Is there a relationship between borderline personality

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Is There a Relationship Between Borderline Personality Disorder and Sexual Masochism in Women?

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Abstract Sexual masochism disorder is considered the most prevalent paraphilia among women. However, little is known about the etiology and clinical correlates involved in this mental disorder. We aimed at addressing this issue through a potentially high-risk clinical cohort. A case-control study consisted of 60 women who met DSM-IV criteria for borderline personality disorder (BPD) and 60 women with other personality disorders was performed from November 2012 to December 2014. For both groups, sexual masochism disorder comorbidity was assessed through the Structured Clinical Interview, Sexual Disorders Module. Several etiological, psychosexual and personality features were measured. Sexual masochism disorder was 10 times higher in BPD women than in women with other personality disorders (10% vs. 0%). Among BPD women, those with sexual masochism disorder reported greater child sexual abuse, more hostile/dismissing attachments, higher sensation seeking and more frequently exploratory/impersonal sexual fantasies. Correlation analysis confirmed a significant positive relationship between disinhibition and sexual masochism severity for BPD women. Our findings point out that BPD women may represent a high-risk cohort, especially those with higher disinhibition and detached attachment. Childhood sexual abuse may also play a predispositional role on this comorbidity. Further research may help to elucidate the intriguing relationship between both disorders. Keywords: Borderline personality disorder, sexual masochism, comorbidity, sexuality

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Introduction Sexual masochism disorder constitutes a poorly understood pathology despite being recognized as a psychopathological construct by the traditional psychiatry since the second half of the nineteenth century (Kraft-Ebing, 1965). Several theories have been raised to explain the development of this mental disorder thus far, most of them from either a psychodynamic or a neurobiological perspective. On the one hand, the former theory points out that sexual masochism may somehow represent a self-destructive mechanism (Freud, 1924). On the other hand, the latter theory postulates that sexual masochism may reflect an emotional self-regulation process (Sagarin, Cutler, Cutler, Lawler, & Matuszewich, 2009). In spite of these approaches, there is a lack of empirical research aimed at addressing the potential risk factors and clinical correlates, irrespective of aprioristic models (APA, 2013). This is particularly striking because sexual masochism disorder has been subsumed into the psychiatric nosology since the DSM-II (APA, 1968) and also has remarkable implications from legal, somatic and sociological perspectives (White, 2006). Moreover, epidemiological data are also scarce and have stemmed from forensic (sex offenders/abusers) and clinical (paraphilic) samples, yielding heterogeneous findings on its prevalence (Krueger, 2010). Within this context, borderline personality disorder (BPD) could represent a high-risk cohort for sexual masochism disorder. To date, there is no empirical evidence concerning the prevalence, psychosocial risk factors and clinical features of sexual masochism disorder among BPD patients. In spite of this, several indirect clinical clues may account for this potential relationship and justify this research. First, BPD tends to be more prevalent in women (vs. men) and sexual masochism disorder is believed to be the most prevalent paraphilia among women (APA, 2013). Second, BPD patients have proved to exhibit other sexual risk behaviors (e.g., not using condom), mainly related to hypersexuality (Sansone, Lam, & Wiederman, 2011; Sansone & Wiederman, 2009). Third, childhood sexual trauma is

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considered an unspecified vulnerability factor for BPD and it is suspected to be implied in paraphilic disorders in general and sexual masochism disorder specifically (Cohen et al., 2014; Marsh et al., 2010; Zhang, Chow, Wang, Dai, & Xiao, 2012). By focusing on this issue some light could be shed on the etiology and clinical features of sexual masochism disorder. For instance, preliminary reports found that BDSM (bondage, dominance, sadism-masochism) practitioners were less neurotic (e.g., perfectionism), more open to new experiences, and had higher subjective well-being compared with controls (Wismeijer & van Assen, 2013). In addition, it could help clinicians and researchers to understand the extent to which BPD patients may exhibit some psychopathology previously overlooked and which particular characteristics may define those with this comorbid condition.

Aims of the Study Hence, this pilot study is expected to preliminarily respond to some enquiries: 1.

Is sexual masochism disorder more prevalent among women with BPD than those with other personality disorders?

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Is there any psychosocial risk factor that may account for an increased risk for sexual masochism disorder among a subset of BPD women?

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Do BPD women with sexual masochism disorder exhibit a different pattern of adult attachment relative to those without this comorbidity?

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Which distinctive personality features define BPD women with sexual masochism disorder relative to those without it?

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Is there any relationship between sexual masochism and other psychosexual characteristics among BPD women?

