SEXUAL AND PERSONALITY DISORDERS😊

SEXUAL AND PERSONALITY DISORDERS

Phases of Sexual Response Cycle

• Phases experienced during sexual activity.

• Mnemonic: 'DEOR spray for seduction'
• Desire Phase
• Includes sexual urges, sexual wishes.
• Excitement (Arousal) Phase
• Subjective feelings of sexual pleasure.
• Accompanied by physiological changes.
• Increase in heart rate, blood pressure, sweating.
• Physiological changes:
• Males: Penile erection.
• Females: Vaginal lubrication.
• Disorder: Erectile dysfunction in males.
• Orgasm Phase
• Smallest stage, lasts 3-15 seconds.
• Peak of sexual pleasure.
• Changes occurring:
• Males: Ejaculation of semen.
• Females:
• Involuntary contraction of
• lower 1/3rd of vagina,
• uterus.
• Disorder: Premature ejaculation.
• Resolution
• Lasts for 10-15 mins.
• Body returns to resting stage.

Sexual Dysfunctions

Male Erectile Disorder (Erectile Dysfunction)

• Marked difficulty in obtaining or maintaining erection during sexual activity.

• Disorder of excitement phase.

Causes:

• Psychogenic Erectile Dysfunction
• Caused by psychological factors like anxiety, marital problems.
• Experiences early morning erections and nocturnal erections.

• Organic Erectile Dysfunction
• Caused by medical causes:
• Diabetes mellitus.
• Arteriosclerosis.
• Neurological disorders.
• Does not experience early morning or nocturnal erections.

Investigations:

• Nocturnal penile tumescence.

• Penile plethysmography (measures blood pressure in penis).

Treatment:

Pharmacotherapy

Psychotherapy

• Dual Sex Therapy (Sex Therapy)
• Derived by Masters and Johnson.
• Effective for other sexual disorders.
• Treats the couple, not the individual.
• Both partners are involved.

• Sensate focus exercises
• Two stages:
• Non-genital sensate focus.
• Genital sensate focus.

Premature Ejaculation

• Disorder of orgasm phase.

• Persistent or recurrent ejaculation with minimal sexual stimulation.

• Occurs before or immediately after vaginal penetration.

• DSM-5: Ejaculation within <1 minute following vaginal penetration.

Treatment:

Psychotherapy

• Squeeze technique
• By Masters & Johnson.
• When feeling of impending ejaculation occurs,
• he or partner squeezes the coronal ridge of glans.
• Results in inhibition of ejaculation.

• Stop-Start technique
• By Semans (Semans technique).
• When feeling of impending ejaculation occurs,
• sexual activity is stopped.
• Restarted once excitement has decreased.
• Mnemonic: Semen varathirikkan seman technique

Pharmacotherapy

• SSRI's (selective serotonin reuptake inhibitors)
• Delayed ejaculation is a side effect.
• Used to treat premature ejaculation.

Nymphomania

• Excessive sexual desire in females.

Satyriasis

• Excessive sexual desire in males.

Gender Identity Disorders

• DSM-5: Gender Dysphoria.
• D for D

• ICD-11: Gender Incongruence.
• I for I

• Gender identity is a sense of being male/female.
• Most often corresponds to anatomical sex.

Gender Identity Disorder of Childhood

• Marked incongruence between expressed and assigned gender.

• Seen in prepubertal children.

• Strong desire to be of the other gender.

• Preference for:
• Cross dressing.
• Toys or games of the other gender.

• May have dislike of one's sexual anatomy.

Transsexualism

• Desire to live and be accepted as a member of the opposite sex.

• Accompanied by discomfort with one's own anatomical sex.

• Patient may say “I am a man trapped in the body of a woman”.

• Transsexual identity must be present for at least 2 years for diagnosis.

• Treatment:
• For patients insisting on sex change,
• sex reassignment surgery can be done.
• Usually accompanied by hormonal therapy.

Personality Disorders

• Pattern of behaviours and inner experiences deviating from cultural standards.

• Leads to clinically significant distress or functional impairment.

• Onset:
• Usually in adolescence or early adulthood.

• Pattern is stable for a long duration.
• Symptoms remain stable once developed.

• Some disorders (antisocial, borderline) may become less evident with age.
• Maturation occurs by 40 years.

