A difficult case of satyriasis in an adolescent responding ultimately to a combination of paliperidone palmitate and naltrexone

Abstract

A 15-year-old Kuwaiti male was brought to hospital by his mother for oversexualized behaviors of few months duration. Because of his acting out behavior and concern for the safety of his family members, he was admitted to an IP facility. He was a product of elective cesarean section and a non-consanguineous monogamous family. He had a twin brother and two younger sisters. He experienced an uneventful developmental trajectory. He was 10thgrader in a public mainstream school with average scholastic attainment. He had no medical history of note. There was no history of seizures, head trauma, toxic exposures, or illicit substance use. He had a home-bound schizophrenic father. Anamnestic history suggested Attention-Deficit/Hyperactivity Disorder (ADHD) symptom profile. Shortly prior to admission, he has been assessed in a private psychiatric facility for repetitive washing, a diagnosis of Obsessive-Compulsive Disorder (OCD) was made and fluoxetine 20 mg/d was prescribed but he refused to comply.On admission, he looked euphoric, disinhibited, uttering obscenities, showing sexual gestures, totally insightless, and with a "viscous" character. However, he demonstrated average psychomotor activity and sound sleep. Although he was not overtalkative, speech was noted for verbigeration. No history of sexual abuse was elicited, but access to adult material was reported by mother. Wechsler Intelligence Sclae for Children-3rd edtion (WISC-3) scored Full scale IQ (FSIQ) of 79 (borderline) but with no scatter. Extensive medical work-up, including neuroimaging and electroencephalogram (EEG) was unremarkable. A tentative diagnosis of bipolar spectrum disorder was entertained and given the genetic load, he was commenced on paliperidone 3 mg titrated up to 9 mg/d with clonazepam 0.5 mg/d. He developed asymptomatic hyperprolactinemia at this dose and gained some weight.In view of the history suggestive of ADHD, a trial of short-acting methylphenidate was tried. He rapidly experienced psychotomimetic side effects that mandated premature abortion of the trial with complete resolution of these transient psychotic symptoms.He was discharged but hypersexuality and erratic compliance with treatment remained a problem. Hence, he was shifted to IM paliperidone palmitate 156 mg q 4 weeks and enrolled in an extensive behavioral program. Given the compulsive nature of his behavior, a trial with fluoxetine was commenced and increased to 40 mg/d without benefit. As an impulse dyscontrol, valproate was introduced at 600 mg/d. He developed extrapyramidal rigidity with no clinical improvement. In view of continued problem behaviors, hormonal treatment was suggested but declined by mother. Exploring the problem as an addictive behavior, we suggested to embark on an off-label trial of naltrexone. Viva voce informed consent of mother, the legal guardian, was obtained beforehand. Baseline liver function tests (LFTs) were normal. Naltexone was started at 25 mg/d. Over 4-week duration, there was marked reduction of sexual behavior, as reported by mother and...