abnormal quiz 4 Flashcards
(107 cards)
1
Q
What is a transdiagnostic construct?
A
• Disorders share many core features
• Transdiagnostic processes or constructs:
a. Feature across several disorders
b. Represent a causal mechanism across several disorder
2
Q
Death anxiety
A
• Central part of the human condition
• ‘the worm at the core’ of our existence
• We are the only species to understand our own mortality
• Throughout recorded history
- Religion, ritual, myth
- literature, art and theatre
- Philosophy
- Psychology
3
Q
Death anxiety: absence of theory
A
• Becker (1973)
- Motivation to live + inevitability of death = crippling fear
- Cultural theory
• Death anxiety: absence of clinical theory
4
Q
Terror management theory
A
• TMT: two buffers against death anxiety
1. Cultural worldviews - Gain virtual immortality by buying into beliefs 2. Self-esteem - Gain meaning by fulfilling expectations of cultural worldview
5
Q
death anxiety - transdiagnostic
A
• Death anxiety might be a transdiagnostic construct
- Might underpin a number of disorders: anxiety disorders, OCD, eating disorders, PTSD, depression etc.
• Revolving door of mental health
- Separation anxiety disorder > panic disorder > OCD
6
Q
Panic disorder - death anxiety
A
• Fears of death argued to play a central role
• “I am having a heart attack”, “I am going to die”
• Panic disorder patients reported significantly higher death fears than social phobia patients and controls
- Those with comorbid disorders also reported high levels of death anxiety than individuals who only met criteria for 1 disorder
7
Q
Somatic symptoms disorder, illness, anxiety and hypochondriasis - death anxiety
A
• Death anxiety argued to be a central feature
• Worrying about physical health – particular physical symptoms being experienced, think this means you are unwell
• May repeatedly consult GP’s and specialists, check body (e.g. blood pressure, bruises, pulse, stools) for symptoms, or seek reassurance from others
• “is this a headache or a brain tumour?”
• Hypochondriasis patient’s vs matched medical and non-hypochondriacal psychiatric patients
• Those with hypochondriasis:
- Attended more closely to bodily sensations
- Were more likely of distrust doctor’s judgements
- Reported more fears of
death and disease
8
Q
Agoraphobia and separation anxiety - death anxiety
A
• Many symptoms are associated with death fears
- Fears of harm when leaving home
- Increased focus on internal sensations (e.g. change in heart rate, dizziness)
- Hypochondriacal concerns
- Frequent catastrophic death-related fears
• “I can’t go out – I could be attacked”
• Onset of agoraphobia is often preceded by traumatic events (e.g. loss of a loved one or physical threat)
• Fear of death and separation anxiety are positively correlated among individuals with agoraphobia
- Suggests that fear of separation from loved ones may increase as death anxiety increases
• Increased death anxiety and separation anxiety among individuals with BPD and schizophrenia, compared to controls
- Suggest separation anxiety may mask death anxiety
9
Q
Specific phobias - death anxiety
A
• Freud argued that fears of death underlie phobias
• Heights, snakes, spiders, water, flying – most common fears, they have potential to be fatal
• Phobias may occur when death anxiety focuses on smaller, more manageable threats
• Strachan tested whether mortality saliences could increase phobic behaviours
- 32 students who met criteria for specific phobia of spiders, 30 non-phobic
- Primed with death or control
- For those with spider phobia, reminders of death (MS):
o Increased avoidance of spider-related stimuli
o Increased perceived threat (i.e. “how likely is it that the spider in the first picture is dangerous to humans?”)
10
Q
PTSD - death anxiety
A
• DSM-5: the person was exposed to: death, threatened death, actual or threatened serious injury or actual threatened sexual violence
• Death anxiety argued to play a role in development and maintenance
- I can’t leave the house at night – I could be attacked again’
• Suggest severe PTSD is characterised by impaired suppression of death thoughts
- Anxiety-buffering defences are disrupted in PTSD
11
Q
Depressive disorders: TMT
A
• MS study with mildly depressed individuals
- Following priming, being given opportunity for worldview defence was associated with increased belief that life is meaningful
• Bolstering worldview beliefs may increase meaning among depressed individuals
- Consistent with idea depression is associated with weaker buffers against death anxiety
12
Q
Eating disorders - death anxiety
A
• Women diagnosed with anorexia show significantly higher death anxiety than controls
• Goldenberg found reminders of death led women (but not men) to:
- Perceive themselves as further from their ideal thinness
- Eat 40% less in a ‘taste-testing’ task than controls
• Death anxiety may be driving women to strive for thinness promoted by their cultural worldviews
13
Q
Social anxiety disorder - death anxiety
A
• Social exclusion meant literal death
• Strachan used MS with student’s high vs low in social anxiety
1. Primed with MS or . control
2. Allowed to decide when to join a group discussion (social avoidance)
• Reflecting on own death led socially anxious participants to wait longer before joining a group discussion
- Death priming produced significantly more social avoidance among socially anxious participants
14
Q
OCD - death anxiety
A
- Thoughts of death can worsen OCD symptoms (e.g. hand washing)
- Double time spent washing
15
Q
panic disorder - death anxiety
A
- Among panic disorder, illness anxiety, and somatic symptom disorder, thoughts of death can worsen symptoms
o Body checking
o Threat perception
o Reassurance seeking from GP
16
Q
Implications - death anxiety
A
- Results of recent research suggest we may need to rethink treatment of these conditions
- What do treatments for anxiety look like?
