Lothlórien

The Effect of Automatic Thoughts on Sexual Dysfunction

*Part of a paper for my Sexuality class. Topic: Factors Affecting Sexual Functioning

Aaron T. Beck, the "father" of Cognitive-Behavioral Therapy, defines automatic thoughts as images or thought patterns present in an individual that result from core beliefs that are activated by a particular event or situation. These images, or thoughts, reflect the meaning that the individual attributes to the event and is deeply connected with an emotional and behavioral response in the individual (Pinto-Gouveia, 2008). Pinto-Gouveia (2008) conducted a study to compare the content of these automatic thoughts between  sexually healthy individuals  and individuals with a DSM-IV diagnosis of sexual dysfunction.

The study surveyed 491 individuals. One hundred sixty-three women and 232 men in the study did not have a sexual dysfunction while 47 women and 49 men had a current DSM-IV diagnosis of a sexual dysfunction. His hypothesis is that sexually healthy individuals focus their attention during sex on sexual and erotic material while individuals with sexual dysfunction focus their attention on non-sexual thoughts (Pinto-Gouveia, 2008).

The men in the study were assessed with The International Index of Erectile Function (IIEF), and the women were assessed with The Female Sexual Function Index (FSFI). Both men and women were further assessed with the Sexual Modes Questionnaire (SMQ) that measures the thoughts, emotions, and sexual responses of individuals during sex. This latter scale has three subscales: Automatic Thoughts, Emotional Response, and Sexual Response (Pinto-Gouveia, 2008).

Pinto-Gouveia (2008) used a multivariate analysis of covariance (MANCOVA) to analyze the results of the study. He found that overall the individuals with diagnosed sexual dysfunction had more negative thought patterns during sexual activity than did those who had healthy sexual functioning.  Men with a diagnosed sexual dysfunction reported more thoughts related erectile concerns, anticipation of failure, and lack of erotic thoughts/images. Women with a diagnosed sexual dysfunction reported more thoughts related to failure and disengagement, sexual abuse (ex. “he only wants to satisfy himself”, etc.), and lack of erotic thoughts/images. These results in both the men and women were significantly stronger than those reported by individuals with healthy sexual functioning.

Pinto-Gouveia (2008) noted that both women and men reported significantly more negative thought patterns during sex as well as thoughts of failure and a lack of erotic thoughts/images. He states that “cognitive distraction from erotic cues is strongly associated with sexual dysfunction”. He also recommends Cognitive Behavioral Therapy and a positive treatment for individuals with sexual dysfunction. Cognitive Behavioral Therapy involves closely looking at these automatic thoughts and connecting them to the core beliefs they are associated with. These automatic thoughts are looked at in depth as they relate to the emotions and behaviors that they elicit. Clients are helped to make connections between thoughts, emotions, and behaviors, and are guided to explore how these thoughts help them and how they may hurt them. Often clients come to new thoughts and adjustments in their core beliefs which directly impacts their emotions and behaviors.

References

Pinto-Gouveia, José 1, J. (2008). Differences in Automatic Thoughts Presented During Sexual Activity Between Sexually Functional and Dysfunctional Men and Women. Cognitive Therapy and Research, 32(1), 37-49.

Copyright© 2011 by Lothlorien– All Rights Reserved

History of Abuse and Sexual Dysfunction

*Part of a paper for my Sexuality class. Topic: Factors Affecting Sexual Functioning

Statistics show that over a quarter of the US population reports a history of abuse at some point in their lifetime.  The abuse could be emotional, physical, or sexual. Intimate partner abuse and sexual abuse rates are higher in women, and physical abuse is higher in men. Medically speaking, abuse has been associated with gastroenterologic and genitourinary symptoms and pain. Psychologically speaking, abuse is associated with depression, posttraumatic stress disorder, and substance abuse.

Some survivors of sexual abuse have reported lacking desire for sex while others have reported being hypersexual. Previous studies on the issue have found women who were sexually abused had increased difficulty with arousal as well as other areas of sexual functioning. The affects of associated depression in these same women have shown mixed results. This study attempts to control  for the affects of depression in order to isolate the affects of abuse as much as possible (Link, 2008).

