Reduction of sexual dysfunction: by-product of cognitive-behavioural therapy for psychological disorders?

Transcription

1 Sexual and Relationship Therapy Vol. 24, No. 1, February 2009, Reduction of sexual dysfunction: by-product of cognitive-behavioural therapy for psychological disorders? Ju rgen Hoyer*, Stefan Uhmann, Jana Rambow and Frank Jacobi Department of Clinical Psychology and Psychotherapy, TU Dresden, Dresden, Germany (Received 30 July 2008; final version received 21 November 2008) The purpose of the study was to assess changes in sexual dysfunctions among patients undergoing cognitive-behavioural therapy for a psychological disorder. Examinations were made of 451 unselected outpatients (68.1% female, mean age ¼ 36.0 years) of a university outpatient clinic. Using the German version of the Massachusetts General Hospital Sexual Functioning Questionnaire before and after treatment, they rated their sexual interest, ability to become sexually aroused and to achieve erection or lubrication and orgasm, and their general sexual satisfaction. Almost two-thirds of the patients (63.2%) reported having a sexual dysfunction prior to therapy. Sexual dysfunctions improved in a significant number of patients but only after successful treatment for the psychological disorder. Even after the primary disorder had fully remitted, a sexual dysfunction was still present in about 45% of the patients who were originally affected. Results for patients suffering primarily from depression were similar to those who suffered from other psychological disorders. Although many of the co-morbid sexual dysfunctions of patients receiving CBT clearly improve or entirely remit, a relevant portion of patients continues to report sexual dysfunctions. Recognition of sexual dysfunctions and their integration into case formulations should therefore be improved. Keywords: sexual dysfunction; prevalence; co-morbidity; cognitive-behavioural therapy Introduction Sexual dysfunctions are common (Dunn, Croft & Hackett, 1998; Nicolosi et al., 2004; Simons & Carey, 2001), especially when they are included as a co-morbid disorder of another psychological disorder such as anxiety or depression (Bonierbale, Lancon, & Tignol, 2003; Labbate & Lare, 2001; Reinecke, Scho ps, & Hoyer, 2006; Van Lankveld & Grotjohann, 2000). The association between sexual dysfunctions and other psychological disorders has been reported on a descriptiveepidemiological level and it might be expected that successful treatment of a primary co-morbid disorder would be accompanied by improvement in, or even remission of, a secondary sexual dysfunction. Indeed, there is clear evidence that cognitive behavioural therapy (CBT) that focuses on a primary disorder also decreases symptom severity of a co-morbid disorder, even though it was not directly targeted in the treatment. This phenomenon has been shown for panic disorder (e.g. Craske *Corresponding author. hoyer@psychologie.tu-dresden.de ISSN print/issn online Ó British Association for Sexual and Relationship Therapy DOI: /

2 Sexual and Relationship Therapy 65 et al., 2007; Tsao, Mystkowski, Zucker, & Craske, 2002) and generalized anxiety disorder being the primary disorder (e.g. Borkovec, Abel, & Newman, 1995). There is, however, no clear evidence that such beneficial, indirect effects of successful treatment also generalizes to sexual dysfunctions. It therefore remains unclear whether co-morbid sexual dysfunctions persist or remit when another psychological disorder has been successfully treated. As Barlow (2002) suggested, both anxiety disorders and affective disorders share a number of risk factors and pathological processes (e.g. heightened selfawareness) with sexual dysfunctions (see also Hartmann, Philippsohn, Heiser, Kuhr, & Mazur, 2008; Nobre & Pinto-Gouveia, 2008). The assumption of shared pathological processes strengthens the prediction that successful treatment of an anxiety or affective disorder would reduce the risk of developing a sexual dysfunction or would improve a sexual dysfunction that already exists. Although this prediction is plausible clinically, it has not been demonstrated empirically. On the other hand, many sexual dysfunctions are independent of a co-existing psychological disorder or have a defined medical cause (Nicolosi et al., 2004). Furthermore, from a systemic perspective, even though a sexual dysfunction might be associated with a psychological disorder, it might persist or even be intensified when the psychological disorder remits because this disorder has served to stabilize the interpersonal system (cf. Halford, Bouma, Kelly, & Young, 1999). One study that assessed a small sample of depressed patients to determine whether successful CBT for the depression affected their sexual functioning, yielded inconsistent results (Nofzinger et al., 1993). Sexual functioning varied considerably among the patients and, although subjective indicators of sexual dysfunction (i.e. sexual satisfaction) improved with remission of depression, more objective indicators (nocturnal penile tumescence) did not. In view of the inconsistencies and the weak empirical base, it is unclear to what extent successful psychotherapy for another psychological disorder is associated with improvement in a co-morbid sexual dysfunction. The present study, therefore, assessed this relationship in a large sample of outpatients receiving psychotherapy. We expected that improvement would occur in all aspects of self-reported sexual dysfunction in those psychotherapy outpatients who successfully completed their treatment but not in those who did not respond to treatment. We expected to find these effects even when the sexual dysfunction had not been explicitly addressed in the therapy. Methods Sample and procedure All of the assessments were included as part of the routine diagnostic procedures at the outpatient unit of the Dresden University of Technology, for which patients gave informed consent. Of the 545 patients who completed therapy during the study period (September 2003 to February 2008), 50 (9.2%) declined to provide information about their possible sexual problems. Forty-four additional cases (8.1%) could not be included because of missing data. The 94 patients with no or incomplete data were older (F[2, 92] ¼ 5.99, p ¼.003) and more likely to be female (w 2 [2] ¼ 10.43, p ¼.005). The remaining 451 unselected outpatients (68.1% female, mean age ¼ 36.0 years) who completed CBT (average duration ¼ 30.5 sessions, SD ¼ 15.1) were assessed. All patients were reliably diagnosed (Wittchen, 1994)

