Sexual Dysfunctions in Neuroses

Lecture

Interest in the problem of the relationship between sexual disorders and neuroses arose after R. Krafft-Ebing's description of «sexual neurasthenia» in 1886. •Soon a large number of works appeared linking sexual disorders with psychological factors. •At the beginning of the 20th century, two directions emerged: .neuroses as a causal factor of sexual disorders, i.e., secondary disturbances (more often in men) .the identification of sexual disorders as one of the causes of neuroses, or primary disturbances (to a greater extent in women).

.In the first half of the 20th century, a view formed that sexual disorders are an inherent feature of neurasthenia. .The illusion of simplicity was dispelled by Kinsey (1948, 1953), who showed that such disorders also occur in healthy individuals.

Prevalence of the problem

•Most authors speak of the possibility of the sexual sphere being involved in the clinical picture of neurosis.

•Sexual function disorders in neuroses occur in 12% to 40-50%, and even up to 78% of cases.

•Differences in statistics are largely related to the diagnosis of the disease and the methodology of data collection.

For example:

•36% of men with neurasthenia and hysterical neurosis show disorders of sexual function

•Only 27% of women with neurasthenia show no changes in the sexual sphere

Secondary disorders

.It is generally accepted that the addition of sexual disturbances to the clinical picture constitutes an additional psychological trauma for the patient, worsens their condition, and thereby contributes to a protracted course of the illness.

.Studies have shown that in men with the addition of potency disorders, there is more than a twofold predominance of protracted forms of neurosis over acute ones.

•it is important to remember the multifactorial nature of sexual disorders, with mandatory consideration of .biological, .psychological, and .social factors in their etiology and pathogenesis

•Sexual psychological traumas –sexual dysfunction, psychosexual dissatisfaction, experienced violence or an attempt at it.

•What matters is not so much the objective characteristics and content of the psychological trauma, but its significance for the individual.

•Most authors have abandoned the identification of «sexual neuroses» and «sexual neurasthenia» as separate entities.

•These disturbances are one of the components in the structure of a developed neurosis.

Given unfavorable factors such as: .weak sexual constitution, .incorrect information in the area of sex, .sexual-erotic and sexual-behavioral maladaptation, the probability of sexual dysfunction arising against the background of neurosis is high.

.The mechanisms of development and course of secondary disorders have features related to the form and character of the course of the neurosis that caused them.

.In the course of a neurosis, sexual motivation and the motives of sexual behavior may change, sometimes leading to a de-actualization of sexual life or an aversion to it.

.The pattern of the patient's sexual behavior changes, which often causes psychoemotional dissatisfaction and emotional reactions in their spouses.

.The somatic-biological constitutional background is of paramount importance.

.As a rule, in patients with neuroses accompanied by sexual disturbances, constitutional indicators fall within the range characterizing a weak, or less often a weakened, level of sexual constitution, which indicates a clear weakening of their initial premorbid neurohumoral background.

.Some authors believe that a weak neurohumoral background not only facilitates the easy occurrence of sexual disturbances in neurosis, but also facilitates the very development of the neurosis under the action of psychological trauma (predetermining the weakness of adaptive mechanisms and reducing the body's resistance).

•In the complex constellation of factors leading to the occurrence and further formation of sexual disorders in each individual patient, one can identify predisposing, precipitating, contributing, and aggravating factors. In each specific case, the disturbance is determined by an individual combination of pathogenic causes and conditions, so in different individuals the same factor may play roles of varying significance (in some –precipitating, in others –aggravating).

In most cases, among the predisposing premorbid factors are found:

.weakness of the neurohumoral component of the copulatory cycle, due to features of the sexual constitution;
.weakening of the neurohumoral component of the copulatory cycle, associated with the patient's age;
.accentuation of character traits of the anxious-suspicious type;

•Among the factors precipitating («triggering») a sexual disorder are found:

.psychogenies not related to neurosis

.Contributing factors are those leading to dysrhythmia of intimate relations, including:

.de-actualization of sexual relations, caused by the neurosomatic and psychopathological manifestations of the neurosis

.interpersonal disharmony between partners

.Aggravating factors:

.secondary diseases of the urogenital system
.secondary interpersonal disharmony caused by the couple's sexual maladaptation
.secondary pathogenetic disintegration of the copulatory cycle
.inadequate therapy
.early involution

Sexual disorders in men

•in men suffering from neuroses, according to Skripnikov (1998), .secondary forms account for 54-62%, .of which 34% are maladaptive forms, .24% are secondary sexual dysfunctions,

Primary sexual dysfunctions account for 37-45%.

.The communicative form of sexual maladaptation occurs with approximately equal frequency across all forms of neurosis (11-14%); .the «gender-role form» of maladaptation is noted in 4-12% with neurasthenia, 2-6% with hysteria, 0-10% with obsessive-compulsive neurosis.

