Psychiatry and Behavioral Health Rotation

Psychiatry EOR: Paraphilic Disorders; Sexual Dysfunctions (Pearls)

Sexual dysfunctions DSM-5
To fulfill the DSM-5 criteria of the sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors and is not at­tributable to the effects of a substance/medication or another medical condition.
Delayed ejaculation Either of the following symptoms must be experienced on almost all or all occasions (approximately 75%-100%) of partnered sexual activity and without the individual desiring delay for a minimum duration of approximately 6 months

  • Marked delay in ejaculation
  • Marked infrequency or absence of ejaculation

TX: There isn’t an approved drug treatment for delayed ejaculation “off-label” treatments may include:

  • Testosterone, buspirone, amantadine, oxytocin, and cabergoline
  • Other treatments include cognitive-behavioral therapy, masturbatory retraining, etc.

References: UpToDate

Erectile disorder
Patient will present as → a 34-year-old heterosexual male who presents to your clinic for concerns regarding erectile dysfunction. He works for Facebook and admits to working long hours in a very stressful environment. He reports having morning and night-time erections. The problem started approximately one year ago and has had a significant impact on his relationships. Often times he is unable to obtain an erection and when he does his penis is often flaccid and it is difficult to achieve penetration. This has resulted in significant distress and he has almost completely stopped dating.

At least one of the three following symptoms must be experienced on almost all or all (approximately 75%-100%) occasions of sexual activity for a minimum duration of approximately 6 months.

  • Marked difficulty in obtaining an erection during sexual activity
  • Marked difficulty in maintaining an erection until the completion of sexual activity
  • Marked decrease in erectile rigidity

TX: Treatment options include oral phosphodiesterase inhibitors - These drugs include sildenafil (Viagra), vardenafil, avanafil, and tadalafil

  • Intraurethral or intracavernosal prostaglandins, vacuum erection devices, and surgical implants

References: Merck Manual · UpToDate

Female orgasmic disorder

Presence of either of the following symptoms and experienced on almost all or all (ap­proximately 75%-100%) occasions of sexual activity for a minimum duration of approximately 6 months.

  • Marked delay in, marked infrequency of, or absence of orgasm
  • Markedly reduced intensity of orgasmic sensations

TX: First-line treatment of female orgasmic disorders is directed masturbation, which involves a series of prescribed exercises

  • Sex therapy, cognitive-behavioral therapy

References: Merck Manual · UpToDate

Female sexual interest/arousal disorder
Patient will present as → a 33-year-old woman with a chief complaint of trouble having intercourse. She is completely disinterested in sex and she is not receptive to her partner’s attempts to initiate foreplay. She reports that when they do have sex she never achieves orgasm. This is affecting her current relationship with her boyfriend.

Lack of, or significantly reduced, sexual interest/arousal, as manifested by at least three of the following for a minimum duration of approximately 6 months

  • Absent/reduced interest in sexual activity
  • Absent/reduced sexual/erotic thoughts or fantasies
  • No/reduced initiation of sexual activity, and typically unreceptive to a partner’s at­tempts to initiate
  • Absent/reduced sexual excitement/pleasure during sexual activity in almost all or all (approximately 75%-100%) sexual encounters
  • Absent/reduced sexual interest/arousal in response to any internal or external sex­ual/erotic cues (e.g., written, verbal, visual)
  • Absent/reduced genital or nongenital sensations during sexual activity in almost all or all (approximately 75%-100%) sexual encounters (in identified situational con­ texts or, if generalized, in all contexts)

TX: Education about sexual anatomy and function

  • Effective sexual stimuli may include nonphysical, physical nongenital, and nonpenetrative genital stimulation
  • Cognitive-behavioral therapy
  • Hormonal therapy - testosterone, etc.

References: Merck Manual · UpToDate

Genito-pelvic pain/penetration disorder

Persistent or recurrent difficulties with one (or more) of the following for a minimum duration of approximately 6 months

  • Vaginal penetration during intercourse
  • Marked vulvovaginal or pelvic pain  or penetration attempts
  • Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of vaginal penetration
  • Marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration

TX: Treatment of cause when possible (eg, topical estrogen for atrophic vaginitis)

  • Education about chronic pain and its effects on sexuality
  • Psychologic therapies
  • Pelvic floor physical therapy
  • Progressive desensitization

References: Merck Manual · UpToDate

Male hypoactive sexual desire disorder
Patient will present as → a 53-year-old male complaining of a lack of desire for sex with his wife causing him marked distress for the past year. His wife has been very hurt by his lack of response to her advances and he reports that this is having a significant strain on their relationship. Prior to this, he was interested in sex and he and his wife would have intercourse 1-2x per month. He is very active and continues to compete in triathlons. He has no significant past medical history.

Persistently or recurrently deficient (or absent) sexual/erotic thoughts or fantasies and desire for sexual activity for a minimum duration of approximately 6 months

  • The judgment of deficiency is made by the clinician, taking into account factors that affect sexual functioning, such as age and general and socio­ cultural contexts of the individual’s life

TX: Common treatments for HSDD include testosterone therapy and other medications, as well as sex therapy

References: Merck Manual · UpToDate

Premature (early) ejaculation

A persistent or recurrent pattern of ejaculation occurring during partnered sexual activ­ity within approximately 1 minute following vaginal penetration and before the individ­ual wishes it

  • Must be experienced on almost all or all occasions (approximately 75%-100%) of partnered sexual activity and without the individual desiring delay for a minimum duration of approximately 6 months.

