Mental Illness 2016; volume 8:6546

A case of mania presenting al thoughts and activity in the first stage and then progressing to sexual preoccupation and Correspondence: Michelle R. Heare, University of with hypersexual behavior ending in sexual delusions.9 A small body of lit- California, Irvine CA 92697, USA. and gender dysphoria that erature also exists which describes hypersexu- Tel: +1.530.902.7573. resolved with valproic acid ality in amphetamine users. Angrist and E-mail: [email protected]. Gershon described intensified sexual feelings, Key words: Psychiatry; mania; hypersexual; gen- Michelle R. Heare,1 Maria Barsky,1 and increased sexual tension amongst amphet- 10 der dysphoria. Lawrence R. Faziola2 amine users in their paper published in 1976. Gender confusion in the context of mania is Contributions: MRH, data collecting, manuscript even less often described in the literature than 1University of California, Irvine; writing, references search; MB, manuscript writ- hypersexuality. Chakrabarti and colleagues 2Department of Psychiatry and Human ing and references search; LRF, manuscript described a case of a male patient who exhib- reviewing and writing. Behavior, University of California, Irvine, ited problematic provocative behavior as well CA, USA as expressed a desire to be female and had a Conflict of interest: the authors declare no poten- delusion that he was married to a man. He tial conflict of interest. eventually improved with lithium and electro- convulsive therapy.11 In some case reports, Received for publication: 16 April 2016. Abstract manic episodes precipitate or intensify the Revision received: 2 June 2016. desire to be another gender, while in others, Accepted for publication: 2 June 2016. Hypersexuality and gender dysphoria have the manic episode made these desires less This work is licensed under a Creative Commons 12-14 both been described in the literature as symp- pronounced. Attribution-NonCommercial 4.0 International toms of mania. Hypersexuality is listed in the This case report describes a young homo- License (CC BY-NC 4.0). Diagnostic and Statistical Manual of Mental sexual man presenting in a manic episode Disorders 5 as part of the diagnostic criteria for with co-morbid amphetamine abuse whose ©Copyright M.R. Heare et al., 2016 bipolar disorder. Gender dysphoria is less often mania was marked by hypersexuality and the Licensee PAGEPress, Italy described and its relation to mania remains desire to be a woman. Both of these symptoms Mental Illness 2016; 8:6546 doi:10.4081/mi.2016.6546 unclear. This case report describes a young of mania resolved with treatment of the manic homosexual man presenting in a manic episode with valproic acid. episode with co-morbid amphetamine abuse whose mania was marked by hypersexuality their family. During his first day in the hospi- and the new onset desire to be a woman. Both tal, the patient reported that his mood was of these symptoms resolved with the addition Case Report good and denied any hallucinations, paranoia, of valproic acid to antipsychotics. This case or suicidal ideation. He remained disorgan- report presents the existing literature on A 28-year-old homosexual male was brought ized, and spent his first night in the hospital hypersexuality and gender dysphoria in mania to the emergency department after he was pacing the unit without sleep. He was started and describes a treatment option that has not found destroying property at his home. On on risperidone 0.5 mg twice a day for psychosis been previously reported. presentation, he was very disorganized and and risperidone 0.5 mg as needed every 8 stated that he had blood coming from his rec- hours for anxiety and agitation. He was placed tum. On physical exam, no rectal bleeding was on precautions for possible alcohol withdrawal found. He appeared euphoric and stated that due to possible recent alcohol use, which was Introduction his mood was happy and scared. He denied any reported by his mother. On hospital day two, past psychiatric history and any prior use of the patient was seen coming out of the bath- Sexual or erotic excitement has been noted psychiatric medications. His urine toxicology room with another male patient. At this time, as a feature of mania since 1892.1 In the screen was positive for amphetamines. He was he was placed on hypersexual precautions and Diagnostic and Statistical Manual of Mental admitted to the acute adult inpatient psychi- was instructed to maintain a 10-foot distance Disorders 5, hypersexuality is listed as part of atric unit for observation. from all other patients. That same day, the the diagnostic criteria for bipolar disorder. Collateral information from his mother con- patient suggestively groped