Journal of Affective Disorders 131 (2011) 364–367 Contents lists available at ScienceDirect Journal of Affective Disorders j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j a d Brief report Sexual behavior in women with bipolar disorder Marianna Mazza a,⁎, Desiree Harnic a, Valeria Catalano a, Marco Di Nicola a, Angelo Bruschi a, Pietro Bria a, Antonio Daniele b, Salvatore Mazza b a b Department of Neurosciences, Institute of Psychiatry and Psychology, Bipolar Disorders Unit, Catholic University of Sacred Heart, Rome, Italy Department of Neurosciences, Clinical Neurophysiology and Epilepsy Center, Catholic University of Sacred Heart, Rome, Italy a r t i c l e i n f o Article history: Received 18 August 2010 Received in revised form 5 November 2010 Accepted 5 November 2010 Available online 4 December 2010 Keywords: Sexuality Bipolar disorder Sexual behavior Hypersexuality Women a b s t r a c t Introduction: There is a lack of studies regarding sexuality and sexual behavior in women with bipolar disorder. The aim of this study is to investigate sexual behavior in women affected by bipolar disorder in order to stimulate interest and debate in this area of care. Methods: Sixty women (30 BD I and 30 BD II) consent to participate in the study and were included in the sample. Moreover, sixty female healthy subjects without histories of psychiatric disorders were recruited as normal controls. Patients and healthy subjects were given the Sexual Interest and Sexual Performance Questionnaire, a questionnaire devised to explore various aspects of sexual behavior. Results: The results of the present study suggest an increase of sexual interest in patients with BD I as compared both with BD II patients and healthy controls. In women with BD I such increase of interest was detected on some items of section I of the Sexual Interest and Sexual Performance Questionnaire, in particular “Actual Value of Sexuality” and “Implicit Sexual Interest”, which implicitly explore sexual interest without overtly focusing upon sexual problems. Moreover, we observed a higher desired frequency of intercourse in women with BD I than BD II and a higher occurrence of repeated sexual intercourse in women with BD I than BD II. Conclusions: The main finding of the present study was an increase of sexual interest in BD I as compared with BD II female patients and normal controls. This result was detected when sexual interest was explored implicitly. Our study is limited by the small size of our subject groups. Further investigations on larger subject samples are needed to better clarify particular aspects of sexual behavior of BD patients. © 2010 Elsevier B.V. All rights reserved. 1. Introduction In patients with bipolar disorder (BD) excessive involvement in pleasurable activities including hypersexuality is a criterion for the diagnosis. Recently some researchers have suggested that hypersexuality be included as a criterion for juvenile BD as well. Hypersexuality may be primary and intrinsic to BD in youth, secondary and associated with it as the result of psychosocial influences or psychodynamic ⁎ Corresponding author. Institute of Psychiatry and Psychology, Bipolar Disorders Unit, Catholic University of Sacred Heart, Rome, Via Ugo De Carolis, 48 00136 Roma, Italy. Tel.: + 39 06 35348285; fax: + 39 06 35501909. E-mail addresses: marianna.mazza@rm.unicatt.it, marianna.mazza@rm.unicatt.it (M. Mazza). 0165-0327/$ – see front matter © 2010 Elsevier B.V. All rights reserved. doi:10.1016/j.jad.2010.11.010 factors, or due to general aggression and disruptive behavior (Adelson, 2010; Bakare et al., 2009). On the other hand, impairment in sexual function is frequent and underestimated in patients with mood disorders. A recent study (Dell'Osso et al., 2009) showed that life impairment in the sexual response cycle, including desire, excitement, and ability to achieve orgasm, was significantly more common in patients with mood disorders (Bipolar I Disorder and Unipolar Depression) compared with control subjects. Besides, increase in sexual activity and promiscuity was significantly more common in patients with BD versus the other two groups. There is a lack of studies regarding sexuality and sexual behavior in women with bipolar disorder. Patients with bipolar disorder warrant special consideration with regard to 365 M. Mazza et al. / Journal of Affective Disorders 131 (2011) 364–367 sexual health because the nature of the manic, or hypomanic, mood state is associated in some cases with sexually risky transmitted diseases (McCandless and Sladen, 2003). The aim of this study is to investigate sexual behavior in women affected by bipolar disorder in order to stimulate interest and debate in this area of care. 2. Methods Participants were recruited from June 2009 to December 2009 among female outpatients referring to the Bipolar Disorder Unit of the Department of