3 66 J. Hoyer et al. using the DSM-IV Munich-Composite International Diagnostic Interview (M-CIDI: Wittchen & Pfister, 1997), a modified version of the WHO-CIDI (World Health Organization, 1990). More than 83.8% of the patients had at least one anxiety or depressive disorder. Of the patients, 13.7% were suffering from a moderate or severe depressive episode. None of the patients was being treated explicitly for a sexual dysfunction. Assessment of sexual dysfunctions Using the German version of the Massachusetts General Hospital Sexual Functioning Questionnaire (MGH: Labbate & Lare, 2001) before and after treatment, participants rated their sexual functioning during the past four weeks on the following dimensions: (1) sexual interest, (2) ability to achieve sexual arousal, (3) ability to achieve orgasm, (4) ability to achieve erection or lubrication and (5) general sexual satisfaction. Rather than using a global functioning rating, we defined sexual dysfunction as having rated at least one of the dimensions as moderately diminished, markedly diminished or totally absent. This is a more conservative criterion than proposed by Labbate and Lare (2001). As a practical and widely used one-item observer rating of treatment response, we used Guy s (1976) Clinical Global Impression Scale. Determination of overall therapy outcome Therapy outcome was measured using the following stage definitions: (1) Remission (31.9%, N ¼ 144): having no diagnosis of a psychological disorder plus a clinical global impression (CGI) rating of much improved or very much improved after therapy; (2) Response (34.8%, N ¼ 157): still fulfilling the criteria for a psychological disorder after therapy but having a CGI rating of much improved or very much improved ; (3) Non-response (33.3%, N ¼ 150): having a CGI rating not higher than moderately improved. The three outcome groups differed slightly, though significantly, on age (Remission: M ¼ 34.7, SD ¼ 12.9; Response: M ¼ 34.7, SD ¼ 13.1; Non-Response: M ¼ 38.7, SD ¼ 14.4; F[2,448] ¼ 4.41, p 5.05). There were also fewer females in the Non-Response Group than in the other two groups (Remission Group: 70.1% females; Response Group: 75.2%; Non- Response Group: 58.7; w 2 [2] ¼ 10.02, p 5.01). Age and gender were statistically controlled in the subsequent multivariate analyses. Statistical analyses The study s main hypothesis implied that the frequency with which symptoms of sexual dysfunction were reported would decrease only when therapy for the comorbid disorder was successful. Using w 2 and McNemar s w 2 -tests, we tested this hypothesis first by determining whether rates of sexual dysfunction decreased more in the Remission and Response Groups than in the Non-Response Group. Additionally, we computed repeated-measures ANCOVAs (Outcome Group 6 Gender 6 Time, with age as the covariate) to determine whether individual sexualdysfunction symptoms (the individual items on the MGH) improved. Significant Outcome Group 6 Time interactions would indicate that the hypothesis was supported. All statistical analyses were conduced using SPSS version 15.

