Pedophilia and temporal lobe disturbances

Executive function profiles of pedophilic and nonpedophilic child molesters

There is increasing evidence of neurocognitive dysfunction among child molesters, supporting the notion of brain anomalies among pedophiles. However, approximately half of child molesters are not pedophilic (i.e., are not primarily attracted to children), and neurocognitive differences between pedophilic (PED) and nonpedophilic (NPED) child molesters are not well understood. The purpose of this study was to assess neurocognition, specifically executive functioning (EF), among phallometrically defined PED and NPED child molesters, relative to nonsexual offenders (NSO). Participants (N = 89) were compared on seven EF domains. Results revealed that (a) child molesters exhibited an overall executive profile that was different from that of NSOs, with PEDs differing from NSOs but not from NPEDs; (b) child molesters on the whole performed better than NSOs on abstract reasoning and more poorly on inhibition; and (c) PEDs performed better than NPEDs on planning and exhibited better overall performance accuracy relative to NPEDs. These results suggest that PEDs exhibit a more deliberate, planful response style characterized by greater self-monitoring; whereas NPEDs appear to respond more impulsively. The current report further elucidates neurocognition among child molesters and highlights the need for future research examining subtypes of child molesters.

Executive dysfunctions in pedophilic and nonpedophilic child molesters

INTRODUCTION

There is some evidence that child molesters show neuropsychological abnormalities which might reflect specific structural and/or functional brain alterations, but there are also inconsistencies in the existing findings which need to be clarified. Most of the different outcomes can either be explained by the fact that different types of child molesters were examined or by not having accounted for basically confounding factors such as age, education/intelligence, or criminality.

AIM

The present study therefore sought to determine whether pedophilic and nonpedophilic child molesters, compared to relevant control groups, show different profiles of executive dysfunction when accounting for potentially confounding factors.

METHODS

The performance of 30 child molesters (15 pedophilic and 15 nonpedophilic) and 33 age- and education-matched controls (16 nonsexual offenders and 17 healthy controls) was assessed regarding several neuropsychological functions.

MAIN OUTCOME MEASURES

Scores on different neurocognitive tests and semistructured diagnostical interviews.

RESULTS

Results indicate that pedophilic child molesters exhibited less performance deficits in cognitive functioning than nonpedophilic child molesters. Compared to healthy controls and nonsexual offenders, the pedophilic child molesters only showed executive dysfunction concerning response inhibition, whereas the nonpedophilic child molesters revealed more severe dysfunction, especially on tasks associated with cognitive flexibility and verbal memory.

CONCLUSIONS

These results enhance our knowledge about executive dysfunction associated with criminality and/or pedophilia, as they suggest different profiles of impairment between groups. In summary, data suggest that nonpedophilic child molesters showed more severe cognitive deficits than pedophilic child molesters. However, as response inhibition is associated with prefrontal (i.e., orbitofrontal) functioning, the deficits observed in both child molester groups indicate dysfunction in the orbitofrontal cortex. This has to be further examined with functional imaging approaches in larger samples and a full-factorial approach which allows for a clear distinction between criminality and pedophilia in a factorial manner.

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.

Kluver-Bucy syndrome, hypersexuality, and the law

A 51-year-old right-handed man developed hypersexuality after a second right temporal lobectomy to treat epilepsy. His hypersexuality started with increased marital intercourse and masturbation but he later downloaded child pornography. Hyperphagia and distractibility, other features of the Kluver-Bucy syndrome, also developed. Resection of the amygdala and/or temporal lobe neocortical areas that inhibit other limbic areas may contribute to the pathogenesis of hypersexuality. Neurological factors mitigate the criminal responsibility for hypersexual activity in patients with Kluver-Bucy syndrome. Most previously reported patients were never charged with a crime despite uninvited physical contact in some instances. Our patient was convicted and imprisoned.

