Downloaded - TU Dresden

Sexual and Relationship Therapy
Vol. 24, No. 1, February 2009, 64–73
Reduction of sexual dysfunction: by-product of cognitive-behavioural
therapy for psychological disorders?
Jürgen Hoyer*, Stefan Uhmann, Jana Rambow and Frank Jacobi
Department of Clinical Psychology and Psychotherapy, TU Dresden, Dresden, Germany
Downloaded By: [Hoyer, Jürgen] At: 14:17 23 February 2009
(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, Schöps, &
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. Email: [email protected]
ISSN 1468-1994 print/ISSN 1468-1749 online
Ó British Association for Sexual and Relationship Therapy
DOI: 10.1080/14681990802649938
http://www.informaworld.com
Downloaded By: [Hoyer, Jürgen] At: 14:17 23 February 2009
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
(w2[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)
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.
Downloaded By: [Hoyer, Jürgen] At: 14:17 23 February 2009
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%; NonResponse Group: 58.7; w2[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 w2 and McNemar’s w2-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.
67
Sexual and Relationship Therapy
Results
Downloaded By: [Hoyer, Jürgen] At: 14:17 23 February 2009
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
(w2[6] ¼ 26.88, p 5 .001, see Table 1). The reduction occurred among both patients
in remission (McNemar’s w2[1] ¼ 22.77, p 5 .001) and treatment responders
(McNemar’s w2[1] ¼ 26.26, p 5 .001), but there was no significant reduction among
the non-responders (McNemar’s w2[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
(w2[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
Table 1.
Sexual dysfunction trajectories among 451 CBT outpatients.
Any sexual Any sexual
dysfunction dysfunction
pre-CBT
post-CBT
N
% of group
N
% of group
N
% of group
No
No
Yes
Yes
48
10
47
39
33.3
6.9
32.6
27.1
44
11
53
49
28.0
7.0
33.8
31.2
34
19
25
72
22.7
12.7
16.7
48.0
Total
No
Yes
No
Yes
Remission
144
Response
157
Non-response
150
Total
N
%
126 27.9
40 8.8
125 27.7
160 35.5
451
Figure 1. Rates of sexual dysfunction in 144 patients with full remission of other
psychological disorders (157 responders, 150 non-responders).
68
J. Hoyer et al.
Downloaded By: [Hoyer, Jürgen] At: 14:17 23 February 2009
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, Schöps, & 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
General satisfaction
Erection (male)
Lubrication (female)
Orgasm
Arousal
Pre-CBT
Post-CBT
Pre-CBT
Post-CBT
Pre-CBT
Post-CBT
Pre-CBT
Post-CBT
Pre-CBT
Post-CBT
Pre-CBT
Post-CBT
3.04
2.52
2.98
2.45
3.26
2.57
2.88
2.53
2.44
2.16
3.47
2.76
+
+
+
+
+
+
+
+
+
+
+
+
1.50
1.22
1.41
1.06
1.62
1.28
1.48
1.20
1.05
0.69
1.60
1.36
Remission
N ¼ 144
3.43
2.68
3.41
2.73
3.46
2.83
3.02
2.53
3.05
2.41
3.71
3.01
+
+
+
+
+
+
+
+
+
+
+
+
1.72
1.47
1.67
1.46
1.76
1.53
1.50
1.25
1.54
1.07
1.68
1.58
Response
N ¼ 157
Outcome group
3.60
3.31
3.43
3.27
3.62
3.35
3.45
3.15
2.98
2.84
3.94
3.75
+
+
+
+
+
+
+
+
+
+
+
+
1.71
1.69
1.67
1.67
1.77
1.74
1.71
1.60
1.54
1.48
1.73
1.68
Non-response
N ¼ 150
+
+
+
+
+
+
+
+
–
–
3.77 +
3.18 +
3.59
2.97
3.47
2.95
3.76
3.07
3.10
2.71
1.70
1.65
1.72
1.58
1.66
1.55
1.77
1.66
1.57
1.37
Female
N ¼ 307
2.84
2.52
3.58
3.17
+
+
+
+
+
+
–
–
+
+
+
+
1.43
1.21
1.62
1.50
1.44
1.29
1.39
1.19
1.41
1.28
Male
N ¼ 144
2.88
2.55
2.87
2.53
2.78
2.61
Gender
Means and standard deviations for sexual functioning before and after CBT by outcome group and gender (Total N ¼ 451).
