seminar on sexual disorder prepared by tsega t. 2013GC..pptx

seminar on sexual disorder prepared by t. 2022..ppt

1. Sexual Dysfunctions Prepared by: Tsega T. Assessor: Dr. Girma M.

2. Outline The Central Nervous System and Sexual Behavior Neurotransmitters Physiological Responses Definition Classification Sexual Desire Disorders Sexual Arousal Disorders Orgasm Disorders Sexual Pain Disorders Sexual Dysfunction due to a General Medical Condition substance-induced sexual dysfunction sexual dysfunction not otherwise specified. Hx Treatment

3. The Central Nervous System and Sexual Behavior Cortex: is involved both in controlling sexual impulses and in processing sexual stimuli that may lead to sexual activity Limbic system: is directly involved with elements of sexual functioning Brainstem: sites exert inhibitory and excitatory control over spinal sexual reflexes Spinal Cord: Sexual arousal and climax are ultimately organized at the spinal level. Sensory stimuli related to sexual function are conveyed via afferents from the pudendal , pelvic, and hypogastric nerves. Several separate experiments suggest that sexual reflexes are mediated by spinal neurons in the central gray region of the lumbosacral segments.

4. Neurotransmitters Dopamine, epinephrine, norepinephrine , and serotonin, are produced in the brain and affect sexual function Dopamine is presumed to increase libido. Serotonin, produced in the upper pons and midbrain, exerts an inhibitory effect on sexual function. Oxytocin is released with orgasm and is believed to reinforce pleasurable activities.

5. Physiological Responses Sexual response is a true psychophysiological experience William Masters and Virginia Johnson observed that the physiological process involves Increasing levels of vasocongestion and myotonia (tumescence) and The subsequent release of the vascular activity and muscle tone as a result of orgasm ( detumescence )

6. DSM-IV-TR defines a four-phase response cycle: phase 1, desire; phase 2, excitement; phase 3, orgasm; phase 4, resolution. It is important to remember that the sequence of responses can overlap and fluctuate. Additionally, a person's subjective experiences are as important to sexual satisfaction as the objective physiologic response

7. Phase 1: Desire The classification of the desire (or appetitive) phase, reflects the psychiatric concern with motivations, drives, and personality. The phase is characterized by sexual fantasies and the desire to have sexual activity.

8. Phase 2: Excitement The excitement and arousal phase, brought on by psychological stimulation (fantasy or the presence of a love object) or physiological stimulation (stroking or kissing) or a combination of the two, consists of a subjective sense of pleasure. penile tumescence leads to erection in men and vaginal lubrication occurs in women. The nipples of both sexes become erect A woman's clitoris becomes hard and turgid, and her labia minora become thicker as a result of venous engorgement. Initial excitement may last from several minutes to several hours. With continued stimulation, a man's testes increase 50 percent in size and elevate. A woman's vaginal barrel shows a characteristic constriction along the outer third, known as the orgasmic platform.

9. The clitoris elevates and retracts behind the symphysis pubis, and as a result is not easily accessible. Stimulation of the area, however, causes traction on the labia minora and the prepuce and intrapreputial movement of the clitoral shaft. Women's breast size increases 25 percent. Continued engorgement of the penis and the vagina produces color changes, particularly in the labia minora , which become bright or deep red. Voluntary contractions of large muscle groups occur, heartbeat and respiration rates increase, and blood pressure rises. Heightened excitement lasts from 30 seconds to several minutes.

10. Phase 3: Orgasm The orgasm phase consists of a peaking of sexual pleasure, with the release of sexual tension and the rhythmic contraction of the perineal muscles and the pelvic reproductive organs. A subjective sense of ejaculatory inevitability triggers men's orgasms. The forceful emission of semen follows. The male orgasm is also associated with four to five rhythmic spasms of the prostate, seminal vesicles, vas, and urethra. In women, orgasm is characterized by 3 to 15 involuntary contractions of the lower third of the vagina and by strong sustained contractions of the uterus, flowing from the fundus downward to the cervix.

