Fabian M. Saleh, MD

SPECIAL REPORT: FORENSIC PSYCHIATRY, PART II

-Special Report Chair: James L. Knoll IV, MD

Psychopathy is a personality disorder characterized by lack of empathy, grandiosity, shallow affect, deceitfulness, impulsivity, irresponsibility, and disregard for the well-being or rights of others. Few syndromes in medicine have carved as deep of a niche in human cultural thought as the one occupied by psychopathy. The mythos of the psychopath is born of both in extremis of its infamous case examples and of past deficiencies in the empirical research. However, the scientific landscape for psychopathy has expanded significantly over recent decades, and discourse around treatment has become more optimistic.

, sociopath, and antisocial are often used interchangeably by clinicians, they are not equal. Psychopathy and sociopathy both describe the same personality syndrome. However, many experts identify them as separate but overlapping entities with distinct etiological mechanisms.

 Psychopathy remains empirically the better described of the 2 and is the term most often used to denote the cluster of personality traits in question.

The term antisocial is often clinically used as a short-hand reference to the DSM-V diagnosis of antisocial personality disorder (ASPD), which is based almost entirely on behaviors. A lack of empathy and disregard for the safety of others are neither necessary nor sufficient for the diagnosis. In contrast, psychopathy is a set of personality traits which may or may not be associated with obvious misconduct. It must not be assumed that an individual who meets diagnostic criteria for ASPD also has psychopathic/sociopathic personality traits, because this is often not the case.

Psychopathy seems to have some degree of hereditability, although genetic and epigenetic factors are not entirely sufficient to account for disorder. A prevalence of between 15% to 25% has been described in incarcerated populations, and approximately 1% in the general population, with a male to female ratio of about 3:1.

 One study found 4% of corporate managers exhibited significant psychopathic traits.

Psychopathy has been associated with deficits in multiple cognitive domains, including attention, judgement of risk and reward, and the emotional processing.

 The brains of individuals with psychopathy have identifiable structural and functional differences from the brains of those without, which appear to account for some of the cognitive and behavioral manifestations of the disorder. Reduced gray matter volumes in the amygdala and multiple areas of the prefrontal cortex have been described. On fMRI, psychopathic brains have exhibited dysfunctional activity in the default mode network, including limbic and paralimbic structures.7 People with psychopathy have also been found to exhibit impaired communication between the visual prefrontal cortex and the amygdala.8 Increased activity in the ventral striatum in the context of reward expectancy has also been described in association with criminal activity among those with psychopathy.

Unsurprisingly, psychopathic personalities are identified more frequently in forensic than community settings. The odds of encountering a patient with psychopathy in the general outpatient setting, however, are significant. As with other personality syndromes, these patients often present to a psychiatrist seeking treatment for a comorbid condition, and only through careful assessment does the character pathology become apparent to the clinician. Psychopathy is most often associated with substance use disorders and with other Cluster B personality syndromes, such as narcissistic personality disorder.

The impairment caused by this condition should not be underestimated. In the forensic setting, this is usually evident. In the community, however, impairment may be less conspicuous. Deficits in attention and risk-reward assessment may result in harmful financial decisions, poor judgement at work, gambling, and other impulsive behaviors. Callousness, deceitfulness, and grandiosity may lead to brief and combustive relationships. One may encounter a patient who cannot seem to maintain employment despite ability and qualification; instrumentally engages socially with others and is undisturbed when relationships fall apart; and exhibits a pattern of poor decision making accompanied by a psychological scotoma for personal responsibility. Psychopathic personality traits may also present adaptively in one domain of life, such as a boardroom

, and maladaptively in another, such as marriage.

The gold standard instrument for assessing psychopathy is the 

In the forensic setting, performance of the PCL-R is accompanied by extensive collateral investigation, psychiatric interview, and review of the individual’s medical, social, and criminal history. There is also a screening version of the PCL-R, the PCL-SV, which can be performed outside of the specialized forensic setting (

 good interrater reliability and can potentially be useful when leveraged by objective and ethical evaluators who are trained to interpret the instruments and to provide honest and impartial professional opinions. However, concerns have been raised about the susceptibility of the tests to bias when performed by individuals who lack this expertise.

 These tools have also exhibited wide variability in their ability to predict future violence and their use in the assessment of risk must be approached with caution. There are significant ethical concerns regarding the potential misuse of these tests in legal and clinical decision making when the fate of an individual’s liberty or the safety of others is at stake.

 While the items in the PCL-R and PCL-SV may help guide formulation, the diagnosis of psychopathy in the general outpatient setting must be made carefully and only with substantial amounts of data gathered through the physician-patient relationship over time.

The differential diagnosis for psychopathy includes a personality disturbance due to another mental illness or physical condition. For example, individuals with frontotemporal dementia may present with impulsive behavior and an apparent lack of regard for others. Autism spectrum disorders may also present with impaired mentalization and apparent lack of empathy. Psychotic illnesses may produce a flattened affect with the appearance of shallow or blunted emotional responses. Patients who are dependent on a substance may exhibit manipulativeness and recklessness when their disorder is decompensated, and then improve when receiving appropriate treatment.

