Comorbidity of paraphilia and depression in Mexico

The comorbidity of paraphilia-related disorders and other psychiatric disorders is high, but the paraphilia-related disorder often remains untreated until patients seek help for the comorbid disorder. A case of a patient in Mexico with comorbid paraphilia and depressive disorder, who was effectively treated with antidepressive medication and psychotherapy, is reported. The effect of stigmatization of homosexuality on the access to care of persons with sexual disorders is discussed.


Introduction
Among males with paraphilias according to DSM-IV and paraphilia-related disorders, mood disorders have been found to be the most frequent comorbid axis I diagnosis, with a lifetime prevalence of 71.6%. 1 This has important implications for treatment strategies, as antidepressant medication, mainly selective serotonin reuptake inhibitors (SSRIs), can be effective for both disorders. 2,3 The most effective treatment options for paraphilia-related disorders are considered to be cognitive-behavioral therapy (CBT), antiandrogen drugs or antidepressant medication, while the combination of pharmacotherapy and psychosocial interventions are suggested. 3,4 However, patients from low income groups and especially in less developed countries have less access to effective treatment. Much more important than the mere treatment synergy is the fact that the paraphilia will remain untreated until the patient seeks treatment for the comorbid disorder. In countries where sexually related disorders are highly stigmatized and sometimes underlie severe repression, the comorbid disorder can allow the patient to access treatment, which can then be expanded to the treatment of the sexual disorder.

Case Report
A 53-year old man came to an introductory meeting at a center for psychotherapy for low income persons (PAAT: Psicoterapia al Alcance de Todos) 5 in Cuernavaca, Mexico. He described feelings of distress that had been present for about two years with an increasing tendency in the last year. The main complaint was a depressive mood, accompanied by extensive sleep disorders, problems with concentration and thinking, as well as increased anxiety. Besides reducing his feelings of well-being, the symptoms had led to an overall decrease in the level of social functioning, resulting in a sharp decrease of productivity at work. The key event leading to his decision to seek help was a panic attack with intense anxiety, tachycardia and chest pain, leading to a one-night hospitalization. Due to the extent of symptoms, the patient was prescribed an antidepressant (sertraline 100 mg/d) in combination with weekly psychotherapy sessions.
It was not until the third session that the man found enough confidence in the therapeutic relationship to be able to disclose his sexual preferences. Already at an early age of ten years he had found pleasure in having objects inserted in his anus. His first such experience resulted in a playful interaction with a sexually aroused dog, which had mounted him while he was kneeling. The pleasure from the sexual act of the dog resulted in the man seeking similar actions also with other dogs. As the dogs were not always sexually aroused, he started inserting other objects, such as bottles, into his anus. It was not until the age of 19, after hearing of public restrooms where men sought sex with other men, that he first had sexual contacts with other men. Our subject was always the partner receiving anal intercourse from other men. These visits continued irregularly over the years, mainly due to fears of having these tendencies become known to his social surroundings. On the other hand, he regularly sought pleasure using dildos or other objects.
There was no evidence of underlying childhood trauma. Parallel to the sexual inclination, the man had an apparently normal sexual development, with girlfriends from the age of 16 and first sexual intercourse with a woman at the age of 19. He got married at the age of 25 to a 22-year old woman who he had fallen in love with. A year later their first and only child, a boy, was born. They had fairly regular sexual intercourse (about weekly in the first few years, decreasing slowly over the years to about monthly) until three years prior to the man's onset of depressive symptoms. At this point, his wife had a hysterectomy due to myomas and thereafter reported pain during intercourse. Since he did not want to pressure his wife to have sex with him, he increased his paraphilic masturbation activity as well as his visits to restrooms to receive anal intercourse. As it became more and more difficult to keep this activity hidden from his wife, he decided to disclose some of his inclinations to her, telling her about the pleasure he derived from inserting dildos and about what he believed was a "homosexual" inclination. He was surprised to receive full support from his wife, who apparently was relieved that she did not have to play the role of a sexual object. This support led to an initial euphoria and tension relief for the man who could pursue his inclinations without worrying about his wife.
However, the initial tension relief soon turned into the above mentioned depressive mood and anxiety. Parallel to his mental state, he started worrying about his work: the man's sexual activity increased gradually and started to become a factor impeding his work. He described a daily compulsive craving for sexual pleasure, resulting in sexual activity several times a day. The symptoms of anxiety that followed further decreased his productivity, leading to a sharp decrease in income and in turn additional emotional strain.
The man understood his sexual inclination to be a sign that he was really a homosexual. Mexico is a country where homosexuality is greatly stigmatized to the extent that the governing party (PAN) has even tried to pass state legislation to prohibit homosexuality. Therefore his belief of being a homosexual, while at the same time not having feelings of love toward a man, created further ambivalence and insecurity.
In line with psychotherapeutic work with low income groups, 5,6 psychotherapy was limited to 12 sessions and focused on underlying specific issues. One key aspect was to focus on his understanding of his sexuality, mainly that he was really a heterosexual, while explaining the mechanism of his concomitant paraphilic sexual inclination. Along with this, it was important for him to verbalize his desire to have a renewed sexual relationship with his wife, which had been sublimed by him for now several years. Coupled with the antidepressive effect of the drug, the man's symptoms decreased gradually, while the craving for sexual pleasure also decreased. Follow-up meetings at three, six and 12 months after the end of the 12-session psychotherapy showed continued, but much less intense, symptomatology of the paraphilia, but no more signs of clinical depression.

Discussion
Treatment was sought by the patient due to the depressive disorder which had developed over the previous three years. Due to a good therapeutic relationship, the patient was able to open up and convey his problems related to his sexuality. Considering the limited financial resources, the combination of pharmacotherapy and a short-term psychotherapeutic intervention can be considered an adequate treatment regime, close to standards suggested in the lit-erature. 4 The patient's fear of being homosexual reflects the high stigmatization of homosexuality in Mexican society, which prevents an open discussion on this topic. Nonetheless, in a country where homosexuality is highly stigmatized, self-disclosure of homosexuality may be protracted and could present itself through abnormal sexual activity. However, this could not be confirmed in the above case, as no homosexual inclinations remained after treatment. The case shows the importance of treating comorbid disorders in order to even be able to address sexual disorders.