Assessment, diagnosis, and management of hypersexual disorders

Assessment, diagnosis, and management of hypersexual disorders Liam E. Marshalla,b and Peer Brikenc a Rockwood Psychological Services, Kingston, bRoyal Ottawa Healthcare Group, Brockville, Ontario, Canada and cInstitute for Sex Research and Forensic Psychiatry, University Medical Centre, HamburgEppendorf, Hamburg, Germany Correspondence to Liam E. Marshall, Rockwood Psychological Services, 303 Bagot Street, Suite #304, Kingston, ON K7K 5W7, Canada Tel: +1 613 530 3606; fax: +1 613 530 2895; e-mail: [email protected] Current Opinion in Psychiatry 2010, 23:570–573 Purpose of review This review examines recent advances in conceptualizing and treating hypersexual disorders. Recent findings Studies on hypersexual disorders, inferred from research on their associated descriptors, suggest that these disorders have a strong relationship to a number of areas of functioning, in particular, self-regulation and sexually offensive behavior. Summary The proposed inclusion of hypersexual disorders in the upcoming Diagnostic and Statistical Manual of Mental Disorders-V may address many of the current issues related to the lack of empirical research on hypersexuality. Although there have been some gains made on understanding hypersexuality, there remains a lack of consensus and empirical research on hypersexual disorders. There are also an insufficient number of controlled studies on the efficacy of pharmacological and psychological treatments for hypersexual behavior problems. Keywords excessive sexual desire disorder, hypersexual disorders, sexual addiction, sexual compulsivity, sexual impulsivity Curr Opin Psychiatry 23:570–573 ß 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins 0951-7367 Introduction Methodological considerations Hypersexual behavior is a phenomenon easily recognized by those who work with persons suffering from it; however, there has been much speculation and debate regarding the best descriptor to be used [1,2]. Clearly, there are individuals who struggle with their ability to control their sexual thoughts, fantasies, and behaviors, for example, those who spend excessive time on the internet for sexual purposes, engage in high rates of consenting sex with other adults, or who exhibit high rates of masturbation. Assessing the presence and treatments of hypersexual behavior problems presents many challenges. For example, as a result of the groundswell of support for Carnes’ [4,5] notion of sexual addiction in the 1980s and its association with the 12-step Alcoholics Anonymouslike approach, and the subsequent rejection of this view in the 1990s, the field has suffered from a lack of empirical research. Although there was much theoretical debate on the topic, this did not prompt, until very recently, much empirical research. Further, this lack of agreement in the existing literature on the features of problematic or disordered hypersexuality has made it impossible to determine whether researchers are reporting on a similar problem or whether there are multiple types of hypersexual disorders. Nowhere is hypersexuality more of a serious social issue than in the case of those whose hypersexual behavior is associated with sexually offensive behavior towards others. Indeed, meta-analytic studies on the dynamic risk factors of sexual offenders show that sexual preoccupation (a term with similarities to the construct of hypersexual disorder) is the single best predictor of sexual reoffending [3]. Therefore, it is important to better understand it so as to help individuals struggling with this problem as well as their families and friends, and also to be able to protect innocent victims of sexual abuse, typically women and children. 0951-7367 ß 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins The purpose of this paper is to critically review recent advances in conceptualizing and treating hypersexual disorder. The literature was reviewed using PubMed and PsycINFO for the period between January 2008 and May 2010. Keywords used were ‘hypersexual’, ‘sexual addiction’, ‘sexual compulsivity’, and ‘sexual DOI:10.1097/YCO.0b013e32833d15d1 Management of hypersexual disorders Marshall and Briken 571 impulsivity’. Articles or book chapters were selected if they contained or reported data from empirical studies. Neither case reports nor theses are reported in this paper. Other clinically and theoretically important