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Neuropsychology in Adult & Adolescent Sex Offenders. Joseph J. Sesta, Ph.D., M.S.Pharm., ABPN Postdoctoral Master of Science in Clinical Psychopharmacology Fellowship Trained & Board Certified in Neuropsychology Added Qualifications in Forensic Subspecialty

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Neuropsychologyin Adult & Adolescent Sex Offenders

Joseph J. Sesta, Ph.D., M.S.Pharm., ABPN

Postdoctoral Master of Science in Clinical Psychopharmacology

Fellowship Trained & Board Certified in Neuropsychology

Added Qualifications in Forensic Subspecialty

Diplomate, American Board of Professional Neuropsychology


Content Outline

  • Assumptions in Neuropsychology Assessment

  • Theories of Sexual Offending

  • Literature: Biology & Sexual Violence

  • A Neuropsychological Theory of Sexual Violence

  • Neuroanatomical Abnormalities

  • Neurochemical Abnormalities

  • Psychopharmacological Treatments

  • Volitional Control & Paraphilia

    • Paraphilia NOS, Non-Consenting Persons

  • Forgotten Scientific Concepts in SVP Assessments


Neuropsychology in Sexual Violence Assessment: Summary

1.The brain is the organ of mentation, emotion and behavior, there is no other source of these functions

2.There is an understandable relationship between the function of the brain and human behavior

3. It is possible to assess the functional integrity of the human brain


Neuropsychology in Sexual Violence Assessment: Summary

4. Neurology, Neuropsychiatry & Neuropsychology are recognized specialties within Medicine & Psychology that study the functioning of the human brain

5. Neuropsychology is literally defined as the study of brain-behavior relationships

6. There are standardized, validated, published neuropsychological tests/batteries with established sensitivity and specificity to various forms of brain impairment


Neuropsychology in Sexual Violence Assessment: Summary

7. Neuropsychological tests can help identify disease/injury/dysfunction of brain areas related to specific cognitive and behavioral disorders (agnosia, apraxia, aphasia, disinhibition, abulia, anosognosia, anosodiaphoria, moria)

8. Although the brain functions as an integrated whole of neural systems, there is a significant degree of functional specialization (lateralization, localization; primary, secondary, tertiary cortex)


Neuropsychology in Sexual Violence Assessment: Summary

9. “Executive functions” mediated by anterior tertiary cortex and associated cortical-subcortical loops (frontal systems) include the capacity to: plan, organize, initiate, terminate, inhibit, modulate, regulate and otherwise “control” behavior; and such functions can be scientifically tested (D-KEFS, Lurian tasks, WCST, HCT)


Neuropsychology in Sexual Violence Assessment: Summary

10. When appropriate history, clinical examination and neurometric testing indicate that such executive functions are intact, the individual has the neurological capacity to control their behavior, although they may choose not to do so for a variety of reasons (psychological, social, cultural, economic, political, religious)


Theories of Sex Offending

  • Psychoanalytic/Psychiatric

  • Family Dynamics

  • Culture, Patriarchy and Misogyny

  • Mating Strategies

  • Evolution

  • Biology

  • Victim of Sexual Abuse

  • Mental Disorder

  • Psychopathy

  • Faulty Moral Reasoning and Inept Social Skills

  • Other Possible Causes (Revenge/Punishment, Opportunistic, Alcohol Abuse, Developmental Events)


Theories of Sex Offending

  • “There is no generally accepted scientific explanation of why sex offenders commit sex crimes. Indeed, it is very possible that there are a number of different and independent causes. If so, this suggests that a variety of identification, prevention, treatment, and monitoring methods may be needed to reduce sexual victimization.” (LaFond, 2005)


Theories of Sex Offending

  • “Some researchers have suggested that biological factors, especially research focusing on regions of the brain or neurotransmitters, may cause people to engage in sexually deviant behavior.”

