Psychopathology: Anxiety, OCD, Feeding/Eating, Sleep/Wake, Sexual Dysfunctions, Gender Dysphoria

Question 1

What is the most common disorder according to the global burden of disease study?

Answer 1

anxiety disorders
(share features of excessive fear and anxiety and related behavioral disturbances)

Question 2

Diagnostic criteria for separation anxiety disorder?

Answer 2

• developmentally inappropriate and excessive fear or anxiety about being separated from attachment figures
• 3 of 8 symptoms: excessive distress when anticipating or experiencing separation from attachment figures, persistent reluctance to go to school, work or other place away from home because of fear of separation from attachment figures, repeated complaints of physical sx when separated or anticipating separation

(school refusal could be separation anxiety or social anxiety - school refusal looks like wanting to stay with parents, complain of physical symptoms, cry, plead, bargain, panic sx’s when its time to go to school)

• sx last for 4 weeks for children/adolescents or 6 months for adults
• develops after exposure to a stressful event (e.g. parental divorce, death of relative or pet)

Question 3

Treatment for separation anxiety?

Answer 3

• CBT (psychoed, exposure, relaxation techniques, cognitive restructuring - effectiveness increases with parent training)
• target school refusal to prevent development of social isolation, academic failure, secondary impairments)

Question 4

Diagnostic criteria about specific phobias?

Answer 4

• intense fear of or anxiety about a specific object or situation accompanied by avoiding the object ot situation or enduring it with intense distress
• fear or anxiety must be out of proportion to the actual danger posed by the object or situation
• persistent (ordinarily lasting for at least 6 months)
• specifiers: animal, natural environment (e.g. lightening, heights), blood-injection-injury, situation (e.g. elevators, bridges), other (e.g. situations that may cause vomiting, choking, catching an illness)
• onset usually in childhood, mean age about 10 years (twice as common in girls than boys)

Question 5

What is the two-factor theory explanation for the development of specific phobias?

Answer 5

• attributes phobic reactions to a combination of classical and operant conditioning

Classical conditioning - a previously neutral object or event becomes a conditioned stimulus and elicits a conditioned response of anxiety after being paired with an unconditioned stimulus that naturally elicits anxiety

Operant conditioning - person learns that avoiding the conditioned stimulus allows them to avoid experiencing anxiety. Avoidant behavior is negatively reinforced. Conditioned response isn’t extinguished bc person never has opportunities to experience the conditioned stimulus without the unconditioned stimulus.

Question 6

Treatment for specific phobias?

Answer 6

• exposure and response prevention (ERP) to extinguish the conditioned anxiety (exposure and preventing avoidant response)
• 2 types of EPR in vivo or imagination:
  1: Flooding - immediately exposing a client to most feared object/situation until anxiety decreases
  2: Graded/Graduated - constructing a list of about 10 anxiety provoking situations beginning with low level anxiety and ending with highest level of anxiety - each stage until the anxiety decreaes
• both types of exposure are considered to be effective - ppl are less likely to drop out of graded exposure
  – some evidence shows in vivo exposure is better than imagination, therapist led better than self-directed, virtual reality just as good as in vivo (esp heights and flying)
  – some phobias respond better to EPR and another intervention
  —blood-injection-injury subtype typically reacts to a feared stimulus with an increase in heart rate and BP followed by a decrease leading to fainting – EPR and applied tension helps to increase BP and prevent fainting

fear of heights = acrophobia

Question 7

Diagnostic criteria for social anxiety (social phobia)?

Answer 7

• fear or anxiety reaction to at least one social situation where the person is exposed to scrutiny by other
• person must fear exhibiting sx will be negatively evaluated and in response avoids situation or endures with intense fear
• fear or anxiety must be excessive to the actual threat - fear/avoidance must be persistent (at least 6 months) cause significant distress

Question 8

Treatment for social anxiety?

Answer 8

• CBT (cognitive restructuring and exposure) and antidepressants (SSRIs and SNRIs)
• CBT for children, adolescents and adults
• for adults: internet guided cbt is equivalent to in person for sx reduction of social anxiety and other anxiety disorders
• for children/adolescents: school based cbt is beneficial

Question 9

Diagnostic criteria for panic disorder?

