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Compulsive Sexual Behavior: a Nonjudgmental Approach

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Compulsive Sexual Behavior: a Nonjudgmental Approach Compulsive sexual behavior: A nonjudgmental approach Despite limited evidence, this disorder can be accurately diagnosed and successfully treated ompulsive sexual behavior (CSB), also referred to as sexual addiction or hypersexuality, is character- Cized by repetitive and intense preoccupations with sexual fantasies, urges, and behaviors that are distressing to the individual and/or result in psychosocial impairment. Individuals with CSB often perceive their sexual behavior to be excessive but are unable to control it. CSB can involve fan- tasies and urges in addition to or in place of the behavior but must cause clinically significant distress and interference in daily life to qualify as a disorder. Because of the lack of large-scale, population-based epidemiological studies assessing CSB, its true prevalence among adults is unknown. A study of 204 psychiatric WIESLAW SMETEK/SCIENCE SOURCE WIESLAW inpatients found a current prevalence of 4.4%,1 while a Jon E. Grant, JD, MD, MPH university-based survey estimated the prevalence of CSB at Professor approximately 2%.2 Others have estimated that the prevalence Department of Psychiatry and Behavioral Neuroscience is between 3% to 6% of adults in the United States,3,4 with University of Chicago, Pritzker School of Medicine 5 Chicago, Illinois males comprising the majority (≥80%) of affected individuals. CSB usually develops during late adolescence/early adulthood, and most who present for treatment are male.5 Mood states, including depression, happiness, and loneli- ness, may trigger CSB.6 Many individuals report feelings of dissociation while engaging in CSB-related behaviors, whereas others report feeling important, powerful, excited, or gratified. continued on page 38 Disclosure Dr. Grant receives grant or research support from the National Center for Responsible Gaming, the American Foundation for Suicide Prevention, the TLC Foundation for Body Focused Repetitive Behaviors, Brainsway, and Takeda Pharmaceuticals; receives yearly compensation from Springer Publishing for acting as Editor-in-Chief of the Journal of Gambling Studies; and has received Current Psychiatry royalties from Oxford University Press, American Psychiatric Publishing, Inc., Norton Press, Johns 34 February 2018 Hopkins University Press, and McGraw Hill. continued from page 34 Why CSB is difficult to diagnose urges, or behaviors in response to stress- Although CSB may be common, it usually ful life events; (d) repetitive but unsuc- goes undiagnosed. This potentially prob- cessful efforts to control or significantly lematic behavior often is not diagnosed reduce these sexual fantasies, urges, or because of: behaviors; and (e) repetitively engaging in • Shame and secrecy. Embarrassment sexual behaviors while disregarding the and shame, which are fundamental to CSB, risk for physical or emotional harm to self Compulsive appear to explain, in part, why few patients or others.9 sexual behavior volunteer information regarding this behav- These 2 proposed approaches to diagno- ior unless specifically asked.1 sis are somewhat similar. Both suggest that • Patient lack of knowledge. Patients the core underlying issues involve sexual often do not know that their behavior can be urges or behaviors that are difficult to con- successfully treated. trol and that lead to psychosocial dysfunc- • Clinician lack of knowledge. Few tion. Differences in the criteria, however, health care professionals have education or could result in different rates of CSB diag- training in CSB. A lack of recognition of CSB nosis; therefore, further research will need Clinical Point also may be due to our limited understand- to determine which diagnostic approach A lack of recognition ing regarding the limits of sexual normal- reflects the neurobiology underlying CSB. ity. In addition, the classification of CSB is of CSB may be unclear and not agreed upon (Box,7-9 page due to limited 39), and moral judgments often are involved Avoid misdiagnosis understanding of in understanding sexual behaviors.10 Before making a diagnosis of CSB, it is the limits of sexual important for clinicians to consider whether they are stigmatizing “negative conse- normality No consensus on diagnostic quences,” distress, or social impairment criteria based on unconscious bias toward certain Accurately diagnosing CSB is difficult sexual behaviors. In addition, we need to because of a lack of consensus about ensure that we are not holding sex to dif- the diagnostic criteria for the disorder. ferent standards than other behaviors (for Christenson et al11 developed an early set example, there are many things in life we of criteria for CSB as part of a larger sur- do that result in