Diagnostic issues,multiple paraphilias,and comorbid disorders in sexual offenders: Their incidence and treatment

This paper critically appraises the criteria for DSM diagnoses of the paraphilias relevant to sexual offenders. It is concluded that these criteria leave a lot to be desired and that a more helpful approach would be to rate the features of each type of sexual offender along dimensions ranging from normal to seriously problematic. Next consideration is given to the evidence on the incidence of multiple paraphilias and comorbid disorders. It is not yet completely clear from this evidence that sexual offenders typically have multiple sexual outlets although some obviously do. What is clear is that incidence of comorbid disorders is sufficiently high to warrant concerns about how to effectively address these additional disordered aspects of sexual offenders in treatment. Finally, suggestions are offered about how to address in treatment both multiple paraphilic offenders and those with associated comorbid disorders.     

The relationship between comorbid personality disorders and treatment received in patients with anxiety disorders

Few studies have addressed the relationship between the presence of a comorbid personality disorder and the amount of psychiatric treatment received by patients with an Axis I disorder. This issue has not been studied in patients with anxiety disorders. In a prospective, naturalistic, longitudinal study of anxiety disorders, 526 subjects were assessed with the Personality Disorder Examination, and types of treatment received in 1991 and 1996 were identified. In 1991, compared to subjects without a personality disorder, subjects with a personality disorder were as likely to receive medication and they received a greater number of medications. Subjects with borderline personality disorder were more likely to receive heterocyclic antidepressants and interventions characteristic of psychodynamic psychotherapy and cognitive therapy; they also reported receiving a greater number of medications and types of psychosocial treatment than other subjects. In 1996, subjects with borderline personality disorder were more likely to receive psychodynamic interventions. These findings suggest that in patients with an anxiety disorder, the presence of a comorbid personality disorder is associated with receiving a greater number of medications but not with a greater likelihood of receiving pharmacologic or psychosocial treatment. However, the presence of borderline personality disorder is associated with a greater likelihood of receiving, and receiving a greater number of, certain types of somatic and psychosocial treatments.     

Childhood-onset multiple sclerosis and mood disorders: a case study.

Multiple Sclerosis (MS) is rare in children. Little research exists regarding emotional and behavioral disorders in childhood-onset MS, despite the occurrence of such problems in adults with MS. This paper describes the cognitive and behavioral characteristics of a boy diagnosed with MS at age 9 and mood disorder at age 10. He displayed no cognitive or behavioral problems prior to the onset of physical symptoms of MS. Three years after diagnosis, this child showed persistent problems with speed of processing, visual-motor skills, and parent and teacher-reported executive functioning. In addition, he had difficulties with emotional lability, behavioral disinhibition, depression, and social interaction. As with adults, children with MS may be at increased risk for mood disorder compared to their peers. Mood disorders in children with MS are likely to be multiply determined, although the specific causal mechanisms are unknown.     

PTSD,comorbid depression,and the cortisol waking response in victims of intimate partner violence: preliminary evidence

Posttraumatic Stress Disorder (PTSD) and Major Depressive Disorder (MDD) are two highly comorbid and debilitating disorders experienced by more than half of intimate partner violence victims (IPV). Hypothalamic–pituitary–adrenal (HPA) abnormalities are common in both disorders, though the direction of abnormalities often differs. The present study examined the relationship between comorbid PTSD and MDD, and the (salivary) cortisol waking response in 104 recently abused IPV victims. Waking cortisol levels, area under the waking curve with respect to ground (AUCg), and AUC with respect to increase (AUCi) were examined to determine the relation of HPA dynamics to comorbidity for basal versus more dynamic measures. Prior to accounting for comorbidity, women with PTSD or MDD showed significantly greater AUCi than women without the respective disorder. Accounting for comorbidity, PTSD only did not differ from other groups, while MDD only and PTSD + MDD showed greater AUCi than women with neither disorder. Results were nonsignificant for waking cortisol levels or AUCg. Results suggest that MDD drives elevated waking cortisol response, but not basal cortisol activity in recently abused IPV victims. Results demonstrate the importance of examining comorbid diagnoses and HPA activity from a dynamic perspective. Therapeutic implications are discussed.     

Clinically useful assessments: substance use and comorbid psychiatric disorders

This review addresses the assessment of substance use and related constructs with persons having severe and persistent mental illness. The review contains two major sections. The first section focuses on issues particular to the assessment of substance use and abuse in the context of major mental illness; these include the social and motivational context of assessment, the impact of mental status and acute symptoms, limitations associated with acute and chronic cognitive impairment, and the psychosocial relevance of assessment items. The second section highlights a selected set of substance assessment tools for use with this population; evidence for the reliability, validity, and/or feasibility of these tools is summarized. Each instrument meets the criteria of being: (a). relatively brief; (b). easy to administer and interpret; and (c). useful for treatment planning, motivational feedback, and/or monitoring change.     

Testing hypotheses regarding the causes of comorbidity: examining the underlying deficits of comorbid disorders

The authors examined the validity of a method commonly used to test alternative hypotheses regarding the causes of comorbidity: the examination of underlying deficits of comorbid disorders. The authors simulated data in which the true causes of comorbidity were known, then compared the patterns of underlying deficits of the comorbid disorders found in the simulated data with the predicted results. The method of examining the underlying deficits of comorbid disorders could distinguish between several comorbidity models, including those that could not be distinguished well using other methods. The ability to distinguish the correct model decreased as the sample size and the correlation between the underlying deficits and the symptom scores decreased, suggesting that the issue of power should be considered carefully.     

