Addressing and Confronting Bias and Prejudice

CHAPTER 8

Morrison, J. (2014). DSM-5 made easy: The clinician’s guide to diagnosis. New York, NY: The Guilford Press.

Somatic Symptom and Related Disorders

Quick Guide to the Somatic Symptom and Related Disorders

When somatic (body) symptoms are a prominent reason for evaluation by a clinician, the diagnosis will often be one of the disorders (or categories) listed below. As usual, the link indicates where a more detailed discussion begins.

Primary Somatic Symptom Disorders

Somatic symptom disorder . Formerly called somatization disorder, this chronic condition is characterized by unexplained physical symptoms. It is found almost exclusively in women.

Somatic symptom disorder, with predominant pain . The pain in question has no apparent physical or physiological basis, or it far exceeds the usual expectations, given the patient’s actual physical condition.

Conversion disorder (functional neurological symptom disorder) . These patients complain of isolated symptoms that seem to have no physical cause.

Illness anxiety disorder . Formerly called hypochondriasis, this is a disorder in which physically healthy people have an unfounded fear of a serious, often life-threatening illness such as cancer or heart disease—but little in the way of somatic symptoms.

Psychological factors affecting other medical conditions . A patient’s mental or emotional issues influence the course or care of a medical disorder.

Factitious disorder imposed on self . Patients who want to occupy the sick role (perhaps they enjoy the attention of being in a hospital) consciously fabricate symptoms to attract attention from health care professionals.

Factitious disorder imposed on another . A person induces symptoms in someone else, often a child, possibly for the purpose of gaining attention.

Other specified, or unspecified, somatic symptom and related disorder . These are catch-all categories for patients whose somatic symptoms fail to meet criteria for any better-defined disorder.

Other Causes of Somatic Complaints

Actual physical illness. Psychological causes for physical symptoms should be considered only after physical disorders have been eliminated.

Mood disorders . Pain with no apparent physical cause is characteristic of some patients with major depressive disorder and bipolar I disorder, current or most recent episode depressed. Because they are treatable and potentially life-threatening, these possibilities must be investigated early.

Substance use . Patients who use substances may complain of pain or other physical symptoms. These may result from the effects of substance intoxication or withdrawal.

Adjustment disorder . Some patients who are experiencing a reaction to environmental circumstances will complain of pain or other somatic symptoms.

Malingering . These patients know that their somatic (or psychological) symptoms are fabricated, and their motive is some form of material gain, such as avoiding punishment or work, or obtaining money or drugs.

CHAPTER 12

Morrison, J. (2014). DSM-5 made easy: The clinician’s guide to diagnosis. New York, NY: The Guilford Press.

Sexual Dysfunctions

Quick Guide to the Sexual Dysfunctions

DSM-5 addresses three sorts of issues directly tied to sexual functioning. In DSM-IV and before, they were all included in the same chapter; now the sexual dysfunctions, gender dysphoria, and paraphilic disorders are spread out over three different chapters. As with most other diagnoses, patients can have problems in multiple areas, which can in turn coexist with other mental diagnoses. Addressing and Confronting Bias and Prejudice

With the exception of substance-induced sexual dysfunction, the sexual dysfunctions are gender-specific. DSM-5’s organization is alphabetical; I’ve grouped these disorders by gender and stage in an act of sex at which the dysfunction occurs. The link indicates where a more detailed discussion begins.

Sexual Dysfunctions

Male hypoactive sexual desire disorder . The patient isn’t much interested in sex, though his performance may be adequate once sexual activity has been initiated.

Erectile disorder . A man’s erection isn’t sufficient to begin or complete sexual relations.

Premature (early) ejaculation . A man experiences repeated instances of climax before, during, or just after penetration.

Delayed ejaculation . Despite a normal period of sexual excitement, a man’s climax is either delayed or does not occur at all.

Female sexual interest/arousal disorder . A woman lacks interest in sex or does not become aroused enough.

Genito-pelvic pain/penetration disorder . Genital pain occurs (only in women) during sexual intercourse, often during insertion.

Female orgasmic disorder . Despite a normal period of sexual excitement, a woman’s climax either is delayed or does not occur at all.

Substance/medication-induced sexual dysfunction . Many of these problems can also be caused by intoxication or withdrawal from alcohol or other substances.

Other specified, or unspecified, sexual dysfunction . These are catch-all categories for sexual problems that do not meet the criteria for any of the foregoing sexual dysfunctions.

Other Causes of Sexual Difficulties

Paraphilic disorders . These include a variety of behaviors that most people regard as distasteful, unusual, or abnormal. Nearly all are practiced almost exclusively by males.

Gender dysphoria . Some people strongly identify so strongly with the opposite gender that they are uncomfortable with their assigned gender roles.

Nonsexual mental disorders. Many patients develop sexual dysfunctions as a result of other mental disorders. Lack of interest in sex may be encountered especially in  somatic symptom disorder ,  major depressive disorder , and  schizophrenia .

CHAPTER 13

Morrison, J. (2014). DSM-5 made easy: The clinician’s guide to diagnosis. New York, NY: The Guilford Press.

