12_Semple_Chap12.indd 464 12/7/2012 3:42:30 PM MENSTRUAL-RELATED DISORDERS 465 Assessment Exclude other causes of mood disturbance. Particular attention should be paid to past psychiatric history and current social history. Management Evidence for HRT is inconclusive, although if mood symptoms are secondary to phy sical symptoms this may have a role (HRT may also augment effects of antidepressants).4 Tre atment is with standard approaches for depression/anxiety. Table 12.1 Frequency of premenstrual symptoms1 Symptom Frequency, % of cycles Fatigue 92 Irritability 91 Bloating 90 Anxiety and/or tension 89 Breast tenderness 85 Mood lability 81 Depression 80 Food cravings 78 Acne 71 Increased appetite 70 Oversensitivity 69 Swelling 67 Expressed anger 67 Crying easily 65 Feeling of isolation 65 Headache 60 Forgetfulness 56 Gastrointestinal symptoms 48 Poor concentration 47 Hot \202 ushes 18 Heart palpitations 14 Dizziness 14 1Mortola JF, Girton L, Beck L, et al. (1990) Diagnosis of premenstrual syndrome by a simple prospective reliable instrument. Obstet Gynecol 72: 302. 1 Mishell DR (2005) Epidemiology, and etiology of premenstrual disorders. Managing the spec trum of premenstrual symptoms, a clinician \200\231s guide, pp. 4 \200\2239. San Antonio, D annemiller Foundation/Med Pro Communications. 2 Cooke DJ (1985) Psychosocial vulnerability to life events during the climacteric. Br J Psychiat 147: 71 \200\2235. 3 Sagsoz N, Oguztur k O, Bayram M, et al. (2001) Anxiety and depression before and after the menopause. Arch Gy necol Obstet 264: 199 \200\223202. 4 Birkhauser M (2002) Depression, menopause and estrogen s: is there a correlation? Maturitas 41 (Suppl. 1): S3 \200\2238. 12_Semple_Chap12.indd 465 12/7/2012 3:42:30 PM CHAPTER 12 Reproductive psychiatry and sexuality 466 Premenstrual disorders Etiology Evidence supports a genetic vulnerability conferring increa sed sensitivity to normal changes in hormone levels throughout the menstrual cycle. This ca uses alterations in the normal cyclic ovarian steroid interactions with central neurotransm itters and neurohormones. Cyclic changes in ovar- ian steroids alone do not lead to PMS/PMD D. Most evidence supports involvement of the serotonergic system, endorphins and GABA, and the renin \200\223angiotensin \200\223aldosterone system. The autonomic and peripheral nerv ous systems may be involved in certain symptoms. Minimal or no evidence for: trace vitamin and element de \201 ciencies, personality factors, and stress. Stress also has little effe ct on PMS severity, and PMS is more likely to cause stress than vise versa. Morbidity These disorders can extend over a woman \200\231s entire reproductive cycle, from approximately age 14 to 50. Symptoms are relatively constant between cycles, and can cause an aggregate total of years of disability over a lifetime. This negatively affects quality of life and can have both direct and indirect economic consequences. Psychiatric consultation For already diagnosed premenstrual symptoms this is rare unless em o- tional symptoms are marked and/or there are vegetative symptoms, sui- cidal ideation, or a frequent inability to function. Differential diagnosis Up to 40% of women presenting to a physician with presumed PMS have another mood disorder; many meet the criteria for a depressive or anxi- ety disorder.1 PMDD can be a premenstrual exacerbation of an underlying psychiatric disorder or of a medical c ondition. Medical disorders such as migraine, chronic fatigue syndrome, and irritable bowel syndrome can have exacerbations prior to or during menses. Exclude perimenopause, gynae- c ological disorders (dysmenorrhoea, post-partum status, polycystic ovary disease, and endome triosis) and hypothyroidism and nutrient de \201 ciencies (e.g. manganese, magnesium, B vi tamins, vitamin E, and linoleic acid). Investigations \200 There are no speci \201 c tests diagnostic of premenstrual disorders. Prospective charting of daily symptoms for at least two menstrual cycles is essential to con \201 rm the cycli cal pattern. If menses are not regular and/or if they have length <25 days or >36 days refe rral should be made for a reproductive endocrine evaluation. For concomitant medical condit ions consultation with a general practitioner or gynecologist for a physical exam and exclu sion of medical disorders as well as appropriate routine blood tests including TFTs may be warranted. 