Abnormal Psych Notes
Abnormal Psych Notes Psyc 3330 - 01
University of Louisiana at Lafayette
Popular in Abnormal Psychology
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This 20 page Class Notes was uploaded by Lauren Notetaker on Monday March 21, 2016. The Class Notes belongs to Psyc 3330 - 01 at Tulane University taught by Constance Patterson in Winter 2016. Since its upload, it has received 17 views. For similar materials see Abnormal Psychology in Psychlogy at Tulane University.
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Date Created: 03/21/16
• Religious founders of our country had very repressed views of sexual behavior (“puritanical”) • Sex continues to be viewed within religious traditions as necessary for procreation and generally discouraged for any other reasons • Result: Very little open conversation about sex, sexuality, and sexual practices and sex education remains “under attack” Early research on sexuality • Alfred Kinsey, Indiana University: Sexual Behavior in the Human Male (1948) and Sexual Behavior in the Human Female (1953) • Documented range and frequency of sexual behaviors across people from different walks of life • Highly controversial • Methods criticized but likely accurate Human sexual response • William H. Masters and Virginia E. Johnson studied the human sexual response, and diagnosis and treatment of sexual disorders and dysfunctions, working from 1957 until the 1990s ◦ Had surrogate ppl with multiple sex partners and ppl asked how does that make this different from prostitution • Human Sexual Response (1966) and Human Sexual Inadequacy (1970) • Worked at Washington University, St. Louis and later in a private research facility in St. Louis What is "normal" sexual behavior? • Middle school students have reported popularity of *rainbow parties where girls put on different shades of lipstick and have oral sex with multiple partners, leaving “rainbows” on the boys’ penises • 61% of 13 year olds in a recent survey said oral sex is NOT sex. • *Note: some have argued this is a media creation and not a real phenomenon • 36% of teens (15-17) have had oral sex. • 75%of teens (15-17) who have had intercourse have also had oral sex • 13 % of teens (15-17) who never had intercourse have engaged in oral sex. • 25% of 10th graders, in upper middle class school district (New England) reported multiple oral sex partners in past year. • Females reported 3 – 4 partners. • Freud originally proposed that everyone was born bisexual and through development, became either heterosexual or homosexual and that either was “normal” • Kinsey found a broad range of sexual behaviors were common among the general public • NOTE: It is important not to confuse behavior and identity • Sociocultural factors/tradition deﬁne “normal” • Gender roles/social attitudes guide the judgments about what is “normal” and acceptable behavior • Roles of family, culture, social group, religion all impact expression of sexuality • Despite the same hormones, similar body types and feelings, people express sexuality differently • Sexuality is more ﬂuid than we have believed • Expression of sexuality = varied and not necessarily linked to sexual orientation/identity: Behavior does not provide deﬁnition: Asexuality, Heterosexuality, Homosexuality, Bisexuality • Gender noncomformity is increasingly common • A growing number of young people do not embrace labeling and do not want to be identiﬁed by their sexual orientation or their sexual behavior Grouping in dsm-5 • Somewhat arbitrary grouping • Inclusion of categories of “problems” traditionally inﬂuenced by social values ◦ In 1973, millions were “cured” of their mental illnesses when Homosexuality was deleted from the DSM by the American Psychiatric Association ◦ 43 years later, we are still ﬁghting the assertion that this is a condition that can be “cured” Gender dysporia and sexual disorders • DSM-5 changes “Gender Identity Disorder” to Gender Dysphoria (unhappiness): a person believes that they were born in the wrong body and should be the other sex ◦ Born into the wrong body • There are 2 additional categories of sexual disorders we will discuss: ◦ Sexual dysfunctions – problems with sexual responses (Desire/ Excitement/Orgasm/Pain) ◦ Paraphilias – sexual urges and fantasies in response to socially inappropriate objects or situations Sexual identity • Three Parts of Sexual Identity: ◦ 1. Direction of sexual orientation: heterosexual, homosexual, or bisexual. ◦ 2. Style of behavior, e.g., female may be "tomboy" or feminine-type; male may be "macho guy" or a "sensitive boy." ◦ 3. Core gender identity, essentially the deep inner feeling about whether he or she is a male or female. • May 12, 2001 issue of New Scientist; #3 is most difﬁcult to ascertain Gender dysporia • Gender dysphoria (also called transgender) is about core identity ◦ People with this disorder persistently believe they were born as the wrong biological sex • They usually want to