ANXIOUS SEXUAL FAILURE EXPECTATION SYNDROME IN MEN AND CHARACTERISTICS OF SEXUAL DYSFUNCTION
G. S. Kocharyan
Ukrainian Institute of Advanced Training for Doctors
Special literature does not have any data about the rate of anxious sexual failure expectation syndrome (ASFES). The available researches make it possible to form only indirect judgments. As an example it is possible to cite statistical data about sexual disorders in psychopathological disturbances with prevalence of exogenous (reactive, situational) factors and primary affection of the sexual sphere. These disorders fulfill the dominant (“pivotal”) function in the organization of sexual disturbances in 23.1 % of patients according to G. S. Vasilchenko’s data [2], or in 43.2 % according to R. P. Kondratenko’s data [3]. At the same time among the disorders from the above classification heading the anxious-phobic forms, into which we should put the overwhelming majority of cases with ASFES, take 61.6 % [2]. The above syndrome is revealed in males with sexual disorders so often (in 20.6 % – G. S. Kocharyan [6]), that in fact it can be called one of the most universal sexopathological syndromes [5]. Nevertheless until recent time [6] it did not become the subject of any comprehensive advanced study, this fact having an impact on the state of knowledge about sexual dysfunctions and mechanisms of their formation in males with the above pathology.
In order to study sexual dysfunctions and formation of symptoms in patients with ASFES we thoroughly examined 254 patients at the age of 16-69 years. In these patients mostly neuroses were diagnosed. Despite the presence of ASFES, 5 cases (2.0 ± 0.9 %) did not reveal any copulative disturbances (imaginary sexual disorders). Three patients (1.2 ± 0.7 %) had only predictable symptoms, because after the appearance of ASFES they did not make any attempts to have intimacy. One patient (0.4 ± 0.4 %) did not live a sex life during last 7 years, and therefore it was difficult to prognosticate the concrete character of his copulative disturbances. Analysis of symptoms in the remaining 245 patients (general group) showed that in compliance with their rate decrease the order was as follows. Disorders of erection were in 214 people (87.3 ± 2.1 %), of ejaculation in 121 (49.4 ± 3.2 %), of libido in 65 (26.5 ± 2.8 %), of orgasm in 33 (13.5 ± 2.2 %). Prevailing among ejaculation disorders was premature ejaculation – 114 patients (94.2 ± 2.1 %). Delayed ejaculation was observed in 5 cases (4.1 ± 1.8 %), and anejaculation in 2 (1.7 ± 1.2 %).
Besides the above symptoms, some patients had the symptom of sexual hypoesthesia-anesthesia, and one patient had the symptom of sexual hyperesthesia. A special inquiry of 67 patients revealed that a mild degree in the decrease of acuity of contact perception of their female partner during intimacy was in 15 men (22.4 ± 5.1 %), a moderate degree in 11 (16.4 ± 4.5 %) and a marked degree in 6 (9.0 ± 3.5 %). The total loss of this perception was found out in 2 patients (3.0 ± 2.1 %), while 32 men (47.8 ± 6.1 %) did not feel any decrease of the above perception, and one person (1.5 ± 1.5 %) even felt its increase. Thus the total number of patients with a partial or total blockade of contact perception of their female partner was 34 people (50.7 ± 6.1 %). Characterizing sexual-erotic hypoesthesia-anesthesia, we would like to emphasize that usually its degree is not rigidly fixed. As a rule, it changes in compliance with the fluctuation of intensity of anxious failure expectation and the degree of hypercontrol over penile tension. Thus, for example, the intensity of contact perception of his female partner by one of our male patients during the preliminary period gradually decreased from 100 to 20 %, this intensity depending upon the above factors. In a number of cases we stated the undulating character of changes in the intensity of this perception, when this intensity repeatedly changed during intimacy: at one moment decreasing, at another moment increasing again.
Analysis of the only case, where we revealed sexual hyperesthesia, demonstrated that the intensity of sensations during contacts with the female partner in that case was probably caused by basic pathology (paracentral lobule syndrome), typical for which is lowering of the threshold of sexual excitability.