Gender Dysphoria

Quick Guide to Gender Dysphoria

As in earlier chapters, the link indicates where a more detailed discussion begins.

Primary Gender Dysphoria

Gender dysphoria in adolescents or adults . Patients strongly identify with the gender other than their own assigned gender role, with which they are uncomfortable. Some request sex reassignment surgery to relieve this discomfort.

Gender dysphoria in children . Children as young as 3 or 4 years can be dissatisfied with their assigned gender.

Other specified, or unspecified, gender dysphoria . Use one of these categories for gender dysphoria symptoms that do not meet full diagnostic criteria.

Other Causes of Transgender Dissatisfaction or Behavior

Schizophrenia . Some patients with schizophrenia will express the delusion of being the other gender.

Transvestic disorder . These people have sexual urges related to cross-dressing, but do not wish to be of the other gender.

F64.1 [302.85] Gender Dysphoria in Adolescents and Adults

Adult patients with gender dysphoria (GD) feel intensely uncomfortable with their own assigned gender (sometimes called natal gender). Some actually detest their own genitalia. They wish to live as members of the other gender, and many of them do adopt opposite-gender dress and mannerisms. Cross-dressing (though not for sexual stimulation) is a common first step toward a complete gender change. Next, they may request to take hormones to stop menstruation, enlarge their breasts, suppress male characteristics, or otherwise change their body appearance or functioning.

A few persons with GD feel so uncomfortable with their nominal, assigned gender that they request hormone treatment or reassignment surgery. Although many patients who have such surgery are reportedly satisfied and live contentedly in their new gender, some ultimately request to change back. A few genetic males retain their genitals but have their breasts augmented chemically or through surgery.

GD, popularly still referred to as transsexualism (though far from all patients with GD desire sex reassignment measures), is one of the more recently described disorders in DSM-5. Until the 1950s, clinicians did not even recognize the existence of people with GD. It was through the widespread publicity that occurred in 1952, after Christine Jorgensen received sex reassignment surgeries in Denmark and emerged as a woman, that this disorder became generally acknowledged. Even now, GD is relatively infrequent (around 1% for natal males and perhaps one-third that for females). It begins in early childhood (typically, preschool) and appears to be chronic. Causation isn’t known for sure. However, there is evidence support at least a weak genetic component.

Many natal males with GD have low sex drive; if they engage in sex at all, most prefer men. Nearly all affected women are sexually attracted to women. Addressing and Confronting Bias and Prejudice

Posttransition Specifier

The posttransition specifier indicates that the patient now lives exclusively as a person of the desired gender and has undergone (or is undergoing) one or more cross-sex medical procedures. These would include regimens such as regular cross-sex hormone treatments and gender reassignment surgery to the desired gender. Surgery would entail orchiectomy, penectomy, and vaginoplasty in a genetic male, mastectomy and phalloplasty in a genetic female.

Army Private First Class Bradley Manning was convicted in 2013 of the WikiLeaks publication of 700,000 documents. The day after he was sentenced to 35 years in prison, he announced that he wanted hormone therapy and wished to live the rest of his life as a female, Chelsea Manning.

Michelle Kosilek has languished for the past 20 years in a Massachusetts prison, sentenced for killing her wife during a domestic dispute (despite nearly life-long gender dysphoric issues, when married, Michelle still occupied her natal gender). Five specialists have recommended sex change surgery.

The lives of these two people highlight how far we have come in recognizing this fraught condition, and how far we have yet to go.

PSY645 Fictional Sociocultural Case Studies

Case #1

Frank is a 45-year-old male who identifies as gay. He stated his reason for seeking out

psychotherapy “is because my boyfriend doesn’t want to have sex with me.” When asked about

the frequency of his sexual activity with his boyfriend, he reported that they have sex at least

once a week. While this tends to be the average amount of sex that couples generally have, he

repeated, “You don’t understand. I just want him to have sex with me!” When asked to share his

boyfriend’s name, Frank responded, “Orlando Bloom… you know, the actor in those movies.”

Frank appeared well groomed with logical thought and poor insight into his problems. He denied

symptoms of depression and anxiety. Addressing and Confronting Bias and Prejudice

Case #2

Chrissy is a 28-year-old female of Argentinean descent. Chrissy was born in the United States

two years after her parents emigrated. She stated her reason for seeking out psychotherapy “is

because my family won’t let me be the person I want to be.” She endorses symptoms of

depression and chronic passive suicidal ideation with a plan but no intent. One of her goals in life

is to be an independent entrepreneur, as she wants to start a designer clothing line for pregnant

women. However, this goes against her family’s expectation that she become a stay at home

mom and raise children of her own. She appeared well groomed with logical thought and

moderate insight into her problems.

