Addictive Sexual Disorders Richard R. Irons, MD 0 Jennifer PgSchneider, MD,PhD Indulgence in the gratification of sexual de‑ gage in fantasy and seductive behavior with sires and appetites to excess has been a major out significant consequences to their persona subject in literature, myths, and the creative or professional life. However, for some, it i: arts from the begirming of recorded history. notpossible to limitthe intensity of their desire One example of the hyp'ersexual predatory or expression of sexual behavior. For them male is DonJuan, the legendary lover of many sexual excesses can become addictive in nature women, who suffered a multitude of adverse and represent a serious mental disorder. consequences, including death, as a result of A distinction mustbe madebetween a situa‑ his behavior. He is immortalized asthe sexual tional and a pervasive use of sex. Twc athlete who worshipped the female body as surveys" 2 confirm that unmarried persons the ideal object of desire, created for himto be have more sexual partners than married peo consumed and ravished, and who had to make ple. For most,sexual variety is situational. Oth‑ his escape from each one before potential en‑ ers, dealing with a life crisis such as the gulfrnent by intimacy in a relationship. His breakup of a relationship, may find themselves story was immortalized in the plays of Cor‑ using sex compulsively for a brief period. For neille, Moliere, Shaw, and Rostand, in Byron’s those with addictive sexual disorders, on the unfinished poem, and in Mozart’s Don Gio‑ other hand, sex is the pervasive organizing vanni. He has become an infamous symbol for principle of their lives. a hedonistic, narcissistic male who engages in recurrent sexual affairs. Women with cultur‑ ally defined excessive sexual appetite were Current Nosology given the diagnosis of nymphomania, a term According to the Diagnostic no longer in clinical use. We have evolved into a society obsessed‑ andStatistical Manual of with the pursuit of pleasure and materi‑ Mental Disorders alism-and for some, sexual materialism. In our sensually driven society, sexual excesses The DSM-IV3 classification of sexual disor‑ and deviances are regularly reported by the ders includes sexual dysfunctions and para‑ media and served up as entertainment in philias. The sexual dysfunctions are character‑ books, movies, and television. Corporations ized by disturbance in sexual desire and in the have learned through advertising campaigns psychophysiological changes that constitute that sex sells. The majority of adolescents, the sexual response cycle and cause marked adult men, and women in our society can en‑ distress and interpersonal difficulty. The sex‑ 441 442 . CHAPTER 48 Q uaI dysfunctions include sexual desire disor‑ Table 48-1. AXIS l DIFFERENTIAL DIAGNOSIS OF EXCESSIVE SEXUAL BEHAVIORS ders, sexual arousal disorders, orgasmic disor‑ ders, sexual pain disorders, sexual dysfunction Common Infrequent due to a general medical condition, substance~ Paraphilias Substance-induced anxiety induced sexual dysfunction, and sexual dys~ Sexual disorder NOS disorder (obsessive‑ function not otherwise specified (NOS). lmpulse control disorder compulsive symptoms) The paraphilias are characterized by recur‑ NOS ' Substance-induced mood rent intense fantasies, or Bipolar affective disorder disorder (manic features) sexual urges, behav‑ (type I or II) Dissociative disorder iors that involve unusual objects, activities, or Cyclothymic disorder Delusional disorder situations and cause clinically significant dis‑ Posttraumatic stress (erotomania) tress or impairment in social, occupational, or disorder Obsessive-compulsive other important areas of functioning. The para~ Adjustment disorder disorder [disturbance of conduct] Gender identity disorder philias include exhibitionism, fetishism, frot‑ Delirium, dementia, or teurism, pedophilia, sexual masochism, sexual other cognitive disorder sadism, transvestic fetishism, voyeurism, and _________________.__._‐‐‐‐‐‐‐‐‐‑ paraphilia NOS. NOS, not otherwise specified. Gender identity disorders are characterized by strong and persistent cross-gender identifi~ cation accompanied by persistent discomfort features noted in addition to specific paraphilic with one’s assigned sex. behaviors are those of addiction, exploitation, Sexual disorder NOS is included for coding predation, romance,coercion, professional mis‑ disorders of sexual functioning that are not conduct, sexual offense, and sexual assault. classifiable in any of the specific categories. It The severity of the disorder, the duration, the is important to note that notions of deviance, current level of activity, and amenability to standards of sexual performance, and concepts treatment should also be presented. In the dif- 5,43. of appropriate gender role can vary from cul‑ ferential diagnosis of sexual improprieties and féfi ture to culture.3 excesses, axis II characterological disorders and "" The essential feature of impulse control dis‑ traits are often contributory or may be consid- "5. orders is the failure to resist an impulse, drive, ered the primary cause of paraphilic sexual -.