Sexual Disorders

Understanding Sexual Dysfunction

Sex has become a topic discussed with serious intent. While situations and cultures vary, contention surrounding sex has been voiced openly by all sides. Women and men are embracing their sexual identity and preferences with a renewed vigor. The dark side of sex has also been exposed, with the emergence of social movements representing communities who have been victims of sexual assault and unwanted sexual advances. Sex, in general, has become a constant conversation however, there are hardly any discussions concerning people who for various reasons, have trouble or difficulty with sex. Conversations involving sexual dysfunction often target men struggling with impotence, plights commonly turned into jokes driven by stigma and sensationalism. Ignorance hinders people from addressing topics that are important. Furthermore, a large population is excluded from the conversation frequently due to embarrassment.

Sexual dysfunction is referred to as “a problem occurring during any phase of the sexual response cycle that prevents the individual or couple from experiencing satisfaction from the sexual activity,” (Cleveland Clinic, n.d., para. 1). The sexual response cycle has four stages: excitement, plateau, orgasm, and resolution (Cleveland Clinic, n.d.).  Excitement involves elevated heart rate, increased genital blood flow and secretion of a lubricating substance (MedicineNet, n.d.). Excitement is different for every person and can range from minutes to hours (MedicineNet, n.d.). Plateau suggests intensification of excitement stage characteristics, lasting seconds to minutes (SexInfo, n.d.). Orgasm, the shortest stage, usually lasts seconds (SexInfo, n.d.). Orgasm involves reproductive organ contractions and ejaculation of semen in men. Resolution, the final stage is commonly associated with fatigue and intimacy (SexInfo, n.d.). Resolution in men includes a refractory period preventing subsequent arousal lasting seconds to days increasing with age (SexInfo, n.d.).

Sexual dysfunction can be present at any age displaying a negative correlated with health, with people over 40 more likely to experience dysfunction (Cleveland Clinic, n.d.). Sexual dysfunction consists of four diagnostic categories: desire disorders, arousal disorders, orgasm disorders, and pain disorders (Cleveland Clinic, n.d.). Desire disorders deal with lack of desire or interest in sex. Arousal disorders imply inability to become excited or physically aroused during sexual activity. Orgasm disorders involve inability to climax or delay orgasm, whereas pain disorders suggest pain during intercourse.

Causes of sexual dysfunction vary. Physical causes include diabetes, hormonal imbalance, drug side effects and chronic disease (Cleveland Clinic, n.d.). Psychological causes include trauma, anxiety, depression, body image concerns and relationship problems (Cleveland Clinic, n.d.). Mood disorders, psychotic disorders, and anxiety are often comorbid with sexual dysfunction (Ciocca, Ochoa, & Jannini, 2018). Research suggests sexual dysfunction is common but insufficiently recorded (Ciocca et al., 2018), with) “43% of woman and 31% of men report some degree of sexual difficulty (Cleveland Clinic, n.d., para. 2). Mental health and sexual dysfunction are negatively correlated with higher rates of dysfunction exhibited in people with mental illness (Ciocca et al., 2018). Men experiencing psychological stress display higher prevalence of sexual dysfunction (Gürtler, Brunner, Dürsteler-MacFarland, & Weisbeck, 2019).

“Despite growing research investigating sexual desire disorders, little is known or understood about the impact on individuals, their partners, and relationship functioning” (Frost, & Donovan, 2019, para. 1). Sexual dysfunction may affect relationships and confidence but it’s important to acknowledge it’s common and often natural (SexInfo, n.d.). Sexual dysfunction can be managed by medication, psychoeducation, mechanical aids, behavioral treatments, psychotherapy and sex therapy (Cleveland Clinic, n.d.). Mindfully discussing sexual dysfunction will aid in others feeling more comfortable and inclined to seek treatment, no one should be judged or ridiculed for something they cannot control.


Cleveland Clinic. (n.d.). Sexual Dysfunction. Retrieved from

MedicineNet. (n.d.). Sexual Response Cycle (Phases of Sexual Response). Retrieved from

SexInfo. (n.d.). The Sexual Response Cycle. Retrieved from

Jannini, E. A., & Siracusano, A. (2018). Epidemiology of sexual dysfunctions in persons suffering from psychiatric disorders. In Sexual dysfunctions in mentally ill patients (pp. 41-51). Cham, Switzerland: Springer.

