Paraphilic disorders

Gender dysphoria is the marked incongruence between a person's experienced gender and the sex assigned at birth, present for at least 6 months and accompanied by clinically significant distress or impairment; gender nonconformity alone is not a disorder. Diagnosis is clinical, and management is a stepped, individualized plan of psychosocial support and social transition, pubertal suppression or gender-affirming hormone therapy for those who want it, and surgery considered only after at least 1 year of continuous hormone therapy.

Obsessive-compulsive disorder (OCD) is defined by ego-dystonic obsessions and/or compulsions that are time-consuming or cause significant distress and functional impairment, distinguishing it from the ego-syntonic perfectionism of obsessive-compulsive personality disorder. Diagnosis is clinical. First-line treatment combines cognitive behavioral therapy using exposure and response prevention with a high-dose selective serotonin reuptake inhibitor, with clomipramine as an effective second-line tricyclic and an OCD trial that can take up to 10 weeks to judge full response.

Bipolar I disorder is a chronic mood disorder defined by at least one manic episode lasting a week or requiring hospitalization, with three or more DIG FAST symptoms causing marked impairment. Diagnosis is clinical after substances and medical mimics are excluded. Acute mania is treated with lithium or valproate, often with an atypical antipsychotic, and most patients need lifelong mood-stabilizer maintenance.

Frontotemporal dementia (FTD) is the second most common neurodegenerative dementia in patients under 65, comprising a behavioral variant marked by early personality and disinhibition change and language variants (primary progressive aphasia) marked by isolated progressive language decline. Diagnosis rests on clinical criteria supported by MRI or FDG-PET showing frontotemporal atrophy; there is no approved disease-modifying or symptomatic drug therapy.

Parkinson disease is a slowly progressive neurodegenerative disorder from loss of substantia nigra dopaminergic neurons with alpha-synuclein Lewy body pathology, presenting with asymmetric rest tremor, bradykinesia, rigidity, and gait impairment. Diagnosis is clinical; first-line treatment is levodopa-carbidopa or a dopamine agonist.

Antisocial personality disorder is a pervasive, adult pattern of disregard for and violation of others' rights, with deceitfulness, impulsivity, and lack of remorse, diagnosable only at age 18 or older and only with documented conduct disorder before age 15. Management leads with consistent limit-setting; psychotherapy has limited proven benefit, and pharmacotherapy targets comorbid depression, impulsivity, or substance use disorder rather than the personality disorder itself.

Sexual dysfunction spans desire, arousal, orgasmic, and pain disorders in men and women, most often from a mix of vascular, neurologic, hormonal, medication, and psychological causes. Diagnosis rests on a structured sexual history plus screening for diabetes, cardiovascular disease, and androgen deficiency. First-line treatment is an oral phosphodiesterase type 5 inhibitor for erectile dysfunction, an SSRI for premature ejaculation, and flibanserin or bremelanotide for female sexual interest and arousal disorder, alongside treatment of the underlying cause.

Alcohol use disorder is a chronic pattern of drinking meeting 2 or more of 11 DSM-5 criteria within a 1-year period, screened with the CAGE or AUDIT-C and confirmed by history. First-line management combines a brief behavioral intervention and cognitive behavioral therapy with naltrexone or acamprosate, reserving disulfiram for highly motivated patients who can maintain abstinence.