Acessibilidade / Reportar erro

Sexual dysfunction in psychiatric settings: is there a place for psychotherapy?

Disfunção sexual em psiquiatria: há lugar para a psicoterapia?

Sexual dysfunctions (SD) are often associated to psychiatric disorders, either as part of the psychopathology, or as adverse effect of psychotropic medication. When sexual complains are secondary to the clinical condition, it is expected to remit with treatment. Substance-induced sexual dysfunctions, on the other hand, tend to persist, even after pharmacotherapy is over, with deleterious impact in sexual function. Therefore, it is plausible to affirm that a significant number of patients in psychiatric settings, and even a relevant percentage of the general population, will be exposed to the deleterious effects of psychotropic medication in sexual function11. Williams V, Edin H, Hogue S, Fehnel S, Baldwin D. Prevalence and impact of antidepressant-associated sexual dysfunction in three European countries: replication in a cross-sectional patient survey. J Psychopharmacol. 2010;24(4):489-96.. These problems deeply affect patients’ and partners’ sexual satisfaction, threatening relationship stability and partnership-related quality of life aspects. It also negatively impacts pharmacotherapy adherence, thus affecting therapeutic outcomes22. Montejo AL, Montejo L, Baldwin DS. The impact of severe mental disorders and psychotropic medications on sexual health and its implications for clinical management. World Psychiatry. 2018;17(1):3-11..

Current medical literature provides a two-step approach for sexual problems in this population: (a) improve sexual function and satisfaction assessment and (b) hone methods aiming to reduce SD incidence and its negative consequences. In this sense, there is clear recommendation for directly and routinely asking patients about sexuality from baseline, throughout the duration of pharmacological treatment. This active approach would also be helpful in collecting data often neglected nowadays, that could potentially lead to better comprehension of factors associated to sexual complains and, consequently, inform more effective interventions33. Schweitzer I, Maguire K, Ng C. Sexual side-effects of contemporary antidepressants: review. Aust New Zeal J Psychiatry. 2009;43(9):795-808.. Even though there are some available therapeutic options to manage sexual adverse effects of psychotropic medication, evidence of efficacy is still controversial and clinical outcomes are often insufficient to impact sexual satisfaction44. Taylor MJ, Rudkin L, Bullemor-Day P, Lubin J, Chukwujekwu C, Hawton K. Strategies for managing sexual dysfunction induced by antidepressant medication. Cochrane Database Syst Rev. 2013;(5):CD003382.,55. Schmidt HM, Hagen M, Kriston L, Soares-Weiser K, Maayan N, Berner MM. Management of sexual dysfunction due to antipsychotic drug therapy. Cochrane Database Syst Rev. 2012;(11):CD003546.. Besides that, there is consistent data highlighting the lack of attention to sexual problems given by practitioners as well as barriers reported by patients in addressing sexuality with health professionals66. Kelly K, Posternak M, Alpert JE. Toward achieving optimal response: understanding and managing antidepressant side effects. Dialogues Clin Neurosci. 2008;10(4):409-18.. Mediating factors between SD, tolerance to sexual adverse effects of medication and treatment adherence warrant further investigation.

Being aware that SD is multifactorial, and that gold standard treatment approaches are often multidisciplinary, is probably a key element to better address the problem in psychiatric settings. Literature emphasize the relevant role of psychotherapy in managing SDs, notably cognitive-behavioral interventions77. Pereira VM, Arias-Carrión O, Machado S, Nardi AE, Silva AC. Sex therapy for female sexual dysfunction. Int Arch Med. 2013;6:37.

8. Melnik T, Soares B, Nasello AG. Psychosocial interventions for erectile dysfunction. Cochrane Database Syst Rev. 2007;(3):CD004825.
-99. Melnik T, Althof S, Atallah AN, Puga ME, Glina S, Riera R. Psychosocial interventions for premature ejaculation. Cochrane Database Syst Rev. 2011;(8):CD008195.. Empirical data demonstrate yet that maladaptive sexual beliefs might act as a vulnerability factor to SD development1010. Nobre PJ, Pinto-Gouveia J. Dysfunctional sexual beliefs as vulnerability factors to sexual dysfunction. J Sex Res. 2006;43(1):68-75., and that non-erotic automatic thoughts in sexual situations are a distinctive phenomenon in sexually dysfunctional patients´ experience of sex1111. Peixoto MM, Nobre P. Cognitive schemas activated in sexual context: a comparative study with homosexual and heterosexual men and women, with and without sexual problems. Cognit Ther Res. 2015;39(3):390-402.. It is therefore noteworthy to address and restructure sexual cognitions when treating SD. Curiously, however, sexual psychotherapy has not been yet studied or systematically considered as a therapeutic option in managing SD in psychiatric patients, been rarely mentioned and poorly evaluated in terms of feasibility and efficacy.

There is also a potential preventive role of early detection and intervention in cognitive sexual vulnerability still to be explored. Imagine if practitioners could count, since baseline, on a decision algorithm to inform whether that single patient would present an increased risk for developing sexual complains and if that would be a disturbing factor to pharmacotherapy adherence. It is also likely that other aspects of sexuality – such as gender, sexual roles and sexual cognitions –, play an important part in the development and maintenance of substance induced SD, as well as in its burden in treatment and patient’s quality of life1212. Cohen S, Kühn KU, Bender S, Erfurth A, Gastpar M, Murafi A, et al. Sexual impairment in psychiatric inpatients: focus on depression. Pharmacopsychiatry. 2007;40(2):58-63.. Psychotherapy sexual interventions in prevention and/or treatment of SD in psychiatric settings is, therefore, a promising research area, resting to be further explored.

