Articles, Newsletters, Podcasts, and Video
In this series, I dig a little deeper into the meaning of psychology-related terms. This week, we’ll look at paraphilic disorders.
Paraphilias involve atypical patterns of sexual arousal. Paraphilic disorders are a more extreme version of paraphilias, involving arousal patterns that are a) intense and persistent and b) cause significant distress or functional impairment or cause harm to nonconsenting others.
Types of paraphilic disorders
There are a variety of paraphilias, but the DSM-5 identifies these specific paraphilic disorders:
- pedophilic disorder (I’ve opted not to include this particular disorder in the scope of this post)
- voyeuristic disorder
- transvestic disorder
- exhibitionist disorder
- sexual masochism disorder
- sexual sadism disorder
- fetishistic disorder
- frotteuristic disorder
Individuals may have a combination of multiple paraphilic disorders.
In the DSM-5, the naming of these disorders was revised from the previous names in the DSM-IV to more clearly separate the paraphilias from the associated disorders. The American Psychiatric Association has explicitly stated that people who engage in consenting atypical sexual behaviour should not be inappropriately diagnosed with a disorder.
Most people who have voyeuristic interests don’t have voyeuristic disorder. It rises to the level of disorder when it involves repeated and intense arousal by secretly observing unsuspecting individuals (watching porn wouldn’t count towards this) as well as either acting out of urges with nonconsenting individuals or experiencing functional impairment. As an example of functional impairment, people may spend so much time searching for viewing opportunities that it interferes with work or other areas of functioning.
To be diagnosed, the condition must be present for at least 6 months, and the individual must be at least 18 years old. It’s estimated that as many as 12% of males and 4% of females have this condition, but most don’t seek out evaluation or treatment. The disorder tends to be chronic.
Most people who cross-dress don’t have transvestic disorder. This is a disorder of sexual arousal, not a question of what clothes people choose to wear. Arousal by items of clothing themselves is considered to be a form of fetishism, while transvestic disorder is arousal from wearing the clothing or fantasizing about doing so.
The disorder involves repeated and intense sexual arousal produced by cross-dressing, as well as clinically significant distress or impairment in functioning. The condition must be present for at least 6 months for a diagnosis.
Transvestic disorder occurs almost entirely in males. In the DSM-IV, the diagnosis was limited to heterosexual males, but this restriction was removed in the DSM-5. There may be a pattern of accumulating items that one feels aroused in, experiencing guilt and shame, and then purging these items.
Again, most people who are into exhibitionism don’t have an exhibitionist disorder. To be diagnosed with the disorder, there must be clinically significant distress or functional impairment, or else people have acted out their urges with a nonconsenting person. This may involve public masturbation.
This disorder is estimated to occur in about 2-4% of males, and it’s less common in females. There may be co-occurring antisocial personality disorder or conduct disorder.
Most people with the disorder don’t engage in physically aggressive sexual behaviours. Among those who offend criminally, recidivism rates are higher than other sex offenders, at 20-50%.
Sexual masochism disorders
Sexual masochism (being aroused by being humiliated or abused) is not a disorder; however, it can rise to the level of disorder when it causes clinically significant distress or impairment in functioning.
Sexual sadism disorder
Sexual sadism involves experiencing arousal from inflicting suffering on others. To be considered a disorder, it must involve either acting out urges on a nonconsenting person or clinically significant distress or impairment in functioning. The condition must be present for at least 6 months. It’s particularly problematic if it co-occurs with antisocial personality disorder.
The onset of sadistic activities tends to occur by early adulthood, and they often increase in severity over time.
Less than 10% of rapists are diagnosed with this disorder, but it’s much more common among people who have committed sexually-motivated homicides (37-75%).
Fetishes involve intense arousal by nonliving objects or specific nongenital body parts. The disorder involves clinically significant distress or impairment in functioning, and the fetishes don’t involve genital vibrators or clothing used in cross-dressing.
Frotteuristic disorder involves at least six months of recurrent and intense arousal involving touching or rubbing against a nonconsenting person, with either acting out on those urges or clinically significant distress or functional impairment. The acts typically take place in crowded environments, and they’re most commonly performed by those between the ages of 15 and 25.
