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The modification of dysfunctional patterns of sexual arousal through false physiological feedback and… Palace, Eileen Marie 1992

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THE MODIFICATION OF DYSFUNCTIONAL PATTERNS OF SEXUAL AROUSAL THROUGH FALSE PHYSIOLOGICAL FEEDBACK ZND SYMPATHETIC ACTIVATION by EILEEN MARIE PALACE  M.A.,  B.A., Whitman College, 1981 The University of British Columbia,  1988  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY  in THE FACULTY OF GRADUATE STUDIES Department of Psychology  We accept this thesis as conforming to the required standard  Signature(s) removed to protect privacy  THE UNIVERSITY OF BRITISH COLUMBIA July 1992  © Eileen Marie Palace, 1992  In presenting this thesis in  partial fulfilment of the  requirements for an advanced  degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department  or  by  his  or  her  representatives.  It  is  understood  that  copying  or  publication of this thesis for financial gain shall not be allowed without my written permission.  Signature(s) removed to protect privacy (Signature)  Department of  Psycho1oy  The University of British Columbia Vancouver, Canada Date  DE-6 (2/88)  July 31, 1992  ii  ABS TRACT  The effects of sympathetic activation, eliciting film,  induced by an anxiety-  and false positive vaginal blood volume  (VBV)  feedback were examined to identify the mechanisms by which cognitive and physiological response components mediate sexual arousal and may be modified to reverse the dysfunctional process.  Sixty—four matched sexually dysfunctional women were  randomly assigned to one of four conditions:  (a)  anxiety—  evoking or neutral—control preexposure film stimulus paired with an erotic stimulus followed by, VBV feedback or no feedback.  (b)  false positive  Sexual arousal was measured  physiologically with a vaginal photoplethysmograph, subjectively with a self—report rating scale.  and  All subjects  (1)  viewed stimulus series 1 and rated their sexual arousal,  (2)  received the feedback condition and rated their  expectations,  and finally,  (3)  rated their subsequent arousal. Gorzalka  (1990),  viewed stimulus series 2 and Consistent with Palace and  anxiety as compared to neutral preexposure  significantly enhanced the rate and magnitude of genital arousal.  Women who received false VBV feedback reported  significantly greater subjective expectations of sexual arousal,  and consequently demonstrated a significant increase  in their actual vasocongestive responses.  Women who received  false feedback and neutral preexposure subsequently also reported significantly greater perceptions of sexual arousal. Comparison of women in the false feedback groups who significantly increased their expectation with those who  iii  exhibited no change,  revealed that within 30 seconds,  positive  expectancy caused significant increases in actual physiological response.  Finally,  comparison of the subjective and genital  responses of the four groups revealed that women exposed to anxiety—eliciting stimuli and false VBV feedback demonstrated the greatest increases in cognitive expectations and subsequent genital response.  At stimulus series 2,  dysfunctional women  in this group achieved levels of vasocongestion comparable to sexually functional women in the Palace and Gorzalka investigation.  These results  (1)  (1990)  reveal that cognitive and  physiological processes are key components of sexual response, (2)  identify interactive mechanisms by which these components  mediate sexual arousal,  (3)  model of sexual dysfunction,  suggest a cognitive—physiological and  (4)  provide evidence that  interventions directed toward increasing physiological response and cognitive expectancy via sympathetic activation and feedback will reverse the dysfunctional process and initiate a positive cognitive-physiological feedback loop of sexual arousal.  iv  TABLE OF CONTENTS  Page Abstract  ii  List of Tables  vii  List of Figures  viii  Acknowledgments  x  Introduction  1  Patterns of Sexual Arousal  2  Anxiety and Sexual Arousal  9  False Physiological Feedback  20  Vaginal Blood Volume Feedback and Sexual Arousal  27  Sympathetic Activation and False Positive VBV Feedback  31 34  Method Subjects  34  Apparatus and Materials  36  Film Stimuli  36  False Positive VBV and No Feedback Stimuli  37  Physiological Measurement  38  Subjective Measurement  39  Multiaxial Descriptive System for the Sexual  40  Dysfunctions Derogatis Sexual Functioning Inventory State—Trait Anxiety Inventory Procedure  (STAI)  (DSFI)  41 41 42  Session 1  42  Session 2  44  V  Page Data Sampling and Reduction  50  Vaginal Blood Volume  50  Heart Rate  51  Results  51  Characteristics of Matched Groups  52  Adequacy of the False and No Feedback Manipulations  52  Internal Validity of VBV Measures  52  Changeover  52  Preexposure Stimuli  54  Internal Validity of Sympathetic Activation—Eliciting  54  Stimuli Pilot Investigation Physiological Autonomic Arousal  54 (Heart Rate)  55  Subjective Autonomic Arousal  55  Effects of Sympathetic Activation  56  Physiological Sexual Arousal  56  Subjective Sexual Arousal  59  Effects of False Positive VBV Feedback  59  Subjective Sexual Arousal  59  Physiological Sexual Arousal  62  Relationship Between Subjective and Physiological  66  Responses Effects of Sympathetic Activation and False Positive  67  VBV Feedback  Physiological Sexual Arousal  67  Subjective Sexual Arousal  70  vi  Page Discussion  72  Sympathetic Activation Enhances Genital Arousal  73  False Positive VBV Feedback Increases Cognitive  78  Expectations and Experience False Positive VBV Feedback Increases Actual Genital  79  Response Positive Expectations Increase Actual Physiological  80  Response Sympathetic Activation and False Positive VBV Feedback  80  Elicit the Greatest Cognitive Expectations and Physiological Arousal Cognitive and Physiological Response Components Mediate  82  Sexual Arousal Processes of Female Sexual Arousal  83  A Cognitive—Physiological Model of Sexual Dysfunction  88  The Modification of Dysfunctional Patterns of Sexual  89  Arousal Bibliography Appendix Film Scale  93 102 103  £9  J0  SD  ueU1o tuOTDunsIca iciinxes o sdno PeTDDJ,I SJ8.3JqD  DJewoqDIcSd  pTrn Dqde.t6OmeQ  .  ef sa’ivi .o isi’i  TTA  viii LIST OF FIGURES Page Figure 1. Mean vaginal blood volume from baseline)  (millivolts deviation  58  sampled 5 times/second for matched groups  of sexually dysfunctional women during stimulus series 1: anxiety—erotic  (A—E)  or neutral—erotic  (N—E)  stimuli prior  to false positive vaginal blood volume feedback or no feedback. Figure 2. Mean subjective ratings of sexual arousal for  61  matched groups of sexually dysfunctional women during anxiety—erotic  (A—E)  or neutral—erotic  (N—E)  stimuli  and false positive vaginal blood volume feedback or no feedback, rating 2  at rating 1  (following stimulus series 1),  (following feedback),  and rating 3  (following  stimulus series 3) Figure 3. Mean vaginal blood volume from baseline)  (millivolts deviation  sampled 5 times/second for matched groups of  sexually dysfunctional women during anxiety—erotic  (A—E)  neutral—erotic  (prior  to)  65  (N—E)  stimuli,  and stimulus series 2  at stimulus series 1  (following)  or  false positive  vaginal blood volume feedback or no feedback. Fiaure 4. Mean vaginal blood volume from baseline)  (millivolts deviation  sampled 5 times/second for matched groups  of sexually dysfunctional women during stimulus series 2: anxiety—erotic  (A—E)  or neutral—erotic  (N—E)  stimuli  following false positive vaginal blood volume feedback or no feedback.  69  ix  Page Figure 5. Processes by which cognitive and physiological response components interact to mediate sexual arousal: (a)  process by which sympathetic activation  autonomic arousal)  enhances sexual arousal,  (increased (b)  process by  which false positive VBV feedback enhances sexual arousal, and  (c)  proposed process by which sympathetic activation  combined with accurate VBV feedback reverses the dysfunctional process and initiates a positive cognitive— physiological feedback loop of sexual arousal.  84  x  ACKNOWLEDGEMENTS The author wishes to express her appreciation to Dr. Boris Gorzalka, research supervisor, for his insight, advice, and direction, and for his courage to collaborate in initiating a program of research on women’s sexual behavior and a new Sexual Psychophysiology Laboratory in the Department of Psychology. I extend my deepest appreciation to Dr. Jerry Wiggins, for his support, encouragement, and inspiration from conception to completion of this investigation, and for generously volunteering his time as Departmental Committee Chair. I would also like to express my gratitude to the members of the supervisory committee: Dr. Wolfgang Linden, Dr. Anita DeLongis, and Dr. Rebecca Collins for their invaluable advice, support, and guidance throughout this investigation; to Dr. Charlotte Johnston and Dr. Lawrence Ward for their interest and considerate provision of their time; and to Dr. George Szasz for his time, advice, and assistance in recruiting subjects for initial studies in this program of research. This research was supported by University of British Columbia Killam Fellowship to the author and a University of British Columbia Humanities and Social Sciences Grant to Boris Gorzalka. I would especially like to acknowledge the significant contributions of Loren M. Greenen, systems analyst and electronics engineer, who was instrumental in developing an innovative computerized psychophysiological recording and stimulus presentation system for this program of research. Despite major commitments and professional responsibilities, he put forth much time and effort for technical support and trouble—shooting. I am deeply indebted for his unwavering generosity, support, encouragement, and perserverance. The author also wishes to thank Dr. John Wincze for providing erotic film stimuli and Dr. Julia Heiman for providing the subjective Film Scale that were adapted for use in the present study. Gratitude is expressed to journalists Mia Stainsby of the Vancouver Sun Editorial Life section, and Kathy Tait of the Province Editorial Living Department; and therapists Anne Davies, Bianca Rucker, and Dr. Noelle Vogel for their time, interest, and considerable efforts in recruiting women for this study. I am extremely grateful to Julie Foster, Michele Bowers, Camille Bush, Alison Isaacson, Deanna Leippi, Cindy Meston, and Ingrid Moe for their effort, enthusiasm, and commitment to conducting this investigation with sensitivity and professionalism. Finally, I would like to thank the many anonymous women who provided the most valuable contribution in their own right by expending the time and effort to further our knowledge and understanding of women’s sexual behavior.  1  The Modification of Dysfunctional Patterns of Sexual Arousal through False Physiological Feedback and Sympathetic Activation Three decades of research have been directed toward identifying the interrelationship between subjective and physiological response components in the determination of human emotion.  Since Schachter and Singer’s  of emotion,  and Valins’  (1966)  (1962)  two—factor theory  reformulated cognitive theory,  extensive research has been devoted to clarifying these processes in the mediation of fear and anxiety.  In contrast,  psychophysiological research on the mechanisms mediating sexual arousal is still in its infancy Specifically,  (Rosen & Beck,  1988)  innovative and promising research to identify the  relationship between cognitive and physiological processes in women has been initiated over the past two decades.  However,  research progress on women has lagged behind that of men. Controversy exists in the literature regarding how best to operationalize the construct of female sexual arousal,  and  which response components reliably discriminate clinical from nonclinical patterns of sexual response.  Identification  of key response components and their interactive processes in mediating sexual arousal has major implications for (a)  defining the construct of sexual arousal,  valid and reliable assessment measures,  (C)  etiological theory of sexual dysfunction,  (b)  determining  deriving an  and  (d)  developing  effective treatment methods for the alleviation of sexual dysfunction in women.  2 Patterns of Sexual Arousal Until recently  (Palace & Gorzalka,  1992),  contradictory  findings in the literature on the relationship between subjective and physiological patterns of sexual arousal in women were unresolved.  Wincze,  Hoon,  and Hoon  (1976)  compared  the responses of six women seeking treatment for heterogeneous sexual dysfunctions and six nonclinical women during the presentation of a 7—minute erotic stimulus that consisted of a silent black and white videotape of a couple engaging in sexual foreplay.  A battery of self—report measures included rating  the degree of sexual arousal on a 7—point Likert scale. Physiological data were obtained using the direct current  (d—c)  signal from the vaginal photoplethysmograph which measures vaginal blood volume  (VBV)  and reflects location—specific  changes in the pooling of blood in the tissue.  Their results  revealed that dysfunctional women exhibited significantly less physiological sexual arousal in response to erotic stimuli than functional women.  Contrary to the authors’ hypotheses, no  significant group differences were found on subjective ratings of sexual arousal.  Wincze et al.  suggested that these ratings  may reflect demand characteristics of the experimental setting, causing dysfunctional women to report higher levels of arousal than actually experienced. (a)  They concluded that these findings  provide evidence for the validity of VBV as a diagnostic  indicator of sexual dysfunction,  and  (b)  support a behavioral—  physiological interpretation of sexual dysfunction which suggests that dysfunctional women possess a constrained or  3  narrowed repertoire of sexual behavior that may be gradually increased in variety and frequency in order to enhance physiological response. Morokoff and Heiman  (1980)  reported several potential  confounding factors in the Wincze et al.  (1976)  investigation  including the use of unmarried sexually functional subjects as a comparison group for the married dysfunctional women, and a design where half of the functional but none of the dysfunctional women viewed a dysphoric film prior to the erotic stimulus.  In an attempt to clarify and extend the findings  of Wincze et al.,  Morokoff and Heiman used a 9—minute erotic  stimulus that consisted of a silent color videotape of a couple engaging in foreplay and intercourse, a 6—minute erotic audiotape,  and sexual fantasy to compare the responses  of 11 women experiencing low arousal and inorgasmia to 11 nonclinical women.  Subjective measures included rating  the degree of sexual arousal on a 5—point Likert scale. Physiological data were obtained using the alternating current (a—c)  signal from the vaginal photoplethysmograph which  measures vaginal pulse amplitude  (VPA)  and reflects the  strength of the cardiac pulse in the vaginal tissue. to the authors’ hypotheses,  Contrary  no significant group differences  were found on physiological response.  However,  dysfunctional  women rated their sexual arousal as significantly lower than functional women.  No significant correlations were found  between VPA and ratings of sexual arousal during the film condition for either group.  They concluded that these findings  4  (a)  provide evidence for the validity of subjective measures as  diagnostic indicators of sexual dysfunction,  and  (b)  support a  cognitive—affective interpretation of sexual dysfunction which suggests that women with low arousal do not attend to genital and that cognitive techniques focusing on the experience  cues,  of arousal may enhance subjective perceptions Morokoff & Heiman,  (1980)  results,  1977;  1980).  Comparison of the Wincze et al. Heiman  (Heiman,  (1976)  and Morokoff and  investigations reveals seemingly opposite  conclusions,  and implications.  Whereas Wincze et al.  found that sexually functional and dysfunctional women experience different physiological but similar subjective responses to erotic stimuli, Morokoff and Heiman found that these groups experience similar physiological but different subjective responses. Palace and Gorzalka to  (a)  To resolve the apparent discrepancy,  (1992)  conducted an investigation designed  systematically replicate the contradictory findings  using erotic stimulus videotapes adapted from the original investigations;  (b)  reconcile the discrepancy by providing  data supporting an explanation for the seemingly contradictory findings; and (c)  provide empirical evidence clarifying the  structural patterns of physiological and subjective sexual response in sexually functional and dysfunctional women. The Palace and Gorzalka  (1992)  investigation extended the  methodology of previous research in several respects. in addition to the original erotic stimulus videotapes,  First, a  videotape was included that contained a wide range of sexual  5 stimuli  (i.e.,  interactions)  color,  sound,  sexual activities,  This stimulus was found to reliably evoke  .  sexual arousal in sexually functional women 1990;  and verbal  (Palace & Gorzalka,  J. P. Wincze, personal communication, May 27,  1987)  Second, the system of data collection and reduction was designed to provide more valid and reliable physiological data. Hand—calculated deviations from baseline polygraph recordings sampled at 4—second intervals  (Wincze et al.,  1976),  or a  single mean derived from the peak—to—peak amplitude of the two 10—second intervals with the greatest response magnitude (Morokoff & Heiman, to—digital  1980), were replaced by the direct analog—  transfer of 0.0001 mV changes in VBV at  (A/D)  0.20—second intervals across the duration of the stimulus presentations.  Third,  although an extensive battery of self—  report measures were employed in previous studies and Heiman,  1980; Wincze et al.,  1976),  investigators measured  subjective sexual arousal by a single item. broader definition,  (Morokoff  To provide a  encompassing a range of perceptions that  may be attributed as sexual arousal,  sexual arousal was defined  by five self—report items adapted from a more recent version of the Film Scale  (Heiman and Rowland,  1983).  