Struggling with schizophrenia and sexuality: Connecting veterans' first psychotic breaks while deployed to issues with sexual intimacy

In working with veterans with schizophrenia at a Veterans Affairs (VA) treatment center for veterans with severe mental illnesses, we have observed salient patterns in several cases that suggest a connection between sexual experiences in veterans' narratives of their initial psychotic breaks and ongoing struggles with sex and sexuality. Veterans with schizophrenia report being both terrified of and long for intimate relationships. Those who connect their first psychotic break to sexual experiences while deployed seem to have particular difficulty integrating sex, love and emotional intimacy into their lives following the onset of schizophrenia. Such individuals report seeing intimate contact with others as threatening, while they simultaneously desire sexual contact and meaningful romantic relationships. The purpose of this article is to encourage military and VA psychologists to consider the impact that service members' and veterans' initial psychotic breaks have on their subsequent ability to form healthy romantic relationships. We focus on the pragmatic implications that schizophrenia has for our military personnel and veterans in relation to their sexual identity formation. In addition, "intimacy" is an inherently subjective and complex tem to define. For the purposes of this article, we use it to connote the physical and emotional components involved in sexual contact and relationships.

Psychotic breaks most commonly appear in men between 15 and 24 years of age and in women between 25 and 34 years of age. It is not uncommon for people to enlist in military service at 18 years of age. These years correspond with crucial developmental stages in which young adults are moving away from home for the first time to enter military service. They are exposed to a variety of stressors, including the opportunity for sexual experiences, either with other service members or in the communities surrounding their areas of training and deployment. The military serves as a culturally sanctioned institution in which young men and women gain experience in a variety of ways, including job and career training but also in terms of socialization due to living in close quarters with their peers and bonding through the common experiences encountered in military service. Developmentally, young adults leaving home experience greater freedom to explore their sexuality. Experimenting with sexuality is a principle task for young adults, and it coincides with joining the military where others surrounding them are struggling with the same developmental tasks. Concerns about sex, sexual identity, and emotional intimacy in romantic relationships are common at this time when young people are still in a process of adult identity formation.

One veteran who developed schizophrenia during his deployment reported, "I saw three prostitutes four times [overseas], and before I knew it someone was telling me to see a psychiatrist. Then I found myself in an army mental hospital back in the US." He continued, "I thought that if I could get somebody to kiss me, I could get somebody to love me. So I followed this girl around [the area I was deployed], kind of like, skirt-chasing, I guess . . . but now I'm not sure if she was real or not." The experience of this first break, including hallucinations and delusions related to guilt and paranoia about his sexual behavior overseas, continue to affect his functioning and ability to incorporate sexuality into his current life.

If anxieties around sexual intimacy are not addressed in contemporary military culture, there is the possibility of increased psychological breakdowns partially resulting from intra- and interpersonal conflicts related to sex and sexuality. Whether you are forced to have a sexual experience (through military sexual trauma) or it is actively sought out because of social expectations (peer pressure to visit brothels), the emotional overwhelm brought on by the experience is possibly the trigger that tips the scale and induces the psychotic break. "Every time the boys pulled me into town and set me in front of a woman, I wanted to scream, my brain was itching and I got hot feet. I wanted to show them I was a man, but it was wrong for my belief. Now I am paying for this." On his morning runs, this veteran sees devils sitting in the trees taunting him for his past behavior, which he correlates with his experiences with prostitutes overseas.

Given that psychotic breaks can occur after any type of extreme stressor, we are attempting to portray how having a break subsequent to or in response to a sexual experience while deployed is qualitatively different than other stressors. We consider sexuality in itself to be relevant for the veteran's identity and coherence in his or her conceptualization and treatment. The sexual nature of the trigger is not simply a part of the historical narrative but rather is seen by the veterans themselves as an important aspect in how they relate to their psychotic symptoms and their ambivalence regarding sexuality.

We have observed that the context in which the initial psychotic break takes place remains an important aspect of psychotic symptoms in military personnel and veterans with schizophrenia. In particular, anxieties related to sexual intimacy and sexual identity, which are normal for adolescents and young adults, become especially pronounced and can act as triggers in those individuals predisposed to schizophrenia. These anxieties continue to affect the content of the delusions that these individuals experience later in life. Memories of the intolerable anxiety aroused by sexual experiences just prior to the psychotic break can become fused with the eruption of psychotic symptoms during that time. These memories impact the individual's daily life decades later in the form of repetitive paranoid fantasies about this initial sexual contact. The same veteran who reported wanting to scream while in the brothels reports, "I saw so many women in different ports that I can no longer have sex with my wife. I see their faces when she leans in to kiss me. I can't help thinking about them." While he continues to take antipsychotic meditation and sees a therapist weekly, these delusions impact his ability to sustain an intimate relationship with his wife.

The individual, who, for a variety of reasons, is unable to deal with overwhelming anxiety related to his or her sexual identity or experience may become fragmented and disintegrated during the crucial developmental stage at which many young people enter military service. Schizophrenia, with its neurobiological and genetic influences, also becomes a reaction to the pain of rejection and feelings of extreme shame and guilt around sexual intimacy. The act of sex itself is scary for those who lack the coherence of a unified self. The feeling of closeness and intimacy (both emotional and physical), involved in sexual intercourse, requires a certain amount of psychological resources in order to preserve one's identity in such close contact with another.

