Substance Use Disorders and Antisocial Personality Disorder among a Sample of Incarcerated Individuals with Inadequate Health Care: Implications for Correctional Mental-Behavioural Health and Addiction Services.

Epidemiological estimates of substance use disorders (SUD) are critical for the planning of evidence-informed intervention and services. In this study, 250 incarcerated individuals in Nigeria were interviewed with the Mini International Neuropsychiatric Inventory (MINI) to diagnose SUD and antisocial personality disorder (ASPD). Most of the participants were males (97.6%), and the mean age was 35.4 (SD=13.5) years. Substance use disorder and ASPD were prevalent in 57.6% and 11.2% of the participants, respectively. Of those diagnosed with SUD, 35.2% and 22.4% had poly-SUD and mono-SUD respectively. Psychotic and dependence syndromes involving cannabis misuse were the most prevalent poly-SUD, and mono-SUD was characterized by alcohol, nicotine, and opioid dependence syndromes. Substance use disorder was more likely in participants charged with robbery and convicted, while ASPD was associated with prior and long-term imprisonment. There is a need for effective integration of treatment for ASPD/SUD into correctional mental health services in settings with inadequate health care using an appropriate model and a viable strategy.

Concordance of Paraphilic Interests and Behaviors.

We examined the concordance of paraphilic interests and behaviors across 13 themes in an online sample of 1,036 men and women. Paraphilic interests were significantly and positively correlated with behaviors across all 13 themes. Associations were strongest for masochism and sadism, and weakest for pedohebephilia and frotteurism. Paraphilic interest and behavior were significantly and positively correlated after accounting for gender and sexual orientation. Moderated moderation analysis was significant for five themes. Gender was a moderator for eroticized gender, but only among heterosexual participants, where concordance was higher for heterosexual men than for heterosexual women. For both exhibitionism and frotteurism, gender was a significant moderator, but only for nonheterosexual participants, where concordance was stronger for nonheterosexual men than for nonheterosexual women. For pedohebephilia, interest was significantly associated with behavior for heterosexual men, heterosexual women, and nonheterosexual men, but not for nonheterosexual women. For zoophilia, there was a significant association between interest and behavior for heterosexual men, nonheterosexual men, and nonheterosexual women, but not heterosexual women. Additional analyses found sex drive moderated the positive associations of 7 of 13 paraphilic themes, with 5 of these 7 showing the expected effect of higher concordance of interests and behaviors at higher levels of sex drive.

Vicarious Trauma and PTSD in Forensic Mental Health Professionals.

In their article about countertransference and vicarious trauma in work with sexual offenders, Barros and colleagues highlight the importance of awareness of risk for vicarious trauma in forensic psychiatrists and psychologists. This commentary supports the need for more research related to the risk of vicarious trauma and posttraumatic stress disorder (PTSD) in forensic experts. Also, forensic mental health professionals need to be aware of the level of risk to which they are exposed in their work evaluating and treating sexual offenders. As more knowledge has developed about PTSD and the diagnostic criteria have evolved between the fourth and fifth editions of the Diagnostic and Statistical Manual of Mental Disorders, there is also more awareness of the effects of traumatic exposure on different professional groups and laypeople. For example, judicial authorities in Canada have recently become aware of the traumatic impacts of evidentiary material on jurors, including testimony, print, and video material. Workplace exposure to trauma in inpatient psychiatric centers has received limited research focus. Actual or threatened death or sexual violation in these settings can result in compassion fatigue and burnout. Exposure to video material in the workplace, particularly in forensic settings, can result in PTSD.

The World Federation of Societies of Biological Psychiatry (WFSBP) 2020 guidelines for the pharmacological treatment of paraphilic disorders.

