Virtue, Vice, & Addiction KAPLAN and SADOCK’S SYNOPSIS of PSYCHIATRY [17.2] SEX ADDICTION and COMPULSIVITY

Adapted from: KAPLAN and SADOCK’S SYNOPSIS of PSYCHIATRY, Behavioral Sciences/Clinical,Benjamin J. Sadock, Virginia A. Sadock, Pedro Ruiz (Lippincott Williams & Wilkins, Sep 22, 2014)

 

 

[1] whose life revolves around sex-seeking behavior and activities,

[2] who spends an excessive amount of time in such behavior, and

[3] who often tries to stop such behavior but is unable to do so

   DIAGNOSIS

[1] Sex addicts are unable to control their sexual impulses, which can involve the entire spectrum of sexual fantasy or behavior.

[2] Eventually, the need for sexual activity increases, and the person’s behavior is motivated largely by the persistent desire to experience the sex act.

[3a] The history usually reveals a long-standing pattern of such behavior,

[3b] which the person repeatedly has tried to stop, but without success.

[4] Although a patient may have feelings of guilt and remorse after the act, these feelings do not suffice to prevent its recurrence.

[5] The patient may report that the need to act out is most severe during stressful periods or when angry, depressed, anxious, or otherwise dysphoric.

[6] Most acts culminate in a sexual orgasm.

[7] Eventually, the sexual activity interferes with the person’s social, vocational, or marital life, which begins to deteriorate.

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Data from Carnes, Don’t Call it Love. (New York: Bantam Books; 1991).

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The paraphilias constitute the behavioral patterns most often found in the sex addict. The essential features of a paraphilia are recurrent, intense sexual urges or behaviors,including

Paraphilias are associated with clinically significant distress and almost invariably interfere with interpersonal relationships, and they often lead to legal complications. In addition to the paraphilias, however, sex addiction can also include behavior that is considered normal, such as coitus and masturbation, except that it is promiscuous and uncontrolled.

In the 19^th century, Krafft-Ebing reported on several cases of abnormally increased sexual desire. One involved a 36-year-old married teacher, the father of seven children, who masturbated repeatedly while sitting at his desk in front of his pupils, after which he was “penitent and filled with shame.” He indulged in coitus three or four times a day in addition to his repeated masturbatory act. In another case, a young woman masturbated almost incessantly and was unable to control her impulses. She had frequent coitus with many men, but neither coitus nor masturbation sufficed, and she eventually was placed in an institution. Krafft-Ebing referred to the condition as “sexual hyperaesthesia,” which he believed could occur in otherwise normal persons. In this case, the clinician would have to differentiate between a diagnosis of sex addiction or Persistent Genital Arousal Disorder (PGAD). This is not a diagnostic category in DSM-5, but has received attention by sex therapists. Women with PGAD complain that their sense of arousal is not satisfied by orgasm or multiple orgasms. The ongoing sense of arousal is distressing, intensely uncomfortable, and has led to one reported case of suicide. In contrast to sex addicts, women with PGAD are not even temporarily satisfied, physically or emotionally, by orgasm. Some theorists suspect a neurologic etiology.

In many cases, sex addiction is the final common pathway of a variety of other disorders. In addition to the paraphilias that are often present, the patient may have an associated major mood disorder or schizophrenia. Antisocial personality disorder and borderline personality disorder are common.

DON JUANISM. Some men who appear to be hypersexual, as manifested by their need to have many sexual encounters or conquests, use their sexual activities to mask deep feelings of inferiority. Some have unconscious homosexual impulses, which they deny by compulsive sexual contacts with women. After having sex, most Don Juans are no longer interested in the woman. The condition is sometimes referred to as satyriasis or sex addiction.

NYMPHOMANIA. Nymphomania signifies a woman’s excessive or pathological desire for coitus. Of the few scientific studies of the condition, those patients who were studied usually have had one or more sexual disorders, often including female orgasmic disorder. The woman often has an intense fear of losing love and, through her actions, attempts to satisfy her dependence needs rather than gratify her sexual impulses. This disorder is a form of sex addiction.

COMORBIDITY. Comorbidity (dual diagnosis) refers to the presence of an addiction that coexists with another psychiatric disorder. For example, about 50 percent of patients with substance-use disorder also have an additional psychiatric disorder. Similarly, many sex addicts have an associated psychiatric disorder. Dual diagnosis implies that the psychiatric illness and the addiction are separate disorders; one does not cause the other. The diagnosis of comorbidity is often difficult to make because addictive behavior (of all types) can produce extreme anxiety and severe disturbances in mood and affect, especially while the addictive behavior is treated. If, after a period of abstinence, symptoms of a psychiatric disorder remain, the comorbid condition is more easily recognized and diagnosed than during the addictive period. Finally, a high correlation is found between sex addiction and substance-use disorders (up to 80 percent in some studies), which not only complicates the task of diagnosis, but also complicates treatment.

