Paraphilic Disorders Research Articles

Alexithymia in Patients Attending a Sexual Disorders Clinic

We measured alexithymic traits with the Toronto Alexithymia Scale (TAS; Bagby, Taylor, & Parker, 1988) in 170 individuals attending a sexual disorders clinic. We diagnosed 114 of the subjects with a sexual dysfunction and 56 with paraphilic disorders. We determined that 20.2% of the dysfunctional group and 26.8% of the paraphilic were alexithymic when the TAS was measured categorically. When we considered the TAS as a dimensional variable, the subset with paraphilias had significantly higher scores on the TAS only when depressed mood, as measured by the Brief Symptom Inventory (Derogatis, 1993), was covaried. These data suggest that alexithymia in both sexually dysfunctional and paraphilic individuals is related to depressed mood, although the effect is more pronounced in paraphilics.

Treatment Resources for the Paraphilic and Hypersexual Disorders

Treatment Resources for the Paraphilic and Hypersexual Disorders

Behavioral and Psychopharmacological Treatment of the Paraphilic and Hypersexual Disorders

In this article, the second of a two-part series, the authors present information on the clinical assessment of individuals with paraphilias and hypersexual disorders. They review ethical considerations in the assessment and treatment of individuals with paraphilias. The role of interview and subjective and objective instruments in the assessment of individuals with paraphilias and hypersexual disorders is discussed. The authors discuss the use of penile plethysmography or phallometry, polygraphy, and viewing time assessments. Risk assessment of sexual offenders is reviewed. The authors then discuss behavioral, environmental, and psychopharmacological treatments for paraphilias and hypersexual disorders. Cognitive-behavioral therapy appears to be the most effective nonpharmacological strategy. The authors describe cognitive-behavioral techniques for decreasing and/or controlling sexual urges (e.g., satiation, covert sensitization, fading, cognitive restructuring, victim empathy therapy) as well as methods for enhancing appropriate sexual interest and arousal (e.g., social skills training, assertiveness skills training, sex education, couples therapy). The authors also discuss the role of relapse prevention therapy and 12-step programs, as well as other nonbiological therapies such as surveillance networks. The importance of providing appropriate treatment for comorbid conditions (e.g., depression, substance abuse or dependence) is stressed. The authors then review psychopharmacological treatments, including serotonin reuptake inhibitors (SRIs) and antiandrogens, in particular, the use of gonadotropin-releasing hormone (GNRH) agonists. SRIs have been studied in these disorders in an uncontrolled way and appear promising. Earlier antiandrogens (e.g., estrogen, progesterone, and cyproterone acetate) have demonstrated efficacy in the treatment of paraphilias. The newer GNRH agonists have the advantage over the earlier treatments of being available in long-acting depot formulations and having fewer side effects. Preliminary studies and case reports with these agents appear promising. Further study of both the SRIs and GNRH agonists in these disorders is needed. The article concludes with a treatment algorithm, in which the authors suggest beginning with less restrictive treatments (e.g., behavioral or verbal therapies), if possible, and moving to more restrictive alternatives (e.g., biological therapies, institutionalization) as needed. A guide for clinicians and patients about where and how to find appropriate clinicians and treatment resources in the United States is provided.

The Paraphilic and Hypersexual Disorders: An Overview

In this article, the first of a two-part series, the authors present reasons for considering the paraphilic and hypersexual disorders together and provide an overview of these disorders. The DSM-IV diagnostic criteria for paraphilias are reviewed, and proposed criteria for hypersexual disorders are presented. The question of whether the paraphilic and hypersexual disorders should be considered within the spectrum of obsessive-compulsive disorders is considered. The authors then review the epidemiology of these disorders, and discuss some implications of recent sexual predator legislation. The authors discuss the etiology of the paraphilias and hypersexual disorders, and consider the role of endocrinological function, findings from brain imaging and neuropsychological testing, findings from primate research, the monoamine hypothesis, the imprinting hypothesis, social learning theory, the concept of courtship disorder, the role of obsessive-compulsive elements, psychodynamic theories, and genetic factors. The phenomenology of the paraphilias and hypersexual disorders is discussed, including the tendency for multiple paraphilias to co-occur, the lack of a specific offender profile, the predominance of males among those with paraphilias, the incidence of a history of victimization in individuals with paraphilias and compulsive sexual disorders, the onset and course of both types of disorders, and the lack of internal motivation for change in individuals with paraphilias and hypersexual disorders. The authors then discuss disorders that commonly co-occur with paraphilias and compulsive sexual disorders, including mood disorders, substance abuse and dependence disorders, attention-deficit/hyperactivity disorder, anxiety and impulse control disorders, and personality disorders. The second article in the series will discuss the clinical assessment and the behavioral and psychopharmacological treatment of these disorders. A guide for clinicians and patients on where and how to find specialized clinicians and treatment resources in the United States will also be provided.

