BDSM and NSSI: A Proposal for a Survey Study

The following is a mock grant proposal for Self-Destructive Behaviors, written as my final project. I’ve never written a grant proposal before, and as much as I attempted to go off of my professor’s guidelines I really have no idea of the quality (I’ve yet to receive feedback). The point wasn’t so much to be accurate with the structure and choice of measures, but to practice structuring a feasible idea for study. In that regard I believe I came up with something interesting.

I’ve never been interested in the research side of the industry; I have so much more fun being a clinician, but I had a great time this semester studying BDSM. A bit of background, as I’ve posted a couple of my papers I’ve written on the topic, I have personal experience as a BDSM practitioner – I identify as a sub, though I’ve been known to switch. I chose to compare it with NSSI because, as a clinician, I’ve witnessed a stigma associated with patients who practice NSSI that is comparable to the stigma described in BDSM literature. Also, it’s undeniable both are related to an active choice to experience pain, but there’s dissonance between the psychological health of the respective practitioners. I don’t get into it here, but I believe it’s due to solitary versus shared activities. That would be another study entirely though.

I may do my Master’s thesis on BDSM, which I have to start researching in February.

Shibari

Specific Aims

Bondage-discipline, dominance-submission, sadism-masochism (BDSM) and non-suicidal self-injury (NSSI) are practices often engaged in secret, and known motivations behind them are murky at best. It has been suggested that those who practice BDSM and NSSI are doing so for emotional regulation. Stigma associated with each of these practices, particularly in the clinical environment, affects how much we know about why people start and keep intentionally hurting themselves. It has also prevented those who require it from seeking help or fully reporting symptoms. As a result, not much research has been devoted to assessing the personality traits of practitioners. Additionally, no surveys of the incidence of psychiatric diagnoses within BDSM populations have been performed.

It cannot be denied that the common thread in these practices is the persistent desire and choice to repeatedly engage in purposeful and direct harm to the self. Data has shown that NSSI is usually associated with certain personality disorders and other psychiatric diagnoses, whereas BDSM practitioners are more psychologically healthy than controls. It is important to discern what else these two populations have in common because of the disparity in psychological health. It seems a difference is not the hurting itself but who is doing the hurting. This study seeks to compare psychological characteristics of BDSM practitioners with those who engage in NSSI in the following areas:

°         Neuroticism

°         Extraversion

°         Openness to new experiences

°         Conscientiousness

°         Agreeableness

°         Rejection sensitivity

°         Attachment style

°         Subjective well-being

°         Cognitive reactivity

°         Distress tolerance

°         Impulsivity.

This study hypothesizes that BDSM and NSSI practitioners will overlap on traits usually associated with psychopathy: high cognitive reactivity and high impulsivity. However, BDSM practitioners will have higher association with more positive or adaptive psychological characteristics than those who engage in NSSI, thereby giving BDSM practitioners a higher capacity for distress tolerance and less incidence of psychiatric diagnoses (see Figure 2, p. 4 for summarization of hypothesized results).

Background and Significance

BDSM can include many different types of activities, such as bondage, discipline training, role-playing, spanking, whipping, controlled sensory deprivation or overload, objectification, fetish activation, humiliation, and other diverse types of pain administration. Three roles have been identified: dom, sub, and switch. The dom, or the dominant role, is the person exerting control, whereas the sub, or the subordinate role, gives up control; a switch is a person that shifts between roles. BDSM can be performed in private, as in the privacy of the home; in public at clubs that cater to people who have this particular interest; or in the professional sector, as in the role of a professional dominatrix, for example. A professional dominatrix is a person that enacts a BDSM “scene” with a client in exchange for money; though “scenes” are erotic in nature, sexual contact of any kind is usually absent. Traditionally in the public and professional BDSM sectors sexual contact is not allowed or highly frowned upon.

Non-suicidal self-injury involves deliberate destruction of body tissue in the absence of intent to die. Common mechanisms include cutting, burning, hitting, and head banging. Like BDSM, it has also been misunderstood and stigmatized by clinicians and the general public, and is usually practiced in secret. It is often associated with Borderline Personality Disorder, but is also associated with anxiety, depression, suicidality, and other psychiatric disorders. Though, it isn’t always symptomatic of a larger disorder. Recent studies have begun to conceptualize NSSI as serving functions such as affect regulation and communication (Nock, 2009). While on the short term it can lead to distraction from negative emotion, long term effects are harmful. One’s feelings of guilt or shame can increase or intensify; one can become socially isolated; and the body can become permanently scarred (Wilkinson and Goodyer, 2011).

BDSM practitioners, in seeking therapy for issues not associated with BDSM have reported their clinicians more often have serious misconceptions regarding the practice, and therefore jump to conclusions with the client. Reported problems include considering BDSM to be unhealthy, requiring the client to give up the activity as a contingency for continuing to receive treatment, or confusing BDSM with abuse. For these reasons 33.7% report seeking out a “kink-aware” professional and sharing their BDSM interests early in order to gauge how comfortable they will be with that clinician (Kolmes, Stock, and Moser, 2006). NSSI is similarly misunderstood in that the action is sometimes assumed to be a suicidal gesture. This leads to incorrect treatment recommendations, and at times unnecessary placement under suicide watch.

Further study of the psychological characteristics of these populations could lead to more effective treatment options, and educate professionals about how to better interpret symptoms. Much of the literature on BDSM is qualitative or anecdotal; quantitative data would be a valuable addition to the field and oppose the stigma associated with the practice in a more concrete fashion.

 

Preliminary Studies

Much of the recent literature on BDSM bases their demographic and psychological information on a study by Richerts et al., which took place in Australia in 2001-2002 with 19,307 participants aged 16-59, each of whom were interviewed by phone. In the past year, 2.2% of men and 1.3% of women had engaged in a BDSM relationship; overall, 1.8% of men and 1.2% of women had engaged in a BDSM relationship at some point in their lives. BDSM is significantly more likely in bisexual and gay-identified men, and in bisexual and lesbian-identified women. Additionally, women who engage in BDSM are more likely to be aged 16-19 or over 50, and have a regular partner they do not live with. For men and women, practitioners of BDSM had a greater number of sexual partners over the lifetime.

