Sexual dysfunction: a neglected complication of panic disorder and social phobia

Considerations for an evidence-based definition of premature ejaculation in the DSM-V

INTRODUCTION

The Diagnostic and Statistical Manual of Mental Disorders, 4th Ed., text revision (DSM-IV-TR) criteria for premature ejaculation (PE) have been criticized on multiple grounds including that the criteria lack precision, that the requirement of marked distress is inappropriate, and that the specification of etiological subtypes should be deleted. Since these criteria were originally adopted, there has been a tremendous gain in knowledge concerning PE.

AIM

The goal of this manuscript is to review evidence relevant to diagnostic criteria for PE published since 1990.

METHOD

Medline searches from 1990 forward were conducted using the terms PE, rapid ejaculation, ejaculatory disorder, and intravaginal ejaculatory latency. Early drafts of proposed alterations in diagnostic criteria were submitted to advisors.

MAIN OUTCOME MEASURE

Expert opinion was based on review of evidence-based medical literature.

RESULTS

The literature search indicated possible alterations in diagnostic criteria for PE.

CONCLUSIONS

It is recommended that the Diagnostic and Statistical Manual committee adopt criteria similar to those adopted by the International Society of Sexual Medicine. It is proposed that lifelong PE in heterosexual men be defined as ejaculation occurring within approximately 1 minute of vaginal penetration on 75% of occasions for at least 6 months. Field trials will be necessary to determine if these criteria can be applied to acquired PE and whether analogous criteria can be applied to ejaculatory latencies in other sexual activities. Serious consideration should be given to changing the name from PE to rapid ejaculation. The subtypes indicating etiology should be eliminated.

Testosterone deficiency in the aging male and its relationship with sexual dysfunction and cardiovascular diseases

: The relationship between age-associated dec-line of testosterone (T), cardiovascular (CV) risk and sexual dysfunction in males is not completely clear. The aim of the present study was to report our experience in a large series of patients seeking medical care for sexual dysfunction and comparing our results with current evidence.

: Here, we review published data from our laboratory and reported data from a cross-sectional analysis on a consecutive series of 3149 patients seeking medical care at our Unit for sexual dysfunction (between 2000 and 2010). Among them, 1687 (studied between 2000 and 2007) patients were also longitudinally evaluated (mean follow-up 4.3±2.6 years) for forthcoming major cardiovascular events (MACEs). All major findings were discussed in comparison with data reported in the literature.

: T levels were associated with a wide array of biological and psychological factors, which substantially differ as a function of age. Some of these associations were more evident in the youngest patients (psychological symptoms), whereas sexual symptoms, including erectile function, sexual desire and the frequency of sexual intercourse, were associated with T levels only in the oldest patients. We did not find any association between T and MACEs, whereas we reported a close link between CV mortality and low T. Both these observations are in line with data obtained in community-dwelling men.

: T plays a crucial role in regulating different aspects of male sexual function. The effect of T on CV risk needs to be confirmed in larger epidemiological and interventional studies.

Sexual dysfunction in depression and anxiety: conceptualizing sexual dysfunction as part of an internalizing dimension

Sexual dysfunction is often implicated in depression and anxiety disorders, but the current nosology of sexual dysfunction, depression, and anxiety (i.e., DSM-IV) does not adequately address these relationships. Because recent papers (Krueger, R. F., & Markon, K. E. (2006). Reinterpreting comorbidity: A model-based approach to understanding and classifying psychopathology. Annual Review of Clinical Psychology, 2, 111-133) have suggested and provided evidence for latent internalizing and externalizing dimensions that help explain high comorbidity between mental disorders, the current paper suggests that sexual dysfunction might conceptually belong to a latent internalizing factor. To address this, evidence is presented for the relationship among disorders of sexual desire, arousal, and orgasm comorbid with depression and anxiety. A review of sexual disorders is also presented along with a critical examination of the way the current DSM is organized with respect to sexual dysfunction, depression, and anxiety.