Sexual offenders in prison psychiatric treatment: a biopsychosocial description

In this study, 120 males (60 sexual offenders and 60 non-sexual offenders) in psychiatric treatment while in prison were evaluated using neuropsychological, psychological, and sociological/demographic measures. All sexual offenders (N = 60) would be evaluated for potential civil commitment as sexually violent predators before prison release. Non-sexual offenders (N = 60) had not been convicted of a sexual offense. Sexual offenders demonstrated significantly more overall neuropsychological impairment suggesting diffuse brain differences, with dysfunction primarily associated with temporal and frontal brain cortexes; higher Psychopathy Checklist-Revised Factor 1 (Interpersonal/Affective) ratings and Rorschach responses indicated disordered attachment, disordered self-perception, and impulsive emotionality. Sexual offenders also were more likely to be younger and unmarried. Stepwise logistic regression analysis resulted in 80.20% accuracy of prediction of sexual offenders. Potential application of this empirically derived multidimensional description to treatment of sexual offenders is discussed. Potential limitations to generalization of this information are also discussed.

The neurobiology of moral behavior: review and neuropsychiatric implications

Morality may be innate to the human brain. This review examines the neurobiological evidence from research involving functional magnetic resonance imaging of normal subjects, developmental sociopathy, acquired sociopathy from brain lesions, and frontotemporal dementia. These studies indicate a "neuromoral" network for responding to moral dilemmas centered in the ventromedial prefrontal cortex and its connections, particularly on the right. The neurobiological evidence indicates the existence of automatic "prosocial" mechanisms for identification with others that are part of the moral brain. Patients with disorders involving this moral network have attenuated emotional reactions to the possibility of harming others and may perform sociopathic acts. The existence of this neuromoral system has major clinical implications for the management of patients with dysmoral behavior from brain disorders and for forensic neuropsychiatry.

THE ROLE OF PREFRONTAL SYSTEMS IN SEXUAL BEHAVIOR

Research from a variety of methodologies is demonstrating a role for neuroanatomical structures in different aspects of sexual behavior. This article reviews the particular contribution of prefrontal-subcortical systems to sexual behavior, including regions of prefrontal cortex (i.e., dorsolateral, medial, and orbitofrontal cortex), and associated subcortical structures (i.e., basal ganglia and thalamus). Findings are integrated from functional neuroimaging and clinical studies in humans, as well as animal studies, which convergently illustrate the role of different prefrontal systems. In addition to providing a clearer understanding of normal sexual behavior, appreciation of prefrontal systems in sexual behavior has implications for disorders of sexual behavior. Consistent with their role in other forms of cognition, emotion, and behavior, prefrontal systems serve in an executive capacity to regulate sexual behavior.

Lateralisation of self-esteem: an investigation using a dichotically presented auditory adaptation of the Implicit Association Test

INTRODUCTION

Self-esteem is one of the most prominent and influential constructs in psychological science, yet very few neuropsychological/neuroscientific investigations have been undertaken in this area of research. The current study investigated the possibility of hemispheric lateralisation of self-esteem.

METHODS

By creating an auditory version of the Implicit Association Test (IAT) for self-esteem, we were able to present stimuli dichotically and thereby compare left- versus right-hemispheric measurements of self-esteem in 46 healthy adults.

RESULTS

Although left- and right-hemispheric self-esteem measurements were correlated, within-participant analysis revealed that self-esteem levels (as reflected by IAT score) were significantly greater when elicited under right-ear presentation (reflecting left-hemispheric processing).

CONCLUSIONS

We interpret this asymmetry with reference to the approach-withdrawal model of emotion processing and suggest avenues for future research.

Altered emotional morality in frontotemporal dementia

INTRODUCTION

Frontotemporal dementia (FTD), a disorder characterised by abnormal social behaviour and potential sociopathy, provides a window to the neurobiology of moral behaviour. This study investigated the basis of altered moral judgements in patients with FTD.

METHODS

We administered an inventory of moral knowledge, five "reasoned" moral dilemmas, and five "emotional" moral dilemmas where subjects may cause direct harm to another through their own actions, to 21 patients with FTD compared to 21 comparably mildly impaired patients with Alzheimer's disease (AD) and 21 normal controls. Among the FTD patients, the results were compared to findings on functional neuroimaging.

RESULTS

All groups showed retention of knowledge for moral behaviour and the ability to make reasoned moral judgements. In contrast to the other groups, the FTD patients were altered in their ability to make emotional moral judgements. Among the FTD patients, the altered moral judgements corresponded to right hemisphere frontotemporal involvement.

