Understanding psychogenic erectile dysfunction - the most common ED in young men

What is psychogenic erectile dysfunction?

Let’s discuss what psychogenic erectile dysfunction (ED) is and how it should be diagnosed and treated. Psychogenic sexual dysfunctions, which include ED, are the result of the systemic interaction of a number of unfavorable factors: situational, traumatic, partner problems and characteristics of personal response. As a rule, several of the above reasons play a role in the development of psychogenic erectile dysfunction in men. Treatment for psychogenic ED includes psychotherapy and pharmacotherapy. The main group of drugs used for ED is type 5 phosphodiesterase inhibitors, the progenitor of which was Sildenafil (Viagra).

Of all the physiological sexual reactions of a man, erection is the simplest and most phylogenetically ancient, since it is mediated only by vascular and neurogenic mechanisms. An erection can occur due to reflex mechanisms even without sexual desire and arousal. This distinguishes it, for example, from ejaculation, in which motor and excretory functions are also involved. Paradoxically, at the same time, an erection is also the most vulnerable link in a series of psychosexual reactions of a man.

Male sexuality is essentially “phallocentric” (the phallus is the erect penis as opposed to the penis, the resting penis). The presence of an erection (phallus) proves “male competence”, “potency”, that is, the possibility of sexual intercourse itself. In all human cultures, the phallus, symbolically and mythologically, has always been a symbol of power, strength and power. At a subconscious psychological level, for a man, the most significant is not the actual sexual act, but the possibility of it. Therefore, erectile dysfunction is perceived not only as a sexual failure, but also as a collapse of male consistency in general. That is why the Latin term impotentia coeundi has outlived its usefulness and has not been used in international literature in the last decade. It is viewed as outdated, inaccurate and unreasonably having a judgmental subtext that humiliates human (personal) dignity. Instead of "impotence" today we speak of "erectile dysfunction" (ED).

At a young age, psychogenic erectile dysfunction is 4–5 times more common.

ED refers to the inability to achieve or maintain an erection at a level sufficient for copulation in at least 25% of attempts to have intercourse. Psychogenic ED can occur at any age and comes in many forms. More often men complain of a weak erection, which does not allow them to insert the penis into the vagina. Sometimes the patient has a fairly strong erection, but when trying to copulate, it quickly disappears. In other cases, a man is able to achieve a normal erection only under certain specific conditions.

What causes problems with erection?

Erection is driven by two mechanisms. The first is a reflex erection that occurs when the penis is touched, the second is a psychogenic erection that occurs as a result of erotic stimuli. Reflex erection is controlled by peripheral nerves and centers located in the lower spinal cord. Psychogenic erection is controlled by the limbic system of the brain. With the development of a reflex erection, stimulation of the penis causes the release of nitric oxide, which in turn leads to relaxation of the vascular walls in the cavernous bodies of the penis. They fill with blood and an erection occurs. An adequate level of testosterone in the blood is also required for the development of an erection. Thus, erectile dysfunction can occur due to disorders of the hormonal system, diseases of the nervous system, insufficient blood supply to the penis, or psychological problems. In any case, sexual response is a psychosomatic process, and both psychological and somatic factors are usually involved in the origin of sexual disorders. Most often, especially with erectile dysfunction in mature age, it is difficult to determine the relative importance of certain factors; then such disorders can be defined as mixed.

Erectile dysfunction statistics

Globally, more than 80 million young men suffer from ED; over the age of 40, their number doubles.

According to European and American researchers, more than 80 million young men suffer from ED worldwide; over the age of 40, their number doubles. There is a constant debate between specialists: what is more common - erectile dysfunction for psychological reasons or for organic, that is, due to vascular, neurological, urological, endocrine diseases? Psychotherapists, especially the psychoanalytic direction, confidently assess the ratio of psychogenic and organic disorders as 80:20. The leading urologists cite the exact same ratio, but in favor of the organic nature of erectile dysfunction. In fact, both indicators are correct, but only taking into account the age aspect: at a young age, psychogenic disorders are 4–5 times more common, at the age of 40–45 the ratio becomes 50: 50, and then organic causes begin to steadily prevail, and by 65 -years of age, they account for 90% of all causes of erectile dysfunction.

When should you think of treating erectile dysfunction?

Some failures (lack of an erection or its loss at the most inopportune time) can occur in any man - this is quite normal. Such isolated episodes do not indicate sexual weakness; they can be the result of temporary physical stress or some psychological factors (tension, lack of privacy, or the need to get comfortable with a new partner). If a man, instead of taking such incidents calmly, begins to fixate on his failure, think about whether he will be able to achieve an erection the next time, he thereby creates the basis for the emergence of real difficulties. A man's reaction to erectile dysfunction is very diverse - from horror and confusion (probably the most common reaction) to complete indifference (the least typical).