Answer 9

• recurrent unexpected panic attacks with at least one attack followed by 1 month or more of persistent concern about additional attacks or consequences and/or significant maladaptive change in behavior

A panic attack is: “an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes”

• involves at least 4 or 13 sx: heart palpitations, sweating, nausea or abdominal distress, dizziness, fear of losing control or “going crazy,” fear of dying, paresthesia, derealization or depersonalization

(panic attacks can look similar to hyperthyroidism, cardiac arrhythmia, etc.)

Question 10

Treatment of panic disorder?

Answer 10

• Comprehensive CBT
  panic control treatment - combines interoceptive exposure with relaxation and other techniques for controlling symptoms

interoceptive exposure = deliberately exposing the person to the physical symptoms associated with panic attacks by for example having the person run in place, spin in circle, breath through a straw

antidepressants (e.g. imipramine) and benzodiazepines have been found useful for alleviating panic attacks (associated with high relapse if used alone)

Question 11

Diagnostic criteria for agoraphobia?

Answer 11

• marked fear or anxiety in at least 2 of 5 situations: public transportation, being in open spaces, being in enclosed spaces, standing in line or being in a crowd, being outside home alone
• person must fear or avoid situations due to concerns that escape will be difficult or that help will be unavailable if they develop panic symptoms or other embarrassing symptoms
• fear must be excessive to actual threat- must always elicit fear - actively avoided - require the presence of a companion or be endured with intense fear - avoidance must persist for at least 6 months

Question 12

Treatment of agoraphobia?

Answer 12

• invivo exposure and response prevention
• graded exposure (flooding is just as effective and may have better long-term effects)
• combining in vivo exposure with applied relaxation, breathing retraining, cognitive techniques does NOT improve outcomes – the key contributor to effectiveness of exposure is learning to tolerate high levels of fear and anxiety

Question 13

Diagnostic criteria for Generalized Anxiety Disorder (GAD)?

Answer 13

• excessive anxiety and worry about multiple events - occurs on most days for at least 6 months
• difficult to control - worry about a large # of events and are more likely to be associated with somatic sxs
• sxs must cause significant distress
• at least 3 of the following (or at least one for children): restlessness, being easily fatigued, difficulty concentrating, irritability, muscle tension, sleep disturbance
• worries are age related: children/adolescents worrying about catastrophic events and competence in sports, school. Adults worry about health and safety
• Most common comorbid disorders in order: major depressive disorder, social anxiety, specific phobia, PTSD

Question 14

RIsk factors for GAD and brain abnormalities?

Answer 14

• risk factors: family hx, temperament dimensions of behavioral inhibition, neuroticism, harm avoidance, childhood trauma, chronic stress
• brain abnormalities: ventrolateral and dorsolateral prefrontal cortex, anterior cingulate cortex, posterior parietal cortex, amygdala and hippocampus
  – reduced connectivity between regions of prefrontal cortex and anterior cingulate cortex and amygdala (weak top-down control of amygdala reactivity)

Question 15

Treatment for GAD?

Answer 15

• CBT and pharmacotherapy (SSRIs and SNRIs)
• People who do not respond to antidepressants may benefit from anxiolytic buspirone (Buspar) or benzodiazepine
• combined tx is effective: motivational interviewing + CBT for GAD, anxiety disorders, OCD (promising but unproven)

Question 16

Diagnostic criteria for OCD?

Answer 16

• recurrent obsessions and/or compulsions that are time consuming (more than 1 hour each day)

Obsessions: recurrent and persistent thoughts, urges, or images that are intrusive and unwanted - attempts to ignore or suppress and usually cause anxiety/distress

Compulsions: repetitive behaviors or mental acts that feel driven to perform either in response to an obsession or accordingly to rigidly applied rules (goal of compulsion is to reduce anxiety/distress or prevent an undesirable situation from happening) - excessive or not connected in a realistic way

Specifiers - based on level of insight into the veracity of beliefs and tics

• 90% of ppl with ocd have comorbid disorders: anxiety most common, depressive or bipolar, impulse control, substance use

Question 17

Prevalence rates and brain abnormalities of OCD?

