Pedophilia is defined as a continued sexual attraction toward prepubertal children.1 However, the diagnostic and statistic manual (DSM)-5 distinguishes between pedophilia and pedophilic disorder, whereby the former is considered a nonpathologic sexual preference toward prepubertal children,2 and the latter as the presence of recurrent and intense fantasies of sexual arousal, and sexual impulses toward prepubertal children, associated to marked anxiety and interpersonal difficulties, or that the individual may have acted upon these sexual impulses at behavioral level (the use of pornography and/or abusive sexual acts).3
Men with pedophilic disorder often have a long history of other psychiatric disorders that can render the diagnostic and therapeutic approach more complex.4 Among those diagnosed with pedophilic disorder who received outpatient or inpatient treatment, two thirds had a history of mood or anxiety disorders throughout their lives, 60% had a history of substance abuse throughout their lives,5 and 60% met the criteria for a personality disorder whereby obsessive-compulsive (25%), antisocial (22.5%), narcissistic (20%), and avoidance behavior (20%) were the most common.6
Pedophilia has also been associated to poor cognitive functioning and lower than average Intelligence Quotient (IQ).7,8 Despite the initial data being considered controversial, Blanchard et al9 found that the relationship between pedophilia and cognitive function is genuine, supporting the hypothesis that neurodevelopmental disturbances increase the risk of pedophilia in men.
Very few cases have been published on pedophilic disorder associated to substance-use disorders (SUDs) and even less so in the context of patients with intellectual disability. This article presents a case of pedophilic disorder associated to multiple psychoactive SUD and mild intellectual disability; we discuss the clinical implications of this complex comorbidity.
DESCRIPTION OF THE CLINICAL CASE
The 21-year-old single male patient, hospitalized in an addictive behavior unit. He was first treated in the emergency department at the age of 18 when he was taken in by his mother due to a clinical picture of 2 months of heteroaggressiveness toward family members associated to criminal conduct such as armed robbery associated to psychoactive SUD.
In the initial assessment, when the patient was admitted his behavior was aggressive and he manifested signs of recent consumption of marijuana and cocaine. At the time, he exhibited restricted affect, aggressive attitude, restriction in the production of ideas, a low tone and poor ideoverbal abilities, with below average intelligence. He showed no sense-perceptual alterations, delusions, or suicidal thoughts. He showed impulsive personality traits, a low level of tolerance to frustration, poor ability to reflect on his own behavior. It is due to this episode that he was hospitalized.
His mother reported that she had found him, at age 14, watching child pornography while he masturbated. She added that on one occasion (also when he was 14) “he tried to touch his younger brother’s genitals and to pull down his underwear.” At that same age, he began to feel exclusive sexual attraction toward boys under the age of 12. He manifested “tingling” in his genitals when he saw boys of this age, and that he had sexual fantasies related to them. He denies close contact with underage boys; however, he mentions that conflict had been generated in the neighborhood after he expressed his sexual desire for a 12-year-old friend and that after this happened his neighbors rejected and made fun of him. The patient manifested that he cannot control his sexual inclinations, which he considers “strange,” he admits that he needs help and that he does not want to hurt anyone. He mentioned that when he was 17, he had sexual relations with older men in exchange for money to maintain his psychoactive substance use, without manifesting arousal. He denies any attraction or desire for physical contact with women or older men.
He was raised by his maternal grandmother from the age of 4 to the age of 12 due to the family’s financial problems, without the loss of parental contact. The patient and his parents affirm that he had not been the victim of sexual abuse. He currently lives with his parents and brother. The family believes in God and considers itself Catholic.
