Year : 2015 | Volume
: 20 | Issue : 1 | Page : 38--40
Compulsive masturbation in a patient with delusional disorder
Sagar Karia, Avinash De Sousa, Nilesh Shah, Sushma Sonavane
Department of Psychiatry, Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
Avinash De Sousa
Carmel, 18, St. Francis Road, Off SV Road, `Santacruz West, Mumbai - 400 054, Maharashtra
Compulsive masturbation is a type of paraphilia related disorder in which a person engages in masturbatory behavior to such an extent that it causes socio-occupational dysfunction. The psychiatric co-morbidities associated with it include mood and anxiety disorders, substance use disorders, etc. Here, we report a case of a patient with the delusional disorder having compulsive masturbation.
|How to cite this article:|
Karia S, De Sousa A, Shah N, Sonavane S. Compulsive masturbation in a patient with delusional disorder.J Mental Health Hum Behav 2015;20:38-40
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Karia S, De Sousa A, Shah N, Sonavane S. Compulsive masturbation in a patient with delusional disorder. J Mental Health Hum Behav [serial online] 2015 [cited 2022 May 21 ];20:38-40
Available from: https://www.jmhhb.org/text.asp?2015/20/1/38/164825
Historically compulsive masturbation has been included in paraphilia related disorders, which also include protracted promiscuity, dependence on pornography, telephone sex dependence, severe sexual desire incompatibility and ego-dystonic persistent use of sexual accessories such as drugs (e.g., amyl nitrate, cocaine) or objects (e.g., dildos) used specifically in association with sexual behavior. According to one study, compulsive masturbation was significantly associated with the other paraphilia related disorders, and it was the most common form of sexual release over the lifetime, regardless of marital or relationship status.  In general, it is more prevalent in men. Compulsive masturbation, protracted promiscuity, and severe sexual desire incompatibility, as well as cybersex, have also been described in women.  Drugs helpful for treatment of compulsive masturbation include lithium, buspirone, tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), atypical antipsychotics, naltrexone, and mirtazapine. ,,,,, Here, we report a case of compulsive masturbation in a patient having a delusional disorder.
A 30-year-old, 12 th standard educated unmarried male, working in a shop had presented to the outpatient department. He presented with chief complaints of fearfulness that a friend of his would kill him along with pain in the genital region and repeated masturbation since 4 years. He was apparently alright 4 years prior to the presentation when he had an altercation with one of his friends in his village over a petty issue and had a verbal spat with him. The patient at that time had threatened to kill his friend by throttling him. After this incident, he came to Mumbai and started working here in a shop as a helper. However, after 1-month of his stay in Mumbai, 1-day while at work he saw a man walking by the road and he felt that this person looked like the friend with whom he had the altercation. He started feeling fearful that the friend has come to Mumbai to kill him. He would continue going out to work, but remained fearful. Initially, his fear would last for few minutes, but gradually over a period of 6 months his fear had increased lasting for the majority of the day. He told his room partner who was from the village about this fear and the room partner mentioned that the person he was talking about was still in the village and had never come to Mumbai. In spite of this reassurance, the patient continued to remain fearful. His sleep reduced from 7 h a night to 3-4 h at night due to the same. He was even made to speak on the phone to the friend who told him that he forgot about the altercation and had forgiven him but this did not satisfy the patient.
Around the same time, he complained of feeling an itching sensation on his penis, which he would feel more when he would have free time and have nothing to do. While he was engaged in work, the itching did not bother him. Due to the itching he used to scratch the genital regions, and that would bring relief to him. He used to do so even at his workplace but had to find some isolated place to do the same. The itching increased once to such an extent that in order to seek relief, he applied cockroach killer gel on it, feeling that it might be due to some worm infestation. He was not sure whether there were insects crawling under the skin, but he did admit that it was a foolish move to apply cockroach killer gel on his genitals.
