INT'L. J. PSYCHIATRY IN MEDICINE, VOI. 21 (4) 379-382,1991
FLUOXETINE AND ORGASMIC SEXUAL EXPERIENCES
PHILIP L. P. MORRIS, M.D., PH.D. Maryland Psychiatric Research Center Baltimore, Maryland
ABSTRACT
The purpose of this article to describe a unique potential side effect of fluoxetine. A case report of a patient with post stroke depression treated with fluoxetine is presented. Fluoxetine was associated temporally with frequent short episodes of sexual excitement described by the patient as feeling like an orgasm. The relationship was dose dependent. Serotonergic medications, like fluoxetine, may induce sexual stimulation as a side effect. The mechanism for this effect is unclear but patients with organic brain disease may be at higher risk for this complication. (Intl J. Psychiatry in Medicine, 21 :379-382, 1991)
Key Words: fluoxetine, post stroke, depression, side effect, adverse reaction, sexual experience, orgasm
FLUOXETINE AND ORGASMIC SEXUAL EXPERIENCES This article describes the case of a man with major depression following a stroke who experienced an unusual side effect of fluoxetine, a serotonergic antidepressant.
Case History The patient was a sixty-nine-year-old married male who suffered two strokes in the two years before he first was seen (June 1990). The first stroke (March 1988) produced right sided weakness and the second stroke (March 1989) affected his speech. He had made a good recovery from his motor weakness and was able to 379
0 1991, Baywood Publishing Co., Inc.
doi: 10.2190/JUNJ-XXQ2-ER17-96LR http://baywood.com
380 I MORRIS
comprehend and speak fluently. However, about two months following the second stroke he developed depressed mood associated with passive suicidal thoughts, insomnia, anorexia, weight loss, frequent crying spells (usually precipitated by sad thoughts), poor concentration, and a pessimistic view of his future. Buspirone (5 mg qd) and trazodone (50 mg bid) in small doses had been prescribed without clinical benefit. The patient’s children brought him for psychiatric consultation, concerned about his failure to improve emotionally despite evidence of physical recovery and the effect this was having on the patient’s spouse who was disabled from multiple sclerosis. The patient had a long history of insulin dependent diabetes and peripheral vascular disease which had resulted in a left below knee amputation. There was no family history or past personal history of psychiatric disorder. At the time of interview he was receiving 30 units of insulin per day, and taking an aspirin and one 5 mg buspirone tablet per day. The patient had ceased sexual intercourse two years previously because of impotence (due presumably to his diabetes and vascular disease) and his wife’s disability. Prior to that time the couple had infrequent but enjoyable sexual relations. On examination there was evidence of minimal right side weakness and hyperflexia, but otherwise the neurological findings were unremarkable. He was left handed. His mood was depressed but reactive and there was no evidence of emotional lability. The patient was not psychotic but had passive suicidal thoughts. He was alert and oriented but had subjective complaints of poor concentration. Clinical testing revealed minor problems with concentration (serial 7’s) and difficulty in recalling three-items at five minutes. Laboratory investigations showed a mild anemia (Hb = 13.1 g/dl) and a MRI scan revealed an old pontine infarct and a newer ischemic area in the region of the right medial temporal lobe. There was no cerebral atrophy noted. Neuropsychological testing was undertaken. He was of average IQ but had difficulties in visuomotor performance, reading ability (alexia) and verbal memory capacity. Verbal fluency was not affected. A diagnosis of major depression following stroke was made and the patient was started on nortriptyline 10 mg qhs, slowly building to 50 mg qhs. Unfortunately he was unable to tolerate the medication due to oversedation, lethargy, and lightheadiness despite a sub-therapeutic serum level (23 ng/ml). Fluoxetine 20 mg every alternate day was initiated. A month later the patient was little improved and fluoxetine was increased to 20 mg per day. At the next visit (one month later) the patient complained of unusual sensations since taking the higher dose of fluoxetine. He described the sensations as frequent (2-4 times per day) bursts of sexual excitement, feeling like an orgasm, lasting 10-30seconds often associated with a tingling feeling over his skin. The sensations were not genitally focussed and did not cause an erection. Clinically, the patient was much less depressed and felt more able to concentrate. To test whether the reaction was dose dependent, his fluoxetine was reduced to 20 mg on alternate days and at this dose the sexual
