Homer Brine is a forty-three-year-old Caucasian male referred by the Division of Family Services for a psychological evaluation to assess the current level of cognitive functioning, behavioral functioning, and emotional functioning to gain mental health service recommendations and family reunification. Arrested for sexually abusing his daughter, Homer underwent a psychological evaluation to determine the potential of him re-victimizing his daughter. The oldest of a two-child home, Homer was raised with a “traditional Christian foundation”, stay-at-home mother, and mine worker father. Homer indicated difficult time learning and received special education in high school. He also felt awkward in social situations and chose to avoid them for fear of rejection. Having difficulty maintaining employment led him to the Office of Vocational Rehabilitation to learn social skills and job training. Homer also met his wife here. Homer perceived his wife in a negative manner describing her as irresponsible, “mentally retarded,” slow, having difficulty making decisions, and lacking parenting skills. Marriage history consisted of physical and verbal aggression often resulting in him feeling remorse for his words. His wife conflicted with Homer’s parents and rejected them for fear that they would take her daughter away. Since Homer’s arrest, their daughter was placed in his mother’s care.
Homer discussed the abuse claiming he was naked in the closet with his daughter and often showed her a pornography magazine. He claims no recognition of touching her. However, Homer admits to multiple incidents that grew in invasiveness over time beginning with exposure, to fondling, to digital and oral penetration. However, he claims all incidents were void intercourse, and his wife had walked in on them but never acknowledged what she witnessed.
There is no significant history of substance abuse. Homer does have an Arson charge from 1990; he served ten days in jail and one-year probation. Assessments indicate low academic functioning with the possibility of a learning disability. His personality assessment reveals he avoids social interaction, has difficulty trusting and understanding others emotional cues and feelings, may become reactive in stress and fail to consider others points of view. The parenting assessment indicated the parent-child relationship as stressful indicating potential for dysfunctional parenting behaviors.
- Principal Diagnosis: Obsessive Compulsive Disorder
Homer Briner appears to have an obsession with sexual fantasies and urges (American Psychiatric Association, 2013) towards a prepubescent child(ren) he gratified through his daughter. He exhibits compulsions through the sexual abuse he imposed on his young daughter through increasing invasiveness over time. Due to his persistent, unwanted thoughts, Briner presented avoidance of social interactions as these were stressful times for him (American Psychiatric Association, 2013). Additionally, he admitted that he feared rejection from peers, specifically his female counterparts. According to the DSM-5, individuals with OCD may exhibit avoidance as a way to avoid causing harm or situations that may prove to be stressful (American Psychiatric Association, 2013). Also consistent with the DSM-5 criteria is that obsessions or compulsions cause distress in occupational, social, or other areas of functioning (American Psychiatric Association, 2013) evident in homers inability to maintain employment and a functional family life.
- Secondary Diagnosis: Pedophilic Disorder
Homer Brine was found guilty of sexually abusing his daughter. Homer was in the closet naked with his daughter and a pornography magazine. He admitted to genital exposure, fondling, and digital and oral penetration with his daughter. According to the DSM-5, pedophilic disorder is a condition claiming there must be a period of six months in which “recurrent, intense sexually arousing fantasies,” urges, or sexually oriented behaviors with a prepubescent child(ren) (with prepubescent declared as under the age of thirteen) has occurred (American Psychiatric Association, 2013). The individual must have at some point acted on the sexually natured urges or fantasies or exclaimed a marked distress / interpersonal difficulty due to the urges or fantasies (American Psychiatric Association, 2013). Additionally, the individual must be five years older than the child(ren), be at least sixteen years old, and void of an ongoing sexual relationship with a twelve or thirteen-year-old (American Psychiatric Association, 2013). Homer Briner’s recollection of sexual behavior with his daughter is consistent with the DSM-5 criteria for Pedophilic Disorder with a specifier of incest (Patricelli 1995-2016).