The concept of psychopathy in pediatric patients is complex and controversial. Psychopathy is similar to other personality disorders in that it is not diagnosed prior to adulthood, due to the fluidity of personality traits during early development and the inability to predict which children will go on to develop a disorder and which will not. Furthermore, multiple items in the adult diagnostic criteria are predicated on the patient having had sufficient years of life to fulfill them (such as parasitic lifestyle or multiple short-term marital relationships). Any assessment of psychopathic traits in a child or adolescent patient must be approached with extreme caution.

A perilous belief once persisted in the scientific community that psychopathy was not only untreatable, but that attempting to treat a 

 While incarceration is the definitive “treatment” for some, psychopathy exists on a spectrum like any other mental disorder; more recent research suggests the condition is capable of responding to treatment. Although data are still limited, the treatment of psychopathy has begun to gain traction as a target for clinical research. The substantial evidence supporting the existence of cognitive and emotional processing deficits in people with psychopathy suggests that these are potential treatment targets. Indeed, cognitive behavioral and cognitive remediation 

Some have also suggested that the interpersonal and affective symptoms of psychopathy may be amenable to modified dialectical behavioral therapy techniques.

Data are limited regarding the use of medication to target psychopathic personality traits. The best approach to pharmacotherapy is to target and treat comorbid psychiatric disorders.

Although it may be daunting to encounter a patient with psychopathy in the general practice setting, this syndrome is well defined and can be approached clinically in a manner similar to other personality disorders. Essential elements include examination of the history and patient’s motivation for care, assessment and treatment of comorbid conditions, and collaboration with family members and other treatment providers. Psychopathy is associated with an increased risk of violence; however, this relationship is more complex than it appears and remains the subject of ongoing research.

 As neurological and psychological investigations continue, the future appears more promising than previously thought.

is a child & adolescent and forensic psychiatrist. He is the director of the Sexual Violence Prevention & Risk Management Program at Beth Israel Deaconess Medical Center, and a Harvard Medical School faculty. His forensic practice focuses on criminal and civil cases including sex offender, threat, competency, and criminal responsibility assessments. 

is fourth year psychiatry resident at Beth Israel Deaconess Medical Center in Boston, MA. She will be matriculating to the forensic psychiatry fellowship program at the University of Massachusetts Medical School.

1. Walsh A, Wu H-H. Differentiating antisocial personality disorder, psychopathy, and sociopathy: evolutionary, genetic, neurological, and sociological considerations. 

2. Werner, KB, Few, LR., Bucholz, KK. Epidemiology, comorbidity, and behavioral genetics of antisocial personality disorder and psychopathy. 

3. Hart, SD, Storey, JE. Clinical and forensic issues in the assessment of psychopathy. In: Weiner, IB, eds. 

4. Babiak, P, Neumann, CS, Hare, RD. Corporate psychopathy: Talking the walk. 

5. Anderson, NE, Steele, VR, Maurer, JM, Rao, V, Koenigs, MR, Decety, J, Kosson, DS, Calhoun, VD, Kiehl, KA. 2017. Differentiating emotional processing and attention in psychopathy with functional neuroimaging. . 

6. Baskin-Sommers AR, Curtin JJ, Newman JP. Altering the Cognitive-Affective Dysfunctions of Psychopathic and Externalizing Offender Subtypes with Cognitive Remediation. 

7. Johanson M, Vaurio O, Tiihonen J, Lähteenvuo M. A Systematic Literature Review of Neuroimaging of Psychopathic Traits. 

8. Contreras-Rodríguez O, Pujol J, Batalla I, et al. Disrupted neural processing of emotional faces in psychopathy. 

9. Geurts DE, von Borries K, Volman I, Bulten BH, Cools R, Verkes RJ. Neural connectivity during reward expectation dissociates psychopathic criminals from non-criminal individuals with high impulsive/antisocial psychopathic traits. 

10. Steinert SW, Lishner DA, Vitacco MJ, Hong PY. Conceptualizing successful psychopathy: An elaboration of the moderated-expression model.

The Psychopathy Checklist–Revised, 2nd ed. 

12. Hare RD, Hart SD, Cox DN. The Hare PCL:SV—Psychopathy Checklist Screening Version. Multi-Health Systems; 1995.

Psychopathy, the PCL-R, and criminal justice: Some new findings and current issues

Canadian Psychology/psychologie Canadienne. 

14. DeMatteo D, Hart SD, Heilbrun K, et al. Statement of concerned experts on the use of the Hare Psychopathy Checklist—Revised in capital sentencing to assess risk for institutional violence. P

15. Singh JP, Fazel S, Gueorguieva R, Buchanan A. Rates of violence in patients classified as high risk by structured risk assessment instruments. 

