Paraphilic disorder

......PARAPHILIA.....

1. MODERATOR: Dr. ASHUTOSH GUPTA PRESENTATOR: Dr. RAMASHANKAR PARAPHILIC DISORDER

2. Paraphilia (perversion) Derived from the Greek words “ para” meaning next to “ philia ” meaning love . The etymological definition of paraphilia is “next to or along side of love .” “Recurrent , intense sexually arousing fantasies, sexual urges, or behaviors generally involving i ) non-human objects , ii) the suffering or humiliation of oneself or one’s partner, or iii) children or other non-consenting persons that occur over a period of at least 6 months ”** **( p.566, [DSM-IV]).

3. The term paraphilia denotes any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, phys­ically mature, consenting human partners .* A paraphilic disorder 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 pg. 685

4. DSM-5 CRITERIA FOR PARAPHILIC DISORDER Criterion A S pecifies the qualitative nature of the paraphilia (e.g., an erotic focus on children or on exposing the gen­itals to strangers). Criterion B Specifies the negative consequences of the paraphilia (i.e ., distress , impairment , or harm to others).

5. Characteristics of persons with a Paraphilia Beside normal sexual behaviour, paraphilic disorder involve aggression, victimization , and extreme one-sidedness . The behaviors exclude or harm others and dis­rupt the potential for bonding between persons. Usually lasts for 6 months. Always thinking to carry out their unusual behavior. Overly obsessed that if the individual cannot get to their desired object, they get stressed. The individual will lose sight of other goals and concentrate of the fulfilment of their sexual desires if worse.

6. It causes intense personal distress or impairment in social, work and other areas of life functioning. Except for Sexual Masochism & sadism almost all cases of Paraphilia Involve MEN . Paraphilias commonly involve sexual arousal and orgasm, usually achieved through masturbation and fantasy.

7. Historical aspect Richard von Krafft-Ebing, a German psychiatrist credited with formally introducing the study of sexology as a psychiatric phenomenon, identified paraphilias first in his 1886 Psychopathia Sexualis (Sexual Psychopathy ). The term paraphilia was coined by psychologists in the early 1900s Previously, these were called perversions . The term paraphilia first appeared in the third version of the DSM classification. In the first version of the DSM published in 1952, sexual deviations were conceptualized as a subclass of sociopathic personality disturbance . In DSM-II sexual deviations were classified with the personality disorders.

8. Prevalence Prevalence rates for paraphilias are difficult to obtain due to changes in criterion over time and between cultures* Ahlers   et al . surveyed a sample of 1,915 German men aged 40-79 and found 62.4% reported at least one paraphilia-associated sexual arousal pattern, and that this caused distress in only 1.7% of cases .** Langstrom and Seto surveyed a sample of 2,450 individuals aged 18-60 years and found that 3.1% of participants reported at least one incident of being sexually aroused by exposing their genitals to a stranger and 8% admitted being sexually aroused spying on others having sex.  *** * Bhugra D, Popelyuk D, McMullen I. Paraphilias across cultures: contexts and controversies. J Sex Res. 2010;47:242–56. doi : 10.1080/00224491003699833 . ** Ahlers CJ, Schaefer GA, Mundt IA, Roll S, Englert H, Willich SN, Beier KM. How unusual are the contents of paraphilias ? Paraphilia-associated sexual arousal patterns in a community-based sample of men. J Sex Med. 2011;8:1362–70. doi : 10.1111/j.1743-6109.2009.01597.x . ***   Långström N, Seto MC. Exhibitionistic and voyeuristic behavior in a Swedish national population survey. Arch Sex Behav . 2006;35:427–35. doi : 10.1007/s10508-006-9042-6.

9.   Briken   et al.   reported that in a study of sexual murderers, there were higher levels of sexual sadism alongside other paraphilic-related interests and disorders .* * Briken P, Habermann N, Kafka MP, Berner W, Hill A. The paraphilia-related disorders: an investigation of the relevance of the concept in sexual murderers. J Forensic Sci. 2006;51:683–8. doi : 10.1111/j.1556-4029.2006.00105.x.

10. Etiology The etiology of paraphilias is unknown . Psychoanalytical Theory T hese conditions represent a regression to or a fixation at an earlier level of psychosexual development, resulting in a repetitive pattern of sexual behavior that is not mature in its application and expression . T hese conditions are all expressions of hostility in which sexual fantasies or unusual sexual acts become a means of obtaining revenge for a childhood trauma

11. The persistent, repetitive nature of the paraphilia is caused by an inability to erase the underlying trauma completely . Behaviorist Theory T he paraphilia begins via a process of conditioning. Nonsexual objects can become sexually arousing if they are frequently and repeatedly associated with a pleasurable sexual activity.

12. The following are situations or causes that might lead someone in a paraphiliac direction: P arents who humiliate and punish a small boy for strutting around with an erect penis; A young boy who is sexually abused; A n individual who is dressed in a woman's clothes as a form of parental punishment; F ear of sexual performance or intimacy; Excessive alcohol intake; P hysiological problems; S ociocultural factors; P sychosexual trauma.

