Main findings
ED in the past, called impotence, refers to the man in continuous sexual stimulation of the penis that cannot achieve or maintain enough hardness to complete satisfactory sexual intercourse. As a disorder with a high prevalence and incidence, ED negatively affects the quality of life and psychological health of patients and their partners. The normal erectile function of the penis needs the coordination of vascular, nerve, hormone, spongy body and other factors, including psychological factors, among which the abnormality of any of these can lead to ED. ED is usually classified into three groups according to the causes: organic ED, psychological ED and mixed ED. Aetiological studies of ED found that approximately 39% of patients with ED had non-organic ED. Psychological stress is closely related to ED, such as daily marital disharmony, asymmetric or lack of sexual knowledge, bad sexual experience, work or financial pressure, incorrect understanding of media, fear of illness, adverse drug reactions, and so on.10 11
The introduction of oral drugs such as sildenafil has radically changed the treatment of ED, reducing the use of other treatments such as medicated urethral system for erection, vacuum constrictor, vascular surgery and penile prosthesis. Sildenafil is traditionally taken as needed. Clinical studies have shown that continuous daily administration of 100 mg of sildenafil can significantly improve the IIEF score of patients and sexual quality of life for both men and women, as well as improve the endothelial diastolic function and erectile hardness of patients with ED, and improve tolerance of patients with ED.12–15 It has generally been accepted that patients presenting with ED are treated with sildenafil regardless of aetiology. However, a reasonable share of sildenafil non-responders have a non-organic ED. Unfortunately, studies on the aetiology of ED found that about 39% of patients with ED belong in the non-organic category. From a biopsychosocial perspective, the effects of vascular and hormonal mechanisms in ED are limited and transient, only by providing patients with an integrated medical and psychological approach could the effectiveness of treatment be increased.
Rosen reported that sexual psychotherapy (SP) in combination with sildenafil is effective for patients who do not respond to sildenafil monotherapy.16 In our view, medical and psychosexual therapies are not indeed two distinct therapeutic entities to be used in different clinical settings, but are two important tools to be simultaneously considered (and often simultaneously employed) to fully rescue the sexual satisfaction of the couple. SP should be considered a useful chance on all occasions. When non-organic causes are predominant, SP could help in solving the problem. Conversely, when ED is mainly a symptom of an organic disease, SP should be considered as an important support, reducing the net contribution of marital and/or intrapsychic components and improving responsiveness and compliance to medical treatments.
Concerning the psychological intervention, several modes of psychotherapy including cognitive–behavioural therapy, sex therapy, behaviour therapy, educational intervention, and other psychotherapies, which include mindfulness meditation, hypnotherapy and rational emotive therapy have been developed. In the treatment of ED, the unique value of psychodynamic psychotherapy is far more than the improvement of symptoms. Psychodynamic psychotherapy works on the symptoms, and explores the emotional conflicts, defence mechanisms, developmental deficits and personality structure underlying the symptoms to work through them. Contemporary psychoanalysis has evolved drastically away from sexuality. Today, five psychologies of psychoanalysis have been employed in the psychodynamic understanding of patients. They are the theory of drive and emotional conflicts, the theory of ego, superego and ego ideal functions, the theory of narcissism and self-psychology, object relationship theory and attachment theory. These theories have enriched the clinical thinking and methods of traditional psychodynamic therapy.
