An integrated model to assess and treat compulsive sexual behaviour disorder.

Contrary to common belief, hypersexual or compulsive sexual behaviour disorder is not a current fashion diagnosis. Nevertheless, the introduction of dedicated diagnostic guidelines for International Classification of Diseases 11th Revision (ICD-11) brings an opportunity for more accurate diagnosis and, therefore, improved research into the disorder's aetiology, assessment and therapy. A considerable proportion of both men and women consider themselves to have a problem with pornography and an even greater proportion experience their sexual behaviour as insufficiently controllable. For these people, the interplay between excitatory and inhibitory factors could be in dysbalance. In this context, biological correlates are important, but social factors, such as negative attitudes towards pornography or hostile attitudes to sexuality, also have a role. In patients with compulsive sexual behaviour disorder, excessive pornography consumption, masturbation and/or promiscuity that are out of control and lead to distress and impairment are usually present. Differential diagnoses, such as neuropsychiatric syndromes that can exhibit hypersexuality as a symptom, such as frontal lobe lesions, should be investigated and treated, as should comorbid disorders such as depression. Therapeutic approaches can be based on the Dual-Control Model and the Sexual Tipping Point Model. In each patient, an individualized therapeutic approach is multimodal and includes psychopharmaceuticals such as selective serotonin reuptake inhibitors and naltrexone as well as specific psychotherapeutic approaches. The efficacy of some therapeutic approaches has now also been supported by initial randomized controlled trials in this patient population.

[Review of cases of zoophilia in patients with Parkinson's disease]. / Revision de casos de zoofilia en pacientes con enfermedad de Parkinson.

INTRODUCTION: Parkinson's disease (PD) is characterized by motor symptoms such as bradykinesia, rigidity, alteration of postural reflexes and tremor at rest and other non-motor symptoms such as changes in sleep patterns and sexual behavior. However, little is known about paraphilic sexual behaviors. AIM: To summarize the number of cases of zoophilic behaviors in patients with PD between January 2000 and December 2017. DEVELOPMENT: A review was carried out in PubMed, Scopus and Virtual Health Library. Eleven articles were identified by title; six were excluded because they did not present cases related to zoophilic behavior. We found five cases of men, usually with PD of several years of course, taking dopamine agonists and who presented the zoophilic behaviors followed increasing of the dose. The zoophilic behaviors decreased with reducing doses of dopamine agonists and taking atypical antipsychotic such as clozapine or quetiapine. CONCLUSIONS: It is limited the case reports of zoophilic behaviors in patients with PD. The patients reported are men in whom the dose of dopamine agonists was increased. It is important that the clinical follow-up of patients with PD disease includes a careful review of sexual behaviors including those of the paraphilic spectrum.

TITLE: Revision de casos de zoofilia en pacientes con enfermedad de Parkinson.Introduccion. La enfermedad de Parkinson (EP) se caracteriza por sintomas motores, como bradicinesia, rigidez, alteracion de reflejos posturales y temblor en reposo, y otros sintomas no motores, como cambios en el patron de sueño y el comportamiento sexual. Sin embargo, se conoce poco sobre los comportamientos sexuales parafilicos. Objetivo. Resumir el numero de casos de comportamientos zoofilicos en pacientes con EP entre enero de 2000 y diciembre de 2017. Desarrollo. Se realizo una revision en PubMed, Scopus y la Biblioteca Virtual en Salud. Se identificaron por el titulo 11 articulos; se excluyeron seis porque no presentaban casos relacionados con un comportamiento zoofilico. Se encontraron cinco casos de hombres, generalmente con EP de varios años de curso, polimedicados con agonistas dopaminergicos, quienes presentaron los comportamientos parafilicos despues del incremento de la dosis. Los comportamientos zoofilicos cedieron con la reduccion de la dosis de los agonistas dopaminergicos y antipsicoticos atipicos, como clozapina o quetiapina. Conclusiones. Es limitada la notificacion de casos de comportamientos zoofilicos en pacientes con EP. Los pacientes notificados son hombres en quienes se incremento la dosis de agonistas dopaminergicos. Es importante que el seguimiento clinico de los pacientes con EP incluya una revision de los comportamientos sexuales, incluidos los del espectro parafilico.

Zoophilia in an adolescent with high-functioning autism from Sri Lanka.

