DAVID FOLK THOMAS: Welcome to our
webcast. I'm David Folk Thomas, and our topic tonight is performance
anxiety. I'm a little anxious, myself. To put that into perspective
-- I think most of you know about that -- it's mostly erectile dysfunction,
and to put that in even more lay terms, when guys have trouble "getting
it up." Joining me to discuss this and help bail me out of this a
little bit are two experts. On my left is Dr. Robert J. Filewich.
He's a clinical psychologist specializing in anxiety disorders. He's
also the Executive Director for the Center for Behavior Therapy.
That's in White Plains, New York. Sitting next to Dr. Robert Filewich
is Dr. Ken Rosenberg. He is a psychiatrist affiliated with New York
Presbyterian Hospital and Cornell University Medical Center in New York
City. He's also in private practice in New York, specializing in
substance abuse and sexual disorders.
I had a little performance anxiety there, gentlemen, but
let's get right down to it. Dr. Filewich, what is performance anxiety?
ROBERT J. FILEWICH, PhD: Performance anxiety, in
sexual terms and with sexual problems, is where a person has an anticipation
of some sort of problem occurring in the sexual act. As a consequence
of that, they develop a sense of anxiety which translates into an inability
to become erect or an inability to go ahead and have sex for a certain
duration before they actually achieve orgasm, or premature ejaculation.
DAVID FOLK THOMAS: Dr. Rosenberg, your turn.
KEN ROSENBERG, MD: Performance anxiety refers to
just what Dr. Filewich said. It's more of a popular term than a medical
term. You can't really find "performance anxiety" in a medical book.
It's the common term for erectile dysfunction or impotence. It also
can lead to premature ejaculation in some. We were not made to be
anxious and have sex at the same time. When we're anxious, we're
running away from dinosaurs, we're not ready to have intercourse.
So our plumbing does not work when we become anxious, and therefore when
we're extremely anxious we just can't perform very well sexually.
ROBERT J. FILEWICH, PhD: And the anxiety is usually
fear-based. It's the sense of fear of being rejected, fear of performing
in a certain way where you're partner's going to be disappointed.
DAVID FOLK THOMAS: Does that happen with couples?
Does it happen when you're just meeting somebody for the first time, or
does it matter?
ROBERT J. FILEWICH, PhD: It doesn't matter.
KEN ROSENBERG, MD: There are so many reasons.
There are immediate causes, there are deeper causes. Erectile dysfunction
is so multi-determined it ultimately is a biological phenomenon.
It's ultimately a fact of the blood staying in the penis. Why or
how the blood stays in the penis could be any number of reasons from psychological
to biological to cultural reasons, as well.
DAVID FOLK THOMAS: Does this always manifest --
I guess the stereotype seems to be you're ready for sex, maybe you've even
been turned on prior to getting down to the wire, and then right when you're
ready to go the wind goes out of the sails, so to speak?
ROBERT J. FILEWICH, PhD: It can happen whereby you
do get erect, and as you're about to have sex, you lose your erection,
or it can be when you're actually in the course of having intercourse,
you lose the erection, or you don't get erect at all. So it can happen
in any of those kind of ways. Usually what happens is that the person
is focusing more or less on the final goal, which is orgasm or pleasing
the partner with an orgasm, and not really focusing on all the rest of
what goes on in the sexual encounter, which is really one of the things
that we try to do as therapists, to try to get the person to focus more
on the relationship and the sensory experiences that they're having as
opposed to the final goal -- more focusing on the process rather than the
product.
DAVID FOLK THOMAS: We'll stick with concentrating
on this male part of the issue, but are women also subject to performance
anxiety?
KEN ROSENBERG, MD: Of course women suffer from that.
It, again, is not called performance anxiety for women, it more characteristically
would be anorgasmia, the inability to have an orgasm, or vaginismus, the
inability to allow the penis -- or the finger, for that matter -- to enter
the vagina because a woman is so anxious that her vaginal muscles are contracting.
So for women, anxiety certain plays a role, and behavioral techniques and
medicines and couples therapy and all sorts of therapies could be of enormous
benefit for women as is true for men.
