- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
- Inpatient treatment indications
- Patients are suicidal, homicidal, or gravely disabled (Suicide risk is high if they feel exposed or confronted.)
- Patients are dangerous to themselves, others, or cannot take care of themselves
- Psychotherapy
- Cognitive-behavioral therapy: This type of therapy involves applying behavioral therapy techniques to modify the patient's sexual deviations by altering distorted thinking patterns and making patients cognizant of the irrational justifications that lead to their sexual variations. This therapy also incorporates relapse prevention techniques, helping the patient to control the undesirable behaviors by avoiding situations that may generate initial desires. Many times, therapists apply the technique of "covert sensitization," in which patients' harmful sexual variation is paired with an unpleasant stimulus, such as that of a person with alcoholism who is administered Antabuse, in order to deter them from repeating the act. This approach has been proven effective in cases of pedophilia and sadism.
- Another technique employed by therapists is that of orgasmic reconditioning. In this approach, a patient is reconditioned to a more appropriate stimulus by masturbating to his or her typical, less socially acceptable stimulus. Then, just before orgasm, the patient is told to concentrate on a more acceptable fantasy. This is repeated at earlier times before orgasm until, soon, the patient begins his masturbation fantasies with an appropriate stimulus.
- Social skills training: Because many believe that paraphilias develop in patients who lack the ability to develop relationships, many therapists and physicians use social skills training to treat patients with these types of disorders. They may work on such issues as developing intimacy, carrying on conversations with others, and assertive skills training. Many social skills training groups also teach basic sexual education, which is very helpful to this patient population.
- Twelve-step programs: Many physicians and therapists refer patients with paraphilias to 12-step programs designed for sexual addicts. Similar to alcoholics anonymous, these programs are designed to give control to group members, who lead most of the sessions. The program incorporates cognitive restructuring with social support to increase awareness of the problem. The group also focuses on the sense of a "higher power" and each individual's reliance upon his or her spirituality.
- Group therapy: This mode of therapy involves breaking through the denial so commonly found in people with paraphilias by surrounding them with other patients who share their illness. Once they begin to admit that they have a sexual divergence, the therapist begins to address individual issues such as past sexual abuse or other problems that may have led to the sexual disorder. When these issues have been identified, beginning Gestalt-type therapy (with the victim, if any) may be desirable to help patients get past the guilt and shame associated with their particular paraphilia. The goal of this type of therapy is to lead the patient to a "healthy remorse." These patients require lifetime therapy in order to reduce the likelihood of relapse.
- Individual expressive-supportive psychotherapy: This type of therapy requires a psychologically minded patient willing to focus on the paraphilia. The therapist should not set high goals but needs to break through the denial. Countertransfence and avoidance of the patient can be a problem with this form of therapy. If the patients can break through the denial, then the patient can work on the unconscious meaning behind the paticular paraphila.
- Medications
- Antidepressants
- Long-acting gonadotropin-releasing hormones (GnRH, ie, medical castration)
- Antiandrogens
- Phenothiazine
- Mood stabilizers
- Sex education and therapy
- Social skills and training
Surgical Care
Surgical castration
Consultations
- Neurologist, if neurological signs are present
- Attorney
- Pastor
Activity
Restrict activity if patients represent a danger to themselves, to others, or if they are gravely disabled.
Medication
The goals of pharmacotherapy are to reduce morbidity and prevent complications.
Antidepressants
May be used to decrease aggression and treat underlying illness.
Fluoxetine (Prozac)
Antidepressant (SSRI) used to treat impulse control problems or underlying illness. Selectively inhibits presynaptic serotonin reuptake with minimal or no effect in the reuptake of norepinephrine or dopamine.
Adult
10-80 mg PO qd
Pediatric
<18 years: Not established; initial dose of 20 mg/d in children aged 6-14 y has been used
>18 years: Administer as in adults
Increases toxicity of diazepam and trazodone by decreasing clearance; also increases toxicity of MAOIs and highly protein-bound drugs
Documented hypersensitivity; concurrently taking MAOIs or having taken them in the last 2 wk
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in hepatic impairment and history of seizures; discontinue MAOIs at least 14 d before initiating fluoxetine therapy
Lithium (Eskalith)
Indicated for treating bipolar disorder. Influences reuptake of serotonin and/or norepinephrine at cell membrane.
Adult
300 PO tid/qid
Pediatric
<6 years: Not established
6-12 years: 15-60 mg/kg/d PO tid/qid; not to exceed usual adult dose
>12 years: Administer as in adults
Lithium increases toxicity of thiazide diuretics, haloperidol, phenothiazines, neuromuscular blockers, carbamazepine, fluoxetine, and ACE inhibitors
Documented hypersensitivity; severe cardiovascular disease
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Lithium toxicity (ie, diarrhea, vomiting, tremor, ataxia, drowsiness, muscle weakness); lithium toxicity is closely related to serum levels and can occur at therapeutic doses; serum lithium determinations are required to monitor therapy
Antiandrogens
Used to reduce androgen serum levels.
Medroxyprogesterone (Depo-Provera)
Derivative of progesterone. Used for breast cancer, contraception, secondary amenorrhea, and abnormal uterine bleeding. May be used to reduce sex drive.
