olfactory (sensing odors)

• Attentional deficiencies

  • Screening out background noises/other stimuli

  • Attention: ability to focus on relevant stimuli/ignore irrelevant 

  • With schizo people have difficulty filtering out irrelevant stimuli - makes it hard to focus attention, organize thoughts, filter out unimportant info 

Etiology of Schizophrenia-week 10

• Biological explanations: Genetic

  • Some inherit; disposition triggered by exposure to extreme stress

  • Family studies: increased risk of genetic relationship becoming closer; risk of other disorders

  • Twin studies: concordance for MZ twins (48%), DZ twins (17%)

  • Adoption studies: children without contact of schizophrenic mothers still likely to develop disorder; good environment reduces risk

  • Genetic linkage studies: regions on numerous chromosomes 

• Biological explanations: Biochemical

  • Dopamine hypothesis

    • Originally assumed its caused by excess dopamine 

      • Developed from accidental discovery of antipsychotic drugs

      • Provided by amphetamines and development of amphetamine psychosis - causes release of norepinephrine/dopamine

    • Newer assumptions: excess/oversensitive dopamine receptors over high level of dopamine play a role

      • Excessive stimulation of striatal dopamine receptors

      • Prefrontal dopamine receptor deficiency 

    • Prefrontal activity from glutamate transmission

• Biological explanations: Brain Structure

  • Brain scans show abnormalities in physical structures and brain functioning 

  • Enlarged ventricles found in majority 

  • Frontal lobe abnormalities - hypofrontality 

  • Abnormal functioning/lose of brain tissue in prefrontal cortex

  • Abnormalities in brain circuitry - connects to prefrontal cortex/lower brain structures 

  • Causes: genetics, poor nutrition, fetal development, immune reactions etc. 

• Social-cultural explanations

  • Stress: lead to predisposition

  • Social economical status: increases rates; found in central city areas inhibited in lowest SES

    • Socio-genic hypothesis - stress associated with low social class

    • Social-selection theory - reverses casualty direction between social class and schizo

  • Family functioning: some high in expressed emotion (EE), increasing relapse risk

• Treatment of schizophrenia

  • APA multi-point treatment course

    • Antipsychotic medication controls acute psychotic symptoms

    • Treatment of comorbid disorders include substance abuse and depressive disorders

    • Use of psychosocial treatment

• Biological treatments - drug therapies: First Gen - typical

  • helps control flagrant patterns (keeps positive symptoms from coming back)

  • Blocks dopamine receptors

  • Antipsychotics: phenothiazines, chlorpromazine, thioridazine, trifluoperazine, fluphenazine

  • Side effects: dizziness, blurred vision, restlessness

  • Extrapyramidal side effects: nerve tracts dysfunctions descend from brain to spinal motor neurons 

    • Tremors of fingers

    • Drooling

    • Dystonia: muscular rigidity

    • Dyskinesia: abnormal motion of voluntary/involuntary muscles 

    • Akathisia: inability to remain still

    • Akinesia: expressionless face, slow motor activity 

  • Tardive dyskinesia

    • Mouth muscles involuntarily make sucking, lip-smacking, chin-wagging motions

    • Whole body can have involuntary motor movements 

    • Affects 20-50% patients using antipsychotics for long period/not responsive 

• Biological treatments - drug therapies: Second Gen - atypical

  • Largely replace earlier gen

  • Advantage: carries less neurological side effects/lower risk of Tardive dyskinesia

  • Positive and negative symptoms 

  • Includes: clozapine, risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole

• Impact of Schizophrenia on Life

  • delusions/hallucinations cause distress

  • Cognitive impairment and avolition makes employment hard

  • Strange behaviour and social skills can cause loss of friends 

  • High substance abuse rates 

  • Suicide rate is high

  • Homelessness

  • Stigmatization

Personality Disorders-week 11

• Personality: unique expressed characteristics influencing behaviour, emotion, thought, and interpretation

• Personality disorders: persistent patterns of emotions, cognitions, and behaviour resulting in emotional distress

  • Overly rigid/maladaptive behaviours reflecting variations of personality traits; undue suspiciousness, excessive emotionality, impulsivity

  • Seen in adolescence or early adulthood

  • Warning signs in childhood

    • Ego syntonic: feelings perceived as natural/compatible - most PDs!!!

    • Ego dystonic: feelings perceived foreign to self-identity

• Categories or dimensions?