11. Both men and women have involuntary contractions of the internal and external anal sphincters. These and the other contractions during orgasm occur at 0.8-second intervals. Other manifestations include voluntary and involuntary movements of the large muscle groups, including facial grimacing and carpopedal spasm. Blood pressure rises 20 to 40 mm (both systolic and diastolic), and the heart rate increases up to 160 beats per minute. Orgasm lasts from 3 to 25 seconds and is associated with a slight clouding of consciousness

12. Phase 4: Resolution Resolution consists of the disgorgement of blood from the genitalia ( detumescence ), which brings the body back to its resting state. If orgasm occurs, resolution is rapid and is characterized by a subjective sense of well-being, general relaxation, and muscular relaxation. If orgasm does not occur, resolution may take from 2 to 6 hours and may be associated with irritability and discomfort. After orgasm, men have a refractory period that may last from several minutes to many hours; in that period they cannot be stimulated to further orgasm. Women do not have a refractory period and are capable of multiple and successive orgasms.

13. Definition In DSM-IV-TR, a sexual dysfunction is defined as a disturbance in the sexual response cycle or as pain with sexual intercourse Are categorized as Axis I disorders

14. Classification Seven major categories of sexual dysfunction are listed in DSM-IV-TR: sexual desire disorders sexual arousal disorders orgasm disorders sexual pain disorders sexual dysfunction caused by a general medical condition substance-induced sexual dysfunction and sexual dysfunction not otherwise specified. Either type of disturbance can occur alone or in combination.

15. lifelong or acquired generalized or limited to a specific partner or a certain situation diagnosed only when they are a major part of the clinical picture

16. Sexual dysfunctions are frequently associated with other mental disorders, such as depressive disorders anxiety disorders personality disorders and schizophrenia

17. Sexual Desire Disorders divided into two classes: Hypoactive sexual desire disorder , characterized by a deficiency or absence of sexual fantasies and desire for sexual activity Sexual aversion disorder , characterized by an aversion to, and avoidance of, genital sexual contact with a sexual partner or by masturbation

18. Abstinence from sex for a prolonged period sometimes results in suppression of sexual impulses. Loss of desire may also be an expression of hostility to a partner or the sign of a deteriorating relationship In making the diagnosis, clinicians must evaluate a patient's age, general health, and life stresses and must attempt to establish a baseline of sexual interest before the disorder began.

19. The presence of desire depends on several factors: biological drive adequate self-esteem the ability to accept oneself as a sexual person previous good experiences with sex the availability of an appropriate partner and a good relationship in nonsexual areas with a partner. Damage to, or absence of, any of these factors can diminish desire.

20. A variety of causative factors are associated with sexual desire disorders. Patients with desire problems often use inhibition of desire defensively, to protect against unconscious fears about sex. Sigmund Freud conceptualized low sexual desire as the result of inhibition during the phallic psychosexual phase of development and of unresolved oedipal conflicts. Some men, fixated at the phallic state of development, are fearful of the vagina and believe that they will be castrated if they approach it. Freud called this concept vagina dentata ; because men unconsciously believe that the vagina has teeth, they avoid contact with the female genitalia. Equally, women may suffer from unresolved developmental conflicts that inhibit desire. Lack of desire can also result from chronic stress, anxiety, or depression.

21. DSM-IV-TR Diagnostic Criteria for Hypoactive Sexual Desire Disorder Persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity. The judgment of deficiency or absence is made by the clinician, taking into account factors that affect sexual functioning, such as age and the context of the person's life. The disturbance causes marked distress or interpersonal difficulty. The sexual dysfunction is not better accounted for by another Axis I disorder (except another sexual dysfunction) and is not due exclusively to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. Specify type:     Lifelong type     Acquired type Specify type:     Generalized type     Situational type Specify :     Due to psychological factors     Due to combined factors

22. DSM-IV-TR Diagnostic Criteria for Sexual Aversion Disorder Persistent or recurrent extreme aversion to, and avoidance of, all (or almost all) genital sexual contact with a sexual partner. The disturbance causes marked distress or interpersonal difficulty. The sexual dysfunction is not better accounted for by another Axis I disorder (except another sexual dysfunction). Specify type:     Lifelong type     Acquired type Specify type:     Situational type     Generalized type Specify :     Due to psychological factors     Due to combined factors

23. Sexual Arousal Disorders divided by DSM-IV-TR into female sexual arousal disorder , characterized by the persistent or recurrent partial or complete failure to attain or maintain the lubrication-swelling response of sexual excitement until the completion of the sexual act male erectile disorder , characterized by the recurrent and persistent partial or complete failure to attain or maintain an erection to perform the sexual act The diagnosis takes into account the focus, intensity, and duration of the sexual activity in which patients engage

