How Psychological Erectile Dysfunction Works

October 30, 2020

4 mins

The relationship between mental health and erectile dysfunction has been established conclusively over the years, pointing to a high correlation of ED in depressed and anxious men.

But the relationship gets a little more complicated than just "ED due to mental health." Anxiety, stress, and depression can all cause ED, but they can also be caused by ED, and this tie-up is what makes psychologically induced ED a little more challenging to suss out than other medical issues that can cause ED, like obesity or diabetes. 

Consider, for example, a 29 year old man who gets together with an intimate partner after drinks one night. After some foreplay, he realizes he's having a hard time performing, and despite some coaxing, never gets things all the way hard (perhaps due to the alcohol). He leaves feeling some shame, and never calls the would-be partner again. 

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At home over the following weeks, he masturbates to completion – no problem.

Time goes on and he finds himself in the same situation a few months later. This time, as he heads back to her place, the nagging fear that he won't be able to get it up causes more anxiety and stress. Anxiety-ridden, he again can't perform like he's able to at home, and he leaves in a hurry. 

Clearly, this healthy young man – who can masturbate just fine at home – isn't fighting a physical cause. It's all in his head. 

Erectile dysfunction is NOT always in your head. It's believed that less than 20% of erectile dysfunction cases have psychological causes. While medications like Viagra and Cialis may be the fastest, simplest ways to deal with erectile dysfunction in the short-term, guys suffering from ED need to think broadly – ideally with the help of a physician – about what underlying health conditions might be causing their ED. Depending on your situation, ED meds may alleviate the symptoms but leave the core issue festering.

Quick Facts About Psychological ED

ED is generally physical in nature (associated with medical conditions like high blood pressure, diabetes, etc.), due to lifestyle choices (smoking, drug use), or due to mental health/psychological issues (anxiety, depression, etc.).

Psychological issues can both lead to ED but also cause ED. Unraveling mental health and ED can be challenging, but it is absolutely treatable. 

Causes of ED typically fall into three categories: physical, lifestyle choices, and psychological.

The Most Common Physical Causes of ED

Physical causes of ED are well understood, and this is the first place a physician will likely begin to look when assessing ED. Common physical causes of ED include:

• Obesity

• High Blood Pressure

• Hormonal Disorders

• Heart Disease

• Diabetes

These issues all have one thing in common: they generally affect blood flow. Of course, elevated blood flow in the penis is precisely what leads to an erection. Impede blood flow, impede the erection. 

All of the above are known risk factors for ED, meaning that when they're present in a male they raise the likelihood (the risk) that the man will suffer from ED. Addressing these health conditions first is one of the best ways to start dealing with your ED. 

How Lifestyle Choices Affect Men's Health (Yes, Down There)

Hand-in-hand with these physical causes are lifestyle choices, many of which in turn lead to the physical and psychological issues detailed in this article.

For example, smoking raises blood pressure and can contribute to physical ailments like heart disease and obesity. Alcoholism does too, and drug abuse can damage these same organs – as well as mental health – all the same. 

Inversely, positive habits like regular exercise and a good diet can work to reverse these affects.

When ED Is Psychological

Which finally leads us to the mental health and psychological issues that contribute to ED. 

As in our example above, performance anxiety can both cause and stem from ED. So can stress, depression, guilt, relationship problems, and possibly even an addiction to pornography. So how exactly is mental health tied to erectile dysfunction?

Stress, Anxiety and Depression

Depression, stress and anxiety are often interlinked, and these three afflictions can go hand-in-hand depending on severity. Low-grade social anxiety left unaddressed can lead to depression, stress, etc. But one thing is for sure: depression, anxiety, and stress can all be linked to ED.

A 2015 research paper elucidated the link between anxiety, depression, and erectile dysfunction by examining case records for men with sexual dysfunctions (ED or premature ejaculation). 12.5% of men had depressive disorders and 23.4% had anxiety disorders, all of which predated the onset of sexual dysfunction in the majority of patients. Alarmingly, men with depression had higher rates of suicidal ideation or behavior related to their sexual dysfunction and were more likely to report a lack of libido. Men with pre-existing anxiety disorders were more likely to experience performance anxiety related to sex. 

This research was about association, not necessarily causation, meaning which caused which isn't clear. Mental health and ED issues can be a self-fulfilling cycle. According to the researchers, "The relationship between depression and ED is bi-directional: depressed affect can impair sexual arousal and cause ED, while decreased sexual activity and lack of satisfaction with one's sexual life can trigger depressive symptoms. Further complicating this relationship are the well-documented sexual side-effects of antidepressants."

A 2005 study found similar results, with "psychiatric morbidity highly prevalent in patients with ED...and lifetime psychological problems were reported by more than half of the patients."