information (including that published before 2008) is also included when relevant. Diagnosis The lack of available empirical evidence on hypersexual or comparable disorders has resulted in their complete absence from prior versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Although DSM-III-R (1987) made reference to sexual addiction as one example of a ‘Sexual Disorder Not Otherwise Specified’ (p. 296), it was not included in previous or subsequent versions of the manual. However, hypersexual disorder is now being considered for inclusion in the May 2013 release of DSM-V as a distinct clinical disorder and a draft disorder. Disorder criteria have been proposed by the DSM-V Working Groups (see [6,7] for a description). Included in the preliminary draft for DSM-V is the following definition of hypersexual disorder: Over a period of at least 6 months, recurrent and intense sexual fantasies, sexual urges, and sexual behavior in association with four or more of the following five criteria: (A1) A great deal of time is consumed by sexual fantasies and urges, and by planning for and engaging in sexual behavior; (A2) Repetitively engaging in these sexual fantasies, urges, and behavior in response to dysphoric mood states (e.g., anxiety, depression, boredom, irritability); (A3) Repetitively engaging in sexual fantasies, urges, and behavior in response to stressful life events; (A4) Repetitive but unsuccessful efforts to control or significantly reduce these sexual fantasies, urges, and behavior; (A5) Repetitively engaging in sexual behavior while disregarding the risk for physical or emotional harm to self or others. There is clinically significant personal distress or impairment in social, occupational, or other important areas of functioning associated with the frequency and intensity of these sexual fantasies, urges, and behavior. These sexual fantasies, urges, and behavior are not due to the direct physiological effect of an exogenous substance (e.g., a drug of abuse or a medication). The various proposed subtypes of the proposed hypersexual disorder are excessive masturbation, pornography use, sexual behavior with consenting adults, cybersex, telephone sex, strip clubs, and others. This proposed inclusion of hypersexual disorder in DSMV not only acknowledges the various facets of the differing descriptors that have been used before, including thoughts, urges, and behaviors, but also identifies the problem as a response to stress and negative mood states [7]. However, this proposal is not without its critics. For example, Winters [8] has argued that including aspects of the addiction model of dysregulated sexuality into the proposed diagnosis demonstrates at least two problems with these criteria: first, expressed sexuality may serve as a means to ameliorate the negative effect associated with some other underlying mental disorder that, when treated, also alleviates the problematic hypersexuality; and second, if repeatedly engaging in sexual behaviors to enhance mood is symptomatic of a distinct sexual disorder, then we must also be willing to accept that repeatedly engaging in nonsexual but rewarding behaviors for a similar effect is symptomatic of other corresponding mental disorders, in particular if accompanied by impairment in day-to-day functioning. There have also been critiques of the use of the term hypersexual disorder, for example, by those who favor the term sexual addiction [9]. However, few would argue against the inclusion of some descriptor for this disorder in diagnostic manuals so that individuals suffering from it can get the treatment they need and desire, clinicians can be paid for treating these patients, and that empirical examinations can be conducted and compared. Assessment The majority of patients self-referred to treatment for a hypersexual disorder are males. To date, there have still not been any large-scale epidemiological studies on hypersexual disorder [10]. This, of course, is partly due to the lack of agreement on what should be measured, and what would be the best method to measure hypersexual behavior, such as, observer diagnosis versus selfreport. For example, there has been shown a tendency for lower socioeconomic individuals to over-report sexual addiction whereas sexual offenders tended to underreport [11]. Given the previous lack of clear criteria of hypersexual disorder, there are a number of problems with interpreting research based