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 LETTERS TO THE EDITOR

Anticonvulsant treatment of compulsive sexual behavior

D. Stewart Bell, MD

Ontario Mental Health Department, Kaiser Permanente, Fontana Medical Center, Ontario, CA, USA

KEYWORDS: compulsive sexual behavior, sexual addiction, topiramate, levetiracetam, paraphilia, psychopharmacology

ANNALS OF CLINICAL PSYCHIATRY 2012;24(4):323-324

TO THE EDITOR:

Compulsive sexual behavior may cause financial, health, and relationship problems. Inappropriate computer use also may cause employment problems. Treatment includes psychotherapy or involvement in 12-step programs. Open-label trials and case reports describe the use of lithium, tricyclic antidepressants, selective serotonin reuptake inhibitors, nefazodone, antipsychotics, and naltrexone.1

Below are 2 cases of sexually compulsive behaviors treated with topiramate. Topiramate was selected because literature supports its use in compulsive and addictive behaviors.2,3 Both cases responded to topiramate; 1 individual developed cognitive impairment resulting in discontinuation. However, that individual’s treatment with levetiracetam was effective.

Case report 1

Mr. H, age 25, presented for treatment of a 7-year history of exhibitionism. He experienced exhibitionist urges twice monthly, and acted on them every 8 months. He also suffered from obsessive-compulsive disorder (OCD) and hypomanic traits. Family history included hypersexuality, OCD, and uncontrolled anger.

Treatment with fluoxetine, 20 mg/d, resulted in increased exhibitionism. Fluoxetine was discontinued and topiramate was initiated and titrated to 50 mg/d, resulting in no improvement in OCD symptoms and decreased libido. Topiramate was increased to 100 mg/d and escitalopram was prescribed and titrated to 30 mg/d. The patient’s OCD symptoms partially improved, and he noted an absence of exhibitionist urges. He said he felt, “normal,” and could speak to females as friends without wanting immediate physical gratification. He also reported a loss of his prior interest in pornography. Experiencing sedation and amotivation, he discontinued both medications for 5 days, resulting in increased sexual preoccupation.

Topiramate was resumed and was the mainstay of the patient’s treatment over the next several years. Augmentation with risperidone, 2 mg/d, for OCD symptoms was attempted but discontinued because of side effects. Venlafaxine also was added to topiramate with some improvement in OCD, but was insufficient for the patient to continue venlafaxine.

The patient discontinued topiramate on at least 3 other occasions. The first time resulted in increased sexual preoccupation. The second time he reported that, “sexual thoughts were consuming me,” and he made sexually inappropriate comments at church. The third time, the patient tried to expose himself in public and spent $900 in 2 days at strip clubs. With topiramate, he reported, “I have no desire to even turn the computer on and do those addictive things.” He left treatment after 4 years.

Case report 2

Mr. R, age 26, requested treatment after an arrest for soliciting prostitution. His marriage was in jeopardy. He reported using pornography for 4 hours daily by the seventh grade. He met criteria for OCD and attention-deficit/hyperactivity disorder. Topiramate was titrated to 50 mg/d. At follow-up, he reported decreased impulses towards extramarital sexual activity, stating “I can think about the consequences,” but he experienced cognitive dysfunction. Topiramate was continued and mixed amphetamine salts, 10 mg twice a day, were added without cognitive benefit. Mixed amphetamine salts were continued, topiramate was discontinued, and levetiracetam was titrated to 250 mg twice a day.

Over several months, he reported a cessation in strip club involvement and a 4-week period without pornography use vs daily use before medication. Side effects included sedation and sexual dysfunction. The patient stopped both medications for 6 weeks. His compulsive counting and sexual behaviors resumed and he stopped attending 12-step meetings. He resumed taking mixed amphetamine salts and levetiracetam, 125 mg twice a day, with good results, without attending 12-step meetings and with no side effects. Impulses to be unfaithful to his wife or visit strip clubs decreased from constant to once every 3 days. Pornography use decreased from 30 minutes daily to 5 minutes, every other day.

  DISCUSSION

When off medications, both patients experienced loss of control of compulsive behavior, and both experienced improved control when they resumed medications. Advice to eliminate home computers and, in Mr. H’s case, attend 12-step meetings could have improved treatment.

Mr. R experienced significant cognitive side effects while using topiramate, but not with levetiracetam. Topiramate use is limited by its significant cognitive side effects. Topiramate also causes metabolic acidosis in some patients resulting in bone loss if not detected and treated.4 Levetiracetam generally is well-tolerated without cognitive impairment.5 Side effects include sedation, aggression, and hyperirritability. The FDA warns of increased suicidality with anticonvulsants. Further study of treating compulsive sexual behavior with anticonvulsants, including levetiracetam, is indicated.

DISCLOSURE: Dr. Bell reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

ACKNOWLEDGEMENT: The author would like to thank Maher S. Kozman MD, and George B. Bell for their assistance in the preparation of this letter.

    REFERENCES

  1. Raymond NC, Grant JE, Kim SW, et al. Treatment of compulsive sexual behaviour with naltrexone and serotonin reuptake inhibitors: two case studies. Int Clin Psychopharmacol. 2002;17:201–205.
  2. Fong TW, De La Garza 2nd, Newton TF. A case report of topiramate in the treatment of nonparaphilic sexual addiction. J Clin Psychopharmacol. 2005;25:512–514.
  3. Thorens G, Billieux J, Manghi R, et al. The potential interest of topiramate in addiction. Curr Pharm Des. 2011;17:1410–1415.
  4. Tartara A, Sartori I, Manni R, et al. Efficacy and safety of topiramate in refractory epilepsy: a long-term prospective trial. Ital J Neurol Sci. 1996;17:429–432.
  5. Bootsma HP, Ricker L, Diepman L, et al. Long-term effects of levetiracetam and topiramate in clinical practice: a head-to-head comparison. Seizure. 2008;17:19–26.

CORRESPONDENCE: D. Stewart Bell, MD, Psychiatry, Kaiser Permanente, Ontario Mental Health, 3330 Centrelake Drive, Ontario, CA 91761 USA, E-MAIL: Dwight.S.Bell@kp.org