JOURNAL OF PSYCHOPATHOLOGY Original article

2018;24:187-191

G. Ciocca1, C. Solano1, Hypersexuality: the controversial mismatch

L. D’Antuono2, L. Longo3,
E. Limoncin1, E. Bianciardi3, C. Niolu3, of the psychiatric diagnosis
A. Siracusano3, E.A. Jannini1,
G. Di Lorenzo3
Chair of Endocrinology and Sexual Medicine
1 

(ENDOSEX), Department of Systems

Medicine, University of Rome Tor Vergata, Summary
Rome, Italy; 2 Independent Researcher,
Brussels, Belgium; 3 Chair of Psychiatry,
Hypersexuality is characterized by intrusive fantasies and thoughts regarding sex, excessive
Department of Systems Medicine, University of sexual behaviours, and the inability to control one’s own sexuality, resulting in an impairment
Rome Tor Vergata, Rome, Italy of relational and social life. While several clinical histories and empirical research consider
hypersexuality as a disorder, the last version of the Diagnostic and Statistical Manual of Men-
tal Disorders (DSM-5) does not include hypersexuality as a psychopathological category in
se. This has generated controversy among clinicians and researchers and a mismatch with
the 11th revision of the International Classification of Diseases (ICD-11). However, different
theoretical models are related to hypersexuality, i.e. the compulsivity model, the impulsivity
model and the addiction model. This paper addresses the psychopathology of hypersexuality,
including treatment and related comorbid conditions.

Key words
Hypersexuality • Comorbidity • Treatment • ICD-11 • DSM-5

Introduction
Sexual behaviour represents a fundamental aspect of human life, mainly
involving pleasure, reproduction and couple relationships. Sexual physi-
ology consists of several phases according to the gender and problems
can occur in some cases. The most common sexual problems are erectile
dysfunction and premature ejaculation in males and anorgasmia or sex-
ual pain in females  1. In some cases, the main cause of a sexual impair-
ment is hypoactive sexual desire disorder, i.e. lack of libido, that causes
a decrease of sexual activity. On the contrary, hypersexuality includes
excess of sexual activities, the obsession toward sex and its consequenc-
es. Hypersexual behaviours include excess of compulsive masturbation,
pornography, sexual behaviour with consenting adults, cybersex or tel-
ephone sex use and strip clubs attendance 2.
In the last years, the debate was on whether to include hypersexuality
within the last version of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-5), with some proposals based on diagnostic criteria, but
to date the psychiatric nosography has not considered hypersexuality a
mental disorder per se. On the contrary, the World Health Organization
has recently proposed to include hypersexuality within the last version
© Copyright by Pacini Editore Srl of the International Classification of Diseases (ICD-11) as a disorder of
sexual compulsive behaviour (compulsive sexual behaviour disorder,
OPEN ACCESS CSBD)  3. This generates a mismatch and controversy for the clinical and
diagnostic praxis. Is hypersexuality a disorder for psychiatrists and clini-
cal psychologists? In 2010, prominent American psychiatrist M.P. Kafka
Correspondence proposed the criteria to detect hypersexuality 4, but the American Psychi-
Giorgio Di Lorenzo atric Association (APA) still does not include this condition as a category
Chair of Psychiatry, Department of Systems
of mental disorder, although the debate is currently open  5. However, the
Medicine, University of Rome Tor Vergata, via
Montpellier 1, 00133 Rome, Italy impossibility to diagnose hypersexuality according to DSM-5 criteria does
• E-mail: [email protected] not mean that this condition does not exist, since several empirical data

