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Sex And Psychiatry

Sex And Psychiatry. Dr Riccardo N Caniato. Qualifications. MBBS FRANZCP Sexual Health Clinic Forensic Psychiatry Private Practice. Sexual problems. Importance of Sexual functioning Sexual dysfunction or issues are common and distressing

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Sex And Psychiatry

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  1. Sex And Psychiatry Dr Riccardo N Caniato

  2. Qualifications • MBBS • FRANZCP • Sexual Health Clinic • Forensic Psychiatry • Private Practice

  3. Sexual problems • Importance of Sexual functioning • Sexual dysfunction or issues are common and distressing • Sexual dysfunction/ disorders are an unclear area of medicine • Complex ethical issues • Common primary diagnosis • Common co-morbidities to mental illness • Secondary to psychiatric medications

  4. Clinical Scope • 1) Sexual dysfunction- arousal, interest and performance • 2) Paraphilias/ arousal disorders • (Paedophilia / sexual offending) • 3)Transgender disorders/gender identity disorders

  5. Classification-DSM IV • Sexual and gender identity disorders • 1) Sexual dysfunction • 2) Paraphilias • 3) Gender identity disorders

  6. Classification- ICD 10 • F 52- sexual dysfunction not caused by organic disorder or disease • F 64 – gender identity disorders • F 65 –disorders of sexual preference • F 66 – psychological and behavioural disorders associated with sexual development and orientation

  7. Other classification systems • CCMD-3 • Culture bound syndrome • Koro

  8. Key issues / differences • Sexual preference/orientation (adults) no longer considered a disorder (removed from DSM and ICD) • Ego dystonic sexual orientation coded for in ICD but not DSM IV • Paedophilia is universally considered abnormal • No general category for perpetrators of adult sexual assault (but there is for victims)

  9. Aetiology of sexual function • Complex • Multiple factors • Biological • psychological • social • Poorly understood

  10. 1) Sexual dysfunctions - (interest, arousal, and performance) • A) sexual desire disorders • Hypoactive sexual desire disorder • B) sexual arousal disorder • Sexual aversion disorder • Male erectile disorder • C) orgasmic disorders • Premature ejaculation • D) sexual pain disorders • Dyspareunia • Sexual dysfunction nos A, B, C or D Due to GMC

  11. Epidemiology • High- • Very hard to get valid statistics • Usually secondary in clinical practice- ( mental health issues, substance use, medications or GMC) • Males • Erectile • Interest • Orgasmic

  12. Assessment“To ask or not too ask” • Not part of a usual medical interview • Difficulty of ascertaining normality • Role of physician- line between a medical problem and a lifestyle issue • Marked individual variations • Usually a secondary person / patient • Subjective change and dissatisfaction is most common marker- can be flawed • Change in functioning- normal change with age

  13. Presentation • Sexual problems are rarely the PC • Asking- vs Ticket of entry • Assess comorbidity- depression • Medical history • Psychiatric history • Medications • AD, antihypertensives, Drug and alcohol history

  14. Sexual History“ How much do you really want to know” • Guidelines to taking a sexual history (medical) • Psychological Guidelines for assessing sexual functioning • More detailed- frequency, duration, quality, dreams, fantasies • “how is your sexual functioning” • Relationship quality • Structured interviews or standardised self reported assessments

  15. Psychometric assessments • Standardised • Less time consuming • comparative • SFQ • AMS • Marital relationship

  16. Investigations • Hormone assays- testosterone, free testosterone, FSH • Prolactin • Markers of vascular pathology- smoking, cholesterol, blood pressure • Drug/ alcohol use- LFTs CDT cannabis

  17. Diagnostic formulation • Diagnosis • Primary or secondary • co-morbidities • Formulation- main biological, psychological and social factors

  18. a) Major Depression • Probably Main comorbidity to sexual dysfunction • Depression nearly always affects sexual function • Nearly all antidepressants affection sexual functioning • Further comorbidities • Medical • Substance use

  19. Case Report 1 • MR PG 56 year old male with depression, • You have Treated with him with lexapro 20 mg, but he is still depressed • Other medications are, simvastatin 10 mg, verapamil, diaformin • Hx of hypertension, obesity, snoring, smoking, drinks 10 drinks/ week • Investigations- borderline low testosterone, poorly controlled diabetes, bp 150/90 • At the end of the session he mentions than he hasn’t had sex for a while

  20. Causes of his sexual dysfucntion • Multiple • Depression • Medical problems • Vascular risks • Medications • Substance use

  21. Treatment guidelines ??“What’s most important” • A) Treat major depression • -assumes if depression improves, sexual function should improve • B) Target his medical problems • -main focus as medical practitioners • C) Target substance use • D) Treat sexual functioning • -assumes if sexual functioning improves, depression improves • E) simultaneous assessment and treatment

  22. Pharmacotherapy of sexual dysfunction in depression“ • A) Antidepressant treatments with fewer sexual side effects • B) Medications that improve sexual function • C) Minimising general medication with sexual side effects • D) target substance use

  23. Sexual side effects of AD • SSRIs- very high rate of sexual side effects= 30 -70 % • Impaired orgasm • Reduced interest

  24. Neurotransmitters of sexual function (Stahl) • Interest • Dopaminergic (mesolimbic reward system) • Testoserone • Estrogen Arousal NO (nitrous oxide) acetylcholine Orgasm serotonergic -ve noradrenaline +ve Others- mutliple-

