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Behm. Res. Thw. Vol. 24, No. I. pp. 9-17, 1986 im5-7%7&s $3.00 + 0.00
Printed in Grw Britain. All rights reserved Copyright C 1986 Pergamon Press Ltd
THE EFFECTS OF ANXIETY AND ATTENTIONAL
FOCUS ON SEXUAL RESPONDING-I
PHYSIOLOGICAL PATTERNS IN ERECTILE DYSFUNCTION*
J. GAYLE BECK* and DAVID H. BARLOW*
‘Department of Psychology, University of Houston, University Park, Houston, TX 77004, U.S.A.
“Center for Stress and Anxiety Disorders, State University of New York at Albany, NY 12222, U.S.A.
(Received 24 April 1983
Summary-The present investigation explored the interactive effects of an anxiety-producing demand for
performance and two forms of attentional focus on men with secondary erectile dysfunction. Penile
turning and subjective arousal were monitored continuously. The results indicate that threat of
electrical shock significantly diminished tumescence for sexually functional Ss, relative to no threat under
these instructional sets. Dysfunctional Ss showed a trend towards elevated responding during shock threat
under spectator focus instructions, but no other significant effects were observed. Correlations between
tumescence values and ratings of subjective arousal indicated a trend towards lower concordance during
shock threat under spectator focus instructions. The results are discussed in the context of previous
research and clinical formulations concerning maint~ning factors in erect& dysfunction.
Since the advent of Masters and Johnson’s (1970) seminal work, ffuman Sexual Inadeqtracy,
treatment of sexual dysfunction has focused on specific maintaining factors and has involved a
range of techniques intended explicitly to address these concerns. As stated by these authors, the
primary factors maintaining the arousal disorders (erectile dysfunction in men and anorgasmia in
women}, are anxiety and performance demand. Masters and Johnson write,
“‘many men contending with fears of sexual function have distorted the basic natural
response pattern to such an extent that they literally break out in a cold sweat as
they approach sexual opportunity.“’ (p. 11)
As illustrated by this quote. anxiety is stipulated as central in maintaining diminished sexual
responding. Other authors (Kaplan, 1981; Lobitz and LoPiccolo, 1972) similarly have placed
considerable importance on the role of performance fears in maintaining disorders of sexual
arousal.
Hypothetically, ‘spectatoring’ is one consequence of sexual perfo~an~ anxiety (Masters and
Johnson, 1970). This refers to an attentional process wherein the individual adopts a third-party
perspective on his own sexual performance, monitoring the degree of his erection while minimizing
his awareness of sexual feelings. While clinical writers are often unclear with respect to the cause
and effect relationship between anxiety and spectatoring, treatment is aimed at reducing per-
formance concerns and redirecting the patient’s attention to his internal state, specifically his sexual
feelings and fantasies. The most commonly employed treatment technique used to accomplish this
is sensate focus exercises, in which the individual is taught to attend solely to sexual sensations.
Simultaneously, performance demands are reduced through a therapeutic prohibition on inter-
course.
While this conceptualization has proved fruitful in application (cf. Marks, 1981; Crown and
D’Ardenne, 1982), the current state of understanding specific maintaining factors in the sexual
arousal disorders is deserving of clarification. As discussed by Beck and Barlow (1984), current
*This ssudg is based on portions of a Doctoral Dissertation submitted by f. G. Beck to the State University of New
York-Albany, in partial fulfillment of the requirements for the Doctoral Degree.
9
10 J. GAYLE BECK and DAVID H. BARLOW
theoretical accounts blur the distinction between definitions of anxiety and related factors such as
distraction and spectatoring. Recent investigations have begun to explore these factors in isolation
and in interaction. In one of the earlier accounts, Geer and Fuhr (1976) examined the effects of
three levels of increasingly complex distractions and found an inverse linear relationship between
the degree of distraction and tumescence in sexually functional males. With increasing amounts
of distraction, greater decrements in tumescence were noted. Similar findings have been reported
with sexually functional volunteers by Farkas, Sine and Evans (1979) with male Ss, and with female
Ss by Lifshitz and Adams (1980) and Adams, Haynes, Brayer and Goranson (1981).
More direct investigations of the effects of anxiety on sexual responding have been conducted.