Carol Link (2008) conducted a survey from April 2002 to June 2005 of 3,205 women in the Boston area to determine the relationship between abuse and sexual dysfunction in women. Data was analyzed from the Boston Area Community Health Survey that is a community-based epidemiological study of sexual symptoms and risk factors among a racially and ethnically diverse random sample of women. Each woman was also given a self-administered questionnaire developed by Leserman et al. to determine if the individual had an abuse history, and if so, what type of abuse was experienced. The group was also assessed with the Female Sexual Function Index (FSFI), which measures sexual functioning among six dimensions: desire, arousal, lubrication, orgasm, pain, and satisfaction.

After completing the sexual abuse history questionnaire, 17% of the sample showed positive signs for a history of childhood emotional abuse, and 26% showed a history of childhood sexual abuse. Of all the women 34% scored significant for sexual dysfunction on the FSFI. When the scores were analyzed together, several conclusions were made. Sexual activity did not appear to be statistically different in women who had been abused when compared to those who had not. Of the women who had been abused, 48.9% stated that they had sexual activity in the last four weeks, and 52.9% of the non-abused women reported sexual experience in the same time period. There appears to be little difference in sexual activity abused and non-abused women. However, there are differences in the quality of those sexual experiences. Emotional and sexual abuse were positively associated with female sexual dysfunction. In fact, the more types/incidents of abuse a woman had, the higher the score for sexual dysfunction was, showing a positive correlation between abuse and sexual dysfunction. Though the total percent of subjects that scored significantly for sexual dysfunction was 34%, when the data of those 34% were divided up between women with a history of abuse and women without, 28.2% of them had no abuse history, and 44.9% had two or more types of abuse in their history.  This was statistically significant with a p-value of 0.006.  The study found that abuse nearly doubles the probability of sexual dysfunction. The study also found that in this particular sample the two dimensions assessed that appeared to be the most problematic for these women were pain and satisfaction (Link, 2008).

Link suggests that professionals be aware of the affects of abuse on sexual functioning. She recommends a multi-modal approach to treatment which incorporates medical intervention where needed as well as psychosocial intervention, and counseling.

References

Link, C. (2008). An examination of the association of abuse (physical, sexual, or emotional) and female sexual dysfunction: results from the Boston Area Community Health Survey. Fertility and Sterility, 90(4), 957-964.

Copyright© 2011 by Lothlorien– All Rights Reserved

Processing "THE" Trauma-Part 4

I had another EMDR session. The "negative charge"/SUD is continuing to go down and move out, but still when I pull up the image of the lights (the first thing I saw when I woke up) my eyes immediately sting and tears just stream down my face. So, my therapist and I started with that image.

Before we started, as my T was getting all set up, I felt this overwhelming clingy-ness. I wanted to pull her close to me and wrap my arms around her like I was drowning! I really had to hold myself back from pulling on her, reaching for her hand, etc. (I didn't want to look ridiculous!) Though I didn't act on it, I did tell her I felt very clingy.

We started the EMDR, and the feelings went right to intense fear and longing. The phrase "I want my Mommy" was screaming through my consciousness! Another set yielded panic and,"I want my Mommy. I want her now, now, now, now, now!!!!" One more set of that and then on another set I began to go numb, I could feel myself pushing it away and then found myself in the dark bliss of dissociation (in my thoughts, memories, emotions--not really dissociated in that moment).It occured to me then how powerfully reinforcing the dissociation was. Being able to "get away" helped me feel powerful in a situation where I was really powerless. It also took the pain away (physically and emotionally).

Interesting session! Interesting because I don't ever recall "wanting my mommy" for anything at any point in my life. I guess because after that, perhaps I never "reached out for her again." I know I was angry with her when the surgery was over. I remember feeling dead to her. Looking at her and looking away. We did EMDR with this as well and those feelings were strong and the thought, "Where were you?" followed by a disregard of her on my point passed through my consciousness. I felt like, "You weren't there when I really needed you. I don't want you now." And then to tell her,"I know what they did," and have that responded with a dismissive, "No you don't. You were asleep," sealed the deal. I was detached.

