Diagnosis and differential diagnosis

The most cost-effective method of diagnosing paraphilias is to conduct a comprehensive psychiatric history, to use psychophysiological assessment methods to determine sexual interest, and to differentiate organic or psychiatric disorders that can impact on an individual's sexual interest and activity. Interviewing the potential paraphiliac, especially a paraphiliac who has been involved in felonies, requires a non-judgemental clinician. The first step in the interview process is to obtain a client's consent to assessment, with special reference to laws that may legally require the therapist to break confidentiality should a paraphiliac reveal a specific victim that he has sexually abused or a victim he plans to molest. This issue is relevant when a child molester reveals specific names of children that he or she has molested. To proceed with the interview without first explaining this mandatory reporting requirement would be unethical.

The major objective of the initial interview is for the therapist to identify core issues which will motivate a patient to change his or her paraphilic activity. The major obstacle to an effective interview is that the paraphiliac is frequently ashamed regarding his sexual assaults or behaviours, and for years has practised concealing from others the very nature of his sexual interest. Unfortunately, many therapists have been taught that if patients fail to reveal the nature of their problems, then it is their fault that they do not receive treatment. Such training can lead to the paraphiliac not revealing a serious sexual problem and the therapist not attempting to uncover the problem; as a consequence, the patient is not helped and the therapist does not attempt to assist the patient in revealing his or her paraphilic interest. Thus, more individuals are victimized.

A number of methods can be used by the therapist to increase the likelihood of the paraphiliac revealing his or her true sexual interest. Therapists should explain that the more knowledgeable they are about the activities or allegations that led to the referral, the more they will be able to help the patient. The therapist should review all available records before seeing the patient so as to understand the problems that led to his referral. The therapist needs to attempt to block the patient from taking a strong position of innocence, from which he may have to retreat later in the assessment. Should the patient adamantly deny culpability, the therapist should ask questions about whether the victim might have misunderstood the patient's actions. When the patient initially denies inappropriate behaviour, the interviewer should focus on other aspects of the psychological history rather than going into details regarding the allegations. Sometimes the patient's denial is reduced after the interviewer pauses and explains the many components of treatment available and the effectiveness of treatment. The average paraphiliac is frequently unaware of treatment that can help control deviant behaviour; thus, providing details about treatment components helps the paraphiliac to appreciate that there are effective treatment options and that he should, therefore, actively participate in his treatment. A key component of the initial assessment is delineating the client's sexual fantasies during masturbation or sexual activity. Often patients will reveal these fantasies, thereby presenting an opportunity for therapists to appreciate what they find most erotic. Interviewers must avoid reacting emotionally to clients' sexual behaviours. No matter what that behaviour might involve, communication of disapproval of such activity by the therapist obstructs the gathering of critical information needed to help the patient.

A common error is for therapists to ask about only a limited number of paraphilias, usually the paraphilia for which the patient was referred for evaluation. Crossing of diagnoses, or having a variety of paraphilias, is fairly common and therefore the therapist should ask about all paraphilias. When paraphilias are revealed by the client, the therapist should find out the age of onset of such behaviour, the age at which the behaviour stopped, the age and gender of victims, the specific nature of the relationship between the client and his or her victims, the degree of force used during the commission of paraphilic acts, the extent to which the paraphilias occupy the client's fantasy life, and the client's current control over urges to carry out paraphilic behaviour.

It is also helpful for the therapist to use leading questions. Rather than asking if the individual has exposed himself, the therapist might ask 'How often have you exposed yourself?' By querying the client this way, the interviewer gives the message that it is acceptable that such exhibitionism has transpired and gives the patient responsibility for correcting the interviewer if he or she has never been involved in such activity. Near the close of the interview, it is helpful to ask a catch-all question such as: 'What other sexual behaviour have you been interested or involved in that might be problematic if known to others?'

The patient, if accused of paraphilic interest but denying it, usually pressures the therapist to agree with his position of innocence. The therapist should clarify that the purpose of the evaluation is to determine the likelihood of such behaviour, based upon information that is gathered during the psychological interview, psychophysiological assessment, paper-and-pencil testing, and review of records. Only after such information has been collected can the therapist offer an opinion to the patient. At the end of the first interview it is helpful to explain to the patient the importance of being as honest as possible during all phases of the assessment. Clinical interviewing of alleged paraphiliacs is difficult to balance. The goals of the therapist should be to do no harm, to help the patient understand his or her possible sexual interest, and to explore what can be done to help him or her lead a life of closer intimacy with adult partners without injury.

Do Not Panic

Do Not Panic

This guide Don't Panic has tips and additional information on what you should do when you are experiencing an anxiety or panic attack. With so much going on in the world today with taking care of your family, working full time, dealing with office politics and other things, you could experience a serious meltdown. All of these things could at one point cause you to stress out and snap.

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