He is the oldest child of a family made up of a father, mother, a brother 4 years younger than himself, and a sister 13 years younger. He was delivered via C-section due to the umbilical cord being entangled around his neck, and with a low APGAR score, with neonatal sepsis at 8 days of life, managed by 2 weeks in an intensive care unit. He presented delayed speech development for which he went to a special institution for the first 2 years of school. At the age of 9, he began normal school where he was the victim of exclusion, he was made fun of because he was shy, and he had poor relations with other boys his age. He failed first, fourth, and sixth grades for poor understanding of the thematic content. Thus, he began studying at a secondary institution following a semester schedule at 16 where he had to interact with people older than himself and where he began to use psychoactive substances. He finished high school but he has never worked. His circle of friends is limited to psychoactive substance use.
The patient began to consume alcohol at the age of 16, nicotine at the age of 17, cocaine, cannabinoids, sedatives, and inhalants at the age of 18. He presented a progressive increase of consumption of these substances, failed attempts at stopping, sociofamily difficulties, criminal behavior, uncontrolled use, and withdrawal symptoms.
The patient began an intrahospital rehabilitation program, which he finished in 6 months. However, 2 weeks later, he abandoned the pharmacological treatment and began to use cannabis, smoking cocaine (basuco), and using inhalants. Twelve months later and due to aggressiveness and prolonged absences from the family home, the patient was admitted to a rehabilitation center not associated to the health system from where he ran away and went back home. Once there, his parents decided to take him to the psychiatric emergency unit due to a clinical picture of initial insomnia, delusions of a mystical-religious nature, associated to delusions of persecution and in reference to family and carers. The mental examination showed a hallucinatory attitude, he mentioned complex auditory hallucinations, his judgment and reason were impaired, and he presented deficient introspection. He was hospitalized with a diagnosis of acute psychotic episode induced by the use of psychoactive substances for which he received treatment with increasing doses of quetiapine, requiring 800 mg a day to control the symptoms. The initial tests (Table 1) did not reveal renal, hepatic, thyroid alterations, or sexually transmitted infections, but, in the urine test, he tested positive for cocaine and cannabis.
IQ tests were applied, obtaining a global score of 75 (Table 1) and cerebral magnetic resonance imaging reported as normal.
The patient is currently in his sixth month of hospitalization in his second rehabilitation treatment for psychoactive substance use. The current mental examination shows no psychotic symptoms. He manifests continued ego-dystonic sexual attraction for boys under the age of 12.
The presence of chronic and recurrent sexual attraction for boys the age of 12 or under, related sexual fantasies, the use of child pornography and his interpersonal problems allow us to conclude that the patient presented in this clinical case meets the diagnostic criteria for pedophilic disorder according to the DSM-5. Pedophilia is a paraphilia with a chronic course, which is defined by the presence of intense and recurrent sexual needs and fantasies that produce arousal and may conclude in some form of sexual activity with prepubertal children (generally aged 13 or under). These have to be present for at least 6 months, they have to produce discomfort or deterioration in different areas of the person’s activities, and sufferers must be at least 16 years of age, and at least 5 years older than the child.10 Despite the fact that our patient has not carried out sexual acts with children, the other phenomena such as the fantasies and the use of pornography mean that he meets the criteria for the diagnosis of pedophilic disorder. In fact, masturbatory sexual fantasies constitute a characteristic pattern in these patients.11,12
The DSM-5 distinguishes between exclusive and nonexclusive subtypes of pedophilic disorder (whether the person can feel aroused only by children or also by older people), sex preferences and whether this is limited to incest.1 In our case, the patient showed exclusive sexual attraction for boys under the age of 12. Although the patient had homosexual relations with older men to be able to buy psychoactive substances, his sexual preference is for prepubertal boys, given that he clearly affirmed not having felt sexual arousal for older men and that the reasons behind these sexual relations were different.
