Sexual, gender identity and personality disorders

Question 1

What are the 5 stages of falling in love?

Answer 1

1) HYPOTHALAMUS releases dopamine (ecstasy and excitement)
2) As dopamine increases, serotonin levels drop (feelings of infatuation/obsession)
3) Body releases Nerve Growth Factor (most prevalent in new lovers), which directly correlates with intensity of romantic feelings
4) Oxytocin and vasopressin also released by hypothalamus, responsible for feelings of connection and commitment - hormones are then stored in the PITUITARY GLAND which secretes hormones into body, entering bloodstream at times of extreme passion
5) Hormones affect different brain areas - activity increases in romantic core, AMYGDALA deactivates, standards for judging others grow blurry, person in love feels less stress and fear, and the result is overall feeling of unity between the people in love

Question 2

What key factors are involved in defining one’s sexual orientation?

Answer 2

Biological - genetics, prenatal hormones
Sociocultural - childhood temperament (aggression, activity level etc), playmate preferences and sex-typical/atypical activities (societal pressure involved, and also wont always relate to gender identity)

Around 10yrs, feelings of being different from opposite or same-sex peers, and into adolescence we see non-specific attraction (autonomic arousal) to a sex
Eventually this becomes more targeted and erotic/romantic, and at this stage someone is usually aware of their sexual orientation (admitting it is a separate issue)

Question 3

What is meant by “sex”?

Answer 3

Label, male or female
Assigned by doctor at birth, based on genitals, hormones and chromosomes
When someone’s sexual and repro anatomy doesn’t fit typical male or female, described as INTERSEX

Question 4

What is “gender”?

Answer 4

More complex - a social and legal status
Set of expectations from society about gender roles, behaviours, characteristics etc that serve as the basis of formation of a person’s social identity in relation to other members of society
Each culture has standards about how people should behave based on their gender

Question 5

What is meant by gender identity?

Answer 5

How someone feels inside themselves and how they express their gender through clothing, behaviour and appearance
Most people with identify as either male or female, some may feel different degrees of masculine and feminine; some may not feel either male or female, however, and may choose labels like “genderqueer” or “gender fluid”
Feelings about gender identity begin as early as 2-3 years

Question 6

How do assigned sex and gender identity interact?

Answer 6

Some people’s are pretty much the same, in line with each other –> CISGENDER
Other people feel their assigned sex is the opposite gender to their gender identity –> TRANSGENDER

Question 7

What is meant by sexual orientation?

Answer 7

Different from sex, gender and gender identity, this is about who you’re attracted to rather than who you are
Heterosexual - attracted to opposite gender
Homosexual - attracted to same gender
Bisexual - attracted to both male and female
Pansexual/queer - attraction spans many gender identities
Curious - unsure about orientation
Asexual - don’t experience any attraction to anyone

Question 8

What is believed about sexual orientation?

Answer 8

It isn’t yet clear how it is determined, but it is thought that it is likely caused by biological factors starting before birth
Orientation is not even set during life, but will be “fluid” - scientists believe orientations are on a spectrum and most people are somewhere in the middle between fully gay and fully straight
It has also been found that 11% of americans acknowledge some same-sex attraction, but only 3.5% actually label themselves as gay/bisexual etc - what people feel or do is not always the same as how they actually identify themselves

Question 9

How do different identities interact with each other?

Answer 9

Biopsychosocial processes influence individual identity (inc sexual orientation), sexual and gender identity development, and also social identity such as group membership
Sexual orientation and social identity also feed into sexual identity development, while also influencing each other at the same time

Question 10

What is gender identity disorder/gender dysphoria?

Answer 10

Condition in which someone feels trapped in the body of the wrong gender, uncomfortable with their body/assigned sex esp during puberty and/or the expected roles of their gender; a very stressful condition which has a number of psychological comorbidities and can impact on relationships
The driving force of the condition is to assume the identity of the correct sex, with no sexual goals involved

Question 11

How does the gender conflict of gender dysphoria affect people?

Answer 11

Affects different people in different ways - can influence behaviour, clothing, self-image. Some people may want to cross-dress, some may want to socially transition (pronouns and bathrooms), others may want to medically transition with sex change surgery/hormone treatments

Question 12

How does gender dysphoria differ from gender non-conformity?

