Igor I. Galynker, MD, PhD

The relationship between mental illness and violence is controversial. On the one hand, there is considerable unfounded stigma and discrimination toward the mentally ill based on the popular notion that psychiatric patients are dangerous people. On the other hand, there is a legitimate need for psychiatrists to identify and manage what risk of violence does exist in their patients. Research that examines how and why violence occurs in the mentally ill is necessary for psychiatrists to determine as accurately as possible which patients are prone to violence and to manage their care accordingly.

Traumatic experiences in childhood have been linked to the potential for violence in adulthood as well as to vulnerability to psychiatric disorders.

 Bipolar disorder has been linked to traumatic childhood experience and to the potential for violence.

In this review, we explain the association between bipolar disorder, trauma, and violence, and we suggest ways of assessing violence potential in bipolar patients.

DSM-5 defines trauma as exposure to an event that involves “actual or threatened death, serious injury, or sexual violence.” The traumatic event can be experienced firsthand or by learning that the event occurred in a close family member or friend. Moreover, the traumatic event is experienced repeatedly or there is extreme exposure to the details of the event.

A history of childhood traumatic experience has been associated with increased vulnerability to multiple mental disorders, including mood disorders and personality disorders.

 Etain and colleagues6 found that a history of 2 or more types of trauma is associated with a 3-fold increase in the risk of bipolar disorder. Prognosis and course of bipolar disorder are worse when there is a history of trauma. Trauma history is associated with earlier onset of bipolar disorder; faster cycling; increased rates of suicide; and more comorbidity, including anxiety disorders, personality disorders, and substance use disorders.

 have shown that in patients with bipolar disorder, more than 50% report childhood trauma, with a high incidence of emotional abuse; 63% of the patients had experienced 2 or more forms of trauma as well as more severe forms. Conus and colleagues

 found that about 80% of patients with bipolar disorder had experienced at least 1 stressful life event. Among them, 16% had been physically abused, 15% had been sexually abused, 40% had experienced parental separation, and 20% had problems with a partner.

There are several pathways by which childhood trauma could lead to the development of bipolar disorder. Any one or a combination of these pathways could be operational in the development of bipolar disorder in individuals who have experienced childhood trauma. Thus, either the trauma itself or the factors that lead to trauma-or both-could affect the development and course of bipolar disorder.

• Affective disturbances in relationships between parents and their children directly predispose the children to affective disturbances in adulthood

• Children in whom bipolar disorder later develops are prone to more behavioral disturbances in childhood (a prodrome, or early onset, of bipolar disorder), which could disrupt relationships with parents and lead to dysfunctional parenting

• Children of affectively ill parents could be affected by genetic transmission of affective illness predisposition as well as by parental psychopathology, which increases the likelihood of childhood trauma

The link between trauma and violence in bipolar disorder

Childhood trauma history has been found to correlate with increased aggression in adults with and without affective disorders.

In addition, there is an overlap between the neurochemical changes found in adults with histories of traumatic stress and those found in adults with increased impulsive aggression-in particular, increased functioning of both the catecholamine system and the hypothalamic-pituitary-adrenal axis.

The prevalence of childhood trauma in persons with bipolar disorder combined with the risks that arise from the symptoms of the disorder itself renders bipolar patients at increased risk for violent behavior. Because childhood trauma has been associated with earlier onset and a greater number of episodes, there is more cumulative time when aggressive behavior is most likely to manifest. In addition, a history of trauma is associated with an increase in rates of substance abuse, which itself is associated with significant violence risk. Aggressiveness is often shown in different clinical settings, including bipolar, borderline, and antisocial personality disorders. Comorbidity with borderline personality disorder is associated with a higher risk of aggression in bipolar disorder during periods of euthymia.

Persons with bipolar disorder are at significantly increased risk for violence, with some history of violent behavior ranging from 9.4% to just under 50%, often in the presence of comorbid diagnoses.