4 Table 1. Any sexual dysfunction pre-cbt Sexual dysfunction trajectories among 451 CBT outpatients. Any sexual dysfunction post-cbt Sexual and Relationship Therapy 67 Results Prevalence rates before and after therapy Before therapy, a large proportion of the respondents across the three outcome groups reported having at least some sexual dysfunction (63.2%, overall; females, 67.8%; males, 53.5%). As expected, after treatment the rates were significantly lower (w 2 [6] ¼ 26.88, p 5.001, see Table 1). The reduction occurred among both patients in remission (McNemar s w 2 [1] ¼ 22.77, p 5.001) and treatment responders (McNemar s w 2 [1] ¼ 26.26, p 5.001), but there was no significant reduction among the non-responders (McNemar s w 2 [1] ¼ 0.57, p ¼.45, see Figure 1). More detailed inspection of the results (see Table 1) shows that many of the patients who initially reported having a sexual dysfunction also indicated symptoms of dysfunction after therapy (Table 1, fourth row). Interestingly, a smaller number of the patients reported symptoms of sexual dysfunction after but not before therapy (Table 1, second row). Obviously, the onset of sexual problems after therapy occurred less frequently in the two groups with a positive therapy outcome (w 2 [2] ¼ 5.99, p 5.05). Furthermore, inspection of the subgroup suffering from moderate or severe depressive episodes (n ¼ 62) reveals a similar picture. Among these patients, the following ones continued to indicate relevant symptoms after therapy: 35.7% (of 14 patients who remitted and who had indicated symptoms of sexual dysfunction before therapy), 47.1% (of 17 patients who showed a positive response and who had indicated symptoms of sexual dysfunction before therapy) and 83.3% (of 18 who did not respond to therapy and who had indicated symptoms Remission Response Non-response Total N % of group N % of group N % of group N % No No No Yes Yes No Yes Yes Total Figure 1. Rates of sexual dysfunction in 144 patients with full remission of other psychological disorders (157 responders, 150 non-responders).

5 68 J. Hoyer et al. of sexual dysfunction before therapy). In total, 49 (79%) of the depressed patients reported some sexual dysfunction before therapy. This number decreased to 31 (50%) after therapy. Improvement in sexual dysfunction ANCOVAs (Outcome Group 6 Gender 6 Time) conducted for each item of the MGH revealed the following results (see Table 2 for descriptive statistics and Table 3 for inferential statistics). Age was a significant covariate across all symptoms of sexual dysfunction. Correlations between age and sexual-dysfunction symptoms were consistently positive and significant (see Table 4), making it important to control for age in all further analyses. Significant main effects for Gender and Outcome Group were obtained for all sexual dysfunction symptoms. All of the symptoms were more severe among women (see Table 2). Follow-up analyses of the Outcome Group main effect using pairwise comparisons revealed that sexual-dysfunction symptoms were consistently less intense in the Remission Group than in the Non-Response Group (sexual interest: Bonferroni adjusted p 5.001; arousal: p 5.001; orgasm: p 5.01; lubrication: p 5.05; erection: p 5.05; general satisfaction: p 5.001). Symptoms were less intense in the Response Group than in the Non-Response Group only for sexual interest (p 5.05) and general satisfaction (p 5.01). There were no significant differences between the Remission Group and the Response Group (all p 4.15). A significant main effect for Time was found only for the ability to achieve orgasm. There was also a significant interaction between Gender and Time (p 5.01), indicating that improvement in the ability to achieve orgasm was more pronounced among women than men. The interaction between Outcome Group and Time for general sexual satisfaction (see Table 3) indicates that improvement in sexual satisfaction was associated with overall therapy outcome. Finally, there was a trend toward an interaction between Outcome Group and Time for sexual interest (p ¼.099), ability to achieve sexual arousal (p ¼.051) and ability to achieve erection (p ¼.06). Discussion Patients examined in this study attended the outpatient clinic because of a psychological disorder other than sexual dysfunction. Nevertheless, more than 60% of them reported having at least one kind of sexual dysfunction prior to therapy. These results are consistent with those of previous studies (e.g. Labbate & Lare, 2001) showing a high prevalence of sexual problems among psychotherapy patients, even though these problems often remain untreated (Reinecke, Scho ps, & Hoyer, 2006). Also consistent with previous results (e.g. Nicolosi et al., 2004) we found that having symptoms of sexual dysfunction was generally positively associated with age and being female. In accordance with the main hypothesis of the study, the symptoms of sexual dysfunction significantly improved among patients who either improved or fully remitted in terms of their presenting problem. Conversely, patients who did not show a positive change with regard to their presenting problem also did not show improvement in their sexual functioning. Additionally, the onset of sexual problems during treatment occurred less frequently among the successfully treated patients

