[Failure of a study in forensic psychiatric hospitals : Clinical trial to investigate the additive effect of triptorelin on the efficacy of psychotherapy]. / Vom Scheitern einer Studie in Maßregelvollzugskrankenhäusern : Klinische Prüfung zum additiven Effekt von Triptorelin auf die Wirksamkeit von Psychotherapie.

BACKGROUND: A testosterone-lowering medication is relatively commonly used as a form of treatment for sexual offenders with severe paraphilic disorders in German forensic psychiatric hospitals; however, a double-blind, controlled and randomized study, which investigates the efficacy of this medication, is still lacking. AIM: This article describes the process from the planning to the rejection of a clinical trial over the period from 2009 to 2015. METHODS AND RESULTS: Despite the careful planning with an interdisciplinary team and giving special consideration to the complex legal situation, the Federal Institute for Drugs and Medical Devices (BfArM) rejected the proposed trial in a brief formal letter with reference to the German Drug Law (§ 40 para. 1 p. 3 nr. 4 AMG). The ethics committee of the Hamburg Medical Association considered that clinical research is basically not possible with patients detained in a forensic psychiatric hospital. DISCUSSION: In the opinion of the authors, the described facts illustrate how legal regulations that should protect vulnerable groups in medical research, in a specific case can lead to the fact that a therapy form relevant to the corresponding patient group cannot be scientifically investigated.

Relationship factors in sex offender couples: a pilot study in an outpatient setting.

Research indicates that sex offenders' relationships are often unstable and superficial. Sex offenders are portrayed as showing little empathy toward their partners and being incapable of sharing intimacy. This study aimed to explore sex offenders' intimate relationships and identify potential stabilizing factors in an outpatient setting. In an exploratory pilot study, the authors used standardized instruments to assess 17 heterosexual sex offenders and their intimate partners. Results indicate that both partners rate high in attachment anxiety. The authors found a high level of correlation between both partners with regard to attachment avoidance. The sex offender couples demonstrate similarly low scores for "dominance, pugnaciousness, and aggression" in intimate relationships, and the female partners revealed high neuroticism and conscientiousness scores.

Genital abnormalities in early childhood in sexual homicide perpetrators.

INTRODUCTION.: The present study investigates the relevance of genital abnormalities (GA) like cryptorchidism, hypospadias, and phimosis usually diagnosed in early childhood for the development of psychosexual problems and deficits in a sample of N = 163 convicted sexual homicide perpetrators. AIMS.: The first aim was to investigate the prevalence of early childhood GA in a sample of sexual homicide perpetrators. The second was to explore differences in the psychosexual development of participants with GA in early childhood compared with those without GA. It was expected that offenders with GA show specific problems in their psychosexual development compared with offenders without GA. METHODS.: The data for the present study were obtained by reanalyzing an existing database derived from a large-scale research project about sexual homicide. Using a predominantly exploratory design we, therefore, divided the total sample into two subgroups (with vs. without indicators of GA). MAIN OUTCOME MEASURES.: Main outcome measures were the number of sexual homicide perpetrators showing GA in early childhood and the differences of subjects with and without GA with regard to their psychosexual development (i.e., according to sexual deviant interests or sexual dysfunctions). RESULTS.: The prevalence of GA is substantially higher in this sample than epidemiological studies indicated in the normal population. This result provided first support for the importance of GA in the population of sexual homicide perpetrators. Further analyses indicate significant differences between both subgroups: Offenders with GA in early childhood showed indicators for more sexual dysfunctions (e.g., erectile dysfunction) in adulthood and a distinct tendency of more masochistic sexual interests. CONCLUSION.: Even if the exploratory design of the present investigation allows no causal conclusions between GA and sexual homicide offenses, the result provided support for the relevance of early childhood sexual diseases in the assessment (and treatment) of offenders who have committed severe sexual violence.

Pleasure seeking and the aspect of longing for an object in perversion. A neuropsychoanalytical perspective.

