Abstract
Depression can often present similar to compulsive sexual behavior (CSB) disorder is defined by the International Classification of Diseases, Eleventh Revision, as a persistent pattern of failure to control intense, repetitive sexual impulses, or urges, resulting in repetitive sexual behavior. This includes compulsive masturbation, persistent use of pornography, frequent indulgences in sexual intercourse in a day, and unsafe sex, all of which cause marked distress or impairment in personal, familial, social, educational, or occupational areas of functioning. Stigma against mental health is one of the limiting factors for the presentation of patients with CSB disorders at large at psychiatry outpatient services. Association of negative mood states has been found with CSB disorders which often respond well with pharmacotherapy like SSRI’s apart from other non-pharmacological measures.
Introduction
Masturbation is a topic that has been stigmatized and taboo for a very long time, which has resulted in a lot of false information and myths about it. However, individuals of all ages engage in it naturally. 1 It is important to note that societal and religious views on masturbation are influenced by cultural, historical, and moral beliefs, which can change over time. Despite being a prevalent sexual activity, masturbation is largely viewed negatively, and almost all major religions prohibit it. 2
Although there is no universally accepted definition of compulsive sexual behavior (CSB), the term is generally used to indicate excessive sexual behaviors or sexual cognitions that lead to subjective distress, social or occupational impairment, or legal and financial consequences. 3 In fact, recent research has revealed a connection between CSBs and heightened sensitivity to erotic rewards4,5 or the signals that go along with those rewards. 6 Some suggest that those who engage in CSBs may be more cue-conditioned for erotic cues 7 or more anxious. 8 Guilt feelings related to masturbation can arise depending on an individual’s personal beliefs, cultural background, or religious upbringing. Societal and cultural norms and religious teachings can influence one’s attitudes and perceptions toward masturbation.9,10 The somatization of guilt and psychological anxiety associated with semen loss might have more than known consequences on the individual. 11 When talking about masturbation with patients who feel guilty or ashamed about this behavior, doctors may run into challenges. Healthcare professionals should create a safe and non-judgmental environment where patients feel comfortable discussing their concerns. Additionally, healthcare providers may consider referring patients to mental health professionals, if necessary, who can provide further support in addressing any emotional or psychological issues related to masturbatory guilt.
In this case series, we present four scenarios where CSBs, particularly masturbation, were found to be aggravated in the background of depressive disorder. After obtaining the institutional ethical clearance, informed consent was sought from the patients.
Case Scenarios
Case 1
A 18-year-old male presented with a history of pervasive low mood, crying spells, decreased interaction with family and peers, occasional death wishes for 5 years, along with low self-confidence and self-esteem, and ongoing marital discord between his parents (parental discord). A history of decreased academic performance for the past 5 years was noted by the parents. A history of irritability and anger outbursts was also reported by the mother for 6 months. A history of repeated masturbation was reported by the father for 6 months which was continued inappropriately at both home and college environments which was initially brought to notice by the college faculty. The patient also reports sleep disturbances with delayed onset, decreased duration, and decreased appetite, leading to a weight loss of 4-5 kgs in the last 3 months. Stressors: The patient initially denied it but later admitted to the same. The patient was diagnosed with major depressive disorder with compulsive masturbation behaviors. The patient was treated with Cap. fluoxetine 20 mg. The patient showed improvement in all the above symptoms at 2 months follow-up.
Case 2
An 18-year-old man attended the outpatient psychiatric clinic. A history of pervasive low mood, loss of interest, anxiety, easy fatigability, helplessness, and crying spells, presently associated with death wishes began after admission to residential college 3 years ago. The patient developed irritability and anger outbursts with minimal provocation, often leading to frequent fights among family members and peers, along with repeated complaints from his teachers. A history of deteriorating scholastic performance, with decreased interest and concentration, lasting for 2 years. A history of one attempt to hang himself at his residence, which was averted by his mother, 1 year ago. He also described two episodes of fleeing away from home for 1-2 days. A history of watching porn videos for 2 months which started with peer influence continued with repeated urges followed by acts of masturbation around 5-6 times a day. The patient reports using masturbation as a means of alleviating anxiety and stress. He describes an uncontrollable urge to engage in this behavior whenever he experiences stress, despite numerous unsuccessful attempts to significantly reduce or control his repetitive sexual behavior. Additionally, he continues this behavior despite deriving minimal satisfaction from it. He had interrupted and non-refreshing sleep, poor appetite, and loss of taste.
