Paraphilias, perversions, personality disorders and psychoanalysis: Diagnostic controversies

Jessica Yakeley

In reviewing the current psychiatric classification and diagnostic criteria for the mental disorder of paraphilias, their focus on overt sexual symptomatology whilst neglecting personality pathology can be criticised. From a psychoanalytic viewpoint, sexual fantasies and behaviours which are problematic are usually conceptualized as perversions and seen to be symptoms of underlying personality difficulties and it is these which become the focus of treatment, rather than the behaviours themselves.  At the Portman Clinic we have been using the Shedler-Westen Assessment Procedure (SWAP-200, Westen & Shedler, 1999) since 2010. The SWAP is a psychoanalytically-informed clinician-rated assessment of personality disorder as well as personality functioning. It is a statistically robust, reliable and valid methodology whilst at the same time allows space for clinical perspectives as well as possibilities of a richer, much more comprehensive understanding of the subject under study as it collects both quantitative and narrative data. In this research lecture, we would like to explore the link between paraphilias and personality disorders, presenting both our diagnostic results as well as possible changes that have happened as the results of psychoanalytic psychotherapy. In discussing our findings, we propose that in some cases, paraphilic fantasies and behaviours may be considered to be a personality disorder in itself. This clearly has implications for future assessment and treatment of these disorders.

Jessica Yakeley is a Consultant Psychiatrist in Forensic Psychotherapy and Director of the Portman Clinic, and Director of Medical Education, Tavistock and Portman NHS Foundation Trust. She is also a Fellow of the British Psychoanalytic Society and Editor of the journal Psychoanalytic Psychotherapy. She specializes in the psychoanalytic and psychodynamic treatment of people presenting with violent and sexual problems at the Portman Clinic, a National Health Service out-patient clinic in London. She has published widely on topics including medical education, violence, risk assessment, prison health, and antisocial personality disorder, and is the author of Working with Violence: A Contemporary Psychoanalytic Approach (Palgrave MacMillan (2010), and has edited three other books on Medical Education, Medical Psychotherapy, and Forensic Psychotherapy respectively. She is Research Lead for the Royal College of Psychiatrists Psychotherapy Faculty and for the British Psychoanalytic Council. She is currently leading the national development and implementation of new services for a multi-site randomised-controlled trial of mentalization-based treatment for antisocial personality disorder as part of the UK Government’s National Personality Disorder Offender Pathways Strategy.