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Self-help groups based on the 12-step concept used in Alcoholics Anonymous (AA) have been used successfully with many sex addicts. They include such groups as Sexaholics Anonymous (SA), Sex and Love Addicts Anonymous (SLAA), and Sex Addicts Anonymous (SAA). The groups differ in that some are for men or women, or for married persons or couples. All advocate some abstinence from either the addictive behavior or sex in general. Should a substance-use disorder also be present, the patient often requires referral to AA or Narcotics Anonymous (NA) as well. Patients may enter an inpatient treatment unit when they lack sufficient motivation to control their behavior on an outpatient basis or may be a danger to themselves or others. In addition, severe medical or psychiatric symptoms may require careful supervision and treatment best carried out in a hospital.

A 42-year-old married businessman with two children was considered a model of virtue in his community. He was active in his church and on the boards of several charitable organizations. He was living a secret life, however, and would lie to his wife, telling her that he was at a board meeting when he was actually visiting massage parlors for paid sex. He eventually was engaging in the behavior four to five times a day, and although he tried to quit many times, he was unable to do so. He knew that he was harming himself by putting his reputation and marriage at risk.

The patient presented himself to the psychiatric emergency room, stating that he would prefer to be dead rather than continue the behavior described. He was admitted with a diagnosis of major depressive disorder and started on a daily dose of 20 mg of fluoxetine. In addition, he received 100 mg of medroxyprogesterone intramuscularly once a day. His need to masturbate diminished markedly and ceased entirely on the third hospital day, as did his mental preoccupation with sex. The medroxyprogesterone was discontinued on the sixth day, when he was discharged. He continued to take fluoxetine, enrolled in a local SA group, and entered individual and couples psychotherapy. His addictive behavior eventually stopped, he was having satisfactory sexual relations with his wife, and he was no longer suicidal or depressed.

PSYCHOTHERAPY. Insight-oriented psychotherapy may help patients understand the dynamics of their behavioral patterns. Supportive psychotherapy can help repair the interpersonal, social, or occupational damage that occurs. Cognitive behavioral therapy helps the patient recognize dysphoric states that precipitate sexual acting out. Marital therapy or couples therapy can help the patient regain self-esteem, which is severely impaired by the time a treatment program is begun. It is also helpful to the partners who need assistance in understanding the disease and dealing with their own complex reactions to the situation. Finally, psychotherapy may be of help in the treatment of any associated psychiatric disorder.

PHARMACOTHERAPY. Most specialists in general addiction avoid the use of psychotropic agents, especially in the early stages of treatment. Substance-dependent persons have a tendency to abuse those agents, especially agents with a high abuse potential, such as the benzodiazepines. Pharmacotherapy is of use in the treatment of associated psychiatric disorders, such as major depressive disorders and schizophrenia.

Certain medications may be of use in treating sex addiction, however, because of their specific effects on reducing the sex drive. SSRIs reduce libido in some persons, a side effect that is used therapeutically. Compulsive masturbation is an example of a behavioral pattern that may benefit from such medication. Medroxyprogesterone acetate diminishes libido in men and, thus, makes it easier to control sexually addictive behavior.

The use of antiandrogens in women to control hypersexuality has not been tested sufficiently, but because androgenic compounds contribute to the sex drive in women, antiandrogens could be of benefit. Antiandrogenic agents (cyproterone acetate) are not available in the United States but are used in Europe with varying success. Use of the antiandrogenic medications is controversial, and objected to by clinicians who see it a chemical castration and believe that is an inappropriate treatment approach.

 

 

 

PERSISTENT AND MARKED DISTRESS ABOUT SEXUAL ORIENTATION

Distress about sexual orientation is characterized by dissatisfaction with sexual arousal patterns, and it is usually applied to dissatisfaction with homosexual arousal patterns, a desire to increase heterosexual arousal, and strong negative feelings about being homosexual. Occasional statements to the effect that life would be easier if the speaker were not homosexual do not constitute persistent and marked distress about sexual orientation.

Treatment of sexual orientation distress is controversial. One study reported that with a minimum of 350 hours of psychoanalytic therapy, about a third of 100 bisexual and gay men achieved a heterosexual reorientation at a 5-year follow-up; this study has been challenged, however. Behavior therapy and avoidance conditioning techniques have also been used, but these techniques may change behavior only in the laboratory setting. Prognostic factors weighing in favor of heterosexual reorientation for men include being younger than 35 years of age, having some experience of heterosexual arousal, and feeling highly motivated to reorient.

Another and more prevalent style of intervention is directed at enabling persons with persistent and marked distress about sexual orientation to live comfortably with homosexuality without shame, guilt, anxiety, or depression. Gay counseling centers are engaged with patients in such treatment programs. At present, outcome studies of such centers have not been reported in detail.

Few data are available about the treatment of women with persistent and marked distress about sexual orientation, and these are primarily from single-case studies with variable outcomes.