Undergraduate Lecture: Eating, Sleep & Sexual Disorders

1. Behavioral Syndromes
Associated With Psychological
Disturbances
Dr Zahiruddin Othman
Department of Psychiatry
School of Medical Sciences

2. Lecture Outline
Sleep disorders
Eating disorders
Sexual disorders

3. Sleep Disorders
Sleep Architecture
Classification of Sleep Disorder

4. Sleep Stages Across the Night
EEG findingsEEG findings EMG findingsEMG findings
Muscle tone and activityMuscle tone and activity
Wakefulness Alpha wavesAlpha waves
PresentPresent
SleepSleep
NREMNREM
Stage 1Stage 1 Theta wavesTheta waves
Stage 2Stage 2
Theta wavesTheta waves
sleep spindlessleep spindles
K-complexesK-complexes
SlowingSlowing
Stage 3 & 4Stage 3 & 4 Delta wavesDelta waves ≥≥ 50%50% Markedly decreasedMarkedly decreased
REMREM Low voltage mixed-Low voltage mixed-
frequency wavesfrequency waves AbsentAbsent

5. REM Sleep
 “Paradoxical sleep”
 “Hallucinating brain in paralyzed body”

6. Sleep Patterns Across the Lifespan
AgeAge
TimeTime
in Bedin Bed
TimeTime
AsleepAsleep
Stage 1Stage 1
StageStage
3 and 43 and 4
REMREM
BirthBirth 17-24 h17-24 h 16 h16 h 5%5% -- 50%50%
12 y12 y 8.5 h8.5 h 8 h8 h -- 15-20%15-20% 20%20%
25-45 y25-45 y 7.5 h7.5 h 7 h7 h -- -- 20%20%
Old ageOld age 8.5 h8.5 h 6.5 h6.5 h 15%15% 0%0% 20%20%

7. Classification of Sleep Disorders
PrimaryPrimary
Sleep DisordersSleep Disorders
SecondarySecondary
Sleep DisordersSleep Disorders
Related To AnotherRelated To Another
Mental DisorderMental Disorder
Related To GeneralRelated To General
Medical ConditionMedical Condition
DyssomniasDyssomnias
ParasomniasParasomnias
Substance-InducedSubstance-Induced
Sleep DisordersSleep Disorders

8. Primary Sleep Disorders
PrimaryPrimary
Sleep DisordersSleep Disorders
DyssomniasDyssomnias
ParasomniasParasomnias
Primary sleep disorderPrimary sleep disorder
that result in complaintsthat result in complaints
of eitherof either too little ortoo little or
too muchtoo much sleepsleep
(insomnia or hypersomnia)(insomnia or hypersomnia)
Sleep disorders in whichSleep disorders in which
undesirable eventsundesirable events arisearise
during specific stages orduring specific stages or
at the transition betweenat the transition between
wakefulness and sleepwakefulness and sleep

9. DYSSOMNIASDYSSOMNIAS
PrimaryPrimary
InsomniasInsomnias
PrimaryPrimary
HypersomniasHypersomnias
Breathing-RelatedBreathing-Related
Sleep DisordersSleep Disorders
Circadian RhythmCircadian Rhythm
Sleep DisordersSleep Disorders
Dyssomnias NOSDyssomnias NOS
Obstructive Sleep ApneaObstructive Sleep Apnea
Central sleep apneaCentral sleep apnea
Jet lag syndromeJet lag syndrome
Shift-work sleep disorderShift-work sleep disorder
““night owls”night owls”
Periodic Limb Movement DisorderPeriodic Limb Movement Disorder
Restless Leg SyndromeRestless Leg Syndrome
Kleine-Levin syndromeKleine-Levin syndrome
Sleep State MisperceptionSleep State Misperception
Idiopathic insomniaIdiopathic insomnia
NarcolepsyNarcolepsy

10. Primary Insomnias
Sleep-state
misperception
(Subjective insomnia or non-
restorative sleep)
 Subjective complaint of
insomnia in the absence of
objective polysomnogram
evidence
Idiopathic insomnia
 Chronic insomnia
present from childhood
 Most likely the result of
underlying innate
process

11. Presenting Characteristics of
Chronic Insomnia
Sleep pattern Delayed sleep onset
Frequent or prolonged awakenings
Night to night variability in pattern
Sleep quality Anxious or agitated before and during sleep
Sleep experiences negative and not
enjoyable
Daytime
correlates
Sleepy or fatigued
Poor concentration
Poor problem solving
Tense, irritable

