Paraphilic Coercive Disorder in the DSM: the right diagnosis for the right reasons

Other Specified Paraphilic Disorder: Patterns of Use in Sexually Violent Predator Evaluations

"Sexually violent predator" (SVP) legislation requires, in part, that an individual has a mental abnormality that causes difficulty in controlling sexual behavior. Previous research has found paraphilia not otherwise specified (NOS) as one of the most prevalent diagnoses proffered in SVP evaluations. However, the fifth edition of the Diagnostic and Statistical Manual (DSM-5) modified paraphilia NOS diagnosis in two ways. First, this diagnosis was divided into two new diagnostic categories: other specified paraphilic disorder (OSPD) and unspecified paraphilic disorder. Second, OSPD required an added specifier to indicate the individual's source of sexual arousal. To date, no study has systematically explored how the revision to paraphilia NOS has affected diagnoses within SVP evaluations. The current study explored the frequency and diagnostic reliability of paraphilic disorders in a sample of 190 adult men evaluated for SVP civil commitment using the DSM-5. Results indicated that OSPD was the second most common paraphilic disorder, next to pedophilic disorder. However, there was poor to fair agreement (kappa = 0.21, p < .01) between independent evaluators in providing this diagnosis. Additionally, the two most common OSPD specifiers were non-consent and hebephilia, despite recent debate and rejection of these constructs from the DSM-5. While these constructs were the most prevalent, the specifiers contained quite varied terminology, suggesting vague diagnostic tendencies within these evaluations. Given that the presence of a mental abnormality is the cornerstone to the constitutionality of SVP commitment, diagnostic practices should be based in reliable and valid techniques.

Sexual Sadism Disorder and Coercive Paraphilic Disorder: A Scoping Review

BACKGROUND

Valid and reliable diagnostic criteria are essential in forensic psychiatry and sexual medicine due to the severe implications of potential misdiagnoses. One challenge in this field is the poor operationalization of sexual sadism disorder (SSD) and coercive paraphilic disorder (CP+) definitions.

AIM

The aim of this scoping literature review is to provide a comprehensive overview of the key conceptual differences between SSD and CP+, as well as consider pragmatic and clinically useful approaches to their diagnostic formulation.

METHODS

Arksey and O'Malley's methodological framework was followed. A literature search of Medline, PsychInfo, Web of Science, and Cumulative Index to Nursing and Allied Health Literature electronic databases was conducted. Publications in English describing the construct and/or operational definition of SSD or CP+ were included. Full-text studies were reviewed by 2 authors and data was charted and synthesized qualitatively.

RESULTS

The initial search provided 1,271 records, after which 120 full-text papers were considered for eligibility and 48 studies were ultimately included. The most common sources of definitions for SSD and CP+ were the Diagnostic and Statistical Manual of Mental Disorders (n = 53) and the International Classification of Disease (n = 12). There was more variation of terms used for CP+ than SSD. Both CP+ and SSD are critiqued by reviewed literature for having low validity, reliability, and consistency, as well as being conflated with sexual crime. SSD is better described due to having diagnostic criteria and validated diagnostic tools.

CLINICAL IMPLICATIONS

Currently, clinicians rely mostly on the DSM to diagnose SSD or CP+. As applications of SSD and CP+ definitions vary, interpretations may not be generalizable between clinicians. Furthermore, specific diagnoses may be practically unhelpful and unreliable. It may therefore be beneficial for treatment to be determined by risk of harm. In addition to these concerns, the stigma associated with SSD and CP+ may also impact treatment.

STRENGTHS & LIMITATIONS

Strengths of this study include duplicate review and charting to increase methodological rigor, transparent reporting to minimize publication bias, and encompassing a comprehensive scope. Limitations include the weaknesses of low strength of reviewed literature and risk of publication bias.

CONCLUSION

Despite their significant implications, the definitions of SSD and CP+ are inconsistent and lack reliability. Future research is necessary to develop stronger diagnostic criteria and tools. Liu A, Zhang E, Leroux EJ et al. Sexual Sadism Disorder and Coercive Paraphilic Disorder: A Scoping Review. J Sex Med 2022;000:1-11.

What is a mental disorder? An exemplar-focused approach

The question of 'what is a mental disorder?' is central to the philosophy of psychiatry, and has crucial practical implications for psychiatric nosology. Rather than approaching the problem in terms of abstractions, we review a series of exemplars - real-world examples of problematic cases that emerged during work on and immediately after DSM-5, with the aim of developing practical guidelines for addressing future proposals. We consider cases where (1) there is harm but no clear dysfunction, (2) there is dysfunction but no clear harm, and (3) there is possible dysfunction and/or harm, but this is controversial for various reasons. We found no specific criteria to determine whether future proposals for new entities should be accepted or rejected; any such proposal will need to be assessed on its particular merits, using practical judgment. Nevertheless, several suggestions for the field emerged. First, while harm is useful for defining mental disorder, some proposed entities may require careful consideration of individual v. societal harm, as well as of societal accommodation. Second, while dysfunction is useful for defining mental disorder, the field would benefit from more sharply defined indicators of dysfunction. Third, it would be useful to incorporate evidence of diagnostic validity and clinical utility into the definition of mental disorder, and to further clarify the type and extent of data needed to support such judgments.