16. Larsen RR. Psychopathy Treatment and the Stigma of Yesterday’s Research. 

17. Sewall LA, Olver ME. Psychopathy and treatment outcome: Results from a sexual violence reduction program. 

18. Wong SCP, Gordon A, Gu D, Lewis K, Olver ME. 

The effectiveness of violence reduction treatment for psychopathic offenders: Empirical evidence and a treatment model

International Journal of Forensic Mental Health. 

19. White BA, Oliver ME, Lilienfeld SO. Psychopathy: Its relevance, nature, assessment, and treatment. 

20. Camp JP, Skeem JL, Barchard K, Lilienfeld SO, Poythress NG. Psychopathic predators? Getting specific about the relation between psychopathy and violence. J

Articles

While incarceration is the definitive “treatment” for some, psychopathy exists on a spectrum like any other mental disorder; more recent research suggests the condition is capable of responding to treatment. 

Psychopathy: Insights for General Practice

Medicine and law have a rich collaborative history in the management of persons convicted of sex offenses. Despite different assumptions about the offender and different perspectives about management and goals that may only partly overlap, each discipline offers significant expertise that promotes healing and risk management strategies while increasing community safety.

The term “sex offender” is a legal, not a psychiatric, designation. Sex offenders make up a psychiatrically heterogeneous group of individuals whose only unifying characteristic is that they have violated the law governing sexual expression in a given culture.

 The law may not greatly concern itself with the biopsychosocial antecedents of illegal sexual behavior, although it recognizes that questions of intent and incompetence or diminished capacity are important considerations.

Psychiatrists, like all physicians, view sexual behavior in terms of health. Normal sexual behavior is roughly equated with healthy sexual behavior; abnormal sexual behavior invites psychiatric intervention to restore a patient’s sexual health.

In our experience, psychiatrists infer the presence of a sexual disorder or abnormality from certain statistically rare sexual behaviors and/or self-reported distress. Like all physicians, psychiatrists then arrive at a diagnosis congruent with the clinical picture. Differential diagnosis is important because identical behaviors or symptoms often have very different etiologies. Diagnosis typically informs the psychiatrist’s choice of therapies intended to diminish or control the patient’s sexually abnormal behavior.

Psychiatrists tend to believe that factors that motivate sexual behavior are intrinsic to the organism. Such intrinsic factors might include psychosis, PTSD, and abnormal biological drive states and, therefore, are more constant across history than the ethical and philosophical underpinnings of a culture as expressed in its laws. The legal construct of a “sex offense,” is more tightly culture-bound. Social attitudes toward sexual behaviors are not immutable, however, and laws change, both reflecting and reshaping cultural values.

In contrast to psychiatry, the law may criminalize conduct irrespective of the underlying cause or motivation. The law tries to enforce compliance by imposing such sanctions as fines, incarceration, “assisted” outpatient treatment, and civil commitment.

The concept of sexual illness or wellness is often influenced by prevailing social values concerning what sexual behavior is appropriate or inappropriate. The distinction between lawful and unlawful sexual conduct has also been affected by psychiatric views of what constitutes mentally ill sexual behavior and what does not.

For example, in the past 50 years, society and psychiatry have radically changed perspective and judgment of homosexuality. Before the 1970s, most of the psychiatric community viewed homosexuality as a mental disorder, a concept enshrined in DSM in 1952. In this first DSM, homosexuality was categorized as a “sexual deviation” presumed to be a “personality disorder of psychogenic origin or without clearly defined tangible cause or structural change.” In 1973, the American Psychiatric Association eliminated homosexuality as a mental disorder in the sixth printing of DSM-II, substituting a new category, Sexual Orientation Disturbance.

Laws about homosexuality also reflect changing psychiatric and social attitudes. Legally, same sex behavior could be lawful in one state and criminalized in another. For example, in 1986, the US Supreme Court affirmed the illegality of engaging in homosexual behavior in Georgia that was not illegal in other states, declaring that “to hold that the act of homosexual sodomy is somehow protected as a fundamental right would be to cast aside millennia of moral teaching.”

 Thus, Georgians engaging in sodomy were officially “sex offenders” while residents of many other states who engaged in sodomy were not. Less than 2 decades later, however, the Court reversed itself, declaring that laws prohibiting sodomy between consenting adults, in the 14 states that still had them, were unconstitutional.

In the past year, 2 of those states (Montana and Virginia) have repealed their anti-sodomy statutes, but in 12 other states (Alabama, Florida, Idaho, Kansas, Louisiana, Michigan, Mississippi, North Carolina, Oklahoma, South Carolina, Texas, and Utah), engaging in consensual sodomy (ie, oral and/or anal sexual activity) continues to make one a sex offender.

Psychiatric and legal professionals agree that some sex offenders can be dangerous to society. Both professions are invested in preventing dangerous sex offenders from doing harm to others and to the social order. From the legal perspective, harm prevention generally means removing offenders from free society through incarceration or involuntary detention.