12. NARCOLEPSYNARCOLEPSY
How common?How common?
How does it present?How does it present?
What are theWhat are the
treatments?treatments?
•RareRare; incidence 0.07%
•Commonest type ofCommonest type of
primary hypersomniasprimary hypersomnias
TetradTetrad
•Sleep paralysisSleep paralysis
•Sleep attacks + SOREMPsSleep attacks + SOREMPs
•CataplexyCataplexy
•Hypnagogic hallucinationsHypnagogic hallucinations
Psychostimulants
Imipramine

13. OObstructivebstructive SSleepleep AApneapnea
How common?How common?
How does it present?How does it present?
What are theWhat are the
treatments?treatments?
•Prevalence 1-2%Prevalence 1-2%
•CommonestCommonest
organic hypersomniasorganic hypersomnias
•Risk factors - obesityRisk factors - obesity
•ObstructionObstruction
•Sleep apneaSleep apnea
•AI > 5AI > 5
•RDI > 10RDI > 10
•Excessive daytimeExcessive daytime
sleepinesssleepiness
Nasal continuous PAP
Bilateral PAP

14. Wake-SleepWake-Sleep
Transition DisordersTransition Disorders
Light SleepLight Sleep
Stage DisordersStage Disorders
NREMNREM
Sleep DisordersSleep Disorders
REMREM
Sleep DisordersSleep Disorders
DiffuseDiffuse
Sleep DisordersSleep Disorders
SleepwalkingSleepwalking (somnambulism)(somnambulism)
Night terrorsNight terrors (pavor nocturnus)(pavor nocturnus)
Nightmare DisorderNightmare Disorder
REM sleep behavior disorderREM sleep behavior disorder
Nocturnal EnuresisNocturnal Enuresis
Sleep-related seizureSleep-related seizure
Sleep starts (hypnogogic jerks)Sleep starts (hypnogogic jerks)
Rhythmic movement disordersRhythmic movement disorders
SleeptalkingSleeptalking (somniloquism)(somniloquism)
BruxismBruxism (teeth grinding)(teeth grinding)
PARASOMNIASPARASOMNIAS

15. SLEEPWALKINGSLEEPWALKING
Epidemiology
Presentation
Treatment
•Walking and otherWalking and other
semipurposeful activitiessemipurposeful activities
•Unresponsive to effortUnresponsive to effort
to wake them upto wake them up
•Amnestic to the eventAmnestic to the event
after awakenafter awaken
ReassuranceReassurance
Safe place for sleepSafe place for sleep
HypnosisHypnosis

16. NIGHT TERRORSNIGHT TERRORS
Epidemiology
Presentation
Treatment
•Scream and sit up in bedScream and sit up in bed
∀↑↑ Autonomic activitiesAutonomic activities
•1-10 minutes1-10 minutes
•UnresponsiveUnresponsive
•Amnestic of the eventsAmnestic of the events
•11stst
half of the nighthalf of the night
Psychotherapy
Stress reduction
Benzodiazepines

17. NIGHTMARE DISORDERSNIGHTMARE DISORDERS
Epidemiology
Presentation
Treatment
•Terrifying dreamsTerrifying dreams
•Lack autonomic arousalLack autonomic arousal
•22ndnd
half of the nighthalf of the night
•Muscle atoniaMuscle atonia
Reduce the underlying stress

18. NOCTURNAL ENURESISNOCTURNAL ENURESIS
Epidemiology
Presentation
Treatment
Children > adults
Often self-limited
Involuntary micturition
without conscious arousal
Bladder training
TCA

19. Differences Between
Nightmares and Night Terrors
NightmaresNightmares Night terrorsNight terrors
Sleep stage REM sleep NREM sleep
Timing Late in sleeping period
Often during first hour
after sleep onset
Recall Usual Usually absent
Behavior
during event
Quickly in contact with
the surroundings
Often “out of reach”
Family
pattern
Not confirmed Yes
treatment
Clomipramine,
psychotherapy
Sleep hygiene,
benzodiazepines

