International Journal of Neuropsychopharmacology (2005), 8, 635–636.
Copyright f 2005 CINP
doi:10.1017/S1461145705005493
Hypersexuality and its response to citalopram
in a patient with hypothalamic hamartoma and
precocious puberty
Received 23 June 2004; Reviewed 1 November 2004; Revised 17 January 2005; Accepted 23 January 2005
Hypersexuality has been defined as the subjective
experience of loss of control over sexuality (Catalan
and Singh, 1995). It is known to be associated with
mood, impulse and compulsive disorder (Coleman
and Kafka, 1991) and with biological factors such as
brain injury involving septal nuclei (Gorman and
Cummins, 1992) and dementia (Potocnik, 1992). Sexual
addiction is synonymous with hypersexuality, which
is defined as a condition in which some form of sexual
behaviour is employed in a pattern that is character-
ized by two key factors : (1) recurrent failure to control
the sexual behaviour and (2) continuation of the sexual
behaviour despite significant harmful consequences
(Goodman, 1998). Kafka (1991) defined non-paraphilic
sexual addictions as culturally acceptable sexual
interests and behaviours that increase in frequency
or intensity so as to significantly interfere with the
desired capacity for a sustained intimate sexual
relationship. These behaviours may include compul-
sive masturbation, dependence on anonymous sexual
outlets like pornography, or telephone sex, and re-
petitive promiscuity involving using people as sexual
objects.
Over recent times a lot of interest has been generated
in understanding the physiological aspects and phar-
macological management of hypersexuality/sexual
addiction/compulsive sexual behaviour. Selective
serotonin reuptake inhibitors (SSRIs) have been pro-
posed as a treatment option following studies dem-
onstrating their inhibitory effect on 5-HT2 receptors
(Kafka, 1995). Here we report a case believed to be
the first of its kind of a patient with hypothalamic
hamartoma and hypersexuality who responded to
citalopram.
Case report
A 34-year-old caucasian single man was assessed
with the complaints of excessive sexual desire and
Address for correspondence : Dr A. N. Singh, Department of
Psychiatry, Pilgrim Hospital, Sibsey Road, Boston PE21 9QU, UK.
Tel.: 01205 364801 (ext. 3634) Fax : 01205 442176
E-mail : ashok.singh@lpt.nhs.uk
T H E ED I T O R
L E T T ER T O
paraphilic fantasies. He was born with pubic hair and
attained erection at a very early age. He started to
masturbate at a very early age of 7 yr and to ejaculate
at 9 yr of age. At the age of 7 yr he was diagnosed as
having precocious puberty, with plasma testosterone
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levels of 11.6 nmol/l (adult range 6–30 nmol/l). He
was also found to have a hypothalamic hamartoma
diagnosed through MRI brain scan. A surgical inter-
vention was not thought to be necessary. At this stage
he was started on cyproterone acetate at the age
of 7.2 yr, with the bone age of 12.6 yr. He was
masturbating at least twice a day every day since the
age of 7 yr, and was always preoccupied with sexual
thoughts and fantasies. At the age of 31 yr he also de-
veloped a seminoma, which needed left orchidectomy
with insertion of testicular prosthesis.
The patient was seen in psychiatric outpatient clinic
when hypersexuality was identified with no as-
sociated mental illness. The sexual fantasies involved
sex with pre-pubescent girls, although there were no
incidents of legal or forensic concern. He was screened
with the ‘Preoccupation with sex’ questionnaire (J.
Catalan and A. N. Singh, unpublished questionnaire).
Citalopram 20 mg was commenced and the question-
naire was repeated at regular intervals to assess the
outcome. A course of cognitive–behavioural therapy
(CBT) was commenced at the same time to enhance his
self-esteem. On review at 3 wk he reported that he had
masturbated only twice and that his sexual urges were
markedly reduced. Three months later he stopped
masturbating completely and the sexual fantasies
were also less frequent. He remained on citalopram
for 10 months and then reduced to alternate days
and stopped. He was reviewed for further 6 months
without medications and no increase was reported
in his symptoms. His confidence improved and he
was able to concentrate much better on his college
courses. He was discharged from the clinic and
subsequent follow up at 2 yr showed no signs of
relapse. The serum testosterone level was 20.3 nmol/l
a year after discontinuation of citalopram, which
is within the normal adult range. However, testos-
terone levels are not available during the course of
treatment.
636 S. S. Malladi and A. N. Singh
Discussion
Hypersexuality (compulsive sexual behaviour/sexual
addiction) is an extremely distressing problem for the
patients. There are several biological and psychologi-
cal factors that can contribute towards this problem
(Coleman and Kafka, 1991). However, evidence is
virtually non-existent for a direct association between
hypothalamic hamartoma and hypersexuality al-
though precocious puberty is a well known compli-
cation of hypothalamic hamartoma (Judge et al., 1977).
It has been postulated that sexual paraphilias
(Greenburg and Bradford, 1997) and sexual addictions
(Kafka, 1994) are a manifestation of serotonergic dys-
function, possibly at a hypothalamic level. There is an
observation that serotonin depletion in the presence of
testosterone results in hypersexuality (Gessa et al.,
1970), as the serotonergic system possibly regulates
hypothalamic control of testosterone levels (Greenburg
and Bradford, 1997).
In this patient, the most likely mechanism by which
citalopram may have worked is by impairing sexual
performance by acting via serotonergic receptors.
However, an alternative mechanism of action can be
proposed. Studies suggest that hypothalamic hamar-
tomas may cause precocious puberty by autonomous
production and release of luteinizing-hormone-
releasing factor into blood vessels that communicate
with the pituitary portal blood system ( Judge et al.,
1977). It is possible that the above mechanism has re-
sulted in the abnormal production of testosterone in
our patient who had adult levels of testosterone at age
7 yr. Serotonin has previously been shown to inhibit
the secretagogue action of luteinizing hormone re-
leasing factor (LHRH) on gonadotrophs (Payette et al.,
1985). This raises the interesting possibility in this
patient of SSRIs reducing the sex drive through the
negative feedback effect on hypothalamic–pituitary–
gonadal axis. This hypothesis however needs to be
explored further before any conclusions can be reached.
The clinical improvement in this patient remained
even after discontinuation of citalopram. This can be
attributed to the potential synergistic effect of citalo-
pram and CBT as has been observed where psycho-
logical therapies were unlikely to be successful on
their own (Grubin, 2004).
With several case reports suggesting the benefits
of SSRIs in hypersexuality a double-blind study is
needed to demonstrate clinical efficacy of SSRIs in
these patients.
Acknowledgements
None.
Statement of Interest
None.
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Srinivasa Sastry Malladi, Ashok Nandan Singh
Department of Psychiatry, Pilgrim Hospital, Boston, UK