Fourth,  for preexisting levels of sexual experience,  to control  rather than  matching functional and dysfunctional groups on the number of years married,  groups were matched on  (a)  the duration of  sexual experience calculated as the difference between age at first intercourse and current age, experienced sexual behaviors,  and  (b)  the range of  assessed by Experience subtest  6  scores from the Derogatis Sexual Functioning Inventory Derogatis,  1978)  .  Finally,  (DSFI;  in accord with suggestions in the  literature that the lack of group differences in subjective ratings may be related to experimental demand 1976)  (Wincze et al.,  or social dictates which inhibit women from reporting  sexual arousal  (Palace & Gorzalka,  1990),  scripts were  specifically designed to minimize reactivity to assessment by promoting honesty and assuring anonymity and confidentiality. Palace and Gorzalka physiological responses  (1992) (VBV)  compared the subjective and  of sixteen women referred from  therapists for treatment of heterogeneous sexual dysfunctions and sixteen nonclinical women during the presentation of the three erotic stimuli.  Systematic replication of the original  methodology employed by Wincze et al. Heiman  (1980)  (1976)  and Morokoff and  resulted in the replication of several seemingly  contradictory findings.  Analysis of subjective ratings for  the single item “sexually aroused” revealed no significant differences between functional and dysfunctional groups on the Wincze et al.  stimulus;  and a significant difference on the  Morokoff and Heiman stimulus.  Since the Wincze et al.  stimulus  was marginally less subjectively arousing than the Morokoff and Heiman stimulus for functional subjects,  a single subjective  item was unable to statistically differentiate groups. Analyses of subjective ratings across a range of items designed to assess sexual arousal revealed that the dysfunctional group reported significantly less sexual arousal than the functional group in all three stimulus conditions.  Consistent with the  7  findings of Wincze et al.,  analysis of the physiological data  using 4—second time samples revealed a significant difference between groups on the Wincze et al. findings of Morokoff and Heiman,  stimulus.  Contrary to the  a significant difference was  also found on the Morokoff and Heiman stimulus using both their film stimulus and data reduction technique.  Analysis of  physiological response using 0.20—second time samples revealed that the dysfunctional group demonstrated significantly less genital arousal that the functional group in all three erotic stimulus conditions within 30 seconds.  These findings, using  VBV sampled and reduced by three different strategies  (ranging  from 4— to 0.20—second time samples and 1 to 45 time blocks) across three significantly different arousal—eliciting stimulus conditions,  consistently revealed significant differences  between functional and dysfunctional women.  We suggested that  VBV is a more sensitive indicator of sexual arousal than VPA since it reliably discriminates dysfunctional from functional patterns of sexual response. The findings from the Palace and Gorzalka investigation are threefold:  First,  (1992)  they replicated several  seemingly contradictory findings in the literature Heiman,  1980; Wincze et al.,  1976)  .  Second,  (Morokoff &  they reconciled  the discrepancy by providing evidence that contradictory findings may be explained and resolved by the use of improved methods of physiological data collection and reduction, broader assessment of subjective arousal, manipulation checks to assess the arousal—eliciting capacity of erotic stimuli,  and scripts  8  designed to reduce social demand.  Third,  they provided strong  evidence that sexually functional and dysfunctional women exhibit different patterns of physiological and subjective sexual response.  These results reveal that subjective  experience and genital vasocongestion are two primary components of sexual response that reliably discriminate dysfunctional from functional arousal patterns, where dysfunctional women exhibit significantly lower levels of physiological and subjective arousal within 30 seconds of responding to sexual stimuli. These findings have major implications:  First,  they  suggest that physiological response and cognitive experience are critical components in defining the construct of sexual arousal.  Second,  they reveal that VBV and subjective ratings  reliably detect group differences and may provide valuable measures for the diagnosis and assessment of sexual dysfunction.  Third,  they support a cognitive—physiological  etiology of sexual dysfunction where both components are integral to the facilitation or inhibition of sexual arousal. That is,  sexual dysfunction may be the result of an interactive  process whereby negative cognitions and decreased physiological responsivity form a negative feedback loop.  Finally,  these  findings suggest that effective treatment methods may be directed toward modifying negative cognitions and enhancing physiological response in order to reverse the dysfunctional cycle and initiate a positive cognitive—physiological feedback loop of sexual arousal.  9 The key questions that remain concern the mechanisms by which cognitive and physiological components interact to mediate sexual arousal, and can be modified to reverse the dysfunctional process.  That is,  how do cognitive and  physiological processes interact to produce arousal, conversely,  or  to prevent arousal and produce a dysfunctional  pattern of sexual response?  To investigate these questions,  two areas of research will be reviewed.  Physiological  mechanisms will be explored by examining the effects of modifying sexual arousal through anxiety—induction.  Cognitive  mechanisms will be explored by examining the effects of modifying cognitions through false physiological feedback. Anxiety and Sexual Arousal Anxiety has been viewed as a major determinant of low sexual arousal and a leading cause of sexual dysfunction in men and women.  Wolpe  (1958,  1982)  has claimed that anxiety  reciprocally inhibits the parasympathetic response components that elicit sexual arousal.  Masters and Johnson  (1970)  described anxiety as the greatest known deterrent to sexual arousal due to its effect of inhibiting physiological response by interfering with the reception of sexual stimuli. Similarly,  Kaplan  (1974,  1988)  has identified anxiety as the  critical mechanism that prevents physiological sexual arousal through the disruption of autonomic nervous system functioning. Based on these assumptions,  researchers and clinicians have  widely adopted anxiety—reduction techniques in their treatment of sexually dysfunctional men and women.  However,  programs  10  incorporating sensate focus for the alleviation of performance anxiety in women experiencing orgasmic dysfunction have revealed failure rates ranging from 26% to as high as 75% (e.g., Andersen,  1983; Cooper,  Kuriansky & Sharpe,  1981)  .  1981;  Crown & D’Ardenne,  In addition,  1982;  a review of controlled  studies that employed systematic desensitization for the treatment of inorgasmia revealed no significant change in orgasmic frequency  (Andersen,  1983)  One explanation for the questionable efficacy of anxiety— reduction techniques for the treatment of sexual dysfunction is the assumption that autonomic control of sexual arousal is predominantly parasympathetic.  Despite general acceptance  that parasympathetic activation is required for the arousal response, the autonomic pathways and processes by which sexual excitation is initiated and heightened remain a matter of conjecture  (Schnieden & Rees,  1985)  that anxiety—reduction techniques,  .  Barlow  (1986)  has argued  which are presumed to  enhance sexual arousal by increasing parasympathetic response and/or decreasing sympathetic response,  are derived from  etiological hypotheses based on clinical inferences rather than empirical data.  Techniques such as sensate focus therefore  enjoy widespread clinical popularity despite their lack of a theoretical rationale supported by empirical knowledge of the initiating stimuli and autonomic processes that control female sexual arousal.  Contrary to etiological assumptions of more  than 30 years, a growing research literature indicates that heightened anxiety,  characterized by sympathetic activation,  11  may enhance rather than inhibit sexual arousal. P. W.  Hoon,  Wincze,  and Hoon  (1977b)  demonstrated that  sexual arousal is enhanced in sexually functional women when they are exposed to an anxiety—evoking rather that relaxation— inducing film stimulus prior to exposure to sexual stimuli. Investigations with sexually functional men have also demonstrated a facilitatory effect of anxiety on sexual arousal,  in which anxiety has been operationally defined as  crossing a fear—arousing suspension bridge  (Dutton & Aron,  1974),  viewing an anxiety—evoking film segment  1980),  receiving the threat of a shock contingent on the size  of erection  (Barlow,  Sakheim,  & Beck 1983),  (Woichik et al.,  and receiving  performance demand instructions to self—monitor and maintain an erection  (Heiman & Rowland,  1983)  These studies provide  .  evidence against the role of anxiety as an inhibitory mechanism and demonstrate that in certain conditions,  anxiety enhances  sexual arousal in functional men and women. To examine the effects of anxiety on sexually dysfunctional men, (1984,  J. G. Beck, Barlow,  cited in Barlow,  shock threat paradigm  1986)  Sakheim,  and Abrahamson  systematically replicated their  (Barlow et al.,  1983)  sexually dysfunctional and functional men.  using matched Penile tumescence  was measured during each of three counterbalanced conditions in which subjects viewed an erotic film: (performance anxiety), anxiety), (1983)  and  (c)  (b)  no shock.  (a)  contingent threat  noncontingent threat Similarly,  (generalized  Heiman and Rowland  compared self—reported sexual arousal and penile  12  tumescence in two preexposure conditions paired with erotic tapes: a performance demand set,  instructing the subjects in  the importance of self—monitoring and maintaining an erection, and a non—demand sensate focus set,  instructing the subjects  to relax and enjoy any pleasurable sensations that might occur. The results of these investigations revealed that sexually functional and dysfunctional men respond differently to pairings of anxiety—evoking and erotic cues:  Anxiety,  defined  as performance demands to maintain an erection either by verbal instruction or contingent on shock,  increased physiological  sexual arousal in functional men and decreased physiological sexual arousal in dysfunctional men. An additional investigation provides insight to the interaction between response components in the mediation of sexual arousal in men.  To examine the effect of visual genital  feedback on subjective and physiological response, Barlow,  Beck,  and Abrahamson  (1984)  Sakheim,  exposed sexually functional  men to erotic films judged to be of varying intensity. Subjects were prevented from viewing their genital responding by covering the genital area with a sheet in one condition, and allowed visual attention to penile response in the second. The results revealed that when functional men are exposed to intense erotic stimuli,  visual attention to penile tumescence  elicits significantly greater levels of physiological arousal. This finding suggests that visuosensory awareness of genital arousal provides a significant cue for subjective appraisal of sexual arousal.  Accordingly, the literature suggests a high  13  degree of concordance between physiological and subjective sexual response in men 1988; 1981)  (Heiman & Rowland,  Steinman, Wincze, .  Sakheim,  Barlow,  1983; Rosen & Beck, & Mavissakalian,  The finding that under certain conditions anxiety  inhibits sexual arousal in dysfunctional men 1986,  1988;  Heiman & Rowland,  Barlow,  (e.g.,  1983) may therefore involve a  complex interactive process between subjective expectancies and genital cues. Barlow  (1986,  Based on these and a related series of studies, 1988)  has proposed an etiological model that  delineates the process by which cognitive and physiological factors interact in a feedback loop to produce functional or dysfunctional patterns of sexual response. model,  anxiety  (i.e.,  According to this  increased autonomic arousal)  enhances  sexual arousal for functional subjects by facilitating their ability to focus on and attend to erotic cues. dysfunctional subjects however,  For  anxiety inhibits sexual  arousal by facilitating the efficiency with which they distract themselves from sexual stimuli by focusing on nonerotic cues.  Barlow (1986)  contends that the processes of cognitive  interference and anxiety interact in a negative feedback loop to produce dysfunctional patterns of sexual response in men and women.  Until recently however  (Palace & Gorzalka,  1990),  the effects of anxiety on sexual responding in dysfunctional subjects have been tested exclusively with men. To investigate the effects of anxiety on sexual arousal in sexually dysfunctional women, Palace and Gorzalka  (1990)  compared the physiological and subjective responses of sixteen  14  dysfunctional and sixteen matched functional women to two videotape conditions: an anxiety—evoking and neutral—control preexposure stimulus, experimental stimulus.  each paired with a sexual arousal—evoking Changes in sexual arousal were measured  physiologically with a vaginal photoplethysmograph subjectively with a self—report rating scale. the findings of P. W. Hoon et al.  (VBV),  and  Consistent with  (1977b), the results revealed  that anxiety preexposure elicited enhanced genital arousal in sexually functional women.  Contrary to the findings with men,  dysfunctional women also achieved a significantly enhanced rate and magnitude of genital arousal following exposure to the anxiety stimulus.  Despite their increased physiological  responses, both groups rated the anxiety—erotic condition as significantly less sexually arousing.  These findings reveal  the potential for a desynchronous relationship between cognitive and physiological sexual response in women. The finding that the components of female sexual response are not necessarily concordant & Gorzalka,  1990;  (Morokoff & Heiman,  Steinman et al.,  1980; Palace  1981; Wincze et al.,  1976)  suggests that women and men may differ in the physiological— subjective processes mediating sexual arousal to erotic stimuli.  We have suggested  (Palace & Gorzalka,  1990)  several factors may account for this discrepancy.  that  First,  social dictates and double standards of sexual etiquette may discourage women from attending to or verbally acknowledging genital cues.  This interpretation is consistent with the  finding that discordance for the functional women was as great  15  as for the dysfunctional women,  and that no group differences  were revealed in perceptions of physical sexual change, autonomic change,  or affective response to erotic stimuli.  In some instances, this lack of attentional focus may become a conditioned response,  attenuating or extinguishing the arousal  response to sexual cues.  Second, because women possess a  less obvious physiological feedback system (e.g., vasocongestion versus erection),  vaginal  some women may experience more  difficulty attending to bodily cues  (Heiman,  1977),  yielding  a lack of synchrony between physiological and subjectively experienced arousal.  This is not to suggest that genital  arousal is less intense in women than in men, but rather that the lack of a physically observable reminder may facilitate social demands for women to ignore or habituate to sexual arousal similar to the way that men and women often disregard other internal cues such as hunger or fatigue. The findings of the Palace and Gorzalka  (1990)  investigation challenge several explanations for the effects of anxiety.  The finding that both functional and dysfunctional  women reported a significantly greater level of autonomic arousal  (anxious,  perspiration,  worried,  faster breathing,  feelings of warmth,  faster heart beat,  and physical reaction)  during  the erotic stimuli following anxiety as compared with neutral preexposure suggests that anxiety arousal carried over to the erotic condition  (i.e.,  was experienced simultaneously)  .  It  is important to note that these cognitions did not inhibit physiological arousal, but rather accompanied enhanced genital  16  response. (Wolpe,  This finding cannot be explained by anxiety relief  1978)  given that anxiety was reported throughout the  erotic exposure and there were no significant differences in VBV between stimulus conditions at changeover. explained by misattribution Dutton & Aron,  1974)  (Beggs,  Calhoun,  It is also not  & Woichik,  1987;  given that subjective and physiological  reports were opposite and not reciprocally influenced.  Neither  did anxiety serve to diminish genital arousal by facilitating distraction from erotic cues  (Barlow,  1986,  1988),  physiological arousal was significantly enhanced.  given that Rather,  these findings suggest an alternative explanation for the effects of anxiety on sexual arousal:  Anxiety may enhance  sexual arousal through the direct instigation and facilitation of sympathetic activation heart rate,  (i.e.,  increased blood pressure,  respiration, and muscle tension)  prepare the individual for sexual arousal  which serves to  (vasocongestion)  Cognitive expectancy may provide a secondary component that further increases or decreases the physiological effect elicited by activation of the sympathetic nervous system An additional finding from the Palace and Gorzalka  (SNS) (1990)  study may be relevant to understanding the components mediating sexual response.  Comparison of the physiological responses of  functional and dysfunctional women revealed that the functional women experienced significant decreases in VBV during anxiety preexposure, Similarly,  whereas dysfunctional women experienced no change.  it was noted that a jagged line across preexposure  and erotic stimuli reflected greater fluctuations in the  17  individual genital responses of functional women. smooth line for the dysfunctional women however, a high degree of VBV consistency.  