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The Relationship Between Anxiety Disorders and Sexual Dysfunction

Anxiety can be defined as a feeling of apprehension and fear characterized by physical, psychological, and cognitive symptoms. In the context of stress or danger, these reactions are normal. However, some people feel extremely anxious with everyday activities, which may result in distress and significant impairment of normal activity.

Anxiety disorders are a group of clinical entities in which an abnormal level of anxiety is the prominent symptom. This group includes panic disorder, specific and social phobia, obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), acute stress disorder, and generalized anxiety disorder. Sexual dysfunctions (SDs) are defined in DSM as disturbances of the 3 phases of the sexual response cycle: desire, arousal, and orgasm, in addition to sexual pain disorder.

Anxiety plays an important role in the pathogenesis and maintenance of SDs. This co-presence is very common in clinical practice: patients with SDs will often present with an anxiety disorder, and in many cases it is unclear which is the primary disorder. On the other hand, for many patients with a psychiatric disorder an SD may be a persistent disturbance.

Anxiety represents the final common pathway by which social, psychological, biological, and moral factors converge to impair sexual response. The neurobiological expression of anxiety is complex, but it mainly involves a release of adrenergic substances (epinephrine and norepinephrine(Drug information on norepinephrine)). Sympathetic dominance is also negatively involved in the arousal and orgasm phases and may interfere with sexual desire.1,2

Psychological elements are generally considered important in the pathogenesis of SD, but it is difficult to explore these factors with standardized instruments. There are few studies that explore this hypothesis using diagnostic tools, and in some cases these studies have considered anxiety as a feeling and not as a clinical entity.

In this article, we examine the relationship between anxiety disorders and SDs, using DSM-IV-TR categories, although we are conscious of the limits of this approach. In doing so, we will consider not only the dichotomy between normal and pathological functioning but also the issue of sexual satisfaction as part of wellness. We review studies that report on sexuality in anxiety disorders and on those that report on anxiety in patients who have SDs.

Anxiety disorders in patients with sexual dysfunction

The complex relationship between anxiety disorders and desire disorders is rarely clarified in the medical literature. Kaplan1 underlines a strong prevalence of panic disorder (25%) in patients affected by sexual aversion disorder. Anxiety is also relevant in sexual arousal. Induced by different stressors, anxiety can distract from erotic stimuli and impair sexual arousal, principally through an increased sympathetic tone.3,4 This may result in poor erection in males and a reduction in lubrication and clitoral tumescence in females.

Various aspects of anxiety are historically considered in arousal disorders, particularly the vicious circle of anxiety/dysfunction/performance anxiety.5 Honeymoon impotence is a specific example of this, as suggested by Shamloul,6 who studied 100 patients with this problem.

Several studies have found that the prevalence of anxiety disorders varies from 2.5% to 37% in males affected with erectile dysfunction (ED).7-9 However, these studies failed to point out a significant correlation between a sin-gular type of anxiety disorder and ED. Recently, however, a link between free-floating anxiety and ED has been suggested.10 Others report that the association between anxiety (as a feeling) and ED is strongest in patients aged 45 to 54 years.11

One study found that the presence of anxiety symptoms in patients with arousal disorders was associated with poor treatment outcomes.7 Hyperarousal syndromes, such as persistent sexual arousal, are not found in DSM-IV-TR. The specific role of anxiety in these cases is unknown. Leiblum and colleagues12 described 103 women with involuntary genital and clitoral arousal. An anxious experience represented the trigger in one third of these women. Anxiety-related symptoms such as worry, panic attacks, and obsessive thoughts or behaviors were also seen in significant numbers of these patients, as were secondary anxiety symptoms (worry and embarrassment).

