What does it really mean to describe
Erectile Dysfunction as Psychogenic or Organic?
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Benjamin D Sachs of the University of
Connecticut has questioned whether or not the distinction that we tend to
make between the psychogenic, i.e. psychological, origin of erectile
dysfunction and the organic, i.e. physical, origin of erectile
dysfunction is genuine and meaningful.
He observes that the traditional distinction into the two
categories was maintained in a recent report of the International
Society for Sexual and Impotence Research (admittedly this report was written in
2002.) However, he says that the major problem with this distinction is
that the traditional view of mind / body separation may be obsolete, and certainly
does not take into account the neurobiology of psychological disorders. In
essence, he claims, such a distinction disregards the fundamental meaning
of psychosomatic. One consequence of this distinction, Sachs maintains, is
that patients may often be told that their erectile dysfunction is "all in
the mind". He claims that the distinction is now counter-productive in the
diagnosis, the classification, and indeed in the treatment of erectile
dysfunction, and that it can obfuscate research into the causes of ED.
An alternative classification of erectile
dysfunction is based on a proposal
that reclassifies as organic several of the etiologies of ED that are currently
considered to be psychological, whilst others will be classified as
situational (this is a particular class of ED defined for
episodic occurrences of ED which are due to certain
characteristics of an individual sexual experience).
Sachs makes it clear in his paper, published in the International Journal of
Impotence Research, that his goal is to bring to an end the artificial
distinction between organic and psychogenic ED, as he sees it. This is a
response to the International Society For Sexual and Impotence
Research's attempt to maintain the traditional distinction between organic
and psychogenic ED, a classification which he claims has not been adopted by
the membership of the organization.
In his attempt to
argue against the traditional distinction, Sachs raises several problems with
the concept of psychogenic erectile dysfunction:
1) Psychogenic ED is based
on an obsolete view of mind body distinctions
What he means by this is that
modern physiological research produces evidence that runs counter to the
traditional separation of mind and body, a separation that takes no
account of the principle that all psychological processes have a somatic
basis. The essence of this view is expressed by the philosopher JR Searle,
who has observed that once we have the vision to see that consciousness is
indeed a biological phenomenon like any others, then it can obviously be
investigated neurobiologically. If one maintains that consciousness is entirely
caused by neurobiological processes which can be inferred from the
activity of certain brain structures, and if one assumes that all
psychological processes are in fact regulated by brain functions, the
logical conclusion is that there can be no psychogenic dysfunction that does
not involve an organic process.
Obviously this means that erectile dysfunction
(ED) cannot be
"all in the mind." Certainly it is true that some brain function is essential
to the stimulation and the inhibition of a man's erection, and once again
this process is mediated by functions of the brain.
2) Psychogenic erectile dysfunction disregards knowledge of the
neurobiology of psychological disorders
Sachs discusses the example of depression which is referred to as a
negative mood state in the classification mentioned above; in which
situational ED is included as a psychological distress or adjustment
related condition. The validity of such a classification can be questioned in the light of
the progress that has been made by neurobiologists in discovering the origin
of emotions such as depression in the neural activity of the
brain. Depression, stress and anxiety are in fact clearly
associated with major neurochemical and neuroendocrinological changes in brain activity.
Obviously it's
quite likely that some of these changes would have an impact on a man's
erectile function. So to classify stress and depression as a psychogenic
cause of erectile dysfunction without relating this to the neurobiological
and neurochemical changes in the brain may be inappropriate. For example,
psychogenic causes of ED may simply be related to the organic (physical) issue of impaired release of nitric oxide in the penis as part of
an underlying pathophysiology.
Sachs goes on to say that these neurochemical discoveries have led to drug treatments
which have had a
major impact on negative mood states; accordingly these treatments most
likely
have the capacity to reduce erectile dysfunction associated with these
conditions; in other cases drugs will alter the neurochemical balance
of the nervous system in such a way that they actually impair sexual
function, causing side effects such as ED,
delayed ejaculation, or lowered sexual desire.
All of this means that if psychogenic erectile dysfunction is viewed as a kind
of brain ED whose origin lies within the neural activity of the brain,
then psychotropic drugs would be expected to increase or increase
or reduce this brain related erectile dysfunction.
