Treatment of multiple distressing spontaneous orgasms with citalopram and their re-emergence following discontinuation of prolonged use of citalopram in an adult female survivor of child sexual abuse.

Serotonin reuptake inhibitors-induced orgasmic dysfunctions including spontaneous orgasms have been reported in women. Spontaneous orgasm is experiencing orgasm in the absence of sexual sensory stimulation. A woman with sexual abuse in her childhood who later developed distressing spontaneous orgasms is discussed. She stopped experiencing these orgasms with citalopram. However the orgasms soon re-emerged following the abrupt discontinuation of prolonged use of citalopram but disappeared again once the citalopram was re-introduced. To the best of the author's knowledge the therapeutic effect of citalopram to cause cessation of distressing spontaneous orgasms of this kind in a child sexual abuse (CSA) survivor has not been reported. The mechanism of action of SSRIs-induced sexual side effects including orgasmic dysfunctions is complex and poorly understood. It is suggested that the therapeutic cessation of spontaneous orgasms in this case could be due to anorgasmic sexual side effect of Citalopram.

INTRODUCTION

Serotonin reuptake inhibitors (SSRIs) are associated with a variety of sexual dysfunctions in women, including diminished libido, anorgasmia, vaginal xerosis, and decreased tactile sensitivity in the genital region.[1-3] Orgasmic dysfunctions, both reduced libido and arousal, occur in 30–50% with SSRIs.[4] Orgasmic dysfunctions induced by SSRIs are more varied in women, e.g. fluoxetine has been linked with spontaneous orgasms,[5] delayed orgasms, and anorgasmia,[6] and fluvoxamine has been associated with an increase in libido and multiple orgasms.[7]

A wide range of sexual dysfunctions including hyper- or hypo-arousal, aversion, dyspareunia, vaginismus, and orgasmic dysfunction have been reported by child sexual abuse (CSA) survivors.[8] Some survivors of CSA, instead of suffering from impaired orgasm, may indeed experience sexual arousal “out of blue” as a result of flashback of their earlier sexual experiences.[9] Sometimes, the orgasms may be associated with non-sexual stimulation (vibration from riding a subway, sensation from a bowel movement) and may also commence after the sex stimulation has been stopped.[10] Orgasmic experiences in the form of auras have also been reported in association with seizure activity both in men and women. These orgasms may be experienced as “unwelcome”[11] or as pleasurable.[12] The occurrence of orgasm in the absence of gynecological, hormonal, or overt psychological disturbances may be caused by epileptic seizures as part of an organic brain disease.[13]

It is not uncommon to experience discontinuation symptoms with SSRIs, which usually appear within 1-3 days of their abrupt cessation.[14] The common discontinuation symptoms are dizziness, light-headedness, faintness, vertigo, ataxia, or a “spaced out” sensation that markedly worsens with movement.[15] Although these discontinuation symptoms are not dangerous, they can be distressing and uncomfortable to the patients. Usually these discontinuation symptoms last from 1 to 3 weeks and can be relieved within 24 h of the re-commencement of the antidepressant medication.[14]

The mechanism of SSRIs to cause sexual dysfunction including anorgasmia is complex and poorly understood, but in simple term the drugs that enhance serotonin or block dopamine tend to decrease sexual activity; drugs that increase dopamine or block specific serotonin receptors tend to enhance sexual activity.[16] Similarly drugs that increase synaptic levels of serotonin, cortisol, prolactin, and opioid adversely affect sexual functioning.[17] The role of other central neurotransmitters in influencing female sexual function is not much known, but peripherally serotonin exerts an inhibitory effect on sexual arousal and orgasm in both sexes, while oxytocin facilitates this function.[18] Apart from serotonin, its receptor subtypes, 5HT2 and perhaps 5HT3, are also responsible for these disabling sexual effects.[19]

The aim of presenting this case is to discuss a female CSA survivor who experienced multiple distressing spontaneous orgasms following sexual abuse by her father and responded well to citalopram. However, these orgasms re-emerged following the cessation of the prolonged use of citalopram and disappeared with its reintroduction. She suffered from epilepsy and cerebrovascular accident, but these were not etiological in nature as orgasmic dysfunctions appeared much earlier to the cerebrovascular accident and epilepsy. The sexual side effect of anorgasmia with citalopram proved therapeutic in this CSA survivor.

