Distinguishing between organogenic and psychogenic erectile dysfunction

&hav. Res. Ther. Vol. 25, No. 5, pp. 379-390, 1987 Printed in Great Britain

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Pergamon Journals Ltd

DISTINGUISHING BETWEEN ORGANOGENIC AND PSYCHOGENIC ERECTILE DYSFUNCTION DAVID K. SAKHEIM,*DAVID H. BARLOW,DANIEL J. ABRA?KAMSON* and J. GAYLE BECKY Department of Psychology, Center for Stress and Anxiety Disorders, State University of New York at Albany, NY 12222, U.S.A. (Received 6 Jamary 1987) ~-Wang assessment of erectile responses using erotic tihns and self-stimulation differentiated psychogenic and organogenic erect& dysfunction. The high number of false positives among the organogenics and false negatives among the psychogenics indicate that there is no single biological marker for organogenic crectile dysfunction. On a continuous cognitive measure psychogenics consistently underestimated their degree of erection, while organogenics overestimated their amount of erection. The results suggest that one session of waking erectile assessment provides as much or more information than more expensive and time-consuming nocturnal penile tumescence recordings. The data also strongly suggest that organogenic and psychogenic are not dictotomous categories and that a multi-faceted assessment of erectile potential, psychological factors, etiologbl factors and the current social and interpersonal context of sexual behavior, is necemary for successfitl medical or psychological treatment planning. INTRODUCTION

Recent advances in both psychological and medical treatments for erectile dysfunction have made the accurate differential diagnosis of psychogenic and organic contributions to etiology increasingly important. Until very recently, the vast majority of patients who presented with erectile problems were thought to have a psychogenic dysfunction. An organic diagnosis was typically assigned only if the patient presented with clear evidence of alcoholism, diabetes or cardiovascular disease. Without such syndromes, the patient was considered psychogenic. In addition, since neither biological nor psychological treatments for impotence were particularly successful, the differential assessment of their respective influence was not particularly critical. Two recent developments have altered this state of affairs. The first has been the development of surgical procedures for correcting erectile insufhciency through penile implant or revascularization surgery (Scott, Bradley and Trimm, 1973; Shishito, Shirai and Matsuda, 1975; Small, 1976; Ankenman, Sullivan, Wright and McLou~in, 1981; Ensor, 1981) as well as the development of psycholo~~l treatments of unprecedented effectiveness (Masters and Johnson, 1970; Kaplan, 1974). The second development has been the recent finding that a large percentage of male sexual dysfunction may be caused by vascular disease (Fisher, Schiavi, Edwards, Davis, Reitman and Fine, 1979; Blavas, O’Donnel, Gottlieb and Labib, 1980; Schiavi, 1981; Lane, Appleberg and Williams, 1982) and by other organic factors (Slag, Morley, Elson, Trence, Nelson, Nelson, Kinlaw, Beyer, Nuttall and Shafer, 1978; Montague, James, DeWolf and Martin, 1979; Leiter, 1981; Whitehead, 1981). Although the exact ratio of psychogenic to organic etiologies is still controversial (Boyarsky and Boyarsky, 1978), and prevalence estimates appear to have been greatly influenced by the clinical setting in which they occur, it would appear that many more patients have organic components than was believed previously. Early attempts at differential diagnosis involved either clinical judgment or the use of pencil-and-paper surveys. Unfortunately, none of these has proved consistently reliable or valid (Ellis, 1972; Beutler, Karacan, Anch, Salis, Scott and Williams, 1975; Staples, Ficher, Shapiro, Martin and Gonick, 1980). A second approach to the problem was to assess personality variables that might discriminate psychological etiologies from medical causes. It was suggested that psychogenic patients might show more disturbance on a number of psycholo~~l variables such as hostility or neuroticism than would medically-impaired individuals (Cooper, 1968a, b; Kaplan, *Now at the Center for Adolescent and Adult Psychotherapy, South Windsor, CT, U.S.A. tNow at the Department of Psychology, University of Houston, TX, U.S.A. 379