The Paraphilia-Related Disorders: A Proposal for a Unified Classification of Nonparaphilic Hypersexuality Disorders

This article introduces a description of a group of nonparaphilic hypersexual behavior disorders, the paraphilia-related disorders (PRDs). The rationale for the definition and characterization of these behaviors is described and empirical literature supporting the concept of PRDs is reviewed. The common paraphilia-related disorders include compulsive masturbation, protracted promiscuity, pornography dependence, cybersex dependence, telephone sex dependence, severe sexual desire incompatibility and paraphiliarelated disorder not otherwise specified. The comorbid associations and clinical characteristics supporting the evidence that PRDs are indeed related to paraphilic disorders are described. The case is made that the classification of nonparaphilic hypersexual disorders as "paraphilia-related disorders" avoids the confusing use of characterizations such as "addiction" or "compulsivity" when applied to a broad range of sexual appetitive behavior disorders.

The paraphilia-related disorders: An empirical investigation of nonparaphilic hypersexuality disorders in outpatient males

The frequency distribution of nonparaphilic hypersexual behaviors was investigated in an outpatient sample of 206 consecutively evaluated males seeking help for sexual impulsivity disorders (SIDs), either paraphilia-related disorders (PRD; n = 63) or paraphilias (PA; n = 143). Paraphilia-related disorders associated with help-seeking behaviors included compulsive masturbation (sample prevalence, 69%), protracted heterosexual or homosexual promiscuity (51%), pornography dependence (50%), telephone-sex dependence (24%), and severe sexual desire incompatibility (12%). Eighty-six percent of the PA sample reported at least one lifetime PRD. The subgroup of males with both PAs and lifetime PRDs (n = 123) self-reported the greatest number of lifetime SIDs, the highest incidence of physical and sexual abuse, the fewest years of completed education, and the highest likelihood of current unemployment or disability. As well, the subgroup of males with PAs but no lifetime PRDs (n = 20) self-reported the fewest lifetime SIDs; this subgroup was not statistically different from the PRD group on these aforementioned variables. These data suggest that social disadvantage, as assessed in this sample, is associated with the cumulative incidence of SIDs but not necessarily with the diathesis to develop paraphilic disorders

Treatment of the paraphilic disorders: A review of the role of the selective serotonin reuptake inhibitors

Alternative psychopharmacological interventions in the treatment of paraphilic disorders have previously been limited. This article briefly reviews previous psychopharmacological treatment as well as more recent therapeutic advances. During the past 5 years there have been 14 case reports or open trials documenting the efficacy of selective serotonin reuptake inhibitors (SSRIs) in the treatment of paraphilics. The authors discuss the hypothetical role of serotonin in human sexual behavior and review the results of the efficacy of SSRIs in the treatment of these disorders. The limitations and possible indications of these medications are discussed. Although no double-blind placebo-controlled studies have been completed, the results seem to hold new promise for these alternative medications in the treatment of the paraphilic disorders and, possibly, in individuals with an inappropriately high sexual drive.

Treatment of the Paraphilic Disorders: A Review of the Role of the Selective Serotonin Reuptake Inhibitors

Altemative psychopharmacological interventions in the treatment of paraphilic disorders have previously been limited. This article briefly reviews previous psychopharmacological treatment as well as more recent therapeutic advances. During the past 5 years there have been 14 case reports or open trials documenting the efficacy of selective serotonin reuptake inhibitors (SSRIs) in the treatment of paraphilics. The authors discuss the hypothetical role of serotonin in human sexual behavior and review the results of the efficacy of SSRIs in the treatment of these disorders. The limitations and possible indications of these medications are discussed. Although no double-blind placebo-controlled studies have been completed, the results seem to hold new promise for these alternative medications in the treatment of the paraphilic disorders and, possibly, in individuals with an inappropriately high sexual drive.

A monoamine hypothesis for the pathophysiology of paraphilic disorders.

A monoamine pathophysiological hypothesis for paraphilias in males is based on the following data: (i) the monoamines norepinephrine, dopamine, and serotonin are involved in the appetitive dimension of male sexual behavior in laboratory animals; (ii) data gathered from studying the side effect profiles of antidepressant psychostimulant, and neuroleptic drugs in humans suggest that alteration of central monoamine neurotransmission can have substantial effects on human sexual functioning, including sexual appetite; (iii) monoamine neurotransmitters appear to modulate dimensions of human and animal psychopathology including impulsivity, anxiety, depression, compulsivity, and pro/antisocial behavior, dimensions disturbed in many paraphiliacs; (iv) pharmacological agents that ameliorate psychiatric disorders characterized by the aforementioned characteristics, especially central serotonin enhancing drugs, can ameliorate paraphilic sexual arousal and behavior.

