1. Paraphilias and personality disorder – are they linked?
Jessica Yakeley
Heather Wood
Portman Clinic

2. The Portman Clinic

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
Exhibitionism
Fetishism
Frotteurism
Pedophilia
Sexual masochism
Sexual sadism
Transvestic fetishism
Voyeurism
Paraphilia 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).

5. Subjective experience
paraphilias
Legal –
e.g fetishism,
Coprophilia,
cross dressing
Illegal if enacted e.g.
Paedophilia,
voyeurism,
exhibitionism
Ego syntonic
Ego dystonic
Subjective experience
of compulsion,
adverse consequences
CJS
Ego dystonic –
CJS + psychother?

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 disorders
DSM-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 validity
Ethical and socio-political problems in equating particular sexual interests with psychopathology
Patients often fulfill diagnostic criteria for several different paraphilias concurrently or longitudinally
Focus on unusual or problematic sexual fantasies and behaviours
Confusion regarding relationship with criminality

8. Our criticisms of DSM IV
Paraphilias Axis 1 disorders
But can involve pervasive sexualisation of interpersonal relationships
Quality of attachments often of “exciting hatred / hostility” rather than true ambivalence
Wide ranging symptomatic enactments of sexually deviant behaviours
Disturbance 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 defence
Fusion of sexualisation and aggression
Defends against anxieties aroused by intimacy: claustro-agoraphobic, fears of aggression, anxieties about adequacy
Bestows a sense of control and triumph
The 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 functioning
In severe form – pervasive disruption of personality functioning
Enactment often compounds self-disgust
Relationships distorted by sexualisation
Actual or imagined harm to self and/or others

11. Do some paraphilias meet criteria for PD?
Enduring pattern of inner experience and behaviour
Pervasive across a broad range of personal and social situations
Leads to clinically significant distress or impairment
Stable 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 category
New 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 paraphilias
Few studies have examined prevalence of personality disorders in paraphilias
Most studies are of sex offenders, particularly child molesters, and do not distinguish paraphilic from non-paraphilic samples
Samples usually post-conviction
Sex 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 disorder
Leue et al (2004) in study of 55 sex offenders showed correlation with cluster B and cluster C pd, social phobia more common in paraphilic offenders
Bogaerts et al (2006) found higher rates of depressive and avoidant pds in sample of 33 exhibitionists compared to 33 matched controls
Bogaerts 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 relationship
B. Co-morbidity
C. Personality disorder a contributory factor in the aetiology or expression of the paraphilia
D. 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 paraphilias
2. 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 disorders
Q-sort method of prototype matching 200 statements, each describing a different aspect of personality or psychological functioning
Produces 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 syndromes
Good reliability and validity for both non-forensic and forensic populations
Excel-based programme, 45 minutes for the clinician to complete

18. SWAP Analysis
PD t scores – match the patient to prototypical personality descriptions corresponding to DSM IV TR
Factor (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 PD
34% 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 PD
18%

21. PD T scores >1 n=44

22. PD T scores – PD and traits >1 n=44

23. Factor T scores n=44 38% have sexual conflict
20% have sexual conflict + oedipal conflict
16% have sexual + oedipal conflict + dissociation

24. Factor 12 sexual conflict
Appears to associate sexual activity with danger
Tends to feel guilty or ashamed about his or her sexual interests or activities
Tends to see sexual activities as somehow revolting or disgusting
Experiences a specific sexual dysfunction during intercourse or attempts at intercourse
When romantically or sexually attracted, tends to lose interest if the other person reciprocates
Has 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 PD
52% meet criteria for PD or traits of PD
Type of PD notably varied – schizoid, borderline, o-c, passive – aggressive
plus avoidant traits
Factor 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=9
MCMI
Risk 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 rank
Portman
Bracton
1. 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
Portman
Bracton
Cluster A
44%
40%
Cluster B
22%
26%
Cluster C
59%
2+ clusters present
33%
20%

30. Is this a low-risk sample?
Static 99
Portman (n=9)
Bracton (n=160)
Low
2 (22%)
56 (35%)
Medium low
51 (32%)
Medium high
3 (33%)
36 (22%)
High
4 (44%)
19 (12%)

31. Portman sample cf Hall and Hall review of paedophilia [2007, Mayo Clinic Proc, 82 (4) 457-471]
Affective illness
60-80%
Anxiety disorder
50-60%
67%
Lifetime diagnosable PD
70-80% ?%
Cluster A PD
18%
44%
Cluster B PD
33%
22%
Cluster C PD
43%

32. Portman group High rates of PD and multiple personality disorders
Profile of avoidant, dependent and schizoid individuals
High levels of anxiety (67% with clinical syndrome)

33. Clinical implications
Severe difficulties in relation to adult intimacy
Anxious not psychopathic
Identification with (child’s?) dependency and vulnerability

34. Attachment status of CS offenders

35. Correlation of attachment style with PD in CSA sample
All those with dismissive attachment style, definite avoidant PD
All those with preoccupied attachment style have borderline traits

36. RF scores comparing AAI and forensic questions
Forensic RF
Paired samples t-test
T=3.54
P<0.01

37. What is the relationship between paraphilias and personality disorder?
All paraphilic pts in SWAP study
CSA group on MCMI
A. No relationship
48% with no traits of PD
0% with no traits
B. Co-morbidity
[reaching criterion for PD]
34%
78%
C. PD contributes to clinical syndrome
52% with traits of PD
100% with probable PD
D. Paraphilia is, in effect, a form of PD
16% with sexual + oedipal conflicts + dissociation
100%?

38. Thanks to….. Assistant psychologists:
Ros Watts
Susie Rudge
Phil Lurie
Alexa Byrne
Meera Desai
And to Gill McGauley for Broadmoor data and use of AAI forensic questions

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