- All of these treatments produce great pre- post- measures
- But we often assume success from a single measure of a single disorder
- Is the problem that treatment studies are measuring the thing we’re targeting in the treatment, not necessarily the core problem?
- Increased functionality, but are these contributing to the ‘revolving door’ of mental health?
17
Q
Treating death anxiety
A
• CBT produced largest improvements in death anxiety
- Exposure therapy
o Get people to write their tombstone, write a eulogy
18
Q
Anger
A
- Anger (17%) was the most frequently reported negative emotion, well ahead of sadness (12%) and fear (2%)
- 8% of the normal population reported that anger had been a problem for them for 6 months or more
19
Q
The damage - anger
A
- Critical mediator in various forms of aggression, from domestic violence through to assault, murder and rape
- Consistently identified as a risk factor in hypertension and heart-related illness
- Anger interferes with judgement, problem-solving, negotiating; leads to risky behaviours
- It’s been estimated that as much as 1/3 of crashes and 2/3 o traffic related deaths are attributable to angry-aggressive driving
- Anger impacts adversely on relationships
20
Q
Neuroticism partner effect
A
- Neuroticism partner effect: the neurotic your partner is the higher they are in negative emotions, the less satisfied you are with the relationship.
21
Q
Anger and the DSM-5
A
- Anger in the DSM-5 is both everywhere and nowhere
- It travels across the full gamut of psychopathology, but has no real ‘home’ – there’s no (adult) anger disorder proper, much less an anger disorders section
22
Q
Intermittent explosive disorder (IED)
A
• The disorder most commonly diagnosed to people presenting with anger issues – even without aggression)
A. Recurrent behavioural outbursts representing a failure to control aggressive impulses as manifested by either:
1. Verbal outbursts, or physical aggression that does not result in damage or injury, twice weekly (on average) for at least 3 months
2. Behavioural outbursts that do result in damage and/or injury, three times in 12 months
B. The aggression s disproportionate to the provocation
C. The outbursts are not premediated (i.e. they are impulsive and/or anger-based) and are not committed to achieve some tangible objective (e.g. money, power, intimidation)
D. These outbursts cause distress and/or impairment
E. The individual must be at least 6 years old
F. The outburst are not better explained by another mental disorder or medical condition (e.g. Head trauma or Alzheimer’s)
• This is an aggression disorder, not an anger disorder
23
Q
Overemphasis on ‘impulse control’
A
- DSM appears to be suggesting that the aggression in IED is caused by a general impulse-control problem
- DSM-5 themselves concede: “IED appears to be quite common regardless of the presence or absence of ADHD or disruptive, impulse-control, and conduct disorders”
- They fail to account for the fact that most IED’s refrain from outbursts with policemen, their bosses, etc.
- IED thus fails to capture the method in the madness…
24
Q
Oppositional defiant disorder (ODD)
A
• A pattern of angry/irritable mood, argumentative/defiant behaviour, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms from any of the following categories and exhibited during interaction with at least one individual who is not a sibling.
• Angry/irritable mood
1. Often loses temper
2. Is often touchy or easily annoyed
3. Is often angry or resentful
4. Often argues with authority figures
5. Often actively defies or refuses to comply with requests from authority figures or with rules
6. Often deliberately annoys others
7. Often blames others for his or her mistakes or mis-behaviour Vindictiveness
8. Has been spiteful or vindictive at least twice within the past 6 months.
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Disruptive mood dysregulation disorder (DMDD)
a. Severe recurrent temper outbursts that are grossly out of proportion to the situation or provocation
b. They are inconsistent with developmental level
c. They occur on average 3 or more times weekly
d. The mood between outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others (e.g. parents, teachers, peers)
• Terminology aside, so far so good! …Oh, but wait:
• Criteria G and H: The Dx should not be made for the first time after 18, and the age of onset must be before 10
• Explicit directive of the DSM was not to create an anger disorder, but to prevent children being diagnosed as Bipolar.
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Why is anger so neglected?
* Because the angry themselves often resist therapy, and clinicians are unwilling to treat it: supply matches demand
* Anger is often conceptualised as part of a conflict involving multiple parties, not an individual problem
* Hx of overly behavioural theories (which edit out the emotional component) and an emphasis on aggression generally because of its more obvious impact
* Hx of overly Freudian theories (which relate anger to the status of rationalisation or secondary symptom)
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Anger fallacies abound…
fallacies:
- Venting is useful (pillow techniques)
- Low self-esteem is the culprit (treated as depression)
- Anger is biological, physical, genetic
- Anger is a social skills problem (assertiveness etc.)
