A Case of Manual Overdrive: A Case Report Highlighting Diagnostic Challenges and Management

Hypersexual behavior, characterized by recurrent and excessive sexual urges or behaviors associated with impaired control and functional distress, continues to pose diagnostic and therapeutic challenges in clinical psychosexual practice. While hypersexual disorder was proposed for DSM-5 but not formally included, the recognition of compulsive sexual behavior disorder (CSBD) in ICD-11 has provided clinicians with a useful diagnostic framework. ¹ We present a brief case vignette highlighting the clinical phenomenology and management approach in a young adult male.

A 21-year-old unmarried heterosexual male, pursuing undergraduate studies, presented with a history of academic decline, poor concentration, and excessive engagement in pornography consumption and masturbation over the preceding 2–3 years. He had been raised in a structured family environment with limited exposure to digital media. At the age of 18 years, he relocated away from home for competitive examination preparation, marking his first prolonged period of independence with unrestricted internet access.

Within months of relocation, he experienced homesickness, academic stress, sleep deprivation, and anxiety. On peer suggestion, he began accessing online pornographic material as a coping strategy. Initially limited in duration, the behavior gradually escalated in frequency and intensity. Over time, he reported spending several hours daily watching pornography and masturbating multiple times per day. He began avoiding classes, withdrawing socially, and prioritizing privacy to engage in sexual behaviors.

Tolerance developed, with a shift toward paid and interactive online sexual content, leading to financial strain and deceptive behaviors. Despite repeated efforts to reduce or stop the behavior, he reported persistent loss of control and continuation despite academic failure and emotional distress. During periods of restricted access, he employed maladaptive strategies to maintain the behavior. There was no history suggestive of manic symptoms, obsessive intrusive thoughts, paraphilic interests, substance use, or neurological illness.

A mental status examination revealed an anxious affect with preserved cognition, judgment, and insight. Sexual urges were described as ego-syntonic and pleasure-driven rather than anxiety-relieving. Physical examination and baseline investigations were unremarkable. Psychometric assessment using the Hypersexual Disorder Screening Inventory yielded a score of 20/28, consistent with clinically significant hypersexual behavior. ² Differential diagnoses, including obsessive-compulsive disorder, bipolar affective disorder, and other impulse control disorders, were considered and ruled out clinically. ³

The patient was managed using a biopsychosocial approach. Pharmacotherapy with Fluoxetine tablets was initiated to address impulsivity and sexual preoccupation, along with short-term anxiolytic support. Psychotherapeutic interventions included motivational enhancement, cognitive-behavioral strategies focusing on urge management, stimulus control, psychoeducation, and family involvement. At the one-month follow-up, the patient reported a reduction in the frequency and duration of sexual behaviors, improved sleep, and better academic engagement.

This vignette illustrates the developmental trajectory of hypersexual behavior in the context of psychosocial stressors and digital accessibility. Early recognition, appropriate psychometric assessment, and structured multimodal intervention are crucial in preventing long-term psychosocial impairment.^4,5