Sexual abuse of children in a patient with schizophrenia

Manuscript type : Case Report | Article Date : 2015/07/26

  • Autors

    1. Kholasehzadeh Golrasteh
    2. Nadi Sakhvidi Mohammad
    3. Ahmadi Nastaran
  • Abstract

    A 38-year-old woman with 2 sons after the second childbirth bleeding (uterine inertia) rejected her husband"s sexual demands. Then, she began to sexually abuse her children. The patient did not have any problem before the second child"s birth. There was no history of child abuse in her childhood. However, she had a family history of schizophrenia. After receiving diagnosis of schizophrenia, she was treated with daily antipsychotic. After being discharged from hospital the problems with her children decreased gradually and after almost 6 months, did not apply for sexual abuse of children. . . . . . . . . . . .
  • Description

    INTRODUCTION

    INTRODUCTION Schizophrenia is a puzzle within a puzzle and there is no single prescription for recovery. Emil Kraepelin considered that his life’s work had resulted merely in progress in understanding the psychoses, not a solu-tion. Schizophrenia can be considered as the most severe form of the psychiatric disorders with a prev-alence of 0.5–1 %. Early onset and chronicity of this disorder can increase its lifetime prevalence. Nega-tive symptoms and cognitive deficits are features that have a greater impact on personal, social, occupation-al and other important areas of functioning than de-lusions and hallucinations which appear in relapses.1 A proportion of patients with schizophrenia present with reductions in social, sexual, and motivational drives, the ability to experience and express emotions, and the ability to derive pleasures from physical and social activities. Social anhedonia results in social isolation and withdrawal from family and friends, and lack of intimate relationships, the latter being further complicated by the lack of sexual interest.2 There is a lack of range of emotions that patients with schizophrenia experience, both in terms of the variety of emotions and the depth of the feelings expressed. This presents as a restriction of facial expression, even when speaking about the experience of an emo-tion (e.g., patient tells the clinician about feeling sad-ness in an event without displaying sadness), lack of inflections of tone of the patient’s speech, and defect in expression of feelings through gestures and body language. Some of these patients appear to have a paucity of thought. Their communications with oth-ers are reduced to few simple ideas, and their speech is either restricted in content or to repetitions of the same concepts.3 Negative symptoms may be seen secondary to anti-psychotic treatment or due to other symptoms associ-ated with schizophrenia. Extrapyramidal side effects of these drugs imitate affective flattening. Antipsy-chotics may influence motivation by interfering with functions of the dopamine reward system. In addition sedation that can impair social interactions and be-haviors, may also be presented as negative symp-toms.4 Sex intercourse and sexuality are important parts of human being. Sexual behavior in the normal popula-tion has been well studied. However, for those with severe psychiatric disorders such as schizophrenia, sexual functioning has received little consideration and recognition, while this is an important aspect of their quality of life. Since it was thought that they should not get involved with sexual activity, until recently, discussing sexual issues with schizophrenic patients was accounted out of place.5 This neglect may show a bias on the part of psychi-atric practitioners. Their avoidance of exploration may be due to their discomfort and concern that recognition and discussion of sexuality may trigger or implicitly condone inappropriate sexual behavior. Until 10 years ago, sexual behavior of people with schizophrenia, especially men, was considered to be autoerotic. However, more recent studies have shown that 60-70% of these patients were sexually active in the last year and about 30% reported two or more partners.6 It is striking how little attention has been paid to the area of sexual functioning in schizophrenic patients. Satisfying evidence reveals that patients with schizo-phrenia are comfort to speak about their sexual func-tions, and more than 75% of those with severe mental illness believe that discussing sexual issues may be beneficial for their outcomes.7 Anyway, some studies have recommended that sexu-al functioning is both qualitatively and quantitatively different in people with schizophrenia compared with the normal people. People with schizophrenia engage in less overall sexual activity of any type yet are more likely to experience autoerotic behavior.5 In addition, the signs and symptoms of schizophrenia are not exactly similar in women and men. The type of delusions, which in large part is culturally deter-mined, defer in two sexes. Delusions in women are less bizarre, with more somatic and romantic con-tents. Men are more preoccupied with political con-spiracy and spying activities. Men have more grandi-ose delusions of power, royalty, and Supreme Being. Women have delusions of being pregnant when, in reality, they are not or not being pregnant when, in reality, they are. Women experience delusions of jeal-ousy.2 In general, women’s delusions seem relatively under-standable to clinicians; men’s delusions appear more bizarre. Symptoms of apathy, flat affect, paucity of speech, and social isolation, with their consequent negative impact on relationships, are more often pres-ent in men.2 This study introduces a schizophrenic woman who presents with some sexual symptoms and sexual abuse of her children in course of her severe mental disorder.