Hoon, Wincze and Hoon (1977) demonstrated that exposure to anxiety-producing films heightened
subsequent vasocongestion in sexually functional women during erotic stimuli, relative to neutral
preexposure. Wolchik, Beggs, Wincze, Sakheim, Barlow and Mavissakalian (1980) conducted a
partial replication of this study with male volunteers, with similar results.
While these findings are counter-intuitive in light of clinical formulations concerning the
presumed detrimental effect of anxiety on sexual arousal, the possibility that this pattern of
responding represents an anxiety-relief phenomena clouded clear interpretation (Wolpe, 1978). To
address this concern, Barlow, Sakheim and Beck (1983) examined anxiety, operationalized as threat
of electrical shock, simultaneous with erotic stimuli with male volunteers. Shock threat that was
contingent upon adequate tumescence, as well as noncontingent shock threat, resulted in
heightened tumescence, relative to a neutral control condition.
In a subsequent study, Beck, Barlow, Sakheim and Abrahamson (1984) examined differing levels
of shock threat (half tolerance, tolerance and twice tolerance, including a no-shock control) during
erotic audiotapes. This report demonstrated that anxiety appears to operate in an inverse U-shaped
function, as it affects tumescence in sexually functional males. Penile responding was significantly
diminished during moderate levels of anxiety (tolerance threat) but unaffected during more intense
threat (twice tolerance threat). This investigation employed a stimulus recognition task to
determine if the observed effects of anxiety operated by focusing the S’s attention outward upon
the erotic audiotape. Relative to no shock threat, stimulus-focused attention was most accurate
during low and moderate levels of threat (half and tolerance threat), where tumescence was most
diminished. Under intense threat, Ss’ accuracy in stimulus recognition was equivalent to scores
achieved during no shock threat and there was increased reporting of a wide range of affective states
(e.g. ratings of ‘happy’ and ‘aroused’). The implication of this is that anxiety enhances cognitive
performance on a task at moderate levels, as suggested by Yerkes and Dodson in 1908, but that
this occurs at the expense of sexual arousal if both sexual and nonsexual cognitive demands are
present. This indirectly suggests that a minimal degree of focused attention is necessary for
adequate sexual responding. By consequence, anxiety may reduce tumescence by distracting the
male from his own internal arousal processes: sexual images, fantasies and feelings.
The foregoing body of research provides an important foundation for understanding the factors
that influence sexual function and dysfunction. It is possible, however that individuals experiencing
sexual dysfunction respond differently to these factors, given more problematic histories and
negative expectations concerning adequate sexual functioning (cf. Bernstein and Paul, 1971). Three
studies have been reported with sexually dysfunctional samples examining anxiety and attentional
focus. Beck, Barlow and Sakheim (1983) explored the effects of self- vs partner-directed attention,
in combination with level of stimulus partner’s sexual arousal (highly aroused, unaroused or
unknown), in sexually functional and dysfunctional men. When the stimulus partner was perceived
as highly aroused and under instructions to attend to her, dysfunctional Ss demonstrated lower
levels of tumescence while functional Ss showed increased arousal. Postexperimental interviews
indicated that in actual sexual situations, the sexually functional Ss reported that high partner
arousal facilities their own responding, while dysfunctional Ss perceived this as creating pressures
to perform and decreasing their arousal.
A related study was conducted by Heiman and Rowland (1983). In this report, prestimulus
instructions were given to mirror sensate focus or performance demand, to sexually functional and
dysfunctional men. Functional males showed greater tumescence to an erotic audiotape if preceded
by demand instructions, while dysfunctional males showed greater arousal to the tape if preceded
by sensate focus instructions. Additionally, the dysfunctional sample showed greater awareness of
Anxiety and attentional focus on sexual response-I I1
a range of physiological responses and more negative cognitive-affective states during the
experimental session.