24. Female Sexual Arousal Disorder The DSM-III-R defines female sexual arousal disorder in terms of the physiological arousal response A subjective sense of arousal is often poorly correlated, however, with genital lubrication in both dysfunctional and normal women A woman complaining of lack of arousal may lubricate vaginally, but may not experience a subjective sense of excitement

25. William Masters and Virginia Johnson found women particularly desirous of sex before the onset of the menses. Other women report feeling the greatest sexual excitement immediately after the menses or at the time of ovulation. Alterations in testosterone, estrogen, prolactin , and thyroxin levels have been implicated in female sexual arousal disorder. Also, medications with antihistaminic or anticholinergic properties cause a decrease in vaginal lubrication.

26. DSM-IV-TR Diagnostic Criteria for Female Sexual Arousal Disorder Persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate lubrication-swelling response of sexual excitement. The disturbance causes marked distress or interpersonal difficulty. The sexual dysfunction is not better accounted for by another Axis I disorder (except another sexual dysfunction) and is not due exclusively to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. Specify type:     Lifelong type     Acquired type Specify type:     Generalized type     Situational type Specify :     Due to psychological factors     Due to combined factors

27. Male Erectile Disorder also called erectile dysfunction and impotence A man with lifelong male erectile disorder has never been able to obtain an erection sufficient for vaginal insertion. In acquired male erectile disorder, a man has successfully achieved vaginal penetration at some time in his sexual life but is later unable to do so. In situational male erectile disorder, a man is able to have coitus in certain circumstances but not in others; for example, he may function effectively with a prostitute but be impotent with his wife.

28. Freud ascribed one type of impotence to an inability to reconcile feelings of affection toward a woman with feelings of desire for her. Men with such conflicting feelings can function only with women whom they see as degraded (Madonna Putana complex). Other factors that have been cited as contributing to impotence include a punitive superego, an inability to trust, and feelings of inadequacy or a sense of being undesirable as a partner. A man may be unable to express a sexual impulse because of fear, anxiety, anger, or moral prohibition. In an ongoing relationship, impotence may reflect difficulties between the partners, particularly when a man cannot communicate his needs or his anger in a direct and constructive way.

29. DSM-IV-TR Diagnostic Criteria for Male Erectile Disorder Persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate erection. The disturbance causes marked distress or interpersonal difficulty. The erectile dysfunction is not better accounted for by another Axis I disorder (other than a sexual dysfunction) and is not due exclusively to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. Specify type:     Lifelong type     Acquired type Specify type:     Generalized type     Situational type Specify :     Due to psychological factors     Due to combined factors

30. Orgasm Disorders Female orgasmic disorder sometimes called inhibited female orgasm or anorgasmia , is defined as the recurrent or persistent inhibition of female orgasm, as manifested by the recurrent delay in, or absence of, orgasm after a normal sexual excitement phase that a clinician judges to be adequate in focus, intensity, and duration in short, a woman's inability to achieve orgasm by masturbation or coitus

31. Research on the physiology of the female sexual response has shown that orgasms caused by clitoral stimulation and those caused by vaginal stimulation are physiologically identical Freud's theory that women must give up clitoral sensitivity for vaginal sensitivity to achieve sexual maturity is now considered misleading, but some women report that they gain a special sense of satisfaction from an orgasm precipitated by coitus. Women who can achieve orgasm by one of these methods are not necessarily categorized as anorgasmic , although some sexual inhibition may be postulated.

32. A woman with lifelong female orgasmic disorder has never experienced orgasm by any kind of stimulation. A woman with acquired orgasmic disorder has previously experienced at least one orgasm, regardless of the circumstances or means of stimulation, whether by masturbation or while dreaming during sleep. Kinsey found that only 5 percent of married women over 35 years of age had never achieved orgasm by any means. The incidence of orgasm increases with age. Lifelong female orgasmic disorder is more common among unmarried women than married women.

33. The overall prevalence of female orgasmic disorder from all causes is estimated to be 30 percent A recent twin study suggests that orgasmic dysfunction in some females has a genetic basis

34. Numerous psychological factors are associated with female orgasmic disorder: They include fears of impregnation, rejection by a sex partner, and damage to the vagina; hostility toward men; and feelings of guilt about sexual impulses Some women equate orgasm with loss of control or with aggressive, destructive, or violent impulses; their fear of these impulses may be expressed through inhibition of excitement or orgasm. Cultural expectations and social restrictions on women are also relevant Many women have grown up to believe that sexual pleasure is not a natural entitlement for so-called decent women. Nonorgasmic women may be otherwise symptom free or may experience frustration in a variety of ways; they may have such pelvic complaints as lower abdominal pain, itching, and vaginal discharge, as well as increased tension, irritability, and fatigue.