DAVID FOLK THOMAS: If you're a man and this is a
problem that you're having and you go to seek treatment, what is the treatment?
ROBERT J. FILEWICH, PhD: There is actually a multitude
of different treatments. One of the treatments that was developed
some time ago by Masters and Johnson is what is known as a sensate focus
technique. Through a series of four stages, what a person begins
to learn to do is to stop focusing on the end result, which is orgasm,
and worrying about whether or not you can go ahead and achieve that or
provide your partner with the opportunity to achieve that, and start focusing
more on what the sensory stimulation is like, what it feels like to actually
enjoy being stimulated, what are the ways in which you can go ahead and
pleasure each other, and it takes the focus off of what's happening at
the end. So you'll start off with a stage where you'll keep your
clothes on, and you'll actually just go ahead and touch each other and
communicate with each other. Once you're doing that for a while and
you're comfortable with that, you'll move to the second stage.
DAVID FOLK THOMAS: You move to the second stage
during that session, or the next --
ROBERT J. FILEWICH, PhD: No, this is after several
sessions of you getting comfortable.
DAVID FOLK THOMAS: You do one stage at a time?
ROBERT J. FILEWICH, PhD: The idea is that if you're
with your partner a good number of times where the expectation of an orgasm
is not there, then the whole experience now starts to take on a completely
different kind of flavor, so you're now realizing that there's so much
more that's going in terms of you and your partner that orgasm becomes
less important. When it becomes less important -- of course, if I
say, "Don't think of pink elephants," you're going to think of pink elephants
-- but when your mind is completely away from that and you're not focusing
on that, you're not going to be thinking about performance. You're
going to be thinking about other things, and you're going to actually enjoy
the experience, which will result in you becoming aroused.
KEN ROSENBERG, MD: If people, because of anxiety,
lose their erections, if you take the emphasis off the erection, off the
orgasm, you kind of say, "Just enjoy it" -- in fact, the first homework
assignment that we give our patients is, "You can't even have an orgasm.
Erection is not the goal" -- you actually encourage the person to not even
be thinking about that --
DAVID FOLK THOMAS: And that's in the first stage?
KEN ROSENBERG, MD: -- and even encourage them to
think of it as a violation of their homework assignment so you totally
take the pressure off of them, and hopefully they begin to enjoy sex and
not worry, "Am I going to have an orgasm?" because patients say, "Well,
Dr. Ken said I can't have an orgasm. I can't have an erection, so
that's not something for me to worry about because it's not a performance
I need to do."
ROBERT J. FILEWICH, PhD: And they permission not
to achieve orgasm and it takes the pressure off, and their partner understands
that they're not to have that expectation, either. So they'll move
to the second stage where they'll be caressing and touching and communication
without clothes. The third stage is actually being inside your partner
but not thrusting, and the last stage is actually thrusting. But
the focus is on the sensations. That's why they call it "sensate
focus."
DAVID FOLK THOMAS: And that's the Masters and Johnson
technique. We have a few e-mail questions from our audience out there.
I've just read these, but let me toss them out and see where they fit in.
One person writes, "I can't have an orgasm when my girlfriend gives me
oral sex. Is this performance anxiety, and if so, is there anything
I can do?" Dr. Rosenberg, do you want to take this?
KEN ROSENBERG, MD: I don't think it's an easy question
to answer without really talking to a live patient. Some people are
just built that way. I think that one of the nice things that you
learn in sex therapy is that if oral sex is your thing, that's great; if
it's not your thing, that's okay, too. So there could be any number
of reasons. It could be because they're very anxious. It could
be because they have some psychological fear that the woman will devour
their penis. You could create some kind of fantasy like that.
DAVID FOLK THOMAS: You hate when that happens.
KEN ROSENBERG, MD: You hate when that happens, right?
