DSM-IV on Sadism

Sexual Sadism

Definition

Sexual sadism denotes fantasies, urges or behaviors that involve real acts (not simulations) in which the suffering of another person is found sexually exciting.

Diagnostic criteria

The DSM-IV criteria for the diagnosis of sexual sadism state that: there must be recurrent, intense sexually arousing fantasies, sexual urges or behaviors involving acts (real, not simulated) in which the psychological or physical suffering of the victim is sexually exciting to the person; these fantasies, urges or behaviors must have a duration of at least 6 months; the fantasies, urges or behaviors must cause significant distress or functional impairment.

ICD-10 gives diagnostic criteria for a single diagnosis of sadomasochism.

Symptoms and signs

By definition, sexual sadism involves sexual excitement derived from the physical of psychological suffering or humiliation of another person; the fantasies, urges or behavior must have been present for at least 6 months; and they must cause distress or functional impairment.

Patients with sexual sadism often come to medical attention only as a result of legal problems, although self-referral is not unknown.

Some patients may report sadistic fantasies that occur during sexual activity but that are not acted upon. The most commonly reported fantasy is of having complete control over the victim, who is terrified of the sadistic act about to be committed.

Other patients may report that they sadistic behaviors with consenting partners (who usually have sexual masochism) or with non-consenting partners.

Acts of sexual sadism include: activities that indicate the dominance of the sadist over the victim (e.g. forcing the victim to adopt humiliating postures or locking them in a cage); verbally abusing the victim; physical restraint of the victim ('bondage'); blindfolding the victim ('sensory bondage'); smacking, whipping, beating the victim or inflicting physical pain in other ways; administering electrical shocks; cutting the victim; mutilating the victim; torturing the victim; killing the victim.

Not all sexual sadists rely sadistic fantasies or behavior to achieve sexual arousal.

Some patients with sexual sadism may engaging in sadistic acts for years without any increase in the potential injuriousness of their activities; however, the severity of the acts usually increases with time.

Sexual sadists whose activities involve non-consenting partners usually continue their activities until they are apprehended.

The age of onset varies but is commonly be early adulthood. Most patients with sexual sadism can trace sadistic fantasies back to their childhood.

Investigations

The diagnosis is a clinical one based on the patient's history. No laboratory investigations are indicated.

Psychological testing may identify additional psychiatric disorders and paraphilias that are contributing to the severity of the sexual sadism.

Penile plethysmography may offer additional information to establish arousal associated with sadistic behavior and assess the patient for arousal associated with other paraphilias; however, the reliability of this measure is questionable and may result in false-negative information.

Complications

Complications of sexual sadism: legal problems resulting from the sadistic behavior - sexual sadism may result in sadistic injury to others, rape or murder, as well as a variety of other illegal activities. impaired social or sexual functioning, especially if sexual arousal is impossible without sadistic activities or if the sadistic behavior extends beyond sexual sadism to involve other areas of life and functioning; infection and other medical problems, which may arise from the activities engaged in, such as violent sexual behavior, exposure to fecal matter, drinking blood and eating body parts or organs (as in the case of some sadistic killers).

Paraphilias that frequently coexist with sexual sadism include: urophilia; coprophilia; vampirism (sexual arousal associated with drawing or drinking blood); piqueurism (the act of stabbing the victim in the breasts or buttocks before escaping); necrophilia (sexual arousal associated with corpses or mutilating corpses, which may occur directly after a murder or may involve a victim who has been dead for some time).

Differential diagnosis

The differential diagnosis of sexual sadism includes: mild degrees of consensual sadomasochistic stimulation that is used to enhance otherwise normal sexual activity and that does not fulfill the criteria for sexual sadism; psychotic disorders that may lead to sadistic behavior for reasons other than sexual excitement.

Prognosis

Without treatment, sexual sadism tends to have a chronic course. Sadistic behaviors may decrease in old age, although fantasies may remain voyeuristic in content.

Indicators of a poor prognosis include: early age of onset; no feelings of guilt or remorse for sadistic behavior; high frequency of engaging in sadistic behavior; poor sexual and social relationships.

Treatment and Outcome

Treatment aims

The aims of treatment are:: to reduce sadistic behavior; to improve the patient's sexual functioning with consenting partners; to prevent relapse.

Pharmacological treatment

Very little data have been collected about treatment modalities or treatment efficacy for sexual sadism. Antidepressants and hormonal therapies have been tried.

Antidepressant medication: Most antidepressant medications given for paraphilias, including sexual sadism, are thought to work by treating the 'obsessional' nature of the disorder and by taking advantage of the sexual side-effect profile of these medications.

Selective serotonin reuptake inhibitors (e.g. fluoxetine**, fluvoxamine**, paroxetine**) generally have fewer side effects than the tricyclic antidepressants (e.g. clomipramine**, imipramine**) and may be considered first-line agents, especially for patients on few or no other medications.

Appropriate dosages have not been determined, but it is generally accepted that medications should be prescribed in doses similar to those given in the treatment of obsessive-compulsive disorder or depression. Doses can be adjusted until symptoms are controlled or side-effects become intolerable.

** off-label use

Standard dosage

Standard doses are: fluoxetine: 20mg/day (maximum dose 60mg/day); fluvoxamine: 100mg/day initially (maximum dose 300mg/day); paroxetine: 20mg/day (maximum dose 50mg/day); clomipramine: 30-150mg/day; imipramine: 75mg/day initially, then up to 150-200mg/day.

