Erectile dysfunction (ED) is a condition characterized by difficulty or inability to get or maintain an erection firm enough for satisfying sexual activity.
Erectile dysfunction (ED) is a condition characterized by difficulty or inability to get or maintain an erection firm enough for satisfying sexual activity. Roughly a quarter of men in the United States are estimated to be affected by ED, making it an extremely common sexual health issue. Research has also shown that ED affects men of all ages, but that it tends to become more common in older men.
It’s commonly thought of as a sexual problem linked to physical health conditions, such as blood vessel issues, diabetes, or poor cardiovascular fitness. While those are indeed factors that can contribute to ED, they don’t add up to an exhaustive list. The reality is that sometimes, erectile dysfunction is associated with a psychological condition. In these cases, it’s referred to as psychological ED, or psychological impotence.
Your mental health plays a big role in determining your erection ability and quality. Psychological conditions—including depression, high stress, and performance anxiety and condom anxiety—can all potentially affect your ability to get and maintain an erection when you’re ready for sexual activity.
If this sounds familiar, know you’re not destined to a life of unsatisfying sex. Below, learn more about the symptoms, causes, and treatments for psychological ED that can help manage the condition.
The characteristic signs and symptoms of ED can include:
Difficulty achieving and maintaining an erection
Difficulty maintaining an erection firm enough for sexual activity
ED may coexist with other sexual concerns, though these are separate conditions:
Reduced sexual desire
Delayed or premature ejaculation (PE)
Loss of confidence
You may also develop signs or symptoms related to the underlying cause of psychological ED.
For example, if depression is the root cause of your psychological ED, symptoms may include:
Persistent sadness
Loss of interest or pleasure in regular activities
Low libido
Fatigue
Changes in appetite
Insomnia or oversleeping
Feelings of worthlessness or guilt
Difficulty concentrating or making decisions
Irritability or restlessness
Physical aches or pains with no clear cause
Thoughts of death or suicide
In that same vein, if performance anxiety is the underlying cause of psychological ED, symptoms may include:
Negative thoughts about sexual performance
Fear of rejection or embarrassment
Avoidance of sexual activity
Low self-esteem or confidence in sexual situations
As is the case with physical ED, there’s no single psychological cause that triggers erectile dysfunction in all men. Instead, a variety of issues can contribute to psychological ED, directly and indirectly. Common causes include:
Performance anxiety
High stress or anxiety
Relationship problems
Depression
Guilt and low self-esteem
Excessive pornography use
Many of these triggers are closely linked, and it’s entirely possible that multiple could affect you simultaneously. It’s important to remember that the connection between ED and mental health is often bidirectional.
For instance, one review found that ED can lower self-esteem and sexual satisfaction, leading to stress and increasing the risk of anxiety and depression. While the exact link isn’t fully clear, experts believe ED and mental health issues can exacerbate each other over time.
Let’s take a closer look at each potential cause to understand how it can play a role in the development of psychological ED.
In many ways, performance anxiety can become a self-fulfilling prophecy in the bedroom as it relates to psychological ED. If you feel nervous about your sex life and being able to satisfy your partner, you might be more apt to panic and not perform as you would like once you’re actually in the bedroom.
In some cases, sexual performance anxiety may be triggered by negative self-talk. For instance, if you’ve convinced yourself that you won’t be able to achieve an erection, won’t please your partner, or will ejaculate too early, that reality may ultimately take place.
If you’ve found it difficult to get an erection in the past, these experiences may also stick in your mind and affect your ability to relax in the bedroom and perform.
Stress and anxiety can both be contributing factors of erectile dysfunction.
Erectile dysfunction has been associated with many different anxiety disorders, such as:
Post-traumatic stress disorder (PTSD)
Obsessive-compulsive disorder (OCD)
Social anxiety disorder
Panic disorder
Dealing with high levels of stress may make staying in the moment and not falling victim to continuous mental wandering difficult.