Building on the Richters et al., Wismeijier and van Assen sought to delve deeper into the psychological characteristics of BDSM practitioners. In 2013, 902 BDSM and 434 control participants filled out online questionnaires measuring rejection sensitivity, attachment style, level of subjective well-being, and the Five Factor Model, which covers neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness. Results are summarized in Figure 1; Figure 2 shows a summarization of hypothesized psychological characteristics of BDSM and NSSI practitioners.

 

  Neuroticism Extraversion Openness

To New Experiences

Conscientiousness Agreeableness Rejection Sensitivity Attachment Style Subjective Well-Being
P Less More More More Less Less Lower need for approval; less anxiously attached Higher
NP More Less Less Less More More Higher need for approval; more anxious attachment Less

Figure 1: Comparison of psychological characteristics in BDSM practitioners (P) and controls (NP) (data from Wismeijier and van Assen 2013).

 

  Neuroticism Extraversion Openness to New Experiences Agreeableness Rejection Sensitivity Attachment Style Subjective Well-Being Cognitive Reactivity Distress Tolerance Impulsivity
BDSM Less More More Same Less Lower need for approval, secure Higher Same Higher capacity Same
NSSI More Less Less Same More Higher need for approval, insecure Lower Same Lower capacity Same

Figure 2: Hypothesized comparison of psychological characteristics

 

Neurologically, the experience of pain releases endorphins, which are neurotransmitters that modulate the experience of pain. Schneider (2009) argues that this causes an altered state of mind, allowing a person to have a new perception of how to control a situation. He further argues that pain is not an objective experience, but a social construct whose definition of experience relies on context. If a person is able to be in control of their pain it can produce feelings of pride, accomplishment, catharsis, and positive identity.

Addressing possible motivations for engaging in a BDSM relationship, Lindemann (2011) interviewed a series of professional dominatrices reporting they viewed themselves as “therapists” and described the value of their work in four categories:

  1. Healthful alternatives to sexual repression, due to societal stigma
  2. A means by which people can atone for their past
  3. Mechanisms for gaining control over prior traumas
  4. A way to experience psychological revitalization through shame

Likewise, Wilkinson and Goodyer identify four reasons why a person may choose to engage in NSSI:

  1. To relieve an intense, distressing affect such as sadness, guilt, or shame
  2. “Deserved” self-punishment
  3. Attention-seeking
  4. Social association with others that engage in self-harm

Similarities between the two populations seem to revolve around seeking relief of distressing emotions or experiences, atoning for a perceived wrong-doing, and desire to associate with other practitioners.

 

Research Design

Participants and Procedure: This study will assess adults, age 18 and older. BDSM practitioners will be those who have been involved in a BDSM relationship at least once in the lifetime. A BDSM relationship will be defined as a period of time in which a person repeatedly performs BDSM activities with another person (ex. significant other, professional dominatrix) or in a particular setting (ex. private club). Those who engage in NSSI are participants reporting having deliberately caused physical harm to their body at least once in the lifetime without intent to die. Participants will be solicited from both clinical and nonclinical populations, and those with a preexisting psychiatric disorder will not be excluded. Participants will be offered access to treatment if they report distress, or scores on a given measure indicate a clinical necessity. Those who report active suicidal ideation will be excluded and referred for treatment.

 

Measures: Measures will be used to discover any overlap in personality characteristics of BDSM and NSSI practitioners. Surveys will be computer based and accessible online. The following is a listing of proposed measures and possible questionnaires for each measure:

°         Five Factor Model

>        Neuroticism Extraversion Openness Personality Inventory  (NEO PI-R)

°         Attachment style

>        Attributional Style Questionnaire (ASQ) – measures how a person perceives themselves in relationships, determining attachment style to be either secure, avoidant or anxious

°         Rejection Sensitivity

>        Rejection Sensitivity Questionnaire (RSQ) – measures anxious expectations of rejection by significant others

°         Subjective well-being

>        World Health Organization Five Well-Being Index (WHO-5) – measures how a person has been feeling in the last two weeks

°         Cognitive reactivity

>        Leiden Index of Depression Sensitivity, revised (LEIDS-r) – measures the extent to which dysfunctional cognitions are triggered when a person is feeling sad

°         Distress tolerance

>        Distress Tolerance Test (DTT) – measures the level of frustration a person can handle in a given task (Nock and Mendes, 2008)

°         Impulsivity

>        UPPS Impulsive Behavior Scale – measures impulsivity across the dimensions of the Five Factor Model

°         Frequency of practice

>        How many times per week, month, or year a person engages in BDSM or NSSI

°         Duration of practice

>        How long a person has been engaging in the activity; at what age a person started

°         Co-occurring psychiatric disorders

>        Listing any current or past psychiatric diagnoses

°         Type of activity

>        Selection from common activities associated with each practice

  • BDSM: bondage/restraint, discipline, humiliation, infliction of physical pain, sensory deprivation/overload
  • NSSI: cutting, burning, head banging, intentionally breaking bones, ingestion of chemicals

 

Data Analysis: Data from the BDSM population will be compared with the NSSI population, and overlapping psychological constructs will be noted (see Figure 2, p. 4 for a summary of hypothesized results). Analyses will be conducted after input into an SSPS system. This study hopes to glean data from a relatively large population size, so a data collection period of at least 2 years is recommended.

 

Conclusion

This study hypothesizes that BDSM and NSSI practitioners will overlap in psychological characteristics that are risk factors for psychopathy, namely high cognitive reactivity and high impulsivity. In the presence of stressful life events the degree to which a person is capable of tolerating distress determines how and when a person reacts. Other personality traits will either strengthen or reduce distress tolerance. In both of these populations choosing to experience pain is a common factor, but initial studies show that long term effects differ. Positive psychological characteristics are associated with BDSM practitioners and negatives ones are associated with those who engage in NSSI. Discovering the cause of this disparity could lead to new treatment directions for both populations. Additionally the issue of experiencing pain as a means of recovery, or pain as a positive experience might be viewed more objectively and without stigma.