Sexual interest
Table 2.
Downloaded By: [Hoyer, Jürgen] At: 14:17 23 February 2009
3.36
2.84
3.28
2.82
3.45
2.92
3.10
2.71
2.84
2.52
3.71
3.18
+
+
+
+
+
+
+
+
+
+
+
+
1.66
1.51
1.60
1.46
1.72
1.56
1.57
1.37
1.43
1.21
1.68
1.60
Total
N ¼ 451
Sexual and Relationship Therapy
69
F (1, 444) ¼ 0.57
p ¼ .45
F (2, 444) ¼ 2.33
p ¼ .099
F (1, 444) ¼ 2.51
p ¼ .14
F (1, 444) ¼ 0.55
p ¼ .46
F (2, 444) ¼ 3.00
p ¼ .051
F (1, 444) ¼ 0.97
p ¼ .34
F (1, 444) ¼ 98.81
p 5 .001
F (2, 444) ¼ 6.90
p 5 .01
F (1, 444) ¼ 34.65
p 5 .001
F (2, 444) ¼ 0.14
p ¼ .87
Arousal
Note. There were no other significant (triple) interaction effects.
Time 6 Gender
Time 6 Group
Within factors
Time
Group 6 Gender
Gender
Group
F (1, 444) ¼ 86.19
p 5 .001
F (2, 444) ¼ 7.66
p 5 .001
F (1, 444) ¼ 38.05
p 5 .001
F (2, 444) ¼ 0.32
p ¼ .72
Sexual interest
F (1, 444) ¼ 7.82
p 5 .01
F (2, 444) ¼ 1.23
p ¼ .29
F (1, 444) ¼ 8.66
p 5 .01
F (1, 444) ¼ 66.29
p 5 .001
F (2, 444) ¼ 6.22
p 5 .01
F (1, 444) ¼ 46.62
p 5 .001
F (2, 444) ¼ 0.27
p ¼ .76
Orgasm
F (1, 303) ¼ 0.20
p ¼ .66
F (2, 303) ¼ 0.56
p ¼ .57
–
–
F (1, 303) ¼ 51.38
p 5 .001
F (2, 303) ¼ 3.44
p 5 .05
–
Lubrication (female)
Results of repeated-measures ANCOVAs for each kind of sexual dysfunction.
Between factors
Age (Covariate)
Table 3.
Downloaded By: [Hoyer, Jürgen] At: 14:17 23 February 2009
F (1, 140) ¼ 0.01
p ¼ .93
F (2, 140) ¼ 2.84
p ¼ .06
–
–
F (1, 140) ¼ 71.89
p 5 .001
F (2, 140) ¼ 3.91
p 5 .05
–
Erection(male)
F (1, 444) ¼ 0.38
p ¼ .54
F (2, 444) ¼ 4.05
p 5 .05
F (1, 444) ¼ 0.61
p ¼ .44
F (1, 444) ¼ 33.96
p 5 .001
F (2, 444) ¼ 9.53
p ¼ .001
F (1, 444) ¼ 4.30
p 5 .05
F (2, 444) ¼ 0.57
p ¼ .56
General satisfaction
70
J. Hoyer et al.
71
Sexual and Relationship Therapy
Table 4.
1.
2.
3.
4.
5.
6.
7.
Correlations of each MGH item with age among 451 CBT outpatients.
Age
Sexual interest (pre-CBT)
Arousal (pre-CBT)
Orgasm (pre-CBT)
Lubrication (female, pre-CBT)a
Erection (male, pre-CBT)b
General satisfaction (pre-CBT)
1
2
3
4
5a
6b
7
–
.33
.35
.24
.54
.35
.25
–
.84
.68
.63
.65
.68
–
.76
.83
.73
.66
–
.85
.57
.67
–
–
.44
–
.59
–
Downloaded By: [Hoyer, Jürgen] At: 14:17 23 February 2009
Note. All correlations are significant at p 5 0.01; aN (female) ¼ 307, bN (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
Downloaded By: [Hoyer, Jürgen] At: 14:17 23 February 2009
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, Schöps, & 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
Jürgen 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.
Sexual and Relationship Therapy
73
Frank Jacobi, Assistant Professor, Department of Clinical Psychology and Psychotherapy,
Dresden University of Technology, Germany.