  • Categorical

1. Problematic personality are present or absent 

2. Personality disorder either displayed or not displayed

3. Person suffering from PD is not troubled by personality traits outside disorder

   1. Issues distinguishing PD from other clinical symptoms

   2. Overlapping disorders 

   3. Difficulty distinguishing between normal and abnormal behaviour

   4. Labels confused with explanations 

• Advantages of dimensional model

  • Some differ from degree than kind

  • Advantages:

    • Retains more info

    • More flexible due to categorical/dimensional differentiation

    • Avoids arbitrary decision assigning a person to a category 

  • Model considered focuses on continuum of: self (how a person views themself) and interpersonal functioning (intimacy abilities)

  • Some suggest Big 5 model

• Clusters of personality disorders 

  • Cluster A: characterized by odd behaviour (ie. paranoid, schizoid, schizotypal)

  • Cluster B: characterized by dramatic, emotional, and erratic behaviour (ie. anti-social, borderline, histrionic, narcissistic)

  • Cluster C: characterized by anxious behaviour (ie. avoidant, dependent, obsessive-compulsive)

• Cluster A: Paranoid Personality Disorder (PPD)

  • Characteristics: suspicious, expectation of mistreatment, won’t confide in others, tendency to blame others, extreme jealousy

  • Differential diagnosis and comorbidity: hallucinations/full-blown delusions, less impairment in social/occupational functioning, comorbid with schizotypal, avoidant, BPD

  • Etiology and treatment

    • Genetics, childhood trauma, schemas, cultural

    • Cognitive therapy 

• Cluster A: Schizoid Personality Disorder

  • Characteristics: no desire for social relationships, appear dull/bland, rarely show emotions, no interest in sex, experience less activities they like, indifferent to praise/criticism, loners 

  • Prevalence and comorbidity:

    •  prevalence <1%

    • comorbid with schizotypal, avoidant, paranoid disorders

  • Etiology and treatment 

    • Childhood shyness, abuse, neglect etc.

    • Social skills training

• Cluster A: Schizotypal Personality Disorder

  • Characteristics: similar interpersonal difficulties, eccentric thinking

  • Prevalence and comorbidity:

    • Prevalence <1%

    • Comorbidity higher than other disorders

    • Comorbid with borderline, avoidant, paranoid disorders

  • Etiology and treatment

    • Genetics, left hemisphere damage

    • Antipsychotic, medication CBT

• Cluster B: BPD

  • Characteristics: impulsive/instability, feelings towards other vary/swing, erratic, argumentative and sarcastic, cannot tolerate being alone

  • Prevalence and comorbidity: 

    • Prevalence 1-2%; 20-25% of psychiatric admissions

    • More common in women

    • Comorbid with mood disorder, substance abuse, PTSD etc.

  • Etiology and treatment:

    • Genetics, related to mood disorders, early trauma

    • Antipsychotic and antidepressants, dialectical behavioural therapy

  • Self-mutilation

    • Engage in impulsive acts like cutting oneself to escape deep/emotional pain

    • Expression of anger

    • Intended to counteract feelings of numbness

• Cluster B: Histrionic Personality Disorder

  • Characteristics: overly dramatic/attention-seeking, used physical appearance for attention, emotion displayed extravagantly, self-centered, overly concerned with attractiveness

  • Prevalence and comorbidity

    • Prevalence <1%

    • Common in women

    • Comorbid with depression and BPD

  • Etiology and treatment

    • Sociocultural: co-occurs with antisocial personality disorder

    • Improve problematic interpersonal relationships

• Cluster B: Narcissistic Personality Disorder

  • Characteristics: grand view of own abilities, preoccupied with fantasies of great success, requires constant attention/admiration, lacks empathy, envious of others, and arrogant/entitled 

  • Prevalence and comorbidity:

    • Prevalence 1%

    • Comorbid with BPD

  • Etiology and treatment:

    • Failure of empathy

    • Coping strategies, CBT

• Cluster B: Antisocial Personality Disorder 

  • Two main components

1. Conduct disorder before age of 15

2. Pattern of antisocial behaviour continuity into adulthood

• Characteristics: violation of social norms, lack of long-term goals, impulsive, violent, lacks empathy

• Prevalence and comorbidity

  • Prevalence 1.7-3.7%; 50% in prison

  • More common in men

  • Comorbid with substance abuse

• Etiology and treatment

  • Gene-environment, under-arousal of cortex

  • Multifaceted, CBT, preventing best approach

• Psychopathy

  • Related to APD but emphasizes thoughts/feelings

    • Lacks remorse, charming, manipulative, thrill seeking; impulsive, arrogant, deficient, early onset

    • Many psychopaths can have APD but many with don’t meet criteria 

• Criminality

  • Tend to think APD as synonymous with criminals

  • Not all criminals have antisocial disorders/not all with it become criminals

  • Many are law abiding 

  • Some criminals do not meet the criteria

• Cluster C: Avoidant Personality Disorder

  • Characteristics: fear of social situations, sensitive to criticism/rejection, reluctant to enter relationship

  • Prevalence and comorbidity

    • Prevalence 1%

    • Comorbid with dependent personality disorder, depression, generalized social phobia

  • Etiology and treatment

    • Integrated biological/psychosocial influences

      • Born with difficult temperament, rejection etc.