If you have occasional failures to develop erection, you don’t need to go to a doctor. But if it seems to you that the problem occurs more than once in four intercourses then it’s time to look for the underlying reason.

Factors causing erectile dysfunction in young men

Psychogenic sexual dysfunctions include functional psychogenic sexual disorders that arise with the direct participation of psychological mechanisms and are manifested by qualitative or quantitative disorders that are not associated with organic pathology. Here it is necessary to clarify that erectile dysfunction that occurs in severe mental illness, sexual perversion, are actually not psychogenic, but psychopathological (psychiatric) disorders. Most often they are mediated by endogenous mechanisms and are not associated with psychological stress. This is becoming especially relevant at the present time in connection with a change in the attitude towards depression as an endogenous rather than psychogenic disease. That is, erectile dysfunction with obvious depression should not be considered as psychogenic and, accordingly, should be treated according to completely different principles, which will be discussed below.

Psychogenic sexual dysfunctions are the result of the systemic interaction of a number of unfavorable factors: situational, traumatic, partner problems, and characteristics of personal response.
 
Situational factors include the lack of conditions for complete privacy; the ability to be caught off guard by other people; fear of unwanted pregnancy; fear of contracting a venereal (sexually transmitted) disease; an actual mental or physical “weakened state” due to fatigue, prior stress, somatic malaise, alcoholic intoxication; improper conduct of the preliminary period of sexual intercourse, when the occurrence of transcendental inhibition as a result of super-strong excitation of the genital centers from too long foreplay leads to a breakdown of the physiological program; external stimulus of considerable strength (sudden shout, knock, scream, shot), leading to a disruption of sexual intercourse by the mechanisms of external inhibition; a very long period of "sexual abstinence" (in the absence of masturbatory activity), when due to "lack of training" time is needed for a gradual full restoration of function.

Psychogenic ED can develop as a result of even a seemingly insignificant fact such as the impossibility of having intercourse with a condom. The policies of many pharmaceutical companies, heavily influenced by the media, lead many young people to believe that sex without a condom is completely unacceptable. Meanwhile, for a number of psychological reasons, putting a condom on the penis is a certain stress for a man, which is often completely incompatible with a normal erection.

Traumatic experiences can be painful memories of previous sexual failures, including the partner's dissatisfaction with the quality of sexual intercourse; anxious fears about their own sexual inferiority and the fear of being rejected if you cannot “satisfy” your partner properly; fear of losing an erection or premature ejaculation.

Relationship problems are a violation of interpersonal relationships, frequent conflicts, and growing negative emotions; mutual distrust or cooling of partners; inappropriate behavior of a sexual partner, who can behave aggressively, derisively, or demonstrates coldness and unwillingness to intimacy; difference in sexual preferences (range of acceptability, sexual technique) and disharmonious sexual interaction between partners.

Personal characteristics include anxious and suspicious character traits; low self-esteem; the tendency to constant self-control during intercourse; an unattainable in reality setting for maximum satisfaction from each sexual contact; erroneous attitudes regarding sexuality (due to the lack of correct knowledge about sexual life, due to improper upbringing or personal negative experience of intimate contacts); unconscious hostility to the opposite sex; feelings of guilt in connection with sexual pleasure, as well as a deep fear of intimacy in a romantic relationship.

Sexual disorder can also be caused by sexual illiteracy and blind faith in myths. An example of the influence of cultural myths on the formation of people's attitudes towards sex and their sexual behavior is, in particular, the conviction that sexual functions necessarily fade with age, or that a man must necessarily be the initiator and leader in sexual relations.

As a rule, several of the above reasons play a role in the development of psychogenic erectile dysfunction in men. Of great importance is the so-called “the sexual constitution” of a particular man. Sexual constitution in sexology is understood as a set of innate properties (anatomical, physiological, hormonal, etc.) of the organism, which determines the individual need for sexual activity, its maximum value and resistance of the genital area to pathogenic influences. Naturally, the weaker is the sexual constitution of a particular man, the easier external mental influences can trigger the development of sexual dysfunctions.

The most common form of psychogenic disorder leading to ED is anxious expectation of failure syndrome. A typical stereotype of the development of this disorder is as follows. An accidental, often situationally-conditioned sexual failure in the form of a sharp decrease or even disappearance of an erection raises doubts about one's own abilities, prevents the next sexual intimacy. Fear of possible failure - "Will I be able to keep an erection?", "Will I be able to satisfy my partner?" - leads to oppression of sexual arousal and loss of erection. The stronger these fears, the higher the likelihood that they will come true (on the principle of self-hypnosis), and the man will begin to feel a genuine inability to achieve an erection and keep it. Over time, fear of failure can cause a weakening of interest in sex (avoidance), loss of self-esteem and attempts to overcome insecurity (this usually violates the immediacy of intercourse, increasingly turning it from pleasure into some kind of “action”).