12_Semple_Chap12.indd 466 12/7/2012 3:42:31 PM PREMENSTRUAL DISORDERS 467 Assessment tools Prospective Record of the Impact and Severity of Menstruation (PRISM), the Calendar of Premenstrual Experiences (COPE), and the Daily Record of Severity of Problems (DRSP). The DRSP is available online at M http:// www.pmdd.factsforhealth.org/have/dailyrec ord.asp. Treatment of PMS and PMDD First-line therapy \200 Antidepressants are effective for PMDD, with \202 uoxetine the most studied. At a dose of 20mg/day the overall response is 60 \200\22375%. Other SSRIs and venlafaxine have also sho wn ef \201 cacy in placebo-controlled trials. Luteal phase therapy: therapy in the luteal phase alone, starting 14d prior to the expected next menses, and terminating with the onset of menses. Second-line therapy \200 \200 Alprazolam (250 \200\223500mcg tid) for luteal phase depression. For severe PMDD, refractor y to other treatment, refer to a specialist. Potential treatments include medical oophoriec tomy with a GnRH agonist (e.g. leuprorelin, danazol). There are signi \201 cant side-effec ts related to hypoestrogenism (e.g. hot \202 ashes, long-term effects of estrogen de \201 ciency, osteoporosis, etc.). For patients who respond well, treatment can continue ove r the long term (>6mths) with continuous add-back of estrogen (+ progesterone when indicate d) to decrease and/or prevent these side-effects. For rare, refractory cases with severe di sabling symptoms, surgical bilateral oophoriectomy may be considered. Other promising possible treatments or adjuncts \200 RCTs initially failed to demonstrate the effectiveness of OCP in treating PMS or PMDD. Newe r placebo-controlled trials are showing that a 24-day (rather than 21-day) hormonal formula tion is ef \201 cacious for PMDD.2 Diuretics for severe oedema, e.g. furosemide, spironola ctone; danazol for mastalgia. There is some evidence for the ef \201 cacy of pyridoxine (v itamin B6) (no more than 100mg/day), vitamin E, calcium, vitamin D, and magnesium. No evide nce for multiple other treatment options including progesterone treatment, ginkgo biloba, e vening primrose oil, essential free fatty acids. 1 Keenan PA, Stern RA, Janowsky DS, et al. (1992) Psychological aspects of premenstrual syn - drome. I: Cognition and memory. Psychoneuroendocrinol 17: 179 \200\22387. 2 Yonkers KA, B rown C, Pearlstein TB, et al. (2005) Ef \201 cacy of a new low-dose oral contraceptive wit h drospirenone in premenstrual dysphoric disorder. Obstet Gynecol 106(3): 492 \200\223501. 12_Semple_Chap12.indd 467 12/7/2012 3:42:31 PM CHAPTER 12 Reproductive psychiatry and sexuality 468 Disorders associated with pregnancy Anxiety/mood symptoms in normal pregnancy Although ther e is usually an increase in symptoms of anxiety and depres- sion during pregnancy, these ar e quite normal and usually related to \200\230adjustment \200\231 in the 1st trimester and \200\230fears \200\231 in the 3rd trimester. Unless there is a past history of psychiatri c illness, there is no reported increase in the incidence of psychiatric disorders.1 Risk factors Family or personal history of depression; ambivalence about the pregnancy; hig h levels of neuroticism; lack of marital, family, or social supports. Treatment Usually will focus on psychosocial interventions; speci \201 c psychiatric disor ders should be identi \201 ed and treated appropriately (see Prescribing in pregnancy b p. 968). Miscarriage and abortion2 There is an increase in psychiatric morbidity, with over 50% of w omen experiencing an adjustment disorder (grief reaction) with signi \201 cant depressive symptoms. Chronic symptoms are rare, but risk is increased when there is a history of previ ous miscarriage or abortion, or where con \202 ict is experienced related to religious or cultural beliefs. Hyperemesis gravidarum3 Vomiting in pregnancy that is suf \201 ciently pernicious to produ ce weight loss, dehydration, acidosis from starvation, alkalosis from loss of HCl in vomitu s, and hypokalaemia. Occurs in 1 \200\22320/1000 pregnant women. Although psychological fac tors may be important in benign forms, these are now regarded as secondary rather than prim ary (i.e. not a somatoform disorder). Complications Muscle weakness, ECG abnormalities, tetany, psycho- logical disturbance, and more seriously (but rarely): oesophageal rupture, Wernicke \200\231s encephalopathy, centra l pontine myelinosis, retinal haemor- rhage, renal damage, spontaneous pneumomediastinum, i ntrauterine growth retardation, and fetal death. Associations Transient hypothyroidism (60% of cases), H. pylori infection. Management Admis sion to hospital (724%), parenteral \202 uid, electrolyte replacement, vitamin supplement ation, anti-emetics or short-term ster- oids, diazepam (for nausea and associated distress) . Pseudocyesis4 A condition in which a woman \201 rmly believes herself to be pregnant and develops objective pregnancy signs (abdominal enlargement, menstrual disturbance, apparent fetal movements, nausea, breast changes, labor pains, uterine enlargement, cervical softeni ng, urinary frequency, positive pregnancy test) in the absence of pregnancy. 