Alcool et inaptitude

Abstract

Le DSM-5 s’écarte sur de nombreux points des éditions précédentes, apportant plusieurs changements concernant les paraphilies. Ces changements ont été principalement motivés par des considérations légales. Plusieurs modifications ont été apportées au texte descriptif de ces troubles, au détriment des critères diagnostiques qui étaient soumis à beaucoup moins de révision. L’Association Américaine de Psychiatrie a opté pour la conservation intégrale des huit catégories des troubles paraphiliques, en association avec deux catégories résiduelles : « autre trouble paraphilique spécifié » et « trouble paraphilique non spécifié ». Les différents changements ayant concerné les critères des troubles paraphiliques exigent principalement la considération des faux positifs potentiels, ayant comme risque notamment le fait d’assigner plus facilement des diagnostics psychiatriques aux prédateurs sexuellement violents. La classification de certains comportements sexuels comme pathologiques, même en l’absence de détresse, révèle une conception morale sous-jacente qui continue à sanctionner des comportements socialement répréhensibles. De ce fait, certains auteurs remettent en question la fiabilité diagnostique des paraphilies, et vont jusqu’à suggérer des changements révolutionnaires, dépathologisant les paraphilies et les supprimant des systèmes de classification des troubles mentaux.The 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) aimed to improve the reliability of psychiatric diagnoses, to address problems identified in DSM-IV, and to improve its clinical and forensic utility. Some of the changes in the diagnostic criteria for the paraphilic disorders in the DSM-5 were guided by forensic concerns, since these are the ones of most interest to forensic psychiatrists. The aim of this paper is to describe and comment the changes made from DSM-IV to DSM-5 concerning paraphilic disorders, and to discuss their legal implications.PubMed and Medline search, Scopus, journal and textbook articles have been accessed for a detailed literature review on DSM-5 changes related to paraphilic disorders. We conducted the search using the following keywords: Paraphilia; DSM-5; Diagnosis; Diagnostic criteria.Several minor but important changes have been made to the paraphilic disorders diagnostic criteria in DSM-5. DSM-5 redefines the term “paraphilia” which now refers to non pathological, atypical sexual interests (Criterion A); and introduced the term “paraphilic disorder” which is reserved for individuals who meet both Criterion A and Criterion B (individuals who have clinically significant distress or impairment). The DSM-IV category of “paraphilia not otherwise specified” has been replaced with two disorders in DSM-5, “other specified paraphilic disorder” and “unspecified paraphilic disorder”. Both of these categories are considered to be residual. The decision to use one or other of the two disorders depends on whether the clinician wants to specify explicitly the type of atypical paraphilic focus. These residual categories don’t have the same degree of utility as the specific named categories, and can be misused in forensic contexts. In addition, for all of the paraphilic disorders except pedophilic disorder, there are two new course specifiers, “in full remission” and “in a controlled environment”. The decision to provide a specific duration threshold at which the individual must not have acted on his paraphilic urges nor have experienced any distress or impairment, was mainly motivated by forensic issues. Otherwise, three conditions were considered for inclusion in DSM-5: “hypersexual disorder”, “paraphilic coercive disorder”, and “pedophebophilic disorder”. Hypersexual disorder was defined as intense interest in normal sex that was causing problems. Paraphilic coercive disorder was defined as sexual arousal by coercive sex in men who do not meet the diagnostic criteria for sexual sadism. In pedophebophilic disorder, the range of pathologic sexual interest was extended to include adolescents. These proposed diagnosis have received considerable Criticism, and have been abandoned, largely due to a lack of empirical evidence.Changes proposed in the DSM treatment of paraphilic disorders are relatively modest and the core of the DSM-IV diagnostic criteria is retained. Many of the changes that occur in paraphilic disorders diagnostic criteria increase the risk of false-positive diagnoses by making it easier to assign a specific paraphilia to an individual, and must be considered with caution. The classification of certain sexual behaviors as pathological, even in the absence of distress, reveals an underlying moral design. As a result, some authors question the validity and reliability of paraphilic disorders, and suggest revolutionary changes, depathologizing paraphilias and removing them from systems of mental disorder classification.