Treatment Implications of Psychological and Psychiatric Comorbidity of Paraphilias and Paraphilia-Re

The identification of consistent developmental events, psychological "traits," or psychiatric comorbid diagnoses would be helpful in understanding developmental antecedents, risk factors, or possible pathophysiological correlates associated with PAs and PRDs. Such an understanding then would be beneficial in treatment planning. In addition, it may be imperative to assess, diagnose, and treat concurrent comorbid conditions to improve treatment efficacy for primary PAs or PRDs.

Many of the studies examining comorbid psychiatric disorders in sexually aggressive paraphilic individuals assess symptoms or symptom clusters derived from personality inventories, most commonly the Minnesota Multiphasic Personality Inventory (MMPI; Hathaway and McKinley 1943) (Anderson et al. 1979; Kalichman 1990; Langevin et al. 1990a, 1990b; McCreary 1975). The specificity of the MMPI, however, at least in the delineation of a sex offender typology, has not been adequately demonstrated (Marshall and Hall 1995; Schlank 1995), nor do these studies specifically identify psychiatric diagnoses as defined by DSM-III and DSM-IV Axis I nomenclature.

Clinical characteristics in paraphilic males, including sex offenders, identified by psychological rating instruments include substance abuse, especially alcohol abuse (Langevin and Langs 1990; Mio et al. 1986; Rada 1975); dysphoric affects, including anger/anxiety/depression (American Psychiatric Association 1994; Becker et al. 1991; Fagan et al. 1991; Grossman and Cavanaugh 1990; Kavoussi et al. 1988; Proulx et al. 1996; Wise et al. 1991); social anxiety with concomitant social skills/attachment deficits (Baxter et al. 1984; Levin and Stava 1987; Marshall 1989; Ward et al. 1995); lifestyle impulsivity (Knight and Prentky 1990; Prentky and Knight 1986); and psychopathy (Seto and Barbaree 1997). Paraphilic men are usually regarded as heterogeneous, at least in regard to these psychological attributes.

Several small-scale studies have used current psychiatric (DSM-III or DSM-IV) diagnoses assessed in paraphilic males, including sex offenders. Axis I disorders identified include conduct and attention-deficit/hyperactivity disorder (ADHD) (Fago 1999; Hunter and Goodwin 1992; Kafka and Prentky 1998; Kavoussi et al. 1988; Vaih-Koch and Bosinski 1999), mood disorders (Kafka and Prentky 1994, 1998; Kruesi et al. 1992; McElroy et al. 1999; Raymond et al. 1999), anxiety disorders (Kafka and Prentky 1994, 1998; McElroy et al. 1999; Raymond et al. 1999), and psychoactive substance abuse (alcohol) (Kafka and Prentky 1994, 1998; McElroy et al. 1999; Raymond et al. 1999). The great majority of PA (and PRD) males are not psychotic, and despite the characterization of their sexual behavior as "compulsive," only a minority (11%-15%, as assessed in the aforementioned studies) have comorbid obsessive-compulsive disorder. In all of the aforementioned studies, several lifetime comorbid Axis I diagnoses were identified for the average subject.

Developmental factors are presumed to be significant determinants differentiating sexually aggressive paraphilic individuals from those whose sexual impulsivity does include sexual assault. In sexual aggressors, a history of physical/sexual abuse (Hanson and Slater 1988), paternal alcoholism and antisocial personality (Langevin et al. 1985), and family instability with inconsistent limit setting (Langevin et al. 1985; Prentky et al. 1989; Rada 1978) are hypothesized to contribute to general antisocial behavior, including sex offending.