# 199 - 6D36 Paraphilic disorder involving solitary b # 6D36 Paraphilic disorder involving solitary behaviour or consenting individuals Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders Paraphilic disorder involving solitary behaviour or consenting individuals Essential (required) features • A sustained, focused and intense pattern of atypical sexual arousal – as manifested in sexual thoughts, fantasies, urges or behaviours – that involves consenting adults or solitary behaviour is required for diagnosis. • One of the following two elements must be present. • The individual is markedly distressed by the nature of the arousal pattern and the distress is not simply a consequence of rejection or feared rejection of the arousal pattern by others. • The nature of the paraphilic behaviour involves significant risk of injury or death either to the individual (e.g. asphyxophilia or achieving sexual arousal by restriction of breathing) or to the individual’s partner (e.g. consensual sadism that results in injuries requiring medical attention). • If the diagnosis is assigned based on significant risk of injury or death, this risk should be directly and immediately connected to the paraphilic behaviour. For example, a presumed risk of increased exposure to sexually transmitted infections is not a sufficient basis for assigning this diagnosis. Additional clinical features • Paraphilic disorder involving solitary behaviour or consenting individuals should not be diagnosed among children, and should be diagnosed only with the utmost caution among adolescents. Sexual experimentation is typical during adolescence, and sexual acts may occur impulsively or opportunistically rather than representing a recurrent pattern of sexual arousal. • Diagnosis of paraphilic disorder involving solitary behaviour or consenting individuals generally requires a report of sexual thoughts, fantasies, urges and behaviours directly from the individual in order to document a sustained, focused and intense pattern of atypical sexual arousal, and the degree and sources of related distress. Boundary with normality (threshold) • The fact that an individual’s pattern of sexual arousal deviates from social or cultural norms is not a basis for assigning a diagnosis of paraphilic disorder involving solitary behaviour or consenting individuals. An arousal pattern that involves consenting adults or solitary behaviour, and that is not associated with marked distress that is not simply a consequence 6D36 Paraphilic disorders | Paraphilic disorder involving solitary behaviour or consenting individuals 589 Paraphilic disorders of rejection or feared rejection of the arousal pattern by others or with a significant risk of injury or death, is not considered a disorder. • The occurrence or a history of atypical sexual behaviours is not sufficient to establish a diagnosis of paraphilic disorder involving solitary behaviour or consenting individuals. Some atypical sexual behaviours may occur impulsively or opportunistically, or as a means of personal and sexual exploration, and are not associated with a sustained underlying arousal pattern. The diagnosis of paraphilic disorder involving solitary behaviour or consenting individuals requires these behaviours to be a manifestation of a sustained, focused and intense pattern of paraphilic sexual arousal, in addition to distress or significant risk of injury or death. • When distress related to an arousal pattern involving consenting adults or solitary behaviour is entirely attributable to rejection or feared rejection of the arousal pattern by others (e.g. a partner, family, society), a diagnosis of paraphilic disorder involving solitary behaviour or consenting individuals should not be assigned. Instead, categories from the grouping QA15 Counselling related to sexuality in Chapter 24 on factors influencing health status or contact with health services may be considered. • This diagnosis should not be applied to individuals who are distressed about homosexual or bisexual sexual orientation. If an individual is presenting for treatment based on such distress, categories from the grouping QA15 Counselling related to sexuality in Chapter 24 on factors influencing health status or contact with health services may be considered. If the pattern of distress-related symptoms meets the diagnostic requirements for another mental disorder (e.g. adjustment disorder, a depressive disorder, an anxiety or fear-related disorder), that diagnosis should be assigned. Course features • Individuals with paraphilic arousal patterns involving solitary behaviour or consenting individuals often report the onset of paraphilic sexual interest during adolescence. • Paraphilic arousal patterns are relatively stable after young adulthood, but sexual thoughts, fantasies, urges and behaviours, as well as any associated distress, may change over time, such that an individual who was assigned a diagnosis of a paraphilic disorder involving solitary behaviour or consenting individuals no longer meets the diagnostic requirements. Developmental presentations • Advancing age may be associated with decreasing paraphilic sexual arousal and decreasing related behavioural manifestations due to increased impulse control and decreased sexual drive. Paraphilic disorders | Paraphilic disorder involving solitary behaviour or consenting individuals Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders Sex- and/or gender-related features • Paraphilic arousal patterns involving solitary behaviour or consenting individuals are much more prevalent among men. • Paraphilic arousal patterns involving masochism are more prevalent among women than other paraphilic arousal patterns. If other diagnostic requirements are met (e.g. marked distress or significant risk of injury or death), a masochistic paraphilic arousal pattern may be a part of the basis for diagnosis of paraphilic disorder involving solitary behaviour or consenting individuals. Boundaries with other disorders and conditions (differential diagnosis) Boundary with compulsive sexual behaviour disorder Both paraphilic disorder involving solitary behaviour or consenting individuals and compulsive sexual behaviour disorder may involve repetitive sexual impulses, urges or behaviours that result in marked distress or impairment. Paraphilic disorder involving solitary behaviour or consenting individuals is characterized by sexual impulses, urges or behaviours that are manifestations of a sustained, focused and intense pattern of atypical sexual arousal that is associated with either marked distress or significant risk of injury or death. In contrast, compulsive sexual behaviour disorder is characterized by a persistent pattern of failure to control sexual impulses, urges or behaviours, regardless of the focus of sexual arousal. If an individual with paraphilic disorder involving solitary behaviour or consenting individuals is able to exercise some degree of control over the behavioural expressions of the arousal pattern, an additional diagnosis of compulsive sexual behavioural disorder is generally not warranted. Boundary with disorders due to substance use Episodes of sexual behaviour that are atypical for the individual may occur during substance intoxication. Such episodes may not be a manifestation of a sustained, focused and intense sexual arousal pattern. At the same time, some individuals with paraphilic disorders may use substances with the intention of engaging atypical sexual behaviour that does reflect an underlying paraphilic arousal pattern. A diagnosis of paraphilic disorder involving solitary behaviour or consenting individuals may be assigned together with a disorder due to substance use if the diagnostic requirements for both are met. Boundary with other mental disorders in the context of rejection or feared rejection If distress related to rejection or feared rejection of the arousal pattern by others has reached a point that presenting symptoms meet the diagnostic requirements for another mental disorder (e.g. adjustment disorder, a depressive disorder, an anxiety or fear-related disorder), that diagnosis should be assigned rather than paraphilic disorder involving solitary behaviour or consenting individuals. Paraphilic disorders | Paraphilic disorder involving solitary behaviour or consenting individuals