OBJECTIVE: Zoophilia is a rare paraphilic disorder with intense sexual urges involving animals. Autism is characterised by impairments in social communication and repetitive, restricted behaviours (RRB). Reported cases of zoophilia are limited worldwide, and zoophilia in autism is rarer. METHOD: This is a case report describing this unique and relatively unrecognised association in a male adolescent from Sri Lanka. RESULTS: A 17-year-old boy diagnosed with autism has average intelligence and academic capabilities. He had spent increasing time at his grandparents' cattle house. First, he was found masturbating near the cows and later having penetrative intercourse with a heifer. The shocked parents first sought traditional healing in the form of 'thovil', a demonic ritual of exorcist nature. Later, clinical evaluation found intense sexual urges towards cattle, which had led to marked distress and academic impairment. Sex hormone profile was normal. The adolescent was treated with a combination of cognitive-behaviour therapy and a selective serotonin reuptake inhibitor. CONCLUSION: We postulate that his persistent social difficulties contributed to the development of a paraphilic disorder. Unlike with his RRBs, he was markedly distressed about this sexual behaviour. Further research is required to explore this rarely reported, potential association.

Interpersonal violence, early life adversity, and suicidal behavior in hypersexual men.

Background and aims There are significant gaps in knowledge regarding the role of childhood adversity, interpersonal violence, and suicidal behavior in hypersexual disorder (HD). The aim of this study was to investigate interpersonal violence in hypersexual men compared with healthy volunteers and the experience of violence in relation to suicidal behavior. Methods This case-control study includes 67 male patients with HD and 40 healthy male volunteers. The Childhood Trauma Questionnaire - Short Form (CTQ-SF) and the Karolinska Interpersonal Violence Scale (KIVS) were used for assessing early life adversity and interpersonal violence in childhood and in adult life. Suicidal behavior (attempts and ideation) was assessed with the Mini-International Neuropsychiatric Interview (version 6.0) and the Montgomery-Åsberg Depression Rating Scale - Self-rating. Results Hypersexual men reported more exposure to violence in childhood and more violent behavior as adults compared with healthy volunteers. Suicide attempters (n = 8, 12%) reported higher KIVS total score, more used violence as a child, more exposure to violence as an adult as well as higher score on CTQ-SF subscale measuring sexual abuse (SA) compared with hypersexual men without suicide attempt. Discussion Hypersexuality was associated with interpersonal violence with higher total scores in patients with a history of suicide attempt. The KIVS subscale exposure to interpersonal violence as a child was validated using the CTQ-SF but can be complemented with questions focusing on SA for full assessment of early life adversity. Conclusion Childhood adversity is an important factor in HD and interpersonal violence might be related to suicidal behavior in hypersexual men.

Sexuality in autism: hypersexual and paraphilic behavior in women and men with high-functioning autism spectrum disorder.

Like nonaffected adults, individuals with autism spectrum disorders (ASDs) show the entire range of sexual behaviors. However, due to the core symptoms of the disorder spectrum, including deficits in social skills, sensory hypo- and hypersensitivities, and repetitive behaviors, some ASD individuals might develop quantitatively above-average or nonnormative sexual behaviors and interests. After reviewing the relevant literature on sexuality in high-functioning ASD individuals, we present novel findings on the frequency of normal sexual behaviors and those about the assessment of hypersexual and paraphilic fantasies and behaviors in ASD individuals from our own study. Individuals with ASD seem to have more hypersexual and paraphilic fantasies and behaviors than general-population studies suggest. However, this inconsistency is mainly driven by the observations for male participants with ASD. This could be due to the fact that women with ASD are usually more socially adapted and show less ASD symptomatology. The peculiarities in sexual behaviors in ASD patients should be considered both for sexual education and in therapeutic approaches.

Al igual que los adultos normales, los sujetos con trastornos del espectro autista (TEA) presentan toda la gama de conductas sexuales. Sin embargo, debido a los síntomas centrales del espectro del trastorno, que incluyen déficits en las destrezas sociales, hiper e hipo sensibilidad sensorial y conductas repetitivas, algunos sujetos con TEA pueden desarrollar intereses y conductas sexuales hipernormales o no habituales. Se revisa la literatura más relevante sobre la sexualidad en sujetos con TEA de alto funcionamiento y se presentan los nuevos hallazgos provenientes de los estudios del grupo de trabajo sobre la frecuencia de las conductas sexuales normales y sobre la evaluación de las conductas y fantasías hipersexuales y parafílicas. Al parecer los sujetos con TEA tienen más conductas y fantasías hipersexuales y parafílicas que lo sugerido por estudios en población general. Sin embargo, esta inconsistencia se debe principalmente a las observaciones realizadas en los hombres con TEA. Esto podría deberse al hecho que las mujeres con TEA están más adaptadas socialmente y presentan menos síntomas del TEA. Las peculiaridades en la conducta sexual de los pacientes con TEA deben ser tomadas en cuenta para la educación sexual y en los abordajes terapéuticos.