Answer 12

Non-conformity refers to behaviours not matching gender norms/stereotypes e.g. girls behaving in ways more socially expected of boys
This is not a mental disorder

Question 13

How does gender dysphoria differ from being transgender?

Answer 13

Transgender=non-medical term to describe individuals whose gender identity/expression differs from assigned sex. These individuals may not identify with either binary category, so may use terms such as bigendered or genderqueer
Not all transgender people suffer from gender dysphoria - this mental disorder only occurs when the difference between the gender they were assigned and the gender they identify with leads to serious emotional distress
Psychological challenges faced by transgender individuals are caused by rejection and discrimination, not by the fact of having their transgender identity

Question 14

What does the term “transsexual” mean?

Answer 14

Individuals who have undergone medical/surgical treatment for gender reassignment
Some transsexual people identity as transgender but others primarily identify as the male or female gender to which they have transitioned

Question 15

What are some proposed causes of gender dysphoria?

Answer 15

Hormones that trigger development of biological sex may not work properly on brain, repro organs and genitals, causing differences
This may be caused by additional hormones in maternal system (maybe due to meds during pregnancy) or foetal insensitivity to hormones i.e. androgen insensitivity syndrome

Question 16

What two rare conditions may gender dysphoria result from?

Answer 16

Congenital adrenal hyperplasia - high level of male hormones produced in female foetus, causing genitals to become more male and in some cases the baby may be thought to be biologically male when born
Intersex conditions - babies born with genitals of both sexes/ambiguous (parents advised to wait until child old enough to decide own gender identity before changes made)

Question 17

What are non-surgical medical procedures to assist with gender dysphoria?

Answer 17

Hair growth/removal therapies
Hormone therapy
Psychological options involving realignment of psychological gender with biological sex (conversion therapy) DO NOT WORK and can lead to lasting depression, substance abuse and even suicide
Many transgender individuals do find counselling to be helpful for issues such as coming out, and dealing with stigma and repercussions and discrimination

Question 18

What do sexual dysfunction disorders affect?

Answer 18

Any stage of the sexual functioning process i.e. desire, arousal or orgasm stage, and any intervening aspects
There are parallel versions of most of the disorders for both genders
These disorders can be lifelong or acquired, and can be generalised or situational

Question 19

What are the 5 stages of the human sexual response cycle?

Answer 19

Desire - sexual urges in response to sexual cues/fantasies
Arousal - subjective sense of sexual pleasure and physiological signs of arousal e.g. penile tumescence, vasocongestion and vaginal lubrication
Plateau - Brief period before orgasm
Orgasm - In males, feeling of inevitability of ejaculation followed by ejaculation; in females, contractions of the walls of lower third of vagina
Resolution - Decrease in arousal after orgasm esp in men

Question 20

Which two disorders affect the desire stage of the cycle?

Answer 20

Hypoactive sexual desire disorder - little/no interest in sexual activity , masturbation/sexual fantasies etc are rare, very common condition
Sexual aversion disorder - Little interest in sex associated with extreme and intense fear/disgust relating to physical/sexual contact

Question 21

What two disorders affect the arousal stage of the cycle?

Answer 21

Male erectile disorder and female sexual arousal disorder (difficulty achieving/maintaining adequate lubrication)
Men more troubled than women by symptoms

Question 22

What are the two orgasm disorders?

Answer 22

Inhibited orgasm - female and male orgasmic disorder –> inability to achieve orgasm despite adequate desire and arousal, rare in adult males but most common complaint for women
Premature ejaculation - occurring before man/partner wishes it to, most prevalent dysfunction in men, most common in younger and inexperienced males

Question 23

What are sexual pain disorders and what are 2 examples?

Answer 23

Associated disorders which can drive some of the others e.g. causing intense fear of sex - defined by marked pain during intercourse
Dyspareunia - extreme pain during sex, despite adequate desire, arousal and orgasms; must rule out medical reasons for pain, other causes may be emotional/psychological, or physical issues such as not enough lubrication, more common in women
Vaginismus - Outer third of vagina in involuntary spasm - feels like ripping, burning or tearing, potentially linked to anxiety as prevalence higher in more conservative countries

Question 24

What are the stages of diagnosis for a sexual dysfunction disorder?

Answer 24

Comprehensive interview - detailed history of sexual behaviour, lifestyle etc
Medical exam - possible medical causes ruled out
Psychophysical evaluation - exposure to erotic material to see if any reaction, determine extent and pattern of physiological and subjective arousal, penile strain gauge in males and vaginal photoplethysmograph in females

Question 25

What are some possible causes of sexual dysfunction?

