PARAPHILIC DISORDERS

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.

In other times, it may be defined as any sexual interest greater than or equal to
normophilic sexual interests. Some paraphilias are also better described as
preferential sexual interests rather than intense sexual interests.
 PARAPHILIC DISORDERS

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.

A paraphilia is a necessary but not a sufficient condition for having a

paraphilic disorder and a paraphilia by itself does not necessarily justify or
require clinical intervention.
 PARAPHILIC DISORDERS

Only eight paraphilic disorders are listed in the DSM 5 because of two
reasons: they are relatively common, in relation to other paraphilic disorders,
and some of these result into actions that, because of their noxiousness or
potential harm to others, are classed as criminal offenses.

However, take note that almost any paraphilia can rise to the level of a
paraphilic disorder. (Other specified and unspecified paraphilia disorder are
important and required in many cases)
 PARAPHILIC DISORDERS

In DSM 5, the paraphilic disorders are grouped into two.

1. Based on anomalous activity preferences
A. Courtship disorders - resemble distorted components of human courtship
behavior.
(Voyeuristic disorder, exhibitionistic disorder and frotteuristic disorder)

B. Algolagnic disorders - involves pain and suffering.

(Sexual masochism disorder and sexual sadism disorder)
 PARAPHILIC DISORDERS

In DSM 5, the paraphilic disorders are grouped into two.

2. Based on anomalous target preferences
A. Directed at other humans
(Pedophilic disorder)

B. Directed elsewhere
(Fetishistic disorder and transvestic disorder)
 VOYEURISTIC DISORDER

DIAGNOSTIC CRITERIA
Criterion 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.

Criterion B
• The individidual 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.

Criterion C
• The individual experiencing the arousal and/or acting on the urges is at least 18 years of age.
 SP ECIFY IF:

In a controlled environment: This specifies is primarily applicable to individuals

living in institutional or other settings where oppurtunities to engage in voyeuristic
behavior are restricted.

In full remission: The individual has not acted on the urges with a nonconsenting
person, and there has been no distress or impairment in social, occupational, or
other areas of functioning, for at least 5 years while in an uncontrolled
environment.
 SPECIFIERS

• The “in full remission” specifier does not address the

continued presence or absence of voyeurism per se,
which may still be present after behaviors and
distress have remitted.
 RISK AND PROGNOSTIC FACTORS

 Temperamental - Voyeurism is a necessary precondition for

voyeuristic disorder, hence, risk factors for voyeurism should also
increase the rate of voyeuristic disorder.

 Environmental - Childhood sexual abuse, substance misuse, and

sexual preoccupation/ hypersexuality have been suggested as risk
factors, although the causal relationship to voyeurism is uncertain and
the specificity unclear.
 DIFFERENTIAL DIAGNOSIS

 Conduct disorder and Antisocial Personality disorder - Conduct disorder in

adolescents and antisocial personality disorder would be characterized by additional
norm-breaking and antisocial behaviors, and the specific sexual interest in secretly
watching unsuspecting others who are naked or engaging in sexual activity should be
lacking.

 Substance use disorder- Might involve single voyeuristic episodes by intoxicated

individuals but should not involve the typical sexual interest in secretly watching
unsuspecting persons being naked or engaging in sexual activity. Hence, recurrent
voyeuristic sexual fantasies, urges, or behaviors that occur also when the individual is
not intoxicated suggest that voyeuristic disorder might be present.
 COMORBIDITY

 Such comorbidities presented in voyeuristic disorder are hugely based on

research with males suspected of or convicted for acts involving the secret
watching of unsuspecting nude or sexually active persons.

 Conditions which occur comorbidly with voyeuristic disorder include

hypersexuality and other paraphilic disorders, particularly exhibitionic
disorder. Depressive , bipolar, anxiety, and substance use disorders;
attention deficit/hyperactivity disorder; and conduct disorder and
antisocial personality disorder are also frequent comorbid conditions.
 EXHIBITIONISTIC DISORDER

DIAGNOSTIC CRITERIA

Criterion 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.

