What is PSSD? Post SSRI Sexual Dysfunction and How To Manage PSSD?

What is PSSD? Why does it happen? Who is more likely to get it? And how do you treat it? In this video, I’m going to go over all of these questions.

How is PSSD defined?

PSSD has been defined in 2022 as an individual who one has taken an SSRI, either Prozac, Zoloft, Lexapro, Celexa, et cetera. And has had a long lasting change in general sensation, even after treatment has stopped. That’s a pretty broad definition.

That definition requires that there was no history of sexual dysfunction (similar to this) prior to taking the medication. And there should be no other meds that can better account for these symptoms, and no medication or substance misuse can also account for the symptoms.

PSSD symptoms include any type of sexual dysfunction, including genital numbing, pleasure-less or weak orgasm, decreased sex drive, erectile dysfunction, or premature ejaculation.

Others have described some symptoms, such as inability to feel certain emotions, skin numbness, cognitive slowing, other sensation disturbances, depersonalization, changes in menstrual cycle and lack of pleasure in doing things.

Patients have described their lives as being completely ruined as if they’re now living in a black and white life, and it just suddenly switched. They also describe a world without love, passion, or excitement. The sex lives for many is a core component of wellbeing, positivity, vibrancy, fulfillment and joy. So obviously it’s a major component of one’s life.

What is the rate of PSSD?

The rate in which PSSD occurs is unknown, partially because there are no studies that looked at it directly. Many scientific articles refer to there being case reports of it. Meaning and implying that it’s not very common.

If I were to put a number on it, I would say it’s less than 2% of people who take SSRI, but given that there’s millions of people out there who take SSRI’s, that’s kind of a big deal. There’s a Reddit PSSD forum that has over 6,000 members on it.

Whenever you get a relatively uncommon symptom with many confounding potential confounding variables. You’re going to definitely get some controversy around it. Especially, because we don’t know exactly why it happens. As a result, people who have experienced this are feeling that they’re not being heard, they’re being invalidated or they’re being overlooked. Or even worse, they’re told that it’s not happening because of the medication.

Although it’s not common, that doesn’t mean it’s impossible to occur. And consequently people then argue about whether or not it exists. I do believe it exists because we don’t know everything there is to know about medicine. And we definitely need to learn from their experiences so we can tell other people about it too.

What is well-known is that close to 100% of people who take SSRI’s have some degree of genital sensory change within 30 minutes of taking them. And in fact, some people even take these medications– certain individuals take them– for performance enhancement, to improve their stamina sexually.

Although it’s very difficult to imagine something causing side effects for more than three months after it stopped. That’s not completely unheard of. Both finasteride and retinoids, they both are well known to cause general anesthesia and decreased libido after they’ve been stopped. And also medications in the anti-psychotic category can cause tardive dyskinesia. And even after you stopped them, the tardive dyskinesia can continue to perpetuate. Also we understand and acknowledge the fact that alcohol can have effects on sleep for up to a year afterwards and same with the antidepressants that can also cause REM suppression that persists even after stopping it.

What could be the biologic reason for why it happens?

There are a few theories as to why it happens. One could be the epigenetic gene expression of the 5-HT1a receptor. It could also affect the protein expression of ACE2. If ACE2 is affected, that affects the ability to degrade that vasoconstricting hormone called angiotensin-2 to angiotensin.

People also say that it could be because it changes the resting potential of neurons or that it has an effect on estrogen and testosterone production. However, there are some people who have no changes in estrogen and testosterone production yet have PSSD and vice versa, thus makes it very difficult to discern what is the true underlying cause of this?

Furthermore to complicate matters even more, even if there’s an underlying biologic basis for it, and then somebody develops psychologic reasons for worsening of sexual dysfunction, that can also perpetuate the issue. Say you have some sort of sexual dysfunction during the use of SSRIs, then you lose your confidence in yourself because of some insecurity regarding sexual performance, this could make it very easy to have a fear of failure about worsening sexual performance and continue to perpetuate the issue. Even though there was an initial biologic reason, that’s not the only reason for it now for it to continue to go onward.

What have been my experiences with this professionally? I personally have not had a patient who had seemed to meet the criteria for PSSD where they had no history of any sexual dysfunction. And then the sexual dysfunction was experienced for more than three months after stopping the offending medication. I’ve definitely had patients report ongoing on and off struggles with sexual issues that could have been worsened by SSRIs. We would come off the SSRIs, and the sexual issues would return to their previous rate of occurrence within days to weeks afterwards.

Is it common for people who use or go off SSRI’s? It’s most common in people who are taking SSRIs? I have not had any patients who had no sexual side effects from SSRIs, then experienced new sexual side effects after stopping the medication. So usually there’s some warning sign that they’re having sexual side effects while on SSRIs, and it continues to perpetuate afterwards.

Also keep in mind within the SSRIs, certain medications like paroxetine or Paxil seem to be more prone to these types of symptoms. According to one study Paxil was found to induce sexual dysfunction at 75% followed by citalopram at 28.9%.