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1974). Tests such as the MMPI were utilized to assess these hypothesized differences, however, as has been the case with all such personality measures, decision rules developed in one study would not be supported in later replication attempts (Marshall, Surridge and Delva, 1980; Marshall, Morales and Surridge, 1981a; Munjack, Ozief, Kanno, Whipple and Leonard, 1981). Derogatis, Meyer and Dupkin (1976) attempted a third approach in which they tried to relate specific variables concerning sexuality to the differential diagnosis of organic and psychogenic impotence. Although they found significant relationships, a later study, once again, was not able to replicate these findings (Segraves, Schoenberg, Zarins, Knopf and Camic, 1981). Thus, despite substantial work in this area, there are as yet no clear personality, descriptive, or sexual characteristics that have been shown to reliably discriminate between organic and psychogenic impotence. One of the most exciting developments in this area of study has been recent work in the assessment of nocturnal penile tumescence (NPT). In 1970, Karacan published the first use of NPT as an aid in the differential diagnosis for impotence. He suggested that psychogenic patients would show normal NPT since there was nothing wrong with the physiological mechanism of erection in these patients, and psychological factors assumed to be causing the impotence would not be expected to be operating during sleep. Organic patients, on the other hand, would show absent or disturbed NPT since their problem was in the mechanism of erection and should therefore be equally present during a waking or dreaming state. Karacan and his colleagues (Karacan, Williams, Thornby and Salis, 1975; Karacan, Scott, Salis, Attia, Ware, Altinel and Williams, 1977) published data supporting this hypothesis. It appeared that clinicians finally had an objective means of determining the etiology of impotence. Unfortunately, further work determined that both false positives and false negatives occur with the NPT procedure. For example, a number of studies have demonstrated that known organics can demonstrate significant NPT (Michal and Pospichal, 1978; Fisher et al., 1979; Wasserman, Pollack, Speilman and Weitzman, 1980a; Beutler and Gleason, 1981; Marshal er al., 1981a; Marshall, Surridge and Delva, 1981b; Wein, Fishkin, Carpiniello and Malloy, 1981) although such erections may be somewhat different from those of normal subjects (e.g. briefer, less frequent, significant base-tip difference or insufficient rigidity for penetration). Nevertheless, there are clear data that medically impaired patients can show significant nocturanal penile circumference changes, even as great as 32-40 mm of circumference change (Muhr, 1982). Kenepp and Gonick (1979) point out that there is substantial overlap in normal and organic NPT values, probably as a result of the wide normative range of circumference values that constitute full erection, a finding supported by other investigators (Marshall, Morales and Surridge, 1982). These data include instances where clear psychogenics would have been misdiagnosed as organic based on their minimal NPT tracings. In fact, it is now well documented that at least 20% of psychogenic patients will be diagnosed organic by an NPT evaluation. Thus, despite continued enthusiasm from clinicians, careful researchers are beginning to conclude that the minimal reliability and validity data on NPT to date would suggest “the diagnosis of organic impotence should not be made solely on the basis of significantly impaired NPT measurements” (Wasserman et al., 1980b). In addition, other problems are associated with NPT evaluation (Wasserman et al., 1980a; Allen, 198 1; Nath, Menzoian, Kaplan, Millian, Siroky and Krane, 198 1). Despite its widespread use, there have been few attempts to determine reliability or validity of the NPT procedure. Data that have been reported are not strongly supportive. For example, one study found a 21% reversal of diagnosis from one night to the next. Nine out of 71 subjects would have been labelled organic who later showed full NPT on retesting (Pro&, Moss, Boyd and Barron, 1983)! Many investigators such as Wasserman et al. (1980b) are hopeful however, that if the formal evaluation is supplemented by other procedures and is conducted on three different occasions including direct observation and photography of the patient’s erection, utilizing measures of penile rigidity and of an erectile duration, then the evaluation will eventually be shown to be reliable and valid. Nevertheless, it would appear that although quite imperfect, a thorough NPT evaluation is still the closest that a clinician can come, at present, to objectivity in the differential diagnosis of impotence. In light of the above problems with the NPT procedure, as well as its cost and intrusiveness, experimental work is beginning on alternative approaches. For example, Kockott, Feil, Fersl,