    CASE REPORT

    The authors describe a 38-year-old married woman with 2 sons, residing in Yazd with primary education. Due to repeatedly abusing her children sexually, she was referred to a psychiatrist by her husband. Accord-ing to her husband, she repeatedly prompted to have sex with their children, aged 17 and 6 years, by force. Even crying and screaming of her sons could not stop her. Her first child stopped her by beating his mother and often imprisoned himself in a room or in the rela-tives’ homes. It happened about 3 or 4 times in a week at a period of 6 years. Sometimes, because of the fear of her husband, she left the house with the little son under the pretext of shopping and attempted to have sex in a quiet place. Onset of the disorder occurred 6 years earlier follow-ing the second childbirth bleeding (uterine inertia). Soon she was severely distressed and insomniac. She prevented people from entering her home, even her mother; because she thought that the others are some-how going to hit her or her child. She was gradually isolated and had no contact with her friends and fam-ily. She often talked to herself. She did not consider the personal affairs and family life as well. For almost one year she had not had sex with her husband stating that her uterus would be damaged, until she commit-ted sexual harassment of her first child that was 10 years old and gradually the second child experienced sexual harassment as well. Then, a sexual relation-ship with her husband arose gradually. However, it was sometimes by force and in inappropriate places such as street, park and sometimes in the presence of their children. Clinical Findings: She did not have a history of phys-ical abuse on her children but if the children resisted the sex, she neglected them and began physical abuse. The mother did not allow the younger son to sleep alone. Sometimes at midnight others were awake by the noise of crying of a child that had been raped. At the time of this study, breastfeeding continued for the second child who was six years old and the med-ical examination of the mother’s breast showed a se-cretion of milk. The patient did not have any problem before the sec-ond child’s birth. There was no history of child abuse in her childhood. There was no history of mental or physical disorder but her aunt had a history of schizo-phrenia. The patient was hospitalized in Yazd Psychiatric Cen-ter for diagnostic evaluation. She totally denied her husband words and attributed all those words to her husband. Diagnostic Focus and Assessment: After taking the patient history and mental status examination in ac-cordance with the diagnostic criteria of DSM-IV-R, she received the diagnosis of schizophrenia. Therapeutic Focus and Assessment: She was treated with 15 mg Olanzapine daily and also received psy-chotherapy. Follow up and Outcomes: During hospitalization, there were no symptoms of hyper sexuality and she was secluded, sometimes she talked to herself. Treatment continued after being discharged from the hospital. Gradually the problems with her chil-dren decreased and according to her psychiatrist, after almost 6 months she did not apply for sexual abuse of her children. She had relatively better per-formance and her relationship with her spouse and children improved. However, at the time of this study,