We are not arguing that sexual experiences cause schizophrenia or psychotic breaks. The physical and emotional overstimulation associated with intimacy can trigger breaks or the emergence of schizophrenia as would any other intense stressor. Traumatic and psychotic responses can occur from any perceived or actual stressor. However, for schizophrenic veterans who are stuck in the delusions of their first break, sexuality issues can be obstacles for living a values-driven life. One veteran, looking back over 40 years of struggling with schizophrenia, said, "I think I would feel better about dying if I had children. I never had a wife or children." The ability to express feelings of loss in terms of what he feels his illness has cost him signified a new way of talking about sexuality and schizophrenia. This was an opportunity to move beyond the delusions and into a realistic exploration of difficult emotions. The following is another example of how a context-based and acceptance approach to understanding the role of sexuality within the context of schizophrenia can be clinically helpful.

With one veteran, weekly sessions guided by this approach have allowed for a process of integration to occur around his conflicting self-identities. These include his sense of being deformed by his schizophrenia and his desire for sexual contact and love. With him, this approach required a certain level of long-term care, extensive rapport building, and consistent weekly sessions to establish the trust necessary to discuss such intimate details. The work has drawn together his need for closeness and acceptance during his childhood and adolescence, the terrifying account of his psychotic break while deployed overseas, the content of his ongoing paranoid delusions, and his current desires for intimacy. In recent sessions, this veteran has been able to directly confront and incorporate a relationship to his schizophrenia in a way that allows him greater self-awareness. He has also attained a more nonjudgmental attitude toward his illness that relieves some of his internalized stigma. This, in turn, allows his desire for greater intimacy to be communicated, as his associations to sex threaten him less. After one poignant session in which this veteran expressed remorse for not having engaged in sexual relationships since his break, he returned the following week asking, for the first time, to learn more about schizophrenia without his usual defensiveness, disdain, and cynicism about his illness.

This constitutes a new direction in terms of moving beyond the stigma and shame around his illness that had been intertwined with his ambivalence around his sexuality. Although there is more work to be done with this veteran and other individuals who express an overt connection between their schizophrenia and sexuality, we suggest that actively engaging in dialogue about these interrelated issues can begin a process of positive change.

Recommendations

What relationship do we want our veterans to have with their sexual memories as it impacts their current relationships? How can we help patients accept the trigger event and be able to reinvest in their sexual identity, not in spite of, but alongside living with schizophrenia?

We recommend that it is increasingly important to directly address issues of sexuality among young recruits, particularly in the context of the repeal of "Don't Ask, Don't Tell" and with the proposed inclusion of female service members in combat operations. Military psychologists might educate military personnel to recognize the importance and relevance of these experiences in patients' ongoing psychotic symptoms. Clinicians at the VA may also address veterans' continued anxiety around issues of emotional and sexual intimacy and the ambivalence that arises when contemplating the prospect of entering into intimate relationships.

We have found it helpful not to hesitate or avoid talking about sexuality with those veterans who struggle with schizophrenia. Ignoring the context in which the psychotic break emerged can neglect the whole picture that the patients present, leading to misunderstandings and misrepresentations of the client's concerns. We can help patients name the variety of stressors that were involved during their first break, including those mentioned above regarding the challenges of being newly deployed and enlisted. Normalizing these stressors and educating the patient about the psychological implications that schizophrenia has for developing relationships are important aspects of the treatment. Finally, we suggest helping the patients connect their fears, guilt, shame and excitement about their initial sexual experience to their current challenges connecting intimately with others.

Through clinical observations with veterans with schizophrenia from various eras who had their first psychotic break while in the military, we have seen a striking pattern of delusional and paranoid content related to sexual experiences that accompanied the first psychotic break. By examining the experiences of veterans who have lived with schizophrenia for decades, we are hoping to improve the military's ability to attend to these issues so that preventative measures and subsequent care can be provided with new recruits and veterans alike.

About the Authors

Michael Sapiro, MA, is completing his PsyD degree in clinical psychology at John F. Kennedy University. He holds a master's degree in clinical psychology and a master's degree in English with an emphasis on feminist and social justice pedagogy. He currently trains at a Veterans Affairs center working with combat veterans with posttraumatic stress disorder, traumatic brain injury and severe mental disorders. He sits on the board of directors for the Institute of Spirituality and Psychology and presents on clinical applications of mindfulness practices for treating posttraumatic stress disorder. He is the cofounder and director of Maitri House Yoga.

Jonathan H. Rousell, MA, is completing his PsyD degree at the Wright Institute. He holds a master's degree in clinical psychology and a bachelor's degree in East Asian studies and History. He is currently completing his 3rd year of clinical training at the Department of Veterans Affairs, where he provides psychological services to veterans with a diverse range of presenting concerns, including combat-related posttraumatic stress disorder, severe mental illnesses such as schizophrenia and various psychosocial issues. His research interests include cross-cultural expressions of psychopathology, the intersections between psychology and other academic disciplines, and contemporary applications of psychodynamic theory and practice.