Aggression and sexuality are critical human drives that societies attempt to mold as they move toward optimal socialization.  Pathological aggression, violence, and sexual deviancy, whether through verbal threats, physical abuse, violent acts, or sexual intrusions spur fear in all sectors of society.  These fears pose challenges, not only for the public but for mental health professionals and their systems of care alike.  The resultant stigma of criminalization for the perpetrators and the often poorly organized systems of mental health care in the criminal justice system leave many marginalized from society, while the often lifelong suffering of  victims and their families triggers a cascade of human misery.  While communities struggle with these issues, mental health professionals, including psychiatrists, grapple with their role.  They are often ambivalent about getting involved.  Involvement entails confronting the often serious questions as to whether these problem behaviours are more reflective of “badness,” “madness,” or “illness,” and expressions of dismay, hopelessness, and helplessness may be common.

The development of forensic mental health and psychiatry as a field of expertise is necessary to advance knowledge and skills and modify attitudes in this area.  Mullen recently emphasized the need for more progress in this area of mental health. He encourages a broad definition of forensic mental health and psychiatry to include the assessment and treatment of those who are both mentally disordered and whose behaviour has led or could lead to offending (1).

While advances continue, forensic mental health still faces many conundrums, conflicting information, and challenges. For example, although violent crime has been reduced in the US by 10% in the last 5 years, there has been a 45% increase in the prison population, a large proportion of which is afflicted with mental illness. While mental hospital beds empty, prisons are filling with individuals who have mental disorders (2,3).  The previously accepted dogma that mental illness, crime, and violence aren’t significantly related has now been debunked by a number of good studies (4).  The public’s perception, fostered by the media, that there are few good outcomes for sexual offenders needs to be adjusted, since recent good research demonstrates that treated sexual offenders have a recidivism rate of only 20% (5).  Such difficult problems as personality disorders, which afflict a significant number of violent offenders, pose treatment dilemmas for forensic psychiatry (6). There is increasing evidence that genetic and neurobiological substrates for aggression, when combined with personality disorders, Axis I mental disorders, substance use disorders, and family and community dysfunction, form a predictive toxic combination for eventual violence (7). Finally, tolerance for aggression by society and even mental health caregivers is decreasing. There is less confidence in the ability of mental health services to cope with aggression, due in part to the shift in the locus of care from mental hospitals to the community and general hospitals.  This has led to an escalation of forensic service referrals and to a push for management by the criminal justice system (3).

Two review papers in this issue will shed light on these areas and provide professionals with an up-to-date understanding of these commonly misunderstood topics.  This information will enable them to better treat people who are perceived to be—and in reality often are—threatening.

In the first article, Dr John Bradford of the University of Ottawa provides a review of recent evidence on the neurobiological basis of the paraphilias and compulsive sexual behaviour and their treatment.

In the second, Dr Emil Coccarro and Dr Royce Lee of the University of Chicago extensively detail the development of our understanding of the neurobiology of aggression, particularly impulsive aggression.

Dr Bradford’s paper highlights the relation between obsessive–compulsive disorder (OCD) and the sexual disorders.  He emphasizes the importance of recognizing the diverse pathophysiology of sexual disorders and advocates the inclusion of the term “hypersexuality” under sexual dysfunction disorders.  He proposes to expand the classification scheme of the paraphilias and stresses the importance of  specifying whether they  occur in the presence or absence of hypersexuality. He presents an algorithm for the treatment of various degrees of paraphilia.  Dr Bradford describes what is known of the  neurobiology and pharmacology of sexual disorders and their treatment.  Although our knowledge of the neuroendocrine basis of specific disorders (be they paraphilias, nonparaphilic compulsive sexual disorders, or nonparaphilic hypersexual disorders) is still very incomplete, many people can be successfully treated with pharmacological interventions. The role of serotonin and the use of serotonin reuptake inhibitors (SSRIs) in the treatment of sexual disorders is an area of intense current interest.  

Dr Coccaro and Dr Lee analyze impulsive aggression and point to its role in criminal and noncriminal behaviour.  They highlight some of the most up-to-date neurochemical and genetic information related to this area.  They emphasize an apparent lifelong link between individual temperament, its early expression as impulsive aggression in certain individuals, and its apparent relative stability through the life cycle.  This implicates certain biological determinants.  The importance of the serotonergic system is supported by evidence from  psychopharmacological challenge studies that reflect serotonergic abnormalities, particularly low serotonin levels.  The authors discuss medical-imaging studies, which, although in their infancy, do point to prefrontal cortical abnormalities.  The paper then briefly touches upon the most promising strategies in dealing with impulsive aggression, which involve the use of SSRIs or mood stabilizers.

References

1.  Mullen PE. Forensic mental health. Brit J Psych 2000;176:307–11.
2.  Skodol AE. Psychopathology and violent crime (Foreword). In: Oldham  JM, Riba MB, editors. Annual Review of Psychiatry (Vol 17). Washington (DC): American Psychiatric Press; 1998.  p xiii–xviii.
3. Gunn JE. Future directions for treatment in forensic psychiatry. Brit J Psych 2000;176:332–8.
4. Beck JC, Wencel H. Violent crime and Axis I pathology. In:  Oldham  JM, Riba MB, editors. Annual Review of Psychiatry (Vol 17). Washington (DC): American Psychiatric Press; 1998. p 1–27.
5. Greenberg DM. Sexual recidivism in sexual offenders. Can J Psychiatry 1998; 43:459–65.
6.  Coid JW. Axis II disorders and motivation for serious criminal behavior. In: Oldham  JM, Riba MB, editors. Annual Review of Psychiatry (Vol 17). Washington (DC): American Psychiatric Press; 1998.  p 53–97.
7. Soyka M. Substance misuse, psychiatric disorder and violent and disturbed behavior. Brit J Psych 2000;176:346–50.

David L Keegan, MD
Guest Editor