Anxious and depressive symptoms and disorders have been identified in paraphilic sex offenders (Kavoussi and others; Grossman and Cavanaugh), nonoffender paraphiliacs (Wise and others) and men with paraphilia-related disorders (Kafka and Prentky 1994). DSM-IV notes that "symptoms of depression may develop in individuals with paraphilias and may be accompanied by an increase in the frequency and intensity of the paraphiliac behavior."
Before 1988, only a handful of case reports suggested that mood disorders and paraphilias might be comorbid and that thymoleptic treatment could ameliorate both depressive and anxious symptoms as well as deviant fantasies, urges and sexual behaviors. Since 1989, there have been increased reports suggesting that serotonergic antidepressants, in particular serotonin reuptake inhibitors (SRIs), can ameliorate both paraphilias and paraphilia-related disorders even in the absence of a concurrent mood disorder diagnosis (Fedoroff 1993; Kafka and Prentky 1992b; Kafka 1994b).
Research data regarding mammalian sexual behavior and monoamine neurotransmitters suggest that decreased central (i.e., brain) serotonin (5-hydroxytryptamine [5-HT]) and increased dopamine(Drug information on dopamine) neurotransmission may disinhibit or promote sexual behavior and, conversely, enhancing central serotonin activity or inhibiting dopamine receptors in the brain may inhibit sexual behavior in some mammalian species (Mas). These data, in addition to the burgeoning research and clinical literature on the role of serotonin in the regulation of mood, anxiety, impulsive and obsessive-compulsive disorders, provide a reasoned etiological framework to approach sexual impulsivity as a group of diverse sexual impulsivity disorders that might share a common pathophysiology, diminished central serotonin neurotransmission and be ameliorated by serotonergic antidepressants.
Of the serotonergic agents reported, fluoxetine(Drug information on fluoxetine) (Prozac) has received the most attention (e.g., Fedoroff 1993; Kafka and Prentky 1992b), although lithium(Drug information on lithium) (Cesnik and Coleman), clomipramine(Drug information on clomipramine) (Anafranil) (Kruesi and others; Rubey and others) buspirone (BuSpar) (Fedoroff 1988; Pearson and others), fluvoxamine(Drug information on fluvoxamine) (Luvox) (Zohar and others) and sertraline(Drug information on sertraline) (Zoloft) (Bradford 1995b; Kafka 1994b) are reported as effective as well in case reports and open clinical trials with outpatients. One report, although limited by a small sample size, suggests that both clomipramine and desipramine (Norpramin) are equally effective in reducing paraphilic behaviors (Kruesi and others).
SRIs can be prescribed in the usual “antidepressant” doses for sexual impulse disorders even in the absence of significant affective symptomatology. When effective, SRIs can selectively mitigate sexual impulsivity and preserve “normative” sexual desire and behaviors associated with reciprocal affectionate activity. A distinct effect on sexual as well as depressive symptoms is commonly apparent by week 4 after initiating pharmacotherapy (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 sexual offending behaviors. Because of these effects on nonsexual target symptoms and syndromes, serotonergic drugs may offer additional therapeutic benefits in comparison with antiandrogens.
Currently, in this writer's practice as well as in some sex offender treatment programs, SRIs are the primary biological treatments for sex offenders and men and women with paraphilia-related disorders. It is important to emphasize that any single subject may fail to respond to one drug but have a beneficial response to a second or third drug of the same class. It is well-known that pharmacological tolerance may develop to the beneficial effects of serotonin reuptake inhibitors as well as other antidepressants during the treatment of depressive conditions. This same problem has been noted during the treatment of sexual impulsivity disorders as well (Kafka 1994b). In that context, antidepressant augmentation with either lithium carbonate (300 to 900 mg per day) or psychostimulants (e.g., methylphenidate(Drug information on methylphenidate) [Ritalin], pemoline(Drug information on pemoline) [Cyclert], dextroamphetamine [Dexedrine]) while maintaining the same dose of the primary serotonergic antidepressant is usually effective in helping to recapture the therapeutic response and diminish the risk of subsequent relapse.
Other alternative augmentation strategies that may be effective include adding low dose of a secondary amine tricyclic (e.g., desipramine 10 to 75 mg per day, buspirone(Drug information on buspirone) 10 to 30 mg per day, or pindolol(Drug information on pindolol) [Visken] 5 to 10 mg per day) to the primary SRI.
With one exception (Kruesi and others), there are virtually no systematic data regarding the efficacy of tricyclic antidepressants, MAO inhibitors, buproprion (Wellbutrin), nefazodone(Drug information on nefazodone) (Serzone) or venlafaxine (Effexor) prescribed for sexual impulsivity disorders. Although serotonin reuptake inhibitors have the clinical advantage of being more readily prescribed and accepted by both the medical and patient community, there have been no published double-blind or placebo-controlled studies of their use in either incarcerated or outpatient sex offenders and there are no published reports describing recidivism rates of sex offenders treated with SSRIs.
Given these clinical caveats, antiandrogens should still remain as the treatment of choice for sexually dangerous paraphiliacs. Pharmacotherapy with serotonergic antidepressants requires a highly motivated patient inasmuch as no antidepressant is currently available as a parenteral preparation. In that regard, fluoxetine in comparison to the other SSRIs has the advantage of a long metabolic half-life, so that an occasional missed dose should not affect clinical status.
Last, from this clinician's experience, the antiandrogen medroxyprogesterone(Drug information on medroxyprogesterone) acetate (and likely cyproterone(Drug information on cyproterone) acetate), either as an oral or parenteral preparation, can be combined safely and administered concomitantly with an SRI. In these circumstances, this combination has several potential advantages, including the use of a relatively lower dose of antiandrogen to have a beneficial clinical effect, a potential additive effect to rapidly control socially deviant sexual arousal and the ability to maintain control over sexual impulsivity symptoms when switching from one SRI to another agent.
Paraphilias and paraphilia-related disorders are more clinically prevalent than most clinicians suspect. Since these disorders are cloaked in shame and guilt, it is common that the diagnosis of these conditions may not be adequately revealed until a therapeutic alliance is firmly established. Even then, it is more helpful to inquire directly about sexual impulsivity disorders than to hope or expect that a patient will be spontaneously forthcoming. Once a diagnosis is established, appropriate psychoeducation regarding sexual diagnoses, associated Axis I comorbidity and appropriate use of psychopharmacological agents can greatly improve the prognosis for these conditions.
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