![Diagnostic and Statistical Manual of Mental Disorders 2022 [TR ]DSM 5 PAPERBACK](https://images-na.ssl-images-amazon.com/images/I/71C6pej4cAL._AC_UL160_SR160,160_.jpg)
I am retired so I can spend a little bit more time than the rest of you putting this review together. I spent 16+ years on a state SO Board.
Every 10 years or so, the American Psychiatric Association comes forth with a new or revised dictum on the right way to look at and ultimately diagnose mental disorders. This is a very exacerbating, costly and unpredictable task that makes the outsider question the mental stability and masochistic needs of this very respectable and highly educated group of men and women. The end result is always affirmed by some, criticized by others, and nullified by yet a third group who think that the whole experiment of upgrading psychiatric nomenclature in lieu of the WHO's ICD-9 and ICD-10-CM (International Statistical Classification of Diseases and Related Health Problems) is ridiculous and unwarranted.
This review is not geared toward taking a stand on the DSM-V (even though I must confess that I am impressed) but mainly to take one segment and bring it into some level of sensibility. The primary area of concentration deals with paraphilias.
The DSM-IV-TR is and was a workable treatise and the DSM-5 (published on May 17, 2013), as far as paraphilic components are concerned is a continuation of the same. The nomenclature, though, is slightly different:
DSM-IV-TR DSM-V
Exhibitionism Exhibitionistic disorder
Fetishism Fetishistic disorder
Frotteurism Frotteuristic disorder
Pedophilia Pedophilic disorder
Sexual masochism Sexual masochism disorder
Sexual sadism Sexual sadism disorder
Transvestic fetishism Transvestic disorder
Voyeurism Voyeuristic disorder
Paraphilia NOS Other specified paraphilic disorder
Unspecified paraphilic disorder
These paraphilic disorders can be explained (DSM-5) as:
Disorder Behavior
Anomalous Activity Preferences
"Courtship Disorders"
Voyeuristic disorder -spying on others in private activities
Exhibitionistic disorder -exposing the genitals
Frotteuristic disorder -touching or rubbing against a nonconsenting individual
"Algolagnic Disorders"
Or Pain and Suffering
Sexual masochism disorder -undergoing humiliation, bondage or suffering
Sexual sadism disorder -inflicting humiliation, bondage or suffering
Anomalous Target Preferences
Or Human Target
Pedophilic disorder -sexual focus on children
Other than Human Target
Fetishistic disorder -using nonliving objects or having a highly specific focus on non-genital body parts
Transvestic disorder -engaging in sexually arousing cross-dressing
Published on May 17, 2013 the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition or DSM-5 is the formal (and DSM-5 abbreviated) name of the manual. It bases diagnoses by "prioritizing behavior over biology... (Relies) primarily on physical or behavioral symptoms to categorize and diagnose psychological disorders." (Parks, 2013) Yet, the structure of the DSM-5 "should improve clinicians' ability to identify diagnoses in a disorder spectrum based on common neural circuitry, genetic vulnerability, and informal exposures." (American Psychiatric Association, DSM-5, 2013, p. xlii) The DSM-5 is many things, which will likely all be debated, with one special ingredient - cogency. It is clear and concise and except for some discrepancies fairly research based.
Clinicians when dealing with cases of sexual assault and particularly Megan's Law should make sure that they are familiar with, at a minimum, such terms/phrases as anomalous activity preferences, anomalous target preferences, algolagnic disorders, paraphilia, normal sexual behavior, intense, persistent, normophilic (sexual interest), orientation, benign paraphilia, other specified paraphilic disorder, unspecified paraphilic disorder, admitting individual and preferential.
Almost all the paraphilic disorders listed in the DSM-5 are likely criminal (when acted upon with non-consenting persons) and in many Commonwealths when adjudicated on a registered type sexual offense, violent (by statute). Some paraphilias relate to a person's erotic actions while others relate to the focus of same or the "target." The paraphilic disorders noted in the DSM-5 are the most common of the paraphilias but there are many others. None of the listed paraphilic disorders actually require physical contact, contrary to the DSM-IV-TR where sexual sadism did.
A paraphilic disorder is a paraphilia but the latter is "a necessary but not a sufficient condition for having a paraphilic disorder and a paraphilia by itself does not necessarily justify or require clinical intervention." Simply some people identify with a paraphilia, e.g., transvestism, and have an intense and persistent interest in cross-dressing but they (a genetic male) are able to go to work on some days dressed as a woman and on other days as a man, are accepted by their supervisors and coworkers, like to fondle their wife's genitals and have her fondle his, and have coitus with their playful and consenting wife while dressed as a woman. They may have had some distress about their cross-dressing when younger but now find themselves accepting of who they are and do not put themselves or others in harm's way (or at any risk).
