Transvestic Disorder,Obsessive Compulsive Disorder,and Bipolar Disorder in an Adolescent Male: Diagnostic Conundrums and Management Difficulties

Abstract

Transvestic disorder with comorbid obsessive-compulsive disorder and bipolar disorder (BD) is a rare presentation, with only 1 case report in available literature. It may be an arduous task to differentiate between the phenomenology of transvestic disorder and obsessive-compulsive disorder. We, herein, report the case of a 17-year-old boy who presented with complaints of cross-dressing which was difficult to be differentiated from sexual obsessions. He also suffered from BD that complicated the management.

Introduction

Transvestic disorder is described as experiences of intense sexual arousal from cross-dressing, as manifested by fantasies, urges, or acts, which cause clinically significant distress or socio-occupational impairment. Furthermore, often these clinical features are similar to the sexual obsessions observed in obsessive compulsive disorder (OCD). ¹ However, unlike transvestic disorder, patients with OCD rarely derive gratification from their sexual obsessions and often aim to minimize the obsessions by performing compulsions. The act of cross-dressing in transvestism is often followed by guilt, while cross-dressing in OCD is a compulsion to reduce anxiety. The clinical picture may be muddled further due to adolescent onset and presence of an affective disorder especially bipolar disorder (BD) which often hinders the utilization of serotonergic drugs beneficial for management of either transvestic disorder or OCD. The search of literature for transvestic disorder, with comorbid OCD and BD, yields only 1 case report till date. ² We, herein, present a similar case with transvestic disorder with comorbid OCD and BD and discuss the diagnostic and management challenges.

Case Description

A 17-year-old boy was brought with complaints of cross-dressing for 4 years and episodic mood disturbance for 2 years. He was temperamentally an easy child. However, his childhood was significantly impacted by financial difficulties and his father’s suicide 5 years ago. He lived with his mother, sister, and grandfather and had been an average student before the onset of illness.

He first wore his mother’s clothes at 13 years of age to satisfy his curiosity; derived sexual gratification by masturbating in clothes, but felt disgusted thereafter. But, he did not stop there and often cross-dressed, even wore female undergarments or imagined himself in female clothes and often watched transgender pornography. He fantasized himself in female typical roles, having a vagina and breasts and imagined to have intercourse with males. Eventually, his mother discovered his cross-dressing; he was reprimanded and asked to refrain from it. Nevertheless, his attempts to stop cross-dressing failed and he continued it secretly. His cross-dressing was more during mood states of boredom, stress, or while alone at home. The frequency of this behavior varied from 1 to 4 times/day. Very rarely, he was able to abstain for more than 24 hours. But he denied any desire to be a female and claimed to have a heterosexual orientation. He had poor sexual knowledge, which was mostly derived from Internet and pornography. Two years later, he suffered from a severe depressive episode for which a psychiatry consult was sought for the first time. The episode was characterized by persistent low mood, irritability, anhedonia, weakness, pessimistic thoughts, decreased sleep and appetite, decreased interaction with others, and reduced psychomotor activity along with reduced self-care. Within 6 weeks of treatment with antidepressants (initially escitalopram 10 mg/d for 2 weeks and later on paroxetine 25mg/d), he switched to opposite set of symptoms characterized by an increased talkativeness and often talked loudly, had reduced sleep, increased planning to study (which remained unproductive), and made ambitious plans about his future. His mood largely remained irritable, activity levels more than his usual, got aggressive without provocation, and often hurled abuses at family members. His appetite was also increased and often ate from outside. The diagnosis was revised to BD with severe mania without psychotic symptoms. Lurasidone up to 120 mg and olanzapine up to 30 mg per day were given sequentially for adequate duration along with sodium valproate 1,000 mg per day and clonazepam up to 8 mg/day. However, there was no improvement and therefore admitted for inpatient treatment. Eventually, he remitted after administration of 4 sessions of modified electroconvulsive therapy (with informed consent from his parents) and pharmacotherapy with lithium carbonate 800 mg/d, amisulpride 400 mg/d, and risperidone 9 mg/d. His cross-dressing reappeared after remission of mania and now he also exhibited inappropriate sexual behavior of touching and kissing mother/sister and even suddenly appeared undressed in front of them. He acknowledged sexual gratification from these acts but was also distressed and remorseful for his behavior. In view of his cross-dressing behavior and the new symptoms of inappropriate undressing in front of females in the family, he began to think that he would eventually have to undergo gender reassignment surgery. These thoughts of undergoing gender reassignment were very distressing for him. Ultimately, he made efforts to stop cross-dress on his own. He attempted to seek sexual gratification by watching heterosexual porn but failed to attain ejaculation/orgasm that further compounded his distress. He also had thoughts and images of naked girls in his mind which came against his will and were irresistible. Consequently, opinion was sought from another psychiatrist and a neurosciences center. Prior to presenting to us, he had suffered from 1 more episode of mania 6 months before index admission (induced by fluvoxamine 100 mg/d, which was started for management of OCD) and 1 episode of major depression (1 month before the index admission).

