Background: Paraphilias are psychosexual disorders that are usually conceptualized as deviant in nature. Yet in some cases, paraphilia can be conceptualized as an obsessive compulsive disorder. Method: We describe an exhibitionist treated under partial single-blind conditions (patient was blind to placebo but was aware he was receiving desipramine and fluvoxamine) with the serotonin selective reuptake inhibitor fluvoxamine, followed by desipramine and a placebo that looked like fluvoxamine, in an ABACA design. He was serially assessed with the Yale-Brown Obsessive Compulsive Scale. Results: Fluvoxamine eliminated the undesired impulse and behavior without affecting sexual desire. Desipramine and single-blind fluvoxamine-placebo treatment were both associated with relapses. Conclusion: A subset of paraphiliacs may be suffering from obsessive-compulsive-related disorders and may benefit from serotonergic agents. (J Clin Psychiatry 1994;55:86-88)
Received March 21,1991; accepted Dec. 11, 1992. From the Division of Psychiatry, Chaim Sheba Medical Center, Ramat Gan, Tel-Hashomer (Dr. Zohar), and the Division of Psychiatry, Beer Sheva Mental Health Center, Israel (Drs. Kaplan and Benjamin). Reprint requests to: Joseph Zohar, M.D., Chaim Sheba Medical Center, Division of Psychiatry. Ramat Gan, Tel-Hashomer 52621, Israel.
Sexual offenders are usually dealt with by the legal professions often without regard for treating the deviant behavior. When offenders are referred to psychiatrists, they are regarded as cases of sexual deviations, and the common treatment strategy is simply pharmacologic reduction of sexual drive. However, approaching the disorder as obsessive-compulsive-related has started to get some attention.(2) We are aware of a case (3) in which sexual behavior was conceptualized as obsessive compulsive in nature (as opposed to deviant), and of another two cases(4,5) in which a serotonergic drug (buspirone) was offered to a fetishistic transvestite and an atypical paraphiliac. Another report(6) describes two patients who had unwanted erections in parallel with ego-dystonic, obsessive fears of displaying inappropriate sexual behavior, but they did not exhibit, masturbate, or in any other way act on their obsessions. Four paraphiliacs, two of them exhibitionists, responded to the specific serotonin selective reuptake inhibitor (SSRI) fluoxetine. (7,8)
Here we report the successful use of another specific SSRI, fluvoxamine, in a case of compulsive exhibitionism and masturbation.
Mr. A, a 36-year-old married "blue-collar" worker and father of four children, referred himself to our unit because he was persistently masturbating in front of women in public. Aberrant sexual impulses first appeared at the age of 10, when he began surreptitiously to touch women's buttocks in crowded places. When he was 17, he began to masturbate in the open, and ever since, had not only spent many of his waking hours consumed with thoughts of these acts, but also feared that he would once more carry them out and be caught. Although he considered his acts reprehensible, and his fantasies were. accompanied by anxiety and shame, he would sometimes actively seek out situations in which he might expose himself. At times the acts were unaccompanied by erection or ejaculation and seemed more in the manner of only touching or exposing his genitals; but at other times he reported unequivocal sexual arousal. He had exposed himself in front of his children, had been arrested more than once, and had one conviction.
There was no history of obsessive compulsive disorder or Tourette's syndrome. Mr. A had been treated elsewhere with supportive psychotherapy and thioridazine 50 mg/day without success. At this point, Mr. A came to our unit asking to be castrated. He was about to lose his job, and his marriage was on the verge of collapse. While waiting outside the examiner's office, he was seen lowering his trousers and masturbating. During the interview he was agitated, distressed, and despondent. There were no other significant findings. On the ward, we were impressed by the persistent, intrusive, and partly egodystonic nature of his thoughts and by the temporary relief of anxiety that appeared to follow his yielding to them. These seemed to us reminiscent of obsessive compulsive disorder no less than of paraphilia. On the Yale-Brown Obsessive Compulsive Scale (Y-BOCS)(9,10). Mr. A had a score of 34 out of a possible 40 and a Global Severity score of 6 out of a possible 6 (Figure 1).
Mr. A was started on the SSRI fluvoxamine, up to 300 mg/day. After 2 weeks, the impulses and acts had disappeared entirely, and his scores had accordingly fallen to zero. He thereafter was treated as an outpatient (point a, Figure 1).