20. Comparison of Sleep Disorders in
Children
DreamsDreams NightmaresNightmares SleepwalkingSleepwalking Night terrorsNight terrors
Sleep stage
Light NREM andLight NREM and
REMREM
REMREM StageStage 4 NREM4 NREM StageStage 4 NREM4 NREM
Time after sleep (h) 3-63-6 3-63-6 1-21-2 1-21-2
Sounds NoneNone
OccasionalOccasional
unintelligibleunintelligible
soundssounds
OccasionalOccasional
meaningless speechmeaningless speech
ScreamScream ±±
continuous loudcontinuous loud
meaningless speechmeaningless speech
Motor movement Little or noneLittle or none
Little until point ofLittle until point of
wakingwaking
Usually purposefulUsually purposeful
and unpredictable;and unpredictable;
child rarely stays inchild rarely stays in
bed or roombed or room
PurposelessPurposeless
movement; childmovement; child
usually stay in bedusually stay in bed
Response to parent
Awakes easily toAwakes easily to
stimulistimuli
Awakes easily toAwakes easily to
stimuli; reorients instimuli; reorients in
several minutesseveral minutes
Little to noneLittle to none Little to noneLittle to none
Memory of event
Can describeCan describe
immediatelyimmediately
Can describeCan describe
immediately; oftenimmediately; often
able to rememberable to remember
event the followingevent the following
dayday
NoneNone NoneNone

21. SecondarySecondary
Sleep DisordersSleep Disorders
Sleep Disorders Related ToSleep Disorders Related To
Another Mental DisorderAnother Mental Disorder
Sleep Disorders Related ToSleep Disorders Related To
General Medical ConditionGeneral Medical Condition
Substance-InducedSubstance-Induced
Sleep DisordersSleep Disorders
Secondary Sleep Disorders

22. Secondary Sleep Disorders
Sleep Disorders Related ToSleep Disorders Related To
Another Mental DisorderAnother Mental Disorder
PsychosisPsychosis DepressionDepression ManiaManiaAnxietyAnxiety
Difficulty initiating and maintaining sleep (DIMS)
Initial insomnia
Terminal insomnia
Reduced need for sleep

23. Lack of exercise
Hunger/starvation
Pain/discomfort
Noise
Light
Apnoea
Temperature extremes
Stress
Alcohol/hypnotic withdrawal
Psychotic arousal
Anxiety
Guilt
Sadness
Anger
Elation
Sexual frustration
Ideas/problem/doubt
Caffeine/other stimulants
SLEEPSLEEP
EROSIONEROSION
SOME FACTORS THAT CAN
ERODE SLEEP

24. Secondary Sleep Disorders
Sleep Disorders Related ToSleep Disorders Related To
General Medical ConditionGeneral Medical Condition
InsomniaInsomnia
(May mimic any(May mimic any
of Primary SD)of Primary SD)
Gastroesophageal refluxGastroesophageal reflux
Cluster headachesCluster headaches
Cardiovascular diseaseCardiovascular disease
Metabolic disordersMetabolic disorders
AsthmaAsthma
SeizuresSeizures
SymptomaticSymptomatic
DefinitiveDefinitive
CommonCommon
PresentationPresentation
CommonCommon
CausesCauses
TreatmentTreatment

25. Secondary Sleep Disorders
Substance-InducedSubstance-Induced
Sleep DisordersSleep Disorders
CNS stimulantsCNS stimulants
Intoxication: InsomniaIntoxication: Insomnia
Withdrawal: SedationWithdrawal: Sedation
AmphetamineAmphetamine
CaffeineCaffeine
SymptomaticSymptomatic
DefinitiveDefinitive
CommonCommon
PresentationPresentation
CommonCommon
CausesCauses
TreatmentTreatment
CNS depressantsCNS depressants
Intoxication: SedationIntoxication: Sedation
Withdrawal: InsomniaWithdrawal: Insomnia
AlcoholAlcohol
BenzodiazepinesBenzodiazepines

26. Basic Sleep Hygiene
 Limit in-bed time to the amount
before sleep disturbance
 Lie down only when sleepy, and
sleep only as much as
necessary to feel refreshed
 Use the bed for sleep only
 Maintain comfortable sleeping
condition and avoid excessive
warmth and cold
 Avoid day time naps
 Exercise regularly, but early in
the day
 Limit sedatives
 Avoid alcohol, tobacco, and
caffeine near bedtime
 Eat at regular times daily and
avoid large meals near bedtime
 Eat a light snack, if hungry, near
bedtime
 Practice evening relaxation
routines, such as PMR,
meditation, or taking a very hot,
20 min, body temperature raising
bath near bedtime

27. Summary
 Primary insomnia is rare
 Patients may need long term treatment with
hypnotic drugs
 Secondary insomnia is more common
 Treat the underlying cause

Psychiatric disturbance

Physical disease

Chronic pain

Misuse of substance, particularly alcohol

28. Eating Disorders
…… disordered patterns of eating, accompanied by distress

29. “Eating disorders are characterized by
disordered patterns of eating,
accompanied by distress,
disparagement, preoccupation, and/or
distortion associated with one’s eating,
weight or body shape”

