somatoform and factitious disorders and sexual disorders
What are the sexual changes women see in aging?
In women: - Orgasmic potential may improve - Vaginal dryness related to hormonal changes
What are sexual disorders that affect the arousal phase of the sexual response cycle?
Inability to achieve sufficient physiological or emotional arousal during sexual activity Female sexual interest/arousal disorder: failure to attain/maintain adequate lubrication, swelling of vagina/labia Male erectile disorder: failure to attain or maintain erection until completion of sexual activity
What are factitious disorders?
Falsification of physical or psychological signs/symptoms OR induction of injury or disease, associated with identified deception •Presents him/herself as ill, impaired, or injured •Deceptive behavior evident despite lack of external incentives for the behavior •Goal: occupy the "sick role" May not consciously understand what they are doing. Includes Munchhausen syndrome and Münchhausen syndrome by proxy
What is genito-pelvic pain/penetration disorder?
The new DSM-5 classification of sexual pain disorders Difficulties with one or more of the following: - Vaginal penetration during intercourse - Marked pain during intercourse - Marked fear/anxiety about pain related to intercourse - Marked tensing/tightening of pelvic floor muscles during attempted penetratio
what is Voyeurism/voyeuristic disorder?
Voyeurism/voyeuristic disorder 6-month period of recurrent fantasies/urges/behaviors involving - The act of observing an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity Causes distress/impairment
What is "La Belle indifference" in terms of somatic symptom disorders
Where a patient with conversion disorder is aware of but sometimes indifferent to the sensory or motor symptoms attributed to their disorder
What is Transexualism
Where an individual wants to alter social role and secondary sex characteristics to match opposite sex think sex change, etc.
What is male hypoactive desire disorder?
characterized as a lack or absence of sexual fantasies and desire for sexual activity, as judged by a clinician over a 6 month time period
What is female sexual interest disorder disorder?
characterized by a low interest in sex with a reduced/absent sexual excitement/pleasure during sexual activity - 6 month duration
What is sexual sadism disorder?
6-month period of recurrent fantasies/urges/behaviors involving - Acts in which the psychological or physical suffering of the victim is sexually stimulating to the person Causes distress/impairment
What is Frotteurism/frotteuristic disorder?
6-month period of recurrent fantasies/urges/behaviors involving - Touching/rubbing against a nonconsenting person (subway, crowded area) Causes distress/impairment
What is Transvestic disorder?
6-month period, in a heterosexual male, of recurrent fantasies/urges/behaviors involving - Cross-dressing Causes impairment/distress
What is Gender identity disorder/gender dysphoria?
Strong persistent cross-gender identification Manifested by - Statements of desire to be, or insistence that he/she is, the other sex - Preference for stereotypical choices of other sex (clothing, hobbies, roles) Persistent discomfort for his/her sex
What are the leading sexual disorders in Men?
- Early ejaculation (27%) - Erectile difficulties (21%) (especially if over 50) - Lack of interest (18%) - Anorgasmia (15%)
What are the DDX of sexual dysfunction?
-Drugs --Antihypertensives, neuroleptics, SSRI's, Ethanol -Diseases --Depression, Diabetes, STI's Psychological --Performance anxiety Autonomic --Lambert-eaton myasthenic syndrome Nerve -spinal issues to S2 S3, or S4
What are the sexual changes men see in aging?
-Erections Take longer to achieve Take physical stimulation to achieve Are not as stiff - Refractory period increases - Intravaginal ejaculatory latency time (IELT) decreases with age
What is conversion disorder most commonly seen in?
-Lower socioeconomic backgrounds -lower education -Women -Adolescents -Young adults
What is exhibitionistic disorder?
-month period of recurrent fantasies/urges/behaviors involving - exposure of one's genitals to an unsuspecting stranger Causes significant distress or impairment in social or occupational functioning
What are the phases of the human sexual response cycle? What are the broad categories of sexual dysfunction tied to them?