- Anger is an impulsive problem (self-instructional training)
- Anger is classically conditioned (repeated exposure to barbs
28
Personality disorders: core features
1. Functional inflexibility
- Failure to adapt to situations: rigid response
2. Self-defeating
- Behavioural responses damaging
3. Unstable in response to stress
- Emotional, behavioural and cognitive instability
• Lack of insight: failure to recognize dysfunctional aspect of personality
- Lack of reflective capacity, will blame others for their impairments in functioning
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Borderline personality disorder
people constantly test relationships, want attention and to establish that the person loves them. They continue to push the other person until the other person can’t take it anymore
30
DSM-5 personality disorder (summary)
• A personality disorder is an enduring pattern of inner experience and behaviour that:
- Deviates markedly from the expectations of the individual’s culture
- Is pervasive and inflexible
- Has an onset in adolescence or early childhood
- Is stable over time
- Leads to distress or impairment
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DSM-5 general personality disorder
• To diagnose a personality disorder, the following criteria must be met:
- Significant impairments in self (identity or self- direction) and interpersonal (empathy or intimacy) functioning
- One or more pathological personality trait domains/facets
• In addition, these features must be:
- Relatively stable across time and consistent across situations
- Not better understood as normative for the individual’s developmental stage or socio-cultural environment
- Not solely due to the direct psychological effects of a substance (e.g. drug of abuse, medication) or a general medical condition (e.g. severe head trauma).
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clusters personality disorder
- Cluster A: auto-eccentric traits
- Cluster B: dramatic and emotional traits
- Cluster C: anxious and fearful
• Not just these ten types of traits, multiple clusters show
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categorical approach to PD
• DSM-5 represents a categorical approach of personality disorders (PD’s)
- More compatible with disease classification systems used in medicine
- Assumes that PD’s represent distinct clinical syndromes
• Advantages: clarity and ease of communicating information
• Disadvantages: difficult to distinguish the threshold where the person goes from what’s considered ‘normal’ personality traits through to meeting criteria for a personality disorder
34
DSM-IV: a multi-axial system - personality disorders
• Axis 1: major clinical disorders with acute systems that need treatment
• Axis 2: personality disorders (and intellectual disabilities)
- Early age of onset
- Enduring and more pervasive effects on daily functioning
- Involvement of self and identity
- Presumed poorer self-awareness
- Lower treatment response
• BUT high degree of co-occurrence of symptoms
• Heterogeneity within diagnoses
• Diagnostic unreliability
• Lack of robust scientific evidence
DSM-5: a single axial model
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Cluster A- odd and eccentric
- Paranoid
- Schizoid
- Schizotypal
• High levels of introversion
• People isolate themselves, are suspicious of others
• Traces back to childhood
• See people as malicious and deceptive – take advantage of people
• Not disclose personal information as they think it will be used against them
• Negative perception of what people will do – always expect the worst
• Can’t take compliments
as everything is taken negatively
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Paranoid PD
• Consistent and pervasive pattern of distrust, sus piousness and prolonged grudges held:
- Believes others intentionally exploit, harm or deceive them
- Reluctance to disclose personal information for fear it may be used against them
- Severely sensitive to criticism and threat > hypervigilant for signs of others to harm them
- Misinterprets comments to individuate concealed hidden or malevolent intent or motivation
- Hostility, aggression and anger to perceived insults
- Jealousy (distrust and misinterpretation)
• 2/3 meet criteria for other PD’s
- E.g. schizotypal, narcissistic borderline and avoidant
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Schizoid personality disorder
• Very detached, aloof
• Cannot connect with people with this disorder
• Emotions are threatening and confronting
• Not distressed by being isolated
• Detachment and disinterest in social relationships
- Withdrawal into internal world to avoid affect and maintain distance from others
• Sees others as intrusive and controlling
• Flatness of affect: coldness, aloofness, self-absorption, social ineptitude or conceit
• Unresponsive to social criticism: sexually apathetic reflecting incapacity to form interpersonal bonds
• Anhedonia
• Comorbid with schizotypal and avoidant PD’s
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Schizotypal personality disorder (prevalence 3.9-4.6%)
• Bizarre and eccentric
• Marked interpersonal deficits, behavioural eccentricities and distortions in perception and thinking (that do not meet criteria for schizophrenia_
- E.g. magical thinking, extreme superstition, belief in paranormal phenomenon
• Odd thoughts and speech patterns: vague, abstract but retains coherence
• Often seek treatment for anxiety, depression and effective dysphoria (constricted or inappropriate affect)
• Comorbid with borderline, avoidant, paranoid and schizoid PD’s
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Cluster c – avoidant personality disorder
* Low self-esteem
* Believe they are inferior
* Anticipate rejection from others
* Core beliefs: I am not good, un-loveable, worthless
* Don’t like company due to this
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Avoidant PD
* Pervasive social inhibition; avoidance of activities involving personal contact and groups
* Intense feelings of inadequacy, low self-esteem and self-loathing
* Underlying assumptions: “ I am no good, un-loveable” “if people get to know me they will reject me”