.The sexual-erotic form of maladaptation occurs more often with neurasthenia –in 12-18% and less often –6-12% with hysteria and 4-12% –with obsessive-compulsive neurosis.

.The constitutional form of maladaptation occurs mainly with neurasthenia –9-15%, with hysteria and obsessive-compulsive neurosis –3% and 2-8% respectively.

•In men, the predominant complaints are decreased intensity or even complete absence of sexual desire, a feeling of insecurity when attempting intimacy, weakening or absence of adequate and spontaneous erections, premature ejaculation, and in some cases dulling of orgasmic sensations. The manifestations are combined in character.

•In all forms of neurosis, the well-known tetrad is observed

.erection disorder
.ejaculation
.libido
.orgasm

Neurasthenia (men)

.Disturbances in the pace of sexual maturation are often noted, mainly its retardation and asynchronies, caused by psychogenic and sociogenic factors. .Sexual constitution is usually weak or medium.

Transformation of gender behavior

.The overwhelming majority belong to the passive-submissive variant of the male psychosexual type, less often –to the «man-son» type.

Type of sexual motivation:.more often homeostabilizing or template-regulating,

Motive for sexual intercourse: .relief of sexual tension, achieving orgasm, or fulfilling marital duty.

.Disruption of the preliminary period of the copulatory cycle.

With the hyposthenic form of neurasthenia: .decreased sexual desire, alibidemia, .weakened erection; the weakened erection may be present from the very onset of the neurosis. .Hypoerection + premature ejaculation. .Usually accompanied by decreased sexual activity and initiative.

With the hypersthenic variant of neurasthenia, .along with erectile dysfunction, premature

ejaculation and blunting of orgasm occur.

.With asthenic and astheno-hypochondriac syndrome –a feeling of sexual inadequacy, decreased sexual initiative.

Neurasthenia (men)

•Over the course of the first year, marital disharmony gradually develops.

•Factors of disharmony:

.impaired potency in the husband,
.decreased sexual desire for the husband on the wife's part
.socio-psychological maladaptation of the spouses due to the man's emotional instability and irritable weakness

.Verbal assessment of the wives' leading personality traits (skepticism, stubbornness) and .emotional perception of them as weak, dependent, sick persons in need of support and care, which reflects the men's unrealized striving for leadership and a peculiar transference of their own feelings onto their wives.

.At the initial, hypersthenic stage, along with growing irritability and lack of self-control,

impatience, an increase in patients' sexual initiative is noted: more frequent sexual intercourse, taking place in inadequate conditions, an increase in extramarital contacts (Tregubov I.B., 1987)

•The main manifestation –premature ejaculation.

.Against the background of developing asthenia and lethargy –decreased sexual activity, up to complete cessation of sexual life.

•During this period, weakening of erection and decreased libido are noted.

.The disorganizing role of anticipation of failure.

.A fear of intimacy may develop –coitophobia as a consequence of failure or merely as a result of ideas about the possibility of failure.

.Sexual intercourse may be accompanied by increased asthenia and other neurotic symptoms.

.A fear arises that sexual activity may harm the heart, blood vessels, etc.

.Even frequent nocturnal emissions can become an object of hypochondriacal concern.

.This leads to an extremely rare frequency of sexual intercourse (several times a year) with satisfactory erection and duration.

.In all married couples there is sexual-erotic maladaptation, expressed .in a narrowing of the range of acceptability, .a shortening of the duration of the preliminary period of intercourse, which aggravates the situation.

.Decline in mood before and after intimacy.

Hysterical neurosis (men)

.Puberty is often disturbed; combined and complex asynchronies of sexual development are characteristic of them.

.Sexual constitution is weak or weakened-average.

.Deviations of psychosexual development are observed in them more often than in patients with neurasthenia –transformation of gender behavior and hyper-role behavior, .paraphilic tendencies, homoerotic contacts combined with heterosexual ones.

.Psychosexual type «man-son» and the aggressive variant of the «man–man» type.

.The type of sexual motivation is mainly stereotyped-regulated, sometimes pseudo-playful

.Motive of the sexual act: achieving orgasm.

Sexual dysfunction

.weakening of sexual desire, up to alibidemia,
.decreased erection,
.premature ejaculation.

.In some patients – deactualization of the sexual sphere, up to refusal of sexual life,

.In those continuing sexual activity –hyperactualization of sexual function.

.The subjective assessment of the success of the sexual act suffers more often, with a decrease in self-assessment of the act, although formal indicators may be higher.

.Men tend to blame their spouse for the failure of the sexual act, often behave theatrically, demonstrating heightened passion.

.In order to compensate for sexual weakness, patients resort to an inadequate expansion of the range of acceptability.

