SCOTTSDALE, ARIZ. — Some paraphilic stalking behaviors may be associated with right-hemispheric brain dysfunction, Montgomery Brower, M.D., said at the annual meeting of the American Academy of Psychiatry and the Law.
The brain's right hemisphere deals with visual-spatial functions, and right-hemispheric dysfunction “is something that exerts its effect early because it's either developmental or an early acquired syndrome,” said Dr. Brower of Harvard Medical School, Boston.
In either case, the dysfunction “has a developmental impact which manifests itself as a developmental learning disorder,” he noted.
The most common sign of right hemispheric dysfunction is a gap between verbal and performance IQs. “A split of 15 points is considered significant,” he said.
Patients with right hemispheric-related learning disorder, for example, often have poor recall when asked to construct a diagram from memory. However, since the left side of the brain is not impaired, these patients can often do quite well in school because their verbal and remote memorization skills are quite good. “In fact, they're often hyperdeveloped in that area,” Dr. Brower added.
Another manifestation of right-hemispheric brain dysfunction is social skills deficits. “This tends to manifest with a flat affect and diminished prosody,” he said.
These patients don't understand “the nonverbal components of interpersonal communication. They will often commit faux pas in social settings. They have trouble understanding wit and irony, and often grossly misinterpret what they're seeing, and it can sometimes result in serious interpersonal conflict because they fail to appreciate the emotional impact of their behavior on the other person,” Dr. Brower explained.
At least one study has found increased prevalence and underidentification of adult psychiatric patients with this syndrome. Other studies have found that these patients “frequently collect multiple diagnoses, none of which seem to fit comfortably,” he said.
The social skills deficits can lead to frustration in interpersonal relationships and continuing pursuit of people who are not interested in them, as was the case with one 20-year-old male who was in a juvenile facility.
“He didn't have a history of mental illness, but he showed the diminished affect, prosody, and impairments of social judgent,” Dr. Brower said. This patient also showed dysmorphic facial features consistent with fetal alcohol exposure, and he had mild impairments on visual-spatial tasks in addition to a 17-point difference in verbal and performance IQ.
This patient “didn't understand why he couldn't go and resume normal relationships with the family members of the incest victims of his pedophilia,” Dr. Brower said. “He couldn't imagine the emotional impact of trying to resume a normal family relationship with them.”
In the area of stalking behavior, one case involved a male patient who had a history of making homicidal threats to female partners who had tried to break up with him; he had been the subject of a restraining order for telephone stalking of one female victim.
During serial hospitalizations, the patient engaged in recurrent, socially inappropriate unwanted pursuit of female patients and hospital staff. He would become romantically obsessed and pursue them “and had a great deal of difficulty understanding why what he was doing was inappropriate,” Dr. Brower said.
Overall, “right-hemispheric dysfunction appears to be associated with disturbances in psychosexual development, which may contribute in some cases to paraphilic sexuality and possibly related sex-offending behavior,” he concluded. “Also, specific cognitive deficits and impairments in social skills seen in right-hemispheric dysfunction may contribute to stalking and erotic fixations.