ROLE OF SELF-BELIEF IN ŚUKRAGATAVĀTA (PREMATURE EJACULATION) AND ITS MANAGEMENT WITH RATIONAL EMOTIVE BEHAVIORAL THERAPY-A CASE SERIES.

Dr. Deshmukh Prashant Nareshrao, Dr. Suryawanshi Payal Prataprao and Dr.Pawankumar Godatwar. 1. Assistant Professor, Rog Nidan Evam Vikriti Vigyan, M.S.M. Institute of Ayurveda, Khanpur Kalan, Sonepat, Haryana. 2. Assistant Professor, Rog Nidan Evam Vikriti Vigyan, Gangaputra Ayurved College, Jind Haryana. 3. Professor, Rog Nidan Evam Vikriti Vigyan, National Institute of Ayurveda, Jaipur. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 12 February 2019 Final Accepted: 14 March 2019 Published: April 2019


925
on Sexual Health defined it as "persistent or recurrent ejaculation with minimal stimulation before, on or shortly after penetration and before the person wishes it, over which the sufferer has little or no voluntary control which causes the sufferer and / or his partner bother or distress" The ability to perform in sexual act is directly related to the maleness. Thus, any dysfunction regarding sexuality becomes an eye catcher for both partners. Premature ejaculation is a psychosomatic disturbance due to a psychologically overanxious personality was first suggested by Schapiro. He classified PE as primary (lifelong) or secondary (acquired).
In Ayurveda, Vāta is the chief motivator responsible for all movement in the body; both Pitta and Kapha are dependent on Vāta for their respective movements. Śukra is the terminal Dhātu and supreme vital essence of all the Dhātus. In Ayurveda, the problem premature ejaculation is discussed under the term Śukragatavāta. The problem is occurs due to vitiation of Vāta which causes hyper stimulation of Mana and lack of control over ejaculation. The pathology of Śukragata Vāta occurs with the combination of three entities -Vāta, Śukra and Mana; hence the involvement of these should be taken into account while planning its management. Śukragatavāta is a distinct pathological entity characterized by a group of clinical presentations related with ejaculation impairment and seminal abnormalities among which Kṣipraṁ Muṅcati, Sukrasya Śīghram Utsarga and Atiśīghra Pravṛtti (Premature Ejaculation) is one Vātakara Āhāra-Vihāra and Manoabhighāta (mental trauma) cause vitiation of Vāta and Śukradhātū. All Indriya including Upastha are under the control of Mana and Mana itself is at the control of Vāta. Ācārya Caraka has explain Saṁkalpo Vṛṣyāṇāṁ where Saṁkalpa is consideration, determination of mind about a thing; means Mana plays very important role in ejaculation process also. Hence taking all this into consideration I have selected following three patients having sign and symptoms of premature ejaculation to evaluate the effect of Rational Emotive Behavioral Therapy (REBT) in the management of Śukragatavāta (Premature ejaculation).
PE can lead to secondary symptoms such as distress, embarrassment, anxiety, and depression. Premature ejaculation is characterized by a lack of voluntary control over ejaculation. It is a sexual dysfunction making a lot of frustration and interpersonal difficulties in the married life. It has been considered as a psychological disease. Belief on selfability and unconditional self-acceptance are very important factors in dealing with psychological aspect of premature ejaculation. Psychotherapy in form of Rational Emotive Behavioral Therapy (REBT) can be an effective and safe option to treat psychological aspects of premature ejaculation. This is a Case series of three patients of premature ejaculation with different causes especially psychological as per definition of DSM-V. I counselled 3 times for approximately 30 minutes in the interval of 7 days each time by REBT. The improvement in the patient was assessed mainly on the basis of relief in the sign and symptoms of the disease such as IELT, voluntary ejaculatory control, number of penile thrusts and sexual satisfaction in both.
Case Descriptions: Case 1-32 year married male came to OPD of Roga Evam Vikṛti Vijñāna, National Institute of Ayurveda, Jaipur with the problem explaining that he has quick ejaculation only with touch with his partner or sometimes only with the thought of intercourse. He was unable to enjoy sexual life. Due to this his married life was totally disturbed. He took oral medication for that but didn't find any effect. All the test for hormones and penile hypersensitivity was normal.