A relatively reflected  Group differences in  physiological response may therefore also be explained by individual differences in response lability, physiological capacity for autonomic arousal.  defined as the It may be that  the lability of the autonomic response system facilitates both heightened anxiety  (sympathetic activity)  arousal in functional women. dysfunctional women,  Conversely,  in sexually  an underreactive autonomic response system  may suppress both of these responses. finding,  as well as sexual  Jupp and McCabe  (1989)  Consistent with this  revealed a curvilinear  relationship between self—reported general arousability and sexual dysfunction,  such that women reporting both extreme  high and low levels of arousability were also more likely to experience low sexual desire.  It may be that sexual arousal  is enhanced with increasing sympathetic activity to an optimal point,  at which time further increases in sympathetic activity  cause a suppression of sexual arousal.  Whereas some women  with high autonomic lability may therefore experience an overstimulation of SNS and phobic anxiety of sexual stimuli, more frequently,  women with low autonomic reactivity may  experience inadequate stimulation of SNS and therefore the suppression of sexual arousal. Based on the Palace and Gorzalka  (1990,  1992)  findings,  it is proposed that the sexual arousal experienced by women consists of two components:  (1)  a biologically predetermined  18  or conditioned physiological capacity for autonomic arousal (response lability),  and  (2)  for sexual arousal.  Physiologically,  a conditioned cognitive expectancy “anxiety” may enhance  sexual arousal in both sexually functional and dysfunctional women because generalized sympathetic activation directly provides a “jump start” or preparedness for sexual arousal. When sexual cues are provided,  this enhanced sympathetic  responsivity may activate specific genital responses.  Women  with greater response lability may therefore experience proportionately more anxiety as genital arousal.  (sympathetic activity)  as well  The conditioned cognitive expectancy for  “failure” or responding “inadequately” to sexual stimuli may encourage women to ignore erotic cues and thereby facilitate the extinction of genital arousal. the Palace and Gorzalka  (1990)  This interpretation of  findings suggests that anxiety  enhances genital arousal for both functional and dysfunctional women through sympathetic activation, but that both conditions yield lower arousal for dysfunctional women as a result of the interaction of a physiological tendency toward low response lability and negative expectancy,  which produces a negative  feedback loop of dysfunctional sexual response. The Palace and Gorzalka  (1990)  findings suggest that  common components of treatment for sexually dysfunctional women,  directed toward extinguishing anxiety and increasing  parasympathetic response, may be counterproductive to the physiological elicitation of sexual arousal. interpretation does not,  of course,  Whereas this  rule out a role in sexual  19  arousal for the parasympathetic nervous system,  it suggests a  more significant role for the sympathetic nervous system than previously assumed.  Accordingly,  anxiety—reduction techniques  may serve to inhibit the sympathetic activation required for the instigation and enhancement of physiological arousal. Schwartz and Masters  (1988)  claim that sensate focus techniques  are appropriate to all cases of inhibited sexual desire. However,  results of the Palace and Gorzalka  (1990)  study  revealed that of the dysfunctional sample experiencing low desire,  100% experienced enhanced genital arousal following  exposure to the anxiety—eliciting stimulus.  This effect was  consistent across a heterogeneous population including women experiencing low desire, inorgasmia,  low arousal, primary and secondary  and dyspareunia.  These findings suggest that  treatment may instead be directed toward  (a)  providing  sympathetic activation as a means of physiological preparedness for genital response,  especially in those instances where  response lability may be low,  and  (b)  altering conditioned  negative expectancy regarding sexual response when exposed to erotic stimuli.  Although some women who experience phobic  anxiety of sexual stimuli may not find this treatment effective, these findings suggest that for most women, sympathetic excitation may be the process whereby sexual arousal is elicited and enhanced. We proposed that the interactional influences of physiological response lability and cognitive expectancy produce a positive feedback loop of sexual arousal,  or  20  conversely, response.  a negative feedback loop of dysfunctional sexual Accordingly,  effective treatment may focus on  strategies whereby women learn response synchrony such that physiological excitation, that occurs naturally through sympathetic activation,  and cognitive expectation are directed  toward a positive feedback ioop of sexual arousal. False Physiological Feedback Traditionally, the strategy for experimental modification of subjects’  cognitions has involved false feedback.  False  feedback techniques are directed toward inducing subjects to infer that they have responded physiologically in a manner contrary to their expectations.  This paradigm has been used  extensively in research examining the response components mediating emotions such as fear and anxiety. Valins and Ray  (1967)  For example,  conducted a prototypical study where  subjects fearful of snakes were presented with slides depicting snakes,  and slides of the word “shock” followed by a finger  shock.  During the slide presentation, experimental subjects  received auditory stimuli described as heart rate feedback, while control subjects heard the same sounds described as extraneous noise.  For all subjects,  the frequency of these  sounds increased during the shock slides, but remained stable during the snake slides. false heart rate feedback,  They found that subjects who received indicating that physiologically they  did not react fearfully to the phobic stimuli,  subsequently  showed more snake—approach behavior than control subjects. In two additional studies, Valins  (1966,  1967)  presented male  21  subjects with slides of seminude females while listening to prerecorded sounds identified as heart rate feedback or extraneous noise.  During the presentation of each slide,  subjects heard these sounds increase, constant. groups,  decrease,  or remain  The results revealed that for false feedback  slides accompanied by a change in heart rate,  increased or decreased,  whether  received greater subjective ratings of  attractiveness than slides accompanied by stable heart rate. Further,  slides paired with heart—rate increase feedback  received the greatest ratings of attractiveness. The findings of the Valins’ (Valins,  1966,  and Singer’s  series of investigations  1967; Valins & Ray,  (1962)  1967)  challenge Schachter  theory which asserts that an emotional  response is produced when cognitive labels are attached to ambiguous physiological states of arousal.  Valins asserts  that changes in an emotional state may be accomplished in the absence of physiological changes.  Given his finding that bogus  physiological feedback altered both subjective perceptions (Valins,  1966,  1967)  and behavioral response  (Valins & Ray,  1967), he suggests that cognitive factors alone are sufficient to elicit an emotional response.  That is,  when subjects  believed they were less afraid, they were able to behave in a less fearful manner, response.  regardless of alterations in physiological  These findings have been used to support cognitive,  as opposed to physiologically mediated techniques for the treatment of anxiety disorders. Numerous investigators employing this paradigm have  22  replicated the finding that false physiological feedback heart rate,  electrodermal activity  [EDA])  is effective in  modifying subjective perceptions of fear and anxiety Borkovec, Wall,  & Stone,  Holmes & Frost,  1976; Kent, Wilson,  1973;  Lick,  1975; Rosen,  attractiveness  Clark, 1974;  Stern,  Botto,  Giesen,  & Grant,  Dubois,  1978)  & Reid,  & Van Gelderen,  & Herrick,  In general,  1973),  1971; Bloemkolk, 1971;  Botto,  Gaibraith,  1972; Hirschman,  1978; Misovich & Charis,  & Clark,  and depression  1972;  1972; Koenig,  1972), unpleasantness  1975),  (e.g.,  & Galbraith,  1972; Wilson,  & Mettee,  Hirschman,  & Borden,  1980), .  Stern,  & Nelson,  1977; Kerber & Coles,  1976; Young,  (Hendrick, Ewy,  Rosen,  1974; Goldstein, Fink,  & Hawk,  & Hagan,  Gaupp,  (e.g., Barefoot & Straub,  Defares, Van Enckevort, & Stern,  1974;  (i.e.,  (Thornton  1982), persuasion  life stress (Stern,  (Stern, Miller,  Berrenberg,  Winn,  the literature reveals a positive  linear relationship between the level of false physiological feedback and the modification of emotional experience cognitions or subjective perceptions)  .  (i.e.,  One major criticism  of these investigations has involved the frequent absence of measures to identify the effect of false feedback on actual physiological response.  The finding that false feedback  modifies actual autonomic arousal would challenge Valins’ theory that emotion is an entirely cognitive phenomenon. Rather,  it would provide evidence that both cognitive and  physiological processes are involved in the mediation of emotion and the resultant behavioral response. In an attempt to clarify the relationship between false  &  23 feedback,  subjective experience,  Woll and McFall Valins  (1966,  (1979)  1967)  and physiological response,  systematically replicated and extended  investigation by adding the accurate  measurement of heart rate during all conditions.  This is  the only investigation in the literature that has examined the effects of false feedback on subjective ratings of attractiveness and heart rate in women. previous findings with men Botto et al.,  (e.g.,  Consistent with  Barefoot & Straub,  1974; Goldstein et al.,  1972),  false feedback  was successful in modifying subjective perceptions. is,  1971;  That  slides of seminude men accompanied by bogus heart rate  increases were rated as significantly more attractive and more arousing than slides accompanied by no change in heart rate. Further,  slides paired with increased false heart rate showed  significantly greater changes in actual heart rate.  Despite  the effect of false feedback in modifying both subjective ratings and cardiac activity,  correlations between these  response measures were generally nonsignificant. The Woll and McFall  (1979)  finding that false feedback  elicited changes in actual physiological activity has received mixed support in the literature.  Some researchers have found  that bogus feedback exerts an effect on actual physiological processes  (i.e.,  heart rate,  with fear and anxiety Glasgow, (e.g.,  (e.g.,  1973; Gaupp et al.,  Bloemkolk et al.,  unpleasantness  EDA,  alpha activity)  Borkovec, 1972;  1973; Borkovec &  Lick,  1975),  1971; Kerber & Coles,  (Hirschman & Hawk,  1978;  associated  attractiveness 1978),  Young et al.,  1982),  24  alpha experiences discomfort 1976),  (Plotkin,  (Hirschman,  1980; Valle & Levine,  1975),  and attitude  1975),  (Detweiler & Zanna,  while other studies have revealed contradictory  findings.  For example,  heart rate,  EDA,  no actual physiological effects  electromyograph response,  (i.e.,  alpha activity)  have  been found in response to false feedback associated with fear and anxiety Maynard,  (e.g.,  Turns,  Borkovec et al.,  & Taunton—Blackwood,  Watson,  Smith,  & Gaas,  et al.,  1972),  attractiveness  & Charis,  1974;  Stern et al.,  1972),  Valle,  1977; Pressner & Savitsky,  alpha experiences  .  Therefore,  1976;  (Hirschman et al.,  1976),  1977)  1979; Gatchel,  1977; Holmes & Frost,  Hagan,  Canter,  1974; Gatchel,  1977),  Elkin,  Hatch, Rosen  1977; Misovich  unpleasantness  (DeGood,  Hatch,  (Thornton &  Lessin,  and headaches  & (Kondo &  despite the modification of  cognitive and/or behavioral processes,  false physiological  feedback has been found to be effective in modifying actual physiological processes for only some emotional responses and some investigations. Explanation of these contradictory findings may involve the experimental confounds of subject demand and attention. Parkinson  (1985)  suggests that subject demand characteristics  may have contributed to the subjective ratings obtained in some of these investigations.  For example,  subjects may report  higher ratings of attractiveness based on the assumption that the experimenter expects those slides displaying the greatest heart rate to obtain the highest ratings,  or based on a desire  not to appear foolish by contradicting objective physiological  25  evidence.  Changes in subjective ratings during the bogus  feedback condition may therefore reflect experimental demand rather than the direct modification of cognitions.  In  situations where bogus feedback failed to influence actual autonomic responses,  it is difficult to interpret whether the  modification of cognitions had no effect on physiological response,  or the cognitive ratings reflected subject demand  as opposed to an actual modification of cognitive expectancy. The latter explanation may account for the finding that some investigations have not revealed a physiological change corresponding to the modification of subjective perceptions. In regard to attentional factors,  the majority of these  investigations have employed an “extraneous noise” condition as a control for continuous auditory false feedback. et al.  (1972)  Stern  revealed that attentional factors were as  important as false feedback in modifying subjective ratings. That is,  subjects in the extraneous noise condition who were  instructed to attend to these stimuli while viewing slides of automobile accident victims, false feedback group,  i.e.,  exhibited ratings similar to the slides accompanying increases in  noise frequency were rated as significantly more unpleasant. Since changes in autonomic activity deceleration) processes  (e.g., heart rate  have been found to accompany attentional  (Lacey,  1967;  Lacey & Lacey,  1974),  the attentional  component alone may modify subjective and physiological arousal.  This interpretation suggests that  (a)  attentional  factors need to be adequately controlled in order to determine  26  the effects of bogus feedback on subjective response, (b)  and  the differential attention—eliciting nature of the feedback  may explain contradictory findings regarding the ability of false feedback to modify actual physiological response. Investigations directed toward minimizing subject demand and providing equivalent attention—eliciting information to both control and experimental groups may rule out alternate hypotheses regarding the effects of feedback on subjective response,  and provide less ambiguous information regarding its  effects on physiological response. Despite the influence of demand and attentional factors in obscuring the interpretability of the literature on the effects of false feedback, many researchers support Valins’  contention  to minimize the importance of physiological activity in emotional experience. and Clark  (1983)  In a review of the literature, Hirschman  conclude that “to the extent that cognitive  factors generally are prepotent,  it may be necessary to  reassess some of the assumptions underlying physiologically— based theories of emotion and physiologically—based treatments for anxiety”  (p.  Rosen and Beck  209)  (1988)  .  Similarly,  in regard to sexual arousal,  claim that “an individual’s awareness or  self—report of internally experienced arousal is primary in defining a response as sexual,  irrespective of the nature or  extent of his or her physiological reactions”  (p.  28—29)  The finding that these response components may be discordant for many women 1990,  1992;  (Morokoff & Heiman,  Steinman et al.,  1980; Palace & Gorzalka,  1981; Wincze et al.,  1976) but  27  concordant for men Steinman et al.,  (Heiman & Rowland,  1981),  1983; Rosen & Beck,  1988;  and that dysfunctional women exhibit  significantly less subjective and physiologically experienced sexual arousal than functional women 1992),  (Palace & Gorzalka,  suggests that understanding the influence of both these  components is imperative for identifying the mechanisms that mediate sexual arousal.  If false feedback is able to elicit  changes in both subjective and physiological processes,  it may  elicit an alternate interactional pattern of sexual response. That is,  for those women where false feedback concurrently  modifies subjective perceptions of sexual arousal and genital arousal,  there may be an increase in response synchrony similar  to that generally experienced by men,  and the initiation of a  positive cognitive—physiological feedback ioop. Vaginal Blood Volume Feedback and Sexual Arousal To date,  only four investigations have examined the  effects of genital feedback on sexual arousal, feedback.  (i.e.,  vaginal vasocongestion)  and only one of these has employed false  These investigations were directed toward examining  voluntary control of the vaginal vasocongestive response,  and  the efficacy of biofeedback as a therapeutic technique for facilitating control of genital arousal.  Cerny  presented women with one of three conditions: accurate feedback,  continuous noncontingent  (1978)  continuous  (false)  feedback,  or no feedback while viewing a 3—minute erotic videotape. Subjects were instructed to increase their vasocongestive response  (VBV and VPA)  for half of the trials,  and to suppress  28  it for the remaining trials.  Although subjects were able  to demonstrate voluntary control of genital vasocongestion, feedback was not found to facilitate enhancement of genital or subjective sexual response. between groups using VBV,  That is,  no differences were found  while VPA data revealed that the  false and accurate feedback groups achieved lower levels of physiological sexual arousal than the no feedback control group.  No significant differences were found in the VPA  responses of women in the false and accurate feedback groups. Similarly,  P. W. Hoon,  Wincze,  and Hoon  with continuous visual VBV feedback,  (1977a)  provided women  instructions to fantasize,  or VBV feedback in combination with instructions to fantasize. The results revealed that over repeated trials, biofeedback in combination with erotic fantasy produced significant increases in VBV whereas biofeedback alone was ineffective in facilitating genital arousal.  