Answer 17

• males have earlier age of onset than females
• slightly higher prevalence in males in childhood
• females slightly higher prevalence in adulthood
• lower-than-normal levels of serotonin
• elevated activity: caudate nucleus, orbito frontal cortex, cingulate gyrus, thalamus

Question 18

Treatment for OCD?

Answer 18

• Exposure response prevention (ERP) [exposure and ritual prevention]

– in vivo and or imagination exposure to anxiety-arousing thoughts, objects or situations and preventing engagement in ritualistic behaviors

– combined ERP and SSRI (or tricyclic clomipramine) is most effective in some circumstances (when one isn’t working on their own, severe OCD sxs, or comorbid disorders that respond well to antidepressants)

– CBT and ACT are also effective for OCD

Question 19

Diagnostic criteria for Body Dysmorphic Disorder and treatment?

Answer 19

• preoccupation with a perceived defect or flaw in physical appearance that’s not observable or appears to be minor to other people
• must have performed repetitive behaviors or mental acts because of defect or flaw (e.g. mirror checking, skin picking)
• many have ideas or delusions of reference (they believe that other people are mocking or taking special notice of them because of their physical appearance)
• may seek medical treatment to correct defect or flaw

– considered an obsessive - compulsive related disorder

Question 20

What are feeding and eating disorders?

Answer 20

Persistent disturbance of eating or eating related behavior that results in altered consumption or absorption of food and that significantly impairs physical health or psychosocial functioning

Question 21

What is pica?

Answer 21

• persistent eating of non-nutritive, nonfood substances (e.g. paper, paint, coffee grounds) for at least 1 month that’s inappropriate for the person’s developmental level and is not a culturally or socially acceptable practice
• can occur at any age - most common among children and elevated rate among pregnant women
• can lead to intestinal obstruction, lead poisoning, other medical complications

Question 22

Diagnostic criteria for anorexia nervosa?

Answer 22

– restriction of energy intake that causes significantly low body weight for the person’s age, sex, developmental trajectory, physical health

– must have (a) an intense fear of gaining weight or becoming fat or engage in behavior that interferes with weight gain
(b) a disturbance in the way they experience their weight or shape, self-evaluations that are too influenced by weight and shape or lack of awareness of the seriousness of their low weight

specifiers: restricting or binge-eating/purging
course: in partial remission or full remission
severity: determined by person’s current BMI

– often co-occurs with depression or anxiety (esp OCD) (anxiety often preceded onset of anorexia)

– medical complications usually a direct result of malnutrition and extreme weight loss - affects nearly all of the major organ systems, can lead to death

Question 23

Prognosis of anorexia nervosa?

Answer 23

• involves frequent relapses before a stable pattern of eating and weight maintenance is attained
• one of the most difficult to treat because people with the disorder often deny they have a eating problem and resist treatment
• prognosis is often considered worse than bulimia - some evidence shows that they may be similar

9 year follow up: 31.4 % of those with anorexia and 68.2% of those with bulimia recovered

22 year follow up: 62.8 % of those with anorexia and 68.2% of those with bulimia recovered

Question 24

General treatment goals for anorexia ?

Answer 24

• restore person to a healthy weight and address physical complications

(a) increasing person’s motivation to participate in treatment

(b) providing person with education about healthy nutrition

(c) helping person identify and change beliefs, attitudes, and emotions that are contributing to ED

(d) treat underlying psychological conditions such as low self-esteem, impulse control problems

(e) enlisting family support and providing family therapy when appropriate

(f) identify strategies to prevent relapse

Question 25

Treatment options for anorexia nervosa?

Answer 25

CBT for anorexia nervosa: post hospitalization based on the assumption that “shape- and weight-related concerns engender dietary restriction and other extreme methods of weight control that maintain anorexic symptoms” – behavioral strategies to establish regular eating patterns and eliminate frequent body-checking and cognitive strategies to identify and replace problematic thinking and enhance motivation

CBT-E (enhanced CBT for eating disorders): transdiagnostic treatment - proposes eating disorders share the same core psychopathology - excessive value given to physical appearance and weight. Personalized and flexible treatment that focuses on factors maintaining symptoms

FBT (family-based treatment for A): outpatient for adolescents who are medically stable. 3 phases: (1) parents take charge of adolescents nutritional rehab and weight restoration with help of therapist (2) control over eating is gradually returned to adolescent (3) adolescent developmental issues are addressed - age appropriate independence and healthy parent-child relationships

Pharmacotherapy: inconsistent results - antipsychotic olanzapine can be useful for fostering initial weight gain. SSRI fluoxetine improving weight maintenance (mostly recommended to treat comorbid symptoms)

Question 26

Diagnostic criteria for bulimia nervosa?

