Naltrexone for Acute Management of Compulsive Sexual and Obsessive Symptoms in a Patient With a Neurodevelopmental...

Compulsive sexual behavior disorder (CSBD) is characterized by persistent difficulty controlling sexual urges and behaviors associated with marked distress or impairment. Population-based data indicate that ~8.6% of US adults experience distress related to difficulty controlling sexual urges, feelings, and behaviors, while large international screening studies suggest that ~5% of individuals may be at high risk for CSBD, yet only a minority seek treatment. Diagnostic classification remains challenging in early or evolving presentations and in patients with complex psychiatric and neurodevelopmental comorbidities. The International Classification of Diseases, 11^th Revision (ICD-11) requires a 6-month symptom duration for formal diagnosis and specifies exclusion when symptoms are better explained by another mental disorder, substance use, or medication effects. Here we describe a man in his 20 s with bipolar I disorder, attention-deficit/hyperactivity disorder, anxiety, and intellectual developmental disorder (IDD), along with medical comorbidities, who was hospitalized for severe intrusive sexual thoughts associated with distress and safety concerns. Phenomenology suggested overlap between obsessive-compulsive disorder (OCD) with sexual obsessions and an emerging CSBD-like syndrome, with ego-dystonic intrusive cognitions alongside strong gratification-driven urges and restraint primarily driven by anticipated negative consequences. Given symptom severity and imminent risk of behavioral enactment, the presentation was conceptualized as an early CSBD-like syndrome despite not meeting the ICD-11 duration criterion. Symptoms remained acutely refractory despite multiple psychotropic optimizations; the most temporally associated improvement occurred after initiation of naltrexone, with marked improvement within 5 days and resolution of intrusive sexual thoughts by hospital day 16. Although concurrent medication changes preclude attribution to naltrexone monotherapy, the rapid response supports further investigation of reward- and impulse-targeted interventions for severe subthreshold presentations and highlights the need for clearer diagnostic frameworks and evidence-based guidance for acute management of diagnostically ambiguous compulsive sexual and sexual obsessive syndromes.