30. EATING DISORDERSEATING DISORDERSEATING DISORDERSEATING DISORDERS
AnorexiaAnorexia
NervosaNervosa
AnorexiaAnorexia
NervosaNervosa
BulimiaBulimia
NervosaNervosa
BulimiaBulimia
NervosaNervosa
Binge-eatingBinge-eating
DisorderDisorder
Binge-eatingBinge-eating
DisorderDisorder
Eating DisorderEating Disorder
NOSNOS
Eating DisorderEating Disorder
NOSNOS
RestrictingRestricting
TypeType
RestrictingRestricting
TypeType
Binge-eating/Binge-eating/
Purging TypePurging Type
Binge-eating/Binge-eating/
Purging TypePurging Type
PurgingPurging
TypeType
PurgingPurging
TypeType
Non-purgingNon-purging
TypeType
Non-purgingNon-purging
TypeType
Eating Disorders,Eating Disorders,
Atypical SymptomsAtypical Symptoms
Eating Disorders,Eating Disorders,
Atypical SymptomsAtypical Symptoms
Partial SyndromePartial Syndrome
Eating DisorderEating Disorder
Partial SyndromePartial Syndrome
Eating DisorderEating Disorder

31. Prevalence
Prevalence among
young adult females
Anorexia nervosa 0.28%
Bulimia nervosa 1.0%
Binge-eating disorder 2.6%

32. Anorexia Nervosa
… self-imposed starvation

33. DSM-IV Diagnostic
Features ...
 Refusal to maintain
minimally normal
weight
 85% of expected
body weight or BMI
17.5
 A fear of gaining
weight or becoming
fat

34. ... DSM-IV Diagnostic
Features
 A disturbance in the
way one’s weight or
body shape is
experienced
 Amenorrhea
 Absence of at least 3
consecutive cycles in
postmenarcheal
females

35. Frequently Associated Features
• Perfectionism
• Low self-esteem
• Anxiety
• Dichotomous thinking

36. Warning Signs of AN …
 Obsessive dieting
 Precipitous weight loss
 Preoccupation with food, calories and
nutrition
 Cessation of menstrual periods
 Claiming to feel fat when obviously not
overweight
 Excessive exercising

37. … Warning Signs of AN
 Frequent weighing
 Measuring self-worth in terms of
weight and shape
 Hiding and collecting food
 Denial of hunger
 Preparing food for others but not
self
 Vomiting to eliminate food eaten
 Use of laxatives or diuretics

38. Signs And Symptoms Of AN
…
 Slowed heart rate
 Low blood pressure
 Low body temperature
 Hair loss
 Dry and yellowed skin
 BRITTLE NAILS

39. … Signs And Symptoms Of
AN
 Thin coating of LANUGO
 AMENORRHEA
 Early morning awakening
 Intolerance of cold
 Abdominal pain
 Constipation

40. … Signs And Symptoms Of
AN
 Weakness
 Light-headedness
 Hyperactivity
 Impaired concentration
 Depression

41. Treatment Difficulties
 Symptoms are EGO-SYNTONIC
 Defensive and resistant patients and
families
 Manipulative patients
 Physical condition precludes effective
psychotherapy
 Long-term treatment

42. Prognosis
 About 50% recovers fully
 About 30% partially recover
 About 20% remain chronic
 Death occurs in 10-20%
 Some develop other
psychiatric disorders
 Death usually due to
starvation or suicide

43. Famous Anorexic
The Spice Girl told the Mirror newspaper:
"They keep saying how thin I am, hinting
I must be anorexic or bulimic or
something. It is so upsetting."
The 25-year-old pop star admitted having
lost weight since giving birth to her son
but said "vicious" reports about her
weight were getting her and her family
down.
"I'm not anorexic, I'm not bulimic and I'm
not a skeleton. I'm 7.5 stone, very fit and
I feel great," she added.
1 December, 19991 December, 1999

44. Famous Anorexics
“Many female athletes fall
victim to eating disorders in
a desperate attempt to be
thin in order to please
coaches and judges. Many
coaches are guilty of
pressuring these athletes to
be thin by criticizing them or
making reference to their
weight”
Nadia Comaneci

45. Famous Anorexics
 According to a 1992 American
College of Sports Medicine
study, eating disorders affected
62 percent of females in sports
like figure skating and
gymnastics
 Cathy Rigby, a 1972 Olympian,
battled anorexia and bulimia for
12 years. She went into cardiac
arrest on two occasions as a
result of it