The third study to employ both clinical and nonclinical Ss was reported by Abrahamson,
Barlow, Sakheim, Beck and Athanasiou (1985). This investigation examined the effects of
distraction on tumescence during high- and low-arousal film conditions. The results indicate that
a neutral distractor significantly reduced tumescence for functional Ss, while dysfunctional males’
responding was not affected during distraction. This pattern of findings suggests that there may
be qualitative differences in cognitive responses to distracting stimuli during sexual arousal for
sexually functional and dysfunctional men. More specifically, while a neutral distractor appeared
to disrupt cognitive processes which would normally facilitate responding in functional males, the
dysfunctional sample appeared uninfluenced by an external cue. These three reports suggest that
one dimension of clinically relevant contrast between sexually functional and dysfunctional men
lies in differing perceptions of environmental events as ‘threats’ and the effect to which this
influences focused attention and subsequent sexual responding.
The current investigation was designed to explore an anxiety-producing performance demand
in interaction with two forms of attentional focus, using sexually dysfunctional men and
age-matched control Ss. As in prior studies, threat of electrical shock was chosen to operationalize
anxiety and instructions were given that this shock threat was contingent on adequate responding,
to heighten the performance demand. Additionally, two forms of attentional focus were in-
vestigated; instructions were delivered to ‘spectator’ tumescence or to focus on sexual feelings and
thoughts (sensate focus). The four experimental conditions were introduced during erotic films, in
a repeated-measures design.
METHOD
Subjects
Two groups of 12 Ss each were included in this investigation. The sexually dysfunctional sample
consisted of men referred by urologists for psychological assessment of secondary erectile
dysfunction. Ages ranged from 22 to 60 yr (8 = 43.8 yr). All Ss were heterosexual (Kinsey score
0) and 8 of the 12 had steady sexual partners. All members of the dysfunctional sample were
screened for absence of organic factors contributing to their sexual dysfunction by an independent
physician including a physical examination and Doppler assessment of vascular function. Erectile
dysfunction was defined as an inability to achieve and maintain an erection during at least 25%
of all sexual contacts, excluding masturbation (Masters and Johnson, 1970). Average duration of
impotency was 6.9 yr (range l-30 yr) and all Ss reported adequate functioning in the past, although
not within the year preceding participation.
The control sample included sexually functional men seeking routine urological exams and
medical personnel. Ages ranged from 29 to 64 yr (R40.9 yr). All Ss were heterosexual and 8
members had ongoing sexual relationships. Control Ss were matched by age, relational status and
occupation with clinical Ss. All control Ss were screened for absence of any form of sexual
dysfunction and medical complications.
Subjects in both groups were administered an initial screening battery and reported average levels
of sexual information and attitudes towards sexuality. Additionally, all participants were screened
for absence of other DSM-III emotional disturbance, using the Psychiatric Diagnostic Interview
(Othmer, Penick and Powell, 1981). Following participation, clinical Ss received a detailed
assessment report, while control Ss were paid for their involvement.
Measures and instrumentation
Tumescence was measured using a mechanical strain gauge, consisting of a lightweight metal ring
which the S himself placed midway on the shaft of his penis. Two strain gauges are mounted on
the ring and a differential resistance signal is recorded as the ring expands during tumescence
(Barlow, Becker, Leitenberg and Agras, 1970; Rosen and Beck, 1985). The device was calibrated
to permit transformation of the data to millimeters of circumference.
I2 J. GAYLE BECK and DAVID H. BARLOW
Additionally, a continuous measure of subjective sexual arousal was employed (Wincze, Hoon
and Hoon, 1977), consisting of a lever which moves through a 90” arc, calibrated on a O-100 scale.
A previous investigation (Wincze, Venditti, Barlow and Mavissakalian, 1980) has revealed that the
use of this device is not distracting to males, except at extremely low levels of arousal. In this
investigation, the subjective lever was employed to operationalize the attentional focus instructions,
as discussed below.
Three Beckman Ag-AgCI electrodes were used to assess EKG. This measure was taken from
the S’s chest, with a ground placed on his left forearm. Skin conductance was monitored with two
Ag-AgCl electrodes on the palmer surface of the S’s left hand. These four measures were recorded
on a Grass 7D polygraph and online data sampling using an LSI-11 minicomputer was employed.