Further, erections are strongly linked to a variety of bodily functions and systems, including hormones, emotions, and the nervous system. These systems can all also be adversely affected by anxiety and stress, causing hormone fluctuations (or resulting from fluctuations) not generally seen in healthy men. Testosterone, for example, is key to a strong libido and healthy sexual function in men, and depression is associated with low testosterone. Lower testosterone in men happens naturally as part of the aging process, but it can also be a clinical condition addressable by a physician. 

While the exact interplay between depression, anxiety, stress, and erectile dysfunction is not perfectly understood, we know that alleviating these mental health issues can help with erectile dysfunction. Is erectile dysfunction in your head? Kind of, and a trained physician can help make this determination in the diagnosis process for ED, as well as consider the best ways to address and treat them for any man's situation. 

Guilt and Pornography

Pornography-Induced Erectile Dysfunction (PIED) has become a buzzword in the world of ED over the last decade as free, online pornography has become easier than ever to access for men of all ages. This idea – that excessive pornography consumption can lead to ED – has taken hold especially in younger men, and the rate of younger men dealing with ED has increased.

The issue is still debated by researchers. It's not been proven that consuming too much pornography leads directly to ED. But researchers are increasingly sure about a few things:

1. That pornography can make men's expectations about their sexual partners unrealistic, leading to disappointment (for them AND their partner)

2. That the guilt associated with excessive pornography use – not necessarily the consumption itself – may lead to ED.

3. That excessive masturbation can lead to "hyperstimulation", where vaginal or oral sex are insufficient to achieve an orgasm.

Regardless of the precise explanation, excessive pornography use may impact sexual performance and satisfaction. If it's something you're concerned about, the best solution is to scale back your pornography consumption, both in terms of frequency and in terms of graphic intensity.

The feeling of guilt can go hand-in-hand with pornography, but it can also be in relation to the inability to please your partner. For men who suffer from ED, guilt can exacerbate the problem and lead to low self-esteem and a loss of confidence. This feeling of inadequacy can lead to depression, which we know is a risk factor for ED. 

How To Know If Your ED Is Psychological

ED is not just a part of growing old, and while myriad physical conditions can lead to ED, mental health is equally important. Ask yourself questions like:

Can you readily identify mental health issues that may be affecting more than just your demeanor, like depression?

Are you able to get an erection while masturbating, but not when it comes to intimacy with a partner?

Do you have an atypical amount of stress lately, or dealing with relationship issues?

Are external factors at play, like pornography use or past events that trigger performance anxiety?

If you answered yes to any of these questions, it may make sense to consider a mental health evaluation with a healthcare professional. Additionally, a physical examination with the help of a medical provider can help you rule out common or likely physician medical conditions, like diabetes or hypertension. A physician will also be able to identify medications, lifestyle choices, or facets of your medical history that might be clear red flags for ED.

How To Overcome Psychological ED

As has become abundantly clear, the psychogenic causes of ED can be closely related and lead from one to another. Mental health and ED is a complex web that takes time and thoughtfulness to evaluate and treat.

But treatment of psychological ED causes is still very much possible and can alleviate the core problem.

A trained healthcare professional can help, and in some scenarios, treatment with medications like Viagra or Cialis may make sense; however, these medications are designed to get things working when the plumbing has issues, so they may not be a great fit depending on your situation. 

A mental health professional may recommend a therapy approach that focuses on changing your reaction or perception to certain situations that cause anxiety or stress, including performance anxiety. This powerful approach, called cognitive behavioral therapy, can help to reframe the situation that's creating the issue. 

You should also consider whether there are external or lifestyle factors that are affecting your mental health: an overbearing boss at work, financial issues, relationship trouble. 

Some possible solutions to psychological ED that you can consider implementing right away include:

Meditation or mindfulness can be a powerful tool in improving mental health and awareness of your own thought process. Taking 10-15 minutes daily to put down your phone, eliminate distractions, and focus on yourself through rhythmic breaths can be a great way to reset. There are many approaches to meditation, so experiment with what works well for you and your schedule. 

Exercise is good for your body AND your mind, and taking the time for a 20-30 minutes of light exercise every other day can help to reduce stress and improve wellbeing. To begin, don't overthink it: It can be as simple as a brisk walk around the neighborhood.

Talking to a friend or your partner about the anxieties or stressors in your life (you don't have to mention ED) can help get these thought processes out of your head, and talking through them may help you find workable solutions. 

These are just some simple ways to begin alleviating stress in your life. It's never too late to get help from a professional, and with telemedicine offerings today you can do so without ever leaving home. Sharing with a professional about what's going on can be a powerful first step in resolving the problem. Rex MD can help.