I don't think that one incident is where the attachment went awry. I know from the way my mother raised me and how she interacted with my own kids as infants that the attachment was damaged already. But I think I had just enough positive attachment to emotionally reach out to her in the face of "terror" and/or "death". I suppose it makes sense because when I think about it, if I had experienced that incident and NOT felt an intense need for my Mommy in that moment, I would probably have Reactive Attachment Disorder instead of DID. The attachment would've had to be unbelievably severely damaged for me to not want my Mommy in a situation like that. So there was some attachment, albeit a damaged one which was further damaged after this.

So now I'm drawn to the clingy-ness for which I am SO noted for with my therapists! ;) And there it is! My little self was still reaching out for comfort---perpetually reaching for what was needed, never could get, and never could resolve. That's it! And you know what? Since this EMDR session,  it is as if that intense desire has faded. Like a huge "a-ha" moment has occurred, and I'm ok. I don't feel like I need to do that....I do not feel the "desparate" need for attachment....not at all! Of course I still want attachments, but I don't have that desparate quality to it. I feel fine and safe within myself, and it's a good feeling. I'm ok, and the little part of me is ok too.

I really should've known the cliny-ness I experienced with my therapist was due to attchment issues with my mom because I do not have a history of being clingy in general. No one who knows me outside of therapy would ever characterize me that way. Interestingly, it has only presented itself in therapy situations, where (duh--!!) I have tended to have female therapists who were, on average, about 20 years older than me and, by virtue of the therapeutic relationship, were very responsive to me emotionally. Transference, transference, and more transference! So, duh-----it's all been about resolving attachment needs (re: my mom). I was always seeking attachment to a "mother figure"..... always seeking that comfort, that "soft place to fall", and a "grown up" to lean on. I used to liken myself to one of Harlow's monkeys when it came to my desire to be in close proximity to my therapists. These poor therapists I have seen. How patient they all were! One of the four T's I've seen saw this clingy-ness in me and slapped a Borderline diagnosis on me. None of the other T's did, not even a specialist in BPD that led a DBT group I was in. I'm not Borderline, nor have I ever been. I just had an aching heart, and thanks to some patience, trauma processing, and EMDR that aching heart has been soothed. :)

This has all helped me so much. I feel like a different person (not like DID--LOL). Just so much happier, free, etc. My perceptions of things are changing....changing to a more integrated perception as opposed to a focused, tunnel-visioned perception. I am getting a proper distance from it all which puts me in a place of being able to look at it all with some objectivity, free of the intense emotions.

My previous therapist, who I still keep in touch with from time to time said that integration can be a lonely time for peoplewith DID. However, so far, I feel significantly less lonely! I feel more connected to people in my life. I think for me I was very lonely with DID. Probably because I was in my own internal world and not as open as I could be to the world around me. I can actually feel the connections I have with people. I feel "out" not "in", and it feels good. Life is also much calmer.

My session was actually yesterday. Today I have felt ok. I have felt good for the most part, but I feel very pensive about the attachment stuff, I feel sad for myself, and a bit tearful about my life as a kid. What this has also brought up is that with my attachment with my mom so damaged, I clung to my father who was available for attachment. He did things my mother never did.....things all parent should do. He told me he loved me, he hugged me, gave me kisses (appropriate ones), told me stories, let me sit next to him, even on his lap if I wanted! However, he was two Daddies. The one I just described was the sober Daddy. There was also the drunk Daddy who blurred the boundaries, kissed me inappropriately, blah, blah, blah (not going there). The realization this attachment stuff brings up is that I had to do whatever I could to keep that attachment with my father because it was the only attachment I had. Catch-22. It is just painful, so sometimes I do not feel so good, and I know there is so much more ahead of me on this journey called therapy. However, mostly I feel good because the processing I have done has helped so much. I feel so much growth. I feel great overall.I just keep taking it day-by-day.

