Treatment Implications of Psychological and Psychiatric Comorbidity of Paraphilias and Paraphilia-Re

The identification of consistent developmental events, psychological “traits,” or psychiatric comorbid diagnoses would be helpful in understanding developmental antecedents, risk factors, or possible pathophysiological correlates associated with PAs and PRDs. Such an understanding then would be beneficial in treatment planning. In addition, it may be imperative to assess, diagnose, and treat concurrent comorbid conditions to improve treatment efficacy for primary PAs or PRDs.

Many of the studies examining comorbid psychiatric disorders in sexually aggressive paraphilic individuals assess symptoms or symptom clusters derived from personality inventories, most commonly the Minnesota Multiphasic Personality Inventory (MMPI; Hathaway and McKinley 1943) (Anderson et al. 1979; Kalichman 1990; Langevin et al. 1990a, 1990b; McCreary 1975). The specificity of the MMPI, however, at least in the delineation of a sex offender typology, has not been adequately demonstrated (Marshall and Hall 1995; Schlank 1995), nor do these studies specifically identify psychiatric diagnoses as defined by DSM-III and DSM-IV Axis I nomenclature.

Clinical characteristics in paraphilic males, including sex offenders, identified by psychological rating instruments include substance abuse, especially alcohol abuse (Langevin and Langs 1990; Mio et al. 1986; Rada 1975); dysphoric affects, including anger/anxiety/depression (American Psychiatric Association 1994; Becker et al. 1991; Fagan et al. 1991; Grossman and Cavanaugh 1990; Kavoussi et al. 1988; Proulx et al. 1996; Wise et al. 1991); social anxiety with concomitant social skills/attachment deficits (Baxter et al. 1984; Levin and Stava 1987; Marshall 1989; Ward et al. 1995); lifestyle impulsivity (Knight and Prentky 1990; Prentky and Knight 1986); and psychopathy (Seto and Barbaree 1997). Paraphilic men are usually regarded as heterogeneous, at least in regard to these psychological attributes.

Several small-scale studies have used current psychiatric (DSM-III or DSM-IV) diagnoses assessed in paraphilic males, including sex offenders. Axis I disorders identified include conduct and attention-deficit/hyperactivity disorder (ADHD) (Fago 1999; Hunter and Goodwin 1992; Kafka and Prentky 1998; Kavoussi et al. 1988; Vaih-Koch and Bosinski 1999), mood disorders (Kafka and Prentky 1994, 1998; Kruesi et al. 1992; McElroy et al. 1999; Raymond et al. 1999), anxiety disorders (Kafka and Prentky 1994, 1998; McElroy et al. 1999; Raymond et al. 1999), and psychoactive substance abuse (alcohol) (Kafka and Prentky 1994, 1998; McElroy et al. 1999; Raymond et al. 1999). The great majority of PA (and PRD) males are not psychotic, and despite the characterization of their sexual behavior as “compulsive,” only a minority (11%-15%, as assessed in the aforementioned studies) have comorbid obsessive-compulsive disorder. In all of the aforementioned studies, several lifetime comorbid Axis I diagnoses were identified for the average subject.

Developmental factors are presumed to be significant determinants differentiating sexually aggressive paraphilic individuals from those whose sexual impulsivity does include sexual assault. In sexual aggressors, a history of physical/sexual abuse (Hanson and Slater 1988), paternal alcoholism and antisocial personality (Langevin et al. 1985), and family instability with inconsistent limit setting (Langevin et al. 1985; Prentky et al. 1989; Rada 1978) are hypothesized to contribute to general antisocial behavior, including sex offending.

Studies of comorbid Axis I disorders in nonoffending paraphilic individuals are very limited. Many authors have anecdotally commented on the “thrill-seeking” characteristics of hypersexual men in general (Carnes 1983; Stoller 1975; Wise et al. 1991). Person (1989) noted that, as a general characteristic, paraphilic individuals who present for treatment are “depression prone.” Perhaps the best-studied group of nonoffending paraphilic individuals are fetishistic transvestites. Individuals in this group have been found to report a high incidence of anxiety, depression, impulsivity, interpersonal sensitivity, and social alienation, as measured by (non-DSM-III-R related) symptom rating scales (Fagan et al. 1988; Wilson and Gosselin 1980; Wise et al. 1991), but as G. R. Brown and colleagues (1996) noted in their report of a study of “non-patient” transvestites, these characteristics could also have been associated with social distress and help seeking (G. R. Brown et al. 1996).

Family psychopathology has been suggested to play a role in the developmental pathway to PRDs (Anderson and Coleman 1990; Carnes 1983, 1991; Coleman 1995), but lack of a control group limits these findings. The reported prevalence of childhood physical and sexual abuse in persons diagnosed with PRDs varies from 19% (N = 63 consecutively evaluated male PRDs [Kafka and Hennon 1999]) to approximately 80% (N = 289 male/female “sex addicts” including paraphilic individuals [Carnes 1991]; N = 290 male/female “sex addicts” including paraphilic individuals [Carnes and Delmonico 1996]). These marked discrepancies are likely due to differences in both sample ascertainment and sample composition. It is certainly possible that specific developmental trauma or conditions such as sexual abuse, repetitive preadolescent exposure to sexually implicit or explicit behavior, early exposure to pornography, preadolescent or early adolescent sexual experience, or overly restrictive prohibitions regarding the normalcy of both sexual and affectionate expression could be risk factors that affect a vulnerable child or adolescent and predispose to PAs and/or PRDs.

In the few studies that have systematically evaluated Axis I diagnoses in “sexually compulsive” males and females (Black et al. 1997) or in males with PRDs (Kafka and Prentky 1994, 1998), one of the major findings is that, like paraphilic individuals, most subjects with these disorders have multiple lifetime comorbid mood, anxiety, psychoactive substance abuse, and/or other impulse disorder diagnoses. For example, Black found, in 36 male and female respondents to an advertisement for “compulsive sexual behavior,” a lifetime prevalence of any psychoactive substance abuse (64%, primarily alcohol abuse), any anxiety disorder (50%, especially phobic disorders), any mood disorder (39%, major depression and dysthymia), and an unspecified but significant total incidence of impulse-control disorders, including compulsive buying. Kafka and Prentky (1994, 1998), studying two outpatient male samples, reported that the typical male with PRDs without PAs (combined sample N = 44) had multiple lifetime Axis I disorders, including any mood disorder (61%-65%, especially dysthymic disorder), any psychoactive substance abuse (39%-47%, especially alcohol abuse), any anxiety disorder (43%-46%, especially social phobia), ADHD (17%), and any impulse-control disorder (7%-17%). It is of clinical interest that in both of these studies, males with PRDs did not differ significantly from males with PAs in lifetime prevalence of mood, anxiety, psychoactive substance abuse, or impulse-control disorders. In the 1998 study, however, males with PAs were more likely than males with PRDs to be retrospectively diagnosed with ADHD.

Although I was unable to find a systematic study of Axis I disorders in the “sexual addiction” literature, it is noteworthy that several authors have reported “depression” (Blanchard 1990; Turner 1990) and other impulse-control disorders or behavioral addictions (Carnes 1991; Carnes and Delmonico 1996) in recovering sex addicts.

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Revision date: July 8, 2011
Last revised: by Tatiana Kuznetsova, D.M.D.