      • Links to social anxiety 

    • CBT, systematic desensitization, anxiety meds

• Cluster C: Dependent Personality Disorder

  • Characteristics: lacks self-reliance, overly dependent, intense care needs, uncomfortable alone

  • Prevalence and comorbidity:

    • Comorbid with bipolar disorder, depression, anxiety, bulimia

  • Etiology and treatment:

    • Genetic; disruptions in early childhood

    • Develop confidence

• Cluster C: OCPD

  • Characteristics: perfectionist, preoccupied with details/rules etc., serious and rigid, can’t discard useless items

  • Differential diagnosis

    • Obsessive compulsive personality disorder (OCPD) differs from OCD

  • Prevalence and comorbidity:

    • Prevalence 2% of population

    • Comorbid with OCD (20%), panic disorder, depression, GAD, avoidant personality disorder

  • Etiology and treatment

    • Genetics

    • Relaxation techniques; CBT

Sexual Dysfunctions and Paraphilic Disorders-week 12

• Sexual dysfunctions

  • Persistent problems with sexual interest, arousal, or response

  • Affects 40-45% of adult women

  • Affects 20-30% of adult men

  • Lifetime disorder vs acquired disorder

  • Situational disorder vs generalized disorder

• Categories of sexual dysfunctions

  • Sexual desire disorders

    • Male hypoactive

      • Absent sexual urges

      • Little-no interest 

      • 20-30% general adult pop.

    • Female sexual interest/arousal 

      • Low sex drive to become aroused

      • 20% prevalence 

      • In both desire and arousal phases 

  • Sexual arousal disorders

    • Male erectile disorder

      • Problems becoming aroused

      • Have sexual urges

      • 7-70% prevalence

      • Age dependent - common in aging populations

  • Orgasmic disorders

    • Female disorder

      • Absence of orgasm after normal sexual excitement 

      • 16-46% prevalence

      • 10% women never experience an orgasm

    • Male disorder

      • Delayed ejaculation: infrequency, 2-8% prevalence

      • Premature ejaculation: recurrent pattern with minimal sex drive, affects 40% of men 

  • Sexual pain disorders

    • Genito-pelvic pain/penetration disorder

      • Vaginismus: involuntary spasm of outer third of vagina that makes sex harder, normal arousal possible with oral/manual stimulation

      • Dyspareunia (genito-pelvic pain): recurrent pain during sex, associated with low sexual desire 

  • Assessing sexual behaviour

    • Interviews

      • Talking to clinician about issues

      • Can include questionnaire

    • Medical exam

      • Helps rule out medical cause

    • Psychophysiological

      • Assesses ability to become aroused

      • Ie. penile strain gauge, vaginal photoplethysmography (VPG)

• Biological explanations

  • Hormone imbalances

    • Deficient testosterone/estrogen production and over/underactivity of thyroid 

  • Medical conditions 

    • Temporal physical conditions, nerve damage, diabetes, lung disorder etc.

  • Medications 

    • Antihypertensive meds, antiandrogens, antidepressants, anti anxiety meds

    • Illicit drugs 

• Psychological explanations

  • Cognitive interference 

    • Irrational beliefs and attitudes

    • Performance anxiety: excessive concern about performance abilities

  • Mental health

    • Depression, anxiety, stress

    • Poor body image

    • Traumatic sexual experiences 

  • Communication and relationship issues

    • marital/relationship issues

    • Resentments and conflicts 

• Sociocultural explanations

  • Sexual scripts theory

    • Guidelines for appropriate behaviours

    • Gendered

      • Men expected to be enthusiastic more so than women

      • Stereotypes that sexual pleasure is mostly for men

  • Sociocultural beliefs ie. religion

  • Sexual taboos ie. paraphilia 

  • Early traumatic sexual events 

  • Current life/relationship difficulties

• Psychosocial treatments

  • Human sexual inadequacy

  • Anxiety reduction

  • Directed masturbation

  • Change attitudes

  • Skill and communication training 

  • Couples therapy

• Sexual dysfunction treatments

  • Medication: testosterone gel patch, sildenafil (viagra), birth control, vasodilator injection, SSRIs

  • Physical: treat underlying physical issues (ie. STI, UTI)

  • Surgery: penile prosthesis/vacuum devices, vaginal dilators, unblocking of blood vessels 

• Paraphilic disorders

  • Para: deviance; philia: attraction = bad attraction

  • Conditions involving sexual attraction to atypical objects/unusual sexual behaviours 

