INTRODUCTION

Telephone scatologia is a type of paraphilic disorder characterized by making obscene phone calls to derive sexual arousal and gratification accompanied by sexually stimulating fantasies or sexual urges or behaviors to a nonconsenting person. ‘Telephone scatologia’ is also known as ‘telephone scatophilia” and “telephonicophilia”. It is categorized as other specified paraphilic disorder in DSM-5 (1). This group includes telephone scatologia (obscene phone calls), necrophilia (corpses), zoophilia (animals), coprophilia (feces), klismaphilia (enema), urophilia (urine) and other paraphilias which do not meet the diagnostic criteria for one of the specific categories and are less frequent (2-4). Although paraphilic disorders are categorized by paraphilic objects, a pathognomonic fantasy and related sexual urges and behaviors do exist in a repetitive manner in all paraphilic disorders. Arousal and orgasm occur due to ideation of fantasy and completion of behavioral fulfillment. Sexual arousal may be obtained from smell, touch, taste, sight, hearing senses and combination of these senses, also masturbation may be used as a satisfaction method (5). Sexually stimulating fantasies, sexual urges and behaviors are present at least for a six month period and this leads to clinically significant distress and interpersonal problems (6,7). These diagnostic criteria help to distinguish telephone scatologia from phone calls as a joke.

Although all telephone and internet scatologia are obscene not all obscene calls are telephone scatologia (6). Telephone calls made as a prank may sometimes be obscene but because they do not aim to cause sexual arousal or satisfaction they are not categorized as scatologia (5).

It is difficult to reach paraphilic individuals. Most of obscene telephone calls are less likely to result in forensic evaluation. Therefore, most of the information about these people is obtained from paraphilics who had problems or got into legal involvement (8). Obscene phone calls are commonly observed, but it is very rare to be arrested by the police. Telephone scatologia is a relatively ignored paraphilic disorder. Moderate nature of the disease, presence of a misconception that it is a non-aggressive disorder may be the possible reason of this (9).

CASE

Our case was a 21 years old, single, male who was expelled from the high school, working as a waiter and living with his family. The patient, applied to our hospital accompanied by his mother, expressed that he had telephone perversion, and also he told us that he felt the need of touching everything twice, and thought that his mother would die, if he did not touch. In his previous history, it was learned that his complaints started five years ago when he was attending the first year of the high school. He started to wash hands very frequently, and was spending too much time in the bathroom, felt as if his brain would explode, and felt a desire to harm himself, so he tried to cut down his arms with a razor. At the same time, he had the idea that people in the house were staring at his penis, so he started to wear double pijamas and wrap himself with blankets and told his mother to stop staring at his penis. It was also told that at that period he was not going out of the house, he was always straightening curtains and carpets, having fears of getting hurt. He had feelings of persecution, and fear of some neighbors and relatives for nearly three years, and these complaints increased recently. He claimed that he did not improve serotonin reuptake inhibitor treatment which was tried for his obsessions. In more than the last three years, he started to call his female relatives and talk with them in a sexual content quietly for about two minutes and masturbate during the telephone encounter. He said that he was driven by the sexual pleasure, especially if he heard voice of a woman on the phone. He was breathing heavily, and masturbated during the phone call. Although family members who noticed this situation tried to stop this behavior, the patient continued it persistently and was referred for prosecution upon complaint of a neighbor. Also an absence seizure was noticed occasionally during the last year by the family members. It was learned that he was staring, ‘blanking out’ and going on with his work after a couple of seconds.

The patient presented with a history of normal motor-mental development. He had separation anxiety while getting started to primary school. He had poor learning skills, hyperactivity and carelessness and he was the most mischievous and unsuccessful student in the class. He had failed in the second year of the secondary school. He had almost no friends during primary and secondary school. He was verbally or physically harmful to students during the first year of high school. He failed two times during the first year of high school, so he was expelled from the school. He had to quit every job he got, because of frequent fights with other people.

In his sexual history, he was circumcised when he was two years old, started masturbating when he was fifteen and continued regularly. He had his first sexual intercourse with a prostitute when he was eighteen. During the first sexual intercourse, erection and ejaculation did not take place, but he had similar intercourses in which erection and ejaculation took place. He told that he had no masturbation fantasy and he could not gain as much /enough arousal in other types of relationships as he got by telephone. He had no emotional intimacy or a girlfriend.

In the family history, his father’s cousin had committed a suicide and died, his father had alcohol abuse, and the patient had no substance use other than smoking.