on observer diagnoses, not the least of which is the low inter-rater agreement on some of the sexual disorders with clear criteria already in the DSM (e.g., [12]). Using the various proxy measures as estimates remains the only method of inferring the potential rates of hypersexual disorder in the general and special populations. However, many of these proxy measures do not give an indication of a cutoff score for ascribing the presence of or indications for a disorder, and much of the research on these measures is on a selfreferred clinical population, leaving it impossible to determine actual prevalence rates. There are two exceptions to this general rule, the Sexual Addiction Screening Test (SAST) [5] and the Hypersexual Behavior Inventory (HBI) [13]. The creator of the SAST recommends a cutoff score of 13, out of a possible maximum of 25, for indications for the presence of sexual addiction in respondents. 572 Clinical therapeutics A number of authors have stated that the rates of sexual addiction in the general population are between 3 and 6% [5,14]; however, the methods and criteria used for these estimates are unclear. In a recent study on indicators for the presence of sexual addiction in incarcerated sexual offenders and a low socioeconomic community comparison group, Marshall et al. [11] report rates of more than 40% for the sexual offenders and more than 17% for the community comparison group with values above the cutoff score in the SAST. Although the rates of those individuals with values above the cutoff score in the sexual offender group appear high, this is perhaps not surprising, as it is similar to the rates of sexual preoccupation in sexual offenders reported by Hanson and MortonBourgon [3]. The rate in the comparison group (17%), however, is significantly higher than the previously mentioned estimates of the prevalence in the general community. Marshall et al. hypothesize that sexual behavior could be less expensive and, therefore, more easily available to low socioeconomic individuals than other forms of dysfunctional coping strategies such as the excessive use of alcohol, drugs, or gambling. However, it could also be that the cutoff score of the SAST is too low and leads to an overestimation of the problem. In addition, the SAST is constructed for screening, not for a formal diagnosis of sexual addiction or hypersexual disorder. Further research is needed to better understand these findings. Although it is yet to be described in detail in a peerreviewed publication, the HBI [13] is a 19-item measure of hypersexual behavior that reflects many of the components of the proposed DSM-V criteria and provides a cutoff score for diagnostic purposes. The HBI has three subscales: control over sexual thoughts, urges, and behavior; consequences associated with hypersexual behavior; and the extent to which an individual uses sex to cope with uncomfortable or unpleasant affective experiences. The HBI also provides a cutoff score (53 out of a possible 95) for a diagnosis of hypersexual behavior. Unfortunately, the majority of the research on this measure uses clinical populations, leaving the prevalence of hypersexual disorder still unknown. With regard to sexual offenders, Marshall and O’Brien [20] have recently argued that there are many overlapping features of Carnes’ notion of sexual addiction and empirical research on issues associated with sexual offending. In reports using the SAST with sexual offenders, sexual addiction was found to be related to using sex as a means to cope, inappropriate sexual urges, and fantasies, but unrelated to type of sexual offender (child molesters versus rapists), frequency, age of onset, diversity of sexual behaviors, or other measures of addictive behaviors, such as the use of alcohol and drugs [20,11]. This last finding of a lack of relationship to other addictive behaviors is also reported for nonoffenders in a study using the HBI [21]. The SAST has also been demonstrated to be related to the number of victims of sexual offenders, with those sexual offenders with three or more victims demonstrating greater problems with sexual addiction as measured by the SAST [22]. The HBI has been shown to be correlated to problems with executive functioning, most notably in emotional self-regulation, problem solving, planning, and selfmanagement [23]. In a study examining the effects of hypersexual disorder on coping with shame about hypersexual