a male staff mem- Despite descriptions of hypersexuality in firmed that he had a normal development and ber’s hand while receiving food. He was placed mania, there have been few formal studies on childhood and graduated from high school. She on one to one supervision due to his inappro- the matter. A literature review reveals no pre- stated that he had always identified as a homo- priate behaviors. During his second night in cise definition of hypersexuality in bipolar dis- sexual male, and had never expressed feelings the hospital he was recorded to have slept 4.5 order, no extensive description hypersexual of being a different gender or the desire to be hours. For the rest of his stay, he slept 7-10 behavior, and scant information about the a woman. He did not show any signs of mental hours each night. Risperidone was increased manifestations and frequency of hypersexual illness until 3 years prior to his hospitalization gradually to 4 mg nightly for psychotic mania behavior in specific populations. when his mother states that he fell into a and valproic acid extended release 1500 mg at The data that exist about hypersexuality in depression, which was characterized by talking nighttime was started with a goal of improving mania is largely derived from seven observa- to himself, lack of self-care, and loss of sleep impulsivity and hypersexuality. Three days fol- tional studies published between 1969-1979. and appetite. She corroborated that the patient lowing initiation, serum values of valproic acid Hypersexuality was observed in 57% of manic had never taken psychiatric medications. At were 75 mcg/mL, with normal complete blood patients (averaged across seven studies, rang- this same time his mother stated that she count and liver function. ing from 25 to 80%).2-8 In 1973, Carlson and believes he started to use alcohol and drugs Modest improvement in intrusive and hyper- Goodwin observed 20 manic-depressive heavily, although she did not know what type sexual behaviors allowed for the discontinua- patients and concluded that a manic episode or how often he used them. She denied any tion of the one to one sitter, but continued sub- has three stages, starting as heightened sexu- other mental illness or substance abuse in optimal response led to transition from risperi-

[page 28] [Mental Illness 2016; 8:6546] Case Report done to quetiapine on hospital day eight. On mania.2 Volavka and colleagues found that 1990. the 13th day of his hospitalization, the patient bipolar women were more likely than men to 2. Allison J, Wilson W. Sexual behavior of voiced that he felt like he was a woman. He engage in sex with IV drug users and with part- manic patients: a preliminary report. stated that he heard voices telling him that he ners who had AIDS.15 Meade and colleagues South Med J 1960;53:870-4. was a beautiful woman, and he asked to speak found that patients with co-occurring bipolar 3. Carlson G. The stages of mania. Arch Gen with a doctor as soon as possible about getting and substance abuse exhibited high-risk Psychiatry 1973;28:221. gender reassignment surgery. He continued to hypersexual behaviors that increased their 4. Leff J, Fischer M, Bertelsen A. A cross- voice feeling like a woman for two more days. risk for HIV.16 A literature review did not yield national epidemiological study of mania. He also began to wear bright pink lipstick and any studies of manifestations of hypersexuali- Br J Psychiatry 1976;129:428-42. dance and sing loudly. ty in homosexual patients. Further study into 5. Loudon J, Ashworth C, Blackburn I. A study On the 15th day of his hospitalization, his the frequency and characteristics of hypersex- of the symptomatology and course of symptoms of mania remained uncontrolled, uality in patients with co-morbid ampheta- manic illness using a new scale. Psychol valproic acid extended release was increased mine abuse and mania may help to elucidate Med 1977;7:723. to 2000 mg nightly, and quetiapine was cross- any unique risk factors in this population. 6. Carlson G, Strober, M. Affective disorders titrated to perphenazine. By the 23rd day of his Our case illustrates hypersexuality and gen- in adolescence. Psychiat Clin N Am hospitalization, with valproic acid levels of 88 der dysphoria resolving with adequate mood 1979;2:511-26. mcg/mL, he no longer had any hallucinations stabilization. Perhaps mood stabilizers, and in 7. Clayton P, Pits FN Jr, Winokur G. Affective or paranoid ideation, was no longer hypersex- particular valproic acid, have a special role in disorder: IV. Mania. Compr Psychiat ual, did not have feelings of gender dysphoria, treatment of mania marked by hypersexuality. 