SP should be fulfilled throughout the course of treatment and may be given alone or in combination with other therapies.17 Therefore, this study adopted a combination of BPP with Viagra in the treatment of non-organic ED. Compared with LTPP, BPP is characterised as brief, goal focused (symptom relief and a certain degree of personality change) and placing importance on client initiative (guiding patients to keep the theme in focus). This therapy focuses more on the role of the focal conflict in the treatment and works around it. The focal conflict consists of three parts: wish, response from the others and response from the self. In short, it is the main problem of the patient. During the treatment, more attention should be paid to the focal conflict and working around it. The so-called focal conflict is simply the crux of the patient’s main problem. In clinical work, we should try not to rely on free association, and focus instead on related causes, early life experiences and behaviour patterns to find the focal conflict. Or techniques such as dream interpretation and transference analysis can be used. These are characteristic of BPP, and let patients find out the focal conflict. Time-limitedness and structural settings are another features of BPP. Compared with LTPP, which relies on the loose arrangement of free association and the treatment lasting 6 months to several years, BPP generally lasts about 2–3 months. The frequency of counselling sessions at least twice a week ensures the effectiveness of treatment, and the clinical objectives are well defined in the treatment phases. In the first stage (lasting one to three sessions), the therapist generally puts emphasis on the universality of the theme pattern in the patient’s life. In the second stage (lasting 14–18 sessions), the focus is on the working-through this pattern. In the third stage (the final one to three sessions), the therapy is focused on termination and separation.18 19 Because the treatment time and effect are controlled and expected, it is suitable for clinical research in psychology. Of course, due to the limitation of the duration of treatment, the treatment process focuses on the change of a certain problem, and the lack of emphasis on extensive personality analysis is also its main disadvantage. The subject of this study, sex, is very complex. It means a great deal to the overall shaping of personality and is premised on ego strength, stability and tolerance. For psychologists, sexual function is not simply the hyperaemia, swelling, pleasure and excretion of an organ after stimulation; nor is sex simply mechanical. As the subject of sex, it also calls for the necessity to deal with the closeness, empathy and self-confidence.20–22 From the perspective of object relations,23–25 sex can be the object to control the relationship, in which the adjustment of sexual contact presents the possibility of superiority, which means power struggle or passive aggression. Therefore, for men, especially Chinese men, who are generally regarded as the dominant party of sexual activity in eastern cultures, sex is not simply the erectile function of the penis, but also a reflection and reference of power, social status, dominant relationship, personal dignity, male charm, and so on. Sex has a deeper meaning in the nature of unconscious fantasy, including ambition, attachment, intimacy, gender identity, aggression, hostility, and so on. Contemporary psychoanalysis provides clinicians with complex insights into ED. The essence of psychodynamic psychotherapy is to explore the aspects that are not yet fully understood, particularly their performance and potential impact in the occasional therapeutic relationship.26 27 Seven features of process and technique reliably distinguished psychodynamic therapy from other therapies. They are focused on affect and expression of emotion, exploration of defence mechanisms and resistance, identification of recurring themes and patterns, discussion of past experience, focus on interpersonal relations, focus on the therapy relationship and exploration of fantasy life.
The author gradually realised that lack of intimacy, fear of castration, covert punishment and obstruction of fusion were the main focal conflicts in the psychodynamic level of ED from the summarising of the treatment process and previous experience. Often based on this, ED can be improved directly or indirectly (increasing clinical drug efficacy).28–30 As both a clinician and a psychotherapist, the author innovatively used an innovative BPP combined with sildenafil on demand for ED treatment, making significant achievements.
Limitations
First of all, we did not enroll a large number of cases in this study due to the lack of funds and some patients declined to participate in this study. In addition, as the study involved patients’ privacy, many participants discontinued during the treatment. Therefore, there are inevitably some deviations and deficiencies in this study.
Second, this experiment is divided into groups according to the patients’ individual treatment wishes. Although the patients’ marital status is the same (all of them are married), factors such as cardiovascular disease and infectious disease were excluded, and bad habits such as alcohol and tobacco use were inquired about (two in the treatment group and three in the control group have a history of smoking, no one had long-term alcohol and other substance dependence history), and the age and course of the patients in the treatment group and the control group were generally the same.
Third, due to the limitation of experimental funds and time conditions, the patients with partial abscission mentioned in the general data are not reflected in table 1, and there may be bias in the complete analysis.