According to Medscape, as many as 30% of men may experience frotteuristic disorder. That initially struck me as very high, but given how many allegations keep coming up of sexual misconduct, maybe that is accurate.
How/why they occur
These patterns are typically established by the time an individual reaches puberty (although in exhibitionist disorder, the onset is usually during adolescence). In general, paraphilias are more common in men, although it’s not clear why this is.
Their development may be influenced by trauma that impacts normal development or exposure to highly charged sexual experiences. Childhood sexual abuse is thought to be a key contributor.
Symbolism and accidental conditioning may also play a role. Abnormalities in brain functioning may be involved in the development of these disorders, but that remains unclear.
Sexologist Kurt Freund suggested that paraphilic disorders could arise from distortion of the courtship phases of search, pretactile interaction, tactile interaction, and genital union (i.e. sex).
Unsurprisingly, there are plenty of ideas on paraphilias from the field of psychoanalysis. For example, exhibitionists are thought to view their mothers as rejecting them based on their different genitalia. For an adult man, displaying his penis would be a way to prove his manhood to adult women and force them to accept him. In the case of fetishistic disorders, the fetish is seen as serving a defensive function as an adjunct to a penis whose potency is otherwise uncertain.
Paraphilic disorders are commonly comorbid with other conditions, including personality disorders, substance use disorders, anxiety disorders, or mood disorders. People with personality disorders involving low self-esteem or problems with anger management or delayed gratification are particularly vulnerable.
The majority of people with paraphilic disorders don’t seek out treatment voluntarily. No treatments for the actual paraphilias themselves have been identified, and interventions are aimed at managing behaviours.
Psychotherapy (particularly cognitive behaviour therapy) and support groups may be helpful. In the case of fetishistic disorder, treatment tends to be more effective when the focus is on underlying dynamics rather than the fetish itself.
Orgasmic reconditioning is a behavioural approach that involves masturbation beginning with the individual’s usual fantasies, and then switching to a more acceptable fantasy just before orgasm. This is repeated with the aim to substitute fantasies progressively earlier before orgasm.
SSRI antidepressants may have some benefit in some cases of voyeuristic disorder and exhibitionist disorder. Transvestic disorder doesn’t tend to respond to medications, but SSRIs may be helpful if there’s an OCD element present. Mood stabilizers may have some benefit in terms of impulse control in paraphilic disorders.
Antiandrogen drugs, like gonadotropin-releasing hormone analogues or medroxyprogesterone acetate, may be used to reduce testosterone levels. These drugs may be able to reduce behaviours that are likely to lead to arrest.
Sexual sadism disorder is generally not responsive to treatment.
I like that the DSM-5 makes a distinction between paraphilias and paraphilic disorders. Even if they do exist on a continuum, it makes sense to me to at least try to avoid unnecessarily pathologizing people and factor in actions directed at nonconsenting individuals. Then again, perhaps using behaviour that would be considered criminal as a deciding factor diagnostically is a bit weird.
What are your thoughts on this group of disorders?
- American Psychiatric Association: Paraphilic Disorders
- Medscape: Paraphilic Disorders
- Merck Manual Professional Version:
- StatPearls: Paraphilia
The Psychology Corner has an overview of terms covered in the What Is… series, along with a collection of scientifically validated psychological tests.
Losing Our Minds: The Challenge of Defining Mental Illness by psychologist Lucy Foulkes explains why it’s so hard to define what mental illness is and how it happens. The author herself has experienced mental illness, and while this is not a major focus in the book, I thought it was great that she did bring that perspective into it.
The author explains that it’s important to understand not only what mental illness is, but also what it isn’t. Regarding the medicalization of mental illness, she advocates for making a distinction between normal, unavoidable human distress and the more severe manifestations that constitute illness. The book takes a very middle ground kind of approach, acknowledging that psychological pain exists, causes distress, and is valid, but recognizing that not all suffering constitutes a disorder.
The first chapter looks at reported rates of mental illness in the population, breaking down what those numbers mean and questioning whether or not more people are experiencing mental illness now compared to in the past. I thought the author did a good job of taking readers through her process of evaluating different statistics and making it clear that numbers can’t simply be taken at face value.