CONCLUSIONS

In FTD patients, these findings suggest a decreased emotional responsiveness to others and a tendency to respond to moral dilemmas in a calculated fashion. Such a disturbance may result from ventromedial frontal dysfunction in FTD and supports the presence of a "morality" network in the brain, predominantly in the right hemisphere.

Neurocognitive differences between pedophilic and nonpedophilic child molesters

Although some evidence exists that child molesters may be characterized by structural and functional brain abnormalities, findings across studies are inconsistent. Past cognitive research in this area has been extensively criticized for relying on conceptually weak batteries, measures of questionable reliability, and poorly defined samples (i.e., failing to distinguish between pedophilic and nonpedophilic child molesters). The present study aimed to address the weaknesses of past research by comparing 40 child molesters (20 pedophilic and 20 nonpedophilic) and 20 demographically matched nonoffender controls on six well-defined neurocognitive composite scores of comparable reliability (i.e., semantic knowledge, executive functioning, processing speed, motor speed, auditory memory, and visual memory). Results indicated that pedophilic child molesters exhibit slower processing speed, nonpedophilic child molesters exhibit poorer semantic knowledge, and both molester groups exhibit executive weaknesses as compared to nonoffender controls. This study is the first to compare the two molester types on neurocognitive functions. The observed differences between the molester groups help explain inconsistencies in past research and demonstrate the need to distinguish between the two types of child molesters when studying neurobiologic underpinnings of sexual offending.

Facial and prosodic affect recognition among pedophilic and nonpedophilic criminal child molesters

The present study compared facial and prosodic affect recognition abilities among pedophilic and nonpedophilic child molesters and community-dwelling controls. Pedophilic child molesters are characterized by primary sexual interest in prepubescent children, whereas nonpedophilic child molesters are characterized by offending against children despite being primarily sexually attracted to adults. The results showed that nonpedophilic child molesters made more errors in recognizing both facial and prosodic affect, performing more poorly than both controls and pedophilic child molesters. These findings are consistent with greater psychopathic tendencies among nonpedophilic molesters as well as with prior findings of smaller amygdala volume among child molesters.

Neurobiologische Forschung bei Pädophilie – Ergebnisse und deren Konsequenzen für die Diagnostik pädosexueller Straftäter

Die Schwierigkeit bei der Diagnostik pädophiler Sexualstraftäter liegt in der validen Einschätzung eines pädosexuellen Interesses. Die aktuell angewendeten Verfahren und Methoden können die psychometrischen Gütekriterien nur zum Teil erfüllen. Angesichts einer zunehmenden Fülle bildgebender Befunde zu den neuronalen Korrelaten pädophilen Erlebens scheinen sich neue Möglichkeiten für die Diagnostik pädosexueller Straftäter zu ergeben. Die Zusammenfassung aller bisherigen neurobiologischen Untersuchungen zeigt allerdings sehr heterogene Ergebnisse. Diagnostisch relevante Befunde, die auf die Einzelperson valide übertragen werden können, existieren noch nicht. Auch eine Überprüfung der psychometrischen Gütekriterien für die angewendeten neurobiologischen Paradigmen steht noch aus. Ihr Potential in Hinblick auf die Diagnostik pädosexueller Straftäter muss die neurobiologische forensisch-psychiatrische Forschung erst noch unter Beweis stellen.

Understanding hippocampal sclerosis in the elderly: epidemiology, characterization, and diagnostic issues

Hippocampal sclerosis (HS) is a pathologic term used to describe severe loss of neurons and reactive gliosis without cystic cavitation in the CA1 sector of the hippocampus. In late life, HS is associated with hippocampal atrophy, severe amnesia, and slowly progressive dementia without clinical seizure activity. HS is difficult to distinguish clinically from Alzheimer's disease and is often diagnosed postmortem. In autopsy series, HS may be found without significant other pathology (2%-4% of cases), but it occurs frequently in combination with other vascular and neurodegenerative disorders (12%-20% of cases). HS is found bilaterally in 50% of cases and unilaterally in 50% of cases, with similar predilection for the right versus left hemisphere. The pathogenesis of HS is unknown and may be multifactorial in origin, possibly due to anoxic/ischemic injury or TDP-43-related neurodegeneration. Little is known about the prevention and treatment of late-life HS, although circumstantial evidence suggests the importance of identifying and treating vascular risk factors.

