He Couldn't Stop — Then Psychiatrist Found the Real Cause

Medscape

22-05-2025

A 25-year-old engineer was admitted to the hospital with sudden, irresistible urges for sexual gratification, leading him to seek commercial sex workers. The condition was progressive with an increasing number of sexual encounters and masturbation.
Following a detailed history and physical and mental examination, a diagnosis was established and treated with a combination of pharmacotherapy and psychotherapy.
The case report by Srishti Sharma, a resident doctor in psychiatry at the Department of Psychiatry, Government Medical College and Hospital, Chandigarh, India, and colleagues shed light on an often taboo psychiatric illness.
The Patient and His History
The patient presented to a hospital in Chandigarh, India, with a 2-year history of progressively intensifying compulsive sexual urges. Apart from encounters with commercial sex workers, he also watched pornographic content available online for about 1-2 hours at night, followed by masturbation. His frequency of visits increased from three to four times per month initially to three to four times per week over 5-6 months. He would not use a condom or any protection during intercourse.
Although he reported an urge to watch pornographic content, the act did not give him as much sexual gratification as visiting commercial sex workers. He continued to experience initial excitement during the anticipation of sexual intercourse, which perpetuated the cycle, but soon followed by feelings of guilt and worthlessness following the encounters.
He reported not being in any romantic relationship at the time of presentation. Although he is a diploma holder in mechanical engineering, he works as a cab driver. Gradually, he felt that his desire for sexual gratification was excessive and beyond his control, as he was unable to focus on his academic and professional goals due to preoccupation with thoughts of acquiring sexual pleasure.
Other psychiatric disorders, including substance use, were ruled out, and he denied having any family history of psychiatric disorders.
Findings and Diagnosis
The patient's vital signs were measured at the time of admission. Blood pressure, oxygen saturation on room air, body temperature, respiratory rate, and heart rate were all within normal ranges. Physical examination revealed molluscum contagiosum. Auscultation, palpation, and percussion revealed no pathologic findings. Routine laboratory test results were unremarkable.
The patient scored 59/110 on the Compulsive Sexual Behaviour Inventory-13 (CSBI-13) and 36/40 on the Sexual Compulsivity Scale.
On the basis of the overall findings, hypersexuality was diagnosed.
Following the diagnosis, treatment was started on fluoxetine 20 mg once daily and tablet clonazepam 0.25 mg as needed. He was initially enrolled in supportive therapy sessions, which later proceeded to behavioural therapy and relaxation exercises. A dermatological consultation was arranged for the treatment of molluscum contagiosum.
Within 2 weeks of treatment initiation, the patient reported 20%-30% improvement. However, he still engaged in excessive viewing of pornographic content, followed by masturbation.
Tablet fluoxetine was increased to 40 mg/d, and after another 3 weeks, the patient reported an overall 60%-70% improvement. To achieve further progress, the focus of psychotherapy shifted to identifying the underlying causes.
In subsequent sessions, he was able to identify that the lack of a romantic partner made him feel inadequate and unworthy, and visiting commercial sex workers had become a sort of reassurance seeking.
Based on the clinical interview and therapy sessions, the patient had poor exposure to individuals of the opposite sex during his adulthood, including the absence of peer circles and women in his adolescence, which could have further led to communication deficits and anxiety in initiating conversations with them.
After 6 months of combined therapy, the patient achieved a CSBI-13 score of 31/110. The Sexual Compulsivity Scale was reduced to 13/40.
The patient reported increased confidence in his ability to attract partners as a result of therapy.
Discussion
'In the Indian context, where open conversations about sex itself are generally taboo, it is imperative to explore reasons for distress and encourage healthy discussions regarding sexual disorders so that people can seek help and not just continue to live in shame and guilt, thinking that there is something inherently wrong with them and there is no solution to their problems,' the authors wrote.