Evaluation of the female sexual function index in a population based sample from Finland

The factor structure and reliability of the Female Sexual Function Index (FSFI) was evaluated in a Finnish population based sample of 2,081 women, age 33-43 years. In addition, associations between female sexual function and age, psychological distress, alcohol use, hormone based contraceptives, child sexual abuse (CSA), and adult sexual abuse were examined. The results supported a six factor solution for the FSFI with high internal consistencies, in line with earlier research in clinical populations. Psychological distress was positively associated with every dimension of the FSFI except desire problems. Age was associated with fewer pain problems. Alcohol use was associated with every dimension of the FSFI, but the direction of the association depended on if it was drinking in general or in connection to intercourse. More drinking in general was related to fewer sexual function problems while drinking in connection to intercourse was related to more sexual function problems. No significant correlation was found between adult sexual abuse and sexual function but between CSA and lubrication, satisfaction, and pain problems. Usage of oral contraceptive pill was not significantly associated with sexual function. The use of hormone based intrauterine systems was significantly associated with less pain and more desire, arousal, and satisfaction. In conclusion, the study supports use of the FSFI for assessing sexual function not only in clinical samples but also in population based samples. The associations found between sexual function and other important variables showed the complexity of sexual function.

Rapid ejaculation: a review of nosology, prevalence and treatment

Information concerning the epidemiology, etiology and treatment of premature (rapid) ejaculation is reviewed. Evidence concerning the prevalence of premature ejaculation indicates that subjective concern about rapid ejaculation is a common concern worldwide. Hypotheses concerning the pathogenesis of premature ejaculation include: (1) that it is a learned pattern of ejaculation maintained by interpersonal anxiety, (2) that it is the result of dysfunction in central or peripheral mechanisms regulating ejaculatory thresholds and (3) that it is a normal variant in ejaculatory latency. Current evidence based treatment interventions include behavioral psychotherapy and the use of pharmacological agents, including topical anesthetic agents and selective serotonin reuptake inhibitors.

Sexual function and dysfunction in Brazilian patients with obsessive-compulsive disorder and social anxiety disorder

We compared the history, the profile, and the severity of sexual symptoms of 31 patients with obsessive-compulsive disorder (OCD) to those of 26 patients with social anxiety disorder (SAD) by means of the Sexual Inventory of the Institute of Psychiatry of the Federal University of Rio de Janeiro, the Clinical Interview for the Diagnosis of DSM-IV Sexual Disorders, the Female Sexual Function Index, the International Index of Erectile Function, the Arizona Sexual Experience Scale, and the Sexual Behavior Inventory. Patients with OCD reported more difficulties to reach orgasm (p = 0.009), less frequent effective erections (p = 0.05), and a positive history of sexual abuse (p = 0.006) significantly more often than patients with SAD. Male patients with SAD reported not using contraceptive methods significantly more frequently than male patients with OCD (p = 0.007). Patients with OCD and patients with SAD exhibit different profiles of sexual behavior.

Social phobia and premature ejaculation: a case-control study

In a previous case-control study, we found marked differences between a group of patients with male sexual disorders and a control group without any sexual disorder regarding the percentage of social phobia (SP) in each group. On this basis, our aim in this study was to test the hypothesis that premature ejaculation (PE) as a specific sexual disorder and SP might be strongly related, by comparing subjects with PE to a control group without any sexual disorder regarding the diagnosis of SP. Subjects with PE were recruited at private practice sexology settings in France. Control subjects were recruited among inpatients in a surgical ward. Diagnosis of SP was made with the Composite International Diagnostic Interview. Diagnosis of PE was clinician-rated according to DSM-IV criteria. Eighty-five subjects with PE only were compared to 93 control subjects without any sexual disorder. Forty (47%) subjects with PE versus 8 (9%) controls were diagnosed with SP (chi(2)=3.35, df=1, P=.001). Logistical analysis showed that SP and PE were strongly associated (odds ratio=10.97, 95% CI=4.49-26.06; chi(2)=28.28, df=1, P=.0001). This study is the first to show a clear relationship between SP and PE. Although requiring confirmation by further studies, this finding has immediate clinical consequences given that SP and PE can be treated by the same medication, a selective serotonin-reuptake inhibitor (SSRI). Moreover, since SP is a likely risk factor for PE, this might argue for preventive action on both disorders in children.

