Mr. N is a 50-year-old man who was referred to inpatient residential treatment services for substance use treatment. He has a history of alcohol dependence in early full remission in controlled setting, amphetamine dependence in early full remission in controlled setting, and cocaine dependence in early full remission in controlled setting. He also has been diagnosed with paraphilias (transvestic fetishism and a history of bestiality), substance-induced mood disorder (depression), and personality disorder – not otherwise specified with cluster B traits.
His alcohol dependence began in his teens. He met criteria for dependence at age 19, with the criteria of legal and social problems, tolerance and withdrawal. His maximum drinking began in his early 30s, when he was drinking up to a fifth of vodka daily. This pattern continued until his present admission. He has had 11 convictions for driving under the influence and has served a total of 5 years in prison for alcohol-related charges.
Mr. N has snorted, smoked, and injected cocaine since age 15, meeting criteria for dependence when he was 20 years old with tolerance, withdrawal, and financial problems. He also has ingested and injected amphetamines since age 20, meeting criteria for dependence when he was 23 years old with tolerance, withdrawal, and legal problems. Although he does not meet criteria for dependence or abuse for any other drugs, Mr. N reports heavy LSD use from age 16 to 18. He used it intravenously and had many “bad trips,” during which he actively hallucinated.
Mr. N has had one significant (18-month) period of sobriety from ages 47 to 49. During this time, he did not use any drugs and was actively involved in a dual diagnoses program. He reports that drinking and drug use enhance the pleasure of cross dressing and self mutilations and decrease the shame and guilt related with these activities.
Mr. N reports a lifelong history of cross-dressing behaviors that began as early as age 2, when he put on a doll's clothes. This behavior became regular at age 9, when he began playing with his sister's clothes. He would sporadically put on female attire and masturbate. These “sexual release” rituals continued until age 28 or 29, after which he began wearing female undergarments on a regular basis. As time passed, these behaviors became more and more ego syntonic, and the initial disgust was replaced by less severe shame and guilt, which he masked by abusing drugs and alcohol. He does not meet criteria for gender identity disorder.
Mr. N reports depressive symptoms with onset around age 31. He identifies feelings of guilt, helplessness, hopelessness, difficulty concentrating, and anhedonia as his main symptoms. His worst depressive episodes coincided with his periods of heavy drug and alcohol use. He has a history of violence with onset in early childhood. He had five expulsions from school for cruelty toward animals, fire setting, theft, and bullying other children who appeared physically weaker than him. He did not exhibit remorse toward these activities.
Mr. N was raised by his biological parents and does not have any history of physical, sexual, or emotional abuse. He has had one significant 4-year relationship, beginning at age 30. He has no significant medical problems.
Mr. N has undergone one long-term addiction treatment, which led to 18 months of sobriety. He has had more than 15 psychiatric admissions, most based on danger to self in context of alcohol intoxication and drug use.
He has been treated with maximum doses of paroxetine, fluoxetine, venlafaxine, and citalopram but developed sexual side effects on all of these medications. He has never received any other treatments for depression and paraphilias.
During his previous hospitalization, Mr. N participated well in the residential recovery program, shared his drug addiction issues in the therapeutic community, and gave and received valuable feedback from his peers. However he continued to wear female lingerie and did not discuss his paraphilias with anyone. As his sobriety increased, he reported increasing depressive symptoms, perpetuated by his struggle to stop his cross dressing. He reported early morning awakenings, low energy, chronic, and pervasive low mood and guilt. He said he actually found it easier to quit taking cocaine and amphetamines than to stop cross dressing.
These options could be considered as appropriate management strategies for the clinician.
Begin treatment with mirtazapine.
Begin treatment with a tricyclic antidepressant.
Begin treatment with bupropion and refer to a dual-diagnosis program offering cognitive-behavior therapy and communication and skills training.
Begin treatment of paraphilic behaviors with hormones.
Option 3 was chosen. Mr. N was started on bupropion, given its negligent sexual side effect profile. He tolerated the medication well and his depressive symptoms improved, but his paraphilia remained unchanged. He was referred to a dual diagnosis program and his treatment plan included several aspects of psychoeducation.
The program emphasized the importance of making healthy life choices and of leisure planning, the necessity of caring for body, mind, and soul to achieve recovery, the recognition of reasons why he had not done this in the past, and the importance of safe, self-nurturing activities as life enrichment. The program offers cognitive-behavior therapy using such methods as triple-column techniques to recognize thought distortions and applying healthy reframe. Education regarding relapse prevention and recovery principles, identification of warning signs of relapse, and finding healthy ways to cope with triggers are provided, as are training in effective communication skills and classes in creative expression. The program also includes education in community values such as diversity and tolerance, getting rid of stigma and labels, clarifying treatment ethics and philosophy, and exploring ethical issues, honesty, and relevant community issues and themes as they arise.
As his depression improved and his sobriety grew, Mr. N did well. He was accepted into a work-training program and continues to make progress. He plans to return to work full time.
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This case was provided by Nirmaljit Kaur MD, staff psychiatrist, Veterans Administration Palo Alto Health Care System, Palo Alto, CA.