  • “The research, so far, does not establish a causal connection between biology and sexually deviant conduct.” (LaFond, 2005)


Literature: Biology & Sexual Violence

  • H.A. Miller, A.E. Amenta & M.A. Conroy(2005). Sexually Violent Predator Evaluations: Empirical Evidence, Strategies for Professionals, and Research Directions. Law & Human Behavior, 29(1), pp. 29-54.


Literature: Biology & Sexual Violence

  • “…evidence linking personality disorders or paraphilias to neuropsychological abnormalities is, at present, correlational.”

  • When did correlational data become a bad thing ?

  • Does the State have causal evidence on why human being commit sex offenses ?

  • Don’t they always present correlational evidence ? (i.e., actuarials, meta analysis)


Literature: Biology & Sexual Violence

  • “The area of volitional control is the element of sexual predator evaluations that would appear to have the least empirical support or scientific evidence”

  • “The most promising area of research for this element seems to be physiological or neuropsychological in nature”


Literature: Biology & Sexual Violence

“Currently there is growing evidence indicating that certain offenders, particularly psychopaths and violent offenders may have different physiological/neurological underpinnings that increase the likelihood of violent behavior.”


Biology & Sexual Violence

  • “Research in this area may continue to provide evidence that brain function (or brain abnormality) affects volition.”

  • “However, it is important to note that actual testing must establish the presence of neurological or neuropsychological deficits rather than simply assuming offenders who are psychopathic or incarcerated have brain abnormalities because correlational evidence has been found.”


Biology & Sexual Violence

  • “Perhaps the most promising area of research likely to establish scientific evidence of diminished behavioral control is psychophysiological. Miller et al (2005)

  • Psychosis, organicity, senility and mental retardation as disinhibiting factors that may “…contribute to the relaxation of controls and the expression of a preexisting tendency to engage in a particular behavior. Prentky & Burgess (2000)


Biology & Sexual Violence

  • Orbitofrontal abnormalities have been reported to be associated with “poor impulse control, aberrant sexual behavior, and personality disorders.”

  • Bechara, Damasio & Damasio, 2000; Blair & Cipolotti, 2000; Saver & Damasio, 1991.


Biology & Sexual Violence

  • “All of these findings imply a similar, nonpsychosocial basis for sexual deviance and other anomalous sexual preferences.” (Quinsey & Lalumiere, 1995)

  • “These considerations and early findings point to an increasing scientific interest in sexual aggression and sexual deviance as biological phenomena.” (Quinsey, Harris, Rice & Cormier, 1998)


Biology & Sexual Violence

  • “Perhaps the most promising area of research likely to establish scientific evidence of diminished behavioral control is psychophysiological. Miller et al (2005)

  • Psychosis, organicity, senility and mental retardation as disinhibiting factors that may “…contribute to the relaxation of controls and the expression of a preexisting tendency to engage in a particular behavior. Prentky & Burgess (2000)


Biology & Sexual Violence

  • Orbitofrontal abnormalities have been reported to be associated with “poor impulse control, aberrant sexual behavior, and personality disorders.”

  • Bechara, Damasio & Damasio, 2000; Blair & Cipolotti, 2000; Saver & Damasio, 1991.


Biology & Sexual Violence

  • “Biological tests predict criminal disposition with about the same strength as the best measures of individuals’ environmental circumstances—correlations on the order of .20 to .40.”

  • Correlation for the ratio of prefrontal grey matter volume to whole brain volume with APD = .40

  • (Rowe, 2002. Biology and Crime)


Biology & Sexual Violence

  • MRI studies show 11% decrease in the volume of prefrontal cortex in psychopaths

  • Numerous studies have found deficits in frontal lobe functions in psychopaths vs. nonpsychopathic criminals

  • Of interest, psychopaths had great difficulty labeling odors; a deficit common to patients with frontal lobe damage

  • (Englander, 2003. Understanding Violence)


Neuropsychological Theory of Sexual Violence

  • Brain Areas important to Sexual Violence

  • Limbic System

    • Hypothalamus

    • Amygdala

    • Orbital Frontal Cortex


Anatomy: Hypothalamus


Digital Anatomy: Hypothalamus


Neuropsychological Theory of Sexual Violence: Hypothalamus

  • Hypothalamus: 4 F’s of Biology

    • Feeding

    • Fighting

    • Fleeing

    • Sexual Behavior

  • Hypothalamus: “Eye turned inward” / “Id”

