Axis I psychiatric disorders, paraphilic sexual offending and implications for pharmacological treatment

Abstract

Background: Axis I non-sexual psychopathology, especially if associated with other manifestations of impulsivity, could be important to consider during the assessment and pharmacological treatment of paraphilic sexual offenders.

Method: The author performed a Medline literature search using combinations of the following terms "sexual offender," "paraphilia," "Axis I," and "comorbid." In addition, individual paraphilic disorders including "exhibitionism," "voyeurism," "frotteurism," "sexual sadism" and "pedophilia" were searched with the terms "Axis I" and "comorbid." From the literature retrieved, 18 relevant specific articles and additional references were reviewed that utilized either a comprehensive prospective methodology to ascertain Axis I psychopathology or a specific diagnosis not typically included in structured diagnostic instruments was ascertained with validated rating instruments.

Results: Unipolar and bipolar mood disorders, social anxiety disorder, attention deficit hyperactivity disorder and other neurodevelopmental conditions (mental retardation, fetal alcohol spectrum disorder, Asperger's disorder) are Axis I psychopathologies reported as co-associated with paraphilic sexual offending. The aforementioned Axis I psychiatric disorders typically manifest during childhood or adolescence, the same age of onset as paraphilic disorders. Alcohol abuse is prevalent among paraphilic offenders as well and its presence serves as an additional disinhibitor. Research supporting the concurrent pharmacological treatment of Axis I comorbidities is modest but offers support that such treatment could mitigate paraphilic behavior.

Limitations: This review was organized to emphasize positive findings. Studies reviewed varied in both sample types and settings as well as ascertainment and diagnostic methodologies. The literature reviewed is modest in size and additionally limited by small samples.

Conclusions: A subset of males with Axis I diagnoses of mood disorders, social anxiety disorder, substance use disorders, and ADHD or other childhood neurodevelopmental disabilities may be co-associated with sexual disinhibition and aggression manifested as paraphilias. Pharmacological treatments addressing Axis I comorbidites and paraphilias have been reported to mitigate both sets of disorders but the treatment data should be regarded as preliminary.