* Socially inept/incompetent, personally unappealing, inferior to others
* Hypersensitivity to criticism, disapproval, shame and ridicule > fear of rejection so strong that they rarely form any relationships
* Self-imposed isolation
* Comorbid with dependent PD and mood, anxiety and eating disorders
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Cluster C – dependent personality disorder
* Constantly need approval of others
* Don’t say no
* Pervasive need to be taken care of
* Exaggerated fear of being incapable of doing things or taking care of things on their own – reliance on others
* Lacking self-confidence and requiring constant reassurance
* Often find themselves exploited and in abusive relationships, fearing abandonment
* Self-views: needy, weak, helpless and incompetent
* View of others: strong caretaker idealised. Function well as long as he idealised figure accessible
* Threats: rejection or abonnement
* Strategy: cultivate a dependent relationship by subordinating
* Affect: anxiety heightened – disruption to the relationship. Depression if their strong figure is removed, euphoria/gratification when dependent wishes granted
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Cluster C – obsessive-compulsive disorder (OCD)
* 70% of western society show these features
* Pervasive patterns of perfectionism and orderliness
* Ridgely, inflexibility and stubbornness
* Excessive need for control interfering with ability to maintain interpersonal relationships or employment
* Preoccupied with rules, minor details, structure
* Attention to detail interferes with ability to complete tasks all together or on time
* Unrealistic standards of mortality, ethics or values
* Reluctance to delegate tasks
* Comorbid: borderline, narcissistic, histrionic, paranoid, schizotypal PD’s
* Self-view: responsible for themselves and others, driven by ‘should’
* View of others: too casual, irresponsible, self-indulgent and incompetent
* Threats: any flaws, errors, disorganisation. Catastrophic thinking: ‘things will be out of control’
* Strategy: system of rules, standards and ‘should’. Overly directing, punishing and disapproving
* Affect: regrets, disappointment, and anger toward self and others because of perfectionistic standards
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Cluster B – histrionic personality disorder
* Excessive emotionality, attention-seeking, ego-centric, flirtatious, seductiveness (focus on grooming)
* Denial of anger and hostility
* Gregarious, manipulative, low frustration tolerance, suggestibility, somatization
* Displays of emotions: shallow and fickle in interpersonal relationships
* Comorbid: narcissistic, borderline, anti-social PD’s and psychoactive substance abuse
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Histrionic PD mode model
* punitive parent 'you are not loveable' leads to vulnerable child feeling unloved, which leads to attention seeking behaviours
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Cluster B – borderline personality disorder
• Emotional instability/affective dysregulation in reaction to environmental and interpersonal situations
- Wide range of extreme emotions, intense anxiety, anger, dissociation
• Impulse control
- Promiscuity, self-harm, spending, binge eating, poor limit setting, suicidal behaviour (10% suicide)
• Identity/insecure attachments
- Unstable self-concept, frantic efforts to avoid real or imagined relationships
- Inability to integrate positive and negative aspects of self-leading to a sense of emptiness
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Cluster B: borderline PD mode model
* punitive parent 'devalues the patient, invalidates their emotions', leads to abandoned child or angry/impulsive child, with then leads to detached behaviours
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Cluster B: anti-social PD
• Repeated reckless disregard for others
• Victimising and blaming others for inadequacies
• Shallow and manipulative interpersonal relationships
• Self-centred focus and failure to adhere to regulations
• Impulsive, aggressive, charismatic, deceitful
• Experience guilt and depression but lack capacity to empathize
• Antisocial behaviour: criminal behaviours may or may not be present
• Co-morbidity with borderline, narcissistic, histrionic and schizotypal PD’s
• Rational assumption: people act in a rational manner guided by logic, rules and social convention/norms
• So why does a subgroup of individuals engage n repeated behaviours that are:
- Carried out with scant regard for consequences
- Reflect an inability to delay gratification
- Apparently self-defeating (cause harm to themselves or to others)
- Irrational in that aversive outcomes outweigh reward.
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Cluster B: narcissistic personality disorder
* Personalities organised around maintenance of self-esteem by eliciting external admiration to compensate for internal sense of falseness
* Fragile self-esteem, envy, self-consciousness and vulnerability: “image replaces substance”
* Compensatory reaction: self-righteousness, pride, contempt, vanity and superiority
* Pervasive pattern of grandiosity, sense of entitlement, privilege or expectation of preferential treatment, exaggerated sense of self-important, arrogant behaviour and attitudes
* Focus on own issues with insensitivity ir impatience to problem of others: cold, disinterested, snobbish, patronizing
* Comorbid with: anti-social, histrionic, borderline PD’s and substance abuse
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narcissistic mode model
* demanding parent 'high standards for success', leads to vulnerable or enraged child, leads to self-aggrandizer
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stigma PD
* Problematic behaviours are considered maladaptive – behaviour that once served as adaptive function but is no longer adaptive
* Behaviours that are commonly labelled using stigmatizing language: ‘acting out’/ ‘manipulative’ / ‘self-destructive’ are described using non-judgemental, descriptive language that recognize unmet emotional needs
* Be careful about using judgemental language