    • Concerned only w/ internal state of organism

  • Raw, primitive, reflexive emotions

    • Non-focused, short-lived

    • Pleasure, pain, hunger, thirst


Hypothalamic Stimulation


Anatomy: Amygdala


Digital Anatomy: Amygdala


Neuropsychological Theory of Sexual Violence: Amygdala

  • Amygdala is a more advanced brain region

  • control and mediation of all higher-order emotional and motivational activities

  • amygdala is capable of inducing extreme feelings of pleasure , fear, rage

  • An “Eye turned outward” / “Ego”

  • Damage: extreme tameness, docile, hyperorality, social agnosia


Amygdala Lesion


Amygdala Lesion


Anatomy: Frontal Lobe


Anatomy: Prefrontal Lobe


Anatomy: Lateral View


Anatomy: Anterior View


Anatomy: Orbital View


Neuropsychological Theory of Sexual Violence: Orbital Frontal Cortex

  • Orbital-Frontal Cortex: Executive of the Social-Emotional Brain

  • Highest level of control over lower “limbic” brain structures (hypothalamus/amygdala)

  • Rich connections to Limbic System

  • Neurologic structure responsible for emotional and behavioral control over lower brain impulses

  • “Super Ego”


Phineas Gage (1848)


Neuropsychological Theory of Sexual Violence: Executive Functions

  • Goal formulation

  • Concept formation

  • Planning/Organization

  • Carrying out goal-directed plans

  • Effective performance

  • Self-monitoring

  • Ability to utilize feedback to modify behavior


Neuropsychological Theory of Sexual Violence: Executive Functions

  • Dysexecutive Syndrome: symptoms include changes in personality &social behavior resulting from:

    • disinhibition

    • impulsivity

    • decreased frustration tolerance

    • decreased ability to delay gratification

    • poor self-awareness & self-monitoring

    • poor modulation of affect (lability)


Neuropsychological Theory of Sexual Violence: Executive Functions

  • Possible brain deficits in sexual violence:

    • Disinhibition

    • Impulse Control Deficits

    • Poor Frustration Tolerance

    • Poor Organization & Planning

    • Impaired Verbal Mediation of Behavior

    • Limited Behavioral Repertoire

    • Inability to Appreciate Wrongfulness and/or Consequences of Behavior


Neuropsychological Theory of Sexual Violence: Executive Functions

  • Executive functions are “necessary for appropriate, socially responsible, and effectively adult conduct.” A Dictionary of Neuropsychology (1989)

  • Located in the frontal lobe particularly in the prefrontal regions in the orbital or medial structures (Damsio, 1979; Hecaen & Albert, 1978; Luria, 1966, 1973; Seron, 1978)


Neuropsychological Theory of Sexual Violence: Executive Functions

  • Ecological Validity of Executive Functions:

  • Poor performance on WCST associated with violent acts committed by psychiatric patients while in the community (Krakowski et al., 1997)

  • Criterion-related validity is more important (MRI, PET, fMRI)


Neuroanatomical Abnormalities

  • “The close proximity of sexual arousal and fight-or-flight responses in the brain is implicated in disorders of sexual violence” (Money, 1990)

  • There are case reports of individuals developing pedophilic or hypersexual behaviors after some type of cerebral insult--CVA, TBI, neurological disease (Hyde, 2005)


Neuroanatomical Abnormalities

  • Disinhibited sexual behavior and paraphilias have been reported following lesions in the frontal lobe, hypothalamus and septum (Frohman, Frohman, & Moreault, 2002; Miller, Cummings, Ebers & Grode, 1986)

  • Brain abnormalities are most often reported in paraphilic CSB; although as a group paraphilics do not differ from controls in brain abnormalities (Hyde, 2005)


Neuroanatomical Abnormalities

  • Frontal lobe dysfunction can lead to disinhibition of sexual behavior an hypersexuality or CSB

