Higher Risk Taking and Impaired Probability Judgment in Behavioral Addiction.

BACKGROUND: Accumulating evidence suggests that deficits in decision-making and judgment may be involved in several psychiatric disorders, including addiction. Behavioral addiction is a conceptually new psychiatric condition, raising a debate of what criteria define behavioral addiction, and several impulse control disorders are equivalently considered as types of behavioral addiction. In this preliminary study with a relatively small sample size, we investigated how decision-making and judgment were compromised in behavioral addiction to further characterize this psychiatric condition. METHOD: Healthy control subjects (n = 31) and patients with kleptomania and paraphilia as behavioral addictions (n = 16) were recruited. A battery of questionnaires for assessments of cognitive biases and economic decision-making were conducted, as was a psychological test for the assessment of the jumping-to-conclusions bias, using functional near-infrared spectroscopy recordings of prefrontal cortical (PFC) activity. RESULTS: Although behavioral addicts exhibited stronger cognitive biases than controls in the questionnaire, the difference was primarily due to lower intelligence in the patients. Behavioral addicts also exhibited higher risk taking and worse performance in economic decision-making, indicating compromised probability judgment, along with diminished PFC activity in the right hemisphere. CONCLUSION: Our study suggests that behavioral addiction may involve impairments of probability judgment associated with attenuated PFC activity, which consequently leads to higher risk taking in decision-making.

Conceptualization, History, and Future of the Paraphilias.

There is no accepted definition of the term paraphilia despite its being listed as an essential feature of a class of mental disorders known as the paraphilic disorders. The origin of the term, history of its inclusion as a diagnosis, and logical flaws inherent in the various definitions are discussed in this review. We examine the basis for pathologizing individuals with paraphilias, consider what paraphilias can tell us about how humans develop their sexual interests, and question the usefulness of dividing sexual interests into paraphilias and normophilias. The construct of the paraphilias appears to be poorly conceived and has outlived its usefulness.

Advances in the Assessment of Sexual Deviance.

PURPOSE OF REVIEW: This paper reviews recent research into four different approaches to the assessment of offense-related sexual deviance. RECENT FINDINGS: Two of these approaches, structured rating scales and phallometry, have a sufficient basis in research for clinical use but have undergone significant refinements in recent years. One approach, the use of cognitive tasks to indirectly assess sexual deviance, is approaching the point where it has a sound research basis for clinical use though too many promising tasks have yet to make the transition from laboratory to clinical practice. This approach has however begun to map the earlier stages of sexual response including preconscious processes. The final approach, assessment through neuroimaging, is at the earliest stage of development with research findings having yet to reach sufficient stability for clinical application. Existing assessment technologies, despite their limitations, allow professionals to assess offense-related sexual deviance. New approaches, currently being developed, potentially allow a better understanding of underlying processes and, when sufficiently mature, will be more therapeutically useful.

Zoophilia in an adolescent with high-functioning autism from Sri Lanka.

OBJECTIVE: Zoophilia is a rare paraphilic disorder with intense sexual urges involving animals. Autism is characterised by impairments in social communication and repetitive, restricted behaviours (RRB). Reported cases of zoophilia are limited worldwide, and zoophilia in autism is rarer. METHOD: This is a case report describing this unique and relatively unrecognised association in a male adolescent from Sri Lanka. RESULTS: A 17-year-old boy diagnosed with autism has average intelligence and academic capabilities. He had spent increasing time at his grandparents' cattle house. First, he was found masturbating near the cows and later having penetrative intercourse with a heifer. The shocked parents first sought traditional healing in the form of 'thovil', a demonic ritual of exorcist nature. Later, clinical evaluation found intense sexual urges towards cattle, which had led to marked distress and academic impairment. Sex hormone profile was normal. The adolescent was treated with a combination of cognitive-behaviour therapy and a selective serotonin reuptake inhibitor. CONCLUSION: We postulate that his persistent social difficulties contributed to the development of a paraphilic disorder. Unlike with his RRBs, he was markedly distressed about this sexual behaviour. Further research is required to explore this rarely reported, potential association.

Deep brain stimulation to reduce sexual drive.