- Etiology of Obsessive Compulsive Disorder
The definitive causes of OCD remain undefined (American Psychiatric Association, 2013). However, research implicates potential causes that will be addressed. Twenty-five percent of cases have an onset by the age of fourteen and males typically have an earlier onset than females with twenty-five percent of males exhibiting onset by age ten (American Psychiatric Association, 2013). Non-invasive research implicates abnormal patterns of circuitry in the cortico-striato-thalamo-cortical (CSTC) loops (Ting & Feng, 2011). Research has also found the basal ganglia circuit function describes numerous partially closed and parallel loops through the CSTC pathway believed to promote disjoined cognitive or motor function (Ting & Feng, 2011). However, a revision of the model incorporates the hypothesis which posits the manifestation of OCD is related to the hyperactivity of the orbitofrontal-subcortical loops (Ting & Feng, 2011). The hyperactivity is caused by the “disruption in the balance of activity through the” basal ganglia pathway (Ting & Feng, 2011) which is ultimately responsible for compulsive behavior (Grant & Kim, 2014).
Impulsiveness illustrates the manner in which rewards are achieved (Grant & Kim, 2014). Reward value tracking is associated with the prefrontal cortex and ventral striatum and response control associates with the right inferior frontal gyrus (Grant & Kim, 2014). Impulsive choices link to an overactive reward drive, and compulsive behavior is accredited to a malfunction of the inferior right frontal gyrus as explained through the previously discussed CSTC loops and basal ganglia circuit functions (Grant & Kim, 2014). As the circuitry overlaps decisions and motivation coincide to direct compulsive and impulsive behaviors observed in individuals (Grant & Kim, 2014).
In Homer Brine’s case, compulsive sexual thoughts drive the motivation for his impulsive behavior of acting on the compulsions because the reward of self-gratification is stronger than the outcome, despite having the knowledge that he is harming his daughter. It is believed his self-inflicted isolation manifested as a means of coping to avoid harming others due to his compulsions. According to the DSM-5, OCD behavior may have a slowly progressing onset (2013), as implicated by Homers admittance that invasiveness grew over time from exposure to fondling to digital and oral penetration.
- Etiology of Pedophilic Disorder
Theoretically, brain dysfunction, in a sense, is attributed to the development of pedophilia (Liu, 2012). According to Liu, abnormalities within the temporal lobe is associated with hypersexuality and deviations in the development of the prefrontal cortex cause the inability to inhibit sexual urges (2012). These deficits define Kluver-Bucy syndrome which is characterized by cognitive and sexual disturbances marked by the failure to associate meaning with visual stimuli, oral fixations, reduced sexual inhibition, and increased sex drive (Liu, 2012). Additionally, temporal lobe damage is linked to speech and language deficits, which is causation for lacking in adult relationships and increasing the attraction to children (Liu, 2012).
Through the use of imaging, researchers have identified abnormal activity in the areas of the brain including the hypothalamus, periaqueductal gray, and dorsolateral prefrontal cortex in response to visual erotic stimuli (Liu, 2012). Since these regions are associated with emotions related to sexual arousal, dysfunction may be responsible for the lack of sexual interest in adults (Liu, 2012). Confirming this hypothesis was a study that indicated higher activation in these areas of the brain for pedophiles when erotic stimuli featuring children were introduced (Liu, 2012).
Several psychological theories have implicated causes of pedophilia as well. The Attachment theory links poor quality attachments to sexual offending by explaining men who sexually abuse children lack social skills ad self-confidence necessary to develop effective peer relationships (“Bishop-Accountability”, 2004). Research studies attribute frustration with deficiencies in social skills that cause the individual to seek out intimacy with children due to problems accurately perceiving social cues, deciding appropriate behavior, and skills necessary to enact affective behavior (“Bishop-Accountability”, 2004). Integrated Theory presents four stages of offending beginning with emotional congruence (“Bishop-Accountability”, 2004). Emotional congruence manifests when the individual experiences low self-esteem and efficacy in social relationships that cause the individual to find comfort with children believed to be due to the sense of power and control that can be exerted on them (“Bishop-Accountability”, 2004). Sexual arousal is considered to manifest due to experience in childhood or observation of modeled behavior (“Bishop-Accountability”, 2004). Disinhibition clarifies stressful factors cause the manifestation of cognitive distortions which eventually leading to the offender to act on urges and fantasies (“Bishop-Accountability”, 2004).