In addition to desire and arousal, orgasm may also be impaired by anxiety. While it is widely accepted that anxious thoughts or feelings disrupt female orgasm, few studies have examined this relationship or tried to identify specific aspects of anxiety related to impaired orgasm.13-15

Negative emotions, including anxiety or fear of failing to meet a partner’s expectations, represent one of the most common causes of premature ejaculation (PE).16-20 This has been explained by investigators as being caused by a sympathetic hyperactivity that reduces ejaculation control.20-22 Others have pointed to the role of attention, suggesting that men who are anxious during sexual intercourse are worried about sexual performance or sexual adequacy, and that these thoughts may distract attention from the sexual sensations that precede orgasm and ejaculation.18,21,23

Hyperattention to performance and fear of inadequacy in meeting others’ expectationare typical of social phobia, in which concern about performance and judgment reflect a high sympathetic tone. This has been confirmed by Tignol and colleagues24 and Corretti and colleagues,25 who report that the prevalence of social phobia is 47% and 25.5%, respectively, in patients with PE. This link between social phobia and PE was also substantiated by reports of 2 cases in which worry about social performance led to uncontrolled ejaculation.26

Other investigators propose a significant role of free-floating anxiety in PE.10 The relationship between anxiety and retarded ejaculation is unclear, although some investigators suggest that sexual performance anxiety can contribute to retarded ejaculation.18,27

Anxiety disorders and pain disorders

High levels of anxiety have been found in women with dyspareunia,28-30 who seem to experience severe pain during sexual intercourse.31 The pathophysiological factors that regulate this phenomenon are unknown. An interesting hypothesis suggests that a strong relationship exists between anxiety and hypervigilance in patients with anxiety and SD, with attention being allocated to threatening stimuli during sexual intercourse.32-34

Recent studies have significantly increased the understanding of pain perception and have demonstrated that a complex series of spinal, midbrain, and cortical structures are involved in pain perception.35 Pain perception can be roughly divided into a lateral, somatosensory system involved in discrimination of pain location and intensity,36 and a medial system that mediates the anticipatory, fearful, affective quality of pain through limbic structures.37 Dysfunctions of these limbic structures, including the hippocampal cortex, may be involved in SDs in which pain represents the prevalent symptom.38 Patients with chronic pelvic pain have often been found to have a history of sexual trauma or abuse. Moreover, similar alterations in limbic structure have been demonstrated both in patients with chronic pelvic pain and in survivors of trauma.39 This may suggest that pain represents not only a symptom of SD but also a symptom of a more specific anxiety disorder such as PTSD.

Sexual dysfunction in patients with anxiety disordersLooking at the other side of the picture, sexual difficulties are common in patients affected by anxiety disorders. Often, in fact, a sexual symptom is the first reason for consulting a physician.

Kaplan1 suggested a prevalence of SD of 75% in patients with panic disorder.1 These data were confirmed by Figueira and colleagues,40 who retrospectively evaluated the sexual function and the sexual history of 30 patients with panic disorder and social phobia. They found that sexual aversion disorder is the most common SD in patients with panic disorder, and that its prevalence in this population is greater than in the general population. Furthermore, they found that in their series, sexual aversion was secondary to panic disorder: patients said that they avoided sex because they feared having a panic attack during intercourse. These results were found in both men and women and suggest that sexual aversion may be part of the agoraphobic spectrum.40

Sexual avoidance may also be caused by ED in males affected with panic disorder. An analysis of 60,949 patients with ED showed that men with panic disorder have an increased risk (odds ratio) of ED in the range of 1.33 to 2.29.41

Studies on sexuality in patients with social phobia show a comorbidity of about 30%. Arousal disorders (loss of desire during sexual intercourse)42 and orgasm-ejaculation disorders are most common in males with social phobia. Some studies that have analyzed social phobia in male populations found a high prevalence of PE (47%),40 while others found a link with retarded ejaculation (33%).42 The correlation between PE and social phobia is accepted, but there is also a relationship between retarded ejaculation and social phobia, which underlines that the specific role of anxiety is still unclear.