E. F. Hoon  (1980)  further  compared the effects of auditory and visual feedback modalities,  and no feedback control conditions during  instructions to increase or decrease genital response. Consistent with the Cerny  (1978)  findings, VBV, VPA,  and  subjective levels of sexual arousal were significantly higher under instructions to increase arousal,  and correlations  between subjective and physiological response were found only for VBV.  Although compared to audio feedback,  visual feedback  was found to elicit significantly greater overall control of sexual arousal,  consistent with previous findings  P. W. Hoon et al.,  (Cerny,  1977a), biofeedback did not appreciably  1978;  29  improve voluntary control of genital arousal. One explanation for the finding that continuous feedback is ineffective in the modification of genital arousal 1978; P. W. 1988)  Hoon et al.,  1977a)  is distraction.  (Cerny,  Barlow  (1986,  has suggested that sexual arousal in functional men is  decreased by tasks competing with the processing of erotic stimuli and performance—related sexual cues.  Although visual  attention to penile tumescence has been found to elicit significantly greater levels of physiological arousal et al.,  1984),  distraction  passages from a novel)  (i.e.,  audiotape of nonsexual  while viewing erotic films has been  found to significantly decrease sexual arousal Barlow,  Sakheim,  Beck,  & Athanasiou,  1985)  .  (Abrahamson,  Similarly,  attention to a continuous auditory or visual display or false)  (Sakheim  (accurate  of one’s physiological response may create a strong  diversion from erotic stimuli.  According to Barlow’s model,  continuous feedback may decrease sexual arousal by inhibiting the ability to focus on and attend to erotic stimuli. Continuous visual or auditory feedback of vaginal vasocongestion in the form of “beeps” or lines may not be equivalent to the continuous feedback inherent in visual attention to penile tumescence, and may divert attention from,  rather than direct attention to,  erotic stimuli.  This distraction confound may explain the findings that (a)  continuous biofeedback did not improve voluntary control of  sexual arousal  (Cerny,  1978; P. W. Hoon et al.,  1977a),  (b)  no  feedback was superior to accurate or false continuous feedback  30 in facilitating voluntary control of sexual arousal 1978),  and  (c)  (Cerny,  biofeedback combined with erotic fantasy was  superior to feedback alone in facilitating genital arousal (P. W. Hoon et al.,  1977a)  (i.e.,  erotic fantasy may distract  the individual from distracting feedback, arousal)  .  thereby enhancing  Also consistent with this interpretation is the  finding by Zingheim and Sandman  (1978)  that significant  increases in VPA were achieved in one experimental trial when a discriminative control procedure using operant techniques was employed,  i.e.,  a feedback light was displayed contingent upon  achievement of the desired response.  Because these subjects  were not presented with a continuous auditory or visual display of vasocongestive response patterns,  they may have been less  distracted from cognitive or physiological techniques employed to increase vasocongestion.  Similarly, because they were not  exposed to erotic film or slide stimuli,  this feedback may  have provided less distraction from exogenous erotic stimuli. The results from investigations examining the effectiveness of biofeedback in modifying genital arousal suggest that sexually functional women can exert voluntary control of vaginal vasocongestion 1980),  (Cerny,  1978; E. F. Hoon,  that accurate feedback can facilitate modification of  physiological responding  (VPA)  (Zingheim & Sandman,  1978),  and that cognitions in the form of erotic fantasy can enhance physiological responding  (VBV)  (P. W. Hoon et al.,  1977a).  These investigations also contraindicate the use of continuous feedback in paradigms examining sexual arousal because  31  distraction may confound the effects of feedback on voluntary control of genital arousal. Sympathetic Activation and False Positive VBV Feedback We have proposed  (Palace & Gorzalka,  1990,  1992)  that the  interactional influences of a physiological tendency toward low response lability and negative cognitive expectancy produce a negative feedback loop of dysfunctional sexual response. Accordingly,  strategies directed toward enhancing physiological  responsivity via sympathetic activation and modifying negative cognitions via false positive VBV feedback are hypothesized to reverse the negative dysfunctional cycle and initiate a positive cognitive—physiological feedback loop of sexual arousal. To date, no one has investigated the effects of false feedback of vaginal vasocongestion in the modification of cognitions,  or the extent to which cognitive expectations  mediate actual genital response.  In addition,  this is the  first investigation to examine the effects of feedback on sexual arousal in sexually dysfunctional women. The purpose of the present study was to identify the mechanisms by which cognitive and physiological response components mediate sexual arousal,  and may be modified to  reverse the dysfunctional process.  Five questions will be  addressed: 1.  Does sympathetic activation arousal)  (increased autonomic  enhance physiological  sexual arousal?  (VBV)  and subjective  32  2.  Does false positive feedback of genital vasocongestion (VBV)  modify cognitive response  (subjective  expectations and the subsequent experience of sexual arousal)? 3.  Does false positive VBV feedback modify actual physiological response?  4.  Does the modification of cognitive expectations alter actual physiological response?  5.  Do the combined effects of sympathetic activation and false positive VBV feedback elicit the greatest increases in physiological and subjective sexual arousal in sexually dysfunctional women?  Palace and Gorzalka  (1990,  1992)  found that sexually  dysfunctional women report significantly lower levels of autonomic arousal and exhibit less autonomic lability than sexually functional women.  A pilot study was therefore  conducted with functional women to select videotape stimuli that,  compared to neutral stimuli,  activation  elicited sympathetic  (increased autonomic arousal)  as defined by  increased mean levels of heart rate and subjective ratings of anxiety and autonomic arousal. questions,  To investigate the above  sympathetic activation was induced in sexually  dysfunctional women by exposure to these anxiety—eliciting videotapes  (threatened amputation and impending danger),  and  autonomic activity was measured by heart rate and subjective ratings of anxiety and autonomic arousal.  Positive expectancy  was induced by providing subjects with false feedback of a  33  high vaginal vasocongestive response,  and was measured by  the comparison of subjective ratings of sexual arousal to erotic stimuli prior to and following the feedback condition. Sexually dysfunctional women were assigned to one of four conditions:  (a)  anxiety—evoking or neutral—control preexposure  videotape stimulus paired with an erotic videotape stimulus followed by,  (b)  false positive VBV feedback or no feedback.  All subjects  (1)  viewed stimulus series 1 and rated their  sexual arousal,  (2)  received the feedback condition and rated  their expectations, and finally,  (3)  viewed stimulus series 2  and rated their subsequent perceptions of sexual arousal. Physiological  (VBV)  and subjective measures of sexual arousal  were assessed for all subjects in response to the two presentations of anxiety—erotic or neutral—erotic stimuli, prior to and following the feedback condition.  In order to  maximize attentional factors and minimize distraction,  all  subjects received a discrete analogue chart of VBV responses reported to be their own, film series.  following presentation of the first  The false feedback groups were provided with  information regarding their vasocongestive responses to erotic stimuli, whereas the no feedback groups were provided only with information regarding their vasocongestive responses to orienting and neutral stimuli,  and no feedback regarding  their genital responses to erotic stimuli.  Subject demand was  minimized by having subjects seal their subjective ratings in an envelope.  In addition,  scripts were specifically designed  to decrease subject demand and assure confidentiality.  An  34 accurate feedback group was not employed because  (a)  feedback  depicting a decrease in VBV in response to erotic stimuli might have validated negative expectations and reinforced dysfunctional response patterns, Cerny  (1978)  study,  and  (b)  as evidenced by the  feedback depicting an increase in VBV in  response to erotic stimuli would mimic the false feedback manipulation.  Finally,  Palace and Gorzalka  in accord with  (1990)  (b)  suggestions by  that low autonomic lability may be  related to sexual dysfunction and  (a)  (inadequate stimulation of SNS),  the finding by Jupp and McCabe  (1989)  that self—report  measures reveal a curvilinear relationship between general arousability and sexual dysfunction,  sexually dysfunctional  women were matched on pretest self—report indices of state— dependent anxiety. Method Subjects Sixty—four women experiencing psychogenic sexual dysfunction participated in the investigation.  Subjects  were recruited from the community through local newspaper advertisements requesting women experiencing “current complaints of low or decreased sexual desire, arousal,  or other sexual difficulties.”  decreased sexual  Subjects included in  the investigation were 22 years of age and above, taking medications of any kind, orientation,  were not  had an exclusive heterosexual  and reported dissatisfaction with their current  sexual functioning.  Women did not participate if they were  menstruating, pregnant,  or had begun menopause.  During an  35 initial interview, profile descriptions of each woman’s sexual behavior were obtained using the Multiaxial Descriptive System for the Sexual Dysfunctions & LoPiccolo,  1982)  .  (Schover,  Friedman, Weiler, Heiman,  All women included in the investigation  experienced subjective,  behavioral,  or physiological problems  associated with one or more of the desire, phases of the sexual response cycle, pain.  arousal,  or experienced coital  In addition, the Sexual Functioning Index  Global Sexual Satisfaction Index  or orgasm  (GSSI)  (SF1)  and  subscales of the DSFI  were used to corroborate verbal reports and clinical profiles. The DSFI scores of all women included in the investigation fulfilled at least one of two criteria:  (a)  scored at least  1 SD below the 50th percentile on both the SF1  (i.e., the  overall level of sexual functioning was less than the mean for the normative sample)  and GSSI  (i.e.,  their current level  of sexual functioning rated poor to could not be worse), (b)  or  scored at least 1 SD below the 50th percentile on either  the SF1 or GSSI subscales other),  (and below the 50th percentile on the  and negatively endorsed the satisfaction subtest item,  “Usually I have a satisfying orgasm with sex.”  These criteria  were developed in order to prevent excluding women who were orgasmic but experienced low drive or arousal  (Criterion a)  and those who experienced normal levels of arousal but were unable to reach orgasm  (Criterion b; Palace & Gorzalka,  Finally, the Brief Symptom Inventory  (BSI; Derogatis,  1992)  1975)  subtest of the DSFI was used to screen all subjects for absence of general psychopathology using the 30th percentile as the  36 cutoff criterion  (i.e.,  within 2 SD of the mean for the  normative sample) Subjects were matched on the following criteria: (b)  duration of sexual experience,  experience, (e)  (d)  age,  repertoire of sexual  level of state—dependent anxiety,  sexual dysfunction,  four groups  (c)  (a)  and  and randomly assigned to one of the  (16 per group).  The experience subtest of the DSFI  was used to verify that all subjects experienced a similar repertoire of sexual behaviors, of sexual experience,  and reported a similar duration  calculated as the difference between age  at first intercourse and current age.  State—dependent anxiety  was assessed by the state—anxiety scale of the State—Trait Anxiety Inventory  (STAI;  Spielberger,  1983)  .  Profile  descriptions from the Multiaxial Descriptive System for the Sexual Dysfunctions were used to assess sexual dysfunction. Participation in the study was voluntary, prior to treatment,  occurred  and did not affect the course of further  treatment or medical care.  All subjects were paid $20 for  their participation and provided with a list of referrals to local therapists specializing, in the treatment of sexual dysfunction. Apparatus and Materials Film stimuli.  Preexposure stimuli consisted of four  3—minute videotapes: two neutral sequences that depicted nature in the Arctic and Antarctica,  and two anxiety—eliciting  sequences that depicted threatened amputation and impending danger.  The experimental stimuli,  or erotic sequences,  37  consisted of two 3—minute videotapes of a nude heterosexual couple engaging in foreplay and intercourse.  The contents of  the erotic scenes were matched on the number,  order, type,  and  duration of sexual activities and contained the same actors and setting. To assess the validity of the stimulus manipulations,  a  separate pilot study was conducted with five potential anxiety— eliciting and two potential neutral videotape segments.  Ten  sexually functional women viewed the randomly assigned anxiety and neutral segments.  The two anxiety—evoking segments that  elicited the greatest mean heart rate in beats per minute and subjective ratings of anxiety and autonomic arousal were selected. and VBV)  These segments elicited equivalent physiological and subjective ratings of anxiety,  and sexual arousal. these measures.  autonomic arousal,  The neutral segments were also matched on  The erotic videotapes have previously been  found to evoke equivalent levels of genital subjective sexual arousal,  (VBV)  1990,  and  and to reliably elicit sexual  arousal in functional and dysfunctional women Gorzalka,  (HR  (Palace &  1992)  False positive VBV and no feedback stimuli.  A prerecorded  polygraph chart from a vaginal photoplethysmograph that depicted the VBV responses of a sexually functional woman during the presentation of a 3—minute erotic stimulus was employed as false positive VBV feedback.  This record displayed  an analogue VBV response that originated at baseline and increased to ceiling levels of pen deflection  (i.e.,  5 my or  38 35 millimeters pen deflection)  .  This chart showed the greatest  increase in blood volume deviation from baseline levels in response to erotic stimuli observed in the individual charts of 32 sexually functional women  (Palace and Gorzalka,  1990,  1992)  A prerecorded polygraph chart from a vaginal photoplethysmograph that depicted the analogue VBV responses of a sexually functional woman during the presentation of a neutral stimulus was selected as the no feedback stimulus. This VBV response remained highly stable  (i.e.,  0 my or  0 millimeters pen deflection from baseline) Physiological measurement. (Sintchak & Geer,  1975)  was used to measure physiological  sexual arousal by changes in VBV, in VPA.  A vaginal photoplethysmograph  and heart rate by changes  Direct measures of genital response are the only  physiological indices capable of clearly and reliably discriminating sexual arousal from general autonomic arousal  (Zuckerman,  1971),  and the specificity of vaginal  photoplethysmography to sexual stimulation is well established (P. W. Hoon,  1979).  Vaginal blood volume was selected to  measure sexual arousal in accordance with suggestions in the literature that,  although there are two vasocongestive measures  that can be obtained from the photoplethysmograph,  VBV which is  thought to reflect location—specific changes in the direction, rate,  and magnitude of vaginal blood flow during engorgement  may be the maximally sensitive measure of genital vasocongestion Hoon,  Wincze,  (J. G. Beck, & Hoon,  1976;  Sakheim,  & Barlow,  Palace & Gorzalka,  1983; P. W. 1992; Rosen &  39  Beck,  1988)  To minimize potential light history and  temperature sensitivity effects, stability,  and to assess baseline  the photoplethysmograph was allowed a 45—minute  warm—up period prior to insertion,  followed by a 10—minute  recorded adaptation period prior to the onset of videotape stimuli.  The signal from the Geer gauge and module  Instruments)  (Farrall  was channeled through an optical isolator—power  supply and monitored on a Beckman Type R 611 dynagraph.  The  VBV signal for each subject was recorded at a sampling rate of 5 times/second using the Data Translation A/D converter and Labtech Notebook software 1986)  (Laboratory Technologies Corporation,  installed on a Compaq 386 microcomputer.  The software  program timed the administration of the videotape stimuli and employed a trigger signal to initiate recording and mark stimulus changeover. Subjective measurement.  A self—report rating scale  comprised of 12 items was used to assess subjective perceptions of physical sexual change autonomic arousal  (5 items),  (5 items),  for complete item list)  .  and anxiety  (1 item)  (1 item),  (see Appendix  Subjective sexual arousal was  defined by six items on this scale: sensations,  sexual arousal  warmth in genitals,  genital pulsing or throbbing,  Sexually aroused,  breast  genital wetness or lubrication,  and any genital feelings.  Subjects rated the degree to which they experienced these items on 7—point Likert scales from not at all  (1)  to intensely  The subjective reaction scale was adapted from Heiman and Rowland  (1983)  and has been determined to be a sensitive  (7)  40  indicator of emotional reactions to erotic stimuli Hatch, 1992)  .  1980; Morokoff & Heiman,  (Heiman &  1980; Palace & Gorzalka,  1990,  No significant differences have been found in results  obtained by methods of discrete versus continuous subjective measurement  (Steinman et al.,  1981)  Multiaxial Descriptive System for the Sexual Dysfunctions. The Multiaxial Descriptive System for the Sexual Dysfunctions (Schover et al.,  1982)  behavior on six axes:  provides a profile description of sexual (a)  desire,  (b)  phases of the sexual response cycle;  arousal, (d)  and  (C)  orgasm  types of coital pain;  (e)  dissatisfaction with the frequency of sexual activity; and  (f)  qualifying information including unusual sexual preferences  that may affect compatibility with partners, may influence the prognosis of therapy,  and problems that  e.g., physical abuse,  severe marital distress,  substance abuse,  possibly affecting sex.  