35. DSM-IV-TR Diagnostic Criteria for Female Orgasmic Disorder Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase. Women exhibit wide variability in the type or intensity of stimulation that triggers orgasm. The diagnosis of female orgasmic disorder should be based on the clinician's judgment that the woman's orgasmic capacity is less than would be reasonable for her age, sexual experience, and the adequacy of sexual stimulation she receives. The disturbance causes marked distress or interpersonal difficulty. The orgasmic dysfunction is not better accounted for by another Axis I disorder (except another sexual dysfunction) and is not due exclusively to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. Specify type:     Lifelong type     Acquired type Specify type:     Generalized type     Situational type Specify :     Due to psychological factors     Due to combined factors

36. Male Orgasmic Disorder In male orgasmic disorder, sometimes called inhibited orgasm or retarded ejaculation, a man achieves ejaculation during coitus with great difficulty, if at all A man with lifelong orgasmic disorder has never been able to ejaculate during coitus. The disorder is diagnosed as acquired if it develops after previously normal functioning orgasmic anhedonia :- men who ejaculate but complain of a decreased or absent subjective sense of pleasure during the orgasmic experience

37. The incidence of male orgasmic disorder is much lower than the incidence of premature ejaculation or impotence Lifelong male orgasmic disorder indicates severe psychopathology. A man may come from a rigid, puritanical background; he may perceive sex as sinful and the genitals as dirty; and he may have conscious or unconscious incest wishes and guilt. He usually has difficulty with closeness in areas beyond those of sexual relations. In a few cases, the condition is aggravated by an attention-deficit disorder, A man's distractibility prevents sufficient arousal for climax to occur. The problem is more common among men with obsessive-compulsive disorder (OCD) than among others. In an ongoing relationship, acquired male orgasmic disorder frequently reflects interpersonal difficulties

38. DSM-IV-TR Diagnostic Criteria for Male Orgasmic Disorder Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase during sexual activity that the clinician, taking into account the person's age, judges to be adequate in focus, intensity, and duration. The disturbance causes marked distress or interpersonal difficulty. The orgasmic dysfunction is not better accounted for by another Axis I disorder (except another sexual dysfunction) and is not due exclusively to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. Specify type:     Lifelong type     Acquired type Specify type:     Generalized type     Situational type Specify :     Due to psychological factors     Due to combined factors

39. Premature Ejaculation In premature ejaculation, men persistently or recurrently achieve orgasm and ejaculation before they wish to. No definite timeframe exists within which to define the dysfunction; the diagnosis is made when a man regularly ejaculates before or immediately after entering the vagina.

40. Clinicians need to consider factors that affect the duration of the excitement phase, such as age the novelty of the sex partner and the frequency and duration of coitus Masters and Johnson conceptualized the disorder in terms of the couple and considered a man a premature ejaculator if he could not control ejaculation sufficiently long enough during intravaginal containment to satisfy his partner in at least half their episodes of coitus. This definition assumes that the female partner is capable of an orgasmic response

41. Premature ejaculation is more commonly reported among college-educated men than among men with less education. The complaint is thought to be related to their concern for partner satisfaction, but the true cause of this increased frequency has not been determined. Premature ejaculation is the chief complaint of about 35 to 40 percent of men treated for sexual disorders.

42. Some researchers divide men who experience premature ejaculation into two groups: those who are physiologically predisposed to climax quickly because of shorter nerve latency time and those with a psychogenic or behaviorally conditioned cause. Men whose early sexual contacts occurred largely with prostitutes who demanded that the sex act proceed quickly or whose sexual contacts took place in situations in which discovery would be embarrassing (e.g., in the back seat of a car or in the parental home) might have been conditioned to achieve orgasm rapidly.

43. With young, inexperienced men, who are more likely to have the problem, it may resolve in time. In ongoing relationships, the partner has a great influence on a premature ejaculator, and a stressful marriage exacerbates the disorder.

