29 year old serving Nk/Clk self-reported on 15 Apr 10 with complaints of difficulty in completing his job, increasing irritability & marital disharmony of one and half years duration. However, detailed evaluation revealed significant difficulties since several years in his sexual behavior and ability to complete a task on time
At 10 years of age he had started rubbing his genitalia on bed to get pleasurable effects but had no sexual thoughts attached. At 13 years of age started having repeated sexual thoughts after reading pornographic material, also fantasized of having sex & continued self stimulation by rubbing his penis on the bed or pole and ejaculate at a frequency of once every 2 or 3 days to about 2-3 times daily.
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By age of 14 years he also had repeated intrusive thoughts that while bathing soap has not been properly washed from the body and keep on taking bath and drying his body, spending 30-35 min in the bathroom, that his hands are dirty and had to be washed repeatedly. Individual would keep ruminating about the daily activities and frequently get late for his school. He was having repeated thoughts to arrange things in particular pattern and spent lot of time doing so and used to get irritated when his pattern was disturbed. This resulted in deterioration of academic performance. He would often fondle his unsuspecting, young female relatives non-consensually & thereafter would masturbate. He would feel guilty for the same even before doing the act and considered it as wrong but was not able to stop himself.
Over the next couple of years masturbated excessively with pleasure, but developed guilt & distress post-act. Often tried to ward off urge to masturbate by chanting Hanuman Chalisa. Came to Pune in 1996 for further studies but he began arranging his things in a particular pattern and got irritated when it was disturbed. He would remain annoyed until he had rearranged them & spent excessive amount of time on these thoughts and actions. Unable to concentrate on studies his academic performance deteriorated gradually.
By age of 18 years the frequency of his sexual thoughts increased and he started touching unsuspecting females and rubbing his penis against females in crowded places. For doing this he would purposefully board crowded buses. After failing thrice in 12th he returned to his village.
By age of 20 years he would peep in the houses of people to see women changing clothes. Peep into other’s houses to catch glimpse of people engaged in intercourse, or women changing clothes or in compromised dresses. Thereafter would masturbate either at that place or after returning to his home.
With great difficulty he passed 12th and joined army at age of 21 years and the frequency and duration of these thoughts decreased during training period. After the unit moved to field area in 2006 he started calling unknown females on phone to talk on sexually explicit matters. Followed by masturbation and was spending Rs 1500- 2000 /- month on such phone calls. After marriage at age of 25 years had satisfactory sexual activity with spouse, but had sexual fantasies about other females even while having intercourse with his wife. His irritability increased as he was not satisfied with the cleanliness maintained by his wife and also because she would disturb the pattern of kept things in the house. Because of this he developed marital discord in 2007, consulted a psychiatrist but discontinued medication after 15 days as he perceived no improvement.
While working in the unit had repeated doubts whether he has typed the letters correctly and placed the letter in the right envelope and would check the same 3-4 times. Took longer to complete a given task, irritability increased, had disturbed sleep, had bi-temporal headache throughout the day. In Jan 2010 at age of 29 years he consulted civil psychiatrist again. He was diagnosed as a case of OCD and was started on Tab Clomipramine 75 mg and Tab Resperidone 2 mg. He had irregular drug compliance and developed restlessness, tremors, stiffness of the body and difficulty in concentrating in work. He therefore self-reported at MH Belgaum and subsequently transferred to CH (SC).
He has had no significant past or family history of psychiatric morbidity. Born in 1981, being only son was more looked after than sisters, was brought up in strict environment and was expected to be good in studies. History of irritability and temper tantrums when his demands were not met educated till 12th and joined army in 2002 as clerk in infantry. Married in 2006, had marital discord within a month of marriage over the issue of cleanliness and arrangement of things in the house. He consumed about 120 ml of rum 2-3 times a month & claimed no exposure to CSW.
Examination
General and systemic examination was within normal limits. Mental status examination revealed an anxious mood and affect with no evidence of any psychotic symptoms. He had insight, but biodrives were deranged. Investigations revealed normal testosterone. Yale Brown Obsession Compulsion Scale scores were 15/20 for obsession, 10/20 for compulsion. Rorschach Psycho diagnostic test revealed feelings of inadequacy, restlessness, high sensuality & features suggestive of OCD.
Final diagnosis
A.Paraphilia
1. Voyeurism (F65.3)
2. Other disorders of sexual preference (F65.8)
a) Frotteurism
b) Scatologia
B. Obsessive Compulsive Disorder (F 42.0)
Management
He was managed with Tab Clomipramine, psychotherapy. He showed good response and most of his OCD symptoms remitted and claimed to have had remission of most of his paraphelic symptoms as well while he was on sick leave.
What is an obsession?
Obsessions are recurrent, intrusive, and distressing thoughts, images, or impulses that are usually unpleasant and increase a person’s anxiety. The patient recognizes them as his own, as irrational & egodystonic, unable to successfully resist them.
