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Psychsexual disfunction and depression

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Dear All

I would like to have your feedback about this assay , which was the cause of my failure in the written exam last time . your critical feedback is most welcomed

“Psychosexual problems are neglected in psychiatric practice”. Discuss this statement critically and the role of psychiatrist in the assessment and management of psychosexual difficulties with particular reference to depression.

Assay plan :



Importance o the subject

What will be discussed


Relation between depression and sexual dysfunctions

Is it neglected and why?






The assay

Depression has been known to be existing since the down of civilization . even the relation between sexual problems had been mentioned in Ebers Papayrus 5000 years ago by ancient Egyptians .Since then in has been consistently mentioned in medical writings over centuries, as it was mentioned by Robert Burton in the 16th Century in his book “anatomy of melancholia”

Depression and Depressive disorders are common disorders. They have life time prevalence ranging between 6-15% according to the Epidemiological catchment area study in the US. Beside the wide prevalence of depressive disorders there are good body of evidences that sexual dysfunctions are not uncommon in depression. In addition , to their prevalence , depressive illnesses are one of the most handicapping illness according to the WHO atlas of mental disorders, as in 2020 is it estimated for depression to be the first cause of disability between women in developed countries and the third most common cause of disability between men in these countries. In addition to that, sexual impairment, would add to the poor quality of life of the depressed patients. It could also reflect on the whole family and children if they led to marital disharmony.

In this assay , I will discuss the following sexual dysfunctions, the lack of sexual interest in both sexes, erectile dysfunctions in males, anorgasmia / delayed orgasm in both sexes and premature ejaculation in males. I will not discuss paraphilias.

Sexual problems are one of the diagnostic criteria of depression in DSM and ICD systems. However , the relation between depression and sexual dysfunctions are more complex than that , as they could be symptoms of depression , side effect of antidepressant medication , precipitants for depression , caused by another factor that can itself cause depression , as in the case of antihypertensive medication alphamethyldopa, or merely coincidental symptom of any other illness.

Lack of sexual desire is a common symptoms of depression , which can also present the pervasive lack of interest in anhedonia in depression .Meanwhile , in erectile dysfunction , though it could be a symptom of depression , they are more common a side effect of antidepressant medications , especially those with anticholinergic properties such as TCA. This is also the case of delayed orgasm or anorgasmia , as it could happened with depression , it is also a side effect of antidepressant medications of the SSRIs class, as, serotonin tend to inhibit orgasmic reflex in the spinal cord ( Stahl,2000).On the opposite side, premature ejaculation tend to happen with depression , especially when there is a high levels of anxiety .

But how common these symptoms are explored by psychiatrists or reported by patients ?

Due to the sensitive nature of sexual problems , patients are usually reluctant to disclose these difficulties to there doctors or psychiatrists . Patients also may feel overwhelmed by other symptoms of depression . On the other side, psychiatrist may feel reluctant to enquire about these symptoms in there first encounter with patients with depression or get distracted by other symptoms if depression especially those involving risk to the patient such as suicidal ideas or attempts.

In the contrary, some patients present with sexual problems which may turn to be a symptom to a depressive illness, especially when their depression is of masked type or with reactive affect. Also , some psychiatrist are interested to assess this aspect in their patient which may show interest in helping them in such problems . This also could be reassuring to patients presenting with sexual presentation with depression. Even, explaining the possible sexual side effects when prescribing antidepressants and explaining how they would deal with these side effect should they happen , would increase the compliance of patient with their medications .

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In assessment of sexual dysfunction in depression it is important to know if this dysfunction is due to depression , any other factor or as a side effect of medication . In order to achieve that it is important to know the chronology of symptoms if they were present before or after the start o treatment, also how long have they been there . it is also important to assess the dynamic of the relation between the couple . It could be also important to enquire if such problems are person specific , or situation specific. For example , some patient may find it difficult to achieve erection with their partners , and not during masturbation .assessment of complications of sexual disorders is another important part of assessment , which includes assessment of the reflection of these problems on the marital relation and coping mechanisms in dealing with these problems , such as abuse of substances and alcohol. In erectile dysfunctions, enquiring about night tumescence could help in determining organic from functional problems. Some psychiatrist even use the help of polysomnogram to record any erection that may happen during REM sleep.

Managing sexual problems in depression depends on good assessment of what may be the cause. This management usually falls into two large categories, either psychological treatments of physical treatments; through medications . One of the famous psychological modalities of treatment of premature ejaculation is the squeezing technique , which depends on deconditioning of the rapid ejaculation reflex and mastering the timing of achieving orgasm in males. another psychological technique that is used in lack of sexual desire in the sensate focus exercise , in which bath partners engage in series of exercises that aim to rediscover what can turn them on .

At the moment the only approved medications for treatment of sexual dysfunctions are group of drugs called phosphodiesterase 5 inhibitors. They are licensed to treat erectile dysfuctions . There are 3 drugs in this class , sildinail , tadalail and vardenafil. These 3 drugs differ in their pharmacokinetic properties. Some medications are used off license such as cyproheptadine , which is used in treatment of delayed orgasm induced by SSRIs, as it blocks the 5HT2 receptors , which are responsible for this side effect . on the other side in premature ejaculation , there are group of drugs in the pipeline such as depoxetine , which is in phase III clinical trials for premature ejaculations.

In conclusion , though depression associated with sexual dysfunction is a common problem , it is likely to be under reported and treated . Also , there is a need for more research in this area to know more about the causes and the prevalence and to help in development of new , effective and safe modalities of treatment.

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Sexual desire disorders : Dysfunctional regulation of sexual motivation

New sex therapy : Active treatment of sexual dysfunctions

Erectile dysfunction : Integrating couple therapy , sex therapy , and medical treatment

Couples and Sex : An Introduction to Relationship Dynamics and Psychosexual Concepts


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read the chapter in shorter oxford textbook of psychiatry ,i think it gives a good essay

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did this as well and passed.

Why is it neglected

1.It has been a tabboo topic that is awkard for psychiatrists and patients alike to talk about

2.It is a relatively new area in terms of robustness of data and research

3.An inexperinced psychiatrists may not know the right time to ask the patient questions.For example it is awkward to ask a severely depreed pt details of sexual habit.So needs to be asked at follow up.

Depression leads to sexual problems which leads to more depression.It is a circle.

Sexual problems include orie ntation dysphoria and also problems in females.

There is need fior more research

Main question :Is it neglected.Yes to a certain extent because of its sensitive nature but the problem does not lie on the psychiatrist alone because detection and management is multidisciplinary and interdisciplinary,using a biopsychosocial model such as looking at relaTIONSHIP DIFFICULTIES AND LIASING WITH UROLOGISTS,phYSICIANS,GYNAECOLOGISTS.

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