46. Bulimia Nervosa
… binge-eating with compensatory behavior

47. Diagnostic Features …
 Recurrent, episodic BINGE EATING
 Recurrent, inappropriate
COMPENSATORY BEHAVIORS to
prevent weight gain
 A self-evaluation that is unduly
influenced by weight or body shape
 Symptoms do not occur exclusively
during episodes of AN

48. Compensatory Behavior

49. Frequently Associated Features
• Perfectionism
• Low self-esteem
• Anxiety
• Dichotomous thinking
• Impulsive behaviors
• Drug / alcohol abuse

50. Warning Signs of BN …
 Obsessive dieting followed by binge
eating
 Rapid fluctuations in weight
 Overeating associated with stress
and/or anxiety
 Trips to the bathroom right after eating
 Vomiting to eliminate food eaten
 Use of laxatives or diuretics

51. … Warning Signs of BN
 Frequent weighing
 Overconcern with weight
 Secretive eating
 Excessive exercising
 Measuring self-worth in terms of weight
and shape
 Swollen glands beneath the jaw

52. Most Common Clues
 Trips to bathroom right after eating
 Large volumes of missing food

53. Signs And Symptoms Of BN
…
 Abdominal pain,
heartburn, stomach
cramps
 Dental and gum
problems
 Swollen salivary glands
 Edema
 Menstrual irregularities
Teeth Erosion

54. … Signs And Symptoms Of
BN
 Dry skin
 Dry, brittle hair
 Weakness and/or
dizziness
 Frequent weight
fluctuations
 CALLUS formation
above knuckles over
index fingers
Russel’s sign

55. Dangerous Method of Weight Control
 Ipecac syrup
 Laxatives
 Diuretics
 Diet pill

56. Ipecac Syrup
 help induce vomiting
 It can cause irregular heartbeats, chest
pains, breathing problems, rapid heart
rate and cardiac arrest

57. Laxatives
 Laxatives have little or no effect on reducing
weight because by the time they work, the
calories have already been absorbed
 Laxative abuse can cause bloody diarrhea,
electrolyte imbalances and dehydration
 It can lead to permanent damage to the
bowels, severe medical complications and
even death

58. Diuretics (Water Pills)
 When taken, a person will only lose vital fluids
and electrolytes.
 Within a day or two the body will react and
start to retain water, which is usually what
causes a person to use them repeatedly.
 Once the electrolytes go out of balance, the
person is at a very high risk for heart failure
and sudden death

59. Diet Pills
 Phenylpropanolamine can produce symptoms
such as increased heart rate, dizziness, high
blood pressure, nausea, anxiety, irritability,
insomnia, dry mouth and diarrhea.
 Fenfluramine can cause diarrhea, high blood
pressure, dry mouth, rash, palpitations and
chest pains.
 Ephedrine has been linked to many deaths
from heart attacks, seizures and strokes.

60. Diana, Princess of Wales, one of
the world's most beloved
women, suffered from bulimia.
It is said to have developed
during her unhappy marriage
to Charles, prince of Wales.
When she married, princess
Diana was normal weight. By
1987, she was emaciated. At
the time of her tragic death in
an auto accident in 1997, she
seemed to be in recovery
Famous Bulimic

61. Jane Fonda, actress, activist, athlete,
wife and mother, was one of the
first famous women to openly
discuss her eating disorder. In the
late 1970s, she went public with her
"bulimarexia," the binge-and-vomit
cycle that nearly ruined her health.
Overwhelmed by the the demands
of the Hollywood culture, she spent
nearly 20 years in the relentless
pursuit of thinness.
Famous Bulimic

62. Binge-eating Disorder
… binge-eating without inappropriate compensatory measures

63. Diagnostic Features
 Recurrent, episodic binge-
eating without inappropriate
compensatory measures to
prevent weight gain
 The binge-eating episodes are
associated with marked
distress
 Symptoms do not occur
exclusively during AN or BN

64. AN and BN
Key Differences and Similarities
Anorexia nervosaAnorexia nervosa Bulimia nervosaBulimia nervosa
issue Differences
Eating / weight Extreme diet; minimally belowExtreme diet; minimally below
normal weightnormal weight
Binge eating & compensatoryBinge eating & compensatory
behavior; normal weightbehavior; normal weight
View of disorder Denial of anorexia; proud of “diet”Denial of anorexia; proud of “diet” Aware of problem; secretive /Aware of problem; secretive /
ashamed of bulimiaashamed of bulimia
Feelings of control Comforted by rigid self-controlComforted by rigid self-control Distress by lack of control overDistress by lack of control over
binge eatingbinge eating
Similarities
Self-evaluation Unduly influenced by body weight / shape
Comorbidity of AN /
BN
Some cases of AN also binge and purge;
Many cases of BN have history of AN
SES, age, gender Prevalent high among high SES, young, female

