Charmaine Borg

Feelings of Disgust and Disgust-Induced Avoidance Weaken following Induced Sexual Arousal in Women

Background Sex and disgust are basic, evolutionary relevant functions that are often construed as paradoxical. In general the stimuli involved in sexual encounters are, at least out of context strongly perceived to hold high disgust qualities. Saliva, sweat, semen and body odours are among the strongest disgust elicitors. This results in the intriguing question of how people succeed in having pleasurable sex at all. One possible explanation could be that sexual engagement temporarily reduces the disgust eliciting properties of particular stimuli or that sexual engagement might weaken the hesitation to actually approach these stimuli. Methodology Participants were healthy women (n = 90) randomly allocated to one of three groups: the sexual arousal, the non-sexual positive arousal, or the neutral control group. Film clips were used to elicit the relevant mood state. Participants engaged in 16 behavioural tasks, involving sex related (e.g., lubricate the vibrator) and non-sex related (e.g., take a sip of juice with a large insect in the cup) stimuli, to measure the impact of sexual arousal on feelings of disgust and actual avoidance behaviour. Principal Findings The sexual arousal group rated the sex related stimuli as less disgusting compared to the other groups. A similar tendency was evident for the non-sex disgusting stimuli. For both the sex and non-sex related behavioural tasks the sexual arousal group showed less avoidance behaviour (i.e., they conducted the highest percentage of tasks compared to the other groups). Significance This study has investigated how sexual arousal interplays with disgust and disgust eliciting properties in women, and has demonstrated that this relationship goes beyond subjective report by affecting the actual approach to disgusting stimuli. Hence, this could explain how we still manage to engage in pleasurable sexual activity. Moreover, these findings suggest that low sexual arousal might be a key feature in the maintenance of particular sexual dysfunctions.

Vaginismus: Heightened Harm Avoidance and Pain Catastrophizing Cognitions

INTRODUCTION Catastrophic appraisal of experienced pain may promote hypervigilance and intense pain, while the personality trait of harm avoidance (HA) might prevent the occurrence of correcting such experiences. Women inflicted with vaginismus may enter a self-perpetuating downward spiral of increasing avoidance of (anticipated) pain. In vaginismus the anticipation of pain may give rise to catastrophic pain ideation. This may establish hypervigilance toward painful sexual stimuli, which consequently results in negative appraisal of sexual cues. This process could impair genital and sexual responding, intensify pain and trigger avoidance, which in turn may contribute to the onset and persistence of symptoms in vaginismus and to certain extent also in dyspareunia. AIMS To investigate whether women suffering from vaginismus are characterized by heightened levels of habitual pain catastrophic cognitions, together with higher levels of HA. METHODS This study consisted of three groups: a lifelong vaginismus group (N = 35, mean age = 28.4; standard deviation [SD] = 5.8), a dyspareunia group (N = 33, mean age = 26.7; SD = 6.8), and women without sexual complaints (N = 54, mean age = 26.5; SD = 6.7). MAIN OUTCOME MEASURES HA scale of Cloningers tridimensional personality questionnaire, and the pain catastrophizing scale. RESULTS Specifically women inflicted with vaginismus showed significantly heightened levels of catastrophic pain cognitions compared with the other two groups, as well as significant enhanced HA vs. the control group, and a trend vs. the dyspareunia group. Both traits were shown to have cumulative predictive validity for the presence of vaginismus. CONCLUSION This study focused on the personality traits of catastrophizing pain cognitions and HA in women with lifelong vaginismus. Our findings showed that indeed, women suffering from vaginismus are characterized by trait of HA interwoven with habitual pain catastrophizing cognitions. This study could help in the refinement of the current conceptualization and might shed light on the already available treatment options for women with vaginismus.

