The DSM Diagnostic Criteria for Vaginismus

Abstract

Vaginal spasm has been considered the defining diagnostic characteristic of vaginismus for approximately 150 years. This remarkable consensus, based primarily on expert clinical opinion, is preserved in the DSM-IV-TR. The available empirical research, however, does not support this definition nor does it support the validity of the DSM-IV-TR distinction between vaginismus and dyspareunia. The small body of research concerning other possible ways or methods of diagnosing vaginismus is critically reviewed. Based on this review, it is proposed that the diagnoses of vaginismus and dyspareunia be collapsed into a single diagnostic entity called “genito-pelvic pain/penetration disorder.” This diagnostic category is defined according to the following five dimensions: percentage success of vaginal penetration; pain with vaginal penetration; fear of vaginal penetration or of genito-pelvic pain during vaginal penetration; pelvic floor muscle dysfunction; medical co-morbidity.

Appendix: Diagnostic Guidelines for the Assessment of Genito-Pelvic Pain/Penetration Disorder

Five dimensions are proposed for the assessment and diagnosis of genito-pelvic pain/penetration disorder: (1) percentage success of vaginal penetration; (2) pain with vaginal penetration; (3) fear of vaginal penetration or of genito-pelvic pain during vaginal penetration; (4) pelvic floor muscle dysfunction; (5) medical co-morbidity.

The description of each dimension includes the following: (1) proposed assessment questions; (2) diagnostic threshold criteria; (3) diagnostic exclusion criteria; (4) interference questions; (5) medical co-morbidity. It is recommended that a woman who complains of difficulties in experiencing vaginal penetration or of pain during sexual intercourse/penetration be assessed on all five dimensions.

The proposed assessment questions are suggested as the minimum assessment that any clinician should make for a woman complaining of difficulties in having vaginal penetration or pain during intercourse/penetration. All of these questions can be directly asked of the client by a mental health clinician though a full assessment of pelvic floor muscle dysfunction and medical comorbidity will require a physical examination and expertise outside of the mental health domain.

The diagnostic threshold criteria provide the specifications by which a clinician can determine that a client is diagnosable with a genito-pelvic pain/penetration disorder. These thresholds are based on the available data and the author’s judgment. These thresholds should be modified when new research is available. To be diagnosed with genito-pelvic pain/penetration disorder, a client must exceed the threshold for only one of the first four dimensions. Clients who exceed the threshold for only the fifth dimension, medical co-morbidity, will be diagnosed with the appropriate medical condition. All dimensions should be assessed for all clients even if they are already diagnosable based on one or two dimensions because this information will be useful in treatment planning and research. Based on the literature review, it is quite likely that most clients will exceed diagnostic thresholds for more than one dimension.

The exclusion criteria provide other diagnoses or information that would exclude a diagnosis of genito-pelvic pain/penetration disorder. For example, a woman would probably not be diagnosed with genito-pelvic pain/penetration disorder if she has never had a partner with an erection sufficient for penetration (or equivalent forms of penetration). Clinician judgment must often be used in determining these exclusion criteria or diagnostic thresholds since not all potential diagnostic circumstances can be specified. For example, the first dimension (percentage success of vaginal penetration) requires at least 10 attempts at intercourse in the last 6 months before the diagnostic threshold can be reached. Some women will not have had 10 attempts in the previous 6 months for a variety of reasons (e.g., they and their partner have “given up trying” or they didn’t have a partner for most of this period). The clinician can determine whether there have been “sufficient” previous attempts to warrant a diagnosis.

The interference questions attempt to determine the degree of interference related to the dimension. These are not diagnostic questions but highlight the important finding that the severity or intensity of a symptom is often not directly related to real life interference. For example, some women reporting excruciating vulvar pain may continue to have intercourse/penetration at relative high frequencies.

Dimension 1: Percentage Success of Vaginal Penetration

• 1. How many times have you attempted to have intercourse or penetration in the last 6 months?

• 2. How many times has there been full penetration into the vagina during this period?

Diagnostic Threshold Criteria

Must have tried to have vaginal intercourse or penetration at least 10 times in the last 6 months and must have failed at least 50% of the time.

Diagnostic Exclusion Criteria

• 1. Lack of adequate erection (or equivalent types of penetration).

• 2. Has not tried at least 10 times.

Interference Question

What is the most important reason that you want to have sexual intercourse or penetration?