In modern psychiatric classifications the term paraphilia has replaced the term perversion by changing the scope of the definitions from avoided procreation to failures of relationship-aspects of sexuality. Contemporary psychoanalysts also seem less interested in pleasure seeking aspects, which were so important within original Freudian thought, and instead concentrate interpretation on hostility and the history of the representation of objects. This paper discusses the connection between distinct object representations in perversions and attachment theory and neurobiological representations. It will discuss the observation that the neglect of pleasure seeking in perversion often results in a failure to recognise the addiction-like aspects of perversion, which seem to be particularly relevant to modern psychiatric and psychological thinking. The SEEKING-system (Panksepp, 1998) is used to conceptualise a neurobiological basis for pleasure seeking. This SEEKING-system may be "hijacked" by rewards in different forms of addiction as well as in sexual obsessions. The polarity between "drive representation" and "object representation," as created by Freud (1933, 1940a), may correspond to the polarity identified in contemporary thinking between the addictive or compulsive characteristics of sexual gratification (drive representation) and the influence of early object representation on the later ability to integrate instinctual wishes into relationships (object representation).

Sexual murderers with adult or child victims: are they different?

This study investigates characteristics differentiating sexually motivated murderers targeting child victims (CV; n = 35) from those with only adult victims (AV; n = 100). In the initial phase, psychiatric court reports were evaluated using standardized instruments (SCID-II, PCL-R, HCR-20, SVR-20, Static-99). In the second phase, data on duration of detention and reconviction rates were obtained from German federal criminal records. The CV group showed more often diagnostic criteria of pedophilia (43% vs. 4%) and less often alcohol abuse and drug dependency (31% vs. 55%), sexual dysfunctions (9% vs. 29%) and narcissistic personality disorder (0% vs. 13%). No significant differences were found regarding PCL-R and total risk assessment scores. Child victim perpetrators were more likely to have committed acts of sexual child abuse before the sexual homicide (46% vs. 16%) but were less likely to have committed rape or sexual assault (17% vs. 42%) or caused bodily injury (26% vs. 50%). The CV group was detained more frequently in forensic psychiatric hospitals (59% vs. 26%), but the two groups showed the same rates of release and reconviction for sexual (22% for both groups), nonsexual violent (CV 25% vs. AV 15%) and nonviolent offenses (CV 63% vs. AV 59%). Although well-known differences between nonhomicidal sexual child abusers and rapists were replicated in this study on sexual homicide perpetrators, the groups showed more similarities than differences. The high prevalence of violence and antisocial personality disorder in both groups seem to be important risk factors for committing a (sexual) homicide and might have outweighed other differences.

Criminal recidivism in sexual homicide perpetrators.

Forensic psychiatric reports on 166 sexual homicide perpetrators in Germany were retrospectively analyzed for criminal risk factors. Follow-up information about release and reconvictions from federal criminal records was available for 139 offenders; 90 (64.7%) had been released. The estimated recidivism rate (Kaplan-Meier analyses) for 20 years at risk was 23.1% for sexual and 18.3% for nonsexual violent reoffences. Three men (3.3%) were reconvicted for attempted or completed homicide. Only young age at the time of sexual homicide resulted in higher sexual recidivism, whereas increased nonsexual violent recidivism was related to previous sexual and nonsexual delinquency, psychopathic symptoms, and higher scores in risk assessment instruments. Increased recidivism with any violent reoffence was associated with age-related factors: young age at first sexual offence, at homicide, and at release and duration of detention. The impacts of the results for risk assessment, relapse prevention, and supervision are discussed.

Sexual sadism and sadistic personality disorder in sexual homicide.

Controversies exist about the diagnostic validity of sexual sadism and its relation to sadistic personality disorder in sex offenders. The aim of this study was to investigate which diagnostic, developmental, and criminal characteristics differentiate sexual sadistic from non-sadistic sexual homicide perpetrators. Psychiatric court reports on 166 men who had committed a sexual homicide were evaluated regarding psychiatric, sexual and criminal history. Sixty-one offenders (36.7%) with sexual sadism (SeSd) were compared with 105 (63.3%) offenders without this diagnosis (NSeSd). Besides the sexual sadistic symptoms, there were seven factors that discriminated best between the two groups (sexual masochism, sadistic personality disorder, isolation in childhood, multiple sexual homicide, previous rape, previous tendencies for similar behavior, and long duration of the homicidal act). Sexual sadism is connected with circumscribed other characteristics and has to be considered in risk assessment and treatment of sex offenders.

The paraphilia-related disorders: an investigation of the relevance of the concept in sexual murderers.