65. Comparisons of Eating Disorders
Symptoms ANAN – restricting– restricting
typetype
ANAN – binge /– binge /
purge typepurge type
BNBN – purging– purging
typetype
BNBN – non– non
purging typepurging type
Binge-EatingBinge-Eating
disorderdisorder
Body weightBody weight Must be <Must be <
15%15%
underweightunderweight
Must be <Must be <
15%15%
underweightunderweight
Often normalOften normal
or somewhator somewhat
overweightoverweight
Often normalOften normal
or somewhator somewhat
overweightoverweight
Often
significantly
overweight
Body imageBody image SeverelySeverely
disturbeddisturbed
SeverelySeverely
disturbeddisturbed
OverconcernOverconcern
with weightwith weight
OverconcernOverconcern
with weightwith weight
Often
disgusted with
overweight
BingesBinges No Yes YesYes YesYes YesYes
Purges or otherPurges or other
compensatory behaviorcompensatory behavior
No Yes Yes No No
Sense of lack of controlSense of lack of control
over eatingover eating
No During binges YesYes YesYes YesYes
Amenorrhea in femalesAmenorrhea in females YesYes YesYes Not usuallyNot usually Not usuallyNot usually No

66. Restricting or
dieting behavior
“Purgers”
“Nonpurgers”
Binge-eating
behavior
Body weight
obese
“normal”
emaciated
The Overlap in Eating Disorder
Symptoms
Weight threshold for
anorexia nervosa

67. AN –AN –
binge/purgebinge/purge
15% below15% below
underweightunderweight
Normal orNormal or
overweightoverweight
AN –AN –
restrictingrestricting
body
weight
bingesbinges
purgespurges
purgespurges
BN –BN –
purgingpurging
BN –BN –
non purgingnon purging
BEDBED
yes yesno no
EATING DISORDERSEATING DISORDERS

68. Treatment
Medical
Nutritional
Psychiatric

69. Criteria for Inpatient Treatment of
Anorexia Nervosa
• Very low weight or rapid decrease in weight
• A recent fall in serum potassium levels or other
serious medical complications
• Suicidal threats or intents or other severe
psychiatric co-morbidities
• Lack of response to outpatient treatment or severe
worsening of symptoms
• An intolerable family situation
• Lack of community resources for treatment

70. Criteria for Inpatient Treatment of
Bulimia Nervosa
• Binge-purge cycle out of control
• A recent fall in serum potassium levels or other
serious medical complications
• Suicidal threats or intents or other severe
psychiatric co-morbidities
• Lack of response to outpatient treatment or severe
worsening of symptoms
• An intolerable family situation
• Lack of community resources for treatment

71. Medical Treatment
 Weight restoration
 Correction of hypokalemia and other
electrolytes
 Vitamin supplementation
 Estrogen and progestin
 Avoid conception
 Stool softeners or bulk-forming laxatives
 Dental care

72. Nutritional Counseling
 Monitoring of dietary patterns and
weight
 Clarification of caloric requirement and
nutritional deficiency
 Introduction and reinforcement of
behavioral strategies for establishment
of healthful patterns of eating

73. Psychiatric Treatment
TherapyTherapy ANAN BNBN BEBE
DD
Cognitive-behavioral therapyCognitive-behavioral therapy  
Interpersonal therapyInterpersonal therapy  
Psychodynamic therapyPsychodynamic therapy
Family therapyFamily therapy 
Group psychotherapyGroup psychotherapy   

74. Causes of Eating Disorders
Biological
Psychological
Sociological

75. Contributing Factors to Eating Disorders
 Biological factors
 Certain chemicals in the brain that control hunger, appetite,
and digestion have been found to be imbalanced in some
individuals with eating disorders
 The exact meaning and implications of these imbalances
remains under investigation

76. Contributing Factors to Eating Disorders
 Biological factors
 Psychological factors
 Low self-esteem
 Feeling of inadequacy or lack of control in life
 Depression, anxiety, anger, or loneliness
 Failure to separate from the family
 Lack of identity formation
 “Peter pan” syndrome, including repression of sexuality
 Excessive control over the body as a response to over-
control by the environment