A healthy relationship is essential for maintaining a strong sexual relationship. Relationship problems could be a cause of stress that leads to ED. Or in reverse, having ED could lead to strain on your relationship. How a couple reacts to ED can also play a big role in the degree to which it affects a relationship. If ED leads to discomfort, emotional distance, or conflict, it may create a cycle—less intimacy, less time together, and poor communication—all of which can make the root issue worse.
Communication is the best first step for resolving this particular cause of psychological ED. If that feels difficult to broach on your own, know that you have options. For instance, couples counseling is a safe space for two people to get help learning to listen and find the magic again.
Research consistently supports the existence of a link between depression and higher rates of ED. Depression can contribute to the development of ED, and for some men, ED may contribute to depression.
One small study revealed that men with ED, PE, or other sexual issues frequently faced underlying mental health challenges. Of the participants, 12.5% were diagnosed with depression, and 23.4% had anxiety disorders. Researchers noted that these conditions often go undetected and untreated.
As if the connection between erectile dysfunction and depression weren’t already complex enough, some medications used to treat psychological issues, such as antidepressants, can also play a role in the development of erectile dysfunction.
Depression is far from the only mental health condition that can affect your libido — there’s also a close relationship between PTSD and erectile dysfunction.
Many men who deal with erectile dysfunction feel guilty about not being able to satisfy their partner. If the problem persists, the guilt may grow, potentially also contributing to the ongoing cycle of mental ED.
Low self-esteem may also keep you down in more ways than one. For instance, lacking confidence about your sexual performance, or worrying that your partner doesn’t find you attractive enough can heighten your risk of sexual performance issues.
As is the case with many other aspects of psychological erectile dysfunction, low self-esteem and sexual performance issues often exacerbate the issue.
Some researchers suggest that excessive pornography use may contribute to ED in certain men, possibly due to altered sexual expectations or desensitization, though evidence is still emerging.
ED related to pornography use is sometimes referred to as porn-induced erectile dysfunction. While watching porn isn’t inherently bad or harmful, excessive use of pornography may contribute to both depression and sexual performance issues such as ED. (Our guide to pornography consumption and depression is worth reading if you’re unsure about your own relationship to porn.)
Research also suggests that if you spend a lot of time watching (and masturbating to) pornography, you may develop unrealistic expectations about sex or about your sexual partners and romantic relationships.
Some factors may make some people more prone to developing psychological ED than others. For starters, some personality types may contribute.
Current evidence suggests that people who are more anxious and less outgoing may have a higher risk of ED, partly because these traits may make you more likely to smoke and be less physically active—two things that are known to increase the risk of erectile dysfunction. Additionally, having risk factors for psychological conditions such as depression may increase your chances of developing psychological ED. For example, risk factors for depression include having a chronic illness and traumatic childhood experiences.
If you’re physically healthy and feel worried that you may have psychological ED, the first step is to talk to your healthcare provider.
After discussing your medical history, your healthcare provider may complete a physical exam, ask you some questions, and run some tests to rule out medical causes for your ED.
In order to rule out physical ED or ED related to medical conditions, your healthcare provider may perform tests including the following:
Complete blood count (CBC)
Fasting glucose or glycated hemoglobin (A1C)
Comprehensive metabolic profile
Thyroid-stimulating hormone
Lipid profile
Serum total testosterone
In addition to these laboratory tests, your healthcare provider may also ask you questions about your:
Sexual desire
Your ability to get and maintain an erection
Your ability to reach orgasm
Your level of satisfaction from sexual intercourse
Your general sexual satisfaction.
Based on your answers and the results of your lab tests, your healthcare provider may recommend a psychological evaluation to further explore the potential cause of your ED. If they suspect a physical problem, such as Peyronie’s disease they may refer you to a specialist in urology.
Whether or not you’ve talked to a healthcare professional, there are a few questions to consider that may help answer whether your erectile dysfunction is psychological in nature:
Are you able to achieve an erection while masturbating?
Do you experience morning erections?
Are you under a lot of stress or experiencing an abnormal amount of anxiety?
Do you get nervous about pleasing your partner?
