A Case of Late-Onset Pedophilia and Response to Sertraline

Prim Care Companion J Clin Psychiatry. 2007; 9(3): 235–236.

Naren Prahlada Rao, M.B.B.S.,1 Prabhat K. Chand, M.D., D.N.B.,2 and Pratima Murthy, D.P.M., M.D.3

1National Institute of Mental Health and Neurosciences, Bangalore, India2Department of Psychiatry Kasturba Medical College, Manipal, India3National Institute of Mental Health and Neurosciences, Bangalore, India

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References
 
Sir: Pedophilia is a psychiatric disorder in a person at least 16 year old that is characterized by sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a pre-pubescent child (aged 13 years or younger).1 These fantasies are acted out and cause marked distress or interpersonal difficulties. Pedophilia is a common and often overlooked syndrome that risks the child victim’s well-being and further psychosocial development and adaptive functioning. While a majority of cases of pedophilia begin among adolescents,2 in the elderly it is relatively rare and confined to a few case reports.3–5 In the present report, we describe a patient with emergence of pedophilia in late life, the assessment, and response to treatment with sertraline.
Case report. Mr. A, a 70-year-old man, was hospitalized in 2005 with a history of engaging in sexual behavior with female children 6 to 7 years old. The history was obtained from Mr. A’s adult son, as the patient initially denied any problem. During the last 13 years, Mr. A had been giving young girls money, later taking them to remote places and undressing them and fondling their genitals. On 1 or 2 occasions, he had apparently attempted intercourse (based on reports from the victims’ families of vaginal bleeding). No legal complaint had been filed by the victims’ families. However, Mr. A’s family was concerned that he may molest these children and get arrested and thus locked him in the house often. He is married and heterosexually oriented and was living with his wife and children. The patient reported no recent change in the sexual relationship with the wife, which was corroborated by her. Mr. A’s medical history was notable for a cataract surgery in the left eye 3 months before admission. He had no history of psychiatric or developmental problems and had exhibited no prior deviant sexual behavior. There was no history suggestive of cerebrovascular disease or dementia.
On examination, Mr. A was cooperative and had good eye-to-eye contact. His thought processes were logical and clear. He denied any hallucinations or delusions and appeared to be euthymic. He was alert and attentive and scored 29 of 30 on the modified Mini-Mental State Examination,6 missing an item in attention and concentration. Results of repetition, naming, memory, and constructional tasks were within normal limits. His ability to perform simple constructions was also within normal limits, and he had no difficulty with an alternating motor patterns test. Mr. A’s neuropsychological assessment showed deficits in focused attention, design fluency, and visual working memory. His abstract ability was within normal limits. Physical examination, including detailed neurologic examination, found no abnormalities. Results of laboratory tests, including liver, thyroid, and renal function; hemogram; electrocardiogram; serum Veneral Disease Research Laboratory test; ELISA for human immunodeficiency virus; and serum testosterone levels (measured by chemiluminescent immunoassay), were all in the normal range. Structural magnetic resonance imaging of the brain showed findings within normal limits.
After a couple of weeks of inpatient stay, Mr. A corroborated his sexual attraction to young girls and recognized that this was a potential problem for him in the village. He fulfilled DSM-IV-TR criteria for pedophilia.1 He was started on sertraline, 50 mg/day, which was increased to 100 mg/day after 3 weeks. He also became engaged in individual counseling, which initially involved establishing a therapeutic alliance and gaining the patient’s confidence. With this regimen and increased supervision, Mr. A had a significant behavioral improvement with no reports of similar incidents during the next 1 year of follow-up and reported a decrease in desire on a visual analogue scale.