**Image is "mother love"......what I wanted, what I needed, what I spent most of my life seeking. That "soft place to fall".

Copyright© 2011 by Lothlorien– All Rights Reserved

Antidepressant Medication and Sexual Functioning

*Part of a paper for my Sexuality class. Topic: Factors Affecting Sexual Functioning

According to Osis and Bishop (2010), depression affects 19 million Americans every year, and 16.2% will experience a major depressive episode in a year.  Selective Serotonin Reuptake Inhibitors (SSRI’s) such as Prozac, Zoloft, or Lexapro have long been the first line of defense in treating depression (Osis and Bishop, 2010; Safarinejad, 2010).  These drugs have been shown to have effectiveness rates anywhere between 50% and 70% according to randomized controlled studies of efficacy. However, the prevalence of sexual side effects from these medications ranges from 30-70% (Osis and Bishop, 2010; Safarinejad, 2010), with some researchers claiming the incidence is as high as 80% (Brill, 2004). These side effects are huge reason why approximately 90% of individuals will discontinue the use of their SSRI at some point during treatment (Safarinejad, 2010). The sexual side effects are particularly bothersome because they interfere with quality of life and are ongoing. Whereas most side effects of SSRI’s will dissipate over time (usually within the first eight weeks of treatment), the sexual side effects do not. They continue so long as the SSRI is continued (Osis and Bishop, 2010; Brill, 2004).

Sexual side effects from SSRI’s have been reported to affect people differently at different doses. Also, in some people it may only affect one area of sexual functioning, but in others it may affect more. SSRI’s have the potential to affect each stage of sexual functioning: desire, arousal, and orgasm. Osis and Bishop (2010) explain that various neurotransmitters and hormones affect each stage of the sexual response. The SSRI’s work against some of these neurotransmitters. For example, serotonin affects each stage of sexual functioning from desire to arousal to orgasm. Antidepressants that increase the amount of serotonin in the brain through inhibiting the reuptake of serotonin (SSRI’s) inhibit these processes. The neurotransmitters dopamine and norephinephrine are important too. Too much serotonin floating around and not enough dopamine or norepinephrine can wreak havoc on a person’s sexual process.

Brill (2004) and Safarinejad (2010) claim that many people have had success in combatting these side effects by either changing from SSRI’s to Wellbutrin or Wellbutrin SR which works on the neurotransmitters dopamine and norepinephrine. Wellbutrin has the lowest incidence of sexual side effects of any of the antidepressants on the market. There have also been studies that show that adding Wellbutrin to an SSRI can offset at least some of the sexual side effects of the SSRI. Some people have recommended taking a “drug holiday” prior to sexual interaction, but this does not always work out so well. For one thing, the SSRI’s have such a long half-life that it will still be in their system to some degree and hence, have some affect on sexual response. The other reason this doesn’t work so well is that many people do not have this kind of “advanced notice”. For now, many people attempt to manage on the lowest possible effective dose of SSRI to manage their depression while minimizing the side effects as much as possible, or they take other drugs to offset these side effects. On a personal note, I think it is a sad state of affairs when a person has to choose between emotional stability and sex. Hopefully there will be more advancement in this area as researchers do more to understand and manage these affects.

References

Brill, M. (2004). Antidepressants and sexual dysfunction. Sexuality, Reproduction & Menopause, 2(1), 35-40.

Osis, L. (2010). Pharmacogenetics of SSRIs and Sexual Dysfunction. Pharmaceuticals, 3(12), 3614-3628. doi:10.3390/ph3123614

Safarinejad, M. R. (2011). Reversal of SSRI-induced female sexual dysfunction by adjunctive bupropion in menstruating women: a double-blind, placebo-controlled and randomized study. Journal of Psychopharmacology, 25(3), 370-378.