The "paraphilia" is the condition, the "paraphilic" is the disorder. There is a need for unusual sexual stimulation but there is not a need for "extreme or dangerous" practices "in order to achieve sexual arousal or orgasm." (Encarta)
What is normal adult sexual behavior? The DSM-5 denotes "paraphilia" as "any intense and persistent sexual interest other than a sexual interest in general stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners." The interpretation of the DSM-5 definition leads one to believe that "normal" is sexual behavior that is age and maturity appropriate, consensual, humanly exchanged or in some way shared, and geared to feeling and/or rousing oneself and/or another. The DSM-5 uses the term "phenotypically normal" as part of its definition of sexually normal interactions. Phenotype means, I believe, physical appearance or "I am who I am;" e.g., my genes and environment formed me and I look and behave as such. Anything else is a paraphilia or "any intense and persistent sexual interest" other than normal sexual interests as described above. Nonetheless, and in special cases, "intense" can "be defined as any sexual interest greater than or equal to normophilic sexual interests."
The paraphilias are broken down into an "individuals erotic activities" and an "individuals erotic targets." To have a paraphilic disorder the "paraphilia has to cause distress or impairment to the individual or where the paraphilia's satisfaction has entailed personal harm, or risk of harm, to others." For a diagnosis of a paraphilic disorder both criterion A and criterion B has to be met (See DSM-5 Manual).
Without going into every paraphilic condition, a few components of the DSM-5's Paraphilic Disorder section needs to be brought to the reader's attention. Some factors below might be looked upon as criticisms of the DSM-5 when in actuality they are more questions as to "why?"
1- A paraphilia is a paraphilia (as mentioned) but it does not have to be a paraphilic disorder;
2- Two or more paraphilias can exist and each can be listed as a paraphilic disorder in its own right (p.686);
3- Self and clinician-rating measures can be an acceptable tool(s) to determining the "strength of the paraphilia" and its level of consequence (p.686). Will this acknowledgement of such rating scales prove to be a troubling element, especially in criminal prosecution of sex offenders?
4- Reactive variables (distress and impairment in other areas of functioning) in conjunction with criterion B should be a direct effect of the paraphilic disorder and not some other psychosocial dilemma. The DSM-5 promotes the quantifying of these life variables (p. 686) but how astutely can they be measured?
5- "In a controlled environment" as a remission factor - is it used more for semantics and description of reason for milieu (institutional or hospital) based respite of the condition?
6- "In full remission" requires 5 years of control and reasonably good adjustment in an "open setting" but does it not preclude a latent presence of the paraphilic disorder (pp. 686-705)?
7- Underlying some of the paraphilic disorders (i.e., excluding frotteuristic, sexual masochism, fetishistic and transvestic) is whether or not the person is attracted to prepubertal children, which ultimately are the most harmful and disturbing of the paraphilias listed. This is usually a case of comorbidity;
8- Consenting persons who experience the paraphilic disorder is not clearly explained in the DSM-5. Are these people looked upon as sublimates' (to channel impulses or energies regarded as unacceptable, especially sexual desires, toward an activity that is more socially acceptable - Escarta) or are they ardors to cooling the illegality (indiscretion) of the passion or neutral factors in an paradoxical abyss?
9- Although much research (Karl Hanson, Dennis Doren, Gene Able, Robert Hare - see page 765 under "alternative...," David Thornton, Howard Barbaree, Anna Salter, Michael Seto and many others) has been done in the last 15 years into paraphilias and sex offending, have factors related to prevalence, course, etiology, prognostics, gender, differential diagnosis and comorbidity been actuarially dismissed? Have studies done in England and Canada either been ignored or diplomatically side stepped?
10- Can a "sexual interest" (behavior, orientation, sexual orientation or arousal) versus a paraphilic disorder still be criminal if there is direct and ascertained victimization?
11- Perpetrators often rationalize to the extreme. There are only a few (admitters or "admitting individuals") who open up and acknowledge the specifics of their condition right from the start. Examiners need to look at "past episodes," arrest history, mental health records, victimization frequency, "separate patterns," and so forth (collaborating evidence) to determine whether the aspects of "recurring, motivated, distress and harm" and other DSM-5 factors within the Criterion apply. Simply, objectivity as well as common sense must be employed;
12- The DSM-5 promotes itself with impartiality, scientific findings and evidence, latest research, validated diagnoses, and empirically supported statements but are there too many unknowns, clarity problems, estimates, "might occur," "sometimes" and "have reported" among the paraphilic disorders in conjunction with associated features, prevalence, development, course, age at onset, and functional consequences (See#9)?
13- Should sexual masochism disorder be considered a primary or secondary sexual offense or a felony in and of itself or a common law crime? What of other participants? Should they be charged for abetting or encouraging this self-harming behavior? It may often co-occur or be a derivative of another paraphilia, but the pseudo-primary narcissistic components of this condition leave it in somewhat of nebulous position. What is the masochist's true goal and how should his or her actions be perceived? Can this not also be the case with transvestic and fetishistic disorders?
14- If the data on paraphilias is interpreted correctly, the DSM-5 task force are implying that in the neighborhood of 20% of our population has a paraphilia or is oriented at times (atypical sexual interest) to same. Is it really that bad? What about a recidivistic position - isn't that what our Courts and society in general are looking for?