Comme les adultes non atteints, les personnes ayant un trouble du spectre de l'autisme (TSA) présentent le tableau complet des comportements sexuels. Cependant, certaines personnes ayant un TSA peuvent développer des intérêts et comportements sexuels hypernormaux ou non standard, à cause des symptômes fondamentaux du trouble, comme les déficits de socialisation, les hyposensibilités et hypersensibilités et les comportements répétitifs. Après une analyse de la littérature pertinente sur la sexualité des personnes ayant un TSA de haut niveau, nous présentons des données nouvelles, issues de notre propre étude sur la fréquence des comportements sexuels normaux et sur l'évaluation des comportements et fantasmes hypersexuels et paraphiliques chez les personnes ayant un TSA : celles-ci semblent avoir de tels comportements plus souvent que les études de population générale ne le suggèrent. Cependant, cet écart est principalement le fait des observations des participants masculins ayant un TSA, peut-être parce que les femmes ayant un TSA sont habituellement plus adaptées socialement et moins symptomatiques. Les particularités des comportements sexuels des patients ayant un TSA devraient être prises en charge à la fois pour une éducation sexuelle et des approches thérapeutiques.

Hypersexuality, Paraphilic Behaviors, and Gender Dysphoria in Individuals with Klinefelter's Syndrome.

INTRODUCTION: An increased risk of autistic traits in Klinefelter syndrome (KS) has been reported. In addition, some studies have shown an increased incidence of gender dysphoria (GD) and paraphilia in autism spectrum disorder. AIM: The aim of this study was to evaluate the presence of (i) paraphilic fantasies and behaviors; and (ii) GD symptomatology in KS. METHODS AND MAIN OUTCOMES MEASURES: A sample of 46 KS individuals and 43 healthy male controls (HC) were evaluated. Subjects were studied by means of several psychometric tests, such as Autism Spectrum Quotient (AQ) and Reading the Mind in the Eyes Revised (RME) to measure autistic traits, Gender Identity/GD questionnaire (GIDYQ-AA), and Sexual Addiction Screening Test (SAST). In addition, body uneasiness psychopathological symptoms were assessed using Symptom Checklist 90 Revised (SCL-90-R). The presence and frequency of any paraphilic fantasy and behavior was assessed by means of a clinical interview based on Diagnostic and Statistical Manual of Mental Disorders, 5th Edition criteria. Finally, all individuals included were assessed by Wechsler Adult Intelligence Scale-Revised to evaluate intelligence quotient (IQ). Data from a subsample of a previous published series of male to female GD individuals, with the battery of psychological measures useful to provide a psychopathological explanation of GD in KS population available, was also considered. RESULTS: When compared with HC, KS reported significantly lower total, verbal and performance IQ scores and higher SCL-90 obsession-compulsive symptoms (all P < 0.001). In line with previously reported findings, KS showed higher autistic traits according with both RME and AQ tests (P < 0.001). With respect to sexuality, KS showed a significant higher frequency of voyeuristic fantasies during masturbation (52.2% vs. 25.6%) and higher SAST scores (P = 0.012). A mediation role of obsessive symptoms on the relationship between Klinefelter and SAST was confirmed (unstandardized estimate b = 2.75, standard error = 0.43 P < 0.001). Finally, KS individuals showed significantly higher gender dysphoric symptoms than HC (P = 0.004), which were mediated by the presence of autistic traits (Sobel's test; P < 0.05). CONCLUSIONS: KS is associated with hypersexuality, paraphilic behaviors, and GD, which were mediated by obsessive-compulsive and autistic traits.

Paraphilias and paraphilic disorders in Parkinson's disease: A systematic review of the literature.

