From diagnosis to treatment, paraphilias and paraphilic disorders present unique challenges for the general psychiatrist. Individuals with paraphilic disorders typically do not present in a general outpatient setting for management of sexual thoughts and behaviors. Once an individual discloses thoughts, feelings, or behaviors concerning for a paraphilic disorder, the psychiatrist must identify the range and extent of atypical sexual interests and stratify the individual’s risk in order to determine appropriate treatment options.
If the treatment is accepted, the patient must undergo detailed informed consent due to the potential adverse effects of the medications used to address problematic sexual behaviors. It is therefore crucial that the general psychiatrist understand the basics of diagnosis and treatment for paraphilic disorders.
The publication of DSM-5 marked the first time that the authors of the manual defined a category of paraphilic disorders as distinct from paraphilias. The text defines a paraphilia as “any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners.”
The Sexual and Gender Identity Disorders Work Group, responsible for the paraphilic disorders chapter, differentiated between paraphilias and paraphilic disorders “sought to draw a line between atypical human behavior and behavior that causes mental distress to a person or makes the person a serious threat to the psychological and physical well-being of other individuals.”1 A paraphilic disorder, then, is a paraphilia “that is currently causing distress or impairment to the individual or a paraphilia whose satisfaction has entailed personal harm, or risk of harm, to others.”
DSM-5 delineates criteria for eight specified paraphilic disorders. Table 1 lists these paraphilic disorders and the associated atypical sexual interest. In order to make a diagnosis of a paraphilic disorder, an individual must have a history of recurrent and intense sexual arousal to the atypical focus lasting at least 6 months that manifests as sexual fantasies, urges, or behaviors. This means that an individual who engages in atypical sexual behaviors, for instance while intoxicated, but lacks the requisite duration and intensity of arousal, does not have a paraphilia or paraphilic disorder.2 DSM-5 also provides diagnoses of other specified paraphilic disorder or unspecified paraphilic disorder for clinicians who see patients who present with atypical sexual interests that do not meet the criteria for one of the specified disorders.
Dr Holoyda is Forensic Psychiatrist and Chair, Sexual Offenders Committee, American Academy of Psychiatry and the Law, Sacramento, CA. He reports no conflicts of interest concerning the subject matter of this article.
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