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Paraphilic Disorders

Paraphilic disorders are characterized by intense sexual interests that are manifested as unusual behaviors or fantasies other than normal genital stimulation used to reach sexual arousal. They are directed toward persons, animals Animals Unicellular or multicellular, heterotrophic organisms, that have sensation and the power of voluntary movement. Under the older five kingdom paradigm, animalia was one of the kingdoms. Under the modern three domain model, animalia represents one of the many groups in the domain eukaryota. Cell Types: Eukaryotic versus Prokaryotic, or objects and cause significant clinical distress or functional impairment for the patient. Treatment involves psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy, sexual education, and medication. However, these disorders are very difficult to treat due to social stigma and the legal ramifications associated with the diagnosis.

Last updated: 21 May, 2021

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Overview

Definition

Paraphilic disorders are defined as intense sexual interests or urges lasting more than 6 months that cause significant clinical distress or functional impairment for the patient or harm to others. The interest may be aimed at situations, animals Animals Unicellular or multicellular, heterotrophic organisms, that have sensation and the power of voluntary movement. Under the older five kingdom paradigm, animalia was one of the kingdoms. Under the modern three domain model, animalia represents one of the many groups in the domain eukaryota. Cell Types: Eukaryotic versus Prokaryotic, or objects considered atypical.

Epidemiology

  • Only a small percentage of people suffer from paraphilic disorders. 
  • Most paraphilias occur almost exclusively in men, but sadism, masochism, and pedophilia may also occur in women. 
  • Most common ages: 15–25
  • Voyeuristic and pedophilic disorders are the most common paraphilic disorders.
  • Commonly coexist with personality disorders Personality Disorders A major deviation from normal patterns of behavior. Cluster A Personality Disorders (cluster A, cluster B, cluster C), substance abuse, anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder disorders, OCD OCD Obsessive-compulsive disorder (OCD) is a condition characterized by obsessions (recurring and intrusive thoughts, urges, or images) and/or compulsions (repetitive actions the person is compelled to perform) that are time-consuming and associated with functional impairment. Obsessive-compulsive Disorder (OCD), or affective disorders.

Classification

Table: Classification of paraphilic disorders
Courtship disorders Frotteuristic disorder Sexual arousal by touching or rubbing against a nonconsenting person (usually in crowded areas)
Voyeuristic disorder
  • Sexual arousal from observing a person undress, in the nude, or engaging in sexual acts (often with binoculars/camera)
  • Patient must be at least 18 years of age.
Exhibitionistic disorder Sexual arousal from exposure Exposure ABCDE Assessment of one’s genitals in public to unsuspecting person(s)
Algolagnic disorders: Sexual arousal is secondary to pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways and suffering. Sexual masochism disorder Sexual arousal from the act of being humiliated, beaten, bound, or made to suffer
Sexual sadism disorder Sexual arousal from the infliction of physical or psychological suffering on another person
Anomalous target preferences Fetishistic disorder
  • Sexual arousal related to non-living objects (e.g., shoes or pantyhose) or nongenital body parts
  • Objects must be something other than sex Sex The totality of characteristics of reproductive structure, functions, phenotype, and genotype, differentiating the male from the female organism. Gender Dysphoria toys or sexual clothing.
Pedophilic disorder
  • Fantasies involving sexual acts with prepubertal children (13 years of age or younger)
  • DSM-5 specifies that the patient must be at least 16 years old and at least 5 years older than the child.
Transvestic disorder
  • Sexual arousal from cross-dressing
  • Not always associated with homosexuality Homosexuality The sexual attraction or relationship between members of the same sex. Sexual Physiology
Other specified paraphilic disorders Zoophilia Sexual arousal from or fixation on non-human animals Animals Unicellular or multicellular, heterotrophic organisms, that have sensation and the power of voluntary movement. Under the older five kingdom paradigm, animalia was one of the kingdoms. Under the modern three domain model, animalia represents one of the many groups in the domain eukaryota. Cell Types: Eukaryotic versus Prokaryotic
Coprophilia Sexual arousal from sexual acts involving feces or defecation Defecation The normal process of elimination of fecal material from the rectum. Gastrointestinal Motility
Urophilia Sexual arousal from sexual acts involving urine Urine Liquid by-product of excretion produced in the kidneys, temporarily stored in the bladder until discharge through the urethra. Bowen Disease and Erythroplasia of Queyrat or micturition
Necrophilia Sexual arousal from cadavers
Hypoxyphilia
  • Sexual arousal from reduction of oxygen flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure ( hypoxia Hypoxia Sub-optimal oxygen levels in the ambient air of living organisms. Ischemic Cell Damage) to the brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification
  • Strangulation Strangulation Inguinal Canal: Anatomy and Hernias is usually used as a means to enhance orgasmic pleasure.

