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Sexual addiction is a psychological condition in which an individual has an inability in managing his or her sexual behavior. Some sexologists prefer to call the condition sexual dependency or sexual compulsivity. The existence of the condition is not universally accepted and its etiology, nature and validity is the subject of continuing debate.

Proponents of the concept have offered varying descriptions and models of the putative condition. Some proponents offer an addiction model, which they define by analogy to substance addiction; while others offer lack-of-control models, which refer to it as "sexual compulsivity" and offer definitions based on obsessive-compulsive disorder (OCD).

Definition

Sexologists have not reached any consensus regarding whether sexual addiction exists or, if it does, how to describe the phenomenon.[1][2] Some experts, like Dr. Drew Pinsky, believe that sexual addiction is literally an addiction, directly analogous to alcohol and drug addictions. Other experts believe that sexual addiction is actually a form of obsessive compulsive disorder and refer to it as sexual compulsivity.[3] Still other experts believe that sex addiction is itself a myth, a by-product of cultural and other influences.[4][5]

The American Psychiatric Association publishes and periodically updates the Diagnostic and Statistical Manual of Mental Disorders (DSM), a widely recognized compendium of acknowledged mental disorders and their diagnostic criteria. The most recent version of that manual, DSM-IV-TR, was published in 2000 and does not mention sexual addiction as a mental disorder.[6] Although some authors had expressed that excluding sexual addiction from the DSM represents a problem,[7] the proposed diagnosis was rejected for consideration for inclusion in the DSM-5.[8] Darrel Regier, vice-chair of the DSM-5 task force, said that "[A]lthough 'hypersexuality' is a proposed new addition...[the phenomenon] was not at the point where we were ready to call it an addiction."

The DSM-IV-TR does, however, include a miscellaneous diagnosis called Sexual Disorders Not Otherwise Specified, and includes as one of the examples of it: "distress about a pattern of repeated sexual relationships involving a succession of lovers who are experienced by the individual only as things to be used." Other examples include: compulsive fixation on an unattainable partner, compulsive masturbation, compulsive love relationships, and compulsive sexuality in a relationship.[6] Hypersexuality, by itself, is a criterion symptom of hypomania and mania in bipolar disorder and mania in schizoaffective disorder as they are currently defined in the DSM.

The World Health Organization produces the International Classification of Diseases (ICD), which is used globally and is not limited to mental disorders. The most recent version of that document, ICD-10, includes "Excessive sexual drive" as a diagnosis (code F52.7), subdividing it into satyriasis (for males) and nymphomania (for females).[9]

Symptoms and proposed diagnostic criteria

Proposals based on addictions models

Irons and Schneider have noted that "Addictive sexual disorders that do not fit into standard DSM-IV categories can best be diagnosed using an adaptation of the DSM-IV criteria for substance dependence."[7] Similarly, Lowinson and colleagues use the addiction model and define sexual addiction as a condition in which some form of sexual behaviour is employed in a pattern that is characterized at least by two key features: recurrent failure to control the behaviour and continuation of the behaviour despite harmful consequences.[10] Patrick Carnes, another proponent of the addiction model of sexual addiction, argued that most professionals in the field agree with the World Health Organization's definition of addiction.[11]

Carnes

Patrick Carnes, a proponent of the idea of sexual addiction, proposed using:[12]

  1. Recurrent failure (pattern) to resist impulses to engage in acts of sex.
  2. Frequently engaging in those behaviors to a greater extent or over a longer period of time than intended.
  3. Persistent desire or unsuccessful efforts to stop, reduce, or control those behaviors.
  4. Inordinate amount of time spent in obtaining sex, being sexual, or recovering from sexual experience.
  5. Preoccupation with the behavior or preparatory activities.
  6. Frequently engaging in sexual behavior when expected to fulfill occupational, academic, domestic, or social obligations.
  7. Continuation of the behavior despite knowledge of having a persistent or recurrent social, academic, financial, psychological, or physical problem that is caused or exacerbated by the behavior.
  8. Need to increase the intensity, frequency, number, or risk of behaviors to achieve the desired effect, or diminished effect with continued behaviors at the same level of intensity, frequency, number, or risk.
  9. Giving up or limiting social, occupational, or recreational activities because of the behavior.
  10. Resorting to distress, anxiety, restlessness, or violence if unable to engage in the behavior at times relating to SRD (Sexual Rage Disorder).