His mental status examination at time of admission revealed depressed mood, sexual obsessions (sexual thoughts, images, and impulses, which included thoughts and images of having sex with men), aggressive impulses (of blurting obscenities and sexual aggression), and masturbatory guilt. He was on sodium divalproex 1,000 mg/d, olanzapine 20 mg/d, and escitalopram 2.5 mg/d at that time and escalation of the dose of escitalopram to 5 mg/d led to hypomanic symptoms. We diagnosed him with BD, OCD, and transvestic disorder (with autogynephilia) and probably an exhibitionistic disorder. In view of poor response to various trials of psychotropics for the OCD and transvestic disorder, psychological interventions were emphasized upon. The later included psychoeducation, sex education, addressing expressed emotions, and orgasmic reconditioning therapy. However, it was difficult to engage patient in therapy. Eventually, supportive psychotherapy (muscular relaxation, resumption of hobbies, reassurance, and validation) was undertaken which resulted in some reduction of his cross-dressing and culmination of exhibitionism.

Discussion

Differentiating between paraphilic disorders like fetishistic transvestism and OCD with sexual obsessions is often difficult due to similar features in the form of recurrent sexual thoughts, urges, and behaviors. The thoughts (fantasies) and behaviors in transvestic disorders are often ego-syntonic and gratifying to the person during the process, although they later lead to feelings of guilt. The thoughts, urges, and images in OCD, on the other hand, are often ego-dystonic, distressing, and unwanted. The sexual behaviors (if any) are termed as compulsions, as they are primarily aimed at reducing anxiety due to the repeated thoughts. Many authors consider both these illnesses to be distributed along different dimensions of a spectrum of disorders rather than separate entities. ¹ This diagnostic conundrum is further complicated by comorbid affective disorders. The BD-OCD comorbidity has been well established. Amerio and colleagues ³ have reported the pooled prevalence of BD in OCD to be 18.35%. Similarly, paraphilic disorders have also been reported in a few cases of BD.^2,4,5 This comorbidity of OCD and paraphilias like transvestic disorder with BD not only lead to diagnostic but also therapeutic challenges.

Cross-dressing in the index patient started with typical features of transvestic disorder such as ego-syntonic, pleasurable sexual behavior often followed by guilt. But in due course of illness, the patient expressed symptoms which were akin to sexual obsessions and compulsions with ego-dystonic and anxiety-provoking content. Hollander and Wong ⁶ have described that such behaviors may be classified in lines of an OCD spectrum with true obsession on one end and paraphilias on the other. Similar evidence is also provided by response to serotonergic medication in both OCD and transvestism. But the situation is further complicated in patients who have comorbid BD and the utilization of serotonergic drugs may not be possible. The index case is somewhat similar to that reported by Galli et al, ² with multiple paraphilias, OCD, and BD. However, their patient responded well to fluoxetine therapy and psychological intervention. In another case of transvestism and BD, Ward ⁵ hypothesized that the mania was the catalytic event for initiation of transvestism and depressive episodes led to its maintenance which is partly true for the index case too. Further understanding of the index case may be arrived at psycho dynamically as described by Jon Meyer. ⁷ He proposed that perversions may be organized or borderline, that is, nearing a psychotic syndrome. The organized perversions are complex, evolved, neurotic-level pathological formations which are structured akin to a neurosis and are composed of preoccupations, elaborate, and conscious erotic fantasies which are central to sexual arousal and orgasm. Furthermore, the erotic behaviors express the text of the fantasies, and during the times of stress there is increased preoccupation with the fantasy and thus perversion. It is dissimilar from the borderline or near-psychotic syndrome wherein regression and disorganization occur and there is fetishistic cross-dressing that tends to lead to transsexualism eventually. Meyer further elaborated that in organized transvestism there is an abomination of fantasies which go in direction of seeking female hormones or in castration. Such patients are often intrigued by the process of undergoing sex change surgery, but do not want to adopt this in actuality. Hence, the index case, as per description provided by Meyer, bore resemblance to an organized transvestism and attempted to protect his bodily integrity.

A significant proportion of child and adolescents with BD have comorbid anxiety disorders, and OCD with sexual and aggressive obsessions are common occurrence. ⁸ The management implications for this group is that it has poorest treatment outcomes. ⁹

Lastly, treatment with antipsychotic agents especially those with anti-serotonergic profile such as second generation antipsychotic (SGA) like clozapine and risperidone have been hypothesized to be responsible for induction of obsessive symptoms. ¹⁰ The index case has also received risperidone as well as other SGAs for significant duration which could have possibly influenced the sexual and aggressive obsessions. The serotonergic reuptake inhibitors may cause a switch or worsening of the course of BD and data is limited for the utilization for CBT in patients with comorbid OCD and BD. ¹⁰ In the index case too, use of serotonergic medications was limited due to switch to hypomania and probably led to an increase in frequency of mood episodes. Also, the attempts to utilize systematic psychological interventions were impeded by the limited participation by patient.

To conclude, transvestic disorder in adolescence with comorbid OCD and BD presents unique diagnostic and management challenges. Presence of paraphilias adds an extra dimension to the OCD-BD spectrum and therefore needs to be researched further.