Co-Morbidity of Alcoholism and the Paraphilias

Alcoholism has been related to a wide variety of crimes. Various authors have studied the prevalence of alcoholism in relationship to incest, rape and pedophilia. This study evaluates the co-morbidity of alcoholism and the specific paraphilias including sexual sadism, fetishism, incest, pedophilia, exhibitionism and transvestism. Rapists were included although by definition it is not strictly a paraphilic disorder. Seven hundred and twenty eight paraphilic individuals were evaluated. More than 50% of sexual sadists were alcoholics. Alcoholism in association with sexual sadists was statistically significant as compared to transvestites, rapists, pedophiles, and incest offenders. Transvestism had the lowest relative rate of alcoholism. The authors discuss these findings and the role alcoholism plays in causing violent sexual behavior in individuals with paraphilias.

Cognitive-Behavioral Therapy with an Incarcerated Exhibitionist

Successful approaches to the treatment of exhibitionism, an important paraphilic disorder with respect to offense frequency, are limited in the recent literature. The use of individual cognitive-behavioral treatment with a long-term, incarcerated exhibitionist is presented. Emphasis was placed on the development of insight through informed decision making, as well as improvement in communication style and social network enhancement. Deviant sexual fantasies were targeted for change and more appropriate fantasies encouraged. Phallometric data showed a decrease in deviant responses over therapy and an increase in appropriate arousal.

Sexual disorders in Huntington's disease.

This study assessed the frequency and type of sexual disorders associated with Huntington's disease (HD) in an unbiased sample. Of 39 HD patients and 32 of their partners, 82% and 66%, respectively, had one or more sexual disorders by DSM-III-R criteria. The most frequent for both groups was hypoactive sexual disorder. Significantly more patients who had both inhibited orgasm and increased sexual interest also had paraphilic disorders. Findings support the hypotheses that sexual disorders are frequent among HD patients and their partners and that sexual disorders among HD patients may take the form of increased sexual interest or paraphilias. The association between inhibited orgasm, increased sexual interest, and paraphilic disorders will require further investigation but suggests a possible etiology for some paraphilias.

Medroxy-Pregesterone Acetate in the Treatment of Paraphilic Sexual Disorders

Results are presented of an open retrospective study in which 46malepatients withparaphilic sexual disorders were followed for 5 or more years in the Johns Hopkins Sexual Disorders Unit. All patients received equivalent amounts of group psychotherapy. Of these, 17/46 (37%) relapsed. The rate of relapse among subjects receiving treatment with medroxy-progesterone acetate (MPA) was 4 out of 27 subjects (15%) whereas the rate of relapse among subjects not receiving MPA was 13/19 (68%) (Chi-square = 13.80; df = 1; p = 0.0002). The lower rate of relapse among subjects who were receiving MPAcontinued to be demonstrated when other variables were accounted for including age, race, marital status, employment, socioeconomic status, diagnosis, and sexual orientation. It is concluded that among paraphilic male outpatients treated with weekly psychotherapy for 5 or more years, the addition of MPA is associated with a decrease in the rate of relapse. Limitations of this study and suggestions for future research are dis...

Successful Treatment of Paraphilic Coercive Disorder (a Rapist) with Fluoxetine Hydrochloride

A rape assailant with intrusive and persistent paraphilic rape fantasies was successfully treated with the antidepressant fluoxetine hydrochloride. Symptoms of impulsiveness, anxiety and depression were also markedly improved.

Paraphilic Coercive Disorder

The work group of the American Psychiatric Association to revise DSM-III in 1985 proposed a controversial new sexual disorder titled paraphilic rapism. Subsequently the criteria defining paraphilic rapism was narrowed and the category was renamed paraphilic coercive disorder to reduce some of the objections. Eventually the diagnosis was withdrawn front the DSM-III-R because of the ensuring controversy. The intent of the present study was to establish whether clinicians agree on the prototypical features of the disorder and to identify specific descriptors for use as diagnostic criteria. A collection of 87 possible traits from the literature on rapists was made and the traits were combined with evaluative (good or bad) concepts from Osgood's semantic differential studies. The traits were rated for their prototypicality in describing individuals with paraphilic coercive disorder by two groups: (1) the staff of a sex offender treatment program and (2) a national sample of clinicians working with sex offender...

Essay on the diagnosis and nature of paraphilia

Increasing clinical experience has allowed the formulation of three psychodynamic viewpoints about the nature of the paraphilic disorder. Paraphilia is a disorder of sexual identity development, often solely of the intention component, that has three characteristics: a long-standing, highly arousing, unusual erotic preoccupation; a pressure to act upon the erotic fantasy; sexual dysfunction with a partner during conventional sexual behavior. Paraphilia is also a disorder of self-regulation characterized by a considerable gap between personal aspirations and behaviors. Finally, paraphilia is a dramatic impairment in the capacity to love. Two rarely recognized issues complicate the nosology of paraphilia: Many related sexual problems are often confused with paraphilia, and some paraphilias manifest themselves as variations in gender identity and object choice. The defensive functions of paraphilia are discussed and common terms used in conjunction with paraphilia are redefined.