Objectives: The primary aim of these guidelines is to evaluate the role of pharmacological agents in the treatment and management of patients with paraphilic disorders, with a focus on the treatment of adult males. Because such treatments are not delivered in isolation, the role of specific psychotherapeutic interventions is also briefly covered. These guidelines are intended for use in clinical practice by clinicians who diagnose and treat patients, including sexual offenders, with paraphilic disorders. The aim of these guidelines is to bring together different views on the appropriate treatment of paraphilic disorders from experts representing different countries in order to aid physicians in clinical decisions and to improve the quality of care.Methods: An extensive literature search was conducted using the English-language-literature indexed on MEDLINE/PubMed (1990-2018 for SSRIs) (1969-2018 for hormonal treatments), supplemented by other sources, including published reviews.Results: Each treatment recommendation was evaluated and discussed with respect to the strength of evidence for its efficacy, safety, tolerability, and feasibility. The type of medication used depends on the severity of the paraphilic disorder and the respective risk of behaviour endangering others. GnRH analogue treatment constitutes the most relevant treatment for patients with severe paraphilic disorders.Conclusions: An algorithm is proposed with different levels of treatment for different categories of paraphilic disorders accompanied by different risk levels.

The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the treatment of adolescent sexual offenders with paraphilic disorders.

The primary aim of these guidelines was to evaluate the role of pharmacological agents in the treatment of adolescents with paraphilic disorders who are also sexual offenders or at-risk of sexual offending. Psychotherapeutic and psychosocial treatments were also reviewed. Adolescents with paraphilic disorders specifically present a different therapeutic challenge as compared to adults. In part, the challenge relates to adolescents being in various stages of puberty and development, which may limit the use of certain pharmacological agents due to their potential side effects. In addition, most of the published treatment programmes have used cognitive behavioural interventions, family therapies and psychoeducational interventions. Psychological treatment is predicated in adolescents on the notion that sexually deviant behaviour can be controlled by the offender, and that more adaptive behaviours can be learned. The main purposes of these guidelines are to improve the quality of care and to aid physicians in their clinical decisions. These guidelines brought together different expert views and involved an extensive literature research. Each treatment recommendation was evaluated and discussed with respect to the strength of evidence for efficacy, safety, tolerability and feasibility. An algorithm is proposed for the treatment of paraphilic disorders in adolescent sexual offenders or those who are at risk.

Pharmacologic treatment of paraphilias.

The treatment of paraphilias remains a challenge in the mental health field. Combined pharmacologic and psychotherapeutic treatment is associated with better efficacy. The gold standard treatment of severe paraphilias in adult males is antiandrogen treatment with cognitive behavioral therapy. Selective serotonin reuptake inhibitors have been used in mild types of paraphilia and in cases of sexual compulsions and juvenile paraphilias. Antiandrogen treatments seem to be effective in severe paraphilic subjects committing sexual offenses. In particular, gonadotropin-releasing hormone analogs have shown high efficacy working in a similar way to physical castration but being reversible at any time. Treatment recommendations, side effects, and contraindications are discussed.

Can sexual offenders be treated?

There are many misconceptions about sexual offender treatment. This is not only a problem in the lay press and media but is also a problem amongst mental health professionals. In part, this relates to the inadequate teaching about sexual deviation in medical schools and psychiatric residency programs and even in forensic psychiatric fellowships. Other disciplines, such as psychology, have educated mental health professionals in a more balanced way related to the assessment and treatment of sexual offenders but still the understanding, knowledge and acceptance that sexual offender treatment is available, is evidence-based, and is successful as shown in treatment outcome studies is still misunderstood. This review covers the evidence-based studies that support the efficacy of sexual offender treatment.

Familial paraphilia: a pilot study with the construction of genograms.

Biological factors are likely predisposing and modulating elements in sexually deviant behavior. The observation that paraphilic behavior tends to cluster in some families is intriguing and potentially raises questions as to whether shared genetic factors may play a role in the transmission of paraphilia. This pilot study introduces five families in which we found presence of paraphilia over generations. We constructed genograms on the basis of a standardized family history. Results document the aggregation of sexual deviations within the sample of families and support a clinical/phenomenological heterogeneity of sexual deviation. The concept of paraphilia in relation to phenotypic expressions and the likelihood of a spectrum of related disorders must be clarified before conclusions can be reached as to family aggregation of paraphilia based on biological factors.

Commentary: sildenafil in phallometric testing--an evidence-based assessment of sexual offenders.