Procedure
Shock training. Prior to the experimental procedure, each S’s level of shock tolerance was
determined. This was included to maintain credibility of the shock threat manipulation used during
the subsequent experimental phase. After obtaining informed consent, each S was told that he
would be receiving shocks in gradually increasing intensities, until his tolerance level or 14mA
intensity was reached. A 1”-square site on the left ventral forearm was prepared by rubbing the
skin with fine-grained sandpaper and alcohol; this preparation decreases skin resistance and reduces
inter-S variability in tolerance levels. A bipoled electrode was then attached to this area with a
Velcro strap and the S was instructed to indicate verbally when this shock tolerance level had been
reached. From an adjacent chamber, the experimenter began delivering shocks with a Grass SD-9
stimulator on a variable time-interval schedule, starting with a shock of 1.0 mA and progressing
in 1.5 mA steps until the S indicated that his tolerance level had been reached. Shock parameters
were predetermined based on guidelines from Grass Instrument Co. and Butterfield (1975). All
shocks were signaled by a light, to establish a contingency relationship. Average shock tolerance
was 10.0 mA (SD = 3.7) and 5 Ss reached tolerance at the 14 mA level.
Experimental session. Each S was assessed individually. After the S placed the strain gauge, the
experimenter attached the electrodes and explained the shock instructions, stating that during some
of the stimuli, a S’s tumescence would be monitored and there was a 60% chance of receiving an
electrical shock if he was not as aroused as the average research subject. During the remaining films,
no threat of shock existed. Two signal lights were employed to indicate these conditions.
The experimenter also explained the two attentional focus strategies to the S at this point. The
S was asked to use two different focusing strategies during the session, signaled by instructions
preceding each film. For the spectator focus conditions, he was asked to “attend to your genital
response. Focus on your penis and your degree of erection as if from an outsider’s perspective-like
you are watching yourself.” For the sensate focus conditions, he was asked to “focus on your
sensations and feelings of arousal. Pay attention to your internal feelings, irrespective of what other
responses your body is making.” To facilitate compliance with the directional focusing instructions,
the S was asked to use the subjective rating lever in two different fashions. During spectator focus
conditions, he was asked to indicate the degree of tumescence, while during sensate focus
conditions, the lever was used to rate internal sensations of arousal.
After establishing stable physiologic signals, a 5-min habituation period was begun, followed by
a neutral travelogue, to control for stimulus-orienting responses. Four moderately arousing,
explicit erotic films were utilized as stimuli. These had been equated previously and contained 3-min
of heterosexual foreplay. Order of presentation was counterbalanced across Ss and pairing of films
and experimental instructions was randomized. Each S viewed the four stimuli in a repeated-
measures design, with adequate baselines between presentations to allow for return to basal levels
of responding. Following the experimental session, each S was debriefed to determine his belief
in the experimental manipulation and to explain the deception.
Data sampling and reduction
Data from the four physiological measures were sampled in IO-set epochs, yielding a total of
18 epochs per film. Strain gauge data were transformed to millimeters circumference, based upon
presession calibrations. Each S’s mean prestimulus basal value was subtracted from values
recorded during the stimulus, to control for the Law of Initial Value (Wilder, 1953). Subjective lever
Anxiety and attentional focus on sexual response-1 13
data were transformed to a O-100 scale, based upon calibration. EKG was scored as beats per
minute (bpm) and galvanic skin conductance was transformed from millimeters pen deflection to
mhos conductance.
RESULTS
An initial repeated-measures ANOVA (demand x focus of attention x film sequence) on the
experimental orders indicated randomization of film presentation and experimental instructions as
no significant effects were observed. Data from these four measures were then analyzed with a
group x (demand x focus of attention x epoch) design. For the strain gauge, a significant
group x demand x epoch effect was found [F(17,374) = 2.87; P < O.OOl]. Duncan’s multiple-range
tests comparing condition differences for each group at each epoch indicated that responding under
shock threat instructions was significantly lower for the functional Ss during the final 5 epochs
of the stimuli (P < 0.05). These data are plotted in Fig. 1 and indicate that sizable differences
between the shock threat and no-shock conditions occurred for functional Ss. Dysfunctional Ss,
in contrast, responded to these two conditions with approximately equivalent tumescence,
although a nonsignificant trend towards lower responding was noted during the no-shock
condition.