Paraphilias are intense urges or behaviors involving non-normative sexual interests. The newly approved diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) have established that, although paraphilias should not be regarded as inherently pathological, they ought to be qualified as paraphilic disorders if resulting in distress, impairment, or harm to the affected individual or others. Recent evidence documents that both phenomena can emerge as relatively uncommon iatrogenic consequences in Parkinson's disease (PD) patients. To outline the clinical characteristics of paraphilias and paraphilic disorders in PD patients, we summarized the available evidence on these phenomena. The review encompasses all studies on paraphilias in PD patients identified by a search on the Pubmed and Scopus online databases through May 2014. Twenty-two case reports on a total of 31 PD patients with paraphilias or paraphilic disorders were identified. These phenomena were typically associated with dopaminomimetic treatment (with a mean levodopa-equivalent daily dose of 1,303 ± 823 mg/d) in male patients with motor complications, young age at PD onset, and long disease duration. Paraphilias were highly concomitant with impulse-control disorders or dopamine dysregulation syndrome. Although evidence on paraphilias and paraphilic disorders in PD patients remains anecdotal, available data point to these phenomena as likely sequelae of high-dose dopaminomimetic treatment. Accordingly, the intensity of paraphilic urges is typically attenuated by the reduction of dopaminomimetic doses, sometimes in association with atypical antipsychotics. Failure to recognize paraphilic disorders may significantly impair the relational functioning of the affected PD patients. Practitioners should routinely inquire about paraphilias during their clinical assessment of PD patients.

Paraphilia or perversion?

Human sexual instincts can become fixated on a wide variety of targets, resulting in behaviours ranging from harmless fetishism to child abuse. The recent flood of investigations into historic cases in the UK has brought child protection issues to the top of the news agenda and shown that society is still far from addressing these problems in a rational, evidence-based way maximising harm reduction.

Abuso sexual na infância e desenvolvimento da pedofilia: revisão narrativa da literatura / Child sexual abuse and development of pedophilia: a narrative review of the literature

Abuso sexual na infância pode acarretar várias consequências: desde danos psicológicos até alterações funcionais e mudanças na estrutura anatômica cerebral. Pode contribuir para a instalação de quadros psicopatológicos na idade adulta, como é o caso da pedofilia. Com o avanço da neurobiologia, novos estudos vêm sendo propostos no sentido de identificação das alterações biológicas e do desenvolvimento de psicopatologia a partir da vivência do trauma. Alterações neurobiológicas consequentes à vivência de abuso sexual podem estar relacionadas ao desenvolvimento da pedofilia. A literatura mostra pontos em comum dessas situações, o que pode ajudar no esclarecimento da gênese dessa parafilia, bem como propor medidas de prevenção. Os trabalhos reforçam a necessidade de integração de várias áreas de investigação e de mais estudos nessa direção.

[Urinary disorders, sexual dysfunction and hypersexuality in Parkinson's disease]. / Trastornos urinarios, disfunción sexual e hipersexualidad en la enfermedad de Parkinson.

INTRODUCTION: As Parkinson's disease progresses, its non-motor manifestations become increasingly more apparent to the point where, in advances phases of the disease, they are the most important clinical symptoms. A very wide range of non-motor symptoms can appear in Parkinson's disease. Impairment of the urinary function and the sexual function (understood as the capacity to carry out sexual activity) can be seen as belonging to the dysautonomic disorders. Hypersexuality would be included within the group of impulse control disorders. DEVELOPMENT: This study reviews the epidemiology, phenomenology and treatment of urinary disorders, sexual dysfunction and hypersexuality as non-motor symptoms of Parkinson's disease. CONCLUSIONS: Urinary disorders are the most frequent non-motor symptom in Parkinson's disease. They usually present as nocturia, urgency and increased mictional frequency (pollakiuria). Preferred treatment is with anticholinergic agents. Sexual dysfunction is a frequent complaint in patients with Parkinson. It has a multifactorial aetiology and is more frequent in males than in females. In males it manifests mainly as incapacity to achieve an erection, premature ejaculation or loss of the capacity to ejaculate, whereas in females the predominant signs are decreased libido, lowered arousal and difficulty in reaching an orgasm. Hypersexuality affects young males above all and has been related to the use of dopamine agonists.

"Sleeping Beauty paraphilia": deviant desire in the context of bodily self-image disturbance in a patient with a fronto-parietal traumatic brain injury.