Paraphilic disorders (PAs) and sexual preoccupation are known risk factors for recidivism in sexual offenders. Nonparaphilic sexual excessive behaviors-so-called paraphilia-related disorders (PRDs), like paraphilias, are also characterized by sexual preoccupation and volitional impairment and can be diagnosed in paraphilic men. The prevalence and clinical significance of PRDs in sexual homicide perpetrators, however, is unknown. We investigated the relationship between PAs and PRDs retrospectively in a sample of 161 sexual murderers. Four groups were compared: men without a PA or a PRD diagnosis, men with at least one PRD but no PA, men with at least one PA but no PRD, and finally, those with a combination of both (PA+PRD). The PA+PRD group had the most lifetime cumulative sexual impulsivity disorders, more developmental problems, the highest persistent frequency of sexual activity, the highest number of previous sexual offences, more sexual sadism, and compulsive masturbation. Men of the PRD subsample had suffered more from childhood sexual abuse, showed more promiscuity, psychopathy, and alcohol problems. The use of the PRD concept in this special offender group should be further investigated with prospectively designed studies.

The influence of brain abnormalities on psychosocial development, criminal history and paraphilias in sexual murderers.

The aim of this study was to investigate the number and type of brain abnormalities and their influence on psychosocial development, criminal history and paraphilias in sexual murderers. We analyzed psychiatric court reports of 166 sexual murderers and compared a group with notable signs of brain abnormalities (N = 50) with those without any signs (N = 116). Sexual murderers with brain abnormalities suffered more from early behavior problems. They were less likely to cohabitate with the victim at the time of the homicide and had more victims at the age of six years or younger. Psychiatric diagnoses revealed a higher total number of paraphilias: Transvestic fetishism and paraphilias not otherwise specified were more frequent in offenders with brain abnormalities. A binary logistic regression identified five predictors that accounted for 46.8% of the variance explaining the presence of brain abnormalities. Our results suggest the importance of a comprehensive neurological and psychological examination of this special offender group.

Pharmacotherapy of paraphilias with long-acting agonists of luteinizing hormone-releasing hormone: a systematic review.

BACKGROUND: In addition to psychotherapy, pharmacotherapy is an important treatment option for paraphilias, especially in sexual offenders. Cyproterone acetate (CPA) and medroxyprogesterone acetate (MPA) are commonly used but can have serious side effects. Selective serotonin reuptake inhibitors (SSRIs) may also be effective in less severe cases. Recent research shows that luteinizing hormone-releasing hormone (LHRH) agonists may offer a new treatment option for treatment of paraphilic patients. METHOD: MEDLINE was searched for clinical trials, case-control studies, case reports, and other clinically and theoretically important literature published between 1980 and November 2002 on the treatment of paraphilia with LHRH agonists. Keywords included LHRH agonists, GnRH- agonists, antiandrogens, paraphilia, pedophilia, and sex offenders. RESULTS: We found 4 case reports, 1 case- control study, 7 open uncontrolled studies, and 1 study comparing patients receiving CPA with those receiving LHRH agonist treatment in forensic hospitals. In total, the studies reported on a sample of 118 treated patients with different forms of paraphilias (sadism, pedophilia, exhibitionism, voyeurism). Nearly all of the studies used self-reports to measure the effects of medication. Duration of follow-up was between 6 months and 7 years and revealed that there were no relapses if patients remained under treatment. Patients previously treated with other agents like CPA, MPA, or SSRIs reported better effects when taking LHRH agonists. CONCLUSION: Although there is a need for further research, LHRH agonists offer a treatment option for patients with severe paraphilia. We propose a differentiated pharmacologic treatment regarding side effects, symptomatology, and severity.

Sexual sadism.

Definitions of sexual sadism in ICD-10 and DSM-IV will be presented as well as the historical routes of the concept. Today studies on differently selected clinical samples reveal a different distribution of sexual sadism versus masochism with masochism prevailing in general especially outpatient psychiatric facilities, and sadism prevailing in forensic settings, thus corroborating the concept of two separated diagnoses sadism versus masochism. In forensic settings the diagnosis of a sadistic character disorder (sadistic personality disorder [SPD] according DSM-III-R) is found to a much higher degree than in other clinical samples (50-fold). Our own follow-up study on a forensic sample implies that sadism as a paraphilia is of relevance for relapse-rates of sex-offenders. Symptoms of SPD can be combined with sexual sadism, or occur independently. This may corroborate arguments in favor of a dimensional concept of sexual sadism. Symptoms of SPD may then be a sign of generalization of sadistic traits at least in some cases. A concept of two factors contributing to sadistic pleasure is suggested, one taking the aspect of bodily gratification by sexual-aggressive stimuli as decisive, and the other taking inner representation of hostile objects into consideration (stressing the antisocial-anger-rage aspect).