Answering “yes” to any of these questions doesn’t always mean that you have psychological ED, but it’s nevertheless a sign that one or several psychological factors may play a role in your symptoms. Morning erections in particular (also called nocturnal erections) happen on their own during a stage of sleep called REM. If a man still gets morning erections regularly, but has problems getting it up during intimate moments, it usually means his body—especially the nerves, blood flow, and hormones needed for an erection—is working as it should.
It’s especially important to talk to a healthcare provider if you think that your ED symptoms may have something to do with a mental health issue such as anxiety or depression.
Just like erectile dysfunction caused by physical health issues, psychological ED is almost always treatable. The best way to beat psychological erectile dysfunction is to address the root of the problem, whether it’s a mental illness, feelings of guilt related to sex, or otherwise.
The many approaches can be categorized neatly into three groups:
Medications
Therapy
Lifestyle changes
Treating psychological ED isn’t always quite as simple as taking a tablet of sildenafil (the active ingredient in Viagra®) before sex.
Although medications like Viagra®, tadalafil (Cialis®), vardenafil (Levitra®) and avanafil (Stendra®) are effective at treating ED for many men, they're not magical cures that create libido or sexual interest. Rather, they only work when you're actually in the mood.
These drugs help with the physiological causes of ED, such as poor blood flow or damage to your nervous system. They may give you a little more confidence, but they’re not going to get rid of your anxiety or other psychological causes of ED.
However, it’s important to note that if physical problems are contributing factors to psychological ED, these medications may help.
Hims offers several United States Food and Drug Administration (FDA)-approved ED medications online. To get a prescription, you’ll first have a virtual consultation with a licensed healthcare provider who will then determine whether a treatment is appropriate for you and your symptoms.
There are several types of therapy that can help you with performance problems.
Cognitive behavioral therapy (CBT) is a common type of psychotherapy often used to treat depression and anxiety. During a CBT session, your provider helps you identify and change any unhealthy thought and behavioral patterns. Research also suggests that CBT can be a useful intervention for men with ED.
CBT operates under the understanding that your inability to achieve or maintain an erection isn’t the core problem. Instead, it holds that you’re thinking about intimacy in a way that may be causing issues.
When you better understand your thought patterns, you may be able to change them in a positive way to resolve your issues.
Another option is psychosexual therapy, or sex therapy. This is a specialized form of counseling that’s designed to help you (and, in many cases, your partner) overcome sexual issues such as erectile dysfunction.
If you aren’t quite ready to talk to a therapist about your psychological ED, there are numerous alternative therapies you can try at home. These include:
Meditation. Although there’s no high-quality research on the effects of meditation on erectile dysfunction, it may potentially help some people reduce stress or anxiety.
Relaxation techniques. Other techniques for promoting relaxation and reducing stress, such as rhythmic breathing and other forms of mindfulness, may also help you improve your sexual function.
Ways you may be able to prevent psychological ED and ED in general, as well as other forms of sexual dysfunction include:
Engaging in regular exercise to help improve your circulation, reduce stress, and lower your risk of conditions such as obesity, heart disease, or high blood pressure (hypertension).
Keep alcohol consumption moderate (no more than two standard drinks per day). It’s especially important to avoid alcohol before sexual activity since it can cause “whiskey dick.”
Eating a healthy diet rich in fruits, vegetables, lean proteins, and whole grains to support your blood vessel health.
Getting adequate sleep, which for most people is more than seven hours per night.
Practice mindfulness techniques such as meditation, deep breathing, or progressive muscle relaxation daily to help reduce stress.
Discuss fears or performance pressures with your partner in a nonjudgmental environment.
Set realistic expectations and explore intimacy with your partner beyond penetrative sex (such as sensual touch or massage).
Quit or avoid smoking to improve your overall well-being and sexual health.
Consult a mental health professional if you experience persistent anxiety, depression, or other mental health problems.
If you or someone you know is struggling or having thoughts of suicide, call or text the 988 Suicide & Crisis Lifeline at 988 or chat at 988lifeline.org . In life-threatening situations, call 911.
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