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Journal of Cognitive and Behavioral Psychotherapies, Vol. 12, No. 1, March 2012, 77-84.

METACOGNITION IN PATIENTS WITH PREMATURE EJACULATION AND ERECTILE DYSFUNCTION

Erman BAGCIOGLU1, Bulent ALTUNOLUK2, Yasin BEZ3, Haluk SOYLEMEZ4, Ahmet ASIK5, Murat EMUL*5
1

Department of Psychiatry, University Hospital of Sutcu Imam, Kahramanmaras, Turkey 2 Department of Urology, University Hospital of Sutcu Imam, Kahramanmaras, Turkey 3 Clinics of Psychiatry, Ergani State Hospital, Diyarbakir, Turkey 4 Clinics of Urology, Ergani State Hospital, Diyarbakir, Turkey 5 Department of Psychiatry, University Hospital of Kocatepe, Afyonkarahisar, Turkey Abstract Anxiety is the most common intrapsychic component in male sexual dysfunction. Metacognition is considered to be the way of thinking about thinking which could be associated with anxiety. The aim of the study was to investigate the metacognition level of patients with premature ejaculation. Forty patients with premature ejaculation and 40 with erectile dysfunction, and a matched number of healthy people participated. Participants were asked to fill out Meta-cognitions Questionnaire-30, Beck Depression and Beck Anxiety Inventories. The total metacognition score was significantly higher in patients with premature ejaculation (p < .05) and erectile dysfunction (p < .05) than healthy controls. Total metacognition score was not significantly differed between sexual disorder groups (p > .05). The positive beliefs, negative beliefs scores were significantly higher in patients with sexual disorders (p < .05). The cognitive self consciousness score was significantly higher in patients with premature ejaculation than erectile dysfunction group (p < .05) and healthy controls (p < .05). Patients with sexual disorders might endorse the metacognitive belief that worrying about worriable problems can have positive effects in solving problems and avoiding unpleasant situations, which may be associated with sexual disorder. Keywords: metacognition, premature ejaculation, erectile dysfunction, anxiety, worry