remove their primary and secondary sex characteristics and acquire the characteristics of the opposite sex • BUT is this truly a disorder? Should it be in DSM-5? • The awareness emerges in childhood and becomes acute with adolescence • People with gender dysphoria usually feel uncomfortable wearing the clothing associated with their biological sex and may adopt clothing styles of the other gender ◦ NOTE: This is distinctly different from a transsexual fetish cross dressing; there is no sexual arousal related to dress ◦ This is also different from intersex situations where the person is born with ambiguous or multiple sexual characteristics (genitalia) • Research group that said if you were born with both, how they'd assign the sex and be treated • Male to female transgender outnumber Female to male transgender 3 to 1 (are there potential difﬁculties with data?) • Sexual attraction/arousal is independent of identity (heterosexual/ homosexual) • People with gender dysphoria often experience pervasive anxiety or depression, may feel trapped in their own bodies, and may have thoughts of suicide • Several theories have been proposed to explain this disorder, but research is limited and generally weak • Some clinicians suspect biological, perhaps genetic factors, for example: ◦ Abnormalities in the hypothalamus (particularly the bed nucleus of stria terminalis) are a potential link ◦ Hormonal differences for mom while pregnant may provide at least partial explanation • Cultural expectations may or may not allow variation ◦ (Expectations begin before birth when gender is known) • Up until the 1880s and in some tribes in the present, Native American tribes in the plains states honored a tradition of “two spirit” people • Mexico: Zapotec culture includes a third gender, the Muxe • Samoa: speciﬁc roles for male to female transgender individuals as Fa’afaﬁne Treatment for gender dysporia • Signiﬁcant psychotherapeutic intervention is required before sexual reassignment surgery is allowed • Generally must spend at least 1 year living as the sex they believe they should be • Some adults with Gender Dysphoria change sexual characteristics using hormones; others also have sexual reassignment (“sex change”) surgery; Some do both. "cruel and unusal punishment" • A transgender inmate (Massachusetts) won the right to have the state pay for her gender-reassignment surgery (2006); US District Court agreed surgery was medically necessary (2012); First Circuit Ct. ruled against Kosilek; Upon appeal, the U.S. Supreme Court declined to hear the case which functioned as a rejection of Kosilek’s request for sexual reassignment surgery (2014) • Kosilek: “Everybody has the right to have health care needs met, whether they are in prison or out on the streets…People in prisons who have bad hearts, hips or knees have surgery to repair those things. My medical needs are no less or more important than the person in the cell next to me.” Sexual dysfunctions • Sexual dysfunctions are disorders in which people cannot respond normally in key areas of sexual functioning ◦ Healthy humans may have ﬂeeting characteristics of these problems which are not pathological ◦ Problems can occur regardless of sexual orientation ◦ During a lifetime, up to 31% of men and 43% of women in the U.S. could be diagnosed with this kind of dysfunction ◦ Sexual dysfunctions cause considerable distress, result in sexual frustration, guilt, lower self-esteem, and problems in interpersonal relationships • The human sexual response consists of a cycle with four phases: ◦ Desire ◦ Excitement ◦ Orgasm ◦ Resolution • Sexual dysfunctions can affect one or more of the ﬁrst three phases • Note experience of pain may also inhibit sexual functioning and lead to dysfunction • Charts • Some experience normal sexual functioning before developing a disorder = “acquired type” • Some people struggle with sexual dysfunction their whole lives = “lifelong type” • When dysfunction is present during all sexual situations = “generalized type” • Some cases are tied to particular situations = “situational type” Sexual desire disorders • Desire phase of the sexual response cycle • Consists of urge to have sex, sexual fantasies, and experience of sexual attraction to others • (both physiological and psychological components) • Two dysfunctions are diagnosed for this phase: ◦ Male Hypoactive Sexual Desire Disorder ◦ Female Sexual Interest/Arousal Disorder • Male Hypoactive Sexual Desire Disorder ◦ A general lack of interest in sex and a low level of sexual activity ◦ Physical responses when engaged in sexual behavior may be normal • About 16% of men ◦ Keep in mind men are less likely to get help • Persistent or recurrent deﬁciency of sexual thoughts or fantasies and desire for sexual activity, lasting 6 months or more • Signiﬁcant distress or impairment • Female Sexual Interest/Arousal Disorder ◦ Lack of sexual interest and/or arousal for 6 months or more with at least three of these: • Absent/reduced frequency or intensity of ▪ sexual interest ▪ sexual thoughts or fantasies ▪ sexual initiation or receptiveness to a partner’s sexual initiation ▪ sexual interest, excitement or pleasure during almost all sexual encounters ▪ responsiveness to sexual cues ▪ genital and non-genital sensations during almost all sexual encounters • Human sex drive is determined by biological, psychological, and sociocultural factors in combination. Features of any of these may affect (increase or decrease) sexual desire ◦ Low levels of sexual desire or sexual aversion are usually caused by and/or complicated by sociocultural and psychological factors ◦ Biological conditions can also cause lower sex drive ◦ Effects of stress, anxiety, and depression • Biological causes ◦ A number of hormones interact to produce sexual desire and behavior • Abnormalities in hormone secretion and activity can result in lower sex drive • Hormones include prolactin, testosterone, and estrogen for both men and women • Some data points to excessive dopamine and serotonin • Chronic illness, some medications, some psychotropic drugs, and illegal drugs are known to negatively impact sex drive and performance • Psychological causes • Increases in anxiety or ongoing frustration and anger may reduce sexual desire for both women and men • Fears, attitudes, and memories may contribute to sexual dysfunction (e.g., sexual abuse and other trauma) • Psychological disorders, including depression and obsessive-compulsive disorder, may be associated with sexual desire disorders • Sociocultural -Social context impacts attitudes, fears, and psychological disorders and these contribute to sexual desire disorders • Many with desire disorders are experiencing ongoing situational pressures • Examples: divorce, death, job stress, infertility, and/or relationship difﬁculties • Cultural standards can impact the development of these disorders (family messages/media/religion) • Trauma associated with a history of sexual molestation or sexual assault is likely to produce sexual dysfunction Research has demonstrated longstanding gender diff in sex behaviors in the us have largely disappeared over time, except for A large number of those seeking help for sex dysfunction are effectively treated using ina misguided attempt to help ﬁx women with the same treatment of men failed to help post menapausal women Understanding the spectrum of "normal" human sexual behaviors? • “…, a wonder-drug, named Lybrido, touted as the ‘female Viagra’ is scheduled to be approved by the FDA within about a year. This magical drug promises to treat hypoactive sexual desire disorder in women. Some of its developers, however, fear the unintended consequence of turning womankind into an army of uncontrollable nymphomaniacs which would destroy society.” • “The status of asexuality as a mental illness already reeks of orientation- policing. How long is it going to be before asexuals are acknowledged as a normal part of the broad spectrum of human sexual expression?” Sexual arousal disorders • Excitement phase of the sexual response cycle ◦ Marked by changes in the pelvic region, general physical arousal, and increases in heart rate, muscle tension, blood pressure, and rate of breathing • In men: erection of the penis • In women: clitoral swelling and vaginal lubrication • Male Erectile Disorder (formerly called “impotence”) • Previously: Female sexual arousal disorder ◦ Characterized by repeated inability to maintain proper lubrication or genital swelling during sexual activity ◦ The disorder was known to be usually comorbid with an orgasmic disorder, so researchers usually studied the two together – now combined into one disorder ◦ It has been estimated that more than 10% of women experience this disorder • Erectile Disorder (ED) ◦ Characterized by repeated inability to attain or maintain an adequate erection during sexual activity (lasting 6 months or more) ◦ An estimated 10% of men experience this as a disorder ◦ According to surveys, half of adult men have at least occasional erectile difﬁculty during intercourse which is generally ﬂeeting and not pathological in nature • Erectile disorder results from an interaction of biological, psychological, and sociocultural processes ◦ Even minor physical problem with erection response may make a man vulnerable to the effects of psychosocial factors ◦ Question: What is the impact of having Bob Dole discuss ED? - normalizes • Biological causes ◦ Hormonal imbalances that can cause hypoactive sexual desire can also produce ED ◦ Vascular problems are most commonly involved • ED can also be caused by damage to the nervous system from diseases, disorders, or injuries ◦ Certain medications and substances may interfere with erections • Biological causes ◦ Medical devices have been developed for diagnosing biological causes of ED • One strategy involves measuring nocturnal penile tumescence (NPT) ▪ Men typically have erections during REM sleep; we