12_Semple_Chap12.indd 468 12/7/2012 3:42:31 PM DISORDERS ASSOCIATED WITH PREGNANCY 469 Differential diagnosis Possible medical disorders should be excluded (ectopic pregnancy, co rpus luteal cyst, placenta praevia, pituitary tumor, pelvic tumor). Etiology Regarded as a somatoform disorder or variant of depression, it may present as a co mplication of postpartum depression or psychosis with amenorrhoea. It may be related to Cou vade \200\231s syndrome in expectant fathers (see b p. 90). Treatment Tends to include supp ortive or insight-orientated psychother- apy and a trial of an antidepressant. 1 Klein MH and Essex MJ (1995) Pregnant or depressed? The effect of overlap between symptom s of depression and somatic complaints of pregnancy on rates of depression in the second tr imester. Depression 2: 308 \200\22314. 2 Clare AW and Tyrrell J (1994) Psychiatric aspects of abortion. Ir J Psychol Med 11: 92 \200\2238. 3 Kuscu NK and Koyuncu F (2002) Hyperemesis gravidarum: current concepts and management. Postgrad Med J 78: 76 \200\2239. 4 Small GW ( 1986) Pseudocyesis: an overview. Can J Psych 31: 452 \200\2237. 12_Semple_Chap12.indd 469 12/7/2012 3:42:31 PM CHAPTER 12 Reproductive psychiatry and sexuality 470 Disorders related to childbirth 1 Always ask about thoughts of self-harm or harming the bab y. Despite the signi \201 cant life event that pregnancy is, psychiatric admission and com pleted suicide are less common in pregnancy than at other times. There may be subclinical m ild anxiety or mood disturbance, worse in the third and \201 rst trimesters. 10% risk of clinical depression in the \201 rst trimester associ- ated with past history of depressio n, previous abortion, previous intrauter- ine loss, unwanted pregnancy. Third trimester dep ression may persist as post-partum depression. Avoid drug treatment in the \201 rst trime ster. Baby blues Up to of new mothers will experience a short-lived period of tearful- ness an d emotional lability starting two or three days after birth and lasting 1 \200\2232 days. T his is common enough to be easily recognizable by midwifery staff and requires only reassur ance and observation towards resolution. There is weak evidence that it may be related to p ost-partum reduc- tions in levels of estrogen, progesterone, and prolactin (which do occur around 72hrs after the birth). Postnatal depression (PND) A signi \201 cant depressive episode, temporally related to chi ldbirth, occur- ring in 10 \200\22315% of women within 6mths post-partum (peak 3 \200\2234w ks). The clinical features are similar to other depressive episodes, although thought conte nt may include worries about the baby \200\231s health or her ability to cope adequately wi th the baby. There may be a signi \201 cant anxiety component. 90% of cases last less than 1mth; 4% greater than 1yr. Risk factors Personal or family history of depression, older ag e, single mother, poor relation- ship with own mother, ambivalence towards or unwanted preg nancy, poor social support, signi \201 cant other psycho-social stressors, severe \200 \230baby blues \200\231, previous post-partum psychosis (no evidence for association with o bstetric complications). Management Early identi \201 cation and close monitoring of those \200\230at risk \200\231 (use of Edinburgh Postnatal Depression Scale in primary care set ting \200\224see Box 12.1); prevention by education, support, and appropriate pharmacologic al intervention; depressive episode treated in usual way with antidepressants and/or brief CBT, if severe or associated with thoughts of self-harm or harm to baby, may require hospit al admission. Postpartum psychosis An acute psychotic episode, occurring following 1.5/1000 live births, peak occurrence at 2wks postpartum. Etiology Unknown, but may relate to reduction of estrog en (leading to DA super-sensitivity), cortisol levels, or postpartum thyroiditis. Symptoms 3 common clinical presentations: promi- nent affective symptoms (80%) \200\224mania or depr ession with psychotic symp- toms; schizophreniform disorder (15%); acute organic psychosis (5%). Common features Lability of symptoms; insomnia; perplexity, bewilderment, and disorie ntation; thoughts of suicide or infanticide. Risk factors Personal or family history of maj or psychiatric disorder; lack of social support; single parenthood; previous postpartum psy chosis (30% risk of psychosis; 38% risk of PND). Management Prevention Identi \201 cation, education, support, and 12_Semple_Chap12.indd 470 12/7/2012 3:42:31 PM DISORDERS RELATED TO CHILDBIRTH 471 treatment of \200\230at risk \200\231 individuals; Treatment Admission to hospital (specia l- ist mother \200\223baby unit if possible); for major affective disorder there is good ev idence for ECT, mood stabilizers (esp. carbamazepine), and early use of antidepressants; ps ychotic symptoms should be treated with usual protocol (see b p. 192). Box 12.1 Edinburgh Postnatal Depression Scale (EPDS)1 As you have recently had a baby, we would like to know how you are feeling. Please UNDERLIN E the answer which comes closest to how you