Answer 25

Biological - Physical disease, prescription meds (esp for mood disorders), substance abuse
Psychological - Anxiety vs distraction, psychological profiles associated with sexual dysfunction
Sociocultural - Erotophobia (learned negative attitudes), negative/traumatic sexual experiences, deterioration of interpersonal relationships and lack of communication

Question 26

What are some non-medical treatments for these dysfunctions?

Answer 26

Education
Master’s and Johnson’s Psychosocial intervention - also involves education, alongside sensate focus and non-demand pleasuring to help eliminate performance anxiety
Squeeze technique for premature ejaculation
Masturbatory training for female orgasm disorder
Use of dilators for vaginismus
Exposure to erotic material for low sexual desire

Question 27

What are medical treatments for sexual dysfunction like?

Answer 27

Mainly for erectile dysfunction, very few available for women
Viagra for erectile dysfunction but little effect on disorders of desire/drive
Injection of vasodilating drugs into penis
Penile prosthesis or implants
Vascular surgery
Vacuum device therapy

Question 28

What are paraphilias?

Answer 28

Disorders in which an individual experiences sexual attraction/arousal to inappropriate people/objects, and these people often experience more than one paraphilic pattern of arousal
High comorbidity with anxiety, mood and substance abuse disorders

Question 29

What are the 5 main types of paraphilias?

Answer 29

Fetishism - attraction to inanimate objects, key problem being that such behaviours become learned via conditioning in response to reward of orgasm and as such real disorders ultimately develop where arousal is ONLY possible in these ways
Voyeurism - arousal from observing an unsuspecting individual undressing/naked, risk of peeping is arousing
Exhibitionism - expose own genitals to unsuspecting stranger
Transvestic fetishism - sexual arousal with act of cross-dressing, males may show highly masculinised compensatory behaviours
Sexual sadism/masochism - Sadism is when gratification comes from harm on someone else, while masochism is when harm to self; some rapists are sadists but most don’t show paraphilic patterns of arousal (instead aroused by violence of sexual and non-sexual kinds)

Question 30

What causes paraphilic patterns of behaviour to develop?

Answer 30

Primarily some kind of reward in response to inappropriate behaviour –> dopamine and oxytocin released and behaviour becomes learned and sought after. Paradoxically, attempts to inhibit such behaviours can actually make patterns stronger
Root causes can include possible inadequate development of consensual adult arousal patterns or appropriate social skills for relating to adults, or early inappropriate sexual associations/experiences

Question 31

What is pedophilia?

Answer 31

Most distressing paraphilia in which attraction occurs to young people
Rare in females - strong gender imbalance suggests hormonal cause (androgenic) or possibly genetic

Question 32

What do most pedophiles try to do?

Answer 32

Rationalise the behaviour and engage in other moral compensatory behaviours

Question 33

How can pedophilic disorder be diagnosed?

Answer 33

In people who are willing to disclose it, or in people who deny sexual attraction to children but demonstrate objective evidence of pedophilia
Individual must either act on sexual urges or experience significant distress or interpersonal difficulty as a result of their urges
Without these criteria a person may have a pedophilic sexual orientation but not pedophilic disorder

Question 34

What are 3 proposed causes of pedophilia?

Answer 34

History of childhood sexual abuse - behavioural learning models suggest someone may become conditioned to imitate the behaviour
Potential relationship between hormones and behaviour, particularly role of aggression and male sex hormones
Less white matter

Question 35

What does psychophysical assessment of pedophilia involve?

Answer 35

Assessing extent of deviant pattern of arousal, assessing extent of desired sexual arousal to adult content, and assessing social skills and ability to form relationships

Question 36

What are psychosocial treatment options for pedophilia?

Answer 36

Behavioural and target deviant and inappropriate sexual associations -
Covert sensitisation - imaginal procedure involving aversive consequences
Orgasmic reconditioning - associating masturbation with appropriate stimuli
Family/marital therapy - addressing underlying interpersonal problems
Coping and relapse prevention - self control and handling risk
70-100% of individuals show improvement (except rapists and people with multiple paraphilias)

Question 37

What are sine drug-related treatments for pedophilic disorder?