Desire -Low desire/aversion Arousal -erectile dysfunction Platueau Orgasm -anorgasmia/premature ejactulation Resolution -Pain is other dysfunction (not associated with resolution) --dyspareunia, vaginismus
What is pedophilia/pedophilic disorder?
6-month period of recurrent fantasies/urges/behaviors involving - Sexual activity with a prepubescent child or children - The person with pedophilia must be at least 16 and at least 5 years older than the child/children - Causes impairment/distress - Subtypes: attracted to males or females; limited to incest; exclusive vs nonexclusive
What is Fetishism/fetishistic disorder?
6-month period of recurrent fantasies/urges/behaviors involving - use of nonliving objects Causes significant distress or impairment
What is Münchhausen syndrome?
A Chronic factitious disorder with predominantly physical signs and symptoms Characterized by a history of multiple hospital admissions and willingness to undergo invasive procedures
What is Malingering?
A NON disorder (its just lying) where a patient CONSCIOUSLY fakes, profoundly exagerates, or claims to have a disorder in order to attain a specific secondary gain --external gain, like avoiding work or getting compensation Characterized by poor compliance with treatment or follup of diagnostic tests. Complaints cease after gain
What is Alprostadil?
A PGE1 synthetic variant used to decrease vasulcar tone. Used to treat erectile dysfunction by injection or placement into the eurethra Also used by ingection to maintain a patent ductus arteriosus in newborns with congenital heart defects
What is Illness anxiety disorder (Hypochondriacism)
A disorder characterized by preouccpation with having or acquiring a serious illness Associated with: -Somatic symptoms are mild or non-existent -high health anxiety -excessive health related behaviors OR maladaptive avoidance of treatment Preoccupation last 6 months Generally see: - Doctor shopping •Men = women •Age of onset: 40s-50s •Chronic course, waxes and wanes •Commonly afflicts
What is Pseudocyesis?
A false, nondelusional belief of being pregnant. May have signs and symptoms of pregnancy but IS NOT pregnant Consider a somatopsychotic May have signs of pregnancy to include: -Abdominal distension -morning sickness May resolve under general anesthesia
What is Conversion disorder?
A neurological disorder where One (or more) symptoms of altered voluntary motor or sensory function, usually following an acute stressor. - Symptoms are incompatible with recognized neurological or medical conditions - Symptoms/deficits are not better explained by another medical problem - Symptoms produce significant distress or social/occupational impairment •Typical symptoms: - Blindness - Deafness - Paralysis - Inability to speak - Seizures - Inability to walk or stand Symptoms MAY be symbolic, dont match patterns of neurological distribution Resolves quickly
What is Female orgasmic disorder?
A persistent or recurrent delay in/absence of orgasm after normal sexual excitement phase --NOT diagnosed solely on inability to reach orgasm
What is Somatization disorder?
A specific form of very chronic somatic symptom disorder, "Histeria" -Affects primarily women -starts in young adulthood (before age 30) Symptoms are NOT intentionally feigned or produced Characterized by multiple symptoms in multiple organ systems
What is Sildenafil? (and similar drugs, vardenafil, tadlafil)
An erectile dysfunction drug that inhibits PDE-5 --Does this by blocking cGMP breakdown, causing an increase in cGMP, leading to smooth muscle relaxation and vasodilation in corpus cavernosum Can also work to treat pulmonary hypertension!
What is Münchhausen syndrome by proxy?
An illness in a child or elderly patient caused or fabricated by a caregiver to push them into the "Sick" role to receive the sick role by proxy A form of child/elder abuse
How can you tell if erectile dysfunction is physiological or psychological?
Ask patient if morning erection still occurs. If it does, then the process and pathways still work fine and it is likely psychological nocturnal penile tumescence monitor can also measure the difference If it is psychological, therapy can also help fix!
What are sexual disorders that affect the desire phase of the sexual response cycle?
Lack of interest in/desire for sex - Global lack of interest in sexual activity - Affects about 18% of men, up to 33% of women - May or may not be bothersome to the patient - Many causes Hormonal Situational (e.g., sleep deprivation, stress) - Patient may be able to function sexually -male hypoactive desire disorder -female sexual interest desire disorder
What are the leading sexual disorders in women?