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Aldenhoff and Besinger (1980) and Sakheim, Barlow and Beck (1987) elicited full erectile responses from psychogenic Ss who were awake by either showing them erotic films or asking them to stimulate themselves in the laboratory setting. Kockott et al. (1980) demonstrated that while a group of organic patients showed minimal erectile changes, a group of psychogenic patients could show significant penile responses during the presentation of an erotic film. Sakheim et al. (1987) observed that sleep was not a mandatory part of an erectile potential exam, and in fact, that wakefulness had many advantages for assessment purposes, such as the opportunity to examine individual differences in cognitive components of the arousal response. In what may be a potentially important finding, the psychogenic Ss underestimated their degree of erection when compared to normals at equivalent circumference changes, a finding also reported by Fisher et al. (1979). In addition to erotic films, self-stimulation seems a very straightforward method of examining erectile capability. Psychogenics usually do not show disturbed erectile functioning with masturbation. For example, in a review of sex therapy records, Graber and Kline-Graber (1981) noted that only 7% of psychogenic dysfunctionals reported impaired erections with masturbation. However, as yet no one has utilized this approach in a systematic fashion to differentiate clinical groups. The present study was therefore designed to evaluate the clinical usefulness of a simple waking, erectile potential assessment (EPA). The waking EPA was implemented in two ways. One involved showing clearly defined groups of organic, psychogenic, and functional men highly arousing erotic film sequences. The other method consisted of asking each subject to self-stimulate. Both of these simple evaluations included measurement of self-report and objective penile circumference data. METHOD

Subject selection procedures

Ten psychogenic patients, ten organic patients, and ten sexually functional volunteers between the ages of 21 and 60 were studied. Since the definition of Ss was crucial to this study, the procedure for S assignment will be described in some detail. In order to establish carefully known organic and psychogenic etiologies on the basis of independent clinical criteria, the recommendations of Marshall et al. (1981b) were followed and extended. Following detailed examinations by psychologists and urologists, all patients can be categorized into one of four groups (organic, psychogenic, mixed organic and psychogenic, and uncertain) depending on the presence or absence of sufficient psychological or medical factors to account for erectile dysfunction. The patients utilized in the present study were only those for whom impotence could be clearly identified as psychogenic or organic. Those patients for whom etiology was uncertain were excluded (See Table 1). Patient assignment to each group was based on clear pre-assignment criteria taken from the literature in this area (Masters and Johnson, 1970; Finkel, 1979; Schiavi, 1979; Velcek, Sniderman, Vaughan, SOS and Muecke, 1980; Leiter, 1981; Vliet and Meyer, 1982) and an attempt was made to equate Ss on background characteristics by soliciting all participants (including the functionals) from a small group of urological service units. In order to classify patients, four examination procedures were conducted. (1) General physical and vascular examination. This procedure was conducted by a physician and consisted of a thorough physical examination including height, weight, body type, vital signs (temperature, pulse, respiration, blood pressure), head, ears, eyes (arcus senilus, vessels, xanthalasma, fundi), neck (thyroid, bruits), heart (auscult), genitals (testes, penis, bulbocavemosus reflex, doppler exam), rectal, extremities (pulses, temperature), use of medications, allergies, current medical treatments, etc. The doppler and penile blood pressure examinations were conducted because clinical investigators (e.g. Weiler, 1982, personal communication) have found that 4&60% of patients otherwise diagnosed as psychogenic were found to have vascular problems using a doppler assessment. Magee (1980) also reported on 30 cases previously diagnosed as psychogenic with pudendal artery obstruction. A number of methods for measuring penile blood pressure and flow have been presented (e.g. Britt, Kemmerer and Rolison, 1971; Abelson, 1973; Gaskell, 1981). Recent work suggests that the most useful assessment consists of calculating the penile to brachial