Finally, because there is no special training, qualification assessment and treatment manual for BPP in China, the treatment of these patients was mainly based on the content of BPP in the practice guide of short-term dynamic psychotherapy and other relevant domestic literature.18
Implications
Sildenafil, an inhibitor of cyclic guanosine monophosphate (c-GMP)-specific PDE5 degrading c-GMP, increases intracellular c-GMP concentration by inhibiting PDE5, causes smooth muscle relaxation, which increases the arterial blood flow in the corpus cavernosum, and then promotes penile erection. Although sildenafil has been well recognised for ED, still about 20%–30% patients with ED do not adequately respond to sildenafil (especially patients with psychological impotency).31 The addition of adjuvant (androgen) to sildenafil-ineffective patients can improve the therapeutic effects, but there are several adverse reactions such as liver and kidney damage, dependence and high incidence of reproductive system tumours. Therefore, in recent years, studies on adjuvant therapies for ED have gained much attention. Among non-organic ED, psychological ED is the largest source accounting for more than half of the clinical cases.6 Thus, psychotherapy is a common treatment for ED. Psychoanalysis differs from other psychotherapeutic orientations in the sense that it is a cure by making people conscious about their unconscious abilities involving their history. Psychologists can solve the problems rooted in the unconscious mind. In other words, psychoanalysis can solve symptoms on the surface, essentially combing the whole spiritual history of human beings, reaching the symptoms of direct confrontation and reconstructing the self-renewal of personality.32 33 To reconcile inner conflicts, not only to satisfy material pursuits, people seek psychoanalysis to realise their spiritual values. Psychoanalytic orientation often has a good effect on sexual dysfunction which is irreplaceable to other therapies. Freud, who claimed that a person, from birth to late life, had sexual colour in all behavioural motives, was subject to the impulse of sexual instinct, first proposing pansexualism at the beginning of psychoanalytic theory. The occurrence of neurosis is the result of the dissatisfaction or suppression of the sexual instinct impulse. Psychoanalytic theory states that there is a strong motivation behind sexual desire, which drives people to pursue pleasure. This is known as libido, also known as sex drive. The development of libido is divided into: the oral period, anal period, genital period, incubation period and reproductive period. Therefore, using psychoanalytic motivational listening therapy techniques such as free association is possible to understand the sexual experience and experience of the patient in childhood. This helps to find out the ‘sexual problem’ and ‘privacy’ that the patient has forgotten and found hard to talk about. 'Privacy' means something in the patient's heart of hearts that is not expressed in the usual therapy such as the handling of previous interpersonal relationships, childhood shadows, history of bullying, or past events which engender negative emotion, and these things may cause mental illness and affect erectile function. The outcomes of psychoanalytic therapy gradually unfold. These outcomes are encouraging clients to surmount ‘ resistance’, to analyse ‘ transference’ and to find ‘crux’, in order to help patients further ‘interpret’, ‘clarify’ and ‘ work through’ and so on. That is the key to determining the success or failure of psychoanalytic psychotherapy.9 31 These outcomes are difficult to achieve using other psychotherapeutic methods, even if they are effective for the moment.32 As the famous psychologist Li Ming said: ‘”It was a relatively long process to achieve a person’s growth through psychoanalysis, and to a certain extent it was painful. At the same time, it was a process full of joy and of moving towards the true self by being clearer to ourselves.” The BPP used in this study, which differs from traditional LTPP, emphasises the change of a certain problem more efficiently. It does not pursue the deep excavation of the conflicts within the patient’s personality, but to deal with the psychodynamic characteristics caused by ED, which makes the problem more prominent by focusing on the effects of the problem.33
This study indicated that BPP combined with sildenafil significantly improved the clinical symptoms of patients with non-organic ED, and the improvement with combined treatment was more significant than with sildenafil alone (optimal efficiency = 19% > 10%). In addition, the improvement of the drug combined with psychodynamic psychotherapy was significantly better than the control group (PIIEF=0.040, PSAS=0.006, PSS=0.045, PEHS=0.041).
The observations suggest that the combination of drug with BPP is superior to drug alone in the treatment of non-organic ED. The method is safe and effective, and has certain clinical promotion value.
