DSM-IV-TR Sexual and Gender Identity, Impulse Control Disorders

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Paraphilias, types

Exhibitionism, fetishism, frotteurism, pedophilia, sexual masochism, sexual sadism, transvestic fetishism, paraphilia NOS

Sexual dysfunctions, types

Sexual desire disorders, arousal disorders, orgasmic disorders, pain disorders, sexual dysfunction due to GMC, substance induced, NOS

Sexual dysfunctions, general description

Disturbance in the processes that characterize the sexual response cycle, or by pain associated with sexual intercourse

Sexual response cycle

1. Desire 2. Excitement 3. Orgasm 4. Resolution

Sexual dysfunction subtypes

Lifelong type vs. acquired type
Generalized type vs. situational type
Due to psychological factors vs. due to combined factors

Hypoactive sexual desire disorder

A. Persistently or recurrently deficient or absent sexual fantasies and desire for sexual activity
B. Significant distress or interpersonal difficulty
C. Not better accounted for by another axis I disorder, not due to substance or GMC

Sexual aversion disorder

A. Persistent or recurrent extreme aversion to and avoidance of, all (or almost all) genital sexual contact with a partner
B. Marked distress or interpersonal difficulty
C. Not better accounted for by other axis I

Female sexual arousal disorder

A. Persistent or recurrent inability to attain, or maintain adequate lubrication-swelling response of sexual excitement
B. Marked distress or interpersonal difficulty
C. Not better accounted for by other axis I, not due to substance or GMC

Male erectile disorder

A. Persistent or recurrent inability to attain, or maintain an adequate erection
B. Marked distress or interpersonal difficulty
C. Not better accounted for by other axis I, substance, or GMC

Female orgasmic disorder

A. Persistent or recurrent delay in, or absence of, orgasm following normal sexual excitement phase
B. Marked distress or interpersonal difficulty
C. Not better accounted for by other axis I, substance, GMC

Male orgasmic disorder

A. Persistent delay in, or absence of, orgasm following a normal sexual excitement phase during sexual activity that is adequate in focus, intensity, and duration
B. Marked distress or interpersonal difficulty
C. Not better accounted for by other axis I, substance, or GMC

Premature ejaculation

A. Persistent or recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes
B. Marked distress or interpersonal difficulty
C. Not due exclusively to direct effects of the substance

Dyspareunia

A. Recurrent or persistent genital pain associated with sexual intercourse in either a male or female
B. Marked distress or interpersonal difficulty
C. Not caused exclusively by vaginismus or lack of lubrication, not better accounted for by other axis I, substance or GMC

Vaginismus

A. Recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with sexual intercourse
B. Marked distress or interpersonal difficulty
C. Not better accounted for by other axis I, or GMC

Sexual dysfunction due to a GMC

A. Clinically significant sexual dysfunction that results in marked distress or interpersonal difficulty
B. Evidence that sexual dysfunction is fully explained by effects of a GMC
C. Not better accounted for by another mental disorder

Substance induced sexual dysfunction, specifiers

With impaired desire
With impaired arousal
With impaired orgasm
With sexual pain
With onset during intoxication

Substance induced sexual dysfunction, criteria

A. Clinically significant sexual dysfunction resulting in marked distress or interpersonal difficulty
B. Evidence that sexual dysfunction is fully explained by substance use as manifested by either 1 or 2:
1. Symptoms develop during, or within a month of substance intoxication
2. Medication use is etiologically related to the disturbance
C. Not better accounted for by another sexual dysfunction
Note: diagnose instead of intoxication only when sexual dysfunction is in excess of that usually associated with intoxication

Sexual dysfunction NOS

Sexual dysfunction that does not meet criteria for any specific sexual dysfunction

Paraphilias, general features

Recurrent, intense sexually arousing fantasies, urges, or behaviors generally involving:
1. Nonhuman objects
2. Suffering or humiliation of oneself or partner
3. Children or other nonconsenting persons
Duration 6+ months

Exhibitionism

A. 6+ months, recurrent, intense sexually arousing fantasies, urges, or behaviors involving exposure of one's genitals to an unsuspecting stranger
B. Person has acted on these urges, or causes marked distress or interpersonal difficulty

Fetishism

A. 6+ months, recurrent, intense sexually arousing fantasies, urges, or behaviors involving the use of nonliving objects
B. Clinically significant distress or impairment
C. Fetish objects not limited to articles of female clothing used in cross-dressing, or devices designed for the purpose of tactile genital stimulation

Frotteurism

A. 6+ months, recurrent, intense sexually arousing fantasies, urges, or behaviors involving touching and rubbing against a nonconsenting person
B. Person has acted on these urges, or causes marked distress or interpersonal difficulty

Pedophilia

A. 6+ months, recurrent, intense sexually arousing fantasies, urges, or behaviors involving sexual activity with a prepubescent child or children (generally < 13 years)
B. Person has acted on urges, or marked distress or interpersonal difficulty
C. Person is 16+ years old, and 5+ years older than the child or children in A.
Note: do not include individual in late adolescence involved in an ongoing sexual relationship with a 12 or 13-year-old

