Compulsive Pornography Use to Relieve Constipation: Double Whammy of Shame

Obsessive compulsive disorder (OCD) is one of the common mental disorders that is associated with socio-occupational dysfunction and also with distress due to the nature of symptoms. Besides the shame of having a mental illness, many patients of OCD also develop shame which is symptom-based and bodybased, which act as a double blow [1]. In this case-report we depict the case of OCD having a rare presentation and also discuss the neurobiological and psychodynamic backgrounds behind this rare presentation.


Introduction
Obsessive compulsive disorder (OCD) is one of the common mental disorders that is associated with socio-occupational dysfunction and also with distress due to the nature of symptoms. Besides the shame of having a mental illness, many patients of OCD also develop shame which is symptom-based and bodybased, which act as a double blow [1]. In this case-report we depict the case of OCD having a rare presentation and also discuss the neurobiological and psychodynamic backgrounds behind this rare presentation.

Case Study
The following is the case of Mr. A, a male aged 27 years, hailing from a family of middle socio-economic strata, currently employed in service. He presented with the complaint that he has constipation since two years and he needed to watch pornography in order to clear his bowel over past one year.
Mr. A elaborated that he had been suffering from difficulty in achieving complete evacuation of his bowel since past two years. As a result, when he would be out of his home he would often feel that he needs to defecate. To prevent this, he started to spend more time in the toilet. In about 6 months since the onset, he usually spent around 30-35 minutes in the toilet as opposed to his usual habit of 5 minutes. During this, he would strain and in most cases he would pass mucus with little fecal matter. The patient would be distressed due to the fact that he had to spend so much time in the toilet and that would cause delay in his daily routine. But, he continued with it in order to prevent discomfort throughout the day. Over time, due to boredom he started watching pornographic videos. Within a few days of starting to watch pornography, he started to feel that his bowel cleared better while watching pornography. He felt that he no longer felt bothered to go out of his home. However, on days when he could not watch pornography due to some reason, he felt that the previous symptoms re-appeared. Gradually over time, the time spent in the toilet started to increase. He would spend close to 1 hour in the toilet in order to achieve complete evacuation.
However, after about a year, he started to feel distressed on having to use pornography to facilitate defecation. He felt that watching pornography was no longer associated with the previous degree of erotic pleasure. He also became distressed in having to waste significant time in the morning due to his bowel habits. He started to run into trouble as he was often discovered to be watching pornographic materials by his parents or maid, which caused him social embarrassment. He also landed in trouble at his workplace since he could not stick to the schedule. His attempts to avoid pornography were associated with significant anxiety that his bowel will not be cleared. He attempted other modes to facilitate bowel movement, in order to Psychology and Behavioral Science International Journal cut down pornography use like drinking fluids and adhering to a strict dietary habit, but the results were dismal. So, finally since his symptoms were increasing, he decided to seek a medical consultation.
The clinical evaluation of the patient revealed no medical or psychiatric comorbidty including depressive symptoms. His birth and developmental history was normal. There were no past psychiatric symptoms and he had a well-adjusted premorbid personality. Laboratory investigations also revealed no abnormality.

Discussion
According to our knowledge this was the first case presenting with use of pornography for achieving proper evacuation of bowel. We found that the patient's belief that watching pornography helps in clearing the bowel was a magical thinking and the act of watching porn though initially was pleasurable had later turned into an irrational and distressing act which the patient clearly accepts to be his own volition. As a result, we diagnosed the above patient to be suffering from obsessive compulsive disorder, predominantly compulsive acts (ICD-10, F42.1).
To explain this rather rare phenomenology we can look into the rather recent concept of excessive reliance on habitual action strategies as opposed to the goal-directed action strategies in OCD [2]. Goal directed behaviors are those which are reevaluated on the basis of the outcome, whereas habitual actions are those which persist even when the outcome is not rewarding. The control of the goal directed action strategies lies in the striatum and the medial pre-frontal cortex (mPFC), a region that is known to be dysfunctional in the patients with OCD [3].
This has also been replicated in studies employing functional imaging using fMRI where it was found that patients with OCD had an imbalance in the control of the goal directed and habitual action strategies [4]. However a critical area where patients of OCD differ from normal persons with habits is the failure to develop an adaptive response to the act, which results in distress associated with the act. This can be explained by the maladaptive goal-directed uncertainty monitoring, leading to repetitive behaviors. This aspect seems to be under the control of the sub thalamic nucleus (STN) and the orbito-frontal cortex (OFC), where the uncertainty of stimulus identity is coded [5].
This should also be seen in conjunction with the fact that neuropsychological studies having found out those patients with OCD have a trait level impairment in decision making in ambiguous situations but perform adequately in situations involving risks [6]. Studies have also found out that these deficits are dependent on the stage and severity of the illness and are expected to improve along with the response to treatment.
The complaint of constipation has been found to be common in cases of OCD as opposed to general population [7]. This is especially important when we view it under the light of the psychodynamic theory of origin of OCD in the anal stage of psychosexual development, stemming from the conflict of the child whether to soil the clothes or not. The use of pornography here could be the manifestation of attempts to displace the efforts to gain anal eroticism. This is also supported by the fact that use of pornography was found to be higher in patients showing higher obsession trait in their personality assessments [8].
This presentation also smothers the concern that the psychodynamic explanation of OCD has lost its relevance. Though our case can be explained in light of the above evidence, it should be noted that there is a significant dearth of data in the neuropsychological profiles of patients with OCD, and this case highlights the further need of research in that respect in various stages of the disorder.

Conclusion
To conclude we must highlight that this was a rare case of OCD presenting predominantly with compulsive watching of pornography in order to achieve complete evacuation of the bowel. The case highlights the varied presentation of the illness and also the relevance of both the newer theories of neurobiology and older psychodynamic theories in explaining the disorders.