TX: SSRIs are first-line treatment

  • Available agents and dosages include paroxetine (10 to 40 mg/day), sertraline (50 to 200 mg/day), fluoxetine (20 to 40 mg/day), citalopram (20 to 40 mg/day), and escitalopram (10 to 20 mg/day)
  • Topical anesthetics, sex therapy, and tricyclic antidepressants

References: Merck Manual · UpToDate

Substance/medication-induced sexual dysfunction Substance-induced sexual dysfunction refers to a condition in both men and women in which patients have difficulties with sexual desire, arousal, and/or orgasm due to a side effect of certain medications (legal or illicit)

TX: Remove offending agent

Paraphilic disorders DSM-5
Voyeuristic disorder
Patient will present as → a 20-year-old male college student was reported by others for spying through the windows of his fellow female dormmates. 

Recurrent and intense sexual arousal from observing an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity.

  • Over a period of at least 6 months
  • The individual has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause clinically significant distress

TX: If patients have committed a sexual offense, treat with psychotherapy and SSRIs first

  • If additional treatment is needed and if informed consent is obtained, treat with antiandrogen drugs

References: Merck Manual

Exhibitionistic disorder
Patient will present as → a 23-year-old male who goes to city park during the summer months in an overcoat. He enjoys walking around the park exposing his genitals to strangers. He then runs away so as to avoid getting caught.

Over a period of at least 6 months, recurrent and intense sexual arousal from the exposure of one’s genitals to an unsuspecting person, as manifested by fantasies, urges, or behaviors.

  • The individual has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

TX: If patients have committed a sexual offense, treat with psychotherapy and SSRIs first

  • If additional treatment is needed and if informed consent is obtained, antiandrogen drugs may be considered

References: Merck Manual

Frotteuristic disorder
Patient will present as → a 29-year-old male who was brought in by his wife and older brother. According to them, the patient has a desire to rub his privet area against other people, when the opposing person is not looking. He has done this action in their home, and to his wife when she is doing the dishes, or even cooking dinner and began to rub against his brother when he would be helping his with things around the house.

Sexual gratification attained by touching or rubbing against a nonconsenting individual

TX: Treating frotteurism usually includes psychotherapy and behavior therapy

  • Psychotherapy focuses on identifying triggers for frotteuristic behavior and coming up with strategies to redirect thoughts and feelings
Sexual masochism disorder
Patient will present as → a 23-year-old male who concerned that his behavior has resulted in his inability to maintain a relationship. He reveals that he requires his partners to strangle him and humiliate him in order for him to achieve and maintain an erection.

Sexual gratification in response to undergoing humiliation, bondage, or suffering

  • Asphyxiophilia is considered a subtype of sexual masochism disorder
  • Over a period of at least 6 months
  • The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in functioning

TX: Treatment for sexual masochistic disorder typically involves psychotherapy and medication that can reduce sex drive

  • Antidepressant medications may also be used to reduce sex drive

References: Merck Manual

Sexual sadism disorder
Patient will present as → a 42-year-old white man seeking help for depression and suicidal ideations. In a detailed interview, the patient reveals his involvement in sexual acts that make him guilty. He reports that he and his girlfriend of the last two years had been involved in cutting and drawing blood from each other’s bodies while engaging in sexual activity. The two also drink each other’s blood while involved in these sexual activities, and he reports that cutting and drinking his partner’s blood is the only way that he can reach orgasm. On physical exam, you note numerous scars on his arms and chest that are very deep and in different stages of healing.

Sexual gratification in response to inflicting humiliation, bondage, or suffering

TX: Sexually sadistic interests do not require treatment unless causing significant impairment or distress, or harm to self or another has occurred

  • Psychotherapy
  • Antidepressants (SSRIs) and testosterone blockers (anti-androgens and GnRH analogs)

References: Merck Manual

Fetishistic disorder
Patient will present as → a female brings her 29-year-old boyfriend to a couples therapist because she is uncomfortable with his behavior. She found him clutching her feet during intercourse, and noticed that he insists on being able to see her feet while they engage in sexual acts.

Sexual arousal is obtained by specific objects

  • Over a period of at least 6 months, recurrent and intense sexual arousal from either the use of nonliving objects or a highly specific focus on nongenital body part(s), as manifested by fantasies, urges, or behaviors

TX: Treatment of fetishistic disorder may include psychotherapy, drugs, or both

  • Selective serotonin reuptake inhibitors have been used with limited success in some patients who request treatment

References: Merck Manual

Pedophilic disorder
Patient will present as → a 33-year-old male gymnastics teacher insists that all his students take a shower after class. He supervises the children showering and becomes sexually aroused.

Repeated and intense sexual urges or fantasies about watching, touching, or engaging in sexual acts with children (generally 13 years or younger), and either act on these urges or experiences clinically significant distress or impairment

  • Over a period of at least 6 months
  • The individual has acted on these sexual urges, or the sexual urges or fantasies cause marked distress or interpersonal difficulty

TX: In the US, the treatment of choice for pedophilia is IM medroxyprogesterone acetate

  • The GnRH agonist leuprolide, which reduces pituitary production of LH and FSH and thus reduces testosterone production, is also an option and requires less frequent IM injections than medroxyprogesterone.

References: Merck Manual

Transvestic disorder Defined as a condition in which there is persistent (at least 6 months), recurrent, and intense sexual arousal from wearing clothes associated with the opposite gender as evidenced by fantasies, urges, or behaviors

TX: Most cross-dressers do not present for treatment. Those who do are usually brought in by an unhappy spouse, referred by courts, or self-referred out of concern about experiencing negative social and employment consequences

  • Social and support groups for men who cross-dress are often very helpful
  • Psychotherapy, when indicated, is aimed at self-acceptance, family therapy, and modulating risky behaviors.
  • No drugs are reliably effective, although SSRIs have been tried and occasionally are beneficial in patients with a substantial obsessive-compulsive component to their presentation.

References: Merck Manual

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