Case Study Jon and Linda

Jon and Linda were referred to the author by Jon's current psychopharmacolo-gist. Jon is a 62 years old financier who has been married to Linda (53 years old) for over 20 years. She began HRT 4 years ago, which successfully stopped her hot flashes. This is his second marriage and her first marriage. They had three teenage children together. Their marriage was marked by periods of disharmony secondary to multiple etiologies. Jon and Linda had a symbiotic relationship where she dominated much of their daily life. She tended to be explicitly critical of him, which he resented but managed passive-aggressively. This, of course, merely exacerbated their marital tension. Linda was particularly sensitive to rejection, and was considerably upset when Jon withdrew from her in response to her criticism. This infuriated her and she provoked confrontations. He eventually responded, becoming loud and aggressive, which initially dissipated his tension. He then felt guilty as she expressed hurt and disappointment in his behavior. This push-pull process would begin anew, characterizing the rhythm of their marriage. Despite all these difficulties in the relationship, both Jon and Linda were fortunate enough to be capable of engaging in successful sex to reduce their stress and anxiety; unlike those needing to be stress free in order to function. Jon and Linda enjoyed high frequency successful coital activity with mutually enjoyable coital orgasms, despite their intermittent marital disharmony over a 15-year period.

Three years ago, Jon started SSRI treatment for depression, secondary to work stress. His depression exacerbated his insecurity about his intelligence and abilities. He developed ED and could not erect, but his sexual desire was still strong. Medication helped his moodiness and reduced his depression. They both wanted Jon on the antidepressant medications, yet their marital conflict increased. His psychopharmacologist tried reducing the SSRI and augmenting with bupropion. This did not help! If anything, it uncharacteristically, worsened his sex life. They tried switching him from paroxetine to bupropion to escitalopram. During this time, he lost his job, and money problems became worse. He needed to move to a different city in order to find work, uprooting Linda and the kids. He also used a low dose, blood pressure (BP) medication, which had not caused ED, although it was a risk factor. Possibly, the BP medication exacerbated the anti-sexual impact of the SSRI, culminating in his severe ED. His typical male withdrawal from sex and affection once the ED emerged, only exacerbated her rejection sensitivity and deep feeling of abandonment. This left her slightly depressed, but predominantly, critical of him and doubting the viability of their marriage.

His Chicago psychopharmacologist referred them to a well-known NYC urologist, when they first moved from Chicago. The urologist prescribed 50 mg of sildenafil, which was increased to 100 mg. There were multiple attempts at 100 mg, which all failed. The urologist then prescribed "trimix." They used "trimix" ICI, 15 times, resulting in three coital erections and orgasms. Neither Jon, nor Linda liked the "lack of spontaneity." The urologist recommended a penile prosthesis, but Jon declined and terminated that treatment.

Some months later, still on 10 mg of escitalopram, a new, NYCpsychophar-macologist referred Jon to this author. Jon and Linda were seen six times conjointly and three times individually. She was helped to reframe his withdrawal, as insecurity, not rejection or abandonment of her. This reduced her anger and resentment. He was encouraged to be affectionate when not angry at her. Her criticalness was reduced, which led to a reduction in his passive-aggressive behavior. Although not resolving the individual and marital dynamics, these insights increased harmony enough, for a sexual pharmaceutical to become effective. The author recommended tadalafil to Jon's PCP, because of Linda's rejection sensitivity. The drug's longer duration of action allowed him to respond to her receptivity cues, which she "dropped like a hankie." For 1 month, he took tadalafil, Friday and Tuesday. Quoting her: "it covered him for the week." They now use it, as needed, and are back to twice weekly coitus. She said, "I could do a commercial. It's doing a fabulous job. It's a really good drug for us. It is causing greater emotional warmth that leads to physical intimacy." This, of course tends to be true for all the PDE-5s when they work, not just tadalafil. He reported, "it takes away the uncertainty, allowing me to feel able."

Reportedly, both individual and relationship satisfaction were increased and Jon continued to be followed by his PCP and his psychopharmacologist.

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