Examining the scope of questionable diagnostic reliability in Sexually Violent Predator (SVP) evaluations

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.

The Development, Content Validation, and Pilot Testing of the Paraphilic Interests and Disorders Scale

The prevalence rates of paraphilic interests and disorders in the general population have been understudied, in large part due to the lack of a standardized assessment measure. As a result, the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 provides little information regarding the prevalence of paraphilic disorders. The present study involved the development of a self-report measure, Paraphilic Interests and Disorders Scale (PIDS), that can be used to assess for the eight paraphilic interests/disorders in the DSM-5 for use with general population samples. Study 1 established the content validity of the PIDS using feedback from 22 experts in the field, and recommendations from these experts were utilized to modify the measure. In Study 2, the PIDS was piloted on 100 individuals in the general population, which supported the feasibility of implementation and its limited-efficacy. While the PIDS requires further psychometric support, the current research suggests the PIDS is a promising tool to gather self-report, population-based data on DSM-5 paraphilic interests and disorders.

California Sexually Violent Predator (SVP) Evaluations in the Field: Static-99R and Diagnostic Field Reliability

Tests and diagnoses used in sexually violent predator (SVP) evaluations must be reliable, as reliability is foundational to validity. The current study contained a stratified sample of evaluations of 395 individuals referred as potential SVPs between 2012 and 2017. Each individual was initially evaluated by at least two experts. The sample included three groups: individuals not meeting SVP criteria (N = 200, or 400 evaluations), individuals meeting SVP criteria (N = 95, with 190 evaluations), and individuals where evaluators disagreed (N = 100, with 200 evaluations). The sample also included 200 subsequent independent evaluations on these "disagree" cases. Static-99R score intraclass coefficient (ICC) interrater reliability was good to excellent within each group and overall. Evaluators scored the Static-99R within one point of each other 87% of the time. Cohen's kappa diagnostic agreement for Pedophilic Disorder was substantial. ASPD and substance abuse kappa were in the "fair" range, while OSPD diagnoses in the positive group were at the "moderate" level of agreement. Ethnic differences in diagnoses were consistent with other studies, with equivalent Static-99R ICC values across ethnic groups. There were no significant differences between state civil servants versus contracted experts in Static-99R ratings or final determinations. The results suggest that Static-99R scores have acceptable reliability in these evaluations, and Pedophilic Disorder (the most common paraphilic disorder in our study) and OSPD can be reliably diagnosed. We discuss limitations of the study, as well as the need for care in high-stakes evaluations given the imperfect reliability of psychological measurements.

The imperfect fit: Fetal alcohol spectrum disorder as the basis to commit individuals involuntarily as sexually violent predators/persons

Prenatal alcohol exposure produces a broad range of primary disabilities that lead to adverse life course outcomes in children raised in adverse environments. Inappropriate sexual behaviors are a commonly occurring secondary disability, with a large minority of individuals with fetal alcohol spectrum disorder (FASD) displaying sexual aggression. Adults with FASD who commit repeated criminal sexual acts may be subject to legal proceedings for indefinite involuntary civil confinement as sexually violent predators/persons (SVP) in certain jurisdictions in the United States. Studies about the diagnostic practices among psychologists and psychiatrists retained by states to evaluate individuals as SVP do not recognize FASD as a mental disorder, despite the likelihood that hundreds of individuals petitioned for involuntary commitment suffer from FASD. Establishing an FASD diagnosis may provide exculpatory evidence to refute a government petition that an individual suffers from a mental condition that affects emotional or volitional capacity by predisposing the person to committing criminal sexual behavior. This article provides a framework for identifying, assessing, and deciding whether individuals with the FASD diagnosis suffer from the legally defined mental disorder that is necessary to indefinitely confine individuals as SVP.

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.

Sexually violent predator risk assessments with the violence risk appraisal guide-revised: A shaky practice

Twenty-two jurisdictions in the United States permit the involuntary civil confinement of sexual offenders upon expiration of their criminal sentence and, if committed, these individuals face possible lifetime commitment. One of the legal requirements that psychologists must address in sexually violent predator evaluations is the likelihood that an individual will engage in dangerous sexual behavior and consideration of the probabilities for sexual recidivism contained in actuarial experience tables best address this inquiry. Clinicians find it increasingly difficult to affirm the likelihood threshold in the face of decreasing base rates and score-wise probability estimates for sexual recidivism reported in contemporary actuarial experience tables. The Violence Risk Appraisal Guide-Revised (VRAG-R) has been promoted to assess sexually violent predators because it has been presented as a more accurate predictor of sexual recidivism and the results more likely satisfy the legal standard of sexual dangerousness. This article conducts an in-depth analysis of the predictive and psychometric properties of the VRAG-R that are most relevant to the fit of the VRAG-R when addressing the sexual dangerousness standard proscribed by SVP laws. Recommendations for future research are offered to improve the fit of the VRAG-R to the legal inquiry of sexual dangerousness and implications for using the current iteration of the VRAG-R in forensic practice are discussed.