Pharmacotherapy for inappropriate sexual behaviors in dementia: a systematic review of literature

The aim of this study is to systematically review the published literature on pharmacotherapy for inappropriate sexual behaviors in dementia. Literature search of the 5 databases (PubMed, MEDLINE, EMBASE, PsychINFO, and COCHRANE collaboration) and the analysis of the data available for the pharmacotherapeutic treatments of inappropriate sexual behaviors in dementia were carried out. There are no published randomized controlled trials of pharmacotherapy for inappropriate sexual behaviors in dementia, but available data form uncontrolled trials, case series, and individual case reports suggest efficacy for antidepressants, antipsychotics, mood stabilizers, hormonal agents, cimetidine, and pindolol for the treatment of these behaviors. Although there are no controlled data for the treatment of inappropriate sexual behaviors in dementia, available data suggest efficacy for some commonly used pharmacotherapeutic agents.

The neural basis of moral cognition: sentiments, concepts, and values

The human moral nature has perplexed laymen and academics for millennia. Recent developments in cognitive neuroscience are opening new venues for unveiling the complex psychological and neurobiological mechanisms underling human morality and its impairments. Here we review these lines of evidence and key topics of debate and explain why investigating the mechanisms of cognition-emotion interaction and of the neural bases of moral sentiments and values will be critical for our understanding of the human moral mind.

Neurophilosophical perspectives of neuroimaging in forensic psychiatry-giving way to a paradigm shift?

Forensic psychiatry is concerned with the relationship between psychiatric abnormalities and legal violations and crimes. Due to the lack of available biological criteria, evaluation and therapy in forensic psychiatry have so far been restricted to psychosocial and mental criteria of offenders' personalities. Recent advances in neurosciences allow a closer approach to the neural correlates of personality, moral judgments and decision-making. We propose to discuss the introduction of biological criteria in the field of forensic psychiatry and to establish rules as to what extent such biological criteria will be a better and more reliable choice in judging mentally ill criminals by using all available information that can be obtained by biological means. Psychosocial and subjective criteria in forensic evaluation will be more and more accomplished by biopsychosocial and objective criteria. The responsibility of having committed a criminal act will no longer be exclusively defined by judging free and voluntary decision-making, but rather by brain-behavior relationships. What is often referred to as psychosocially determined mental processes thus could be complemented by estimating the degree of biopsychosocially determined neural processes. We conclude that such a process could contribute to a paradigm shift in forensic psychiatry, which will have profound implications for offenders, forensic psychologists and psychiatrists, the law and society in general.

Multidisciplinary design and implementation of a day program specialized for the frontotemporal dementias

To supervise activities for patients with frontotemporal dementias presents major challenges to day programs typically equipped to care for more elderly, frail patients. In this article, we present the development and immediate outcomes of integrating a day program specialized for patients with frontal lobe disturbances into an already established day program. Planning required new collaborations between the ambulatory memory clinic and the day program staff. Immediate outcomes have included relief of burden for an under-served group of caregivers and behavioral management that more seamlessly combines strategies for medication titration, environmental adjustments, and activity participation.

Structural brain abnormalities in the frontostriatal system and cerebellum in pedophilia

Even though previous neuropsychological studies and clinical case reports have suggested an association between pedophilia and frontocortical dysfunction, our knowledge about the neurobiological mechanisms underlying pedophilia is still fragmentary. Specifically, the brain morphology of such disorders has not yet been investigated using MR imaging techniques. Whole brain structural T1-weighted MR images from 18 pedophile patients (9 attracted to males, 9 attracted to females) and 24 healthy age-matched control subjects (12 hetero- and 12 homosexual) from a comparable socioeconomic stratum were processed by using optimized automated voxel-based morphometry within multiple linear regression analyses. Compared to the homosexual and heterosexual control subjects, pedophiles showed decreased gray matter volume in the ventral striatum (also extending into the nucl. accumbens), the orbitofrontal cortex and the cerebellum. These observations further indicate an association between frontostriatal morphometric abnormalities and pedophilia. In this respect these findings may support the hypothesis that there is a shared etiopathological mechanism in all obsessive-compulsive spectrum disorders.