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Table 1. Flow chart of subject selection criteria Urologic

pa1icnt referrals & Meets criteria for DSM-III diagnosis other than inhibited-Yes-Excluded sexual excitement

I No

Excluded-Yes-History

Of

any sexual+-Noproblems I No

Meets research criteria

for erectile dysfunction (DSM-III inhibited sexual excitement plus failure to achieve erections more than 75% of coital connections) Yes i From psychological and medical evaluation ratings 4

I Group I (normal) No crectile dysfunction

I

4 Group 2 (psychogenic) Insticicnt medical sufficient psychogleni

4 Group 3 (organtc) Sufkicnt medical Insufficient psychogenic

I

i Group 4 (mixed) Sufficient medical Sufficient psyyhogenic

k Group 5 funeertainf Insufficient medical Insufficient psyShogcnic

flow index (Abelson, 1973; Engel, Bumham and Carter, 1978; Lane et al., 1982). This index was utilized in the present study with a cut-off value of 0.90 as suggested by Engel et al. (1978) and a grading made of the penile volume waveform as suggested by Kempczinski (1979). (2) Urological examination. This procedure was conducted by a urologist and covered typical symptoms (duration, severity, libido, self-report of nocturnal penile erections, previous sexual history), urological history (voiding dysfunction, prostatitis, genital trauma, Peyronies disease), a relevant medical history (diabetes, vascular disease, neurological disease, previous injury), relevant medications (antih~~ensive, antidepressant, alcohol), a physical exam (blood pressure, pulse, secondary sexual characteristics, abdomen, genitalia, prostate) and relevant laboratory tests (complete blood count, profile I [glucose, blood urea and nitrogen, electrolytes], profile II [e.g. liver and cardiac enzymes, and miscellaneous electrolytes], 5-hr glucose tolerance test, serum testosterone, FSH, LH, serum prolactin). Following these two medical examinations a physician reviewed the data and decided if the patient showed significant medical complications to account for the erectile dysfunction. (For example, a finding that the erectile dysfunction followed the initiation of a medication known to cause impotence, or a history of penile vascular insufficiency, would result in a positive rating for the role of medical factors). The physician assigned each patient a rating on a O-5 scale to indicate the significance of organic findings. Only those patients who showed the clear presence (or absence) of such organic factors were included in the present investigation. (3) Psychiatric diagnostic interview (Othmer, Penick and Powell, 1981). This fully-structured interview is designed to enable accurate psychiatric diagnosis according to the third edition of the American Psychiatric Association’s (1980) Diagnostic and Statistical Manual (DSM-III). The interview was used in the present study to rule out Ss with an Axis-I diagnosis, and to help provide detailed background information about the Ss included in this study. (4) Semi-structured sexual history interview. This interview consists of fifty forced choice questions which are asked of each S in our laboratory, with follow-up questions on unusual or unclear answers. The interviewer first establishes a S’s sexual preference (Kinsey rating) and then obtains basic demographic information as well as a brief mental status exam. The remainder of the interview is designed to provide the information necessary to determine if sufficient psycho-

