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Intimacy disorders and sexual panic

states
a
Helen Singer Kaplan M.D., Ph.D.
a
Human Sexuality Program , New York Hospital-Cornell Medical
Center , 30 East 76 Street, New York, NY, 10021
Published online: 14 Jan 2008.

To cite this article: Helen Singer Kaplan M.D., Ph.D. (1988) Intimacy disorders and sexual panic
states, Journal of Sex & Marital Therapy, 14:1, 3-12, DOI: 10.1080/00926238808403902

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 Intimacy Disorders and
Sexual Panic States
Helen Singer Kaplan, M.D., Ph.D.

This paper explores the question: Is sexual avoidance a manifestation

of intrapsychic barriers to emotional closeness? I n some cases it clearly
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is, but in other cases it is the result of other deteminants such as a

partnerS excessive demands for intimacy and communication and his
or her intolerance for even normal emotional distance. Our finding
that couples with this dynamic and with sexual aversions have a n un-
usually high prevalence of panic disorder is considered in the light of
its clinical implications.

There are two types of progress in science: linear and circular. Linear
progress refers to the development of an entirely new idea, while the
improvement of an already existing concept is called circular progress.
For example, for millions of' years humans hunted for meat by throwing
rocks at animals. This was an inefficient method of hunting and the tribe
of'ten went without sufficient protein. Then a creative individual came
u p with the idea of the bow and arrow. T h a t is an example of linear
progress in that it represents a conceptual discontinuity, an entirely new
and more effective solution to the problem of food procurment, which
greatly eased the meat shortage. Thereafter, for several thousands of
years, generations of innovators tinkered with and improved and refined
the basic bow and arrow design to devise cross-bows and long-bows of
enormous accuracy and power, and arrows with sharper points and truer
aim. These technical developments and improvements of the basic bow
and arrow concept provided society with a n evermore effective means
of procuring meat, and are circular forms of progress. When the gun
was invented, a new linear progression was established.
As I see it, before Masters and Johnson we were throwing rocks at our
enemy, sexual disorders, with very uncertain results. When I was in med-
ical school, some 25 years or so ago, sexual medicine was in such a pri-
~~ ~~

Helen Singer Kaplan, M.D., Ph.D., is Director of the Human Sexuality Prograrri of'l'he New York
Hospital-Cornell Medical Center. This article is adapted from a talk presented at the Annual Meeting
of thc Society for Sex Therapy and Research, New Orleans, Louisiana, March 15, 1987.
Address correspondence to: Helen Singer Kaplan, M.D., Ph.D., 30 East 76 Street, New York, N Y
10021 .

Journal of Sex & Marital Therapy, Vol. 14, No. 1, Spring 1988 0 Brunner/Mazel, Inc.
3
 4 Journal o f s e x & Marital Therapy, Vol. 14, No. 1, Spring 1988

