Hocken, K

Kaul, A

Skett, S

Winder, B

Nottingham Trent Institutional Repository (IRep)

Medication to Manage Sexual ArousalOffender Personality Disorder pathwaySarah Skett, Belinda Winder, Adarsh Kaul, Kerensa Hocken, Don Grubin, Christine Norman, Jessica Faulkner, Helen Elliot & Rebecca Lievesley.A Pathway of Services (short version)MMSA – What is it?• SSRIs or anti-libidinal medication• For offenders who experience psychological difficulties and distress in the form of intrusive and obsessive thoughts about sex, compulsive sexual behaviour,  compulsive masturbation, and very frequent sexual arousal, and for offenders in whom sexual arousal is associated with negative mood states.    • Can assist users to engage in offending behaviour programmes and services, or help them avoid high risk situations.• Always offered within a psychologically informed frameworkWho is it for?• Offenders with a sexual element to their offending • Over 18, men and women• Who complain of:– sexual pre-occupation– high levels of  sexual arousal– deviant sexual fantasy which is subjectively difficult to control– sex as way of coping with low mood or anxiety• Completely voluntary• Offered at an appropriate time in sentencePsychological difficulties and distress including: Intrusive and obsessive thoughts about sex, deviant arousal or problem sexual behaviour associated with low mood or anxiety, sexual arousal or behaviour that is subjectively difficult to manage, high sex drive.   Psychometrically determined sexual preoccupation.Low Symptom Medium symptom High SymptomRisk of harmful sexualoffendingas measured by a suitable risk assessment (RM2000,  OSP, or SARN)Low risk of harmNot indicatedNot indicated IndicatedMedium risk of harm Not indicated Consider IndicatedHigh risk of harm Consider Consider IndicatedSome basic principles of sexual arousal• sex drive is biological• no one chooses their sexual arousal profile• difference between arousal and control of arousal• attitudes & beliefs, emotional state, self-management,influence sexual behaviour• the most important male sex organ is:Sexualthoughts, driveAttitudes, beliefsEmotional stateBehaviouralcontrolsM dicat onMedication for sex offendersmedical treatmentvsocial control- consent- confidentiality• some work with you• some are ambivalent• some don’t want to knowThe Neurobiology of Sexual ArousalHypothalamusPituitaryTestesGonadotropin hormonereleasing hormone(GnRH)Lutenising hormone(LH)Follicle stimulating hormone(FSH)Testosterone~5% produced byadrenal glandsTHE REST OF THE BRAINT neg. feedbacklimbic system5-HT                dopamineTestosterone reduces sexual interest more than sexual functionAnti-androgens: depo-Provera (Oregon) (Maletzky, Tolan & McFarland, 2006))Provera No Provera Not recom.n=79 n=55 n=141sex recidivism 0 10 (18%) 21 (15%)sex breech 1 12 (22%) 6  (4%)in prison 0 11 (20%) 19 (13%)‘doing well’ 70 (89%) 24 (44%) 89 (63%)GNRH agonists: Triptorelin (Rosler & Witztum, 1998)n = 30“hypersexual”: masturbate 32/weekfantasise     48/weekbehaviour   5/monthfailed on other Rxdropout = 6 (20%){3 from side effects}Triptorelin (Rosler & Witztum, 1998)RESULTSfollow-up to 31/2 yearsmasturbation       = 0-1 per weekdeviant fantasies = 0behaviours          = 0reoffences = 0 {except for 2 side effectdrop outs}testosterone reduction: 95%LH reduction: 90%bone mineral density:  40-50%Schober (www.clinicaltrials.gov)N=5CBT for 2 years; luprolide year one, saline year twoResults- decrease but no difference in ppg, Abel Screen- all reported decreased in fantasies, urges and masturbation- polygraph: at baseline and placebo, deceptiveanti-androgens side effects• menopausal symptoms(hot flushes, depression, weight gain, cvs)• gynaecomastia• osteoporosis• carbohydrate metabolism, other endocrineGnRH side effect kinder?SSRIs: the studiesdecrease in strength and frequency of fantasiesdecrease in sexual urgesdecrease in masturbationdecrease in behavioursdelay in ejaculationSSRIs: Mode of Action?• OCD• impulsivity• mood enhancement• all of the above• reduction in sex drive• reduction in orgasmic enjoymentSexual DevianceEvaluation of the use of MMSA- BelindaNottingham Trent University (SOCAMRU),HMP Whatton & Nottinghamshire Offender Healthcare Dr Belinda WinderDr Kerensa HockenRebecca LievesleyHelen ElliottDr Christine NormanJessica FaulknerDr Adarsh KaulBackground• Interventions with sex offenders in UK prisons are primarily psychological in nature, adopting a CBT approach.• High levels of sexual preoccupation and hypersexuality in high risk offenders appears to interfere with engagement on psychological treatments, potentially resulting in poor outcome on programmes.• Evidence suggests the potential for use of medical treatment in aiding the management and treatment of risk factors such as sexual preoccupation / obsession.