Introduction In the last two decades, the majority of sexual problems including premature ejaculation (PE) and erectile dysfunction (ED) have been related to
Correspondence concerning this article should be addressed to: E-mail: muratemul@yahoo.com Metacognition in patients with premature ejaculation and erectile dysfunction 77
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anxiety. PE is further believed to have psychological consequences (i.e., low selfesteem, shameful feelings, depression) in patients suffering from this condition (Corona et al., 2006). Anxiety was found to be the most common psychological component in PE (Corona et al., 2004). Thus, it has been classically associated with anxiety-induced excessive sympathetic outflow (Corona et al., 2004; Rowland, Strassberg, de Gouveia Brazao, & Slob, 2000). PE is reported to be an early symptom of ED because of high anxiety experiences and feeling of frustration due to soft erection (Waldinger, 2002). Thus, a bidirectional relationship has been proposed between dysfunctional sexual response and negative emotional states including depressive, anxiety or obsessive compulsive symptoms which may contribute to, or be the consequence (Corona et al., 2008). Metacognition is defined as stable knowledge or beliefs about ones own cognitive system and knowledge about factors that affect the functioning of cognitive the system (Marcantonio et al., 2010). In a metacognitive model, worry is viewed as an inflexible means of coping (Wells & King, 2006) and becomes a problem when negative beliefs concerning the uncontrollability and the dangers of worrying develop and lead to unhelpful control strategies. Patients with PE or ED have been described as preoccupied with thoughts about controlling their orgasm along with the anxious anticipation of a possible failure and thoughts about keeping their erection. We hypothesized that patients with PE or ED might endorse metacognitive thoughts such as Worrying will help me get sexual problems sorted out in my mind or Ruminating will help me solve this sexual problem . Thus, for the first time in the literature, we aimed to investigate the metacognitive characteristics of patients with PE and ED and to compare them with healthy controls, using a recently adapted form of the metacognition questionnaire (Wells & Cartwright-Hatton, 2004). Method Participants Forty eligible patients with primary PE and forty patients with ED who met the criteria according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Revised Text (DSM-IV, TR) participated in the study at the clinical settings of the University Hospital of Kahramanmaras Sutcu Imam, and Ergani State Hospital. Psychiatrists E.B and Y.B utilized a semi-structured clinical interview (according to DSM-IV, TR) to diagnose PE or ED after possible organic causes of these sexual disorders were excluded by urologists B.A and H.S. The exclusion criteria were as follows: having any Axis I psychiatric disorder, past history of sexual disorders other than PE or ED, medical conditions such as endocrine diseases (i.e., diabetes mellitus, hypothyroidism or hyperthyroidism), and using any drug which may influence PE or ED (i.e., offlabel use of specific serotonin reuptake inhibitors, anti/dopaminergic agents,
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phosphodiesterase type 5 inhibitors), hypogonadism (plasma testosterone level <250 ng/dL), pelvic surgery or trauma, treated prostate disease. Forty demographically matched healthy volunteers who were staff members of the above mentioned hospitals and who did not meet the exclusion criteria, according to their self reports, participated in the study. We examined healthy volunteers for medical illnesses such as diabetes mellitus, hyper/hypothyroidism, mental disorders (i.e., depression, anxiety disorders, and sexual disorders) and for drug use (i.e., specific serotonin reuptake inhibitors, anti/dopaminergic agents, inhibitors of phosphodiesterase type 5) that might have affected results. Incidentally, the patients were all smokers. Therefore, the control group also involved healthy smokers. All participants in the sample were married and had an active sexual life with their partners. Measures Upon giving written informed consent for enrolling in the study, all participants were asked to fill out the meta-cognitions questionnaire, the Beck Depression Inventory (BDI) (Beck & Steer, 1987), and the Beck Anxiety Inventory (BAI) (Beck et al., 1988). The local Ethics Committee approved the study, and the research was performed in accordance with the Helsinki declaration criteria. Metacognitions questionnaire-30. An adapted form of the 65-item metacognitions questionnaire (MCQ), consisting of 30 questions (MCQ-30), was used in the study (Wells & Cartwright-Hatton, 2004). The MCQ-30 is comprised of five factors: (1) positive beliefs about worry (the belief that worrying helps to solve problems and avoid unpleasant situations), (2) negative beliefs about thoughts concerning uncontrollability and danger (the belief that it is necessary to control ones worrying in order to function well as a person and beliefs about the mental and physical dangers of worrying), (3) cognitive confidence (assessing confidence in attention and memory), (4) negative beliefs about thoughts including superstition, punishment and responsibility (i.e., superstitions which imply that the individual could be punished for having or not having certain thoughts), and (5) cognitive self-consciousness (the tendency to focus attention on thought processes). Tosun and Irak (2008) adapted the MCQ-30 in Turkish on a sample of college students. In this study, the inter-item correlations for the MCQ-30 ranged from 0.09 to 0.764, which were consistent with the original form. The MCQ-30 indicated good testretest reliability for items (0.400.94) and subscales (0.70 0.85). The Cronbachs alpha coefficient was 0.86 for the full-scale and supported good internal consistency. Beck Depression Inventory (BDI). Depression was assessed by Beck's self-report 21-item inventory. The BDI cut-offs are <10 absence or minimal depression, 1018 mild to moderate depression, 1929 moderate to severe depression, and 3063 severe depression (Beck & Steer, 1987). Validity and
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reliability data of the BDI in Turkish are available and indicate god psychometric properties (Hisli, 1989). Beck Anxiety Inventory (BAI). The scale consists of 21 questions. BAI cut-offs are <7 minimal anxiety, 815 mild anxiety, 1625 moderate anxiety, and 2663 severe anxiety (Beck et al., 1988). Validity and reliability data of the BAI in Turkish are available and indicate god psychometric properties (Ulusoy, ahin, & Erkmen, 1998). Statistical analysis We used SPSS for Windows 16.0 version for all statistical analyses in this study. The socio-demographic data, depression and anxiety scores along with the total and sub-factor scores of MCQ between patients with PE, ED and healthy controls were compared by one way ANOVA and post hoc Tukey HSD test. A p value of less than .05 was statistically significant for all analyses. Results The age range was 21-51 in patients with PE, 22-58 in patients with ED, and 20-47 in healthy controls, with mean ages of 31.77 (SD = 7.15), 39.97 (SD = 8.57), and 31.52 (SD = 6.24), respectively. Patients with ED were significantly older than the other two groups (p=.000), while there was no significant age difference between patients with PE and healthy controls. The education levels between groups were not significantly different. The self-reported intravaginal ejaculatory latency time (IELT) was 95 (SD = 25) seconds in patients with PE; the mean latency time was 430 (SD = 30) seconds in healthy controls. The mean BDI score was 15.02 (SD = 10.96) in PE patients, 24.32 (SD = 9.67) in ED patients, and 8.77(SD = 7.38) in healthy controls. The BAI scores were 16.80 (SD = 13.30), 17.90(SD = 10.22) and 5.52 (SD = 7.12), respectively. Depression and anxiety levels were significantly higher in patients than healthy controls (p<.001). Also, depression was significantly higher in ED than in PE patients (p < .001). The total MCQ-30 score was significantly higher in patients with sexual problems than in healthy controls (p = .003, for PE vs. controls; p = .025 for ED vs. controls). The positive belief scores were significantly higher in patients than healthy controls (p = .003 for PE vs. controls; and for ED vs. controls p = .003) and there were not significant differences between patients with PE and ED (p = .74). The uncontrollability-danger scores and cognitive confidence scores were not significantly different between groups. The negative beliefs score was significantly higher in patients with PE and ED than healthy controls (p = .032 and p = .007, respectively). Negative believes levels were not significantly different between patients with PE and ED (p = .86). The cognitive selfconsciousness score was significantly higher in patients with PE than patients with ED (p = .033) and healthy controls (p = .004) while there was no significant difference between patients with ED and healthy controls (p = .76). The mean and
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SD of metacognitive sub-factor and total scores among groups are shown in Table 1.
Table1. The metacognitive sub scores and total scores of the groups
Positive beliefs Patients with PE Patients with ED Healthy controls P values1 P values
2