mitive state, that most patients who were afflicted with what we now
consider to be “simple” sexual problems, were doomed to remain dys-
functional o r to d o without sex entirely for the rest of their lives. But
today, largely because of Masters and Johnson’s truly linear innovations,
sexual disorders have become the most readily treatable human ills and
have, for the most part, excellent Certainly much of my
own work has consisted of extending Masters and Johnson’s basic sex
therapy model in a circular manner.
1 was asked to address the question: Are sexual phobias, inhibited sexual
desire (ISD), and other sexual avoidance behaviors symptomatic manifestations of
intrapsychic barriers to emotional closeness?
O n the basis of our experience over the past 15 years with more than
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3,000 couples and individual patients with sexual difficulties, the answer
is very clear: In some cases a patient’s phobic avoidance of sex is quite
obviously an expression of intrapsychic conflicts about intimacy, while in
other cases sexual aversion can be traced to entirely different causes.
T h e relationship between intimacy and sexual passion is very complex,
with cultural as well as intrapsychic variables determining the extent to
which an individual can meld emotional closeness and sexual passion for
the same person. In some societies, sexuality is considered more as an
art form like dancing, than as an expression of love. Thus, for example,
the notion that he should develop a long-term committed relationship
with each Geisha partner would probably seem ludicrous to a Japanese
gentleman. But the ideal vision of sexuality in our romantic Western
tradition is as an inseparable part of commitment and love, and we tend
to denigrate the “zipless f ~ c k or ” ~“the business of sex,”5 that is, physical
love outside of a long-term, monogamous relationship. This attitude is
reflected in the American health establishment’s position that the expres-
sion of physical lust between two strangers, whose primary point of con-
tact is limited to their commitment to the shared erotic pleasure of the
moment, is pathological, o r at best undesirable and, if habitual, many
therapists believe the person requires treatment.
I do not share this view. I n my clinical experience the truly healthy
man or woman can enjoy a sensuous, erotic encounter with an attractive
stranger, but also has the capacity to experience ongoing erotic passion
as an integral part of an intimately shared life.
That is not to say of course, that real commitment and intimacy conflicts
don’t exist. Of course they do. In fact, these neurotic patterns are com-
mon, and often highly destructive, driving the person again and again,
like the doomed Sisyphus, from relationship to relationship, while the
pleasures of an unfractured, emotionally close, companionable shared
life eternally elude him.
l h e Madonna-Whore syndrome* is clearly pathological, but it is just
as pathological if a person can enjoy erotic pleasure only with a partner
who loves him/her deeply, is exclusively committed to him/her, and with

* l h e inability to maintain sexual arousal within an intimate and committed relationship has been
termed the Madonna-Whore complex in the psychoanalytic literature. However, this is a misnomer,
as this syndrome also occurs in wonien.
 Intimacy Disorders and Sexual Panic Slates 5

whom s/he has a long-term intimate connection. In other words, it is also

a problem if an individual’s ability to become sexually aroused and or-
gastic is limited to relationships that entail absolutely no risks of rejection
or abandonment. However, it goes without saying that it is clearly not
pathological if a person consciously chooses monogamy when this is in
his o r her partner’s best interest.
The Split Between Sex and Intimacy as an Expression of Intrapsychic ConfZict
T h e typical patient with an intimacy problem is able to enjoy sexual
pleasure and function well with strangers, but develops sexual avoidance
and/or aversion when he or she becomes emotionally too involved with
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a T h e intimacy or commitment “comfort zone,” in other

words, the point of emotional closeness at which an individual begins to
become anxious and begins to defend him/herself by avoiding sex, varies
considerably. Some of our patients with commitment and intimacy con-
flicts can function only until they are asked, “What are we doing next
weekend?” T h e partner’s assumption of even such a limited commitment
is so threatening that the individual loses hidher sexual interest. Sexual
avoidance does not surface in persons with a somewhat greater intimacy
tolerance until the partner wants to move in. Others d o not become
sexually blocked until they feel pressured to become engaged or married.
ISD, sexual aversions, and the phobic avoidance of sex frequently have
their onset on the honeymoon, or when the couple buy a home, or when
children are contemplated o r born. At a certain point of commitment or
emotional closeness, sex becomes “dangerous” and the patient then phob-
ically avoids sexual contact with that partner. Depending on the individ-
ual’s dynamics, this might occur at the point when the partner symbolically
becomes a parent. Then, on an unconscious level, sex becomes an inces-
tuous act, and this evokes a defensive avoidance. In other cases, the
person retains sexual desire until he o r she feels too vulnerable to protect
him/herself against being hurt or abandoned by the partner. Sexual avoid-
ance is precipitated in others when the relationship taps into unresolved
and repressed childhood fears of being controlled and overwelmed by
a powerful parental figure, or when the degree of intimacy reawakens
long-buried and threatening desires to regress to a passive position and
to be taken care of by a loving, omnipotent parent.

I n sex therapy with individuals who suffer from this kind of “emotional
claustrophobia,” we attempt to widen their constricted emotional “com-
fort zone” by “severing the past from the present.”’