Psychiatry of the Catholic University of Sacred Heart of Rome. Inclusion criteria were: 1) currently meeting DSM-IV criteria for bipolar disorder I (BD I) or bipolar disorder II (BD II); and 2) age 18 to 60 years. Participants were excluded if a diagnosis of mental retardation or documented IQ b70 was present. The Institutional Review Board approved the study; written informed consent was asked after a complete description of the study was provided to each subject. Sixty women (30 BD I and 30 BD II) consent to participate in the study and were included in the sample. Moreover, sixty healthy female subjects without histories of psychiatric disorders were recruited as normal controls. Control group was matched for age and educational level with BD I and BD II groups. Patients underwent a naturalistic treatment, with conventional antipsychotics (phenothiazines and haloperidol), atypical antipsychotics (olanzapine, risperidone, quetiapine, clozapine, and aripiprazole), both established mood stabilizers and new antiepileptic drugs (lithium, valproate, carbamazepine, lamotrigine, topiramate, oxcarbazepine, pregabalin, and gapabentin), antidepressants (SSRI, SNRI, NaSSA, and unspecific antidepressants). BD diagnosis was established by trained psychiatrists using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) (First et al., 1995). Patients and healthy subjects were given the Sexual Interest and Sexual Performance Questionnaire (Azzoni et al., 1987), a questionnaire devised to explore various aspects of sexual behavior. This questionnaire is composed of four sections. Section I implicitly explores the whole field of “interests” and “values” of the subject, without overtly focusing upon sexual life. The remaining three sections of the Questionnaire (sections II–IV) explicitly explore several aspects of sexual behavior. The questionnaire has been created for use in epileptic patients, particularly the ones with temporal lobe epilepsy (Daniele et al., 1997). Some years later, it has been revised and adapted to psychiatric patients, in particular patients affected by Schizophrenia, Schizoaffective Disorder or BD (Azzoni and Raja, 2004). The questionnaire consists of an introductory section including demographic and clinical data, a general section for both sexes, and a specific section for each sex. Items are designed to explore sexual desire, arousal, and performance, as well as the subject's sexual satisfaction. Attention is focused on peculiarities and deviation in sexual life, on the risk of contracting sexually transmitted diseases, and on the effects of psychotropic medications on sexual interest and sexual performance (Azzoni and Raja, 2004). 3. Results The results obtained by BD I and BD II patients on the “quantitative” items assessed by sections I–III of the Questionnaire are reported in Table 1. BD I patients have been compared with BD II patients and each BD group has been compared with control group. For each of the 11 items of sections I–III these comparisons between groups were made by means of the nonparametric Mann–Whitney U test. Parametric statistical methods could not be used, since the data were measured on an ordinal scale and the assumption of normal distribution of data was not met. The BD I group obtained significantly higher scores as compared with the BD II group on the items (1) “Actual Value of Sexuality”, (3) “Implicit Sexual Interest”, (5) “Desired Frequency of Sexual Intercourse” and (8) “Occurrence of Repeated Intercourse”. No significant difference between BD I and BD II groups was found for any remaining item of sections I–III. A similar pattern was observed in the comparison Table 1 Mean scores obtained by female controls (C), women with Bipolar I Disorder (BD I) and women with Bipolar II Disorder (BD II) on the items assessed by sections I–III. SR 1) Actual Value of Sexuality 2) Theoretical Value of Sexuality 3) Implicit Sexual Interest 4) Explicit Sexual Interest 5) Desired Frequency of Sexual Intercourse 6) Sexual Satisfaction 7) Actual Frequency of Sexual Intercourse 8) Occurrence of Repeated Intercourse 9) Duration of Sexual Intercourse 10) Sexual Orgasm 11) Dyspareunia SR: score range. SD: standard deviation. ns: not significant. 