paraphilias: Treatment & Medication

Medical Care

* Inpatient treatment indications
o Patients are suicidal, homicidal, or gravely disabled (Suicide risk is high if they feel exposed or confronted.)
o Patients are dangerous to themselves, others, or cannot take care of themselves
* Psychotherapy
o 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.
o 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.
o 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.
o 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.
o 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.
o 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
o Antidepressants
o Long-acting gonadotropin-releasing hormones (GnRH, ie, medical castration)
o Antiandrogens
o Phenothiazine
o 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.

Lithium (Eskalith)

Indicated for treating bipolar disorder. Influences reuptake of serotonin and/or norepinephrine at cell membrane.

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.

Phenothiazines

Are effective in treating emesis possibly due to their effects in the dopaminergic mesolimbic system.

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.

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.

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.

Website: http://emedicine.medscape.com/article/291419-treatment

From the same website here is the psychotherapy treatments.

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.

Thank you for adding to the thread Forensic2

Thanks for starting it, it's good quality information.

I thought it was important to have the psychotherapy up to see that medication is not the only form of therapy. Often medication isn't used at all.

I agree

All that is well and good but there's no stopping the feeings completely, it's all about control and that just isn't enough for me. I've tried drugs (the legal kind) therapy and hypnosis. IT DOESN'T WORK!!! I wish it did though. I hate the feelings I have.

All that is well and good but there's no stopping the feeings completely, it's all about control and that just isn't enough for me. I've tried drugs (the legal kind) therapy and hypnosis. IT DOESN'T WORK!!! I wish it did though. I hate the feelings I have.

From what I've read, I actually prefer Acceptance and Commitment Therapy (ACT) to traditional Congnitive-behavioral Therapy (CBT), though it seems they're essentially meant to effect similar results.

ACT involves accepting your emotions, not simply your reactions thereto, letting both your loudest and most subtle feelings be part of you willingly both positive and negative, and that you attempt to change how you react to those emotions.

For many, reaction and emotion seem to be one and the same or inseparable, and so they evaluate how they feel based on how they automatically react to their feelings. It's a habit that leads us to try and change how we feel rather than how we react, and it doesn't help much for many people, only temporarily. What does help long term is to learn to separate the stress (positive or negative) from the reaction and to alter our reaction while still embracing the stress we feel. It's certainly easier said than done, but like all things gets easier with practice. Often, when trying to be mindful or observe my thoughts and emotions, I evaluate things in terms of desirable or undesirable, good and bad, rather than to simply observe what's happening. This defeats the purpose of being mindful. Instead of labeling/categorizing everything, mindfulness works more like a gentle guide to all our thoughts and emotions than it does like a judge. It allows us to see ourselves more clearly so that we can then, with care, stimulate happiness and avoid stimulating misery through our actions, but still accept misery as it occurs.

Thich Nhat Hahn in The Sun My Heart (p. 13) wrote:Like the physical sun, which lights every leaf and blade of grass, our awareness lights our every thought and feeling, allowing us to recognize them, be aware of their birth, duration, and dissolution, without judging or evaluating, welcoming or banishing them. It is important that you do not consider awareness to be your "ally," called on to suppress the "enemies" that are your unruly thoughts. Do not turn your mind into a battlefield. Do not have a war there; for all your feelings--joy, sorrow, anger, hatred-- are part of yourself. Awareness is like an elder brother or sister, gentle and attentive, who is there to guide and enlighten. It is a tolerant and lucid presence, never violent or discriminating. It is there to recognize and identify thoughts and feelings, not to judge them as good or bad, or place them in opposing camps in order to fight with each other.

With awareness/mindfulness we change reactions rather than thoughts and emotions. With enough practice and effort we can alter our behavior this way long term to the point of living a life of fulfillment.

Wikipedia wrote:As a simple way to summarize the model, you can say that ACT views the core of many problems to be due to the acronym, FEAR:

- Fusion with your thoughts
- Evaluation of experience
- Avoidance of your experience
- Reason giving for your behaviour

And the healthy alternative is to ACT:

- Accept your reactions and be present
- Choose a valued direction
- Take action

Anyone may disagree with me, but I feel the process, ACT, is more effective than traditional CBT because, instead of altering our thought processes in order to do (or not do) certain things, (as in CBT), we rather alter our behavior in light of our thoughts, feeling, and personal values in order to to feel a certain way. This means happiness and peace are our goals rather than thinking a certain way or becoming society's ever-changing idea of "normal."

Those are some nice thought-provoking Acronyms S3, though I am a little confused with relating fear to 'evaluation of experience' and 'reason giving for behaviour'.

I understand the 'fusion with thoughts' thing though because detaching enough from thinking to analyze the thoughts is what allows us to find loops that are going nowhere or errors in thinking that can be disregarded. In that same way we can analyze reasons for behaviour.

For example if we reason a behaviour as "I choose this action because it presently works towards a direction I value" then it would overlap with ACT right?

Not sure if other people have the same reaction, but a lot of these treatments seem pretty unappealing.

If somebody was a pedophile (disclaimer: I'm not), it seems they would be more likely to hide their condition rather than exposing it, and risk being chemically emasculated (whether through explicit anti-androgens or SSRI side-effects), or potentially being put on a "watch list" of some sort.

I also get the impression there are two broad categories of patients: Those who have an obtrusive condition and are willing to work to get rid of it, and those who's condition is integrated into the core of their personality, similar to OCD vs OCPD. It seems like the majority of these solution (accepting psychotherapy, social/sexual skills training, and maybe ACT) focus on behavior vs root cause. If the root cause isn't addressed, won't the behavior just return over time?