The Pathological Need for Intimacy

Much has been written about the fear of commitment and intimacy, but
its mirror image, the pathological need for total, risk-free, absolute in-
timacy has been neglected. However, this reverse type of intimacy dis-
order can be just as devastating to a person’s sexual and romantic
 6 Journal of Sex €3Marital Therapy, Vol. 14, No. 1, Spring 1988

relationships. We have seen numbers of cases where an insecure partner’s

insistence on excessive intimacy and emotional closeness, and hidher in-
tolerance to separations, criticisms and rejections, create a pressuring,
intrusive, emotionally stifling ambiance which drives the other away.

SEXUAL AVOIDANCE, INTIMACY PROBLEMS,

AND PANIC DISORDER
We have observed some interesting interrelationships between sexual
avoidance, the excessive need for intimacy with a partner, and panic
disorder, which have important clinical ramifications. For one, we found
a high incidence of panic disorder in patients who phobically avoid sex
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o r who complain of active sexual aversions.9

Between 1976 and 1986 we saw and studied 106 couples with the chief
complaint of phobic sexual avoidance o r sexual aversion, and 267 who
quietly avoided sex. These patients were seen in o u r private practice
group, and at the New York Hospital-Cornell Medical Center.g
More specifically, of the 106 patients in o u r sample, who responded
to sexual stimulation with intense anxiety or revulsion, 25% (27) met the
diagnostic criteria for panic disorder, an additional 25% (26) were atypical
in that they had the characteristic emotional signs and symptoms of panic
disorder, but could not recall having had spontaneous panic attacks. Fifty
percent of our sexually phobic patients ( 5 3 ) had no evidence of under-
lying phobic-anxiety syndrome.9*
In contrast the prevalence of panic disorder in those patients who
complained of loss of sexual interest andlor other forms of “quiet sexual
avoidance” was significantly lower. In our sample of 267 quiet avoiders
the incidence was only 8% (23).**
T h e date from the 49 couples who presented with complaints of low
sexual frequency*** and bilateral sexual avoidance was particularly strik-
ing with regard to intimacy problems and panic disorder. We found that
the partner’s underlying panic disorder with its accompanying separation
anxiety and excessive needs for emotional closeness was a critical factor
in the dynamics of 20% of the 49 cases in this cohort, all of whom had
classic o r atypical forms of panic disorder.****

Panic Disorder
A brief description of the clinical features of panic disorder may clarify
how this syndrome predisposes the individual to develop intimacy and
*D.F. Klein initially called the condition now known as panic disorder, “phobic-anxiety syn-
dronic.”l”
**At the suggestion of Ursula Schaeffer we divided the 373 individuals in our sample who had
primary complaints of low sexual frequency into “quiet”and “phobic” avoiders.
***We borrowed our definition of low sexual frequency from Raul Schiavi, namely, less h m one
sexual encounter every two iueeki. In actual fact, in almost all of our cases the frequency was considerably
lower.
****There were 10 cases in rhis group. ’Two met the criteria for classic panic disorder, eight had
atypical manifestations of’phobic anxiety syndrome. All the differences cited above were significant
at < .OO 1.
 Inlimacy Disorders and Sexual Panic Slates 7

relationship problems. T h e clinical criteria for panic disorder have been

clearly delineated by Donald F. Klein who first described this syndrome.’“
I Y Panic disorder is a drug-responsive anxiety state that is characterized

by spontaneous panic attacks, which lead to a state of anticipatoy unxiety,

and also put the person at high risk of developing phobic avoidances of
various situations. Agoraphobia is a severe expression of the syndrome.I3
T h e syndrome is believed to represent a biological abnormality of the
central nervous system’s alarm-regulating apparatus. Klein has advanced
the hypothesis that the pathologically low panic threshold which char-
acterizes this condition is caused by a genetically determined failure of
the person’s separation anxiety modulating mechanism to mature nor-
mally. More specifically, Klein believes that the “protest phase” of the
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infant’s response to separation from the maternal figure” fails to diminish

