What is PSSD: Causes, Symptoms, Diagnosis, Treatments
What is PSSD?
Post-SSRI sexual-dysfunction (PSSD) is an iatrogenic syndrome (induced in a patient by the treatment) that consists of a group of symptoms that occur after stopping Selective serotonin reuptake inhibitors (SSRIs), Norepinephrine Reuptake Inhibitors (SSRI’s, SNRI’s), and Tricyclic antidepressants (TCA’s).
Some patients develop sexual side effects on antidepressants which either remain in full or don’t resolve completely when the drug is stopped. For others, the condition only appears when they stop the medication or begin to reduce the dosage.
PSSD affects both men and women. It can happen after only a few days of exposure to an antidepressant and can persist for months, years, or indefinitely. There is no known cure. PSSD gained official recognition after the European medical agency concluded that PSSD is a medical condition that persists after discontinuation of SSRI’s and SNRI’s.
How common is PSSD?
It isn’t known how many people regain 100% of their original sexual function and sensation after using an antidepressant. Based on the available data, PSSD may be quite common.
The condition can vary in severity between individuals. Some people may not realize they are suffering from it. They might have had sexual side effects while on an antidepressant which seemed to resolve when they stopped, but they still notice that their sexual function isn’t the same as it used to be, or that sexual activity feels different.
For example, a patient can find that they can now achieve orgasm after previously being unable to do so while on the medication, but it now feels weaker compared to before using the antidepressants. As they are no longer on the drug, they might think they are imagining it or that it must be due to another reason such as a relationship issue.
PSSD can be extremely distressing to those affected. It can lead to marriage break-up, job loss, and suicide. But for some sufferers, the loss of sexual desire means they are no longer interested in sex and are unconcerned that they have the condition.
There is currently no way of determining who will develop PSSD when the drug is stopped or any way to actively prevent it. Stopping an antidepressant gradually (tapering) does not prevent the problem. There is no evidence that adding another drug to an antidepressant to combat sexual side effects eg. bupropion (Wellbutrin) will prevent PSSD when the antidepressant is stopped.
Examples of drugs that can cause PSSD are:
- Escitalopram (Lexepro)
- Desvenlafaxine (Pristiq)
- Duloxetine (Cymbalta)
- Levomilnacipran (Fetzima)
- Venlafaxine (Effexor XR)
- Citalopram (Cipramil)
- Dapoxetine (Priligy)
- Escitalopram (Cipralex)
- Fluoxetine (Prozac or Oxactin)
- Fluvoxamine (Faverin)
- Paroxetine (Seroxat)
- Sertraline (Zoloft or Lustral)
- Vortioxetine (Brintellix)
What are the symptoms of Post-SSRI sexual-dysfunction (PSSD)?
PSSD symptoms include:
- Decreased libido
- Decreased or loss of nocturnal erections
- Delayed or inability to orgasm (anorgasmia)
- Erectile dysfunction and decreased vaginal lubrication in women
- Pleasureless, weak or “muted” orgasms
- Premature ejaculation
- Reduced genital sensation or genital anesthesia
- Reduced response to sexual stimuli
- Reduced nipple sensitivity
- Flaccid glans during erection
Some patients experience a noticeable reduction in tactile sensation – genitals feel like they were exposed to an anesthetic. Others notice a reduction in sexual sensation.
Orgasm is experienced with a decreased or loss of pleasurable feeling, often referred to as a pleasureless or muted orgasm. There can also be noticeably weaker muscle contractions. Cases of premature ejaculation after stopping an SSRI have also been reported.
Recently, accumulated data from numerous case-reports suggest additional non-sexual symptoms that include:
- Anhedonia
- Apathy
- blunted affect.
How do you know if you have PSSD?
There is no simple test to diagnose PSSD. A diagnosis is made by considering several factors including medication history, onset and profile of the symptoms, and by eliminating other possible causes. Diagnostic criteria were published in 2021.
Quantitative sensory testing (QST) of the penis routinely detects reduced sensitivity in male PSSD patients, but it’s not a widely available test.
While PSSD can often result in lower than normal testosterone levels, this is not responsible for the condition. Restoring hormone levels back to normal with medication fails to resolve the problem.
PSSD is often misdiagnosed as a psychological problem when it is actually pharmacological in origin. Antidepressant sexual side effects are in no way related to depression or any other mental health disorder.
Does PSSD go away?
PSSD is considered currently as a permanent iatrogenic damage, there is no approved treatment or any cure for it. Exposure (even by one single pill), and can last indefinitely after the toxin is withdrawn.
While some cases of PSSD involve sexual side effects that remain completely unchanged when the drug is stopped, there are a number of people who find that their sexual function improved after stopping the SSRI, but it isn’t the same as it used to be. Some of them remain a long way from their pre-drug baseline and fit a typical case of PSSD, but others seem to return to what could loosely be described as near normal.
Unlike some of the more severe cases, these people generally report being able to engage in normal or reasonably normal sexual activity, but nevertheless, something isn’t the same. They can have less interest in sex or find it more difficult to become aroused. Orgasms are sometimes weaker. There can be a sense that sex doesn’t feel the same as it used to – something indefinable seems to be missing.
The fact that their sexual function showed a substantial improvement when the antidepressant was stopped leads them to assume that the drug is no longer involved and that any remaining deficiency must be due to something else, despite the fact that they had completely normal functioning immediately prior to starting the medication.
Even those who deny any persisting effects and claim that their sexual function completely returned to normal after stopping an antidepressant will sometimes admit that on reflection, it isn’t quite the same.
Some of those affected try to make sense of this by assuming that it must be related to other aspects of their health or other things going on in their lives. They may not even regard themselves as having a significant sexual dysfunction, just a reduced interest or enjoyment of sex. Those who have been on an antidepressant for a while may assume that it is a normal part of life.
In many hospitals, treatment of PSSD is dependent on which symptoms you are suffering from and often include a combination of medical and behavioral components and are tailored for the individual patient.