77. Contributing Factors to Eating Disorders
 Biological factors
 Psychological factors
 Interpersonal factors
 Troubled family and personal relationships
 Difficulty expressing emotions and feelings
 History of being teased or ridiculed based on size or weight
 History of physical or sexual abuse

78. Contributing Factors to Eating Disorders
 Biological factors
 Psychological factors
 Interpersonal factors
 Sociocultural factors
 Cultural pressures that glorify "thinness" and place value on
obtaining the "perfect body“
 Narrow definitions of beauty that include only women and
men of specific body weights and shapes
 Cultural norms that value people on the basis of physical
appearance and not inner qualities and strengths

79.  Psychological
underpinnings
 Personality features
 Cultural obsession
EATING DISORDERS

80. Sociological Perspective
 Expectations of women

81. Commercialized
Cult of Thinness
Sociological Perspective

82. Sexual Disorders
Disorder of Sexual …
Function
Orientation
Identity

83. Sexual Disorders
 Sexual disorders: “5 layers of erotic life”
 Gender identity
 Sexual orientation
 Sexual preference
 Sex role
 Sexual performance

85. SEXUAL DISORDERSSEXUAL DISORDERSSEXUAL DISORDERSSEXUAL DISORDERS
Sexual
Dysfunctions
Sexual
Dysfunctions
ParaphiliasParaphilias
Gender Identity
Disorders
Gender Identity
Disorders
Impairment
of normal sexual
interest and/or
performance
Abnormalities of
gender identity
Abnormalities of
sexual preference

86. DSM-IV Sexual Disorders
 Gender Identity Disorders:
You have the sexual anatomy of a male but inside
you feel like a female (or vice versa).
 Paraphilias:
You feel like the man or woman that you are but
your sexual preference is socially unacceptable or
illegal.
 Sexual Dysfunctions:
You feel like the man or woman that you are and
your sexual preference is socially acceptable but
you aren’t enjoying it.

87. Stages of Normal Sexual Response
The Four-step Model (Masters & Johnson)The Four-step Model (Masters & Johnson)
Excitement Arousal
PlateauPlateau The phase of maximum arousal before orgasmThe phase of maximum arousal before orgasm
Orgasm A stage that involve muscle contraction
ResolutionResolution A phase leading to a return to baselineA phase leading to a return to baseline

88. The Four-step Model (Masters & Johnson)

89. Stages of Normal Sexual Response
The Triphasic Model (Kaplan)The Triphasic Model (Kaplan)
Desire
ExcitementExcitement
AA vascularvascular phenomenon, caused by innervationphenomenon, caused by innervation
of theof the parasympatheticparasympathetic nervous systemnervous system
Orgasm
A muscular reaction, caused by innervation of
the sympathetic nervous system

90. Classification of Sexual Dysfunction
Desire phase disordersDesire phase disorders
Hypoactive sexual desire, sexualHypoactive sexual desire, sexual
aversionaversion
Excitement phase disorders
Sexual arousal disorder (f),
erectile disorder (m)
Orgasm phase disordersOrgasm phase disorders
Orgasmic disorder, prematureOrgasmic disorder, premature
ejaculation (m)ejaculation (m)
Sexual pain disorders Dyspareunia, vaginimismus (f)

91. Desire Phase Disorders
Hypoactive sexual desire
 … Persistently deficient
sexual fantasies and
infrequent desire for sexual
activity
 Lifetime prevalence is 40% in
women and 30% in men
Sexual aversion disorder
 … Persistent and extreme
aversion to, and avoidance
of, all or almost all genital
sexual contact with the
sexual partner
 A/w phobic avoidance of
sexual activity
 ¼ Has panic disorder

92. Sexual Arousal Disorders
Male erectile disorder
 Formerly called
“impotence”
Female sexual arousal
disorder
 Formerly called
“frigidity”
Vacuum Device Therapy

93. Sexual Performance (Cont’d)
 Sexual orgasmic disorders
 Premature ejaculation
 Male orgasmic disorder (retarded ejaculation)
 Female orgasmic disorder
 Sexual pain disorders
 Dyspareunia
 Vaginismus

95. The Causes of Sexual
Dysfunctions
 Biological contributions
 Diabetes and kidney disease
 Cardiovascular diseases
 Chronic illnesses
 Prescription medications
 Using alcohol and other drugs

96. The Causes of Sexual
Dysfunctions
 Biological contributions
 Psychological contributions
 Depression
 Performance anxiety
 The role of distraction
 Arousal level is underestimated

97. The Causes of Sexual
Dysfunctions
 Biological contributions
 Psychological contributions
 Social and cultural contributions
 Learn that sexuality is negative
 Traumatic sexual experiences
 Poor interpersonal relationship
 Inaccurate beliefs and myths