Materials and Method Participants Patients were referred to us by clinicians from the Adult Outpatient Mental Health Center of the Department of Psychiatry at the Hospital of Mataró (Barcelona, Spain) between November 2012 and December 2014. Inclusion criteria were: i) diagnosis of personality disorder; ii) being female; iii) being 18 to 65 years old. Exclusion criteria were: i) previous diagnosis of comorbid mental retardation; ii) previous diagnosis of comorbid psychotic disorder. Overall, 132 subjects who were potentially suitable for the study were consecutively recruited. Six of them were unwilling to participate because of the nature of the study (sexuality issues), mainly patients characterized by paranoid or obsessive-compulsive traits who were likely to fit into the non-BPD group. In addition, six other patients did not fully meet criteria for a diagnosis of personality disorder diagnosis. Instead, they evidenced maladaptive traits. Overall, 12 potentially suitable patients were excluded from the final sample. Hence, this case-control study was comprised of 120 patients who were assigned to one of the two clinical groups according to DSM-IV (APA, 1994) criteria for BPD without other comorbid personality disorders (case group: “BPD,” n=60) and other personality disorders rather than BPD (control group: “non-BPD,” n=60). Diagnoses of PDs were determined by the Spanish version of the Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II) (APA, 1994). To assess current (past year) and lifetime comorbidity with sexual masochism disorder we administered the Spanish

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version of the Structured Clinical Interview for DSM-IV-TR Patient Edition (SCID-I/P), Sexual Disorders Module (APA, 2000; First, Spitzer, Gibbon, & Williams, 2002). The same patients who met lifetime diagnosis of comorbid sexual masochism disorder were those who met current diagnosis of this paraphilic disorder. To avoid false positive diagnosis of sexual masochism disorder, we carried out in-depth interviews to distinguish those who could endorse non-relevant sexual masochism behaviors from those who could engage in hazardous, restrictive and/or egodystonic behaviors/fantasies (e.g., risk of being exposed to rape by walking alone at night in dangerous areas, asphixiophilia, severe injuries, being the only way to reach orgasm). All the participants were interviewed directly by the authors of the manuscript, who are clinically experienced in both PDs and paraphilic disorders. The study was approved by the hospital’s Institutional Review Board, and informed consent was obtained from all patients after a full explanation of the nature of the study.

Measures Childhood trauma. Potentially traumatic childhood events were measured through the Spanish validation of the Childhood Trauma Questionnaire (CTQ) (Bernstein & Fink, 1998; Hernández et al., 2013). CTQ is a standardized, retrospective 25-item self-report inventory that measures the severity of different types of childhood trauma, producing five clinical subscales each comprised of five items: emotional abuse, physical abuse, sexual abuse, emotional neglect and physical neglect. Participants rated each item on a 5-point scale, ranging from “never” (=1) to ”very often” (=5). Internal consistency reliability coefficients were good to excellent (α values from 0.66 to 0.94). Adult attachment. Type of adult attachment bonds were ascertained by the Adult Attachment Questionnaire (AAQ) (Melero & Cantero, 2008). It consists of a 40-item selfreport inventory measuring four types of adult attachment according to Bartholomew and

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Horowitz theory (1991): secure, preoccupied, dismissing and hostile. Participants rated each item on a 6-point scale, ranging from “strongly disagree” (=1) to ”strongly agree” (=6). Internal consistency reliability coefficients were good to excellent (α values from 0.68 to 0.86). Self-esteem. Self-esteem was measured through the Spanish validation of the Rosenberg Self-Esteem Scale (RSE) (Rosenberg, 1965; Vázquez, Jiménez, & Vázquez, 2004). It is a 10-item self-report scale that measures global (uni-dimensional) self-worth. Participants rated each item on a 4-point scale, ranging from “strongly disagree” (=1) to ”strongly agree” (=4). RSE presents adequate internal consistency (α= 0.87). Sensation seeking. Sensation seeking was assessed by the Spanish validation of the Sensation Seeking Scale Form V (SSS-V), which comprises a 40-item self-report questionnaire in forced-choice format (Pérez & Torrubia, 1986; Zuckerman, Eysenck, & Eysenck, 1978). The SSS-V produces an overall score as well as scores on four factoranalytically derived subscales: thrill and adventure seeking, experience seeking, disinhibition and boredom susceptibility. Internal consistency reliability coefficients were good (α values from 0.77 to 0.82) Perfectionism. Perfectionism was measured by the Spanish validation of the Multidimensional Perfectionism Scale (MPS) (Carrasco, Belloch, & Perpiñá, 2009; Frost, Marten, Lahart, & Rosenblate, 1990). MPS comprises a 35-item self-report questionnaire measuring four dimensions from this construct instead of the originally proposed six dimensions: fear of mistakes, parental influences, achievement expectation and organization. Participants rated each item on a 5-point scale, ranging from “never” (=1) to ”always” (=5). The sum of all 35 items also provides a total perfectionism score. Internal consistencies for the global scale and its subscales were excellent (α values ranging from 0.87 to 0.93).