0–10 0–10 0–10 0–5 0–5 0–5 0–4 0–3 0–3 0–5 0–10 C BD I BD II p Mean ± SD Mean ± SD Mean ± SD BD I versus BD II BD I versus C BD II versus C 2.4 ± 1.7 4.1 ± 1.9 3.7 ± 2.2 2.8 ± 1.6 2.6 ± 0.5 2.8 ± 1.6 2.6 ± 0.8 0.6 ± 1.5 2.5 ± 0.3 3.1 ± 1.7 4.9 ± 2.5 4.3 ± 2.0 4.3 ± 2.0 5.6 ± 2.4 2.9 ± 1.5 3.9 ± 1.0 2.9 ± 1.6 2.8 ± 1.7 1.5 ± 0.6 2.6 ± 0.4 3.6 ± 1.3 5.0 ± 2.5 2.6 ± 1.9 4.0 ± 2.6 3.9 ± 2.3 2.7 ± 1.1 2.9 ± 1.2 2.7 ± 1.4 2.5 ± 0.9 0.5 ± 1.4 2.4 ± 0.7 3.2 ± 1.4 4.9 ± 2.0 .05 ns .03 ns .05 ns ns .02 ns ns ns .08 ns .003 ns .05 ns ns .10 ns ns ns ns ns ns ns ns ns ns ns ns ns ns 366 M. Mazza et al. / Journal of Affective Disorders 131 (2011) 364–367 between BD I group and normal controls. By contrast, no significant difference on any item assessed by sections I–III was observed between women with BD II and the control group. As for the “descriptive” items assessed by section IV, we considered the proportion of “yes” and “no” answers to the questions concerning the various “events”. Comparisons were made by means of the Fisher's exact probability test between the BD I group and the BD II group, and between each BD group versus the control group. For all items, no significant difference in the incidence of the relevant “events” was found between the BD I and the BD II groups, and between each BD group with control group. Menstrual disorders were reported by 34% and 25% of BD I and BD II patients, respectively. A stable sexual relationship was referred by 20% and 35% of the BD I and BD II patients, respectively. Intercourse was the prevalent sexual activity in 65% and 75% of the BD I and BD II patients, respectively. “Peculiarities” were reported by 3 BD I patients (usual viewing of pornographic movies). A decrease of libido after the beginning of treatment with AEDs was noticed by 3 BD I patients (treated with valproic acid) and 1 BD II patient (treated with oxcabazepine). 4. Discussion The results of the present study suggest an increase of sexual interest in patients with BD I as compared to both with BD II patients and healthy controls. In women with BD I such increase of interest was detected on some items of section I of the Sexual Interest and Sexual Performance Questionnaire, in particular “Actual Value of Sexuality” and “Implicit Sexual Interest”, which implicitly explore sexual interest without overtly focusing upon sexual problems. Moreover, we observed a higher desired frequency of intercourse in women with BD I than BD II and a higher occurrence of repeated sexual intercourse in women with BD I than BD II. On the other hand, no significant difference was observed between BD I and BD II groups on “Explicit Sexual Interest”, which overtly explores sexual interest. Furthermore, we could not detect any significant difference between BD I versus BD II groups and between both BD I and BD II groups versus normal controls for most aspects of sexual performance, including the actual frequency and duration of intercourse, frequency of orgasm, and dyspareunia. Finally, no statistically significant differences between BD I and BD II groups were found in the incidence of the various possible events assessed by section IV of the Questionnaire. Antipsychotics, lithium and antiepileptic medications have an effect in regulating hypersexuality (Carey, 2006), but in our sample there is not a significant correlation between increase of sexual interest and medication doses. As expected, we have observed a significant prevalence of manic symptoms in BD I women as measured by the Young Mania Rating Scale (Young et al., 1978) compared to BD II and controls (mean value ± standard deviation: 5.1 ± 1.2, 3.2 ± 1.4, and 1.5 ± 1.0, respectively; p = 0.05). Interestingly, there was a positively correlation between higher scores of “Implicit Sexual Interest” and more manic symptoms in BD I group, although it did not reach a statistical significance. Some authors outlined that there are gender-related differences in the prevalence, course and treatment response characteristics of mood disorders (Ozcan and Banoglu, 2003; Mazza et al., 2008; Halbreich, 2010). Nevertheless, in our sample laboratory tests for estrogen, free and total testosterone, and serum sex hormone binding globuline (SHBG) showed no significant difference between BD I, BD II patients and controls. Laboratory sleep disturbances have been described in BD patients (Murray and Harvey, 2010). It is well known that a reduced amount of sleep results in disinhibition, which is associated with hyperphagia, aggressive outbursts, and hypersexuality. In our sample an assessment of quality of sleep has been performed using the Pittsburg Sleep Quality Index (PSQI) (Carpenter and Andrykowski, 1998), but, although patients showed insomnia symptoms and altered sleep patterns, no significant difference was observed between BD I and BD II women. In summary, the main finding of the present study was an increase of sexual interest in BD I as compared with BD II female patients and normal controls. This result was detected when sexual interest was explored implicitly. Possibly, a tendency to minimize or deny the increased sexual interest in female patients with BD I could lead them to underreport this interest when it is explicitly explored. Probably the Sexual Interest and Sexual Performance Questionnaire could be useful to detect in BD patients a covert increase in sexual interest that could be correlated or reflect the presence of maniac symptoms. Our study is limited by the small size of our subject groups. 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