Management of sexual difficulties in patients with psychiatric disorders

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A number of studies show that patients with troubles psychiatric are more frequently affected by troubles sexual than in the general population.

This is all the more important since the total number of patients affected by these disorders is certainly underestimated, a large part of the patients indeed find it difficult to broach the subject of intimacy with their doctor.

Many health professionals, general practitioners, psychiatrists or psychologists do not sufficiently address the subject of sexuality with their patients, or who do it superficially and expeditiously.

Yet a sexuality blooming contributes greatly to Goodto be psychiatric patients. The effective treatment of their sexual disorders must therefore be an integral part of the management of their mental pathology.

In patients suffering from psychotic disorders, sexual difficulties are extremely frequent, especially in non-hospitalized patients: up to 50% of women and 70% of men.

The repercussions of psychiatric pathologies on sexuality are generally induced by treatments neuroleptics (drugs used in the management of psychiatric disorders) and, therefore, are often sources ofdrug non-compliance. They can therefore be responsible for therapeutic failure and relapses! This is why it is essential to take it into account when taking charge of psychiatric patients.

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What are psychoses?

Psychoses are a group of mental pathologies defined by a altered sense of reality brief or prolonged.

The most well-known psychosis to the general public is undoubtedly the schizophrenia. The latter has been widely discussed in the cinematographic and literary fields, often in an exaggerated and fantasized way. It is also the most common, its prevalence is estimated to be around 1% of the world’s population.

The schizophrenia usually manifests in early adulthood, earlier in men than in women. It is characterized by 2 kinds of symptoms:

  1. Positive symptoms: they are manifestations which are in addition to the normal mental functions of the patient. These manifestations appear during the acute phase of the disease, also called the “decompensation phase”. The most frequently observed positive symptoms are:
    • Changes in perception: the patient perceives sensory, internal or psychic stimuli which do not exist as such in reality, such as:
      • Visual hallucinations: the patient sees objects or people that do not exist.
      • Auditory hallucinations: the patient hears sounds or voices that do not exist. Most often they are hostile and threatening voices.
      • Olfactory hallucinations: the patient feels odors that are not present, most often unpleasant. He may even wake up in the morning and smell a scent that gives him the sure impression of having been raped during the night!
      • Taste hallucinations: the patient feels the taste of food or substances in his mouth, it can be either pleasant or extremely painful tastes.
      • Tactile hallucinations: the patient has the impression that an object or a person is touching him, most often in the private parts (breasts, buttocks and genitals).
      • Cenesthetic hallucinations: the patient has sensations that come from inside his body. For example, he may have the impression that one of his organs is disappearing or changing.
    • Changes in thought: the patient expresses delusional ideas, kinds of convictions. Delusions can be of many types, one of the most frequently observed is the delirium of persecution where the patient is deeply convinced that he is the target of malicious intentions of those around him. There are other types of delusions such as mystical delusions, delusions of grandeur (or megalomaniacs), possession, disclosure of thought, etc.
    • Speech changes: the patient’s speech is completely disorganized and inconsistent. For example, he will go from one subject to another suddenly and without establishing any logical link between the different subjects (passage from rooster to donkey).
    • Behavior changes: the patient can perform actions that have no logical objective, which seem strange to those around him. He can even become aggressive towards himself or others (self-aggression or hetero-aggression).
  2. Negative symptoms: they are more difficult to detect because they are less impressive and noisy than the positive symptoms. They are also the most disabling for patients. These negative or deficient symptoms reflect the loss and deterioration of the patient’s usual mental functions. They can manifest clinically as:
    • Alogy or difficulty in communicating and social withdrawal;
    • An anhedonia, that is to say a loss of pleasure;
    • Abulia, that is to say a lack of motivation and energy;
    • Poor thought and speech;
    • Emotional dullness and decreased expression of emotions (coldness).
neurological consequences of schizophrenia
Neurological consequences of schizophrenia

Alongside the positive and negative symptoms, there is a real declining cognitive abilities of the patient (cognitive decline). In other words, his brain loses its capacities for processing information, analyzing and memorizing. This results in difficulty concentrating, memory loss (especially in the short term), impaired decision-making, learning disabilities, reduced body hygiene …

It should be noted that the symptoms of schizophrenia are extremely variable from one patient to another in terms of frequency, intensity, type, association between different manifestations. However, the majority of patients with schizophrenia, and any other psychiatric illness, have a unstable relational and emotional life. The association of different symptoms has a considerable impact on the social interactions of patients, disturbing significantly their sexuality.