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logical factors are present to account for erectile dysfunction. The questions cover behavioral frequencies of various sexual activities, sexual satisfaction, sexual info~ation, sexual history, and problems related to sexual functioning. The section covering specific sexual problems assesses the presence of inhibited sexual desire, inhibited sexual excitement, premature ejaculation and atypical psychosexual disorders. In addition to a determination of the diagnosis of any of these DSM-III categories, the interview also followed a functional analytic approach to each problem area. That is, the onset, duration, development and course of each apparent problem is pursued, as well as the antecedents, responses and consequences that typically surrounded its occurrence. Following the two psychological examinations the interviewer completed a form to indicate if, in his/her judgement, there were sufficient psychological factors to account for the erectile dysfunction, The interviewer followed the decision rules proposed by Schiavi (1979) and by Vliet and Meyer (1982) coupled with the criteria used in DSM-III and his/her own clinical judgement. A high psychogenic rating would include such findings as a sudden onset, a report of a masturbator pattern that is not disturbed, erectile failure following a severe depression, marital problems, the presence of performance demands, etc. Each S was then assigned a number from 0 to 5 to indicate the significance of psychogenic etiological and maintaining factors. Independent judgments of these factors by a second rater yielded a reliability coefficient of 0.90 when an exact match of specific ratings was required. As with the organic coding, only those patients who showed a clear presence of psychogenic factors were included in the present study. At this point, it became possible to classify those Ss who were not ruled out of the study by the Diagnostic Interview Schedule into one of five categories based on the revised proposals of Marshall et al. (1981 b) (see Table 1). (1) Normal. A S was classified as normal if he was currently sexually active and never had experienced premature ejaculation, impotence, nor inhibited sexual desire. (2) psychogenic. A S was classified as psychogenic if no organic cause could be found by the physician. In addition, psychogenic .factors of sufficient severity to account for the onset of impotence were present. Thus, this category necessitated a history of erectile failure coupled with a rating of 4 or 5 on the psychogenic scale and 0 or 1 on the organic scale. (3) Organic. A S was classified as organic if a medical cause could be established for his erectile failure. The criteria utilized were that organic factors known to cause impotence were present, that these were of sufficient severity to account for the impotence, and that the impotence and organic factors were related in time. In addition, no relevant psychogenic factors were present. Thus, this category necessitated a finding of erectile failure coupled with a rating of 4 or 5 on the organic scale and a 0 or 1 on the psychogenic scale. (4) Mixed organic and psychogenic. A S was classified as mixed organic and psychogenic if signifi~nt organic and psychogenic factors were both present. In other words, ratings of 3 or greater on each of the two scales. These Ss were excluded. (5) Uncertain. A S was classified as uncertain if neither organic nor psychogenic factors of sufficient severity to account for the impotence could be found. This necessitated a finding of erectile failure that could be classified in any of the previous categories. These Ss were also excluded. Measures Physiological measurement. A mechanical penile strain gauge (Barlow, Becker, Leitenberg and Agras, 1970) was used to assess penile circumference changes during all conditions. This device was positioned two thirds of the way down the shaft of the penis toward the base and a continuous d.c. signal recorded changes in electrical output caused by expansion of the gauge. ~~bjectjve measurement. A continuous measure of subjective sexual arousal was recorded using a mechanical lever which a S could move through a 90” arc to produce a continuous d.c. signal calibrated to indicate a O-100 scale. Ss were asked to use this lever to indicate their percentage of full erection. Zero signaled no genital arousal and 100 indicated a full erection. Data sampiing and analysis. All data from the subjective rating lever and the penile measure were measured by a Grass Model 7P1 polygraph and were simultaneously sampled and processed by an LSI-II microprocessor. The computer continuously sampled and stored data, calculating the

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means for each measure end of each session the could be translated into it has been anticipated laboratory setting, the baseline.

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every 10 set, and the maximum for each condition. At the beginning and gauge was calibrated on a graduated metal cone so that pen deflections actual millimeters of penile circumference based on cone readings. Since that some of the 24 Ss would be unable to achieve full erections in the penile data were analyzed in terms of mm circumference change from

Stimuli

The stimuli consisted of a previously validated highly arousing erotic videotape of various heterosexual activity (Wincze, Venditti, Barlow and Mavissakalian, 1980; Beck, Barlow and Sakheim, 1983) as well as the travelogue film. Procedure Ss were assessed individually. Each S first completed the two medical and two psychological examinations before being scheduled for the physiological session. He then proceeded to the experimental room where he reclined in a comfortable chair that was positioned in such a way as to allow him to view the screen of a television monitor. After the S positioned the strain gauge and a sheet was draped across the arms of the recliner he was first shown a 2-min travelogue film to control for orienting responses. Subsequent to this he was shown the highly arousing videotape and then asked to try to stimulate himself to full erection either manually or through fantasy or both. The videotape lasted 3 min and the self-stimulation phase lasted until the S reported that he felt ‘maximally aroused’. Between the two phases, the S was given at least 2 min to return to baseline subjective and physiological responding. If he did not return to such a level, he was asked to perform mental arithmetic tasks until he no longer showed any signs of sexual arousal. Debrie@ng