Criterion 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.
 EXHIBITIONISTIC DISORDER

DIAGNOSTIC CRITERIA
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.

Specify if:
In a controlled environment: This specifier is primarily applicable to individuals living in
institutional or other settings where opportunities to expose one's genitals are restricted.
In full remission: The individual has not acted on the urges with a nonconsenting person,
and there has been no distress or impairment in social, occupational or other areas of
functioning, for at least 5 years while in an uncontrolled environment.
 EXHIBITIONISTIC DISORDER

SPECIFIERS

The "in full remission" specifier does not address the continued presence or absence of
exhibitionism per se, which may still be present after behaviors and distress have remitted.
 EXHIBITIONISTIC DISORDER

RISK AND PROGNOSTIC FACTORS

Temperamental. Exhibitionism is a necessary precondition for exhibitionistic disorder,
risk factors for exhibitionism should also increase the rate of exhibitionistic disorder.
Antisocial personality disorder, alcohol use disorder, and pedophilic interest may be
considered risk factors for exhibitionistic disorder in males with exhibitionistic sexual
preferences.

Environmental. Childhood sexual and emotional abuse and sexual

preoccupation/hypersexuality have been suggested as risk factors for exhibitionism,
although the causal relationship to exhibitionism is uncertain and the specificity unclear.
 EXHIBITIONISTIC DISORDER

DIFFERENTIAL DIAGNOSIS
Conduct disorder and antisocial personality disorder. Conduct disorder in adolescents
and antisocial personality disorder would be characterized by additional norm-breaking and
antisocial behaviors, and the specific sexual interest in exposing the genitals should be
lacking.

Substance use disorders. Alcohol and substance use disorders might involve single
exhibitionistic episodes by intoxicated individuals but should not involve the typical sexual
interest in exposing the genitals to unsuspecting persons.
 EXHIBITIONISTIC DISORDER

COMORBIDITY

Conditions that occur comorbidly with exhibitionistic disorder at high rates include
depressive, bipolar, anxiety and substance use disorders; hypersexuality; ADHD; other
paraphilic disorders and antisocial personality disorder.
 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.
 SPECIFY IF:

 In a controlled environment: This specifier is primarily applicable to

individuals living in institutional or other settings where oppurtunities to
touch or rub against a nonconsenting person are restricted.

 In full remission: The individual has not acted on the urges with a
nonconsenting person, and there has been no distress or impairment in social,
occupational, or other areas of functioning, for at least 5 years while in an
uncontrolled environment.
 SPECIFIERS

The “in remission” specifier does not adress the

continued presence or absence of froteurism per se,
which may still be present after behaviors and
distress have remitted.
 RISK AND PROGNOSTIC FACTORS

Temperamental

• Nonsexual antisocial behavior and sexual

preoccupation/hypersexuality might be nonspecific risk factors,
although the causal relationship to frotteurism is uncertain and the
specificity unclear.

• On the other hand, Frotteurism is a necessary precondition for

frotteuristic disorder, so risk factors for frotteurism should also
increase the rate of frotteuristic disorder.
 DIFFERENTIAL DIAGNOSIS

Conduct disorder and antisocial personality disorder.

• Conduct disorder in adolescents and antisocial behaviors, and the specific sexual interest
in touching or rubbing against a nonconsenting individual should be lacking.

Substance use disorders

• Particularly, those involving stimulants such as cocaine and amphetamines, might involve
single frotteuristic episodes by intoxicated individuals but should not involve the typical
sustained sexual interest in touching or rubbing against unsuspecting persons.

• Hence, recurrent frotteuristic sexual fantasies, urges, or behaviors that occur also when
the individual is not intoxicated suggest that frotteuristic disorder might be present.
 COMORBIDITY

• Comorbidities presented in frotteuristic disorder are largely based on research with males
suspected of or convicted for criminal acts involving sexually motivated touching of or
rubbing against a nonconsenting individual.