Copyright© 2011 by Lothlorien– All Rights Reserved

Depression and Sexual Functioning

*Part of a paper for my Sexuality class. Topic: Factors Affecting Sexual Functioning

There are approximately 18 million Americans diagnosed each year with Major Depressive Disorder. Of those 18 million, 12-18 million of them will be prescribed and antidepressant medication to manage the disorder. Individuals with Major Depressive Disorder experience a depressed mood, loss of interest in activities that were previously satisfying, a change in their appetite/weight, reduced self-confidence, disturbed sleep patterns, feelings of guilt and worthlessness, and reduced ability to concentrate (Hartmann, 2007). Given those symptoms, it is no surprise that affective disorders and sexual functioning disorder often go hand in hand.  According to Hartmann (2007), the comorbidity of the two classes of disorders is highly prevalent and the two have a bidirectional relationship, meaning one affects the other, and vise versa.  Hartmann (2007) goes on to say that the issue of depression co-existing with sexual dysfunction is further complicated by the antidepressants prescribed for depression. They, too, have an impact on sexuality.  His article is a review of the literature surrounding the co-existence of depression and sexual dysfunction, with an attempt to weed out the influence of antidepressant medication. He says that few studies have been done on people prior to being put on antidepressant medication, so sorting out the effects of depression versus the effects of antidepressants is difficult.

Overall depression appears to affect a woman’s desire for sex. In men it appears to cause low desire as well as erectile dysfunction.  The most common effects of depression on sexual functioning are in the areas of low desire and low arousal. Some studies show low interest in sex in as much as 67% of people with severe depression, whereas only 27% of healthy controls experience low sexual desire (Hartmann, 2007). Hartmann (2007) cites two studies, which he refers to as “landmark studies” on the relationship between sexual dysfunction and depression. Both studies examined the prevalence of psychiatric symptoms among individuals with various types of sexual dysfunction. One such study was conducted by Derogatis et al. His study was conducted with 325 individuals (199 male; 126 female) who were all undergoing treatment for sexual dysfunction. He assessed each one for co-occurring psychiatric disorders and found that one-third of the men and half of the women met criteria for at least one other diagnosis in addition to a sexual disorder. Men with erectile dysfunction score tended to score high for severe depression. Women with anorgasmia, dyspareunia, and vaginismus also score quite high for depression. In another landmark study, conducted by Schreiner-Engal and Schiavi, 46 individuals (22 male; 24 female) with sexual functioning disorders were matched with 36 controls and assessed for depression and schizophrenia. The study found that those with sexual disorders had marked elevated scores for lifetime prevalence of psychiatric disorders. Though none of the individuals in this sample were currently experience depression, those with low sexual desire had double the depression rate as controls, meaning they had struggled with depression at some point in their lives. In fact, they also found that with 88% of the men and 100% of the women, depressive symptoms either coincided with the onset of the sexual disorder or preceded it (Hartmann, 2007).

Another study called the Massachusetts Male Aging Study (MMAS) depression and anger were both highly correlated with erectile dysfunction in men. According to this study, almost all men with Major Depressive Disorder had some degree of erectile dysfunction. In fact, the more severe the depression, the more complete the erectile dysfunction was. Moderate to complete erectile dysfunction was 1.82 times higher in those males with depression (Hartmann, 2007).

Hartmann (2007) also discusses medical factors that could play a role in the connection between depression and sexual dysfunction. Depression causes heart disease because it causes overactivyt of the autonomic nervous system and hypothalamic-pituitary-adrenal dysregulation. These factors alone could be a cause for some of the sexual difficulties people with depression face.

In light of the connection between depression and sexual disorders, it is recommended that people with sexual dysfunction also be screened for depression. Likewise, those individuals who are being treated for depression should be assessed for sexual dysfunction. The author states that more studies need to be done with individuals prior to antidepressant therapy in order to get a really clear picture of exactly what role depression plays in sexual dysfunction. For now, the issue is still quite complex, but there is no doubting that a connection does, in fact, exist.

Reference

Hartmann, U. (2007). Depression and sexual dysfunction. The journal of men's health & gender, 4(1), 18-25.

Copyright© 2011 by Lothlorien– All Rights Reserved