Pleasure and sexual satisfaction are impaired in persons with social phobia.40,42-44 Women with social phobia are more likely to have concomitant desire disorders (46%), pain during sex (42%), and less frequency of sexual thoughts and sexual intercourse.42

SDs have a prevalence of 39% in females with OCD.45Patients may report sexual disgust, the absence of sexual desire, very low sexual arousal, anorgasmia, and high avoidance of sexual intercourse.46,47 Patients with OCD show severe impairment in both interpersonal and sexual relationships48 and they tend to perceive themselves as less sensual in comparison to patients with other anxiety disorders.46 The results are a poor level of sexual pleasure47 and a strong dissatisfaction with their sexuality (73%).45

PTSD affects emotional, social, professional, and sexual life.49,50 It is still unclear whether populations with PTSD have normal levels of sexual desire.51,52 Certainly, these patients have ED (prevalence of about 69% in combat veterans with PTSD) and problems with orgasm, and thus report a poor level of sexual satisfaction.41,51,52

Unresolved problems and future targets

The relationship between anxiety and sexual function is complex because it has been considered in 2 symmetrical directions: the primary symptom and the secondary consequence. Understanding the cause-effect link in clinical practice necessitates experience and an expanded point of view.

The relationship between anxiety and sexuality can be theoretically described as one of the following:

  • Anxiety may cause sexual failure.
  • SDs may cause anxiety.
  • SDs and anxiety are not causally related.
  • Anxiety and SDs may be different expressions of the same processes.

The analogies in neurobiology and the good response to similar treatments (psychotherapy and/or SSRIs)53-56 seem to confirm the last hypothesis, suggesting a common root of these 2 manifestations. Obtaining a complete psychopathological and sexual history represents an important step in diagnosis that can influence prognosis with either pathology.

When investigating anxiety disorders, it is important to consider the patient’s sexual life, and vice versa. When we evaluate SD, anxiety disorder should always be considered. In our practice, failure to investigate the patient’s psychological background negatively influences the treatment goal of a patient with an SD.

The clinical evaluation should not be restricted to the patient but should extend to the partner. In particular, partners of men with SDs frequently have not only an unsatisfactory sexual life but an anxiety disorder as well.57

Dr Corretti is a psychiatrist and sexologist at the Sexology and Psychiatry Clinic in Livorno, Italy. Dr Baldi is attendant psychiatrist at the Postgraduate School of Developmental Neurology and Child and Adolescent Psychiatry at the University of Pisa in Italy. The authors report no conflicts of interest regarding the subject matter of this article.