An older study conducted by Glasser, et al. attempted to reveal a direct link to adult-child sex offenders to a historical cycle of violence, but was unable to do so (Glasser, et. al., 2001). Although the study revealed that a potential link among individuals who experienced both incest and pedophilia as a child were more likely to offend, the statistics implied a relatively similar outcome for those who not abused and turned perpetrators (Glasser, et. al., 2001). Consistent with Liu’s research, Homer Brine exhibits the inability to inhibit sexual urges as well develop affective adult relationships indicative of brain dysfunction (2012). Homer indicated a fear of rejection by females and it is inferred he suffered low self-esteem due to his inability to develop successful social relationships which caused him to self-isolate. Additionally, he admitted that he had difficulty with interpersonal relationships with coworkers and appropriately handling conflict and anger with supervisors. Denying himself socialization with peers may have led to stress necessitating relief which led to his sexual attraction to his young daughter. He desired power and control over his daughter, as dysfunctional parenting skills are evident and currently expresses stress due to financial hardship, familial relations, and court involvement which all hold potential to trigger the manifestation of distorted cognitions. Other stressful factors include his wife’s mental state; he admits difficulty in understanding, the strain between his mother and wife, and the difficulty he has maintaining employment to support his family. When the stress became too much to endure, he began to act on the cognitive distortions of sexual fantasies and urges by sexually abusing his daughter.
- Therapeutic modality
A behavioral and pharmacotherapeutic approaches are necessary for regards to Homer Brine. A behavioral approach will force Homer to understand the negative behavior and triggers that motivate those actions (“National Alliance On Mental Illness”, 2016). Behavior therapy will also allow Homer to adopt positive social skills and coping techniques when faced with situations that trigger obsessive and compulsive thoughts and behaviors while learning to redirect his anger in a positive manner (“National Alliance On Mental Illness”, 2016). Medications can balance the brain and reduce obsessive thoughts that trigger the impulsive behaviors (Pittenger, Kelmendi, Bloch, Krystal, & Coric, 2005). Other medications can reduce sexual desire as a way of deterring possible sexual misconduct in persons with Pedophilia (“Harvard Health Publications Harvard Medical School”, 2010).
Both Obsessive Compulsive Disorder and Pedophilia can benefit from the use of Cognitive Behavior Therapy in treatment. Cognitive Behavior Therapy addresses the manners in which the individual thinks and it effects behavior (“National Alliance On Mental Illness”, 2016). Confronting the thoughts of Homer Brine will bring to light the evolution of his mental illness. Finding the causes of his antisociality will help define the basis of his fear of rejection which will, in turn, aid in defining productive ways to incorporate positive socialization skills into daily life. Cognitive Behavior Therapy via Relapse Prevention teaches the individual to anticipate and recognize the situations that increase the chance of sexually harming a child as well as ways to avoid or productively deal with these situations (“Harvard Health Publications Harvard Medical School”, 2010). Homer appears to have directed distorted cognitions, believed to be triggered by daily stress, towards his daughter as an escape from volatile salutations. Learning to identify potential triggers and developing ways to deal with them will help Homer redirect his distorted cognitions and avoid harming his child. Studies have implicated a reduction in recidivism using this form of Cognitive Behavioral Therapy (“Harvard Health Publications Harvard Medical School”, 2010).
Drug interventions such as testosterone suppression has also proven to decrease the frequency and intensity of sexual desire as well as give the advantage of monitoring as follow-up visits are necessary (“Harvard Health Publications Harvard Medical School”, 2010). SRI’s have proven to be beneficial in normalizing the orbitofrontal activity (Allen, King, & Hollander, 2003), clarified through the research of Ting and Feng (2011). Additionally, upon release at the completion of sentencing, Homer Brine will greatly benefit from outpatient civil commitment which will closely monitor his interaction with family and continue support after release. Testa and West explain outpatient civil commitment as a way to allow the individual back into society, but mandates continued treatment (2010). Outpatient Civil Commitment allows the state to continue to monitor the individual while in our community, and the mandated treatment ensures the person does not become harmful to others or themselves (Testa & West, 2010). Additionally, with this type of commitment does allow easier hospitalization commitment at the earliest stage of deterioration or if the individual fails to comply with mandated orders (Testa & West, 2010).