On one occasion after scratching he followed it up with an act of masturbation. After the act, he felt better and relieved of his worries too. He started masturbating daily at night and this continued for 6 months. Gradually, the frequency of masturbation started increasing. He started doing so even at the workplace. He had to masturbate 4-5 times in a day and felt anxious if he did not do so. He claimed that if he stopped masturbating, he would not get sleep, feel irritable and uneasy. He tried to divert his mind by listening to music or watching television but no results. He said that due to this habit now since the past 6 months his work performance has deteriorated. He was not able to concentrate at work and was always looking for a place to masturbate. His mind would be preoccupied with thoughts related to the same throughout the day.
He decided to meet us at the advice of a friend whose relative was under treatment in our department. He did not have any hallucinations, disorganized behavior or any other suspiciousness. He did not have the persistent sadness of mood, decreased interest in daily activities or suicidal ideation. He did not have a history suggestive of any substance use. He did not have any significant medical or surgical illness or history of taking any medications. There was no family history of psychiatric illness. General and systemic examination did not reveal any significant findings. On mental status examination, his mood was anxious. Furthermore, he had a delusion of persecution that his friend would find his home and kill him. He was upset due to his repeated masturbatory habit but claimed that he could not suppress it. He did not have any perceptual abnormalities. We diagnosed him as having delusional disorder persecutory type and compulsive masturbation. We started him on oral risperidone 4 mg/day and trihexyphenidyl 4 mg/day. He followed up in a fortnight showed 20% improvement. He had reduced the fear of his friend. His masturbatory behavior, however, continued. We increased risperidone to 6 mg/day, and he showed 50% improvement in another 2 weeks. His fear had almost gone, and masturbatory frequency reduced from 4-5 to 1-2 times/day. We then started him on fluoxetine 20 mg/day at morning for his masturbatory behavior and raised the dose to 40 mg/day in a week. Currently on 40 mg of fluoxetine, he has reduced masturbation to twice a week. He was also educated about masturbation, sexual myths, and general sexual knowledge. He is currently following up with us.
Compulsive sexual behaviors (CSB) are characterized by inappropriate or excessive sexual cognitions or behaviors that lead to subjective distress or impaired functioning in one or more important life domains and can be divided into paraphilic and nonparaphilic subtypes. There is no diagnostic and statistical manual of mental disorders, fifth edition category that corresponds to the nonparaphilic forms of CSB. Various psychiatric co morbidities are seen with CSB like mood disorder and anxiety disorder. , It has also been reported with attention deficit hyperactive disorder, substance use disorder and pathological gambling. ,,, The prevalence rates of CSB across studies have been reported to be 15-78% based on varying criteria and diagnostic methods that have been used. ,,,,,
Compulsive masturbation is usually an impulse control disorder and may be seen as a part of the obsessive-compulsive spectrum disorder.  In those cases, there is often an intense urge to masturbate to seek relief from anxiety or to prevent something unfortunate from happening, and the behavior is repeated multiple times a day.  It has also been reported as a part of hypersexual behavior that may be seen in schizophrenia.  To the best of knowledge, it has not been reported in conjunction with delusional disorder. The relevance of our case report lies in the fact that the primary reason for masturbation was both reliefs from anxiety and the patient also felt relief from his delusion of parasites on the penis. Compulsive masturbation as a response to seek relief from delusional parasitosis is rare and deserves mention. There are no case reports found in literature as per our knowledge of compulsive masturbation in patient with delusional disorder though we found one report on successful treatment in fluoxetine in a patient with schizophrenia who had compulsive masturbation. 
It is important to mention that in our case the patient had an insight with regards to his masturbatory behavior being unreasonable and incorrect, but did not have an insight into the fact that the delusions he harbored were irrational. Thus on one hand, we had a psychotic spectrum disorder leading to a neurotic spectrum condition and the neurotic symptoms were aimed at relieving the psychotic ones. It is of importance that clinicians keep in mind, that in cases of both schizophrenia and other psychotic disorders, there is a possibility of patients developing anxiety and impulse control symptoms for which they may have clear insight while refusing to accept the psychotic disorder.
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