Psychotic and Sexually Deviant Renee Sorrentino, MD, Leah Bauer, MD, and Daniel Reilly, MD

Cases That Test Your Skills

Psychotic and sexually deviant Renee Sorrentino, MD, Leah Bauer, MD, and Daniel Reilly, MD

During evaluation for psychotic symptoms, Mr. P, age 21, reveals How would you that he has been viewing child pornography for 2 years, but has handle this case? Visit CurrentPsychiatry.com not acted on his fantasies. How would you treat him? to input your answers and see how your colleagues responded

CASE Paranoid and distressed “First, I started looking for 15- or 16-year- Mr. P, age 21, is a single, white college stu- olds. They would work for a while [referring to dent who presents to a psychiatric emergency sexual gratification], but then I would look for room with his father at his psychotherapist’s younger girls.” He says the images of younger recommendation. The psychotherapist, who girls are sexually arousing, typically “young has been treating Mr. P for anxiety and depres- girls, 8 to 10 years old” who are nude or in- sion, recommended he be evaluated because volved in sex acts. of increased erratic behavior and paranoia. Mr. Mr. P denies sexual contact with prepubes- P reports that he has been feeling increasingly cent individuals and says his thoughts about “anxious” and “paranoid” and thinks the securi- such contact are “distressing.” He reports that ty cameras at his college have been following he has viewed child pornography even when him. He also describes an increased connec- he wasn’t experiencing psychotic or mood tion with God and hearing God’s voice as a symptoms. Mr. P’s outpatient psychotherapist commentary on his behaviors. Mr. P denies reports that Mr. P first disclosed viewing child euphoria, depression, increased goal-directed pornography and his attraction to prepubes- activities, distractibility, increased impulsivity, cent girls 2 years before this admission. or rapid speech. He is admitted voluntarily to the psychiatric unit for further evaluation. What would you do first? During the hospitalization, Mr. P discloses a) start Mr. P on an atypical antipsychotic that he has been viewing child pornography b) report his child pornography viewing to for 2 years, and during the past 6 months he the police has been distressed by the intensity of his c) refer him back to his outpatient sexual fantasies involving sexual contact with psychotherapist prepubescent girls. He also continues to expe- d) consult with a specialist in paraphilias rience paranoia and increased religiosity. Mr. P says he began looking at pornogra- The authors’ observations phy on the internet at age 14. He says he was DSM-IV-TR diagnostic criteria for pedo- watching “regular straight porn” and he would philia (Table 1, page 38)1 are based on a use it to masturbate and achieve orgasm. Mr. Dr. Sorrentino is Instructor in Psychiatry, Department of Psychiatry, P began looking at child pornography at age Harvard Medical School, Boston, MA. Dr. Bauer is Chief Resident, 19. He stated that “regular porn” was no longer Department of Psychiatry, Massachusetts General Hospital, Boston, MA. Dr. Reilly is Attending Psychiatrist, Department of Current Psychiatry sufficiently arousing for him. Mr. P explains, Psychiatry, Cambridge Health Alliance, Everett, MA. Vol. 12, No. 5 37 Cases That Test Your Skills