Answer 26

• recurrent episodes of binge eating accompanied by a sense of a lack of control, inappropriate compensatory behavior to prevent weight gain (e.g. self-induced vomiting, excessive exercise), self-evaluation that’s excessively influenced by body shape and weight
• at least once a week for 3 months or more (binge eating and compensatory behavior)
• specifiers indicate course & severity: partial or full remission & average number of episodes of inappropriate compensatory behavior per week

(frequently co-occurs with depression and anxiety, anxiety often precedes)
(most are within normal weigh range or overweight)
(medical complications from compensatory behavior - purging can cause dental erosion, caries, gastroesophageal reflux, dehydration - electrolyte imbalance can lead to heart arrhythmias and death)

Question 27

Treatment for bulimia nervosa?

Answer 27

• Nutritional rehab + CBT
• Enhanced CBT for eating disorders (CBT-E)
• Interpersonal therapy (IPT)
• Family-based treatment for bulimia (similar to protocol for anorexia - difference is that 1st phase is to interrupt adolescents binging, purging, restrictive dieting and other undesirable methods - establishing healthy eating) [teens with bulimia are more ego-dystonic and motivated to change - treatment is more collaborative]
• SSRIs (esp fluoxetine) effective for alleviating comorbid depression and for reducing bing eating and purging for patients without depression (combined CBT and antidepressants more effective than medication alone, not necessarily better than CBT alone)

(CBT, CBT-E and IPT have comparable effects but CBT/CBT-E are preferred bc IPT takes too long)

Question 28

what are the phases of CBT-E (Eating Disorder)

Answer 28

CBT-E (enhanced CBT for eating disorders): transdiagnostic treatment - proposes eating disorders share the same core psychopathology - excessive value given to physical appearance and weight. Personalized and flexible treatment that focuses on factors maintaining symptoms

Stage 1: engaging patient in treatment - jointly creating a formulation of the patient’s eating problem that identifies the processes that are maintaining the problem. Establish self-monitoring of eating and relevant behaviors, thoughts, feelings and events - providing education about weight and eating - establishing a pattern of regular eating

Stage 2: brief transitional stage reviewing patients progress - identifying new problems and barriers to change - revising formulation

Stage 3: addressing patients over-evaluation of shape and weight and exploring its origins - identifying events that trigger undesirable eating - addressing clinical perfectionism, low self-esteem, interpersonal problems

Stage 4: helping patient identify ways to maintain progress and reduce risk of relapse

Question 29

Difference between in person and telepsychology for individuals with bulimia?

Answer 29

• generally comparable - slightly different outcomes
• same in acceptability to clients and retention
• abstinence from binge eating and purging were slightly (non-significantly) higher for in person cbt
• in person cbt significantly greater reduction in eating-disordered cognition

Question 30

Difference in motivation between those with bulimia and those with anorexia?

Answer 30

• those with bulimia are more distressed by their symptoms and more motivated to change behavior
• higher levels of autonomous/intrinsic motivation predicted greater reduction in overall symptoms and a low risk for dropping out of treatment (compared to controlled/extrinsic motivation) for bulimia, anorexia and other feeding or eating disorders

Question 31

Diagnostic criteria for Binge Eating Disorder (BED)?

Answer 31

• recurrent episode of binge eating that involves eating an amount of food that is larger than what most people would eat during a similar period of time and in similar circumstances + a lack of control over eating during episodes
• must have at least 3 of 5 characteristic symptoms: eating more rapidly than usual, eating until uncomfortably full, eating large amounts when not hungry, feeling alone due to embarrassment about one’s binge eating, feeing disgusted, depressed or very guilty about binge eating
• have had episodes that occurred on average at least once a week for 3 months

sx severity: mild, moderate, severe, extreme - determined by number of episodes each week

• 2 to 3 times more common in women than in men and occurs in people who are normal weight, overweight or obese

Question 32

Differences between Binge Eating Disorder and Bulimia?