Prefrontal and Striatal Volumes in Monozygotic Twins Concordant and Discordant for Schizophrenia

Frontostriatal networks mediating important cognitive and motor functions have been shown to be abnormal structurally and functionally in schizophrenia. However, the influence of genetic risk for schizophrenia on structural abnormalities in these areas is not well established. This study therefore aimed to investigate prefrontal and striatal volume alterations in schizophrenia and to define the extent to which they are dependent on genetic vulnerability for the condition. We employed structural magnetic resonance imaging (sMRI) in monozygotic (MZ) twins with or without schizophrenia. A sample of 129 twins completed sMRI, consisting of 21 MZ twin pairs concordant for schizophrenia, 17 MZ schizophrenic twins and 18 MZ nonschizophrenic twins drawn from 19 pairs discordant for schizophrenia, and 26 MZ control twin pairs without schizophrenia. Groups did not significantly differ in age, gender, handedness, height, level of education, parental socioeconomic status, and ethnicity. Using a region-of-interest approach, we measured the gray matter volumes (in cm(3)) of superior, middle, inferior, and orbital frontal cortices (SFC, MFC, IFC, and OFC, respectively); the caudate; and putamen. Covarying for whole-brain volume, age, and gender, we found that concordant but not discordant twins with schizophrenia had significantly lower volumes of MFC and OFC than control twins. In contrast, both patient groups had significantly lower SFC volumes than both groups of nonschizophrenic twins. There were no significant group differences in IFC and the striatum. We conclude that the prefrontal cortex shows a heterogeneous pattern of genetic influences on volumetric reductions in schizophrenia.

Giving In to Arousal or Staying Stuck in Disgust? Disgust-Based Mechanisms in Sex and Sexual Dysfunction

Sex and disgust seem like strange bedfellows. The premise of this review is that disgust-based mechanisms nevertheless hold great promise for improving our understanding of sexual behavior, including dysfunctions. Disgust is a defensive emotion that protects the organism from contamination. Accordingly, disgust is focused on the border of the self, with the mouth and vagina being the body parts that show strongest disgust sensitivity. Given the central role of these organs in sexual behavior, together with the fact that bodily products are among the strongest disgust elicitors, the critical question seems not whether disgust may interfere with sex but rather how people succeed in having pleasurable sex at all. We argue that sexual arousal plays a critical role in counteracting disgust-induced avoidance via lowering the threshold for engaging in “disgusting sex.” Following this, all mechanisms that interfere with the generation of sexual arousal or enhance the disgusting properties of sexual stimuli may hamper the functional transition from a sex-avoidance into an approach disposition. Since prolonged contact is the most powerful means to reduce disgust, disgust-based mechanisms that counteract sexual approach may give rise to a self-perpetuating cycle in which enhanced sexual disgust becomes a chronic feature.

Anticonvulsant pharmacotherapy for generalized and localized vulvodynia: a critical review of the literature

Abstract Anticonvulsant therapy has occasionally been recommended to treat vulvodynia. However, convincing evidence to support this therapeutic option is lacking. The goal of this study was to critically review studies published on the effectiveness of anticonvulsants for the treatment of vulvodynia. Evaluation of the methodological quality of relevant publications was the main outcome measure. MEDLINE, PubMED and Cochrane were used to identify studies published in English between January 1999 and February 2013. Searches were performed between December 2012 and February 2013. Articles were appraised with the Oxford Centre for Evidence-Based Medicine – Levels of Evidence. Eight relevant studies were identified: two case reports, three retrospective studies, two non-randomized prospective studies and one open-label pilot trial study. Gabapentin formed the main focus (87.5%) to reduce vulvar pain; success rates ranged from 50 to 82%. Lamotrigine was used in one study (12.5%) to relieve symptoms; satisfaction was reported in 82%. These results seem promising, but the majority of studies have several methodological weaknesses regarding sample size and design. Insufficient evidence was available to recommend anticonvulsants for the treatment of vulvodynia. Further studies are necessary with double-blind, randomized-controlled designs to investigate the effectiveness of anticonvulsant therapy for vulvodynia.