negative consequences and vey of impulse control disorders. They yet do not classify as a mental disorder, such used the following 2 criteria to diagnose as indulging in less healthy food choices). CSB: (1) excessive or uncontrolled sexual Furthermore, excessive sexual behaviors behavior(s) or sexual thoughts/urges to might be associated with the normal com- engage in behavior, and (2) these behaviors ing out process for LGBTQ individuals, or thoughts/urges lead to significant dis- partner relationship problems, or sexual/ tress, social or occupational impairment, gender identity. Therefore, the behavior or legal and financial consequences.11,12 needs to be assessed in the context of these During the DSM-5 revision process, a psychosocial environmental factors. second approach to the diagnostic criteria was proposed for hypersexuality disorder. Under the proposed criteria for hyper- Differential diagnosis sexuality, a person would meet the diag- Various psychiatric disorders also may nosis if ≥3 of the following were endorsed include excessive sexual behavior as part Discuss this article at over a 6-month period: (a) time consumed of their clinical presentation, and it is www.facebook.com/ by sexual fantasies, urges, or behaviors important to differentiate that behavior CurrentPsychiatry repetitively interferes with other impor- from CSB. tant (non-sexual) goals, activities, and obligations; (b) repetitively engaging in Bipolar disorder. Excessive sexual behav- sexual fantasies, urges, or behaviors in ior can occur as part of a manic episode in response to dysphoric mood states; (c) bipolar disorder. If the problematic sexual Current Psychiatry 38 February 2018 repetitively engaging in sexual fantasies, behavior also occurs when the person’s mood is stable, the individual may have Box CSB and bipolar disorder. This distinction is Classifying compulsive important because the treatment for bipolar sexual behavior disorder is often different for CSB, because anticonvulsants have only case reports arious suggestions have been proposed attesting to their use in CSB. Vfor the classification of compulsive sexual behavior (CSB). It may be related to obsessive-compulsive disorder (OCD), Substance abuse. Excessive sexual behav- forming an “obsessive-compulsive ior can occur when a person is abusing spectrum;” to mood disorders (“an affective spectrum disorder”)7,8; or as a symptom substances, particularly stimulants such as of relationship problems, intimacy, and cocaine and amphetamines.13 If the sexual self-esteem. Grouping CSB within either behavior does not occur when the person is an obsessive-compulsive or an affective spectrum is based on symptom similarities, not using drugs, then the appropriate diag- comorbidities, family history, and treatment nosis would not likely be CSB. responses. Similar to persons with OCD, CSB patients report repetitive thoughts Obsessive-compulsive disorder (OCD). and behaviors. Unlike OCD, however, the sexual behavior of CSB is pleasurable and Individuals with OCD often are preoccu- often is driven by cravings or urges. Given Clinical Point pied with sexual themes and feel that they these descriptions, CSB also may share Approximately one- think about sex excessively.14 Although features of substance use disorders, and has generated a theory of sexual behavior being half of adults with patients with OCD may be preoccupied an addiction. There is still much debate as with thoughts of sex, the key difference to how best to understand this cluster of compulsive sexual is that persons with CSB report feeling symptoms and behaviors—as a separate behavior meet criteria disorder or as a symptom of an underlying excited by these thoughts and derive plea- problem. DSM-5 did not find sufficient for at least 1 other sure from the behavior, whereas the reason to designate sexual addiction as a psychiatric disorder sexual thoughts of OCD are perceived psychiatric disorder.9 as unpleasant. Other disorders that may give rise to hyper- sexual behavior include neurocognitive of men with CSB (N = 103) found that 71% disorders, attention-deficit/hyperactivity met criteria for a mood disorder, 40% for disorder, autism spectrum disorders, and an anxiety disorder, 41% for a substance depressive disorders. use disorder, and 24% for an impulse con- trol disorder such as gambling disorder.17 Adverse effects of medication. It is impor- Therefore, to successfully treat CSB, clini- tant to ask the patient whether he (she) cians also may need to focus on how and developed CSB after starting a medica- to what extent these co-occurring disorders tion. Certain medications (eg, medications drive the sexual behavior. for Parkinson’s disease or restless leg syn- Co-occurring medical conditions also drome, or aripiprazole to treat depression are common among individuals with CSB. or psychosis) may cause
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