The admissibility of other specified paraphilic disorder (non-consent) in sexually violent predator proceedings

Following the advent of sexually violent predator (SVP) legislation in the early 1990s, forensic evaluators began to apply diagnostic labels related to a paraphilic interest in rape as a mental condition predisposing individuals convicted of sexual offenses to recidivate. The most recent iteration of the concept, other specified paraphilic disorder (non-consent) (OSPD (non-consent)), is a commonly utilized diagnostic entity in SVP proceedings. Research on paraphilic interest in coercive sex has failed to define a valid methodology or set of criteria to make a diagnosis of OSPD (non-consent) and has repeatedly demonstrated that the diagnostic construct has poor interrater reliability. The state of the science pertaining to OSPD (non-consent) thus raises serious concerns regarding its admissibility in SVP proceedings. Indeed, there are recent cases in which courts have deemed it inadmissible. The forensic expert involved in SVP proceedings should understand admissibility concerns related to OSPD (non-consent) and how to address them in court.

State of the Art Treatment Options for Actual and Potential Sexual Offenders and New Prevention Strategies

Sexual violence is a significant and devastating issue for men and women throughout the world. Its consequences are not only disastrous for victims of sexual violence but are also extremely costly (estimated cost of $41,000 per rape) for society. Successful treatment of sexual offenders is therefore an important goal for society as well as for victims and offenders themselves. Over the years, multiple treatment approaches for sex offenders have been developed. Treatment programs range from the risk-need-responsivity (RNR) model, which focuses on providing tailored treatment for high-risk and low-risk offenders, to psychodynamic models. This article presents an overview for clinicians of state-of-the-art offender treatment, describing the most common treatment approaches, in particular the RNR model, cognitive-behavioral programs (relapse prevention programs, sexual offender treatment programs), psychodynamic approaches (transference-focused psychotherapy, mentalization-based therapy), the Good Lives Model, as well as pharmacological options. In addition, it provides an evaluation of the various treatment programs. However, given the fact that most acts of sexual violence will never be reported to the police, the question arises if treating convicted perpetrators is enough. Do we need rather-in terms of preventive work-a program for potential sexual offenders and men with delinquent sexual fantasies? Given the prevalence of sexual violence and its impact on victims, society, and the medical community, it would be remiss not to try to reach potential/unconvicted perpetrators. This article offers novel ideas and a project the goal of which is to prevent sexual offenses against women by introducing the "I CAN CHANGE" program from Hannover Medical School.

Sexual disorders in DSM-5 and ICD-11: a conceptual framework

PURPOSE OF REVIEW

The nature and classification of sexual disorders has been a focus during work on the development of DSM-5 and ICD-11. This article proposes different conceptual approaches to the sexual disorders, including classical, critical and integrative positions. Disorders associated with sexual orientation, gender dysphoria/incongruence and paraphilias/paraphilic disorders are discussed from each of these positions.

RECENT FINDINGS

A range of conventional and nonconventional consensual sexual behaviours are prevalent but not necessarily indicative of a mental disorder; there is little diagnostic validity or clinical utility for including these in the nosology. When such behaviours are clinically excessive and associated with distress or impairment, however, a disorder may be present. Debate surrounds the medicalization of some sexual behaviours that are criminal in nature.

SUMMARY

The classification of sexual behaviour as disordered is necessarily theory-dependent and value-laden. Nevertheless, reasoned debate about the relevant data and values is possible, and will hopefully further improve the diagnostic validity and clinical utility of psychiatric nosology.

Psychoanalytic principles as a heuristic framework to bridge the gap between psychology and the law in SVP evaluations: Assessing emotional and volitional impairment

The legal concepts of emotional and volitional impairment in SVP evaluations are vague and ill-defined. This article reviews the legal terms of emotional and volitional impairment as they have been contemplated in extant SVP statutes, SVP case law, logical constructions, and limited empirical studies. To bridge the gap between psychiatry and the law, a broad, theory-based heuristic framework is furnished for understanding emotional and volitional impairment at a deep psychological (and intra-psychic) level. Specifically discussed are the concepts of transference, repetition compulsion, fixation, cathexis, regression, identification with the aggressor, and the object-relations and self-psychology concepts related to a loss of possession of the self.

