Eating, Substance, Sexual/Gender, Sex, and Personality Disorders
The Diagnostic and Statistical Manual of Mental Disorders IV-TR, which was published in 2000, is a multi-axial diagnostic tool used by clinicians, psychologists, psychiatrist, and medical professionals for the classification of mental disorders (Hansell & Damour, 2008). Axis I and Axis II of the DSM-IV-TR cover symptom disorders—those typified by unwelcome types of distress and/or impairment—and personality disorders—those exemplified by inflexible personality traits that bring about impairment and/or distress—respectively. It is possible to be diagnosed with both symptom disorders and personality disorders. Notwithstanding, the basic distinction between Axis I and Axis II disorders is that personality disorders tend to be enduring, pervasive, and subjectively indistinguishable; whereas, symptom disorders tend to be acute, specific, and subjectively discernible. This paper will address the biological, emotional, cognitive and behavioral components of four Axis I symptom disorders: anorexia bulimia, alcohol abuse, sexual pain disorder, and exhibitionism; and one Axis II personality disorder: schizoid personality disorder.
Eating Disorders
The DSM-IV-TR includes two Axis I categories of eating disorders: anorexia nervosa—restricting and binge-eating/purging types—and bulimia nervosa—purging and non-purging types (BehaveNet, 1997-2010, n.p.). Anorexia nervosa affects between 0.5% and 1% of the general population in the United States currently and bulimia nervosa affects up to 3% (Hansell & Damour, 2008). When considering eating disorders it is important to take into account that some sub-groups in the American culture have extremely low body, such as gymnast and models, which complicates the diagnosis of eating disorders.
Bulimia Nervosa
Bulimia nervosa begins with, “…eating, in a discrete period of time (e.g. within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances” (BehaveNet, 1997-2010, n.p.). From there a person can purge—vomit or use laxatives, diuretics, or enemas—or use inappropriate compensatory behaviors. A genetic component to bulimia nervosa has been found to exist, as seen in a concordance rate of 35% and 30% for monozygotic and dizygotic twins, respectively (Fairburn & Harrison, 2003). Eating disorders are characterized by the cognitive estimation that “…one’s physical shape reflects one’s value or worth” (Hansell & Damour, 2008, p. 296). Furthermore, compensatory behavior (e.g. excessive exercise, fasting, or medications) can occur concurrently or in exclusion to purging behavior (BehaveNet, 1997-2010). On an subjective level, bulimia nervosa can be a “…purely emotional response to the world—under pressure, binge and purge; sad and lonely, binge and purge; feeling hungry, binge and purge…” (Hansell & Damour, 2008, p. 282). In all, bulimia nervosa is a complex disorder, rooted in genetic predisposition, but precipitated by sociocultural influences, cognitive estimations, and emotional responses.
Substance Disorders
Substance disorders fall into two major Axis I categories: abuse or dependency; with a wide range of possible resulting disorders (BehaveNet, 1997-2010). The potential substances that can be abused or misused in the DSM-IV-TR include: alcohol, caffeine, cannabis, cocaine, hallucinogens, inhalants, nicotine, opioids, phencyclidine or; sedative, hypnotic or anxiolytic abuse. These categories of substance abuse are made relevant by the fact that nearly 25% of deaths in the United States each year are drug and alcohol related (Hansell & Damour, 2008).
Alcohol Abuse
Physiological dependence occurs when a drug or other substance becomes necessary for normal bodily functions and the cessation of said substance brings with it withdrawal symptoms (Chapman, Meyer & Weaver, 2009). What is more, “Clinicians often note that when serious substance problems begin, an individual’s emotional development stops” (Hansell & Damour, 2008, p. 325). The efficacy of drug use is driven by the expectancy of good feelings, a sense of relaxation, and less emotional stress. Alcohol abuse is characterized by, “…continued substance-related use despite having persistent or recurrent social or interpersonal problems” (BehaveNet, 1997-2010, p. 291.9). In sum, alcohol abuse is continued because normal bodily functions become dependent on the drug, even in the face of recurrent social or interpersonal problems.
Sex/Gender Disorders
Sex and gender disorders fall into the Axis I categories of: sexual dysfunctions (sexual desire/sexual arousal), sexual pain disorders, and gender identity disorder (BehaveNet, 1997-2010). When considering sex and gender disorders it is imperative to keep in mind that normal and abnormal behaviors occur on a continuum and that the factors of impairment and distress most often signify abnormality (Hansell & Damour, 2008).
Sexual Pain Disorders
“Most cases of painful intercourse…are caused by physical factors such as genital infections or scarring, lack of lubrication, medication side effects, or…female circumcision” (Hansell & Damour, 2008, p. 378). Sexual pain disorders are marked by distress or interpersonal difficulty as a result of pain during sex (BehaveNet, 1997-2010, n.p.). The cognitive factors that perpetuate sexual pain disorders are the product of, “…occasional attempts[s] at intercourse resulting in pain and/or penetration failure [that] reinforce[s] fear and anxiety and maintain[s] the negative feedback cycle” (Davis & Reissing, 2007, p.251). In addition, partners can contribute to sexual pain disorders through a contingent response, subsequently adding to the pain experience of the sufferer. Overall, sexual pain disorders can be explained most of the time through physical factors, but cognitive factors encourage the continuation of the disorder.