Hypersexuality in inpatient children and adolescents: recognition, differential diagnosis, and evaluation

We describe a 17-year-old girl with hypersexuality resulting from virilization, the latter a consequence of polycystic ovary syndrome, and we review the literature pertinent to hypersexuality in children and adults. Inappropriate sexual behavior (a common cause of disruption among children who are hospitalized for psychiatric disorders) may be caused either by hypersexuality or by simply ill-regulated behavior: a definition of hypersexuality is proposed that can be applied at the bedside (namely, sexual behaviors or fantasies that have abruptly increased in frequency by comparison with a previous baseline, are of sufficient excessiveness to disrupt expected or usual social, academic, or occupational functioning, or constitute a source of distress), so that this distinction can be made promptly, and we present a differential diagnosis for hypersexuality to direct its evaluation. Virilization does not seem to be a common cause of hypersexuality in children and adolescents, but it should not be overlooked when it does exist. The differential diagnosis of hypersexuality in adults, which we present for comparison, is much larger than it is in children.

Review of medical reports on pedophilia

The present report is a review of all 554 papers published on Medline on pedophilia. The first discussion is the history of the disorder from ancient Greece to the present time, especially the influence of the liberal country of the Netherlands, the North American Man-Boy Love Association, and the sexual crisis in the Catholic Church. One important question is the relationship between homosexual pedophilia and adult homosexuality. Evidence for and against this relationship is presented. Next discussed are the characteristics of the victim and the long lasting serious effects of sexual abuse. Laboratory correlations are included, especially phallometric tests in order to objectively measure the physical responses to sexual stimuli. Electrophysiological and radiographic tests are also mentioned, including electroencephalography, computed tomography, magnetic resonance imaging, and positron emission tomography scans. An important section is the characterization of pedophiles with emphasis on their frequent previous sexual abuse, their past, their present, and their anticipated future. The final topic is treatment of this disorder with surgery, medication, behavioral therapy and the combination of medication and behavioral therapy.

Neurological control of human sexual behaviour: insights from lesion studies

We review the human literature examining the effects of neurological insult on human sexual behaviour. We provide a synthesis of the findings to date, and identify key brain regions associated with specific aspects of human sexual behaviour. These include subcortical and cortical regions, with the mesial temporal lobe and the amygdala in particular being a crucial structure in the mediation of human sexual drive.

Pedophilia is linked to reduced activation in hypothalamus and lateral prefrontal cortex during visual erotic stimulation

BACKGROUND

Although pedophilia is of high public concern, little is known about underlying neural mechanisms. Although pedophilic patients are sexually attracted to prepubescent children, they show no sexual interest toward adults. This study aimed to investigate the neural correlates of deficits of sexual and emotional arousal in pedophiles.

METHODS

Thirteen pedophilic patients and 14 healthy control subjects were tested for differential neural activity during visual stimulation with emotional and erotic pictures with functional magnetic resonance imaging.

RESULTS

Regions showing differential activations during the erotic condition comprised the hypothalamus, the periaqueductal gray, and dorsolateral prefrontal cortex, the latter correlating with a clinical measure. Alterations of emotional processing concerned the amygdala-hippocampus and dorsomedial prefrontal cortex.

CONCLUSIONS

Hypothesized regions relevant for processing of erotic stimuli in healthy individuals showed reduced activations during visual erotic stimulation in pedophilic patients. This suggests an impaired recruitment of key structures that might contribute to an altered sexual interest of these patients toward adults.

What frontotemporal dementia reveals about the neurobiological basis of morality

There is evidence that moral behavior is a product of evolution and an innate aspect of the human brain. Functional magnetic resonance studies in normals, investigations of psychopaths, and acquired sociopathy from brain lesions suggest a neurobiology of moral behavior. Reports of sociopathy among patients with frontotemporal dementia (FTD) have provided a further opportunity to clarify the neurobiology of morality. They confirm a morality network that includes the ventromedial frontal cortex, the orbitofrontal cortex, and the amygdalae. The right ventromedial region is critical for the emotional tagging of moral situations, the orbitofrontal cortex responds to social cues and mitigates impulsive reactions, and the amygdalae are necessary for threat detection and moral learning. Alterations in moral behavior in FTD may result from a loss of the emotional label of moral dilemmas, coupled with disinhibited responses. More investigations are needed to fully understand how the brain mediates moral or ethical behavior.

An investigation of moral judgement in frontotemporal dementia

OBJECTIVE

To investigate the basis of disturbed moral judgment in patients with frontotemporal dementia (FTD).