SEXUAL EXPERIENCES / 381
experiences ceased. A month later his clinical state remained the same, with a few remaining depressive symptoms. Fluoxetine was increased to 20 mg per day and the sexual experiences returned, but at reduced frequency. The patient has continued on fluoxetine (dosage varying from daily to alternate day) for the past six months and has not suffered any deterioration in mood. DISCUSSION This case illustrates an unusual potential side effect of fluoxetine; that of orgasmic sexual experiences or sensations. While fluoxetine can cause either increased or decreased libido, ejaculation problems or other sexual dysfunctions (manufacturer’s prescribing information), sexual sensations of the kind reported here rare [l]. Increased libido and sexual arousal has been noted with the use of the serotonergic agent, fenfluramine 121, but, on the other hand, cyproheptadine (a serotonin antagonist) has been used to treat fluoxetine induced sexual dysfunctions [3]. Thus, the actual role of serotonin in mediating sexual experience is unclear. The reaction of my patient lo fluoxetine is difficult to explain but may be related to his cerebrovascular brain injuries. Serotonin receptor function is known to be affected by stroke, with receptor up-regulation occurring after right hemisphere lesions [4,5]. It is possible that if the patient had up-regulation of cortical serotonin receptors after his right hemisphere infarct, then even routine doses of fluoxetine (a serotonin re-uptake blocker) might overstimulate the serotonin system, and produce the sexual phenomena. As a consequence, it seems reasonable to suggest that patients with organic brain disease should be prescribed fluoxetine cautiously. Although this case describes another possible side effect of fluoxetine, the sensations experienced were not unpleasant and did not result in discontinuation of the drug. REFERENCES 1. J. G. Modell, Repeated Observations of Yawning, Clitoral Engorgement, and Orgasm Associated with Fluoxetine Administration(letter),Journal of Clinical PsychopharmaC O I O ~ ~963-65,1989. , 2. R. W. D. Stevenson and L. Solyom, The Aphrodisiac Effect of Fenfluramine:Two Case Reports of a Possible Side Effect the Use of Fenfluraminein the Treatmentof Bulimia, Journal of ClinicalPsychopharmacology,10:69-71,1990. 3. S . Mc Connick, J. O h , and A. W. Brotman, Reversal of Huoxetine-Induced Anorgasmia by Cyproheptadinein Two Patients,Journal of Clinical Psychiatry,51383-384, 1990. 4. H.Mayberg, R. Parikh, and P. L. P. Morris, et al., Spontaneous Remission of Poststroke Depression and Temporal Changes in cortical Serotonin S2 Receptors Measured by Positron Emission Tomography, Journal of Neuropsychiatry and Clinical Neuroscience, 3:30-83,1991.
382
I
MORRIS
5. H. Mayberg, R. G . Robinson, D. F. Wong, et al., PET Imaging of Cortical S2 Serotonin Receptors Following Stroke: Lateralized Changes and Relationship to Depression, American Journal of Psychiatry, 145~937-943,1989.
Direct reprint requests to: Philip L. P. Morris, MD, PhD Maryland Psychiatric Research Center P.O. Box 21247 Baltimore, MD 21228
FLUOXETINE AND ORGASMIC SEXUAL EXPERIENCES
PHILIP L. P. MORRIS, M.D., PH.D. Maryland Psychiatric Research Center Baltimore, Maryland
ABSTRACT
The purpose of this article to describe a unique potential side effect of fluoxetine. A case report of a patient with post stroke depression treated with fluoxetine is presented. Fluoxetine was associated temporally with frequent short episodes of sexual excitement described by the patient as feeling like an orgasm. The relationship was dose dependent. Serotonergic medications, like fluoxetine, may induce sexual stimulation as a side effect. The mechanism for this effect is unclear but patients with organic brain disease may be at higher risk for this complication. (Intl J. Psychiatry in Medicine, 21 :379-382, 1991)
Key Words: fluoxetine, post stroke, depression, side effect, adverse reaction, sexual experience, orgasm
FLUOXETINE AND ORGASMIC SEXUAL EXPERIENCES This article describes the case of a man with major depression following a stroke who experienced an unusual side effect of fluoxetine, a serotonergic antidepressant.
Case History The patient was a sixty-nine-year-old married male who suffered two strokes in the two years before he first was seen (June 1990). The first stroke (March 1988) produced right sided weakness and the second stroke (March 1989) affected his speech. He had made a good recovery from his motor weakness and was able to 379
0 1991, Baywood Publishing Co., Inc.