6 Sexual and Relationship Therapy 69 Table 2. Means and standard deviations for sexual functioning before and after CBT by outcome group and gender (Total N ¼ 451). Outcome group Gender Remission Response Non-response Female Male Total N ¼ 144 N ¼ 157 N ¼ 150 N ¼ 307 N ¼ 144 N ¼ 451 Sexual interest Pre-CBT Post-CBT Arousal Pre-CBT Post-CBT Orgasm Pre-CBT Post-CBT Lubrication (female) Pre-CBT Post-CBT Erection (male) Pre-CBT Post-CBT General satisfaction Pre-CBT Post-CBT

7 70 J. Hoyer et al. Table 3. Results of repeated-measures ANCOVAs for each kind of sexual dysfunction. Sexual interest Arousal Orgasm Lubrication (female) Erection(male) General satisfaction Between factors Age (Covariate) F (1, 444) ¼ F (1, 444) ¼ F (1, 444) ¼ F (1, 303) ¼ F (1, 140) ¼ F (1, 444) ¼ p p p p p p Group F (2, 444) ¼ 7.66 F (2, 444) ¼ 6.90 F (2, 444) ¼ 6.22 F (2, 303) ¼ 3.44 F (2, 140) ¼ 3.91 F (2, 444) ¼ 9.53 p p 5.01 p 5.01 p 5.05 p 5.05 p ¼.001 Gender F (1, 444) ¼ F (1, 444) ¼ F (1, 444) ¼ F (1, 444) ¼ 4.30 p p p p 5.05 Group 6 Gender F (2, 444) ¼ 0.32 F (2, 444) ¼ 0.14 F (2, 444) ¼ 0.27 F (2, 444) ¼ 0.57 p ¼.72 p ¼.87 p ¼.76 p ¼.56 Within factors Time F (1, 444) ¼ 0.57 F (1, 444) ¼ 0.55 F (1, 444) ¼ 7.82 F (1, 303) ¼ 0.20 F (1, 140) ¼ 0.01 F (1, 444) ¼ 0.38 p ¼.45 p ¼.46 p 5.01 p ¼.66 p ¼.93 p ¼.54 Time 6 Group F (2, 444) ¼ 2.33 F (2, 444) ¼ 3.00 F (2, 444) ¼ 1.23 F (2, 303) ¼ 0.56 F (2, 140) ¼ 2.84 F (2, 444) ¼ 4.05 p ¼.099 p ¼.051 p ¼.29 p ¼.57 p ¼.06 p 5.05 Time 6 Gender F (1, 444) ¼ 2.51 F (1, 444) ¼ 0.97 F (1, 444) ¼ 8.66 F (1, 444) ¼ 0.61 p ¼.14 p ¼.34 p 5.01 p ¼.44 Note. There were no other significant (triple) interaction effects.

