Psychological Causes of ED — Is It All in Your Head?

Erectile dysfunction (ED) is a common sexual performance issue that occurs in men of all ages and backgrounds. If you’re prone to ED, you may find it difficult or impossible to get or maintain an erection that’s firm enough for sex.

Although many people think of erectile dysfunction as an older man’s problem, statistics show that ED actually affects men of all ages. In fact, some research suggests that approximately 26 percent of new ED cases occur in men under the age of 40.

Erectile dysfunction can occur for a variety of reasons. In older men, it’s often caused by health issues such as heart disease, atherosclerosis (clogged arteries), diabetes, multiple sclerosis or hypertension (high blood pressure).

But what about young, healthy men? In younger men unaffected by cardiovascular disease and other serious health issues, that explanation is there for erectile dysfunction?

In the absence of physical health problems, we need to delve deeper to determine the cause of erectile dysfunction. 

What you might not know is that for many men, psychological factors are a significant factor for erectile dysfunction.

Below, we’ve explained what erectile dysfunction is, as well as how psychological factors play a role in its development. We’ve also talked about what you can do to treat psychological ED and enjoy a fulfilling, satisfying sex life.

What is Erectile Dysfunction?

Erectile dysfunction is a common sexual health condition. If you have ED, you might not be able to get an erection that’s firm enough for sex or maintain an erection for long enough to have sex with your partner.

ED varies in severity. For some men, it’s an occasional annoyance that can get in the way of sex every now and then. For others, ED may be a severe, long-term issue that has a serious impact on the person’s ability to enjoy sex.

An estimated 30 million men in the United States are affected by ED, making it an extremely common issue. 

Certain factors may increase your risk of developing erectile dysfunction. You might be more prone to ED if you’re older, have been diagnosed with a disease or medical condition, take a prescription medication or have certain habits, such as smoking or excessive drinking.

What are the Most Common Psychological Causes of ED?

Although most causes of erectile dysfunction are physical in nature, many cases of ED develop as a result of emotional or psychological issues. 

When erectile dysfunction is related to a psychological problem, it’s referred to as psychological ED, or psychological impotence. 

Like with physical ED, there’s no single psychological cause that can trigger erectile dysfunction in men. Instead, a variety of issues can all cause or contribute to psychological ED, such as:

• Anxiety, whether general in nature or specifically related to sex

• Fear or sexual failure or poor sexual performance

• Feelings of guilt about engaging in sexual activity

• Stress about sex or chronic stress related to other issues

• Depression and other mood disorders

• Relationship problems

• Excessive porn consumption

• Low self-esteem

Some medications used to treat psychological issues, such as antidepressants, can also play a role in the development of erectile dysfunction.

Many of these triggers are closely linked, and it’s entirely possible that you could be affected by one or more at a 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.

Stress and Anxiety

Though stress and anxiety are two different things, they’re closely related when it comes to the issue of erectile dysfunction.

Stress is often an underlying factor in ED. But over time, stress can cause anxiety, which in turn triggers more stress, creating a vicious cycle that’s bad for both your mental health and your sex life. 

If you take a look at the physical side of things, however, you’ll easily see that stress and anxiety are even more closely related than you may realize.

Many men do not realize that there are several different types of erections -- three, to be exact. 

A reflexive erection is caused by physical stimulation, while a psychogenic erection is triggered in response to a specific visual or mental image. A nocturnal erection is exactly what it sounds like -- an erection that occurs during sleep. 

All three of these involve specific bodily systems, including hormones, muscles, blood vessels, nervous system and emotions. If any of these systems become compromised, it can cause or contribute to ED.

To give you some evidence of the link between anxiety, stress and ED, consider the results of a study published in 2015.

In a study of case records for 64 men with erectile dysfunction or premature ejaculation (PE), a significant link was found between ED and anxiety or depression. Of the 64 participants, eight had comorbid depressive disorders and 15 had anxiety disorders.

In the majority of the study participants, the disorders predated the onset of sexual dysfunction, suggesting that they may have been a contributing factor. 

Relationship Problems

Cultivating and maintaining a healthy relationship is not an easy task. It takes time to truly get to know someone and trust them.