 Bipolar patients are prone to agitation that can result in impulsive aggression during manic and mixed episodes. However, depressed states can involve intense dysphoria with agitation and irritability, which can also increase the risk of violent behavior. Bipolar patients may have chronic impulsivity during euthymia, predisposing them to aggression. This is especially true with comorbid features of borderline personality disorder. In fact, particularly high levels of impulsivity and aggression in a bipolar patient could be a strong indicator of comorbidity with borderline personality disorder.

Impulsive aggression (as opposed to premeditated aggression) is most commonly associated with bipolar and other affective disorders. In animal models, premeditated aggression corresponds to predatory behavior, while impulsive aggression is a response to perceived threat (the fight in fight-or-flight). As either a state or trait, increased impulsive aggression is driven by an increase in the strength of aggressive impulses or a decrease in the ability to control these impulses. Neurochemically, impulsive aggression has been associated with low serotonin levels, high catecholamine levels, and a predominance of glutamatergic activity relative to Î³-amino-butyric acid (GABA)ergic activity.

In many ways, the assessment of violence risk in patients with bipolar disorder is similar to risk assessment in any patient. Certain data from the patient’s history and mental status examination are universally important:

• A history of violent acts, especially recent ones and especially if there were any legal consequences.

• The extent of alcohol and drug use, because there is a strong association between substance abuse and risk of violence.

• Trauma history has a unique relationship with bipolar disorder, and it should be assessed in all patients to determine the risk of violence. Trauma is associated with increased aggression in adults in general, regardless of whether an affective disorder is present.

• Other important historical data include demographic information (young men of low socioeconomic status who have few social supports are the most likely to be violent) and access to weapons.

• In the mental status assessment, it is important to note psychomotor agitation as well as the nature, frequency, and severity of violent ideation.

• Use of an actuarial instrument, such as the Historical, Clinical, and Risk Management-20 (HCR-20) violence assessment scheme, can help integrate systematic inquiry about evidence-based risk factors into assessment of the clinical scenario.

 Although such instruments are often developed for use in forensic populations, they can be integrated into the assessment of other populations; for example, the 10 historical items of the HCR can be used as a structured checklist in conjunction with a clinical assessment (

In assessing patients with bipolar disorder, pay special attention to violent behavior that may have occurred when the person was manic. Also consider violence during euthymic periods, especially in patients who are substance abusers or who have Axis II comorbidity. If at all possible, obtain collateral information about the history of violence. Patients may minimize previous violent actions or not remember them, especially if they were in the midst of a manic episode.

Bipolar patients are most prone to violence during manic or mixed states-when maximum behavioral dyscontrol is combined with unrealistic beliefs. Patients with dysphoric mania and mixed states may be at especially high risk; the assessment for concurrent depression in a manic patient should therefore be a priority.

Symptoms of bipolar disorder often overlap with those of borderline personality disorder. Comorbid borderline personality disorder, which is often associated with trauma history, has been shown to predict violence potential in bipolar patients, especially during periods of euthymia.

 Impulsivity is a prominent feature of bipolar disorder. Information about previous impulsive acts, especially acts of impulsive aggression, can give the clinician an idea of a person’s likelihood to commit violence on impulse. Often, patients with bipolar disorder will use alcohol and other drugs to self-medicate mood episodes or as part of the pleasure-seeking behavior of a manic episode.

Prevention and management of violence in bipolar patients

The bipolar diagnosis introduces some unique aspects to violence prevention and management, although the general principles are similar to those for patients with other disorders. There are 7 areas that are particularly important in the prevention and management of violence in bipolar patients.

. This can be a challenge in bipolar patients who may have low motivation for treatment, especially if they have poor insight or if they enjoy their manic symptoms. In addition, a history of childhood abuse can lead to diminished capacity for trust and collaboration with the clinician.

 To improve the alliance with a reluctant bipolar patient, identify his or her particular barriers to acceptance of treatment and work to diminish them. It may be helpful to normalize the enjoyment of mania and to empathize with the patient’s resistance to treatment as an understandable desire to be healthy and independent.