Under the law, there are 5 commonly accepted goals of incarceration: incapacitation, punishment, rehabilitation, deterrence, and restitution.

 More recently, in the era of sexually violent predator statutes, isolation from the culture at large may continue following incarceration by stigmatizing the offender with the lifelong designation of registered sex offender and possible indefinite civil commitment for treatment.

The perspective is somewhat different for psychiatrists, particularly those who do not consider themselves to be forensic specialists. Without denying that sex offenders have committed crimes, some psychiatrists may see the individual offender as a patient first and an offender second. The physician-patient relationship includes a fiduciary duty to ameliorate the patient’s pain and suffering and restore him or her to healthier psychosocial functioning. For some psychiatrists, this duty clashes with such legal requirements as reporting mandates.

The psychiatrist’s understanding of sexual behavior, legal or illegal, is that sexual activity takes place in the context of arousal mediated by a biologically based drive. Disordered arousal and behavior are the legitimate focus of psychiatric intervention. Psychiatrists also know that disordered sexual behavior is a feature of a number of psychiatric conditions other than arousal disorders.

 reported on a series of 6 case examples of rape with disparate motivation: a sociopathic, opportunistic rapist; an “angry” rapist; a developmentally impaired rapist; a psychotic rapist; a sexually driven rapist; and sexual assault by a voyeuristic rapist (a rare case). Rape is clearly criminal behavior. Thus, all of Berlin and associates’ patients were sex offenders. Psychiatry would perceive these patients’ criminal conduct as having very different causes. Treatment would also vary. Courts and prisons would attend to victim harm, mitigating factors, treatment efficacy, rehabilitative potential, and future risk to society to determine the prisoner’s condition and duration of confinement.

Psychiatrists also know that some criminalized sexual behaviors are not directly related to mental disorders. Exposing one’s genitals to unsuspecting victims, for example, may be a focus of both legal and psychiatric concern in the context of paraphilic exhibitionism, traumatic brain injury, or command auditory hallucinations. While “streaking” at a football game or public urination may be construed as indecent exposure and, therefore, sex offenses, psychiatrists are unlikely to see these behaviors as mentally disordered.

Psychiatrists can often assist both the patient and the legal system by providing information about the differential diagnosis applicable to a particular sex offender and the likelihood that psychiatric treatment might lower the risk of recidivism and, therefore, future harm to society.

It is important to determine whether an offender has a paraphilic disorder related to his sex offense because the hallmark of the paraphilias is recurring, intense sexually arousing fantasies, urges, or behaviors. This raises issues of volition and competence to conform behaviors to expected norms.

 Unless they are in legal jeopardy, patients with paraphilias rarely seek professional help because of the associated stigma and shame. As Berlin and colleagues

 point out, mandatory reporting laws for certain sexual crimes may also reduce the number of patients who seek voluntary treatment.

Intellectual disabilities, pervasive developmental disorders, ADHD, conduct disorder, personality disorders, psychotic disorders, mood disorders, anxiety disorders, and (especially) substance use disorders are sometimes diagnosed concurrently in sex offenders. Any of these comorbid conditions may require treatment in addition to sex offender–specific treatment, since they may actually be precipitating or maintaining the illegal sexual behaviors. Even if the comorbid disorder has little or nothing to do with the sexual offense, it must be managed so it does not interfere with the intense regimen of sex offender–specific treatment.

Treatment of comorbid conditions associated with sex offending is generally bimodal, employing both biological and psychosocial interventions.

 The goal is to eliminate sexually abusive fantasies and work toward more healthy sexual expression, although it is not easy to manage the harmful while concurrently nurturing the helpful in treating potentially dangerous sexual patterns such as pedophilia.

 suggested a multidisciplinary model employing a cognitive approach to relapse prevention; substance use treatment; and an assessment for major mental illnesses, including paraphilias. Evidence-based integrated treatment approaches-eg, the Good Lives Model-use directive cognitive-behavioral therapy with instruction in appropriate expression and regulation of emotions to help patients build self-esteem, learn how to take responsibility for behaviors, identify the pathways to offending, control deviant sexual interests, and develop coping and mood-management skills.

Effective psychological methods include strategies for prevention as well as psychoeducation and skills-building typically based on social learning, behavioral/cognitive-behavioral, and sometimes psychodynamic theories.

 Techniques include olfactory aversion conditioning, covert sensitization, masturbatory satiation, and masturbatory reconditioning. Regardless of the method, the goal is to decrease problematic sexual arousal and cultivate appropriate sexual response patterns.

Pharmacological methods focus on reducing, and in some cases eliminating, sex drive and associated cravings, and thoughts and fantasies that can become so intense and/or overpowering that a medication is needed to dampen the drive sufficiently to allow for learning; other management techniques may also be used. Medications are used to treat the primary and comorbid disorders.