What is a compulsion?
Compulsions are repetitive, seemingly purposeful, behaviours that a person feels driven to perform to reduce anxiety, recognized by the individual as ineffectual, pointless makes repeated attempts to resist them. Resistance to carrying out a compulsion results in increased anxiety.
What is voyeurism?
Voyeurism is sexual gratification achieved from watching people undressing or nude, or observing them during sexual acts without their knowledge or consent.
What is frotteurism?
Frotteurism refers to the sexual gratification achieved by touching or rubbing a nonconsenting person. This behavior often occurs in busy, crowded places, such as on busy streets or on crowded buses or subways
What are the common themes of obsession?
Common themes of an obsession are contamination, doubt, rumination slowness and symmetry.
What are the common themes of compulsions?
The common themes of compulsions are cleaning, washing checking and arranging rituals
What is scatologia?
Calling on telephone known or unknown females to carry out sexually provocative conversations.
What is paraphilia?
The term paraphilia, is defined as intense, recurring sexual fantasies, sexual urges or behaviors that involve nonhuman objects, children or nonconsenting adults, suffering or humiliation (to self or to others), lasting for at least 6 months with resultant clinically significant distress or impairment in social, occupational, or other important areas of functioning.
What are the common co-morbid psychiatric illnesses associated with paraphilia?
Axis I disorders- mood disorder, dysthymic disorder, substance abuse, anxiety disorders, and social phobias.
Axis II disorders- Personality disorders, Obsessive compulsive personality disorder, Borderline personality disorder
When would you suspect organic aetiology in a case of paraphilia?
Following suggest organicity:
a) altered sensorium /seizure prior to paraphilic act
b) use of excessive aggression
c) atypical paraphilia
d) h/o mental retardation, ADHD, dyslexia
e) sadistic/ aggressive behaviour concomitant with problems of sexual identity and transvestic fetishism
What are the risk factors in children to develop paraphilias?
The following are situations or causes that might lead children in a paraphiliac direction:
A young boy who is sexually abused
An individual who is dressed in a woman’s clothes as a form of parental punishment
Psychosexual trauma
Lack of emotional attachment at home
What is normal level of serum testosterone?
Normal sexual interest and capacity maintained at levels of 275-875ng/dl. Hyper sexuality/paraphilia may occur beyond this upper limit
What are the diagnostic criteria for Obsessive Compulsive Disorder?
Obsession symptoms or compulsive acts, or both, present for at least 2 successive weeks distress or interference with activities. The obsession symptoms should have the following characters-recognised as the individuals own thoughts or impulses not in itself be pleasurable must be unpleasantly repetitive.
What is the neurobiological basis of paraphilia?
Increased prefrontal, caudate activity increased opiate activity in the cingulate, temporal and frontal cortex. Testosterone converted to estradiol in the brain acts as a sexual stimulant, decreased serotonin levels in brain.
What medical conditions can lead to paraphilic manifestations?
Multiple sclerosis
Cognitively impaired older individuals
What is pedophilia?
Pedophilia involves sexual act with a child of at least 5 years younger than the perpetrator, with the perpetrator being at least 16 years of age or more.
What are the pharmacological interventions approved for treatment of paraphilias?
Approved interventions are:
SSRI:- Fluvoxamine, Sertraline, paroxetine
TCA:- Clomipramine
Anti-androgens:
Leuprolide Acetate(analog of LHRH) – 7.5mg IM every 3 months
Triptorilline (analog of GnRH) — 3.75mg IM. Mthly (along with Futamide 250mg tds for one month
Ciproterone Acetate 50-200 mg/day
Medroxy progesterone acetate 300-400mg IM (depot), up to 200mg orally.
Others : Naltrexone 150mg daily
What are the emerging trends in relation to paraphilia?
Traumatic brain injury has been suspected as an etiology for hypersexuality pedophilia & fetishism or neurodevelopmental delay increase proneness to accident &pedophilia. Iatrogenic Paraphilia implicated with use of Levodopa & Pergolide. Role of parenting styles of over indulgence & over control, premature sexualisation by exposure to sexuality on media, childhood psychological trauma confuses need for affection with sexual arousal.
Further reading
Saldanha D, Chaudhary S, Ryali VSSR, Goyal S, Srivastava K, editors, Handbook of Undergraduate Psychiatry. AFMC, Pune, India. 2007.
Sadock BJ, Sadock VA. Concise Textbook of Clinical Psychiatry. 10th Edition. Lippinkott Williams & Wilkins.New Delhi.2008.
Sethi S. Textbook of Psychiatry. 1st Edition . Elsiever .New Delhi.2008.
Gelder MG, J Lopez-Ibor Jr, Andreassen NC. Editors. New Oxford Textbook of Psychiatry. Vol1. Oxford University Press. Oxford. 2009.
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