Goodman

Goodman proposed a maladaptive pattern of behavior, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:[13]

  1. tolerance, as defined by either of the following:
    1. a need for markedly increased amount or intensity of the behavior to achieve the desired effect
    2. markedly diminished effect with continued involvement in the behavior at the same level or intensity
  2. withdrawal, as manifested by either of the following:
    1. characteristic psycho-physiological withdrawal syndrome of physiologically described changes and/or psychologically described changes upon discontinuation of the behavior
    2. the same (or a closely related) behavior is engaged in to relieve or avoid withdrawal symptoms
  3. the behavior is often engaged in over a longer period, in greater quantity, or at a higher intensity than was intended
  4. there is a persistent desire or unsuccessful efforts to cut down or control the behavior
  5. a great deal of time spent in activities necessary to prepare for the behavior, to engage in the behavior, or to recover from its effects
  6. important social, occupational, or recreational activities are given up or reduced because of the behavior
  7. the behavior continues despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the behavior

Proposals based on obsessive/compulsive models

Schneider identified three indicators of sexual addiction: compulsivity, continuation despite consequences, and obsession.[14]

  1. Compulsivity: This is the loss of the ability to choose freely whether to stop or continue a behavior.[15]
  2. Continuation despite consequences: When addicts take their addiction too far, it can cause negative effects in their lives. They may start withdrawing from family life to pursue sexual activity. This withdrawal may cause them to neglect their children or cause their partners to leave them. Addicts risk money, marriage, family and career in order to satisfy their sexual desires.[16] Despite all of these consequences, they continue indulging in excessive sexual activity.
  3. Obsession: This is when people cannot help themselves from thinking a particular thought. Sex addicts spend whole days consumed by sexual thoughts. They develop elaborate fantasies, find new ways of obtaining sex and mentally revisit past experiences. Because their minds are so preoccupied by these thoughts, other areas of their lives that they could be thinking about are neglected.

Eli Coleman proposed:[17]

  1. involves recurrent and intense normophilic (nonparaphilic) sexually arousing fantasies, sexual urges, and behaviors that cause clinically significant distress in social, occupational, or other important areas of functioning; and
  2. is not due simply to another medical condition, substance use disorder, or a developmental disorder

Epidemiology

Sexual addiction is hypothesized to be (but is not always) associated with obsessive-compulsive disorder (OCD), narcissistic personality disorder,[18][19] and manic-depression.[20] There are those who suffer from more than one condition simultaneously (co-occurring disorder), but traits of addiction are often confused with those of these disorders, often due to most clinicians not being adequately trained in diagnosis and characteristics of addictions, and many clinicians tending to avoid use of the diagnosis at all.[1][21][22]

Specialists in obsessive-compulsive disorder and addictions use the same terms to refer to different symptoms. In addictions, obsession is progressive and pervasive, and develops along with denial; the person usually does not see themselves as preoccupied, and simultaneously makes excuses, justifies and blames. Compulsion is present only while the addict is physically dependent on the activity for physiological stasis. Constant repetition of the activity creates a chemically dependent state. If the addict acts out when not in this state, it is seen as being spurred by the obsession only. Some addicts do have OCD as well as addiction, and the symptoms will interact.[21]

Addicts often display narcissistic traits, which often clear as sobriety is achieved. Others do exhibit the full personality disorder even after successful addiction treatment.[18]

Etiology

Proponents of the concept have described sufferers as repeatedly and compulsively attempting to escape emotional or physical discomfort by using ritualized, sexualized behaviors such as masturbation, pornography, including obsessive thoughts. Some individuals try to connect with others through highly impersonal intimate behaviors: empty affairs, frequent visits to prostitutes, voyeurism, exhibitionism, frotteurism, cybersex, zoophilia, and the like.