In the psychiatric examination, he had poor personal hygiene or decline in self-care, motor activity was normal and affect was flattened. Patient who was reluctant to interview only answered the questions asked. He was describing his mood as restless. His affect was flat, his gestures and facial expressions were decreased and he was responding with a monotonous tone. No disturbances in perception were detected. Non-systematic paranoid delusions were present in thought content. He was afraid of being hurt by his relatives or neighbors. His associations were tangential. Cleaning, controlling and order obsessions were present and he was not finding these obsessions meaningless, because he believed that these actions must be taken to prevent his mother’s death. Cognitive functions were adequate. Judgement was poor and insight was not present. Physical examination revealed seven to eight superficial stab incision scars on the left inner forearm. Neurological examination revealed absence seizures lasting one or two seconds for about one year and jerks all over the body for two months which were consistent with juvenile myoclonic epilepsy. Neuronal hyperexcitability was present in EEG and suspected right mesiotemporal sclerosis was present in MRI. Routine laboratory tests, chest radiography and ECG tests were within normal limits. Alexander IQ test revealed borderline intellectual functioning with an IQ of 71. Rorschach test revealed rigidity in thought, poverty of associations and weakening in social cohesion. According to observations at clinic, he was usually compatible, not making any trouble while receiving medications, not interacting much with other patients, being indifferent and reluctant towards issues related with the service and other patients.

The patient was treated with haloperidol 20mg/day, but he did not response. Then, considering the obesity ziprasidone 160mg/day, valproic acid 1000mg/day and clomipramine 75mg/day were started. The two of these antipsychotic drugs caused a poor improvement in delusions of the patient. Because of the resistance to antipsychotic trials, treatment was switched to clozapine. Seizures were stopped during the treatment. Global functional assessment revealed 50 during admission and 65 during discharge.

In conclusion, the patient diagnosed with obsessive compulsive disorder with poor insight, other specified paraphilic disorder (telephone scatologia), psychotic disorder not otherwise specified, borderline mental retardation and juvenile myoclonic epilepsy was referred to the outpatient follow-up.

DISCUSSION

Our case was diagnosed with ‘telephone scatologia’ according to DSM-5, because the patient was not able to live sexually stimulating fantasies, sexual urges and behaviors without telephone or telephone fantasia (1). Scatologia is the revealing of aggressive sexual impulses in a secure environment, in other words, it is a defense against sense of insecurity and sexuality (5). Paraphilia is more prevalent in men and more than half of the paraphilic cases start before the age of 18 (10). Paraphilic behavior usually occurs at the highest rate between the ages of 15 and 25 years (8). Our case is consistent with the literature, he was a 21-year old male, and the onset of symptoms was before age of 18 years. Usually educational status of these cases is high school graduate at most, only some of the cases have college education and most of them work in unqualified jobs (5).

In some cases, unusual behavior might be actual sexual activity in the individual’s life. These individuals rarely come by themselves (6). They often come when their behaviors conflict with their sexual partners or society (1,4). In our case, the family was informed by the complaint of the neighbor whom the patient called repetitively and the patient was admitted, accompanied by his mother.

In some studies with paraphilic patients, organic abnormalities were reported. Organic abnormalities reported were abnormal hormone levels in 74%, neurological or soft neurological signs in 27%, chromosomal abnormalities in 24%, epilepsy in 9%, dyslexia in 9%, abnormal EEG findings in 4%, major mental disorders in 4%, and intelligence problems in 4% (8). In our case, EEG findings and mental retardation appeared to be consistent with this information.

Patients’ seizures were not accompanied by loss of memory or alteration of consciousness which distinguishes his seizures from complex partial ones. Complex partial seizure is an epileptic seizure that is associated with automatisms, which was not observed in our patient. He suffered from myoclonic jerks, also had seizures and his consciousness was clear (11).

Patient was with borderline intellectual function and explained his sexual behaviors as derived from sexual arousal and pleasure. Borderline intellectual function was characterized by some behavioral problems, but unlike retardation he was aware of inconvenience of his attitudes, he concealed his symptoms and was keeping doing them secretly. These symptoms helped us to rule out behavioral problems depending on mental retardation. Sexual arousals may be obtained from smell, touch, taste, visual and hearing senses, and combinations of these senses in paraphilias, and also masturbation may be the sexual satisfaction method (5). Telephone scatologia and telephone sex addiction are both disorders associated with telephone use. Of the scatologia, 95% is accompanied by masturbation, and 45% is accompanied by telephone sex addiction (9,12). Telephone scatologists often masturbate during talking or dreaming the telephone speech, and this is usually completed after the connection is over (8). In our case, the patient masturbated during a telephone conversation and achieved self-fulfillment.