Comorbidity between social phobia and premature ejaculation: study on 242 males affected by sexual disorders

Several studies have reported high comorbidity between psychiatric and sexual disorders, particularly between anxiety and mood disorders and sexual dysfunction. The goal of the present study is to examine the comorbidity between premature ejaculation and Axis I psychiatric disorders. Of 242 males referred to an outpatient clinic of sexology between November 2000 and July 2003, 52 were diagnosed with premature ejaculation (PE). These patients were also administered the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID; First, Spitzer, Gibbon, & Williams, 1995) for the evaluation of Axis I psychiatric disorders and a modified SCID based on Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 2000) criteria for the evaluation of sexual disorders. We also determined the age of onset of the disorders. We found that 21.5% of the overall clinical population was affected by PE, and 64.4% of PE patients were affected by at least one Axis I psychiatric disorder. PE was highly associated (p=0.015) with social phobia (SP), with an odds ratio of 2.55. The debut of SP preceded the onset of PE. Social phobia may represent risk factor for the development of PE, and adrenergic hyperactivity may represent a pathophysiology common to both disorders.

Sexual dysfunction in female patients with panic disorder alone or with accompanying depression

Objective. The aim of this study was to evaluate sexual dysfunction in female patients with panic disorder and to investigate the impact of accompanying depression with regard to sexual dysfunction. Method. Twelve patients who met the diagnostic criteria for panic disorder without depression (P) and 28 patients who met the diagnostic criteria for panic disorder with depression (PD) were compared to 13 control cases (C). Arizona Sexual Experience Scale (ASEX) was used to measure sexual experience. Results. ASEX scores were significantly different between the three groups (P=0.001). In two group comparisons sexual desire and aversion subscores of ASEX were significantly decreased in group PD when compared with groups P and C (P=0.01). Also, our results show that the difference of orgasmic experience subscore of ASEX in groups PD and C was found to be statistically significant (P=0.01). On the other hand, there was no statistical difference between P and PD groups in terms of orgasmic experience (P=0.16). Conclusion. These results suggest that decreased sexual desire and high sexual aversion may be presenting symptoms of depression in patients with panic disorder. If there is no depression, patients with panic disorder should be questioned especially for orgasmic problems.

The impact of anxiety on sexual arousal in women

This study examined the impact of state anxiety, trait anxiety, and anxiety sensitivity on physiological and self-report measures of sexual arousal and sexual function in a non-clinical sample of women. Physiological sexual responses to an erotic stimulus were assessed using vaginal photoplethysmography, and subjective reactions were measured using questionnaires. Results suggested a curvilinear relationship between state anxiety and physiological sexual arousal (vaginal pulse amplitude; VPA). Trait anxiety and anxiety sensitivity were correlated with self-reported sexual arousal outside the laboratory. The findings may be interpreted in light of sympathetic nervous system (SNS) influences on sexual arousal and potential cognitive interference mechanisms associated with anxiety.

Individual differences in male rat ejaculatory behaviour: searching for models to study ejaculation disorders

In addition to investigating sexual function in rats that display normal ejaculatory behaviour, studying rats that are either 'hyposexual' or 'hypersexual' may provide important insights into the aetiology of ejaculatory dysfunctions in men, such as premature and retarded ejaculation. To this end, rats were matched into groups of 'sluggish', 'normal' and 'rapid' ejaculators based on their ejaculation frequencies displayed in a series of weekly sexual behaviour tests. Selecting rats on this parameter revealed large and stable differences in other parameters of sexual behaviour as well, including ejaculation latency and mount frequency but not intromission frequency and mount latency, putative indices of sexual motivation. Neuroanatomically, Fos immunoreactivity as a measure of neuronal activation was increased in rapid ejaculators compared with sluggish ejaculators in ejaculation-related brain areas, presumably associated with the differences in ejaculatory behaviour. Although the total number of oxytocin neurones within subregions of the hypothalamus did not differ between groups, in the supraoptic nucleus of the hypothalamus more oxytocin neurones were activated in rapid ejaculators compared with the other groups. Apart from the differences observed in ejaculatory behaviour, groups did not differ with respect to their locomotor activity and approach-avoidance behaviour as measured in the elevated plus-maze. Finally, apomorphine-induced stereotypy was similar in sluggish and rapid ejaculators, suggesting no large differences in dopamine susceptibility. Altogether, the present results suggest stable differences in male rat ejaculatory behaviour. Further exploring the neurobiological mechanisms underlying these differences may be a promising approach to gain insights into the aetiology of sexual dysfunctions such as premature, retarded or an-ejaculation.

