Gratification Disorder: A Case Report from the Himalayan Country–Nepal

Introduction

Gratification disorder is also known as “benign idiopathic infantile dyskinesia” or “infantile masturbation.” ¹ Though the condition is called a “disorder,” it is a normal behavioral variant in early childhood. ² It is common in children between the ages of 3 months and 3 years. ³ The gratification behavior in children is surprisingly common and recorded to be in 90%–94% of boys and 50%–60% of girls. It is a type of masturbatory behavior and has a close resemblance with epilepsy, abdominal pain, paroxysmal dystonia, or dyskinesia. ¹ It is not included in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) and International Statistical Classification System of Diseases and Related Health Problems, 10th edition (ICD-10), which categorize it as “Other specified behavioral and emotional disorders with onset usually occurring in childhood and adolescence” (F98.8). The stereotypic motor behavior includes lower limbs scissoring posture and repetitive pelvic movements with rubbing of thighs together and rocking motion of genital region against the bed or other objects. ⁴ This behavior often stops when the child is distracted, which distinguishes it from a seizure. ⁵ Gratification disorder improves with age, generally by reassuring the anxious parents. ⁶ Therefore, we should consider infantile masturbation in the differential diagnosis of childhood epileptic seizures, to avoid unnecessary investigations and inappropriate treatment. ⁷ We present a case of gratification disorder in a 2-year female child presenting in a psychiatry clinic in Nepal.

Case

A 2-year female child presented to the psychiatry OPD by her mother with an illness of abrupt onset and episodic course for the last 3 months characterized by the rocking movement of one lower limb during the time of rest. The movement would be rhythmic and occur in the different limbs in different episodes. One limb would be over the other and the movement would involve rocking of hips as well. The movement was not associated with loss of continence. It would not occur in the deep sleep at night but occur during the time when the child would seem drowsy. The duration of movement would be 3–5 min and would occur almost every day and even two to three times a day. She had normal developmental milestones and had no significant medical history. She had an elder sister who was diagnosed with severe mental retardation. On examination, the child was of an easy-going temperament. Baseline investigations such as complete blood count, liver function test, renal function test, and calcium level were within normal limits. The 20-min EEG and MRI brain (seizure protocol) revealed no abnormality. The case was discussed with a consultant child neurologist from India by sending videos of the event. The diagnosis of gratification disorder was made. Before coming to the psychiatrist, she was started on sodium valproate syrup considering a diagnosis of seizure, which was tapered off once the diagnosis was established. The parents were psycho-educated about the illness. In psycho-education, we described the movement to be benign and assured family members. They were advised to ignore the events and use methods of distraction to the child with other enjoyable activities. The mother was reluctant to accept the diagnosis, but, eventually, they followed the advice. On the fourth month follow-up, both parents were happy and said that the frequency had decreased to one to two times a week. The child has joined a kindergarten and is on two monthly follow-ups with no such movement for the last 6 months.

Discussion

Though common in childhood, gratification disorder could be a diagnostic challenge if the clinician is unaware of the possibility. It would not be obvious as there is no direct genital manipulation like that of adolescents or adults. The clinical presentation can be variable, and they could be wrongly diagnosed. Though it seems to provide some gratification, it becomes more of a habit when the infant is sleepy or bored. ⁸ Some theories explaining such unusual behavior are sleep disorder, genito-urinary irritation, early weaning from breastfeeding, emotional deprivation, neglect, and abuse. ⁹ The most common difficulty is the distinction of masturbatory behavior from a seizure disorder. Those with masturbatory behavior can have altered consciousness with a glassy-eyed, fixed gaze, but the distinct feature is that it ceases with distraction. ¹⁰ Dilemmas in diagnosis and treatment are common even among clinicians, and it is observed that almost one-fourth of children are diagnosed and treated as epilepsy like that of our case.^{11, 12}

Our index case was presented to a pediatrician and was a diagnostic dilemma for 3 months. She was started on an anti-epileptic. Different investigations were done for diagnostic clarification and all investigations were within normal limits. It has been highlighted that the onset of some typical clinical features of gratification disorder could be after 3 months and before 3 years of age, stereotyped episodes of variable duration, vocalizations with quiet grunting, facial flushing with diaphoresis, pressure on the perineum with characteristic posturing of the lower extremities, no alteration of consciousness, cessation with distraction, normal examination, and laboratory studies. ¹³ Our patient reported most of these symptoms. Videotaping of the episode is invaluable for the diagnosis of gratification behavior because the history from the parents can be misguiding. Our diagnosis was made possible after the video clip was seen. Therefore, clinicians should request parents to take video clips to differentiate from neurologic disorders that involve seizures or movement disorders. ¹⁴

Management usually involves parental psycho-education, to make them understand that it is a normal developmental behavior in children and that they will often outgrow it and minimize the stigma through awareness. ⁵ Scolding the child would only result in reinforcement of such behavior and low self-esteem. Therefore, attempts should be made to engage the child in other behavioral modification activities that could redirect their attention from masturbatory behavior.^5,14