Different patterns of recollection impairment in confabulation reveal different disorders of consciousness: A multiple case study

Recollection is used to refer to the active process of setting up retrieval cues, evaluating the outcome, and systematically working toward a representation of a past experience that we find acceptable.In this study we report on three patients showing different patterns of confabulation affecting recollection and consciousness differentially. All patients confabulated in the episodic past domain. However, whereas in one patient confabulation affected only recollection of events concerning his personal past, present and future, in another patient confabulation also affected recollection of impersonal knowledge. The third patient showed an intermediate pattern of confabulation, which affected selectively the retrieval of past information, both personal and impersonal. We suggest that our results are in favor of a fractionation of processes involved in recollection underling different disorders of consciousness.     

Assessing ADHD and comorbid disorders in children: the Child Behavior Checklist and the Devereux Scales of Mental Disorders

Evaluated discriminant validity and clinical utility of selected subscales of the Devereux Scales of Mental Disorders (DSMD; Naglieri, LeBuffe, & Pfeiffer, 1994) and the Child Behavior Checklist (CBCL; Achenbach, 1991a) in 228 children referred to a clinic for the evaluation and treatment of attention deficit hyperactivity disorder (ADHD). The DSMD is a multiaxial behavior rating scale that measures symptomatology for a broad range of child psychopathology as described in the Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev. [DSM-R-III] and 4th ed. [DSM-IV]; American Psychiatric Association, 1987, 1994). Discriminant function analyses as well as sensitivity, specificity, and predictive power analyses were computed to evaluate the discriminant validity and clinical utility of selected DSMD and CBCL subscales for assessing ADHD, oppositional defiant disorder (ODD), and anxiety disorders. Results indicated that the DSMD compared very favorably with the CBCL in the ability to discriminate between children with ADHD and those without ADHD and between children with comorbid ODD and anxiety disorders and children who did not meet criteria for these disorders. The DSMD Attention subscale may be somewhat better at ruling in ADHD combined subtype (ADHD-C) and ADHD inattentive subtype (ADHD-I) than the CBCL Attention Problems subscale, but the CBCL Attention Problems subscale may have slightly better utility than the DSMD Attention subscale in ruling out these subtypes. Both the CBCL and DSMD were more useful for ruling out than for ruling in ODD and anxiety disorders.     

Individual Therapy via the Phenomenon of Hope for Treating Chronic and Complex PTSD

Evidence-based treatment (EBT) supports different types of cognitive-behavioral therapy (CBT) for treating post-traumatic stress disorder (PTSD). Yet, a growing body of evidence shows a high therapy dropout rate and non-response rate among PTSD patients, especially patients with complex PTSD. A different, short-term therapeutic approach is therefore needed which combines CBT and psychodynamic therapy (PDT) because it is better for patients with chronic and/or complex PTSD to work with clarified stages and an end of treatment in mind. The patient's mental structure is conceptualized as a continuum, and functional problems are regarded as stemming from cognitive structures and unresolved developmental conflict. The five phases of the phenomenon of hope model proposed in an earlier article—a connection phase; an agency and pathway phase (developing a goal-oriented decision-making pattern and learning to plan toward goal achievement); a reconstruction phase; a phase of processing the conflict characteristic of PTSD by utilizing the natural power of hope; and a summary and separation phase—advance a short-term therapy that combines CBT and PDT techniques. This integrated therapy is based on notes that were kept relating to the case study of a chronic PTSD patient.     

Co-occurrence of developmental disorders: The case of Developmental Dyscalculia

Five to seven percent of children experience severe difficulties in learning mathematics and/or reading. Current trials that are focused on identifying biological markers suggest that these learning disabilities, known as Developmental Dyscalculia (DD) and Dyslexia (for reading), are due to underlying brain dysfunctions. One ongoing controversy concerns the extent to which arithmetic impairments are specific to DD or shared with other developmental disorders such as Dyslexia. This review explores and develops a hypothesis for cases of DD + Dyslexia. Three factors warrant consideration: (a) the behavioral factor, including definitions of the disabilities and assessment tools; (b) the cognitive factor, including whether co-occurrence of DD and other developmental disorders such as Dyslexia derive from similar or different cognitive risk factors; (c) the biological factor, including consideration of static vs. developmental neuropsychology. Better understanding of the causes of co-occurrence of DD and Dyslexia, or other developmental disorder such as Attention Deficit Hyperactivity Disorder (ADHD), can have an important influence on research that examine the two disorders, including research on therapy and etiology.     

Gender differences in comorbid disorders among offenders in prison substance abuse treatment programs

This study examined gender differences in a range of lifetime psychiatric disorders in a sample of 272 offenders newly admitted to a prison substance abuse program. Although these men and women did not differ in severity of substance use in the six months prior to incarceration, women were significantly more likely than men to report a lifetime psychiatric disorder and a lifetime severe disorder. Furthermore, gender differences emerged in the pattern of lifetime psychiatric comorbidity. Women reported greater lifetime major depression, posttraumatic stress disorder, eating disorder, and borderline personality disorder; men were more likely than women to meet criteria for antisocial personality disorder. Additionally, female offenders were found to have a higher degree of internalizing disorders than male offenders, but there were no gender differences in degree of externalizing disorders. The study concluded that women offenders newly admitted to a prison substance abuse program present with a greater psychiatric vulnerability and a different pattern of psychiatric comorbidity than their male counterparts.