Frame treatment that addresses aggressive behavior in a way that respects the patient’s desire for control; for example, convey that the medication will help the patient control himself rather than saying that the medication will control the patient. A collaborative approach maximizes the patient-physician alliance.

. Because the risk of violent behavior increases during an episode, the sooner mood symptoms can be ameliorated the lower the risk. In addition to the agitation and hyperactivity of mania (or sometimes depression), psychotic symptoms are important targets of violence prevention. Symptoms such as paranoid delusions or command auditory hallucinations can contribute to violent behavior, with a greater number of psychotic-like experiences associated with a higher risk of violence.

 Mixed states may be especially high-risk and may respond better to valproate than to lithium.

. Those close to a person with bipolar disorder can be both potential victims of aggressive behavior and potential sources of help in symptom monitoring, especially for patients with poor insight. Determine with the patient and family what the early warning signs of a mood episode are for that person so that intervention can be instituted early, before behavior becomes unmanageable. Educating friends and family can prevent violence by helping them avoid behavior that could worsen the patient’s aggression; help them understand the need to leave a situation that may become volatile and when urgent intervention is needed (eg, calling 911).

. Bipolar patients may be impulsive even during euthymia, especially if there is comorbid borderline personality disorder. Consider referring the patient for dialectical behavioral therapy if borderline features dominate the clinical picture or if there is a significant history of impulsive risk taking or self-harm during euthymia.

. Substance use disorders are highly comorbid with bipolar disorder and are a major risk factor for violence. Aggressively assess and treat such disorders, and refer the patient to specialized outpatient programs or restrictive residential programs, if needed.

. Use assertiveness training, social skills training, anger management training, and stress management training as needed to help the person express his needs, manage potentially frustrating interactions, avoid stress, and handle any anger that arises.

. If a bipolar patient is an acute danger to others, steps must be taken to incapacitate him. These include involuntary hospitalization and medication. Bipolar patients are most often involuntarily hospitalized during manic episodes. An aggressive pharmacological approach should be taken to address the manic symptoms so as to quickly diminish the risk of aggressive behavior.

Aside from treating the manic episode, other measures may be used if needed to quickly control aggressive behavior. These include sedating medication (eg, benzodiazepines, antipsychotics), seclusion, and restraint. It is important to provide an environment that minimizes overstimulation and includes clear interpersonal communication and limit-setting.

Bipolar disorder is associated with a high prevalence of childhood trauma as well as with the possibility of aggressive and potentially violent behavior. It is important for clinicians to assess a patient’s potential for violence as accurately as possible to minimize risk. Taking clinical and historical information into account, such as mood symptoms and history of violence, substance abuse, childhood trauma, and impulsivity, can help clinicians make an accurate assessment.

Handling emergencies and treating mood episodes pharmacologically are first steps in managing risk; this should be followed up with treating substance abuse and trait impulsivity and with involving significant others and teaching coping skills. Recognizing the impact of early trauma on a patient can help improve the therapeutic alliance and lead to better outcomes.

This article was originally published on November 17, 2010 and has since been updated.

Dr Lee is Assistant Professor of Psychiatry at the Albert Einstein College of Medicine, Bronx, NY. Dr Galynker is Professor of Psychiatry at the Icahn School of Medicine at Mount Sinai, Director of The Family Center for Bipolar Disorder, and Associate Chairman in the department of psychiatry and behavioral sciences at Mount Sinai Beth Israel, New York. Ms Kopeykina is Program Manager and Mr Kim and Ms Khatun are Research Assistants at The Family Center for Bipolar Disorder.

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Articles

What is the association between bipolar disorder, trauma, and violence? Here: a guide to assessing violence potential in bipolar patients.

Violence in Bipolar Disorder

Â Related content:For more on this topic please see “Violence in Bipolar Disorder,” by Allison M. R. Lee, MD and Igor I. Galynker, MD, PhD, on which this slideshow is based.