Given the nature of this investigation, examination of the complete pattern of results appeared
warranted. Average tumescence values by group are plotted in Fig. 2 and indicate several
interesting patterns. As can be seen, under no-shock instructions, functional Ss achieved higher
tumescence during both types of attentional focus, relative to the dysfunctional sample. During
these instructions, spectator focus did not appear to affect arousal in a significantly different fashion
from sensate focus. However, under shock threat instructions, group differences emerged. While
both groups responded with equivalent levels of tumescence to shock threat under sensate focus
instructions, dysfunctional Ss showed elevated responding during the shock threat under spectator
focus conditions.
The subjective lever analysis revealed a significant focus of attention x epoch effect
[F(17,357) = 1.98; P < 0.011, indicating that subjective arousal was higher during sensate focus
instructions relative to spectator focus, in 8 of the 18 epochs. Additionally, a main group effect
was found [F( 1,21) = 3.14; P < 0.051, indicating that functional Ss reported higher levels of
subjective arousal across conditions relative to dysfunctionals. The pattern of subjective arousal
EPOCH
Fig. 1. Mean strain gauge (millimeters circumference change from baseline) under presence and absence
of shock threat, by epoch and group.
J. GAYLE BECK and DAVID H. BARLOW
Fig. 2. Mean strain gauge (millimeters circumference change from baseline) under all conditions, by group.
data is plotted in Fig. 3 and indicates several unexpected results. As can be seen, functional Ss
reported their highest levels of subjective arousal during the two sensate focus conditions. In
contrast, the dysfunctional sample reported slightly increased subjective arousal during the shock
threat conditions. This pattern is in contrast with the tumescence data plotted in Fig. 2.
To explore this discrepancy, Pearson product correlations were computed between the tumes-
cence and subjective lever data for each S under each condition. These values were normalized to
permit parametric analysis by transformation to z-scores (Edwards, 1965). Because the subjective
v/I Functmnals
shock mreot- Shock threcl- No
sensate spcctotor
focus tocur
lock threof- No shock threat-
,nrote SDeClOtor
Fig. 3. Mean subjective lever (O-100 scale, subjective arousal) under all conditions, by group.
Anxiety and attentional focus on sexual response-1 15
lever was used differentially under each type of attentional focus instruction, separate repeated-
measures ANOVAs (group x shock threat) were conducted on the normalized correlations for
spectator and sensate focus conditions. A trend towards a significant shock effect was noted during
spectator focus conditions [F(l,l9) = 3.81; P < 0.061, indicating lower correlations during the
shock threat (I = 0.52) relative to the no-threat condition (r = 0.70). No significant differences
emerged for the sensate focus conditions or between groups.
Data from EKG and skin conductance measures indicate that the shock threat manipulation
produced heightened autonomic arousal. Data from both measures were analyzed with a
repeated-measures ANOVA [group x (demand x focus of attention x epoch)]. For EKG, a
significant group x epoch interaction emerged [F(l7,374) = 2.47; P c O.OOl] indicating that func-
tional Ss showed elevated pulse rates in the final 15 set of the stimuli. The skin conductance
analysis revealed a complex pattern of results. A significant group x demand x focus x epoch
interaction emerged [F(l7,255) = 1.67; P < 0.051. Duncan’s follow-up tests indicated that dys-
functional Ss had lower levels of automatic arousal, relative to the control sample (P < 0.05). The
dysfunctional sample additionally showed lower autonomic arousal during shock threat in-
structions, relative to no-shock instructions (P < 0.05) and higher levels of conductance during
sensate focus instructions, relative to spectator focus during 16 of the 18 epochs (P < 0.05). No
intercondition effects were seen in functional Ss’ skin conductance, indicating less variability in
their degree of autonomic responding.
DISCUSSION
The present investigation explored the effects of two clinically relevant factors, anxiety and
attentional focus, on physiological responding in men with secondary erectile dysfunction and
age-matched controls. The results indicate several potentially important patterns. In this in-
vestigation, unlike earlier research with college-aged males reviewed above, threat of electrical
shock contingent on adequate arousal diminished tumescence for sexually functional males. One
dimension of difference which distinguishes this report from previous studies is the use of slightly
older Ss; the mean age of dysfunctional Ss in this investigation was 43.8 yr. It is possible that
diminished tumescence during anxiety and performance demands resulted owing to Ss’ greater
experience with occasional erectile failure (Frank, Anderson and Rubenstein, 1978) and learned
expectations of sexual requisites, relative to younger males. In contrast, anxiety and a demand for
performance did not significantly affect dysfunctional males’ sexual responding, contrary to clinical
predictions. These Ss achieved their highest levels of responding during the shock threat under
spectator focus instructions, a surprising finding given the presumed importance of both of these
factors in maintaining erectile failure.