• Thus, these comorbidities might not apply to other individuals with a diagnosis of
frotteuristic disorder based on subjective distress over their sexual interest.

• Conditions which occur comorbidly with frotteuristic disorder include hypersexuality and
other paraphilic disorders, particularly exhibitionistic disorder and voyeuristic disorder.
Also the Conduct disorder, antisocial personality disorder, depressive disorders, bipolar
disorders, anxiety disorders, and substance use disorders also co-occur.
 SEXUAL MASOCHISM
DISORDER
DIAGNOSTIC CRITERIA
Criterion A
• Over a period of atleast 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.

Criterion B
• The fantasies, sexual urges, or behaviors cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning.
 SEXUAL MASOCHISM
DISORDER
DIAGNOSTIC CRITERIA
Specify if:
With asphyxiophilia: if the individual engages in the practice of achieving
sexual arousal related to restriction of breathing.

Specify if:
In a controlled environment: This specifier is primarily applicable to
individuals living in institutional or other settings where opportunities to
engage in masochistic sexual behaviors are restricted.
 SEXUAL MASOCHISM
DISORDER
DIAGNOSTIC CRITERIA
Specify if:
In full remission: There has been no distress or impairment in social,
occupational or other areas of functioning, for at least 5 years while in an
uncontrolled environment.
 SEXUAL MASOCHISM
DISORDER
SPECIFIERS
The "in full remission" specifier does not address the continued presence or
absence of exhibitionism per se, which may still be present after behaviors and
distress have remitted.
 SEXUAL MASOCHISM
DISORDER
DIFFERENTIAL DIAGNOSIS
Transvestic fetishism, sexual sadism disorder, hypersexuality, alcohol and
substance use disorders. Also sometimes occur as comorbid diagnoses.

Sexual masochism in the absence of distress. Included as individuals who

conduct masochistic behaviors and are satisfied with their masochistic
orientation.
 SEXUAL MASOCHISM
DISORDER
COMORBIDITY
Disorders that occur comorbidly with sexual masochism disorder typically
include other paraphilic disorders, such as transvestic fetishism.
 SEXUAL SADISM DISORDER

Diagnostic Criteria

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.
 SPECIFY IF:

In a controlled environment: this specifier is primarily applicable to

individuals living institutional or other settings where oppurtunities to engage
in sadistic sexual behaviors are restricted.

In full remission: The individul has not acted on the urges with a
nonconsenting person, and there has been no distress or impairment in social,
occupational, or other areas functioning, for at least 5 years while in an
uncontrolled environment.
 DIFFERENTIAL DIAGNOSIS

 Such conditions which could be differential diagnoses for sexual sadism disorder are;
antisocial personality disorder, sexual masochism disorder, hypersexuality, substance use
disorders, wherein sometimes occur also as comorbid diagnoses.

 It is necessary to carefully evaluate the evidence for sexual sadism disorder, keeping the
possibility of other paraphilias or mental disorders as part of the differential diagnosis.

 The majority of individuals that are active in community networks that practice sadistic
and masochistic behaviors don’t express any dissatisfaction with their sexual interests,
and their behavior wouldn’t meet DSM - V criteria for sexual sadism disorder. Sadistic
interest, but not the disorder, may be considered in the differential diagnosis.
 COMORBIDITY

 Known comorbidities with sexual sadism disorder are

largely based on individuals (almost all males) convicted for
criminal acts involving sadistic acts against nonconsenting
victims.

 Disorder that are commonly comorbid with sexual sadism

disorder include other paraphilic disorders.
 PEDOPHILIC DISORDER

DIAGNOSTIC CRITERIA
Criterion 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).