Slideshows

The bipolar diagnosis introduces some unique aspects to violence prevention and management, although the general principles are similar to those for patients with other psychiatric disorders. More in this slideshow.

7 Steps to Prevent and Manage Violence in Bipolar Patients

From Pedophilia to Addiction, Robert T. Segraves, MD

Female Sexual Dysfunction, Leonard R. Derogatis, PhD

Psychopathology and Personality Traits of Pedophiles, Lisa J. Cohen and Igor Galynker

Sexual Addiction Update, Aviel Goodman, MD

Because of recent scandals, pedophilia is one of the few psychiatric disorders widely known to the general public. Classified in DSM-IV and DSM-IV-TR as a paraphilia, pedophilia is characterized by persistent sexual attraction to prepubescent children. Although patients with pedophilic tendencies are generally seen by specialists in sexual disorders, many other clinicians are likely to encounter such patients as well. This article provides a general overview of the current literature on the psychology and psychopathology of pedophilia so that clinicians who encounter pedophilic patients will be better prepared to make an assessment and decide on the appropriate course of treatment. Moreover, a better understanding of people who are sexually attracted to children is critically important to protect against the severely destructive effects of childhood sexual abuse.


DSM-IV and DSM-IV-TR define pedophilia as “recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving activity with a prepubescent child or children (generally 13 years or younger).” These feelings, urges, or behaviors must persist for at least 6 months. The DSM-IV criterion that such urges must cause clinically significant distress or functional impairment was amended in DSM-IV-TR, such that recurrent pedophilic fantasies or arousal need not be experienced as distressing. This correction reflects the ego-syntonic nature of many pedophiles’ sexual desires and/or behavior.

According to DSM-IV, pedophilia can be diagnosed in the absence of any pedophilic behavior. Nonetheless, because of the potential legal risks of self-reporting pedophilic inclinations, the majority of pedophile research is conducted with participants who are identified by their behavior, most often via their contact with the criminal justice system.

There are 2 problems inherent with this research pool. For one, convicted or arrested sex offenders might differ considerably from pedophilic individuals who have not acted on their urges or who have acted on them but have not been caught. Second, not everyone who sexually molests a child is actually a pedophile; that is, such a person may not have a persistent sexual attraction to prepubescent children.

 Despite these difficulties, current research does reveal sufficiently consistent patterns to provide a basic overview of common psychological features associated with pedophilia.


Most sexual offenders against children are male, although female offenders may account for 0.4% to 4% of convicted sexual offenders.

 On the basis of a range of published reports, McConaghy

 estimates a 10 to 1 ratio of male-to-female child molesters. However, most researchers assume available estimates underrepresent the true number of female pedophiles.

 Several reasons for this have been proposed, including a societal tendency to dismiss the negative impact of sexual relationships between young boys and adult women as well as women’s greater access to very young children who cannot report their abuse.9 Because of the low number of females in pedophile samples, most of the studies discussed below will be drawn from exclusively male samples.


The most important diagnostic issue for clinicians who encounter a possible pedophile is the danger the patient may pose to children, although DSM-IV does not directly address this issue. Several subgroups are listed under the DSM-IV diagnosis of pedophilia:

• Individuals who are sexually attracted to males, females, or both sexes
• Those whose behavior is limited to incest
• Persons who are attracted only to children-exclusive versus nonexclusive

Although not listed in DSM-IV, the distinction between true and opportunistic pedophiles is possibly of greater diagnostic importance.

 Related terms include fixated versus regressed pedophiles or preferential versus situational pedophiles.

True pedophiles are those who show persistent and focused sexual attraction to prepubescent children. They show specific arousal to pedophilic stimuli on physiological measures of sexual arousal and have repeated sexual encounters with or recurrent sexual urges toward children. Opportunistic pedophiles have less of a focused sexual attraction to children. Their sexual engagement with children may depend on circumstances, such as the availability of a child victim, disinhibition secondary to substance abuse, or difficulty in connecting with an adult sexual partner.