Throwing the Baby Out with the Bathwater: The Demise of Vaginismus in Favor of Genito-Pelvic Pain/Penetration Disorder

Over the past 15 years, there has been ongoing debate about whether vaginismus can be differentiated from dyspareunia categorically, dimensionally, or not at all (Reissing, Binik, & Khalifé, 1999). Despite the fact that the debate on diagnostic distinction continues, a significant change was made in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013). The diagnosis of Genito-Pelvic Pain/Penetration Disorder (GPPPD) was introduced to replace the hitherto separate diagnosesofDyspareuniaandVaginismus,previouslyunder thesubcategory of sexual pain disorders (DSM-IV-TR; American Psychiatric Association, 2000). Binik (2005a) argued that the sexual pain disorders were the onlypainconditionsthatwereclassifiedaccordingtotheactivity they interfered with and argued for their removal from the classification of sexual dysfunctions. This was received with broad skepticism from clinicians and researchers alike (Binik, 2005b). The introduction of GPPPD may represent an apparent compromise. The diagnostic criteria for this new category have focused on symptomatology related to pain during sexual activity and/or pain with (anticipated) vaginal penetration. The multidimensional diagnosis of GPPPD is clearly more in line with the outcomes of scientific research and clinical practice than the original categorical classification in DSM-IV-TR as outlined elegantly by Binik’s (2010a, 2010b) summary of the literature. However, GPPPD fails to capture the complexity of sexual difficulties in women who have never been able to experience intercourse (for the purpose of this commentary referred tobythepreviousdiagnostic labelof lifelongvaginismus). Inour opinion, we run the risk that the baby (lifelong vaginismus) is thrown out with the bathwater (sexual pain disorders). By summarizing different aspects of lifelong vaginismus based on the results of recent studies, we will underscore this and offer a temporary solution to assist clinicians and researchers to mediate the omission of lifelong vaginismus from the DSM-5. Vaginismus was first mentioned as a sexual/reproductive problem by the Italian physician Trotula of Salerno in the eleventh century:‘‘On the tightening of the vulva so that even a woman who has been seduced may appear a virgin’’(1940; p. 37). The diagnostic term ‘‘vaginismus’’was coined by the English gynecologist, J. Marion Sims, in 1861. Even in the first description of vaginismus, the confusion between pelvic Charmaine Borg and Symon K. Spoelstra are both second authors.

Brain Processing of Visual Stimuli Representing Sexual Penetration versus Core and Animal-Reminder Disgust in Women with Lifelong Vaginismus

It has been proposed that disgust evolved to protect humans from contamination. Through eliciting the overwhelming urge to withdraw from the disgusting stimuli, it would facilitate avoidance of contact with pathogens. The physical proximity implied in sexual intercourse provides ample opportunity for contamination and may thus set the stage for eliciting pathogen disgust. Building on this, it has been argued that the involuntary muscle contraction characteristic of vaginismus (i.e., inability to have vaginal penetration) may be elicited by the prospect of penetration by potential contaminants. To further investigate this disgust-based interpretation of vaginismus (in DSM-5 classified as a Genito-Pelvic Pain/Penetration Disorder, GPPPD) we used functional magnetic resonance imaging (fMRI) to examine if women with vaginismus (n = 21) show relatively strong convergence in their brain responses towards sexual penetration- and disgust-related pictures compared to sexually asymptomatic women (n = 21) and women suffering from vulvar pain (dyspareunia/also classified as GPPPD in the DSM-5, n = 21). At the subjective level, both clinical groups rated penetration stimuli as more disgusting than asymptomatic women. However, the brain responses to penetration stimuli did not differ between groups. In addition, there was considerable conjoint brain activity in response to penetration and disgust pictures, which yield for both animal-reminder (e.g., mutilation) and core (e.g., rotten food) disgust domains. However, this overlap in brain activation was similar for all groups. A possible explanation for the lack of vaginismus-specific brain responses lies in the alleged female ambiguity (procreation/pleasure vs. contamination/disgust) toward penetration: generally in women a (default) disgust response tendency may prevail in the absence of sexual readiness. Accordingly, a critical next step would be to examine the processing of penetration stimuli following the induction of sexual arousal.