 

References

Barker, M., Iantaffi, A., & Gupta, C. (2007). Kinky clients, kinky counseling? The challenges

and potentials of BDSM.

Baumeister, R.F. & Scher, S.J. (1998). Self-defeating behavior patterns among normal

individuals: Review and analysis of common self-destructive tendencies. Psychological Bulletin, 104, 3-22.

Klonsky, E. D. (2011). Non-suicidal self-injury in United States adults: prevalence,

sociodemographics, topography and functions. Psychological medicine, 41(9), 1981-6.

Kolmes, K., Stock, W., & Moser, C. (2006). Investigating bias in psychotherapy with BDSM

clients. Journal of Homosexuality, 50(2-3), 301-324.

Lindemann, D. (2011). BDSM as therapy?. Sexualities, 14(2), 151-172.

Newmahr, S. (2010). Rethinking kink: sadomasochism as serious leisure. Qualitative

Sociology, 33(3), 313-331.

Nock, M. K. (2008). Actions speak louder than words: An elaborated theoretical model of the

social functions of self-injury and other harmful behaviors. Applied and Preventive Psychology, 12(4), 159-168.

Nock, M. K. (2009). Why do people hurt themselves? New insights into the nature and functions

of self-injury. Current directions in psychological science,18(2), 78-83.

Nock, M. K., & Mendes, W. B. (2008). Physiological arousal, distress tolerance, and social

problem-solving deficits among adolescent self-injurers. Journal of Consulting and Clinical Psychology, 76(1), 28.

Richters, J., De Visser, R. O., Rissel, C. E., Grulich, A. E., & Smith, A. (2008). Demographic

and psychosocial features of participants in bondage and discipline, “sadomasochism” or dominance and submission (BDSM): Data from a national survey. The journal of sexual medicine, 5(7), 1660-1668.

Schneider, A. (2009). The Rhythm of the Whip. Social Psychology Quarterly,72(4), 285-289.

Wilkinson, P., & Goodyer, I. (2011). Non-suicidal self-injury. European child & adolescent

psychiatry, 20(2), 103-108.

Williams, D. J., & Storm, L. E. (2012). Unconventional Leisure and Career: Insights into the

Work of Professional Dominatrices. Electronic Journal of Human Sexuality, 15.

Wismeijer, Andreas A.J. & van Assen, Marcel A.L.M (2013). Psychological Characteristics of

BDSM Practitioners. Journal of Sexual Medicine, 1943-1952.

Wright, S. (2006). Discrimination of SM-identified individuals. Journal of Homosexuality, 50(2-

3), 217-231.

 

 

Proposal: New Personality Disorder – Nonsexual Personality Disorder

The last response paper of the semester for Abnormal Psychology, the question was a toughy:

Suggest a possible additional personality disorder that could be added to DSM -V and list the criteria for diagnosing it. How would the addition of your personality disorder benefit to the field of psychopathology?

puzzle_head

Personality disorders (PD) are distinct from other types of psychiatric disorders because the symptoms are an abnormal or maladaptive expression of traits. Personality traits are enduring patters of perceiving, relating to, and thinking about the environment and the way in which one lives in that environment. Because personality traits are rather stable once formed, PDs are difficult to treat and require a great deal of cognitive restructuring and skills-based training.

PDs are broken down into three clusters, including odd/eccentric, dramatic/erratic, and anxious/fearful; from here, there are 10 subtypes. Given the richly diverse array of people in the world, it seems there are other classifications that could be named. Some PDs have similarities, including hypersexuality and/or inappropriate sexual behavior, but none name an utter absence of sexual desire or behavior. There are some disorders, depression for example, that cause a lack of sexual appetite, but it seems like there are people who experience something more lasting. I propose Nonsexual Personality Disorder; the diagnostic criteria are as follows:

A.  A marked inability to experience sexual attraction, beginning in early adulthood and indicated by 5 or more:

°         Inability to interpret sexual signals

°         Uncomfortable in intimate situations with a partner

°         Avoidance of situations in which sexual activity may occur

°         Lack of attraction to the opposite or same sex

°         Complete lack of sexual thoughts

°         Touch aversion

°         Inability to experience romantic relationships

°         Social isolation

°         Inability to become sexually aroused

B.  Does not occur as a result of sexual dysfunction or medical disorder.

 

It would manifest as something similar to schizoid PD, in which the individual is rather socially detached. However, unlike schizoid PD, this person would take enjoyment in other types of close relationships, such as with family or platonic friends. Additionally, they would not exhibit flattened affect, excepting in sexual situations. In this dimension, this individual does not possess the skills to understand or interpret social cues. A person may develop this due to either a predisposition to a schizotypal-like PD, lack or disregulation of hormones, or a lack of physical contact in childhood.

This is in contrast to individuals who list their sexual identity as asexual. For an asexual person, the thought of sex simply doesn’t occur as it does for others. For instance, a person may have romantic relationships, they may even get married, but sexual activity is never a motivation nor a desire. There are some who engage in sexual activity for procreation, or to please their partner, but for the most part asexuals have no need. Note, asexual individuals are capable of romantic relationships, and at times even sexual arousal, persons with nonsexual PD are not.

This would benefit the field by bringing to light a trait that seems to be hiding in plain sight. It’s easy to understand how a person could become frustrated or ostracized by lacking a desire that’s so prominent in adolescence. The possibility that this PD may result from a lack of physical contact in childhood needs confirmation as well; research has shown that there are devastating effects for these children, but can it be classified as a PD? Additionally, those experiencing this issue who do want to have children can have a chance at getting psychological help. If we understood the etiology of their disorder more clearly, better, more effective help could be provided.