Three Clusters

• Cluster A personality disorder
• Odd/eccentric: Weird
• Includes:
• Paranoid PD
• Schizoid PD
• Schizotypal PD

• Cluster B personality disorder
• Dramatic/impulsive: Wild
• Includes:
• Antisocial PD.
• Borderline PD.
• Histrionic PD.
• Narcissistic PD.
• Mnemonic: B → Border → Society → Nazi History

• Cluster C personality disorder
• Anxious/fearful: Worried.
• Includes:
• Avoidant PD.
• Dependent PD.
• Obsessive compulsive PD.
• Mnemonic: C → A oCd → Avoidant, OCD, Dependent

Cluster A Personality Disorder

Paranoid Personality Disorder

• Long-standing pattern of suspiciousness or distrust.

• No hallucinations and no delusions.

• Suspects others without basis (exploiting, harming).

• Reads hidden threatening meanings in benign events.

• Bears grudges.

Schizoid Personality Disorder

• Long pattern of social withdrawal.

• Emotionally cold, indifferent to praise or criticism.

• Prefers solitary activities.

• Lacks close friends.

Schizotypal Personality Disorder

• Exhibits social difficulties and eccentric behavior.

• Odd beliefs and magical thinking.
• e.g., superstitious, belief in sixth sense, telepathy.

• Speech may be vague, over-elaborated, reflecting odd thinking.

• May have an illusion or ideas of reference.

• Increased risk of schizophrenia.

Cluster B Personality Disorder

Antisocial Personality Disorder (Dissocial Personality Disorder)

• No regard for the rights of others, often violates them.

• Frequently involved in unlawful activities (theft, lying, conning).

• May show irritability and aggressiveness (physical fights, assaults).

• No guilt or remorse.

• May blame others for their actions.

• Substance use disorder may be frequently present.

Borderline Personality Disorder

• More common in females than males.

• Unstable interpersonal relationships (idealization/devaluation).

• Identity disturbance:
• Unstable self-image.
• Sudden shift in goals, values, sexual identity, etc.

• Impulsivity:
• Potentially self-damaging behavior.
• Spending, reckless driving, substance abuse.

• Recurrent suicidal behaviour, gestures, threats (e.g., wrist slash).

• Mood instability:
• Intense episodic anger outbursts.

• Chronic feeling of emptiness.

• Almost always appear in a state of crisis.

• Micro-psychotic episodes with fleeting doubtfulness.

Treatment

• Psychotherapy is the treatment of choice.

• Dialectical behaviour therapy (DBT):
• Corrects all or none phenomenon/ splitting.
• All or none phenomenon:
• Patient sees everything as all good or all bad.

• Mentalization based therapy (MBT).

• Transference focused psychotherapy (TFP).

McDonalds triad

• Animal cruelty

• fire setting

• bed wetting

Histrionic Personality Disorder

• High degree of attention-seeking behavior.

• Speech and emotions are exaggerated.

• Behaves in a colorful, dramatic, extroverted way.

• Wants to be the center of attention.

• Inappropriate sexual seductive behavior, flirtatious.

• Uses physical appearance to draw attention.

Narcissistic Personality Disorder

• Heightened sense of self-importance.

• Expects recognition as superior without achievements.

• Preoccupied with fantasies of power or success.

• Requires excessive admiration.

• Exploitative, may lack empathy.

Cluster C Personality Disorders

Avoidant or Anxious Personality Disorder

• Extremely sensitive to rejection.

• Fear of criticism, disapproval, or rejection.

• Views oneself as socially inept or inferior.

Dependent Personality Disorder

• Difficulty in making everyday decisions.

• Dependent on others for advice and reassurance.

• Needs others to assume responsibility for most areas.

• Difficulty expressing disagreement due to fear of loss of support.

• Lacks confidence, cannot initiate new things.

Obsessive Compulsive Personality Disorder

• ICD 10: Anankastic PD.

• No obsessions or compulsions.

• Preoccupied with details, rules, organization.

• Exhibits perfectionism interfering with task completion.

• Causes significant delays in tasks.

• Exhibits rigidity and stubbornness, often inflexible.

Important Information

• In ICD-11, older classification of personality disorder is removed.

• Personality disorders now classified by severity:
• Mild personality disorder.
• Moderate personality disorder.
• Severe personality disorder.