The patient had no history of medical or psychiatric diseases, no family history of psychiatric illness, and no history of alcohol or illicit substance use. On mental state examination, his mood was depressed with an anxious affect. His basic blood investigations, including complete blood count, complete metabolic panel, thyroid hormone levels, and urine drug screen, were within normal limits. The patient was treated with Cap. fluoxetine 60 mg and Tab. propranolol 40 mg on which the patient showed improvement in all the above symptoms at months follow-up.
Case 3
A 23-year-old woman, unmarried, came with a history of low mood, decreased motivation to initiate any daily activity, anger outbursts, excessive sleep, decreased interest at work, excessive binge eating episodes with increased appetite, and increased weight of 7 kgs in the past 3 months following stressor in the form of relationship failure. The patient reports a history of increased frequency of masturbation over the past month, following a relationship failure. The behavior is driven by anxiety and stress relief, although the patient expresses feelings of guilt associated with the act. Despite recognizing minimal satisfaction from this behavior, the patient finds it difficult to resist the urge to masturbate when experiencing stress and continues to engage in it repetitively, further exacerbating feelings of guilt. No history was suggestive of bipolar affective disorder or obsessive compulsive disorder. The patient was started on Tab. escitalopram 10 mg and was followed up for 6 months. The patient showed improvement in both low mood, with no further episodes of compulsive masturbation by the end of 2 months. Currently maintaining well. No history of hypothyroidism.
Case 4
A 35-year-man presented with a history of low mood, decreased interest in daily activities, anxiety, palpitations, negative ruminative thoughts at work for 5 years with a history of repeated compulsive masturbation on a daily basis increased to around four to five times/day since the last 10 days associated with sleep disturbances and decreased appetite. No history of any comorbidities. The patient reported a history of cannabis use 1 year ago for 6 months and is currently abstinent from any substance use. The patient was treated with Tab. mirtazapine 15 mg at bedtime and showed improvement by 2-3 weeks of treatment.
In all the above cases, a differential diagnosis such as substance use disorder, bipolar disorder, and culture-bound syndrome was ruled out after a detailed history and assessment.
Discussion
In the International Classification of Diseases, Eleventh Revision, World Health Organization, CSB disorder has been kept under impulse control disorders, and it refers to an ongoing inability to control intense and repetitive sexual impulses, leading to repeated engagement in sexual activities which includes compulsive masturbation behavior. Symptoms include the excessive focus on sexual behaviors, resulting in neglect of one’s health, personal care, and other responsibilities. Despite multiple unsuccessful attempts to reduce these behaviors, individuals continue to engage in them despite experiencing adverse consequences and deriving little satisfaction. This pattern persists for an extended period, typically 6 months or more, and significantly impairs functioning in various important areas of life causing marked distress. It is important to note that distress solely based on moral judgments or societal disapproval is insufficient to meet this disorder’s criteria. 12
Obsessive sexual behavior may seem enticing to use as a coping mechanism for sadness and anxiety, but in the end, it is a harmful and futile method. The long-term negative consequences, such as increased distress, impaired relationships, and social isolation, outweigh the temporary relief it provides. Earlier studies hypothesized that processes, such as emotion dysregulation, influence the connection between childhood sexual abuse and CSBs. 13 In all the above case reports, depression was found to be the common psychiatric morbidity with CSBs.
In individuals with sexual compulsivity, the activation of sexual behavior during states of negative mood can be attributed to three distinct pathways.13,14 First, some individuals seek the regulatory purpose of sexual activity as a means to fulfill emotional needs, particularly in cases of depression. They may engage in sexual behaviors to experience feelings of love, validation, or emotional connection, temporarily alleviating the sense of loneliness or low self-esteem associated with their depressive state. Second, sexual arousal can serve as a diversion or distraction for those with depression. By focusing on sexual sensations and pleasure, individuals may momentarily escape from unpleasant emotions and intrusive thoughts that accompany their negative mood, providing a temporary respite. Finally, sexual arousal can act as a mechanism for transferring negative emotions, such as anger and anxiety, onto sexual behavior. Through engaging in sexual acts, individuals may find temporary release or catharsis, channeling their pent-up emotional energy. However, it is crucial to recognize that these pathways may interact and vary in individual cases, emphasizing the complexity of sexual compulsivity and its connection to negative mood states.