The eyeball killer: serial killings with postmortem globe enucleation

Although serial killings are relatively rare, they can be the cause of a great deal of anxiety while the killer remains at-large. Despite the fact that the motivations for serial killings are typically quite complex, the psychological analysis of a serial killer can provide valuable insight into how and why certain individuals become serial killers. Such knowledge may be instrumental in preventing future serial killings or in solving ongoing cases. In certain serial killings, the various incidents have a variety of similar features. Identification of similarities between separate homicidal incidents is necessary to recognize that a serial killer may be actively killing. In this report, the authors present a group of serial killings involving three prostitutes who were shot to death over a 3-month period. Scene and autopsy findings, including the unusual finding of postmortem enucleation of the eyes, led investigators to recognize the serial nature of the homicides.

What is a mental disorder? A perspective from cognitive-affective science

Defining disease and disorder remains a key conceptual question in philosophy of medicine and psychiatry, and is currently a very practical matter for psychiatric nosology, given the new Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and the upcoming International Classification of Diseases, 11th Revision. There have been advances in the cognitive-affective science of human categorization, and it is timely to consider implications for our understanding of the category of psychiatric disorder. The category of mental disorder has graded boundaries, and conditions within this category can be conceptualized using MEDICAL or MORAL metaphors. One key set of constructs used in MEDICAL metaphors relates to the notion of dysfunction, and it may, in turn, be useful to conceptualize such dysfunction in evolutionary terms. For typical disorders, it is relatively easy to agree that dysfunction is present. However, for atypical disorders, there may be considerable debate about the presence and extent of dysfunction. Rational arguments can be brought to bear to help decide whether particular entities should be included in our nosologies, and, if so, what their boundaries should be. However, it is appropriate that there should be ongoing debate on diagnostic validity, clinical utility, and other relevant facts and values, for cases that are difficult to decide. The perspective here can be illustrated using many nosological debates within the anxiety disorders and the obsessive-compulsive and related disorders, including the question of delineating normal from abnormal anxiety, of deciding whether anxiety is psychiatric or medical, and the debate about the optimal meta-structure for anxiety disorders.

Pornography, sex crime, and paraphilia

The current paper reviews research findings concerning the association of pornography with sexual violence and paraphilic interests. Little clarity concerning the causal impact of pornography on sexual aggression or child-oriented sexual behavior has been achieved in the scientific literature. Laboratory experimentation demonstrates that violent pornography may contribute to antiwoman aggression, but the artificiality and constraints of the experimental setting severely limit generalization of these findings to real-world situations, and observational studies in natural settings consistently find no association or an inverse association of pornography with sexual aggression. In addition, although pedophiles often use child pornography, the causal impact of child pornography on child sexual offending is not conclusive. The current analysis considers the confluence of predisposing factors and pornography use as issues requiring clinical judgment in the reduction of sexual aggression and management of paraphilic interest in children.

Comparing sexual offenders at the Regional Treatment Centre (Ontario) and the Florida Civil Commitment Center

Sexual offender civil commitment (SOCC) continues to be a popular means of managing risk to the community in many U.S. jurisdictions. Most SOCC states report few releases, due in large part to the reluctance of the courts to release sexually violent persons/predators (SVPs). Contemporary risk prediction methods require suitable comparison groups, in addition to knowledge of postrelease behavior. Low SVP release rates makes production of local base rates difficult. This article compares descriptive statistics on two populations of sexual offenders: (a) participants in high-intensity treatment at the Regional Treatment Centre (RTC), a secure, prison-based treatment facility in Canada, and (b) SVP residents of the Florida Civil Commitment Center. Results show that these two samples are virtually identical. These groups are best described as "preselected for high risk/need," according to Static-99R normative sample research. It is suggested that reoffense rates of released RTC participants may serve as a comparison group for U.S. SVPs. Given current release practices associated with U.S. SOCC, these findings are of prospective value to clinicians, researchers, policy makers, and triers of fact.

Pedophilia: a diagnosis in search of a disorder

This article presents a critical review of the recent controversies concerning the diagnosis of pedophilia in the context of the preparation of the fifth edition of the DSM. The analysis focuses basically on the relationship between pedophilia and the current DSM-IV-TR's definition of mental disorder. Scholars appear not to share numerous basic assumptions ranging from their underlying ideas about what constitutes a mental disorder to the role of psychiatry in modern society, including irreconcilable theories about human sexuality, which interfere with reaching any kind of a consensus as to what the psychiatric status of pedophilia should be. It is questioned if the diagnosis of pedophilia contained in the DSM is more forensic than therapeutic, focusing rather on the dangers inherent in the condition of pedophilia (dangerous dysfunction) than on its negative effects for the subject (harmful dysfunction). The apparent necessity of the diagnosis of pedophilia in the DSM is supported, but the basis for this diagnosis is uncertain.