Case Study: Diminished Orgasmic Intensity in a Young Adult Male with Untreated Depression and ADHD

Case at a Glance

An 18-year-old male presents with a primary complaint of persistently brief, low-intensity, and unsatisfying orgasms since becoming sexually active. He reports minimal to no pleasure during the arousal phase leading up to ejaculation. The patient has a self-reported history of depression and ADHD, for which he is not receiving treatment. The case highlights the interplay between mental health and sexual function in young adults.

Patient's Story

The patient is an 18-year-old male in a monogamous relationship who presented with concerns about the quality of his orgasms. He describes his orgasmic experience as lasting only 'a second or so' and feeling 'underwhelming' and not 'worth it.' This is in stark contrast to his perception of his girlfriend's orgasms, which she reports as lasting significantly longer and appearing much more intense, leading to feelings of jealousy and concern for the patient. He further notes a significant lack of pleasurable sensation during sexual stimulation (both intercourse and masturbation) prior to the point of orgasm. He identifies his history of depression and a suspected diagnosis of ADHD as potential contributing factors to his condition. He denies any difficulty in achieving orgasm or ejaculation. He is not currently taking any prescription medications.

Initial Assessment

The patient presented as a well-developed young adult, appearing anxious about his symptoms. His chief complaint is orgasmic dysfunction, specifically diminished intensity and duration of orgasm, and sexual anhedonia during the arousal phase. His medical history is significant for self-reported, untreated depression and ADHD. Social history reveals he is sexually active, ejaculating on most days, sometimes more than once per day. He denies any use of pornography for the past six months. He is not on any medications, including antidepressants, which are a common cause of such symptoms. A physical examination, including a genitourinary exam, would be indicated to rule out anatomical abnormalities, although the clinical picture strongly suggests a psychogenic or neurobiological etiology.

The Diagnostic Journey

The diagnostic process focused on a detailed psychosexual history to understand the onset, nature, and context of the symptoms. The patient’s report of minimal pleasure throughout the entire sexual response cycle, not just at orgasm, was a key finding. This suggests a more generalized issue with sexual pleasure rather than an isolated ejaculatory disorder. Given his untreated depression, a primary line of investigation was the impact of his mood state on sexual function. Anhedonia (the inability to feel pleasure) is a core symptom of depression and can extend to sexual experiences. The potential role of ADHD was also considered, as attentional deficits can interfere with the ability to remain present and focused during sexual activity, thereby diminishing pleasure. The high frequency of ejaculation was noted as a possible contributor to decreased sensitivity or intensity. A hormonal workup (testosterone, prolactin, TSH) was considered to rule out endocrinological causes, though the suspicion for an organic cause was low.

Final Diagnosis

Orgasmic Disorder, characterized by markedly diminished intensity of orgasmic sensations. This is likely secondary to untreated Major Depressive Disorder and contributing factors from suspected Attention-Deficit/Hyperactivity Disorder. The lack of pleasure during the arousal phase could be classified as a feature of his depressive anhedonia manifesting as sexual anhedonia.

Treatment Plan

A multi-faceted treatment approach was recommended:

1. Psychiatric Referral: Urgent referral for a comprehensive psychiatric evaluation to formally diagnose and initiate treatment for his underlying depression and ADHD. Treatment could involve psychotherapy (such as Cognitive-Behavioral Therapy) and/or carefully selected pharmacotherapy (e.g., a non-SSRI antidepressant like bupropion, which has a lower risk of sexual side effects).
2. Psychosexual Counseling: Referral for individual or couples therapy specializing in sexual health. This would include psychoeducation on the variability of sexual response, mindfulness techniques (like sensate focus) to increase somatic awareness and pleasure during sexual activity, and strategies for managing performance anxiety and comparisons to his partner.
3. Behavioral Modification: The patient was advised to experiment with a period of reduced ejaculation frequency to assess for any change in orgasmic intensity.
4. Medical Evaluation: A baseline hormone panel was ordered to definitively rule out any contributing organic factors.

Outcome and Follow-up

The patient agreed to a psychiatric referral and began weekly cognitive-behavioral therapy. He was formally diagnosed with moderate depression. He and his partner also engaged in several sessions of psychosexual counseling. The patient reported that focusing on mindfulness techniques during sexual activity significantly increased his awareness of pleasurable sensations. After two months of consistent therapy and a conscious reduction in masturbation frequency, he noted a qualitative improvement in his sexual experiences, describing them as more connected and enjoyable. While the duration of his orgasm did not change dramatically, he reported a significant increase in its subjective intensity and satisfaction. Follow-up appointments were scheduled to monitor his mental health and to continue supporting his progress in sexual function.