Skoptic Syndrome: The Treatment of an Obsessional Gender Dysphoria with Lithium Carbonate and Psychotherapy

Abstract

Cases of body image pathology are often misdiagnosed. Recognition of the obsessional annoyance with body image, especially with primary and secondary sex characteristics (skoptic syndrome), is important in making a differential diagnosis with other psychiatric and gender identity disorders. We have reported the successful use of lithium carbonate in treating two cases of skoptic syndrome. The initial low dosage (600 mg./day) resulted in dramatic reversal of obsessional thoughts of self-mutilization and self-castration. Increased dosages (900 mg./day) are still well below those usually used for manic-depressive illness. Our choice of lithium carbonate was prompted by our experience in successfully treating other forms of sexually related dysphorias at low doses, its ability to act rapidly, and the minimal side effects. These changes have been dramatic and lasting. In addition, there was marked lessening of dysthymia and intense anhedonia manifested by severe isolation, listlessness, and apathy. We believe that these cases are important to report in order that psychotherapists make better differential diagnoses of psychiatric disorders related to body image pathology and gender identity disorders. We also feel it is important to report a medication which was found effective in reducing the threat of self-mutilating behavior and making patients more receptive to psychotherapy. These cases increase our understanding of sexually obsessive and compulsive drives and some methods which have been found efficacious in reducing these symptoms.

Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder

“…Generally, both clinics believe that those adolescents with higher levels of psychopathology, less gender dysphoria, and/or more recent onset of their wish for sex reassignment should be followed over a period of time in order to treat the more obvious psychopathology (e.g. depression, psychosis, body dysmorphic disorder) and tosee if treatment of the psychopathology will lead toa reduction in the wish to proceed to SRS (see case reports of change in wish for SRS with treatment of comorbid psychopathology (Caldwell & Keshavan, 1991;Coleman & Cesnik, 1990;Marks & MataixCols, 1997;Puri & Singh, 1996).…”

A scoping review of research literature on eating and body image for transgender and nonbinary youth

“…ED prevalence was greater than expected based on the observed prevalence estimates in their respective monoracial groups United States Cibich and Wade [ 56 ] N = 1 Eating Disorder One adolescent trans man patient Case report BMI, number of objective binges, subjective binges, and purges per week, Eating Disorder Examination Questionnaire, Depression Anxiety and Stress Scales-21, Clinical Impairment Assessment None Patient viewed restrictive eating as a way to de-emphasize the feminine fat distribution and obtain a masculine physique. Client reduced ED behaviors and reduced the frequency in which he compared himself to masculine males, and reduced his global eating disorder score though cognitive behavioral therapy Australia Coleman and Cesnik [ 50 ] N = 2 Body Image Case 1: 23-year old man Case 2: 23-year-old male Case study Tennessee Self-Concept Scale, Minnesota Multiphasic Personality Inventory, Beck Depression Inventory, Hamilton Depression Scale, Hamilton Anxiety Scale, Brief Psychiatric Rating Scale N/A Lithium carbonate therapy may alleviate the intense obsessional thinking in some cases of gender dysphoria. There may be a biomedical correlate and associated psychopathology to the obsessional drive toward body alteration through hormonal and surgical means United States Cooney et al [ 57 ] N = 1 Eating Disorder 13-year-old trans man Case study BMI, hormone levels N/A The patient became motivated to lose weight after initial weight loss resulted in decrease in pre-op chest size.…”

“…Most were case studies ( n = 18) detailing one to five individual cases of gender dysphoria, eating disorders, body image and dissatisfaction, and body size using a mix of qualitative and quantitative data. The findings from these case reports focused on transgender patients and their outcomes of gender affirming medical treatment [ 30 , 48 , 49 ], psychotherapy [ 50 – 52 ], psychiatric care [ 53 , 54 ], eating disorder treatment [ 55 – 59 ], nutrition assessments [ 33 ], some combination of treatments (e.g., gender affirming medical intervention and eating disorder treatment) [ 60 ], or diagnoses (e.g., autism spectrum disorder, gender dysphoria, and eating disorder) [ 61 ]. Three case reports included detailed patient medical records [ 61 , 62 ].…”

Tenidap sodium decreases renal clearance and increases steady‐state concentrations of lithium in healthy volunteers.

“…In the United Kingdom lithium is currently approved for the prophylaxis and treatment of bipolar disorder, as well as the treatment of self-mutilating behaviour. The drug has also been studied in many other illnesses including cluster headaches [5], aggression in the mentally retarded [6], skoptic syndrome (an obsessional gender dysphoria) [7] and unipolar depressive illness [8,9]. Lithium has a low therapeutic index; therefore, factors which may influence its disposition merit consideration.…”