Answer 32

• no recurrent inappropriate compensatory behaviors
• usually better response to treatment
• dieting often follows the onset of BED vs. dysfuntional dieting precedes bulimia
• BED is associated with significant psychiatric comorbidity that is comparable to comorbidity associated with bulimia and anorexia

Question 33

Treatment of Binge Eating Disorder (BED)?

Answer 33

• CBT - Enhanced (CBT-E) and Interpersonal therapy (IPT)
• both produce significant reduction in binge eating, CBT-E can sometimes be more effective
• SSRIs (fluoxetine, paroxetine, sertraline), anti-seizure medication topiramate, and CNS stimulant lisdexamfetamine
  – medication alone is less effective than CBT (CBT+medication is no more effective than CBT alone)
• focus on binge eating before or concurrently with weight loss with patients who are overweight/obese with BED

Question 34

What are elimination disorders and treatment?

Answer 34

• enuresis (repeated voiding of urine into the bed or clothing) - urination either occurring 2 or more times a week for at least 3 consecutive months. Urination is always or usually involuntary - must be at least 5 years old
• specifier used for time period: nocturnal only, diurnal only, nocturnal and diurnal
• Treatment for nocturnal enuresis: moisture alarm (bell-and-pad) which causes a bell to ring when a child begins to urinate while sleeping
• antidiuretic hormone desmopressin used also reduced or stops bedwetting - associated with high relapse when discontinued

Question 35

What are sleep-wake disorders?

Answer 35

“dissatisfaction regarding the quality, timing, and amount of sleep … [with] resulting daytime distress and impairment”

Question 36

What is insomnia?

Answer 36

• dissatisfaction with sleep quality or quantity thats associated with 1 or more 3 symptoms: difficulty initiating sleep, difficulty maintaining sleep, early-morning awakening with an inability to return to sleep
• must occur at least 3 nights a week
  -present for at least 3 months
  -occur despite opportunities for sleep

3 types of insomnia: most common is a combination of all three types
1 - sleep-onset (initial) insomnia that involves difficulty falling asleep (most common single type)
2 - sleep maintenance (middle) insomnia involves frequent or extended awakening during the night
3 - late insomnia involves awakening in the early morning with an inability to return to sleep

• retrospective subjective reports compared to objective measures (e.g. polysomnography): subjective reports overestimate sleep latencies and time spent awake during the night, underestimate total amount of sleep time

Question 37

Treatments for insomnia?

Answer 37

• multi compotent CBT that incorporates stimulus control or sleep restriction with sleep-hygiene education, relaxation training and/or cognitive therapy
• stimulus control involves strengthening the bedroom and bed as cues for sleep (e.g. by going to bed only when tired and sleeping only in the bedroom)
• sleep restriction involves restricting time allotted for sleep each night to time spent in bed matches sleep requirements

Question 38

What is narcolepsy?

Answer 38

• attacks of an irrepressible need to sleep that causes sleep or daytime naps at least 3 times a week for 3 months or more
• requires episodes of cataplexy (loss of muscle tone), hypocretin deficiency, or a rapid eye movement latency of 15 minutes or less as determined by nocturnal sleep polysomnography
• includes hypnagogic and hypnopompic hallucinations, sleep paralysis when falling asleep or awakening
• cataplexy is often triggered by a strong emotion, so people with narcolepsy may attempt to control their emotions to prevent sleep episodes

Question 39

What are hypnagogic and hypnopompic hallucinationss?

Answer 39

vivid hallucinations just before falling asleep (hypnagogic) or just after awakening (hypnopompic), respectively

Question 40

Treatment for narcolepsy?

Answer 40

Behavioral strategies and medication:

• behavioral strategies (establishing good sleep habits, taking daytime naps and staying active)
• Medications are used to improve alertness and reduce cataplexy
  – medications for alertness include: modafinil and its newer form armodafinil (increases dopamine levels), amphetamines and other psychostimulants (e.g. methylphenidate) - increases dopamine levels and to a lesser degree increases serotonin and norepinephrine
  –medication for cataplexy: antidepressant (venlafaxine, fluoxetine, and clomipramine)

For patients who do not respond to these medications: sodium oxybate - it’s a derivative of a natural chemical in the brain and is taken at bedtime to improve deep sleep at night and reduce cataplexy and daytime sleepiness

Question 41

What are the non-rapid eye movement sleep arousal disorders?