Critique: Whittington et al. – SSRIs and Adolescents

Critique of Whittington et al.’s paper Selective serotonin reuptake inhibitors in childhood depression: systematic review of published versus unpublished data, written for Self-Destructive Behaviors. Citation and link to article below.

meds

In 2004, Whittington et al. performed a meta-analysis evaluating SSRIs versus placebos on adolescents, ages 5-18 years, in the treatment of depression. Five SSRIs were evaluated: Fluoxetine, Paroxetine, Sertraline, Citalopram, and Venlafaxine. Outcome measures included remission, response to treatment, depressive symptom scores, serious adverse events, suicide-related behaviors, and discontinuing treatment due to adverse events. 165 papers were whittled down to five studies the authors report as being relevant to their investigation. It was found that all drugs, except Fluoxetine, appear to cause more harm than good.

The target population for this study is an important, but rather narrow one. Prescribing psychiatric medication to adolescents, for me, is a controversial matter. The brain is still developing, and as little as we know about the mechanism of action of these drugs, the equation becomes more complex when the chemistry of the brain is in flux. Predicting how a medication will affect a still-developing brain is difficult. As this study shows, many medications have adverse reactions in adolescents, sometimes making suicidality more likely.

It appears not much research has been done on the effects of these particular drugs on an adolescent population. This may be why the authors’ inclusion criteria allowed only five papers up for scrutiny. For this reason, all conclusions are rather suspect and require further confirmation in order for results to be generalizable. Results do shed light on the need for a risk-benefit assessment when prescribing psychiatric medications to adolescents. Medications can often be used as a band-aid in treatment. Learning coping skills and effective means of emotional regulation early in life can give a person a better chance of controlling their disorder and of remaining free of possibly harmful medications.

Fluoxetine was the only medication that showed promise for adolescents. This is important for those patients unable to reap any benefit from cognitive behavioral treatments right away due to the severity of symptoms. For these patients, treatment may be too overwhelming to engage with; safe medication would allow for a better chance of reduction of symptoms. Though, only two published studies were available for scrutiny. More information is needed on the efficacy and adverse effects of Fluoxetine.

Missing is an investigation of the incidence of completed suicide; only suicide-related behaviors were assessed. The goal of the study was to assess depression, but completed suicide is a factor of utmost importance when assessing the risks and benefits of a medication. For other types of medications death is listed as an adverse effect if data had shown it to be; it seems completed suicide is in that same vein. This is a reason Fluoxetine remains suspect, despite other positive results. It may not cause observable adverse effects, but this could be a result of reduction of reporting and increased isolation, as opposed to a reduction in depressive symptoms. If this were the case, completed suicide would be more likely and less predictable. Particularly with adolescent males, who are the most likely of the population to complete suicide. Allowing adolescents to learn the tools they need to effectively communicate their thoughts and emotions will normalize the process; hopefully allowing those who may not seek help otherwise the skills to speak up. This variable is needed to decide if Fluoxetine should be prescribed to this population.

 

Whittington et al_2004

  Whittington, C. J., Kendall, T., Fonagy, P., Cottrell, D., Cotgrove, A., & Boddington, E. (2004). Selective serotonin reuptake inhibitors in childhood depression: systematic review of published versus unpublished data. The Lancet363(9418), 1341-1345.

 

BDSM: Perception versus Reality – Distinguishing Between Healthy Practitioners and Paraphilia

The following is my final term paper for Abnormal Psychology; we would write about whatever we wanted, so I chose BDSM. I did a presentation on the topic earlier in the semester for Self-Destructive Behaviors and had so much fun with the research I did more for this paper. In fact, I may do my graduate thesis on BDSM as it relates to nonsuicidal self-injury.

50 shades of hay

Introduction

BDSM is a practice that has been historically misunderstood, stigmatized, and even feared. It is often assumed by the general public and clinicians alike that practitioners of bondage-discipline, dominance-submission, sadism-masochism must engage in such behaviors as a result of a mental illness, past trauma, or an inclination toward criminal activity. Others assume it must be a precursor to or replacement for sexual activity, or it’s just “kinky sex.” Finally, it’s assumed that BDSM is all about the experience or inflicting of pain. For these reasons practitioners have been stigmatized and discriminated against, even when seeking therapy for matters not concerning BDSM, or are presumed to have a paraphilia or other psychiatric diagnosis.

Research has shown that practitioners of BDSM do not fit with these assumptions at all; in fact they are more psychologically healthy than controls in almost all domains examined, and it has been shown the practice is more about sensory pleasure than sex. Many practitioners have referred to the practice as a lifestyle, or a leisure activity. Additionally, what keeps people going back? This paper will examine the current perceptions clinicians in the field have of BDSM practitioners and discuss what researchers have found about their actual psychological state, and use this to clearly distinguish a practitioner from a person with a paraphilia. Then motivations for the practice of BDSM will be discussed, as well as the role of pain.

BDSM and Roles

BDSM is short for bondage-discipline, dominance-submission, sadism-masochism, and can include many different types of activities, such as bondage, discipline training, role-playing, spanking, whipping, controlled sensory deprivation or overload, objectification, fetish activation, humiliation, and other diverse types of pain administration. Because the practice is so varied, a precise definition is difficult; it is agreed that BDSM involves elements of role-play, mutual consent to participate, and mutual definition of activities. It has been suggested that erotic power exchange may be a good descriptor, since the practice may or may not involve sexual activity (Williams and Storm, 2012). Three roles have been identified: dom, sub, and switch. The dom, or the dominant role, is the person exerting control, whereas the sub, or the subordinate role, gives up control; a switch is a person that shifts between roles. BDSM can be performed in private, as in the privacy of the home; in public at clubs that cater to people who have this particular interest; or in the professional sector, as in the role of a professional dominatrix, for example. Wherever and however it is performed, there is a prevailing theme: more often than not sex is not present. In fact, at least in the public and professional domains, it is seen as taboo to combine the practice with sex.