187
G. Ciocca et al.

and the clinical practice demonstrate a large pathologi- opment of the disorder, while abstinence symptoms as
cal spectrum characterizing this particular sexual con- depression, anxiety, and blame are associated to the
dition  6. The aim of the current paper is to highlight the decrease of sexual conducts  11. Moreover, as in other
main theoretical models and the state of art of hyper- forms of addiction, hypersexual subjects spend a par-
sexuality in the field of psychopathology. ticular amount of time looking for novel sexual partners
and compromise their social and relational life, without
taking into account potential negative consequences as
Theories of hypersexuality the sexually transmitted diseases.
Theoretical debate concerning the hypersexuality
started with Freud’s psychoanalytic theories. In par-
ticular some authors in this field discussed about the ICD-11 versus DSM-5
relationship between life instinct and death instinct in The categorial approach towards mental disorders re-
sexual addiction  7. From this perspective, hypersexual/ gards both the ICD and the DSM classifications, how-
addicted subjects attempt to antagonize depressive ever the ICD proposed to include hypersexuality as a
states and death anxiety with the life instinct through condition in its last version (ICD-11). Hypersexuality has
sexual activities, although in a deregulated way. Hence, an estimated prevalence of 2-6%, with males being the
hypersexual behaviours can be bona fide considered a most affected  12 13. This high prevalence, in absence of
defensive behaviour against death anxiety 8. specific diagnostic criteria, drove some clinicians and
However, other theoretical models were developed epidemiologists to categorize and propose hypersexu-
based on different aspects leading to hypersexual dis- ality as a distinct disorder. In particular, the World Health
order: the compulsive sexual behaviour, the sexual im- Organization proposed to describe hypersexuality as a
pulsivity, and the sexual addiction. compulsive sexual behaviour disorder (CSBD), describ-
ing it in the ICD-11 as follows:
Compulsivity model
Coleman described and defined hypersexuality as a Compulsive sexual behaviour disorder is characterized
compulsive sexual behaviour through a parallelism by a persistent pattern of failure to control intense, re-
with the phenomenology of obsessive-compulsive dis- petitive sexual impulses or urges resulting in repetitive
order (OCD), characterized by repetitive and intrusive sexual behaviour. Symptoms may include repetitive
thoughts and then the repetition of sexual experiences. sexual activities becoming a central focus of the per-
These experiences are described by an increase of son’s life to the point of neglecting health and personal
arousal before – and a decrease after – a sexual act  9. care or other interests, activities and responsibilities;
According to this model, thoughts and images consti- numerous unsuccessful efforts to significantly reduce
tute the obsession, while the acting constitutes the com- repetitive sexual behaviour; and continued repetitive
pulsion. However, this psychopathological mechanism sexual behaviour despite adverse consequences or
in hypersexuality is ego-syntonic 6. deriving little or no satisfaction from it. The pattern of
Impulsivity model failure to control intense, sexual impulses or urges and
According to this model, the hypersexual behaviour is resulting repetitive sexual behaviour is manifested over
due to the failure to resist to sexual drive, and to the an extended period of time (e.g., 6 months or more),
incapacity to delay the sexual gratification  6. Based on and causes marked distress or significant impairment
the impulsivity model, the hypersexuality is thus caused in personal, family, social, educational, occupational, or
by impulse dyscontrol, although this proposal has been other important areas of functioning. Distress that is en-
largely criticized. Many hypersexual subjects, in fact, tirely related to moral judgments and disapproval about
carefully plan their sexual activities and behaviours. sexual impulses, urges, or behaviours is not sufficient to
Moreover, the reward system related to the pleasure ex- meet this requirement 14.
perience would reinforce the hypersexual behaviour  10.
However, according to some studies, sexual impulsivity Moreover, an additional controversial aspect is the posi-
and sexual compulsivity are factors characterizing hy- tion of CSBD among the impulse control disorders to-
persexuality together and not separately 10. gether with pyromania, kleptomania and intermittent ex-
plosive disorder, as also the various substance impulse
Addiction model control disorders 14. According to the ICD-11 classifica-
The addiction model is considered the most valid to ex- tion, the only conditions to be excluded when diagnos-
plain the hypersexual disorder. The parallelism between ing CSBD are paraphilic disorders. The ICD-11 made
hypersexuality and the common addiction disorders also a further specification concerning the terminology:
was made in the past 11. The symptomatology concerns hypersexuality or hypersexual disorder is better defined
the increase of sexual activity together with the devel- as compulsive sexual behaviour disorder.

188
 Hypersexuality: the controversial mismatch of the psychiatric diagnosis

On the other hand, hypersexuality was considered for more complex and question the official nosography. In
inclusion as a psychiatric disorder within the section of fact, hypersexual disorder was found in comorbidity with
sexual dysfunctions of the DSM-5. The DSM-5 Working other psychiatric and physical conditions, particularly in
Group on Sexual and Gender Identity Disorders pro- males, such as anxiety and mood disorders, substance
posed possible detailed criteria  4. Also in this case, use disorder, attention-deficit hyperactivity disorder (AD-
as for the ICD-11, the clinicians of DSM-5 considered HD)  16-18. Moreover, some studies , and that hypersexu-
the possible differential diagnosis with paraphilic dis- ality correlates with narcissistic, borderline, antisocial,
orders. Both ICD-11 criteria as putative DSM-5 criteria avoidant, obsessive-compulsive, and passive-aggres-
isolate hypersexuality from paraphilias. However, hy- sive personality disorders; a high comorbidity with para-
persexuality is not a pathological category of DSM-5 noid personality disorder was also found 16 19.
for several reasons, including insufficient evidence, To make the differential diagnosis, it is necessary to dis-
studies or clinical trials on hypersexual subjects, and tinguish hypersexuality from paraphilic disorders. Com-
the potential misuse of this delicate diagnosis in foren- paring to paraphilias, hypersexual subjects and hyper-
sic settings 10 15. sexual behaviours do not concern inanimate objects,
animals, parts of the body, etc.  20. However, paraphilic
patients can also develop hypersexual disorder along
Hypersexuality and comorbid disorders with elements of compulsivity, obsession and distress.
Hypersexuality is very often present along with different Finally, hypersexual behaviours should also be distin-
comorbid disorders, that make the diagnostic process guished from other medical conditions, neuropsychi-

