Gratification Syndrome in a Young Girl: A Diagnostic Dilemma Mimicking Seizure Disorder – A Case Report

INTRODUCTION

Gratification syndrome, often termed as “infantile masturbation,” is a benign and self-limiting behavior observed in young children, often misdiagnosed due to its atypical and variable presentations.^[1] Unlike adult masturbation, this behavior is usually non-genital in nature and may involve rhythmic body movements, posturing, or limb stiffening.^[2] Due to a lack of awareness among clinicians and caregivers, it is frequently mistaken for seizure disorders, movement disorders, or even signs of abuse, leading to misdiagnosis, unnecessary investigations, and distress.^[3] A diagnostically challenging case of gratification behavior in a female child presenting with abnormal jerky limb movements and perineal stimulation, initially suspected to be seizure disorder, is reported here.

CASE REPORT

A girl child aged 2 years 11 months was brought to the Psychiatry out patient department of Gauhati Medical College and Hospital by her parents with complaints of repeated abnormal jerky movements of both upper and lower limbs, primarily occurring while lying in the prone position. During these episodes, the child was observed to press clothes or nearby objects against her perineal region. A short video clip demonstrating the child’s typical gratification episode was recorded and shown in the Video 1. These events occurred 10–15 times a day, lasted variably in minutes, and were occasionally followed by sleep. Notably, the episodes were never observed during sleep and tended to increase when the child was left alone and subsided with distraction by parents with verbal stimuli or engagement in other activities. There was no history of frothing, incontinence, clenching of teeth, or loss of consciousness associated with these events. Due to the motor features and stereotyped nature of episodes, a seizure disorder was initially considered. The child had a history of head injury at around 1 year of age following a fall from a height of 2–3 feet. The girl started to have multiple episodes of abnormal jerky movements of all limbs with stiffening of the body, associated with frothing and transient unresponsiveness lasting for 1–2 minutes after a few days of falling till she was 2 years old. However, there was no associated tongue bite or incontinence. She was evaluated by a neurologist at that time; Magnetic resonance imaging brain, computed tomography scan, and electroencephalogram (EEG) were reported normal. By looking at her presenting symptoms, a provisional diagnosis of Generalised tonic clonic seizure was made. She was started on syrup Levetiracetam and over the next year, her episodes subsided, though Levetiracetam was advised to continue.She remained symptom-free for a few months. But, around the age of 2 years, the child developed a new set of behaviors described above. EEG repeated at this stage once again revealed a normal awake record. The episodes were now distinct from the past seizures involving perineal stimulation and stereotyped positioning, without any impairment of consciousness. She was born to non-consanguineous parents, delivered via lower segment cesarean section due to premature rupture of membranes, with a birth weight of 2.3 kg. There were no NICU admissions or perinatal complications. Milestones were appropriate for age, except for a mild delay in speech, for which she was undergoing speech therapy. No signs of pain, abdomen or urinary tract infection were found on physical or laboratory evaluation.General and systemic examination revealed no findings. Neurological examination revealed no deficit. Mental status examination was within normal limits for age and development. A multidisciplinary evaluation and detailed observation of the child led to the diagnosis of gratification behavior. That the episodes could be interrupted by distraction, occurred more frequently in isolation, and were associated with perineal stimulation was strongly indicative of gratification syndrome.^[4] Her dose of Levetiracetam was gradually tapered. Tablet Clobazam 2.5 mg at bedtime was introduced for its anxiolytic and sedative properties. Parents were also counselled regarding the non-pathological nature of the behavior, the importance of non-punitive distraction techniques, structured playtime, and environmental modification.On follow-up after 4 weeks, a marked reduction in the frequency of episodes was observed. The parents reported improved understanding and better management at home. The child continued to do well in speech therapy and showed no new symptoms suggestive of seizure recurrence.

Video available on: https://doi.org/10.25259/ABMH_44_2025

DISCUSSION

Gratification behavior in young children is a diagnostic challenge due to its diverse and non-genital presentations.^[1,5] Girls, in particular, may exhibit posturing, grunting, limb stiffening, and even rubbing objects on the perineum without overt self-touch. Misinterpretation as epilepsy is common, especially when there is a coexisting history suggestive of seizures, as in this case.^[6] Multiple studies have emphasized that the hallmark feature of gratification syndrome is the presence of consciousness during episodes and cessation upon distraction.^[7] Unlike seizures, these episodes are not associated with EEG changes, and post-event confusion or physical exhaustion is usually absent. Misdiagnosis can lead to overmedication, stigmatization, and unnecessary anxiety in caregivers. Educating parents about the benign nature of the behavior, setting firm but gentle behavioral limits, and ensuring the child receives adequate stimulation and attention can effectively manage the condition. In rare cases where symptoms are distressing or disruptive, short-term pharmacological intervention (e.g., with benzodiazepines) may be considered.^[8-10]

CONCLUSION

Gratification syndrome should be considered in the differential diagnosis of seizure-like episodes in young children, especially when episodes occur in isolation, are behaviorally driven, and the EEG remains normal. Early recognition and appropriate psychoeducation can prevent misdiagnosis, reduce unnecessary interventions, and alleviate caregiver anxiety.