Paradoxical hypersexuality in depression

To the Editor

Loss of libido is a well-known symptom of depression, but the phenomenon of paradoxical hypersexuality has been observed in some patients with concurrent depression. Given the rarity of such presentations, there is a relative paucity of literature about this. We report a case of compulsive sexual behaviour (CSB) in major depressive disorder with psychotic features.

Jason is a 61-year-old man who was referred to a hospital Crisis Team by his ex-partner. He had a 2-week history of depression, insomnia, feeling worthless, and voicing suicidal ideation but with no intent. Jason also expressed paranoid and persecutory delusions about the police wanting to catch him for being a ‘sexual deviant’ after he had masturbated in the airport. This was in the context of his return from Czechoslovakia where he experienced financial stresses, excessive alcohol use and non-adherence to his prescribed mirtazapine treatment. He engaged in compulsive masturbation prior to his admission. Jason has a history of two similar presentations of major depression with compulsive masturbation. Little improvement occurred following an increase in his mirtazapine dose plus lorazepam.

Electroconvulsive therapy was commenced, resulting in mood improvement and decreased compulsive masturbation. Hypersexual disorder has yet to be established as a formal diagnosis in DSM-5 due to the lack of precision in the proposed criteria, and the potential to pathologise normal sexual activity. However, a number of theories have been generated to explain this phenomenon. Hypersexuality is observed in some patients taking anti-parkinsonian treatment, suggesting that the suppression of prolactin through dopamine replacement may contribute to the increased libido (Ivanco and Bohnen, 2005). Other hypotheses (Schultz et al, 2014) for CSB in depression include:

1. A need for self-validation and personal contact.

2. Distraction, re-inforcement and conditioning of the mind to a pleasurable feeling via orgasm.

3. Restrictive attitudes (e.g. religious beliefs) about sexuality results in an inability to conform, promoting a cycle of guilt and CSB.

To date, the use of selective serotonin receptor inhibitors (SSRIs) has been the mainstay of treatment (Levine, 2012) for both depression and CSB. Although SSRIs have shown efficacy in reducing intrusive sexual thoughts and urges, it does not stop an individual from sexually acting out. Anti-androgens are recommended should sexual behaviour be of harm to others. Although further evidence is required for other treatment, such as naltrexone or anti-dopaminergics, a better understanding of CSB is required to provide the best approach for patients.