In order to characterize sexual dysfunctions, observed in relatively “clean” forms of anxious failure expectation syndrome, we selected 113 (“cleaned” group) from the above 245 cases. In this group ASFES played the main part in the organization of sexual disorders and, besides affection of the psychic component of the copulative cycle, only background syndromes could be revealed and these demonstrated deficiency of the neurohumoral component (delay or disharmony of the puberty). Also in a number of observations chronic prostatitis was diagnosed, but findings of the clinical analysis showed that it did not participate in the development of sexual disorders in those cases. The symptoms, revealed in the above group of patients, were in the following order according to their rate decrease: disorders of erection were in 107 people (94.7 ± 2.1 %), of ejaculation in 26 (23.0 ± 4.0 %), of libido in 22 (19.5 ± 3.7 %), of orgasm in 7 (6.2 ± 2.3 %). Characterizing ejaculation disorders, we should note that among them premature ejaculation was in 25 men (96.2 ± 3.7 %), delayed ejaculation and anejaculation in 1 (3.8 ± 3.7 %). Analysis of causes of development of ejaculation disorders in the “cleaned” group showed that in 10 of 26 patients (38.5 ± 9.5 %), who had these symptoms, the duration of coitus was influenced by such factors as sexual dysrhythmia and frustration, while in some cases the above disorders were caused by erectile disturbances. Besides, paracentral lobule syndrome was suspected in 1 patient (3.8 ± 3.7 %). After exclusion of these 11 observations with a clear manifestation of factors, which did not depend on ASFES directly, the number of patients with a possible direct effect of ASFES became 15 people (13.3 ± 3.2 %). At the same time it should be emphasized that the above factors, not caused by the direct influence of ASFES, could be associated with its indirect effect.
Thus, when the group of patients with relatively “clean” forms of ASFES was compared with the general group of patients having the above syndrome, the rate of revealing different sexological symptoms in the former group changed. For example, erectile disturbances became reliably more common (from 87.3 ± 2.1 % in the general group to 94.2 ± 2.1 % in the “cleaned” one; р < 0.02). At the same time, ejaculation disorders were observed significantly less frequently (23.0 ± 4.0 % in the “cleaned” group versus 49.4 ± 3.2 % in the general one, р < 0.001). But if we take into consideration only those ones, where a direct effect of ASFES could not be excluded, then we could state a mild predominance of libido disorders over ejaculation ones in the “cleaned” group (respectively, 19.5 ± 3.7 % and 13.3 ± 3.2 %; р > 0.5). The question may arise, if the change of places of rates of ejaculation and libido disorders in the general group occurred after exclusion of those cases where ejaculation disorders were caused by sexual dysrrhythmia and erectile disturbances. If it were the case then our conclusion concerning the ASFES-dependent specific character of the distribution of the above symptoms would become groundless. The analysis shows that it could not happen, because ejaculation disorders significantly predominated over libido ones in the general group (respectively, 49.4 ± 3.2 % and 26.5 ± 2.8 %; р < 0.001), but this fact was not observed before exclusion of the above variants of ejaculation disorders in the “cleaned” group, where differences in the rates of ejaculation and libido disorders were very insignificant (respectively, 23.0 ± 4.0 % and 19.5 ± 3.7 %; р > 0.5). Orgasmic disorders were observed reliably more frequently in the general group than in the “cleaned” one (respectively, 13.5 ± 2.2 % and 6.2 ± 2.3 %; р < 0.05). The symptom of sexual hypoaesthesia in this group among 28 patients, whom we questioned, was revealed in 13 cases (46.4 ± 9.4 %), and that of sexual anaesthesia in 1 (3.6 ± 3.5 %). The acuity of contact perception of their female partner was not affected in 14 patients (50.0 ± 9.4 %). A mild degree of decrease of this perception was revealed in 4 cases (14.3 ± 6.6 %), a moderate degree in 5 (17.9 ± 7.2 %), and a marked degree in 4 (14.3 ± 6.6 %). Thus, sexual hypoesthesia and anesthesia were all in all found in 14 patients (50.0 ± 9.4 %).