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Sexual satisfaction. Sexual satisfaction was measured by the Spanish validation of the Index of Sexual Satisfaction (ISS) (Hudson, Harrison, & Crosscup, 1981; Iglesias et al., 2009). ISS consists of a 25-item self-report questionnaire assessing sexual satisfaction with their partners within a current or previous relationship. Participants rated each item on a 5point scale, ranging from “never” (=1) to ”always” (=5). A global score is obtained as a mean from the responses for all items. The higher score obtained, the greater sexual satisfaction endorsed. It reaches an internal consistency reliability value of 0.89. Sexual fantasies. Sexual fantasies were determined by the Spanish version of the Wilson Sex Fantasy Questionnaire (WSFQ) (Sierra, Ortega, Domingo, & Vera, 2004; Wilson, 1978). WSFQ is a 24-item self-report questionnaire that assesses four types of sexual fantasies: exploratory (e.g., group sex, promiscuity), intimate (e.g., kissing passionately, oral sex), impersonal (e.g., sex with strangers, watching others engage in intimate behavior) and sadomasochistic (e.g., whipping or spanking, being forced to have sex). Participants rated each item on a 4-point scale, ranging from “never” (=0) to ”often” (=3). The sum of all 24 items also provides a total fantasy score. The internal consistency analysis reveals an internal consistency from 0.66 to 0.90. In addition, we specifically sought to assess masochistic fantasies from a dimensional perspective. Thus, we elaborated a “masochistic” index solely based on the three related items from the sadomasochistic subscale (“being tied”, “being whipped and beaten in the bottom”, and “being forced to do something”). Accordingly, participants could obtain global scores from 0 to 9 points for this ad hoc index. Those who scored up to the theoretical mean (5 or more points) but did not meet criteria for sexual masochism disorder were considered with “relevant sexual masochism fantasies.”

Statistical Analysis

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Statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS for Windows, Version 18.0). To look for between-group differences, we used parametric (Student´s t Test) for continuous variables and chi-square for categorical variables. One-way analysis of covariance (ANCOVA) was employed to control the effect of covariates on the between-group comparisons. To reduce the risk of type-I error, we performed multivariate analysis of variance (MANOVA). Pearson´s correlation were also performed to assess potential relationships between variables. We also estimated effect size by using partial η2. P values of less than 0.05 were considered significant. A vast majority of values were presented as mean and plus/minus S.D.

Results Sociodemographic Features and Prevalence of Sexual Masochism in BPD and non-BPD Women Table 1 shows that women with BPD were younger and had higher rates of single status than non-BPD women. Regarding prevalence data, sexual masochism disorder was 10 times more likely in BPD women than in non-BPD women (n1=6 vs. n2=0). Between-group differences on this comorbidity remained significant after controlling for age and marital status (F=4.48, p=.04, partial η2=0.04). Within BPD women, there were no significant differences on sociodemographic features between those with and without comorbid sexual masochism disorder. Additional data are illustrated in Table 1 and 2.

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Childhood Trauma in Masochistic and non-Masochistic BPD Women With respect to childhood trauma, MANOVA found that masochistic BPD women scored significantly higher in childhood sexual abuse than non-masochistic BPD women as ascertained by the CTQ (F(5,54)=2.32, p=.05, Wilks λ=0.82). The remaining childhood traumas did not yield between-group differences. Accurate data from the CTQ subscales are summarized in Table 3.

Adult Attachment in Masochistic and non-Masochistic BPD Women Regarding adult attachment, MANOVA showed that masochistic BPD women obtained significantly higher scores in hostile and dismissing attachments than non-masochistic BPD women as measured by the AAQ (F(4,55)=3.40, p=.01, Wilks λ=0.80). Accurate data from the AAQ subscales are summarized in Table 4. Furthermore, correlation analysis within the BPD sample indicated that scores on sexual masoquism index was significantly and positively correlated with hostile (r=0.4, p=.002) and dismissing (r=0.31, p=.02) attachments.

Personality Variables in Masochistic and non-Masochistic BPD Women With respect to personality variables, self-esteem as assessed by the RSE did not yield between-group differences. Likewise, MANOVA showed that perfectionism dimensions as measured by the MPS did not evidence differences between masochistic and non-masochistic BPD women (F(4,55)=0.61, p=.66, Wilks λ=0.96). Conversely, sensation seeking in general and disinhibition in particular as assessed by the SSS-V produced significant differences (F(4,55)=5.63, p