To put this more simply, the neuroendocrinological and neurochemical basis
of anxiety and
depression are in effect acting as organic causes of ED. Further illustration of the
problems in classifying ED as psychogenic comes from the committee's decision to include
age-related decline in sexual arousability as a psychogenic cause of
erection problems. Sachs observes that many aspects of sexual functioning
decline in men as they age, and for many, varied reasons: degenerative
changes in the vascular system of the penis, or degenerative changes in
penile collagen, or degenerative changes in the peripheral nerves -- all
of these would
have traditionally been categorized as organic rather than psychogenic causes of ED,
ones that develop with advancing age. However, some of these
changes can clearly contribute to an age-related decline in sexual arousability, and some of the loss
of that sexual arousability may be the result of various age-related neurochemical changes in the brain and nervous system.
Whilst these
changes
are not yet understood, nor have they been clearly demonstrated, they
do indicate
the difficulty of continuing to draw a distinction between psychogenic and
organic ED. More recent research by John Bancroft and Eric Janssen has
indicated that there are three independent underlying processes in sexual
arousal: there is one process associated with sexual arousal, and two
associated with sexual inhibition, and the relative balance of these three
factors is predictive of a man's erectile problems. Bancroft and Janssen allude in
their analysis to the neurobiological
regulation of sexual function and ask, possibly rhetorically, if
psychogenic factors are regulated by orgasmic factors, why maintain a
distinction?
However, they don't
completely discard the distinction but suggest there is a balance between
central brain and peripheral nervous system inhibition (organic) on the one hand
and external problems (psychogenic / situational) on the other hand; this balance
may determine whether a man is prone to erection problems in a particular sexual
encounter. Even so, Bancroft and Janssen note that the processing of
external problems is itself neurobiologically mediated. They observe
that men with high propensity for brain inhibition of sexual response are
more likely to lose sexual interest and erectile responsiveness when
depressed or anxious. This may not depend primarily on cognitive processing, but on the related biochemical changes in the brain which are
relevant to both mood and sexual arousability.
In response to this
Sachs asks why, if psychogenic factors are regulated by organic factors,
they should be maintained as separate classes. Even when some kind
of cognitive function is involved, that processing is itself no less
mediated by neurochemical changes in the brain than any other
process.
3) The term "Psychogenic Erectile Dysfunction" disregards the fundamental meaning of
psychosomatic
Two recently established branches of psychosomatics
are psychoneuroendocrinology and psychoneuroimmunology. These subdivisions of the
science of somatics emphasize the interaction of their parts and not
their separation, which may be a metaphor for not taking psychological
processes to be separate from organic processes, even where erectile
function and dysfunction are concerned.
A general
statement made by Wolff in 1961 to the effect that the human nervous system
is implicated in all types of disease applies just as much to ED as it
does to any other condition. But one clear area where the
psychological and somatic do interact in a man's erection problems is
when a man has fears about the adequacy of his sexual performance -- fears that may be
provoked by the response of his body to the situation he is in.
Bancroft and Janssen, among many
others, including almost every man who has ever had sex, have observed
that even relatively slight and occasional impairments in erectile
capacity can come from many different causes, whether those be medical,
such as vascular problems and peripheral neuropathy, or situational, such as excessive drinking. In any event, when a man worries
about a mild impairment of his erectile function, it is almost certain
that some additional deficit will result. In other words, cognitive
feedback from a slight failure of erection can lead to performance
anxiety, which can reinforce other conditions to further impair his erectile
function.
While performance anxiety is clearly a psychological state, anxiety is in no small measure an organic or
physiological condition which is amenable to treatment with anxiolytic
drugs. It is therefore not surprising that administration of these drugs
can interrupt the feedback cycle that aggravates a man's erection problems: this is no
different than the traditional consumption of alcohol for increasing
sexual desire and reducing performance anxiety.
A study by Cranston-Cuebas et al compared a number of men,
both sexually functional
and dysfunctional, as they viewed erotica. The men were given three placebo
pills in turn: these purported to enhance erection, to impair erection, or
to act as a placebo. It's not surprising to learn that
dysfunctional men had less erectile capacity when they took the pills that were
supposed to be erection impairing; unexpectedly, though, sexually functional men
developed stronger erections with the tablet that was supposed to impair
their erection. Whatever this means, it's a clear indication that
situational erectile dysfunction and situational erectile function vary
according to the beliefs that a man has about the circumstances in
which he is becoming aroused.
