Persistent genital arousal disorder: a clinical challenge
The following case has been reported in BMJ. This case is important in terms of treatment. Despite biological, psychological and social treatment in an aggressive manner, the case remained resistant.

A patient, aged 54 reported anxiety symptoms in social situations and remaining ‘on edge’ for a couple of hours in a typical day. She reported preoccupation with obsessional thoughts with a theme of ‘doubt’ and reported multiple checking rituals in a day. She did not report any depressive features, ‘highs’ or psychotic features. She also reported ‘genital arousal’ multiple times during the week leading to sensation of pain in the lower abdomen. She described such arousal even before she started taking medication (Citalopram).

She was taking citalopram 20 mg/day, zopiclone 7.5 mg at bedtime, clonazepam 0.5 mg twice a day with some good effect on anxiety but not on genital arousal. She was previously seen by a psychiatrist who did not wish to continue with follow-up. No family history of mental illness was noted. In the personal history, she reported an incident of sexual abuse that she now does not dwell upon. The patient did acknowledge that sexual abuse as a child was quite traumatic for her but the patient did not want to discuss that issue. She had a high school education and worked in a shopping mall.

Her marriage lasted for many years and ended up in divorce but the patient got married again and is happy. She has a son 31 years of age. There was no history of alcohol or drug abuse. The patient did not report any medical problem. She was undergoing menopause. No drug allergies were reported. There were no social or legal issues of significance. On Mental Status Examination: she was found to be very cooperative and adequate report was developed. Her mood was assessed to be anxious, speech was normal in rate, rhythm and volume.

Thoughts were preoccupied with ‘obsessions of doubt’. No evidence of perceptual anomaly. There were no safety concerns. Cognitive functions were in normal range. Insight and judgement were preserved. Her primary multiaxial diagnosis:
1. Generalised anxiety disorder versus obsessive compulsive disorder and comorbid genital arousal syndrome
2. Deferred
3. Undergoing menopause
4. Non-specific stress with mild intensity
5. 70–80

• Citalopram 20 mg/day
• Clonazepam 0.5 mg twice a day
• Zopiclone 7.5 mg for sleep at night

The patient was more concerned about her genital arousal problem but was happy with current medications and dosages. The patient did not allow review of the medication as she believed that nothing much will help her. She reported side effects in the past when an attempt to increase the dose of Citalopram was made. She was tried on a number of different psychotropics in the past with no effect. She was not comfortable considering electroconvulsive treatment (ECT).

Learning points
• A thorough sexual and gynaecological history is important.
• Investigation for detecting organic pathology with the use of MRI and/or Doppler ultrasound is helpful.
• Electroconvulsive treatment may be an option for treating this condition.

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