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Complex trauma - PD
```
• ‘small t’ complex trauma
- Repeated, cumulative experiences in childhood of a mis-attuned environment
- Most commonly with replayed throughout the attachment relationship
• Ongoing psychological effects can include:
- Anxiety and depression
- Cognitive distortions
- PSTD
- Dissociation
- identity disturbance
- Affect dysregulation
- Interpersonal problems
- Substance abuse
- Self-mutilation
- Binging and purging
- Unsafe or dysfunctional sexual behaviour
- Somatization
- Aggression
- Suicidality
- Dysfunctional personality traits
```
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Development of the self - PD
• Infant unable to simultaneously hold incongruent pieces of information
- Disrupt formation of self
• Attachment: role of caregivers is essential for emotional regulation
- Parents co-regulate child’s distress
• Child then learns to self sooth
• If child doesn’t learn to self sooth they are left to deal with trauma
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The transactional model of borderline PD
• Emotional dysregulation < > invalidating response style
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PD’s: aetiology
* Repeated trauma in childhoods and deforms the personality. The child trapped in an abusive environment is faced with formidable tasks of adaption. They must find a way to preserve a sense of trust in people who are untrustworthy, safety in a situation that is unsafe, control in a situation that is terrifyingly unpredictable, power in a situation of helplessness
* Unable to care for or protect themselves, they must compensate for the failures of adult care and protection with the only means at their disposable, an immature system of psychological defences
55
Heightened emotional arousal - PD
1. Sensitivity: more likely to notice emotional stimuli at a lower threshold
2. Reactivity: have a stronger emotional reaction
3. Slow return to baseline: take longer to return to baseline
• Metaphor of racing car: very sensitive accelerator, even the slightest touch makes the car rev, the engine is very powerful
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Treatment of personality disorders (BDP)
• Level 1: a meta-analysis or a systematic review of level 2 studies that included a quantitative analysis
• Level 2: a study of test accuracy with: an independent, blinded comparison with a valid reference standard, among consecutive persons with a defined clinical presentation
• Level 1 evidence:
- Dialectical behaviour therapy (DBT)
- Schema therapy
- Psychodynamic psychotherapy
• Level 2 evidence:
- Acceptance and commitment therapy (ACT)
- Cognitive behavioural therapy (CBT)
- Interpersonal therapy
- Psychoeducation
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Dialectical behaviour therapy (DBT)
• Developed for borderline PD in 1993
• 12 month program
• CBT-based intervention for chronically suicidal behaviours
• ‘a synthesis of acceptance and change strategies, as well as practical and theoretically sophisticated strategies, and specific structures that address the therapist’s own need for support’
• Dialectic – a synthesis or integration of opposites/contradictions
- The central dialectic of DBT: acceptance AND change e.g. you’re doing your best, but you need to try harder
• Behavioural reinforcement – using rewards to increase the likelihood of behaviour
- DBT recognises this and uses these principles to promote behaviour change
• Goals of DBT
- ACCEPTING oneself and current situation/life circumstances whilst simultaneously CHANGING behaviours causing suffering
- To enhance behavioural, emotional, cognitive responses and interpersonal interactions
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Standard DBT
• Four modes of treatment
1. Structured individual therapy
- Track emotions
- Family therapy
2. Skills group
- Weekly meeting, where you learn emotional skills
3. Skills coaching
- Can call therapist 24/7 to help you stick to the new strategies
4. Consultation team
- Therapists consult to get the best treatment possible
• Takes 3-4 hours per week
• Individual therapy (1hr per week)
• Group skills training (2.5 hr per week)
• Phone coaching (as needed)
• Therapist consultation team (1-1.5 hr per week)
• Positive reinforcement, important to participate
• 24 weeks for treatment approach – this is repeated over the course of a year
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Core skills modules - PD
1. Mindfulness
- International living with awareness in the present moment
- Without judging or rejection the moment
- Without attachment to the moment
- WISE MIND
2. Distress tolerance
- Goals of distress tolerance
3. Emotion regulation
- Goals:
o Understand the emotions that you experience
o Reduce emotional vulnerability and stop unwanted emotions from starting in the first place
o Decrease emotional suffering; stop or reduce unwanted emotions once they start
4. Interpersonal effectiveness
- Keeping and maintaining healthy relationships
- Getting somebody to do what you want
- Maintaining your self-respect
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Schema therapy for personality disorders
• Individuals all have core emotional needs
- Safety
- A stable base
- Empathy
- Validation of needs and feelings
- Protection
- Love, nurturance, attention, acceptance, praise
• Early maladaptive schemas are unconditional and problematic beliefs about oneself, significant others and environment
• Schemas arise in response to unmet emotional needs in childhood and adolescence; strengthened and elaborated throughout adulthood
• Comprised of thoughts, feelings, memories and physical responses
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Dysfunctional coping modes - PD
* Behavioural responses
* Surrender, avoid or overcompensate
* Surrender compliant surrender
* Avoid: detached protector, detached self-soother, avoidant protector
* Over-compensate: self-aggrandizer, perfectionist over-controller, paranoid over-compensator, bully and attack, conning
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What is sexuality?