44. DSM-IV-TR Diagnostic Criteria for Premature Ejaculation Persistent or recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it. The clinician must take into account factors that affect duration of the excitement phase, such as age, novelty of the sexual partner or situation, and recent frequency of sexual activity. The disturbance causes marked distress or interpersonal difficulty. The premature ejaculation is not due exclusively to the direct effects of a substance (e.g., withdrawal from opioids ). Specify type:     Lifelong type     Acquired type Specify type:     Generalized type     Situational type Specify :     Due to psychological factors     Due to combined factors

45. Sexual Pain Disorders Dyspareunia is recurrent or persistent genital pain occurring in either men or women before, during, or after intercourse. Much more common in women than in men, dyspareunia is related to, and often coincides with, vaginismus . Repeated episodes of vaginismus can lead to dyspareunia and vice versa; in either case, somatic causes must be ruled out. Dyspareunia should not be diagnosed when an organic basis for the pain is found or when, in a woman, it is caused exclusively by vaginismus or by a lack of lubrication

46. Chronic pelvic pain is a common complaint in women with a history of rape or childhood sexual abuse. Painful coitus can result from tension and anxiety about the sex act that cause women to involuntarily contract their vaginal muscles. The pain is real and makes intercourse unpleasant or unbearable. Anticipation of further pain may cause women to avoid coitus altogether. If a partner proceeds with intercourse regardless of a woman's state of readiness, the condition is aggravated. Dyspareunia can also occur in men, but it is uncommon and is usually associated with an organic condition, such as herpes, prostatitis , or Peyronie's disease, which consists of sclerotic plaques on the penis that cause penile curvature.

47. DSM-IV-TR Diagnostic Criteria for Dyspareunia Recurrent or persistent genital pain associated with sexual intercourse in either a male or a female. The disturbance causes marked distress or interpersonal difficulty. The disturbance is not caused exclusively by vaginismus or lack of lubrication, is not better accounted for by another Axis I disorder (except another sexual dysfunction), and is not due exclusively to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. Specify type:     Lifelong type     Acquired type Specify type:     Generalized type     Situational type Specify :     Due to psychological factors     Due to combined factors

48. Vaginismus Vaginismus is an involuntary muscle constriction of the outer third of the vagina that interferes with penile insertion and intercourse. The diagnosis is not made when the dysfunction is caused exclusively by organic factors or when it is symptomatic of another Axis I mental disorder. Vaginismus is less prevalent than female orgasmic disorder It most often afflicts highly educated women and those in high socioeconomic groups

49. Women with vaginismus may consciously wish to have coitus, but unconsciously wish to keep a penis from entering their bodies. A sexual trauma, such as rape, may cause vaginismus ; women with psychosexual conflicts may perceive the penis as a weapon Clinicians have noted that a strict religious upbringing in which sex is associated with sin is frequent in these patients Other women have problems in dyadic relationships; if women feel emotionally abused by their partners, they may protest in this nonverbal fashion.

50. DSM-IV-TR Diagnostic Criteria for Vaginismus Recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with sexual intercourse. The disturbance causes marked distress or interpersonal difficulty. The disturbance is not better accounted for by another Axis I disorder (e.g., somatization disorder) and is not due exclusively to the direct physiological effects of a general medical condition. Specify type:     Lifelong type     Acquired type Specify type:     Generalized type     Situational type Specify :     Due to psychological factors     Due to combined factors

51. Sexual Dysfunction due to a General Medical Condition covers sexual dysfunction that results in marked distress and interpersonal difficulty; the history, physical examination, or laboratory findings must provide evidence of a general medical condition judged to be causally related to the sexual dysfunction

52. DSM-IV-TR Diagnostic Criteria for Sexual Dysfunction Due to a General Medical Clinically significant sexual dysfunction that results in marked distress or interpersonal difficulty predominates in the clinical picture. There is evidence from the history, physical examination, or laboratory findings that the sexual dysfunction is fully explained by the direct physiological effects of a general medical condition. The disturbance is not better accounted for by another mental disorder (e.g., major depressive disorder).