Answer 37

Medications which act as chemical castration for dangerous sex offenders
Cyproterone Acetate - anti-androgen to reduce testosterone, sexual urges and fantasies
Medroxyprogesterone acetate - also reduces testosterone
Triptoretin - inhibits gonadotropin secretion (normally involved in erection and stimulating sex drive)
Drugs do work to reduce sexual desires and fantasies but don’t treat fact that, should desire return, attraction is still inappropriately to children

Question 38

Why does treatment for pedophilia present a problem?

Answer 38

People who have the condition rarely seek help voluntarily - counselling and treatment are often the result of a court order
In order for treatment to be successful, individual must be willing to recognise problem and be willing to participate

Question 39

What are personality disorders characterised by?

Answer 39

Longstanding, pervasive, inflexible and extreme and persistent patterns of behaviour and inner experiences including unstable positive sense of self and inability to sustain close relationships

Question 40

What does the DSM-5 describe?

Answer 40

A 3-cluster format for personality disorders - more inclusive and accommodates for individual differences in symptoms, also helping to capture sub-syndromal symptoms better

Question 41

What are common risk factors across the personality disorder spectrum?

Answer 41

Early adversity e.g. abuse or neglect
Unaffected/aversive parenting style
Twin studies have also suggested relatively high heritability

Question 42

What are the 3 clusters of personality disorders?

Answer 42

Odd/eccentric (similar to schizophrenia but less severe) - paranoid PD, Schizoid PD, Schizotypal PD
Dramatic/erratic - antisocial PD, borderline PD, Histrionic PD, narcissistic PD
Anxious/fearful - avoidant personality disorder, dependent PD, obsessive compulsive PD

Question 43

What are the key characteristics of paranoid PD?

Answer 43

Signs of distrust and suspiciousness beginning in early adulthood - unjustified suspiciousness of being harmed or deceived, unwarranted doubts about ability to trust friends, reluctance to confide, reading hidden messages into benign actions, angry reactions to perceived attacks on character

Question 44

What are the key characteristics of Schizoid PD?

Answer 44

Signs of aloofness and flat affect e.g. lack of desire for/enjoyment of close relationships, little interest in sex, indifference to praise/criticism, lack of friends

Question 45

What are the key characteristics of schizotypal PD?

Answer 45

Judged by outsiders as being similar to schizophrenia - interpersonal detachment, suspiciousness and psychoticism (unusual thoughts and behaviours), magical thinking, illusions (feel presence of something that isnt there), wearing strange clothes, talking to self, flat affect, enlarged ventricles and less temporal grey matter as seen in schizophrenia, and also treated using antipsychotic and antidepressant meds

Question 46

What is antisocial PD characterised by?

Answer 46

Pervasive disregard for rights of others, complete lack of empathy, pattern of irresponsible behaviours, irritability and physical aggression, impulsiveness, little regard for truth and little remorse for misdeeds.
Any sign of positive emotion is usually an act e.g. superficial charm
Risk factor includes development of conduct disorder before 15 years, and comorbid substance abuse is common; thought to be a genetic component to it

Question 47

Why is behaviour modification for antisocial PD difficult?

Answer 47

Demonstrate lack of fear/anxiety, low baseline levels of skin conductance and lower reactions to aversive stimuli, so modification harder as motivation for change is less

Question 48

What is Borderline PD like?

Answer 48

Different from APD as all harmful, impulsive and damaging behaviours are targeted at SELF, still a marked effect on others around though as relationships are often changeable and intense, and fear of abandonment leads to constant asking for feedback
Emotional reactivity - feelings towards others can change rapidly and inexplicably
Unstable sense of self, chronic feelings of emptiness and suicidal thoughts
Also experience transient psychotic or dissociative symptoms

Question 49

What are thought to be some underlying causes of BPD?

Answer 49

Genetics (60%) - gene abnormalities thought responsible for impulsivity and emotional dysregulation
Decreased function of 5HT system, particularly in PFC, and increased amygdala activation (arousal)

Question 50

What are appropriate targets for treatment of BPD?

Answer 50

Could direct at serotonergic imbalances but more effective to target social/environmental causative factors that increase propensity for developing the condition in the first place e.g. parental separation, verbal/emotional abuse during childhood etc

Question 51

What is Linehan’s Diathesis-Stress model?

