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Keywords:

  • Psychological Assessment of Sexual Dysfunction;
  • Sex Therapy;
  • Psychotherapy

ABSTRACT

  1. Top of page
  2. ABSTRACT
  3. Background
  4. Case Study
  5. Discussion
  6. References

Introduction.  Sexual medicine healthcare professionals, who do not normally examine men and women with psychiatric disorders, need to be aware that those with psychiatric disorders can and do present with sexual medicine problems. In particular, psychiatric individuals may present with a variety of delusions including those that have sexual content or sexual implications. The rare disorder of reverse delusional misidentification syndrome may be encountered in schizophrenic patients and may be best managed by the combined team effort of a sexual medicine specialist and psychiatrist.

Aim.  To report a case study that reiterates the assessment and sexual medicine management of a female with sexual dysfunction who believed she was transforming into a male.

Methods.  Case report of a woman who attended an outpatient clinic in an academic medical center.

Results.  A 60-year-old woman with a history of paranoid schizophrenia presented to a gynecologist for ovarian cancer screening. Evaluation revealed complaints that the patient’s ovaries were testes that produced sperm and her clitoris was a penis capable of erection and ejaculation. Gynecological examination revealed only atrophic vaginitis. The patient was treated with local minimally absorbed vaginal estrogens and referred for psychological assessment and counseling. Psychotropic medication compliance was encouraged, weekly psychotherapy was continued, and delusional symptoms were minimized.

Conclusion.  Sexual medicine healthcare providers should be prepared to manage sex health concerns of men and women with psychiatric disorders, including delusional misidentification syndrome, in conjunction with a psychiatrist. Krychman M, and Amsterdam A. Psychiatric illness presenting with a sexual complaint and management by psychotropic medications: A case report. J Sex Med 2008;5:223–226.


Background

  1. Top of page
  2. ABSTRACT
  3. Background
  4. Case Study
  5. Discussion
  6. References

Psychiatric patients may present with a variety of delusions including those that have sexual content or sexual implications. Sexual medicine healthcare professionals need to be aware of the full gamut of sexual health complaints by men and women. Individuals with psychiatric disorders can and do present with sexual medicine problems. It is important for sexual healthcare providers who do not normally examine men and women with psychiatric disorders to be cognizant of this fact.

Individuals with a history of schizophrenia have also been reported to experience delusions of sexual transformation. These thought disturbances may involve delusions of transforming into the opposite sex, including the belief that one’s sexual organs are changing as well [1]. Similarly, delusions of self-misidentification are characterized by a condition in which a patient consistently misidentifies persons, places, objects, or events [2]. Radical misidentification of physical and/or psychological aspects of the self can involve bodily transformation to the opposite sex. The formal study of delusional misidentification syndrome (DMS) began in 1923 when Capgras and Reboul-Lachaux presented cases of patients who had delusional beliefs that a person was replaced with an impostor [2]. In this syndrome of doubles, or the Capgras syndrome, the patient believes that one or more persons in the environment are impostors or physical replicas of the original. Capgras syndrome is common in schizophrenic patients, with an incidence of up to 15% in these patients; the syndrome affects 1.3–4.1% of all inpatient psychiatric patients [2]. Medical and neurological comorbidities include drug intoxication, infectious or inflammatory disease, and endocrine abnormalities [2]. DMS has been associated with Alzheimer’s disease and parkinsonism [2]. In a recent study, Silva et al. reported that DMS may occur in reference to the patient’s own identity [1]. In such a case, in the reverse type of DMS, the affected person experiences erroneous physical and/or psychological attributes that are radically different from their objective identity, which leads the patient to believe he or she is a different person [1].

Other types of DMS, besides the reverse type suffered by our patient, include delusional hermaphroditism, in which patients believe that they are both male and female [2]. Silva et al. described other types of DMS that occur in relation to the patient’s identity. In the subjective type, the affected individual believes that others are impersonating physical or psychological attributes of his or her identity [1]. In Erotomania and Fregoli syndrome, patients believe that unfamiliar people are replaced by physically similar, familiar people [3]. And in a psychological disorder known as Koro, patients fear that their sex organs are retracting into their bodies [4]. Koro is most commonly seen in Asian men, and patients believe that complete retraction of the penis will result in death. A parallel syndrome of shrinkage of the breasts, nipples, or labia has also been reported in women, although less frequently.