To date there are few treatment options to reduce high sexual drive or sexual urges in paraphilic patients with a risk for sexual offending. Pharmacological therapy aims to reduce sexual drive by lowering testosterone at the cost of severe side effects. We hypothesize that high sexual drive could also be reduced with deep brain stimulation (DBS) of circuits that generate sexual drive. This approach would help to avoid systemic side effects of antiandrogenic drug therapies. So far the best investigated target to reduce sexual drive is the ventromedial hypothalamus, which was lesioned unilaterally and bilaterally by stereotaxic interventions in paraphilic patients in the 1970s. Here, we discuss DBS as a treatment strategy in patients with severe paraphilic disorders with a serious risk of sexual offending. There are profound ethical and practical issues associated with DBS treatment of paraphilic patients that must be solved before considering such a treatment approach.

Dark Tetrad personality traits, paraphilic interests, and the role of impulsivity: an EEG-study using a Go/No-Go paradigm.

Maladaptive personality traits, such as 'dark personalities' are found to result in a diverse set of negative outcomes, including paraphilic interests and associated (illegal) behaviors. It is however unclear how these are exactly related, and if related, if then only those individuals higher on dark personality traits and higher impulsivity engage in paraphilic behaviors. In the current study, 50 participants were recruited to investigate the relationship between Dark Tetrad personality traits (i.e., narcissism, psychopathy, Machiavellianism and everyday sadism), paraphilic interests (arousal and behavior) and the moderating role of impulsivity. Personality and paraphilic interests were investigated through self-report questionnaires. Impulsivity was measured both through self-reported dysfunctional impulsivity and the P3 event related potential using electroencephalography during the Go/No-Go task (i.e. response inhibition). The results showed that there was a positive association between psychopathy, sadism and paraphilic interests. Whereas everyday sadism was associated with paraphilic (self-reported) arousal, psychopathy was associated with paraphilic behavior. Although P3 amplitude was not associated with paraphilic interests, self-reported dysfunctional impulsivity was associated with paraphilic behavior specifically. However, there was no moderating role of dysfunctional impulsivity and response inhibition (P3) in the relationship between psychopathy and paraphilic behavior. Findings indicate that the relation between specific dark personalities and paraphilic interests may be more complex than initially thought. Nevertheless, risk assessment and intervention approaches for paraphilia and related behavior both may benefit from incorporating Dark Tetrad and impulsivity measurements.

The role of testosterone in sexuality and paraphilia--a neurobiological approach. Part II: testosterone and paraphilia.

INTRODUCTION: Antiandrogen therapy has been used for 30 years to treat paraphilic patients and sexual offenders. Yet the therapeutic success of antiandrogens is uncertain. Furthermore, there is still a lack of comprehensive knowledge about the effects of androgen-lowering therapy in paraphilic patients. AIM: We discuss endocrinological, neurobiological, and therapeutic aspects of paraphilia with the aim of integrating these on the basis of the current neurobiological and clinical knowledge on testosterone that was set out in Part I of this review. METHODS: Our review of the human literature comprises the current knowledge about the neurobiology of paraphilia and the known endocrinological, pathophysiological, and genetic aspects of this disorder. The role of testosterone is discussed. A survey of antiandrogen therapy and its outcome in paraphilic patients and sex offenders is provided. RESULTS: Although not all data are consistent, current imaging research suggests that structural and functional changes in pedophilia appear for the most part in brain regions also involved in sexual functions. Not exclusively testosterone but also some other endocrinological and neurochemical parameters could be disturbed in pedophilic patients and child molesters; these include changes in hypothalamic-pituitary function, prolactin levels, and dopaminergic or serotonergic functions. There appears to be a sex-steroid-related genetic influence on antisocial traits, externalizing behavior, and sexual behavior. Most of the studies in which antiandrogen therapy in paraphilic patients and sex offenders have been examined were case reports, or observational or open-label studies, and many did not include adequate control groups. Only a few placebo-controlled double-blind studies have been published with inconsistent results concerning treatment effects. Outcome measures differ between the studies and do not seem ideally suited to their purpose. CONCLUSIONS: On the basis of the current knowledge about testosterone and its effects on brain and behavior as described in Part I, and of available results on the relationship between testosterone and paraphilia as well as antiandrogen therapy, we present from a neurobiological perspective an extended scientific proposal for design features to investigate the effects of antiandrogen treatment in large clinical trials.

Is a diagnostic category for paraphilic coercive disorder defensible?