Diagnostic Criteria for Paraphilias

In the DSM, BDSM manifests in Sexual Sadism, Sexual Masochism, and Autoerotic Asphyxiation (AEA). DSM-IV-TR diagnostic criteria for Sexual Sadism are:

  1. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving acts (real, not simulated) in which the psychological or physical suffering (including humiliation) of the victim is sexually exciting to the person.
  2. The person has acted on these sexual urges with a non-consenting person, or the sexual urges or fantasies cause marked distress or interpersonal difficulty.

Krueger proposes the DSM 5 remove the real, not simulated aspect of the definition of Sexual Sadism (Krueger 2009 a). DSM-IV-TR diagnostic criteria for Sexual Masochism are:

  1. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving the act (real, not simulated) or being humiliated, beaten, bound, or otherwise made to suffer.
  2. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Proposed changes to this include again removing real, not simulated, as well as adding a specifier of Asphyxiophilia (sexually aroused by asphyxiation) (Kreuger 2010 b). Autoerotic Asphyxiation is listed in the DSM under Paraphilias Not Otherwise Specified; diagnostic criteria are:

  1. Recurrent, intense sexually arousing fantasies, sexual urges or behaviors involving 1) non-human objects, 2) the suffering or humiliation of oneself or one’s partner, or 3) children or other nonconsenting persons that occur over a period of at least 6 months.
  2. Behavior, sexual urges, or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

It is characterized by intensified sexual arousal by oxygen deprivation, and can be self-administered or done with a partner. It is because of AEA that a fourth focus of criterion A has been proposed: an atypical focus involving human subjects (self or others) (Kafka 2009). It’s estimated that between 250-1,200 deaths annually occur from AEA in the US, and incidence of male to female participation is 50:1 (Cowell 2009).

 hank

 

Demographics and Psychological Characteristics

Much of the recent literature bases their demographic and psychological information on a study by Richerts et al., which took place in Australia in 2001-2002 with 19,307 participants aged 16-59, each of whom were interviewed by phone. The purpose was to determine whether people who engage in BDSM were more likely to have experienced sexual coercion, sexual difficulties, and/or psychological issues. It was found that the three aspects to their hypothesis were completely unsupported. In terms of demographics, the following was found: in the past year, 2.2% of men and 1.3% of women had engaged in a BDSM relationship; overall, 1.8% of men and 1.2% of women had engaged in a BDSM relationship at some point in their lives. BDSM is significantly more likely in bisexual and gay-identified men, and in bisexual and lesbian-identified women. Additionally, women who engage in BDSM are more likely to be aged 16-19 or over 50, and have a regular partner they do not live with. For men and women, practitioners of BDSM had a greater number of sexual partners over the lifetime.

Building on the Richters et al., Wismeijier and van Assen sought to delve deeper into the psychological characteristics of BDSM practitioners. In 2013, 902 BDSM and 434 control participants filled out online questionnaires measuring rejection sensitivity, attachment style, level of subjective well-being, and the Five Factor Model, which covers neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness. The roles in BDSM were also discussed, which hadn’t been covered in the literature up to this point (see Figure 2).

Results showed that BDSM practitioners displayed more favorable psychological characteristics than controls, and doms were more likely to exhibit the most favorable when compared to subs, switches, and controls. Results are summarized in Figure 1. Rates missing from the literature include incidence of specific psychiatric disorders. Most studies investigated terms such as psychological distress, psychological health, and/or psychological well-being; there doesn’t yet seem to be one that has investigated, for example, the incidence of depression or personality disorders in practitioners of BDSM. Though these results would imply that there would be a lower incidence of psychological disorders in this population, the data would provide useful insight to more specific aspects of the effect BDSM has on the psychological health of practitioners. Also missing is whether or not these personality characteristics are present before a person begins practicing BDSM, or if psychological health improves as a person continues to practice. Psychological hardiness would be interesting to measure as well.

Neuroticism Extraversion OpennessTo New Experiences Conscientiousness Agreeableness Rejection sensitivity Attachment Style Subjective Well-Being
P Less More More More Less Less Lower need for approval; less anxiously attached Higher
NP More Less Less Less More More Higher need for approval; more anxious attachment Less

Figure 1: Comparison of psychological characteristics in BDSM practitioners (P) and controls (NP) (data from Wismeijier and van Assen 2013).

Submissive Dominant Switch
Male 33.4% 48.3% 18.3%
Female 75.6% 8% 16.4%

Figure 2: Rates of roles in BDSM (data from Wismeijier and van Assen 2013)

Effect of Negative Clinical Perception on Treatment

Based on the above findings, it seems the stigma that BDSM practitioners carry is rather opposite to the reality. This, taken with the diagnostic criteria of Paraphilias can lead to a better understanding of when the practice of BDSM dips into the realm of a clinical disorder. There is a need for this, as much of the literature indicates the stigma associated with the practice of BDSM has interfered with practitioners receiving psychological treatment, even when their symptoms and distress have nothing to do with their BDSM practice.

Lindemann (2011) reports psychologists previously described a BDSM practitioner as “wandering through the kingdom of hell… a criminal… cannibalism, necrophilism, and vampirism.” Kolmes, Stock, and Moser (2006) identified the following themes of biased care in psychotherapy:

  1. Considering BDSM to be unhealthy
  2. Requiring the client to give up BDSM activity in order to continue treatment
  3. Confusing BDSM with abuse
  4. Client having to educate the therapist about BDSM
  5. Assuming that BDSM interests are indicative of past family/spousal abuse
  6. Therapist misinterpreting their expertise by stating that they are BDSM-positive when they are not actually knowledgeable about BDSM practices.