The figure shows the sexual activities involved in hypersexuality cases in a deregulated and pathological way.

FIGURE 1. Sexual behaviours and hypersexuality.

189
G. Ciocca et al.

atric diseases, neurodegenerative disorders and from is a consequence of another mental disease, as manic
iatrogenic effects of some medications 4 21. phases of bipolar disorder or the effect of substance
abuse? The compulsive sexual behaviour can be con-
sidered a psychotic sign or the onset of a first episode
Treatments of psychosis  26 in the young while an iatrogenic effect
Following the idea of hypersexuality as a mental dis- of Parkinson’s therapy in the elderly  27. However, these
order, some possible treatments can be considered comorbid conditions could be considered into the diag-
along the pharmacological and psychotherapeutic nostic process to detect a primary diagnosis excluding
continua  22. The first includes the noradrenergic and the other consequent pathologies.
serotoninergic reuptake inhibitors, or simply selective In other words, if hypersexuality is not better accounted
serotonin reuptake inhibitor  23. On the other hand, also for by another mental disorder, it could be considered
opiate agonists were experimentally verified for compul- a category per se. This is the case of many mental dis-
sive sexual behaviour in a retrospective study  24. Psy- eases as addiction and eating disorders. In this regard,
chological therapies for hypersexuality are mainly follow when two pathologies are present together, we talk of
cognitive-behavioural approaches, although psychody- dual diagnosis. Therefore, it is crucial to take into ac-
namic psychotherapy focused on trauma and the family count the concept of dual diagnosis involved also in
of origin have also been considered useful 2. Moreover, hypersexual disorder when we adopt a categorial diag-
different styles of group or couple therapy were also nostic method 28.
found to be useful  2 22. Also mindfulness has proven to In conclusion, we believe that when individuals use sex,
be effective in people seeking help for hypersexual be- sexual behaviour and sexual activities as a therapy for
haviour 25. In any case, it is also important the treatment another disorder, such as anxiety or depression, that
of comorbid conditions, such as substance abuse, could be considered as an index of discomfort. In the
mood and anxiety disorders  2. This aspect represents same manner, when a subject suffering from a specific
a crucial point to take into account for the treatment of mental disorder, such as bipolar disorder or schizo-
hypersexual subjects. phrenia, the hypersexual behaviour can be considered
a manifestation of those primary diagnoses. If APA will
include hypersexuality as a disorder, it is important to
Conclusions
define a criterion that clearly specifies whether the dis-
If most of social media recently claimed that “hyper-
order is present alone or in comorbidity, as it has been
sexuality is a mental disorder that regards the compul-
partially proposed  4. On the other hand, many theories
sive sexual behaviour”, based on our article the issue
and hypothesis try to explain the origin and the correct
remains controversial. The psychiatric community sees
definition of hypersexuality according to different ap-
the hypersexuality as a pathological condition, and dif-
proaches, although all studies conclude that more re-
ferent psychological treatments were empirically prov-
search and clinical studies are necessary to be able to
en. Therefore, many psychiatrists and clinical psycholo-
categorize hypersexuality as a specific disorder.
gists prompt to include hypersexuality in the psychiatric
nosography, although some doubts still persist. The
first doubt concerns the differential diagnosis. Is hyper- Conflict of Interest
sexuality an isolated disorder? Or the sexual addiction The authors declare no conflict of interest.