53. Select , code and term based on the predominant sexual dysfunction:     Female hypoactive sexual desire disorder due to …[indicate the general medical condition] : if deficient or absent sexual desire is the predominant feature     Male hypoactive sexual desire disorder due to …[indicate the general medical condition] : if deficient or absent sexual desire is the predominant feature     Male erectile disorder due to …[indicate the general medical condition] : if male erectile dysfunction is the predominant feature     Female dyspareunia due to …[indicate the general medical condition] : if pain associated with intercourse is the predominant feature     Male dyspareunia due to …[indicate the general medical condition] : if pain associated with intercourse is the predominant feature     Other female sexual dysfunction due to …[indicate the general medical condition] : if some other feature is predominant (e.g., orgasmic disorder) or no feature predominates     Other male sexual dysfunction due to …[indicate the general medical condition] : if some other feature is predominant (e.g., orgasmic disorder) or no feature predominates Coding note : Include the name of the general medical condition on Axis I, e.g., male erectile disorder due to diabetes mellitus; also code the general medical condition on Axis III.

54. Diseases and Other Medical Conditions Implicated in Male Erectile Disorder Infectious and parasitic diseases    Elephantiasis    Mumps Cardiovascular disease a    Atherosclerotic disease    Aortic aneurysm     Leriche's syndrome    Cardiac failure Renal and urological disorders     Peyronie's disease    Chronic renal failure     Hydrocele and varicocele Hepatic disorders    Cirrhosis (usually associated with alcohol dependence) Pulmonary disorders    Respiratory failure Genetics     Klinefelter's syndrome    Congenital penile vascular and structural abnormalities Nutritional disorders    Malnutrition    Vitamin deficiencies    Obesity Endocrine disorders a    Diabetes mellitus    Dysfunction of the pituitary-adrenal-testis axis     Acromegaly    Addison's disease     Chromophobe adenoma    Adrenal neoplasia     Myxedema    Hyperthyroidism Neurological disorders    Multiple sclerosis    Transverse myelitis    Parkinson's disease    Temporal lobe epilepsy    Traumatic and neoplastic spinal cord diseases a    Central nervous system tumor    Amyotrophic lateral sclerosis    Peripheral neuropathy    General paresis     Tabes dorsalis Pharmacological factors    Alcohol and other dependence-inducing substances (heroin, methadone, morphine, cocaine, amphetamines, and barbiturates)    Prescribed drugs (psychotropic drugs, antihypertensive drugs, estrogens, and antiandrogens ) Poisoning    Lead ( plumbism )    Herbicides Surgical procedures a     Perineal prostatectomy    Abdominal- perineal colon resection     Sympathectomy (frequently interferes with ejaculation)     Aortoiliac surgery    Radical cystectomy    Retroperitoneal lymphadenectomy Miscellaneous    Radiation therapy    Pelvic fracture    Any severe systemic disease or debilitating condition

55. Substance-Induced Sexual Dysfunction The diagnosis of substance-induced sexual dysfunction is used when evidence of substance intoxication or withdrawal is apparent from the history, physical examination, or laboratory findings. Distressing sexual dysfunction occurs within a month of significant substance intoxication or withdrawal Specified substances include alcohol, amphetamines or related substances, cocaine, opioids , sedatives, hypnotics, or anxiolytics , and other or unknown substances. Abused recreational substances affect sexual function in various ways. In small doses, many substances enhance sexual performance by decreasing inhibition or anxiety or by causing a temporary elation of mood. With continued use, however, erectile engorgement and orgasmic and ejaculatory capacities become impaired

56. The abuse of sedatives, anxiolytics , hypnotics, and particularly opiates and opioids nearly always depresses desire. Alcohol may foster the initiation of sexual activity by removing inhibition, but it also impairs performance. Cocaine and amphetamines produce similar effects. Men usually go through two stages: an experience of prolonged erection without ejaculation, then a gradual loss of erectile capability. Patients recovering from substance dependency may need therapy to regain sexual function, partly because of psychological readjustment to a nondependent state.

57. DSM-IV-TR Diagnostic Criteria for Substance-Induced Sexual Dysfunction Clinically significant sexual dysfunction that results in marked distress or interpersonal difficulty predominates in the clinical picture. There is evidence from the history, physical examination, or laboratory findings that the sexual dysfunction is fully explained by substance use as manifested by either (1) or (2): the symptoms in Criterion A developed during, or within a month of, substance intoxication medication use is etiologically related to the disturbance The disturbance is not better accounted for by a sexual dysfunction that is not substance induced. Evidence that the symptoms are better accounted for by a sexual dysfunction that is not substance induced might include the following: the symptoms precede the onset of the substance use or dependence (or medication use); the symptoms persist for a substantial period of time (e.g., about a month) after the cessation of intoxication, or are substantially in excess of what would be expected given the type or amount of the substance used or the duration of use; or there is other evidence that suggests the existence of an independent nonâ €“substance-induced sexual dysfunction (e.g., a history of recurrent nonâ €“substance-related episodes).