Criterion B
• The individual has acted on these sexual urges, or the sexual urges or fantasies cause
marked distress or interpersonal difficulty.
 PEDOPHILIC DISORDER

DIAGNOSTIC CRITERIA
Criterion 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.
 PEDOPHILIC DISORDER

DIAGNOSTIC CRITERIA
Specify whether:
Exclusive type (attracted only to children)
Nonexclusive type

Specify if:
Sexually attracted to males
Sexually attracted to females
Sexually attracted to both
 PEDOPHILIC DISORDER

DIAGNOSTIC CRITERIA
Specify if:
Limited to incest
 PEDOPHILIC DISORDER

RISK AND PROGNOSTIC FACTORS

Temperamental. There appears to be an interaction between pedophilia and
antisociality, such that males with both traits are more likely to act out
sexually with children.

Environmental. Adult males with pedophilia often report that they were
sexually abused as children. It is unclear whether this correlation reflects a
causal influence of childhood sexual abuse on adult pedophilia.
 PEDOPHILIC DISORDER

RISK AND PROGNOSTIC FACTORS

Genetic and physiological. Any factor that increases probability of

pedophilia also increases the risk of pedophilic disorder. Some evidence also
exist that neurodevelopmental perturbation in utero increases probability of
development of a pedophilic orientation.
 PEDOPHILIC DISORDER

DIFFERENTIAL DIAGNOSIS.

Antisocial personality disorder. Increases likelihood that a person who is

primarily attracted to the mature physique will approach a child, on one or few
occasions, on the basis of relative availability. The individual will often show
other signs of this personality disorder.

Alcohol and substance use disorders. The disinhibiting effects of

intoxication may also increase the likelihood that a person who is primarily
attracted to the mature physique will sexually approach a child.
 PEDOPHILIC DISORDER

DIFFERENTIAL DIAGNOSIS.

Obsessive-compulsive disorder. There are occasional individuals who

complain about ego-dystonic thoughts and worries about possible attraction to
children. Clinical interviewing usually reveals an absence of sexual thoughts
about children during high states of sexual arousal (e.g., approaching orgasm
during masturbation) and sometimes additional ego-dystonic, intrusive sexual
ideas (e.g., concerns about homosexuality).
 PEDOPHILIC DISORDER

COMORBIDITY

Psychiatric comorbidity of pedophilic disorder includes substance use

disorders; depressive, bipolar, and anxiety disorders; antisocial
personality disorder; and other paraphilic disorders.
 FETISHISTIC DISORDER

Diagnostic Criteria

a. Over a period of at least months, recurrent and intense sexual arousal from either the use
of nonliving 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)
 S P E C I FY:

Body part(s)
Nonliving object(s)
Other

Specify if:
In a controlled environment: The specifier is primarily applicable to individuals living
in institutional or other settings whee opportunities to engage in fetishistic behaviors are
restricted.

In Full remission: There has been no distress or impairment in social, occupational, or

other areas of functioning for at least 5 years while in an uncontrolled environment.
 SPECIFIERS

• Although individuals with fetishistic disorder may report intense and recurrent
sexual arousal to inanimate objects or a specific body part, it is not unusual for
non-mutually exclusive combinations of fetishes to occur.

• Thus, an individual may have fetishistic disorder associated with an inanimate

object(e.g., female undergarments) or an exclusive focus on an intensely eroticized
body part (e.g.,feet,hair), or their fetishistic interest may meet criteria for various
combinations of these specifiers (e.g., socks, shoes and feet).
 DIFFERENTIAL DIAGNOSIS

• Transvestic disorder - It is the nearest diagnostic neighbor of fetishestic

disorder. In the diagnostic criteria,fetishistic disorder is not diagnosed when
fetish objects are limited to articles of clothing exclusively worn during cross-
dressing (as in transvestic disorder), or when the object is genitally
stimulating because it has been designed for that purpose (e.g., a vibrator).