After the physiological recording session, each S met with a psychology doctoral student to discuss any feelings or concerns about the session as well as the physiological and subjective responses that had occurred. RESULTS Subject d#erences

To see if the groups were well-matched, a number of S characteristics were assessed. These consisted of age, occupational status, race, years of education, maritial status, sexual experience (from the Beutler (1968) sexual experience questionnaire), and sexual orientation (rated on the Kinsey Scale). These factors were assessed for each S and a one-way ANOVA (group (3) x descriptor) was conducted for each variable in order to determine if the three groups showed differences on these factors. The results of the analyses indicated that the groups were wellmatched, differing only in age. Despite careful S selection attempts, the organics were significantly older than either of the other two groups with mean ages being 55.8 yr for organics, 44.6 yr for psychogenics and 38.1 yr for controls. It is important to note, however, that other researchers have found that age does not correlate with erection magnitude for any of our three S groups (Zuckerman, Neeb, Fisher, Fishkin, Goldman, Fink, Cohen, Jacobs and Weisberg, 1985). The groups did not differ on occupational status (df = 2,25 F = 0.34), race (df = 2,27, F = O.O), years of education (df = 2,27, F = 1.3), maritial status (df = 2,27, F = 0.91), sexual experience (df = 2,27, F = 1.78), or sexual orientation (df = 2,27, F = 0.50). A chi-square analysis was performed that tested the assumption that the three S groups would not differ on erectile potential as determined by a penile change greater than 20 mm (Karacan’s cut-off value (Karacan et al., 1977) for a significant erectile response during either the film or self-stimulation condition. Ss were either assigned to the erectile potential group (maximum above 20 mm) or to the limited response group (maximum below 20 mm) and a chi-square was then computed. McCall (1975) points out that the chi-square distribution is biased in a liberal direction for a 2 x 3 analysis with expected cell frequencies of less than 10. Thus, in light of the seriousness of a Type 1 error and to correct for this bias, the P < 0.01 level of significance was used for this

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Fig. 1. Maximumpenile circumferencechange from baselineduring erotic film condition. analysis. The results reject the null hypothesis that the three groups are the same on erectile potential as assessed in this way (x2 = 8.82, G!!= 2, P < 0.01). Thus, a waking assessment of erectile potential can significantly differentiate groups of organics, psychogenics and controls. While group differences are interesting, the more important analysis concerns individuals. Thus, the individual S data are presented graphically (Figs. l-3) and a calculation was made of both false positives and false negatives resulting from the waking assessment using Karacan’s 20 mm rule for determining erectile potential (Table 2). Using only data from the film condition, there was a 60% overall correct assignment to groups. Using only data from the self-stimulation condition, there was a 77% overall correct assignment to groups. Using the combined film and self-stimulation data, there was a 77% overall correct group assignment. In order to assess if psychogenics underestimate their degree of erection, a repeated measures analysis of variance had been planned using the subjective ratings of percent of erection at successive increases in penile response. The dependent variables were the subjective report values that corresponded to successive levels of penile circumference change (3, 6, 9, 12, 15, 18, 21, 24, 27 and 30 mm). This allowed for the examination of potentially different subjective reporting of perceived erection changes by the three groups at identical 100 :