This study stated that 74.9% of people were not seeking treatment for BDSM interests, whereas 12% and 11% said treatment was either related or tangentially related, respectively. Of those seeking treatment, 65.1% shared their BDSM interests with their therapist, and 28.6% had not. What was most telling, though, was that the people who chose to share their BDSM interests report doing so, and doing so early in treatment, to gauge whether or not they would be comfortable with a particular therapist. Additionally, 33.7% report purposefully seeking out “kink-aware” professionals. The following testimonials, taken from interviews also included in this study, highlight the importance of not allowing one’s prejudices to affect clinical practice, or a patient’s treatment:

“BDSM only came into play when I had to educate her that it was not abuse, that it was not harmful to me, that I was not self-sabotaging with it, nor acting out past family/spousal abuse. It actually took quite a few sessions to get the therapist over their hang ups and misconceptions about BDSM. Time that could have been better spent on the actual issues I was there for.”

 

“I think that there are definitely aspects of BDSM that can be harmful when someone isn’t mindful of their own limits, needs, and such… finding a therapist who would be open to helping me along the path in the healthiest way possible would be invaluable!”

Many liken their participation in BDSM to that of a leisure activity , such as mountain climbing, or hiking (Newmahr 2010). Conceptualizing BDSM in this manner, especially in consideration with the data on the psychological health of practitioners, it seems silly for a clinician to ask a client to justify, or even stop their practice in order to receive treatment. According to Williams and Storm (2012), regular practice promotes trust, communication, spirituality, and intimacy within relationships; can provide new understandings of self and past experiences; and can lead to new insights about unnoticed phenomena.

Pain

By its very nature, though, it is understandable why someone not already involved in the practice might feel fearful. BDSM conjures up images of black leather, whips, and chains. Across the board BDSM involves some element of pain, either physical, psychological, or both. Neurologically, the experience of pain releases endorphins, which are neurotransmitters that modulate the experience of pain. Schneider (2009) argues that this causes an altered state of mind, allowing a person to have a new perception of how to control a situation. He further argues that pain is not an objective experience, but a social construct whose definition of experience relies on context. If a person is able to be in control of their pain it can produce feelings of pride, accomplishment, catharsis, and positive identity.

This seems to support anecdotal findings from Lindemann (2011) in which a series of professional dominatrices (pro dommes) were interviewed in New York and San Francisco. Originally beginning as general field research, Lindemann found that the majority of pro domes viewed themselves as “therapists” and described the value of their work in four categories:

  1. Healthful alternatives to sexual repression, due to societal stigma
  2. A means by which people can atone for their past
  3. Mechanisms for gaining control over prior traumas
  4. A way to experience psychological revitalization through shame

The pro dommes did receive compensation from clients for their services, and though their work can be conceptualized as “erotic labor,” in almost all cases no sexual contact was involved. The majority of women also participated in a BDSM lifestyle outside of the professional capacity, 33% had college degrees, and 39% had graduate degrees.

This study helps to conceptualize a person’s motives for participating in BDSM. Pro dommes describe some of the benefits of their work to extend a participant’s self-awareness. In the case of gaining control over prior trauma, for example, it was said that by re-enacting the scenario on the clients own terms he was able break through his bonds and take the first step toward working past the trauma. For a humiliation scene, “a client has his desires paradoxically affirmed and normalized through the process of shaming… to be heard for who you are is very therapeutic… so it’s a whole thing about trust and letting out this part of yourself that needs to come out” (161). Lindemann also proposes the “Spiderman’s uncle” phenomenon, which states ‘with great power comes great responsibility,’ and highlights the motivations of a client who holds a great deal of power in his professional life but will hire a pro domme in order to give up that power to experience relief.

There are a great deal of motivations, it appears, to utilize the practice of BDSM. Even if a person doesn’t classify themselves as a BDSM practitioner, they can still derive enjoyment from the experience of pain. In a study regarding the experience of sexual pleasure and pain, questions were asked about the experience of being bitten, inflicting pain, and receiving pain; see figure 3 for a summary of rates. Conceptualizing BDSM as therapy as opposed to a leisure activity does require caution, as it could imply that there’s something wrong that needs fixing.

Being bitten Inflicting pain Receiving pain
Male 26% 4.8% 2.5%
Female 26% 2.1% 4.8%

Figure 3: Experience of sexual pleasure to pain (data from Kreuger 2010 a)

BDSM versus Paraphilia

Research has shown that practitioners of BDSM are psychologically healthy, at times more so than controls, and that motivation for the practice is not to act out potentially criminal aggressions, it is to discover more about the self. In distinguishing a practitioner of BDSM from a person with a paraphilia, on must consider two factors: motivation and consent. Practitioners of BDSM almost never consider sex as the primary motivation for their actions; it may not be present at all. Furthermore, consent is always attained for every activity. In fact, the reason the actions are therapeutic is because of consent; consent equals control. Paraphilias on the other hand are sexually motivated and are not consensual. This results in illegal activity and trauma to another person, whereas the result of a BDSM relationship can have very positive results.

Further Directions

As mentioned before, missing from the literature is a discussion of particular psychiatric diagnoses of practitioners of BDSM, and if favorable personality characteristics existed before BDSM practice or they develop with practice. Also missing is a discussion of how people get into the practice in the first place as opposed to any other leisure activity, such as rock climbing.  Additionally, because of the pain component one wonders if there’s a connection between nonsuicidal self-injury (NSSI) and BDSM. Is there any overlap in people who practice one or the other? Would the practice of NSSI ever lead to the practice of BDSM? Additionally, the etiology of BDSM is missing. Further studies are needed to address these questions.

Conclusion

BDSM, a practice long stigmatized and feared, is one that can be considered a leisure activity whose participants are more psychologically healthy and have a higher subjective well-being than controls. Though on the surface it seems to share similarities to those diagnosed with paraphilias or other psychiatric disorders, the two are vastly different in motivation, outcome, and psychological health of practitioners. BDSM may even be considered as a form of therapy to aid people in pushing past prior trauma, fears, and relief from every day stressors. This paper sought to elucidate the psychological state, motives, and activities of BDSM practitioners, as well as dispel any preconceived notions regarding the practice itself or those who enjoy it. Clinicians who may treat a practitioner in the future should seek to educate themselves on safe and healthy practices, rather than allowing stigma to effect treatment. With further research, there may even be a chance to use it in treatment positively in the future.