What do you say to patients about this? My guiding principle is that the meds are really an option of last resort to begin with. They’re not perfect. They have a lot of side effects and we go over the side effects before taking them. I consider SSRIs, as an option last resort because the original symptoms of depression or anxiety were so severe that you didn’t want to live with them. They became unmanageable. But unfortunately, these medications are very clunky and have their own side effects too.

For the vast majority of patients, any experienced sexual dysfunction would return to normal within a few days after stopping the medication, but you should know about the potential for it to be persistent longterm.

Given the regularity of sexual side effects from these medications, I like to take a sexual history by asking a number of questions pertinent to sexual functioning before we start so that we can understand what are the– is the background rate of sexual dysfunction, any ongoing issues that we can address, right off the bat.

And not to let SSRI is off the hook, but there’s an incredible number of other factors that could contribute to one’s libido and sexual performance. So I’d say if there are some issues of sexual concern, I would say let’s try to optimize all these other factors to make any sort of contribution of the SSRIs as small as possible.

Are patients ever concerned about these symptoms? Yes, absolutely. Some patients are, it’s definitely a concern for people who have already had some difficulty reaching orgasm or have lack of sexual desire or, or have poor general response to sex.

Most patients have a general understanding or awareness that the medications can worsen these symptoms. And then they’re particularly mindful of it when it does worsen. The exception to that would be for those with premature ejaculation, the medication side effects could be considered somewhat of an added bonus for those individuals.

[00:07:23] Advice for management

Do you have any advice for people to manage PSSD? I would say, try to avoid it by using one of the medications with the lowest rates of sexual side effects, such as trintellix, remeron, viibryd, or wellbutrin.

Be on the early lookout for any side effects. If the side effects are occurring while taking the medication, try to switch to a different medication. I did read online that PSSD could occur with just one dosage of the medication, but I feel like that would be extremely rare.

So if the sexual side effects are occurring while taking the medication, try to switch to different medication that has a lower rate of sexual side effects if you do still need it or just do therapy.

There’s some thought that bupropion and busipirone could potentially reverse some of the side effects, but these are not a guarantee.

Also communicate with your sexual partner to try to capitalize on peaks of desire, if the issue is decreased libido.

Some patients have used Cialis and Viagra to try to compensate.

One study suggested that low power laser radiation photo therapy has been shown to have some promising results.

[00:08:21] Impact on mental health and quality of life

How might PSSD have a negative impact on one’s mental health and quality of life?

Being less depressed, but having sexual issues is no way to live. Sexual health is vital for people to live a full life. Sexual dysfunction can lead to difficulties in relationships and have significant effects on one sense of wellbeing and vitality. In studies physicians have been shown to underestimate the importance of sexual health and sexual side effects of medications, when compared to patients.

[00:08:50] What needs to be done to further understand and prevent this from happening to more people?

What needs to be done to further understand and prevent this from happening to more people?

First of all, we need to do more research.

You can try to avoid it entirely by not taking any medications and doing therapy or other non-medication type of treatment option like alpha-stim, for example.

A patient could do a trial of a non-serotonergic medication option to try to see what is the background rate of any sort of sexual dysfunction, if any.

Also, they can try to focus on sexual health that they’re are in more control of in the short term, such as rekindling physical intimacy besides intercourse and emotional connection.

They need to recognize the symptoms of sexual dysfunction while on the medications and discuss alternatives.

They need to recognize that not all sexual issues are caused by the medications, so they should not be the reason that other maladaptive sexual behaviors are overlooked.

[00:09:36] What are other physician’s opinions?

What have other physicians said in online forums about PSSD? One has said that “it’s mostly a case of a very vocal minority, making it seem more prevalent than it actually is. There’s also no hard evidence that it actually exists.” Quote unquote, “all of the studies that I’ve reviewed have had either structural issues in the study themselves or confounders.”

Another person has said “my opinion is that people who complain about it likely I’ve had true sexual dysfunction during SSRI therapy that ended up turning into a psychological sexual dysfunction. And that’s what persisted after the SSRI was discontinued.”

Another individual has said “I’ve used SSRIs extensively for over 22 years of practice and never saw it.”

another has said “it’s a post hoc fallacy. Assuming any proceeding event caused any later noticed event, they developed organic and or somatic / psychological sexual dysfunction during or after the SSRI.”

So you can clearly see the type of tone that other physicians have about PSSD. That’s probably why this group of people is so vocal about this because it is a) very debilitating b) people don’t think it exists c) people attributed to other reasons.

I think for all of these reasons, we need to start to listen better to our patients, and start to learn from them, even if there’s a side effect that has rare, listen to their concerns about it and tell other patients about it too, so that if they do have that experience, at least they’re aware of it and know what the early signs are, and they can do something about it early.

I hope that this was helpful in learning about PSSD what it’s about how it’s caused and what you can do about it.

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