Cognitive-behavioral therapy is recognized by its efforts in developing and providing evidence-based psychotherapeutic interventions to various kinds of psychological and interpersonal problems, being this ideological standpoint a trigger to continuous actualization of its theory and practice. Cognitive sexual therapy (CST) is a cognitive-behavioral integrative psychotherapy aimed specifically to address and treat SDs, articulating evidence-based clinical interventions to scientific understandings of human sexuality1313. Sardinha A. Terapia Cognitiva Sexual: Teoria e Prática. Ebook, editor. Rio de Janeiro. 2018. Disponível em: https://go.hotmart.com/X7697587Y.
https://go.hotmart.com/X7697587Y...
. In a CST perspective, distorted sexual cognitions, allied to individuals´ misinterpretations of sexual demands, directly affect emotional, physiological and behavioral regulation in sexual situations. In this sense, restructuring central and intermediate cognitive processes is essential to foster the acquisition of sexual skills and to promote the development of a more adapted sexual repertoire. Thus, cognitions are understood as mediating factors to be modified, aiming sexual skills implementation and emotional regulation during sexual encounters.

Being able to flexibilize sexual scripts and behaviors leads to better adaptation to physiological, environmental and relational changes that negatively impact sexuality over the life cycle, contributing to booster sexual satisfaction even in the presence of sexual function disturbances. The focus of CST interventions is this population would be to aid patients and partners towards the development of more flexible and adaptable sexual cognitions and behavioral patterns. That could permit regain sexual function and satisfaction along and after treatment with psychotropic medication, lessen the negative impact of sexual adverse effects in quality of life and therefore, increase adherence and therapeutic effects of pharmacotherapy. Although the theoretical rationale supporting this proposal is evidence-based, feasibility, efficacy, treatment modalities and procedural aspects of the intervention remain to be empirically tested.

REFERENCES

  • 1
    Williams V, Edin H, Hogue S, Fehnel S, Baldwin D. Prevalence and impact of antidepressant-associated sexual dysfunction in three European countries: replication in a cross-sectional patient survey. J Psychopharmacol. 2010;24(4):489-96.
  • 2
    Montejo AL, Montejo L, Baldwin DS. The impact of severe mental disorders and psychotropic medications on sexual health and its implications for clinical management. World Psychiatry. 2018;17(1):3-11.
  • 3
    Schweitzer I, Maguire K, Ng C. Sexual side-effects of contemporary antidepressants: review. Aust New Zeal J Psychiatry. 2009;43(9):795-808.
  • 4
    Taylor MJ, Rudkin L, Bullemor-Day P, Lubin J, Chukwujekwu C, Hawton K. Strategies for managing sexual dysfunction induced by antidepressant medication. Cochrane Database Syst Rev. 2013;(5):CD003382.
  • 5
    Schmidt HM, Hagen M, Kriston L, Soares-Weiser K, Maayan N, Berner MM. Management of sexual dysfunction due to antipsychotic drug therapy. Cochrane Database Syst Rev. 2012;(11):CD003546.
  • 6
    Kelly K, Posternak M, Alpert JE. Toward achieving optimal response: understanding and managing antidepressant side effects. Dialogues Clin Neurosci. 2008;10(4):409-18.
  • 7
    Pereira VM, Arias-Carrión O, Machado S, Nardi AE, Silva AC. Sex therapy for female sexual dysfunction. Int Arch Med. 2013;6:37.
  • 8
    Melnik T, Soares B, Nasello AG. Psychosocial interventions for erectile dysfunction. Cochrane Database Syst Rev. 2007;(3):CD004825.
  • 9
    Melnik T, Althof S, Atallah AN, Puga ME, Glina S, Riera R. Psychosocial interventions for premature ejaculation. Cochrane Database Syst Rev. 2011;(8):CD008195.
  • 10
    Nobre PJ, Pinto-Gouveia J. Dysfunctional sexual beliefs as vulnerability factors to sexual dysfunction. J Sex Res. 2006;43(1):68-75.
  • 11
    Peixoto MM, Nobre P. Cognitive schemas activated in sexual context: a comparative study with homosexual and heterosexual men and women, with and without sexual problems. Cognit Ther Res. 2015;39(3):390-402.
  • 12
    Cohen S, Kühn KU, Bender S, Erfurth A, Gastpar M, Murafi A, et al. Sexual impairment in psychiatric inpatients: focus on depression. Pharmacopsychiatry. 2007;40(2):58-63.
  • 13
    Sardinha A. Terapia Cognitiva Sexual: Teoria e Prática. Ebook, editor. Rio de Janeiro. 2018. Disponível em: https://go.hotmart.com/X7697587Y
    » https://go.hotmart.com/X7697587Y

Publication Dates

  • Publication in this collection
    26 Aug 2019
  • Date of issue
    Apr-Jun 2019

History

  • Received
    5 July 2019
  • Accepted
    19 July 2019
Instituto de Psiquiatria da Universidade Federal do Rio de Janeiro Av. Venceslau Brás, 71 Fundos, 22295-140 Rio de Janeiro - RJ Brasil, Tel./Fax: (55 21) 3873-5510 - Rio de Janeiro - RJ - Brazil
E-mail: editora@ipub.ufrj.br