Case Study: Jon and Linda
Jon and Linda were referred to the author by Jon’s current psychopharmacolo- gist. Jon is a 62 years old financier who has been married to Linda (53 years old) for over 20 years. She began HRT 4 years ago, which successfully stopped her hot flashes. This is his second marriage and her first marriage. They had three teenage children together. Their marriage was marked by periods of disharmony secondary to multiple etiologies. Jon and Linda had a symbiotic relationship where she dominated much of their daily life. She tended to be explicitly critical of him, which he resented but managed passive-aggressively. This, of course, merely exacerbated their marital tension. Linda was particularly sensitive to rejection, and was considerably upset when Jon withdrew from her in response to her criticism. This infuriated her and she provoked confrontations. He even- tually responded, becoming loud and aggressive, which initially dissipated his tension. He then felt guilty as she expressed hurt and disappointment in his beha- vior. This push – pull process would begin anew, characterizing the rhythm of their marriage. Despite all these difficulties in the relationship, both Jon and Linda were fortunate enough to be capable of engaging in successful sex to reduce their stress and anxiety; unlike those needing to be stress free in order to function. Jon and Linda enjoyed high frequency successful coital activity with mutually enjoyable coital orgasms, despite their intermittent marital disharmony over a 15-year period.
Three years ago, Jon started SSRI treatment for depression, secondary to work stress. His depression exacerbated his insecurity about his intelligence and abilities. He developed ED and could not erect, but his sexual desire was still strong. Medication helped his moodiness and reduced his depression. They both wanted Jon on the antidepressant medications, yet their marital conflict increased. His psychopharmacologist tried reducing the SSRI and aug- menting with bupropion. This did not help! If anything, it uncharacteristically, worsened his sex life. They tried switching him from paroxetine to bupropion to escitalopram. During this time, he lost his job, and money problems became worse. He needed to move to a different city in order to find work, uprooting Linda and the kids. He also used a low dose, blood pressure (BP) medication, which had not caused ED, although it was a risk factor. Possibly, the BP medi- cation exacerbated the anti-sexual impact of the SSRI, culminating in his severe ED. His typical male withdrawal from sex and affection once the ED emerged, only exacerbated her rejection sensitivity and deep feeling of abandonment. This left her slightly depressed, but predominantly, critical of him and doubting the viability of their marriage.
His Chicago psychopharmacologist referred them to a well-known NYC urologist, when they first moved from Chicago. The urologist prescribed 50 mg of sildenafil, which was increased to 100 mg. There were multiple attempts at 100 mg, which all failed. The urologist then prescribed “trimix.” They used “trimix” ICI, 15 times, resulting in three coital erections and orgasms. Neither Jon, nor Linda liked the “lack of spontaneity.” The urologist recommended a penile prosthesis, but Jon declined and terminated that treatment.
Some months later, still on 10 mg of escitalopram, a new, NYC psychophar-macologist referred Jon to this author. Jon and Linda were seen six times con- jointly and three times individually. She was helped to reframe his withdrawal, as insecurity, not rejection or abandonment of her. This reduced her anger and resentment. He was encouraged to be affectionate when not angry at her. Her criticalness was reduced, which led to a reduction in his passive-aggressive behavior. Although not resolving the individual and marital dynamics, these insights increased harmony enough, for a sexual pharmaceutical to become effective. The author recommended tadalafil to Jon’s PCP, because of Linda’s rejection sensitivity. The drug’s longer duration of action allowed him to respond to her receptivity cues, which she “dropped like a hankie.” For 1 month, he took tadalafil, Friday and Tuesday. Quoting her: “it covered him for the week.” They now use it, as needed, and are back to twice weekly coitus. She said, “I could do a commercial. It’s doing a fabulous job. It’s a really good drug for us. It is causing greater emotional warmth that leads to physical intimacy.” This, of course tends to be true for all the PDE-5s when they work, not just tada- lafil. He reported, “it takes away the uncertainty, allowing me to feel able.”
Reportedly, both individual and relationship satisfaction were increased and Jon continued to be followed by his PCP and his psychopharmacologist.
SUMMARY AND CONCLUSION
For those individuals where cost is less of a factor in determining decision-making, consultation with a qualified sex therapist offers a potentially more elegant solution, than merely experiencing a trial of sexual pharmaceuticals, when confronted with SD. Yet, it would be unnecessary to subject everyone to a complex evaluation by a sex therapist in advance of a sexual pharmaceutical prescription and brief counsel- ing by a PCP. In part, patients will seek the treatment they want and prefer. Some will seek herbal supplements purchased on the Internet, whereas others will choose a consultation with a MHP specializing in sex therapy. However, if only due to pharmaceutical advertising, most patients will first consult with a physician who will hopefully possess sex counseling expertise, as well as a prescription pad. This physician would adjust treatment according to the individual and couple’s history, sexual script, and intra and interpersonal dynamics.
All clinicians want to optimize the patient’s response to appropriate medical intervention. However, it is equally important to not collude with the patient’s unrealistic expectations of either his or her own idealized capacities, or an idealization of the treating clinician’s abilities. These fantasies are based on ignorance and may reflect unresolved psychological concerns. There are situ- ations when it is appropriate to either make a referral within a team approach or to decline to treat a patient. Significant, process based, developmental predisposing factors, usually speak to the need for resolution of psychic wounds prior to the introduction of the sexual pharmaceutical. A man with ED or RE who avoids sex with his intrusive, domineering spouse, is even less likely to successfully utilize a sexual pharmaceutical; if his idiosyncratic and hidden masturbation pattern, emerged in response to a critical intrusive mother (35). The more deter- minants of SD are driven by developmental processes, the more likely the patient will benefit from sex therapy in addition to pharmacotherapy. There are situations when it is appropriate to postpone treating the patient for the SD, until psy- chotherapeutic consultation is able to assist the individual in developing a more reality-based view. Although sometimes this can be done simultaneously, other times, treatment for SD must be postponed.
Sexuality is a complex interaction of biology, culture, developmental, and current intra and interpersonal psychology. A bio-psychosocial model of SD pro- vides a compelling argument for CT integrating sex therapy and sexual pharma- ceuticals. Restoration of lasting and satisfying sexual function requires a multidimensional understanding of all of the forces that created the problem, whether a solo physician or multidisciplinary team approach is used. Each clin- ician needs to carefully evaluate their own competence and interests when con- sidering the treatment of a person’s SD, so that regardless of the modality used, the patient receives optimized care. For the most part, neither sex therapy nor medical/surgical interventions alone are sufficient to facilitate lasting improve- ment and satisfaction for a patient or partner suffering from SD. There will be new medical and surgical treatments in the future. Sex therapists and sex therapy will complement all of these approaches. This author is optimistic, for a future, which uses CT, integrating sexual pharmaceuticals and sex therapy, for the resolution of SD and the restoration of sexual function and satisfaction.