The field of medicine has moved toward best practices based on evidence. There is pressure on all medical disciplines, including forensic psychiatry, to adopt this approach. Some areas of forensic psychiatry have a stronger scientific basis that clearly fits the definition of evidence-based medicine than do other areas. One of these areas is the assessment and treatment of sexual offenders, which has a strong scientific basis and meets the definition of evidence-based medicine, as defined by Sackett et al. in 2007. Phallometric testing is an objective, physiological indicator of deviant sexual preferences that support the diagnosis of paraphilias and the assessment of sexual offenders. The current article by Kolla et al. is an effort to improve the reliability of phallometric testing related to diagnosis by pharmacologic stimulation.

The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the biological treatment of paraphilias.

OBJECTIVES: The primary aim of these guidelines was to evaluate the role of pharmacological agents in the treatment and management of paraphilia, with a focus on the treatment of adults males. Because such treatments are not delivered in isolation, the role of specific psychosocial and psychotherapeutic interventions was also briefly covered. These guidelines are intended for use in clinical practice by clinicians who diagnose and treat patients with paraphilia. The aim of these guidelines is to improve the quality of care and to aid physicians in clinical decisions. METHODS: The aim of these guidelines was to bring together different views on the appropriate treatment of paraphilias from experts representing different continents. To achieve this aim, an extensive literature search was conducted using the English language literature indexed on MEDLINE/PubMed (1990-2009 for SSRIs) (1969-2009 for antiandrogen treatments), supplemented by other sources, including published reviews. RESULTS: Each treatment recommendation was evaluated and discussed with respect to the strength of evidence for its efficacy, safety, tolerability and feasibility. CONCLUSIONS: An algorithm was proposed with six levels of treatment for different categories of paraphilias.

The admissibility of expert evidence in Canada.

Recent decisions in Canadian Law suggest that it is evolving in a manner heavily influenced by American law. A recent Supreme Court decision uses the framework of prevailing law and superimposes the more stringent criteria enunciated in Daubert v. Merrell Dow Pharmaceuticals, Inc. We trace this development, reviewing the intervening cases that have contributed, and conclude with a summary of the law as it stands today.

On sexual violence.

PURPOSE OF REVIEW: Sexual violence is a multidimensional concept that is not completely understood even within forensic psychiatry. Violent sexual behaviour such as sexually sadistic homicides would be included within the definition, but it is commonly defined more broadly as any deviant sexual behaviour. In this review, the broadest definition of sexual violence is used in order to facilitate the most comprehensive review of scientific articles in the field. RECENT FINDINGS: This review covers sexual violence from the extreme of sexually motivated homicides to sexual violence in Internet crimes. The review can be divided into four subject areas. The first relates to extreme sexual violence such as sexually motivated homicide, the second area refers to Internet sexual offending, the third relates to studies on the characteristics of the perpetrators of sexual offending behaviour and the fourth relates to risk evaluation and the prevalence of sexual violence. SUMMARY: Significant advances have been made in relation to sexual sadism. Deviant sexual behaviour using the Internet is being studied. Significant research advances continue in understanding clinical characteristics of various types of sexual offenders. Other important areas of research relate to meta-analytical studies of sexual offenders.

Osteoporosis associated with the treatment of paraphilias: a clinical review of seven case reports.

Osteoporosis and long-term androgen suppression in the treatment of paraphilias has been documented with surgical castration and the use of gonadotropin-releasing hormone agonists. The literature has suggested that the use of cyproterone acetate (CPA) may be protective against osteoporosis, although there are case reports of osteoporosis in men treated with CPA. This pilot study represents a case series of seven patients diagnosed with severe paraphilias and treated with CPA, leuprolide, or surgical castration. Two of the four patients treated with CPA developed significant osteoporosis, while the other two had normal bone density studies. The remaining three patients, one treated with leuprolide and two with surgical castration, had osteopenia. Based upon the current literature, the finding of significant osteoporosis in two of four patients treated with CPA, but not those treated with leuprolide or castration, is surprising. Monitoring of all patients treated with long-term androgen suppression for osteoporosis is suggested.