Personality Disorder And Sexual Problems

Personality disorder and sexual problems Department of psychology The first affiliated hospital of ZZU Huirong guo

Personality and its disorders  The need to understand the personalities for four reasons:  First, they may react in unusual ways to physical illness or its treatment, for example by becoming either over-dependent or untrusting and non— compliant  Second, when personality is abnormal the clinical picture of psychiatric disorder changes, making diagnosis more difficult

Personality and its disorders  Third, abnormal personalities may react differently to stressful events, for example, with aggressive or histrionic behavior instead of anxiety  Fourth, abnonna1 personalities may behave in ways that are stressful or even dangerous to other people, for example, a husband who is persistently aggressive may cause his wife to become depressed or act violently towards her

What is personality?  The term personality' refers to the enduring characteristics of an individual as shown in ways of behaving in a wide variety of circumstances  Personality can be thought of as being made up of more circumscribed characteristics known as traits, such as sociability, aggressivity, and impulsivity

What is personality?  When describing abnormal personality it is usually better to list the principal traits, rather than attempt to apply a diagnostic label  However, some abnormal personalities are dominated by a single trait and for these a single descriptive term is useful, as will be explained later. However, even for abnormal personalities it is important to note other features, especially those positive features than might be developed further in treatment

What is personality disorder?  Extreme deviations of personality can be recognized as disordered but it is difficult to define a dividing line between normal and abnormal  If personality could be measured like intelligence, a statistical cut-off could be used  However, although psychologists have devised measures of some aspects of personality there are no reliable and valid measures of the aspects of personality that are most important to clinical practice

What is personality disorder?  In the absence of such measures, a simple pragmatic criterion is used: a personality is disordered when it causes suffering to the person or to other people. This definition may appear simplistic but it is useful in clinical practice, and leads to reasonable agreement between those using it

Common personality traits  (For brevity, only negative attributes are listed. Corresponding positive features should also be noted)  Prone to worry  Strict, fussy, rigid  Lacking self-confidence  Sensitive  Suspicious, jealous  Untrusting, resentful

Common personality traits  Impulsive  Attention seeking  Dependent  Irritable, quarrelsome  Aggressive  Lacking concern for others

Is there personality disorder?  The interviewer decides whether to diagnose a personality disorder by reviewing evidence from the clinical history to decide whether the patient or others has suffered as a result of the patient’s personality  This judgement is subjective and it may be difficult to decide how much the patient’s problems have been caused by personality and how much by circumstances  Despite these difficulties a judgement about personality disorder is useful in planning management

Types of personality disorder  Anxious, moody, and prone to worry  Avoidant (ICD: anxious)  Obsessive-compulsive (ICD: anankastic)  Depressive  Hyperthymic  Cyclothymic  Aggressive and antisocial  Antisocial (ICD: dissocial)

Types of personality disorder  Sensitive, and suspicious  Paranoid  Schizoid  Schizotypal

 Dramatic and impulsive  Histrionic  Borderline (ICD: impulsive)  Dependent

The management of personality disorder  General aspects of management  The general approach should be to help the person gain confidence and learn from mistakes. To achieve these aims, setbacks should be discussed with the patient as opportunities to find out more about the problem, not as signs of failure  The aim is to help the patient to take a series of small steps over a long time, not to bring about a rapid change. The plan should be realistic, clearly understood by the patient, and carried out consistently. The aim is to help patients solve their own problems, not to remove responsibility from them

The management of personality disorder  Also the doctor should recognize that progress will be slow and punctuated by failures. Patience is needed when managing personality disorders  The relationship between patient and doctor is particularly important when treating personality disorder. The patient should feel valued as a person, and able to trust and confide in the doctor

Management  At the same time, the relationship should not become too intense or dependent. When more than one person is involved in treatment, their respective roles should be defined and made clear to the patient  Any attempt to play one off against the other should be discussed between the professionals and with the patient

Management  Great care is needed in setting limits for some patients with personality disorder, especially for those with over-dependent histrionic or aggressive personalities  These limits should be agreed by all those involved in the patient’s care and explained to the patient

Management  Building on strengths. Management should not focus exclusively on defects in the personality. Whenever possible patients should be encouraged to recognized and develop their talents and skills by obtaining further training, changing to a job better suited for their skills or interests, or by developing more satisfying leisure activities

Management  Such actions improve low self-esteem, which is a frequent problem among people with all kinds of personality disorder  Provoking factors. The patient should be helped to identify and find new ways of dealing with any situations that regularly cause problems

Management  Abuse of alcohol and drugs. When abnormal behavior is provoked by the use of alcohol or drugs, help should be given to limit the use of these substances  Help for the family. This may be needed, especially when the personality disorder is of the aggressive or antisocial kind

Management  Specific treatment methods  Drug treatment has little general value in treating personality disorder but there are a few specific uses  Antipsychotic drugs may be calming at a time of increased stress especially for aggressive and antisocial personalities  Lithium carbonate has been claimed to benefit some people with recurrent mood changes; a specialist opinion should be obtained before prescribing