~ or temptation to perform an act that is harmful behavior. 3,~ ., to oneself or to others. For most of- the disor‑ A discussion of these disorders is included {311 ders in this section, the individual feels an in this text on addiction psychiatry because increasing sense of tension or arousal before they often have distinct parallels with other 33,51 committing the act and then experiences plea‑ addictive disorders, commonly coexist with 3-325]; sure, gratification, or relief at the time of com‑ substance-related disorders, may themselves mitting the act. After the act, the person may have features associated with addiction, and or may notfeel regret, self-reproach, or guilt.3 may respond to an addiction model of treat- _. The types of sexual improprieties and ex‑ ment and therapy. Unrecognized and un- 2. cesses that are considered addictive sexual dis‑ treated symptoms of these sexual disorders .. f“ orders can usually be classified into one of currently are frequently being recognized as three major categories: paraphilia, impulse significant factors leading to return to sub-‘ L; control disorder N05,or sexual disorder NOS. stance use in substance-related disorders. _ When the behavior does not fit easily into one Compulsive sexual behavior has significantly ' of;these categories and is not considered a contributed to the growth of the current epli $5,‑ manifestation of some other DSM-IV axis I di‑ dernic of acquired immunodeficiency Sy‘fl‘ji; agnosis, then it is reasonable to use the work‑ drome. --,".-f. n' f. related problem (V 62.2) or relationship prob‑ ,$.‑ 7 lem (V 6.) descriptors. Frequent and infrequent DSM axis I diagnoses associated with sexual Evolution of the Addiction excesses are presented in Table 48‐1. It is help‑ Model ' ful to complete the differential diagnosis on axis I before considering axis II and axis III. BillWilson, in hisclassic Big Book,‘describe; 1 Sexual disorders, impulse control disorders, an alcoholic’s difficulties with sexual behaviQF " and paraphilias, when identified, should be described as precisely as possible. If the NOS ”Now about sex. Many of us needed an‘ category is used, it is important to ap ly ap‑ overhauling there. But above all, we tried to be,-, propriate descriptors that define the eatures sensible on this question. It's so easy to way off the track. Here we find human observed. In our experience, the most frequent opin‘ 0 ‘V' f ADDICTIVE SEXUAL DISORDERS - 443 ions running to extremes-absurd extremes tion rather than on a particular chemical Was perhaps. We do not want to be the arbiter earlier supported by Peele, who in a popular of anyone’s sex conduct. We all have sex prob‑ book’t described addiction as having as much lems. We’d hardly be human if we didn’t. to do with love as with drugs. After critically What can we do about them? reviewing research on addiction, he con‑ We reviewed our conduct over years past. cluded,9 ”Drug addiction is based on the expe‑ . We got this all down on paper and looked rience a drug gives a person and the place this at it. In this way we tried to shape a sane and sound ideal for our future sex life. We experience has in the person’s life. Anything subjected each relation to this test‐was it that produces a comparable experience can selfish or not? We asked God to mould our likewisebe addictive.” Ironically, Peele has be‑ ideals and help us to live up to them. .What‑ come an outspoken critic of the epidemic of ever our ideal turns out to be, we must be addiction in America. Persons who are dually willing to grow toward it.. .. Suppose we fall addicted to drugs and to sexual experiences short of our ideal and stumble? Does this mean describe a euphoria during their sexual acting we are going to get drunk? It depends on us out similar to that experienced when using and on our motives. .. If we are not sorry, mood-altering chemicals. and our conduct continues to harm others, we Quadland10 characterized the disorder as are quite sure to drink. We are not theorizing. These are facts out of our experience. sexual compulsivity, whereas Barth and To sum up about sex: We earnestly pray for Kinder“ suggested the term sexual impulsivity the right ideal, for guidance in each question‑ and reserved the term addiction only for sub‑ able situation, for sanity, and for the strength stance dependence. Schwartz,12 noting the high to do the right thing. If sex is troublesome, we frequency of sexual