doi: 10.2190/JUNJ-XXQ2-ER17-96LR http://baywood.com
380 I MORRIS
comprehend and speak fluently. However, about two months following the second stroke he developed depressed mood associated with passive suicidal thoughts, insomnia, anorexia, weight loss, frequent crying spells (usually precipitated by sad thoughts), poor concentration, and a pessimistic view of his future. Buspirone (5 mg qd) and trazodone (50 mg bid) in small doses had been prescribed without clinical benefit. The patient’s children brought him for psychiatric consultation, concerned about his failure to improve emotionally despite evidence of physical recovery and the effect this was having on the patient’s spouse who was disabled from multiple sclerosis. The patient had a long history of insulin dependent diabetes and peripheral vascular disease which had resulted in a left below knee amputation. There was no family history or past personal history of psychiatric disorder. At the time of interview he was receiving 30 units of insulin per day, and taking an aspirin and one 5 mg buspirone tablet per day. The patient had ceased sexual intercourse two years previously because of impotence (due presumably to his diabetes and vascular disease) and his wife’s disability. Prior to that time the couple had infrequent but enjoyable sexual relations. On examination there was evidence of minimal right side weakness and hyperflexia, but otherwise the neurological findings were unremarkable. He was left handed. His mood was depressed but reactive and there was no evidence of emotional lability. The patient was not psychotic but had passive suicidal thoughts. He was alert and oriented but had subjective complaints of poor concentration. Clinical testing revealed minor problems with concentration (serial 7’s) and difficulty in recalling three-items at five minutes. Laboratory investigations showed a mild anemia (Hb = 13.1 g/dl) and a MRI scan revealed an old pontine infarct and a newer ischemic area in the region of the right medial temporal lobe. There was no cerebral atrophy noted. Neuropsychological testing was undertaken. He was of average IQ but had difficulties in visuomotor performance, reading ability (alexia) and verbal memory capacity. Verbal fluency was not affected. A diagnosis of major depression following stroke was made and the patient was started on nortriptyline 10 mg qhs, slowly building to 50 mg qhs. Unfortunately he was unable to tolerate the medication due to oversedation, lethargy, and lightheadiness despite a sub-therapeutic serum level (23 ng/ml). Fluoxetine 20 mg every alternate day was initiated. A month later the patient was little improved and fluoxetine was increased to 20 mg per day. At the next visit (one month later) the patient complained of unusual sensations since taking the higher dose of fluoxetine. He described the sensations as frequent (2-4 times per day) bursts of sexual excitement, feeling like an orgasm, lasting 10-30seconds often associated with a tingling feeling over his skin. The sensations were not genitally focussed and did not cause an erection. Clinically, the patient was much less depressed and felt more able to concentrate. To test whether the reaction was dose dependent, his fluoxetine was reduced to 20 mg on alternate days and at this dose the sexual
SEXUAL EXPERIENCES / 381
experiences ceased. A month later his clinical state remained the same, with a few remaining depressive symptoms. Fluoxetine was increased to 20 mg per day and the sexual experiences returned, but at reduced frequency. The patient has continued on fluoxetine (dosage varying from daily to alternate day) for the past six months and has not suffered any deterioration in mood. DISCUSSION This case illustrates an unusual potential side effect of fluoxetine; that of orgasmic sexual experiences or sensations. While fluoxetine can cause either increased or decreased libido, ejaculation problems or other sexual dysfunctions (manufacturer’s prescribing information), sexual sensations of the kind reported here rare [l]. Increased libido and sexual arousal has been noted with the use of the serotonergic agent, fenfluramine 121, but, on the other hand, cyproheptadine (a serotonin antagonist) has been used to treat fluoxetine induced sexual dysfunctions [3]. Thus, the actual role of serotonin in mediating sexual experience is unclear. The reaction of my patient lo fluoxetine is difficult to explain but may be related to his cerebrovascular brain injuries. Serotonin receptor function is known to be affected by stroke, with receptor up-regulation occurring after right hemisphere lesions [4,5]. It is possible that if the patient had up-regulation of cortical serotonin receptors after his right hemisphere infarct, then even routine doses of fluoxetine (a serotonin re-uptake blocker) might overstimulate the serotonin system, and produce the sexual phenomena. As a consequence, it seems reasonable to suggest that patients with organic brain disease should be prescribed fluoxetine cautiously. Although this case describes another possible side effect of fluoxetine, the sensations experienced were not unpleasant and did not result in discontinuation of the drug. REFERENCES 1. J. G. Modell, Repeated Observations of Yawning, Clitoral Engorgement, and Orgasm Associated with Fluoxetine Administration(letter),Journal of Clinical PsychopharmaC O I O ~ ~963-65,1989. , 2. R. W. D. Stevenson and L. Solyom, The Aphrodisiac Effect of Fenfluramine:Two Case Reports of a Possible Side Effect the Use of Fenfluraminein the Treatmentof Bulimia, Journal of ClinicalPsychopharmacology,10:69-71,1990. 3. S . Mc Connick, J. O h , and A. W. Brotman, Reversal of Huoxetine-Induced Anorgasmia by Cyproheptadinein Two Patients,Journal of Clinical Psychiatry,51383-384, 1990. 4. H.Mayberg, R. Parikh, and P. L. P. Morris, et al., Spontaneous Remission of Poststroke Depression and Temporal Changes in cortical Serotonin S2 Receptors Measured by Positron Emission Tomography, Journal of Neuropsychiatry and Clinical Neuroscience, 3:30-83,1991.
382
I
MORRIS
5. H. Mayberg, R. G . Robinson, D. F. Wong, et al., PET Imaging of Cortical S2 Serotonin Receptors Following Stroke: Lateralized Changes and Relationship to Depression, American Journal of Psychiatry, 145~937-943,1989.
Direct reprint requests to: Philip L. P. Morris, MD, PhD Maryland Psychiatric Research Center P.O. Box 21247 Baltimore, MD 21228