Case 2-
23 year patient came to us; according to him, he ejaculates when he penetrates or some times during foreplay. During masturbation he has control in ejaculation but don't have control in intercourse and ejaculates quickly. He feels guilty and worried about relationship.

Case 3-
38 year married male came to us with the problem having trouble in controlling his ejaculation. He had normal ejaculation control before but since last few months, he ejaculate quickly and cannot satisfy his partner.

Diagnosis: Śukragatavāta (Premature Ejaculation)
Case 1-having severe lifelong premature ejaculation as he ejaculate even before actual coitus during foreplay even just touch from partner or thinking about sexual action. The causes behind his premature ejaculation were over excitement, uncontrolled imaginary feelings, excessive concern over partner's satisfaction, lack of knowledge about sexual education and fear about intercourse life.
Case 2 -having mild Lifelong Premature Ejaculation. The causes behind his premature ejaculation were fear of caught causing experiences of hurried sexual act, higher expectations, watching porn movies and comparing own sexual power with them causing low self-esteem and self-guilt, Excessive concern over partner's satisfaction and fear of losing partner results in performance anxiety.
Case 3 -having acquired Premature Ejaculation. The causes behind his premature ejaculation were some factors like stress, performance anxiety and other relationship issues was found.
In these three cases, we found more psychological causes than biological, so we decided to manage these patients with psychotherapy and for that we chose Rational Emotive Behavioral Therapy (REBT) and counselled 3 times for approximately 30 minutes in the interval of 7 days. Total duration of the study was 28 days.

Results:-
All the three patients responded very well to the REBT, remarkable change in their behaviour were observed in just 3 settings of counselling. Case 1-shown Very good improvement in intra vaginal latency time as he managed to control ejaculation up to 1 min after penetration. Mild improvement in voluntary control over ejaculation was observed, Anxiety felt in only 75% of sexual act, number of penile thrusts increases to 3-5 thrust, No orgasm but feeling of somehow satisfaction.
Case 2-shown Very good improvement in intra vaginal latency time as he managed to control ejaculation up to 2 min after penetration. Mild improvement in voluntary control over ejaculation was observed, Anxiety decreases to some extent to hampers sexual act, number of penile thrusts increases to 10 thrust, feelings of orgasm in 25% of the sexual act.
Case 3-Intra vaginal latency time increases up to 5 min after penetration. Good improvement was there in voluntary control over ejaculation. Anxiety felt in only 25% of sexual act, number of penile thrusts increases to more than 10 thrust, feelings of orgasm in 25% of the sexual act.
927 None, discharge before penetration increases to 3-5 thrusts Case 2 Less than 5 increases to 10 thrusts Case 3 Less than 10 increases to more than 10 Patient and partner satisfaction

Case 1
No orgasm/satisfaction at all No orgasm but feeling of somehow satisfaction.

Case 2
Lack of enjoyment in almost all encounters In 25% of the sexual act Case 3 Lack of enjoyment in almost all encounters 50% of the sexual act