Antiandrogens, antigonadotropics, and other hormonal agents as well as SSRIs may, in carefully selected cases, diminish sexual interest and associated thoughts and fantasies. SSRIs are latecomers to the pharmaceutical arsenal for managing sex drive and intrusive fantasies and are less well studied than medications that act directly to reduce sex hormones.

 determined that more rigorous study is needed before concluding that SSRIs are effective for treating paraphilic symptoms. SSRIs may be appropriate for compulsive sexual behaviors but should not be relied on exclusively in the treatment of sexual sadism or pedophilia because of the dangerousness of these paraphilias.

Other medications include antipsychotics (eg, thioridazine, fluphenazine, haloperidol), mood stabilizers (eg, lithium, topiramate, car-bamazepine), and other agents (eg, desipramine, imipramine, clomipramine, buspirone, naltrexone).

 These medications are used for the treatment of comorbid psychiatric disorders rather than the primary sexual disorder.

Treatment of sex offenders should be considered a means to manage rather than cure sexual offending behavior and thus reduce sexual recidivism risk. There is certainly some evidence that re-offending behaviors can be reduced for some offenders, but there is not a large literature base of rigorous studies and the behavior is difficult to study accurately.

 Despite the considerable differences in perspective, both psychiatry and the law continue to inform each other’s understanding of treatment and management strategies where sex offenders are concerned. Both disciplines require further scholarly inquiry to inform decisions about recidivism, risk management, and community safety.

Dr Malin is Professor of Clinical Sexology at the Institute for the Advanced Study of Human Sexuality in San Francisco. Dr Saleh is Assistant Clinical Professor of Psychiatry at the Harvard Medical School and Director of the Sexual Violence Prevention and Risk Management Program in the department of psychiatry forensic psychiatry service at the Beth Israel Deaconess Medical Center in Boston. They report no conflicts of interest concerning the subject matter of this article.

 Saleh FM, Grudzinskas AJ Jr, Malin HM, Dwyer RG. The management of sex offenders: perspectives for psychiatry. 

 Fagan PJ. Perspectives on sex and normality. In: Saleh FM, Grudzinskas AJ Jr, Bradford JM, Brodsky DJ, eds. 

Sex Offenders: Identification, Risk Assessment, Treatment, and Legal Issues

. New York: Oxford University Press; 2009:3-11.

 Alabama’s anti-sodomy law is unconstitutional, appeals court rules. June 16, 2014. http://www.huffingtonpost.com/2014/06/16/alabama-anti-sodomy-law_n_5501737.html. Accessed July 7, 2014.

 Grudzinskas AJ Jr, Brodsky DJ, Zeitchik M, et al. Sexual predator laws and their history. In: Saleh FM, Grudzinskas AJ Jr, Bradford JM, Brodsky DJ, eds. 

. New York: Oxford University Press; 2009:386-411.

 Berlin FS, Lehne GK, Malin HM, et al. The eroticized violent crime: a psychiatric perspective with six clinical examples. 

 Berlin FS, Malin HM. Rape: a presumption of guilt? A presumption of severe punishment if guilty. 

J Expert Witness Trial Attorney Trial Judge

 Malin HM, Saleh FM. Paraphilias: clinical and forensic considerations. 

http://www.psychiatrictimes.com/forensic-psychiatry/paraphilias-clinical-and-forensic-considerations

 Berlin FS, Malin HM, Dean S. Effects of statutes requiring psychiatrists to report suspected sexual abuse of children. 

 Berlin FS, Malin HM, Dean S. Flexibility in reporting child sexual abuse: a reply to Kalichman. 

 Raymond NC, Coleman E, Ohlerking F, et al. Psychiatric comorbidity in pedophilic sex offenders. 

 Marshall WL, Marshall LE, Serran GA, Fernandez YM. 

Treating Sexual Offenders: An Integrated Approach

 Saleh FM, Guidry LL. Psychosocial and biological treatment considerations for the paraphilic and nonparaphilic sex offender. 

 Brooks-Gordon B, Bilby C, Wells H. A systematic review of psychological interventions for sexual offenders I: randomized control trials. 

 Dunsieth NW Jr. Flaws in the sexual addiction model. 

 Saleh F. Pharmacotherapy of paraphilic sex offenders. In: Saleh FM, Grudzinskas AJ Jr, Bradford JM, Brodsky DJ, eds.

 Sex Offenders: Identification, Risk Assessment, Treatment, and Legal Issues

. New York: Oxford University Press; 2009:189-207.

 Saleh FM, Malin HM, Grudzinskas AJ Jr, Vitacco MJ. Paraphilias with co-morbid psychopathy: the clinical and legal significance to sex offender assessments. 

 RÃ¶sler A, Witzum E. Pharmacotherapy of paraphilias in the next millennium. 

 Saleh FM. Serotonin reuptake inhibitors and the paraphilias. 

 Grossman LS, Martis B, Fichtner CG. Are sex offenders treatable? A research overview. 