1965;6:313-22. and was much improved in his ability to con- It is important to note that the efficacy of val- 8. Winokur G, Clayton P, Reich T. Manic verse rationally. He was discharged home on proic acid in this case may be due to its effect depressive illness. St. Louis: C.V. Mosby; valproic acid extended release 2000 mg nightly, on antipsychotic augmentation as well as its 1969. perphenazine 6 mg twice daily, and zolpidem 5 mood stabilizing properties. A review of treat- 9. Carlson G. The stages of mania. Arch Gen mg for insomnia. ing inappropriate sexual behavior in people Psychiatry 1973;28:221. with dementia has proposed several possible 10. Angrist B, Gershon S. Clinical effects of pharmacologic agents including antidepres- amphetamine and l-DOPA on sexuality sants, anti-androgens, estrogens, antipsy- and aggression. Compr Psychiat Discussion and Conclusions chotics, GnRH analogues, cholinesterase 1976;17:715-22. inhibitors, antihistamines, beta-blockers, anti- 11. Chakrabarti N, Sinha VK, Parial A. The patient presented in this case report fungals, and diuretics. No clear evidence Secondary gender identity disorder - a had a manic episode marked by hypersexual emerged to support use of one particular case report. Indian J Psychiat 1999;3:257- behavior that progressed through at least two agent.17 Patients with Kleine-Levin syndrome, 9. of the three stages of mania which were a disorder marked by hypersexuality, have 12. Habermeyer E, Kamps I, Kawohl W. A case described by Carlson and Goodwin; sexual been treated with mood stabilizers, but no of bipolar psychosis and transsexualism. thoughts and activity as demonstrated by his studies have demonstrated a significant bene- Psychopathology 2003;36:168-70. inappropriate sexual behavior towards staff fit of mood stabilizers alone.18 13. O’Gorman EC. The effect of psychosis on and sexual delusions of gender dysphoria. This Hypersexuality is an accepted symptom of gender identity. Br J Psychiatry episode of mania was not only characterized by mania, but more subtle forms may be easily 1980;136:314-5. hypersexuality, but also disorganized behavior missed when screening patients. For the 14. Mayer C, Kapfhammer HP. [Coincidence and thought, delusions of rectal bleeding, and patient presented here, hypersexuality was the of transsexuality and psychosis]. mood symptoms of euphoria. It is uncertain if most pronounced symptom that helped to Nervenarzt 1995;66:225-30. [Article in the patient’s amphetamine use exacerbated guide his treatment. Before the patient began German] the hypersexuality that this patient displayed, experiencing overt hypersexuality, it was 15. Volavka J, Convit A, Czobor P, et al. HIV or induced the episode of mania. Given the unclear to the physicians if the patient was seroprevalence and risk behaviors in psy- patient’s inability to express exactly when he having a manic episode or amphetamine chiatric inpatients. Psychiatry Res used amphetamine, the uncertainty of how induced psychosis. When the treating physi- 1991;39:109-14. much he used, and his mother’s ambiguous cians recognized hypersexuality as a symptom 16. Meade C, Graff F, Griffin M, Weiss R. HIV description of his psychiatric history, it is of mania, they decided to add a mood stabilizer risk behavior among patients with co- unclear if the patient had had prior manic to his treatment that ultimately resulted in his occurring bipolar and substance use disor- episodes without the use of amphetamine. recovery. Hypersexuality can cause significant ders: Associations with mania and drug This case adds to the current knowledge of distress to patients in their relationships, as abuse. Drug Alcohol Depend 2008;92:296- hypersexuality in manic patients, particularly well as expose them to substantial risk of com- 300. the materialization of gender dysphoria in a municable disease. Continuing research may 17. Joller P, Gupta N, Seitz DP, et al. Approach patient with comorbid amphetamine abuse. help guide psychiatrists and primary care to inappropriate sexual behaviour in peo- A limited number of prior studies have physicians to both recognize the symptom ple with dementia. Can Fam Physician looked at the differing presentations of hyper- early and treat appropriately. 2013;59:255-60. sexuality in specific populations, and a dearth 18. Miglis MG, Guilleminault C. Kleine-Levin of descriptions exist to relate to this substance syndrome: a review. Nat Sci Sleep misusing homosexual male. In their 1960 2014;6:19-26. study Allison and Wilson studied the sexual References behavior of 24 manic patients and found that women were more promiscuous then men, but 1. Goodwin F, Jamison K. Manic-depressive both sexes had increased sexual intercourse in illness. New York: Oxford University Press;

[Mental Illness 2016; 8:6546] [page 29]