BACKGROUND

FTD is characterized by difficulty in modulating social behavior. Patients lack social propriety and may perform sociopathic acts. In addition, FTD patients often lack empathy for others. These findings suggest alterations in the nature of morality in patients with FTD.

METHOD

We administered an inventory of moral knowledge and two moral dilemmas to 26 patients with the frontal variant of FTD, 26 patients with Alzheimer disease (AD), and 26 normal control subjects. The FTD patients met Consensus Criteria for FTD and had corroborative frontal abnormalities on functional neuroimaging. The FTD and AD patients were comparably impaired on dementia measures.

RESULTS

All these groups showed the retention of knowledge for moral behavior and the ability to make "impersonal" moral judgments. In contrast, the FTD patients were impaired in their ability to make immediate, emotionally based moral judgments compared with the patients with AD and the normal control subjects.

CONCLUSIONS

These findings are consistent with an attenuation of the automatic emotional identification with others that is part of the innate moral sense. Such a disturbance may result from neurodegenerative disease affecting the ventromedial frontal cortex.

Opinion: the neural basis of human moral cognition

Moral cognitive neuroscience is an emerging field of research that focuses on the neural basis of uniquely human forms of social cognition and behaviour. Recent functional imaging and clinical evidence indicates that a remarkably consistent network of brain regions is involved in moral cognition. These findings are fostering new interpretations of social behavioural impairments in patients with brain dysfunction, and require new approaches to enable us to understand the complex links between individuals and society. Here, we propose a cognitive neuroscience view of how cultural and context-dependent knowledge, semantic social knowledge and motivational states can be integrated to explain complex aspects of human moral cognition.

Acquired sociopathy and frontotemporal dementia

BACKGROUND

It is not understood why some patients with frontotemporal dementia (FTD) manifest sociopathic behavior.

OBJECTIVE

To examine the prevalence and characteristics of sociopathic behavior in FTD patients as compared to those with Alzheimer's disease (AD).

METHODS AND PARTICIPANTS

We surveyed a group of FTD patients and a group of AD patients for sociopathic behavior, evaluated the characteristics surrounding their acts, and compared the groups on neuropsychological tests and functional neuroimaging. Twenty-eight outpatients with FTD (15 men, 13 women; 61.9+/-7.1 years; Mini-Mental State Examination score 23.6+/-8.1) were compared with 28 patients with clinically probable AD (13 men, 15 women; 66.1+/-9.2 years; Mini-Mental State Examination score 21.3 +/- 5.3). Main outcome measures included: (a) the prevalence of sociopathic acts; (b) a structured interview; (c) neuropsychological tests including the Frontal Assessment Battery, and (d) clinically obtained positron emission tomography or single photon emission tomography scans.

RESULTS

Sixteen (57%) of the FTD patients had sociopathic behavior compared to two (7%) of the AD patients (chi(2)=13.84, p<0.001). Sociopathic acts among FTD patients included unsolicited sexual acts, traffic violations, physical assaults, and other unacceptable behaviors. On interview, the FTD patients with sociopathic acts were aware of their behavior and knew that it was wrong but could not prevent themselves from acting impulsively. They claimed subsequent remorse, but they did not act on it or show concern for the consequences. Among FTD patients with sociopathy, neuropsychological assessment showed impaired motor inhibition, and functional neuroimaging showed right frontotemporal involvement.

CONCLUSION

The results suggest that sociopathy in FTD results from a combination of diminished emotional concern for the consequences of their acts and disinhibition consequent to right frontotemporal dysfunction. In many jurisdictions, FTD patients with sociopathy would not pass legal criteria for 'not guilty by reason of insanity'.

Inappropriate sexual behaviors in dementia

Dementias are the most common type of neurodegenerative disorder. Behavioral disturbances are seen in more than 80% of patients suffering from these disorders. Although sexually inappropriate behaviors are not as common as some of the other behaviors seen in dementia, they can cause immense distress to all those who are affected. There are no randomized trials for the treatment of these behaviors, but the available data suggest efficacy for some commonly used treatment modalities. In this review, we systematically discuss various aspects of these behaviors and available treatments.