Diagnosis

Diagnosis is clinical and requires thorough examination of both psychiatric and sexual history.

Examiners must:

  • Use open-ended questions. 
  • Avoid stigmatizing attitudes and judgments.

Laboratory testing may be ordered to establish baseline and to screen for other sexual dysfunction Sexual dysfunction Physiological disturbances in normal sexual performance in either the male or the female. Sexual Physiology disorders:

  • Testosterone Testosterone A potent androgenic steroid and major product secreted by the leydig cells of the testis. Its production is stimulated by luteinizing hormone from the pituitary gland. In turn, testosterone exerts feedback control of the pituitary LH and FSH secretion. Depending on the tissues, testosterone can be further converted to dihydrotestosterone or estradiol. Androgens and Antiandrogens 
  • Estradiol Estradiol The 17-beta-isomer of estradiol, an aromatized C18 steroid with hydroxyl group at 3-beta- and 17-beta-position. Estradiol-17-beta is the most potent form of mammalian estrogenic steroids. Noncontraceptive Estrogen and Progestins
  • Progesterone Progesterone The major progestational steroid that is secreted primarily by the corpus luteum and the placenta. Progesterone acts on the uterus, the mammary glands and the brain. It is required in embryo implantation; pregnancy maintenance, and the development of mammary tissue for milk production. Progesterone, converted from pregnenolone, also serves as an intermediate in the biosynthesis of gonadal steroid hormones and adrenal corticosteroids. Gonadal Hormones
  • Follicle-stimulating hormone
  • Luteinizing hormone

Management

Paraphilic disorders are difficult to treat. The majority of patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship receiving treatment are legally required to do so as opposed to seeking treatment voluntarily. Physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship must monitor for signs of abuse and may need to report to authorities if there are signs of child endangerment.

Psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy

  • CBT: aims to disrupt abnormally learned patterns and modify patient behavior
  • Social skills training/programs: individual or group therapy Group therapy A form of therapy in which two or more patients participate under the guidance of one or more psychotherapists for the purpose of treating emotional disturbances, social maladjustments, and psychotic states. Psychotherapy that provides sexual and social education