There is some controversy whether this distinction reflects distinct categories or a continuum.

Clearly, it suggests that people who molest children may have distinctly different motivations. For example, true pedophiles may be motivated more by abnormal sexual desire while opportunistic pedophiles may be better characterized by failure to inhibit their impulses.

 Consequently, the distinction between true and opportunistic pedophiles may be important when considering the often conflicting findings on various psychological features within pedophile research. Perhaps more important, research supports the notion that “true” pedophiles present a higher risk of recidivism.

 Thus, this distinction may be worth addressing in DSM-V.

It is critically important for clinicians to understand that not all pedophiles are the same; in fact they may differ widely. In essence, clinicians should evaluate whether attraction to prepubescent children reflects a long-standing, deviant sexual drive or a more short-term, circumscribed problem that developed in response to circumstances or to comorbid psychopathology. Treatment and prevention implications as well as the risk to the public vary accordingly because research suggests that “true” pedophiles pose the greatest risk of recidivism.


Different psychological features give clues to the mechanisms underlying pedophilic behavior and offer potential treatment targets. More specifically, the person who sexually molests children has both impaired motivation and impaired inhibition. Possible motivational factors include social anxiety and the “abused-abuser theory.” Possible inhibitory factors include impulsivity, cognitive distortions, and psychopathy. In addition, neurobiological abnormalities may pertain to either motivational or inhibitory dysfunction. All of these factors may come into play in any one person, but individual pedophiles may differ widely in their psychological profile.


Pedophiles have been hypothesized to seek sexual relations with children in response to social anxiety, poor self-confidence, or other personality traits that inhibit appropriate sexual relations with adults. While some studies have documented the presence of elevated levels of cluster C personality disorder traits, poor self-esteem, and impaired assertiveness, it is unlikely that these traits are specific to pedophilia.

 There is also the problem of the direction of causality.

In our own recent study of pedophilic persons, narrative data revealed that some turn to children in response to their impaired interpersonal skills. Others reported feelings of shame, low self-esteem, and social avoidance as a result of their pedophilic urges.

The abused-abuser theory offers another model of pedophilic motivation. This suggests that a pedophile’s own history of childhood sexual abuse predisposes him or her to pedophilic tendencies. Indeed this is the one proposed etiological factor that has received robust support in the literature. Estimates of the incidence of childhood sexual abuse in pedophiles’ histories range from 40% up to 100%.

 Female offenders might have an even higher incidence of childhood sexual abuse.

 Moreover, pedophilic offenders have a higher incidence of childhood sexual abuse than do sexual offenders against older age-groups and nonsexual offenders.

Finally, in a randomly selected sample of men living in the community, men who had reported multiple events of sexual contact in their own childhood were almost 40 times more likely to report having sexual contact with children 13 years and younger than men who reported no sexual abuse in childhood (0.2% vs 7.7%).2

Thus, childhood sexual abuse appears to play an important role in the development of pedophilic tendencies. The underlying mechanism for this is not clear. Psychological processes, such as identification with the aggressor and normalization of adult-child sexual activity have been proposed.

 We have suggested that abuse sustained during early childhood may result in neurodevelopmental abnormalities that predispose to pedophilic sexual desire.

Nonetheless, most studies suggest that a sizable proportion of pedophiles were not abused as children.

 While this might reflect underreporting because of denial and/or inadequately processed emotions about past traumas, the data suggest that childhood sexual abuse is neither necessary nor sufficient for the development of sexual attraction to children.

 However, it is also possible that childhood abuse histories are more characteristic of “true” pedophiles than “opportunistic” ones.

A number of studies have investigated the neurobiological or neuropsychological correlates of pedophilia. Some studies have shown lowered IQ in pedophiles compared with healthy controls.

 Cortical abnormalities in frontotemporal regions have also been documented using MRI, positron emission tomography, CT, and electroencephalography, as have subcortical abnormalities in the amygdala and related limbic structures.