    DISCUSSION

    Patients with schizophrenia continue to have sexual lives despite the nature of their illness. Sexuality, sex-ual relationships and sexual functioning are all im-portant quality-of-life issues for these patients. Cli-nicians should be aware of this and inquire about the patient’s experience and functioning in these areas.8 In one research, 20 schizophrenic women and 15 non-schizophrenic women were studied. Data on sexual history and current sexual functioning were collected. Schizophrenic women, compared to non-schizophrenic volunteers, reported a higher inci-dence of sexual abuse before the onset of disorder, particularly during childhood, as well as after the onset of full blown psychosis.9 Patients also learned about sexual function and began menstruating earlier and had more negative feelings toward menstruating. Furthermore, psychosexual dysfunctions were no-ticeably more common in schizophrenic women, both pre- and post-psychosis. 60% of the schizophrenic patients had never experienced orgasm, while it was 13.4% in nonschizophrenic women. Patients did not think that sexual activity aggravated their disorder, and only 20%of the patients believed that their dis-order had adversely affected their sexual function.9 According to this study, it seems that sexual activity in this group may not be related to sexual drive and can be disorganized behaviors. Another study compared characteristics related to sexual history, sexual activities, and psychological tendencies associated with sexuality in 45 young adults with schizophrenia treated with novel neuro-leptics and in 61 young adults from a comparison group. A smaller proportion of young adults with schizophrenia currently had a sexual partner or had been engaged in sexual activity in their lifetime. Whether affected by schizophrenia or not, a smaller proportion of women had masturbated, and a small-er proportion of men currently had a sexual partner. Women masturbated less often, felt less sexual desire, and desired sexual relations less often, compared with men. Proportionally more men with schizophrenia treated with risperidone or olanzapine had at least one sexual dysfunction, lacked sexual desire, and report-ed problems with sexual arousal and ejaculation as compared with men in the comparison group. Women with schizophrenia were more likely to report prob-lems with sexual arousal and galactorrhea, compared with women in the comparison group. Finally, young adults with schizophrenia were more likely to devel-op negative psychological tendencies associated with sexuality than the comparison group.10 This conclu-sion is not consistent with our case. Some studies show that men lose their sexual desire at the beginning of schizophrenia more than women and sexual activity may even be generally set aside. This situation seems to occur less frequently in women and they continue to engage in sexual activity and show interest in this work which can cause sexual exploitation of women.11 The case described in this study could also confirm the claim. The differences in men and women can be explained in terms of the higher incidence of schizophrenia in men. The prev-alence of schizophrenia with negative symptoms in men has been confirmed in many studies.12 Also it was stated in a study that in schizophrenia, despite the impact of the disease on various aspects of sexual life, the patients can experience the intimacy.13 This situation can be seen in this case. Despite the negative sign, the patient continues to experience sex in her life, although anomalous and inelegant. On the other hand, this very important part of life is ignored in treatment of these patients. Most of the time due to the presence of negative symptoms in pa-tients, the clinicians do not examine this area of their lives. This study, along with other studies indicated that this scope of life certainly should be considered and questioned in schizophrenic patients. As shown in a study, asking questions from these patients brings a lot of information.14 Then, Sexual dysfunction is under-recognized and possibly undertreated. In one study, the researchers conducted a survey of the knowledge, attitudes and practices of sexual dysfunction and schizophrenia of general adult psychiatrists. Romanus and et al. showed that “Two-thirds of psychiatrists that they interviewed did not routinely enquire about sexual dysfunction in their patients and only 17% felt com-petent in assessing sexual dysfunction, despite 88% agreeing that good sexual function was important to patients. Most practitioners (81.6%) had had no train-ing in this area and wanted some”.15 Competing Interest The authors declare no conflicts of interest. Authors’ Contribution Golrasteh Kholasehzadeh was the psychiatrist in charge of the patient, prepared and wrote the original data and Mohammad Nadi Sakhvidi followed up the patient. Nastaran Ahmadi was her psychologist, con-ceptualized, did literature survey and wrote the case report. All of the authors read and approved the final document. Acknowledgments The authors would like to thank the patient and Yazd Psychiatric Center. Written consent was obtained from the patient for publication of her details.
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