The Role of Psychiatry in Sex Offender Management

 as sexual disorders characterized by "recurrent, intense sexually arousing fantasies, sexual urges or behaviors generally involving (1) nonhuman objects, (2) the suffering or humiliation of oneself or one's partner, or (3) children or other nonconsenting persons that occur over a period of 6 months" (Criterion A), which "cause clinically significant distress or impairment in social, occupational, or other important areas of functioning" (Criterion B). 

 describes 8 specific disorders of this type (exhibitionism, fetishism, frotteurism, pedophilia, sexual masochism, sexual sadism, voyeurism, and transvestic fetishism) along with a ninth residual category, paraphilia not otherwise specified (NOS).

It has been estimated that some 50 paraphilias have been identified and described in the literature. Many, like klismaphilia (erotic arousal to enemas) are not illegal and therefore do not often come to the attention of therapists even though they may fulfill 

 Criteria A and B requirements. Thus, the category paraphilia NOS comprises most of the paraphilias described in the literature, although not necessarily the largest number of individuals with paraphilias. The sheer variety of erotic material available on the Internet and other adult entertainment venues lends credence to this assumption. A content analysis of these materials would likely provide a reasonably accurate indication of the prevalence of these paraphilias-at least the legal ones.

With the exception of those who are in legal trouble, most, but not all, persons with paraphilia probably do not seek treatment. Indeed, it has been argued that the impact of the mandatory reporting laws enacted for certain sexual crimes has further decreased the number of individuals seeking voluntary treatment.

To the layperson, paraphilias are commonly regarded as "kinky sex." Both canon law and common law proscribed most paraphilic thoughts and behaviors long before they came to be regarded by medical science as indicators of possible mental illness. By the time of Richard von Krafft-Ebing at the turn of the 20th century, medicine's interest in "abnormal" sexual behavior had come into full flower, and Krafft-Ebing made liberal use of such legal terminology as "perversion" and "deviancy" in his case studies.

An attempt to move away from such legally pejorative terminology eventually succeeded in the adoption of the term paraphilia, from the Greek prefix 

 meaning "around" or "beside" (within the context, implying "altered" or "missing the mark") and 

 1 of 3 ancient Greek words for love. Benjamin Karpman gets credit for introducing English speakers to the term paraphilia.

In the end, however, paraphilia and paraphile may be destined to join the pejorative ranks of such descriptors as perversion or pervert. Many well-educated individuals confuse paraphile with pedophile. Perhaps worse, because of a lack of understanding or disregard for the phenomenology of the paraphilias, physicians, lawyers, journalists, and other professionals readily conflate the medical term pedophile with the term child molester. It is a small jump from that error to conceptualizing all persons with paraphilia as sex offenders.

 nosology, and to some extent, therefore, psychiatry's understanding of the paraphilias, has not been consistent. The term paraphilia first appeared in 

 The enumerated paraphilias included zoophilia but not frotteurism and specified a category for atypical paraphilias. 

 dropped zoophilia but added frotteurism and renamed the residual atypical class paraphilias NOS. The 1987 categories remain, with minor semantic changes, the same in the 

 has not always classified paraphilias as sexual disorders. Beginning with the first 

 published in 1952, sexual deviations, as the paraphilias were then called, were conceptualized as a subclass of sociopathic personality disturbances-a category that included most diagnoses "formerly classed as psychopathic personality with pathologic sexuality," adding that the diagnosis should specify the "type of the pathologic behavior, such as homosexuality, transvestism, pedophilia, fetishism, and sexual sadism (including rape, assault, mutilation)."

 were distinguished from psychophysiological autonomic and visceral disorders that were believed to be more physiologically based than certain other mental disorders. As such, they were differentiated from sexual dysfunctions and gender disturbances. The subcategory, psychophysiologic genitourinary reaction appears to have been the rough equivalent of the sexual dysfunctions subcategory of the sexual and gender identity disorders category of 

The debate continues as to whether paraphilias are best conceptualized as sexual disorders unto themselves or are simply a special kind of obsessive disorder, anxiety disorder, or even addiction disorder. Because they are sexually motivated behaviors and their phenomenology is experienced as intensely driven eroticism, it seems appropriate to continue to classify them as sexual and gender identity disorders, as in 

 does not classify paraphilias other than by erotic focus, it is clear from clinical practice that they may be either exclusive or nonexclusive as well as egosyntonic or egodystonic. Patients with the exclusive form of a paraphilia may not be able to be sexually aroused by anything other than their paraphilic imagery or behavior. By contrast, patients with the nonexclusive form may be aroused by other sexual fantasies, stimuli, and behaviors, although their paraphilias may interfere with their overall sexual experiences.

Similarly, any given patient may find his or her paraphilia either congruent with his values and beliefs or at odds with them. Persons with paraphilic phenomenology that does not disturb core personal values are said to have egosyntonic paraphilias, while those who feel their sexual phenomenology is wrong and is not congruent with their internal moral compasses are said to have egodystonic paraphilias. Clearly, better treatment results can be expected with patients who have paraphilias that are egodystonic.