Specific forms of attentional focus appeared to differentially affect these two samples. Responses
collected during the debriefing interview suggested that all Ss were able to comply with the focus
instructions with one exception; dysfunctional Ss reported greater attention to the stimulus film
during the shock threat under spectator focus condition, where their highest levels of tumescence
were-achieved. While this clouds a clear interpretation of the effects of spectator focus with this
group, it is notable that many of these men stated an attempt to ‘spectator’ but found their
attention drawn to the stimulus.
With this exception, attentional focus did not appear to strongly influence tumescence, but
rather, exerted its major effects on subjective arousal. Functional Ss reported higher levels of
subjective arousal during sensate focus instructions, although a parallel pattern was not noted in
the penile measure. Dysfunctional Ss, in contrast, did not evidence significant differences in
subjective arousal during the two attentional focus conditions. Possibly, the observed differences
in subjective arousal between functional and dysfunctional Ss suggest that the dysfunctional
sample discounted their subjective states during spectator focus. For the dysfunctional male,
perceptions of environmental demands may guide his focus of attention in actual sexual encounters,
owing to the saliency of sexual requisites. This speculation implies that experimental paradigms
like that used by Beck et al. (1984), which assessed stimulus-focused attention during varying
intensities of demand, might be better suited for exploration of clinically important processes such
16 J. GAYLE BECK and DAVID H. BARLOW
as directed attention. Additionally, while the data reported here lend indirect support to these
hypotheses, more direct investigations of the role of environmental perceptions and attentional
processes in erectile dysfunction are necessary for empirical validation.
One of the more striking features of these data is the discordance between physiological and
subjective patterns of responding. Examination of these differences can be found by contrasting
Figs 2 and 3. As noted, experimental performance demand influenced tumescence, while attentional
focus instructions affected subjective arousal for functional Ss. Thus, it seems that these two
response domains are influenced by different mechanisms, tumescence being affected by factors that
create autonomic arousal, while subjective states appear to be affected by cognitive factors. With
the exception of the shock threat under spectator focus condition, dysfunctional Ss did not
evidence this pattern, suggesting that this group was responding more to individualized inter-
pretations of the experimental manipulation. This observation suggests that differential treatment
approaches may be required in cases where disruption of functioning occurs in both response
systems (e.g. a male with erectile dysfunction who later has developed diminished sexual arousal).
Interestingly, there were no group differences in correlations between tumescence and subjective
arousal, suggesting that the observed discordance is not a function of inaccurate tracking of
arousal, as suggested by other authors (e.g. Rook and Hammen, 1977) although other studies have
reported that sexually dysfunctional men may underreport the absolute degree of their tumescence
(Sakheim, Barlow and Beck, 1985).
In light of these findings, relevant maintaining factors in erectile dysfunction deserve re-
formulation. While men with this disorder often report feeling pressures to perform, this factor did
not exert a prominent influence on their responding. It is possible that these reports are more
reflective of a different type of ‘anxiety’ process, one more akin to the distraction that occurs during
test anxiety and social phobia. Specifically, dysfunctional men may be overattending to thoughts
concerning potential failure and their partner’s perceived disappointment and frustration (Beck and
Barlow, 1984). While specific hypotheses are outlined in a subsequent report (Beck and Barlow,
1986, this issue, pp. 19-26), this suggests that the notion of performance demands discussed in
the clinical literature may result less from specific actions and statements by the partner and more
from the dysfunctional male’s perceptions of sexual interactions. If accurate, this formulation
implies that sex therapy could benefit from the inclusion of more individual techniques designed
to help the dysfunctional patient attend to more positive, arousing cognitions.
Acknowledgements--Thanks are extended to Edward B. Blanchard, Donn Byrne and Robert Athanasiou for their helpful
comments, This project was supported, in part, by NIMH Award 33553 to D. H. Barlow at the Center for Stress and
Anxiety Disorders.
Reprint requests should be addressed to J. G. Beck.
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