The problem of peculiarities in the frequency characteristic of symptoms in the syndrome under consideration should be discussed from the comparative positions too. Thus, in 600 male patients with different sexual disorders, managed by Vasilchenko G. S. [1], he revealed complaints about erectile disturbances in 453 cases (75.7 ± 1.8 %), those of ejaculation in 313 (52.2 ± 2.0 %) and libido in 175 (29.2 ± 1.9 %). Therefore among those patients, whom we examined, erectile disturbances in the general group were found more frequently than in the unselected cohort of cases (respectively, 87.3 ± 2.1 % and 75.7 ± 1.8 %; р < 0.001). These differences became even more considerable when we compared the rates of erectile disturbances in the “cleaned” group versus the patients, examined by Vasilchenko G. S. (respectively, 94.7 ± 2.1 % and 75.7 ± 1.8 %; р < 0.001). As it follows from the findings, produced by the above author, erectile disturbances in the male patients with different sexual disorders, whom he examined, were found reliably more frequently than those of ejaculation too, but such differences as in our observations after the procedure of “cleaning” were not revealed (respectively, 75.7 ± 1.8 % and 52.2 ± 2.0 %, p < 0.001; 94.7 ± 2.1 % and 23.0 ± 4.0 %, р < 0.001). Besides, ejaculation disorders were observed in the unselected cohort of sexological patients far more frequently than those of libido (respectively, 52.2 ± 2.2 % and 29.2 ± 1.9 %; р < 0.001), this fact contrasting with our findings on the “cleaned” group (respectively, 23.0 ± 4.0 % and 19.5 ± 3.7 %; р > 0.5). The rates of sexological symptoms in patients with ASFES and males having different sexual disorders are shown in the table below.
We analysed causes of changes in the rate of detection of different sexological symptoms in patients with the studied syndrome, when the above changes appeared during the procedure of “cleaning”. As result of this procedure, the specific character of the effect of ASFES on the phenomenology of sexual disorders became more evident. Thus, reliably more frequent erectile disturbances were explained by the fact that the above procedure excluded variants of the aggravating influence of this syndrome on the symptoms, which were initially caused by some other pathology, thereby emphasizing one of the regularities in the formation of symptoms in ASFES more vividly. The essence of this regularity is as follows: by virtue of the greatest significance of erectile disturbances in terms of a possible failure of intimacy, their apprehension is observed most frequently. The rates of ejaculation and libido disorders in the “cleaned” group turned out to be almost the same, because there was no marked decrease in the rate of libido lowering during the procedure of “cleaning”, while ejaculation disorders became considerably less common.
Table
Sexological symptoms in patients with ASFES and males having different sexual disorders
|
Sexological symptoms |
Rate of sexolo-gycal symptoms (P ± Sp) in 245 examined patients with ASFES from the general group |
Probability of a chance in differences (р)* |
Rate of sexological symptoms (P ± Sp) in 113 examined patients with ASFES from the “cleaned” group |
Probability of a chance in differences (p) |
Rate of sexological symptoms (P ± Sp) in 600 males with different sexual disorders (according to G. S. Vasilchenko [1]) |
|
Libido disorders |
26.5 ± 2.8 |
> 0.1 |
19.5 ± 3.7 |
< 0.05 |
29.2 ± 1.9 |
|
Erectile disturbances |
87.3 ± 2.1 |
< 0.02 |
94.7 ± 2.1 |
< 0.001 |
75.7 ± 1.8 |
|
Ejaculation disorders |
49.4 ± 3.2 |
< 0.001 |
23.0 ± 4.0 |
< 0.001 |
52.2 ± 2.0 |
|
Orgasmic disorders |
13.5 ± 2.2 |
< 0.05 |
6.2 ± 2.3 |
– |
not indicated |
* The probability of a chance in differences, equal to 0.05, corresponds to reliability 95 %, 0.02 – 98 %, 0.01 – 99 %, 0.001 – 99.9 %.
