3 DSM-IV Diagnosis of Paraphilias A group of psychosexual disorders characterized by recurrent, intense sexually arousing fantasies, sexual urges or behaviors generally involving 1) nonhuman objects, 2) the suffering or humiliation of oneself or one’s partner, or 3) children or other non-consenting persons that occur over the period of at least six months.
4 DSM-IV Diagnosis Paraphilias ExhibitionismFetishismFrotteurismPedophiliaSexual masochismSexual sadismTransvestic fetishismVoyeurismParaphilia NOS – includes telephone scatologia (obscene phone calls), necrophilia (corpses), partialism (exclusive focus on part of body), zoophilia (animals), coprophilia (faeces), klismaphilia (enemas), and urophilia (urine).
6 History of the paraphilia construct ‘Paraphilia’ first apeared in English in 1925 in translation of Stekel’s Sexual Aberrations – less pejorative than ‘perversion’DSM-I (1952) - classified as ‘sexual deviations’ under personality disorder category (sociopathic personality disturbance)DSM-II (1968) – sexual deviations separated from personality disordersDSM-III (1980) ‘Paraphilia’ replaced ‘sexual deviation’, now category of ‘psychosexual disorders’. Sexual orientation disturbance (homosexuality) removed.DSM-IV (1994) Paraphilias included in broader category – ‘sexual and gender identity disorders’
7 Problems with DSM diagnosis of paraphilias Poor reliability and validityEthical and socio-political problems in equating particular sexual interests with psychopathologyPatients often fulfill diagnostic criteria for several different paraphilias concurrently or longitudinallyFocus on unusual or problematic sexual fantasies and behavioursConfusion regarding relationship with criminality
8 Our criticisms of DSM IV Paraphilias Axis 1 disordersBut can involve pervasive sexualisation of interpersonal relationshipsQuality of attachments often of “exciting hatred / hostility” rather than true ambivalenceWide ranging symptomatic enactments of sexually deviant behavioursDisturbance of sense of self – often highly self-critical, sense of self-disgust, shame
9 Portman model of paraphilias Use of sexualisation as a form of manic defenceFusion of sexualisation and aggressionDefends against anxieties aroused by intimacy: claustro-agoraphobic, fears of aggression, anxieties about adequacyBestows a sense of control and triumphThe sexualised behaviour creates a scenario in which dreaded situation is often reversed
10 Portman model of paraphilias In mild form – ego-syntonic, sexualisation gratifying, defensive structure ‘works’ and there are areas of unimpaired functioningIn severe form – pervasive disruption of personality functioningEnactment often compounds self-disgustRelationships distorted by sexualisationActual or imagined harm to self and/or others
11 Do some paraphilias meet criteria for PD? Enduring pattern of inner experience and behaviourPervasive across a broad range of personal and social situationsLeads to clinically significant distress or impairmentStable and of long duration – onset can be traced back to at least adolescence or early adulthood
12 DSM-V proposals for paraphilias Paraphilias remain under sexual and gender identity disorder categoryNew distinction between ‘paraphilia’ and ‘paraphilic disorder’Introduce new disorder ‘paraphilic coercive disorder’Expand pedophilia to ‘pedohebephilic disorder to include increase range of target children, and child pornography
13 Research on relationship between paraphilias and personality disorders Remarkably little clinical literature on paraphiliasFew studies have examined prevalence of personality disorders in paraphiliasMost studies are of sex offenders, particularly child molesters, and do not distinguish paraphilic from non-paraphilic samplesSamples usually post-convictionSex offenders have high levels of psychiatric co-morbidity, both axis 1 and axis 2 conditions
14 Relationship between paraphilias and personality disorders Dunsieth et al (2004) in study of 113 men convicted of sexual offenses showed paraphilia correlated with avoidant personality disorderLeue et al (2004) in study of 55 sex offenders showed correlation with cluster B and cluster C pd, social phobia more common in paraphilic offendersBogaerts et al (2006) found higher rates of depressive and avoidant pds in sample of 33 exhibitionists compared to 33 matched controlsBogaerts et al (2008) – presence of obsessive compulsive personality disorder distinguished paraphilic from non-paraphilic child molesters
