Transcript The Anxiety Disorders Some Practical Questions & Answers

The Sexual
Problem Patient
A Problem-Oriented Approach to
Diagnosis and Treatment1,2,
A Presentation for SOMC Medical Education
Kendall L. Stewart, M.D.
February 15, 2008
I want to speak frankly, not to offend. From now on, people will expect you to be an expert. Be one.
Please purchase and study, “The New Sex Therapy,” by Helen Singer Kaplan (1974), and “Sex in America,”
by Kolata, Laumann and Michael (1995).
1
2
What are some common clinical misperceptions
about sexual functioning?
• Married people talk
freely about their sexual
preferences.
• Sex makes everything
all right.
• The man is responsible
for his woman's orgasm,
and if she doesn't come
three times he ain't
worth spit.1
1
Most listeners have assumed this is a typo.
• You should go along
with what your partner
wants even if you don't
enjoy it.
• Sex is 99% of marriage.
• You haven't had an
affair until you've had
sex.
• Oral sex is not real sex.
What are some other common clinical
misperceptions about sexual functioning?
Everybody
30%
70%
Have Sexual Problems
• If you're not getting it at
home, it's OK to have an
affair.
• Physicians and other
counselors are comfortable
talking about sex.
• Kids know everything there
is to know about sex these
days.1,2
• Because of HIV, most people
are practicing safe sex.
Don't
I once treated a young woman who was determined to remain celibate. Her boyfriend had a condom, but
neither of them knew how to put it on. Sex is a powerful drive that sometimes occasions regret.
2 An ant married an elephant.
1
What disorders are included in this
category?
• Sexual
Dysfunctions
• Paraphilias
• Gender Identity
Disorders
What are Sexual Dysfunctions?1,2
characterized by
disturbance in sexual
desire and in the
psychophysiologic
changes that
characterize the sexual
response cycle and cause
marked distress and
interpersonal difficulty
1
2
• Sexual Desire
Disorders
• Sexual Arousal
Disorders
• Orgasmic Disorders
• Sexual Pain Disorders
• Sexual Dysfunction
due to a [GMD]
Many sexual problems will turn out to be communication or relationship problems.
I worked with an older couple. The wife hated oral sex.
How do you treat the Sexual
Dysfunctions?
• Dual-sex therapy1
• Specific techniques and
exercises
• Hypnotherapy
• Behavior therapy
• Group therapy
• Analytically oriented sex
therapy
• Biological treatments
It is rare to see an isolated sexual dysfunction outside of troubled relationship context. A woman was
very demanding of her husband, but she saw no relationship between her demands and his ED.
1
What is dual-sex therapy?
• The focus is on the marital unit instead of the
individual.
• The couple “owns” the problem.
• A male and female therapy team meet with the
couple to evaluate, educate and prescribe
behavioral interventions.1
• Sensate focus exercises are the key intervention.
• Psychotherapy sessions follow each period of
exercise.
1 As
always, motivation is a major issue. Few couples will take the time. Few troubled married people will
Invest in marital therapy to the tune of a new wide-screen plasma TV. Marital therapy is straightforward.
What specific techniques and exercises
may be helpful?
• Graduated dilation is helpful for
vaginismus.
• The “squeeze” technique is helpful for
premature ejaculation.1
• Masturbation may be helpful for male
hypoactive sexual desire disorder
• Masturbation using a vibrator may be
helpful for female orgasmic disorder.
1
Here is a treatment protocol for successfully treating premature ejaculation.
What are some of the biological
treatments that are available?
• Sildenafil 50 mg and various “me-too” drugs
have revolutionized the treatment of ED.1
• Treating the underlying mental disorder can
help, but many of these drugs cause sexual
dysfunction on their own.
• Vacuum pumps, constricting rings and self
injection still have some role.
• Surgical procedures have fallen out of favor.
• No widely accepted biological treatments for
female sexual dysfunction currently exist.
1 These
newer drugs are usually very effective for antidepressant-induced sexual dysfunction. I treated a
couple who were very dissatisfied with his penile prosthesis.
What are Paraphilias?
Characterized by
recurrent, intense sexual
urges, fantasies, or
behaviors that involve
unusual objects, activities,
or situations and cause
clinically significant
distress or impairment in
social, occupational, or
other important areas of
functioning1
1 This
• Some Diagnoses
–
–
–
–
–
–
–
–
–
Exhibitionism
Fetishism
Frotteurism
Pedophilia
Sexual masochism
Sexual sadism
Transvestic fetishism
Voyeurism
Paraphilia NOS
is overwhelmingly a male problem. They are rarely self-referred. The court-mandated treatment of
exhibitionists is typical.
How do you treat paraphilias?
Patients in Child Identity
Disorder Clinics
30
25
20
15
10
5
0
Boys
• Insight-oriented
psychotherapy is the most
common approach.
• Motivation is an issue.1
• Negative behavior therapy
has a role in some cases.
• Antiandrogens are
controversial.
• SSRIs have enjoyed
limited success.
Girls
I wouldn’t accept these patients unless there was a “hammer.” I told them that the minimum treatment
was five years.
1
What are Gender Identity Disorders?
Characterized by
strong and
persistent crossgender
identification
accompanied by
persistent
discomfort with
one's assigned sex1
1 These
• Some Diagnoses
– Gender identity
disorder in children
– Gender identity
disorder in adolescents
or adults
– Gender identity
disorder NOS
– Sexual disorder NOS
disorders are rare but dramatic. I have treated a number of them.
How do you treat the gender identity
disorders?
• It is rarely successful if the goal
is to reverse the disorder.
• Secondary depression or
anxiety is the usual focus.
• Surgical treatment is definitive.
• Both sexes may be treated with
hormones in lieu of surgery.
Where can you learn more?1
•
American Psychiatric Association, Diagnostic and
•
Department of Behavioural Neurosciences,
McMaster University, PsychDirect: Evidence Based
Mental Health Education & Information,
http://www.psychdirect.com/anxiety/soc.html
Goldman HH, Review of General Psychiatry, Fifth
Edition, 2000
Kaplan HI, Sadock BJ, Synopsis of Psychiatry, Tenth
Edition, 2007
Jacobson JL and Jacobson AM, Psychiatric Secrets,
Second Edition, 2001
Stahl SM, Essential Psychopharmacology:
•
•
•
•
•
1Please
Statistical Manual of Mental Disorders, Fourth
Edition, Text Revision, 2000
Neuroscientific Basis and Practical Applications,
Second Edition, 2000
Stewart KL, “Dealing With Anxiety: A Practical
Approach to Nervous Patients and an Overview of
the Objectives in the Anxiety Module in the OUCOM
Psychiatry Block,” 2000
visit www.KendallLStewartMD.com to download related White Papers and presentations.
How can you contact me?1
Kendall L. Stewart, M.D.
VPMA and Chief Medical Officer
Southern Ohio Medical Center
President & CEO
The SOMC Medical Care Foundation, Inc.
1835 27th Street
Waller Building
Suite B-01
Portsmouth, Ohio 45662
740.356.8153
[email protected]
[email protected]
www.somc.org
www.KendallLStewartMD.com
1All
speaking and consultation fees are contributed to the SOMC Endowment Fund.
Are there other questions?
www.somc.org

Justin Greenlee, DO
OUCOM 2004
Safety  Quality  Service  Relationships  Performance 