  • Frontal lobe abnormalities were more associated with hypersexuality

  • Temporal lobe dysfuntions were more related to various paraphilias, including pedophilia and fetishes

  • (Miller et al., 1986; Hyde, 2005)


Neuroanatomical Abnormalities

  • Some case reports of comorbidity of paraphilias and temporal lobe lesions and TLE; when the lesion was neurosurgically corrected, the paraphilia disappeared (Money & Lamarz, 1990)

  • TLE has been associated with CSB

  • Kluver-Bucy syndrome, associated with temporal lobe lesions, is characterized by hypersexuality in animals & humans


Neuroanatomical Abnormalities

  • A limited number of case studies suggest that pedophilic interests are associated with abnormalities in the temporal lobe or midbrain adjacent to the hypothalamus (Kolarsky, Madlafousek, & Novotna, 1978; Miller et al., 1986; Ortego et al., 1993)

  • Also suggested that temporal lesions simply result in hypersexual that “unmask” a premorbid pedophilic preference (Mendez et al., 2000)


Neurochemical Abnormalities

  • Testosterone: Rapists whose crimes were most violent had significantly higher plasma testosterone levels than less violent rapists and child molesters (Rada, Laws, & Kellner, 1976)

  • Studies have not been conclusive about testosterone levels, but efficacy of antiandrogen therapy for sex offenders and CSB has been fairly well documented (Bradford, 2000)


Neurochemical Abnormalities

  • Serotonin: Animal studies show decreased 5HT levels enhance sexual arousal and function, whereas increased levels will inhibit sexual function (Marson & McKenna, 1992)

  • SSRIs most common ADR is inhibition of ejaculation/orgasm and decrease in sexual desire (Lane, 1997; Modell et al., 1997)

  • SSRIs useful in treating CSB (Coleman, 1991; Federoff et al., 1993; Kafka & Coleman, 1991)


Neurochemical Abnormalities

  • Dopamine: Plays important role in sexual arousal a.e.b pharmacological studies in both animals and humans

  • DA agonists facilitate sexual drive and function (PD drugs)

  • Cocaine, amphetamine, MDMA have reported aphrodisiac properties


Pharmacological Treatment

  • Numerous pharmacological treatments of CSB have shown clinical efficacy (Coleman et al., 2003; Raymond et al., 2003)

  • SSRI

  • Mood Stabilizers/Anticonvulsants

  • Antiandrogens

  • Naltrexone


Pharmacological Treatment

  • SSRI: useful for depression, anxiety, OCD, impulse-control disorders

    • SSRIs attenuate obsessive sexual thoughts and aid in control of sexual urges in CSB, also augments psychotherapy (Coleman et al., 1992)

    • SSRIs are the frontline medications for CSB

      (Bradford, 2000)


Pharmacological Treatment

  • Mood Stabilizers: Lithium has been used to augment SSRIs in resistant CSB

  • Anticonvulsants: carbamazapine, valproic acid, topirimate has been found useful in disorders of impulse control


Pharmacological Treatment

  • Antiandrogens:

    • Cyproterone acetate (CPA)

    • Medroxyprogesterone acetate (MPA)

      • Used before SSRIs (Money, 1968, 1970)

      • Problematic due to ADRs

        • Liver disease, gynecomastia, thrombophlebitis, hyperglycemia and gall bladder disease

        • Decreased use since SSRIs


Pharmacological Treatment

  • Leuproide acetate (Lupron,Lupron Depot )

    • Synthetic analog of leutinizing hormone-releasing hormone (LHRH)--one of the gonadotropin-releasing hormones

    • Initially stimulates production of testosterone and other testicular steroids (in males)

    • Chronic LPA administration reduces testosterone to castrate levels

    • Fewer ADRs than old antiandrogens


Pharmacological Treatment

  • Naltexone: an opioid antagonist

    • Effective in tx. of urge-driven disorders

    • Pathological gambling, kleptomania, alcohol abuse, borderline PD w/ SIB, eating disorders

    • Reports of success in CSB (Raymond, Grant, Kim & Coleman, 2002)

    • Can be used to augment SSRIs

    • Unknown MOA in tx. of CSB

    • Very limited and preliminary data !!