We chiefly explain the significant rate of libido disorders in patients without any organically caused sexual pathology by emotional responses of these people to sexual problems. Reliably more common complaints about ejaculation disorders in patients from the general group were explained by other diseases and by the fact that in some cases ASFES played an aggravating role, producing its effect on the coitus duration as an accessory factor. A considerably more frequent detection of orgasmic disorders in the general group of patients with ASFES versus the “cleaned” group was associated with the influence of somatic factors. The revealed specific character of ASFES participation in the formation of sexological symptoms was shown to a larger extent when the “cleaned” group was compared with the group of patients having different disorders. The above comparison also revealed a reliable predominance of libido weakening in the latter group versus the former one. This fact is explained by a considerable participation of somatogenic factors in the appearance of the above symptom in the group of patients with different sexual disorders.
The erectile disturbances, revealed in patients from the “cleaned” group, were directly caused by their anxious failure expectation as well as by erection hypercontrol associated with this expectation. These disturbances differed by their degree and dynamic pattern. Thus, the preliminary period could reveal fluctuations in the intensity of penile tension from different degrees of hypoerection to anerection. In some cases, though the erection during the preliminary period did achieve its full degree, the process of “tension increase” was nevertheless extremely protracted (the torpid appearance of erection). Often good or weakened erection decreased its degree either during the preliminary period, or at the moment of insertion, or after some time interval following the beginning of frictions (unstable erection). Sometimes, though weakened in the preliminary period, erection achieved its full degree in the process of frictions. Other variants were also observed when the character of erection was undulating, i.e. the latter fluctuated in its intensity during the preliminary and/or main period. In certain cases the erection was weakened in the preliminary period and during the coitus itself, but “gained its full strength” some time after the beginning of frictions. Extremely seldom the hypoerection, which initially existed in the preliminary period, did not progress during an attempt of introjection, because the latter failed as result of a marked decrease of penile tension. Quite often alternating erectile disturbances were registered, when during some coituses with the same female partner the penile tension was normal, other coituses being characterized by different disturbances of erection. Some cases were observed when the first coitus failed owing to weakened erection at the stage of frictions, while the second coitus on the same day passed normally. Sometimes the character of erectile disturbances was selective: these occurred during intimacy with one woman, but were absent with another one.
In more marked clinical cases both adequate and spontaneous erections were affected. This fact was caused by penile tension hypercontrol, which persisted from the period of intimacy to morning, daytime and sometimes even nighttime hours. Assessing the character of morning erections it is necessary to note their frequent disappearance following a short period after the person wakes up. But at the moment of waking up they could have the full degree. In some patients with ASFES their erection in morning hours is initially weakened and occurs less frequently. Nighttime erections were more secure, because during sleep the patients either did not control their erection at all or this control was less pronounced than after waking up, especially in the conditions of intimacy. Nevertheless a rather pronounced hypercontrol of penile tension can exist during the night sleep too. For example, as result of the above fact one of our patients woke up several times a night when erections appeared. But if he did not wake up, he regarded it as an abnormal phenomenon, because he related the very fact of waking up to the presence of penile tension.
The hypercontrol of erection, whose pathogenic effect has already been mentioned by us, is inseparably linked with anxious expectation of failure. Therefore the question may arise concerning the justification of the separate significance of the first from the above factors. It is possible to produce two arguments, which are still indicative of such justification. Firstly, everybody knows that a transfer from the position of an executor to the position of an observer can result in disautomation of any function, which becomes an object of exaggerated control. For example, if you suggest a pianist, who plays difficult passages with two hands, to control how he does it, you will easily receive evidence that he will simply make a mistake. Secondly, in some cases with use of psychotherapy, when we eliminated anxious expectation of failure, hypercontrol of erection sometimes did not disappear, thereby maintaining disorders in penile tension. In such cases we can say that the hypercontrol of sexual responses loses contact with its origin.