The book then looks at the normal/disorder continuum and how that fits with categorical diagnostic systems like the DSM. Attention is given to various factors that can influence the development of mental illness in the areas of biology, environment, and the various processes going on during adolescence. The author takes the approach that mental illness is complex, and it can’t be reduced down to either all one thing, whether that’s biology or environment.
There’s an interesting chapter devoted to social media, and again, the author’s approach was very balanced. She addressed both positives and negatives associated with social media use, cautioning against oversimplification, especially when there isn’t a lot of data to go on. She suggested that social media may be more likely to reflect and amplify what’s already going on for individuals rather than create brand new issues. For example, cyberbullying is a problem, but most people who are being cyberbullied are also being bullied in their in-person world.
After looking at these different factors that can influence the development of mental disorders, the book returns to the question of whether mental illness is becoming more prevalent, as seems to be a common perception. The author points out how difficult this is to determine. For example, if suicide rates are going up, how much is that influenced by changes in reporting of suicides (in 2018, the standard for reporting suicides in England and Wales shifted from beyond a reasonable doubt to a balance of probabilities) or under-treatment of depression in children and adolescents due to the FDA black box warning on antidepressant use in this population group?
In the chapter devoted to language, the author advocates for reserving some language for serious illness rather than using the language of disorder to refer to all experiences of distress. She adds that linguistic inflation can contribute to people getting the wrong advice for what they’re actually experiencing.
The book ends with two chapters focused on getting help. The first is about professional help, the different forms that may take, and the reality of how difficult it can be to actually access. The final chapter looks at ways we can help ourselves and other people in our lives. The author reiterates that experiencing distress is hard, but it’s a fundamental part of being human, and not everything is immediately fixable.
I really liked this book. There’s so much talk of black and white in popular conversations about mental health and illness, and this book fully embraces the grey areas. The author skillfully validates both illness and non-illness experiences of suffering, while at the same time establishing that treating all experiences of suffering as though they’re the same or as though they’re all disordered doesn’t serve anybody.
The book brings together a lot of different ideas about mental illness in a very balanced way, making it clear that not every idea is going to match up with every individual’s experience. The author draws on a lot of research findings, but these are presented in an accessible way, with appropriate context to help readers understand what those pieces of information actually mean.
I was impressed by the way that the author presented the complexity of mental illness in a simplified way without sacrificing that inherent complexity or getting into reductionism. Overall, I thought that the book was extremely well done, and it will make an interesting read both for people who have personal experience with mental illness and those who do not.
Losing our Minds is available on Amazon (affiliate link).
I received a reviewer copy from the publisher through Netgalley.
Here’s what happened in my life over the past week:
- I hate GIFs, because concentrating to read text is hard enough without images dancing around, and it’s been a source of annoyance that Chrome’s settings don’t let you stop them from animating. This week I discovered the Animation Policy extension, which offers the options to either stop GIFs from playing or to let them play once and that’s it. This is a good thing.
- I am currently quite under-medicated, and the few things that used to hold some interest (blogging and guinea pigs) are doing nothing for me. Yet there are all these hours in a day and I have to do something with them. It makes for a rather tedious existence.
- Based on my WordPress feed, it looks like I’m not the only one who’s not feeling blogging right now.
How has your week been?more
In this series, I dig a little deeper into the meaning of psychological terms. This week’s term is melancholic depression, also known as depression with melancholic features.
The word melancholia comes from the Greek for black bile, part of the ancient four humours medical belief system. In the 5th century BCE, Hippocrates first identified melancholia as a disease with various mental and physical symptoms. In the 16th and 17th centuries, the idea of a melancholic temperament became fashionable in English art and literature.
What is now called depression with melancholic features has been referred to in the past as endogenous (as opposed to reactive) depression, and before that, melancholia.
In the DSM-5, the melancholic features specifier can be used to describe a major depressive episode (in major depressive disorder or bipolar disorder) with a certain cluster of symptoms. That symptom cluster includes:
- anhedonia (near-total inability to feel pleasure)
- lack of positive reaction to normally pleasurable things
- a quality of mood that’s distinct from grief/loss, i.e. it subjectively feels different
- early morning awakening
- psychomotor retardation (slowed movement and thinking) or agitation
- significant loss of appetite
- symptoms that are worse in the morning
- excessive/inappropriate guilt
Either symptom #1 or 2 must be present, in addition to at least 3 symptoms from #3-8. Symptom #5 (psychomotor changes) is nearly always present. The full criteria for a major depressive episode must be met, including the presence of symptoms almost all day, almost every day, for at least 2 weeks, with clinically significant distress or impairment in social and occupational functioning.
