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

Though you might think of erectile dysfunction as an older man’s problem, statistics show that this condition affects men of all ages. In fact, approximately 25% of new ED cases are men under the age of 40.

In older men, erectile dysfunction is frequently linked to underlying health problems such as heart disease or diabetes. But what about young, healthy men? What explanation is there for a 30-year-old man in perfect health to experience erectile issues?

In the absence of physical health problems, we must delve a little deeper to determine the underlying cause of erectile dysfunction. What you may not know is that psychological factors are a major contributing factor for many cases of ED. In fact, statistics show that up to 20% of ED cases are psychological in nature.

If you suffer from erectile dysfunction and you can’t blame it on underlying health conditions, you might feel like your problems are all in your head. While psychological issues may be at the root of your problem, they are just as valid as many physiological causes for ED. Keep reading to learn more about the psychological causes of ED and what you can do to resolve them.

What Are the Most Common Psychological Causes of ED?

In some cases, men who experience abuse or sexual trauma in childhood may develop erectile issues later in life. If you have had this kind of experience, the chances are good that erectile dysfunction is not your only struggle and you should seriously consider seeking professional help. Though childhood trauma is a completely valid reason for developing ED, we’re going to focus on the psychological issues that develop later in life.

When erectile dysfunction is caused by psychological triggers, it is referred to as psychological impotence. Some of the most common causes of this type of ED include the following:

• Stress
• Anxiety
• Relationship problems
• Depression
• Performance anxiety
• Guilt
• Low self-esteem
• Pornography addiction

Many of these triggers are correlated and you may be affected by more than one. Let’s now take a closer look at each of these causes for psychological ED.

Stress and Anxiety

Though stress and anxiety are two different things, they are closely related when it comes to issues of erectile dysfunction. In many cases, stress is the underlying factor, but it causes anxiety which then triggers more stress – it is a vicious cycle. If you take a look at the physical side of things, however, you’ll see that stress and anxiety are even more closely related than you may realize.

Many men do not realize that there are different types of erections – three, to be exact. A reflexive erection is due to physical stimulation while a psychogenic erection is triggered by visual or mental images. A nocturnal erection is one that occurs during sleep.

All three of these involve specific bodily systems including the hormones, muscles, blood vessels, nervous system, and emotions. If any of these systems become compromised, it can cause ED. In the case of anxiety and stress, these things can affect the brain’s ability to send the necessary signals to trigger the desired physical response – an erection. Stress and anxiety can also contribute to an ongoing cycle of ED, as mentioned earlier.

To give you some evidence of the link between anxiety, stress, and ED consider the results of a study published in a 2015 edition of Comprehensive Psychiatry. In a study of case records for 64 men with erectile dysfunction or premature ejaculation, there was a significant link between ED and anxiety disorders or depression. Of the 64 participants, 8 had comorbid depressive disorders and 15 had anxiety disorders. In the majority of patients, these disorders predated the onset of sexual dysfunction which suggests that the disorders may have been a contributing factor.

Relationship Problems

Cultivating and maintaining a healthy relationship is not easy. It takes time to truly get to know someone and to trust them. If you and your partner are experiencing trouble 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 – it is 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.

Depression

Unless you have experienced depression for yourself, you may think of it as something akin to sadness. While depression may cause feelings of sadness, it goes much deeper and it tends to linger well beyond any specific cause or trigger.

Depression acts much like an anchor, weighing you down in body and mind, affecting all aspects of your life – physical and mental.

Some of the most common symptoms of depression include the following:

• Feelings of sadness, emptiness, or hopelessness
• Angry outbursts, irritability or frustration
• Loss of interest in most or all normal activities
• Tiredness or lack of energy
• Anxiety, agitation, or restlessness
• Feelings of worthlessness or guilt
• Difficulty thinking or concentrating

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 Psychosomatic Medicine shows a clear link between depression and erectile dysfunction in men. Using data obtained from the Massachusetts Male Aging Study, researchers were able to conclude that a relationship between depressive symptoms and erectile dysfunction existed and was independent of aging and demographics.

Performance Anxiety

In many ways, performance anxiety becomes a self-fulfilling prophecy wherein you become nervous about being able to satisfy your partner and the nerves lead to sexual dysfunction. In many cases, performance anxiety is triggered by negative self-talk – worries about being able to achieve an erection, pleasing a partner, or ejaculating too early. If you have had erectile issues in the past, those experiences will add to the weight of performance anxiety.

Guilt and Low Self-Esteem

Many men who suffer from erectile dysfunction feel guilty about being unable to please their partner. If the problem persists, the guilt becomes more than just a side effect – it can contribute to the ongoing cycle of ED as well. Guilt is often paired with low self-esteem, and not just in men with erectile dysfunction. Guilt and shame are feelings that are commonly linked to mental health issues such as depression. In fact, feelings of worthlessness and inappropriate guilt is one of the clinical criteria for major depressive disorder, according to the DSM-5.

Not only can guilt affect your ability to perform sexually, but so can low self-esteem. The correlation between erectile dysfunction and low self-esteem seems obvious from one direction – an inability to perform in the bedroom can cause you to feel bad about yourself. But how does low self-esteem cause ED? Self-esteem is defined as, “confidence in one’s own worth or abilities.”