15- DSM-5 task force members are trying to lay the groundwork for science, but how are they ever going to measure a fantasy or an urge? Neuroimaging, EEGs, EMGs and the like have come a long way, but is gauging a fantasy or urge just too far out for our generational neuroscientists? Penile plethysmograph (PPG), vaginal photoplethysmography (VPG), clinical polygraphs and ABLEs (visual timing) have evidently been dismissed by the task force as too controversial and possibly in some states illegal. Maybe the words "fantasy" and/or "urge" should be removed from the diagnostic criteria? But how can they? Can self-reporting be truly measured? Sematic differential scales, but where is the affect?
16- Etiology for paraphilias is now more confusing, hypothetical and lacking than ever (See #9)? From the standpoint of diagnosing, does it really matter?
17- Although not plausible and likely not intended, certain paraphilias and paraphilic disorders can be diagnosed at any age (e.g., voyeuristic disorder, exhibitionistic disorder, frotteuristic disorder, sexual masochism disorder, sexual sadism disorder, fetishistic disorder, transvestic disorder). Are we going to have to keep an eye on our nursery school kids when they run around in their swimming suits?
18- Culture is brought up as a variable of contention in diagnosing certain paraphilic disorders, but doesn't criterion A and criterion B account for the same? What culture has (normative) behaviors that allow (or accepts) recurrent and intense sexual arousal for at least six months? What culture affirms sexual focus on nonliving objects and/or non-genital parts of the body? Who promotes in their culture fantasies, urges and behaviors that cause generic malfunctioning of the person and risks to their neighbor? From studies reviewed, there is only one culture in the world that promotes and approves what we classify as pedophilia and none are necrophilia proponents;
19- Is "other specified paraphilic disorder and unspecified paraphilic disorder" a peripheral alternative for sexual atypical conditions/practices outside the eight main paraphilics' listed and is "unspecified" going to be an argumentative catalyst to a courtroom state of inauspiciousness? and
20- Pornography and Internet sex obsessions which is frequently in the public mindfulness is not mentioned directly (only as associated features) and rape (now viewed as solely criminal) has no place among the paraphilic disorders. Did the task force forget something? Should these (especially pornography and Internet sex obsessions) be seen as sexual narcissistic sublimates, a derivative of a paraphilic, pseudo voyeurism in their own right or more in line with a personality disorder ("an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment" p. 645) than a paraphilic disorder (other specified)? Possibly pornography and internet sex obsessions will be left in a limbo position (where it has seemed to be, not like gambling disorder or internet gaming disorder under "conditions for future study"), i.e., being a means to an end (child porn > pedophilia, sadistic porn > sadism disorder, etcetera) and not an end in itself.
In sum, the DSM-5 Paraphilic Disorders is an upgrade to the DSM-IV-TR and has opened up the door to clearer diagnostic labeling. It seems to pardon offenses of the past and gives societal parameters to accepting non-criminal intentions of sensual satisfaction and sharing. It should be read and studied by all in the professional MH community.
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I HIGHLY recommend the DSM-V! It has been a GOLD MINE since I first utilized it for my first Abnormal Psychology term paper. It was actually not required to purchase, believe it or not, but highly recommended. I decided to buy it just in case as I prefer to be prepared. I can only assume that others made the assumption it was most likely just a dictionary for psychological disorders and a boring one at that like I originally did, because, let's be honest, what young college student has ever said, “well, I am going to take some ‘me’ time and read the dictionary. See you tomorrow!” Maybe it is just because the healthcare field is my passion, but it is actually really interesting and, starting with our first term paper, I have opened the DSM-5 with, and I can’t emphasize this enough, ZERO ideas on what I wanted to write about for EVERY SINGLE essay or required online essay-type discussion, etc. Furthermore, it has surprisingly given me my first idea on what to write about ever since. However, it has not just been on the topic itself, but also has helped me to decide on what exactly each paragraph in the body will focus on. I do not mean this in a generic/already listed symptomatic sense! It has given me unique idea's that the internet has not. Here is feedback from my professor, in addition to my term paper grade, all thanks to the DSM-V, as proof (see attached photo). Finally, it is very well-written and categorized. A lot better than the DSM-IV was. However, the sections that talk about "Unspecified..." or "Other..." disorders for certain categories, I do wish they listed specific examples of what they are talking about. At least for first time university students. Maybe make a DSM-V college edition? Not a bad idea for business ;-) I personally liked it better than our required textbook. In fact, if I am being honest, I stopped reading the textbook, and just read the DSM-V for each module and utilized additional peer-reviewed academic journals pre-approved by our professor and provided by our college as well as other internet resources. It earned me an "A" in the course and I walked away understanding and remembering A LOT more than I expected to. Especially considering I am not even a psychology major. This is just one pre-requisite course recommended for an Associate of Science (Pre-Physician Assistant route).
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