While many people experiencing a major depressive episode experience some of these symptoms, it’s this particular symptom cluster occurring together that gets labelled as melancholic features. There are many different potential combinations of symptoms in a major depressive episode, and not everyone who’s having a major depressive episode has a features specifier of any kind.
There’s some question as to whether melancholic depression represents a distinct illness from depression with atypical features, which involves a cluster of symptoms like increased sleep and appetite, mood reactivity to pleasurable stimuli, and leaden paralysis. At this point, though, the DSM’s categorical system treats them as different features of the same illness.
The biology of melancholia
There do appear to be differences in how melancholic depression affects the brain, including changes that can be seen on electroencephalogram (EEG) and MRI across groups of patients with melancholic vs. non-melancholic depression.
Melancholic depression appears to have a strong biological component, including a genetic element. There appear to be disruptions in the hypothalamic-pituitary-adrenal (HPA) axis that connects the brain and the adrenal glands, as well as elevated inflammation.
Despite these elements that have been observed across groups of patients, no biological feature has been identified, at least at this point, that’s a definite diagnostic marker.
Characteristics of melancholic depression
People with melancholic features tend to have relatively normal childhoods, and when well, they tend not to have significant problems with relationships and work functioning. The depression is more likely to be identified as an imposed illness rather than a logical reaction to life stressors.
Episodes can occur with no apparent situational triggers, and they tend to be more severe than one might expect given the situational circumstances. Melancholic episodes can also occur in response to minor, non-severe stressors, and researchers from Queen’s University have suggested that melancholic depression may be especially sensitive to stress. This would fit with the idea of inflammation playing some role in this particular form of depression.
The Lundby Study, a longitudinal community-based study in Sweden, showed that people whose first depressive episode had melancholic features were at a greater risk for recurrence of their depression compared to people with a non-melancholic first depressive episode.
Melancholic features have been associated with greater cognitive dysfunction than non-melancholic depression, including poorer processing speed, problem-solving, and visual memory. Psychotic features are also more common in this form of depression.
Researchers have observed deficits in reward-based learning tasks, meaning people are less likely to develop behaviours geared towards maximizing rewards. This may be related to dysfunction in dopamine signalling in the brain’s reward areas.
Response to treatment
Melancholic depression tends to respond better to biological treatments like antidepressants and electroconvulsive therapy (ECT) than it does to psychotherapy, and it’s less responsive to placebo than other forms of depression.
Some research has shown an improved response to antidepressants that target multiple neurotransmitter systems rather than just serotonin, although there have been contradictory findings. In keeping with this, some studies have suggested that tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) may be the most effective. It can sometimes be helpful to add other medications to augment antidepressants, including atypical antipsychotics or psychostimulants (e.g. Ritalin, Dexedrine).
My own symptom pattern tends toward melancholic features, although not always. The anhedonia and psychomotor retardation are pretty prominent. I get the early morning awakening, decreased appetite, and guilt, but they’re usually kept under control when I’m well-medicated. I’ve never had atypical features to my depression, and when my sleep and appetite are affected, they’re always decreased, not increased.
If you have a depressive illness, what is your pattern of symptoms like?
You can find the rest of the what is… series in the Psychology Corner.
- Bruun, C. F., Arnbjerg, C. J., & Kessing, L. V. (2021). Electroencephalographic Parameters Differentiating Melancholic Depression, Non-melancholic Depression, and Healthy Controls. A Systematic Review. Frontiers in Psychiatry, 1439.
- Fletcher, K., Parker, G., Paterson, A., Fava, M., Iosifescu, D., & Pizzagalli, D. A. (2015). Anhedonia in melancholic and non-melancholic depressive disorders. Journal of Affective Disorders, 184, 81-88.