Gürtler, M. A., Brunner, P., Dürsteler-MacFarland, K. M., & Weisbeck, G. A. (2019). Sexual dysfunction in primary health care [Abstract]. Praxis, 108(1), 23-30. doi:10.1024/1661-8157/a003172

Frost, R., & Donovan, C. (2019). A qualitative exploration of the distress experienced by long-term heterosexual couples when women have low sexual desire [Abstract]. Sexual and Relationship Therapy, 1-24. doi:10.1080/14681994.2018.1549360

Cleveland Clinic. (n.d.). Sexual Dysfunction: Management and Treatment. Retrieved from

Bipolar Disorder

Use and Abuse: Overlap in Bipolar and Substance Use Disorder

While there is a high rate of comorbidity among mental illnesses in general, there is perhaps no other combination of disorders more dangerous to the individual and those around them than mental illness paired with substance use disorder (SUD). Together, these two illnesses can work in powerful combination, exacerbating the vulnerability and instability already experienced by individuals with poor mental health.  Those with bipolar disorder are particularly at high risk for a comorbid diagnosis of SUD. These two disorders occur together so often that some even believe it should be common practice to screen bipolar individuals (specifically young adults) for drug use as soon as a diagnosis is made.

Why is it, then, that these two illnesses, seemingly distinct and unrelated to each other, are so often linked together?  A recent article on the common prevalence of comorbidity between bipolar and substance use proposes that this phenomenon is due to one or a combination of three different reasons: genetic factors underlying aspects of both diseases occurring in the brain, overlapping neurobiological pathways in the brain, or one disorder fostering another.

It is commonly known that many mental illnesses are comorbid — a single diagnosis of any mental illness puts one at much higher risk for encountering another at some point in life. At any given point during a 12-month period, 50% of adults clinically diagnosed with a psychiatric disorder also had at least one other accompanying mental disorder. Anxiety and depression, for example, are two mental illnesses that have extremely high rates of comorbidity (upwards of 60%).  Similar to the current understanding of how many other mental illnesses develop in conjunction with one another, one theory for understanding the particularly high comorbidity of bipolar and SUD is that they have similar genetic causes. Biological factors that lead to genetic vulnerability toward one disorder also predisposes the person to greater vulnerability toward another disorder.

Along this same trend, some scientists point toward overlapping neurobiological pathways in the brain as the root cause for high rates of SUD and bipolar occurring in conjunction with one another. As both mental illness and substance abuse progress, both disorders display a similar pattern. In bipolar, manic and depressive episodes become more frequent with shorter symptom-free periods as the untreated disease progresses; in substance abuse, addiction becomes more all-consuming as time goes on, causing the drug user to crave the high of the drug more frequently in the case of longer duration of drug use. The theory of overlapping pathways, then, points toward greater “sensitization” from an untreated disorder in the brain as a sort of “kindling,” or fuel, for the other disorder to track down the same destructive pathway when left untreated.

Although this theory explains some of the science of what causes co-occurring disorders, it does not capture the whole picture. Current psychological research describes the development of mental illness in terms of genetic and environmental influences. The environmental contributions to bipolar disorder and SUD can be best understood if SUD is conceptualized as resulting from the bipolar disorder. In an effort to deal with the intense ups and downs and extreme mood swings, people with untreated bipolar will sometimes resort to “self-medicating” with addictive substances such as alcohol, marijuana, or other drugs. Some people rely on these substances so heavily that they can even trigger manic or depressive episodes due to their use. Cocaine, for example, has been shown to potentially send people with mood disorders into a manic or hypomanic episode because of its effect on the body and complex neurotransmitter chemistry in the brain. The person, however, may view the drug as a way to remedy intense depressive episodes experienced from a bipolar “low,” unaware that the resulting hypomanic or manic episode can be just as harmful.

Due to these complex interaction effects from both disorders, it is generally recommended that people receive treatment for bipolar and SUD together and not separately, as was common practice up until recently. The very fact that these two illnesses are linked together so frequently reiterates the importance of understanding their combined effects.  Even further, though, understanding the comorbidity and underlying causes between bipolar and SUD also empowers us with the even greater understanding that each individual and their needs are extremely unique and amazingly varied, making us more compassionate and empathetic practitioners, students, friends, and partners.