References

1. Kaplan HS. Anxiety and sexual dysfunction. J Clin Psychiatry. 1988;49:21-25.
2. Graziottin A. Libido: the biologic scenario. Maturitas. 2000;34:S9-S16.
3. Maggi M, Filippi S, Ledda F, et al. Erectile dysfunction: from biochemical pharmacology to advances in medical therapy. Eur J Endocrinol. 2000;143:143-154.
4. Filippi S, Marini M, Vannelli GB, et al. Effects of hypoxia on endothelin-1 sensitivity in the corpus cavernosum. Mol Hum Reprod. 2003;9:765-774.
5. Masters WH, Johnson VE. Human Sexual Inadequacy. Boston: Little Brown & Co; 1970.
6. Shamloul R. Management of honeymoon impotence. J Sex Med. 2006;3:361-366.
7. Mallis D, Moysidis K, Nakopoulou E, et al. Psychiatric morbidity is frequently undetected in patients with erectile dysfunction. J Urol. 2005;174:1913-1916.
8. Farre JM, Fora F, Lasheras MG. Specific aspects of erectile dysfunction in psychiatry. Int J Impot Res. 2004; 16(suppl 2):S46-S49.
9. Lee IC, Surridge D, Morales A, Heaton JP. The prevalence and influence of significant psychiatric abnormalities in men undergoing comprehensive management of organic erectile dysfunction. Int J Impot Res. 2000; 12: 47-51.
10. Corona G, Mannucci E, Petrone L, et al. Psycho-biological correlates of free-floating anxiety symptoms in male patients with sexual dysfunctions. J Androl. 2006; 27:86-93.
11. Sugimori H, Yoshida K, Tanaka T, et al. Relationships between erectile dysfunction, depression, and anxiety in Japanese subjects. J Sex Med. 2005;2:390-396.
12. Leiblum S, Brown C, Wan J, Rawlinson L. Persistent sexual arousal syndrome: a descriptive study. J Sex Med. 2005;2:331-337.
13. Zuk M. The case of the female orgasm. Perspect Biol Med. 2006;49:294-298.
14. Meston CM, Levin RJ, Sipski ML, et al. Women’s orgasm. Annu Rev Sex Res. 2004;15:173-257.
15. Pauls RN, Kleeman SD, Karram MM. Female sexual dysfunction: principles of diagnosis and therapy. Obstet Gynecol Survey. 2005;60:196-205.
16. Hawton K, Catalan J. Prognostic factors in sex therapy. Behav Res Ther. 1986;24:377-385.
17. D’Ottavio G, Simonelli C. Andrologia e Psicopatologia del Comportamento Sessuale. Rome: Nuova Italia Scientifica; 1990.
18. Zilbergeld B. The New Male Sexuality. New York: Bantam Books; 1993.
19. Dunn KM, Croft PR, Hackett GI. Association of sexual problem with social, psychological, and physical problems in men and women: a cross sectional population survey. J Epidemiol Community Health. 1999;53:144- 148.
20. Williams W. Secondary premature ejaculation. Aust N Z J Psychiatry. 1984;18:333-340.
21. Kaplan HS. The New Sex Therapy. New York: Brunner-Mazel; 1974.
22. Wolpe J. The practice of behaviour therapy. Toronto: Pergamon; 1982.
23. Kaplan HS. PE: How to Overcome Premature Ejaculation. New York: Brunner-Mazel; 1989.
24. Tignol J, Martin-Guehl C, Aouizerate B, et al. Social phobia and premature ejaculation: a case-control study. Depress Anxiety. 2006;23:153-157.
25. Corretti G, Pierucci S, De Scisciolo M, Nisita C. Comorbidity between social phobia and premature ejaculation: study on 242 males affected by sexual disorders. J Sex Marital Ther. 2006;32:183-187.
26. Redmond DE, Kosten TR, Reiser MF. Spontaneous ejaculation associated with anxiety: psychophysiological consideration. Am J Psychiatry. 1983;140:1163-1166.
27. Althof SE, Lieblum SR, Chevert-Measson M, et al. Psychological and interpersonal dimensions of sexual function and dysfunction. In: Lue TF, Basson R, Rosen R, et al, eds. Sexual Medicine: Sexual Dysfunctions in Men and Women. Paris: Editions 21;2004:73-116.
28. Nunns D, Mandal D. Psychological and psychosexual aspects of vulvar vestibulitis. Genitourinary Med. 1997; 73:541-544.
29. Gates EA, Galask RP. Psychological and sexual functioning in women with vulvar vestibulitis. J Psychosom Obstet Gynaecol. 2001;22:221-228.
30. Granot M, Friedman M, Yarnitsky D, Zimmer EZ. Enhancement of the perception of systemic pain in women with vulvar vestibulitis. BJOG. 2002;109:863-866.
31. Pukall CF, Binik YM, Khalife S, et al. Vestibular tactile and pain thresholds in women with VVS. Pain. 2002;96: 163-175.
32. Barlow DH. The causes of sexual dysfunction: the role of anxiety and cognitive interference. J Consult Clin Psychol. 1986;54:140-148.
33. Dove NL, Wiederman MW. Cognitive distraction and women’s sexual functioning. J Sex Marital Ther. 2000;26: 67-78.
34. van den Hout M, Barlow D. Attention, arousal and expectancies in anxiety and sexual disorders. J Affect Disord. 2000;61:241-256.