    • Involve urges, preferred way of seeking gratification

    • At least 6 months

    • Must cause significant distress or behaviour places person/others at harm

      • Paraphilia vs paraphilic disorder 

  • 4 distinguishing features

1. uncommon /atypical from statistical and sociocultural perspectives 

2. Intense interest in sexual activities that do not involve mature, consenting, or human partners 

3. Recurrent and persistent for 6 months

4. Sexual activity is persons preferred/primary way of obtaining gratification

• More common in men 3-5% than woman 1-6%

• High comorbidity 

• Some referred to as Courtship Disorders (ie. Voyeurism, Exhibitionism, and Frotteurism)

• Paraphilic disorders in DSM-5

  • Sexual sadism

    • Inflicting pain/humiliation

    • Practiced with parties (BDSM)

    • Coercive paraphilic disorder 

  • Sexual masochism

    • Arousal from experiencing pain/humiliation

    • Common in women

    • Infibulation: harming one’s body for sexual pleasure

  • Transvestism

    • Arousal from cross-dressing

    • Must be for sexual pleasure 

  • Fetishism

    • Excitement in response to non-sexual object

    • May include body parts (feet), objects (shoes), body features (tattoos), materials (latex), costumes (furries), or stimulation

  • Exhibitionism 

    • Arousal from exposing self/performing sexual acts for those not consenting

      • Flasher vs stripper

  • Voyeurism

    • Arousal from non-consenting watching of others naked/engaed in sexual acts 

      • Peeping Tom vs. porn

    • Most common

  • Frotteurism

    • Arousal from rubbing/touching one’s private parts against those not consenting

    • Common within males 

  • Pedophilia 

    • Attraction to prepubescent children 

      • physical/emotional

      • Pedophilia vs hebephilai (no longer in DSM)

    • Not an act but a deviant sexual orientation

    • Not everyone who offends a child is a pedo

      • Pedophiles vs child molesters 

    • Many never act on attraction

      • High suicide rates

• Other paraphilic disorders

  • Somnophilia: sexual urge to have sex with someone who is sleeping

  • Necrophilia: sexual urge to have sex with a dead body

  • Zoophilia: sexual attraction to animals (bestiality)

  • Telephone scatologia: sexual urge to make obscene phone calls 

  • Urophilia: sexual excitement of urine

  • Coprophilia: sexual excitement from feces 

• Causes of paraphilic disorders

  • behaviour/cognitive perspectives 

    • Multifactorial causes: childhood sexual abuse, disturbed family, insecure attachments

    • Inadequate social skills

    • Early sexual experiences 

    • Learning theories: classical/operant conditioning; modeling

  • biological/neurological perspectives

    • Possible role of Androgen (male hormone-principle)

    • High sex drive - hypersexual

    • Hormonal disturbances in fetal development 

    • Altered brain activity within frontal/temporal areas

• Diagnosing paraphilic disorders 

  • DSM-5 differentiates harmless and harm

    • DSM-4 paraphilia vs DSM-5 paraphilic disorder

  • Two prong assessment 

    • For paraphilia

      • Self-report, indirect measures, physiological measures, vaginal photoplethysmography 

    • distress/non-consenting 

• Paraphilia treatments

  • Medication

    • Antiandrogens

    • SSRIs

  • Psychosocial 

    • Focus on changing thoughts/behaviours

    • Specific techniques to eliminate these behaviours 

      • Aversion therapy

      • Masturbatory station

      • Orgasmic reorientation

      • Relapse prevention 

      • CBT

    • Stigma can affect those to ask for help

      • CAMH talking for change 

Gender Dysphoria-week 12

• Gender identity: ones psychological sense of gender 

• Gender dysphoria: psychological disorder where people experience personal distress between their assigned birth sex and gender identity 

• Transgender identity: whose gender identity/expression differs from assigned birth sex, due to social/cultural expectations 

  • Not the same as transvestic disorder

• Client patterns of gender

  • Cisgender: people who identify with assigned birth gender 

  • Female-to-male GD (trans male): assigned as female at birth but identify as male

  • Male-to-female GD (trans female): assigned male at birth but identify as female 

• Possible explanation of gender dysphoria 

  • Biological

    • Genetic: runs in families, concordance found in identical twins

    • Hormonal: testosterone and estrogen at critical periods of fetal development can genderize the fetus

    • Structural: brain regions help with human sexuality and consciousness- blood flow and size

  • Psychological

  • Cultural

• Treatment options 

  • Supports trans individuals who choose hormonally/surgically changes to body shell and matches internal identity 

  • Hormone treatments

    • Might involve puberty/hormone blockers

    • Assigned male at birth-given estrogen

    • Assigned female at birth-given testosterone

  • Facial/speech surgery

  • Gender confirming surgery/affirming surgery/sexual reassignment surgery

    • Male-assigned: partial penis removal; structure into clitoris and vagina

    • Female- assigned” chest masculinization and hysterectomy; silicone prosthetic penis; phalloplasty