Psychiatric Times.
No. 9
The Relationship Between Anxiety Disorders and Sexual Dysfunction
By Giorgio Corretti, MD and Irene Baldi, MD |
August 1, 2007
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.
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 disorders
Looking 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
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