35. Brooks J, Tracey I. From nociception to pain perception: imaging the spinal and supraspinal pathways. J Anat. 2005;207:19-33.
36. Kanda M, Nagamine T, Ikeda A, et al. Primary somatosensory cortex is actively involved in pain processing in human. Brain Res. 2000;853:282-289.
37. Vogt BA, Berger GR, Derbyshire SW. Structural and functional dichotomy of human midcingulate cortex. Eur J Neurosci. 2003;18:3134-3144.
38. Singer T, Seymour B, O’Doherty J, et al. Empathy for pain involves the affective but not sensory components of pain. Science. 2004;303:1157-1162.
39. Rome HP Jr, Rome JD. Limbically augmented pain syndrome (LAPS): kindling, corticolimbic sensitization, and the convergence of affective and sensory symptoms in chronic pain disorders. Pain Med. 2000;1:7-23.
40. Figueira I, Possidente E, Marques C, Hayes K. Sexual dysfunction: a neglected complication of panic disorder and social phobia. Arch Sex Behav. 2001;30: 369-376.
41. Blumentals WA, Gomez-Caminero A, Brown RR, et al. A case-control study of erectile dysfunction among men diagnosed with panic disorder. Int J Impot Res. 2004; 16:299-302.
42. Bodinger L, Hermesh H, Aizenberg D, et al. Sexual function and behavior in social phobia. J Clin Psychiatry. 2002;63:874-879.
43. Tignol J, Martin C, Auriacombe M, et al. Case study–relationship between prevalence of shyness, social phobia and avoidant personality in male sexual disorders. Encefale. 2001;27:418-422.
44. Ernst C, Foldenyi M, Angst J. The Zurich study: Sexual dysfunction and disturbances in young adults. Data of a longitudinal epidemiological study. Eur Arch Psychiatry Clin Neurosci. 1993;243:179-188.
45. Freund B, Steketee G. Sexual history, attitudes and functioning of obsessive-compulsive patients. J Sex Marital Ther. 1989;15:31-41.
46. Aksaray G, Yelken B, Kaptanoglu C, et al. Sexuality in women with obsessive compulsive disorder. J Sex Marital Ther. 2001;27:273-277.
47. Vulink NC, Denys D, Bus L, Westenberg HG. Sexual pleasure in women with obsessive-compulsive disorder? J Affect Disord. 2006;91:19-25.
48. Lensi P, Cassano GB, Correddu G, et al. Obsessive-compulsive disorder: familial-developmental history, symptomatology, comorbidity and course with special reference to gender-related differences. Br J Psychiatry. 1996;169:101-107.
49. Zatzick DF, Marmar CR, Weiss DS, et al. Posttraumatic stress disorder and functioning and quality of life outcomes in nationally representative sample of male Vietnam veterans. Am J Psychiatry. 1997;154:1690-1695.
50. Solrush LP, Solrush DS. Male erectile disorders in Vietnam combat veterans with chronic post traumatic stress disorder. Special issue: Sexuality and disability in adolescence and beyond. Int J Adolesc Med Health. 1994;7:119-124.
51. Cosgrove DJ, Gordon Z, Bernie JE, et al. Sexual dysfunction in combat veterans with post-traumatic stress disorder. Urology. 2002;60:881-884.
52. Kotler M, Cohen H, Aizenberg D, et al. Sexual dysfunction in male posttraumatic stress disorder patients. Psychother Psychosom. 2000;69:309-315.
53. Althof SE, Leiblum SR, Chevret-Measson M, et al. Psychological and interpersonal dimensions of sexual function and dysfunction. J Sex Med. 2005;2:793-800.
54. Cavallini G. Fluoxetine in the treatment of psychogenic impotence secondary to premature ejaculation. Eur Urol. 1996;3:48.
55. Power-Smith P. Beneficial sexual side-effects from fluoxetine. Br J Psychiatry. 1994;164:249-250.
56. Smith DM, Levitte SS. Association of fluoxetine and return of sexual potency in three elderly men. J Clin Psychiatry. 1998;54:317-319.
57. Shabsigh R, Anastasiades A, Cooper KL, Rutman MP. Female sexual dysfunction, voiding symptoms and depression: common findings in partners of men with erectile dysfunction. World J Urol. 2006;24:653-656.
The Relationship Between Anxiety Disorders and Sexual Dysfunction

This article originally appeared in:

Psychiatric Times

It is reprinted here with permission.


Laurie Martin

 

APA Reference
Corretti,, G. (2011). The Relationship Between Anxiety Disorders and Sexual Dysfunction. Psych Central. Retrieved on August 19, 2018, from https://pro.psychcentral.com/the-relationship-between-anxiety-disorders-and-sexual-dysfunction/

 

Scientifically Reviewed
Last updated: 19 Apr 2011
Last reviewed: By John M. Grohol, Psy.D. on 19 Apr 2011
Published on PsychCentral.com. All rights reserved.