Each axis includes physiological,  subjective,  and medication  and/or behavioral descriptions,  and is modified  according to whether the problem was the presenting complaint of the client and/or determined by the therapist.  The first  five axes are modified along two additional dimensions: lifelong versus not lifelong,  and global versus situational.  This system was selected because unlike the DSM—III—R and other current diagnostic systems for sexual dysfunctions,  the  Multiaxial Descriptive System provides specific operational descriptions of sexual behavior based on empirically—derived quantitative criteria.  It simultaneously provides a  comprehensive descriptive profile of sexual response by  41  accounting for problem areas along a continuum of as many as six equally important areas of sexual functioning. Derogatis Sexual Functioning Inventory  (DSFI).  The DSFI  is a standardized self—report multidimensional inventory comprised of eight distinct subtests designed to measure the current level of sexual functioning.  The Experience subtest  assesses the range of hierarchically scaled sexual behaviors experienced by the individual, progressing from fundamental (“clothed embrace”)  to relatively advanced  stimulation of genitals”)  (“mutual oral  The subtest measuring psychological  .  symptomology is a distinct psychometric diagnostic instrument, the BSI,  empirically validated prior to the development of the  DSFI as an independent measure of psychopathology.  The DSFI  provides a profile score derived from a summation of the subtest scores, the SF1,  reflecting the overall quality of  current sexual functioning;  and a single item score, the GSSI,  reflecting the respondent’s self—perception of the quality of sexual functioning.  This instrument has been determined to  be a valid and reliable measure for differentiating sexually functional and dysfunctional women & Melisaratos,  (Derogatis,  1979; Derogatis & Meyer,  State—Trait Anxiety Inventory scale of the revised STAI  1979)  (STAfl  (Form Y—1;  1980; Derogatis  .  The State—anxiety  Spielberger,  1983)  is  composed of 20 self—report items designed to measure transitory feelings of fear or worry. ranging from 20 to 80,  The scale provides a single score  with higher scores indicating greater  situational anxiety, and presents data on the relative  42  magnitude of perceived anxiety relative to normative and psychiatric patient samples. Procedure The procedure consisted of two sessions each lasting 2 hours.  All subjects were requested to abstain from  psychoactive drugs  (including caffeine and alcohol)  for  24 hours prior to each session. Session 1.  Following an initial telephone interview,  subjects were scheduled for a first session with a female experimenter.  During this session,  laboratory facilities and equipment,  subjects viewed the received verbal  instructions on the use of the photoplethysmograph,  and were  allowed to discuss any questions related to the experiment. They were told that the purpose of the investigation was to learn about emotional and physiological reactions to brief visual stimuli,  some of which may include erotic content.  Subjects choosing to participate signed the standard consent form and completed the following questionnaires and procedures: 1.  Semi—structured interview regarding the presenting complaint  (Multiaxial Descriptive System for the  Sexual Dysfunctions) 2.  Derogatis Sexual Functioning Inventory  3.  State—anxiety scale of the STAI  4.  Baseline assessment of VBV and heart rate  To minimize experimental demand, follows:  subjects were instructed as  43  It is very important to remember that there are no right or wrong answers to any of the information you will give us today.  Each person is unique and only you know about  your sexual history and behavior.  The way that you can be  most helpful to us is to try to be as honest as you can be.  Also remember that all information is completely  confidential.  All of your forms are assigned a code,  so that we will have no record of who gave us this information.  It is important to us that that you feel  comfortable telling us about your background and how you are feeling during the study,  and knowing that this  information is private. The DSFI and State—anxiety scale were completed in a separate subject room.  When these were completed,  baselines of VBV and heart rate were obtained. diagrammed instructions,  resting  With the aid of  subjects were instructed to insert the  photoplethysmograph with the incandescent light source facing the anterior aspect of the vaginal wall. photoplethysmograph in a private, room maintained at a constant 21.7 sterilized in Cidex between uses.  Subjects inserted the  internally-locked subject C.  The instrument was  (long—life activated dialdehyde solution)  A color television monitor was positioned where  subjects could sit comfortably in a recliner with a full view of the screen.  Subjects remained fully clothed and were  covered with a light blanket.  They were instructed through an  intercom to sit quietly for at least 10 minutes prior to the onset of the film for purposes of adaptation,  and to remain as  44  still as possible throughout the session.  All subjects were  presented a 1—minute segment displaying the word “relax,” followed by a 1—minute neutral orientation stimulus, 3—minute neutral stimulus.  and a  VBV and heart rate were recorded  during the last 80 seconds of the neutral stimulus.  Subjects  fulfilling the inclusion criteria were contacted by telephone to schedule a second session for the experimental procedure. Session 2.  To minimize experimental demand,  the second session,  during  subjects were reminded of the previous  instructions: As you know,  we are interested in learning about emotional  and physiological reactions to brief visual stimuli, of which may include erotic content.  some  Although I will be  explaining the details of the experiment and giving you instructions as we go along,  today you will be asked to  sit back and watch a series of short films while I monitor your heart rate and vaginal blood volume on this machine. Following some of the films,  I will ask you to fill out a  short questionnaire regarding your feelings and reactions. At one point,  I will also ask you to lay back and relax  for about 10—15 minutes to assure that your responses look like the resting levels we charted last time. are waiting,  I should be able to show you part of your  physiological record.  Since it is important to get a  large sample of information, baseline levels, Once again,  While you  once your responses are at  we will show you a second group of films.  it is very important to remember that there  45  are no right or wrong answers to any of the information you will give us.  Every person is unique and only you  will know how you feel about the different films we will show you.  The way that you can be most helpful to us is  to be as honest as you can be, the films,  to be the best monitor of your own responses  that you can be. particular, at home!  and while you are watching  Please don’t try to feel anything in  just lay back and watch the movies just like  Also remember that all information is completely  confidential.  All of your forms are assigned a code,  so that we will have no record of who gave us this information.  To assure this confidentiality,  following  each of the forms that you will fill out today,  I will ask  you to seal it in an envelope so that neither I nor my assistant will see your responses.  In this way, we hope  that you will feel comfortable telling us how you are feeling and knowing that this information is private. Following these instructions,  subjects inserted the  photoplethysmograph in accordance with the previous procedure. All subjects underwent the following experimental sequence: 1.  Stimulus Series 1  (A—E or N—E condition)  2.  Rating 1  (subjective rating scale)  3.  Feedback  (false feedback or no feedback condition)  4.  Rating 2  5.  Stimulus Series 2  6.  Rating 3  46  Each stimulus series began with a 1—minute segment displaying the word “relax,” followed by a 1—minute neutral orientation stimulus,  the 3—minute anxiety or neutral preexposure stimulus,  and finally the 3—minute erotic experimental stimulus. Changeover from preexposure to experimental stimuli was immediate.  Stimulus series 1 and 2 contained the same type of  preexposure stimuli,  for example,  subjects viewing A—E stimuli  for the first series viewed the matched A—E stimuli during the second series. condition.  Stimulus series were counterbalanced within  Immediately following the conclusion of each erotic  stimulus presentation,  subjects completed the subjective rating  scale for the preceding series. of rating 1,  Following the completion  the experimenter informed subjects by intercom  that she would enter the subject room to show them their physiological record.  The false positive feedback group was  given the standard false feedback stimulus and information regarding their genital responses to erotic stimuli: This is a preliminary record of your physiological responses to the films.  I thought you might be interested  in seeing what it looks like so far.  We have recorded  your heart rate and vaginal blood volume. bumps you see here are your heart beats. sexually aroused, the vagina.  The little When you become  there is an increase in blood flow to  This is called “vasocongestion.”  Remember  I showed you that the vaginal photoplethysmograph has a small light on the inside.  It is very sensitive to  changes in light and dark on the vaginal wall and converts  47  these changes to an electrical impulse which drives the pens on the polygraph.  When you become sexually  aroused and blood flows into the area, that is, more vasocongestion,  the light can’t reflect off the vaginal  wall as well and the pen line on this chart goes up.  When  you become unaroused and the blood flows out of the area, that is,  less vasocongestion, the light can reflect off  the vaginal wall better, and the line on the chart goes down.  To summarize,  goes up;  remember, more sexual,,arousal —> line  less sexual arousal —> line goes down.  During  the 10—minutes you were resting at the beginning,  during  the time the screen said “relax,” and during the National Geographic film [orienting stimulus],  you can see that  your heart rate and vaginal blood volume were very stable, as we would expect. size and the line flat.  The bumps  (heart beats)  (vaginal blood volume)  In contrast,  as you can see,  are the same  is relatively  once the erotic film  started there is a very large change in your physiological response.  Your heart beats are much larger,  and there  is a steady increase in your sexual arousal.  This chart  displays very clearly an enormous increase in your physiological arousal all the way to the end of the film. In fact,  at the end of the film,  you reached the highest  level of sexual arousal that the pens are set to record for this study.  Since the computer also recorded this  information and can pick up a wider range of responses, I can tell you that it goes even a bit higher.  I will  48  let you look at this for a few moments... it may take awhile for your physiological responses to return to resting levels,  so I would like you to lay back and relax for  another five minutes or so before we begin the next group of films. The no feedback group was given the standard no feedback stimulus and no information regarding their genital responses to erotic stimuli.  They were told that this was a record of  their baseline VBV recorded during the first session. This is a preliminary record of your physiological responses to the nature films you saw last time.  I  thought you might be interested in seeing what it looks like.  We have recorded your heart rate and vaginal blood  volume. beats.  The little bumps you see here are your heart When you become sexually aroused, there is an  increase in blood flow to the vagina. “vasocongestion.”  This is called  Remember I showed you that the vaginal  photoplethysmograph has a small light on the inside. It is very sensitive to changes in light and dark on the vaginal wall and converts these changes to an electrical impulse which drives the pens on the polygraph.  When you  become sexually aroused and blood flows into the area, that is, more vasocongestion, the light can’t reflect off the vaginal wall as well and the pen line on this chart goes up.  When you become unaroused and the blood flows  out of the area,  that is,  less vasocongestion, the light  can reflect off the vaginal wall better,  and the line on  49 the chart goes down.  To summarize,  arousal —> line goes up; down.  remember, more sexual  less sexual arousal —> line goes  During the 10—minutes you were resting at the  beginning,  during the time the screen said “relax,” and  during the National Geographic film  [orienting stimulus],  you can see that your heart rate and vaginal blood volume were very stable, beats) volume)  as we would expect.  are the same size and the line is relatively flat.  Nova film  The bumps  (vaginal blood  Also as you can see, when the  [neutral stimulus]  started, there are relatively  no changes in your physiological response. beats are about the same, remains steady.  (heart  Your heart  and your level of sexual arousal  This chart displays very clearly a stable  physiological responses all the way to the end of the film.  As we would expect,  at the end of the film,  the pen  line is in about the same level as when the films began. Since the computer also recorded this information,  I can  tell you that it also shows a stable resting baseline. I will let you look at this for a few moments... we want to assure that all your physiological responses are at these resting levels now,  so I would like you to lay back and  relax for another five minutes or so before we begin the next group of films. Five minutes after the experimenter left the room,  all  subjects were instructed as follows: We are ready to begin the next group of films.  This group  of films will be similar to the last ones you saw.  Before  50 we show them to you,  I would like you to complete the form  on your left marked “number 2” just as you did before, only this time I would like you to indicate how aroused you “expect” to feel during the next film.  After you  have completed it, please seal it in the envelope marked “number 2,” and let me know when you are finished. Five minutes after the completion of rating 2, readings had not returned to baseline level,  if VBV  subjects were  asked to count aloud backwards by serial numbers from 100 to facilitate decreased arousal. to baseline level,  When VBV readings returned  stimulus series 2 was presented.  conclusion of the experimental session,  At the  a semi—structured  interview was conducted with each subject in order to (a)  assure their comfort with the procedure and understanding  of the instructions, manipulation,  and  (c)  (b)  assess their belief in the feedback  acquire further information regarding  their interpretations and cognitions accompanying feedback. Finally,  all subjects were thoroughly debriefed regarding  the deception,  shown their actual VBV record,  and informed  about the additional purposes and goals of the study. Data Sampling and Reduction Vaginal blood volume.  The level of sexual arousal for  each subject was measured in 0.0001 mV units of VBV deviation from a baseline reference level recorded at the point of changeover from the preexposure to experimental stimulus.  VBV  data were collected 5 times/second during the last 80 seconds of preexposure and the entire 180 seconds of experimental  51  stimuli for both stimulus series 1 and 2 points/subject/series)  (1,300 data  For graphic representation of  .  continuous VBV across subjects,  each time sample was averaged  across all subjects in each group  (i.e.,  2 stimulus conditions  X 2 feedback conditions X 2 stimulus series X 1,300 0.20 second means)  .  For the statistical analyses,  0.20 second time samples  for each subject and stimulus series were averaged across 10—second time blocks to yield 26 means. Heart rate.  Heart rate data were calculated from VPA  recordings in beats per minute during the last 60 seconds of preexposure and the entire 180 seconds of experimental stimuli for both stimulus series 1 and 2. Results Analyses were conducted for two between—group factors, (a)  stimulus condition  (anxiety—erotic vs. neutral—erotic),  (b)  feedback condition  (false feedback vs. no feedback),  two within—subject factors subjective rating  (1 vs.  stimulus series  (C)  2 vs.  3),  and  (18 ten—second VBV time block means)  (d)  (1 vs.  2)  and  and or  time block mean  Since multiple repeated  .  measurements are likely to violate the traditional ANOVA assumptions of independence and sphericity, multivariate tests based on the Pillai—Bartlett trace statistic were used for all data analyses involving more than two repeated measurements (O’Brien & Kaiser,  1985; Olson,  1976)  .  Multivariate F tests  were followed up with univariate analyses and Newman—Keuls contrasts.  An alpha level of  all experimental results.  .01 was set as criterion for  52 Characteristics of Matched Groups Psychometric and demographic characteristics of the four matched groups of sexually dysfunctional women are shown in Table 1.  A 2 X 2 X 6  (Stimulus X Feedback X Measure)  multivariate analysis of variance  (MANOVA)  significant main or interaction effects.  yielded no These analyses  revealed that there were no significant differences in the matched groups of sexually dysfunctional women on the variables of age,  duration of sexual experience,  experience anxiety  (DSFI experience score),  (STAI state—anxiety score),  functioning  (SF1),  functioning  (GSSI).  repertoire of sexual  level of state—dependent overall quality of sexual  or self—perception of the quality of sexual -  Adequacy of the False and No Feedback Manipulations To be effective,  subjects must have perceived and accepted  the false positive feedback of vaginal vasocongestion as an accurate depiction of their own genital responses to erotic stimuli.  