Proserotonergic Pharmacotherapy

As previously described in this chapter, anxious and depressive symptoms and disorders have been identified in paraphilic sex offenders, nonoffender paraphilic men, and men with PRDs. DSM-IV (American Psychiatric Association 1994) notes that symptoms of depression can be associated with an increased frequency and intensity of sexual impulsivity in paraphilic individuals. In addition, there are subgroups of depressed males who self-report increased sexual behavior (Nofzinger et al. 1993). In particular, in my clinical research, dysthymic disorder, early-onset subtype, may accompany hypersexual disorders and be clinically overlooked (Kafka and Prentky 1992b, 1994, 1998). Prior to 1988, there were only a handful of case reports (e.g., Bartova and Nahanek 1979; Snaith 1981; Ward 1975) suggesting that mood or anxiety disorders and PAs might be comorbid and that thymoleptic treatment could ameliorate depressive and anxious symptoms as well as deviant fantasies, urges, and sexual behaviors. Since 1989, however, multiple case reports, open clinical trials, and retrospective chart reviews have indicated that serotonergic antidepressants - in particular, SSRIs - can ameliorate both PAs and PRDs, even in the absence of a concurrent mood disorder diagnosis.

Fluoxetine (Bianchi 1990; Bradford 1995a; Emmanuel et al. 1991; Kafka 1991a, 1991b; Kafka and Prentky 1992b; Lorefice 1991; Perilstein et al. 1991), sertraline (Bradford 1995b; Kafka 1994b), clomipramine (Kruesi et al. 1992; Ruby et al. 1993), fluvoxamine (Greenberg et al. 1996; Zohar et al. 1994), and paroxetine (Abouesh and Clayton 1999) may be effective for the amelioration of both PAs and PRDs when prescribed at the usual antidepressant doses. Citalopram, an SSRI that has been prescribed in continental Europe for over a decade, was recently released in the United States. In my experience, it is as efficacious as the aforementioned medications.

Analogous to the onset of the effects of antiandrogens, a distinct effect on sexual arousal and target symptoms is usually apparent by week 4 after initiating pharmacotherapy with SSRIs (Bradford 1995b; Kafka and Prentky 1992b). In addition, antidepressant pharmacotherapy may diminish the vulnerability to "negative affective states" (e.g., irritability, depressed mood) commonly reported to precede sex-offending behaviors (Marques and Nelson 1989) and to alleviate low self-esteem and social anxiety that frequently accompany social skills deficits in males with sexual impulse disorders (Baxter et al. 1984; Levin and Stava 1987; Marshall 1989). Because of these effects on nonsexual target symptoms and syndromes associated with PAs and PRDs, SSRIs and other proserotonergic drugs may offer distinct therapeutic benefits in comparison with antiandrogens when clinically indicated.

Mr. M was a 30-year-old married man who was self-referred after his wife of 8 years discovered that he was dressing in female attire and insisted that he stop that behavior. Mr. M reported that he had noticed sexual feelings and excitement even prior to the onset of puberty when he played with his older sister's undergarments. During adolescence, he began wearing women's underpants, then lingerie, and finally dresses as well for sexual pleasure. In his early 20s, Mr. M masturbated every day, using either women's undergarments or pornography. Although he was heterosexual, he acknowledged having sexual fantasies, while cross-dressed, of being an attractive female seducing a man.At the time of referral, Mr. M was diagnosed with major depression, social phobia, and alcohol abuse. His lifetime sexual diagnoses included compulsive masturbation and transvestic fetishism. In addition to receiving psychoeducational material describing treatments for paraphilias, Mr. M was instructed to completely abstain from alcohol use. He was subsequently prescribed fluoxetine, adjusted to 30 mg/day, and his cross-dressing behavior became markedly reduced in frequency. In addition, Mr. M reported that he was much more patient at work and with his children, had better motivation to finish household tasks, and experienced less social anxiety. Mrs. M was included in a supportive psychotherapy that helped her to understand that her husband's sexual behavior was a "stress reliever" associated with vulnerability to a mixture of anxious and depressive symptoms. She became less angry and more able to empathize with her husband, because she herself had also experienced a depressive disorder. Over time, without further additional psychotherapeutic treatment, Mr. and Mrs. M's relationship restabilized.