At the same time we cannot exclude those variants, which may concern manifestations of anxiety mainly in the autonomous sphere with resultant copulative disturbances. But if some disorder exists for a certain period of time, than after elimination of ASFES the above disorder may persist outside its borders owing to the fixation of the programme of pathological sexual responses in the mechanisms of memory.
Spontaneous erections in patients with ASFES can be affected by both as result of hypercontrol of penile tension and because of the depotentiating effect, which is produced on the sexual sphere by a mental trauma, caused by unsuccessful real or even imaginary attempts. This is clearly seen in hypothymic states, which sometimes achieve the level of clinical depression or subdepression of the neurotic register, both producing equal effects on the degree of libido and rate of appearance of erotic dreams.
Complaints about reduced libido were presented by the patients themselves or revealed during their active questioning. Degrees of sexual libido reduction differed: from minimum to significantly marked. Our analysis of causes of libido reduction has shown that, besides the above emotional responses to sexual disability, this reduction can be also based on anxious expectation of failure in the conditions of intimacy as well as on the resultant hypercontrol of sexual functions. In some cases we revealed libido reduction, which is not specific for ASFES and is caused by disturbed interpersonal relationships in the married (partner) couple.
Ejaculation disorders in the examined patients, as it was indicated before, were caused by anxious expectation of failure (direct pathogenic influence of the studied syndrome) as well as by its indirect influence. The latter was associated with less frequent sexual activity, protective for the patient (avoidance of the psychotraumatic situation) and his female partner (exclusion of possible appearance of psychic and somatic consequences of sexual frustration), as well as with erectile disturbances owing to ASFES, which in some cases caused different ejaculation disorders (premature ejaculation, delayed ejaculation, anejaculation phenomenon). Besides, we would like to remind that the general group revealed ejaculation disorders, where the influence of ASFES as if were added to effects of other diseases and/or syndromes, which caused ejaculation disorders by themselves. In such cases ASFES as if made an additional contribution to the sexual trouble, which had existed before its development.
The degree of orgasmic disorders in ASFES patients from the “cleaned” group was low and these were caused only by psychogenic factors (the patient’s response to a bad quality of the coitus and his female partner’s behaviour during intimacy because of her dissatisfaction).
We have emphasized more than once that those sexological symptoms can be at issue that depend upon others. But the latter appear under the effect of other factors. In order to have the general picture of the origin of sexological symptoms during studies we developed the concept of symptom formation in sexual disorders [4]. Its essence is as follows. It is not in rare cases that with unambiguous basic (pathogenetic) diagnostic characteristic of sexual disorders these may have heterogeneous symptoms. But the meaning of the symptoms, revealed in one sexual disorder or another, is far from being the same. It is reasonable to distinguish between initial, developmental and derivative symptoms. The initial symptoms should include those ones which are observed in the initial period of the disorder. Developmental symptoms appear during aggravation of the diseases, which underlie sexual disorders, or when the structure of the latter becomes more complicated. For example, if chronic prostatitis manifested itself only with ejaculation disorders and its aggravation developed disturbances of erection, then ejaculation disorders should be regarded as initial symptoms and erectile disturbances as developmental symptoms. Erectile disturbances would be also considered as developmental symptoms in case of their origination from neurosis of failure expectation, which aggravated chronic prostatitis. Primary and developmental symptoms, in their turn, should be regarded as basic ones. But sometimes clinical practice reveals the phenomenon, when one symptom or another does not depend strictly upon the basic (pathogenetic) characteristic of the sexual disorder and is a derivative of another symptom, without which it simply would not originate. For example, it is not in rare cases that a delayed course of the coitus results from an insufficient penile tension. The problem can reach such a stage that hypoerection will cause anejaculation coitus (imaginary absence of ejaculation, according to V. M. Maslov [7]). The symptoms, which appear by the above mechanism, should be regarded as derivative.
The described differential assessment of symptoms that separates basic and derivative ones and ends with selection of target symptoms, which are basic symptoms, is an important process. This process makes it possible to develop the programme of adequate symptomatic therapy.