Because serotonergic mechanisms are thought important in obsessive compulsive disorder, and we wished to examine further the specificity of the treatment that seemed so encouraging, we substituted fluvoxamine with desipramine, another antidepressant but one that has a noradrenergic rather than a serotonergic profile. The procedure was carried out with the full consent of the patient, who was also advised that he might be offered a nonactive form of medication at some stage during his assessment. After 1 week on desipramine treatment, Mr. A's impulses had retumed, but he was able to direct his thoughts to religious themes instead and retained full control over his behavior (point b, Figure 1). Within another week, he had lost the ability to control his thoughts and was touching himself in public two to three times a day. Desipramine treatment was discontinued and fluvoxamine reinstituted; within a fortnight it was as effective as before. However, because of the patient's dizziness and anorexia, the dose was lowered to 200 mgl day, with no loss of efficacy (point c, Figure 1).
After 4 weeks, fluvoxamine was replaced in singleblind fashion by identical-appearing placebo tablets. Two weeks later he felt his impulses were about to return, and he asked us to re-raise his dose. We accordingly increased the dose of placebo from "200 mg" to "300 mg," which brought him temporary relief (point d, Figure 1). However, after 2 weeks his obsessions were once again moderate in intensity, but he was not acting on them. A week later he yielded completely to his impulses and was found masturbating near a group of highschool girls. Active fluvoxamine was reintroduced and was as effective as when it was first administered.
The serotonergic agent fluvoxamine was clearly and repeatedly effective in this case of deviant sexual behavior. Desipramine, a control noradrenergic antidepressant, and a placebo were ineffective. An essential feature of paraphilic behavior is that unusual or bizarre imagery or acts are necessary for sexual excitement, and such imagery or acts tend to be insistently and involuntarily repetitive." It is the inappropriate target (as with children, inanimate objects, chance passersby) of the sexual activity, not merely its quantity (as in satyriasis), or lack of inhibition (as in some dementias, for example), that signifies paraphilia. For most of these patients, the perverse sexual orientation replaces normal sexual activity.
One subtype of paraphilia is exhibitionism. Exhibitionism is defined according to the DSM-III-R as a repetitive act of exposing the genitals to an unsuspecting stranger for the purpose of achieving sexual excitement with no attempt at further sexual activity with the stranger." While Mr. A is an acknowledged exhibition1st, i.e., fits the criteria for paraphilia, we chose to interpret at least part of his behavior as an obsessivecompulsive-related disorder for he showed certain traits of obsessive compulsive symptomatology. His sexual impulses were persistent, intrusive, and frequently egodystonic. Moreover, unlike most paraphilic exhibitionists, he had no desire to provoke any particular response from his audience. Finally, Mr. A enjoyed heterosexual relations with his wife.
Response to serotonergic agents does not of itself amount to a diagnosis of obsessive compulsive disorder. However, the lack of response to a noradrenergic agent (12) and to placebo and the robust and repeated response to fluvoxamine, along with the aforementioned obsessive compulsive features, are in line with the hypothesis that this patient might represent an example of someone with an obsessive-compulsive-related disorder that presents as paraphilia.
An altemative explanation would depict the beneficial response observed in this case as the result of fluvoxamine's lessening the sexual drive. This reaction is a general serotonergic effect in other species; however, direct evidence for such an effect in man has yet to be pro~ Indeed, reduction of sexual desire is a standard procedure for many sexual offenses and excesses. The common agents for reducing sexual desire are antiandrogens like medroxyprogesterone acetate and cyproterone acetate. Neither of these agents has any influence on the abnormal nature of the sexual impulse, and they adversely affect all aspects of libido. These drugs are controversial, and medroxyprogesterone has not been approved by the Food and Drug Administration for this purpose. However, had this drive reduction been the mechanism of action of fluvoxamine in our patient, a general lessening of sexual desire would have been expected. Yet his desire for his wife was not affected, only his pathological sexual behavior.
Our conclusions are subject to all the limitations of a single case study, however carefully performed. But they do derive some support from the partial single-blind ABACA design and the consistent and sustained nature of the clinical response. Thus the possibility exists that some apparent paraphiliacs might in fact be suffering from obsessive-compulsive-related disorders, and might respond to serotonergic medications.
Drug names: buspirone (BuSpar), cyproterone acetate (Androcur). desipramine (Norpramin and others), fluoxetine (Prozac). medroxyprogesterone acetate (Provera and others). thioridazine (Mellaril and others).
J Clin Psychiatry 55:3, March 1994