Uncontrollability Cognitive and danger confidence 14.683.72 13.903.26 13.024.78 0.17 0.59 0.69

Negative beliefs

Cognitive self Total scores consciousness 17.303.38 14.874.20 14.205.05 0.004* 0.76 0.033* 73.5011.63 71.0212.69 61.7720.82 0.003* 0.025* 0.74

14.173.07 14.203.25 11.354.77 0.003* 0.003* 1.00

12.324.11 14.574.33 13.172.91 15.103.84 11.224.61 11.975.28 0.43 0.07 0.60 0.032* 0.007* 0.86

P values3

PE: premature ejaculation, ED: erectile dysfunction. Statistics were performed by One Way ANOVA test, 1 PE versus healthy controls; 2 ED versus healthy controls; 3 PE versus ED *statistically significant

Discussion and conclusions According to the metacognitive model, psychological problems are maintained by maladaptive coping strategies such as perseverative thinking (e.g., worry and rumination), threat monitoring, avoidance and thought suppression (Wells, 2000). Similar to many people, patients with sexual disorders might hold positive beliefs about worrying as an effective means of dealing with threat (i.e., premature ejaculation or erectile dysfunction) and anxiety is perceived to be positive way of coping with threat. However, the co-existence of positive and negative beliefs about worrying about PE and ED may lead to unhelpful vacillation between attempts to avoid and engage in worry, coupled with the use of unhelpful mental regulation strategies such as reassurance seeking and thought suppression. In a recent study, two sub-factors (positive beliefs about worry and beliefs about cognitive confidence) were proposed to serve as metacognitive knowledge about the ineffectiveness of memory. Moreover, these variables were proposed to reflect diminished confidence in coping and the need to anticipate problems (throughout worry) and control cognition in order to function (Irak & Tosun, 2008). In addition, cognitive self consciousness was found to be moderately correlated with meta-worry (De Bruin, Rassin, & Muris, 2005). In the current study, we hypothesized that patients would develop a distorted metacognitive function following premature ejaculation or erectile dysfunction that may activate anxiety and perseverative thoughts (i.e., being an inadequate man). This may in turn lead to maladaptive coping strategies (i.e.,