There is a proposal to establish a paraphilic coercive disorder as a new paraphilia in the DSM-V. The empirical data do not, however, support the hypothesis that a distinct syndrome exists that comprises males who are sexually aroused by the coercive elements of rape per se. Purported evidence for this syndrome has centered on the results of phallometric studies. Higher plethysmographic responses of rapists to coercive rape scenarios may, however, be better explained by the failure of coercive elements to inhibit arousal to sexual aspects of the stimuli rather than by arousal specifically to the coercive elements. In addition, sexual fantasies about forcing sex and about struggling victims are highly correlated with sadistic fantasies and have not been shown to identify a syndrome that can be discriminated from sadism. Finally, taxometric evidence strongly supports the hypothesis that the underlying components of rape are distributed as dimensions and do not constitute a separate taxon. Consequently, the criteria purported to categorize rapists into the proposed syndrome would have to be arbitrarily determined. Not only does there seem to be little empirical justification for the creation of this new syndrome, the inclusion of this disorder among the paraphilias would have serious potential for misuse. It would imply endorsement of Paraphilia, NOS, nonconsent, which is currently inappropriately employed in civil commitment proceedings to justify commitment.

Occurrence and clinical characteristics of Compulsive Sexual Behavior Disorder (CSBD): A cluster analysis in two independent community samples.

BACKGROUND AND AIMS: Compulsive Sexual Behavior Disorder (CSBD) is characterized by a persistent failure to control intense and recurrent sexual impulses, urges, and/or thoughts, resulting in repetitive sexual behavior that causes a marked impairment in important areas of functioning. Despite its recent inclusion in the forthcoming ICD-11, concerns regarding its assessment, diagnosis, prevalence or clinical characteristics remain. The purpose of this study was to identify participants displaying CSBD through a novel data-driven approach in two independent samples and outline their sociodemographic, sexual, and clinical profile. METHODS: Sample 1 included 1,581 university students (females = 56.9%; Mage = 20.58) whereas sample 2 comprised 1,318 community members (females = 43.6%; Mage = 32.37). First, we developed a new composite index to assess the whole range of CSBD symptoms based on three previously validated scales. Based on this new composite index, we subsequently identified individuals with CSBD through a cluster analytic approach. RESULTS: The estimated occurrence of CSBD was 10.12% in sample 1 and 7.81% in sample 2. Participants with CSBD were mostly heterosexual males, younger than respondents without CSBD, reported higher levels of sexual sensation seeking and erotophilia, an increased offline and especially online sexual activity, more depressive and anxious symptoms, and poorer self-esteem. CONCLUSIONS: This research provides further evidence on the occurrence of CSBD based on an alternative data-driven approach, as well as a detailed and nuanced description of the sociodemographic, sexual, and clinical profile of adults with this condition. Clinical implications derived from these findings are discussed in detail.

Construct validity of the Violence Risk Scale--Sexual Offender Version for measuring sexual deviance.

Previous studies have identified sexual deviance as a particularly strong predictor of sexual recidivism in sex offenders. The present study examined the construct validity (i.e., convergent and discriminant validity) of the three dynamic factor domains (Sexual Deviance, Criminality, Treatment Responsivity) of the Violence Risk Scale- Sexual Offender version (VRS-SO) as well as the Screening Scale for Pedophilic Interests (SSPI; for comparison purposes) with respect to phallometric measures of sexual deviance. VRS-SO and phallometric data were collected from 124 federally incarcerated sex offenders from a maximum security forensic psychiatric facility. The Sexual Deviance factor and SSPI were positively correlated to varying degrees with computed arousal indexes (Percent Full Erection, difference scores) for child stimuli but were not significantly correlated with nondeviant arousal, supporting the convergent and discriminant validity of these measures, respectively. Convergent validity also appeared stronger for sex offender subtypes with child victims. Criminality and Treatment Responsivity did not correlate with male stimuli, although they were positively correlated with arousal to female profiles. The VRS-SO Sexual Deviance factor and some phallometric indexes of deviant arousal (e.g., female children) were predictive of sexual recidivism whereas the SSPI was not. The pattern of findings across analyses broadly supports the construct validity of the VRS-SO in assessing sexual deviance.

A practical guide for the evaluation of sexual recidivism risk in mentally retarded sex offenders.