If you and your partner are experiencing difficulty with your relationship, it could very well bleed over into your sex life.

It could also be the case that your erectile dysfunction is creating problems in the relationship --  another example of the cycle of ED that can affect many different aspects of your life.

Communication is the first step in resolving this particular cause for psychological ED, but it is also one of the most difficult steps to take. 

If you find it difficult to communicate with your partner, taking part in counseling may help you with understanding each other’s needs and improving your connection. 

Depression

Unless you have experienced depression for yourself, you may think of it as something akin to sadness. Clinically speaking, it’s a lot more than that.

Depression acts much like an anchor, weighing you down in body and mind, affecting almost all aspects of your life, both mental and physical. Some of the most common depression symptoms include:

• A persistent sad, empty mood

• Feelings of anxiety, pessimism or that your situation in life is hopeless

• Reduced interest in your hobbies and activities

• Feelings of worthlessness or guilt

• Slowed movement and/or speech

• Changes in your appetite and/or body weight

• Insomnia (difficulty sleeping) or oversleeping

• Difficulty focusing, remembering things or making decisions

• Pains, aches and digestive issues without an obvious cause

• Suicidal thoughts and behavior

As you can imagine, these symptoms can make it difficult to take pleasure in much of anything, let alone sex. 

A study published in a 1998 edition of the journal Psychosomatic Medicine shows a clear link between depression and erectile dysfunction in middle-aged men.

Using data obtained from the Massachusetts Male Aging Study, the researchers were able to conclude that a relationship between depressive symptoms and erectile dysfunction occurred and that it was independent of aging and demographics.

In some cases, excessive use of pornography may contribute to both depression and sexual performance issues such as ED. We’ve covered this topic more in our guide to pornography consumption and depression. 

Performance Anxiety

In many ways, performance anxiety becomes a self-fulfilling prophecy in which you feel nervous about being able to satisfy your partner. That nervousness can follow you into the bedroom and may lead to erectile dysfunction. 

​​In some cases, performance anxiety is triggered by negative self-talk -- worries about being able to achieve an erection, please your partner or avoid ejaculating too early.

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. 

Guilt and Low Self-Esteem

Many men who suffer from erectile dysfunction feel guilty about not being able to satisfy their partner. If the problem persists, the guilt becomes more than just a minor issue -- it can often contribute to the ongoing cycle of ED as well. 

Guilt and shame are common feelings that are often linked to mental health issues, including major depression. In fact, feelings of guilt are a common symptom of depression.

Low self-esteem may also contribute to psychological ED. If you feel unconfident about your sexual performance, or worry that you’re not attractive enough for your partner, this can affect your risk of experiencing sexual performance issues.

Like with many other aspects of psychological erectile dysfunction, low self-esteem and sexual performance issues often make each other worse.

In a study published in the BMJ, researchers found that erectile dysfunction can cause serious distress to men, and that this distress can have a real impact on self-esteem and the quality of relationships.

The relationship between erectile function and depression, anxiety and self-esteem is complex, but all the same, the relationship is there.

Pornography Use

While watching porn isn’t inherently bad or harmful, excessive use of pornography may have a negative impact on your erectile function and sexual health. 

Research suggests that if you spend a lot of time watching and masturbating to pornography, it may cause you to develop unrealistic expectations about sex or about your sexual partners.

When this causes you to face difficulties getting or staying hard, it’s referred to as porn-induced erectile dysfunction.

Although research is limited, watching and masturbating to porn may also reduce your level of sexual satisfaction through something called “death grip” syndrome -- a lack of sensitivity that may be caused by masturbating with an overly firm grip.

This combination of porn-induced ED and death grip syndrome can affect your level of function and enjoyment from real-life sex. 

How Do You Know if Your ED is Psychological?

For years, men believed that sexual problems such as erectile dysfunction were a normal part of growing older.

Fortunately, modern medicine and changing attitudes have debunked this myth. It’s now entirely possible to treat issues such as ED and enjoy good sexual fucntion and a fulfilling sex life at any age. 

If you’re physically healthy and feel worried that you may have psychological ED, the first step in making progress is to talk to your healthcare provider.

After completing a physical exam and discussing your medical history, your healthcare provider will ask you some questions and run some tests to rule out medical causes for your ED. 