To the best of the author's knowledge, the therapeutic benefit of cessation of spontaneous orgasms arising from the sexual side effects of anorgasmia with citalopram and later their reinstatement on citalopram discontinuation has not been explored in CSA survivors with orgasmic dysfunction.

CASE REPORT

Ms X, a 55-year-old married Caucasian woman was admitted to psychiatry ward following an overdose of prescribed medication in conjunction with alcohol. This was her first contact with psychiatric services although she had been on citalopram for a long period from her general practitioner. She experienced low mood, suicidal ideation, reduced appetite, poor sleep, and tearfulness following her divorce and removal of her adopted son from her care. She had a difficult childhood and was sexually abused by her father over a long period of time. The sexual abuse was associated with high negative emotions and a lot of anger. About 3 years ago, she suffered from seizures and cerebrovascular accident resulting in weakness in right leg and dysphasia. Couple of months ago, she started drinking alcohol in moderation in order to cope with her feelings of distress and low mood due to divorce and her son's removal from her care. There was no history suggestive of any illicit drug abuse in this lady.

During her current admission, Ms. X disclosed that she had multiple and distressing spontaneous orgasms since her childhood following sexual abuse by her father. These orgasms would generally be coupled with her feeling angry on any account. However, she stopped experiencing these orgasms with the initiation of citalopram but would experience them again if she did not take citalopram for a few days. Unfortunately, when she was hospitalized following cerebrovascular accident about 3 years ago, citalopram was discontinued in error and she started re-experiencing these multiple orgasms. Apart from hypertension, she did not have any other risk factors to have cerebrovascular accident at the age of 52. She could have up to 70 orgasms in a day and felt totally exhausted. She did not demand citalopram out of embarrassment and shame for 3 months and continued to suffer till she was restarted on citalopram following which the orgasms disappeared.

Ms. X was diagnosed to be suffering from adjustment disorder brief depressive reaction based on her current psychosocial stressors and symptoms (F43.20 of ICD-10). She settled fairly quickly on the ward and improved in her low mood and stopped feeling suicidal and was discharged on citalopram (40 mg daily) and her other medications for her physical health problems (bisoprolol 10 mg mane, levetiracetam1 g twice a day, tramadol 100 mg twice a day).

DISCUSSION

Spontaneous orgasm is the experience of orgasm without sexual sensory stimulation and physical explanation.[20] The patient under reference was sexually abused by her father during her childhood and suffered from distressing and multiple spontaneous orgasms as a CSA survivor. This is consistent with the findings reported in CSA survivors in the literature.[821] Seizures have also been reported to produce painful spontaneous orgasms,[22] but this patient had orgasmic dysfunction, which appeared much before the onset of seizures and cerebrovascular accident and was closely linked with the sexual abuse during childhood.

Ms. X stopped experiencing multiple painful spontaneous orgasms when she was commenced on citalopram. The therapeutic effects in the form of cessation of spontaneous orgasms with citalopram may be viewed as originating from anorgasmia due to citalopram. It is interesting to note that sexual side effects of citalopram resulted in the cessation of multiple spontaneous orgasms (orgasms in the absence of any sexual stimuli) in this patient. Orgasmic delay or anorgasmia as a side effect of SSRIs has been reported in many studies,[13] but a CSA survivorwho improved in multiple unwelcoming spontaneous orgasms with citalopram has not been reported. Further, when citalopram was discontinued in error during her hospitalization for cerebrovascular accident, she started re-experiencing those orgasms as a reinstatement of the previous problem that may be seen as reversal of beneficial effect with citalopram.

This case illustrates the use of citalopram for the treatment of spontaneous distressing orgasms in women of CSA survivors and also highlights the risk of re-emergence of the orgasms on its discontinuation.