Paraphilic Disorders Flashcards
why have the 8 disorders in the paraphilias section of the DSM been chosen to be listed specifically (even though it is not an exhaustive list of possible paraphilias)
- they are relatively common
- some of them entail actions for their satisfaction that, because of their noxiousness or potential harm to others, are classified as criminal offenses
what are the “courtship disorders”
voyeuristic
exhibitionistic
frotteuristic
*resemble distorted components of human courtship beahviour
what are the “algolagnic disorders”
sexual masochism disorder
sexual sadism disorder
*involve pain and suffering
what is the commonality among the courtship and algolagnic disorders
“anomalous activity preferences”
what is the other group of paraphilias in the DSM, other than the group reflecting anomalous activity preference
anomalous target preference
define paraphilia
any intense and persistent SEXUAL INTEREST OTHER THAN sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners
*there are also specific paraphilias that are generally better described as “preferential” sexual interests rather than intense sexual interests
define “paraphilic disorder”
a paraphilia that is currently causing DISTRESS or impairment to the person or a paraphilia whose satisfaction has entailed personal harm, or risk of harm, to others
what is criterion B for all the paraphilic disorders
the criterion that requires there be distress/impairment/harm to others (the negative consequences of the paraphilia)
what is the most widely applicable framework for assessing the strength of a paraphilia itself
comparing the paraphilic sexual fantasies/urges/behaviours to the persons normophilic sexual interests and behaviours
criterion A for voyeuristic disorder
over a period of at least SIX MONTHS, recurrent and intense sexual arousal from OBSERVING an UNSUSPECTING PERSON who is naked, in the process of disrobing, or engaging in sexual activity, as manifested by fantasies, urges or behaviours
criterion B for voyeuristic disorder
individual has ACTED ON these sexual urges with a NONCONSENTING person or the sexual urges or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
criterion C for voyeuristic disorder
the patient is at least 18
what are the two specifiers for voyeuristic disorder
in a controlled environment (i.e institutional or other settings where opportunity to engage in voyeuristic behaviour is limited)
in full remission (individual has not acted on the urges with a nonconsenting person, and there has been no distress or impairment, for at least FIVE YEARS while in an UNcontrolled environment)
what is considered “recurrent” spying on unsuspecting persons in the context of voyeuristic disorder
as a general rule: 3 or more victims on separate occasions
which are the most common of potentially law breaking behaviours
voyeuristic disorder
what is the highest possible prevalence of voyeuristic disorder in nonclinical samples
12% males, 4% females
(real prevalence of voyeuristic disorder unknown)
what are 3 possible risk factors for voyeuristic disorder
childhood sexual abuse
substance misuse
sexual preoccupation/hypersexuality
(causal relationship and specificity are unclear)
while gender is more represented amongst clinical samples of voyeuristic disorder
males
ddx voyeuristic disorder
conduct disorder
ASPD
SUDs
criterion A for exhibitionistic disorder
over a period of at least SIX MONTHS, recurrent and intense sexual arousal from the exposure of ones genitals to an unsuspecting person, as manifested by fantasies, urges or behaviours
criterion B for exhibitionistic disorder
individual has acted on these sexual urges with a NONconsenting person, or there is clinically significant distress/impairment
what are the specifiers available for exhibitionistic disorder
- sexually aroused by exposing genitals to pre-pubertal children
- sexually around by exposing genitals to physically mature individuals
- sexually aroused by exposing genitals to prepubertal children and to physically mature adults
- in a controlled environment
- in full remission
what is the highest possible prevalence for exhibitionistic disorder in the male population
2-4% (actual is unknown)
when do adult men often report that they first became aware of sexual interest in exposing their genitals
during adolescence–> at a somewhat later time than the typical development of normative sexual interest in women or men
is there a minimum age requirement or dx of exhibitionistic disorder
no
what factors might increase risk of sexual recidivism in exhibitionistic offenders
antisocial history
ASPD
alcohol misuse
pedophilic sexual preference
criterion A for frotteuristic disorder
6 months
recurring and intense sexual arousal from touching or rubbing against a nonconsenting person as manifested by fantasies, urges, behaviours
what % of those seen in outpatient settings for paraphilic disorders and hypersexuality meet criteria for frotteuristic disorder
about 10-14%
how often do frotteuristic acts happen in the general male population
up to 30%
what disorder can be hard to distinguish from frotteuristic disorder in younger ages
conduct disorder (but these behaviours would not have sexual motivation)
criterion A for sexual masochism disorder
6 months
recurrent and intense sexual arousal from the act of being HUMILIATED, BEATEN, BOUND or otherwise made to SUFFER
what is a specifier for sexual masochism disorder
with asphyxiophilia (practice of achieving sexual arousal related to restriction of breathing)
