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

The Portman Clinic

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.

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).

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?

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’

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

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

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

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

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

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

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

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

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

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

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

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

Proportion of paraphilic patients with PD diagnoses [n=44] 2% 7% 25% 66% 34% meet criteria for PD 34% meet criteria for PD

Proportion of paraphilic pts with PD diagnoses or traits (n=44) 7% 48% 16% 52% meet criteria for PD or traits of PD 18%

PD T scores >1 n=44

PD T scores – PD and traits >1 n=44

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

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

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

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)

PD scores of CS offenders on MCMI n=9 Definite presence of PD in 78% Probable presence of PD in 100%

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%)

Definite presence of PD by cluster Portman Bracton Cluster A 44% 40% Cluster B 22% 26% Cluster C 59% 2+ clusters present 33% 20%

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%)

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%

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)

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

Attachment status of CS offenders

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

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

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%?

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

Contact us: jyakeley@tavi-port.nhs.uk hwood@tavi-port.nhs.uk