Mcgregor, S. Substance Abuse and Bipolar Disorder. Retrieved on February 18, 2018, from

Quello, S. B., Brady, K. T., Sonne, S. C., Mood Disorders and Substance Use Disorder: A Complex Comorbidity. Retrieved on February 18, 2018, from

Cameron, O. G. Understanding Comorbid Depression and Anxiety. Retrieved on February 18, 2018, from

Dual Diagnosis. Bipolar Disorder and Addiction. Retrieved on February 18, 2018, from


Eating Disorders

Diabulimia, Anything but Sweet

What would you sacrifice for a perfect body? A cheesy slice of pizza? Or perhaps a vanilla yogurt with generous quantities of Oreo and rainbow sprinkles? 29-year-old Becky, from Aberdeen, England sacrificed her legs, in her arduous battle with diabulimia (“Diabulimia: The World’s Most Dangerous Eating Disorder,” 2017).

Diabulimia is an eating disorder that affects individuals with Type 1 diabetes, which is a form of diabetes that manifests in an individual’s childhood and requires the life-long intake of insulin. While some individuals with diabulimia may show signs of bulimia (binge eating and purging), diabulimia is distinctly characterized by the affected individual’s refusal to take insulin. Symptoms often include: high blood sugar levels, dehydration, frequent urination, and unexplained weight loss (“Diabulimia,” n.d.).

What makes diabulimia so dangerous is the sensitivity of individuals with Type 1 diabetes to insulin dosage. According to Professor Khalida Ismail, the lead psychiatrist for diabetes at King’s Health Partners—a London-based academic health science center—when individuals with Type 1 diabetes decrease or stop their insulin intake, their blood sugar levels increase, making them vulnerable to damages to their eyes, kidney, and nerve endings, as well as heart failure, loss of limbs, and in severe cases, death (2017). Additional consequences include severe dehydration and coma (Karidis, 2015).

The BBC Three documentary, Diabulimia: The World’s Most Dangerous Eating Disorder follows the stories of women with diabulimia, including Becky and 21-year old Nabeelah, from Leicester, England. Becky’s struggles with diabulimia have resulted in the disintegration of her leg bones, requiring her to walk with crutches, and led to her 16 month-stay as an inpatient at an eating disorder unit. Similarly, the disorder has caused Nabeelah multiple health complications, including the worsening of her eyesight; nerve pains in her feet, hands, and fingers; migraines; and kidney pains.

Despite the perils of diabulimia, sufferers continue to skip their insulin, because as with any other eating disorder, the fear of weight gain outweighs the medical consequences. In the words of Professor Ismail, “People with Type 1 diabetes have a fear that insulin causes weight gain…this fear is so strong that it leads them to omit the amount of insulin they take, in order to have weight loss,” (2017).

Nabeelah’s hands tremble when her EpiPen is in close proximity and she says, “Me being completely recovered would be me being able to inject on a daily basis without the big cloud of depression or the big cloud of weight gain standing over my head,” (2017).

Like many other comorbid disorders, treating diabulimia is challenging, with relapse rates at a whopping 53% (2015). A major challenge to treatment plans is the extreme consequences of skipping insulin, as Professor Ismail states, “If the person with Type 1 diabetes does not take insulin, they will die very quickly.”

The mental and physiological characteristics of diabulimia also contribute to the difficulties in treatment. “With diabetes, there is a focus on numbers: What is your blood sugar? …How many carbohydrates have you consumed?..with eating disorders, people need to learn to let go of the obsession with numbers. So there is a conflict in treatment approaches,” says Marcia Meier, a diabetes nurse educator at the Melrose Center in Minneapolis (2015).

Treatment often includes cognitive and behavioral therapy, as well as group therapy, counseling, therapeutical activities (“Best Diabulimia Treatment Center & Rehab,” n.d.), and in severe cases, surveillance by professionals in treatment facilities (2017).

Approximately 40% of women between 15 and 30 with Type 1 diabetes suffer with either Diabulimia or another form of eating disorder. Additionally, it is estimated that 60% of women with Type 1 diabetes will have encountered an eating disorder by 25 years of age (Colton et al., 2015). However, diabulimia has yet to be recognized on the Diagnostic and Statistical Manual of Mental Disorders (DSM), and awareness is still low.

In England alone, the number of individuals with diabulimia is estimated to be 400,000 (Ollerenshaw, 2016). Despite the sheer magnitude and severity of this disorder, awareness on it runs low. This is further exacerbated by the stigma surrounding mental health and the ever-increasing standards on body image. As this is a childhood disorder, perhaps a possible solution can be incorporating lessons on body image and self-love into elementary/middle school curriculums.


Best Diabulimia Treatment Center & Rehab. (n.d.). Retrieved October 7, 2017, from

Colton, Olmsted, et al. “Eating Disorders in Girls and Women With Type 1 Diabetes: A Longitudinal Study of Prevalence, Onset, Remission, and Recurrence.” Diabetes Care, vol 38, no. 7, Jul. 2015, pp. 1212-1217.

