A Peep Into "Peeping Tom": Successful Management of Cyclothymia Presenting as Voyeuristic Disorder

A Peep Into "Peeping Tom": Successful Management of Cyclothymia Presenting as Voyeuristic Disorder

To the Editor: Voyeuristic disorder is a paraphilic disorder wherein the person experiences recurrent intense sexual fantasies and urges or gets sexual gratification from watching a person naked. The behavior should be present for 6 months, and the individual must be at least 18 years of age.1 Voyeuristic disorder is the most common law-breaking sexual behavior.2 Often seen in the forensic and sexological settings, judgmental attitude and therapeutic nihilism become hurdles in the assessment and management of paraphilia in the general hospital setting. Although mood disorders are not uncommon in patients with paraphilias,3 subthreshold presentations, especially cyclothymia,4,5 are often missed. There are no randomized controlled trials about the use of psychotropic drugs in paraphilia. To date, no literature about the efficacy of sodium valproate in paraphilia has been published. This is a report of voyeurism in a young man, which on exploration revealed an underlying cyclothymic disorder. Voyeurism and cyclothymia were successfully managed with sodium valproate coupled with an effective psychotherapeutic approach.

Case report. Mr A, a 19-year-old man, was brought to a psychiatry outpatient department of a general hospital in December 2015 by his mother with complaints of peeping inside bathrooms when females were taking baths. On average, there were 2 to 3 such incidents per month during the last 4 years. Recently, there were 2 episodes in which he was confronted and assaulted in public. There was no history of any other abnormal sexual behavior, impulse-control disorders, obsessive thoughts or acts, conduct disorder, attention-deficit/hyperactivity disorder, suicidal attempts, sexual abuse, substance abuse, seizures, or head injury. There was no history of mania, major depressive disorder, anxiety, or psychotic disorder. His intelligence was average. There was a history of alcohol-dependence syndrome in his father and paternal second-degree relatives and suicide and alcohol-dependence syndrome in 2 maternal fourth-degree relatives.

When each episode of voyeurism was investigated, it was found that during the days preceding the act of peeping, he would be feeling depressed, and after the act, his mood would improve. He also would feel sexually aroused but later would feel guilty. Comprehensive evaluation revealed fluctuations in mood, from mild elation to mild depression, with concomitant changes in activity levels, most of the time, for 6 years. The urge to peep occurred during the depressive episodes only. There were consequent occupational and social problems; people stopped hiring him for work, and he was socially isolated. The family was also ostracized. He had never received any therapeutic interventions.

His physical examination revealed normal results. There were no abnormalities in thought and perception. A history of mood fluctuations was reported. Cognitive functions were intact, and he had insight into his behavior.

A diagnosis of cyclothymic disorder and voyeuristic disorder were made per DSM-5 criteria.1 Biochemical investigations revealed results within normal limits. A good therapeutic relationship was established with Mr A. Using a medical model, psychoeducation was provided, which relieved his shame and guilt. His mother also received psychoeducation. Mr A was started on tablet sodium valproate 600 mg/d with follow-up for the next 11 months. During each visit, he was motivated to continue treatment and was positively reinforced for desirable behavior change. From the first month after initiation of treatment, there were no mood fluctuations and no urges or episodes of voyeurism. Mr A goes to work regularly. The family reported tremendous satisfaction with his treatment.

Meticulous psychiatric evaluation of young sexual offenders is mandatory. In every case of paraphilia, the possibility of cyclothymia has to be considered. Although cyclothymia is effectively treatable, its diagnosis can be easily missed. Positive reinforcement for desirable behavior facilitated in building a good therapeutic relationship with the patient and helped to deliver effective treatment in a center that is not specialized for treating sex offenders. Sodium valproate was found to be effective in this case, probably by treating the underlying cyclothymia.

In summary, exploration for an underlying subthreshold mood disorder, good therapeutic alliance, and therapeutic optimism were effective approaches to treating this patient. The efficacy of sodium valproate in the management of voyeurism was not evident in the published literature. Further research, especially randomized controlled trials, is warranted. The case also highlights the importance of a biopsychosocial approach in managing a seemingly socially deviant behavior that is of public health importance.

References

1. American Psychiatric Association. Diagnostic and Statistical Manual for Mental Disorders. Fifth Edition. Washington, DC: American Psychiatric Association; 2013.

2. Raymond NC, Grant JE. Sexual disorders: dysfunction, gender identity, and paraphilias. The Medical Basis of Psychiatry. 3rd ed. Humana Press; 2008:267-283. doi:10.1007/978-1-59745-252-6_16.

3. Kafka M. Axis I psychiatric disorders, paraphilic sexual offending and implications for pharmacological treatment. Isr J Psychiatry Relat Sci. 2012;49(4):255-261. PubMed

4. Perugi G, Hantouche E, Vannucchi G, et al. Cyclothymia reloaded: a reappraisal of the most misconceived affective disorder. J Affect Disord. 2015;183(14):119-133. PubMed doi:10.1016/j.jad.2015.05.004

5. Van Meter AR, Youngstrom EA, Findling RL. Cyclothymic disorder: a critical review. Clin Psychol Rev. 2012;32(4):229-243. PubMed doi:10.1016/j.cpr.2012.02.001

Smitha Ramadas, MBBS, DPM, DNBa

dr.smitharamadas@gmail.com

aDepartment of Psychiatry, Government Medical College, Thrissur, Kerala, India

Potential conflicts of interest: None.

Funding/support: None.

Patient consent: Written informed consent was obtained from the patient to publish this report.

Published online: June 8, 2017.

Prim Care Companion CNS Disord 2017;19(3):16l02070

https://doi.org/10.4088/PCC.16l02070

© Copyright 2017 Physicians Postgraduate Press, Inc.