Physicians and patients alike often wrestle with whether some seemingly harmless, egosyntonic paraphilia (for example, fetishistic cross-dressing) should be viewed simply as different-part of the rainbow of sexual diversity-or should be treated as pathological. Each case is different, but the physician should be mindful that when, for example, an individual is driven by his paraphilic urges to steal shoes or undergarments, the picture changes dramatically. Similarly, consensual bondage/ discipline, which some clinicians see as part of the sadism/masochism spectrum, may or may not need to be treated depending on degree.


The paraphilias do not always occur in the absence of other psychopathology. Many paraphilic patients show evidence of major Axis I mental illnesses including affective disorders, substance abuse disorders, schizophrenia, other psychotic disorders, dementia, and other cognitive disorders. Paraphilias can occur within the context of Axis II disorders such as borderline or antisocial personality disorders and mental retardation, and Axis III disorders, such as temporal lobe epilepsy or brain trauma. For example, Mitchell and colleagues

 described the case of a patient with temporal lobe epilepsy and transvestic fetishism whose paraphilic behaviors decreased following temporal lobectomy. Similarly, Mendez and associates

 presented data on 2 men with right temporal lobe hypometabolism and late onset pedophilia. In such cases it can be quite difficult to tease out the discrete disorders; however, treating one co-occurring condition may not always render it unnecessary to treat the other disorder.

For example, the pedophile who also has bipolar disorder may need different kinds of both pharmacological and psychological intervention for each of the disorders. The paraphilia may need to be treated with a testosterone-lowering drug such as leuprolide in conjunction with psychotherapy such as relapse prevention therapy, while the mood disorder might require mood stabilizers and other pharmacological agents in combination with cognitive-behavioral therapy. These combinations are some of many that may be used in treatment modalities that recognize the need to treat each co-occurring condition separately.

There are no reliable data with respect to the incidence of paraphilias and co-occurring mental health conditions. The nature of these co-occurring disorders, however, in addition to the dangers associated with paraphilic disorders, has profound implications for treatment stratagems for the paraphilic component.

 In any event, patients with paraphilias who have a co-occurring condition will require psychiatric treatment for both the paraphilia and any other mental-health conditions.


The cause of paraphilias is unclear. Early theorists postulated that paraphilias, as well as other psychiatric conditions such as feeble mindedness, were part and parcel of brain degeneracy, a significant cause of which was overtaxing the nervous system by such phenomena as masturbation, or "nocturnal pollutions." Degeneracy went hand in glove with "hereditary taint," which was thought to accumulate through the generations. Although mechanisms were not clearly elucidated, exposure to excessive sexual stimulation outside socially sanctioned heterosexual marriage was believed to put individuals at risk for sexual deviations. Why such deviations developed in some individuals and not others was explained by the postulate that less tainted individuals were at less risk than more degenerate individuals for sexual perversions.

Moreover, such excessive stimulation need not always be intentional. For example, one theory enjoying some degree of acceptance in early psychoanalytic circles was that infants born to hereditarily tainted mothers were predisposed to develop a fur fetish by coming into contact with their mother's pubic hair during birth (W. B. Pomeroy, personal communication; 1982). While such explanations seem naive today, the notion that the development and maintenance of paraphilias must be a combination of genetic susceptibility and environmental trauma persists. In reality, we still know very little about the genesis of paraphilias.

The data that have been collected, however, do support at least 1 biological marker for vulnerability: men account for the vast majority of paraphilias. Among the paraphilias specifically delineated by 

 paraphilias are much more infrequently diagnosed in women than in men. Except for sexual masochism, which is still about 20 times less likely to affect men than women, paraphilias are quite unlikely to be diagnosed in women.

Paraphilias, or at least conditions that look very much like paraphilias, have also been reported as the result of brain trauma, neoplasms, temporal lobe damage, or epilepsy and may manifest as hyposexuality or hypersexuality, particularly in men. Lehne

 described a case of a frontal lobe injury in a man who suddenly developed a paraphilic interest in his stepdaughter's breasts. Treatment with conventional methods, including anticonvulsant administration, cognitive-behavioral therapy, and individual/family therapy failed to address his illness adequately but antiandrogens brought his symptoms under control.


Optimal treatment of the paraphilias entails some combination of psychologically and biologically based treatments, although it is not uncommon for therapists of some schools to rely solely on psychological interventions. Among the psychologically based techniques used in the treatment of persons with paraphilia, as well as nonparaphilic sex offenders, are group and individual cognitive and/or behavioral therapies and relapse prevention therapy.

The neurobiology of paraphilias is not completely understood, but pharmacotherapy directed at hormones (through their action on the hypothalamic-pituitary-gonadal axis) known to impact sexual arousal is often helpful in the management of paraphilias.