Volitional Control & Paraphilia

  • “Numerous evaluators have utilized the diagnosis ‘paraphilia not otherwise specified’ to apply to rapists.”

  • “However, the definition of this appellation is so amorphous that no research has ever been conducted to establish its validity (in fact the word rape is not even mentioned in the Paraphilia NOS diagnostic description).”


Volitional Control & Paraphilia

  • “How such a diagnosis would differentiate a class of rapists who suffer from mental abnormality is very unclear.”

  • “…there remains a large portion of rapists who do not meet the criteria for any paraphilia.”


Volitional Control & Paraphilia

  • Levenson, J. (2004). Reliability of SVP Civil Commitment Criteria in Florida. Law & Human Behavior, 28(4), 357-368.

  • Reliability Coefficients in SVP Exams

  • Civil Commitment Selection.54

  • Diagnoses

    • Pedophilia.65

    • Sexual Sadism.30

    • Exhibitionism.47

    • Paraphilia NOS.36

    • Personality D/O NOS.23

    • Any paraphilia.47


Volitional Control & Paraphilia

  • “…The fact that an individual’s presentation meets the criteria for a DSM-IV diagnosis does not carry any necessary implication regarding the individual’s degree of control over the behaviors that may be associated with the disorder. Even when diminished control over one’s behavior is a feature of the disorder, having the diagnosis in itself does not demonstrate that a particular individual is (or was) unable to control his or her behavior at a particular time.” [DSM-IV, Use of DSM-IV in Forensic Settings, Page xxxiii]


Volitional Control & Paraphilia

  • No explanation of the causal nexus between the “disorder” and how it serves to impair the normal inhibitory processes by which others control behavior

  • What psychological or neuropsychological processes are impaired ?

  • Where is the empirical test data to show such impairment ?

  • What do we test and what constitutes an abnormal finding ?


Volitional Control & Paraphilia

  • “…the State must establish some impaired psychological processes or capacities distinct from the pattern of criminal conduct, and it must explain the causal role this impairment plays in producing that conduct.”

  • “Thus, the expert must look beyond the criminal conduct in order to evaluate the offenders’ psychological processes, identify the relevant impairments, and explain the connections between the former and the latter.”


Volitional Control & Paraphilia

  • “Diagnoses that merely identify the person as one who has engaged in the pattern of offenses provide no causal explanation for the offenses and cannot be understood as making the person likely to reoffend in the causal sense.”

  • Schopp, Scalora, Pearce (1999)


Volitional Control & Paraphilia

  • “….we have no clear idea what it could mean to say that they were unable to control their conduct or that they suffered volitional impairment, and we do not have any guidance regarding what would count as evidence of such impairment.”


Volitional Control & Paraphilia

  • “Expert testimony by a neuropsychologist or neurologist regarding the individual’s ability to control that behavior might well meet the Daubert standard for admissibility in any trial in which the individual’s capacity to control the conduct was at issue.”

  • Schopp, Scalora, & Pearce (1999). Expert Testimony and Professional Judgment: Psychological Expertise and Commitment as a Sexual Predator after Hendricks. Psychology, Public Policy, and Law, 5(1), 120-174.


Forgotten Scientific Concepts in SVP Assessments

  • 5 Criteria for Scientific Acceptability

    • TestableCan a test be designed for it ?

    • FalsifiableCan it possibly be proved false ?

    • PreciseAre its terms clearly defined ?

    • RationalDoes it fit with the know info. ?

    • ParsimoniousDoes it involve the simplest possible approach ?


Contact Information

Joseph J. Sesta, Ph.D., M.S.Pharm., ABPN

Suncoast Neuropsychology Laboratories, Inc.

6152 Delancy Station Street

Suite 206

Riverview, Florida 33569

Office: 813-413-8566

Cell: 813-293-9423

Fax:813-413-8245

Email:[email protected]


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