Sexual Performance Anxiety

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 Sexual Dysfunctions. 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). Sympathetic dominance is also negatively involved in the arousal and orgasm phases and may interfere with sexual desire.

Psychological elements are generally considered important in the pathogenesis of Sexual Dysfunction, 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 Sexual Dysfunction, 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 Sexual Dysfunction.
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.

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. Hyperarousal syndromes, such as persistent sexual arousal, are not found in DSM-IV-TR. The specific role of anxiety in these cases is unknown.

An anxious experience represented the trigger. 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 orgasm, few studies have examined this relationship or tried to identify specific aspects of anxiety related to impaired orgasm.

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).

This has been explained as being caused by a sympathetic hyperactivity that reduces ejaculation control. 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.

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 link between social phobia and Premature Ejaculation was also substantiated by reports of 2 cases in which worry about social performance led to uncontrolled ejaculation.

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