- Differential Diagnosis: Antisocial Personality Disorder
The DSM-5 declares Antisocial Personality Disorder as a pattern of behavior that negates regard for and emphasizes violation of others (American Psychiatric Association, 2013). The individual may exhibit nonconformity of social expectations in regards to the law, deceitfulness, impulsivity, aggression, disregard for the safety of others, irresponsibility, or lack of remorse (American Psychiatry Association, 2013). The individual must be eighteen years of age with an onset of conduct disorder before the age of fifteen (American Psychiatry Association 2013). Although Homer has dictated and proven himself as antisocial, it is a coping mechanism for his fear of failure which began at an early age. Although Homer meets several criteria, he lacks the necessary onset of conduct disorder by the age of fifteen. He had only one prior arrest for arson and no other trouble with the law was exposed until his current arrest for sexually abusing his daughter.
- Cultural Factors
Homer is a Caucasian male who explains a normal childhood with a traditional Christian upbringing. In regards to his religious upbringing, if he had manifested symptoms of either OCD or Pedophilia, it is possible that his family may have deviated him as under possession of bad spirits or told to pray through (Behere, Das, Yadav, & Behere, 2013). Not only does religion hold potential for early intervention hindrances, but excessive sexualism is also decried upon which may heighten feelings of shame and guilt inhibiting positive growth (Behere, Das, Yadav, & Behere, 2013). Media has aided in bringing awareness to communities Pedophilia and deviant sexual behavior (Liu, 2012) that is typically deemed as unacceptable no matter the circumstance. However, the media’s promotion of awareness has emphasized the need for understanding the neurobiological aspects of the illness (Liu, 2012), but it seems that society only perceives the negative behavior and continues to emphasize the “wrong” in the individual negating the positive potential. If the individual feels society will not accept him or her after treatment, they may decide treatment is pointless and choose not to comply.
Allen, A., King, A., & Hollander, E. (2003). Obsessive-compulsive spectrum disorders. Dialogues in Clinical Neuroscience, 5(3), 259–271. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181632/#ref138
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Behere, P. B., Das, A., Yadav, R., & Behere, A. P. (2013). Religion and mental health. Indian Journal of Psychiatry, 55(Suppl 2), S187–S194. http://doi.org/10.4103/0019-5545.105526 Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3705681/
Bishop-Acountability. (2004). Retrieved from http://www.bishop-accountability.org/reports/2004_02_27_JohnJay/LitReview/1_3_JJ_TheoriesAnd.pdf
Glasser, M., Kolvin, I., & Campbell, D., Glasser, A., Leitch, I., & Farrelly, S. (2001, December). Cycle of child sexual abuse: links between being a victim and becoming a perpetrator. The British Journal of Psychiatry, 179(6), 482-494. 10.1192/bjp.179.6.482
Grant, J. E., & Kim, W. (2014, May). Brain circuitry of compulsivity and impulsivity. CNS Spectrums, 19(1). Retrieved from http://onlinedigeditions.com/article/Brain_Circuitry_Of_Compulsivity_And_Impulsivity/1672374/202960/article.html
Harvard Health Publications Harvard Medical School. (2010). Retrieved from http://www.health.harvard.edu/newsletter_article/pessimism-about-pedophilia
Liu, P. (2012, March). Pedophilia and brain function. UBCUJP, 1, 1-6. Retrieved from ojs.library.ubc.ca/index.php/ubcujp/article/download/2500/182436
National Alliance on Mental Illness. (2016). Retrieved from http://www.nami.org/Learn-More/Treatment/Psychotherapy
Patricelli, MA, K. (1995-2016). Behvioral connections. Retrieved from http://www.behavioralconnections.org/poc/view_doc.php?type=doc&id=571
Pittenger, C., Kelmendi, B., Bloch, M., Krystal, J. H., & Coric, V. (2005). Clinical Treatment of Obsessive Compulsive Disorder. Psychiatry (Edgmont),2(11), 34–43. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2993523/
Testa, M., & West, S. G. (2010). Civil Commitment in the United States.Psychiatry (Edgmont), 7(10), 30–40. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3392176/
Ting, J. T., & Feng, G. (2011). Neurobiology of obsessive-compulsive disorder: insights into neural circuitry dysfunction through mouse genetics. Current Opinion in Neurobiology, 21(6), 842–848. http://doi.org/10.1016/j.conb.2011.04.010