have felt IN THE PAST 7 DAYS, not just how you feel today. I have been able to laugh and see the funny side of things. As much as I always could/Not q uite so much now/De \201 nitely not so much now/Not at all I have looked forward with enjo yment to things. As much as I ever did/Rather less than I used to/De \201 nitely less than I used to/Hardly at all * I have blamed myself unnecessarily when things went wrong. Yes, most of the time/Yes, some of the time/Not very often/No, never I have been anxious or worr ied for no good reason. No, not at all/Hardly ever/Yes, sometimes/Yes, very often * I have felt scared or panicky for not very good reason. Yes, quite a lot/Yes, sometimes/No, not mu ch/No, not at all * Things have been getting on top of me. Yes, most of the time I haven \200\231t been able to cope at all/ Yes, sometimes I haven \200\231t been coping as well as usual/ No, most of the time I have coped quite well/ No, I have been coping as well as eve r * I have been so unhappy that I have had dif \201 culty sleeping. Yes, most of the time/ Yes, sometimes/Not very often/No, not at all * I have felt sad or miserable. Yes, most of t he time/Yes, quite often/Not very often/No, not at all * I have been so unhappy that I have been crying. Yes, most of the time/Yes, quite often/Only occasionally/No, never * The thou ght of harming myself has occurred to me. Yes, quite often/Sometimes/Hardly ever/Never Response categories are scored 0, 1, 2, and 3 according to increased sever- ity of the symp toms. Items marked with an asterisk are reverse scored (i.e. 3, 2, 1, and 0). A total score of 12+ is regarded as signi \201 cant. 1 1987 The Royal College of Psychiatrists. The Edinburgh Postnatal Depression Scale may be photocopied by individual researchers or clinicians for their own use without seeking pe rmission from the publishers. The scale must be copied in full and all copies must acknowle dge the fol- lowing source: Cox, J.L., Holden, J.M., & Sagovsky, R. (1987). Detection of po stnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Britis h Journal of Psychiatry, 150, 782 \200\2236. Written permission must be obtained from the R oyal College of Psychiatrists for copying and distribution to others or for republication ( in print, online, or by any other medium). Translations of the scale, and guidance as to it s use, may be found in Cox JL and Holden J (2003) Perinatal mental health: a guide to the E dinburgh Postnatal Depression Scale. London: Gaskell. 12_Semple_Chap12.indd 471 12/7/2012 3:42:31 PM CHAPTER 12 Reproductive psychiatry and sexuality 472 Sexual dysfunction 1: general principles A brief note on \200\230talking about sex \200 \231 Discussing sexual issues, particularly sexual dysfunction, may be embar- rassing for t he individual, and this is compounded if the clinician is also uncomfortable. Aside from ex perience of asking about these issues, a few general principles should be borne in mind. \200 \200 \200 \200 \200 \200 An empathic, non-judgemental, understanding approach is essential. Acknowledge the dif \201 culty in talking about sexual problems. Reassure that such problems are common and are treatable. Avoid \200\230medical \200\231 terminology (or explain adequately any terms us ed). Start with general enquiries before moving on to more speci \201 c issues. any assump tions (esp. orientation, practices, experience, Do not make number of partners). Be aware o f common sexual myths (see Box 12.2). De \201 ning sexual dysfunction Despite disagreement about what constitutes \200\230norma l \200\231, there is general consensus that sexual dysfunction is present when there are pe rsistent impairments of normal patterns of sexual interest or response. Usually these manif est as lack or loss of interest/enjoyment of sexual activities, the inability to experience or control orgasm, or a physiological barrier to successful sexual intercourse. Criteria f or a diagnosis of sexual dysfunction include: \200 \200 \200 \200 \200 Inability to participate in a preferred sexual relationship. Presence of the sexual dysfunc tion on (almost) all occasions. Duration of at least 6mths. Signi \201 cant stress or inte rpersonal dif \201 culties. Not accounted for by a physical disorder, drug treatment (or u se), or other mental or behavioral disorder. Subclinical problems Certain individuals will not meet strict criteria for a speci \201 c diagnosis, but nevertheless experience signi \201 cant distress. Usually these problems ar e adjustment dif \201 culties related to timing, frequency, and method of initiat- ing sex ual activity. Any treatment tends to be supportive (for the patient and their partner) and educative (sex education: see Box 12.4). 