• 1. To get pregnant

• 2. To please my partner

• 3. To have pleasure

• 4. To improve our couple relationship

• 5. To improve my sexual self-esteem

• 6. Other (specify)

Clinician Judgment

The clinician should use his/her judgment in determining whether there have been sufficient attempts at intercourse/penetration during the couple’s relationship. It is possible that these have not occurred in the last 6 months. Judgment must also be used in interpreting whether “full penetration” has occurred since some women may not know or may indicate “partial penetration.” It is the author’s experience that “not knowing” or “partial penetration” be interpreted as a failure of penetration though the final judgment should be made by the clinician. If there haven’t been an adequate number of attempts based on the clinician’s judgment and it is believed that that the woman is “avoiding intercourse” based on fear or other factors, then this would be diagnosed under “the fear of vaginal penetration or of pain” dimension below.

Dimension 2: Pain with Vaginal Penetration

• 1. How much pain do you feel pain during (attempted) intercourse/penetration?

  • 0 = No pain

  • 1 = A little pain

  • 2 = Some pain

  • 3 = Moderate pain

  • 4 = Quite a bit of pain

• 2. Could you choose the option which best describes when you feel the pain (you can choose more than one option and pain may also occur independently of intercourse/penetration)?

  • 1. Before (attempted) intercourse/penetration

  • 2. At the beginning of (attempted) intercourse/penetration

  • 3. During thrusting

  • 4. During orgasm

  • 5. After intercourse/penetration is over

  • 6. During gynecological examinations

  • 7. During tampon insertion

  • 8. While wearing tight pants

  • 9. While exercising

  • 10. The pain comes and goes and is not related to intercourse/penetration

  • 11. Other

  • 12. I don’t know (e.g., because I haven’t attempted intercourse/penetration in a long time)

• 3. Looking at the diagram of your genital/pelvic area (see diagram), can you point to where the pain is (it can be in more than one spot)?

• 4. How would you describe the quality of your pain?

The examiner can prompt the interviewee based on the adjectives in the short form of the McGill Pain Questionnaire: throbbing, shooting, stabbing, sharp, cramping, gnawing, hot-burning, aching, heavy, tender, splitting, tiring-exhausting, sickening, fearful, punishing-cruel.

Diagnostic Threshold Criteria

Any reported pain that is directly related to intercourse/penetration and is rated as 3 or 4 should be diagnosed as genito-pelvic pain/penetration disorder.

Diagnostic Exclusion Criteria

If the client reports several different recurrent or chronic pains in non-genital areas, then other diagnoses, such as fibromyalgia or somatization disorder, might be considered. These diagnoses can be co-morbid with genito-pelvic pain/penetration disorder.

Interference Questions

• How much does pain interfere with your ability to experience intercourse/penetration?

• How much does pain interfere with your wish to have intercourse/penetration?

  • 0 = Not at all

  • 1 = A little

  • 2 = Somewhat

  • 3 = Moderately

  • 4 = Quite a bit or always

Clinician’s Judgment

The clinician must use some judgment in interpreting the likely location of the pain since some clients may not be able to answer this question. Judgment may also be necessary in determining how many different pains there are. A superficial vulvar pain as well as a deeper pelvic pain may co-occur in which case both should be noted and rated separately.

Dimension 3: Fear of Vaginal Penetration or of Genito-Pelvic Pain During Vaginal Penetration

• 1. How afraid of, or anxious about, pain do you become when your husband/partner attempts to have intercourse/penetration with you?

  • 0 = Not at all

  • 1 = A little

  • 2 = Somewhat

  • 3 = Moderately

  • 4 = Quite a bit or always

• 2. How generally afraid or anxious do you become about things other than pain, when your partner attempts to have intercourse/penetration with you?

  • 0 = Not at all

  • 1 = A little

  • 2 = Somewhat

  • 3 = Moderately

  • 4 = Quite a bit or always

• 3. How much do you tense up, in general, when your husband/partner tries to have intercourse/penetration with you?

  • 0 = No tension at all

  • 1 = A little tension

  • 2 = Some tension

  • 3 = Moderate tension

  • 4 = Quite a bit of tension.

Diagnostic Threshold Criteria

A rating of 3 or 4 to any of the assessment questions will result in a diagnosis of genito-pelvic pain/penetration disorder.