  25. a) Change to antidepressants with lesser sexual effects • Buproprion- dopaminergic • Trazodone- atypical; priapism • Nefazadone- 5 HT2a agonism • Reboxetine (noradrenergic) • Mirtazepine- 5HT2A (agonism) • Moclobemide-RIMA • SNRI-s Noradrenergic function ? Duloxetine

  26. b) Reduced antidepressant dose • Reduce at earliest time frame ( dose dependant) • Adjuvant with few side effects • Lithium, thyroxine, seroquel • Buspirone- (antidepressant/ adjuvant) • Testosterone

  27. c) Medications for improved sexual functioning ?? a) Erectile medications b) Testosterone

  28. Other putativesexually enhancing compounds • Cyproheptatine (periactin) a first-generation antihistamine with additional anticholinergic, antiserotonergic, and local anesthetic properties.Improve SSRI-induced sexual dysfunction[15][16] • YohimbineYohimbine is an alkaloid with stimulant and aphrodisiac effects found naturally in Pausinystaliayohimbe (Yohimbe). Yohimbine blocks the pre- and post-synaptic alpha-2 adrenoceptors. • Gingko biloba • apomorphine, (dopaminergic) • methylphenidate,- stimulant (sympathomimetic) • Parkinsonian • Opiods –acute phase

  29. Sexual functioning and AnxietyDisorders

  30. Mental State Examination

  31. The Anxious Male

  32. Anxiety Disorders • GAD • Panic disorder (with or without agoraphobia) • Social Phobia • PTSD • OCD

  33. Anxiety disorders • State of flux • Complex overlap with depression • Under-diagnosed in males • Difficult to diagnose in males (with the exception of PTSD) • Far bigger stigma that depression or PTSD

  34. Relationship of anxiety and sexual dysfunction • A) Anxiety and premature ejaculation – • (adrenergic system) • B) Anxiety and reduced desire • (in some people) • C) Anxiety and sexual avoidance • (sexual aversion disorder) • D) Sexual phobias/ panic • E) Anxiety and avoidance of potential partners

  35. Case 2 • 25 year old veteran from IRAQ conflict being treated for PTSD and GAD • Anxiety in social situations, public places, driving, social phobia, agoraphobia • Increasing alcohol consumption • No / reduced sexual interest • ? Anxiety • Sexual anticipatory anxiety, avoidance, anxiety, • ? Sexual aversion disorder (DSM)

  36. Treatment- antidepressants • A) Standard antidepressant treatment • For anxiety • For premature ejaculation • B) Anxiolytic antidepressants • -paroxetine • -TCA-especially clomipramine • (Anticholinergic antidepressants- TCAs, aropax (ACH)

  37. Anxiolytics • Alcohol (self medication) • Benzodiazepines (GABA ergic) • B blockers- propranolol • Calming antipsychotics (vs prolactin) • Antipsychotics • -Dopaminergic, • -Seroquel • Buspirone (azapirone anxiolytic) • GAD, depression (off label) • 5-HT1a partial agonist, dopamine, adrenergic

  38. Case 3 • MR AG 22 old male, • vomiting after orgasm (post coital / orgasmic symptoms) • Other low grade anxiety symptoms • Diagnosis

  39. 3) Psychotic disorders • Complex effect on sexual function- schizophrenia • Bipolar affective disorders- cyclical changes • Antipsychotics- anti-dopaminergic • - prolactinergic (Dopaminergic) • - other

  40. Antipsychotics • Dopaminergic effect-reduces drive and sexual function • Prolactin raising effect- primary effect on sexual functioning • Indirect reduction of testosterone

  41. Mood stabilisers • Very limited data on sexual dysfunction • On face value, reason to believe they have lesser incidence of SSE

  42. Paraphilias“No women allowed” • Almost exclusively the domain of men • Exibitionism • Fetishism • Frotterism • Paedophilia • Sexual masochism • Sexual sadism • Transvestic fetishism • Voyerism • Paraphilia NOS

  43. Paedophilia- Role of general physician • A) to detect • B) to recognise • C) to predict • D) to alert • E) to treat • F) to monitor

  44. Pharmacology • Reduce sexual drive • Reduce arousal • Reduce obsessive/ intrusive thoughts

  45. Reducing Sexual Functioning • ? Sexual offenders • ? Intellectual disabilities- controversial • ? dementia

  46. Medications • Androcur • GnRH antagonists • Dopaminergic antipsychotics • Prolactinergic • SSRI’s- sexual and anti obsessive effects

  47. Sex offenders • Complex • Recognising paedophilia • Roles in informing • Role to explore • Prediction of sexual offending • Role in complex custody issues • Taking a sexual offence history

  48. Predicting sexual (re)offending • Various tools available • HCR-20 • SVR • STATIC-99 • H-PCL • History of previous offence • History of previous allegations

  49. Case 5 • Ms B and her two male children aged 5 and 6 present. • Her children are the identified patients • They are being assessed for anxiety disorders • She has had an acrimonious separation • She mentions she is worried her children are being sexually abused on fortnightly custody visits

  50. Gender Identity disorders • Identity disorders, may overlap with arousal disorders • Sexual Gender preference does not classify as a disorder

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