12_Semple_Chap12.indd 472 12/7/2012 3:42:31 PM SEXUAL DYSFUNCTION 1: GENERAL PRINCIPLES 473 Box 12.2 Common sexual myths1 \200 \200 \200 \200 \200 \200 \200 \200 Men should not express their emotions. All physical contact must lead to sex. Good sex lead s to a wild orgasm. Sex = intercourse. The man should be the sexual leader. Women should no t initiate sex. Men feel like sex all the time. Women should always have sex when her partn er makes sexual approaches. Sex is something we instinctively know about. \200\230Respecta ble \200\231 people should not enjoy sex too much and certainly never masturbate. All other couples have \200\230great \200\231 sex, several times a week, have an orgasm every time, and always orgasm simultaneously. If sex is not good, there is something wrong with the re lationship. \200 1 Adapted from Andrews G and Jenkins R (eds) (1999) Management of mental disorders, UK edn, vol. 2, Sexual Dysfunction, pp. 612 \200\22313. Sydney: World Health Organization Collabor ating Center for Mental Health and Substance Abuse. Box 12.3 Common triggers for sexual problems Psychological Relationship problems; life stressors; anxiety/depression; low self-esteem; s exual performance anxiety; excessive self-monitoring of arousal; feelings of guilt about se x; fear of pregnancy or sexually transmitted diseases (STDs); lack of knowledge about sexua lity/ \200\230normal \200\231 sexual responses; previous signi \201 cant negative sexual e xperience (esp. rape or childhood sexual abuse issues). Environmental (Fear of) interruptio ns (e.g. from children, parents); physical discomfort. Physical Use of drugs or alcohol; me dication side-effects; pain or dis- comfort due to illness; feeling tired or \200\230run d own \200\231; recent childbirth. Factors related to the partner Sexual attractiveness (gend er, physi- cal characteristics); evidence of disinterest, constant criticism, incon- sidera tion, and inability to cope with dif \201 culties (esp. sexual); sexual inexperience/poor technique; preference for sexual activities that are unappealing to the partner. 12_Semple_Chap12.indd 473 12/7/2012 3:42:31 PM CHAPTER 12 Reproductive psychiatry and sexuality 474 Sexual dysfunction 2: problems common to men and women Sexual dysfunction is common in the general population with lifetime prevalence in young adults estimated as in Table 12.2.1 Table 12.2 Prevalence of sexual dysfunction in young adults Problem Male Female Reduced libido 30% 40% Arousal dif \201 culties 50% 60% Reaching orgasm too soon 15% 10% Failure to have orgasm 2% 35% Dyspareunia 5% 15% Lack or loss of sexual desire Lack of pleasure in anticipating, or reduced urge to engage i n, sexual activ- ity. May be primary (always has been absent) or secondary (has declined re cently), situational (speci \201 c settings or partners), or total. For a diagno- sis, los s of desire ought not to be secondary to other sexual problems (e.g. dyspareunia or erectil e failure). Differential diagnosis Sexual aversion, lack of sexual enjoyment, depres- sion, physical ca uses (chronic pain, endocrine disturbance, effects of drugs or alcohol). Management \200 \200 Treat any primary cause found (physical, psychological, psychiatric). Establish the reasons for seeking help, provide information (e.g. common triggers (b p. 473). Address general re lationship issues. Consider specialist referral (behavioral work, graded individual and cou ple exercises require experienced therapist (e.g. \200\230sensate focus \200\231 technique s, see Box 12.4). \200 Sexual aversion and lack of sexual enjoyment Sexual aversion Strong \200\223ve feelings, f ear, or anxiety due to prospect of sexual interaction; of suf \201 cient intensity to lead to active avoidance of sexual activity. Lack of sexual enjoyment Lack of appropriate pleasure, despite normal sexual responses and achievement of orgasm. Management Both conditions tend to be related to dif \201 cult and complex psychosocial fa ctors, often stemming from a previous traumatic sexual experience (e.g. rape or molestation ). For this reason, only a skilled, expe- rienced therapist should attempt treatment. Where possible, refer to a specialist service. Establishing the reasons for seeking help may cla rify sen- sible outcome goals. 12_Semple_Chap12.indd 474 12/7/2012 3:42:31 PM SEXUAL DYSFUNCTION 2: PROBLEMS COMMON TO MEN AND WOMEN 475 Excessive sexual desire Occasionally increased sexual drive may occur, presenting as a prob lem for individuals, partners (on whom \200\230unreasonable \200\231 demands are made), or carers (when sexual disinhibition occurs). Referred to as nymphomania (women) or satyriasi s (men). Usually occurs in late teenage/early adult- hood, secondary to a mood disorder (e. g. mania), in the early stages of dementia, associated with learning disability, secondary to brain injury, or as a side-effect of some drugs. Management Treatment should address any p problem, general relation- ship issues. When the problem is persistent, specialist refer ral may be appropriate (for