Pedophilia, specifiers

Sexually attracted to males, females, or both
Limited to incest
Exclusive type (attracted only two children), vs. nonexclusive type

Sexual masochism

A. 6+ months, recurrent, intense fantasies, urges, or behaviors involving the act (real, not simulated) of being humiliated, beaten, bound or otherwise made to suffer
B. Clinically significant distress or impairment

Sexual sadism

A. 6+ months, recurrent, intense arousing fantasies, urges, or behaviors involving acts (real, not simulated) in which psychological or physical suffering (including humiliation) of the victim is sexually exciting to the person
B. Person has acted on these urges with a nonconsenting person, or causes marked distress or interpersonal difficulty

Transvestic fetishism

A. 6+ months, heterosexual male, recurrent, intense fantasies, urges, or behaviors involving cross-dressing
B. Clinically significant distress or impairment
Specify if: With gender dysphoria (if the person has persistent discomfort with gender role or identity)

Voyeurism

A. 6+ months, recurrent, intense sexually arousing fantasies, urges, or behaviors involving the act of observing an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity
B. Person has acted on these urges, or causes marked distress or interpersonal difficulty

Paraphilia NOS

Paraphilias that do not meet criteria for any specified categories. Examples: telephone scatologia (obscene phone calls), necrophilia (corpses), zoophilia (animals), coprophilia (feces), kilsmaphilia (enemas), urophilia (urine), partialism ( exclusive focus on part of body)

Gender identity disorder, criteria

A. Strong and persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex)
Note: in children, 4+ of:
1. Repeatedly stated desire to be, or insistence that he or she is, the other sex
2. In boys, preference for cross-dressing or simulating female attire; in girls, insistence on wearing only stereotypical masculine clothing
3. Strong and persistent preferences for cross-sex roles in make-believe play or persistent fantasies of being the other sex
4. Intense desire to participate in stereotypical games and pastimes of the other sex
5. Strong preference for playmates of the other sex
Note: in adolescents and adults, manifested by sx such as stated desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or conviction that he or she has typical feelings and reactions of the other sex
B. Persistent discomfort with his or her sex or sense of inappropriateness and the general role of sex
C. Not concurrent with a physical intersex condition
D. Clinically significant distress or impairment

Gender identity disorder, specifiers

In children, vs. in adolescents or adults
Sexually attracted to males, females, both, neither

Intermittent explosive disorder

A. Several discrete episodes of failure to resist aggressive impulses that result in serious assaultive acts or destruction of property
B. Degree of aggressiveness expressed during the episodes is grossly out of proportion to any precipitating psychosocial stressor
C. Episodes not better accounted for by another mental disorder, substance, or GMC

Kleptomania

A. Recurrent failure to resist impulses to steal objects that are not needed for personal use or for their monetary value
B. Increasing sense of tension immediately before committing the theft
C. Pleasure, gratification, or relief at the time of committing the theft
D. Stealing is not committed to express anger or vengeance and is not in response to a delusion or hallucination
D. Not better accounted for by conduct disorder, manic episode, or antisocial PD

Pyromania

A. Deliberate and purposeful fire setting on more than one occasion
B. Tension or affective arousal before the act
C. Fascination with, interest in, curiosity about, or attraction to fire and its situational contexts
D. Pleasure, gratification, or relief when setting fires, or when witnessing or participating in their aftermath
D. Fire setting not done for monetary gain, as an expression of sociopolitical ideology, to conceal criminal activity, to express anger or vengeance, to improve one's living circumstances, in response to delusions or hallucinations, or as a result of impaired judgment
F. Not better accounted for by conduct disorder, manic episode, or antisocial personality disorder

Pathological gambling

A. Persistent and recurrent maladaptive gambling behavior as indicated by 5+ of:
1. Preoccupied with gambling
2. Needs to gamble with increasing amounts of money in order to achieve desired excitement
3. Repeated unsuccessful efforts to control, cut back, or stop
4. Restless or irritable when attempting to cut down or stop
5. Gambles as a way of escaping from problems or of relieving dysphoric mood
6. After losing money, often returns another day to get even
7. Lies to conceal extent of involvement
8. Has committed illegal acts to finance gambling
9. Has jeopardized or lost significant job, relationship, or educational or career opportunity because of gambling
10. Relies on others to provide money to relieve a desperate financial situation caused by gambling
B. Gambling behavior not better accounted for by a manic episode

Trichotillomania

A. Recurrent pulling out of one's hair resulting in noticeable hair loss
B. Increasing sense of tension immediately before pulling out their hair or when attempting to resist the behavior
C. Pleasure, gratification, or relief when pulling out the hair
D. Not better accounted for by another mental disorder, or due to a GMC
E. Clinically significant distress or impairment

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