Although sex offender risk assessment has progressed greatly over the past decade and a half since most states implemented the sexually violent predator/sexually dangerous person (SVP/SDP) laws, there continues to be limited applicability of such models to intellectually disabled sex offenders because there has been no empirical validation. However, SVP/SDP civil commitment programs have reported increased admission of developmentally disabled sex offenders. Differentiating sexual deviance, the primary factor predisposing most individuals to criminal sexual violence, from impulsive, immature, and inappropriate behavior stemming from cognitive deficits presents yet another challenge to the clinician tasked with performing such evaluations. This article reviews actuarial risk models and their limited applicability to mentally retarded sex offenders and offers a conceptual method of assessing the risk of recidivism in intellectually disabled sex offenders under SVP/SDP evaluation.

A Qualitative Exploration of Adult Baby/Diaper Lover Behavior From an Online Community Sample.

This study examined qualitative data on 1,795 male, 139 female, and 78 transgender members of the adult baby/diaper lover (ABDL) online community. Using grounded theory, the analyses examined a description of ABDL practices, explored evidence of subgroups within the ABDL community, and examined the degree to which ABDL behavior involves sexual motivations. Overall, the data suggest there is a fair amount of diversity within the ABDL community. Most participants enjoy wearing diapers or engaging in age regression (as babies or children), and the importance of incontinence may vary. ABDL practices can reflect bondage play for some individuals and a way to cope with medical problems for others. Overall, there is modest evidence of more than two ABDL subgroups. Although a large number of individuals do not see their ABDL practices as sexual in nature, there is a clear contingent that describes sexual motivations. For some, sex during ABDL activity violates conceptions of baby play. Nonsexual motivations include a desire to relax or be carefree as well as a desire to be nurtured. Some diaper lovers and adult babies have the same goals but achieve them in different ways. ABDL practices may be as diverse as seemingly typical sexual behaviors.

[Neurotransmitter mechanisms of paraphilic disorders]. / Neirotransmitternye mekhanizmy razvitiia parafil'nykh rasstroistv.

AIM: To investigate serotonin and catecholamine levels in people with paraphilic disorders and identify correlations between transmitter dysfunction and clinical signs of paraphilic disorders. MATERIAL AND METHODS: Fifteen men with paraphilic disorders were studied using clinical-psychopathological, sexological, biochemical and statistical methods. RESULTS: There were an increase in the levels of serotonin and norepinephrine and a decrease in the concentration of DOPAC (3,4-dihydroxyphenylacetic acid) in the urine of patients with paraphilic disorders. The concentrations of serotonin and norepinephrine are correlated with obsessive disturbances. The level of DOPAC was associated with affective and dissociative disorders. CONCLUSION: The relationships between biochemical and psychopathological signs suggest a role of biological mechanisms in the organization of abnormal sexual behavior. Correlations between psychopathological phenomena and DOPAC indicate a key role of central dopamine in the pathogenesis of paraphilic disorders and disturbances of conscious regulation of behavior.

A neurobiological perspective on attachment problems in sexual offenders and the role of selective serotonin re-uptake inhibitors in the treatment of such problems.

This paper describes what is currently known about attachment from the development, social-cognitive and biological literatures and outlines the impact on organisms given adverse development experiences that can have an effect upon attachment formation in childhood across these three literatures. We then describe the effects that 'insecure' attachment styles arising in childhood can affect brain chemistry and brain function and subsequently adult social/romantic relationships. In the paper, we note that a number of sexual offenders report adverse childhood experiences and that they possess attachment styles that, taken together, make it likely that they will either seek out intimate attachments in ways where they will have sex with children, perhaps confusing sex with intimacy or in aggressive ways as particularly happens with men who sexually assault adult women. The last section of the paper describes chemical treatment for sexual offenders, focusing on the use of selective serotonin re-uptake inhibitors (SSRIs). We note evidence for the role of SSRIs in promoting more social/affiliative behaviors and speculate on the effects that SSRIs have in the treatment of sexual offenders by targeting areas of the social brain. Here, we would argue that it would be useful to carry out treatment where there is a combination of SSRI treatment (to promote more prosocial feelings and behaviors) in conjunction with therapy that typically addresses thoughts and behaviors, i.e., cognitive-behavioral therapy/schema-focused therapy.

The monoamine hypothesis for the pathophysiology of paraphilic disorders: an update.