References

Barker, M., Iantaffi, A., & Gupta, C. (2007). Kinky clients, kinky counselling? The challenges

and potentials of BDSM.

Baumeister, R.F. & Scher, S.J. (1998). Self-defeating behavior patterns among normal

individuals: Review and analysis of common self-destructive tendencies. Psychological Bulletin, 104, 3-22.

Cowell, D. D. (2009). Autoerotic Asphyxiation: Secret Pleasure—Lethal

Outcome?. Pediatrics, 124(5), 1319-1324.

Kafka, M. P. (2010). The DSM diagnostic criteria for paraphilia not otherwise

specified. Archives of sexual behavior, 39(2), 373-376.

Kolmes, K., Stock, W., & Moser, C. (2006). Investigating bias in psychotherapy with BDSM

clients. Journal of Homosexuality, 50(2-3), 301-324.

Krueger, R. B. (2010). The DSM diagnostic criteria for sexual sadism. Archives of Sexual

Behavior, 39(2), 325-345.

Krueger, R. B. (2010). The DSM diagnostic criteria for sexual masochism.Archives of sexual

behavior, 39(2), 346-356.

Lindemann, D. (2011). BDSM as therapy?. Sexualities, 14(2), 151-172.

Newmahr, S. (2010). Rethinking kink: sadomasochism as serious leisure.Qualitative

Sociology, 33(3), 313-331.

Paraphilic Disorders Fact Sheet (2013). American Psychiatric Association.

Richters, J., De Visser, R. O., Rissel, C. E., Grulich, A. E., & Smith, A. (2008). Demographic

and psychosocial features of participants in bondage and discipline,“sadomasochism” or dominance and submission (BDSM): Data from a national survey. The journal of sexual medicine, 5(7), 1660-1668.

Schneider, A. (2009). The Rhythm of the Whip. Social Psychology Quarterly,72(4), 285-289.

Williams, D. J., & Storm, L. E. (2012). Unconventional Leisure and Career: Insights into the

Work of Professional Dominatrices. Electronic Journal of Human Sexuality, 15.

Wismeijer, Andreas A.J. & van Assen, Marcel A.L.M (2013). Psychological Characteristics of

BDSM Practitioners. Journal of Sexual Medicine, 1943-1952.

Wright, S. (2006). Discrimination of SM-identified individuals. Journal of Homosexuality, 50(2-

3), 217-231.

Alcoholism: Disease or Lack of Self-Control

I’m about three weeks from being done with my first semester of grad school. From there, only three more semesters until I have a Master’s in Clinical Psychology. I’ll be pretty happy for a break, but I genuinely missed being in school. The following was written for Abnormal Psychology in response to the question:

Do you feel that alcoholism is a disease or a failure of will power and self-control? Why?

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Etiology of a disorder is important for a number of reasons, particularly when it comes to directing treatment options. Is the disorder primarily biological, necessitating a more medical approach; or is it environmental, such that treatment will be more cognitive and/or behavioral. For alcoholism it seems the jury is still out. There’s a prevailing school of thought siding with the disease model, going so far as to suggest a “gene for alcoholism.” Likewise, there’s a pushback from those who believe alcoholism results entirely from a failure of willpower. Taken individually, neither side provides a full picture of the disorder. For this reason, I feel alcoholism is neither a disease nor a failure, but a combination of a predisposition to certain personality traits, environmental effects, and a lack of adaptive coping strategies.

There’s a very small cluster of disorders that research has found a “gene for;” examples include Huntington’s disease, cystic fibrosis, and Tay-Sachs. The disease model of alcoholism tends to portray the disorder in this light; however, research has yet to find a psychiatric disorder that is inherited in this manner. It is true that alcoholism has been shown to run in families, but to say there’s a gene for alcoholism simplifies the issue far too greatly. When considering inheritance, one must look at the traits associated with alcoholism, such as aggression, anxiety, and impulsivity. This follows with research showing alcoholism is polygenic, and accounts for those who lack a family history of the disorder.

People who lack self-control, regardless of whether or not alcohol is involved, would more than likely exhibit aggression, anxiety, and/or impulsivity in some way or another. The inability to exert willpower over the choice to drink alcohol is a result of an inability to control these traits in the face of stressors, particularly after having had an example of alcohol use as stress control. A person develops this over time, potentially beginning in an alcoholic household; a person could also observe peers or celebrities drinking to excess, a family member need not always be the example. Alcohol begins to function as a maladaptive coping mechanism, or a way by which a person can regulate their emotions.

Treatment is, of course, primarily composed of the 12-step program. Though it does a lot of good, the program assumes the disorder is for life, and alcohol becomes something a person can never again come into contact with. It turns alcoholism into a self-fulfilling prophecy; if someone were to relapse there’s a built in excuse that alcohol can never be conquered and once it touches the lips a cycle begins that can’t be stopped. We would never conceptualize a depression relapse like this; if a person began to slip into depression again we would encourage them to use coping skills to head off a full-blown episode. Thinking about alcoholism as a need to learn to handle one’s emotions in a more effective manner instead of some immovable force may make it more treatable.

The etiology of alcoholism can often lead to heated arguments seeking to assign responsibility for the disorder. In the extremes, it either lies with a person’s genes or solely on the choices they make. Meeting in the middle, a person is dealt a genetic card of a predisposition to certain traits and is then exposed to an environment that either teaches or deprives them of the tools to effectively adapt to stressors. It is neither a disease nor a lack of willpower, but manifestation of the diathesis-stress model.