Pharmacotherapy

  • Beneficial if a patient’s condition is associated with other psychiatric illnesses
  • Goal is to decrease sex Sex The totality of characteristics of reproductive structure, functions, phenotype, and genotype, differentiating the male from the female organism. Gender Dysphoria drive but approach is controversial due to adverse effects. 
  • Antiandrogens Antiandrogens Antiandrogenic drugs decrease the effect of androgens. Classes include androgen receptor blockers, 5-alpha-reductase inhibitors, and androgen synthesis inhibitors. Both men and women may use antiandrogens, which treat advanced prostate cancer, benign prostatic hyperplasia (BPH), alopecia, and hirsutism. Androgens and Antiandrogens
  • Long-acting gonadotropin-releasing hormone Gonadotropin-releasing hormone A decapeptide that stimulates the synthesis and secretion of both pituitary gonadotropins, luteinizing hormone and follicle stimulating hormone. Gnrh is produced by neurons in the septum preoptic area of the hypothalamus and released into the pituitary portal blood, leading to stimulation of gonadotrophs in the anterior pituitary gland. Puberty antagonists
  • Selective serotonin Serotonin A biochemical messenger and regulator, synthesized from the essential amino acid l-tryptophan. In humans it is found primarily in the central nervous system, gastrointestinal tract, and blood platelets. Serotonin mediates several important physiological functions including neurotransmission, gastrointestinal motility, hemostasis, and cardiovascular integrity. Receptors and Neurotransmitters of the CNS reuptake inhibitors
  • Naltrexone Naltrexone Derivative of noroxymorphone that is the n-cyclopropylmethyl congener of naloxone. It is a narcotic antagonist that is effective orally, longer lasting and more potent than naloxone, and has been proposed for the treatment of heroin addiction. Opioid Analgesics

External control

  • Imprisonment in case of sexual crimes 
  • Informing supervisor, peers, or other family members to eliminate opportunities for those with paraphilia to act on their urges

Differential Diagnosis

  • Personality disorders Personality Disorders A major deviation from normal patterns of behavior. Cluster A Personality Disorders: a cluster of mental diseases that involve semi-permanent patterns of thoughts and behavior that can be harmful and obstinate. These individuals have difficulties handling everyday stresses and issues, and their behavior can lead to serious social and laboral issues. Paraphilic disorders may occur in patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with personality disorder. 
  • Bipolar Bipolar Nervous System: Histology disorder: a psychiatric illness characterized by periods of depression and  mania Mania A state of elevated excitement with over-activity sometimes accompanied with psychotic symptoms (e.g., psychomotor agitation, inflated self esteem and flight of ideas). It is often associated with mental disorders (e.g., cyclothymic disorder; and bipolar diseases). Bipolar Disorder/ hypomania Hypomania Bipolar Disorder. Symptoms include impulsivity Impulsivity Attention Deficit Hyperactivity Disorder, hypersexuality, and seeking pleasure regardless of the consequences. While there are sexual interests and behaviors similar to paraphilias, those with bipolar Bipolar Nervous System: Histology disorder are characterized by severe mood symptoms. 
  • OCD OCD Obsessive-compulsive disorder (OCD) is a condition characterized by obsessions (recurring and intrusive thoughts, urges, or images) and/or compulsions (repetitive actions the person is compelled to perform) that are time-consuming and associated with functional impairment. Obsessive-compulsive Disorder (OCD): a condition characterized by recurring intrusive thoughts, feelings, or sensations (known as obsessions Obsessions Recurrent thoughts, images, or urges that are intrusive and recognized as unwanted, causing significant anxiety and distress . Obsessive-compulsive Disorder (OCD)) that are time consuming and cause severe distress; relieved partially by the performance of repetitive actions (known as compulsions Compulsions Repetitive behaviors or mental acts that the individual is driven to perform in relation to an obsession. Obsessive-compulsive Disorder (OCD)). Those with OCD OCD Obsessive-compulsive disorder (OCD) is a condition characterized by obsessions (recurring and intrusive thoughts, urges, or images) and/or compulsions (repetitive actions the person is compelled to perform) that are time-consuming and associated with functional impairment. Obsessive-compulsive Disorder (OCD) may report possible attraction to children; however, history taking will reveal that those without pedophilia do not have thoughts of children during sexual arousal.

References

  1. First Aid for the Psychiatry Clerkship, 4th edition, chapter 16, Sexual dysfunctions and paraphilic disorders, page 176.
  2. Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Chapter 17, Human sexuality and sexual dysfunctions, pages 593-599. Philadelphia, PA: Lippincott Williams and Wilkins.
  3. Naghedechi, L. (2018). Paraphilic disorders. DeckerMed Medicine. Retrieved April 23, 2021. doi:10.2310/im.13034

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