Management  Antidepressants are of value when there is an associated depressive disorder. It has been claimed that, in the absence of a depressive disorder, SSRIs (selective serotonin reuptake inhibitors) diminish impulsive behavior and repeated self-harm but their long-term value is uncertain at the time of writing  Carbamezepine has been claimed to reduce aggressive behavior in some patients. The value is uncertain and, if real, applies to a minority of such patients

Management  Anxiolytic drugs should generally be avoided because although they may improve well-being they may produce disinhibition and dependency  Psychotherapy may help for people with low self-esteem and difficulties in social relationships. Sensitive and suspicious and antisocial and aggressive personalities seldom benefit Cognitive-behavioral methods are generally more appropriate than in changing this

Problems of sexuality and gender  Problems of sexuality and gender are common. Doctors may be asked to give advice about four types of problem :  Sexual dysfunction: impaired or dissatisfying sexual enjoyment or performance  Abnormalities of sexual preference: unusual sexual interests and activities that are preferred to heterosexual intercourse  Disorders of gender identity: in which the patient feels as if they are of the sex opposite to their biological sex  Psychological problems encountered by homosexual people

Disorders of preference of the sexual object  Fetishism  In this condition, an inanimate object is the preferred or only means of achieving sexual excitement. Almost all fetishists are men and most are heterosexual  Among the many objects that can evoke arousal in different people, common examples are rubber garments, women’s underclothes and high-heel shoes. The smell and texture of these objects is often as important as their appearance in evoking sexual arousal. Some fetishists buy the objects, but other steal them and so come to the notice of the police

Disorders of preference of the sexual object  Fetishistic transvestism  In this condition, the person repeatedly wears clothes of the opposite sex as kind of fetishism  Nearly all transvestites are men  At first, the clothes are worn only in private; a few people, however, go on to wear the clothes in public, usually hidden under male outer garments, but occasionally without precautions against discovery

Disorders of preference of the sexual object  Paedophilia  Paedophilia ia repeated sexual activity (or fantasy of such activity) with prepubertal children as the preferred or only means of sexual excitement. Most paedophiles are men  Of the few paedophiles who seek the help of doctors, most are of middle age although the behavior has often started earlier

Disorders of preference of the sexual act  The second group of disorders of sexual preference involves variations in the behavior carried out to obtain sexual arousal. Generally, the act are directed towards other adults but sometimes towards children

Disorders of preference of the sexual act  Exhibitionism  In this condition, sexual arousal is obtained repeatedly by exposure of the genitalia to an unprepared stranger  Nearly all exhibitionists are men. The act of exposure is usually preceded by a period of mounting tension which is released by the act

Disorders of preference of the sexual act  Exhibitionism  Usually, the exhibitionist seeks to shock or surprise a female. Most exhibitionists fall into two groups. The first consists of men with inhibited temperament who generally expose a flaccid penis and feel much guilt after the act  The second consists of men with aggressive personality traits who expose an erect penis while masturbating, and feel little guilt afterwards

Disorders of preference of the sexual act  When exhibitionism begins in middle or late life the possibility of organic brain disorder, depressive disorder, or alcoholism should be considered since these conditions occasionally “release” this pattern of behavior. In other people the exhibitionism may start during a period of temporary stress

Disorders of preference of the sexual act  Voyeurism  Voyeurism is observing the sexual behavior of others as the preferred and repeated way of obtaining sexual arousal. Most voyeurs are inhibited heterosexual men. Some voyeurs spy on couples who are having intercourse, others on women who are undressing or naked

Disorders of preference of the sexual act  Sexual sadomasochism  Sadomasochism is a preference for sexual activity that involves bondage or inflicting pain on another person. If the individual prefers to receive such stimulation, the disorder is called masochism  If the individual prefers to administer such stimulation, the disorder is called sadism. Beating, whipping, and tying are common forms of such activity. Sometimes the acts are symbolic and cause little actual damage, but occasionally the acts cause serious injuries from which the partner may die

Disorders of preference of the sexual act  Some people engage in solitary acts of self-injury; a particularly dangerous example is producing suffocation by covering the head with a plastic bag  Mild degrees of sadomasochistic behavior are common and are considered to be part of normal sexual activity. The disorder should only be diagnosed if sadomasochistic activity is the most important source of gratification or necessary for sexual stimulation

Disorders of identify  Transsexualism  In this rare disorder, the person has the conviction of being of the sex opposite to that indicated by the external genitalia. The person wishes to alter the external genitalia to resemble those of the opposite sex, and to live as a member of that sex  Most transsexuals are men; most women who cross-dress and imitate men are homosexual not transsexual. In transsexuals, the conviction of being a woman usually dates from before puberty, but medical help is not requested until early adult life, when most transsexuals have begun to dress as women

Disorders of identify  Unlike transvestites, they report no sexual arousal from crossdress; and unlike the homosexuals who dress as women, they not seek to attract people into a homosexual relationship  Many transsexuals go to great lengths in their attempts to appear as women  They practise female styles of speaking, gesturing, and walking; they remove body hair by electrolysis; they attempt to increase breast tissue by taking oestrogen or by obtaining a surgical implant; and they may seek an operation to remove the male external genitalia and form and artificial ‘vagina’

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