Differential pharmacological treatment of paraphilias and sex offenders.

This article gives an overview of current pharmacological treatment of paraphilias and sex offenders focusing on the situation in Germany. Information about selective serotonin reuptake inhibitors (SSRI) is followed by data about established antihormonal substances (cyproterone acetate/CPA, and medroxyprogesterone acetate/MPA), as well as a more detailed account on luteinizing hormone-releasing hormone agonists (LHRH agonists). The results of open, uncontrolled clinical studies with SSRIs (n = 16) and LHRH agonists (n = 11) in paraphilic outpatients confirm the positive effects of these substances. A survey about the use of CPA and LHRH agonists in forensic hospitals in Germany shows that half of the patients treated with any kind of (anti-) hormonal agents received an LHRH agonist. The authors present a protocol on side effects, contraindications, and monitoring of CPA and LHRH agonists and develop an algorithm for differential pharmacotherapy of paraphilias.

Personality disorders in men with sexual and violent criminal offense histories.

Little is known about personality disorders (PDs) in offenders with histories of both sexual and (nonsexual) violent offenses. This study aimed to identify possible differences of PD profiles across three different offender groups with both sexual and violent (S+V), only sexual (S), and only violent (V) offenses. Nonviolent (N) offenders were used as a comparison group. Typing of individuals according to their offensive histories was performed on the basis of 259 psychiatric court reports that included the Structured Clinical Interview (SCID)-II for PD diagnostics. Men from the S+V group committed significantly more acts of rape and sexual coercion than the mere sexual offenders. Furthermore, S+V offenders showed the highest rates of PDs overall (68.3%), with every second offender being diagnosed with an antisocial PD and every third offender with a borderline PD. In summary, the results suggest that S+V offenders form a group of individuals with remarkable differences regarding PD profiles, the relatively highest frequencies of conduct disorders, familial addictive problems, and PDs overall.

Double-blind, controlled, clinical trial planned in germany to investigate the efficacy of psychotherapy combined with triptorelin in adult male patients with severe pedophilic disorders: presentation of the study protocol.

BACKGROUND: The treatment of paraphilias, especially of pedophilia, centers upon cognitive-behavioral psychotherapy and pharmacologic interventions. Two open, uncontrolled clinical studies using the synthetic LHRH-agonist triptorelin suggested that, combined with psychotherapy, antiandrogen treatment reduced deviant sexual fantasies, urges, and behaviors in paraphilic patients. There is a need for further research using controlled, randomized trials to examine the effectiveness of sexual offender treatment including psychotherapeutic and pharmacologic interventions. OBJECTIVE: The aim of this pilot study is to evaluate the efficacy and tolerability of cognitive-behavioral psychotherapy together with intramuscular (IM) 3-monthly injections of triptorelin in adult men with severe pedophilia. STUDY DESIGN AND METHODS: In this multicenter, forensic psychiatric hospital-based, double-blind, controlled, parallel group phase IV trial conducted in Germany, convicted male sexual offenders aged ≥ 18 years with pedophilia, as defined by DSM-IV-TR criteria, will be randomized to receive study-specific psychotherapy together either with triptorelin or placebo for 12 months (total of 4 injections). This is a pilot study, therefore exploratory data analyses will be carried out of three different target parameters: 1. Changes in psychosexual characteristics using the Multiphasic Sex Inventory (scale: sexual abuse of children) 2. Changes in the risk of violent sexual behavior using the Sexual Violence Risk-20 total score 3. Changes in serum testosterone concentration Treatment effects will be assessed by comparing baseline values with those at the final examination (month 12). LIMITATIONS: The absence of real-life stimulants to test for actual recidivism limits possible findings. The study will be conducted in agreement with the European GCP-guideline, all relevant legal requirements, and the legal framework for voluntary treatment of convicted sexual offenders in Germany.