Downloaded By: [Hoyer, Jürgen] At: 14:17 23 February 2009
References
Barlow, D.H. (2002). Anxiety and its disorders (2nd ed.). New York: Guilford.
Borkovec, T.D., Abel, J.L., & Newman, H. (1995). Effects of psychotherapy on comorbid
conditions in generalized anxiety disorder. Journal of Consulting and Clinical Psychology,
63, 479–483.
Bonierbale, M., Lancon, C., & Tignol, J. (2003). The ELIXIR study: Evaluation of sexual
dysfunction in 4557 depressed patients in France. Current Medical Research and Opinion,
19, 114–124.
Craske, M., Farchione, T.J., Allen, L.B., Barrios, V., Stoyanova, M., & Rose, R. (2007).
Cognitive behavioural therapy for panic disorder and comorbidity: More of the same or
less of more? Behaviour Research and Therapy, 45, 1095–1109.
Dunn, K.M., Croft, P.R., & Hackett, G.I. (1998). Sexual problems: A study of the prevalence
and need for health care in the general population. Family Practice, 15, 519–524.
Guy, W. (1976). ECDEU assessment manual for psychopharmacology (revised). Rockville:
National Institute of Mental Health.
Halford, W.K., Bouma, R., Kelly, A., & Young, R.M. (1999). Individual psychopathology
and marital distress: Analysing the association and implications for therapy. Behavior
Modification, 23, 179–216.
Hartmann, U., Philippsohn, S., Heiser, K., Kuhr, A., & Mazur, B. (2008). Why do women
with panic disorders not panic during sex (or do they)? Results of an empirical study on
the relationship of sexual arousal and panic attacks. Sexual and Relationship Therapy, 23,
203–216.
Labbate, L.A., & Lare, S.B. (2001). Sexual dysfunction in male psychiatric outpatients:
Validity of the Massachusetts General Hospital Sexual Functioning Questionnaire.
Psychotherapy and Psychosomatics, 70, 221–225.
Nicolosi, A., Laumann, E.O., Glasser, D.B., Moreira, E.D., Paik, A., & Gindell, C. (2004).
Sexual behavior and sexual dysfunctions after age 40: The global study of sexual attitudes
and behaviors. Urology, 64, 991–997.
Nobre, P., & Pinto-Gouveia, J. (2008). Cognitions, emotions and sexual response: Analysis of
the relationship among automatic thoughts, emotional responses and sexual arousal.
Archives of Sexual Behaviour, 37, 652–661.
Nofzinger, E.A., Thase, M., Reynolds III, C.F., Frank, E., Jennings, R., Garamoni, G.L.,
Fasiczka, A.L., & Kupfer, D. (1993). Sexual function in depressed men. Archives of
General Psychiatry, 50, 24–30.
Reinecke, A., Schöps, D., & Hoyer, J. (2006). Sexuelle dysfunktionen bei patienten einer
verhaltenstherapeutischen hochschulambulanz: Häufigkeit, erkennen und behandlung
[Sexual dysfunctions in patients of a CBT outpatient clinic]. Verhaltenstherapie, 16, 166–
172.
Simons, J.S., & Carey, M.P. (2001). Prevalence of sexual dysfunctions: Results from a decade
of research. Archives of Sexual Behavior, 30, 177–219.
Tsao, J.C.I., Mystkowski, J.L., Zucker, B.G., & Craske, M.G. (2002). Impact of cognitivebehavioral therapy for panic disorder on comorbidity: A controlled investigation.
Behaviour Research and Therapy, 43, 959–970.
Van Lankveld, J., & Grotjohann, Y. (2000). Psychiatric comorbidity in heterosexual couples
with sexual dysfunction assessed with the Composite International Diagnostic Interview.
Archives of Sexual Behavior, 29, 479–498.
Wittchen, H.-U. (1994). Reliability and validity studies of the WHO-Composite International
Diagnostic Interview (CIDI): A critical review. Journal of Psychiatric Research, 28, 57–84.
Wittchen, H.-U., & Pfister, H. (1997). DIA-X Interview. Frankfurt, Germany: Swets and
Zeitlinger.
World Health Organization (1990). Composite International Diagnostic Interview (CIDI).
Geneva, Switzerland: World Health Organization, Division of Mental Health.