Discussion:-
As per the history given by the patients, the main causes behind their premature ejaculation were low self-belief, irrational thought about intercourse life, higher demand from themselves and over anxious about partner's satisfaction. All these factor together cause early ejaculation. They all were taking Ayurvedic drugs but has very little improvement as there were psychological cause behind quick ejaculation. Thus we used Rational Emotive Behavioural Therapy (REBT) which is an action and results oriented psychotherapy which teaches individuals how to identify their own self-defeating ideas, thoughts, beliefs and actions and replace them with more effective, lifeenhancing ones. REBT detect irrational ideas and motivate the individual to transform them into rational ideas. If disturbance-creating ideas are vigorously disputed by logical/empirical thinking, they can be eliminated or minimized. REBT also, teach client how to dispute self-belief and their behavior in facing problems. REBT help the patient to understand how changing thoughts about the problem and yourself actually help to ameliorate the physiological reaction of early ejaculation. The most common behavioral component of treatment for PE is to become more familiar with the feelings and sensations surrounding the time leading up to ejaculation. Another thing which helps in premature ejaculation is unconditional Self-Acceptance. REBT teaches clients how to accept some things which are hard to accept about self. This unconditional self-acceptance deal with negative feelings and increases self-belief which ultimately helps in managing premature ejaculation.
Ācārya Caraka has divided the process of ejaculation of Śukra into 4 stages. They are Saṁkalpa, Ceṣṭā, Niṣpīḍana and Śukra Cyutī. So the process starts from the initiation of intercourse up to orgasm and ejaculation. The clarity of the senses and happy position of mind is necessary for good arousal. That is why Ācārya Caraka has placed Saṁkalpa among the Agrya Dravya of Vṛṣya. From the description of the eight factors responsible for ejaculation, it can be pointed out that psychological, neurological as well as physical properties of Śukra have their role in the process of ejaculation. Vāta is explained as stimulator (Praṇetā) and controller (Niyantā) of Mana. Different functions attributed to Śukra viz Dhairya, Cyavana, Prītī, Harṣa etc. can be explained on neuropsychological axis. Harṣa Śakti depends on Deha Śakti as well as Sattva Śakti. Suprasannah Mana is necessary for Harṣaṇa. The control and stimulation are the bifold activity of same initiation which is antagonistic in nature. A balance between these two is necessary for an optimal arousal, activity and achievement of target action. A vitiated Vāta may cause the mental activities adversely in different dimensions. As far as the particular problem of premature ejaculation is concerned vitiated Vāta causes over stimulation leading to lack of control over physiological and psychological activities. Manoabhighāta (Psychological stress) lead to derangement in the mental faculties. It may produce a comparative aggregation of raja and tama and reduction of Sattva. Dhṛti and Smṛti faculties of mind. This phenomenon leads to mental disturbance during sexual act, cognitive impairment and lack of control over sexual act. Vyāna Vāyu that is responsible for the deposition of Śukra in the vagina along with Apāna Vāyu, which is responsible for Dhāraṇa as well as Niṣkramana of Śukra. Dhairya (courage), Cyavana (ejaculation) and Prīti (Satisfaction) are interdependent and their chronological order is significant in the context of human sexual response. An impairment of these functions leads to lack of Dhairya (performance anxiety), Śīghra Cyavana (early ejaculation) and Prīti Abhāva (lack of satisfaction).
In case of first patient there was misconceptions about intercourse are formed by socio-cultural beliefs about masturbation, nocturnal emission, value of semen, size and shape of genital organ etc. which causes more anxiety which leads to early ejaculation but as REBT improves rational thought about all these an anxiety is overturn and improvement in premature ejaculation also occurs.
In second case there was fear to be caught and misconceptions about sexual standards and normality; when a he find he is not able to meet the so called "normal standards" whether in terms of penile size or time of sexual intercourse, he starts feeling guilty and anxious and even consider himself a failure. REBT removes all these misconceptions and fear and improvement was observed.
In third case as he had acquired premature ejaculation that causes due to his demand from his body that he should stay long as he was when he was very young and that results into anxiety and low self-confidence. Albert Ellis a renowned psychotherapist explained it as problem of musturbation (a tendency to meet often perfectionist and difficult target before achieving success) that he must perform all the time and his partner must satisfy all the time and if I failed to do that all the time I must be a worthless person. This tendency causes premature ejaculation but through REBT we can dispute this problem of musturbation.

Conclusion:-
The case series concluded that anxiety, stress and irrational belief about self are the triggering factor for Śukragatavāta (Premature Ejaculation). Masturbation is not a cause of premature ejaculation but it's a musturbation which is bigger cause. So while treating a patient of Premature Ejaculation psychological counselling is very important. In PE generally male facing a thoughts of self-defeat or failure, so restructuring their beliefs and convert irrational thoughts in to rational one is the main treatment protocol so that the problem can eventually remit. Psychological counselling enhanced confidence and self-esteem in the patients and helps them to think positively and to partake sexual act enthusiastically by reducing performance anxiety. Finally it is concluded that REBT is found to be effective in the management of psychological background premature ejaculation.