References 5
Kraus SW, Krueger RB, Briken P, et 9
Coleman E, Raymond N, McBean A. As-
1
Ciocca G, Limoncin E, Di Tommaso S, al. Compulsive sexual behaviour dis- sessment and treatment of compulsive
et al. Attachment styles and sexual dys- order in the ICD-11. World Psychiatry sexual behavior. Minn Med 2003;86:42-7.
functions: a case-control study of fe- 2018;17:109-10. 10
Walton MT, Cantor JM, Bhullar N, et al.
male and male sexuality. Int J Impot Res 6
Garcia FD, Thibaut F. Sexual addictions. Hypersexuality: a critical review and intro-
2015;27:81-5. Am J Drug Alcohol Abuse 2010;36:254-60. duction to the “Sexhavior Cycle”. Arch Sex
Kaplan MS, Krueger RB. Diagnosis, as-
2 Behav 2017;46:2231-51.
7
Watter DN. Existential issues in sexual
sessment, and treatment of hypersexual- medicine: the relation between death
11
Orford J. Hypersexuality: implications for a
ity. J Sex Res 2010;47:181-98. anxiety and hypersexuality. Sex Med Rev theory of dependence. Br J Addict Alcohol

3
Potenza MCG M, Voon V, Kor A, et al. Is 2018;6:3-10. Other Drugs 1978;73:299-10.
excessive sexual behaviour an addictive 8
Ciocca G, Limoncin E, Lingiardi V, et al.
12
Klein V, Rettenberger M, Briken P. Self-
disorder? Lancet Psychiatry 2017;4:663-4. Response regarding existential issues reported indicators of hypersexuality and
Kafka MP. Hypersexual disorder: a pro-
4
in sexual medicine: the relation between its correlates in a female online sample. J
posed diagnosis for DSM-V. Arch Sex Be- death anxiety and hypersexuality. Sex Sex Med 2014;11:1974-81.
hav 2010;39:377-400. Med Rev 2018;6:335-6. 13
Kuzma JM, Black DW. Epidemiology, prev-

190
 Hypersexuality: the controversial mismatch of the psychiatric diagnosis

alence, and natural history of compulsive 19

Black DW, Kehrberg LL, Flumerfelt DL, et sive sexual behavior: a case series. Ann
sexual behavior. Psychiatr Clin North Am al. Characteristics of 36 subjects report- Clin Psychiatry 2010;22:56-62.
2008;31:603-11. ing compulsive sexual behavior. Am J 25
Reid RC, Bramen JE, Anderson A, et al.
14
WHO. International Classification of Dis- Psychiatry 1997;154:243-9. Mindfulness, emotional dysregulation,
eases (ICD-11). 2018 (https://icd.who.int/ 20
Di Lorenzo G, Gorea F, Longo L,et al. impulsivity, and stress proneness among
browse11/l-m/en#/http://id.who.int/icd/en- Paraphilia and paraphilic disorders. In: hypersexual patients. J Clin Psychol
tity/1630268048). Jannini EA, Siracusano A, Eds. Sexual 2014;70:313-21.
Kafka MP. What happened to hypersexual
15 dysfunctions in mentally ill patients. New 26
Ciocca G, Usall J, Dolz M, et al. Sexual
disorder? Arch Sex Behav 2014;43:1259-61. York, NY: Springer 2018. dysfunctions in people with first-epi-
16
Raymond NC, Coleman E, Miner MH.
21
Bereau M. Hypersexuality in neurological sode psychosis assessed according
Psychiatric comorbidity and compulsive/ disorders: from disinhibition to impulsivity. to a gender perspective. Riv Psichiatr
impulsive traits in compulsive sexual be- Front Neurol Neurosci 2018;41:71-6. 2015;50:239-44.
havior. Compr Psychiatry 2003;44:370- 22
Hook JN, Reid RC, Penberthy JK, et al. 27
Nakum S, Cavanna AE. The prevalence
80. Methodological review of treatments for and clinical characteristics of hypersexu-
17
Kafka MP, Hennen J. A DSM-IV Axis I co- nonparaphilic hypersexual behavior. J Sex ality in patients with Parkinson’s disease
morbidity study of males (n = 120) with Marital Ther 2014;40:294-308. following dopaminergic therapy: a sys-
paraphilias and paraphilia-related disor- 23
Coleman E, Gratzer T, Nesvacil L, et al. tematic literature review. Parkinsonism
ders. Sex Abuse 2002;14:349-66. Nefazodone and the treatment of non- Relat Disord 2016;25:10-6.
18
Niolu C, Lisi G, Siracusano A. Sexual paraphilic compulsive sexual behavior: 28
Luciano M, Sampogna G, Del Vecchio V, et
dysfunctions and mood and anxiety dis- a retrospective study. J Clin Psychiatry al. Critical evaluation of current diagnostic
orders. In: Jannini EA, Siracusano A, Eds. 2000;61:282-4. classification systems in psychiatry: the
Sexual dysfunctions in mentally ill pa- 24
Raymond NC, Grant JE, Coleman E. Aug- case of DSM-5. Riv Psichiatr 2016;51:116-
tients. New York, NY: Springer 2018. mentation with naltrexone to treat compul- 21.

191