 Biologically based treatment includes agents that reduce testosterone levels, such as medroxyprogesterone (or cyproterone acetate outside the United States). More recently, there has been a switch away from medroxyprogesterone and cyproterone toward luteinizing hormone-releasing hormone agonists such as leuprolide. The tendency to keep pharmacological treatments in reserve for refractory cases when the psychologically based therapies seem ineffective appears to be giving way to using pharmacotherapy as a first-line adjunct to therapy.

A discussion of treatment would be incomplete without acknowledging concerns about countertransference. In the treatment of persons with paraphilia in general, and particularly with those whose behaviors arising from paraphilic ideation are illegal, it has been commonplace to define countertransference as emotions experienced by a treatment provider that may interfere with the delivery of appropriate patient care. The treatment of a patient for paraphilia may be compromised by the feelings and negative opinions of a clinician toward the patient.

For effective treatment to occur, a treatment provider must be aware of countertransference and be capable of keeping it in check. While a patient with paraphilia may provoke a range of emotional responses ranging from boredom to amusement or anger in the treating clinician, such personal responses may be quite damaging if they spill over into the treatment process. Not all treatment providers want to work with a pedophile or a necrophile; however, those who attempt this difficult task should be scrupulously honest with themselves with respect to whether they can be competent and comfortable working with these patients.


Simply having paraphilia is, obviously, not illegal. Acting in response to paraphilic urges, however, may be illegal and in some cases subjects the person with paraphilia to severe sanctions. The distinguishing phenomenological characteristic of paraphilias is an intense craving or urge to fantasize or engage in some form of sexual expression that most people would not find erotic. Most people simply do not experience such cravings. These urges are often difficult and, in some cases, may even be impossible to control. It is this putative lack of impulse control that underlies the insanity defense in trials alleging sexually criminal behavior. Such defenses are based on impaired mental capacity and are sometimes, although infrequently, successful.

The importance of these distinctions, particularly the phenomenology of paraphilias, cannot be overemphasized: sex offenders are not necessarily persons with paraphilia and persons with paraphilia are not all sex offenders. Forensic considerations aside, it is quite possible to be a person with paraphilia on the proverbial desert island without becoming a sex offender.

It is also crucial to recognize the differences between working in the forensic arena and more conventional treatment settings. Treatment providers who are not comfortable with the adversarial nature of forensic psychiatry and the milieu of the courtroom may be reluctant to treat patients with paraphilia who are also sex offenders.


While neither the causation of nor the specific modes of action of the various modalities for managing the paraphilias are well understood, evidence suggests that treatment is worthwhile, both in reducing the rate of recidivism and subsequent danger to society from sex crimes and in relieving the suffering of individuals with paraphilias and comorbid conditions. It seems well worth the efforts of psychiatrists to continue to refine both their diagnostic and treatment skills toward this end.

 Berlin FS, Malin HM, Dean S. Flexibility in reporting child sexual abuse: a reply to Kalichman: 

. Buffalo, NY: Prometheus Press; 1989:19.


 Saleh FM, Berlin FS, Malin HM, Thomas K. Treatment of the nonpedophilic and nontransvestitic paraphilias. In: Gabbard GO, ed. 

3rd ed. Washington, DC: American Psychiatric Association. In press.


 Mitchell W, Falconer MA, Hill D. Epilepsy with fetishism relieved by temporal lobectomy. 

 Mendez MF, Chow T, Ringman J, et al. Pedophilia and temporal disturbances

 Berlin FS, Saleh FM, Malin HM. Comorbid psychiatric illness in sex offenders. In: Saleh FS, Grudzinsky A, Bradford J, Brodsky D, eds. 

Sex Offenders: Identification, Risk Assessment, Treatment, and Legal Issues. 

New York: Oxford University Press. In press.


 Lehne GK. Brain damage and paraphilia: treated with medroxyprogesterone acetate. 

 Saleh FM, Berlin FS. Sex hormones, neurotransmitters and psychopharmacological treatments in men with paraphilic disorders

 Malin HM. Should you work with sex offenders? 

Paraphilias are defined by DSM-IV-TR as sexual disorders characterized by "recurrent, intense sexually arousing fantasies, sexual urges or behaviors generally involving (1) nonhuman objects, (2) the suffering or humiliation of oneself or one's partner, or (3) children or other nonconsenting persons that occur over a period of 6 months" (Criterion A), which "cause clinically significant distress or impairment in social, occupational, or other important areas of functioning" (Criterion B). DSM-IV-TR describes 8 specific disorders of this type (exhibitionism, fetishism, frotteurism, pedophilia, sexual masochism, sexual sadism, voyeurism, and transvestic fetishism) along with a ninth residual category, paraphilia not otherwise specified (NOS).

Fabian M. Saleh, MD

Articles

Psychopathy: Insights for General Practice

The Role of Psychiatry in Sex Offender Management

Paraphilias: Clinical and Forensic Considerations