Answer 51

Emotional dysregulation and reactivity have a possible biological diathesis, which interacts with social factors such as family members invalidating/discounting emotional experiences, punishing or ignoring demands –> official disorder and emotional outbursts by child to which parents attend

Question 52

Why is treatment of BPD tricky and what are some options?

Answer 52

Interpersonal problems tend to play out in therapy and patients may try to manipulate therapist
Meds include antidepressants and mood stabilisers
Dialectical behavioural therapy - focuses on acceptance and empathy plus CBT and emotion-regulation
Mentalization-based therapy - ability to think about thinking; long-term form of psychotherapy that helps make sense of thoughts and feelings and link these to behaviours.
Schema-focused cognitive therapy - identifying maladaptive assumptions that underlie cognitions

Question 53

What do you do in mentalization-based therapy?

Answer 53

Focus on difficulties in current life to improve understanding of self and others
Focus on what is going on in your mind and think about what might be going on in minds of others, particularly in situations that may cause a strong emotional reaction and problematic behaviours

Question 54

What is histrionic PD characterised by?

Answer 54

Constant attention seeking
Emotional overreactions and tendency to dramatize
Seductive behaviour and use physical appearance to draw attention to themselves
Highly suggestible and easily influenced
More common in women

Question 55

What is narcissistic PD characterised by?

Answer 55

Grandiose view of self
Preoccupation with fantasies of success
Self-centred behaviours such as demanding attention and adulation
Lack empathy
Signs of arrogance, envy and entitlement - enraged when not admired
Seek out high-status partners

Question 56

What does Kohut’s self-psychology model of Narcissistic PD suggest?

Answer 56

Many of the characteristics are actually masking low self-esteem with roots in childhood where maybe they felt valued not for their own self-worth but as a means to boost self-esteem of parents
Over-emphasis on achievements

Question 57

What is the social cognitive model of narcissistic PD?

Answer 57

Also posits idea of low self-esteem - interpersonal relationships as a way to bolster self-esteem rather than to actually experience any closeness

Question 58

What are the key features of avoidant PD?

Answer 58

Fear of criticism, rejection or disapproval - will avoid interpersonal situations for fear of embarrassment
Behave in restricted and inhibited ways in public out of feelings of inferiority and inadequacy
Avoid taking risks or trying new things
High comorbidity with social anxiety disorder and major depression

Question 59

How can avoidant PD be treated?

Answer 59

As for social anxiety, can use SSRIs (PFC has such high density of serotonin receptors a lot of imbalances can be treated this way) - elevating serotonin elevates mood
Social skills training
Psychotherapy

Question 60

What does dependent personality disorder involve?

Answer 60

Excessive need to be taken care of and have somebody else take responsibility for most major life areas
Struggle with decision-making without excessive advice/reassurance
Struggle to disagree with others - don’t want to lose their support
Do unpleasant things to obtain approval, helpless when alone
Preoccupied with fear of having to care for themselves

Question 61

What are people with obsessive compulsive personality disorder like?

Answer 61

Perfectionists, preoccupied with rules, details, schedules and organisation
Overly focused on work with limited time for leisure
Reluctant to delegate or make decisions
“Control freaks” - rigid and inflexible
Doesn’t involve obsessions and compulsions of OCD
Most commonly comorbid with avoidant personality disorder

Question 62

What are 4 differences between OCD and OCPD?

Answer 62

1) Signs and symptoms tend to remain same in PD while in OCD they vary in severity over time
2) Motive for unusual behaviour stems from need to be perfect, rather than need to prevent an imaginary disaster
3) Reluctant to seek help as don’t see problem, while in OCD they usually accept their condition and seek help
4) Seek help due to everyday conflicts with family/friends rather than due to need to control symptoms and tension on day-to-day activities

Question 63

What is the positive feedback loop associated with functional sexual performance?

Answer 63

Demand for sexual performance as start point
Positive affect and expectancies, perception of control –> attentional focus on erotic cues –> increased autonomic arousal –> increasingly efficient focus on erotic cues –> functional performance, and the positive feedback loop leads to repeated approach behaviours

Question 64

What is the negative feedback loop of dysfunctional sexual performance?

Answer 64

Demand for sexual performance as start point
Negative affect, perceived lack of control –> attentional focus on public consequences of not performing/other non-erotic issues –> Increased autonomic arousal –> Increasingly efficient attentional focus on consequences of not performing etc –> dysfunctional performance, and negative feedback leading to avoidance behaviours