cognitive, behavioral, or, rarely, pharmacological therapy Box 12.4). Box 12.4 \200\230Sensate focus \200\231 (Masters and Johnson 1966)1 A series of speci \201 c exercises for couples (essentially a form of in vivo \200\230des ensitization \200\231 to reduce sexual anxiety), initially encouraging each partner to take turns in paying increased attention to their own senses. There are a number of stages to a course of therapy: Stage one The couple take turns to touch each other \200\231s body (with the breasts and ge nitals off limits), to establish an awareness of sensations (touching and being touched) an d usually in silence (to avoid distrac- tions). If sexual arousal does occur, they are not to proceed to inter- course. If any touch is uncomfortable, the partner being touched must let his or her partner know, either verbally or non-verbally. Stage two Touching is expanded to include the breasts and genitals, still with an emphasis on awareness of sensations and not the expectation of a sexual response (intercourse and or gasm are still prohibited). A \200\230hand riding \200\231 technique is used (placing one hand on top of the partner \200\231s hand while being touched) to indicate more or less pre ssure, faster or slower pace, or change to a different spot. Stage three The couple try mut ual touching (not taking turns), to prac- tise a more natural form of physical interaction. Intercourse is still off limits. Stage four Mutual touching continues, moving to the femal e-on-top position without attempting penetration. The woman can rub the penis against her c litoral region, vulva, and vaginal opening regardless of whether or not there is an erectio n, still focusing on the physical sensations, and stopping or returning to non-genital touc hing if either partner becomes orgasm-orientated or anxious. In later sessions, she may pro gress to putting the tip of the penis into the vagina if there is an erection, and after co mpleting a few sessions in this way, couples are usually comfortable enough to proceed to f ull intercourse. 1 Masters WH and Johnson VE (1966) Human sexual response. New York: Bantam Books. 1 Haas K and Haas A (1993) Understanding human sexuality. St Louis: Mosby. 12_Semple_Chap12.indd 475 12/7/2012 3:42:32 PM CHAPTER 12 Reproductive psychiatry and sexuality 476 Sexual dysfunction 3: problems speci \201 c to women Failure of genital response This is u sually due to vaginal dryness or lack of lubrication, due to psycho- logical factors (e.g. anxiety), physical problems (e.g. infection), estrogen de \201 ciency (esp. post-menopausa l), or secondary to lack or loss of sexual desire. Management \200 General aims: increasing arousal levels during periods of sexual activity (see Orgasmic dys function), alleviating vaginal dryness (with use of lubricating gel, estrogen replacement), and reducing factors that may inhibit arousal (see Common triggers b p. 473). If problems persist, referral to a specialist should be considered. Orgasmic dysfunction The most common sexual complaint in women. Experience of orgasm is del ayed or does not occur at all, despite normal sexual arousal and excite- ment. Individuals may consider this to be normal and not complain of dysfunction. Problems may be primary (ne ver had an orgasm in any situa- tion), secondary (previously able, but not currently), situ ational (problems only occur in certain situations), or total (in all situations). Complica ting factors may include secondary lack or loss of sexual desire, other sexual dysfunctions , and relationship problems. Management \200 \200 Complex cases should be referred to a specialist sex therapist. Less complex cases may resp ond to a directed self-help program. This usually includes directed masturbation, \200\230 sensate focus \200\231 for couples, Kegel \200\231s pelvic \202 oor exercises, and use of sexual fantasy. 1 Non-organic vaginismus Penetration is impossible or painful due to blockage of the vaginal opening caused by spasms of the pelvic \202 oor muscles. Usually related to anxie- ties o r fearful thoughts \200\224e.g. fear of pain on penetration, previous sexual assault, belie f in premarital sex being wrong or sinful, childhood punish- ment for masturbation, general fear of sex (esp. the \201 rst experience of intercourse is likely to be painful or bloo dy), fear of pregnancy and painful labor. Vaginismus leads to pain during intercourse, thus reinforcing these beliefs. Management \200 Physical examination (to exclude vaginal obstruction due to a growth, a tumor, or the hymen ). Vaginismus is best treated by an expert and management will include: education (to dispe l myths and tackle misunderstandings or negative attitudes), relaxation techniques, and str ategies to achieve penetration (e.g. self-exploration, Kegel \200\231s exercises, use of gr aded trainers, sensate focus exercises, involvement of partner, graded attempts at intercou rse, reassurance for the partner; see Box 12.5). 