Sexual complaints can present as delusions that may be initially associated with a mental illness, and careful history is always necessary with patients who have a mental disorder as often sexual delusions can be elicited with history. We present a patient with paranoid schizophrenia with DMS of the reverse type, in which the patient believed her ovaries were testes that produced sperm and her clitoris was a penis capable of erection and ejaculation.

Case Study

  1. Top of page
  2. ABSTRACT
  3. Background
  4. Case Study
  5. Discussion
  6. References

A 60-year-old woman with a history of paranoid schizophrenia previously hospitalized in a mental health facility presented to the gynecology division at our institution for ovarian cancer screening. Hospital guidelines recommended that the patient be monitored every 6 months with pelvic ultrasonography, bimanual examination, and serum CA-125 levels. Physical examination was remarkable for a moderately enlarged myomatous uterus and vulvar and vaginal genital atrophy. The adnexa were normal by examination and ultrasound. During her routine screening course, the patient was referred to the sexual health program at our institution to evaluate her complaints of abnormal thoughts pertaining to her clitoris and ovaries. All standard institutional regulations for patient privacy and consent were obtained during the initial consultation. The patient claimed that her ovaries were testes that produced sperm. She also believed that her clitoris was a penis, which was capable of erection and ejaculation. Upon further questioning, the patient, who lived with a companion and worked as a receptionist, stated that she was not distressed by her perceived transformation.

Upon additional psychiatric evaluation, the patient denied suicidal or homicidal ideation, persecutory delusions, or hallucinations. However, she had abnormal thoughts and obsessions concerning her rectum. More specifically, she believed that despite being fully clothed, others were able to see her rectum, making her “offensive.” She also revealed that she was hospitalized in a psychiatric health facility 14 years before presenting at our institution, when she believed that her vagina had been lacerated. According to the patient, examination at that time did not find genital or pelvic defects or any evidence of any laceration. The patient did not smoke, drink, or consume illicit drugs. Her psychiatric treatment history included 20 electroconvulsive shock therapy sessions when she was 20 years old.

Additional history included a modified radical mastectomy with axillary lymph node dissec-tion for stage II breast cancer, treatment with adjuvant chemotherapy and hormonal manipulation, chronic obstructive pulmonary disease, asthma, and cataracts. Her medications at presentation included olanzapine, lorazepam, clomipramine, anastrozole, alendronate, calcium, and a multivitamin; however, compliance was variable.

Sexual medicine treatment consisted of minimally absorbed 17β-estradiol vaginal tablets and water-based moisturizers for her vaginal atrophy [5]. Vaginal lubricants were recommended for extra lubrication during sexual intercourse. The patient was taught alternative positions for sexual intercourse that would allow her to better control the level of vaginal penetration and potentially minimize discomfort. She was strongly advised to maintain consistent psychiatric care with her mental health team. In addition, she was consulted on the importance of compliance with her psychiatric and other medications. At follow-up intervals of 3 and 6 months, the patient was without distressing psychosexual complaints. She had consistently reported sexual satisfaction and arousal with orgasm. She stated that her intrusive thoughts of her clitoris becoming a penis and her ovaries transforming into semen-producing testicles were less frequent. She understood that these were abnormal thoughts associated with her schizophrenia. She also reported being compliant with her medication schedule.

Discussion

  1. Top of page
  2. ABSTRACT
  3. Background
  4. Case Study
  5. Discussion
  6. References

Delusions of misidentification involving the self have not been reported frequently. In 1923, Capgras and Reboul-Lachaux first reported on the rare phenomenon of DMS, which is characterized by the patient believing that familiar people are replaced by impostors of identical appearance [2]. The Capgras syndrome and other forms of DMS are frequently encountered in schizophrenic and psychotic patients. The etiology of Capgras syndrome has been hypothesized to arise from neurological deficits within the right brain hemisphere, primarily within areas associated with nonverbal memory and visual, special, and constructional skills [6]. More specifically, information-processing deficits have been localized to the right frontal region, which mediates working memory [7]. Although the absolute etiology of DMS remains elusive, it may represent an adverse effect from electroconvulsive therapy, which the patient in this case did receive [2]. It has also been reported in patients on diazepam and disulfiram [2].