- Intimacy (loving and being loved; expressing mutual care)
- Loving relationships
- Any type of sexual acidity
- Physical appearance, body image
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Sexual dysfunction:
Is the various ways in which an individual is unable to participate in sexual relationship… he/she would wish
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Sexual health
is a state of physical, emotional, mental and social well-being relating
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Prevalence of sexual problems and dysfunction
• A widespread public health problem
• At least one sexual dysfunction
- 40-45% of women
- 20-30%
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Kaplan's triphasic (3 stage) model of sexual response
1. desire
2. excitement
3. orgasm
• Validity challenged > simplistic and linear; focus on genital responses
• Neglects emotional and relational aspects; as well as cognitive/external stimuli
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Re-conceptualisation of female sexual dysfunction
- A circular rather than linear model
| - > recognising the complexity and the importance of intimacy and psychosocial aspects of sexual relating
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Definition of sexual dysfunction DSM-5
* A clinically significant disturbance in a person’s ability to respond sexually or to experience sexual pleasure
* A minimum duration of 6 months
* Symptoms must cause significant distress
* Experienced in almost all or all occasions of sexual activity (75%-100%)
* Important to consider cultural values and age
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DSM-5 specifiers/subtypes - sexual dysfunction
1. Nature of the onset: lifelong or acquired
- Lifelong if you’ve experienced the dysfunction since first sexual encounter
2. Context: generalised or situational
- Generalised if they can never become stimulated
- If you can get arousal by yourself but not with a partner for example it is situational
3. Severity: mild, moderate, severe – based on level of distress
- Premature ejaculation is specified by time of ejaculation
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Sexual desire disorders
• Persistent disinterest in sexual activity
• The person is distressed by their lack of interest
• Prevalence: 7-33%
- Age differences: women: <44 years 9% vs 45-68 years: 12%, >69 years: 7%
- Gender differences: Australia: men 8% vs women 55%
• Most common female sexual dysfunction
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Male hypoactive sexual desire disorders
* A lack of interest in sex and little sexual activity and fantasizing
* Physical response may be normal
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Female sexual interest/arousal disorder
* Interest/desire: a lack of, or indignantly reduced, sexual interest in sexual activity and fantasising
* Arousal: difficulty attaining or maintaining adequate lubrication until completion of the act
* Prevalence rates: uncertain due to high overlap with other female sexual disorders (30-50%)
* Less research focused on females (much more on males)
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Male sexual arousal disorders
• Erectile disorder (ED)
- Marked difficulty in obtaining or maintaining an erection (until completion) of sexual activity, or marked decrease in erectile rigidity
- Often spontaneously remits
- Up to 50% of adult men have erectile difficulty during intercourse at least some of the time
o Steep age-related increase of ED
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Male orgasmic disorders
• Delayed ejaculation
- Maintains erection, but marked delay (or inability) to achieve ejaculation, without the person desiring delay
- Experienced on almost all or all occasions of partnered sexual activity
- ‘thrusting is a chore, rather than a pleasure’
- Prevalence: 4% the least common male sexual complaint
• Premature early ejaculation
- Ejaculation with only minimal stimulation (less than 1 minute after vaginal penetration) and before the man wishes it
- Prevalence 8%
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Female orgasmic disorder
• Marked delay in, marked infrequency of, and/or absence of orgasm, or markedly reduced intensity of orgasmic sensations
• Adequate stimulation essential: if orgasm achieved with clitoral stimulation but not with penetration > does not meet criteria
• Woman must be clinically distressed about these symptoms
• Lifelong vs acquired; can be situational
• Orgasm is a learned (not automatic) response
- Improved with experience
• Prevalence: 51%
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Genito-pelvic pain/penetration disorder
• Persistent or recurrent difficulties in any one of the following:
- Vaginal penetration during intercourse
- Marked vulvovaginal or pelvic pain during vaginal intercourse or penetration attempts
- Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation or during, or as a result or vaginal penetration
- Marked tensing or tightening of the pelvic floor muscles resulting during attempted vaginal penetration
- Taking a detailed history important
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Aetiology of sexual dysfunction
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• Biological/physical factors
- Aging
- Illness
- Disability
- Medications
- Substance use/abuse
• Psychosocial factors – commonly strongly implicated
- Cultural and religious beliefs
- Self-acceptance (identity, orientation)
- Body image
- Depression, anxiety
- Life stressors
- Past experiences (abuse, trauma)
- Inexperience
- Perfectionism/performance anxiety
• interpersonal factors
- attraction to partner
- partner performance and technique
- excessive goal orientation
- relationship quality and conflict
- routinized, changed roles
- lack of partner
• environmental factors
- lack of privacy
- lack of time
- physical discomfort
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medical treatments for male sexual dysfunction: erectile dysfunction
• pharmacotherapy/medication
• highly effective (70-90%)
• dose modifications may be necessary over time
• lead to increased satisfaction in both men and women
• penile injections
- injections of smooth muscle relaxing drugs into erection chambers
- erection: 30-45 mins
• vacuum devices
- erection limited to 30 minutes
- results: 80-90% but high dropout rate
- complications: coolness, numbness, pain with ejaculation
• penile prosthesis (inflatable)
- ‘last-resort’ treatment
- Out-patient surgery
- Minimal complications (<5%), high satisfaction rate
• Important not to neglect psychological disturbances
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Medical treatments for female sexual dysfunction
• Pharmacological interventions/medication
- Hormonal therapy: (vaginal or systemic) oestrogen and androgen
- Addyi: oral medication for low sexual desire in premenopausal women
o Approved in 2015
o Originally developed as an anti-depressant
o Effective for a small group of women