Answer 41

• sleepwalking and sleep terrors - recurrent episodes of incomplete awakening from sleep that usually occur during Stage 3 or 4 sleep in the first third of a major sleep period

Sleepwalking involves getting out of bed during sleep and walking about and may include sleep-related eating or sexual behavior

episodes of sleep terror involve an abrupt arousal from sleep that usually starts with a panicky scream and is accompanied by intense fear and autonomic arousal (e.g., tachycardia, rapid breathing)

• unresponsive to attempts to awaken or comfort them during a sleepwalking or sleep terror episode
• on awakening, has little or no memory of dream imagery and cannot recall the episode.
• occur most often in childhood and decrease in frequency with increasing age.

Question 42

What is a nightmare disorder?

Answer 42

• “repeated occurrences of extended, extremely dysphoric, and well-remembered dreams that usually involve efforts to avoid threats to survival, security, or physical integrity”
• usually occur during REM (rapid eye movement) sleep in the second half of a major sleep period.
• when awakened during a nightmare, person is usually oriented and alert but may continue to experience a dysphoric mood

Question 43

What are the general characteristics of all sexual dysfunction disorders?

Answer 43

“a clinically significant disturbance in a person’s ability to respond sexually or to experience sexual pleasure”

Rule out: (1) nonsexual mental disorder
(2) serious relationship disturbance or other stressor
(3) effects of a drug or medical condition

All but one (genito-pelvic/pain penetration disorder - onset or severity) have the following specifiers:
(1) onset: lifelong or acquired
(2) extent: generalized or situational
(3) severity: mild, moderate, severe

Question 44

Diagnostic criteria for erectile disorder?

Answer 44

• at least 1 of 3 symptoms on 75%-100% of all occasions of sexual activity
• symptoms for at least 6 months
• marked difficulty obtaining an erection during sexual activity
• marked difficulty maintaining an erection until completion of sexual activity
• marked decrease in erectile rigidity

(organic etiology can be ruled out if the person has spontaneous erection when not planning to engage in sexual activity - has morning erections - or has erections when masturbating or when with a sexual partner other than usual partner)

Question 45

Treatment for Erectile Disorder?

Answer 45

• Behavioral techniques: reducing performance anxiety and increasing sexual stimulation (e.g. sensate focus - series of activities for a couple to focus on pleasurable sensations associated first with non-sexual touching, then sexual touching and finally sexual intercourse
• Pharmacotherapy: sildenafil citrate (viagra), tadalafil (Cialis), vardenafil (levitra) - all increase blood flow to penis

Question 45

Diagnosis and treatment for premature (early) ejaculation?

Answer 45

• persistent or recurrent pattern of ejaculation during partnered sexual activity within approximately one minute of vaginal penetration and before person desires it
• symptoms present for 6 months or more, 75-100% occasion of sexual activity
• Treatment: sensate focus (reduce performance anxiety), start-stop technique or pause-squeeze technique to help learn control ejaculation
• some evidence shows that low level of serotonin contributes - SSRI (paroxetine) taken daily can delay ejaculation

Question 46

Diagnosis and treatment of genito-pelvic pain/penetration disorder?

Answer 46

for at least 6 months or longer –
persistent or recurrent problems with at least 1 of the following:
(1) vaginal penetration during intercourse
(2) marked vulvovaginal or pelvic pain during intercourse or penetration attempts
(3) marked anxiety about vulvovaginal or pelvic pain before, during or as the result of vaginal penetration
(4) marked tensing of pelvic floor muscles during attempted vaginal penetration

• could be linked to a history of sexual and/or physical abuse or onset after a history of vaginal infections
• interventions: relaxation training, sensate focus, topical anesthetic, vaginal dilators, kegel exercises (gain control of pelvic floor muslces)

Question 47

Diagnosis and treatment of female orgasmic disorder (FOD)?