4) Psychogenic erectile dysfunction is often diagnosed by exclusion
Sachs observed that diagnosing ED's etiology generally involves a
thorough medical examination and a psychological history as well. It's not
uncommon for a penile tumescence test to be taken as the man sleeps: if his capacity to get a sleep-related erection is normal,
and there
is no evidence of any organic cause for his erectile dysfunction, then a
diagnosis of psychogenic ED would most likely be made.
However, Sachs
points out that this conclusion is unreliable because conditions like
depression can themselves impair sleep related elections. (Also, recent
research has demonstrated that the area of the brain that is responsible
for erections during the night is different from the area of the brain
that is responsible for erections during sexual arousal.) Sachs lists a number of
examples which demonstrate that while the neuroendocrinological varies
with the sexual contexts, the
organic basis of erection in one situation may or may not be
predictive of erectile dysfunction in a different one.
5) Psychogenic ED is not all in the mind
It's certainly true that many people regard medical problems and
psychological problems differently, and psychological problems tend to
be more stigmatized. It's therefore not surprising
that medical problems with psychosomatic features have been described as
"all in the mind", and have developed a negative association. Sachs
makes the observation that describing a man's condition as psychogenic
ED may be no less demoralizing and demeaning for the individual concerned
than describing his condition as impotence (a term which has long since
fallen out of use in most contexts because it is regarded as disparaging).
The point is that if there is actually an organic basis for
what appears to be chronic psychogenic erectile dysfunction, then it's possible that the
stigma associated with the condition could be reduced and men would be
more likely to seek appropriate treatment.
Sachs observes that recent
evidence has emerged that seems to show that psychotherapy can be responsible for changes in brain
physiology; maybe psychotherapy for ED acts by changing
the underlying physiology of the brain.
In conclusion, Sachs observes
that it's possible classification of erectile dysfunction will never be as
clear as classification for other medical conditions, but one
alternative to the traditional classification of ED might be to
associate the term organic erectile dysfunction with "peripheral" or "central" problems,
meaning "outside" or "within" the brain and spinal column, respectively.
This means that central problems would include
ED caused by neurobiological and neuroendocrinological examination,
as well as ED resulting from conditions such as stress or depression,
since these are clearly mediated through brain activity. This group would
also include factors related to ageing when things such as age-related peripheral pathology
have been ruled out as a cause.
Furthermore, a classification such as this
would allow a distinction to be drawn between peripheral problems such as primary hypogonadism
and androgen
receptor insensitivity in the genital tissues, and central problems such
as those of brain origin, for example inadequate gonadotropin releasing hormone or other issues that relate
to hormone metabolism in the brain.
And finally the term "situational
erectile dysfunction" would be only applied to clear cases of ED arising in
the context of certain partners, events or environments, or situations
where a man perceives that his performance may be impaired by the
expectations placed on him.
Sachs does admit that his proposed
classification retains some dichotomies, notably organic versus
situational, and peripheral versus central. However, he makes the point
that separating situational ED from organic ED does not imply there is
no clear organic basis for situational ED; and this may well still be
treatable with drugs such as anxiolytics or Viagra. However, limiting
situational ED as a term to refer to the more transient occurrences of ED that depend on
circumstance rather than any long-term cause implies no
chronic pathology of the central nervous system and would not warrant a
man's erectile dysfunction being diagnosed as organic.
In conclusion, Sachs observes that most
pathologies include central and peripheral factors, and the expression of
those would be affected by a man's perception of his partner, his
environment and his sexual performance. In other words, diagnosing the
causes of erectile dysfunction might in fact end up being a matter of
assigning priority, seeking out the thing that is most likely to cause the
problem, and treating that before others. It's also interesting to note
that even if there is no organic cause identifiable there may still be an
organic cure -- and he draws the parallel of treating premature
ejaculation with Dapoxetine. he mentions the possibility that men who have
difficulty in delaying ejaculation and men who frequently have erectile
dysfunction in certain situations may lie outside of normal ranges of
neurotransmitters or receptor density or sensitivity. This might allow a
physician to prescribe drugs which would interfere with brain chemistry
and provide a solution to a man's ED.
International Journal of Impotence Research
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