We can speculate that frontal dysfunction may underlie disinhibition while temporolimbic abnormalities may relate to abnormal motivation via aberrant sexual arousal patterns. However, not all studies have documented such impairment and the neurobiological and neuropsychological literature has been contradictory.

 In our study of 20 pedophiles and 24 demographically matched healthy controls, we found no difference on tests of executive function despite highly significant differences on personality measures.


With regard to inhibitory dysfunction, 3 areas to consider include impulsivity, cognitive distortions, and psychopathy. Impulsivity can impede inhibition via inadequate consideration of consequences, cognitive distortions through misunderstanding of the implications of the pedophilic behavior, and psychopathy through inadequate concern with the harm done to others, particularly young victims.

Considerable data point to high levels of impulsivity or impulse control disorders within pedophile samples.

 Nonetheless, these findings are not consistent and may reflect comorbid psychopathology in those pedophiles with the most severe psychopathology and/or those most likely to get caught. In addition, the findings may characterize pedophiles on the opportunistic side of the spectrum.

 the majority of pedophilic crimes (70% to 85%) were premeditated rather than impulsive. Likewise, in our study, pedophiles displayed lower scores on an impulsivity scale than a group of opiate-addicted controls. Moreover, the pedophiles’ scores were virtually indistinguishable from those of healthy controls.14 The relatively high prevalence of pedophiles who maintain demanding jobs with high levels of responsibility, such as pedophile priests, also argues against a central role of impulsivity.

 Thus, impulsivity may characterize some pedophiles but not all.

One finding that has robust support is the tendency toward grossly distorted thinking.

Pedophiles commonly experience their sexual urges as ego-syntonic. Presumably in an effort to justify behavior that is widely socially condemned, pedophiles frequently rationalize, minimize, and normalize their sexual interaction with children, sometimes to the point of delusional ideation. Relatedly, several studies have noted high levels of schizotypal and other cluster A personality traits in this population.

Finally, engaging in sexual activity with children violates strongly held taboos as well as criminal law. Thus, we can predict that the participation in child sexual abuse may be associated with elevated psychopathic traits. Indeed, many studies have supported this finding.

Nonetheless, the degree of psychopathic traits appears to vary across subgroups. A study of pedophilic priests found that this subgroup had lower levels of psychopathy than a sample of nonclerical pedophiles.

In sum, research shows highly consistent evidence for cognitive distortions and sexual abuse histories, fairly consistent evidence for psychopathic traits, and mixed evidence for avoidant personality traits, impulsivity, and neurobiological or neuropsychological impairment. Future research is needed to address the extent to which:

• These traits pertain to either motivational or inhibitory dysfunction
• They are characteristic of true versus opportunistic pedophiles

Consequently, when evaluating a pedophilic patient, clinicians should consider the level of comorbid impulsivity, social inhibition, neurocognitive dysfunction, psychopathic traits, and cognitive distortions. These traits may give a fuller picture of motivating factors as well as impediments to the inhibition of pedophilic urges.


Because pedophiles are not always truthful, full assessment of pedophilia is best performed with multiple modalities and multiple sources of information. When the criminal justice system is involved, examination of court records is critical. Likewise, objective measures of sexual response styles are often necessary because pedophiles routinely minimize their pedophilic tendencies.

The most common objective methodology involves plethysmographic measures, in which erectile response to targets of different ages and genders is recorded.

Measures of galvanic skin response and respiration rate can also accompany plethysmographic measures. The Abel Assessment for Sexual Interests (AASI) offers an alternative measure of observable behavior, recording visual reaction time to a range of images.

 The AASI also comes with a lengthy self-report questionnaire. Two other self-report instruments, the Clarke Sexual History Questionnaire–Revised and the Multiphasic Sex Inventory, contain validity scales to detect lying.