15 What is the possible relationship between paraphilias and personality disorders? A. No relationshipB. Co-morbidityC. Personality disorder a contributory factor in the aetiology or expression of the paraphiliaD. Paraphilia pervades relating to self and others and is, in effect, a form of personality disorder
16 Portman exploratory studies 1. Use of a clinician-rated measure of personality (SWAP) as part of outcome monitoring of all patients accepted for treatment – N=44 with paraphilias2. Self-report measures (MCMI) of a cohort of child sex offenders offered group psychotherapy
17 The Shedler-Westen Assessment Procedure-200 (SWAP-200) Clinician-rated assessment measure of personality disordersQ-sort method of prototype matching 200 statements, each describing a different aspect of personality or psychological functioningProduces profile of personality disorders and traits matched to formal DSM-IV Axis II diagnoses, as well as a set of more psychoanalytically-informed SWAP personality syndromesGood reliability and validity for both non-forensic and forensic populationsExcel-based programme, 45 minutes for the clinician to complete
18 SWAP AnalysisPD t scores – match the patient to prototypical personality descriptions corresponding to DSM IV TRFactor (trait) t scores – 12 underlying factors derived by factor analysis, including psychological health, emotional dysregulation, oedipal conflict, dissociation and sexual conflict
19 Proportion of paraphilic patients with PD diagnoses [n=44] 2%7%25%66%34% meet criteria for PD34% meet criteria for PD
20 Proportion of paraphilic pts with PD diagnoses or traits (n=44) 7%48%16%52% meet criteria for PD or traits of PD18%
23 Factor T scores n=44 38% have sexual conflict 20% have sexual conflict + oedipal conflict16% have sexual + oedipal conflict + dissociation
24 Factor 12 sexual conflict Appears to associate sexual activity with dangerTends to feel guilty or ashamed about his or her sexual interests or activitiesTends to see sexual activities as somehow revolting or disgustingExperiences a specific sexual dysfunction during intercourse or attempts at intercourseWhen romantically or sexually attracted, tends to lose interest if the other person reciprocatesHas difficulty directing both tender feelings and sexual feelings towards the same person
25 Summary of Portman SWAP study 34% of pts with paraphilias meet criteria for PD52% meet criteria for PD or traits of PDType of PD notably varied – schizoid, borderline, o-c, passive – aggressiveplus avoidant traitsFactor T scores suggest a slightly more coherent syndrome: sexual conflicts, dissociation and oedipal conflicts
26 Evaluation of a treatment group for convicted child sex offenders Baseline n=9MCMIRisk measures (Static 99 +)AAI + additional offence-related questions(rated for attachment status and RF)
27 PD scores of CS offenders on MCMI n=9 Definite presence of PD in 78%Probable presence of PD in 100%
28 Comparison of Bracton [Craissati, Webb and Keen, 2007] and Portman samples – probable presence of PD by rankPortmanBracton1. Avoidant (67%)1. Avoidant (39%)2= Dependent (56%)2. Dependent (39%)2= Schizoid (56%)3. Schizoid (33%)4= Borderline (33%)4. Borderline (12%)4= Antisocial (33%)5. Paranoid (10%)
29 Definite presence of PD by cluster PortmanBractonCluster A44%40%Cluster B22%26%Cluster C59%2+ clusters present33%20%
30 Is this a low-risk sample? Static 99Portman (n=9)Bracton (n=160)Low2 (22%)56 (35%)Medium low51 (32%)Medium high3 (33%)36 (22%)High4 (44%)19 (12%)
31 Portman sample cf Hall and Hall review of paedophilia [2007, Mayo Clinic Proc, 82 (4) 457-471] Affective illness60-80%Anxiety disorder50-60%67%Lifetime diagnosable PD70-80%?%Cluster A PD18%44%Cluster B PD33%22%Cluster C PD43%
32 Portman group High rates of PD and multiple personality disorders Profile of avoidant, dependent and schizoid individualsHigh levels of anxiety (67% with clinical syndrome)
33 Clinical implications Severe difficulties in relation to adult intimacyAnxious not psychopathicIdentification with (child’s?) dependency and vulnerability
37 What is the relationship between paraphilias and personality disorder? All paraphilic pts in SWAP studyCSA group on MCMIA. No relationship48% with no traits of PD0% with no traitsB. Co-morbidity[reaching criterion for PD]34%78%C. PD contributes to clinical syndrome52% with traits of PD100% with probable PDD. Paraphilia is, in effect, a form of PD16% with sexual + oedipal conflicts + dissociation100%?
38 Thanks to….. Assistant psychologists: Ros WattsSusie RudgePhil LurieAlexa ByrneMeera DesaiAnd to Gill McGauley for Broadmoor data and use of AAI forensic questions
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