Types of Personality

Type A Personality

• Competitive.

• Time urgency.

• Hostility.

• Ambitious.

• Impatient.

• Two-fold risk of Myocardial infarction and CAD-related mortality.

Type B personality

• Easy going.

• Relaxed.

• Non-competitive.

• Focuses more on enjoyment than on winning.

• Mnemonic: Bae → relaxed → come here

Type D personality

• Negative affectivity:
• Tendency to experience negative emotions.

• Social inhibitions:
• Tendency to not express emotions.

• Predisposed to development of coronary heart disease.

FORENSIC PSYCHIATRY

Mental Health Care Act: MHCA 2017

• New legislation for treatment and rights of patients with mental illness.

• Decriminalisation of suicide
• Earlier punished under section 309 of IPC.

National Mental Health Programme

• Covers all types of mental illness.

• National Mental Health Policy: 2014

• Mental health clinics established at district level.

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Criteria for Mental Health (IQ)

• Wechsler intelligence scale

• IQ formula: (Mental age / Chronological age) × 100

• Average for child = 90

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Wing’s Comprehensive Handicaps, Behaviour and Skills Schedule (HBS)

• Measures:
• abilities
• disabilities

Capacity

• Capacity to make mental health care or treatment related decisions.

• Ability to understand information relevant to treatment decisions.

• Understand consequences of decision or lack of decision.

• Ability to communicate decisions (verbally or in writing).

Advance directive

• Every person who is not a minor can make an advanced directive.

• Can mention:
• The way he wishes to be treated for a mental illness.
• The way he wishes not to be treated for a mental illness.
• Whom he wants to appoint as a nominated representative.

• Applicable only when capacity to take decisions is lost.

Nominated representative

• Any person can appoint a nominated representative.

• If person loses capacity, representative will help take decisions.

Admission of person with mental illness

• Independent admissions
• If the person wishes to get admitted.
• When they have capacity to make decisions.

• Supported admission
• For one who needs admission due to:
• Threatened/attempted bodily harm to self or others.
• Inability to take care of self, leading to risk of harm.
• Has lost capacity to make decisions.
• Needs high level support from nominated representative.
• Nominated representative can consent for admission.
• Section 89:
• Admission and treatment with high support needs up to 30 days.

Prohibited procedures

• ECT without muscle relaxants and anasthesia

• ECT for minors
• If psychiatrist considers it necessary:
• Take informed consent from guardian.
• Get permission from mental health review board.

• Restriction of psychosurgery for persons with OCD
• If psychiatrist considers it necessary:
• Take informed consent from patient.
• Get approval from mental health review board.

Other techniques

• Non-invasive.

• Invasive.

Non-invasive

ECT

rTMS (Repetitive Transcranial Magnetic Stimulation)

• Definition:
• Uses short pulses of magnetic energy to stimulate nerve cells.
• Repeated pulses →
• focal secondary electrical stimulation of cortical regions.

• Procedure:
• Patient: Awake & conscious.
• No Anesthesia
• Non Convulsions

• Indication:
• FDA approved for depression not improving with ≥1 antidepressant.

• Advantages:
• Safe side-effect profile.
• No cognitive side effects.

• Side effect:
• Most common:
• Scalp pain/discomfort.

Invasive

VNS

• Vagal nerve stimulation.

• Left vagal nerve stimulated by electrodes.

• Pulse generator implanted on chest.

• Serotonin neurons are stimulated.

• Long term adjunct treatment for chronic/recurrent depression in adults.
• For those with inadequate response to 4+ antidepressants.

Deep brain stimulation

• Implantation of leads into specific brain areas.

• Studied for chronic, intractable depression.

Psychosurgery

• Specific areas are targeted.

• Used for OCD.

Omega sign

• Omega shaped fold in forehead above root of nose.

• Due to excessive use of corrugator muscle.

• Seen in depression.

Veraguth's fold

• Triangular fold in the nasal corner of upper eyelid.

• Due to change in tone of corrugator and zygomatic facial muscles.

• Seen in depression.

• Mnemonic: Veruth jivikkumbo

Bender gestalt test/ bender visual motor gestalt test

• Assesses cognitive functions:
• Memory, sensory and motor functions.
• Language, executive functions.
• Arithmetic, visual spatial functions.

• Used as a screening tool for organic brain disorders.