Diagnostic Exclusion Criteria

This dimension is designed to reflect a fear of vaginal intercourse/penetration or fear of genito-pelvic pain during intercourse/penetration. If the client reports generalized anxiety about all aspects of sexuality or all aspects of social interaction or meets criteria for a generalized anxiety disorder, then alternative diagnoses might be more appropriate. These alternative diagnoses can be comorbid with a diagnosis of genito-pelvic pain/penetration disorder.

Interference Question

How much does fear/anxiety interfere with your ability to have intercourse/penetration?

• 0 = Not at all

• 1 = A little

• 2 = Somewhat

• 3 = Moderately

• 4 = Quite a bit or a lot

Clinician Judgment

The clinician should determine how specific the fear or worry is to vaginal penetration. Some women will deny any fear/worry but will behaviorally avoid any attempts at vaginal penetration by closing their legs or turning away during attempted intercourse or gynecological examinations. Such avoidance might be reasonably interpreted as “fear/anxiety” by the clinician. Such a diagnosis can be made based by asking about tampon use, frequency of gynecological examinations, and frequency of attempted intercourse/penetration. Reissing et al.’s (2004) research criteria of an average of less than 1 attempt at vaginal intercourse every two months over the past year despite adequate opportunity or being involved in a relationship, and also meeting one of the following two criteria (never having seen a health professional for, or never having successfully completed a pelvic exam; never having used tampons) might be useful in determining if a woman is avoiding vaginal penetration.

Dimension 4: Pelvic Floor Muscle Dysfunction

How much do the muscles around your vagina tense or tighten up when your husband/partner tries to have intercourse/penetration with you?

• 0 = No tension at all

• 1 = A little tension

• 2 = Some tension

• 3 = Moderate tension

• 4 = Quite a bit or a lot of tension

Interference Question

How much does this muscle tension (spasm) interfere with your ability to experience intercourse/penetration?

• 0 = Not at all

• 1 = A little

• 2 = Somewhat

• 3 = Moderately

• 4 = Quite a bit or always

Diagnostic Threshold Criteria

Any rating of 3 or 4 on the interference question would result in a diagnosis of genito-pelvic pain/penetration disorder.

Exclusion Criteria

None specified.

Clinician Judgment

In this dimension, the interference question is the crucial diagnostic one. It has not been typical in the past for women to be asked about their genital tension/spasm and it is not clear that there is a diagnosable problem if the woman reports tension/spasm but no interference. A full assessment of pelvic floor muscle functioning is usually best made a pelvic floor physical therapist.

Dimension 5: Medical Co-morbidity

• 1. Do you suffer from any medical/physical conditions or take any medications or have you had any surgery that might have caused your difficulties with penetration or your pain during intercourse? Yes (specify_______________), No, Don’t Know

• 2. Have you (ever) had (completed) a (recent) gynecological examination? Yes (if yes, when) No

• 3. Did you tell your gynecologist about your difficulties with penetration/pain? Yes, No

Diagnostic Threshold Criteria

A mental health professional is not usually in a position to make a medical/gynecological diagnosis of this kind.

Diagnostic Exclusion Criteria

The existence of a medical condition does not exclude or preclude the diagnosis of genital pain/penetration disorder.

Interference Question

Do you think that there is a physical reason for your pain? Yes No Don’t Know

Clinician Judgment

Traditional practice has suggested that physical causes be excluded before psychological diagnoses are made. This model may no longer be appropriate for genital pain/penetration disorder. In fact, it is often impossible to determine with any degree of certainty whether there is or how much basis there is for physical causation. Current pain assessment strategies emphasize multidisciplinary and biopsychosocial models. Prudent current practice for women complaining of genito-pelvic pain/penetration problems suggests that a comprehensive gynecological examination should always be carried out by a health professional familiar with vulvar/pelvic pain syndromes. Mental health professionals should inform gynecologists if the patient they are referring has never completed a gynecological examination. There are, in fact, a very large number of potential physical problems which may be related to genital pain or difficulties in penetration. The mental health professional should attempt to carefully balance the need for multiple invasive gynecological examinations with the chances of finding a treatable physical cause. Unfortunately, there is no available empirically based algorithm on which to base one’s judgment.

Note. In order to assess genito-pelvic pain/penetration disorder in women who are bisexual or lesbian or for women who engage in vaginal penetrative behavior that does not involve penile–vaginal intercourse, the wording of the assessment questions has been written in a manner to allow the assessment of behavioral equivalents of penile–vaginal intercourse/penetration.