12_Semple_Chap12.indd 476 12/7/2012 3:42:32 PM SEXUAL DYSFUNCTION 3: PROBLEMS SPECIFIC TO WOMEN 477 Non-organic dyspareunia Pain during intercourse that may be felt super \201 cially (at the entrance of) or deep within the vagina. Management \200 Exclude physical causes of pain (e.g. infection, tender episiotomy scar, endometriosis, ova rian cyst). Provide information about ensuring adequate arousal, variation of intercourse p ositions to avoid \200\230deep \200\231 penetration. Relaxation techniques (including Kege l \200\231s exercises) and \200\230positive self- talk \200\231 may help reduce anxiety an d ensure the woman feels \200\230in control \200\231. Where deep pain is experienced to pe lvic congestion syndrome (with symptoms similar to premenstrual syndrome) caused by accumul ation of blood during arousal without occurrence of orgasm. Achieving orgasm (by intercours e, masturbation, or use of a vibrator) may help to alleviate this congestion. For complex c ases, with vague or intermittent problems, associated secondary sexual or psychiatric probl ems, or when initial treatment is unsuccessful, referral to a specialist is indicated. after intercourse, this may be due Box 12.5 Kegel \200\231s exercises These are pelvic \202 oor muscle exercises. The muscle can be identi \201 ed by attempti ng to stop urine \202 ow, and contraction of this muscle may need to be practiced before voluntary control is mastered. The exer- cises should be practiced for a few minutes every day. Repeat (a) and (b) ten times initially (building up to 30 times over 4 \200\2236 weeks ) and (c) and (d) \201 ve times (building up to 20 times over 4 \200\2236 weeks). (a) Bre athing normally, quickly contract and relax the muscle. (b) Breathing normally, contract th e muscle for a count of three, and then relax. (c) Inhale slowly, contracting the muscle fo r a count of three, hold for a count of three, then, exhaling slowly, relax to a count of t hree. (d) With the muscle relaxed, bear down (as if trying to push something out of the vag ina) for a count of three. 1 Heiman JR and LoPiccolo J (1988) Becoming orgasmic. London: Piatkus Books. 12_Semple_Chap12.indd 477 12/7/2012 3:42:32 PM CHAPTER 12 Reproductive psychiatry and sexuality 478 Sexual dysfunction 4: problems speci \201 c to men Erectile failure (failure of genital re sponse) Inability to develop or maintain an erection, leading to failure of coitus or sexua l intercourse. Subtypes Primary Never been able to sustain an erection; Secondary Able to d o so in the past; Situational Only successful under certain circumstances; Total Not under any circumstances. Contributing factors Moral/religious views on sex and masturbation; prev ious negative sexual experiences (may undermine sexual con \201 dence and increase \200 \230performance anxiety \200\231); sec- ondary to other sexual dysfunction (e.g. premature ejaculation); use of alcohol and drugs; stress and fatigue. Management Physical assessment to exclude organic causes (disease or surgery affecting the blood supply of the penis, side-effects of drugs or medication) especially in older men; re fer to expert on sexual problems if primary, total, long-standing (years), or not associate d with obvious trig- gers. General Education (about physical and psychological factors that may contribute to erectile failure) and self-help exercises1,2 (better if part- ner involv ed). Physical Sildena \201 l (Viagra); training in self-administration of papaverine or pr ostaglandin E1 into the penis prior to intercourse; use of a vacuum constriction device; su rgical implantation of semi-rigid or in \202 at- able penile prostheses. Note: relapse com mon (775%), usually related to clear triggers, and will improve naturally or through use of previously suc- cessful techniques. (Seeing this as a \200\230normal \200\231 situation m ay help relieve anxiety and reduce the sense of failure which might otherwise prolong probl ems further.) Orgasmic dysfunction (or \200\230inhibited ejaculation \200\231) Relatively rare in men. O rgasm delayed/does not occur at all, despite normal sexual excitement and arousal. Situatio nal dysfunction usually has a psychological cause (see Common triggers b p. 473); total dys function may have a variety of causes. Management Main aims: reducing \200\230performance anxiety \200\231, increasing arousal an d physical stimulation, i.e. addressing any common triggers, rela- tionship problems, assoc iated feelings of anxiety or guilt, or memories of past traumatic/unpleasant sexual experie nces. Education (dispelling myths, understanding \200\230normal \200\231 physiology, the e ffects of alcohol); use of sensate focus techniques. Persistent problems should be referred to an expert. Premature ejaculation The inability to control ejaculation adequately for both partners to enjoy the sexual interaction. Ejaculation may occur immediately after penetration, or in th e absence of an erection. Differential diagnosis Delayed erection (prolonged stimulation needed to achieve adequate e rection; short time to ejaculation); organic impairment (esp. pain); \200\230normal \200 \231 rapid ejaculation in young or sexually inexperienced men (control is learned with prac tice); secondary to psychological stres- sors; transient problem following a period of redu ced sexual activity. Management Expert advice should be sought for complex cases or where there is associated or gasmic dysfunction/lack or loss of sexual desire. 