somatic symptom disorder, sexual dysfunction, and gender dysphoria

1. SOMATIC SYMPTOM
DISORDERS, SEXUAL
DYSFUNCTIONS, AND
GENDER DYSPHORIA

2. SOMATIC SYMPTOM DISORDERS

3. WHAT ARE SOMATIC SYMPTOM
DISORDERS?
 People with these disorders have an excessive or maladaptive response to physical
symptoms or to associated health concerns.
 Its shorthand label is known as “medically unexplained physical symptoms”
 It includes the following disorders:
 Somatic Symptom Disorder
 Illness Anxiety Disorder
 Conversion Disorder (Functional Neurological Symptom Disorder)
 Psychological Factors Affecting Other Medical Conditions

4. SOMATIC SYMPTOM
DISORDER
 Clients may continually feel weak and ill
 Persistent for more than 6 months
 Psychological/behavioral factors, particularly anxiety and distress, are compounding the severity and
impairment associated with the physical symptoms
 It appears to be real and it hurts whether there are clear physical reasons or none
 People with panic disorder typically fear only immediate symptom-related catastrophes that may occur
during the few minutes they are having a panic attack
 People with somatic symptom disorders focus on a long-term process of illness and disease

5. TREATMENT
 Requires management rather than treatment
 Cognitive-Behavioral Therapy
 Note for the Doctors:
 Encourage a long-term supportive relationship to prevent “doctor shopping”
 See patients on regular appointments as opposed to being on demand to avoid the reinforcement
 View complaints as a form of communication as opposed to evidence of a disease
 Minimize psychotropic drugs or analgesics
 Help in encouraging adaptive behavior and ignoring the sick role

6. ILLNESS ANXIETY DISORDER
 Formerly known as “hypochondriasis”
 Preoccupation with bodily symptoms and misinterpreting them as indicative of illness
or disease that almost any physical sensation becomes a basis of concern
 Reassurances from doctors may provide a small-term effect, but they tend to
continue to seek opinions of other doctors in order to rule out disease and are more
likely to demand unnecessary treatments. Despite the assurances, they remain
unconvinced
 If one or more physical symptoms are relatively severe and are associated with
anxiety and distress, the appropriate diagnosis is somatic symptom disorder

7. CAUSES
 Interpreting the ambiguous stimuli as threatening
 Hypersensitivity can make them guarded at all times
 It may be learned from family members who focus their anxiety on specific
physical conditions
 Stressful life events
 A disproportionate incidence of disease in the family

8. TREATMENT
 Mental health professionals may well be able to offer reassurance in a more
effective and sensitive manner, devote sufficient time to concerns, and to
attend to the meaning of symptoms
 Cognitive-Behavior Therapy is focused at identifying and challenging illness-
related misinterpretations of the physical sensations and showing how
patients may create symptoms by focusing attention on certain body areas
 Family doctors are now trained to manage patients

9. CONVERSION DISORDER
 Physical malfunctioning such as paralysis, blindness, or difficulty speaking without
physical or organic pathology to account for the malfunction
 Globus hystericus: lump in the throat that makes it difficult to swallow, eat, or
sometimes talk
 La belle Indifference: indifference to the symptoms
 CAUSES:
 Preceding stress
 Conversion tremors were associated with lower activity in the right inferior parietal cortex

10. TREATMENT
 Identify and attend to the traumatic/stressful life event, if it is still present in
real life or memory
 Reduce any secondary gain from the conversion symptoms

11. FACTITIOUS DISORDER
 Formerly known as “Munchausen syndrome”
 These symptoms are under voluntary control, but no obvious reason for
producing the symptoms except due to a need for one to assume the sick role
and receive an increased attention
 It can also be imposed on another (factitious disorder imposed on
another/Munchausen syndrome by proxy)

12. PSYCHOLOGICAL FACTORS
AFFECTING OTHER MEDICAL
CONDITIONS
 Characterized by the adverse effect of one or more clinically significant
psychological or behavioral factors on a medical condition
 Psychological/behavioral factors may increase the risk for suffering, death, or
disability
 It is believed to be a more common diagnosis than somatic symptom disorder

13. DIAGNOSTIC ISSUES (ZVOLENSKY,
ET AL., 2020)
 As a category, somatic disorders lack conceptual coherence and clearly defined
diagnostic criteria. Thus, it lacks a unifying principle
 Comorbidity is frequent and a somatic symptom disorder diagnosis may accompany
anxiety or depression
 Some researchers suggests the removal of this category and re-categorize each under co-
syndromal disorder
 Individuals with somatic disorders were 2.2 times to likely be diagnosed with a personality
disorder
 Diagnostic criteria overlap greatly with other psychiatric disorders