Diabulimia. (n.d.). National Eating Disorders Association. Retrieved October 1, 2017, from

“Diabulimia: The World’s Most Dangerous Eating Disorder.” Youtube. Uploaded by BBC Three, 24 September, 2017,

Karidis, A. (2015, October 28). When Diabetes Leads to an Eating Disorder. Retrieved October 7, 2017, from

Ollerenshaw, T. (2016, September 8). Diabulimia: Diabetes and eating disorder service launching in UK. Retrieved October 7, 2017, from


The DSM and Depression: Flawed Labeling Leads to Misdiagnoses and Increased Stigma

The DSM has long been hailed as psychiatry’s “bible”; clinicians across the country have used the Diagnostic and Statistical Manual as their guide to identifying mental illness. However, in recent years, the reliability of the DSM has been called into question by psychiatrists and doctors alike. For depression, specifically, the DSM falls short in field tests, with test-retest reliability being extremely questionable. Depression screening and treatment is currently based on an extremely flawed set of standards, and this is providing a basis for misdiagnoses and false positives (Nemeroff et. al., 2013). Furthermore, although the compartmentalization of mental illnesses into specific categories may be necessary for treatment, strict categorization is contributing to an increased number of diagnoses per patient, which is creating labels and causing negative stigma (Szalavitz, 2013).

The DSM V lists nine criterion for depression, and goes on to put these symptoms under one of two categories: 1) depressed mood and 2) loss of interest or pleasure. It states that five (5) of these nine criterion must be met in order for a patient to have depression. The manual goes on to list 4 more categories that specify conditions that must be met in order to make sure the patient has depression (APA, 2013). There are two main issues with this approach. Firstly, the symptoms proposed by the DSM vary widely, but the treatment options for varying degrees of depression are very similar. This can be highly detrimental to the patient because the treatment is not specialized enough (Szalavitz, 2013).  Additionally, a lot of the symptoms for depression can be indicators for symptoms of other mental illnesses such as anxiety. This leads to false positives and diagnostic inflation, which is when a patient is over diagnosed with a multitude of mental illnesses, and perceived comorbidity, which is when two chronic illnesses are present simultaneously.

For a lot of patients, diagnostic inflation and false positives can lead to feelings of hopelessness and despair, as in the case of Maia Szalavitz. In her 2013 article for TIME magazine, Szalavitz states that she has been diagnosed with no fewer than six mental illnesses over the course of her lifetime. Szalavitz goes on to say:

My multiple diagnoses are the rule, not the exception, and one criticism of the DSM structure is that if you qualify for one diagnosis, you typically also qualify for others. Which one should be treated? Or do they all require interventions? And what if the therapies conflict with each other? You see the problem” (Szalavitz, 2013).

Although diagnostic labels are sometimes needed for treatment, over diagnosing patients can lead to risky medication combinations and incorrect labeling (Szalavitz, 2013). An increased number of diagnoses can understandably lead to more despair in the patient without providing a concrete solution to the patient’s problems (Batstra et. al., 2012).

Diagnoses are not at all an exact science, and the DSM tries to treat them as such. Overall, not enough is known about mental illnesses such as depression to narrow symptoms down to a precise list of categories. Labels for mental illnesses are far from perfect, and over labeling adds to stigma and only increases patient distress. To some extent, we do need labels, but mental health professionals should realize that these labels are not set in stone.


Special thanks to Dr. Nicholas Eaton for providing information for this article

Batstra, L., & Frances, A. (2012). Holding the Line against Diagnostic Inflation in Psychiatry. Psychotherapy and Psychosomatics, 81(1), 5-10. doi:10.1159/000331565

Hunt, C., Slade, T., & Andrews, G. (2004). Generalized Anxiety Disorder and Major Depressive Disorder comorbidity in the National Survey of Mental Health and Well-Being. Depression and Anxiety, 20(1), 23-31. doi:10.1002/da.20019

Nemeroff, C. B., Weinberger, D., Rutter, M., MacMillan, H. L., Bryant, R. A., Wessely, S., … Lysaker, P. (2013). DSM-5: a collection of psychiatrist views on the changes, controversies, and future directions. BMC Medicine, 11(1). doi:10.1186/1741-7015-11-202

Pearson Clinical. (2013). Major Depressive Disorder. Retrieved from

TIME. (2013, May 17). Viewpoint: My Case Shows What’s Right — and Wrong — With Psychiatric Diagnoses. TIME Magazine.