Lack of interest: 33% Arousal difficulties: 27% Anorgasmia: 25% Pain during sex: 14%
what is the general observation involving gender sexual dysfunction affect by antidepressent treatments?
Men experience side effects more often Women experience more severe side effects Most common - Lack of desire - Orgasm del
What is Erectile disorder?
One or more of the following during nearly all sexual encounters Marked difficulty obtaining an erection Marked difficulty maintaining an erection Marked decrease in erective rigidity 6 month duration
what is meant by Primary or secondary gains in a factitious or somatoform illness?
Primary gains are psychological, such as the care and comfort one receives in the "Sick" role Secondary gains are rewards that are achieved in life, such as compensation, time off of work, or monetary gain.
What is sexual masochism disorder?
Sexual masochism disorder 6-month period of recurrent fantasies/urges/behaviors involving - The act of being humiliated, beaten, bound, or otherwise made to suffer Causes impairment/distress
What is the screening mnemonic for somatization disorder?
Somatization Disorder Besets Ladies And Vexes Physicians -Shortness of breath -Dysmenorrhea -burning genitalia, mouth, rectum -lump in throat -Amnesia -Vomiting -Painful extremities
What is the treatment for Hypochondriasis (Illness anxiety disorder)
Treat with regular visits, reassuring, benign recommendations DONT miss general medical problems or depression! Pharm treatment: MAOI's (anxiety)
What is bicycle seat neuropathy
Where continous bicycling may eventually thicken the sacrotuberous and/or sacrospinous ligaments and trap the nerve between them (pudendal nerve entrapment) Pain is positional and is worsened by sitting. Other symptoms include genital numbness, fecal incontinence and urinary incontinence
What is premature ejaculation?
persistent condition where ejaculation occurs -with minimal sexual stimulation -before/upon/shortly after penetration - Considered a "disorder" only if it causes significant distress per DSM V: -Persistent pattern over 6 months or more -Ejaculation occurs within 1 minute following vaginal penetration and before individual wishes it Treat with Start/stop or squeeze technique; topical anesthetics; SSRIs
What are red flags for somatization disorder?
•Multiple, vague symptoms •History usually disorganized, conflicting •Large # of symptoms involving many organ systems •Dramatic, flamboyant, exaggerated symptoms - Headache = "Men walking on my brain with hobnail boots" - Brown-tinged sputum = "Vomiting blood" •Or may exhibit "la belle indifference" (vague, unconcerned Exhibitionistic dress and grooming •Symptoms usually begin in teens or 20s - Often dysmenorrhea •Few spontaneous remissions but •No increase in mortality
What is the treatment for Conversion disorder?
•Reassurance •Suggestion •Hypnosis •Lorazepam/sodium amytal - use in emergency setting. Usually helps symptom •"Uncovering" psychotherapy
What are somatiform disorders and their key points?
•Somatic symptom disorder •Illness anxiety disorder •Conversion disorder Characterized by: •Physical symptoms for which no general medical etiology can be found, or symptoms are out of proportion to that which is expected •UNCONSCIOUS psychological factors contribute •Perceived symptoms are "real" to them - Patients with somatoform disorders are not "faking it" •Common diagnoses in primary care •more common in women
What are the Red flags for factitious disorder?
•Symptoms "too perfect" •Overuse of medical jargon •Symptoms resemble an uncommon but interesting medical syndrome ("fascinoma," "zebra") •Pattern of approximate answers •History of AMA (against medical advice) discharges, extensive travel
What are the motivations for symptoms of somatiform and factitious disorders?
•Unconscious production of symptoms, no clear payoff --- Somatic symptom disorder - Illness anxiety disorder - Conversion disorder •Conscious (deliberate) production of symptoms, no clear payoff -- Factitious disorder •Conscious (deliberate) production of symptoms, clear payoff --Malingering