In addition, fear of failure often turns one or both partners into observers, observing and evaluating their own sexual response or the response of the partner. Distracted by observation and assessment of what is happening, a man usually gets less pleasure from sexual activity, which further inhibits his ability to react physically. Thus, a vicious circle is created: a weak erection causes fear of failure, which prompts to become an observer, and this distracts and contributes to erectile dysfunction, increasing the fear of failure. If you do not break this circle, then it is very likely that the erectile dysfunction will be firmly fixed. With the long-term existence of obsessive fear, many men compensatory begin to seek pleasure in other spheres: they overeat, abuse alcohol, look for new hobbies, become “workaholics”, etc.

Very often psychogenic influences are leading in combined erectile dysfunction. For example, the first manifestations of insufficient blood supply to the genitals (due to arteriosclerosis, arterial hypertension, diabetes mellitus) can lead to a slightly decreased erection, its periodic weakening during intercourse, an increase in the period of time until a new erection appears after completed coitus. Sometimes reproaches from a partner, fixation of attention on their own sexual reactions lead to an increase in erectile breakdowns by the mechanism of anxiously obsessive expectation of failure, which is significantly aggravated by insufficient blood supply. Even an effective correction of genital blood flow with the restoration of a sufficient supply of arterial and venous blood does not lead in most patients to normalization of sexual intercourse as long as the obsessive fear of expecting a fiasco persists.

Difference in manifestation of psychogenic and organic erectile dysfunction

Diagnostic signs of psychogenic ED:

1. Sudden onset of the disease.
2. Preserved spontaneous erections during sleep and on awakening in the morning.
3. The presence of erections during masturbation.
4. The episodic nature of erection problems.
5. The emergence of an erection during foreplay with its subsequent weakening when trying to actually have sexual intercourse.
6. The appearance of an erection in situations that provoke sexual arousal, if a man excludes the possibility of sexual intercourse.
7. Selectivity of erectile dysfunction (problems may arise with a specific partner or only in certain situations).
8. Restoration of normal erection after the elimination of external problems.

Treatment for psychogenic ED includes psychotherapy and pharmacotherapy. Psychotherapy is an etiopathogenetic treatment aimed at relieving anxiety and fear of coitus. Behavioral methods are used more often, including the so-called sex therapy, first proposed by the classics of sexological science W. Masters and W. Johnson.

Pharmacotherapy until recently was limited to symptomatic drugs - tranquilizers, which relieve anxiety only for a short time, as well as yohimbine, nicergoline, the mechanism of action of which was associated only with the placebo effect. The situation has changed dramatically in the last 10 years after the appearance in the arsenal of doctors of phosphodiesterase type 5 inhibitors, the founder of which and the most famous representative of the group is the famous Viagra (Sildenafil). Sildenafil and other PDE-5 inbitors Tadalafil (Cialis) and Vardenafil (Levitra) and their generic versions are used for ED of any cause, and with its vascular variant they are the best drugs. Viagra, Cialis, Levitra and their generics are also widely used for psychogenic forms of ED. The powerful vascular effect, which always manifests itself in the presence of sexual desire and stimulation, can be an excellent means of additional psychological protection (“I have nothing to fear, Viagra/Cialis/Vardenafil will help me, even if I panic a little and my erection starts to decrease ...”).

The use of PDE-5 inhibitors should be continued until the psychological defense is restored, it will actually be a “lifesaver”. In this case, the effect of the drug will be both symptomatic and pathogenetic, i.e. eliminating the cause, i.e. psychological pressure. But it must be borne in mind that a strong fear of a possible sexual failure can reduce even the powerful effect of Viagra or Cialis due to violations of the tone of the genital arteries and biochemical imbalance in the cavernous tissue. Therefore, with true psychogenic ED, psychotherapy should be carried out in parallel with the appointment of erection enhancing drugs.

As for the difference between the medications for ED, they mostly differ in the time of effect. Also, if you are allergic to one medicine, you can try to use another, just make sure that you are not buying the same drug under the different trademark.

The longest acting erection-enhancing medication is Tadalafil that is proven to be effective for up to 36 hours (the time depends on the dosage and metabolism of a man). Viagra acts only for 4-6 hours but it is more studied and used for more years in medical practice. Whatever drug you chose, make sure to check the contraindications listed in the package insert or consult your doctor to be sure that the pills won’t do any harm to your health if you already have any health conditions.

Post by: Rachel Lewis, Senior Medical Advisor at Medibank, Sydney, New South Wales, Australia