This case study reiterates the complexity of management for females with sexual complaints. Psychiatric illnesses such as depression, mania, and anxiety can often impact female sexual functioning. When a patient presents with a sexual complaint to a healthcare provider who is not a mental health specialist, it is imperative to elicit a comprehensive psychological and psychiatric history. When a patient with a pre-existing psychiatric illness presents to the clinician, it is critical to question the patient on sexuality and sexual thoughts and actions. The two are often intermeshed. It is also important that sexual medicine clinicians recognize that some patients with psychiatric disorders may manifest their pathologies as sexual fantasies and/or practices that warrant further evaluation and treatment by a mental health professional.

In addition, as discussed by Graziotti and Leiblum, the etiology of sexual dysfunction is a complex multifaceted disorder in the postmenopausal female [8]. This patient had many potential etiologies, including a pre-existing psychiatric illness with delusions. She was on psychotropic medications known to impact the sexual response cycle, and she had documented clinical vaginal atrophy that warranted vaginal therapy with minimally absorbed vaginal estrogen tablets. The importance of sexual biology coupled with the psychosexual concerns and a pre-existing psychiatric illness all acted in concert to compound her sexual complaints. The sexual medicine treatment plan was complex; it combined local estrogen tablets with continued psychiatric care. Increased compliance with her psychotropic medications helped stabilize her sexual delusions. Although many psychotropic medications can affect sexual libido and orgasmic or arousal response, this was not the case in this specific patient. Her medications controlled her sexually based psychotic delusions.

Our patient’s delusions, of testes and a penis replacing her ovaries and clitoris, represent the reverse subtype. However, she was able to retain her female identity, which was demonstrated by labeling herself as “female” during her evaluation. Unlike someone with delusional hermaphroditism, our patient did not believe she was both male and female, rather she was transforming into a male from a female [9]. And, as with many schizophrenic patients with DMS, pharmacological noncompliance was present and contributed to her disorder, which was witnessed by the disappearance of symptoms with proper medication administration. Similar cases of DMS have been reported in association with paranoid schizophrenia. Silva et al. reported on a 40-year-old male who believed he was transforming into a female. Upon treatment with haloperidol, clonazepam, and lithium carbonate, the patient became less irritable and his delusions became less prominent and bothersome [10]. Compliance with medication was essential for controlling his symptoms.

Although the reverse type of DMS is rare, it can be encountered in everyday practice. Educating and instructing schizophrenic patients to comply with psychotropic medications is essential in preventing and treating this disorder. Further research on DMS is needed to help us better understand this rare psychological phenomenon.

Conflict of Interest: None.

References

  1. Top of page
  2. ABSTRACT
  3. Background
  4. Case Study
  5. Discussion
  6. References
  • 1
    Silva JA, Leong GB, Weinstock R, Penny G. Dangerous delusions of misidentification of the self. J Forensic Sci 1995;40:5703.
  • 2
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    Bruggemann BR, Werry C, Garlipp P. Erotomania and Fegoli syndrome: A case report. Nervenarzt 2002;73:4757.
  • 4
    Silva JA, Leong GB, Penny G. Delusion of sexual transformation as delusional misidentification syndrome. Can J Psychiatr 1998;43:9567.
  • 5
    Goldstein I, Alexander JL. Practical aspects in the management of vaginal atrophy and sexual dysfunction in perimenopausal and menopausal women. J Sex Med 2005;2(suppl 3):15465.
  • 6
    Pachana NA, Drake E, Van Gorp WG, Sorensen D. Similarities of neuropsychological presentation in two cases of Capgras syndrome with comorbid depression. NZ J Psychol 1999;28:5560.
  • 7
    Papageorgiou C, Ventouras E, Lykouras L, Yzunoglu N, Cristodoulou GN. Psychophysiological evidence for altered information processing in delusional misidentification syndromes. Prog Neuropsychopharmacol Biol Psychiatry 2003;27:36572.
  • 8
    Graziottin A, Leiblum S. Biological and psychosocial pathophysiology of female sexual dysfunction during the menopausal transition. J Sex Med 2005;2(suppl 3):13345.
  • 9
    Jagadheesan K, Sandil R, Nizamie S. Delusional hermaphroditism: A variant of delusional misidentification syndrome. Psychopathology 2002;35:524.
  • 10
    Silva JA, Leong GB, Shaner AL. A classification system for misidentification syndrome. Psychopathology 1990;23:2732.