Female voice simulation is quite common among telephone scatologists (13). Females constitute the majority of victims of telephone scatologia and 74% of these victims do not know and cannot identify callers (5). Our patient was also talking with a hoarse voice and females were his victims. Telephone scatologists who have difficulties in communication with other people, have sexual stimulation through hiding behind communication tools. It is noteworthy that our patient was unable to establish peer relationships starting from the primary school, his social relationships were poor and he had no girlfriend.

In order to diagnose paraphilia, perverted fantasies or actions should influence mental life, so that trying to suppress them should lead to high levels of anxiety and dysphoria (2). In our case, self-mutilative behaviors were observed after telephone scatologia. Superficial incision scars on the left inner forearm were a kind of self-punishment. Favazza (14) reported that the purpose of self-mutilative behavior was to get rid of dysphoric and depressive emotions and to reduce the anger.

It was thought that there was an important relationship between telephone scatologia, exhibitionism, voyeurism, compulsive masturbation and telephone sex addiction (15,16). Patient complained of comorbid obsessive-compulsive disorders involving concerns of contamination, and his common compulsions include cleaning, ordering and arranging rituals. Compulsive masturbation presented with persistent, intrusive sexual thoughts and an excessive uncontrollable frequency of masturbation. These activities consumed many hours a day. Compulsive sexual disorders were quantified by using the statistics of number of orgasms per week. Usually trials of patients to stop this behavior was unsuccessful (17). Our patient did not have uncontrollable frequency of masturbations, and did not spend several hours masturbating. This was differentiating from compulsive masturbating.

There is a belief suggesting that telephone scatologia is a nonvisual type of exhibitionism. An attempt to scare, shock and disgust the victim is present in both pathologies (9,18). Exhibitionism and voyeurism are potentially dangerous acts in terms of dangerous rapprochement. On the other hand, telephone scatologia is a long distance communication in which the abuser thinks that he can make a woman be aroused from a safe distance (5). Tactile contact’s functions are transferred to communication tools that serve for specific sensations in telephone scatologia. By this way the abuser feels safe and can be sexually aggressive. Telephone scatologists are often recklessly threatening their victims, however, there is no clear evidence that they are prone to follow, commit sexual assault or rape their victims (5). No history of such behaviors was present in our patient.

Sexual sadism refers to the derivation of sexual arousal and pleasure in response to the pain, suffering, or humiliation upon another person. The essential feature of sexual masochism is the feeling of sexual arousal or excitement resulting from receiving pain, suffering, or humiliation (19). Patient has some self-harming behaviors but he does not experience sexual arousal in response to the pain.

Disorders that cause disruption in judgement, social skills or impulse control like mental retardation, dementia, and personality change due to general medical conditions, drug intoxication, manic episodes and schizophrenia may lead to unusual sexual behaviors. These can be distinguished from paraphilia as unconventional sexual behavior in these disorders are not preferred or compulsory and seen only during the course of the illness, also it is not repetitive and age of onset is usually advanced (6).

People with psychotic disorders may have delusional thoughts can lead people to acts of socially unacceptable or abnormal sexual behavior related to these thoughts (20). Even though the patient has paranoid delusions, his inconvenient sexual behavior is not related to these delusions.

There is a common opinion among researchers that telephone scatologia is not seen alone in the clinical environment but with other paraphilias (16). Also ICD-10 indicate that multiple paraphilias are usually present in one person (5,21). Compared to other paraphilias, lifelong paraphilias and paraphilia-related disorders occur more frequently in telephone scatologia (15). In the literature, there is also a sight opposed to the idea that telephone scatologia is seen alone (22).

We thought that it was significant to report this case because contrary to common belief, our case was together with obsessive compulsive disorder with poor insight, other specified paraphilic disorder (telephone scatologia), psychotic disorder not otherwise specified, borderline mental retardation and epilepsy not with other paraphilic disorders. We wanted to draw attention to the possibility that, in parallel with technological developments in audio visual communication tools, different forms of scatologia occurring and being present with other psychiatric disorders.

Conflict of Interest: Authors declared no conflict of interest.

Financial Disclosure: Authors declared no financial support.

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