know it's not a physiological problem ▪ abnormal or absent nighttime erections usually indicate a physical basis for erectile failure • Psychological causes ◦ Psychological causes of hypoactive sexual desire can also interfere with erectile function • 90% of men with severe depression experience some degree of ED ◦ Performance anxiety and the spectator role provide a cognitive explanation for ED • When a man begins to have erectile difﬁculties, he becomes worried during sexual encounters; he becomes a spectator and judge instead of being a participant ▪ Creates a vicious cycle of sexual dysfunction where the fear of failure dominates the situation and the original cause of the problem becomes less important • Sociocultural causes ◦ Sociocultural factors tied to hypoactive sexual desire has also been linked to ED ◦ Employment problems and marital problems are often particularly relevant ◦ Loss of attraction for partner Orgasm disorders • Orgasm phase of the sexual response cycle ◦ Sexual pleasure peaks and sexual tension is released as the muscles in the pelvic region contract rhythmically • For men: semen is ejaculated • For women: the outer third of the vaginal walls contract • There are three disorders of this phase: ◦ Premature ejaculation ◦ Male orgasmic disorder ◦ Female orgasmic disorder • Female orgasmic disorder ◦ Pattern of persistent delay in or absence of orgasm following normal sexual excitement • An estimated 25% of women appear to have this problem at some point, may not be accurate ▪ 10% or more have never reached orgasm ▪ An additional 10% reach orgasm only rarely ◦ Women who are more sexually assertive and more comfortable with masturbation tend to have orgasms more regularly than those who are not ◦ Men are more likely to masturbate - question #1 ◦ Female orgasmic disorder is more common in single women than in married or cohabiting women • Female orgasmic disorder ◦ Biological causes: • Physiological conditions can affect arousal and orgasm (diabetes, multiple sclerosis) • Medications and illegal substances • Postmenopausal changes ◦ Psychological causes • Causes of hypoactive sexual desire and sexual aversion • Memories of childhood trauma and relationship distress • Female orgasmic disorder ◦ Sociocultural causes ◦ For decades, the leading sociocultural theory of female sexual dysfunction was that it resulted from sexually restrictive cultural messages ◦ BUT: This theory cannot completely account for problems: • Sexually restrictive histories are equally common in women with and without disorders • Cultural messages about female sexuality have been changing while the rate of female sexual dysfunction stays constant • Premature ejaculation ◦ Characterized by persistent reaching of orgasm and ejaculation with little sexual stimulation and before the man or partner wishes • About 30% of men experience premature ejaculation during their lifetime; about 21% have ongoing problems meeting the criteria for the disorder ◦ Behavioral explanations of this disorder have more research support than other theories • Most common among young, sexually inexperienced males • May be related to anxiety • Often related to a history of hurried masturbation experiences • Declines with age and experience • Male orgasmic disorder ◦ Pattern of inability to reach orgasm or having a very delayed orgasm ◦ Adequate desire and arousal ◦ Rare: Estimated 8% of the male population ◦ Biological causes include low testosterone, neurological disease, and head or spinal injury • Medications, including certain antidepressants (especially SSRIs) and drugs that slow down the CNS, can also affect ejaculation • Male orgasmic disorder • A leading psychological cause appears to be performance anxiety and the spectator role, the same cognitive factors involved in ED Sexual pain disorders Genito-Pelvic Pain/Penetration Disorder Unusual sexual dysfunctions do not ﬁt a speciﬁc phase of the sexual response cycle Usually associated with tightening muscles which make penetration painful or with a pain condition due to biological or psychological problems May be associated with trauma, abuse or injury Cases of sexual dysfunctions • Interaction of Psychological and Physical Factors • Socially transmitted negative attitudes •+ • Relationship difﬁculties + • • Predisposition to develop performance anxiety What are the general features of sex therapy? • Modern sex therapy is short-term and instructive ◦ The psycho-educational component includes instruction about sex and typical sexual functioning ◦ Therapy typically lasts 15 to 20 sessions ◦ It is centered on speciﬁc sexual problems rather than on broad personality issues • Modern sex therapy includes: ◦ Assessing and conceptualizing the problem ◦ Assigning “mutual responsibility” for the problem ◦ EDUCATION (#2) ABOUT SEXUALITY ◦ Attitude changes - sometimes most difﬁcult to change ◦ Elimination of performance anxiety and the spectator role ◦ Increasing general communication