PE-No, I Don't Mean Physical Exercise! Solving Premature Ejaculation in Men by Nina Bingham

In the case of "Bob & Jane," Bob has presented with Premature Ejaculation (PE), and admits is has been a chronic problem for him. "Premature ejaculation (PE) is widely believed to be the most common male sexual problem, averaging between 20% and 30% prevalence" (Althof, 2007). It has impacted his long-term relationships negatively, and Bob states he is ready to solve the problem. Bob was recently laid-off from his job, and has become increasingly anxious that his girlfriend of 4 months may leave him. This anxiety has been converted into sexual performance anxiety. Both Bob and his girlfriend are eager to resolve the problem.

What Causes PE: He was referred by his medical physician, who ruled out any biological etiology. However, Waldinger et al., (1998) found that 91% of men with lifelong PE had a first relative with lifelong PE. This is convincing evidence that genetics may be involved in lifelong PE. Also, there is other evidence that PE is related to decreased central serotonin neurotransmitions (Waldinger et al., 1998).

Emotional issues are another reason that a male can experience PE: "Anger, frustration, low self-confidence, mistrust, negative body image, and psychosocial stress associated with financial difficulties, occupational problems, and the death of a significant other may be factors (Metz, McCarthy, 2003; Metz, & Pryor, 2000). Chronic psychological disorders such as: bipolar disorder, depression, and generalized anxiety disorder can produce PE. Even temporary psychological difficulties like adjustment disorders can result in the disorder as well" (Metz, & McCarthy, 2003). Lastly, sexologists also attribute PE to problematic relationships (Betchen, 2001; Metz, & McCarthy, 2003).

Treatments Options: In treating this medically: "Anti-depressant medications are often prescribed for premature ejaculation" (McCarthy, Fucito, 2005). This is because Seratonin (a neurotransmitter in the brain) is the primary neurotransmitter which regulates ejaculation. In treating this Psychotherapeutically:
Sexologists attribute PE to problematic-couple relationships. Lack of communication about sex, power and control struggles, (Betchen, 2001, 2006), and haste in intercourse due to shame-based beliefs about sex (Betchen, a991; Kaplan, 1974; Metz, & McCarthy, 2003).

If the couple's relationship seems to be conflictual, "Both partners are urged to attend the first session (counseling). This allows the clinician to evaluate each partner as an individual and in the context of the interaction" (Betchen, 2006). Berman (1982) recommends seeing both partners together increases the chance that the couple will see their problem as systematic rather than the sole responsibility of one partner.
This is a couple who are still relatively new to one another, who are having no other conflicts in the relationship, and the girlfriend is supportive in hopes of finding an answer. According to the DSM-IV-TR, this would be ED which is Lifelong, vs. Acquired. Lifelong disorders can be more challenging to treat, because they have become a conditioned pattern over years. It also seems to be a Generalized Type vs. Specific Type (meaning that the pattern has occurred with all partners), and seems to be due to psychological factors (vs. organic cause).

Treatment Plan: My treatment plan would be to emphasize to Bob that a Lifelong Disorder can be overcome, but it will mean he must be willing to experiment, and try some different approaches and methods. "If the PE is found to be solely organic in origin and is treated successfully with medication, treatment will obviously be brief. In most cases, however, the PE symptom will not dissipate until psychodynamic conflicts have improved—this often takes longer" (Betchen, 2009). I would tell Bob that PE has been successfully treated by use of anti-depressants (SSRI). I would ask if his physician discussed this with him? I would ask Bob to question his physician about the use of anti-depressant for PE if the physician did not review this medical option with him. If Bob wishes to address the issue non-medically, that can be effective, too.

I would next psychoeducate the couple on the 4 stages of sexuality: Desire, Arousal or Excitement, Orgasm and Resolution (DSM-IV-TR, p. 536), and explain it is the Arousal or Excitement Phase wherein Bob needs to build skills, before he reaches the Orgasm phase.

I would ask them each to discuss the problem from their perspective in counseling, including their feelings, how it has impacted them, and their guesses as to why it is happening. This would give me a better understanding as to the inter-personal dynamics, and any underlying conflicts for the couple.

I would explain PE Exercises, and review each of them in detail, and answer any questions that the couple has about execution of the exercises. I would assign them exercises to get started practicing, and ask them to keep a brief journal on the progress and any set-backs they experience or questions they have.

Lastly, I would encourage them to return for a "follow-up" appointment to review how effective the  exercises were for them, and to answer further questions or concerns they might have. Within a few visits, this couple's problem could be a thing of the past.

References:

Althof, S. (2007). Treatment of rapid ejaculation: Psychotherapy, pharmacotherapy,
and combined therapy. In S. Leiblum (Ed.), Principles and practice of sex
therapy (4th ed., pp. 212–240). New York: Guilford.

Waldinger, M. D., Hengeveld, M. W., Zwinderman, A. H., & Olivier, B. (1998). An
empirical operationalization study of DSM-IV diagnostic criteria for premature
ejaculation. International Journal of Psychiatry in Clinical Practice, 2, 287.

Metz, M., & McCarthy, B. (2003). Coping with premature ejaculation: How to overcome
PE, please your partner and have great sex. Oakland, CA: New Harbinger
Publications.

Metz, M., & Pryor, J. (2000). Premature ejaculation: A psychophysiological approach
for assessment and management. Journal of Sex & Marital Therapy, 26, 293–320.

Betchen, S. (2001). Premature ejaculation as symptomatic of age difference in a
husband and wife with underlying power and control conflicts. Journal of Sex
Education and Therapy, 26, 34–44.

McCarthy, B., Fucito, L. (2005). Integrating Medication, Realistic Expectations, and Therapeutic Interventions in the Treatment of Male Sexual Dysfunction. Journal of Sex & marital Therapy, Vol. 31, Issue 4, p. 319-328.

Betchen, S. (2006). Husbands who use sexual dissatisfaction to balance the scales
of power in their dual-career marriages. Journal of Family Psychotherapy, 17,
19–35.

Kaplan, H. S. (1974). The new sex therapy: Active treatment of sexual dysfunctions.
New York: Times Books.

Berman, E. (1982). The individual interview as a treatment technique in conjoint
therapy. American Journal of Family Therapy, 10, 27–37.

American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). American Psychiatric Association, Arlington, VA.

Betchen, S.J. (2009). Premature Ejaculation: An Integrative, Intersystems Approach for Couples. Journal of Family Psychotherapy, 20:241–260. Copyright © Taylor & Francis Group, LLC.