New onset gender dysphoria in bipolar affective disorder - A case series

Abstract

Gender confusion in the context of mania is very less frequently described in the literature. The actuality of a primary psychiatric condition in gender identity complaint has significant bearing on the applicable operation and prognostic. This case series describes cases of bipolar affective complaint presenting in a manic occasion whose mania was marked by hypersexuality and the desire to be of opposite gender. Both of these symptoms resolved with treatment of the manic occasion. Case 1 describes a 17-year-old male presenting with an episodic illness, with current manic episode. He is currently interested in boys and has started enjoying feminine activities. Upon treatment, his symptoms showed improvement. Case 2 describes a 22-year-old gay male, with a total duration of 7 years, current episode mania. Now, he is considering himself a lesbian and feels he is mentally a modern female. After 4 months of treatment, there was significant improvement in his complaints and he stopped cross-dressing as a female. Case 3 shows a 21-year-old female, with manic episode. After 1 month, the patient began acting and speaking more like a boy. The patient has shown improvement while taking lithium 900 mg, divalproex sodium 1000 mg, risperidone 6 mg, and chlorpromazine 150 mg. Gender dysphoria occurring along with a psychotic episode and resolving with management of the primary psychiatric disorder are rarely recorded. The central issue in similar cases is a proper workup and diagnosis. Psychiatrists should be aware of this scenario so that proper treatment strategies for gender incongruence can be planned and not be brushed aside as “just another symptom.”

Despite descriptions of hypersexuality in mania, there have been only few studies on the matter. The data are largely deduced from observational studies published between 1969 and 1979. Hypersexuality was observed in 57 of manic cases.[1,2,3,4,5,6,7] Gender confusion in the environment of mania is indeed less frequently described in the literature than hypersexuality. Chakrabarti et al.[8] described a case of a male patient who exhibited problematic provocative behavior as well as expressed a desire to be female and had a delusion that he was married to a man. He ultimately showed improvement with lithium and electroconvulsive therapy (ECT). In some case reports, mania precipitates the desire to be another gender, while in others, the manic occasion made these solicitations less pronounced.[9,10,11] The actuality of a primary psychiatric condition in gender dysphoria complaint has significant bearing on prognosis. This case series describes cases of bipolar affective disorder (BPAD) in mania marked by hypersexuality and the desire to be of opposite gender. Both symptoms resolved with treatment of the manic occasion. The case series stresses the significance of ruling out underpinning psychotic complaint in a case manifesting with gender identity complaint.

CASE REPORTS

Case 1

A 17-year-old male presented to us with an episodic illness of 2 years with complete inter-episodic remission. The patient was his usual self 3 months back when he was in 11^th standard. Before the onset of his illness, he identified himself as a boy and was sexually attracted towards his female classmates. He had similar interests like his other male classmates and dressed in a masculine manner. His mother started noticing changes in his behavior as he would be unable to sleep, not going to school, dancing in a feminine manner, wearing his sisters’ clothes, and getting angry with family members for no reason. He always felt energized and plans to become a celebrity. Previously he was attracted to females, but now he is interested in boys, as he feels like touching them inappropriately. He started enjoying feminine activities like watching daily soaps and applying make-up. As he has shown attraction towards boys, because of this behavior, his schoolmates pass critical comments on him, due to which he does not want to go to school. He explained his fantasy that his prince charming would come riding on a horse to marry him. On confronted for wearing his sister’s clothes, he would say there is no discrimination in clothes. Past history of mental illness included an episode 2 years back of two months duration with features suggestive of a manic episode with psychotic symptoms. He talked about opening a salon during that episode but expressed no desire to be a girl. He was started on tablet olanzapine 10 mg in divided doses after which his complaints resolved over the course of 3 months. Family, birth, and developmental history of major mental or physical illness were uneventful. He was an average student studying in class 11 when he was brought to our hospital. He had normal external male genitalia, bilateral testicular sensation, and secondary sexual characters. Mental status examination revealed an unkempt, untidy, and restless individual with an effeminate manner and female gestures, though he was dressed in a bright colored shirt and trousers. He had loud overabundant speech, elated affect, and flight of ideas. He was under no delusion regarding his existing sex. He knew that he was a male and addressed himself by his true name. But he started expressing wishes to undergo sex-reassignment surgery after finishing his school. A diagnosis of BPAD, present episode manic with psychotic features (second episode) with secondary gender dysphoria was made. He was started on olanzapine 10 mg twice a day and injectable haloperidol as needed for agitation. On the 10^th day of his hospitalization, his symptoms remained uncontrolled, valproate was added, increased to 1000 mg nightly. He was discharged as he showed improvement on YMRS rating scores on valproate extended release 1000 mg/day and olanzapine 20 mg/day. After receiving treatment for around 2 months gradually he started dressing up as a male like his previous self and he also started having sexual attraction towards female again.