So, we have already characterized a number of factors, which produce their effect on the appearance of sexual dysfunctions in patients with ASFES. But we should also name two more factors, which participate in the formation of symptoms in this pathology, and analyse their influence. One of them is the “semantic field” (semantics) of the apprehension of failure. Here is an explanation of what it is. The patient, who has come to the physician with the above pathology, may tell you not only that he is not sure of the success of intimacy or even sure of its failure, but even about the contents of his apprehensions. When questioned, the patient will specify what he is afraid of: weakening or disappearance of erection or ejaculation disorders (in an overwhelming majority of cases – premature ejaculation). Quite often he may apprehend both. It is this apprehension that is the pathological programme, which may determine the scenario of a defective course of intimacy (“self-fulfilling prophecy”). Besides anxious apprehension of concrete copulative disturbances the “semantic field” of ASFES may also contain such variants as the fear of appearing before the female partner’s eyes as sexually disabled (the fear of disgracing himself) as well as anxiety caused by the prognosis that he will not satisfy the woman. Sometimes the fear of publicity is at issue.
The patient’s apprehensions in the situation of intimacy depend upon the fact which copulative disturbances preceded the development of ASFES, and it does not matter whether these were situational disturbances, “malfunctions” owing to physiological fluctuations in sexual functions, or sexual disorders initially caused by other diseases. For example, it these were erectile “malfunctions”, the semantics of ASFES includes just apprehension of disturbances of erection. At the same time other cases may be observed: though the disorder manifested itself by premature ejaculation, during his subsequent attempts the patient is afraid of the appearance of erectile “malfunctions”, this fear being their possible cause. Such a possibility is quite explainable, as it only confirms our previous thought, according to which ASFES is closely connected just with those copulative disorders, which are more significant for a possible failure of intimacy. It should be noted that the process of ASFES course may rather often demonstrate a tendency to complication of its semantics. Thus, for example, if at first the patient is afraid of appearance of premature ejaculation only, than with time the above fear may be joined by anxiety about the quality of erection.
Another factor, which causes the pathogenic influence of ASFES, is emotional stress on the threshold of and during intimacy with associated disturbances in autonomic regulation of sexual functions. It is possible to reveal this stress by both asking the direct question and receiving answers to special questions, which make it possible to find out its different correlates (muscular hypertonicity, autonomic dysfunctions).
It is quite possible to prove the symptom-forming influence of emotional stress and disturbances, associated with the above stress, in the nervous regulation of sexual functions during the syndrome in question. For example, in some cases we registered that despite the presence of anxious expectation of disorders in penile tension only or premature ejaculation only, both erection and ejaculation functions were affected at the same time.
To sum up the above findings of the analysis of symptom formation in ASFES, we should point out the following symptom-forming factors:
1) semantic field (semantics) of failure apprehension;
2) emotional stress on the threshold of and during intimacy with associated disturbances in nervous regulation of sexual functions;
3) hypercontrol of sexual functions;
4) sexological symptoms, which are initially caused by another kind of pathology, with addition of the aggravating effect of ASFES;
5) personality responses to sexual disorders;
6) sexual dysrrhythmia;
7) basic symptoms, which cause the appearance of copulative disturbances, derivative of these symptoms.
If the first four of the above factors are specific for the studied syndrome, the rest are not and can take part in the organization of copulative disturbances in any sexual disorders.
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Bibliographic information about the article: Kocharyan G. S. Sindrom trevozhnogo ozhidaniya seksual’noy neudachi u muzhchin i kharakteristika seksual’nykh disfunktsiy / G. S. Kocharyan // Sotsial’naya i klinicheskaya psikhiatriya. – 1998. – T. 8, №2. – S. 108–115. [Kocharyan, G. S. Anxious sexual failure expectation syndrome in men and characteristics of sexual dysfunction. (The Article was translated from the Russian language) Social and clinical psychiatry. 1998; 8 (2): 108–115.]
General information about the author, his articles and books (freely available) are on his personal website gskochar.narod.ru