as it should at the stage of development when the individual normally
separates from the family unit.15
Klein’s theory regarding the biological aspects of phobic anxiety syn-
drome is supported, at least in part, by the well-documented response
ofadult patients with panicdi~order,’~-’~children with school avoidance,l”-
p2 and puppies who are separated from their damsz3to anti-panic med-
ication.”
Apart from the specific symptoms of spontaneous panic attacks and
anticipatory anxiety, which constitute the essential clinical features of
panic disorder, these patients also tend to display a destructive triad of
personality traits which consist of separation anxiety, rejection sensitivity, and
overreaction to criticismfrom signficant others, such as parents and louerJ.819
I n the course of studying patients with sexual panic states, w e have
observed a number of fascinating individuals with separation anxiety,
rejection sensitivity, family histories suggestive of a genetic predisposition
to panic disorder,25other soft signs such as mitral valve prolapse,2s and
failure to respond to psychological t h e r a p i e ~ . ~These
’ patients also have
multiple phobic avoidances apart from their phobic avoidance of sex. In
short, these individuals have all the stigmata of phobic-anxiety syndrome,
but do not recall having suffered from spontaneous panic attacks. Since
these individuals and those with classic panic disorder seem to have similar
developmental histories and sexual and relationship problems, we have
proceeded on the hypothesis that they could be afflicted with subclinical
o r atypical forms of panic d i ~ o r d e r Preliminary
.~ observations suggest
that the response to treatment of such “atypical” patients is comparable
to that of patients who do recall having spontaneous panic attacks, but
this impression needs to be verified by scientifically controlled studies.
I believe that atypical o r forme fruste expressions of panic disorder are at
least as common as the classical form of this syndrome. Moreover, this
condition is often riot diagnosed, to the great disadvantage of the nu-
merous patients who need both antipanic medication and sexual therapy
or psychotherapy.

*The following types of drugs h a w been found to raise abnormally low panic thresholds: tricyclic
antidepressants (e.g. Tofranil, Norpramin), monoarninoxidase inhibitors (e.g. Nardil, Marplan),
aprezolam (Xanax), trazedoric (Desyrel).’~.l”lH.’~
 8 Journal of Sex €3Marital Therapy, Vol. 14, No. I, Spring I988

The Epigenesis of Intimacy Problems and Sexual Difficulties in Persons With

Panic Disorder: Clinical Implications

Presumably panic disorder is a lifelong condition which is present at

birth. T h e person’s personality develops around his o r her intolerance
for separation and low panic threshold. These individuals are more
deeply affected by any early emotional traumata, separations and family
conflicts that they might experience than children with a normal panic
threshold would be. Unless their upbringing was exceedingly stable and
sensitive to their special emotional needs, these hypersensitive souls tend
either to defend themselves against their vulnerabilities by reaction for-
mations against their desire to be emotionally fused with their lovers, and
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they avoid close emotional attachments. O r they adopt the opposite

psychic strategy and develop the kind of disturbingly intense and exces-
sive need for intimacy with their lovers that was described earlier in this
paper. This type of intimacy disorder predisposes them to develop spe-
cific types of problematic romantic relationships as well as certain sexual
difficulties. In order to insure a successful treatment outcome, it is of
utmost importance that the clinician recognize these dynamics when eval-
uating couples with sexual and marital difficulties.

Clinical Illustrations

T h e vulnerable partner’s separation anxiety is often heightened to ex-

cessive proportion when he or she senses that the partner is not com-
pletely “with” them. This can occur even when the partner is not really
detached but is simply abandoning him-/or herself to sexual pleasure in
a perfectly normal way. T h e panicky partner’s insatiable quest for reas-
surance, and also his or her rage at being “abandoned,” can precipitate
sexual avoidance and ISD in the partner who has a normal capacity for
anxiety. In such cases, it is the sexually asymptomatic partner’s obsessive desire
for intimacy and constant communication and hislher need to control the partner
which should be the focus of treatment, rather than the “symptomatic” patient’s
sexual avoidance.
I n another common destructive scenario, an individual with separation
problems may become so obsessed with pleasing his or her partner and
with avoiding rejection, that he or she interferes with the lover’s sexual
pleasure. Thus, some anxious husbands insist on a detailed description
of their wives’ experience each time they make love. Others ruin their
sex lives by anxiously checking to see if the partner is lubricating or by
expressing intense dismay if she should fail to have an orgasm. One of
our patients was distressed because his wife liked to have multiple or-
gasms. He felt that if he were “giving” her “really good ones” she would
not “need” more than one! Males, anxious to avoid criticism or rejection,
often destroy their own sexual pleasure and/or give themselves functional
problems with their heroic, but counterproductive efforts to please their
partners. ‘:I try very hard to hold back until she comes” is a typical
statement of this kind of irrational insecurity, which occurs even though
 Intimacy Disorders and Sexual Panic States 9