Answer 47

for at least 6 months:
(1) marked delay in, infrequency or, or absence of orgasm or markedly reduced intensity of orgasmic sensations on all or almost all occasions of sexual activity

• CBT techniques and directed masturbations being the most empirically supported first line of treatment - sex education, sensate focus, anxiety reduction techniques, mindfulness training and/or communication skills training

Question 48

Diagnostic criteria for gender dysphoria?

Answer 48

• incongruence between one’s assigned gender and one’s experienced or expressed gender
• for children, at least 6 of 8 symptoms, for at least 6 months:
• a strong desire to be other gender,
• strong preference for wearing clothes of the other gender,
• strong preference for toys/activities typically used by other gender
• strong preference for playmates of other gender
• strong dislike of own sexual anatomy
• for adolescents and adults: at least 2 of 6 symptoms, for at least 6 months:
• strong desire to be rid of one’s primary and/or secondary sex characteristics
• strong desire to be other gender
• strong desire to be treated as other gender
• strong conviction that one has feelings and reactions that are characteristic of other gender

Question 49

Treatment for gender dysphoria / care for gender diverse youth?

Answer 49

• Dutch protocol: based on the assumption that gender dysphoria, or a transgender identity, persists into adolescence in only a small minority of people - for children under 12 y/o - watchful waiting; first signs of puberty – social transition and puberty-blocking drugs are started for children who are persistent in their gender dysphoria. This gives children time to further explore their gender identity and decide if they want to start cross-sex hormone therapy when they’re 16 years of age and undergo gender-affirming surgeries after they’re 18
• Gender-affirmative model: (most widely accepted model) - based on the assumption that “a child of any age may be cognizant of their authentic identity and will benefit from a social transition at any stage of development” and
  (a) gender variations are not disorders
  (b) gender presentations are diverse and vary across cultures
  (c) gender is not always binary and may be fluid
  (d) child’s psychological problems are often secondary to negative interpersonal and cultural reactions to child
  Steps – social transition followed by puberty blockers, cross-sex hormones and surgeries

Gender affirming surgery: decrease in gender dysphoria, improved self-satisfaction, low incidence of regret. transgender male patient have somewhat more positive outcomes than transgender females - positive outcomes linked to careful diagnostic screening, psychological stability, adequate social support, lack of surgical complications

Question 50

What is paraphilia and a paraphilic disorder?

Answer 50

“intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners” - for at least 6 months

and a paraphilic disorder as a paraphilia that “is currently causing distress or impairment to the individual or … has entailed personal harm, or risk of harm, to others”

Question 51

Treatment for paraphilic disorders?

Answer 51

• CBT + group therapy, marital therapy and/or pharmacotherapy
• CBT strategies: cognitive restructuring, empathy, skills training
• Behavioral strategies: classical conditioning and covert sensitization and orgasmic (masturbatory) reconditioning
• Covert sensitization: aversive counterconditioning that’s conducted in imagination and replaces sexual arousal with fear or other undesirable response
• Orgasmic reconditioning: instructing person to switch while masturbating from fantasizing about paraphilic object to fantasizing about something more appropriate
• Pharmacotherapy: gonadotropin-releasing hormone (e.g. Lupron), antiandrogens (e.g. Depo-Provera) - these drugs reduce sexual desire (serious side effects, relapse as soon as discontinued) - SSRIs for less serious disorders or triggers

Question 52

What is frotteuristic disorder? Transvestic disorder? pedophilic disorder? fetishistic disroder? exhibitionistic disorder? (all paraphilic disorders)

Answer 52

Sexual arousal from:

Frotteuristic disorder: touching or rubbing against a nonconsenting adult as manifested in fantasies, urges, behaviors (must have acted on the urge)

Transvestic disorder: cross-dressing for the purpose of sexual arousal (most men identify heterosexual, may have sexual relations with other men)

Pedophilic disorder: involving sexual activity with a child or children 13 years or younger - must have acted on the urges - must be 16 y/o and at least 5 years old than child/children

Fetishistic disorder: nonliving object or specific non-genital body part

Exhibitionistic disorder: exposing one’s genitals to an unsuspecting person (3 subtypes: exposing genitals to prepubertal children, physically mature individuals, or both children and mature individuals) - can be diagnosed with subjective report or when person denies but there is objective evidence