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=Genito-Pelvic Pain/Penetration Disorder=

Genito-Pelvic Pain/Penetration Disorder is a new diagnosis proposed for the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). Genito-Pelvic Pain/Penetration Disorder would replace the DSM-IV’s diagnoses of vaginismus and dyspareunia. There is a great deal of over lap between diagnoses of vaginismus and dyspareunia, making differential diagnosis unreliable, and calling into question their definitions as separate disorders (Binik, 2009a; Binik, 2009b; Lahaie, Boyer, Khalifé, & Binik, 2010).

Proposed diagnostic criteria
A diagnosis of Genito-Pelvic Pain/Penetration Disorder would require the following:


 * A. Persistent or recurrent difficulties for at least 6 months with one or more of the following:


 * 1) Inability to have vaginal intercourse/penetration


 * 2) Marked vulvovaginal or pelvic pain during vaginal intercourse/penetration attempts


 * 3) Marked fear or anxiety either about vulvovaginal or pelvic pain or vaginal penetration


 * 4) Marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration


 * B.   The problem causes clinically significant distress or impairment


 * C.    The sexual dysfunction is not better accounted for by another Axis I disorder (except another Sexual Dysfunction) and is not due to the effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition

Primary vaginismus
A woman is said to have primary vaginismus when she has never been able to have penetrative sex or experience vaginal penetration without pain. It is commonly discovered in teenagers and women in their early twenties, as this is when many young women in the Western world first attempt to use tampons, have penetrative sex, or undergo a Pap smear. Women with vaginismus may be unaware of the condition until they attempt vaginal penetration. A woman may be unaware of the reasons for her condition.

Vaginismus has been classified by Lamont according to the severity of the condition. He describes four degrees of vaginismus: In first degree vaginismus, the patient has spasm of the pelvic floor that can be relieved with reassurance. In second degree, the spasm is present but maintained throughout the pelvis even with reassurance. In third degree, the patient elevates the buttocks to avoid being examined. In fourth degree vaginismus (also known as grade 4 vaginismus), the most severe form of vaginismus, the patient elevates the buttocks, retreats and tightly closes the thighs to avoid examination. Pacik expanded the Lamont classification to include a fifth degree in which the patient experiences a visceral reaction such as sweating, hyperventilation, palpitations, trembling, shaking, nausea, vomiting, losing consciousness, wanting to jump off the table, or attacking the doctor. The Lamont classification continues to be used to the present and allows for a common language among researchers and therapists. However, it does not provide for a language with which a woman might best be able to verbalise her concerns, pain or problems and might not be an accurate way of classifying the severity of vaginismus. For instance, a woman with a lot of trust in the doctor might be classified as 1 but experience severe pain. A woman with less trust, or a woman who is or has been subjected to harsh examination, might be classified as 4 or 5 even if the physical discomfort she experiences with attempts at penetration in non-clinical settings is comparatively mild.

Though spasm of the pubococcygeus muscle is commonly thought to be the primary muscle involved in vaginismus, Pacik identified two additionally-involved spastic muscles in treated patients under sedation. These include the entry muscle (bulbocavernosum) and the mid-vaginal muscle (puborectalis). This accounts for the common complaint that patients often report when trying to have intercourse: "It's like hitting a brick wall".

Secondary vaginismus
Secondary vaginismus occurs when a woman who has previously been able to achieve penetration develops vaginismus. This may be due to physical causes such as a yeast infection or trauma during childbirth, while in some cases it may be due to psychological causes, or to a combination of causes. The treatment for secondary vaginismus is the same as for primary vaginismus, although, in these cases, previous experience with successful penetration can assist in a more rapid resolution of the condition. Peri-menopausal and menopausal vaginismus, often due to a drying of the vulvar and vaginal tissues as a result of reduced estrogen, may occur as a result of "micro-tears" first causing sexual pain then leading to vaginismus.

Etiology
A number of biological and psychological factors have been proposed to be involved in the cause and maintenance of vaginismus, however many of these factors have not received strong empirical support

Some of the factors that have been proposed as contributing to vaginismus are:
 * Sex guilt or negative attitudes about sex
 * Relationship problems
 * History of sexual or physical abuse: Although one study found that women with vaginismus were twice as likely to have been sexually abused as children, several other studies have found no relationship between vaginismus and abuse
 * Personality traits such as pain-catastrophizing cognitions (e.g. thinking that sex will inevitably be unbearably painful) and harm-avoidance behaviour (e.g. in the context of vaginismus, avoiding sexual contact)
 * Anxiety: Watts and Nettle found that women with vaginismus reported greater trait anxiety, greater levels of state anxiety, and a greater prevalence of anxiety disorders than women without vaginismus
 * Negative emotional reaction towards sexual stimuli, e.g. disgust both at a deliberate level and also at a more implicit level
 * Highly conservative values, low levels of liberal values, and restricted sexual standards

Treatment
According to the Cochrane Collaboration review of the scientific literature, "In spite of encouraging results reported from uncontrolled case series there is very limited evidence from controlled trials concerning the effectiveness of treatments for vaginismus. Further trials are needed to compare therapies with waiting list control and with other therapies." Although few controlled trials have been carried out, many serious scientific studies have tested and supported the efficacy of the treatment of vaginismus. In all cases where the systematic desensitization method was used, success rates were approximately 90% or better. For an example of one of these studies, see Nasab, M., & Farnoosh, Z.; or for a basic review, see Reissing's literature review (links below). The definition of “successful treatment” is another concern in research evaluating treatment for vaginismus. A Dutch study showed that many women were able to be penetrated after treatment, but far fewer women actually enjoyed being penetrated.

Cognitive-Behavioral Therapy
Research suggests that cognitive-behavioral therapy (CBT) is an effective treatment for vaginismus CBT for vaginismus may involve techniques drawn from both cognitive-behavioral sex therapy and cognitive-behavioral therapy for pain management

Physical
Physical treatment for vaginismus may include sensate focus exercises, exploring the vagina through touch, and desensitization with vaginal dilators. Dilation therapy involves inserting objects into the vagina. When treating the spasms through dilation, the dilators, or probes, used are replaced with gradually larger sizes as the woman progresses.

Paralytics
In cases of vaginismus where more traditional treatments have not been successful, a paralytic agent such as Botox may be used. Botox offers an option that allows women who deeply fear penetration to the point where dilators are "too scary" to move ahead despite this fear. The use of Botox relaxes the muscle spasm for about four months. .

Proposed Changes in the DSM-V
A diagnosis of genito-pelvic pain/penetration disorder has been proposed to replace diagnoses of vaginismus and dyspareunia in the DSM-V. In a review of research on vaginismus, Binik (2009) found that although the current edition of the DSM (DSM-IV-TR) lists vaginal muscle spasm as a diagnostic symptom of vaginismus, vaginal muscle spasm is not unique to vaginismus and does not seem to be present in all cases. In addition, Binik found that research does not support the ability of clinicians to reliably diagnose muscle spasm, perhaps due to the lack of a clear definition. Binik also found that distinctions between vaginismus and dyspareunia are unreliable as there is a great deal of overlap between the diagnoses. Replacing the diagnoses of vaginismus and dyspareunia with a diagnosis of genito-pelvic pain/penetration disorder would address the current problems with differential diagnosis.