Excessive Masturbation Association with Mixed Amphetamine Salts

To the Editor:

We present a case of a 14-year-old patient who developed hypersexual symptoms with mixed amphetamine salts therapy. To our knowledge, there is one other case report that stipulates the need for clinician awareness of the possibility that mixed amphetamine salts may induce hypersexuality and excessive masturbation in children. This case highlights another report of such a phenomenon.

Patient A is a 14-year-old male with attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder who presented with his mother to the outpatient psychiatric clinic after making an emergency appointment for continued distractibility and poor impulse control on Adderall-XR 15 mg. Adderall-XR was increased to 20 mg to help with the ongoing symptoms of ADHD. The patient was prescribed no other medications. On 6-week follow-up visit, the patient reported increased sexual desire and excessive masturbation since the increase in the dose of Adderall-XR. He reported significant distress related to increased sexual desire and excessive masturbation and asked for discontinuation of Adderall-XR. No signs to indicate a primary mood disorder were noted. Adderall-XR was discontinued and upon follow-up visit, the patient reported that symptoms of increased sexual desire and excessive masturbation improved in 2 days after discontinuation. The mother and the patient were hesitant in restarting any type of retrial of stimulant therapy.

This case report explores a case in which an increase in dose of mixed amphetamine salts caused hypersexuality and excessive masturbation in an adolescent. The distress in the patient and decrease of symptoms upon discontinuation of mixed amphetamine salts may suggest this to be secondary to the increase of dose of Adderall-XR. In our literature search, one other case report suggests the same phenomenon in which a 7-year-old female presented with excessive masturbation and hypersexuality with the onset of methylphenidate (Bilgic et al. 2007).

Dopamine has been shown to play an important role in libido and sexual arousal (Melis and Argiolas 1995; Hull et al. 2004). Several studies have found significant association of stimulant abuse and increased sexual arousal and sexual high-risk behaviors (Volkow et al. 2007; Jia et al. 2013). These studies attribute hypersexuality to increased dopamine levels in the mesolimbic–mesocortical system that regulates sexual function. Several articles have been published suggesting association between hypersexuality and dopamine receptor agonistic drugs (Uitti et al. 1989; Politis et al. 2013; Moore et al. 2014; Seeman 2015). Case reports of risperidone causing hypersexuality have been published (Xenitidis et al. 2013). The mechanism of risperidone causing hypersexuality can be explained by increasing dopamine levels in prefrontal cortex. A case report of aripiprazole causing hypersexual behaviors is also published (Eğilmez et al. 2016). Partial dopaminergic agonistic effect of aripiprazole is the most likely contributing factor for these behaviors.

In conclusion, this report reiterates, similarly to the other case already noted, the need for clinician awareness of the possibility that mixed amphetamine salts induce hypersexuality and excessive masturbation. We acknowledge the limitation of knowing whether amphetamine is the offending agent without a rechallenge.