While self-esteem can be affected by the perceptions of others, it is largely how you feel about yourself. If you have a negative view of yourself and your abilities, it is going to color your experience and actions on a daily basis. Many people with low self-esteem get so caught up in their own perception of themselves, that they begin to project it onto others. For example, a man with low self-esteem might believe that he is not capable of satisfying a woman and, as a result, he becomes unable to perform in the bedroom. Low self-esteem can also be a sign of other psychological issues such as depression.  

Pornography Addiction

Pornography addiction or dependence is a potential cause for ED that many men fail to consider. If you spend a great deal of time watching and masturbating to pornography, it could cause you to develop unrealistic expectations about sex or about your sexual partners. When this happens, your brain becomes “trained” to not only expect but, in a way, to need that kind of experience in order to achieve arousal and climax. Researchers have actually studied this effect and have given the condition its own name – pornography-induced erectile dysfunction (PIED).

How Do You Know if Your ED is Psychological?

The key to treating erectile dysfunction is to identify the underlying cause. In many cases, it takes a fair bit of trial and error. Because the majority of ED cases are caused by physiological issues, your first step should be to talk to your doctor about your concerns. After completing a physical examination and reviewing your medical history, your doctor will ask you some questions and run some tests to rule out medical causes for your ED.

Some of the medical causes which are often linked to ED include conditions such as diabetes, hypertension, high cholesterol, coronary artery disease, obesity, hormonal disorders, alcoholism, and metabolic syndrome.  In order to rule out these medical conditions, your doctor may perform tests such as the following:

• Complete blood count (CBC)
• Urinalysis
• Fasting blood glucose
• Serum creatanine test
• Lipid profile
• Prolactin level test

In addition to these laboratory tests, your doctor may also ask you to complete a self-report to gauge your level of sexual function. You’ll be asked questions about your sexual desire (libido), your ability to achieve and maintain an erection, your ability to reach orgasm, your satisfaction level with intercourse, as well as your overall sexual satisfaction. Depending on your answers, and the results of your laboratory tests, your doctor may recommend a psychological evaluation to further explore the potential cause for your ED.

Whether you’ve talked to your doctor or not, there are a few signs to look for which might 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?

If you answer “yes” to any of these questions, your ED may well have a psychological link. To confirm this diagnosis, you may want to complete a full psychological evaluation. This is particularly important if you suspect that your ED has something to do with a mental health issue like anxiety or depression that might require additional treatment, either medical or psychosocial.

Treatment Options for Psychological Impotence

Though psychological causes of erectile dysfunction may be more complex than medical causes, they are still treatable. You should know, however, that resolving psychological impotence may not be quite as simple as taking Viagra (sildenafil citrate). ED drugs are designed to sidestep the physiological causes for ED such as low blood pressure or vascular damage – they won’t help you with issues of anxiety, stress, or low self-esteem. The best treatment for psychological ED will address the problem at its root.

Cognitive behavioral therapy (CBT) is a common and highly effective treatment for psychological issues in general, but also for ED. Facilitated by a therapist, this type of treatment helps you to identify and change unhealthy patterns of thought and action which may be contributing to your erectile issues. This kind of treatment is based on the idea that the situation itself (your inability to achieve or maintain an erection) is not the core problem, but rather your reaction to it. If you can learn to better understand yourself and your thought patterns, you can change them in a positive way to resolve your issues.

If you aren’t quite ready to talk to a therapist about your psychological impotence, there are some alternative therapies you can try at home. Relaxation techniques, for example, can be beneficial for many of the causes of psychological ED including stress, anxiety, and depression. Here are a few ideas you can try on your own:

• Rhythmic breathing – Concentrating on your breathing while taking long, slow breaths can help you take a step back from your stress and anxiety to live in the moment. Try inhaling slowly and deeply over a count of 5 then hold your breath for 5 seconds before exhaling slowly over another count of 5.
• Meditation – Just ten to fifteen minutes of meditation a day can drastically reduce your stress and anxiety. There are many different ways to practice meditation, so try a few options to see what works best for you.
• Guided imagery – This practice involves calming your mind and slowing your breathing while creating peaceful imagery in your head. It may also involve positive self-talk, giving yourself affirmations and dispelling negative thoughts.

If you suffer from psychological impotence, you probably have a lot on your mind and the thought of sharing your problems with your doctor, let alone anyone else, can be overwhelming. It is important to realize, however, that discussing your problem with your partner is an important part of the healing process.

You may find that the simple act of acknowledging your issues 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 may even be able to give them some tips on how to help you when you are experiencing difficulties.

Once you have talked to your partner about your issues, you may want to consider taking things one step further with psychosexual therapy. This is a form of therapy in which both you and your partner see a therapist together. The therapist will help you and your partner break out of the cycle of stress and disappointment that has been coloring your sex life and contributing to your ED. Going to a therapist with your partner may also help you work out any relationship issues that have been affecting your sex life so the both of you will be more satisfied.

While erectile dysfunction is a deeply personal issue, it is not something you should suffer through alone. Psychological ED can be particularly damaging to your confidence but opening up to someone about your issues can help. Today is the day to take the first step toward seeking help and resolving your issues. 

This article was reviewed by Ho Anh, MD.