Divalproex sodium in sex offenders with bipolar disorders and comorbid paraphilias: an open retrospective study

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 Neurology of Acquired Pedophilia

The clinicoanatomic cases of acquired pedophilia that have been published in the medical and forensic literature up to 2019 are reviewed. Twenty-two cases fit our inclusion criteria. All but one were men, and in only one case the injury was localized to the left hemisphere. Hypersexuality was present in 18 cases. The damaged areas fell within the frontotemporoinsular cortices and related subcortical nuclei; however, the anterior hypothalamus was spared. Damage to parts of the right frontotemporoinsular lobes with sparing of the anterior hypothalamus seems to be critical for the emergence of acquired pedophilia.

Treatment of Paraphilic Disorders in Sexual Offenders or Men With a Risk of Sexual Offending With Luteinizing Hormone-Releasing Hormone Agonists: An Updated Systematic Review

BACKGROUND

Different pharmacologic agents are used in the treatment of paraphilic disorders in sexual offenders or men with a risk of sexual offending, with luteinizing hormone-releasing hormone (LHRH) agonists being the agents introduced more recently to treatment regimens.

AIM

To summarize the relevant literature concerning LHRH agonist treatment of paraphilic disorders in sexual offenders and update the previously published systematic review by Briken et al (J Clin Psychiatry 2003;64:890-897).

METHODS

The PubMed and Google Scholar databases were searched for literature published from January 2003 through October 2017 using the following key words: LHRH agonists, GnRH agonists, antiandrogens AND paraphilia, pedophilia, sex offenders.

OUTCOMES

Evaluation of the effectiveness and side effects of LHRH agonist treatment of paraphilic disorders in sexual offenders.

RESULTS

After screening for duplicates and applying specific selection criteria, the search yielded 24 eligible studies reporting on a sample of 256 patients. There is increasing evidence that LHRH agonists are more effective than steroidal antiandrogens in lowering paraphilic sexual thoughts and behaviors. Current research also is based on methods that might be less susceptible to faking (eg, eye-tracking, brain imaging, and viewing-time measures). Side effects occurring most frequently are fatigue, hot flashes, depressive mood, weight gain, high blood pressure, diabetes, gynecomastia, loss of erectile function, and loss of bone mineral density.

CLINICAL IMPLICATIONS

Although LHRH agonists seem to be the most effective drugs in the treatment of paraphilic fantasies and behaviors, they should be reserved for patients with a paraphilic disorder and the highest risk of sexual offending because of their extensive side effects.

STRENGTHS AND LIMITATIONS

This systematic review considers all types of research on LHRH agonist treatment in patients with paraphilic disorders, thereby providing a complete overview of the current state of research. However, most studies are case reports or observational studies and randomized controlled clinical trials have not been conducted or published.

CONCLUSIONS

LHRH agonists are a useful treatment when combined with psychotherapy in patients with a paraphilic disorder and the highest risk of sexual offending. However, throughout treatment, close monitoring of side effects is needed and ethical concerns must always be kept in mind. Turner D, Briken P. Treatment of Paraphilic Disorders in Sexual Offenders or Men With a Risk of Sexual Offending With Luteinizing Hormone-Releasing Hormone Agonists: An Updated Systematic Review. J Sex Med 2018;15:77-93.

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.

Searching for behavioral indicators of bipolar II in patients presenting with major depressive episodes: the "red sign," the "rule of three" and other biographic signs of temperamental extravagance, activation and hypomania

BACKGROUND

Since 1977, the work of the author has shown the primacy of behavioral activation, flamboyance, and extravagance in detecting hypomania, the historical hallmark of cyclothymic and the broader spectrum of bipolar II (BP-II) disorders. In other words, the soft spectrum is more likely to declare itself in behavioral rather than mood disturbances. The obligatory search for elation and related mood changes a la DSM-IV (and its interview form, the SCID) during the clinical interview is often doomed to failure, thereby "condemning" the patient to a unipolar diagnosis, and hence to sequential and often tragic failures with antidepressants or combinations thereof.

METHODS

To characterize behavioral signs of good specificity, though individually of low sensitivity for BP-II in patents presenting with major depression, the author undertook a chart review of over 1000 depressive patients he had examined extending over a period of nearly three decades. The Mood Clinic Data Questionnaire (MCDQ) used in the author's Memphis mood clinic permitted systematization of unstructured observations. BP-II had been independently confirmed by hypomania of > or =2 days and/or cyclothymia over the course of the index illness (both of which were validated by family history for bipolarity in earlier research in our clinic).

RESULTS

Triads of behavior or traits in the patients' biographical history-as well as in the biologic kin-involving polyglottism, eminence, creative achievement, professional instability, multiple substance/alcohol use, multiple comorbidity (axis I and axis II), multiple marriages, a broad repertoire of sexual behavior (including brief interludes of homosexuality), impulse control disorders, as well as ornamentation and flamboyance (with red and other bright colors dominating) were specific for BP-II. Temperamentally, many of these individuals thrive on activity-they are indeed "activity junkies."

LIMITATION

The reported findings pertain primarily to the differential diagnosis between BP-II and unipolar depression. Replication of the approach espoused herein will require quantification of the operational definitions of the observed phenomenology.

CONCLUSION

The findings, which make sense in an evolutionary model of the advantage that "dilute" bipolar traits confer to human biography and erotic life, suggest that such behavioral traits can be useful provisionally in assigning a depressive episode to the realm of the bipolar II spectrum. Overall, the perspective espoused in this paper indicates that temperamental excesses and, more generally, a biographical approach, represent a more coherent approach than hypomanic episodes in the diagnosis of BP-II patients. Finally, such a diagnostic approach underscores the importance of incorporating evolutionary considerations and principles in understanding the origin of affective disorders.

Epidemiology and treatment of juvenile sexual offending

The juvenile sex offender is defined as a youth who commits any sexual act with a person of any age against the victim's will, or in an aggressive, exploitative, or threatening manner. The term 'child molester' refers to those who choose only, or primarily, child victims. In this article, we mostly focus on adolescents aged between 13 and 18 years. To reduce sex crimes and the risk of adolescent sexual re-offending, effective treatment strategies have to be implemented for adolescent sexual offenders. Supervision and treatment recommendations for juvenile sex offenders initially emerged from the literature on adult sex offenders. Treatment must include behavioral therapy, family therapy, and psychosocial interventions. Pharmacotherapy is not always a first-line treatment. Antidepressants (especially selective serotonin reuptake inhibitors) offer promise in the treatment of adolescent sexual offending but further controlled studies are needed. In some rare situations, however, especially when severe paraphilic behaviors (such as pedophilia) are present, an hormonal intervention such as cyproterone acetate treatment may be needed.