The Relationship Between Anxiety Disorders and Sexual Dysfunction

Anxiety disorders are a group of clinical entities in which an abnormal level of anxiety is the prominent symptom. This group includes panic disorder, specific and social phobia, obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), acute stress disorder, and generalized anxiety disorder. Sexual dysfunctions (SDs) are defined in DSM as disturbances of the 3 phases of the sexual response cycle: desire, arousal, and orgasm, in addition to sexual pain disorder. Anxiety plays an important role in the pathogenesis and maintenance of SDs. This co-presence is very common in clinical practice: patients with SDs will often present with an anxiety disorder, and in many cases it is unclear which is the primary disorder. On the other hand, for many patients with a psychiatric disorder an SD may be a persistent disturbance. Anxiety represents the final common pathway by which social, psychological, biological, and moral factors converge to impair sexual response. The neurobiological expression of anxiety is complex, but it mainly involves a release of adrenergic substances (epinephrine and norepinephrine). Sympathetic dominance is also negatively involved in the arousal and orgasm phases and may interfere with sexual desire.1,2 Psychological elements are generally considered important in the pathogenesis of SD, but it is difficult to explore these factors with standardized instruments. There are few studies that explore this hypothesis using diagnostic tools, and in some cases these studies have considered anxiety as a feeling and not as a clinical entity. In this article, we examine the relationship between anxiety disorders and SDs, using DSM-IV-TR categories, although we are conscious of the limits of this approach. In doing so, we will consider not only the dichotomy between normal and pathological functioning but also the issue of sexual satisfaction as part of wellness. We review studies that report on sexuality in anxiety disorders and on those that report on anxiety in patients who have SDs. Anxiety disorders in patients with sexual dysfunction The complex relationship between anxiety disorders and desire disorders is rarely clarified in the medical literature. Kaplan1 underlines a strong prevalence of panic disorder (25%) in patients affected by sexual aversion disorder. Anxiety is also relevant in sexual arousal. Induced by different stressors, anxiety can distract from erotic stimuli and impair sexual arousal, principally through an increased sympathetic tone.3,4 This may result in poor erection in males and a reduction in lubrication and clitoral tumescence in females. Various aspects of anxiety are historically considered in arousal disorders, particularly the vicious circle of anxiety/dysfunction/performance anxiety.5 Honeymoon impotence is a specific example of this, as suggested by Shamloul,6 who studied 100 patients with this problem. Several studies have found that the prevalence of anxiety disorders varies from 2.5% to 37% in males affected with erectile dysfunction (ED).7-9 However, these studies failed to point out a significant correlation between a sin-gular type of anxiety disorder and ED. Recently, however, a link between free-floating anxiety and ED has been suggested.10 Others report that the association