Compulsive masterbation treated with combined naltrexone and mirtazapine: Case report and review

Journal:
July-December 2007 Volume 4(2)

Case Report

Author(s):
Avinash De Sousa
Page No:
110

ABSTRACT

Masturbation is a normal part of psychosexual development. It becomes troublesome when it becomes compulsive masturbation. The article reviews the small amount of literature available on compulsive masturbation and provides a case report of an adolescent that presented with compulsive masturbation and was treated successfully with a combination of Naltrexone and Mirtzapine with covert sensitization.

Key words: Naltrexone, Mirtazapine, Compulsive Masturbation.

INTRODUCTION

Masturbation is a normal activity that is common in all stages of life right from infancy to old age. It is a normal precursor of object related sexual behavior. It is stated to be an inevitable part of normal psychosexual development. Re-analysis of the Kinsey data has shown that 94% men have masturbated themselves to the point of orgasm at some point in their lives1. Moral taboos against masturbation have generated myths that it causes mental illness or decreases sexual potency though no scientific data supports this claim2. Masturbation becomes a psychopathological symptom when it becomes a compulsion above and beyond a person’s willful control, thus causing emotional disturbance due to its compulsive nature.

Compulsive masturbation (CM) has been defined as a non paraphilic sexual disorder3. The DSM-IIIR classification of psychiatric disorders has classified it as sexual addiction and puts it under the category sexual disorders not otherwise specified4 while ICD-10 classification of mental diseases puts it in the category of excessive sexual desire5. There is a scarcity of data on the clinical characteristics of such populations. The disorder is rare and though most patients coming for treatment are male, female cases also have been reported6. Cases studied report that 75% had major depression as a com-morbid diagnosis7. The phenomenon may be seen in schizophrenia8 and in gay populations9.

It is reported to be seen even in normal adolescence10-12 or as a part of infantile autism13 and as part of the clinical profile of sexual offenders14. It may be seen even in certain epilepsies or as a manifestation in absence status15.

Here we present a normal adolescent that presented with compulsive masturbation and secondary major depressive features and responded well to a combination of Naltrexone, Mirtazapine and covert sensitization.

CASE HISTORY

A 16 year old male student presented with a history of excessive uncontrollable frequency of masturbation since 1 year. He wanted to quit the habit. He had a lot of guilt associated with the habit. Repeated masturbation had affected his studies and he used to remain preoccupied with sexual thoughts most of the day. He also had physical weakness and symptoms suggestive of major depressive disorder. He attributed all his symptoms to his masturbation. His distress was great as he thought of getting himself castrated, vasectomized or undergoing a penile amputation to help him get rid of the habit. Initially his frequency of masturbation was once or twice a day. The frequency of masturbation gradually increased to 8-12 times per day. He used to spend 4-6 hours a day in the act. When he presented to our clinic, he was started on Naltrexone 50mg /day and Mirtazapine 15mg / day. The Naltrexone was increased to 100mg / day in a span of 2 weeks. He was also started on covert sensitization behavior modification method. At the end of 5 weeks, his masturbatory frequency decreased by 30% compared to baseline. At the end of 8 weeks he was 50% better. The patient was unfortunately lost to follow up.

DISCUSSION

Before initiating treatment in any form, the patient’s motivation for treatment must be established. No controlled trials of drugs are available in the management of this disorder though anecdotal case reports exist. The selective serotonin reuptake inhibitors have been used with a fair degree of success. Reports of the use of Fluoxetine, Fluvoxamine and Citalopram exist 8,9,16. There is also mention of cases that have responded well separately to Naltrexone and Mirtazapine11,13,17. Other therapies like cognitive behavior therapy, covert sensitization and systematic desensitization have been reported to be useful18. To our knowledge the above mentioned case is the first where a combination of Naltrexone and Mirtazapine has been used with success in the management of compulsive masturbation.

REFERENCES

1. Bancroft J. Researching Sexual Behavior: Methodological Issues. Bloomington: Indiana Universiy Press 1997.

2. Agguire B. Fluoxetine and compulsive sexual behavior. J Am Acad Child Adolesc Psychiatry 1999; 38: 943.

3. Albertini G, Polito E, Sara M, Di Gennaro G, Onorati P. Compulsive masturbation in infantile autism treated with mirtazapine. Ped Neurol 2006; 51: 683-8.

4. Black DW, Kehrberg LL, Flumerfelt DL, Schlosser SS. Characteristics of 36 subjects that reported compulsive sexual behavior. Am J Psychiatry 1992; 154: 243-9.

5. Briken B, Habermann N, Kafka MP, Berner W, Hill A. The paraphilia related disorders – an investigation into the relevance of the concept in sexual murderers. J Forensic Sci 1992; 51: 683-8.

6. American Psychiatric Association. Diagnostic and Statistical Manual of Menatl Disorders. 3rd ed R. Washington D.C: American Psychiatry Association, 1987.

7. Gold SN, Heffner CL. Sexual Addictions – many conceptions, minimal data. Clin Psychol Rev 1998; 18: 367-81.

8. Jacome DE, Risko MS. Absence status manifested by compulsive masturbation. Arch Neurol 1983; 40 : 523-4.

9. Kafka MP, Prentky RA. A comparative study of non paraphilic sexual addictions and paraphilias in men. J Clin Psychiatry 1992; 53: 345-50.

10. Kafka MP, Prentky RA. Preliminary observations of the DSM-IIIR axis I comorbidity in men with paraphilias and paraphilia related disorders. J Clin Psychiatry 1994; 53: 481-7.

11. Kafka MP, Hennen J. The paraphila related disorders – an empirical investigation of non paraphilic hypersexuality disorders in outpatient males. J Sex Marital Ther 1999; 25: 305-19.

12. Kornreich C, Den Dulk A, Verbanck P, Pelc I. Fluoxetine treatment of compulsive masturbation in a schizophrenic patient. J Clin Psychiatry 1995; 56: 334.

13. McCarthy BW. Sexually compulsive men and inhibited sexual desire. J Sex Marital Ther 1994 ; 20: 200-9.

14. Nishimura H, Suzuki M, Kasahara H, Ushijima S. Efficacy of lithium carbonate in public and compulsive masturbation – a female case with mild mental disability. Psych Clin Neurosci 1994; 51: 411-3.

15. Raymond NC, Grant JE, Kim SW, Coleman E. Treatment of compulsive sexual behavior with Naltrexone – 2 case studies. Int Clin Psychopharm 2002; 17: 201-5.

16. Ryback RS. Naltrexone in the treatment of adolescent sexual offenders. J Clin Psychiatry 2004; 65: 982-6.

17. Wainberg ML, Muench F, Morgenstern J, Hollander E, Irwin TW, Parsons JT, et al. A double blind study of citalopram versus placebo in the treatment of compulsive sexual behaviors in gay and bisexual men. J Clin Psychiatry 2006; 67: 1968-73.

18. World Health Organization (WHO). International Classification of Diseases . 10th ed. Geneva: WHO, 1992.