Common physical causes of ED include cardiovascular disease, metabolic syndrome, diabetes, hypertension, chronic kidney disease, multiple sclerosis and physical damage that affects your penis and surrounding area. 

In some cases, hormonal issues such as low testosterone levels may affect your level of interest in sex and/or sexual performance. 

In order to rule out these medical conditions, your healthcare provider may perform tests such as 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 to complete a self-report to gauge your level of sexual function. 

You may be asked questions about your sexual desire (libido), your ability to get and maintain an erection, your ability to reach orgasm, your level of satisfaction from sexual intercourse and your general sexual satisfaction.

Based on your answers and the results of your laboratory tests, your healthcare provider may recommend a psychological evaluation to further explore the potential cause of your ED.

Whether you’ve talked to a healthcare professional or not, there are a few signs to look for that may suggest that your erectile dysfunction is psychological in nature. Ask yourself the following questions:

• Are you interested in sex and attracted to your partner, but have trouble performing?

• 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 your ED is psychological, but it’s a sign that one or several psychological factors may play a role in your symptoms.

It’s especially important to talk to a healthcare provider if you think that your ED symptoms may have something to do with a clinical mental health issue such as anxiety or major depression. 

Treatment Options for Psychological ED

Just like erectile dysfunction that’s caused by physical health issues, psychological ED is almost always treatable. 

However, you should know that treating psychological ED isn’t always quite as simple as taking a tablet of sildenafil (the active ingredient in Viagra®) before sex. 

Most ED medications are PDE5 inhibitors that work by increasing blood flow to the soft tissue in your penis. These drugs are designed to sidestep the physiological causes of ED, such as poor blood flow or damage to your nerves.

In addition to sildenafil, other oral ED medications that work this way include tadalafil (Cialis®), vardenafil (Levitra®) and avanafil (Stendra®).

Although these medications are effective at treating ED for many men, they aren’t designed to have any impact on your moods, feelings or thoughts. As such, they may not help you to deal with issues such as low self-esteem, anxiety or depression.

The best way to treat psychological erectile dysfunction is to address the root of the problem, whether it’s a mental illness or simply feelings of guilt about sex. 

Cognitive-behavioral therapy (CBT) is a common treatment for psychological issues, including depression and anxiety. Research also indicates that it’s useful as a form of treatment for men with ED. 

Facilitated by a therapist, this type of treatment helps to identify and change unhealthy patterns of thinking and behavior that may be contributing to your erectile dysfunction and sexual health issues.

This kind of treatment is based on the idea that the situation itself (in this case, your inability to achieve or maintain an erection) isn’t the core problem -- rather, your reaction to it is.

If you can learn to 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:

• Medication. Although there’s no direct research on the effects of meditation on erectile dysfunction, studies have found that some forms of meditation may improve depression and anxiety.

• Relaxation techniques. Other techniques for promoting relaxation and reducing stress, such as rhythmic breathing and guided imagery, may help you to overcome psychogenic ED and improve your sexual function. 

If you suffer from psychological ED, you probably have a lot on your mind. As such, the thought of sharing your problems with your healthcare provider, let alone anyone else, might feel a little overwhelming. 

It is important to realize, however, that discussing ED with your healthcare provider and partner is an important part of the healing process. 

You may find that the simple act of acknowledging the issue and being honest with your partner takes some of the weight off your shoulders. 

Give your partner the opportunity to ask questions to help them understand. You might even be able to give them some tips on how to get you in the mood for sex or help you when you start to experience difficulties getting or maintaining your erection. 

Start Treating Erectile Dysfunction

Erectile dysfunction can occur for a variety of reasons, from physical issues such as high blood pressure and heart disease to psychological ones such as anxiety and depression.

If you’re experiencing ED and think it could be psychological in nature, it’s always best to talk to your healthcare provider. They may be able to detect the cause of your erectile dysfunction and recommend an appropriate form of treatment, such as medication and/or therapy. 

We offer several FDA-approved ED medications online, which are available after a consultation with a licensed healthcare provider who will determine if a prescription is appropriate.

You can find out more about dealing with ED in our complete guide to the most common erectile dysfunction treatments and drugs.