Table 1 phrenia and sexual offending. Convicted sex offenders were nearly 3 times more DSM-IV-TR diagnostic criteria likely than non-offenders in the men- for pedophilia tal health system to be diagnosed with A) Over a period of ≥6 months, recurrent, schizophrenia. This effect was stronger for intense sexually arousing fantasies, sexual urges, or behaviors involving sexual activity individuals with co-occurring substance with a prepubescent child or children abuse. However, few sex offenders had a (generally age ≤13) schizophrenia diagnosis (18 out of 846 of- B) The person has acted on these sexual fenders). Similarly, Alish et al4 found that urges, or the sexual urges or fantasies cause marked distress or interpersonal difficulty 2% to 5% of sex offenders are thought to C) The person is age ≥16 and ≥5 years older have schizophrenia. In a sample of sex than the child or children in criterion A offenders with schizophrenia, patients al- Clinical Point Note: Do not include an individual in late most always displayed psychotic symp- adolescence involved in an ongoing sexual toms at the time of sexual offense, and 33% relationship with a 12- or 13-year-old Although most to 43% showed symptoms of psychosis di- Source: Reference 1 schizophrenia patients rectly related to the offense.5 do not exhibit Table 2 Although most schizophrenia patients sexual deviancy, without a history of sexual offenses do not DSM-IV-TR diagnostic criteria sexual content in exhibit sexual deviancy, sexual content in for a paraphilia hallucinations and delusions is common.6 hallucinations and The essential features of a paraphilia are Confusion about sexual identity and the delusions is common recurrent, intense sexually arousing fantasies, sexual urges, or behaviors generally involving: boundaries of one’s body are common 6 A) nonhuman objects, the suffering or and may contribute to sexual deviancy. humiliation of oneself or one’s partner, or Psychiatric inpatients without a history of children or other nonconsenting persons sexual offenses—including but not limited that occur over a period of ≥6 months to psychotic patients—have higher rates B) The behavior, sexual urges, or fantasies cause clinically significant distress or of sexually deviant fantasies and behav- impairment in social, occupational, or other iors compared with those without psychi- important areas of functioning atric illness.6 In one survey, 15% of men Source: Reference 1 with schizophrenia displayed paraphilic behaviors and 20% had atypical sexual thoughts.7 history of sexual arousal to prepubescent Alish et al4 found that pedophilia was individuals. A subset of sex offenders meet not necessarily linked to psychotic behav- criteria for a paraphilia (Table 2),1 an axis ior or antisocial personality features when I disorder, and a subset of sex offenders comparing pedophilia rates in individuals with paraphilia meet diagnostic criteria with or without schizophrenia. In a sample for pedophilia. Dunsieth et al2 found that of 22 adolescent males who sexually mo- among a sample of 113 male sex offend- lested a child at least once, axis I morbid- ers, 74% had a diagnosable paraphilia, and ity was common, and 55% met criteria for Discuss this article at 50% of individuals with paraphilia met cri- bipolar disorder.8 www.facebook.com/ teria for pedophilia. CurrentPsychiatry Little is known about the relationship between sexual deviancy and psychosis. Few experts in paraphilias Wallace et al3 linked databases of individu- A patient who endorses deviant sexual als convicted of serious crimes with public fantasies should be evaluated by a mental mental health system contact and found health professional with specialized train- Current Psychiatry 38 May 2013 a significant association between schizo- ing in paraphilias. Although paraphilias are continued on page 40 Cases That Test Your Skills

continued from page 38

Table 3 Psychosexual evaluation Aspect of evaluation Measures Sexual behavior history History of sexual abuse Childhood exposure to sex Masturbation history Preferred sexual partners Kinsey Scale Sexual addiction or Total Sexual Outlet measure compulsion Amount of time in sexual fantasy Financial, legal, or social cost of sexual behavior Prior treatment of sexual behavior Clinical Point Sexual interests Sex, age, and number of partner(s) Clinicians are legally Review of criteria for all paraphilias (exposing, voyeurism, cross- dressing, sadistic or masochistic interests) required to report if a patient discloses current sexual not recognized as a subspecialty in psychia- confounding presentation of active major behavior with a try, diagnosing and treating patients with mental illness, medications, and medico- a paraphilia requires additional training. legal implications. A valid psychosexual child with a plan to There is a scarcity of psychiatrists trained to history cannot be obtained when the pa- continue the behavior evaluate and treat patients with paraphilias. tient is unable to participate in a mean- ingful historical report. Mr. P’s attention Sexual evaluation. Evaluating a patient difficulties and psychosis interfered with who presents with problematic sexual his ability to answer questions in a reliable, behaviors includes performing a compre- consistent manner. A psychosexual history hensive psychiatric history with a focus should be reserved for when a patient is no on sexual history. A psychosexual history longer presenting with significant symp- is distinct from general psychiatric evalua- toms of major mental illness. tions because of the level of detail regard- ing a sexual history (Table 3). In addition Medicolegal aspects of a psychosexual to the clinical interview, objective testing evaluation may include mandated report- to determine sexual interests may be use- ing, confidentiality, and documentation. ful in some patients (Table 4).9 Mental health professionals are mandated Actuarial tools—risk assessment instru- to report to law enforcement or child wel- ments based on statistically significant fare agencies when they observe or suspect risk factors—are valid tools for determin- physical, sexual, or other types of abuse in ing the risk of sexual reoffending. There vulnerable populations such as children. are several validated actuarial tools in the In psychosexual evaluations, the evalua- assessment of sex offender recidivism, tor is legally required to report if a patient such as the Static-99R,10 Stable-2007,11 and discloses current sexual behavior with a the Sex Offender Risk Appraisal Guide.12 child with a plan to continue to engage However, these tools are used for sex of- in the behavior. In Mr. P’s case, there was fenders, and would not be used for indi- no duty to report because although he de- viduals who have not committed a sex scribed viewing child pornography and offense, such as Mr. P. had a sexual interest in prepubescent indi- Conducting a psychosexual evaluation viduals, he did not report a history of en- Current Psychiatry 40 May 2013 in a psychiatric hospital is limited by the gaging in hands-on sexual behaviors with Cases That Test Your Skills