98. Gender Identity Disorders

99. The Features of GID
 Man or woman?
 Trapped in the body of the
wrong sex
 Transexualism
 Transgendered
 Rare

100. The Nature of GID
 Goal is not sexual
 No physical abnormalities
 Independent of sexual arousal patterns
 May be attracted to people with desired
identity

101. The Causes GID
 No specific biological link
 Probably learned early in life

102. The Treatment of GID
 Sex Reassignment Surgery
 Cost USD 25-30, 000
 Double for female-to-male
 Female-to-male adjust better
 Psychosocial treatment

103. George @ Christine Jorgenson
 On December 1, 1952, readers of the New
York Daily News were greeted with a
banner headline: EX-GI BECOMES
BLONDE BEAUTY: OPERATIONS
TRANSFORM BRONX YOUTH
 Jorgensen offers an intimate account of
her groundbreaking life as the first world-
renowned transsexual. “Nature made a
mistake,” she writes, “which I have
corrected”

104. Richard Raskin @ Renee Richards
Second Serve is an American Film
made in 1986
This is the Story of Renee Richards, M.D.
(ophtalmologist) who began life as Richard
Raskin. This film is based on Renee
Richards' autobiography of the same name.
It is probably based on the fact that after
ending her career as a tennis player she
went on to serve as coach to Martina
Navratilova
Richard RaskinRichard Raskin
Martina NavratilovaMartina Navratilova

105. Paraphilic Disorders

106. An Overview
 Para = “beyond” or “amiss”
 Philia = “love”
 Sexual stimulation requiring bizarre or
unusual acts, imagery, or objects

107. Fetishism
 Sexual attraction to nonliving objects
 Inanimate
 Tactile stimulation
 Parts of body

108. Exhibitionism
 “The Flasher”
 Expose genitals to
unsuspecting strangers
 Element of risk is important
 Not harmless (many rape /
molest)

109. Voyeurism
 “The Peeping Tom”
 Watching unsuspecting
strangers naked or
undressing

110. Transvestic Fetishism
 “Cross Dresser”
 Sexual arousal by dressing in
clothes of the opposite sex
 Most are male heterosexuals
 Most are married

111. Sexual Sadism and
Masochism
 The “Sadist”
 Sexual arousal by inflicting pain,
humiliation, domination, or
beatings
 The “masochist”
 Suffers the pain / humiliation
 Help the sadist

112. Pedophilia and Incest
 Pedophilia
 Sexual attraction to children
 More aroused to young children
 Incest
 Children related to perpetrator
 May be aroused to adult

113. Other Form of Paraphilias
 Frotteurism – rubbing
 Necrophilia – corpses
 Klismaphilia – enemas
 Coprophilia – feces
 Zoophilia – animals
 Scatologia – obscene calls

114. The Causes
 Psychosocial contributions
 Inability to develop adequate relationships
 Early “unusual” sexual experiences
 Person’s early sexual fantasies
 Excessive sex drive and suppression
 Specific causes are still unclear

115. Causes of Paraphilias
TheoryTheory DescriptionDescription
ParaphiliaParaphilia
best explainedbest explained
Psychodynamic
Fixation at an early psychosexual stage or
regression to that stage
All paraphilias
Behavioral
Arousal is classically conditioned to a
previously neutral stimulus
All paraphilias
Social learning
Children whose parents engaged in aggressive,
sexual behaviors with them learned to engage
in impulsive, aggressive, sexualize acts toward
others
All but
fetishes
Cognitive
Distorted cognitions and assumptions about
sexuality lead to deviant sexual behavior
All but
fetishes

116. Treatment of the Paraphilias
 Lessening the arousal value of deviant sexual stimuli:
 Aversion (learning)

Electrical aversion

Foul smell aversion

Covert sensitization

Shame therapy
 Masturbatory extinction (learning)
 Biofeedback (learning)
 Medroxyprogesterone acetate and Cyproterone (biological)
 Castration (biological)
 Increasing the arousal value of appropriate sexual
stimuli:
 Orgasmic reorientation (learning)

117. Treatment of the Paraphilias
 Lessening the anxiety associated with
appropriate sexual behaviors:
 Social skills training, e.g., Assertiveness training (learning)
 Systematic desensitization (learning)
 Ancillary procedures
 Empathy training for rapists and exhibitionists (cognitive)
 Family therapy for incest (cognitive)
 Marital therapy (cognitive)
 Group therapy (cognitive)