Handedness in pedophilia and hebephilia

A sample of 404 adult men underwent assessment following illegal or clinically significant sexual behaviors or interests. Patients' assessments included: administration of a modified version of the Edinburgh Handedness Inventory; recording of patients' phallometric (penile) responses to erotic stimuli depicting adults, pubescent children, and prepubescent children of both sexes; and a tabulation of the numbers of patients' victims, ages 0-11, 12-14, 15-16, and 17 and older, of both sexes. In Study 1, patients' right-handedness scores correlated negatively with their phallometric responses to stimuli depicting prepubescent children and positively with stimuli depicting adults, replicating the pattern described in a previous report (Cantor et al., 2004). Unlike the previous study, however, patients' handedness scores did not significantly correlate with their numbers of prepubescent victims. To explore this discrepancy, Study 2 combined the patients from this replication sample with those in the previously reported sample, categorizing them by the sex and age group of greatest erotic interest to them. The odds of non-right-handedness in men offending predominantly against prepubescent children were approximately two-fold higher than that in men offending predominantly against adults and three-fold higher after eliminating those men with intrafamilial (i.e., incest) offenses. Handedness differences between men erotically interested in males versus females were not statistically significant. These results indicate that the rates of non-right-handedness in pedophilia are much larger than previously suggested and are comparable to the rates observed in pervasive developmental disorders, such as autism, suggesting a neurological component to the development of pedophilia and hebephilia.

Pedophilia: neuropsychological evidence encouraging a brain network perspective

Although the vast majority of current pathogenetic theories support a neurobiological understanding of psychiatric disorders, the brain functional correlates of pedophilia are largely unknown. Based on prior behavior genetics research on human sexual orientation and phenomenology as well as the phenotypical intersection of pedophilia with other psychiatric spectrum disorders, we hypothesize the involvement of striato-thalamo-cortical processing loops in the formation of pedophilic urges and behaviors. Data from a current neuropsychological pilot study in four pedophiles encourage our brain functional perspective. As deduced from the network model, all four patients exhibited pronounced and circumscribed deficits in cognitive domains mediated by striato-thalamically controlled areas of the frontal cortex. All patients were especially impaired in neuropsychological functions associated with the prefrontal and motor processing loops (e.g., response inhibition, working memory and cognitive flexibility), with a performance level located up to five standard deviations below the normative data. Contrary to this, neuropsychological performances in cognitive domains without a comparable high frontal loading were in all participants unobtrusive. In future, studying gene by environment interactions in combination with functional neuroimaging and neuropsychological assessment is promising to elucidate the pathophysiological relationship of psychiatric disorders that are characterized by inadequate urges and poor behavioral inhibition.

Hypersexuality and dysexecutive syndrome after a thalamic infarct

Hypersexuality can result from insults to several neuroanatomical structures that regulate sexual behavior. A case is presented of an adult male with a thalamic infarct resulting in a paramedian thalamic syndrome, consisting of hypersomnolence, confabulatory anterograde amnesia (including reduplicative paramnesia), vertical gaze deficits, and hypophonic speech. A dysexecutive syndrome also manifested, consisting of social disinhibition, apathy, witzelsucht, motor inhibition deficits, and environmental dependence. Hypersexuality uncharacteristic of his premorbid behavior was evident in instances of exhibitionism, public masturbation, and verbal sexual obscenities. In contrast to the few previous reports of hypersexuality following thalamic infarct, this case neither involved mania nor hemichorea. The relevance of the mediodorsal thalamic nucleus in limbic and prefrontal circuits is discussed.

Alterations of the Sense of “Humanness” in Right Hemisphere Predominant Frontotemporal Dementia Patients

OBJECTIVE

To evaluate the sense of "humanness" in frontotemporal dementia (FTD) patients with right hemispheric involvement.

BACKGROUND

Early in the course, FTD is often asymmetric, and those with predominant right frontotemporal disease have disproportionate disturbances in social behavior and empathy. A disruption in a sense of humanness may underlie these behavioral disturbances.

METHOD

Sixteen patients with asymmetric FTD on functional neuroimaging underwent recognition tests of facial masking, human-animal morphing, and facial distortion. Additional tests evaluated facial discrimination and the recognition of famous faces, facial emotions, and animate-inanimate differences.