Table 4 Objective testing to determine sexual interests Test Results Penile plethysmograph Measures penis circumference with a mercury-in-rubber strain gauge. Used clinically by measuring circumferential changes in the penis while the patient is listening to audio or video stimuli of various sexual vignettes Abel Assessment for An objective method for evaluating deviant sexual interest uses Sexual Interests-3 noninvasive means to achieve objective measures of sexual interest. The subject’s visual response time is measured while viewing images of males and females of varying age. Visual reaction time is correlated with sexual interests Source: Reference 9 Clinical Point children or impulses to do so. When an ual history, including a review of criteria Persistent child individual has engaged in sexual contact for paraphilias. In addition, when appro- pornography with a prepubescent individual, report- priate, the clinician should perform a risk use is a stronger ing is not mandated unless the individual assessment to determine the patient’s diagnostic indicator continues to engage in sexual behavior risk of engaging in sexual offenses with of pedophilia than with a minor. Mental health professionals children. sexually offending are not responsible for calling the police or alerting authorities after a crime has been against child victims committed. OUTCOME Expert consultation The commission of a crime is not an We start Mr. P on risperidone, 1 mg/d, to exception to confidentiality. If a clinician treat his paranoia and request a consultation reports a patient’s criminal activity to the with an expert in paraphilias to determine if authorities without the patient’s consent, Mr. P has a paraphilia and to discuss treat- he or she has breached confidentiality. It ment options. is unknown whether Mr. P and his psy- Mr. P’s initial diagnosis is psychotic disorder chotherapist had a discussion about the not otherwise specified. His viewing of child legal consequences of his viewing child pornography and sexual interest in prepubes- pornography. No legislation requires cli- cent individuals is not limited to his current nicians to report patients who view child mental status, and these interests persist in pornography. the absence of mood and psychotic states. The relationship between viewing child Mr. P’s viewing of child pornography and pornography and pedophilia is unclear. sexual attraction to prepubescent girls meet Some child pornography viewers are pe- the diagnostic criteria for pedophilia. During dophilic, others are sexually compulsive, hospitalization, we educate Mr. P about his and others are viewing out of curiosity diagnoses and need for continued treatment. and have no sexual deviance. Seto et al13 We refer him to a sexual disorders outpatient suggested that child pornography of- clinic, which continues to address his deviant fenders show greater sexual arousal to sexual interests. children than to adults. Persistent child pornography use is a stronger diagnostic The authors’ observations indicator of pedophilia than sexually of- A meta-analysis indicates that a combi- fending against child victims.13 A clinician nation of pharmacologic and behavioral who learns that a patient is viewing child treatments coupled with close legal su- Current Psychiatry pornography should take a detailed sex- pervision seems to reduce the risk of Vol. 12, No. 5 41 Cases That Test Your Skills