skills ◦ Helping people learn to discuss sex (needs/preferences) ◦ Changing destructive lifestyles and marital interactions ◦ Addressing physical and medical factors Assessing sexual behavior: • Interviews ◦ Clinician must demonstrate comfort = “normalize” • Assess multiple dimensions ◦ Sexual attitudes ◦ Behaviors ◦ Sexual response cycle ◦ Relationship issues ◦ Physical health ◦ Psychological disorders • Medical Issues: ◦ Medication side effects ◦ Physical conditions and general health • Psychophysiological ◦ Exposure to erotic material ◦ Sexual arousal response • Males—Penile strain gauge • Females—Vaginal photoplethysmograph What techniques are applied to particular dysfunctions? Hypoactive sexual desire and sexual aversion Among the most difﬁcult to treat because of many issues involved Therapy typically includes a combination of techniques: Awareness of feelings, self-instruction training, behavioral techniques, insight- oriented exercises, and biological interventions such as hormone treatments Erectile disorder Treatments for ED focus on reducing performance anxiety and/or increasing his stimulation May include sensate-focus exercises such as the “tease technique” Biological approaches, used when the ED has biological causes, have gained great momentum with the FDA approval of Viagra Most other biological approaches have been around for decades and include gels, suppositories, penile injections, a vacuum erection device (VED), and penile implant surgery Male orgasmic disorder Techniques to reduce performance anxiety and increase stimulation When the cause of the disorder is physical, treatment may include a drug to increase arousal of the nervous system Premature ejaculation Premature ejaculation has been successfully treated for years by behavioral procedures such as the “stop-start” or “pause” technique Some clinicians prescribe Prozac and other serotonin-enhancing antidepressant drugs These drugs often reduce sexual arousal or orgasm, they may be helpful in delaying premature ejaculation Positive outcomes have been reported, but long-term outcome studies have yet to be conducted Female arousal and orgasmic disorders Speciﬁc treatment techniques for these disorders include self-exploration, enhancement of body awareness, and directed masturbation training A lack of orgasm during intercourse is not necessarily a sexual dysfunction, provided the woman enjoys intercourse and is orgasmic through other means *NOTE: The attitudes toward treating orgasmic disorders seem to include the idea that orgasm is necessary for men but may be optional for women Vaginismus Speciﬁc treatment approaches: Practice tightening and releasing the muscles of the vagina to gain more voluntary control Use of vaginal dilators to increase comfort with penetration Overcome fear of intercourse through gradual behavioral exposure treatment Approximately 75% of women treated for vaginismus using these methods eventually report pain-free intercourse What are the current trends in sex therapy? • Sex therapy continues to evolve and includes a broad range of sexual issues and diverse clients: ◦ Unmarried couples ◦ Clients with other psychological disorders, ◦ Couples with severe marital discord ◦ Elderly ◦ Medically ill ◦ Physically handicapped ◦ Homosexual and bisexual clients ◦ Clients with no long-term sex partner • Therapists are paying more attention to excessive sexuality, which is sometimes called “sexual addiction” • The use of medications to treat sexual dysfunction is troubling to many therapists who are concerned that therapists will choose medication (which may only be useful short term) rather than a more integrated (and potentially long lasting) approach Paraphilic disorders • Nature of paraphilias ◦ If you can ﬁnd someone to do them with you, it doesn’t reach that level of a disorder ◦ Sexual attraction and arousal ◦ Socially inappropriate people or objects ◦ Some cause harm to others ◦ NOTE: Distress and impairment must be present to be a disorder ◦ Multiple paraphilias often occur in one client ◦ High comorbidity with • Anxiety • Mood Disorders • Substance Abuse - makes them more dangerous • Rates of diagnosis are low, but researchers and clinicians believe patterns may be quite common • Theorists have proposed various explanations for paraphilias, there is little formal evidence to support the theories • Treatment of paraphilias are not adequately researched nor are they clearly effective • Biological interventions show some promise Frotteuristic disorder • Fantasies, urges, or behaviors involving touching and rubbing against a nonconsenting person (usually this is anonymous) ◦ Almost always male; the person may fantasize during the act that he is having a caring relationship with the victim • Usually begins in the teenage years or earlier ◦ Acts generally decrease and disappear with age, usually after age 25 Fetishistic disorders • Recurrent intense sexual urges, sexually arousing fantasies, or behaviors