The DSM Diagnostic Criteria for Paraphilia Not Otherwise Specified

Arch Sex Behav DOI 10.1007/s10508-009-9552-0 ORIGINAL PAPER The DSM Diagnostic Criteria for Paraphilia Not Otherwise Specified Martin P. Kafka Ó American Psychiatric Association 2009 Abstract The category of ‘‘Not Otherwise Specified’’ (NOS) Introduction for DSM-based psychiatric diagnosis has typically retained diag- noses whose rarity, empirical criterion validation or symptomatic Prior to an informed discussion of the residual category for expression has been insufficient to be codified. This article re- paraphilic disorders, Paraphilia Not Otherwise Specified (PA- views the literature on Telephone Scatologia, Necrophilia, Zoo- NOS), it is important to briefly review the diagnostic criteria philia, Urophilia, Coprophilia, and Partialism. Based on extant for a categorical diagnosis of paraphilic disorders as well as the data, no changes are suggested except for the status of Partialism. types of conditions reserved for the NOS designation. Partialism, sexual arousal characterized by ‘‘an exclusive focus The diagnostic criteria for paraphilic disorders have been mod- on part of the body,’’ had historically been subsumed as a type of ified during the publication of the Diagnostic and Statistical Man- Fetishism until the advent of DSM-III-R. The rationale for con- uals of the American Psychiatric Association. In the latest edition, sidering the removal of Partialism from Paraphilia NOS and its DSM-IV-TR (American Psychiatric Association, 2000), a para- reintegration as a specifier for Fetishism is discussed here and in a philic disorder must meet two essential criteria. The essential companion review on the DSM diagnostic criteria for fetishism features of a Paraphilia are recurrent, intense sexually arousing (Kafka, 2009). In the DSM-IV and DSM-IV-TR, the essential fantasies, sexual urges or behaviors generally involving (1) non- features of a Paraphilia are recurrent, intense sexually arousing human objects, (2) the suffering or humiliation of oneself or one’s fantasies, sexual urges or behaviors generally involving nonhu- partner, or (3) children or other nonconsenting persons that occur man objects, the suffering or humiliation of oneself or one’s part- over a period of at least 6 months (Criterion A). The diagnosis is ner, or children or other nonconsenting persons that occur over a made if the behavior, sexual urges, or fantasies cause clinically period of at least 6 months (Criterion A). Given consideration for significant distress or impairment in social, occupational, or other the erotic focus of Partialism and Autoerotic Asphyxia, amending important areas of functioning (Criterion B). the operational criteria for Paraphilia should be considered to in- For paraphilic disorders typically associated with sexual clude an atypical focus involving human subjects (self or others). offending, additional caveats are included: For Pedophilia, Voyeurism, Exhibitionism, and Frotteurism, the diagnosis is Keywords DSM-V Á Coprophilia Á Necrophilia Á made if the person has acted on those urges or the urges or Partialism Á Telephone scatologia Á Urophilia Á Zoophilia sexual fantasies cause marked distress or interpersonal dif- ficulty. For Sexual Sadism, the diagnosis is made if the person has acted on these urges with a nonconsenting person or the urges, sexual fantasies or behaviors cause marked distress or interpersonal difficulties. In the fourth edition of the DSM (American Psychiatric Association, 1994) and well as in the text revision of DSM-IV (American Psychiatric Association, 2000, p. 4), the NOS cate- & M. P. Kafka ( ) gories are described as applicable to four situations: (1) The Department of Psychiatry, McLean Hospital, 115 Mill Street, Belmont, MA 02478, USA presentation conforms to the general guidelines for a mental e-mail: [email protected] disorder in the diagnostic class, but the symptomatic picture 123 Arch Sex Behav does not meet the criteria for any of the specific disorders. This Telephone Scatologia would occur either when the symptoms are below the diagnostic threshold for one of the specific disorders or when there is an Telephone Scatologia, a paraphilic disorder characterized by atypical or mixed presentation; (2) the presentation conforms to repetitive telephone calls to unsuspecting victims during which a symptom pattern that has not been included in the DSM-IV they are exposed to covert or overt sexual or obscene content, classification but causes clinically significant distress or impair- has been recognized in association with other paraphilic disor- ment. Research criteria for some of these symptoms patterns ders, most notably Exhibitionism (Abel, Becker, Cunningham- have been included in Appendix B (‘‘Criteria Sets and Axes Rathner, Mittelman, & Rouleau, 1988) and Voyeurism (Brad- Provided for