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Conquering Performance Anxiety

Posted Aug 24 2008 1:49pm
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.

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