Critique of Cha et al.: Attentional Bias Toward Suicide-Related Content

The following was written for the class Self-Destructive Behaviors and is a critique of a 2010 article entitled “Attentional bias toward suicide-related stimuli predicts suicide behavior,” linked below.

confirmation

Cha et al. addressed attention bias toward suicide-related content as a predictor of suicide behavior with a population of adults presenting to a psychiatric emergency department. Demographic and psychiatric factors were obtained, and a history of suicidal behavior was assessed; attentional bias toward suicide-related content was measured via the Stroop task. Both the clinician and the patient made predictions as to whether or not the patient would make a suicide attempt in the next 6 months. It was found that suicide attempters, especially those who had made a recent attempt, showed specific attentional bias to suicide-related content, and this surpassed other clinical procedures for predicting future attempts. The strength of the association was highly linked with how recently attempts had been made; the more recent the attempt the stronger the attentional bias.

This study addresses the need for an important assessment tool missing in the field: an object measurement of risk for suicidal behavior. Self-report is notoriously unreliable, and risk assessments often end with uncomfortable uncertainty because the clinician has to rely on something unverifiable. This measurement appears able to make not only predictions about who is at the greatest risk to exhibit suicidal behavior, but also about the time at which the behavior is most likely to occur.  Thus there’s a possibility of using it with actively suicidal patients in deciding if greater psychiatric intervention should be taken. If so, resources may be more effectively allocated, and people who may have otherwise attempted suicide could potentially be prevented from doing so.

Prevention of suicide based on attention bias means breaking a patient’s fixation on suicide in treatment. This could be accomplished through authoring scripts that focus on topics of hope and future goals, as well as practicing techniques such as thought diffusion and expansion. The goal being separating one’s identity from suicidality, thus being able to get through the current high-risk period, as well as learning skills to protect against future episodes.

The study doesn’t really address how protective factors affect attentional bias; are there certain traits that allow a person to exhibit this tendency without engaging in suicidal behavior? There could be plenty of people focused on suicide or death-related content that don’t engage in suicide behaviors; what prevents them from doing so? Would cognitive flexibility allow a person to more easily refocus on adaptive coping mechanisms? Also, the more creatively inclined may be able to channel their fixation on suicide content into something more productive. Because this study drew from a population of patients in a psychiatric emergency department there may be a certain selection bias. It may be interesting to assess suicidal thoughts and behaviors in a population that reports a baseline interest in suicide or death-related content, but who may or may not have had previous suicide attempts. If it can be found that this measurement can reliably and accurately predict suicidal behavior, populations that are least likely to seek help for thoughts of suicide may be able to be identified.

 Cha et al_2010

Cha, C. B., Najmi, S., Park, J. M., Finn, C., & Nock, M. K. (2010). Attentional bias toward suicide-related stimuli predicts suicidal behavior. Journal of Abnormal Psychology, 119, 616-622.

Creativity and Mood Stabilizers: To Take or Not to Take

The following was written for week 11 of Abnormal Psychology and is a response to the question:

We have evidence that highly creative individuals are at greater risk for mood disorders (especially bipolar disorder) than other individuals. Many creative people claim that mood stabilizers inhibit or “kill” creativity. If you were treating a highly creative individual with bipolar disorder (someone who had already made a substantial contribution in a creative field), would you insist that he or she comply with a mood stabilizing medication regimen? Why or why not?

(article by Dr. Shelly Carson linked below)

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It is well known that creative people often suffer from a mental illness. According to Carson, research has shown 3 types of disorders to be most associated with the highly creative: mood disorders, schizophrenia spectrum disorders, and substance abuse disorders. Those who suffer from mood disorders are most likely to be diagnosed with one from the bipolar spectrum. Kay Redfield Jameson has shown us how difficult it is for someone with BD to remain on medication due to the distasteful side effects. It’s been reported that these medications may stifle, or even kill one’s creative thought process. For a highly creative person this becomes quiet the dilemma: take medication to control unpleasant and even dangerous symptoms, but lose creative drive; or stay off of medication, remain creative, but have to struggle to control potentially uncontrollable symptoms. This dilemma exists for the individual’s treater as well: do you force someone to take medication that would suppress a fundamental part of their personality, or livelihood, for the sake of relieving symptoms? When does symptom management outweigh preservation of the creative process?

You’re treating a highly creative person, someone who has already made a substantial contribution in their field, they present to you with severe Bipolar I and require mood stabilizers. After being on the mood stabilizers for a bit your patient tells you that they no longer wish to be on the medication because they feel it takes away their ability to think and create as they used to. For me the course of treatment would depend on the severity of their symptoms, the degree to which they’re impaired, and how their vulnerability and protective factors manifest. If the patient’s symptoms were moderate, I would be open to having a discussion about alternatives for mood regulation, such as CBT and ACT. If their symptoms were more severe or the level of impairment was very high, the conversation would perhaps be geared more toward reducing rather than stopping the mood stabilizer.

Carson lists reduced latent inhibition, novelty seeking, and neural hyperconnectivity under shared vulnerabilities of creativity and psychopathology; and low IQ, working memory deficits, and perseveration as risk factors. Protective factors include high IQ, working-memory skills, and cognitive flexibility. In discussing shared vulnerabilities, Carson mentions that creative people may depend on these to enhance their work, but may also use them to work through their psychopathy.

Learning to interpret the potentially inappropriate signals a highly creative person receives in new or different ways might allow that person to successfully remain medication-free. For example, someone with BD could feel as though they experience a flight of ideas, or that their thoughts are going very quickly. They could practice reining in these ideas/thoughts with mindfulness exercises; the goal being able to identify an idea, hold onto it long enough to create something, then move on to the next idea without getting distracted by competing thoughts or urges.

If someone is unable to manage their symptoms effectively without medication, keeping their creative impulse may weigh too heavily against simply being able to function in life. No matter what kind of contribution, if any, they’ve made to their field, safety and functionality is more important than the pursuit of creativity. If only temporarily, a medication regime should be kept to until a person can learn to control their symptoms.

Carson – Shared vulnerability

Carson, S.H. (2011). Creativity and psychopathology: A shared vulnerability model. Canadian Journal of Psychiatry, 56(3), 144-153.