the wife climaxes with clitoral stimulation and not on penetration. Sim-
ilarly, rejection-sensitive women may take anything less than an instant,
ramrod hard erection and perfect ejaculatory control as a personal af-
front. These anxious partners create an ambience of performance pres-
sure for themselves and for their lovers, which frequently results in the
couple avoiding sex.
A partner’s sexual panic not only is a major cause of sexual dysfunction
but may give rise to serious resistance to treatment. These anxious in-
dividuals are often exceedingly threatened by the prospect of a partner’s
improvement, even though they desperately want this. For example, dur-
ing sex therapy, the vulnerable partner sometimes spoils the relaxed
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intimate ambience created by sexual assignments with excessively “affec-

tion and intimate” clinging behavior and by pressing the partner for a
detailed accounting and for reassurance that he or she “truly enjoyed it”.
For example, one of our patients became both euphoric and anxious
when he felt emotionally and physically close to his wife for the first time
in his life, following some successful sensate focus exercises. He followed
her around the house all week hugging and kissing her. Not surprisingly,
the wife felt a compelling urge to visit her mother in Arizona, and to
escape from treatment. Until this issue was clarified during the next
conjoint therapy session, she had been afraid to say “no” to him, fearing
that unless she totally acquiesced to his insatiable demands for “love and
intimacy,” she might traumatize him and spoil the treatment.g
l’he unwary therapist can get trapped into playing along with the
anxious partner’s excessive and unreasonable desires for emotional
“closeness,” “communication,” and “sharing.” Generally, this does not
represent a desire for real intimacy o r genuine closeness, but a concealed
demand for continuous reassurance and the need, born of anxiety, to
completely control the partner.
These anxious individuals often present themselves as the healthy
“victims” of their spouse’s alledged “neurotic” detachment or “lack of
intimacy” or “inability to communicate” o r their “overinvolvement” in
work. Again, commitment and intimacy conflicts are often real and se-
rious issues in the dynamics and the treatment of couples with sexual
dysfunctions, sexual avoidances, and ISD. However, intimacy and com-
munication have become so sacrosanct in o u r society and in the mental
health establishment that the pathological need for intimacy is often over-
looked. The “accused” spouse and the unsuspecting therapist may “buy”
the anxious partner’s erroneous assessment of the couple’s sexual prob-
lem. T h e “nonintimate” (but actually normal) partner often feels guilty
about hidher “problem” and may not feel free to object, thinking s/he
should work on hidher “intimacy problem” or hidher “work-a-holism.”
If the therapist agrees to this inappropriate goal, treatment is likely to
fail because the real problem in this case is the panicky partnerS excessive desire
for so-called intimacy and his or her obsessive need for reassurance, contact,
communication, overexpressiveness and control. T h e obsessive individuals
often alienate their spouses and drive them to distraction with their jeal-
 10 Journal of Sex U Marital Therapy, Val. 14, No. 1, Spring 1988

ousies and insatiable emotional demands, which may ultimately cause the
partner to avoid sex.
As another example, “sex talk” during lovemaking is perfectly normal
and can enhance the couple’s sexual pleasure, providing both are turned
on by this. But sex is best for many equally normal individuals if they
distance themselves somewhat and focus on their erotic sensations and
on their fantasies. These individuals need to “tune out” the distractions
of their environment when they are making love, and the pressure to
take care of the partner’s emotional needs interferes with their sexual
functioning and pleasure. But the anxious partner requires the opposite
emotional conditions to enjoy sex, namely an intensely maintained emo-
tional closeness. These rejection-sensitive individuals pressure their part-
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ner overtly or covertly for “intimacy” and insist on ongoing communications

during lovemaking, and the ensuing struggle between one partner’s need
for unbroken and perpetual contact, and the other’s need for distance,
can be destructive to the couple’s sexual relationship.
To illustrate, a husband complained about his wife: “She is so uptight
about sex she won’t talk dirty, and she won’t tell me she loves it while we
make love.” He did not understand that his request that she communicate
verbally during sex intruded on his wife’s erotic arousal. But this perfectly
normal woman “bought” her anxious husband’s erroneous assessment of
the couple’s sexual difficulties. “Doctor,” she complained to me, “I have
this hang-up, I am too blocked to talk during sex, I guess it’s my Catholic
u pbr i n Sing.”

