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Psychostimulant Augmentation During Treatment With Selective Serotonin Reuptake Inhibitors in Men With Paraphilias and Paraphilia-Related Disorders: A Case Series

J Clin Psychiatry 2000;61(9):664-670

Background: We describe an open trial of psychostimulants (primarily methylphenidate sustained release [SR]) added to selective serotonin reuptake inhibitors (SSRIs; primarily fluoxetine) during the course of pharmacologic treatment of men with paraphilias and paraphilia-related disorders (PRDs).

Method: Twenty-six men with paraphilias (N = 14) or PRDs (N = 12) were assessed for lifetime mood disorders and attention-deficit/hyperactivity disorder (ADHD) as defined by DSM-IV. All men were assessed at baseline for total sexual outlet and average time per day associated with paraphilia/PRD sexual behaviors. The indications for the addition of a psychostimulant to a stable dose of SSRI included the retrospective diagnosis of ADHD with persistent adult symptoms despite pharmacotherapy with an SSRI (N = 17); residual paraphilia/PRD fantasies, urges, and activities despite SSRI pharmacotherapy (N = 16); the persistence or presence of residual depressive symptoms despite SSRI pharmacotherapy (N = 6); relapse or loss of SSRI efficacy during the treatment of sexual impulsivity disorders (N = 4); and treatment of SSRI-induced side effects (N = 4).

Results: SSRI pharmacotherapy (mean ± SD duration = 8.8 ± 11.1 months) had statistically significant effects in diminishing paraphilia/PRD-related total sexual outlet (p < .001) and average time/day spent in paraphilia/PRD sexual behavior (p < .001). Addition of methylphenidate SR (mean dose = 40 mg/day; mean ± SD duration = 9.6 ± 8.2 months) was associated with additional statistically significant effects on paraphilia/PRD-related total sexual outlet (p = .003) and average time per day (p = .04) in addition to improvement of putative residual ADHD and depressive symptoms.

Conclusion: Methylphenidate SR can be cautiously and effectively combined with SSRI antidepressants to ameliorate paraphilias and paraphilia-related disorders for the indications listed above.