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circumference values. However,

because many Ss did not contribute data at all of these penile values and a meaningful analysis cannot be done using cells with less than six Ss, a graphic presentation was’made of the data in place of the ANOVA (see Fig. 4). The figure shows the number of Ss in each group who contributed to each data point. Although the latter points in the graph are made up of a diminishing number of Ss, a consistent trend emerges. As predicted, the psychogenics consistently underestimated their degree of erection compared to the other two groups at identical penile deflections. The organics, on the other hand, appeared to overrate their degree of erection. Lastly, in order to examine how accurately each group was able to track their penile responding, correlations between the penile measure and the continuous self-report of percent of full erection were computed for each S. These correlations were then transformed into standardized z-scores so that an analysis of variance could be conducted. Again as predicted, the controls showed the most accurate awareness of erectile changes. The psychogenics showed a somewhat lower awareness and the organics showed the lowest z-scores (0.91, 0.55, and 0.27, respectively). A one-way ANOVA across the three groups with a Duncan’s Multiple Range Follow-up Test revealed that the controls showed significantly higher correlations than the organics (df = 2,27, Table 2. Correct and incorrect group assignments of psychogenics and organogenics using erectile response during erotic films, selfstimulation or a combination correct Using maximum cut-off) Psychogenics Organics Controls Total

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F = 2.9, P < 0.05). There was a trend for the controls to have higher scores than the psychogenics, who in turn tended to have higher correlations than the organics. In summary, in comparison to the controls, the psychogenics underrated their erections at equivalent penile changes and were less accurate in tracking their erectile responding. The organic Ss tended to overestimate any erectile changes that did actually occur and, as expected, they showed the lowest correlations between self-report of penile changes and penile changes actually measured. DISCUSSION The analysis of maximum penile circumference changes demonstrated clear group differences between normals, psychogenically dysfunctional and organogenically dysfunctional males. Interestingly, these significant group differences did not occur during the erotic film, but only were found during the self-stimulation condition. Here the controls showed greater responding than the psychogenics who showed greater responding than the organics. Examination of responses to the erotic film indicates that more of the organic Ss evidenced erectile responses, eliminating significant group differences. In fact, an examination of Fig. 3 reveals that each group contained Ss who were able to show clear erectile potential and Ss who were not. No clear prediction of responding or non-responding in the group emerged from the extensive medical and psychological data base. Thirty to forty percent of the carefully diagnosed organics were able to show ‘full’ erections. Although such findings have also been reported in the NPT literature (e.g. Michal and Pospichal, 1978; Fisher et al., 1979; Kenepp and Gonick, 1979; Wasserman et al., 1980a, b; Beutler and Gleason, 1981; Marshall et al., 1981a) it would seem that insufficient consideration has been given to the lack of accuracy of erectile potential exams suggested by the large number of false positives. Forty percent of our patients with documented organic pathology showed erectile changes that surpassed Karacan’s proposed rule that deflections of 20 mm can be considered as full erections. Thirty percent surpassed the more conservative Fisher er al. (1979) 30 mm requirement. Erectile potential alone seems insufficient to rule out organicity, suggesting once again, that no single biological marker has yet been identified for any specific psychological disorder. Although the data from the masturbation condition appears to show good differential diagnosis of organics and controls based on group averages, such a conclusion would be misleading. The same organic Ss who were not able to demonstrate their erectile potential during masturbation were able to do so during the film conditions. It may be that a careful assessment of erectile potential will require assessment of various types of stimulus situations before concluding that a

