Defining And Conceptualizing The Paraphilias

Paraphilias are defined as psychosexual disorders in which significant distress or impairment in an important domain of functioning results from recurrent, intense sexual urges, fantasies, or behaviors generally involving an unusual object, activity, or situation (5). Although the DSM-IV-TR lists eight specific paraphilias, paraphilia as a broad category represents a heterogeneous group of disorders and diverse behavioral expressions. The DSM-IV-TR defines three subtypes of paraphilias:

those involving nonhuman objects, those involving the suffering or humiliation of oneself or one's partner, those involving children or other nonconsenting persons.

The minimum time duration for a fantasy, urge, or behavior to qualify as a disorder is 6 months. Recurrent by definition, the paraphilias are generally chronic and lifelong, although the associated fantasies, urges, and behaviors diminish over the life span in some adults. Paraphilic fantasies and urges may vary in frequency and intensity over time, often beginning in childhood or adolescence and intensifying in adulthood. Acute episodes may occur and, in some individuals, resolve quickly with treatment. The paraphilic fantasy or behavior may be obligatory, or required for arousal, or nonobligatory, where an individual experiences arousal in response to other erotic stimuli as well. It may be nonobligatory in early life but become increasingly obligatory over time or with increased engagement with the pattern. Individuals with one paraphilia may be prone to develop others, and multiple paraphilias in one individual appear to occur with high frequency (6,7).

The present diagnostic categorizing system, in which paraphilias are defined according to the specific deviant focus, implies that each paraphilia represents a distinct disease process. Difficulties stemming from this conceptualization are apparent in the common scenario of multiple paraphilias co-occurring in one individual, where the multiple paraphilia conceptualization suggests that each paraphilic interest in the individual represents a distinct pathological phenomenon. No clear evidence exists for such an assertion and, further, it is more clinically useful to conceptualize the scenario as multiple paraphilic variations reflecting a shared underlying phenomenon. Lehne and Money proposed the term "multiplex paraphilia," noting variations of paraphilic content expressed over an individual's life span, but all influenced by a common underlying deficit or etiological process (7,8).

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