that involve the use of a nonliving object (inanimate, tactile, or partialism=body part) ◦ The disorder usually begins in adolescence ◦ Almost anything can be a fetish • Women’s underwear, shoes, and boots are especially common • Behaviorists propose that fetishes are learned through classical conditioning • Fetishes are sometimes treated with aversion therapy, covert sensitization, or imaginal exposure • Another behavioral treatment is masturbatory satiation, in which clients masturbate to boredom while imagining the fetish object • An additional behavioral treatment is orgasmic reorientation, a process which teaches individuals to respond to more appropriate sources of sexual stimulation Transvestic disorder • Also known as transvestism or cross-dressing • Fantasies, urges, or behaviors involving dressing up in the clothing of the opposite sex in order to achieve sexual arousal • Typically, a heterosexual male who began cross-dressing in childhood or adolescence • Transvestism is NOT the same as gender identity disorder (transsexualism or transgender); the two are separate patterns • The development of the disorder seems to follow the behavioral principles of operant conditioning Exhibitionistic disorder • Arousal is sought and experienced from the exposure of genitals in a public setting ◦ Also known as “ﬂashing” ◦ Sexual contact is neither initiated nor desired • Usually onset before age 18 and is most common in males (but diagnosed at 18 and older) • Treatment generally includes aversion therapy and masturbatory satiation ◦ May be combined with orgasmic reorientation, social skills training, or psychodynamic therapy Voyeuristic disorder • Repeated and intense sexual desires to observe people in secret as they undress or to spy on couples having intercourse; May involve acting upon these desires ◦ The person may masturbate during the act of observing or while remembering it later ◦ The risk of discovery often adds to the excitement • **Recent research has revealed that this as a ﬁrst stage of development for some serial rapists • The fact that someone doesn't know makes it a disorder • Peeping tom • More men than women Sexual sadism • Finds fantasies, urges, or behaviors involving the thought or act of psychological or physical suffering of a victim sexually exciting ◦ Named for the infamous Marquis de Sade who reportedly tortured people in this manner ◦ People with sexual sadism imagine that they have total control over a sexual victim • May ﬁrst appear in childhood ◦ Pattern is long-term and difﬁcult to change ◦ Appears to be related to classical conditioning and/or modeling ◦ Psychodynamic and cognitive theories - underlying feelings of sexual inadequacy ◦ Biological studies - possible abnormalities in the endocrine system ◦ The primary treatment is aversion therapy • A Clockwork Orange movie ◦ High tolerance for pain, love adrenaline Sexual sadism and sadistic rape • Rape is ALWAYS about power • Considered assault both legally and psychologically • Opportunistic, generally antisocial, lack of empathy, disregard for vulnerable individual • Research has noted that sexual sadists are stimulated by reports of rape Sexual masochism • Fantasies, urges, or behaviors involving the act or the thought of being humiliated, beaten, bound, or otherwise made to suffer • Masochistic fantasies begin in childhood and seem to develop through the behavioral process of classical conditioning Pedophilia • Characterized by fantasies, urges, or behaviors involving sexual activity with a prepubescent child, usually 13 years of age or younger • Some people are satisﬁed with fantasy using child pornography • Others are driven to watching, fondling, or engaging in intercourse with children • May include aggressive, opportunistic attacks • Evidence suggests that about 90% are male; two-thirds of victims are female (but accurate data about perpetrator gender are unknown – why?) • A crime • Develops in adolescence • Some were sexually abused as children • Vast majority self identify as heterosexual • Many were neglected, excessively punished, or deprived of close relationships in childhood • Most are immature, display faulty thinking, and many have an additional psychological disorder • Some theorists have proposed a related biochemical or brain structure abnormality • If identiﬁed with pedophilia, persons are usually imprisoned or forced into treatment • Treatments include aversion therapy, masturbatory satiation, and orgasmic reorientation • Cognitive-behavioral treatment involves relapse-prevention training, modeled after programs used for substance dependence What do you believe? • The deﬁnitions and descriptions of paraphilias, like those of sexual dysfunctions, are grounded in and inﬂuenced by prevailing social norms • Some clinicians believe paraphilic behaviors should not be considered disorders unless someone is harmed by the behaviors • What do YOU think?
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