14. DIAGNOSTIC ISSUES (ZVOLENSKY,
ET AL., 2020)
 Symptom Schemas
 cultural conceptions of suffering and distress which are rooted in cultural causal explanations
 Specific symptoms may be a function of an individual’s culture as opposed to the
underlying biological mechanisms
 A “looping effect” or a reciprocal relation between health anxiety and somatic
symptoms, in which attending to the symptoms may increase the intensity
 The term “somatization” may be unacceptable to patients since it is an implication
that their symptoms are in their mind and not real

15. SEXUAL DYSFUNCTIONS

16. SEXUAL DYSFUNCTIONS
 Problems that arise in sexual interactions may occur in both heterosexual and
homosexual relationships.
 It only covers 3 phases of sexual response cycle: Desire, Arousal, and Orgasm
 Lifelong: if the condition is present during the entire sexual life
 Acquired: begins after sexual activity has been relatively normal
 Generalized: occurs every time an individual attempts sex
 Situational: occurs with some partners or at certain times, but not with others

17. DISORDERS OF DESIRE
 Characterized by low sexual; interest and accompanied by a diminished ability
to become excited or aroused by erotic cues or sexual activity
 Male Hypoactive Disorder
 Female Sexual interest/Arousal Disorder

18. SEXUAL AROUSAL DISORDERS
 Erectile Disorder
 Inability to maintain erection sufficient for insertion (lifelong)
 Successfully achieved penetration, but unable to do so at some time (acquired)
 Ability to have coitus in certain circumstances, but not in others (situational)
 The prevalence appears to be high and increases with age
 For women, this involves the inability to achieve and maintain an adequate lubrication
of the vagina
 May be compensated with commercial lubricant
 Statistics is more difficult since many women do not consider absence of arousal as a problem

19. ORGASM DISORDERS
 Delayed Ejaculation
 Ejaculation during coitus is met with great difficulty
 Rarely present during masturbation
 Premature Ejaculation
 Ejaculation occurs well before the man and his partner wishes to
 Retrograde Ejaculation
 Not a disorder in the DSM-5
 This occurs whenEjaculatory fluids travel backward into the bladder
 Female Orgasmic Disorder
 A woman never or almost never reach orgasm

20. SEXUAL PAIN DISORDERS
 Involves difficulties with penetration during attempted intercourse or significant pain
during intercourse
 The pain is so severe that sexual behavior is disrupted
 Dyspareunia
 Recurrent or persistent genital pain, before, during, or after intercourse
 Vaginismus
 The pelvic muscles in the outer third of the vagina undergo involuntary spasms when
intercourse is attempted

21. ASSESSING SEXUAL BEHAVIOR
 Interviews:
 May be helpful in providing more details
 Clinicians must be prepared to use the language of the patient
 Be careful in asking questions that puts patients at ease
 Cover the nonsexual relationship issues and physical health
 The partner may be interviewed concurrently
 Medical Evaluation:
 Drugs that are prescribed for hypertension, anxiety, and depression disrupt arousal and functioning
 Recent surgery must be evaluated to understand its impact on sexual functioning
 Psychophysiological Assessment:
 Penile strain gauge – as the penis expands, the strain gauge picks up the changes and record them on a polygraph
 Vaginal photoplethysmography – smaller than a tampon, this is inserted in a female’s vagina with two light-sensitive
photoreceptors at the tip
 During this process, patients may view or hear erotic stimuli

22. CAUSES OF SEXUAL DYSFUNCTION
•Neurological diseases and other conditions that may affect the functioning of the nervous system
•In men, constricted arteries and venous leakage
•SSRIs
•Anti-Hypertensive Medication
•Chronic Alcoholism
Biological
•Distraction may decrease arousal and performance as opposed to performance anxiety
Psychological
•Erotophobia
•Early traumatic sexual events
•Marked deterioration in close interpersonal relationships
•Script Theory – we all operate by following scripts that reflect social and cultural expectations and guide
our behavior
•Greater belief in sexual myths
Sociocultural

23. TREATING SEXUAL DYSFUNCTIONS
 Ignorance of the most basic aspects of the human sexual response cycle and
intercourse often leads to long-lasting dysfunctions
 Masters and Johnson created an intensive program that involves therapists of
both sexes to facilitate communication between dysfunctional partners and is
conducted daily for a period of 2 weeks

24. TREATING SEXUAL DYSFUNCTIONS
 Sensate Focus and Nondemand Pleasuring
 Explore body through touching, kissing, hugging, massaging, or anything similar
 In the first phase, sexual parts are excluded
 If successful, the couple moves to genital pleasuring, but with a ban on orgasm and intercourse
 Squeeze Technique
 Penis is stimulated to near erection
 Squeeze the penis near the top of the head where it joins the shaft to reduce arousal
 The penis is briefly inserted in the vagina without thrusting