A monoamine hypothesis for the pathophysiology of paraphilic disorders was first articulated in 1997 by Kafka. This hypothesis was based on four converging lines of empirical evidence. First, the monoamine neurotransmitters, dopamine, norepinephrine, and serotonin serve a modulatory role in human and mammalian sexual motivation, appetitive, and consummatory behavior. Second, the sexual effects of pharmacological agents that affect monoamine neurotransmitters can have both significant facilitative and inhibitory effects on sexual behavior. Third, paraphilic disorders appear to have Axis I comorbid associations with nonsexual psychopathologies that are associated with monoaminergic dysregulation. Last, pharmacological agents that enhance central serotonergic function in particular, have been reported to ameliorate paraphilic sexual arousal and behavior. Contemporary data supporting or refuting a monoaminergic hypothesis as a biological component associated with paraphilic sex offending behaviors will be reviewed. Particular attention will be given to pharmacological-metabolic probe studies, reports of Axis I comorbidity, the proposed role of disinhibited sexual motivation or sexual appetitive behavior, and cumulative pharmacological treatment data sets.

Sexual arousal and arousability in a sexual offender population.

Assessed penile erections in response to descriptions of consenting sex, rape, and nonsexual assault among 78 inpatient male sexual offenders. All forms of sexual arousal were positively correlated, and sexual arousal to consenting stimuli exceeded arousal to coercive stimuli. Subjects who were able to completely inhibit their arousal exhibited less arousal to sexual assault stimuli than did subjects who were unable to completely inhibit arousal when both groups were not instructed to inhibit arousal. Inhibitory ability covaried with victim maturity, and with months spent in a treatment program. The maturity of the victims in the subjects' sexual offenses was not significantly related to sexual arousal. Thus, sexual offenders' sexual arousal as assessed by physiological measures may be more a function of arousability variables than of actual offending behaviors.

Differentiating rapists and non-offenders using the rape index.

Some studies have suggested that phallometrically derived rape indices can differentiate groups of rapists and non-offenders. There are other studies however which cast doubt on this assertion, at least in so far as it applies to all but those few rapists who are sadistic. These studies have used rape indices which are derived from rapists' sexual responses to audiotaped descriptions of mutually consenting sex and brutal sexual assaults. It was hypothesized however, that stimuli which put more emphasis on the degrading and humiliating elements of rape would improve discriminability. Stimuli were compiled to test this hypothesis. The results indicate that neither rape indices derived from the physically brutal elements nor the degrading elements of rape were able to discriminate between rapists and non-offenders. Furthermore, these indices were not related to offence histories. The results are discussed in terms of their implications for the assessment of rapists and theoretical considerations of their behaviour.

The relationship between phallometrically measured deviant sexual arousal and clinical characteristics in juvenile sexual offenders.

The current study examined the relationship between clinical characteristics and a phallometrically derived deviance quotient index in two samples of 44 and 54 juvenile sex offenders. Results support an association between higher measured deviant arousal and having a male victim only, consistent with the literature on adult child molesters. However, results reflected greater fluidity in the offense patterns of the juvenile offenders, and generally less correspondence between measured arousal and offense histories than what has been cited for adults. The authors review whether there is empirical support for a conditioning model of deviant arousal onset in juveniles, and suggest caution in the interpretation of phallometric data with this population.

Sexual asphyxiophilia (Koczwarism) in women and the biological phenomenon of female ejaculation.

Life threatening eroticizing behavior, asphyxiophilia (sexual asphyxia) is practiced in women, as in men, in order to heighten sexual excitement and to achieve orgasm, which is in some women accompanied by expulsions of fluid (ejaculation) from the urethra. The relatively easily achieved orgasm induced by the mechanism of asphyxia is hypothesized to be the common reason for repetitive deviant asphyxiophilic behavior. Moreover, in women of the ejaculatory type (female ejaculators), the desire to induce ejaculatory orgasm by asphyxia may also come into play as this kind of orgasm is usually assessed as sensation of greater delight than orgasm without ejaculation.

Of rats and women: fetal sexuality and hybrid agency.

This paper investigates the way in which the sexuality of women has been posited in relation to rats as experimental subjects, exploring the stakes of a scientific debate that takes the social world of female sexuality as its focus and as a political problem. Studies that purport to understand female sexuality by investigating rat behavior rely on problematic assumptions about sovereign agents motivating sexual behavior. Such studies also aim to do away with so-called deviant sexual behaviors and, as a consequence, gay people. Theories of agential realism and hybridity serve as counterforces to these inherently repressive perspectives by insisting on the multiple determinations of sexuality and subjectivity among women.