Personality Assessment Inventory Scores as Predictors of Evaluation Referrals, Evaluator Opinions, and Commitment Decisions in Sexually Violent Predator Cases

We used data from more than 1,500 offenders to examine the association between Personality Assessment Inventory (PAI; Morey, 1991 ) scores and progress through the sexually violent predator (SVP) screening, evaluation, and commitment process. There was no clear association between PAI scores and referrals for full evaluations, but PAI scores were small to moderate predictors of evaluator opinions and diagnoses among offenders who underwent full evaluations. Higher Antisocial Features (ANT) scores were associated with diagnoses of antisocial personality disorder, but this association was moderated by offender response style. ANT scores were more strongly associated with antisocial personality disorder diagnoses among those responding defensively (d = .71) than among those responding openly (d = .48). The mean ANT score among defensive responders diagnosed with antisocial personality disorder was about 55T, suggesting that even moderate ANT scale elevations could indicate a clinically significant level of antisocial traits among some offenders.

Cognitional Impairment: Is There a Role for Cognitive Assessment in the Treatment of Individuals Civilly Committed Pursuant to the Sexually Violent Predator Act?

Sexually Violent Predator statutes allow the involuntary treatment of individuals who are found to pose a threat to public safety. Most sex offender treatment programs rely on cognitive interventions to reduce the risk of recidivism. The purpose of this study was to examine (a) whether individuals with paraphilia diagnoses have cognitive deficits compared with the general population; (b) whether individuals diagnosed with pedophilia differed on cognitive performance when compared with individuals diagnosed with paraphilia not otherwise specified (NOS), nonconsent; and (c) whether individuals with paraphilia plus antisocial personality disorder (ASPD) differed in cognitive performance when compared with individuals with a paraphilia diagnosis only. The sample consisted of 170 males (M age = 50.21; SD = 10.22) diagnosed with pedophilia or paraphilia NOS, nonconsent, who were detained or civilly committed to a forensic psychiatric hospital. Assessments included Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), Wechsler Abbreviated Scale of Intelligence (WASI), and Wide Range Achievement Test 4 (WRAT4). Individuals diagnosed with pedophilia and paraphilia NOS, nonconsent, obtained lower scores than matched controls based on the RBANS Immediate Memory, Visuospatial/Constructional, Delayed Memory indices and Total Score. In comparison with individuals with paraphilia NOS, nonconsent, those with pedophilia diagnosis had lower scores on the RBANS Delayed Memory. Individuals diagnosed with a paraphilia disorder combined with ASPD demonstrated trends toward lower IQ scores than those with a paraphilia diagnosis only. Treatment programs can improve their chance of success by assessment of cognitive processes, and offer therapy in a style that is consistent with the cognitive abilities of their clients.

Assessment methods and management of hypersexuality and paraphilic disorders

PURPOSE OF REVIEW

The recent implementation of the Diagnostic and Statistical Manual of Mental Disorders, fifth edition introduced some important changes in the conceptualization of hypersexuality and paraphilic disorders. The destigmatization of nonnormative sexual behaviors could be viewed as positive, However, other changes are more controversial. In order to stimulate new research approaches and provide mental healthcare providers with appropriate treatment regimes, validated assessment and treatment methods are needed. The purpose of this article is to review the studies published between January 2013 and July 2014 that aimed at assessing the psychometric properties of the currently applied assessment instruments and treatment approaches for hypersexuality and hypersexual disorders or paraphilias and paraphilic disorder.

RECENT FINDINGS

Currently existing instruments can validly assess hypersexual behaviors in different populations (e.g. college students, gay and bisexual men, and patients with neurodegenerative disorders) and cultural backgrounds (e.g. Germany, Spain, and USA). Concerning the assessment of paraphilias, it was shown that combining different assessment methods show a better performance in distinguishing between patients with paraphilias and control groups. In addition to psychotherapeutic treatment, pharmacological agents aiming at a reduction of serum testosterone levels are used for hypersexual behaviors as well as paraphilic disorders.

SUMMARY

Although the currently applied assessment and treatment methods seem to perform quite well, more research about the assessment and evidence-based treatment is needed. This would help to overcome the existing unresolved issues concerning the conceptualization of hypersexual and paraphilic disorders.