RECONCEPTUALIZING T H E DYNAMICS OF
T H E COUPLE’S SEXUAL PROBLEM

During the initial sesson with couples who present with phony intimacy
problems I often deliberately create a controlled therapeutic crisis by
raising the question as to who actually has the problem. I n such a case,
I say to the one who complains about the other’s “emotional remoteness”:
“I can see that you must feel shut out and abandoned and that you (to
the one who has been accused of insufficient intimacy) feel very pres-
sured, but I can’t tell at this point if you (to the “rejected” one) are
excessively needy or if you (to the “nonintimate” one) are abnormally de-
tached or incapable of emotional closeness. We will need more infor-
mation to figure that out.” Sometimes, when the panicky partner’s
emotional demands are clearly outrageous I am more direct: “I believe
that your demands for attention and companionship and communication
are excessive and would turn off any partner. I would be glad to help
y o u with this problem.”
Such a reconceptualization of the couple’s complaint often amazes and
bitterly disappoints the anxious spouse, who had fully expected the ther-
apist would side with him/her in hidher quest for “greater intimacy.” But
this confrontation is a vast relief for the partner who had been labeled;
as “sick,” and who feared that successful therapy would entail total emo-
 Intimacy Disorders and Sexual Panic States 11

tional slavery. At the same time, this therapeutic strategy serves to engage
the reluctant “nonintimate” partner in the treatment process.
It should be emphasized that similar commitment and intimacy prob-
lems and identical relationship difficulties also occur in patients with
biologically normal CNS anxiety regulating mechanisms. It is of utmost
importance for the clinician to distinguish between couples who have
underlying drug-responsive anxiety disorders and those who d o not.
Antipanic medication is indicated for the former, while pharmacotherapy
is inappropriate for patients with intimacy problems and sexual avoidance
patterns who have biologically normal thresholds for anxiety.
T h e emotional vulnerability to separation, rejection and panic in pa-
tients with underlying panic disorders has a biological basis which cannot
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be altered by insight. However, fortunately, about 85% of these patients

have an excellent response to antipanic medications.12J8 In o u r experi-
ence, even the most skilled sex therapist is likely to fail with these couples
unless the panicky partner is protected with antipanic medication during
the course of treatment. That is because the process and the outcome of
sexual therapy tends to heighten these patients’ vulnerabilities and raise
their anxieties to counterproductive
I do not mean to imply that there is a dichotomy between the patient’s
biological susceptibility to separation anxiety and hidher rejection sen-
sitivity on the one hand, and hidher intrapsychic conflicts and the de-
velopmental deficits s/he has incurred on the other. On the contrary.
Children born with a special sensitivity to separation and panic are more
vulnerable to, and their psychosexual development is likely to be more
deeply affected by, the craziness of their families than are children with
normal o r less sensitive nervous systems. These patients and couples with
the dual diagnosis of panic disorder and sexual aversions or avoidance
require a judicious combination of medication and behavioral and psy-
chodynamic interventions. T h e drugs serve to protect these individuals
from their propensity to panic and from their excessive vulnerability to
rejection and separation. This does not cure the patient, but in good re-
sponders medication creates the psychophysiological stability which en-
ables the therapist to proceed with the therapeutic exposures to previously
avoided sexual and intimate situations without panicking the patient. T h e
drugs can also create an optimal emotional climate necessary for the
successful psychodynamic exploration and resolution of the vulnerable
patient’s unconscious sexual conflicts, and of the deeper destructive dy-
namics of the couple’s marital struggles.

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