Case #3

Harvey and Tina are a middle-aged mixed-race couple who present for counseling after 20 years

of marriage. They state that there are no known problems in their marriage, but they would like

to establish a safe space to discuss issues as they might develop. While gathering history, you

learn that Tina was born as Anthony and went through sex reassignment surgery two years into

her relationship with Harvey. Shortly after going through sex reassignment, Harvey and Tina

married. Harvey and Tina appeared well groomed with superior insight and no plans to use

insurance for counseling. Addressing and Confronting Bias and Prejudice

Tasman, A., Kay, J., & Ursano, R. J. (2013). The psychiatric interview: Evaluation and diagnosis.Chichester, England: John Wiley & Sons. Retrieved from http://www.ebrary.com

The Psychiatric Interview: Evaluation and Diagnosis, First Edition. Allan Tasman, Jerald Kay and Robert J. Ursano.

© 2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd.

Psychiatric Interviews:

Special Populations

Randon Welton and Jerald Kay

5

There is a popular image of the psychiatric interview where the patient and clinician sit

comfortably in soft leather chairs in the psychiatrist’s office surrounded by objets d’art

and built-in bookshelves. The patient speaks clearly, honestly, and succinctly about his or

her problem. The psychiatrist listens intently and understands thoroughly what is being

said. This mutual understanding allows the therapy to begin effectively and proceed

quickly to its successful conclusion. All too often, the reality of psychiatric practice

reflects more challenging situations.

In this chapter, we shall be examining a number of special, but nonetheless common,

clinical circumstances and patient populations that tend to bend the frame of the traditional

psychiatric interview. There are an infinite number of special circumstances of

course, and this chapter could hardly list, much less discuss, them all. Instead we will be

looking at examples within two major themes. Sometimes the interview is extraordinary

because of the circumstances surrounding the interview. At other times, psychiatrists will

be interacting with a distinct population of patients; patients that inherently require an

alteration of our approach. These situations require extra thoughtfulness and adaptation

on the part of the clinician.

Included under the heading of Special Circumstances are patients located on

Inpatient Units, on Medical Wards, or in the Emergency Department (ED). The acuity of

these patients and the lack of privacy in these locations contribute to the difficulty of the

interview. Another set of special circumstances occurs in Mass Casualty or Disaster scenarios.

In those calamities, the psychiatrist may be responsible to assess large numbers of

patients in orthodox settings. Addressing and Confronting Bias and Prejudice

Even when the interview takes place in a more traditional setting, there are Special

Populations that may challenge the psychiatrist. These include patients with severe

Psychotic Symptoms or significant Suicidality. Interviewing Children and Adolescents

can pose a challenge for the non-subspecialist. Also included in these special populations

are those where there is a difference in language between the patient and the psychiatrist.

This creates the need to incorporate Interpreters into the psychiatric interview. Cultural

chapter

Tasman, A., Kay, J., & Ursano, R. J. (2013). <i>The psychiatric interview : evaluation and diagnosis</i>. Retrieved from http://ebookcentral.proquest.com

Created from ashford-ebooks on 2017-10-23 14:03:04. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved.

Akhtar, S. (2009). Turning points in dynamic psychotherapy: Initial assessment, boundaries, money, disruptions and suicidal crises. Retrieved from http://www.ebrary.com

capacity but lacks the second one. As a result, when faced

with disappointments, he gets very hurt and like any other

person who is frequently hurt, he gets angry. This anger

comes in the way of the mind’s peaceful functioning in the

realms of both his relationships and vocation. Life gets

splintered and is lived in pieces. At times, the individual vents

his rage on self and others or tries to get rid of it by numbing

his mind (with the use of substances) or distracting himself by

impulsive gratifications. All in all, borderline personality

disorder is a very painful condition to have.’

• Narcissistic personality disorder. ‘The person with a

narcissistic personality disorder is someone who is

preoccupied with his own self. While it might come across as

such, this is hardly a matter of vanity. The fact is that the

person secretly feels quite worried about his own self and

carries a profound vulnerability to shame. Having been raised

on praise without much love and affection, such a person has

become dependent upon admiration. This is what he

constantly seeks. He feels perpetually compelled to improve

his talents, polish his image, and “sell” himself to others.

Now, all this takes a lot of effort, and energy. It is truly

tiresome. Besides it has the painful consequence of his

becoming unable to pay attention to others and also not

feeling really loved by anybody; he feels that people like him

only because of what he has accomplished not for who he is.

He feels alone in this world. While socially successful and

admired by others, the narcissistic person lives in a private

world of self-doubt, inferiority and insatiable longing for

genuine love and acceptance.’

This manner of telling the patient’s diagnosis to him should

put to rest the prevalent notion that patients misunderstand

Akhtar, S. (2009). <i>Turning points in dynamic psychotherapy : initial assessment, boundaries, money, disruptions and 41

suicidal crises</i>. Retrieved from http://ebookcentral.proquest.com

Created from ashford-ebooks on 2017-10-23 14:00:14. Copyright © 2009. Karnac Books. All rights reserved.

diagnostic terminology and are narcissistically injured by it.

In holding onto this old-fashioned idea, one is liable to

overlook that the interviewer’s cryptic attitude, fudging, and

uncomfortable avoidance can also have alienating and adverse

effects on the patient. Addressing and Confronting Bias and Prejudice