The patient was a 24-year-old male with a past psychiatric history of schizophrenia who was seen in the outpatient clinic due to hypersexuality after starting aripiprazole. The patient had no known health problems. He had no history of head trauma, seizures, sexually transmitted disease, or significant substance abuse problems. He was first diagnosed with schizophrenia at the age of 19 years and was started on olanzapine, which he responded well to for years. The patient was living with his mother and had completed 11th grade level education. He did not have any history of developmental or intellectual difficulties. He was working part time in a fast food restaurant when he started to have the decline. He was single, never married, and had no significant other. The patient did not have very many acquaintances and led a quiet life. He has no known legal issues so far. The patient used cannabis occasionally when he was 17, but denied any use now. He did not have any problems with alcohol and or other illicit substances. He did not have any history of tobacco use. There was no known family history of mental illness.
The patient was previously stable on olanzapine 20 mg/day for four years and then became noncompliant due to unclear reasons, leading to worsening of psychotic symptoms. He was switched to oral aripiprazole 15 mg/day with a plan to switch to a long-acting injectable due to possible nonadherence. During the initial oral one-week trial, the patient became increasingly unstable, with physical and verbal altercations with his mother. The patient also ran away from home and lost his job due to public masturbation at his workplace. His mother also noticed that the patient was increasingly flirtatious and inappropriate in public with females, which were behaviors he had never displayed previously. Given his worsening behaviors, the patient was admitted to the inpatient unit and was switched to intramuscular injection (IM) of aripiprazole 400 mg, assuming that he would benefit from a long-acting injectable and that he could be non-adherent with the oral medication. He became increasingly sexually aroused and was acting inappropriate in the days following. During the hospital stay, there was an instance where he had sex with a female peer and had to be placed on 1 : 1 observation, i.e., one staff was assigned to continuously observe the patient. After discharge from the hospital, the patient needed constant reminders in his group home to keep his hands out of his pants. Despite these attempts to reduce the inappropriate behavior, the patient endorsed that his sexual arousal was more than normal after starting the aripiprazole. At this point in time, the patient had received two doses of aripiprazole 400 mg IM. While on aripiprazole, he did not show any gambling urges and or other impulsivity other than the sexual preoccupations. The sexual preoccupations started within a week of starting with aripiprazole. Further aripiprazole injections were discontinued, and the patient was again prescribed olanzapine 20 mg/day given his previous good response. In the group home, the patient continued to remain occasionally agitated with outbursts and required constant redirection about appropriate sexual behaviors in public. He also continued to display sexually inappropriate behaviors towards females in a day program and was banned from attending the program until he was able to behave appropriately. Although he had reduction in the intense sexual behaviors four weeks after stopping the aripiprazole injections, he did not completely return to baseline. Given his ongoing sexually inappropriateness and possible reports of being internally stimulated, he was started on paliperidone 6 mg/day for augmentation and with plan to taper and stop olanzapine. The patient started to have fewer outbursts and was noted to be in much better mood after three to four weeks of starting the paliperidone. He was noted to be less sexually preoccupied and with reduction in inappropriate behaviors in public. When writing this report, the patient was on both olanzapine 20 mg/day and paliperidone 6 mg/day, with the goal of attaining paliperidone monotherapy, initially oral and subsequently long-acting injections. The patient continued to live in the group home to learn social skills before moving into independent housing. After 12 weeks of paliperidone use, the patient was completely free from hypersexual thoughts and behaviors.