• This is important since sexual preoccupation (both in the offence chain and generally) is the most  frequently occurring ‘strongly present’ risk factor in sex offenders.Proportion of prisoners scoring ‘strongly present’ on most frequently occurring SARN risk factorsContext• HMP Whatton holds approximately 840 adult males convicted of a sexual offence (or where there is a sexual element to their offence). It is one of the largest sex offender prisons in Europe. Forty-two percent have a sentence of more than four years.• 46% are serving an indeterminate sentence including life sentence.• RM 2000 scores o 37 % high / very higho 40 % mediumHMP Whatton started offering MMSA in November 2009• Drugs used o Fluoxetine, Paroxetine (SSRIs)o Cyproterone acetate (CPA, anti androgen)o Triptorelin (GnRH agonist)• Treatment PathwayResults from the Evaluation• Clinical measures:– Captured at regular meetings between participants and Dr Kaul (prescribing psychiatrist)– Data collated during private therapeutic session– Used clinically to discuss and tailor medication– Data then transferred to research team where it is collated and organisedsystematically• Psychometric measures:Dynamic measures (baseline pre-meds, then approximately every 3 months)– Sexual Compulsivity Scale (SCS)• 10 items; 1-4; used means i.e. between 1-4; ‘My desires to have sex have disrupted my daily life’– Hospital Anxiety and Depression Scale (HADS)• Scoring is 0-21 on each sub-scale; caseness 8/21– Severity Indices of Personality Problems (SIPP 118)Time spent thinking about sex High Paired t test shows significant drop between T0 and T3 for SSRI (t=8.53, 41, p=0.001) Clinical measures: number of days masturbating per week01234567T0 T1 T3 T6Number of days masturbate to orgasm Time intervals in monthsSSRIAASSRI &AAClinical measures: number of days masturbating per week - all meds combined01234567T0 T1 T3 T6Number of days masturbate to orgasm Time intervals in monthsMain effect of Time F(3,147) = 31.82 p = 0.001; ηρ2 .394Baseline - T1, P = 0.001T1-T3 nsT3-T6 nsResults from sexual compulsivity scaleFigure 1: Mean Sexual Compulsivity Scores for participants taking medication to reduce sexual preoccupation: pre-medication (T0), three months post-medication (T3) and six months post-medication (T6).Below the levels of ‘typical’ sex offendersSexual Compulsivity                                  Anti-libidinal group have significantly higher Sexual CompulsivitySC of main sex offender population at WhattonYoung sexually active studentsPersonality and sexual offending • Prevalence rate for PD in sexual offending populations varies between 94% (McElroy et al.,1999) and 33% (Fazel, Hope, O’Donnell & Jacoby, 2002) compared to general population of between 2-11%.• Cluster B (dramatic) PDs appear to be more prevalent in rapists, and cluster C (anxious) PDs are thought to be more prevalent in child molesters.• Research has found that problematic personality traits are a key predictor of sexual recidivism, especially when paired with a deviant sexual interest (Hanson & Morton-Bourgon, 2005).• However very little empirical investigation has explored the link between SP and personality. • The theoretical explanations of both SP and problematic personality share some similarities, particularly in relation to self- management factors. For example urge management/impulse control are considered to be problematic mechanisms in both PD and SP.Dimensional concept of PD• The view that personality was not susceptible to change had serious implications for treatment attempts (Andrea et al., 2007). • Research increasingly suggests that personality is more changeable or adaptive than previously believed (see Specht, Egloff & Schmukle, 2011).• Adaptive personality functioning is considered to be a person’s ability to be able to adapt to the situation or environment in relation to their personality traits (Andrea et al., 2007). For example, learning to have control over one’s emotions and impulses. • Maladaptive personality functioning refers to an individual’s inability to adapt their personality to the needs of the environment or situation (Andrea et al., 2007). Analysing PD in the current sample - Procedure• Researchers carried out the SIPP-118 questionnaire with individuals. • Standardised prompts were developed for those with lower understanding of the questions, and response options were presented verbally and in a visual format.  • The first administration of the SIPP-118 occurred before medication was commenced (referred to as ‘baseline’) and this process was repeated approximately every three months after medication.Percentage of clinically significant change of participants between baseline and six months on SIPP-118 scalesScale Baseline % of participants withmaladaptive functioningN (69)Six months % of participantswith maladaptive functioningN (41)% reliablechangeEmotionalregulation 68.12 29.27 38.85Effortful control76.81 46.34 30.47Frustrationtolerance 62.32 26.83 35.49Responsibleindustry 57.97 43.90 14.07Aggressionregulation 47.83 34.15 13.68Intimacy 47.83 24.39 23.44Enduringrelationships 66.67 46.34 20.33Self-respect 57.97 21.95 36.02Results – SIPP - 118• Prior to starting medication the research sample more closely resembled the clinical population (admissions to mental health institutes) than the general population on the SIPP-118. • The facets most problematic were effortful control, self-reflexive functioning, frustration tolerance, emotional regulation and stable self image.• Provides support for the hypothesis that the adaptive personality functioning in the domains of  self-control and relationships, of sexually preoccupied males convicted of a sexual offence was more problematic  than the general population norms. • Both statistical and clinically significant change was observed in adaptive personality functioning on all scales by six months post medication. The percentage of reliable change of adaptive personality functioning was between 13.6% and 38.8%, moving functioning from the maladaptive range to the clinically ‘normal’ range (general population norms). • The majority of participants had moved into the healthy range of personality functioning within six months of taking medication.• The results add some tentative support for the second hypothesis that medication to treat SP improves adaptive functioning on personality areas linked to self-control and relationships.Results – continuedHow do OM and OSs feel about the use of MMSA?• Qualitative study• Participants were 12 OMs/OSs• Thematic analysis of semi-structured interview data• Analysis: Two superordinate themesThe dangers of not knowingWho is taking it?Lack of trustWhat happens next?Treatment AwarenessScepticism to optimismOut of the loopMandatory vs voluntaryQualitative research with prisoners Qualitative research interviews with prisoners Preliminary findings: Reductions in the number and intensity of sexual thoughts and fantasies Improvements in mood and concentration Increased control over impulsive and/or compulsive behaviour –anger, OCD    Reduction in / loss of sexual arousal – implications? Side effects and compliance issuesHow do I access it for my prisoner?• Community on a case by case basis, through the Offender Personality disorder service in your LDUNOTE prisoner does not have to be screened into the pathway to access the medication!• Frankland - HSE• Isle of Wight – Cat B• Hull – Sex offender PIPE• Whatton – Cat C• Usk – Cat C• North Sea Camp – Cat D• Leyhill – Cat DContacts – prison services• Frankland Kimberley.Gibson@hmps.gsi.gov.uk• IOW Jacob.Seaward@hmps.gsi.gov.uk• Whatton philippa.lister@hmps.gsi.gov.uk• Hull Jolene.Jones@hmps.gsi.gov.uk• Leyhill Martine.Ratcliffe@hmps.gsi.gov.uk• North Sea Camp jen.munns@hmps.gsi.gov.uk• Usk - cerys.miles@hmps.gsi.gov.uk• HMPS Lead Martin.Fisher@hmps.gsi.gov.uk• SOTP Lead Jamie.Walton@noms.gsi.gov.ukContacts – OPD commissionersRegion/Function NOMS and NHS LeadsNorth of England Neil Piggin, neil.piggin@noms.gsi.gov.ukMick Burns, mick.burns@nhs.netMidlands and East of England Rachel Wilson, rachel.wilson@noms.gsi.gov.ukPeter Howe, peter.howe1@nhs.netLondon Laura d’Cruz, Laura.dCruz@noms.gsi.gov.ukMary O’Donnell, maryo'donnell@nhs.netSouth of England Nick Joseph, nick.joseph@noms.gsi.gov.ukZoe Thornton, zoe.thornton@nhs.gsi.gov.ukWales Nick.Joseph, nick.joseph@noms.gsi.gov.ukWomen Offenders Laura d’Cruz, laura.dCruz@noms.gsi.gov.ukTherapeutic EnvironmentsTherapeutic CommunitiesKirk Turner, kirk.turner@noms.gsi.gov.ukJennie Slater, jennie.slater@noms.gsi.gov.ukResearch and Evaluation Kathryn Harney, Kathryn.Harney@gmw.nhs.ukHeads of Offender PD teamIan Goode;  Joint Head of Offender Personality Disorder Co-commissioningCommissioning Group, Directorate of CommissioningNational Offender Management Service3rd Floor, Clive House70 Petty France London SW1H 9HDIan.Goode@noms.gsi.gov.uk or PD@noms.gsi.gov.ukSarah Skett; Joint Head of Offender Personality Disorder Co-commissioningNHS England Specialised Commissioningsarah.skett@nhs.net or PD@noms.gsi.gov.ukQuestions?

Outcomes and lessons learnt from the national evaluation of the medication to manage sexual arousal (MMSA) programme for individuals in secure settings

http://irep.ntu.ac.uk/id/eprint/32553/1/10030_Winder.pdf

Outcomes and lessons learnt from the national evaluation of the medication to manage sexual arousal (MMSA) programme for individuals in secure settings

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