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patient has diminished erectile potential. This brings up the interesting possibility that some patients who do not respond to an NPT evaluation might respond to the quite different set of stimulus conditions present in a waking assessment (and vice versa). It would have been possible to frame the present data without stressing the false positives and false negatives. The overall success rate of 70-80% accurate classification would appear to be a successful discrimination of groups and has often been presented as such in NPT studies. Nevertheless, the reporting of individual differences rather than group averages is essential in differential diagnostic work (Barlow, Hayes and Nelson, 1984). Since the present study along with others (discussed above) have shown that neither NPT or waking assessments are certain proof of the presence or absence of organic etiology, much of their value will therefore lie in the amount of suggestive clinical information that this test can provide. Thus, one potential advantage of a waking assessment for erectile potential over NPT studies is that self-reported feelings and perceptions of arousal can be directly assessed. In the present study useful information emerged concerning the subjective experience of patients as well as the relationship between subjective and physiological responses. Specifically, both clinical groups reported feeling less aroused than the controls. In addition, when asked to report size of erection, the psychogenic Ss consistently underrated their percent of full erection, while the organics overrated this percentage (see Fig. 4). This is the first clear demonstration of a phenomenon that has been reported sporadically and unsystematically in other studies (Fisher et al., 1979; Sakheim et al., 1987). It is possible that psychogenic patients maintain negative self-evaluations and expectations despite knowledge of their own erectile potential contributing to a negative feedback loop that interferes with erectile potential (Barlow, 1986). In any case, this may be an important issue in differentiating psychogenic and organic erectile dysfunction. Another important finding concerned subjective accuracy in tracking physiological arousal. Sakheim, Barlow, Beck and Abrahamson (1984) have noted the importance of exploring both the levels and the covariation of response systems in attempting to understand the concordance of subjective and physiological arousal. In the present study the level of subjective responding to the same amounts of physiological arousal differed across groups. In terms of directional response system concordance, analysis of the correlations between self-report and actual erectile changes also showed group differences. As expected, the control Ss were the most aware of genital changes, averaging a (z-transformed) correlation of 0.91, while the psychogenics and organics showed much lower ability to accurately track genital changes (0.55 and 0.27, respectively). Although these correlations may have been influenced by the overall amount of arousal achieved, it is significant that the psychogenics showed such reduced awareness of their genital responses. Coupled with the intensity response system concordance data, it would appear that in contrast to controls, psychogenics not only underrate their degree of erection, but show less awareness of moment to moment erectile changes. Clearly, if replicated, this would suggest that a treatment which teaches a more accurate and realistic self-awareness of erectile changes might be useful. The future of this field is likely to recognize an increasing complexity to diagnosis. ‘Erectile Potential’ exams have led to a focus on dichotomous classification (i.e. ‘organic’ vs ‘psychogenic’). However, a focus on the diagnostic ‘misses’ of erectile potential procedures leads to a more complex view that provides for varying types and intensities of organicity or psychopathology as well as for an interaction of these factors. Knowledge of erectile capacity may not be the most significant data that can be collected prior to a determination of appropriate treatment. The more valuable use of erectile potential evaluations may involve an exploration of cues that maximize arousal accompanied by an assessment of the subjective experiences of patients. For example, Beutler and Gleason (1981) recommended that all patients undergo a psychological and medical examination rather than relying solely on results from erectile potential exams. CONCLUSIONS The waking assessment procedure seemed as useful as an NPT examination in allowing for a demonstration of erectile potential. Eighty percent of the psychogenics and 90% of the controls showed more than the 20 mm of penile circumference change needed to surpass the Karacan criterion for full erection (see Fig. 3) replicating the findings of Sakheim et al. (1987). As in the

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NPT evaluations, waking assessment was able to discriminate organic from non-organic Ss, particularly under the self-stimulation condition where approximately 80% accurate overall classification could be accomplished. This suggests that the simple waking assessment is approximately as powerful a screening device for organicity as is the full NPT exam, without nearly the same degree of intrusiveness nor expense. There is the added advantage of directly assessing the patient’s subjective responses, particularly estimates of erection which is a potentially important contribution to differential diagnosis. Of course, a direct comparison of the two procedures is now needed to explore further their comparative benefits and potential interactions. One recent study that used both procedures demonstrated a relationship between the degree of response while sleeping and waking (Zuckerman et al., 1985) but more direct comparisons are clearly needed. Acknowledgements-This research was completed in partial fulfilment of the Ph.D. at SUNY-Albany by David K. Sakheim, under the supervision of David H. Barlow. We acknowledge with appreciation the assistance of Jennifer Jones in preparing this manuscript. REFERENCES Abelson D. (1973) Diagnostic value of penile pulse and blood pressure: A doppler study of impotence in diabetics. J. Ural. 113, 636439.

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