o Potentially serious side effects: low blood pressure, dizziness and fainting (particularly if mixed with alcohol)
o It is not pink Viagra
• Medical/pharmacological treatments need to be offered into eh context of a holistic care accounting for subjective and relationship experiences
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Non-pharmacological interventions for female sexual dysfunction
• Genito-pelvic pain/penetration disorder
• Kegel exercises and vaginal weights
- Aimed at strengthening the muscle of the pelvic floor
• Vaginal lubricants
- Usually a liquid/gel that is applied around the clitoris, labia, and inside the vaginal entrance and minimise dryness and/or pain during sexual activity
• Vaginal moisturisers
- Non-hormonal products
- Improve overall vaginal health by restoring lubrication and the natural PH level to the vagina and vulva
• Genito-pelvic pain/penetration disorder
- Vaginal dilators
o Plastic/rubber tube used to stretch the vagina
o To treat vaginismus and dyspareunia
• Female sexual arousal disorder
- Eros etd: female vacuum therapy
o FDA-approved; requires prescription
o Creates gentle suction over the clitoris to cause engorgement
o Improves vaginal blood flow and lubrication
o Billups et al (2011, n=32) improved response in sensation, lubrication, orgasm, and satisfaction
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Communication skills training - sexual dysfunction
* Let’s talk about sex
* Likes and dislikes
* Comforts and insecurities
* How to communicate verbally and behaviourally during sex
* Discuss underlying relationship issues impacting sex
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Sensate focus exercises
• A graded series of mutual body-touching exercises:
- Exercise 1: general body pleasuring (focus on sensation of touching their partner)
- Exercise 2: introducing genital body pleasuring in the absence of intercourse
• Non-goal-orientated physical intimacy (in orgasm) > to minimise ‘performance’ pressure/anxiety and reduce ‘spectating’
• Enhancing communication between partners about sensual and sexual experiences
• Effective in treating female desire, arousal and orgasmic dysfunctions and erectile disorders
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Sexual dysfunctions: treatment
• Barriers to treatment uptake and retention
- Patients are unaware of available services and resources
- Lack of referral
- Embarrassment (patients and/or GP providers)
- Lack of engagement (either or both partners)
- Minimal attention to partners (not included or assessed)
• Limitations to treatment research
- Inadequate research methodology
- Limited treatment focus: commonly do not work from a bio-psycho-social perspective
- Small number of studies
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Coping with illness/cancer
• Illness is often a series of sequential traumas rather than a single event
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Critical time-points: before illness develops
- Genetic risk – only look at cancer genes
- Genomic testing – look at all genetics: show other illness, lots of information
o Hard to give consent
o Uncertainty of having an illness can be hard for people to deal with
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Angelina effect
* when Jolie disclosed that she had a double mastectomy there was a large influential shift
- However some people have mastectomy despite having no genetic signs of cancer genes, this purely due to anxiety
• Women diagnosed with breast cancer and tested for BRCA 1/5 gene mutations
- 2007: 70%
- 2013: 95%
• Australia 2004-2024: risk reducing (RRM) mastectomy procedures nearly DOBLED in 10 years
- Not creating panic, the women being tested for the genes have normal reason for doing so (family track records)
- 4% of women who are tested will have the cancer genetics – small probability
- However, if you have these genes it is 80% chance of developing breast cancer and 48% chance of ovarian cancer
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Critical time-points: the diagnosis
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• Common reactions
- Shock
- Numbness
- Disbelief
- Acute distress
- Anxiety
- Anger
- Bargaining
- Protest
- Depression
- Greif
- Denial – you then need to focus on how to deal with the issue, don’t push people through denial (doesn’t work)
- Gradual adjustment
- Acceptance
• BUT
- Wide variations may occur
- Can be calm acceptance
- Denial may continue
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Critical time-points: the diagnosis (2)
• Health professional-patient-family communication can influence the impact of the diagnosis and long term adjustment
- Guidelines for ‘breaking bad news’ and discussing prognosis, communication skills training, audio-taping consultations
• The importance of empathy
- The patient will never care how much you know, until they know how much you care
- This validates what the patient and the family is feeling – there are guidelines for this for clinicians
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Critical time-points: treatment decision-making
• Key features: tailoring communication, ensuring understanding, facilitating involvement, avoiding coercion
• Interventions/strategies
- Clinicians: communication skills training
- Patients/family:
o Coaching patients/family members to ask questions: ask what are my options? What are the possible benefits and risks of those options? How likely are the benefits and risks of each option to occur?
o Psycho-educational resources
o Question prompt sheets
o Decision aids
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Critical time-points: treatment/s
• Surgery: high levels of pre-operative anxiety
• Radiotherapy: often perceived more frightening than surgery
- Depression/anxiety tends to increase at the end of treatment, when side effects are experienced
• Chemotherapy: most feared treatment
- Anticipatory nausea and vomiting
• Hormonal therapy: long term ‘insurance’
• Adequate preparation and post-treatment support is critical:
- Patient and staff attitudes to side effects/pain
- Education (procedural AND sensory information)
- Anxiety management
- Managing side-effects
- Continuity of care (nurse care coordinators)
- Peer support
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What about family carers? - cancer
• Related to patient biologically, legally or emotionally
• Invisible backbone of health care system
• Provide unpaid care for adult cancer patients
• Healthcare
- Attend consultations (60-85% e.g. information and emotional support, patient advocacy)
- Involved in treatment decision-making
- Arrange and attend tests/treatments
- Provide home-based medical care (e.g. wound care, medication, supervision)
• Practical
- Personal hygiene
- Cooking/ cleaning/ transport
- Financial assistance
- Emotional support
• Recent shift in healthcare delivery from inpatient > outpatient > home-based care
• May have a considerable impact on the dynamics + outcomes of consultations/care!