Brem et al found a significant positive bivariate correlation between CSB and depression (r = 0.31, P < .01) as well as between CSB and anxiety (r = 0.31, P < .01). 15 CSB disorders are delicate and individualized, diagnosing one might be difficult. The physical and psychological symptoms of CSB are frequently undetectable or modest, similar to other impulse control problems. The presence of physical injuries to the genital area or sexually transmitted diseases alone does not necessarily indicate the presence of a CSB disorder. Despite the possibility that these symptoms indicate overindulgent sexual behavior, they do not offer a conclusive explanation for obsessive sexual behavior. A compulsive sexual condition cannot be deduced just from a physical examination; rather, the existence of particular actions indicates the need for testing for them. Unhealthy and irrational assumptions of what makes for a satisfying sexual relationship might result from CSBs. Intimacy and personal ties within relationships can be severely harmed by the deceit, secrecy, and betrayal that characterize CSBs. The whole extent and viability of intimate relationships may suffer from the combined effects of these issues.
Incentive motivational processes relate to sexual cue reactivity. CSB versus non-CSB men had greater sex-cue-related activation of the anterior cingulate, ventral striatum, and amygdala. Men with CSB exhibit heightened attention toward pornographic stimuli, suggesting similarities in their early attentional responses to those seen in addictive behaviors.16,17
The argument on whether CSB belongs to one category or another finds its foundation in an argument on the very definition of the behavior. While some authors consider CSB an addiction because of its compulsive nature and potential consequences, others argue that it aligns more closely with psychiatric disorders characterized by impaired impulse control. This would imply the need for further research into the neurobiological basis of CSB, which is not yet clearly understood.
Antidepressants, mood stabilizers, antipsychotics, and antiandrogens are just a few of the pharmaceutical types that have been explored. These medications are justified based on clinical phenomenology and symptoms of other diseases, such as substance use disorders or obsessive-compulsive disorders. Selective serotonin reuptake inhibitors (SSRIs) have been tried for both paraphilic and non-paraphilic CSBs through both case series and open-label studies.18,19 No single SSRI has demonstrated superior efficacy to another. Theoretically, SSRIs may decrease the urges/craving and preoccupations associated with sexual addiction. 20 Especially, for those with pre-existing depression, fluoxetine and other SSRIs have demonstrated effectiveness in the treatment of CSB disorder. Serotonin is a neurotransmitter that helps control mood and can lessen impulsive behavior, and SSRIs operate by raising serotonin levels in the brain. The well-known SSRI fluoxetine is beneficial in treating the symptoms of hypersexuality and is frequently given for unipolar depression. Fluoxetine may lessen the severity of obsessive behaviors and sexual cravings by increasing serotonin levels and modulating the brain’s reward circuits. Apart from SSRIs, naltrexone, an opiate antagonist, has been used in the treatment of CSBs. Individual psychotherapy for CSBs includes common approaches such as cognitive behavioral therapy and psychodynamic psychotherapy. 21
Conclusion
CSB sufferers frequently face crippling emotions of guilt and humiliation. These unfavorable feelings result from the person’s inability to regulate their behavior, which can harm them and the people around them. The combination of these feelings may be so overpowering and lonely for many that they resist asking for assistance or support out of concern that they will be judged or further stigmatized. CSB can be associated with negative mood states and can present as one of the symptoms during an untreated depressive episode as a nonadaptive coping mechanism. CSB usually responds well to antidepressant groups of medications and symptoms tend to recede after 3-4 weeks on SSRIs. Often depression can present with CSBs such as masturbation as described in the above cases. Active screening of depressive disorders in these cases leads to better outcomes and prognosis when treated adequately with suitable pharmacotherapy. To provide people a sense of legitimacy and acceptance as they make progress toward recovery, mental health practitioners must establish secure, caring environments that recognize the intricacies and difficulties of living with compulsive behaviors.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Ethical Approval
The following research was evaluated and approved by the Institutional Ethical Committee, Adichunchanagiri Institute of Medical Sciences, B.G.Nagara; dated 10 June 2023 with reference no: AIMS/IEC/013/2023.
Funding
The authors received no financial support for the research, authorship and/or publication of this article.
Informed Consent
All participants provided their informed consent prior to participating in the research and were debriefed at the conclusion of the study.