behavior, hypersexuals tended to use withdrawal and self-attack as methods of dealing with their shameful feelings [24]. Using other proxy measures of hypersexual disorder, such as the Compulsive Sexual Behavior Inventory and the Sexual Compulsivity Scale, research on men has demonstrated a relationship between hypersexual behavior and engaging in sexual marathons [25], propensity to engage in high-risk sex [26,27], problems with emotional self-regulation [28], and lower levels of relationship intimacy and sexual contentment [29], whereas in women research has demonstrated a relationship between hypersexual behavior and sexual coercion [30] and sexual risk taking [29]. There have also been recent investigations on the relationship between hypersexual disorders and medical issues, such as epilepsy (e.g., [31]); however, these studies tend to be singlecase examinations, but do suggest further investigation into the relationship between hypersexuality and comorbid medical disorders. Correlates As noted before, one of the most commonly used selfreport measures of problematic excessive sexual behavior, which is at least somewhat analogous to hypersexual disorder, is the SAST [5]. This measure has recently received empirical support in terms of its internal consistency [15], construct validity [16], and factor structure [17]. Recent studies have shown sexual addiction as measured by the SAST to be related to increased risk for boundary violation in physicians [16,18], higher attachment anxiety and avoidance [19], and personality disorders [17]. Management As mentioned in the introduction to this paper, there is a dearth of rigorous evaluations of treatment for hypersexual disorders. As this paper is meant to reflect only those papers appearing in the past 2 calendar years and due to space limitations, the interested reader is referred to an excellent review of pre-2008 interventions by Kaplan and Krueger [10]. No empirical evaluations of treatment approaches in the past 2 years could be found using the search engines Management of hypersexual disorders Marshall and Briken 573 described above. Of interest, however, is the empirically based, but untested, attention to the impact of childhood trauma on the therapeutic relationship. Katehakis [32] reports that early negative childhood-attachment experiences have a neuropsychobiological impact on individuals with sexual addiction, which significantly affects their affective, cognitive, and behavioral development. She suggests that therapists should be aware of how these early experiences can disrupt the therapeutic relationship and suggests strategies for dealing with these types of sexually addicted patients. Briken and Basdekis–Jozsa [33] in their conceptual paper describe a three-step psychotherapeutic approach depending on the severity of the disorder. They also recommend pharmacological treatment, especially with serotonin-enhancing medication. Conclusion 9 Samenow CP. Classifying problematic sexual behaviors: it’s all in the name. Sex Addict Compulsivity 2010; 17:3–6. 10 Kaplan MS, Krueger RB. Diagnosis, assessment, and treatment of hypersexuality. J Sex Res 2010; 47:181–198. 11 Marshall LE, Marshall WL, Moulden HM, Serran GA. The prevalence of sexual addiction in incarcerated sexual offenders and matched community nonoffenders. Sex Addict Compulsivity 2008; 15:271–283. 12 O’Donohue WT, Regev LG, Hagstrom A. Problems with the DSM-IV diagnosis of pedophilia. Sex Abuse 2000; 12:95–105. 13 Reid R, Garos S. A new measure of hypersexual behavior. Presented at Meeting of the American Psychological Association; San Francisco, CA; 2007. 14 Kuzma JM, Black DW. Epidemiology, prevalence, and natural history of compulsive sexual behavior. Psychiatr Clin North Am 2008; 31:603–611. 15 Carnes P, Green B, Carnes S. The same yet different: Refocusing the sexual addiction-screening test (SAST) to reflect orientation and gender. Sex Addict Compulsivity 2010; 17:7–30. 16 Swiggart W, Feurer ID, Samenow C, et al. Sexual boundary violation index: a validation study. Sex Addict Compulsivity 2008; 15:176–190. 17 Nelson KG, Oehlert ME. Psychometric exploration of the Sexual Addiction Screening Test in veterans. Sex Addict Compulsivity 2008; 15:39–58. 