• A need to shift healthcare to ‘patient and family centred care’
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Complementary and alternative medicine (CAM)
• Alternative therapies
- When a therapy is used INSTEAD of conventional health approach
- Often be promoted as a cure without evidence > 4 in 10 Americans believe alternative therapies can cure cancer
- May be biologically active, potentially harmful and extremely costly
• Complementary therapies
- The use of non-mainstream approach ALONG with conventional medicine
- Used to help alleviate treatment side effects, enhance wellbeing, contribute to overall care
- If proven safe and effective, may be integrated into mainstream care
• Estimated prevalence of CAM :
- Cancer: average 65% (range 50-80%)
- Diabetes: average 46% (range 17-73%)
- HIV: average 60% • Rheumatoid arthritis: range 28-90%
- General population: 40%
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Critical time-points: End-of-life issues
* Uncertainty / fear of the process of dying
* Fear of pain and suffering, anticipatory grief
* Decision-making: advanced directives
* Carer: feelings of inadequacy
* Practical issues
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Critical time-points: survivorship
• For many survivor’s life after cancer is as good as, and sometimes even better, than before the diagnosis
• Yet, for many others there are challenges
- A common assumptions that survivors will return ‘back to normal’ once their health returned post-treatment
- Continuing existential tension of the survivor => ‘compulsory philosophers’
- Identity disruption => finding a “new normal”
- the body becomes a 'house of suspicion’
- Positive outcomes: post-traumatic growth
• MENTAL HEALTH is the only direct impairment associated with being a cancer survivor
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Psychosocial care during survivorship
• Normalising and validating the experience
• Tailoring care to the needs of the survivor and their family
• SURVIVORSHIP CARE PLANS : to address poorly coordinated follow-up care = formal, written documents that provide details of a person’s:
- cancer diagnosis and treatment
- potential late/long-term effects arising from the cancer and its treatment
- plans for medical follow up
- recommended management of current medical/psychosocial/practical issues;
- advice and coaching regarding healthy lifestyle
- discussion of potential future issues and a plan for management
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Cancer SURVIVAL & the PRESSURE TO BE POSITIVE
• Cancer patients often feel pressure to keep a “positive attitude/fighting spirit” at ALL times:
- Unrealistic => feelings of sadness, fear, anxiety post-cancer diagnosis are normal
- Adds to the patient’s emotional burden
• Rigorous scientific studies show NO correlation between positive thinking & cancer SURVIVAL
• A positive attitude is a useful coping strategy/technique which CAN improve QUALITY of LIFE
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What do scientific definitions define?
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• Answer to the question what is it?
• What it is to be that kind/type of thing
- A kind of substance
- A kind of process
- A kind of behaviour
- A type of cognition
- A kind of emotion
- A kind of effect/phenomenon
- A type of mental disorder (answers the question, what is it to be this kind of disorder? Or what kind of disorder is it?)
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monothetic
* The kinds characteristics or features or conditions without which that kind could not be the kind that it is. i.e. the kind has them necessarily
* These features or conditions are identified as essential or necessary
* Involves the genus – species distinction
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polythetic
there is no one single condition or circumstance where there is a single feature present. Therefore, this concept y is polythetic, and not real, not a genuine kind.
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Difference between concept and kind
Kind is something out in the world, a concept may or may not refer to something in the world (a real kind).
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For genuine science to occur...
the kind has to be a real kind in order to provide a launching point for furthering scientific knowledge, to integrate a model (only through an accurate description of the kind’s essential conditions) that’s you can further knowledge
• Knowing what kind x is, or what concept x refers to is necessary in furthering scientific knowledge. Polythetic cannot provide this launching point.
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DSM-5 scientific definition: associative identity disorder
- Dissociative identity disorder: the presence of two or more distinct personality states or an experience of possession which is not part of a broadly cultural or religious practice (A) AND recurrent episodes of amnesia (B)
o Every case has these two features – they are essential
o Therefore, monothetic
- There was a call for (and it was published) dissociative identity disorder to not be diagnosed according to this monothetic criteria for the reason of (which wasn’t scientific) that it is of no help to clinicians for diagnosis, as it does not provide any diagnostic criteria. We should identify dissociative identity disorder according to its diagnostic criteria
• Most diagnostic criteria is polythetic
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Most diagnostic criteria is polythetic
- this good for clinicians but not for science because you have no unique set of features essential to the kind, therefore you don’t know what it is and isn’t – can’t make categorical decisions
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Scientific definition is not a description of the following:
- The conditions, processes or procedures that cause the kind
- The signs of a general kind or the symptoms are not X itself. E.g. the sings of water (plants growing for example) is not water
- Is not a description of the effects or consequences of a disorder – talking about what x causes not x itself
- Is not the functional purpose of X, you can talk about the function of a shoe, but you are not saying what a shoe is.
- Not a description of the measurement of X
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Not a scientific definition
• Operational definition is merely a description of a procedure – not of the kinds
- Not a scientific definition
• Scientific definition is not ostensive – ostension is pointing to
- The point is that if you point to something you are not telling what the defining features of what you are point at e.g. if you point at a laptop you are not saying what a laptop is
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Definition is not classification:
- Classify: according to knowledge, our needs and our interests. The outcome of our interests, and knowledge will determine our classification. Scientific classification is based on the features of the kind of thing being classified (what they are). Scientific classification depends of scientific definition (cant classify until you know what the types of things are). E.g. the class of dissociative identity disorder each case of dissociative identity – then you can specify where and when. This is with every case, not every person.
- Definition: not polythetic.
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Diagnostic criteria...
- should not be used in constructing a scientific system of classification because the criteria are not definitional (some are polythetic)
- Many symptoms (diagnostic criteria) are seen across multiple disorders – how are you to distinguish between disorders when this is the case