ROBERT J. FILEWICH, PhD: But a major thing to do
is to really teach them how to communicate. If you're talking about
it and you're not taking -- say, she's not feeling, because she can't give
him an orgasm orally, that there's something wrong with her, he just may
not have the certain sensory nerve endings that accommodate that, so it
could be a physical thing. Then the issue becomes, "Is this a problem,
and why is it a problem, and how can the two of you as a couple compromise
and deal with this because he's not into it and you're into it," and maybe
you could do some quid pro quo. On Tuesday you could do it, but the
rest of the week you have off. So you could figure out the situation.
That's a really infrequent problem, by the way. It usually goes the
other way around.
DAVID FOLK THOMAS: That wouldn't be an erectile
dysfunction problem because, obviously, he's erect when he's having that.
ROBERT J. FILEWICH, PhD: That's an anorgasmic problem.
DAVID FOLK THOMAS: Let me see. One more quick
one. We're almost running out of time and we want to get to treatments.
This one, I guess, is also of the oral sex variety, another e-mail: "Sometimes
when I start having intercourse I get so excited that I ejaculate within
the first couple of moments. I feel embarrassed, et cetera.
What can I do to keep that up longer?" Again, very quickly.
ROBERT J. FILEWICH, PhD: Lots of different things.
You could use medication, or the SSRIs can inhibit your sexual response
to the point where you don't prematurely ejaculate. You could have
people use a technique called the squeeze and stop technique where you
actually use your own body as a biofeedback device so you can actually
learn the point of no return so that you never really get to it until you
want to get to it. You can have a person who can go ahead and masturbate
before the situation so that if they're very, very sexually aroused and
they can achieve orgasm pretty readily, again, but you have them masturbate
beforehand it takes a little of the edge off it and therefore they can
have more sustaining power.
KEN ROSENBERG, MD: That disorder, just for the record,
is called premature ejaculation. It happens a lot for men who have
extremely high testosterone levels or are extremely sexual, and one of
the things that you say to such a patient is, "I understand it's a problem,
but understand, you're a very macho guy. You have a high sex drive,"
and that sort of helps, then, as well.
DAVID FOLK THOMAS: Now, very quickly, treatments.
Everybody's heard about Viagra this, Viagra that. Is that a big part
of Viagra, to help people with performance anxiety?
KEN ROSENBERG, MD: Viagra is the drug of choice
nowadays if you're going to use a drug for erectile dysfunction.
It doesn't work to give you an erection. What it does is keeps the
blood in the penis. You need to take it a half hour to an hour before
you're going to have intercourse, because it has to get to your penis.
You have to wait for certain metabolic things to happen, and then you also
need to be stimulated. Once you're stimulated, what Viagra does very
nicely -- it works about 80 percent of the time -- is it keeps the blood
in the penis, so it really keeps the hydraulic system, if you will, going
and enables people to last longer and have second erections, that sort
of thing.
DAVID FOLK THOMAS: To wrap up, Dr. Filewich?
KEN ROSENBERG, MD: But I think it's important to
say and responsible to say that it has side effects and it's not something
to be taken lightly. It's not something to take over the Internet.
DAVID FOLK THOMAS: You need a doctor to prescribe
it.
KEN ROSENBERG, MD: You need a doctor to prescribe,
and I would say you need an educated doctor to make sure you don't have
any cardiac side effects, because it could be a serious, if not dangerous
drug if taken incorrectly.
DAVID FOLK THOMAS: Along these lines, Dr. Filewich,
to wrap up, somebody out there is having performance anxiety, unable to
get an erection, who do they seek out for help? How do they go about
getting help?
ROBERT J. FILEWICH, PhD: They'll go to a certified
sex psychologist or psychiatrist, or a psychologist or psychiatrist who
has had experience in this particular area, to make sure that they're well-referred
and that they're people who are qualified, because you can go to someone
who really isn't that well-educated or trained in the area and they can
give you some misinformation that actually might be harmful.
DAVID FOLK THOMAS: There you have it. I want
to thank my guests, Dr. Robert J. Filewich and Dr. Ken Rosenberg, for coming
by. Our topic has been performance anxiety, and we hope you're learned
something here on this webcast. I'm David Folk Thomas. We'll
see you next time.