BACKGROUND: Several case series and reports describe paraphilia as occurring after brain damage, mostly in the frontal lobes and diencephalic structures. Hypersexuality and paraphilic behaviors are also documented in a variety of other neurologic disorders, (e.g., Kluver Bucy syndrome, and more rarely in multiple sclerosis). In multiple sclerosis, hypersexual behavior and paraphilias have been associated with various focal brain lesions in the frontal and temporal lesions when inflammatory demyelination involves the hypothalamus and septal regions. CASE REPORT: A case of a patient who developed a particular and progressive sexual deviant behaviour after a head trauma. This men felt sexually aroused from seeing sleeping women as well as from taking care of their hands and nails while they were asleep. The patient was diagnosed with a moderate dysexecutive syndrome characteristic of a frontal disorder and a very specific parietal-related bodily self image disorder characterized by an incomplete mental image of his hands. The clinical hypothesis was that the paraphilia might be related to his post-traumatic disturbed bodily self image and more specifically to its related impulsive needs to complete his hands representation. CONCLUSIONS: This case report highlights the potential link between paraphilia, deviant and aggressive sexual behaviour, neurological disturbance and self-representation. The treatment of paraphilias remains very complex, and requires taking into account not only the social and psychological aspects of the disease, but also its organic dimensions.

Erotic target location errors: an underappreciated paraphilic dimension.

Based on studies of heterosexual male fetishists, transvestites, and transsexuals, Blanchard (1991) proposed the existence of a hitherto unrecognized paraphilic dimension, erotic target location errors (ETLEs), involving the erroneous location of erotic targets in the environment. ETLEs can involve preferential attention to a peripheral or inessential part of an erotic target, manifesting as fetishism, or mislocation of an erotic target in one's own body, manifesting as the desire to impersonate or become a facsimile of the erotic target (e.g., transvestism or transsexualism). Despite its potential clinical and heuristic value, the concept that ETLEs define a paraphilic dimension is underappreciated. This review summarizes the studies leading to the concept of ETLEs and describes how ETLEs are believed to manifest in men whose preferred erotic targets are women, children, men, amputees, plush animals, and real animals. This review also describes ETLEs in women; discusses possible etiologies of ETLEs; considers the implications of the ETLE concept for psychoanalytic theories of transvestism and male-to-female transsexualism, as well as for the forthcoming revision of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; suggests reasons why the concept of ETLEs has been underappreciated; and describes what might result if the concept were more widely appreciated.

Pharmacotherapy for inappropriate sexual behaviors in dementia: a systematic review of literature.

The aim of this study is to systematically review the published literature on pharmacotherapy for inappropriate sexual behaviors in dementia. Literature search of the 5 databases (PubMed, MEDLINE, EMBASE, PsychINFO, and COCHRANE collaboration) and the analysis of the data available for the pharmacotherapeutic treatments of inappropriate sexual behaviors in dementia were carried out. There are no published randomized controlled trials of pharmacotherapy for inappropriate sexual behaviors in dementia, but available data form uncontrolled trials, case series, and individual case reports suggest efficacy for antidepressants, antipsychotics, mood stabilizers, hormonal agents, cimetidine, and pindolol for the treatment of these behaviors. Although there are no controlled data for the treatment of inappropriate sexual behaviors in dementia, available data suggest efficacy for some commonly used pharmacotherapeutic agents.

[Review of symptoms and therapy of paraphylias]. / A parafíliák tünettanák és terápiajának áttekintése.

The authors review the historical main milestones in the legislative aspects of sexual deviances, from ancient times through age of enlightenment to present times, including the factors affecting the Hungarian public attitudes towards it. The evolution of nomenclature of sexual orientation disorders is also evaluated thoroughly, detailing the DSM-IV-TR classification and the attempts and difficulties to further develop the present classification system. The authors also review the difficulties of epidemiological studies and sum up the pioneer work of Alfred Kinsey. The etiology of paraphylias is summed up based on biological, psychodynamic and learning theory approaches. Finally, the pharmacological and psychotherapeutic interventions are evaluated considering also comorbidity, outer control and forensic psychiatric aspects.

Sexual revictimization: the role of sexual self-esteem and dysfunctional sexual behaviors.

Disproportionately high rates of sexual revictimization have been noted among former victims of child sexual abuse (CSA), yet researchers have yet to determine the source of this apparent vulnerability to reexperience sexual violence. This study explores this issue by examining sexual self-esteem, sexual concerns, and sexual behaviors among 402 university women. Compared to women without a history of CSA (n = 348), women with a history of CSA (n = 54) had lower sexual self-esteem, poorer sexual adjustment, and were 2 times more likely to have experienced sexual assault since the age of 14 years. Structural equation modeling indicated that the relationship between child abuse (i.e., CSA and child psychological maltreatment) and sexual revictimization was partially mediated by sexual self-esteem, sexual concerns, and high-risk sexual behaviors. This study emphasizes the need for further research on child maltreatment, revictimization, and women's sexual adjustment.