18 Spickard WA Jr, Swiggart WH, Manley GT, et al. A continuing medical education approach to improve sexual boundaries of physicians. Bull Menninger Clin 2008; 72:38–53. There still remains a lack of consensus and empirical research on hypersexual disorders. Thus, the efforts currently made by the DSM-V study group [6,7] to develop diagnostic criteria and to empirically study the reliability and validity of the construct in the planned field trials could lead to an important improvement. Clear diagnostic criteria are a necessary precondition to test the efficacy of pharmacological and psychological treatments in controlled studies in the future. 19 Zapf JL, Greiner J, Carroll J. Attachment styles and male sex addiction. Sex Addict Compulsivity 2008; 15:158–175. References and recommended reading 24 Reid RC, Harper JM, Anderson EH. Coping strategies used by hypersexual patients to defend against the painful effects of shame. Clin Psychol Psychother 2009; 16:125–138. Papers of particular interest, published within the annual period of review, have been highlighted as:  of special interest  of outstanding interest Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 613). 20 Marshall LE, O’Brien MD. Assessment of sexual addiction. In: Beech AR, Craig LA, Browne KD, editors. Assessment and treatment of sex offenders: a handbook. Chichester, UK: Wiley; 2009. 21 Reid RC, Carpenter BN. Exploring relationships of psychopathology in hypersexual patients using the MMPI-2. J Sex Marital Ther 2009; 35:294– 310. 22 Baltieri DA, de Andrade AG. Comparing serial and nonserial sexual offenders: alcohol and street drug consumption, impulsiveness, and history of sexual abuse. Rev Bras Psiquiatr 2008; 30:25–31. 23 Reid RC, Karim R, McCrory E, Carpenter BN. Self-reported differences on measures of executive function and hypersexual behavior in a patient and community sample of men. Int J Neurosci 2010; 120:120–127. 25 Semple SJ, Zians J, Strathdee SA, Patterson TL. Sexual marathons and methamphetamine use among HIV-positive men who have sex with men. Arch Sex Behav 2009; 38:583–590. 1 Goodman A. Sexual addiction: an integrated approach. Madison, CT: International Universities Press; 1998. 26 Smolenski DJ, Ross MW, Risser JMH, Rosser BRS. Sexual compulsivity and high-risk sex among Latino men: the role of internalized homonegativity and gay organizations. AIDS Care 2009; 21:42–49. 2 Kingston DA, Firestone P. Problematic hypersexuality: a review of conceptualization and diagnosis. Sex Addict Compulsivity 2008; 15:284– 310. 27 McBride KR, Reece M, Sanders SA. Using the sexual compulsivity scale to predict outcomes of sexual behavior in young adults. Sex Addict Compulsivity 2008; 15:97–115. 3 Hanson RK, Morton-Bourgon KE. The characteristics of persistent sexual offenders: a meta-analysis of recidivism studies. J Consult Clin Psychol 2005; 73:1154–1163. 28 Winters J, Christoff K, Gorzalka BB. Conscious regulation of sexual arousal in men. J Sex Res 2009; 46:330–343. 4 Carnes P. Contrary to love. Minneapolis: CompCare Publishers; 1989. 5 Carnes P. Don’t call it love: recovery from sexual addiction. New York: Bantam Books; 1991. 6 Zucker KJ. Reports from the DSM-V Work Group on sexual and gender  identity disorders. Arch Sex Behav 2010; 39:217–220. This paper describes the proposed criteria for hypersexual disorder to be included in DSM-V. 7 Kafka M. Hypersexual disorder: a proposed diagnosis for DSM-V. Arch Sex  Behav 2010; 39:377–400. This paper presents an exhaustive review about the literature and describes the conceptualization of the proposed criteria for hypersexual disorder to be included in DSM-V. 8 Winters J. Hypersexual disorder: a more cautious approach. Arch Sex Behav 2010; 39:594–596. 29 Štulhofer A, Jelovica V, Ružić J. Is early exposure to pornography a risk factor for sexual compulsivity? Findings from an online survey among young heterosexual adults. Int J Sex Health 2008; 20:270–280. 30 Schatzel-Murphy EA, Harris DA, Knight RA, Milburn MA. Sexual coercion in men and women: similar behaviors, different predictors. Arch Sex Behav 2009; 38:974–986. 31 Arnedo V, Parker-Menzer K, Devinsky O. Forced spousal intercourse after seizures. Epilepsy Behav 2009; 16:563–564. 32 Katehakis A. Affective neuroscience and the treatment of sexual addiction.  Sex Addict Compulsivity 2009; 16:1–31. This paper is an interesting view on how the early childhood experiences of sexual addicts can impact the ability to successfully treat the disorder. 33 Briken P, Basdekis-Jozsa R. Sexual addiction? When sexual behavior gets out of control [in German]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2010; 53:313–318.