Case 2

A 22-year-old male, 12^th pass with a total duration of illness of 7 years, episodic course with complete interepisodic remission. He presented with complaints of irritable mood, overtalkativeness, having big false claims, overspending, disturbed sleep, and overgrooming like girls since 3 months. As he became conscious of himself, he already knew that he was a male and was attracted to females till 17 years of age, due to which he considered himself to be heterosexual. But now, for five years, he started considering himself a homosexual and feels he is mentally a modern female who cannot adjust in the conservative Indian family. His mother has reported that for 3 months, the patient would be seen doing makeup a lot and would buy clothing of women. As per the patient, he feels mostly irritated, but as soon as he does makeup, he feels good and lasts for some time until he has makeup and again becomes irritating. On the contrary, he had never spent money on other things. Sometimes mother noticed that someday, he would overgroom himself and changes clothes two to three times a day but last for around 10–11 days per month; sometimes, he would not take a bath for 15 days. The patient considers himself as he does not have freedom, due to which he does not interact much with family and likes to stay alone mostly. When asked regarding his future plans, he would aspire to settle down abroad as there is more acceptance of transgender persons in foreign countries. And he also expressed wishes to undergo gender re-assignment surgery in the United States. After detailed assessment and resolution of these complaints in between the episodes, he was started on medications. A diagnosis of BPAD, presents episode manic with psychotic features with secondary gender dysphoria. He was started on sodium valproate 1000 mg/day and olanzapine 10 mg/day. After 4 months of treatment there was significant improvement in his complaints and he stopped cross-dressing as a female.

Case 3

A 21-year-old female, 10^th pass, presented to the psychiatry outpatient department with a total duration of illness being 6 months that had an acute onset, a continuous and progressive course, and talking to oneself. In her premorbid self, she always identified herself as a woman and had romantic interests towards her male friends. She got married recently with one of her friends before the onset of her illness against the wishes of her family. As per the informants, there was alleged history of physical violence from her in-laws family. After the onset of her illness, on occasions, she could be heard singing loudly over terrace. The patient would exhibit aggressive and abusive behavior, would frequently change her clothes, would repeatedly look in the mirror, would worship God three to four times per day, would visit a temple two to three times per day, would have increased energy, would need less sleep, would claim to be a goddess, and would gesture as if she were one. On Lithium 900 mg, six sessions of modified ECT, and risperidone 8 mg, she showed a partial response. After one month of treatment, the patient began acting and speaking more like a boy, shaved her long hair to look like a boy, and stopped wearing make-up. She also asked her parents to buy her shirt trouser. She started having attraction towards female staff in the hospital and would try to touch the female staff inappropriately at times. She also started expressing her wish to undergo sex change surgery in the near future. When her parents and siblings questioned her, she would become agitated and aggressive towards them as well as overly talkative, have less need for sleep, and engage in more goal-directed activity. The patient has shown improvement while taking the medications lithium 900 mg, divalproex sodium 1000 mg, risperidone 6 mg, and chlorpromazine 150 mg. Her symptoms subsided over a period of 2–3 weeks.

DISCUSSION

Gender dysphoria in the context of mania is rarely reported in the literature. The descriptions are largely in the context of acute symptomatic states that resolved with improvements in manic symptoms.[8,9,12] Considering the upbringing of our discussed patients above, where discussions about gender dysphoria are considered taboo, manic disinhibition was probably the only hope for them to be able to voice their wishes. The confidence and psychomotor energy associated with mania might have provided them with the impetus to go ahead with their plans to change their dressing sense and lifestyle.

Our cases illustrate hypersexuality and gender dysphoria resolving with adequate mood stabilization. Perhaps mood stabilizers, and in particular valproate, have a special role in treatment of mania marked by hypersexuality. It is important to note that the efficacy of valproic acid may be due to its effect on antipsychotic augmentation as well as its mood stabilizing properties.[13]

Some of the complexities of the case histories have been highlighted like lack of awareness which can lead to social isolation, stigma of the patient, causing school refusaland ultimately poor academic performance. At times polypharmacy needs to be done to control the symptoms in severe cases.

Gender dysphoria occurring along with a psychotic episode and resolving with management of the primary psychiatric disorder are rarely recorded. However, most case reports of secondary gender dysphoria show associations with schizophrenia. From India, there is one case report of a 20-year-old rural male who developed transsexualism following an acute psychotic episode in a case of schizophrenia.[14,15] Literature regarding the occurrence of secondary gender dysphoria in affective disorders is scarce, which is the uncommon feature of this case series.

CONCLUSION

Gender incongruence symptoms in the setting of mania can also be an unmasking of underlying long-lasting concerns, which have been stifled by society. Psychiatrists should be aware of this scenario so that proper treatment strategies for gender incongruence can be planned and not brushed aside as “just another symptom.”

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.