25. TREATING SEXUAL DYSFUNCTIONS
 Explicit Training in Masturbatory Procedures
 For female orgasmic disorder
 Inserting dilators -> Penis
 For pain disorder
 Sildenafil (Viagra)
 For erectile dysfunction
 Flibanserin
 For hypoactive sexual desire in women
 Injection of Prostaglandin
 For erectile dysfunctions as an attempt to dilate blood vessels and allow its flow to the penis
 Penile Prostheses
 A surgical approach to erectile dysfunction
 Vacuum Device Therapy
 Creating a vacuum in a cylinder placed over the penis, which would draw blood as it is trapped by a ring placed around the base
of the penis

26. GENDER DYSPHORIA
(GOSSELIN & BOMBARDIER, 2020

27. WHAT IS GENDER DYSPHORIA?
 It is the discomfort and/or distress which may occur when a person’s gender
identity and/or gender role expression misaligns with the cultural expectations
associated with their birth assigned sex
 Only some gender nonconforming people experience gender dysphoria at
some point in their lives

28. DEFINITION OF TERMS
Sex Assigned at Birth
• Traits that distinguish between males and females
• Also known as natal sex
• Chromosomes, gonads, internal reproductive organs, and genitalia
Gender/Gender Norms
• Set of norms/expectations that communicate what it means to be a man or woman within a
culture
• May change over time
• May establish what is appropriate and what is not
Gender Identity
• An individual’s internal, deeply held sense of gender as male or female, or any other category

29. DEFINITION OF TERMS
Transgender
• Umbrella term to describe people whose gender identity/expression do not conform to what is
associated with their birth assigned sex
• Not all gender non-conforming people self-identify as transgender
Gender Expression
• Ways which a person communicates gender within a given culture
• It may be consistent or inconsistent on what is culturally prescribed for their birth assigned sex
Cisgender
• Those whose gender identity and gender expression align with the cultural expectations
associated with their assigned sex at birth
Gender Queer
• A person whose gender identity does not align with a binary understanding of gender

30. DIFFERENTIAL DIAGNOSIS
 When making a differential diagnosis, clinician should rule out gender nonconformity,
variant gender expression, or dissatisfaction with society’s gender roles that reflect a
separate issue from the distressing disconnect between one’s sex and gender
 Body Dysmorphic Disorder: obsessive preoccupation with perceived imperfection in
the body part
 In gender dysphoria, the genitals appears to be unwanted
 Skoptic Syndrome: an obsessive dislike of one’s own genital that may lead to self-
mutilation
 This may occur in the context of gender dysphoria or not

31. PREVALENCE OF GENDER
DYSPHORIA
 At a population level, despite its visibility in the pop culture along with the
number of people seeking help, it is still relatively rare
 The majority of adults with gender dysphoria recall an onset in childhood and
among those who seek treatment, transgender women appears to be common
 The first age for a child to identify as transgender is around 8.3 years
 Transgender women identified gender dysphoria at a younger age than
transgender men
 More natal males are diagnosed with gender dysphoria although this may be
partly due to parental disapproval of gender non-conforming behaviors in natal
boys than in natal girls.

32. CAUSES
 Prenatal Sexual Identification of the Brain
 It may be rooted in the divergence between sex differentiation of the brain and the
sexual reproductive organs
 Gender identity is likely heritable, but polygenic
 Gender discontent may precede gender constancy (the ability to fully
comprehend gender)

33. BIOLOGICAL TREATMENT
 Gender Affirmation Surgery
 It is required that the client must be able to live the life of the opposite sex prior to
proceeding with the surgery
 Hormone Therapy
 Patients must not have an untreated artery, untreated heart, blood clotting,
polycythemia, cancers, liver disease, tumor, ovarian cysts and many other conditions’
 Gonadotropin Releasing Hormone – can be used prior to adolescence. This is an
attempt to work through gender identity issues
 Discuss implications on fertility

34. PSYCHOSOCIAL TREATMENT
 Coping strategies and interventions aimed at reducing self stigma
 Managing ruminations
 Psychoeducation through affirmative approaches
 Helping an individual see a wide variety of ways that one may experience gender, which includes
those that are outside the binary
 True Gender Self Child Therapy
 Emphasis on support, attentive listening, and encouragement of creativity in order for the child to
safely explore and express his/her self-harmonious gender identity and liberate them from the
stifling gender expectations imposed by others
 Facilitate an authentic gender journey

35. REFERENCES
 Barlow, D. H., Durand, V. M, & Hoffman, S. G. (2018). Abnormal psychology: An
integrative approach (8th ed.). Cengage
 Gosselin, J. T. & Bombardier, M. (2020). Gender dysphoria. In B. A. Winstead & J. E.
Maddux (Eds.), Psychopathology: Foundations for contemporary understanding (pp.
522-535). Routledge.
 Zvolensky, M. J., Garey, L., Shepherd, J. M., & Eifert, G. H. (2020). Somatic symptom
and related disorders. In B. A. Winstead & J. E. Maddux (Eds.), Psychopathology:
Foundations for contemporary understanding (pp. 341-354). Routledge.