Generally, doctors underestimate the place of sexuality in the life of their patients with psychotic disorders, given the symptoms they present.

In addition to this, some patient statements are often questioned and viewed as potentially part of the delusional symptom, related to their disease. We are indeed sometimes witnessing hallucinations or delusions having a sexual connotation, which does not mean that they should not be taken into consideration.

The acute (or decompensation) phase of psychotic illnesses can sometimes be characterized by disinhibition sexual, which can lead to inappropriate exhibition behaviors, for example, or to risk-taking with an increase in sexual relations and unprotected partners. The disease leads to psychological, physical and social vulnerability which can lead the person to put themselves in danger and thus be the victim of sexual abuse in particular.

The question of the sexual is omnipresent in the clinical expression of psychotic pathologies. We note that patients with psychosis generally express themselves quite freely when the doctor asks them about their sexuality. .

In addition, it is not uncommon for patients hospitalized in a psychiatric ward to have sexual relations with each other, even if this is not authorized in most specialized hospital services. This may be frowned upon by caregivers, as the issue of consent and you discernment of the two partners arises in view of their vulnerability. Indeed, the question of the place of the desire of the other in psychosis arises, the capacity to take into account oneself and the other being altered.

Neuroleptics cause sexual problems

The neuroleptics, drugs belonging to the psychotropic family and used in the treatment of psychosis, are often the cause of troubles sexual. They act through 2 main mechanisms:

  • Increased production of prolactin (hormone involved in particular in the production of breast milk, immunity, growth and behavior): this has the effect of a decrease in sexual desire (libido) and erectile dysfunction in men , decreased desire and amenorrhea (lack of menstruation) in women.
  • A weight increase: neuroleptics induce fairly significant weight gain in patients. This will often lead to a drop in self-esteem and a social and emotional withdrawal..

These symptoms are both the cause of sexual disturbances in psychotic patients. However, the latter generally spontaneously report only weight gain. But when asked specifically about their sexuality, they talk about it quite freely and stress that it is an important element in their balance.

Sexual dysfunctions caused by neuroleptic treatments and often a source of d’inobservance medicated. In other words, psychotic patients stop taking their treatment in the hope of having a better sex life. This will obviously have serious consequences on the course of the disease (aggravation, relapses). Unfortunately, this phenomenon is extremely common. We think that 50% of psychotic patients stop taking their treatment after 1 year, the figure increases to 70% after 2 years. One of the main reasons they do this is most likely the drastic drop in the quality of their sex life.

It is also important to mention that erectile dysfunction is generally perceived by men as a decrease in virility. It is therefore not uncommon for a depression come into being and add to the other symptoms that are already very debilitating.

What you must remember

  • Sexual disturbances are very common in patients with psychiatric disorders.
  • Neuroleptics used in the treatment of mental illness cause sexual dysfunction and decreased desire.
  • The sexual dysfunctions caused by neuroleptics lead psychotic patients to discontinue their treatment.
  • It is important to give a prominent place to socket in charge psychosocial psychiatric patients (integration into a professional environment, a place within the family, the practice of various activities, etc.). We should not bet everything on processing medicated !
  • It is important to ask patients about their sexuality, to listen to them and to provide them with concrete solutions. Because it is an aspect to which they attach a lot of importance and the success of the treatment is strongly linked to it.

Stay informed about sexual health

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Results of the CPD Sexual Health survey


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Management of sexual difficulties in patients with psychiatric disorders

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