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.

 

REFERENCES

 

1. Vasil’chenko G. S. O nekotorykh sistemnykh nevrozakh i ikh  patogeneticheskom lechenii. – M.: Meditsina, 1969. – 184 s.

2. Vasil’chenko G. S. O chastotnykh kharakteristikakh sterzhnevykh seksopatologicheskikh sindromov u muzhchin // Aktual'nye voprosy seksopatologii: Tez. dokl. 1-y vcecoyuz. konf. seksopatologov. – M., 1986. – S. 9–11.

3. Kondratenko R. P. Kliniko-statisticheskaya kharakteristika vpervye obrativshikhsya za seksologicheskoy pomoshch’yu // Aktual’nye voprosy seksopatologii: Tekh dokl. 1-y vsesoyuz. konf. seksopatologov. – M., 1986. – S. 11–13.

4. Kocharyan G. S. K voprosu o simptomoobrazovanii pri seksual’nykh rasstroystvakh i diagnosticheskoy znachimosti otdel'nykh simptomov // Sovremennye problemy seksopatologii. – Kiev – Voroshilovgrad, 1986. –  S. 42–43.

5. Kocharyan G. S. Psikhoterapiya sindroma trevozhnogo ozhidaniya seksual’noy neudachi // G. S. Kocharyan, A. S. Kocharyan. Psikhoterapiya seksual’nykh rasstroystv i supruzheskikh konfliktov. – M.: Meditsina, 1994. – S. 178–207.

6. Kocharyan G. S. Sindrom trevozhnogo ozhidaniya seksual’noy neudachi u muzhchin (formirovanie, patogeneticheskie mekhanizmy, klinicheskie proyavleniya, psikhoterapiya). Avtoref. dis. dokt. med. nauk. – M., 1992. – 46 s.

7. Maslov V. M. Klinicheskaya fenomenologiya aneyakulyatornykh rasstroystv // Diagnostika, lechenie i profilaktika polovykh rasstroystv: Tr. Mosk. NII psikhiatrii MZ RSFSR / Pod red. A. A. Portnova. – M., 1978. – T. 81. – S. 50–54.

 

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 /fear of sexual failure/ in men and characteristics of sexual dysfunctions (the article in Russian, this is its translation into English). 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 kocharyangs.wix.com/garnik-kocharyan