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1 Psychological Sexual arousal disorders involving variant sexual activity (paraphilia), particularly those of a more superficial nature (eg, voyeurism) and those of recent onset, are responsive to psychotherapy in a moderate percentage of cases The prognosis is much better if the motivation comes from the individual rather than the legal system; unfortunately, however, judicial intervention is frequently the only stimulus to treatment, because the condition persists and is reinforced until conflict with the law occurs Therapies frequently focus on barriers to normal arousal response; the expectation is that the variant behavior will decrease as normal behavior increases 2 Behavioral Aversive and operant conditioning techniques have been tried frequently in gender role disorders but have only occasionally been successful In some cases, the sexual arousal disorders improve with modeling, role-playing, and conditioning procedures Emotive imagery is occasionally helpful in lessening anxiety in fetish problems 3 Social Although they do not produce a change in sexual arousal patterns or gender role, self-help groups have facilitated adjustment to an often hostile society Attention to the family is particularly important in helping persons in such groups to accept their situation and alleviate their guilt about the role they think they had in creating the problem 4 Medical Medroxyprogesterone acetate, a suppressor of libidinal drive, is used to mute disruptive sexual behavior in men of all ages Onset of action is usually within 3 weeks, and the effects are generally reversible Fluoxetine or other SSRIs at depression doses (see Table 25 8) may reduce some of the compulsive sexual behaviors including the paraphilias A recent focus of study in the treatment of severe paraphilia has been agonists of luteinizing hormone releasing hormone Although some transsexuals are treated with genital reconstructive surgery, many others are screened out by trial periods of living as the other sex prior to operation.

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1 Medical Identification of a contributory reversible cause is most important Even if the condition is not reversible, identification of the specific cause helps the patient to accept the condition Marital disharmony, with its exacerbating effects, may thus be avoided Of all the sexual dysfunctions, erectile dysfunction is the condition most likely to have an organic basis Sildenafil, tadalafil, and vardenafil, phosphodiesterase type 5 inhibitors, are effective oral agents for the treatment of penile erectile dysfunction (eg, sildenafil 25 100 mg 1 hour prior to intercourse) These agents are effective for SSRI-induced erectile dysfunction in men and in some cases for SSRI-associated sexual dysfunction in women Use of the medications in conjunction with any nitrates, particularly in individuals with coronary artery disease, can have significant hypotensive effects leading to death in some cases The medication, which does not appear to impact sexual desire, should be used only once a day Because of their common effect in delaying ejaculation, the SSRIs have been effective in premature ejaculation 2 Behavioral Syndromes resulting from conditioned responses have been treated by conditioning techniques, with excellent results Vaginismus responds well to desensitization with graduated Hegar dilators along with relaxation techniques Masters and Johnson have used behavioral approaches in all of the sexual dysfunctions, with concomitant supportive psychotherapy and with improvement of the communication patterns of the couple 3 Psychological The use of psychotherapy by itself is best suited for those cases in which interpersonal difficulties or intrapsychic problems predominate Anxiety and guilt about parental injunctions against sex may contribute to sexual dysfunction Even in these cases, however, a combined behavioral-psychological approach usually produces results most quickly 4 Social The proximity of other people (eg, a mother-inlaw) in a household is frequently an inhibiting factor in sexual relationships In such cases, some social engineering may alleviate the problem.

Kostis JB et al Sexual dysfunction and cardiac risk (The Second Princeton Consensus Conference) Am J Cardiol 2005 Jul 15;96(2):313 21 [PMID: 16018863] Sivalingam S et al An overview of the diagnosis and treatment of erectile dysfunction Drugs 2006;66(18):2339 55 [PMID: 17181376] Taylor MJ Strategies for managing antidepressant induced sexual dysfunction: a review Curr Psychiatry Rep 2006 Dec;8 (6):431 6 [PMID: 17094922]

Low self-esteem and lack of confidence Minimal introspective ability with a tendency to blame others for all problems Major difficulties with interpersonal relationships or society Depression with anxiety when maladaptive behavior fails

An individual s personality structure, or character, is an integral part of self-image It reflects genetics, interpersonal influences, and recurring patterns of behavior adopted in order to cope with the environment The classification of subtypes of personality disorders depends on the predominant symptoms and their severity The most severe disorders those that bring the patient into greatest conflict with society tend to be classified as antisocial (psychopathic) or borderline Personality disorders can be considered a matrix for some of the more severe psychiatric problems (eg, schizotypal, relating to schizophrenia, and avoidance types, relating to some anxiety disorders)

Patients with personality disorders tend to show anxiety and depression when pathologic coping mechanisms fail, and their symptoms can be similar to those occurring with anxiety disorders Occasionally, the more severe cases may decompensate into psychosis under stress and mimic other psychotic disorders

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