Semi—structured interviews at the conclusion of  the experimental session revealed that all 32 subjects in the false feedback conditions accepted the bogus VBV feedback as veridical.  In addition,  all 32 of the subjects in the no  feedback conditions believed that the standardized chart depicting stable VBV responses to neutral and orienting stimuli was their own. Internal Validity of VBV Measures Changeover.  To verify that no differences in VBV  occurred between groups or stimulus series at changeover from  39.25 3.57 35-47  Global Sexual Satisfaction Index  SD Range  2-27  49.19 6.87 36-63  36.37 4.10 30-47  37.84 7.42 20-48  50.69 7.38 40-63  14.56 9.03  32.44 9.34 22-48  M  Anxiety-erotic No feedback SD Range  4-26  51.69 7.44 38-64  38.87 2.68 35-45  33.87 7.81 20-45  49.37 8.02 32-63  15.31 6.65  31.56 6.71 22-43  M  Neuiral-erotic False feedback  SD Range  3-31  52.19 7.32 42-66  37.37 3.93 30-45  34.75 8.80 20-48  47.94 7.30 32-63  14.87 7.09  31.94 6.78 22-48  M  Neutral-erotic No feedback  Note. Duration of Sexual Experience is calculated as the difference between age at first intercourse and current age. Means for the Derogatis Sexual Functioning Inventory and the State-Trait Anxiety Inventory are based on raw scores that were converted to established percentile ranicings (T scores).  State Anxiety 50.87 6.99 41-64  38.03 9.08 20-49  Sexual Functioning Index  State-Trait Anxiety Inventory  49.00 9.34 31-63  Experience subtest  Derogatis Sexual Functioning Inventory  4-29  18.25 7.36  Duration of sexual experience  SD Range  35.75 8.64 22-50  M  Age  Measure  Anxiety-erotic False feedback  Demographic and Psychometric Characteristics ofMatched Groups of Sexually Dysfunctional Women  Table 1.  (4)  54 preexposure to experimental stimuli, VBV baseline levels across the last 10 seconds of preexposure stimuli for series 1 and 2 were averaged separately and compared prior to reference level adjustment.  A 2 X 2 X 2  analysis of variance feedback,  series,  (ANOVA)  (Stimulus X Feedback X Series)  revealed no significant stimulus,  or interaction effects.  Preexposure stimuli.  A 2 X 2 X 2 X 8  X Series X 10—second Time Block Mean)  (Stimulus X Feedback  MANOVA was computed to  verify that no significant differences in VBV occurred across the last 80 seconds of neutral or anxiety stimulus preexposure in relation to baseline levels at changeover within or between stimulus series 1 and 2.  The results revealed no significant  main or interaction effects.  These findings validate the  assumption that subjects in each group and stimulus series demonstrated similar levels of genital arousal before the onset of the experimental stimuli. Internal Validity of Sympathetic Activation—Eliciting Stimuli Pilot investigation. X Subjective Items)  A 7 X 6  (Anxiety and Neutral Stimuli  MANOVA was performed on the pilot data to  determine if any of the five anxiety—eliciting stimuli evoked significantly greater autonomic arousal than the neutral stimuli for sexually functional women.  The two anxiety stimuli  that produced the greatest mean levels of heart rate and the highest mean subjective ratings of anxiety and autonomic arousal were also found to elicit increased heart rate as compared to neutral stimuli.  Simple effects analyses to  compare these anxiety—eliciting and neutral stimuli revealed  55 that sexually functional women reported significantly greater perceptions of sympathetic activity during the anxiety stimuli, (1,  9)  =  58.30,  =  .00012.  These reports of enhanced  autonomic arousal included “anxious,” “faster breathing,” “faster heart beat,” “perspiration,” “feelings of warmth” and “any physical reaction at all.”  These findings support the  assumption that for sexually functional women,  the preexposure  stimuli depicting threatened amputation and impending danger elicited moderate levels of sympathetic activation, by increased mean levels of heart rate,  as defined  and subjective ratings  of anxiety and autonomic arousal. Physiological autonomic arousal investigate if,  (heart rate)  for sexually dysfunctional women,  To  .  (a)  the  anxiety manipulation elicited greater heart rate than the neutral preexposure stimuli for series 1 and 2,  and  (b)  this  level of autonomic arousal was equivalent for series 1 and 2, a 2 X 2  (Stimulus X Series)  ANOVA was calculated on the heart  rate data during preexposure conditions.  These analyses  yielded no significant main or interaction effects and reveal that for sexually dysfunctional women,  (a)  heart rate was not  significantly changed by anxiety induction and,  (b)  heart rate  during anxiety preexposure stimuli remained relatively stable between series 1 and 2. Subjective autonomic arousal.  A 2 X 2  (Stimulus X Rating)  ANOVA on subjective ratings of autonomic arousal at ratings 1 and 3 yielded no significant main or interaction effects. Consistent with the heart rate data, this analysis revealed  56 that dysfunctional women in the anxiety—erotic as compared to neutral—erotic conditions did not report significantly greater subjective perceptions of anxiety or autonomic arousal.  These  findings differ from the significantly enhanced autonomic arousal and anxiety reported by sexually functional women in the pilot study. Effects of Sympathetic Activation Physiological sexual arousal.  Mean VBV data for sexually  dysfunctional women during anxiety—erotic and neutral—erotic conditions in stimulus series 1 are presented in Figure 1. 2 X 2 X 18  A  (Stimulus X Feedback X 10—Second Time Block Mean)  MANOVA was computed to investigate if exposure to an anxiety— eliciting stimulus enhances genital arousal.  No significant  feedback effect was found which verifies the assumption that prior to implementing the feedback conditions,  false and no  feedback groups demonstrated similar levels of arousal. multivariate F for stimulus, £(1, time, E(17,  44)  =  7.84,  <  60)  .00001,  =  11.84,  =  The  .0014,  and  effects were significant.  These analyses reveal that whereas both groups demonstrated significant increases in arousal as a function of time, women exposed to anxiety—eliciting as compared to neutral stimuli subsequently demonstrated significantly greater genital arousal.  Specifically, post hoc comparisons between stimulus  conditions at each time block revealed that women exposed to anxiety as compared to neutral preexposure demonstrated significantly greater genital arousal within 10 seconds of the onset of the erotic film.  This arousal—enhancing effect of  57 Figure 1. Mean vaginal blood volume baseline)  (millivolts deviation from  sampled 5 times/second for matched groups of sexually  dysfunctional women during stimulus series 1: anxiety—erotic (A—E)  or neutral—erotic  (N—E)  stimuli prior to false positive  vaginal blood volume feedback or no feedback.  Figure 1.  I  I  a)  —1  0  1  2  3  4  5  -80  -60  -40  — A-E False Feedback — A-E No Feedback N-E False Feedback N-E No Feedback  -20  Preexposure Stimuli  0  20  60 SECONDS  40  80  100  Experimental Stimuli  Stimulus Series 1  120  140  160  180  OD  59 anxiety remained significant at each time block throughout the remainder of the erotic stimuli. Subjective sexual arousal.  Mean subjective ratings of  sexual arousal for sexually dysfunctional women during anxiety— erotic and neutral—erotic conditions at rating 1 are presented in Figure 2.  A 2 X 2  (Stimulus X Feedback)  ANOVA was computed  to investigate the effects of exposure to an anxiety—eliciting stimulus on subjective perceptions of sexual arousal.  No  significant feedback effect or Stimulus X Feedback interaction was found which verifies the assumption that prior to implementing the feedback conditions,  false and no feedback  groups demonstrated similar levels of arousal.  There was also  no significant stimulus effect, which indicates that despite the finding that women exposed to anxiety—eliciting as compared to neutral stimuli demonstrated significantly greater genital responses,  they reported no significant differences in their  subjective perceptions of sexual arousal. Effects of False Positive VBV Feedback Subjective sexual arousal.  To investigate the effects of  false positive VBV feedback on cognitive expectations of sexual arousal,  a 2 X 2 X 3  was performed.  (Stimulus X Feedback X Rating)  MANOVA  Mean subjective ratings of sexual arousal  for sexually dysfunctional women during ratings 1 and 2 are presented in Figure 2.  Rating 1 shows no differences between  feedback groups nested within stimulus conditions. of ratings 1 and 2,  Comparison  shows that each stimulus pair divides  following implementation of the feedback condition.  At  60 Figure 2. Mean subjective ratings of sexual arousal for matched groups of sexually dysfunctional women during anxiety—erotic (A—E)  or neutral—erotic  (N—E)  stimuli and false positive  vaginal blood volume feedback or no feedback, (following stimulus series 1), and rating 3  rating 2  at rating 1  (following feedback),  (following stimulus series 3)  0  I  2  Figure 2.  0  3  4  5  Rating 2 Feedback  Rating 1 Stimulus Series 1  N-E No Feedback N-E False Feedback A-E No Feedback A-E False Feedback  Stimulus Series 2  Rating 3  62 rating 2, the two groups that received false positive VBV feedback demonstrated greater cognitive expectations of sexual arousal than the no feedback groups in both the anxiety—erotic and neutral—erotic conditions.  Simple effects analyses of the  Stimulus X Feedback X Rating interaction were performed to compare perceptions of sexual arousal at rating 1 and future expectations of arousal at rating 2 for each group.  Analyses  revealed that women who received neutral preexposure and no feedback demonstrated no significant change in their expectations of sexual arousal.  In contrast,  women who  received false positive VBV feedback reported significantly increased expectations of sexual arousal in both the neutral— erotic, E(1, =  21.29,  .  <  60)  =  8.15,  .00001,  =  .006,  conditions.  and anxiety—erotic, £(1, Interestingly,  60)  dysfunctional  women exposed to anxiety preexposure and no feedback also evidenced significantly increased expectations, E(l, 11.50,  =  .0016.  60)  =  These findings reveal that false positive  feedback of genital vasocongestion was effective in significantly increasing cognitive expectations of sexual arousal.  It also reveals that exposure to an anxiety—eliciting  stimulus paired with an erotic stimulus was in itself effective in significantly increasing expectations. Physiological sexual arousal.  To investigate the effects  of false positive VBV feedback on actual vasocongestive response,  a 2 X 2 X 2 X 18  (Stimulus X Feedback X Series X  10—Second Time Block Mean) MANOVA was performed.  Mean VBV data  for sexually dysfunctional women during stimulus series 1 and 2  63  are presented in Figure 3.  The data at stimulus series 1 show  that there are no differences between feedback groups nested within stimulus conditions,  and that the two groups exposed to  anxiety preexposure demonstrated significantly greater genital arousal.  Comparison of stimulus series 1 and 2 clearly shows  that each stimulus pair divides following implementation of the feedback condition.  During stimulus series 2,  the two groups  that received false positive VBV feedback demonstrated greater actual genital arousal than the no feedback groups in both the anxiety—erotic and neutral—erotic conditions.  Simple effects  analyses of the Feedback X Series interaction revealed that dysfunctional women who received no feedback regarding their genital responses to erotic stimuli demonstrated no significant change in their genital responses.  In contrast, women who  received false positive VBV feedback subsequently demonstrated a significant increase in their actual vasocongestion, E(l, =  15.86,  =  .0004.  60)  Specifically, post hoc comparisons between  stimulus series 1 and 2 for each group at each time block revealed that women who received false feedback and anxiety preexposure subsequently demonstrated significantly enhanced genital arousal within 30 seconds of the onset of the erotic stimulus.  This group continued to exhibit significantly  greater genital arousal at stimulus series 2 as compared to 1 at each time block throughout the remainder of the stimulus. Women receiving false feedback and neutral preexposure demonstrated less enduring effects.  Significant increases in  genital arousal were found only during the three time blocks  64 Figure 3. Mean vaginal blood volume from baseline)  (millivolts deviation  sampled 5 times/second for matched groups of  sexually dysfunctional women during anxiety—erotic  (A—E)  neutral—erotic  (prior to)  (N—E)  and stimulus series 2  stimuli,  at stimulus series 1  (following)  volume feedback or no feedback.  or  false positive vaginal blood  -80  Figure 3.  2  5  -60  -40  -20  Preexposuat Stimuli  20 60  SBCONDS  40 80  100 120  Experimental Stimuli  Stimulus Series 1  140  160  -80  -60  -40  -20  Preexposuat Stimuli  20  60 SBCONDS  40  80  100  120  Experimental Stimuli  Stimulus Series 2  140  160  c-n  180  A-B False Feedback — A-B No Feedback — N-B False Feedback N-B No Feedback  66 from 90 to 110 seconds.  These findings reveal that false  positive feedback of genital vasocongestion is effective in significantly increasing actual physiological sexual arousal and suggest that this effect is more enduring when combined with sympathetic activation. Relationship Between Subjective and Physiological Responses To investigate whether the modification of cognitive expectation alters actual physiological response,  groups that  received false VBV feedback were divided into subgroups on the basis of cognitive change.  For each subject,  t—tests  for dependent samples were calculated between rating 1 and rating 2.  Those subjects exhibiting a significant positive  change in subjective ratings of sexual arousal from rating 1 to rating 2 were designated group 1  (positive expectations),  and  those with no significant change or a significant negative change,  group 2.  To verify that more women changed their  cognitive expectations following false feedback as opposed to no feedback,  these analyses were also performed for subjects  in the no feedback groups.  Analyses revealed that 14 women  in the false feedback groups and only 7 in the no feedback groups demonstrated a significant positive change in their expectations.  Of all subjects,  only one in the neutral—erotic  and false feedback group exhibited a significant negative change  (.  <  .01).  A 2 X 2 X 2 X 18 Time Block Mean)  (Group X Stimulus X Feedback X 10—Second  MANOVA was performed on subjects that received  false VBV feedback to determine whether significant positive  67  changes in expectations of arousal directly mediate genital response.  Simple effects analyses of the Group X Series  interaction revealed that women who did not exhibit a significant positive change in their expectations in response to false feedback,  subsequently showed no significant change  in genital response at series 2.  In contrast,  significantly increased their expectations,  women who  subsequently  demonstrated a significant increase in their actual vasocongestive response, E(l,  28)  =  11.68,  =  .0023.  Specifically, post hoc comparisons between stimulus series 1 and 2 at each time block revealed that significant positive changes in expectancy subsequently caused a significant increase in physiological response within 30 seconds of the onset of the erotic stimulus. at series 1,  As compared to their responses  at series 2 these women exhibited significantly  greater genital arousal at each time block throughout the remainder of the erotic stimuli.  These findings reveal that  significant positive changes in cognitive expectations of sexual arousal directly and rapidly produce significant increases in physiological responding. Effects of Sympathetic Activation and False Positive VBV Feedback Physiological sexual arousal.  Mean VBV data during  stimulus series 2 are presented in Figure 4. reveal that of the four conditions,  These findings  the combined effects of  sympathetic activation and false positive VBV feedback elicited the greatest absolute levels of physiological arousal.  The  68 Figure 4. Mean vaginal blood volume baseline)  (millivolts deviation from  sampled 5 times/second for matched groups of sexually  dysfunctional women during stimulus series 2: (A—E)  or neutral—erotic  (N—E)  anxiety—erotic  stimuli following false positive  vaginal blood volume feedback or no feedback.  Figure 4.  .  .—  0  4-  .  0  V  V  —1  0  1  2  3  4  5  -80  -60  -40  -20  — A-E False Feedback — A-E No Feedback N-E False Feedback — N-E No Feedback  Preexposure Stimuli  0  20  60  SECONDS  40  80  100  Experimental Stimuli  Stimulus Series 2  120  140  160  180  70  four groups were not statistically compared at stimulus series 2 because it is possible that the group with the greatest absolute level of vasocongestion at stimulus series 2 may not have achieved the greatest increases in genital response from baseline levels at stimulus series 1, series 2.  to stimulus  Recall that only the false feedback groups were  found to demonstrate significant increases in physiological arousal from stimulus series 1 to 2.  To investigate if  sympathetic activation combined with false VBV feedback elicited a greater increase in physiological arousal than false feedback alone, Time Block Mean)  a 2 X 2 X 36  (Stimulus X Feedback X 10—Second  MANOVA was performed.  A simple effects  analysis compared the effectiveness of anxiety versus neutral preexposure and false feedback in increasing physiological arousal as a function of time across stimulus series 1 and 2. This analysis revealed that false positive feedback combined with anxiety preexposure caused significantly greater increases in genital arousal than false feedback alone, E(35, 2.90,  <  .000001.  2100)  =  Of the four conditions, the combined  effects of sympathetic activation and false VBV feedback therefore elicited the greatest increases in physiological arousal. Subjective sexual arousal. sexual arousal during ratings 1, Figure 2.  Mean subjective ratings of 2,  and 3 are presented in  Rating 2 shows that women in the anxiety preexposure  and false feedback group reported the greatest expectations of sexual arousal.  Simple effects analyses of the Stimulus X  71  Feedback X Rating interaction were performed within the initial 2 X 2 X 3 rating 2 group.  (Stimulus X Feedback X Rating) (expectations)  and rating 3  MANOVA to compare  (experience)  for each  Analyses revealed that women in the anxiety preexposure  and false feedback group reported that their subjective experience was significantly less than their expectations, (1,  60)  =  8.52,  =  .0051.  To investigate if sympathetic  activation combined with false VBV feedback elicited a greater increase in subjective perceptions of sexual arousal than sympathetic activation or false feedback alone,  simple effects  analyses were performed to compare ratings 1 and 3 for each group.  Analyses revealed that women in the neutral preexposure  and no feedback group reported no significant change in their experience of sexual arousal at rating 3.  Similarly,  although  women in the anxiety preexposure and no feedback group exhibited a significant increase in their expectations, anxiety preexposure alone did not elicit a significant change in their subjective perceptions of sexual arousal at rating 3.  Despite  the finding that women in the anxiety preexposure and false feedback group reported a significant increase in their expectations and demonstrated the greatest increases in genital vasocongestion, they did not report a significant increase in their subjective perceptions of sexual arousal.  Only the women  who received neutral preexposure and false feedback reported a significant increase in their subsequent experience of sexual arousal, E(1,  60)  =  7.63,  =  .0076.  These analyses revealed  that false positive feedback of genital vasocongestion caused  72  significantly increased subjective perceptions of sexual arousal,  and that of the four conditions,  false VBV feedback  alone therefore elicited the greatest increases in subjective perceptions of arousal. Discussion The findings from this investigation identify the interactive mechanisms by which cognitive and physiological response components mediate sexual arousal,  and provide major  implications for developing a new model and treatment approach for sexual dysfunction.  The results reveal that for sexually  dysfunctional women: 1.  Sympathetic activation enhances genital arousal.  2.  False positive feedback of genital vasocongestion (VBV)  increases subjective expectations  (N—E and A—E)  and the subsequent experience of sexual arousal 3.  False positive VBV feedback increases actual genital response  4.  (N—E)  (N-E and A-E).  Positive expectations following false VBV feedback directly increase actual physiological response.  5.  The combined effects of sympathetic activation and false positive VBV feedback elicit greater increases in cognitive expectations and subsequent genital arousal than either sympathetic activation or false feedback alone.  These results  (a)  reveal that cognitive and physiological  processes are key components of sexual response,  (b)  identify  interactive mechanisms by which these components mediate  73  sexual arousal,  (c)  sexual dysfunction,  suggest a cognitive—physiological model of and  (d)  provide evidence that effective  interventions for the modification of dysfunctional patterns of sexual arousal be directed toward increasing physiological response and altering negative cognitions via sympathetic activation and feedback. Sympathetic Activation Enhances Genital Arousal Women exposed to an anxiety—eliciting as compared to neutral—control stimulus,  demonstrated a significantly enhanced  rate and magnitude of genital arousal within 10 seconds of viewing an erotic stimulus.  As can be seen in Figure 1,  this  effect of stimulus was found for both the false feedback and no feedback groups.  This investigation provides two between—  group replications of the previous within—subject finding that anxiety preexposure elicits enhanced genital arousal for sexually dysfunctional women  (Palace & Gorzalka,  1990),  and is  consistent with the literature on sexually functional women and men Rowland,  (Barlow et al.,  1983; Dutton & Aron,  1983; P. W. Hoon et al.,  1974;  Heiman &  1977b; Woichik et al.,  Despite their increased genital responses,  1980)  women who  viewed anxiety as compared to neutral preexposure stimuli reported no significant differences in their perceptions of arousal at rating 1.  The finding of a desynchronous  relationship between subjective and physiological sexual response in dysfunctional women is consistent with previous research 1992;  (Morokoff & Heiman,  Steinman et al.,  1980;  Palace & Gorzalka,  1981; Wincze et al.,  1976)  .  1990,  These  74 findings may be explained by a combination of cognitive and physiological factors.  First, Palace and Gorzalka  (1990,  1992)  revealed that sexually dysfunctional as compared to functional women were less attentive to bodily cues of autonomic and sexual arousal,  and actually exhibited lower autonomic lability  and vasocongestive response.  Second, because women possess  a less obvious physiological feedback system vasocongestion versus erection),  (e.g.,  vaginal  those women who experience  less physiological responsivity may encounter difficulty attending to and labeling bodily cues.  Finally,  social  dictates and lingering double standards governing women’s sexual behavior may compound these factors by further discouraging women from attending to or verbally acknowledging genital cues, particularly in the context of anxiety—eliciting films. The results of the pilot study for this investigation revealed that anxiety as compared to the neutral stimuli elicited significantly greater anxiety and autonomic arousal for sexually functional women.  From among a group of five  potential anxiety—eliciting stimuli,  including the film  previously used in the P. W. Hoon et al.  (1977b)  investigation,  the two anxiety stimuli employed in the present study produced the greatest mean levels of heart rate and the highest mean subjective ratings of anxiety and autonomic arousal;  and evoked  increased heart rate and significantly greater perceptions of sympathetic activity as compared to neutral stimuli. findings suggest that the anxiety manipulations in the  These  75  present study were effective in eliciting moderate levels of sympathetic activation. The finding that heart rate was not significantly increased during anxiety—eliciting as compared to neutral stimuli for sexually dysfunctional women is consistent with the literature which shows that heart rate is not significantly increased by anxiety induction.  Anxiety,  anxiety—evoking film (P. W. Hoon et al., to maintain an erection  as defined by an 1977b),  (Heiman & Rowland,  threat contingent on erection  1983),  (Barlow et al.,  revealed significant increases in heart rate. et al.  (1977b)  verbal demands and shock  1983),  have not  P. W. Hoon  found that despite the absence of significant  heart rate changes,  sexually functional women described the  films as very vivid and anxiety—producing.  They suggest that  this finding is consistent with the conclusions of Obrist, Lawler,  and Gaebelein  (1974)  that significant heart rate  increases can only be elicited by intense stress or phobic anxiety, which may inhibit sexual arousal,  as opposed to  moderate sympathetic activation. An additional explanation for the finding that heart rate was not significantly increased by anxiety induction is that sexually dysfunctional women have lower autonomic reactivity than sexually functional women,  and were therefore less able to  subjectively or physiologically discriminate anxiety—eliciting or erotic stimuli.  This explanation is supported by the  Palace and Gorzalka  (1990)  finding that sexually functional as  compared to dysfunctional women exhibited greater autonomic  76 response lability,  as demonstrated by greater fluctuations  in their VBV responses to anxiety and erotic stimuli,  and  significantly greater decreases in VBV during anxiety—eliciting stimuli.  Similarly,  Palace and Gorzalka  (1992)  found that  dysfunctional women exhibited consistently lower levels of VBV and subjectively reported sexual and autonomic arousal than functional women.  In addition,  whereas functional women were  able to discriminate erotic stimuli in terms of physiological sexual arousal  (VBV)  and subjective perceptions of sexual  and autonomic arousal, the dysfunctional women were able to discriminate stimuli only on the basis of subjective reports of sexual arousal. men  (J.  G.  These findings are consistent with data on  Beck & Barlow,  1986),  which show that during shock—  threat instructions sexually dysfunction men demonstrated significantly lower autonomic arousal, as defined by EKG and skin conductance measures, than functional men. Taken together, the findings from our program of research suggest that sexually dysfunctional women are less able to attend to or report cues of autonomic arousal than sexually functional women because they actually possess less physiological reactivity to which to attend.  Women  with greater response lability may therefore experience proportionately more anxiety genital arousal.  (sympathetic activity)  Accordingly,  as well as  increasing low response lability  through sympathetic activity may reverse the dysfunctional process by facilitating the physiological responsivity required to subsequently modify conditioned cognitive expectations.  77  This explanation is supported by the present findings that the anxiety—eliciting stimuli were effective in significantly increasing genital arousal and subsequent subjective expectations of arousal. A.  T.  Beck  (Marmor,  1987)  states that when individuals  are in a heightened state of affective arousal, they are more susceptible to therapeutic intervention.  He argues that the  most effective techniques of cognitive and behavior therapy involve arousing anxiety to achieve an increased state of reactivity:  “if change is going to take place,  it has to take  place when the person is in some type of heightened state” (p.  278)  .  This idea is consistent with Lacey’s  (1967)  psychophysiological hypothesis which suggests that changes in heart rate and blood pressure can influence cortical activity and thereby affect sensitivity to stimuli.  In other words,  increased autonomic arousal may facilitate the acquisition of a learned response.  For sexually dysfunctional women,  it may be  that increasing autonomic responsivity not only increases the capacity for heightened physiological response,  but facilitates  learning and therefore a more rapid extinction of conditioned negative response patterns.  Future research is needed to  determine if functional and dysfunctional women differ in general autonomic responsivity to environmental stimuli. present findings suggest,  however,  The  that sexually dysfunctional  women may have low autonomic reactivity which inhibits their ability to respond to autonomic or sexual arousal,  and that  mild levels of sympathetic activation stimulate a sexually  78  functional process of sexual response. False Positive VBV Feedback Increases Cognitive Expectations and Experience False positive VBV feedback,  which indicated floor to  ceiling increases in the subject’s vasocongestive response to an erotic stimulus, was followed by a significant increase in rated expectations of sexual arousal.  This finding validates  the effectiveness of the feedback manipulation in modifying cognitive expectations.  sympathetic activation  Interestingly,  induced by an anxiety—eliciting stimulus and no feedback was also followed by a significant increase in rated expectations of sexual arousal.  This finding suggests that general  autonomic arousal was effective not only in enhancing genital response but,  although not reported at rating 1,  correctly labeled,  was detected,  and subsequently effective in increasing  cognitive expectations of sexual arousal at rating 2. Women who received false positive VBV feedback and neutral preexposure subsequently also reported a significant increase in their subjective experience of sexual arousal.  The finding  that false feedback of genital vasocongestion is effective in modifying subjective perceptions of sexual arousal is consistent with the literature showing that heart rate and electrodermal activity are effective in altering subjective perceptions of fear and anxiety  (e.g.,  Gaupp et al.,  1972; Holmes & Frost,  Koenig,  Lick,  1973;  attractiveness  Borkovec et al.,  1976; Kent et al.,  1975; Rosen et al.,  (e.g., Barefoot & Straub,  1972; Wilson,  1974; 1972;  1973),  1971; Bloemkolk  79  et al.,  1971; Botto et al.,  Hirschman et al., Charis,  1974; 1976;  1975),  life stress  et al.,  Goldstein et al.,  1977; Kerber & Coles,  Stern et al.,  Hagan,  1974;  Young et al.,  1972),  1978; Misovich &  unpleasantness  1982), persuasion  (Stern et al.,  1980),  1972;  (Thornton &  (Hendrick et al.,  and depression  (Stern  1978).  False Positive VBV Feedback Increases Actual Genital Response The actual vasocongestive responses of women who were shown false positive VBV feedback significantly increased following the onset of the erotic stimulus.  Specifically,  women exposed to false feedback and anxiety—eliciting stimuli demonstrated a significant increase in their genital responses within 30 seconds of the onset of the erotic stimulus and remained significantly more aroused throughout the remainder of the film.  In contrast,  women exposed to false feedback and  neutral preexposure demonstrated significantly greater genital responses for only 30 seconds of the erotic stimulus.  Women  who received no feedback about their genital responses to erotic stimuli,  showed no change in vasocongestion in either  stimulus condition.  These findings suggest that the effects  of sympathetic activation potentiate the effects of false positive feedback in enhancing physiological arousal. Despite a consensus in the literature that false physiological feedback is effective in modifying cognitive and behavioral processes,  there are mixed results regarding its  effectiveness in modifying actual physiological processes.  The  present study controlled for the potential confounding effects  80 of attention,  and minimized distraction and subject demand  characteristics that may account for previous contradictory findings.  The finding that false VBV feedback is effective  in modifying actual vasocongestion is consistent with the literature showing that bogus feedback exerts an effect on heart rate,  EDA,  and alpha activity associated with fear and  anxiety  (e.g.,  et al.,  1972; Lick,  et al.,  1971; Kerber & Coles,  Borkovec,  Hirschman & Hawk, (Plotkin, 1975),  1973; Borkovec & Glasgow,  1975), attractiveness  1978;  Bloemkolk  1978), unpleasantness  Young et al.,  1980; Valle & Levine,  and attitude  (e.g.,  1973; Gaupp  1982),  1975),  (Detweiler & Zanna,  (e.g.,  alpha experience  discomfort  (Hirschman,  1976)  Positive Expectations Increase Actual Physiological Response Women who significantly increased their expectations following false positive VBV feedback demonstrated a significant increase in their actual vasocongestive response within 30 seconds of exposure to an erotic stimulus.  In  contrast, women who received false feedback but did not exhibit a significant positive change in expectations, in physiological response.  showed no change  These findings reveal a direct  feedback loop in the mediation of sexual arousal where cognitive expectations of sexual arousal directly and immediately influence actual physiological response. Sympathetic Activation and False Positive VBV Feedback Elicit the Greatest Cognitive Expectations and Physiological Arousal Women who received anxiety preexposure and false positive feedback of genital vasocongestion demonstrated the greatest  81  expectations of sexual arousal.  It is interesting that these  women expected levels of arousal comparable to those reported by sexually functional women in the anxiety—erotic condition in the Palace and Gorzalka  (1990)  investigation.  Women who were  exposed to anxiety—eliciting stimuli paired with false feedback also achieved the greatest increases in genital arousal. stimulus series 2  At  (Figure 4), these sexually dysfunctional  women achieved levels of vasocongestion comparable to sexually functional women in the Palace and Gorzalka investigation.  (1990)  Despite their heightened expectations and  genital responses,  subjects in this group did not report  significantly increased subjective perceptions of arousal at rating 3  (Figure 2)  .  This finding is consistent with the  finding at stimulus series 1 and rating 1 that the subjective and physiological responses of dysfunctional women were desynchronous. The finding that women in the anxiety preexposure and false feedback group did not report significantly increased arousal at rating 3 is particularly curious given that they appeared to detect physiological changes following SNS activation at stimulus series 1,  as evidenced by their  significantly increased cognitive expectations at rating 2. That is,  following exposure to anxiety—eliciting stimuli and  false feedback, these women accurately anticipated their enhanced physiological responses at stimulus series 2, but did not acknowledge it when it subsequently occurred.  One  explanation for this finding is that the neutral nature films  82 provide an ambiance that is more conducive to verbal reports of sexual arousal than the more aversive anxiety—eliciting stimuli.  The use of films for SNS activation,  although  effective in altering physiological response, may create cognitive dissonance where women are aware of heightened arousal but hesitate to report it. Cognitive and Physiological Response Components Mediate Sexual Arousal The results of this investigation challenge the Schachter and Singer  (1962)  and Valins  (1966)  theories of emotion.  Schachter and Singer assert that an emotional response is produced when cognitive labels are attached to ambiguous physiological states of arousal.  The findings at ratings 1  and 3, that women who demonstrated significant increases in genital response following sympathetic arousal did not label their experience as increased sexual arousal, arousal,  or anxiety,  autonomic  does not support this view.  Valins  contends that emotion is an entirely cognitive phenomenon,  and  that changes in an emotional state may be accomplished in the absence of actual physiological changes.  The finding that  false VBV feedback modified actual genital arousal,  challenges  the assumption that changes in behavior are based exclusively on cognitive changes.  