CASE: Paranoid and distressed
Mr. P, age 21, is a single, white college student who presents to a psychiatric emergency room with his father at his psychotherapist’s recommendation. The psychotherapist, who has been treating Mr. P for anxiety and depression, recommended he be evaluated because of increased erratic behavior and paranoia. Mr. P reports that he has been feeling increasingly “anxious” and “paranoid” and thinks the security cameras at his college have been following him. He also describes an increased connection with God and hearing God’s voice as a commentary on his behaviors. Mr. P denies euphoria, depression, increased goal-directed activities, distractibility, increased impulsivity, or rapid speech. He is admitted voluntarily to the psychiatric unit for further evaluation.
During the hospitalization, Mr. P discloses that he has been viewing child pornography for 2 years, and during the past 6 months he has been distressed by the intensity of his sexual fantasies involving sexual contact with prepubescent girls. He also continues to experience paranoia and increased religiosity.
Mr. P says he began looking at pornography on the internet at age 14. He says he was watching “regular straight porn” and he would use it to masturbate and achieve orgasm. Mr. P began looking at child pornography at age 19. He stated that “regular porn” was no longer sufficiently arousing for him. Mr. P explains, “First, I started looking for 15- or 16-year-olds. They would work for a while [referring to sexual gratification], but then I would look for younger girls.” He says the images of younger girls are sexually arousing, typically “young girls, 8 to 10 years old” who are nude or involved in sex acts.
Mr. P denies sexual contact with prepubescent individuals and says his thoughts about such contact are “distressing.” He reports that he has viewed child pornography even when he wasn’t experiencing psychotic or mood symptoms. Mr. P’s outpatient psychotherapist reports that Mr. P first disclosed viewing child pornography and his attraction to prepubescent girls 2 years before this admission.
The authors’ observations
DSM-IV-TR diagnostic criteria for pedophilia (Table 1)1 are based on a history of sexual arousal to prepubescent individuals. A subset of sex offenders meet criteria for a paraphilia (Table 2),1 an axis I disorder, and a subset of sex offenders with paraphilia meet diagnostic criteria for pedophilia. Dunsieth et al2 found that among a sample of 113 male sex offenders, 74% had a diagnosable paraphilia, and 50% of individuals with paraphilia met criteria for pedophilia.
Table 1
DSM-IV-TR diagnostic criteria for pedophilia
| A) | Over a period of ≥6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child or children (generally age ≤13) |
| B) | The person has acted on these sexual urges, or the sexual urges or fantasies cause marked distress or interpersonal difficulty |
| C) | The person is age ≥16 and ≥5 years older than the child or children in criterion A |
| Note: Do not include an individual in late adolescence involved in an ongoing sexual relationship with a 12- or 13-year-old | |
| Source: Reference 1 | |
DSM-IV-TR diagnostic criteria for a paraphilia
| The essential features of a paraphilia are recurrent, intense sexually arousing fantasies, sexual urges, or behaviors generally involving: | |
| A) | nonhuman objects, the suffering or humiliation of oneself or one’s partner, or children or other nonconsenting persons that occur over a period of ≥6 months |
| B) | The behavior, sexual urges, or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning |
| Source: Reference 1 | |
Although most schizophrenia patients without a history of sexual offenses do not exhibit sexual deviancy, sexual content in hallucinations and delusions is common.6 Confusion about sexual identity and the boundaries of one’s body are common and may contribute to sexual deviancy.6 Psychiatric inpatients without a history of sexual offenses—including but not limited to psychotic patients—have higher rates of sexually deviant fantasies and behaviors compared with those without psychiatric illness.6 In one survey, 15% of men with schizophrenia displayed paraphilic behaviors and 20% had atypical sexual thoughts.7