13. Biological Factors sexual deviance is associated with frontal and/or temporal lobe damage, Subtle defects of the right amygdala.

14. Both the ICD-10 and DSM-IV include eight specific paraphilias outlined with additional ‘not otherwise specified (DSM-IV), unspecified (ICD-10), other specified paraphilic disorder and unspecified paraphilic disorder (DSM-5)’ categories.

15. Voyeuristic Disorder DSM-5 DIAGNOSTIC CRITERIA A . Over a period of at least 6 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 behaviors. B. The 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. C. The individual experiencing the arousal and/or acting on the urges is at least 18 years of age.

16. The word comes from the term VOIR , meaning “To See ” Voyeurism , also known as scopophilia . The onset of voyeuristic behavior is usually before the age of 15. This disorder is more common in men . Masturbation to orgasm usually accompanies or fol­lows the event. The voyeur feels frustrated and incapable of establishing a regular sexual relationship with the person he observes.

17. Exhibitionistic Disorder DIAGNOSTIC CRITERIA DSM-5 A. Over a period of at least 6 months, recurrent and intense sexual arousal from the exposure of one’s genitals to an unsuspecting person , as manifested by fantasies, urges, or behaviors. B. The 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. Specify whether : Sexually aroused by exposing genitals to prepubertal children Sexually aroused by exposing genitals to physically mature individuals Sexually aroused by exposing genitals to prepubertal children and to physically mature individuals

18. Exhibitionism, also known as “flashing” or “indecent exposure ,” O ccurs predominately in men In almost 100 percent of cases, those with exhibitionism are men exposing themselves to women . O rgasm is brought about by masturbation during or after the event . The dynamic of men with exhibitionism is to assert their masculinity by showing their penises and by watching the victims ' reactions - fright, surprise , and disgust .

19. Frotteuristic Disorder DIAGNOSTIC CRITERIA A . Over a period of at least 6 months, recurrent and intense sexual arousal from touching or rubbing against a nonconsenting person, as manifested by fantasies, urges, or be­haviors . B. The 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.

20. Derived from the word ‘ Frotter ’ meaning ‘To rub’ Frotteurism is described only in men .

21. Sexual Masochism Disorder DIAGNOSTIC CRITERIA A . Over a period of at least 6 months, recurrent and intense sexual arousal from the act of being humiliated, beaten, bound , or otherwise made to suffer, as manifested by fan­tasies , urges, or behaviors. B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impair­ment in social, occupational, or other important areas of functioning . Specify if : With asphyxiophilia : If the individual engages in the practice of achieving sexual arousal related to restriction of breathing.

22. Sexual Masochism Comes from the name of an Austrian Writer Leopold Baron von Sacher-Masoch . Who is known for his novels about men being sexually humiliated by women. A Masochist is someone who seeks pleasure from being subjected to pain . M ore common among men than among women About 30 percent of those with sexual masochism also have sadistic fantasies . The three main characteristics of masochism are pain, loss of control, and humiliation.

23. Sexual Sadism Disorder DIAGNOSTIC CRITERIA DSM-5 A . Over a period of at least 6 months, recurrent and intense sexual arousal from the phys­ical or psychological suffering of another person , as manifested by fantasies, urges, or behaviors . B. The 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.

24. The term Sadism comes from the name of French author Marquis de Sade , who wrote extensively about obtaining sexual enjoyment from inflicting cruelty. Both terms were coined by Krafft-Ebing , a german physician. In contrast to Sexual Masochism, which does not require a partner, sexual sadism clearly requires a partner to enact sadistic fantasies . The onset of the disorder is usually before the age of 18 years , and most persons with sexual sadism are male . According to psychoanalytic theory, sadism is a defence against fears of cas­tration; persons with sexual sadism do to others what they fear will happen to them and derive pleasure from expressing their aggressive instincts .

25. John money lists five contributory causes of sexual sadism: hereditary predisposition, hormonal malfunctioning, pathological rela­tionships, a history of sexual abuse , and the presence of other mental disorders.

26. Krafft-Ebing sub classified sexual sadism into several categories including: Lust-murder; Mutilation of corpses or necrophilia; Injury to females (stabbing); Defilement of women; Other kinds of assaults on women—symbolic sadism in which, for example, the perpetrator cuts the hair of his victims rather than harming them directly; Ideal sadism or sadistic fantasies alone without acts; Sadism with other objects, for example, whipping boys; Sadistic acts with animals . In some individuals sadistic fantasies and compulsions lead to rape or homicide.

27. Sadomasochism A paraphilia that combines sadistic and masochistic roles in sexual interaction. Sadism is the intentional infliction of pain on another person or the threat to do so, for sexual excitement. Masochism is a condition in which a person derives sexual gratification from being subjected to pain or to the threat of pain.

28. Pedophilic Disorder DIAGNOSTIC CRITERIA DSM-5 A . Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sex­ual urges, or behaviors involving sexual activity with a prepubescent child or children (generally age 13 years or younger). B. The individual has acted on these sexual urges, or the sexual urges or fantasies cause marked distress or interpersonal difficulty. C. The individual is at least age 16 years and at least 5 years older than the child or chil­dren in Criterion A . Note: Do not include an individual in late adolescence involved in an ongoing sexual relationship with a 12- or 13-year-old .