criterion A for sexual sadism disorder
6 months
recurrent and intense sexual arousal from the PHYSICAL or PSYCHOLOGICAL SUFFERING of another person
what is the % of people with sexual sadism disorder among civilly committed sexual offenders in the USA
10%
what is the % of people who have committed sexually motivated homicides with sexual sadism disorder
37-75%
what is the gender balance of people with sexual sadism in forensic samples
almost exclusively male
what effect does age have on the paraphilic disorders
reducing effect
criterion A for pedophilic disorder
6 months
recurrent, intense, sexually arousing fantasies, sexual urges or behaviours involving sexual activity with a prepubescent child or children (generally 13 or younger)
criterion B for pedophilic disorder
individual has acted on these sexual urges or the sexual urges or fantasies cause a marked distress or interpersonal difficulty
criterion C for pedophilic disorder
individual is at least 16 years old and at least 5 years older than the child or children in criterion A
*do not include an individual in late adolescence involved in an ongoing sexual relationship with a 12 or 13 year old
specifiers for pedophilic disorder
exclusive type (attracted only to children)
nonexclusive type
sexually attracted to males/females/both
limited to incest
what is the minimum age for diagnosis of pedophilic disorder
16 years old
is pedophilia lifelong condition
it appears so
but the disorder may fluctuate over time (given need for criteria B to be fulfilled)
what is a temperamental risk factor for pedophilic disorder
interactions between ANTISOCIALITY and pedophilia–> males with both are more likely to act out sexually with children
what is a physiological risk factor for pedophilic disorder
neurodevelopmental perpurbation in utero increases probability of development of pedophilic interest
what is the most researched psychophysiological measure of sexual interest used when hx suggests pedophilic disorder but patient denies sexual attraction to children
penile plethysmography
can also use “viewing time”
what is an important ddx for pedophilic disorder
OCD
*in this case, thoughts are ego dystonic and there is absence of thoughts about children during high states of sexual arousal
criterion A for fetishistic disorder
6b nonths
recurrent or intense sexual arousal from either the use of nonliving objects or a highly specific focus on nongenital body parts
criterion C for fetishistic disorder
fetish objects are not limited to articles of clothing used in cross dressing (as in transvestic disorder) or devices specifically designed for the purpose of tactile genital stimulation
criterion A for transvestic disorder
6 months
recurrent and intense sexual arousal from cross dressing
what are the specifiers for transvestic disorder
with fetishism (sexually aroused by fabrics, materials, garments)
with autogynephilia (sexually aroused by thoughts or images of self as female
how does the presence of fetishism affect the likelihood of gender dysphoria in men with transvestic disorder
decreases the likelihood of gender dysphoria
whereas the presence of autogynephilia increases risk of gender dysphoria
how does transvestic disorder differ from simple cross dressing
in transvestic disorder, there is sexual excitement associated with dressing as the other gender + emotionally distressed by this pattern
what pattern of behaviour may be a clue to the presence of distress in individuals with transvestic disorder
The pattern of behavior “PURGING AND ACQUISITION” often signifies the presence of distress in individuals with transvestic disorder.
During this behavioral pattern, an individual (usually a man) who has spent a great deal of money on women’s clothes and other apparel (e.g., shoes, wigs) discards the items (i.e., purges them) in an effort to overcome urges to cross-dress, and then begins acquiring a woman’s wardrobe all over again.
with which sexual orientation do most men with transvestic disorder identify
heterosexual
list the 5 types of psychiatric interventions that are used to treat persons with paraphilic disorder or paraphilic interests
- external control (i.e prison, telling supervisors etc)
- reduction of sexual drives
- treatment of comorbid conditions
- CBT
- dynamic psychotherapy/insight oriented therapy
what are pharmacological interventions aimed at reducing sexual drive in those with paraphilic disorder
medroxyprogesterone acetate (depo-provera)
–> may reduce drive to behave sexually by decreasing serum testosterone levels to subnormal concentrations
serotonergic agents (ie fluoxetine) have been used with limited success in some patients with paraphilic disorder
how is CBT used in the treatment of paraphilic disorder
to disrupt learned paraphilic patterns and modify behaviour to make it socially acceptable
social skills training, sex education, cognitive restructuring (confronting and destroying the rationalizations used to support victimization of others), development of victim empathy
imaginal desnsitization, relaxation technique and learning what triggers the paraphilic impulse so that such stimuli can be avoided are also taught
what is modified aversive behaviour rehearsal
perpetrators are videotaped acting out their paraphilia with a mannequin
then patient with paraphilic disorder is confronted by a therapist and a group of other offenders who ask questions about feelings, thoughts and motives associated with the act and repeatedly try and correct cognitive distortions and point out lack of victim empathy to the patient