Further Study’’), in which case a page reference to ford, Boulet, & Pawlak, 1992). Abel et al.’s sample of 561 non- the suggested research criteria set in Appendix B is provided; (3) incarcerated paraphiliacs included 19 subjects (3.3% of the there is uncertainty about etiology (i.e., whether the disorder is sample) who acknowledged telephone scatologia and Bradford due to a general medical condition, is substance-induced or is et al.’s sample of 37 men (8.3%) were extracted from a non- primary); and (4) there is insufficient opportunity for complete incarcerated sample of 443 men being evaluated at a specialized data collection (e.g., in emergency situations) or inconsistent or forensic center. contradictory information, but there is enough information to Price,Kafka,Commons,Gutheil,and Simpson (2002)exam- place it within a particular diagnostic class (e.g., the clinician ined an outpatient sample of 206 men with paraphilias and para- determines that the individual has psychotic symptoms but does philia-related disorders (Kafka & Hennen, 1999) and identified not have enough information to diagnose a specific Psychotic 20 men (9.7% of the sample) with a lifetime diagnosis of Tele- Disorder). phone Scatologia. They reported a significant comorbidity be- In the specific case of Paraphilic Disorders, there are no tween Telephone Scatologia and Voyeurism, compulsive mas- Appendix B Criteria Sets provided for further study. In DSM-IV turbation, telephone sex dependence, and a trend association with and in DSM-IV-TR, the Paraphilia NOS category (diagnostic Exhibitionism (p = 06). The Telephone Scatologia subgroup code 302.9) states: ‘‘This category is included for coding Para- had a greater number of lifetime paraphilias and paraphilia- philias that do not meet the criteria for any of the specific catego- related disorders in comparison with other paraphiliacs. The ries. Examples include, but are not limited to, telephone scatolo- particular finding of multiple paraphilias in men with Telephone gia (obscene phone calls), necrophilia (corpses), partialism (ex- Scatologia was also reported by Abel et al. (1988). Although this clusive focus on parts of the body), zoophilia (animals), copro- paper does add to the clinical literature on Telephone Scatologia, I philia (feces), klismaphilia (enemas), and urophilia (urine)’’ find insufficient justification to remove telephone scatologia from (American Psychiatric Association, 1994,p.532). the Paraphilia NOS category. Methodology Necrophilia I performed an Internet-based literature search using the terms ApartfromthesampleaccruedbyRosmanandResnick(1989; ‘‘Paraphilia Not Otherwise Specified,’’ ‘‘telephone scatologia,’’ 122 cases: 88 from the world literature and 34 unpublished ‘‘necrophilia,’’ ‘‘partialism,’’ ‘‘zoophilia,’’ ‘‘bestiality,’’ ‘‘copro- cases), there are no new substantial data on Necrophilia. In their philia,’’ ‘‘coprolagnia,’’ ‘‘klismaphilia,’’ ‘‘urophilia,’’ ‘‘urolagnia,’’ review, Rosman and Resnick noted that the primary motivation and ‘‘undinism,’’ utilizing both PubMed (1948–2008) and Psyc- associated with Necrophilia was the ‘‘possession of an unre- INFO (1872–2008) databases. Inasmuch as DSM-IV was pub- sisting and unrejecting partner.’’Necrophilia could be considered lished in 1994 and its revision was published in 2000 without any as a fetish variant as the sexualized object of desire is ‘‘nonliving’’ designated changes in the status of Paraphilia NOS disorders, I but, in my opinion, there are insufficient data to empirically sup- emphasized empirical data published since 1990, primarily in the port this change to include Necrophilia as a subtype of Fetishism. English language with sample sizes of more than 20 subjects. I Necrophilia can be accompanied by ‘‘sadistic acts’’ and sexually reviewed contemporary sexology book chapters, the Internet, and motivated murder, certainly not behaviors associated with Fetish- other primary sources whenever possible to search for other para- ism as it has been currently defined. Rosman and Resnick also philic disorders that might now qualify as distinct paraphilic diag- reported that 57% of their sample were employed in a profession nosis based on more empirical and clinical data. In relevant pub- that gave them access to dead bodies (e.g., morgue attendant, lications, I reviewed referenced articles as well as those that did not hospital workers, cemetery employee). appear during a computerized search. I reviewed articles and books Clearly, Necrophilia is a very dangerous paraphilic affliction through October 2008. This review does not include new data on but the paucity of systematically reported data and the rarity of autoerotic asphyxia (hypoxyphilia) or paraphilic rapism (para- this important disorder are limitations that, in my opinion,

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