The index patient presented with late-onset sexual activity with prepubescent girls in the absence of schizophrenic, affective, obsessive, or dementia symptoms. In contrast to the typically reported cases of pedophilia, the index patient had an unusual presentation with emergence of pedophilia in late life.
The etiology of pedophilia is unknown. Paraphiliac behavior has been reported secondary to temporal lobe epilepsy, post-encephalitic neuropsychiatric syndromes, septal lesions, frontal lobe lesions, bilateral temporal lobe lesions, multiple sclerosis, and tumors in various sites.7 Recent reports have noted the concurrence of emergence of pedophilia in late life and brain disease. One report described 2 patients with pedophilia who had temporal lobe hypometabolism as revealed by positron emission tomography; 1 patient had frontotemporal dementia and the other had bilateral hippocampal sclerosis.4 No evidence of structural brain lesion, however, was evident in our patient.
Management of pedophilia at any stage poses a serious clinical challenge. Antiandrogens and hormonal agents such as estrogen, medroxyprogesterone acetate, cyproterone acetate, and gonadotropin analogues have been used; however, the effectiveness of treatment was reduced because of the various adverse reactions,7 and only a minority of subjects are likely to take an antiandrogen on their own. Several recent reports suggest successful treatment of paraphilias with selective serotonin reuptake inhibitors, e.g., sertraline, fluoxetine, and fluvoxamine.8–10 However, the efficacy of these drugs in the treatment of pedophilia emerging in late life is not known. The case reported here suggests the efficacy of sertraline in pedophilia. In the elderly, it is critical to evaluate for underlying structural and functional brain abnormalities.
References
  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association. 2000. .
  2. McConaghy N.. Paedophilia: a review of the evidence. Aust N Z J Psychiatry. 1998;32:252–265. [PubMed]
  3. Kurland ML.. Pedophilia erotica. J Nerv Ment Dis. 1960;131:394–403. [PubMed]
  4. Mendez MF, Chow T, and Ringman J. et al. Pedophilia and temporal lobe disturbances. J Neuropsych Clin Neurosci. 2000. 12:71–76.
  5. Burns JM, Swerdlow RH.. Right orbitofrontal tumor with pedophilia symptom and constructional apraxia sign. Arch Neurol. 2003;60:437–440. [PubMed]
  6. Folstein MF, Folstein SE, McHugh PR.. “Mini-mental state”: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189–198. [PubMed]
  7. Bradford JM.. The neurobiology, neuropharmacology, and pharmacological treatment of the paraphilias and compulsive sexual behavior. Can J Psychiatry. 2001;46:26–34. [PubMed]
  8. Greenberg DM, Bradford JM, and Curry S. et al. A comparison of treatment of paraphilias with three serotonin reuptake inhibitors: a retrospective study. Bull Am Acad Psychiatry Law. 1996. 24:525–532. [PubMed]
  9. Kafka MP.. Sertraline pharmacotherapy for paraphilias and paraphilia-related disorders: an open trial. Ann Clin Psychiatry. 1994;6:189–195. [PubMed]
  10. Stein DJ, Hollander E, and Anthony DT. et al. Serotonergic medications for sexual obsessions, sexual addictions, and paraphilias. J Clin Psychiatry. 1992. 53:267–271. [PubMed]

 

Provided by

DR WIDODO JUDARWANTO
FIGHT CHILD SEXUAL ABUSE AND PEDOPHILIA 

Yudhasmara Foundation

JL TAMAN BENDUNGAN ASAHAN 5 JAKARTA PUSAT, JAKARTA INDONESIA 10210

PHONE : (021) 70081995 – 5703646

email : judarwanto@gmail.com, 

https://pedophiliasexabuse.wordpress.com/

Copyright © 2009, Fight Child Sexual Abuse and Pedophilia  Network  Information Education Network. All rights reserved 

Provided by

DR WIDODO JUDARWANTO
FIGHT CHILD SEXUAL ABUSE AND PEDOPHILIA

Yudhasmara Foundation

JL TAMAN BENDUNGAN ASAHAN 5 JAKARTA PUSAT, JAKARTA INDONESIA 10210

PHONE : (021) 70081995 – 5703646

email : judarwanto@gmail.com,

https://pedophiliasexabuse.wordpress.com/

Copyright © 2009, Fight Child Sexual Abuse and Pedophilia  Network  Information Education Network. All rights reserved

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