Rather,  the present findings show that  very real differences in physiological response accompanied cognitive change.  The findings that false positive VBV  feedback modified cognitive expectations, actual physiological response,  and subsequent perceptions of arousal; that altering  83  cognitive expectation directly caused a change in physiological response; and that the interaction of false feedback and sympathetic activation elicited the greatest change in expectations and genital response, provide evidence that the interaction of cognitive and physiological processes mediate the experience of sexual arousal.  Rosen and Beck  (1988)  emphasize that “the subjective experience of arousal should be viewed as the sine qua non for defining a sexual response” (p.  37), however,  these results strongly indicate that the  influence of both cognitive and physiological components of arousal are imperative to understanding and modifying the processes that determine sexual response. Processes of Female Sexual Arousal The present findings identify mechanisms by which cognitive and physiological components interact to mediate sexual arousal. arousal)  Sympathetic activation  (increased autonomic  induced by an anxiety—eliciting stimulus was highly  efficient in directly enhancing physiological sexual response. Interestingly,  sympathetic activation was also successful in  increasing cognitive expectations of sexual arousal. not,  however,  It was  immediately effective in modifying subsequent  physiological response or subjective perceptions of sexual arousal.  This process,  as demonstrated by the A—E no feedback  group in the present study,  is diagrammed in Figure 5  (top).  The process for false positive VBV feedback was somewhat different.  False positive feedback of vaginal vasocongestion  increased cognitive expectations of sexual arousal,  which in  84 a.  mcreased physiological (vasocongestive) response  SYMPATHETIC ACTiVATION (increased autonomic arousal)  increased cognitive expectations of sexual arousal b.  FALSE POSiTIVE VBV FEEDBACK  increased subjective experience of sexual arousal  increased cognitive expectations of sexual arousal  increased physiological (vasocongestive) response C.  SYMPATHETIC ACTIVATION (increased autonomic arousal)  increased physiological (vasocongestive) response ..  increased subjective experience of sexual arousal  \  ACCURATE VBV FEEDBACK  increased cognitive expectations of sexual arousal  )  increased physiological (vasocongestive) response  Figure 5. Processes by which cognitive and physiological response components interact to mediate sexual arousal: (a) process by which sympathetic activation (increased autonomic arousal) enhances sexual arousal, (b) process by which false positive VBV feedback enhances sexual arousal, and (c) proposed process by which sympathetic activation combined with accurate VBV feedback reverses the dysfunctional process and initiates a positive cognitive-physiological feedback loop of sexual arousal.  85  turn directly enhanced actual physiological response.  This  interaction between cognition and physiological response is extremely rapid,  as demonstrated by the finding that  irrespective of stimulus condition, positive changes in expectation were accompanied by a significant increase in genital response within 30 seconds of exposure to an erotic stimulus.  Significant changes in expectation and genital  response consequently also altered subjective perceptions of the experience of sexual arousal. in the present investigation,  Although it was not examined  increased subjective appraisals  of arousal may further influence future expectations, thus completing the feedback loop.  This process,  as demonstrated  by the N—E false feedback group in the present study, diagrammed in Figure 5  is  (middle).  The results of this study reveal that the combined effects of sympathetic activation and false positive VBV feedback false feedback group)  (A—E  surpass the effects of either sympathetic  activation or false feedback alone in the modification of dysfunctional patterns of sexual arousal.  The finding that  false VBV feedback was more effective in increasing genital response following anxiety as compared to neutral preexposure, reveals that the effectiveness of false feedback is moderated by the effects of sympathetic activation.  Because anxiety—  eliciting stimuli enhance genital response, the false feedback was less “false,” for these women,  i.e.,  genital arousal was  amplified and therefore feedback was more accurate and genital cues may have been more easily detected.  Although women in  86  this group did not report increased arousal at rating 1,  false  feedback may have served to substantiate or facilitate the correct labeling of genital cues. (Figure 2),  As can be seen at rating 2  this information subsequently caused significantly  increased expectations that surpassed the expectations reported by women in other conditions.  False positive feedback  therefore has a more rapid and enduring effect for women exposed to anxiety—eliciting stimuli because sympathetic activation provides a very real increase in vasocongestion, which in turn causes greater expectations,  and subsequently a  further increase in actual genital response. Clark  (1983)  and Rosen and Beck  (1988)  Hirschman and  emphasize the importance  of attending to the prepotency of cognitive factors and de—emphasizing physiologically—based treatments. findings reveal,  however,  The present  that sympathetic activation plays an  important role in modifying dysfunctional response since its genital arousing—enhancing effects can replace the false— positive component of feedback with a true—positive response. If accurate feedback were provided to sexually dysfunctional women in the absence of sympathetic activation,  negative  cues of low physiological response could exacerbate the dysfunctional process by validating negative expectations and further impeding physiological response. As evidenced in Figure 4,  the effectiveness of sympathetic  activation is also diminished in the absence of feedback. Sympathetic activation without feedback cannot alter the conditioned lack of attentional focus or facilitate the ability  87 to correctly label these new genital sensations. at ratings 1 and 3  (Figure 2)  The findings  that significantly increased  genital responses for women in the anxiety—erotic conditions were not subsequently accompanied by significantly increased subjective ratings, provide evidence that these women have not learned to recognize or label their genital sensations. that men in the Sakheim et al.  (1984)  Recall  study demonstrated that  visuosensory awareness and attention to penile tumescence provided a significant cue for subjective appraisals of sexual arousal.  Men who were prevented from viewing their genital  responding by a sheet covering their genital area,  exhibited  significantly lower levels of genital arousal than men who were allowed visual attention to penile response. the present study,  Accordingly,  in  the purpose of the polygraph chart depicting  vaginal vasocongestion was to provide dysfunctional women with information similar to that provided by erection. findings are consistent with the Sakheim et al.  The present  (1984)  study,  and reveal that for women as well as men, visual attention to vasocongestion elicits significantly greater physiological levels and subjective appraisals of arousal.  In addition,  although the women who received anxiety preexposure and no feedback demonstrated significant increases in physiological response at stimulus series 1 and reported greater expectations of arousal at rating 2,  without the reinforcement provided by  visual verification that they had responded physically and labeled their sensations accurately,  subsequently showed  no significant change in genital response at series 2 or  88 perceptions of arousal at rating 3.  The additive function  of feedback is therefore to provide information that both facilitates and reinforces the correct labeling of genital responses elicited by sympathetic activation. The present findings clearly reveal that the combined effects of a physiologically-based intervention to enhance sympathetic activation,  and a cognitively—based intervention  to facilitate labeling of genital cues,  was the most effective  method of modifying dysfunctional response.  Women in the  A—E false feedback group demonstrated important steps in the reversal of the dysfunctional process: an increase in physiological response, of this change,  attention to and correct identification  a significant positive change in expectations,  and subsequently a further significant increase in genital response.  It is important to recognize that within 3 minutes  of exposure to an erotic stimulus,  the dysfunctional women in  this group achieved levels of genital arousal comparable to a demographically similar sample of sexually functional women (Palace & Gorzalka,  1990)  A Cognitive—Physiological Model of Sexual Dysfunction The findings of the present study suggest a model whereby cognitive and physiological processes interact to disrupt sexual arousal. 1992)  Research findings  (Palace & Gorzalka,  1990,  suggest that the desynchrony observed in sexually  dysfunctional women may be accounted for by a combination of cognitive and physiological factors: lack of physically observable cues,  low autonomic lability, and social demands.  89  These factors may facilitate a lack of attentional focus and incorrect labeling of bodily cues,  which in turn become a  conditioned negative expectancy that further attenuates or extinguishes physiological response to sexual cues.  Sexual  dysfunction may therefore be viewed as the result of an interactive process whereby cognitive and physiological components form a negative feedback loop of dysfunctional response: women with low physiological response lability) arousal,  (low autonomic  decrease subjective expectations and appraisals of and reciprocally, women with low expectations  of attentional focus or mislabeling of bodily cues)  (lack  further  inhibit physiological responsivity. The Modification of Dysfunctional Patterns of Sexual Arousal The findings of the present study suggest a general approach to the modification of dysfunctional patterns of sexual arousal.  Specifically,  strategies directed toward  enhancing physiological responsivity and modifying negative cognitions via sympathetic activation and feedback may reverse the dysfunctional cycle and initiate a positive cognitive— physiological feedback loop of sexual arousal. The present findings suggest that anxiety—eliciting stimuli facilitate sexual arousal through the direct instigation of generalized sympathetic activation. cues were provided,  When sexual  this enhanced sympathetic responsivity  activated specific genital responses.  In this way,  sympathetic  activation replaces the function of false positive feedback by providing a true—positive enhancement of genital response.  If  90  sympathetic arousal facilitates learning,  it would also hasten  the extinction of conditioned negative response patterns, the acquisition of new positive modes of responding.  and  Feedback  of genital vasocongestion can further provide observable and positive physical cues to validate and reinforce the experience elicited by sympathetic activation.  That is,  feedback can  facilitate attentional focus and the correct labeling of bodily cues,  which in turn will further extinguish conditioned  negative expectations.  The modification of negative  expectations was found to directly facilitate enhanced physiological response to erotic cues and subsequently increase subjective perceptions of sexual arousal, increase cognitive expectations.  which may further  Although women exposed to  anxiety—eliciting stimuli did not report significant increases in perceptions of sexual arousal,  SNS activation was effective  in significantly increasing their expectations regarding their ability to become aroused.  By replacing the anxiety—eliciting  films with a SNS—activating mechanism that is more conducive to acknowledging sexual arousal,  SNS activity may also contribute  directly to an increase in the subsequent reports of subjectively experienced arousal. Accordingly,  strategies directed toward increasing  sympathetic activation through some form of physical activity or exercise, may provide an initial “jump start” or preparedness for sexual arousal which increases the likelihood of providing positively reinforcing genital feedback.  As  demonstrated in this study with false positive VBV feedback,  91  when accurate positive feedback is subsequently provided,  women  seeing positive results are likely to modify their negative expectations about their potential to become aroused. demonstrated in this study,  As also  positive changes in expectations  may further potentiate increased physiological response and subjective appraisals of sexual arousal.  This proposed  arousal—retraining program specifically targets both cognitive and physiological response components and utilizes their interactive nature to reverse and reciprocally enhance the arousal process. (bottom).  This approach is diagrammed in Figure 5  Although the efficacy of such a program awaits  treatment—outcome evaluation,  the present findings suggest  that this approach may be effective in rapidly alleviating dysfunctional patterns of sexual arousal. This investigation provides strong evidence that cognitive and physiological processes form a direct and immediate feedback loop in the mediation of sexual arousal.  The  combined effects of sympathetic activation and false positive feedback of genital engorgement interrupted and reversed the dysfunctional process by enhancing physiological responsivity, increasing cognitive expectations,  and subsequently,  increasing  actual genital response to levels comparable with sexually functional women within 3 minutes.  These findings suggest that  dysfunctional patterns of sexual arousal may be modified by increasing response synchrony through the repeated pairings of sympathetic arousal and accurate feedback, heighten genital response,  which serve to  facilitate attentional focus and  92  positive appraisals of genital experience, potentiate physiological response.  and in turn,  In this way,  further  the mechanisms  by which cognitive and physiological components interact to prevent arousal, may be reversed to produce an upwardly spiraling feedback loop of heightened sexual arousal.  93  BIBLIOGRAPHY Abrahamson, D. J., Barlow, D. H., Sakheim, D. K., Beck, J. G., & Athanasiou, R. (1985) Effects of distraction on sexual responding in functional and dysfunctional men. Behavior Therapy, 1, 503—515. .  Andersen, B. L. (1983) Primary orgasmic dysfunction: Diagnostic considerations and review of treatment. Psychological Bulletin, , 105—136. .  Barefoot, J. C., & Straub, R. B. (1971). 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(1978) Comments on “A test of reciprocal inhibition” by Hoon, Wincze, and Hoon. Journal of Abnormal Psychology, 452—454. .  az,  The practice of behavior therapy Wolpe, J. (1982) New York: Pergamon. .  (3rd ed.)  101  Young, D., Hirschman, R., & Clark, M. (1982). Nonveridical heart rate feedback and emotional attribution. Bulletin of the Psychonomic Society, 2.Q., 301—304. Zingheim, P. K., & Sandman, C. A. (1978) Discriminative control of the vaginal vasomotor response. Biofeedback and Seif—Recrulation, 29—41. .  .,  Zuckerman, M. (1971). Physiological measures of sexual arousal in the human. Psychological Bulletin, ii., 347—356.  £01  TDS W1T  XI UNddV  oI  103 Code No.____  FILM SCALE  Instructions: Please use the following scale to evaluate how you felt during the last film. Please answer honestly and carefully. On the scale, circle any of the numbers from 1 (not at all) to 7 (intensely) During the film,  I felt:  1.  Faster breathing___________________  1  2  3  4  5  6  7  2.  Faster heart beat__________________  1  2  3  4  5  6  7  3.  Perspiration_______________________  1  2  3  4  5  6  7  4.  Feelings of warmth_________________  1  2  3  4  5  6  7  5.  Any physical reaction at all________  1  2  3  4  5  6  7  Continue on to the next page.  104 Code No.____ FILM SCALE  (Continued)  Instructions: Please use the following scale to evaluate how you felt during the last film. Please answer honestly and carefully. On the scale, circle any of the numbers from 1 (not at all) to 7 (intensely) During the film,  I felt:  6.  Breast sensations___________________  1  2  3  4  5  6  7  7.  Warmth in genitals_________________  1  2  3  4  5  6  7  8.  Genital wetness or lubrication______  1  2  3  4  5  6  7  9.  Genital pulsing or throbbing________  1  2  3  4  5  6  7  10.  Any genital feelings________________  1  2  3  4  5  6  7  11.  Sexually aroused___________________  1  2  3  4  5  6  7  12.  Worried_____________________________  1  2  3  4  5  6  7  13.  Anxious____________________________  1  2  3  4  5  6  7  14.  Angry______________________________  1  2  3  4  5  6  7  15.  Disgusted____________________________  1  2  3  4  5  6  7  16.  Embarrassed_________________________  1  2  3  4  5  6  7  17.  Guilty______________________________  1  2  3  4  5  6  7  18.  Sensuous____________________________  1  2  3  4  5  6  7  19.  A desire to be close to someone_____  1  2  3  4  5  6  7  20.  Pleasure____________________________  1  2  3  4  5  6  7  21.  Interested__________________________  1  2  3  4  5  6  7  22.  Attracted___________________________  1  2  3  4  5  6  7  23.  Excited_____________________________  1  2  3  4  5  6  7  24.  Sexy______________________________  1  2  3  4  5  6  7  25.  Dirty_______________________________  1  2  3  4  5  6  7  26.  Loving_______________________________  1  2  3  4  5  6  7  27.  Sexually attractive________________  1  2  3  4  5  6  7  28.  Inhibited___________________________  1  2  3  4  5  6  7  29.  Easy to arouse______________________  1  2  3  4  5  6  7  30.  Incompetent________________________  1  2  3  4  5  6  7  31.  Sexually turned off________________  1  2  3  4  5  6  7  32.  Offended____________________________  1  2  3  4  5  6  7  33.  Bored______________________________  1  2  3  4  5  6  7  34.  Feminine____________________________  1  2  3  4  5  6  7  Stop and wait for further instructions.  

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