Neurochemical theories

Earle has argued that neurochemical changes, similar to an adrenaline rush in the brain, temporarily reduce the discomfort an individual experiences with urges and cravings for sexualized behaviors that can be achieved through obsessive, highly ritualized patterns of sexual behavior.[23]

Psychological distress theories

Patrick Carnes (2001, p. 40) argues that when children are growing up, they develop “core beliefs” through the way that their family functions and treats them. A child brought up in a family that takes proper care of them has good chances of growing up well, having faith in other people, and having self worth. On the other hand, a child who grows up in a family that neglects them will develop unhealthy and negative core beliefs. They grow up to believe that people in the world do not care about them. Later in life, the person has trouble keeping stable relationships and feels isolated. Generally, addicts do not perceive themselves as worthwhile human beings (Carnes, Delmonico and Griffin, 2001, p. 40). They cope with these feelings of isolation and weakness by engaging in excessive sex (Poudat, 2005, p. 121).

Addiction theories

According to Patrick Carnes the cycle begins with the "Core Beliefs" that sex addicts hold:[24]

  1. "I am basically a bad, unworthy person."
  2. "No one would love me as I am."
  3. "My needs are never going to be met if I have to depend on others."
  4. "Sex is my most important need."

These beliefs drive the addiction on its progressive and destructive course:[24]

  • Pain agent — First a pain agent is triggered / emotional discomfort (e.g. shame, anger, unresolved conflict). A sex addict is not able to take care of the pain agent in a healthy way.
  • Dissociation — Prior to acting out sexually, the sex addict goes through a period of mental preoccupation or obsession. Sex addict begins to dissociate (moves away from his or her feelings). A separation begins to take place between his or her mind and his or her emotional self.
  • Altered state of consciousness / a trance state / bubble of euphoric fantasized experience — Sex addict is emotionally disconnected and is pre-occupied with acting out behaviours. The reality becomes blocked out/distorted.
  • Preoccupation or "sexual pressure" — This involves obsessing about being sexual or romantic. Fantasy is an obsession that serves in some way to avoid life. The addict's thoughts focus on reaching a mood-altering high without actually acting-out sexually. They think about sex to produce a trance-like state of arousal to eliminate the pain of reality. Thinking about sex and planning out how to reach orgasm can continue for minutes or hours before they move to the next stage of the cycle.
  • Ritualization or "acting out." — These obsessions are intensified by ritualization or acting out. A sex addict first cruises, then goes to a strip show to heighten arousal until they are beyond the point of saying no. Ritualization helps distance reality from sexual obsession. Rituals induce trance and further separate the addict from reality. Once the addict begins the ritual, the chances of stopping that cycle diminish greatly. They give into the pull of the compelling sex act.
  • Sexual compulsivity — The next phase of the cycle is sexual compulsivity or "sex act". The tensions the addict feels are reduced by acting on their sexual feelings. They feel better for the moment, thanks to the release that occurs. Compulsivity simply means that addicts regularly get to the point where sex becomes inevitable, no matter what the circumstances or the consequences. The compulsive act, which normally ends in orgasm, is perhaps the starkest reminder of the degradation involved in the addiction as the person realizes they are a slave to the addiction.
  • Despair — Almost immediately reality sets in, and the addict begins to feel ashamed. This point of the cycle is a painful place where the Addict has been many, many times. The last time the Addict was at this low point, they probably promised to never do it again. Yet once again, they act out and that leads to despair. They may feel they have betrayed spiritual beliefs, possibly a partner, and his or her own sense of integrity. At a superficial level, the addict hopes that this is the last battle.

According to Mr.Carnes, for many addicts, this dark emotion brings on depression and feelings of hopelessness. One easy way to cure feelings of despair is to start obsessing all over again. The cycle then perpetuates itself.[25]

Treatment

Numerous[citation needed] professional therapists and counselors offer treatment for sexual addiction. It can be very difficult for a person seeking help to admit his addiction and speak about it, even to professionals. It is also difficult to find online sources which deal with the treatment without being lead to solutions or programs requiring religious faith. Some forums allow victims of the addiction to share their struggles in a therapeutic way, but finding little reliable information and solutions.