Although, pedophilia is commonly seen as treatment-resistant, much research suggests this is not the case. Maletzky and colleagues

 reported a treatment failure rate of only 9% over a 20-year period with pedophiles in comprehensive and (frequently) court-mandated treatment. Nonetheless, given the severe consequences of any relapse and the possibility of relapse even decades after the original assessment, clinicians who encounter a patient with pedophilic tendencies would be well advised to consult with a specialist in sexual disorders or even refer the patient to a specialty clinic. Unfortunately, there are far fewer specialty centers than are needed. The Association for the Treatment of Sex Abusers (ATSA) (www.atsa.com), however, can be a useful resource.

Treatment of pedophilia is most effective when it is multimodal, long-term, and perhaps court mandated.

 Cognitive-behavioral treatments have been used to reduce pedophilic sex drive, to increase age-appropriate sexual and affiliative behavior, and to strengthen inhibition of pedophilic behavior. Associative conditioning techniques such as covert sensitization and aversive conditioning, as well as plethysmographic biofeedback and masturbatory satiation are used to reduce pedophilic arousal.

With plethysmographic feedback, pedophilic patients can be provided with objective evidence of their sexual arousal patterns and of the effectiveness of any intervention to reduce pedophilic arousal. This can help cut through the denial and minimization that is such a problem with this population. More recent approaches have emphasized a relapse-prevention model, based on an addiction model of pedophilia.

 Training in interpersonal skills, assertiveness, and empathy are also used in order to enhance relationships with adults.

Finally, confrontation of denial, particularly in group format; cognitive restructuring of cognitive distortions; and training in empathy for victims are all used to strengthen inhibition of pedophilic behavior.

 Given the high rate of childhood abuse in pedophiles’ own histories, exploration of their own abuse and its relationship to their adult pedophilic behavior is also warranted.

In cases in which the risk of recidivism is high and danger to the public is of considerable concern, anti-androgen or other hormonal treatments may be indicated.

 The anti-androgen agent cyproterone acetate is widely used in Europe and Canada but is not available in the United States. Hormonal agents such as medroxyprogesterone and luteinizing hormone-releasing hormone (LHRH) analogues are also used. LHRH analogues, such as leuprolide, triptorelin, and goserelin, are long-acting and can be given via injection.

 Because these treatments reduce global and not just pedophilic sex drive, treatment adherence may pose a serious problem and may depend on external pressures, such as court-mandated treatment.

SSRIs such as fluvoxamine, fluoxetine and sertraline have also been used to treat pedophiles. With a more favorable adverse-effect profile than anti-androgens, treatment adherence with SSRIs may be less of an issue. A few studies have shown some efficacy.

 It is unclear, however, whether these work through reducing depression, reducing compulsive behavior, or reducing general sexual function.


Because of the many legal and ethical complications involved, some clinicians may choose not to treat individuals with pedophilia. It is nonetheless important for all clinicians to be familiar with the basic literature on pedophilia because these patients do present in a wide range of clinical settings. Moreover, given the high incidence of childhood sexual abuse and its pernicious, long-lasting effects, high-quality research, assessment, and treatment of pedophilia are of great public importance. Luckily, current techniques are promising. With better public support, there is opportunity for significant advances in the treatment and prevention of this disabling and destructive disorder.

Drugs Mentioned in This Article
Cyproterone (Cyprostat)
Fluoxetine (Prozac, Sarafem, Symbyax)
Fluvoxamine (Luvox)
Goserelin (Zoladex)
Leuprolide (Lupron, others)
Medroxyprogesterone (Depo-Provera)
Sertraline (Zoloft)
Triptorelin (Trelstar)

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Evidence-Based References
Cohen LJ, Grebchenko YF, Steinfeld M, et al. Comparison of personality traits in pedophiles, abstinent opiate addicts, and healthy controls: considering pedophilia as an addictive behavior. J Nerv Ment Dis. 2008;196:829-837.
Maletzky BM. Factors associated with success and failure in the behavioral and cognitive treatment of sexual offenders. Ann Sex Res. 1993;6:241-258.

Because of recent scandals, pedophilia is one of the few psychiatric disorders widely known to the general public. 

Author | Igor I. Galynker, MD, PhD

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