In a recent study involving 1310 adults in Finland, it was found that sexual interest in children 12 years old and under was lower (0.2%) than it was for children 15 and over (3.3%).13 Some authors differentiate sexual attraction toward prepubertal children (pedophilia) and toward pubescent children (hebephilia);14 although the latter was not explicitly included in the DSM-5,1 from a clinical perspective, both categories account for the clinical heterogeneity of the patients that meet the criteria for pedophilic disorder.15 Our patient is clearly part of the pedophilia group. Similarly, patients with pedophilic disorder showed difficulties in maintaining sexual relations with mature women and they have experienced a greater proportion of sexual and nonsexual abuse in their childhood13,16 which is consistent with our patient’s personal history.
The diagnosis for pedophilic disorder maybe delayed due to the fact that patients tend to deny or minimize the disorder and, currently, the diagnosis depends fundamentally on self-reporting of the symptoms.17 In addition, the fear of legal consequences and stigmatization may lead patients to conceal their symptoms, despite the fact that these can produce discomfort for themselves and their family.18 In the case of our patient, the diagnosis was reached 4 years after the disorder had begun. The difficulty of diagnosis is increased given the complexity of the differential diagnosis, given that pedophilic disorder shares some of the psychopathologic findings with other SUDs and obsessive-compulsive disorder.19
Although our patient’s IQ is within the borderline range, in accordance with the DSM-5 adaptive functioning criteria, despite the fact that his IQ does not classify him as such, our patient meets the criteria for intellectual disability.3,20 Even if the cutoff point for intellectual disability is changed to the fifth percentile (IQ of 75) instead of the second percentile (IQ of 70) the patient’s global score would fall within the diagnosis for mild intellectual disability.20 Studies carried out with sex offenders, have shown that those who present cognitive deficiencies tend to target victims of the same sex, especially if they are male and underage.21,22 The families of these patients have generally been subject to parental separation, violence, negligence and poor control, and patients present poor adjustment to school, behavioral disorders, delinquency and other mental disorders, difficulty in understanding and establishing sexual relations, poor impulse control and influenceability.23 These data are apparent in the personal and family history of our patient.
The comorbidity of pedophilic disorder and SUD has not been frequently reported in literature such as case studies.24 However, epidemiological studies indicate that the presence of SUD in some cohorts of patients that meet the criteria for pedophilic disorder is high.5
The comorbidity of SUD and pedophilic disorder constitutes an additional difficulty for clinicians given that there is an overlap of SUD symptoms and pedophilic disorders.1,4 This comorbid behavior sets out the hypothesis that the pathologic or deviant sexual behaviors observed in patients with pedophilic disorder may be part of an addictive disorder.25 In recent years, a greater number of studies have been carried out on sex addiction or hypersexual disorder characterized by obsessive thoughts, sexual fantasies, excessive masturbation, and the use of pornography among other behaviors.26 Also, the adverse consequences of addiction to sex are similar to the consequences of other addictive disorders and often associated with other addictive, somatic, and psychiatric disorders.27 In our case, in the characteristics associated to sex addiction for impulsiveness associated to SUD does not fairly justify pedophilic disorder as in this patient, the sexual behavior is persistent, aimed at a specific target, and it began before the SUD. However, this topic continues to be controversial and more and more rigorous research is required to solve the problem.25,28
The last time he was hospitalized, our patient presented a psychotic episode, which we consider, given the patient’s history and the course of his symptoms, not primary but substance induced. In the same way as in our patient, psychotic SUDs are caused by the active use of the substance and usually do not persist for >1 month.29,30 Although there is an association between comorbid psychotic disorders and SUD and sexual offenses,31 our patient’s sexual behavior cannot be attributed to psychosis, given that his sexual preferences began before the psychotic episode, they did not increase with it, and they persisted after the reduction of psychotic symptoms.
Pedophilic disorder may be associated to SUDs and intellectual disability making the diagnostic and therapeutic approach more complex. It is important to differentiate the clinical picture of pedophilic disorder from some characteristics of SUDs and intellectual disability. The active search for deviant sexual behavior should be carried out in patients with dual diagnosis. The approach, study, and publication of these cases may help to increase knowledge of this problem.
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