.Disruption of the socio-psychological component due to interpersonal conflict between partners and of the informational-evaluative component of the social component due to a low level of awareness in the sexual sphere.

.Partners assess them as excessively active and insufficiently responsive.

.At the nonverbal level –they are satisfied with their assertiveness, since they are able to direct their activity toward caring for and looking after them.

.Many complaints are not confirmed by partners. What typically turns out to be the case is some weakening of sexual desire and hypoerection, which are more often transient and arise from insufficient intensity and vividness of erotic stimuli.

.Vivid erotic fantasies and imaginings turn out to be more arousing than the real

sexual situation. .sufficient erection during imagined scenes contrasts with the absence of arousal and weakness of erection in the situation of real sexual intercourse. With active behavior on the part of the woman, the insufficiency of erection, as a rule, disappears.

.The desire to be the best, most perfect, «strongest» sexual partner leads to severe distress in cases of failure.

.A woman's assessment is of particular importance, and comparison with other men is always agonizing.

.In asthenic and astheno-hypochondriacal syndrome –a reduction in the frequency of sexual acts with a fairly high level of libido and good erection, occurring under any conditions, as well as normal duration of the sexual act; a feeling of sexual inadequacy.

.In autonomic disorder syndrome –placing excessive demands on oneself

Obsessive-compulsive neurosis (men)

.The type of sexual constitution can be any.

.In about half of men, transformation of gender behavior is noted, and paraphilic tendencies are also frequent.

.Type of sexual motivation: stereotyped-regulated

.Psychosexual type: «man-son»

.Interest in the sexual sphere decreases, sexual activity and initiative decrease, leading to deactualization of sexual life.

.Most typical is a decrease in sexual desire and interest in sexual life due to the dominance of experiences associated with obsessive fears, since patients with obsessive-compulsive neurosis are distinguished by self-doubt, and they develop doubts about the adequacy of their sexual potency.

.Normal potency is often assessed as insufficient.

.In severe forms of obsessive-compulsive neurosis, a decrease in erection may be observed, and discomfort after intimacy (exhaustion, lethargy) may take on an exaggerated character and cause a state of anxiety and fear (especially in cardiophobia).

Sexual disorders in women

•The most common disorders in women:

.decreased sexual desire,

.anorgasmia,

.discomfort during the sexual act and vaginismus.

.Primary sexual health disorders in neuroses account for 82%, .31% of them are maladaptive, .the remaining 69% are primary sexual dysfunctions. .Secondary sexual dysfunctions are less frequent –in 18%.

.In primary disorders: .sexual hyperactualization syndrome, with elevated expectations from intimacy

.In secondary disorders: .often characterized by sexual deactualization,

which determines the development of disharmony

.With a protracted course of neurosis, the motivation of women's sexual behavior and the motives of the sexual act may change.

Neurasthenia (women)

.Weakening of the neurohumoral component

.Most belong to the «woman-daughter» type and the passive-subordinate variant of the «woman-woman» type

.Motive for sexual intercourse: fulfillment of marital duty

•In the hypersthenic variant:

.decreased libido,
.easy arousal, rapid onset, but blunting of orgasm

•In the hyposthenic variant:

.decreased desire down to alibidemia,
.weakening of sexual sensations,
.hypoorgasmia;
.decreased sexual activity and initiative (due to deactualization of sexual function)
.rare sexual acts are carried out at the insistence of the spouse

.Disharmony develops in parallel with the neurotic process. Main mechanisms:.deactualization of the woman's sexual behavior,.sexual dysfunction due to disturbance of the psychic, autonomic, and neurohumoral regulation of sexual function,

.social-psychological maladjustment of the spouses.

.Narrowing of the range of acceptability, sharp reduction of the preliminary period of intercourse, which aggravates the couple's sexual disharmony.

.In husbands, the reactive response is premature ejaculation due to prolonged frustration. This leads to dissatisfaction and an increase in extramarital affairs.

Hysterical neurosis (women)

.Combined and complex asynchronies of sexual maturation.

.Sexual constitution weak or medium.

.Disturbance of gender behavior: hyper-role, sometimes homoerotic tendencies

.Type of sexual motivation: often pseudo-playful,

.Motive for sexual intercourse: obtaining orgasm.

.The «woman-daughter» type and the aggressive variant of the «woman-woman» type.

.Dysfunction in the form of hypoesthesia and .hypo- or anorgasmia.

.Tendency to blame the partner for failure, theatrical behavior with a display of heightened

passion.

.Sometimes they resort to inadequate expansion of the range of acceptability, up to deviant forms, and sometimes they refuse intimacy.

.Gradual wavelike development of disharmony. In its genesis –a low level of social-psychological and sexual-behavioral adaptation of the partners.