- Harkness, K. L., & Monroe, S. M. (2006). Severe melancholic depression is more vulnerable than non-melancholic depression to minor precipitating life events. Journal of Affective Disorders, 91(2-3), 257-263.
- Nöbbelin, L., Bogren, M., Mattisson, C., & Brådvik, L. (2018). Risk factors for recurrence in depression in the Lundby population, 1947–1997. Journal of Affective Disorders, 228, 125-131.
- Parker, G. (2017). An update on melancholia. Psychiatric Times, 34(1).
- Wikipedia: Melancholia and Melancholic depression
- Zaninotto, L., Solmi, M., Veronese, N., Guglielmo, R., Ioime, L., Camardese, G., & Serretti, A. (2016). A meta-analysis of cognitive performance in melancholic versus non-melancholic unipolar depression. Journal of Affective Disorders, 201, 15-24.
Relationship OCD by Sheva Rajaee is written from the perspective of a therapist who herself has dealt with relationship OCD (ROCD). What a perfect combination! I love that more and more mental health professionals are willing to talk about their own mental health challenges.
Throughout the book, the author emphasizes the importance of learning to tolerate uncertainty. She writes that addressing ROCD isn’t just about managing anxiety, but also about changing expectations about what love and partnership should involve. She describes the myth of the one (MOTO) that we’ve been exposed to pretty much forever, and how unlike real relationships that myth is.
If you feel concerned that you don’t feel the “butterflies” that you think that you’re supposed to feel, the author points out that the feeling of butterflies is actually an anxiety response driven by the amygdala, and the steadiness of a non-anxiety-provoking person could actually be a good thing.
The book describes two different areas of focus for anxiety in ROCD. One is partner-focused, which involves a preoccupation with the partner’s perceived flaws. The other is relationship-focused, which is a preoccupation with the quality of the relationship. The author explains that for most people, ROCD comes from some combination of nature and nurture, and she ties this in with attachment styles.
There’s an interesting chapter devoted to sex anxiety. It incorporates cultural myths and moralization about how sex should be, ideas about what kind of fantasizing is okay, and the effects of anxiety on desire and arousal. Real-life sex just isn’t the way it is in movies, it’s not always mind-blowing, and you don’t have to be gettin’ it on multiple times a week for your sex life to be considered acceptable.
The middle section of the book covers strategies that can help with managing ROCD, including addressing cognitive distortions, using acceptance and commitment therapy tools, and doing exposure and response prevention. The author explains that these tools won’t get rid of your anxiety, and that’s not the goal, anyway; rather, they’ll help you to tolerate it more effectively.
The chapter on healing shame talks about how we become indoctrinated into “the cult of what’s normal.” We soak up all kinds of messages about how we should look, feel, behave, and live our lives, and this knowledge is stored implicitly, outside of our conscious awareness. The author explains the benefit of self-compassion to address shame around not living up to these expectations about what’s normal.
There’s also a chapter on what healthy relationships look like, and the author cautions that you shouldn’t trust your gut, as emotions on their own will never be able to confirm for you that you’ve met the right person or that you’ll live happily ever after. I liked that she was very realistic about how there’s no way to predict the future of a relationship, and sometimes divorce ends up being the right thing.
The author was also very realistic about ROCD recovery, writing that intrusive thoughts and uncertainty aren’t going to just disappear. She acknowledges that ongoing maintenance work will probably be needed.
I thought this book did a really good job of popping the bubble of the assorted problematic messaging we’re exposed to regarding relationships. The author balances warmth and kindness with telling readers that being uncomfortable and being uncertain is a necessary part of the process. She’s down-to-earth, and I thought she had a very healthy, realistic outlook on relationships. This book was really well done, and I think it will be very helpful to people dealing with relationship anxiety, whether it’s full-fledged OCD or not.
Now, some more general thoughts about expectations about relationship perfection. We’re exposed to all this myth of the one messaging that has very little to do with reality. I wonder if the issue is less that we’re being presented with it and more that it often gets presented as if it’s truth rather than reality.
While there are certainly relationships that involve really deep connections. The whole soulmate nonsense strikes me as total garbage. Yet if you Google “soulmate,” there are all these articles telling you how to tell if you found yours. One of the related searches Google suggests is “signs your soulmate is thinking of you.” Oh just fuck all the way off. The top search result I see is an article on Marriage.com saying that you thinking of them all the time is a sign that they’re thinking about you. Um, no, it doesn’t work that way.