Erectile and ejaculatory problems in gay and heterosexual men

The prevalence of erectile difficulties (ED) and problems with rapid ejaculation (RE) were studied in a convenience sample of gay men (n = 1379) and an age-matched sample of heterosexual men (n = 1558). ED was reported more frequently by gay men and RE more frequently by heterosexual men. The heterosexual men were more likely to be in exclusive relationships and those in a current relationship (exclusive or non-exclusive) were more likely to report ED than those not in a relationship. Heterosexual men in an exclusive relationship were more likely to report RE than the rest. These associations were not found in the gay sample. The following personality traits were assessed as possible predictors of ED and RE: sexual inhibition proneness (SIS1 and SIS2), sexual excitation proneness, impact of mood on sexuality, and trait measures of depression and anxiety. Age and SIS1 (inhibition due to threat of performance failure) were strong predictors of ED in both gay and heterosexual men. Gay men scored higher on SIS1 whether or not they reported ED, consistent with greater concerns about performance failure in gay men. Anxiety was predictive of RE, but only in the heterosexual men. If replicated in other samples, these differences may reflect a greater importance of erectile function in the sexual lives of gay men and greater importance of ejaculatory control in heterosexual relationships.

A case–control study of erectile dysfunction among men diagnosed with panic disorder

The association between panic disorder and erectile dysfunction (ED) among men was examined in the Integrated Healthcare Information Services National Managed Care Benchmark Database (IHCIS). The IHCIS is a fully de-identified, HIPAA compliant database and includes complete medical history for more than 17 million managed care lives; data from more than 30 US health plans, covering seven census regions; and patient demographics, including morbidity, age and gender. A total of 60,949 ED cases and 243,796 controls were included for analysis. Unconditional logistic regression analyses were first performed to assess the crude risk of ED, and adjusted risks of ED that accounted for comorbid conditions and comedications. A second set of analyses measured the crude and adjusted risks after restricting the patient population to men who were diagnosed with panic disorder at least 1 month prior to an ED diagnosis. In the first set of analyses, men with panic disorder were observed to have more than a two-fold increase in risk for ED (OR=2.29, 95% CI=2.03, 2.58). After adjusting for comorbid conditions, a 52% increase in risk of ED was observed (OR=1.52, 95% CI=1.34, 1.72). Following subsequent adjustment for comorbidities and comedications, a 33% increased risk of ED was detected (OR=1.33, 95% CI=1.17, 1.51). In the second set of analyses studying panic disorder that preceded ED, only a 13% higher risk was noted (OR=1.13, 95% CI=0.97, 1.31). However, after adjusting for comorbid conditions, a 25% reduction in risk was observed (OR=0.75, 95% CI=0.64, 0.88). A 35% risk reduction was seen after adjusting for comorbidities and comedications (OR=0.65, 95% CI=0.56, 0.77).

Frequency of marital intercourse among patients with psychiatric and psychosomatic disorders in Japan

This study investigated the frequency of marital intercourse in 951 patients with psychiatric and psychosomatic disorders and compared it to that in a normative sample. Only fourteen percent of the patient group had sexual intercourse more than once per week; thirty-nine percent were sexually inactive. The groups of patients with eating disorders, mood disorders, or any mental or behavioral disorders complicated by organic diseases such as cancer, ischemic heart disease, and other physical disorders had fewer mean coital frequencies than the controls, whereas the coital frequency of patients with anxiety disorders, somatoform disorders, sleep disorders, or psychosomatic disorders did not differ significantly from that of controls.