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Unusual sexual behaviour and depression: Lankan psychiatrists find potential link

07 Jun 2021

By Ruwan Laknath Jayakody   The possible association between depression and sexual desire and unusual sexual behaviour has been observed by local psychiatrists in a report based on two Sri Lankan cases. This observation was made in “Unusual sexual behaviour associated with female depression”, authored by University of Kelaniya Faculty of Medicine Department of Psychiatry Senior Lecturer Grade II and consultant child and adolescent psychiatrist Dr. Miyuru Chandradasa and University of Kelaniya Faculty of Medicine Department of Psychiatry Cadre Chair Senior Prof. K.A.L.A. Kuruppuarachchi and published recently in the Sri Lanka Journal of Psychiatry.     According to Dr. Chandradasa and Prof. Kuruppuarachchi, even though women, compared to men, have a higher risk of developing depressive disorder (including more atypical symptoms such as fatigue and hypersomnia), as to whether this increased prevalence is due to probable environmental and/or biological factors is under debate. In terms of environmental factors, as J.H. Kim, M.J. Cho, J.P. Hong, J.N. Bae, S.J. Cho, B.J. Hahm, D.W. Lee, J.I. Park, J.Y. Lee, H.J. Jeon, and S.M. Chang found in “Gender differences in the depressive symptom profile: Results from nationwide general population surveys in Korea”, with regard to help-seeking for their health problems, women are recognised as being more proactive. Men, however, tended to report decreased libido and sexual dysfunction more, Dr. Chandradasa and Prof. Kuruppuarachchi noted, pointing to several studies. As far as biological factors are concerned, V. Harsh, S. Meltzer-Brody, D.R. Rubinow, and P.J. Schmidt noted in “Reproductive ageing, sex steroids, and mood disorders”, that depressive disorder has been found to be associated with different female reproductive stages, with there being evidence that ovarian hormonal levels play a role in depressive disorder among women of postmenopausal age. Therefore, Kim et al. noted that when considering gender differences, the response to treatment with chemotherapeutic agents and their adverse side effects should not be ignored. In terms of the presentation of symptoms of depressive disorder, they may, according to Dr. Chandradasa and Prof. Kuruppuarachchi, present in unusual ways, in relation to cultural, belief-related, and communal aspects. In “Depression presenting with genital symptoms – a series of unusual case histories”, K.G. Kapugama, L.N. Obadaarachchi, B.V. Ruwanpriya, and Prof. Kuruppuarachchi found depression presenting with genital symptoms, with patients complaining of unusual vaginal and urethral sensations. Depressive disorder, according to Prof. Kuruppuarachchi and L.T. Wijeratne's “The continuing story of the dhat syndrome”, may also have unusual presentations such as the said syndrome in which male patients report suffering from premature ejaculation or impotence, and also believe that they are passing semen in their urine. As explained by Dr. Chandradasa and Prof. Kuruppuarachchi, sexually disinhibited behaviour confined to depressive episodes in females is somewhat uncommonly reported. The presentations of two Sri Lankan females with unusual sexual behaviour, who were subsequently diagnosed as having depressive disorder were thus reported by Dr. Chandradasa and Prof. Kuruppuarachchi. The two females in question were assessed as outpatients by a consultant psychiatrist using structured clinical interviews. The duo was diagnosed as having a depressive disorder as per the criteria of the 10th Revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10).   Case 1 The first case concerned a middle-aged woman presenting with voyeuristic behaviour, confined to a depressive episode. The 45-year-old married woman reported the recent onset of voyeuristic behaviour for about two to three months. She described that she had recurrent heightened urges to observe other adults undress and have sexual interactions, and also stated that she had acted upon these urges on a few occasions. She had also demanded that her partner have more frequent sexual intercourse with her. As found by R. Mahadevan, N.R. NikJaafar, H. Sidi, M. Midin, and S. Das in “Is increased libido an atypical symptom of bipolar depression? An interesting case”, increased sexual function has been detected and reported in a male patient during a bipolar depressive episode. The onset of this change in the woman's behaviour was accompanied by persistent low mood, lethargy, and suicidal ideation and depressed mood. B.T. Jackson has also identified in “A case of voyeurism treated by counter conditioning”, a case of voyeuristic disorder presenting with depression. No past history of any mood disorder or paraphilic disorder was found in the said female. She was diagnosed as having a moderate depressive episode. She was then commenced on a particular antidepressant. Subsequently, the depressive symptoms reduced and the increased need for sexual pleasure disappeared. She continued her medications for a period of nine months after reaching remission and did not show any recurrence of the voyeuristic behaviour.   