8 Sexual and Relationship Therapy 71 Table 4. Correlations of each MGH item with age among 451 CBT outpatients a 6 b 7 1. Age 2. Sexual interest (pre-cbt) Arousal (pre-cbt) Orgasm (pre-cbt) Lubrication (female, pre-cbt) a Erection (male, pre-cbt) b General satisfaction (pre-cbt) Note. All correlations are significant at p ; a N (female) ¼ 307, b N (male) ¼ 144. than among the non-responders. Since none of the patients was explicitly treated for a sexual problem, it seems that successful CBT for a psychological disorder often has a positive side-effect on a co-morbid sexual dysfunction (or prevents its onset). The mechanisms underlying this phenomenon were, however, not evaluated in the current study and remain unclear. The assumption of shared psychopathological processes among different disorders, such as anxiety disorders and sexual dysfunctions (e.g. Barlow, 2002; Nobre & Pinto-Gouveia, 2008) could at least partially explain the synchronicity of symptom reduction that we observed. Other explanations, however, are also plausible and need to be evaluated. For example, many of the sexual dysfunctions that we identified might be directly attributable to another disorder, as has been shown to be the case specifically for depression (Bonierbale, Lancon, & Tignol, 2003). In such cases, symptoms of sexual dysfunction might be an expression of the primary disorder and would be expected to improve as the primary disorder remits. When sexual dysfunction improves although not directly treated, does this mean that sexual problems need not be explicitly addressed in therapy? Our data definitely do not allow this conclusion. In fact, even after successful treatment for the primary problem, sexual dysfunctions persisted in a significant portion of the cases. This was also observed in the depressed patients. In short, although there was a clear improvement in sexual problems in many of the successfully treated cases, many others remained symptomatic. Closer inspection of the results revealed some specificity regarding the processes of change in the symptoms of sexual dysfunction. Unlike the other sexual problems, the inability to achieve orgasm improved during therapy regardless of whether or not the targeted disorder improved, especially among the women. The reason for this specificity is unclear; perhaps it is because the inability to achieve orgasm is less constant than are other symptoms of sexual dysfunction. The inability to achieve orgasm might also be more closely associated with extraneous factors that we did not assess, such as changes in the quality of the intimate relationship. Except for lubrication problems, most of the other symptoms of sexual dysfunction showed at least a statistical tendency to change that depended on how successful the CBT was. This occurred most clearly for sexual satisfaction but, as pointed out previously (Nofzinger et al., 1993), sexual satisfaction is highly subjective and tends to be affected by the person s overall negative affect. After successful therapy, patients sexual satisfaction might improve because their negative affect has decreased, although more objective indicators of sexual functioning might not change. Sexual interest and the ability to become aroused and to have an erection tended to improve, but further research that includes a broader range of

9 72 J. Hoyer et al. assessments (e.g. interviews) will be necessary to establish whether or not these improvements are clinically significant. There are several limitations of the current study. Firstly, we used only a short self-report measure of sexual functioning. Secondly, we were unable to arrange for a medical examination to identify patients sexual dysfunctions that had a medical origin. Furthermore, possible other treatment modalities and medications were not assessed. Thirdly, the MGH does not assess subjective impairment, thus leaving unanswered the degree to which patients suffered from their sexual dysfunctions and needed treatment. Moreover, because the MGH lacks population norms, we must cautiously interpret the prevalence rates for sexual dysfunctions in the current patient sample. For example, the prevalence rates that we found in the Remission and Treatment-Response Groups should be viewed in the context of the pervasiveness of sexual dysfunctions in the general population (Simons & Carey, 2001). These limitations clearly point to the necessity for further studies to increase our understanding of the co-morbidity between sexual dysfunctions and other psychological disorders in patients in psychotherapy. In summary, this was the first study to explore sexual dysfunctions and their relationship to overall therapy outcome in a large sample of outpatients who received CBT and who had been reliably diagnosed using DSM-IV criteria. More detailed research should explore which reported symptoms remit and to what extent this is a function of third variables such as diagnostic category or medication. Notwithstanding these and other methodological limitations, the pattern of results makes practical conclusions obvious. Despite the observed positive side-effect of successful CBT, therapists should not refrain from exploring, diagnosing and explicitly addressing sexual dysfunction in therapy (Reinecke, Scho ps, & Hoyer, 2006). Instead, it remains important to find out whether CBT for a presenting problem is likely (and sufficient) to improve co-morbid sexual dysfunction or not. This question is not only relevant for research but also for the practical field. For example, a practitioner should be able to answer the question whether an additional specific intervention (e.g. sexual therapy) is necessary. Additional interventions that directly target sexual problems could in many cases be based on a generic CBT rationale, extending principles that patients may have learned in their therapy for anxiety or depression to the field of sexual dysfunction. For example, the role of automatic thoughts seems to be crucial not only for anxiety and depression but also for sexual dysfunctions (Nobre & Pinto-Gouveia, 2008). In short, our results indicate that CBT helps to reduce co-morbid sexual dysfunction even when therapy was not directly focused on it. It remains an interesting research question to what degree remission rates can be further improved when co-morbid sexual dysfunction is more clearly recognized and better integrated into case formulations. Acknowledgements We want to thank W. Miles Cox (Bangor, UK) for his comments on this paper. Notes on contributors Ju rgen Hoyer, Professor and Scientific Director of the Outpatient Clinic, Department of Clinical Psychology and Psychotherapy, Dresden University of Technology, Germany. Stefan Uhmann and Jana Rambow, PhD students, Department of Clinical Psychology and Psychotherapy, Dresden University of Technology, Germany.

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