References Related Resources 1. Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington DC: American Psychiatric • Reijnen L, Bulten E, Nijman H. Demographic and personal- Association; 2000. ity characteristics of internet child pornography download- 2. Dunsieth NW Jr, Nelson EB, Brusman-Lovins LA, et al. ers in comparison to other offenders. J Child Sex Abus. Psychiatric and legal features of 113 men convicted of sexual 2009;18(6):611-622. offenses. J Clin Psychiatry. 2004;65(3):293-300. • Hall RC, Hall RC. A profile of pedophilia: definition, characteris- 3. Wallace C, Mullen P, Burgess P, et al. Serious criminal tics of offenders, recidivism, treatment outcomes, and forensic offending and mental disorder. Case linkage study. Br J issues. Mayo Clin Proc. 2007;82(4):457-471. Psychiatry. 1998;172:477-484. 4. Alish Y, Birger M, Manor N, et al. Schizophrenia sex Drug Brand Names offenders: a clinical and epidemiological comparison study. Leuprolide • Eligard, Lupron Risperidone • Risperdal Int J Law Psychiatry. 2007;30(6):459-466. Medroxyprogesterone • Cycrin, 5. Smith AD, Taylor PJ. Serious sex offending against women Provera by men with schizophrenia. Relationship of illness and psychiatric symptoms to offending. Br J Psychiatry. 1999; Disclosure 174:233-237. The authors report no financial relationship with any company 6. Drake CR, Pathé M. Understanding sexual offending in Clinical Point whose products are mentioned in this article or with manufactur- schizophrenia. Crim Behav Ment Health. 2004;14(2):108-120. ers of competing products. 7. Harley EW, Boardman J, Craig T. Sexual problems in schizophrenia prevalence and characteristics: a cross Pedophilia sectional survey. Soc Psychiatry Psychiatr Epidemiol. 2010; treatment focuses on 45(7):759-766. 8. Galli V, McElroy SL, Soutullo CA, et al. The psychiatric minimizing deviant diagnoses of twenty-two adolescents who have sexually molested other children. Compr Psychiatry. 1999;40(2): 14 sexual arousal repeated sexual offenses. Legal super- 85-88. vision is a general term to describe over- 9. Abel GG, Jordan A, Hand CG, et al. Classification models through behavior of child molesters utilizing the Abel Assessment for sexual sight of offenders in the community by modification, CBT, interest. Child Abuse Negl. 2001;25(5):703-718. supervisory boards, such as probation 10. Hanson RK, Thornton D. Improving risk assessments for and medications sex offenders: a comparison of three actuarial scales. Law or parole, and tracking devices such as Hum Behav. 2000;24(1):119-136. GPS. Currently, pedophilia treatment 11. Hanson RK, Harris AJ, Scott TL, et al. Assessing the risk of sexual offenders on community supervision: The Dynamic focuses on minimizing deviant sexual Supervision Project. Vol 5. Ottawa, Canada: Public Safety arousal through behavioral modifica- Canada; 2007. 12. Quinsey VL, Harris AJ, Rice ME, et al. Violent offenders: tion, cognitive-behavioral therapies, and appraising and managing risk. 2nd ed. Washington DC: testosterone-lowering medications, such American Psychological Association; 2006. 13. Seto M, Cantor JM, Blanchard R. Child pornography as medroxyprogesterone or leuprolide. offenses are a valid diagnostic indicator of pedophilia. J The decision to prescribe testosterone- Abnorm Psychol. 2006;115(3):610-615. 14. Thibaut F, De La Barra F, Gordon H, et al; WFSBP Task lowering medication should be based on Force on Sexual Disorders. The World Federation of informed consent and the patient’s risk of Societies of Biological Psychiatry (WFSBP) guidelines for the biological treatment of paraphilias. World J Biol Psychiatry. dangerous sexual behaviors. 2010;11(4):604-655.

Bottom Line The relationship between paraphilia and psychosis is unclear. No law requires clinicians to report patients who view child pornography to authorities. Treatment starts with a thorough psychosexual evaluation. Therapies include behavioral modification, Current Psychiatry 42 May 2013 cognitive-behavioral therapies, and testosterone-lowering medications.