Sexual Disorders (Paraphilias)
Paraphilias entail aberrant sexual preferences and disordered sexual relationships; in contrast to sexual dysfunctions, which include only persistent sexual difficulties (Hansell & Damour, 2008). Sexual Disorders fall into these Axis I categories: exhibitionism, fetishism, pedophilia, sexual masochism, sexual sadism, transvestic fetishism, and voyeurism. Many of these types of sexual psychopathology are illegal in the United States, as a result most therapy for paraphilias are post-prosecution.
Exhibitionism
The behavior of exhibitionism involves”…sexually arousing fantasies, sexual urges, or behaviors involving the exposure of one’s genitals to an unsuspecting stranger…over a period of at least 6 months” (BehaveNet, 1997-2010, n.p.). A biological cause of exhibitionism can be seen when an elderly person, as a result of dementia, exposes themselves as an expression of disinhibition. It is important to keep in mind that a diagnosis of exhibitionism includes, “…sexual urges or fantasies [that] cause marked distress or interpersonal difficulty” (BehaveNet, 1997-2010, n.p.). Likewise, a deficiency of the cognitive skills necessary to relate with other people in a sexual manner can be the precipitating factor for exhibitionism (Hansell & Damour, 2008). Altogether, the cause is not always necessary to the diagnosis of exhibitionism, as much as the effect the behavior has on the patient and their victims.
Personality Disorders
The different types of personality disorders include: paranoid personality disorder, schizoid personality disorder, schizotypal personality disorder, borderline personality disorder, histrionic personality disorder, narcissistic personality disorder, avoidant personality disorder, dependent personality disorder, and obsessive-compulsive personality disorder. As mentioned in the introductory paragraph, Axis II disorders are more pervasive and less able to be subjectively distinguished. However, personality disorders still include the elements of distress and impairment as guidelines for the diagnosis of dysfunction.
Schizoid Personality Disorder
The DSM-IV-TR stresses that a diagnosis of schizoid personality disorder (SPD) requires, “A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings” (BehaveNet, 1997-2010, n.p.). On the other hand, “The PDM [Psychodynamic Diagnostic Manual] stresses that the patient with SPD tends to be highly sensitive and shy…fearing closeness but simultaneously longing for closeness” (Hesse & Thylstrup, 2009, p. 149). There is clinical verification that some infants are born highly sensitive, which is linked with the onset of SPD (Hansell & Damour, 2008, p. 418). As well, SPD patients suffer from, “…maladaptive beliefs and expectancies, fixed thought patterns, and self-defeating and self-perpetuating behavioral strategies” (Hansell & Damour, 2008, p. 417) and “almost always [choose] solitary activities” (BehaveNet, 1997-2010, n.p.). It is this odd combination of incongruities: fearing closeness but simultaneously longing for closeness and maladaptive beliefs/expectancies and solitary activities; that best characterizes SPD.
Conclusion
In conclusion, even though impairment and distress are the primary diagnostic criteria for the verdict of abnormal disorders in both Axis I and Axis II disorders, the two categories can still be distinguished through the pervasiveness and subjective estimation of the personality disorder or symptom disorder. Furthermore, the Axis I categories of bulimia nervosa, alcohol abuse, sexual pain disorder, exhibitionism are all rooted in biological or genetic predispositions that find their expression through sociocultural, affective, and behavioral triggers. The obvious amendment to this rule would be exhibitionism that is not caused by dementia in elderly people. Even the Axis II diagnosis of SPD has been found to be built upon predisposed temperament as a forerunner for shyness and sensitivity, which can eventually lead to a restricted range of emotions in interpersonal settings. It would appear that the one enduring feature of all these disorders is that inclination acts upon behavioral, cognitive, and affective variables to bring about psychological dysfunction.
References
*Chapman, K., Meyer, R.G., Weaver, C.M. (2009). Case studies in abnormal psychology. New York, NY: Allyn & Bacon.
*Davis, H.J., Reissing, E.D. (2007). Relationship adjustment and dyadic interaction in couples with sexual pain disorders: A critical review of the literature. Sexual & Relationship Therapy, 22(2), 245-254. Retrieved March 2, 2010, from Academic Search Complete.
*Fairburn, C.G., Harrison, P.J. (2003). Eating disorders. Lancet, 361(9355), 407-416. Retrieved March 2, 2010, from Medline database.
Hansell, J. & Damour, L. (2008). Abnormal psychology (2nd ed.). Hoboken, NJ: Wiley & Sons.
Hesse, M., Thylstrup, B. (2009). “I am not complaining”—ambivalence construct in schizoid personality disorder. American Journal of Psychotherapy, 63(2), 147-167. Retrieved March 2, 2010, from Medline database.