Adult
150 mg IM qd/qwk/qmo usually adjusted based on patient response, tolerance, and/or plasma testosterone
Pediatric
Not recommended
May decrease effects of aminoglutethimide
Documented hypersensitivity; cerebral apoplexy; undiagnosed vaginal bleeding; thrombophlebitis; liver dysfunction
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Caution in asthma, depression, renal or cardiac dysfunction, or thromboembolic disorders
Phenothiazines
Are effective in treating emesis possibly due to their effects in the dopaminergic mesolimbic system.
Fluphenazine (Prolixin)
Antipsychotic used to treat underlying illness or decrease aggression.
Adult
1-10 mg PO qd
Pediatric
Administer as in adults
Potentiates CNS depressant effects of benzodiazepines; dronabinol and THC; entacapone; ethanol; general anesthetics; skeletal muscle relaxants; opiate agonists; zaleplon and zolpidem; anxiolytics, sedatives, and hypnotics; potentiates anticholinergic effects of amantadine, benztropine, clozapine, cyclobenzaprine, dicyclomine, diphenoxylate, disopyramide, hyoscyamine, maprotiline, meclizine, molindone, orphenadrine, oxybutynin, propantheline, tolterodine, and trihexyphenidyl
Documented hypersensitivity; narrow-angle glaucoma
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Drowsiness, headache, insomnia, hypertension, blurred vision, dry mouth, and weight gain; endocrine changes (eg, amenorrhea, menstrual irregularity, breast enlargement or mastalgia, libido decrease, impotence, ejaculation dysfunction, priapism) have occurred
Anxiolytics
These agents help induce impulse control.
Buspirone (BuSpar)
Unique anxiolytic that differs from benzodiazepines in that it does not exert anticonvulsant or muscle relaxer for GAD. A 5-HT1 agonist with serotonergic neurotransmission and some dopaminergic effects in CNS. Has anxiolytic effect but may take as long as 2-3 wk for full efficacy.
Adult
15 mg/d PO divided tid and increase by 5 mg/d q2-4d; titrate to 20-60 mg/d; not to exceed 60 mg/d
Pediatric
Not established
Toxicity is increased with MAOIs, phenothiazines, and CNS depressants; increases toxicity of digoxin and haloperidol
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Interference with motor performance, binds to dopamine receptor (some concern with dystonia, TD, and akathisia); caution in hepatic or renal impairment
Long-acting gonadotropin-releasing hormones
These agents are used to reduce release of gonadotropin hormones.
Triptorelin (Trelstar)
Synthetic decapeptide agonist analog of GnRH also known as luteinizing hormone–releasing hormone (LHRH). Reduces LH, FSH, and testosterone, which may lead to reduced sex drive.
Adult
3.75 mg IM qmo
Pediatric
Not established
Drugs that increase prolactin (eg, antipsychotics, cimetidine, methyldopa, metoclopramide, reserpine) down-regulate number of pituitary GnRH receptors
Documented hypersensitivity; pregnancy; spinal cord compression; spinal metastases; prostate cancer
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Tumor flare, hot flushes, loss of libido, breast tenderness or fullness, nausea, diarrhea, bone demineralization
Mood stabilizer
These agents are used to treat bipolar disorders.
Divalproex sodium (Depakote)
Indicated for manic episodes associated with bipolar disorder. Recommended plasma concentration is 50-125 µg/mL.
Adult
750 mg PO qd in divided doses initially;
60 mg/kg/d maximum
Pediatric
10-15 mg/kg/d PO initially; 60 mg/kg/d maximum
Coadministration with cimetidine, salicylates, felbamate, and erythromycin may increase toxicity; rifampin may significantly reduce valproate levels; in pediatric patients, protein binding and metabolism of valproate decrease when taken concomitantly with salicylates; coadministration with carbamazepine may result in variable changes of carbamazepine concentrations with possible loss of seizure control; valproate may increase diazepam and ethosuximide toxicity (monitor closely); valproate may increase phenobarbital and phenytoin levels while either one may decrease valproate levels; valproate may displace warfarin from protein binding sites (monitor coagulation tests); may increase zidovudine levels in HIV-seropositive patients
Documented hypersensitivity; hepatic disease/dysfunction; hyperammonemic encephalopathy and urea cycle disorders
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Thrombocytopenia and abnormal coagulation parameters have occurred; the risk of thrombocytopenia increases significantly at total trough valproate plasma concentrations >110 mcg/mL in females and 135 mcg/mL in males; at periodic intervals and prior to surgery, determine platelet counts and bleeding time before initiating therapy; reduce dose or discontinue therapy if hemorrhage, bruising, or a hemostasis/coagulation disorder occurs; hyperammonemia may occur, resulting in hepatotoxicity; monitor patients closely for appearance of malaise, weakness, facial edema, anorexia, jaundice, and vomiting; may cause drowsiness
More on Paraphilias |
| Overview: Paraphilias |
| Differential Diagnoses & Workup: Paraphilias |
 Treatment & Medication: Paraphilias |
| Follow-up: Paraphilias |
| References |
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Further Reading
Keywords
sexual urges, sexual fantasies, masturbation, voyeurism, frotteurism, zoophilia, exhibitionism, fetishism, pedophilia, sexual masochism, sexual sadism, transvestic fetishism, scopophilia, scatologia, necrophilia, partialism, coprophilia, klismaphilia, urophilia, autogynephilia, asphyxiophilia, hypoxyphilia, autoerotic asphyxiation, infantophilia, video voyeurism