The utility of risk assessment instruments for the prediction of recidivism in sexual homicide perpetrators.

To examine the predictive accuracy of four well established risk assessment instruments (PCL-R, HCR-20, SVR-20, and Static-99) in an important subgroup of sexual offenders, these instruments were assessed retrospectively based on information from forensic psychiatric court reports in a sample of 90 released male sexual homicide offenders (out of an original sample of 166) in Germany. Follow-up information about criminal reconvictions after release were obtained from the federal criminal records. Total scores as well as subscales and single items of these risk assessment instruments did not predict sexual recidivism, and only some of them had moderate predictive power regarding nonsexual violent recidivism. Possible explanations for these unexpected results are the retrospective study design with missing information about influences during the long duration of detention and time after release, the small sample size as well as the possibility that the risk assessment instruments investigated were valid for general sex offender samples, but not for the particular subgroup of offenders with sexually motivated homicides.

Sociodemographic and diagnostic characteristics of homicidal and nonhomicidal sexual offenders.

The aims of this study were to compare the prevalence of psychiatric disorders and "psychopathy" in homicidal and nonhomicidal sexual offenders and to investigate the specificity of previous studies on psychiatric morbidity of a sample of sexual murderers. Information from court reports of 166 homicidal and 56 nonhomicidal sex offenders was evaluated using standardized instruments (SCID-II, PCL-R) and classification systems (DSM-IV). Sexual murderers were diagnosed more often with a personality disorder (80.1% vs. 50%; p < 0.001), especially schizoid personality disorder (16.3% vs. 5.4%; p < 0.05), as well as with sexual sadism (36.7% vs. 8.9%; p < 0.001) and sexual dysfunctions (21.7% vs. 7.1%; p < 0.05). Additionally, they had more often used alcohol during the offense (63.2% vs. 41%; p < 0.05). The results indicate that sexual murderers have more and a greater variety of psychiatric disorders when compared to nonhomicidal sex offenders.

[Antiandrogenic pharmacotherapy of sexual offenders and home leave steps in the forensic psychiatric hospital Berlin]. / Antiandrogene Therapie und Lockerungen bei Sexualstraftätern im Massregelvollzug Berlin.

OBJECTIVE: Evaluation of the relationship between antiandrogenic therapy of sexual offenders and home leave steps in a forensic psychiatric hospital. METHODS: Retrospective evaluation of all sexual offenders (n = 79) who were treated in the forensic psychiatric hospital Berlin between the 1.1.1998 and the 1.1.2005. RESULTS: There is an increase in the number of patients treated with antiandrogenic medication during the observed time period. Patients under this kind of pharmacotherapy receive higher grades of home leave steps. CONCLUSIONS: As possible reasons for the observed changes we discuss the contemporaneous implementation of a new pharmacotherapeutic treatment option (LHRH-agonists) and an aggravation of the German criminal law for sexual offenders.

[Paraphilia, sexual preference disorders. Diagnosis, etiology, epidemiology, treatment and prevention]. / Störung der Sexualpräferenz (Paraphilie): Diagnostik, Atiologie, Epidemiologie, Behandlung und präventive Aspekte.

Hostility towards relationships is one prominent characteristic symptom for disorders of sexual preference (ICD-10) and paraphilias (DSM-IV). Paraphilic symptoms sometimes progress to obsessive or addictive- like forms leading to a loss of self-control but can occur also as single incidents or as episodic events. Besides constitutional aspects, problems in the development of close relationships to primary caregivers (attachment) play an important role in the development of these disorders. Actual relationship- and self-confidence problems often trigger the severity of disturbance, especially in the episodic forms of paraphilia. For patients who are in conflict with the law, cognitive-behavioral therapeutic approaches with the aim to minimize self-deception regarding the effects of the paraphilic behavior have become more and more relevant. Regarding the medical treatment, anti-hormonal therapy plays an important role, but also treatment with serotonergic agents and naltrexone are used. Only little can be advised in terms of prevention; general psycho-hygiene (regarding the parent-child relationship) is recommended. Beside these general measures, institutions which offer special treatment for people in danger to become delinquents may be able to prevent serious harm for possible victims of abuse.