The self-help groups under the name of Sex Addicts Anonymous, Sexaholics Anonymous, Sexual Compulsives Anonymous and Sex and Love Addicts Anonymous, all lead to the same "twelve step" treatment program which require, among many other things, a turn to and/or faith in a higher power. These can be very effective. However, any twelve step based program is a very comprehensive and intensive program of personal and spiritual growth, and therefore cannot be considered a "quick fix" by any means. There are various online support forums for these groups as well as meetings in many cities and towns all over the world.

Due to their effect of reducing libido, SSRIs have been used in research studies and off-label to treat symptoms of overly frequent sexual urges, but their effects are not always robust.[26][27]

See also

References

  1. 1.0 1.1 Francoeur, R. T. (1994). Taking sides: Clashing views on controversial issues in human sexuality, p. 25. Dushkin Pub. Group.
  2. Kingston, D. A.; Firestone, P. (2008). "Problematic hypersexuality: A review of conceptualization and diagnosis". Sexual Addiction and Compulsivity 15: 284–310. doi:10.1080/10720160802289249.
  3. Mayo Clinic Website
  4. Levine, M. P.; Troiden, R. R. (1988). "The myth of sexual compulsivity". Journal of Sex Research 25: 347–363. doi:10.1080/00224498809551467.
  5. Giles, J. (2006). "No such thing as excessive levels of sexual behavior". Archives of Sexual Behavior 35 (6): 641–642. doi:10.1007/s10508-006-9098-3. PMID 17109229.
  6. 6.0 6.1 American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (fourth edition, text revision). Washington, DC: Author.
  7. 7.0 7.1 Irons, R.; Schneider, J. P. (1996). "Differential diagnosis of addictive sexual disorders using the DSM-IV.". Sexual Addiction & Compulsivity 3: 7–21. doi:10.1080/10720169608400096.
  8. Psychiatry's bible: Autism, binge-eating updates proposed for 'DSM' USA Today.
  9. International Classification of Diseases, version 2007.
  10. Lowinson, J. H., Ruiz, P., Millman, R. B., & Langrod, J. G. (2004). Substance abuse. Lippincott Williams & Wilkins.
  11. Carnes, P., & Adams, K. M. (2002). Clinical management of sex addiction. Psychology Press.
  12. Patrick Carnes; David Delmonico, Elizabeth Griffin (2001). In the Shadows of the Net. p. 31. ISBN 1592851495.
  13. Goodman, 2001, pp.195-196
  14. Schneider,[citation needed] 1994, pp.19-44
  15. (Carnes, Delmonico, & Griffin, 2001, p. 18)
  16. Arterburn, 1991, p.123
  17. Coleman, E. (2003). "Compulsive sexual behavior: What to call it, how to treat it?". SIECUS Report 31 (5): 12.
  18. 18.0 18.1 Ulman, Richard B.; Harry Paul (2006). The Self Psychology of Addiction and Its Treatment. Psychology Press. ISBN 1583913076.
  19. Lonely All the Time: Recognizing, Understanding, and Overcoming Sex Addiction, for Addicts and Co-dependents. 1989. p. 57.
  20. Williams, Terrie M. (2008). Black Pain: It Just Looks Like We're Not Hurting. Simon & Schuster. p. 114. ISBN 0743298829. "[..]diagnosed as bipolar or manic-depressive, but his depression first started manifesting itself as sexual addiction,"
  21. 21.0 21.1 Hollander, Eric; Dan J. Stein (1997). Obsessive-compulsive Disorders. Informa Health Care. p. 212. ISBN 0203215214.
  22. Couples Therapy. Haworth Clinical Practice Press. 2001. p. 375. "They found that sexual narcissism is more common among men ... These characteristics are also central to the person with a sexual addiction"
  23. Earle, R., Crow, G. M., & Osborn, K. (1989). Lonely all the time: Recognizing, understanding, and overcoming sex addiction, for addicts and co-dependents. Simon & Schuster.
  24. 24.0 24.1 Patrick Carnes, Out of the Shadows
  25. Patrick Carnes (2006) Facing the Shadow
  26. http://books.google.com/books?id=4eCY--Yw_KkC&pg=PA109
  27. http://ajp.psychiatryonline.org/cgi/content/full/158/10/1590

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