Personally, I see books, tv, and movies that are obviously not real as less problematic than all these sources trying to make it out to be reality. Fantasy is fun to indulge in, especially if you can recognize that there’s a line between it and reality. Pretending that line doesn’t exist is a whole other can of tuna.
Do you have any thoughts on the myth of the one and all that goes along with it?
Relationship OCD is available on Amazon (affiliate link).
I received a reviewer copy from the publisher through Netgalley.more
A coroner has called on the Department for Work and Pensions (DWP) to make urgent policy changes after it ordered a disabled patient to leavemore
Safe, Wanted, and Loved by Patrick Dylan is a memoir about the author’s wife’s experiences of mental illness, how that affected the family, and the difficult journey in the direction of recovery.
The book’s powerful opening line is the author’s wife, Mia, saying “Pat, I am going to prison.” At that point, she was first demonstrating indications of psychosis. The book then moved forward in time, with sections at the beginning of each chapter moving back in time to earlier points in their relationship. I thought the pacing of this was quite well done, hooking the reader’s attention at the beginning and then gradually filling in more bits of backstory to give a view of Pat and Mia’s lives beyond just the way they were affected by mental illness.
The family then faced the issue of how to get proper care for Mia as the psychosis worsened. For people who haven’t dealt with this kind of thing before, this will likely be eye-opening, and for those of us who’ve been on the patient side of things, it’s interesting to see the family member perspective.
Once Mia did end up getting treatment, there was confusion about her diagnosis, which continued for much of the book. The reader is taken through the trial and error process of finding medication that would be helpful for her. Her treatment team’s approach with meds struck me as strange, in a separate post, I’ll address the issue of doctors sometimes relying heavily on benzodiazepines to manage problems that those drugs don’t actually treat. It wasn’t until finally getting diagnostic clarification, which required going not just out of town but out of state, that she was able to find the right medication to keep her illness under control. Mia’s journey is a good example of the challenges so many people with mental illness face trying to get the right diagnosis and the right meds for them.
The issue of medication side effects came up at different points in the book, including people asking Mia if she was pregnant due to medication-induced weight gain (yup, been there, done that). There were also some more severe effects that necessitated stopping the medication. I thought there was a good balance of presenting the pros and cons of medications and weighing particular side effects against the benefits of the associated medication. The book also got into the family’s hesitancy around medication, even while they recognized the necessity for it.
I thought the book was really effective at capturing how frightening psychosis can be for loved ones who don’t understand what’s happening, especially if the unwell individual becomes paranoid about family members. Difficult issues like involuntary treatment and police involvement also came up. The reader learns about psychosis and psychiatric treatment as the author shares his own journey of suddenly being faced with having to learn about these things.
Mia’s illness had a significant impact on the family, and the book explored all of the challenges that the author, his and Mia’s children, and other family members faced in trying to cope. I thought the author’s openness around this was a real strength of the book. I also appreciated that the author was very clear about differentiating the illness from Mia herself, and recognizing that it was the illness causing challenges for the family, and Mia was not to blame for that.
While stigma comes up at different points throughout the book, it’s addressed more explicitly in the epilogue. The author explained that protecting his wife from stigma was very front of mind in deciding how to handle things when she first got sick. However, when they did disclose, suddenly other people were disclosing their own experiences, which is very consistent with my own experiences of disclosure. One of the book’s key take-home messages is that we need to talk more about mental illness and break the taboos that stigma has imposed.
Overall, I thought this was an excellent book. It was well written and demonstrated strength through vulnerability. This would be a particularly valuable read for family members of people dealing with mental illness, but I think it could also be really helpful for people who have a mental illness to see the family member perspective. And more generally, I think the more books out there talking about the reality of mental illness, the better, because people need to hear real human stories to counteract the stereotypes.
This video is an interview the author did with Patrick J. Kennedy.
Safe, Wanted, and Loved is available on Amazon (affiliate link).
You can find Patrick Dylan on his website Safe, Wanted, and Loved.
I received a free copy in exchange for an honest review.