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excessive focus on thought or over-reliance on worry) due to the higher positive beliefs and negative beliefs levels, as assessed by the MCQ-30. If this is the case in individuals with sexual disorders, we hypothesize that patients may ejaculate faster or have impaired erection not only due to preoccupation with thoughts about controlling their orgasm, anxious anticipation of a possible failure, and focus on sexual satisfaction, but also due to believing that worrying about problems has positive effects on problem solving, avoiding unpleasant situations, and being superstitious about punishment for having or not having certain thoughts. Cognitive self-consciousness, meaning extensive attention to ones own thought processes, was found to pre-date obsessional problems. However, there is no evidence to suggest that self consciousness is a cognitive risk factor for obsessive-compulsive disorder (OCD) (Janeck Calamari, Riemann, & Heffelfinger, 2003). Furthermore, the relationship between obsessive-compulsive symptoms and sexual dysfunctions in men has been poorly investigated, whereas many studies evaluated the nature and extent of sexual obsessions in patients with OCD (Corona et al., 2008). In the present study, patients with PE had higher levels of superstition, punishment and responsibility themes. There are currently no studies looking at the relationship between PE and OCD. Therefore, future studies on this relationship may provide more explanations. In addition, cognitive self-consciousness scores were significantly higher in patients with PE than patients with ED. A significant negative correlation between age and cognitive self-consciousness has been found in the Turkish adaptation study of the MCQ30. The significant discrepancy between PE and ED might be due to this negative correlation, as patients with ED were significantly older than patients with PE. We suggest that patients who have higher cognitive self-consciousness scores may have an elevated focus of self and might display intensified responses to threatening stimuli (i.e., controlling ejaculation while having intercourse). Fear of failure or thoughts of inadequacy regarding controlling orgasm would develop a vicious cycle of failure (Sommer, Obenaus, & Engelmann, 2001), which may in turn lead to increases in the sympathetic activation that may cause PE (Corona et al., 2004; Rowland et al., 2000). In recent years, PE has been defined as a neurobiological disorder that may respond to pharmacotherapy (Waldinger, 2002). However, it was stated that "a combination psychosocial and pharmacologic therapy should be prescribed" in patients with PE or ED. In addition, the combination of "multi-causal influences while focusing on fixing the predominant factor in each case, rather than addressing dichotomous factors in isolation" was addressed by an author (Perelman, 2006). If this is the case, modifying metacognitive beliefs (e.g., positive beliefs about worry, superstition of being punished and cognitive self consciousness) may be a new therapeutic approach for patients with sexual disorders. This approach has been called metacognitive therapy in recent years (Wells & Cartwright-Hatton, 2004).

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In the present study, there may be questions about the relatively high anxiety and depression scores of patients with sexual disorders, reaching levels of mild to moderate anxiety and depression. We considered these higher scores in two ways. First, although they had relatively high anxiety and depression scores, the patients did not meet the clinical criteria of depressive and anxiety disorder according to DSM-IV, TR. Second, as mentioned before, the majority of sexual problems is related with anxiety and can lead to psychological consequences such as depression (Corona et al., 2006). However, the influence of these psychological states (i.e., depression and anxiety) cannot be excluded in the current study. The current study is not without limitations. First, the results are based on a relatively small sample size. Therefore, caution should used in interpreting the data. Exclusive reliance on self-report measures is another limitation of our study. Third, given the absence of other clinical groups (i.e., meta-cognitions of patients with anxiety or depression), we can not be sure that our findings are specific to PE or ED. Finally, ED severity evaluation using the International Index of Erectile Dysfunction would be more appropriate for exploring the relationship between ED severity and metacognition. To conclude, this is a preliminary study on a new topic, aiming to understand the role of metacognitive beliefs in sexual disorders. Indeed, problems in sexual disorders seem to be more complex than solely on the cognitive level; metacognitive beliefs appear to influence these patients as well. Metacognitive therapeutic approaches, may therefore serve as a means to relieve the sexual burden of patients.
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