• Sexual masochism disorder or other paraphilic disorders- Fetishestic disorder

occur as well with “sadomasochism” and transvestic disorder. When an
individual fantasizes about or engages in “forced cross-dressing” and is
primarily sex activity, the diagnosis of sexual masochism disorder should be
made.
 DIFFERENTIAL DIAGNOSIS

• Fetishistic behavior without fetishistic disorder- Use of a fetish object for

sexual arousal without any associated distress or psychosocial role
impairment or other adverse consequence would not meet criteria for
fetishistic disorder, as the threshold required by Criterion B would not be
met. Example, an individual whose sexual partner either shares or can
successfully incorporate his interest in caressing, smelling, or licking feet or
toes as an important element of foreplay would not be diagnosed with
fetishistic disorder, nor would an individual who prefers and is not
distressed or impaired by, solitary sexual behavior associated with wearing
rubber garments or leather boots.
 COMORBIDITY

• Fetishistic disorder may co-occur with other paraphilic

disorders as well as hypresexuality. Rarely fetishistic
disorder may be associated with neurological conditions.
 TRANSVESTIC DISORDER

DIAGNOSTIC CRITERIA
Criterion A
• Over a period of at least 6 months, recurrent and intense sexual arousal from cross-
dressing, as manifested by fantasies, urges, or behaviors.

Criterion B
• The fantasies, sexual urges, or behaviors cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning.
 TRANSVESTIC DISORDER

DIAGNOSTIC CRITERIA
Specify if:
With fetishism: if sexually aroused by fabrics, materials, or garments.
With autogynephilia: if sexually aroused by thoughts or images as a female.

Specify if:
In a controlled environment: This specifier is primarily applicable to
individuals living in institutional or other settings where opportunities to
cross-dress are restricted.
 TRANSVESTIC DISORDER

DIAGNOSTIC CRITERIA
Specify if:
In full remission: There has been no distress or impairment in social,
occupational, or other areas of functioning for atleast 5 years while in an
uncontrolled environment.
 TRANSVESTIC DISORDER

SPECIFIERS
The presence of fetishism decreases likelihood of gender dysphoria in men
with transvestic disorder.

The presence of autogynephilia increases the likelihood of gender dysphoria in

men with transvestic disorder.
 TRANSVESTIC DISORDER

DIFFERENTIAL DIAGNOSIS
Fetishistic disorder. May resemble transvestic disorder, in particular, in men
with fetishism who put on women's undergarments while masturbating with
them.

Gender dysphoria. Individuals with transvestic disorder do not report an

incongruence between their experienced gender and assigned gender nor a
desire to be of the other gender; and they typically do not have a history of
childhood cross-gender behaviors, which would be present in individuals with
gender dysphoria.
 TRANSVESTIC DISORDER

COMORBIDITY
Transvestism is often found in association with other paraphilias with the most
frequently co-occuring being fetishism and masochism.
 OTHER SPECIFIED PARAPHILIC
DISORDER

• This category applies to presentations in which symptoms characteristic of a paraphilic

disorder that cause clinically significant distress or impairement in social, occupational,
or other important areas of functioning predominate but do not meet the full criteria for
any of the disorers in the paraphilic disorders diagnostic class.
• Examples of presentations that can be specified using the “other specified” designation
include, but are not limited to, recurrent and intense sexual arousal involving telephone
scatologia (obscene phone calls), necrophilia (corpses), zoophilia (animals), coprophilia
(feces), kismaphilia (enemas), or urophilia (urine) that has been present for at least 6
months and causes marked distress or impairment in social, occupational, or other
important areas of functioning. This can be specified a in remission and/or as occuring
in a controlled environment.
 UNSPECIFIED PARAPHILIC DISORDER

• This category applies to presentations in which symptoms characteristic of

a paraphilic disorder that cause clinically significant distress or impairment
in social, occupational, or other important areas of functioning predominate
but do not meet the full criteria for any of the disorders in the paraphilic
disorders diagnostic class.
• The unspecified paraphilic disorder category is used in situationsin which
the clinician chooses not to specify the reason the the criteria are not met
for a specific paraphilic disorder, and includes presentations in which there
is insufficient information to make a more specific diagnosis.