58. Note : This diagnosis should be made instead of a diagnosis of substance intoxication only when the sexual dysfunction is in excess of that usually associated with the intoxication syndrome and when the dysfunction is sufficiently severe to warrant independent clinical attention.     Code [Specific substance]-induced sexual dysfunction: Alcohol; amphetamine [or amphetamine-like substance]; cocaine; opioid ; sedative, hypnotic, or anxiolytic ; other [or unknown] substance     Specify if:        With impaired desire        With impaired arousal        With impaired orgasm        With sexual pain     Specify if:        With onset during intoxication : if the criteria are met for intoxication with the substance and the symptoms develop during the intoxication syndrome

59. Sexual Dysfunction not Otherwise Specified The category sexual dysfunction not otherwise specified covers sexual dysfunctions that cannot be classified under the categories described above

60. DSM-IV-TR Diagnostic Criteria for Sexual Dysfunction Not Otherwise Specified This category includes sexual dysfunctions that do not meet criteria for any specific sexual dysfunction. Examples include: No (or substantially diminished) subjective erotic feelings despite otherwise normal arousal and orgasm Situations in which the clinician has concluded that a sexual dysfunction is present but is unable to determine whether it is primary, due to a general medical condition, or substance induced

61. Female Premature Orgasm Data on female premature orgasm are lacking; no separate category of premature orgasm for women is included in DSM-IV-TR. A case of multiple spontaneous orgasms without sexual stimulation was seen in a woman; the cause was an epileptogenic focus in the temporal lobe. Instances have been reported of women taking antidepressants (e.g., fluoxetine and clomipramine ) who experience spontaneous orgasm associated with yawning.

62. Postcoital Headache Postcoital headache, characterized by headache immediately after coitus, may last for several hours. It is usually described as throbbing and is localized in the occipital or frontal area. The cause is unknown. There may be vascular, muscle-contraction (tension), or psychogenic causes. Coitus may precipitate migraine or cluster headaches in predisposed persons.

63. Orgasmic Anhedonia Orgasmic anhedonia is a condition in which a person has no physical sensation of orgasm, even though the physiological component (e.g., ejaculation) remains intact. Organic causes, such as sacral and cephalic lesions that interfere with afferent pathways from the genitalia to the cortex, must be ruled out. Psychiatric causes usually relate to extreme guilt about experiencing sexual pleasure. These feelings produce a dissociative response that isolates the affective component of the orgasmic experience from consciousness.

64. Masturbatory Pain Organic causes should always be ruled out; a small vaginal tear or early Peyronie's disease can produce a painful sensation. The condition should be differentiated from compulsive masturbation. Persons may masturbate to the extent that they do physical damage to their genitals and eventually experience pain during subsequent masturbatory acts Such cases constitute a separate sexual disorder and should be so classified. Certain masturbatory practices have resulted in what has been called autoerotic asphyxiation. The practices involve persons masturbating while hanging by the neck to heighten the erotic sensations and the orgasm's intensity through the mechanism of mild hypoxia

65. History Relationship status- casual dating, cohabiting. Sexual orientation Current functioning Onset – gen or situational; life long/ acquired Frequency of partnered sex; desire Description of typical sexual interaction Past sexual history Childhood sex activities Adolescence; Adult sexual activities Special issues; Sex after widowhood…

66. Treatment Dual-Sex Therapy Specific Techniques and Exercises cases of vaginismus , a woman is advised to dilate her vaginal opening with her fingers or with size graduated dilators stop-start technique squeeze technique Vibrator Hypnotherapy Behavior Therapy Group Therapy Analytically Oriented Sex Therapy Biological Treatments pharmacotherapy, sildenafil (Viagra) and its congeners oral phentolamine ( Vasomax ); alprostadil ( Caverject ), an injectable prostaglandin; and a transurethral alprostadil (MUSE), all used to treat erectile disorder surgery, and mechanical devices Male Prostheses Vascular Surgery

67. Reading Assignment Sexual orientation and homosexuality Masturbation And paraphilia

68. Reference kaplan & sadock’s synopsis of psychatry,10 th edition. Harrison’s principle of internal medicine, 18 th edition. Uptodate 19.1

69. THANK U.