Automatic Affective Appraisal of Sexual Penetration Stimuli in Women with Vaginismus or Dyspareunia

INTRODUCTION Current psychological views are that negative appraisals of sexual stimuli lie at the core of sexual dysfunctions. It is important to differentiate between deliberate appraisals and more automatic appraisals, as research has shown that the former are most relevant to controllable behaviors, and the latter are most relevant to reflexive behaviors. Accordingly, it can be hypothesized that in women with vaginismus, the persistent difficulty to allow vaginal entry is due to global negative automatic affective appraisals that trigger reflexive pelvic floor muscle contraction at the prospect of penetration. AIM To test whether sexual penetration pictures elicited global negative automatic affective appraisals in women with vaginismus or dyspareunia and to examine whether deliberate appraisals and automatic appraisals differed between the two patient groups. METHODS Women with persistent vaginismus (N = 24), dyspareunia (N = 23), or no sexual complaints (N = 30) completed a pictorial Extrinsic Affective Simon Task (EAST), and then made a global affective assessment of the EAST stimuli using visual analogue scales (VAS). MAIN OUTCOME MEASURES The EAST assessed global automatic affective appraisals of sexual penetration stimuli, while the VAS assessed global deliberate affective appraisals of these stimuli. RESULTS Automatic affective appraisals of sexual penetration stimuli tended to be positive, independent of the presence of sexual complaints. Deliberate appraisals of the same stimuli were significantly more negative in the women with vaginismus than in the dyspareunia group and control group, while the latter two groups did not differ in their appraisals. CONCLUSION Unexpectedly, deliberate appraisals seemed to be most important in vaginismus, whereas dyspareunia did not seem to implicate negative deliberate or automatic affective appraisals. These findings dispute the view that global automatic affect lies at the core of vaginismus and indicate that a useful element in therapeutic interventions may be the modification of deliberate global affective appraisals of sexual penetration (e.g., via counter-conditioning).

Is disgust sensitive to classical conditioning as indexed by facial electromyography and behavioural responses

Earlier studies provided preliminary support for the role of classical conditioning as a pathway of disgust learning, yet this evidence has been limited to self-report. This study included facial electromyographical (EMG) measurements (corrugator and levator muscles) and a behavioural approach task to assess participants’ motivation-to-eat the actual food items (conditioned stimuli, CS). Food items served as CS and film excerpts of a woman vomiting served as unconditioned stimuli (US). Following acquisition the CS+ (neutral CS paired with US disgust) was rated as more disgusting and less positive. Notably, the conditioned response was transferred to the actual food items as evidenced by participants’ reported lowered willingness-to-eat. Participants also showed heightened EMG activity in response to the CS+ which seemed driven by the corrugator indexing a global negative affect. These findings suggest that classical conditioning as a pathway of disgust learning can be reliably observed in subjective but not in disgust-specific physiological responding.

Optimising Extinction of Conditioned Disgust

Maladaptive disgust responses are tenacious and resistant to exposure-based interventions. In a similar vein, laboratory studies have shown that conditioned disgust is relatively insensitive to Conditioned Stimulus (CS)-only extinction procedures. The relatively strong resistance to extinction might be explained by disgust’s adaptive function to motivate avoidance from contamination threats (pathogens) that cannot be readily detected and are invisible to the naked eye. Therefore, the mere visual presentation of unreinforced disgust eliciting stimuli might not be sufficient to correct a previously acquired threat value of the CS+. Following this, the current study tested whether the efficacy of CS-only exposure can be improved by providing additional safety information about the CS+. For the CSs we included two neutral items a pea soup and a sausage roll, whereas for the Unconditioned Stimulus (US) we used one video clip of a woman vomiting and a neutral one about glass blowing. The additional safety information was conveyed by allowing actual contact with the CS+ or by observing an actress eating the food items representing the CS+. When additional safety information was provided via allowing direct contact with the CS+, there was a relatively strong post-extinction increase in participants’ willingness-to-eat the CS+. This beneficial effect was still evident at one-week follow up. Also self-reported disgust was lower at one-week follow up when additional safety information was provided. The current findings help explain why disgust is relatively insensitive to CS-only extinction procedures, and provide helpful starting points to improve interventions that are aimed to reduce distress in disgust-related psychopathology.