12_Semple_Chap12.indd 478 12/7/2012 3:42:32 PM SEXUAL DYSFUNCTION 4: PROBLEMS SPECIFIC TO MEN 479 Sympathetic partner is crucial to successful management. General education (speci \201 c i ssues of \200\230normal \200\231 time before ejaculation occurs). Reduction of \200\230pe r- formance anxiety \200\231 (as for Orgasmic dysfunction). Use of self-help guides.2 Speci \201 c exercises may include: the \200\230stop \200\223start \200\231 technique (see Box 12.6), the \200\230squeeze technique \200\231 (see Box 12.7), and sensate focus (see b p. 475). Non-organic dyspareunia Pain during intercourse in men; usually has a physical cause (e.g. urethral infection, scarring secondary to STD, tight foreskin) that can be directly treated. If psychological factors are the root cause, reassurance, education, and use of re laxation and cognitive tech- niques may be helpful. Complex cases require expert management . Box 12.6 The stop \200\223start technique (Semans \200\231 technique) Developed by Masters and Johnson;1,2 effective in up to 90% of cases of premature ejaculati on. Aims: To increase the frequency of sexual contact and increase the sensory threshold of the penis. Setting: Best performed in the context of sensate focus exercises \200\224to ensure non-gen ital areas are focused on \201 rst (less threatening for anx- ious individuals, allowing the recognition of sensations leading up to ejaculation, and may make the \200\230quality \200\231 of the sexual experience better), to limit the number of \200\230accidental \200 \231 ejaculations (that may discourage cou- ples early on), and increase good communication and cooperation. Technique: \200 Stimulation of the penis until high arousal (but not the ejaculation threshold) is achieved . Cessation of stimulation for a few minutes to allow arousal to subside. Repetition 4 \200 \2235 times until ejaculation is permitted. \200 Box 12.7 Squeeze technique If control does not develop using the \200\230stop \200\223start \200\231 technique, this method may be used to inhibit the ejaculatory re \202 ex: \200 Stimulation of the penis until high arousal (but not the ejaculation threshold) is achieved . The man (or his partner) applies a \201 rm squeeze to the head of the penis for 15 \200 \22320 seconds. (Fore \201 nger and middle \201 nger are placed over the base of the gla ns and shaft of the penis, and the thumb applies pressure on the opposite side at the base of the undersurface of the glans.) Note: this technique should be practiced before high arousal occurs to establish how \201 rmly the penis may be squeezed without causing pain. 1 Masters WH and Johnson VE (1966) Human sexual response. New York: Bantam Books. 2 Masters WH and Johnson VE (1980) Human sexual inadequacy. New York: Bantam Books. 1 Williams W (1985) It \200\231s up to you. Sydney: Maclennan and Petty. 2 Zilbergeld B (19 80) Men and sex. London: Fontana. 12_Semple_Chap12.indd 479 12/7/2012 3:42:32 PM CHAPTER 12 Reproductive psychiatry and sexuality 480 Disorders of sexual preference 1: general aspects1 Essence Disorders of sexual preference ( the term used in ICD-10) or paraphilias (the term used in DSM-IV) are disorders in which an individual is sexually aroused by inappropriate stimuli. Other terms used include sexual d evia- tion and perversion. There is some overlap between these disorders, sex offending, an d inappropriate sexual behavior, but the three are separate concepts. Homosexuality was pre viously included, but this is no longer the case. Disorders of sexual preference are one of three broad types of sexual disorders. The others are gender identity disorders and sexual dysfunc- tions (see Table 12.3). In some cases tw o or more of these are present. De \201 nition DSM-IV de \201 nes each paraphilia as at least 6mths of recurrent, intense , sexually arousing fantasies, sexual urges, or behaviors involving a par- ticular inapprop riate act or object. These fantasies, urges, or behaviors must cause clinically signi \201 cant distress or impairment in social functioning. ICD-10 has less strict and less detaile d criteria, referring to the particular object or act as being the most important source of sexual arousal or essential for satisfactory sexual response.