Case 2 The second case involved an adolescent girl presenting with highly risky sexual behaviour in the context of a depressive disorder. The girl's parents, in order to obtain an opinion regarding their daughter's mental health, had brought her in for examination by a specialist after she had gone missing from home for one day. According to the said 16-year-old school girl, she had left home without planning, in distress. While travelling in the bus, she had met a young man who was 10 years older to her. They had started talking. He had subsequently invited her to his residence. She had complied without hesitation. As described by her, they had fondled each other. She, however, denied having any penetrative sex. After she had spent hours at his place, the man had phoned her parents about her whereabouts and the parents had come to pick her up. K. Anatale and S. Kelly found in “Factors influencing adolescent girls sexual behaviour: A secondary analysis of the 2011 youth risk behaviour survey” that adolescent females, in this case, high school girls in the US, with symptoms of depression, are more likely to engage in risky sexual behaviours. There had, according to the girl's parents, been no similar or other sexually risky behaviour by her in the past. The bewildered parents had, however, revealed that prior to this act, they had observed her to be increasingly irritable towards others, having less interactions with them (the parents) compared to before, and seemingly suffering from reduced energy and recurrent physical complaints such as headaches. The girl reported a subjectively higher sexual desire during the past few weeks, which coincided with the onset of depressive symptoms. According to the parents, such sexually active behaviour was uncharacteristic of her. On clinical assessment of the mental state, it was found that she had features of a moderate depressive episode including low mood, anhedonia (inability to feel pleasure in normally pleasurable activities), irritability, and depressed mood. She was commenced on a particular antidepressant. The increased sexual desire and related behaviour then subsided. However, the condition returned on defaulting on the medication, where she recommenced approaching male strangers for an intimate relationship and sexual pleasure. Once again, the sexually disinhibited behaviour diminished on recommencing the said antidepressant. In stark contrast to the two afore-described females, L.F. Fabre and L.C. Smith found in “The effect of major depression on the sexual function in women”, that women who suffer from depression have a greater sexual dysfunction compared to that of non-depressed females and that the degree of dysfunction has a relationship to the severity of the mood disorder. Furthermore, D.A. Kalmbach, S.A. Kingsberg, and J.A. Ciesla noted in “How changes in depression and anxiety symptoms correspond to variations in the female sexual response in a non-clinical sample of young women: A daily diary study”, that higher levels of the inability to feel pleasure in normally pleasurable activities were found to be associated with reduced sexual desire on the subsequent day. "In both these local cases, it is possible that sexual pleasure was sought as a form of relief or comfort during the periods of distress. The subsiding of sexual desire and behaviour with the improvement of depression is indicative of a potential association. Both patients had a heightened arousal and an increased need for sexual pleasure prior to the commencement of antidepressants. In contrast, there are reports of heightened libido in women, when treated with certain antidepressants as noted by H. Hori, R. Yoshimura, and J. Nakamura in 'Increased libido in a woman treated with fluvoxamine: a case report'," Dr. Chandradasa and Prof. Kuruppuarachchi explained. In conclusion, whilst noting that further research is required with regard to this uncommonly reported association, Dr. Chandradasa and Prof. Kuruppuarachchi expressed hope that these two case reports would assist other clinicians in assessing and treating females with depressive disorder in different cultural settings.


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