29. Specify whether: Exclusive type (attracted only to children) Nonexclusive type Specify if: Sexually attracted to males Sexually attracted to females Sexually attracted to both Specify if: Limited to incest

30. Most child molestations involve genital fondling or oral sex . Vaginal or anal penetration of children occurs in frequently , except in cases of incest . Fifty to 70 percent of pedophiles can be diagnosed as having another paraphilia, such as frotteurism , exhibitionism, voyeurism, or sadism . Pedophiles are approximately 2.5 times more likely to engage in physical contact with a child than simply voyeuristic or exhibitionist activities.

31. Fetishistic Disorder DIAGNOSTIC CRITERIA DSM-5 A . Over a period of at least 6 months, recurrent and intense sexual arousal from either the use of non-living objects or a highly specific focus on nongenital body part(s), as manifested by fantasies, urges, or behaviors. B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impair­ment in social, occupational, or other important areas of functioning. C. The 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 (e.g., vibrator ). Specify: Body part(s )/Non-living object(s)/Other

32. Fetishism is where a person feels a strong recurrent sexual attraction to a nonliving object . Sexual activity may be directed toward the fetish itself ( e.g ., masturbation with or into a shoe), or the fetish may be incorporated into sexual intercourse (e.g ., the demand that high-heeled shoes be worn). Objects include shoes, gloves, underwear, stockings, swimsuits, etc. Almost exclusively found in men .

33. Partialism Another variant of Fetishism. People with Partialism are solely interested in the sexual gratification from a specific body part , examples are feet, neck, underarms, back, etc.

34. Transvestic Disorder DIAGNOSTIC CRITERIA DSM-5 A . Over a period of at least 6 months, recurrent and intense sexual arousal from cross­ dressing , as manifested by fantasies, urges, or behaviors . B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impair­ment in social, occupational, or other important areas of functioning . Specify if : With fetishism: If sexually aroused by fabrics, materials, or garments. With autogynephilia : If sexually aroused by thoughts or images of self as female.

35. The literal meaning of the word transvestism is to wear the clothing of the opposite sex . Sometimes accompanied by masturbation . T ypically begins in childhood or early adolescence. As years pass , some men with transvestism want to dress and live perma­nently as women Rare in female.

36. RARE PARAPHILIAS

37. Diagnosis Penile pletysmography – measurement of patient’s sexual arousal(of  blood flow to the penis) in response to audio or visual imagery DSM-5 criteria Course and Prognosis Paraphilic behaviors emerge in adolescence and early adulthood . In general paraphilic behaviors are chronic . I ndividuals may cross over from one paraphilia to another D ifficult to treat.

38. Treatment Paraphiliacs seldom seek treatment because of their guilt, shame, and fear of social ostracism and legal problems Five types of psychiatric interventions are used to treat persons with paraphilic disorder and paraphilic interests : external con­trol , reduction of sexual drives , treatment of comorbid condi­tions (e.g. Depression or anxiety ), cognitive- behavioral therapy , and dynamic psychotherapy . The efficacy of treatment in paraphiliacs is unknown.

39. Surgical Treatment Surgical treatment for sex offenders consist of two types: Neurosurgery and castration . The neurosurgical procedure involves stereotaxic removal of parts of the hypothalamus to disrupt production of male hormones and decrease sexual arousal and impulsive behaviors . Surgical castration is the removal of the testes.

40. Pharmacologic Treatment Antiandrogens Testosterone is the most common androgen in man Cyproterone acetate and medroxyprogesterone are the two most commonly used antiandrogen medications . R educe libido, erections, ejaculations, and spermatogenesis . S ide effects such as weight gain, hyperglycemia , hot and cold flashes, liver dysfunction, hypertension, muscle cramps, phlebitis, gastrointestinal complaints, and feminization .

41. Hormonal Agents Leuprolide and triptorelin are hormonal agents referred to as long-acting GnRH agonists. These agents inhibit the secretion of luteinizing hormone with a resulting decrease in plasma testosterone levels and libido. They produce a chemical castration in that the hypothalamic–pituitary axis is exhausted and there is a potent inhibition of gonadotropin.

42. The side effects include decreased bone mineral density or osteopenia, weight gain, hyperglycemia , diabetes, hypertension, and insomnia. The most commonly reported side effects are erectile/ejaculatory problems and gynecomastia . Selective Serotonin Reuptake Inhibitors ( SSRIs ) Sertraline, fluvoxamine, and fluoxetine were equally effective in reducing paraphilic symptoms.

43. Psychological and Behavioral Treatment Cognitive-behavioral therapy is used to disrupt learned paraphilic patterns and modify behavior to make it socially acceptable. The interventions include social skills training , sex education, cognitive restructuring, relax­ation technique, and learning what triggers the paraphilic impulse so that such stimuli can be avoided are also taught. Insight-oriented psychotherapy is a long-standing treatment approach.

44.  Thank you.. 