Contraindications

Fluoxetine, fluvoxamine and paroxetine are contraindicated in mania and should be used with caution in: patients with a history of mania; seizure disorder; cardiac disease; bleeding disorders; hepatic impairment; renal impairment.

Clomipramine and imipramine are contraindicated in: recent myocardial infarction; mania; severe liver disease.

Clomipramine and imipramine should be used with caution in: heart disease; seizure disorder; liver disease; pheochromocytoma; patients with a history of mania; psychosis; closed-angle glaucoma.

Main side effects

The side effects of fluoxetine, fluvoxamine and paroxetine include: gastrointestinal reactions (nausea, vomiting, indigestion, abdominal pain, diarrhea, constipation), which are the most common side effects and are dose-related; cardiac problems; antimuscarinic effects (e.g. dry mouth, constipation, urinary retention); sexual side effects (e.g. anorgasmia); a withdrawal syndrome, seen in up to 60% of patients in whom the drug (especially paroxetine) is stopped suddenly, which can cause dizziness, anxiety, agitation, confusion, tremor, paresthesiae, nausea and sweating.

The side effects of clomipramine and imipramine include: heart block and other arrhythmias; postural hypotension; convulsions; drowsiness; dry mouth; blurred vision; constipation; urinary retention; neuroleptic malignant syndrome (rare).

In longer-term use, they can cause severely decreased reaction times and psychomotor retardation. They can precipitate a manic episode in bipolar patients.

Main drug interactions

Fluoxetine, fluvoxamine and paroxetine must not be used within 2 weeks of stopping of a monoamine oxidase inhibitor.

Similarly, clomipramine and imipramine should not be used within 2 weeks of a monoamine oxidase inhibitor. They should not be used concomitantly with drugs that prolong the QT interval because of an increased risk of ventricular arrhythmias; the most significant interaction is with amiodarone, and the combination should be avoided.

Hormonal agents

Hormonal agents been shown to be effective in suppressing sexual urges, including sadistic urges, but they may truncate the individual's sexual life and result in decreased compliance with medication. Agents that have been used include: medroxyprogesterone acetate**, which lowers testosterone levels and has demonstrated efficacy for decreasing sexual urges, fantasies and behaviors; leuprolide**, which inhibits gonadotropin secretion by blocking gonadotropin releasing hormone receptors in the pituitary gland.

** off-label use

Standard dosage

Standard doses are: medroxyprogesterone acetate: 80mg/day by mouth or 500mg/week by intramuscular injection; leuprolide: 1mg/day by subcutaneous injection or 7.5mg/month by intramuscular injection.

Contraindications

Medroxyprogesterone is contraindicated in: hepatic impairment; severe arterial disease, porphyria.

It should be used with caution in diabetes mellitus, hypertension and renal impairment. Leuprolide is contraindicated in patients with undiagnosed vaginal bleeding.

It should be used with caution in: vascular disease (coronary artery disease, cerebrovascular disease, thromboembolic disease); seizure disorders; hypertension; diabetes mellitus; edema.

Main side effects

The side effects of medroxyprogesterone acetate include: acne; fluid retention; gastrointestinal disturbances. possible carcinogenic effects.

The main side effects of leuprolide include: weight gain; hypertension; lethargy; hot flashes; mood lability (especially early during treatment); phlebitis (rare); gynecomastia (rare).

Non-pharmacological treatment

Cognitive-behavioral therapy seeks to identify antecedent thoughts, situations and behaviors that lead to sadistic behavior. It also seeks to increase the patient's ability to identify these vulnerable situations and intervene to prevent or stop the behavior by using various cognitive skills and behavioral skills.

Follow-up and management

Patients with sexual sadism should be helped to identify situations in which they are vulnerable to help to prevent relapse.

Consensual sexual activities should be encouraged.

It is important to assess patients for their wish or need for counseling for other paraphilias or other psychopathology.

Scientific Background

Etiology

The cause of sexual sadism is unknown, and no theory appears to explain the complexities and range of sexually sadistic behaviors adequately.

Epidemiology

Sadistic-masochistic sexual behaviors between consenting partners is not considered rare. However, sexual sadism with non-consenting partners is considered rare.

The age of onset for sexual sadistic behavior varies but is typically in early adulthood. Most people with sexual sadism can trace sadistic fantasies back to their childhood.

Sexual sadists may be male or female, but sexual sadistic behaviors with non-consenting partners are almost entirely perpetrated by men. a. Comorbidity with other paraphilias or sexual dysfunctions is reasonably common.

References

Bradford JM, Pawlak A Sadistic homosexual pedophilia: treatment with cyprosterone acetate: a single case study. Can J Psychiatry 1987; 22-30.

Briken P, Nika E, Berner W Treatment of paraphilia with luteinizing hormone-releasing hormone agonists. J Sex Marital Ther 2001; 45-55.

Diagnostic and Statistical Manual of Mental Disorders, 4th ed Text Revision (DSM-IV-TR). Washington DC: American Psychiatric Association 2000; 573-574.

Laws DR, O'Donohue W Sexual Deviance. New York: Guilford Press 1997;

Levitt EE The prevalence and some attributes of females in the sadomasochistic subculture: a second report. Arch Sex Behavior 1994; 465-473.

The ICD-10 Classification of Mental and Behavioral Disorders: clinical descriptions and diagnostic guidelines (ICD-10). Geneva: World Health Organization 1992;