RESULTS

On the distorted and morphed face tasks, 8 FTD patients with predominant right hemisphere involvement were significantly more likely to call morphed and distorted faces "human" as compared with both 8 FTD patients with predominant left hemisphere involvement and normal controls. The FTD groups did not differ on thresholds for recognizing masked faces or on other face recognition measures.

CONCLUSIONS

In FTD, right hemispheric involvement may alter the threshold for judging someone as human independent of the recognition of faces or facial affect. These results suggest that a specific sense of humanness facilitates a person recognition network in the right frontotemporal region of the brain.

Sex hormones, neurotransmitters, and psychopharmacological treatments in men with paraphilic disorders

Paraphilic disorders are psychiatric syndromes primarily characterized by deviant sexual thoughts, cravings, urges, and/or behaviors. Paraphilic men may engage in inappropriate sexual behaviors when cravings for socially unacceptable sexual acts become overpowering. These often chronic disorders may not only cause emotional distress and social embarrassment to the afflicted patient but also to the targets of their paraphilic focus. The primary objective of this article is to examine and review data on the efficacy and tolerability of the testosterone-lowering agents medroxprogesterone acetate, cyproterone acetate, and leuprolide acetate. The secondary goal is to review data on less conventional and more innovative pharmacological treatments, particularly the serotonin-specific reuptake inhibitors.

Neuroimaging of sexual arousal: research and clinical utility

The treatment of sexual dysfunction or deviancy requires an understanding of the underlying neural substrates. Neuroimaging techniques offer insight into brain regions involved in sexual arousal and inhibition. The development of robust paradigms has implications for the assessment and treatment of sexual disorder in men and women.

Goals in symptomatic pharmacologic management of frontotemporal lobar degeneration

This review ofpharmacotherapyforfrontotemporal lobar degeneration describes the chemical rationale for agents used and reports observed responses to psychotropic medications. Paroxetine addressed anxiety and repetitive, ritualistic behaviors. Depression was resistant to treatment. Valproic acid and quetiapine calmed agitated subjects without exacerbating Parkinsonism. Donepezil has not emerged as a beneficial medication for this group of subjects. Behavioral disturbances can be alleviatedpharmacologically, but further research might determine guidelines for management of this non-Alzheimer's dementia syndrome that could decrease the frequency of adverse drug events.

Hippocampal pathology in two mentally ill paraphiliacs

Paraphilias or disorders of sexual behavior have markedly increased in prevalence during the last decade. Until now no published neuropathological studies on paraphilia have appeared in the medical literature. A computerized search was done on all available medical and autopsy records of a large urban hospital (St. Elizabeths Hospital, Washington, DC) for any mention of deviant sexual behavior. Cases were then reviewed for presence of a history consistent with DSM-IV diagnoses of paraphilia. Two such cases were identified. Neuropathological examination in both cases revealed simple cell atrophy of pyramidal cells confined to different hippocampal subfields. Reactive astrocytosis was present in the outer strata of the affected regions. The pathological changes in the hippocampus resemble those reported after persistent stress or long-term chronic glucocorticoid administration. The accompanying astrocytosis indicates a reactive, ongoing process. The findings suggest new therapeutic interventions in the treatment of paraphilia.

Treatment of compulsive sexual behaviour with naltrexone and serotonin reuptake inhibitors: two case studies

Although there is no universally accepted definition of compulsive sexual behaviour (CSB), the term is generally used to indicate excessive sexual behaviour or sexual cognitions that lead to subjective distress, social or occupational impairment, or legal and financial consequences. Similar to impulse control disorders, CSB is characterized by a failure to resist the impulse for sex. Opioid antagonists have been effective in treating urge-driven disorders, such as pathological gambling disorder, alcoholism, borderline personality disorder with self-injurious behaviour, cocaine abuse, mental retardation with self-injurious behaviour and eating disorders. Based upon the efficacy of opioid antagonists in treating disorders associated with urges, we hypothesized that naltrexone would reduce both the urges associated with CSB and therefore reduce the sexual behaviour. We present two case reports of individuals with CSB treated successfully with naltrexone, a novel treatment for CSB. In both cases, symptoms dramatically decreased and psychosocial functioning improved with the use of naltrexone. Although more research is needed to determine the mechanism that leads to the excessive sexual behaviour in individuals with CSB, the present case reports suggest that naltrexone may be effective in treating some cases of CSB.