Sexual addiction

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Sexual addiction, also known as sex addiction, is a conceptual model that describes compulsive participation or engagement in sexual activity, despite negative consequences. It is considered by its proponents to be the same thing as hypersexual disorder.[1][2] In clinical diagnostics, the term sexual dependence may also refer to a conceptual model that is used to assess people who report being unable to control their sexual urges, behaviors, or thoughts. Related models of pathological sexual behavior include hypersexuality, erotomania, nymphomania, satyriasis, Don Juanism (or Don Juanitaism), and paraphilia-related disorders.[3][4][5]

Clinicians, such as psychiatrists, sociologists, sexologists, and other specialists, have differing opinions on the classification and clinical diagnosis of sexual addiction. As a result, "sexual addiction" does not exist as a clinical entity in either the DSM or ICD medical classifications of diseases and medical disorders.

Neuroscientists, pharmacologists, molecular biologists, and other researchers in related fields have identified a transcriptional and epigenetic model of drug and behavioral (including sexual) addiction pathophysiology. Diagnostic models, which use the pharmacological model of addiction (this model associates addiction with drug-related concepts, particularly physical dependence, drug withdrawal, and drug tolerance[6]), do not currently include diagnostic criteria to identify sexual addictions in a clinical setting. In the alternative reward-reinforcement model of addiction, which uses neuropsychological concepts to characterize addictions, sexual addictions are identifiable and well-characterized.[7][8] In this model, addictive drugs are characterized as those which are both reinforcing and rewarding (i.e., activates neural pathways associated with reward perception).[6] Addictive behaviors (those which can induce a compulsive state) are similarly identified and characterized by their rewarding and reinforcing properties.

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Mechanisms

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Current research on sexual addiction within the context of the reward-reinforcement model indicates that it is well-characterized as an addiction (in this context, a compulsive behavior)[7][8] and that it develops through the same biomolecular mechanisms that induce drug addictions;[7][9] specifically, sexual activity has been shown to be highly rewarding[8][9] and naturally reinforcing.[8][9] Excessive activation of the associated reward-reinforcement mechanisms has been directly implicated in the development of compulsive (i.e., an addiction to) sexual behavior.[7][8]

In humans, a dopamine dysregulation syndrome, characterized by drug-induced compulsive engagement in sexual activity or gambling, has also been observed in some individuals taking dopaminergic medications.[7] Current experimental models of addiction to natural rewards and drug reward demonstrate common alterations in gene expression in the mesocorticolimbic projection.[7][10] ΔFosB is the most significant gene transcription factor involved in addiction, since its viral or genetic overexpression in the nucleus accumbens is necessary and sufficient for most of the neural adaptations and plasticity that occur;[10] it has been implicated in addictions to alcohol, cannabinoids, cocaine, nicotine, opioids, phenylcyclidine, and substituted amphetamines.[7][10][11] ΔJunD is the transcription factor which directly opposes ΔFosB.[10] Increases in nucleus accumbens ΔJunD expression can reduce or, with a large increase, even block most of the neural alterations seen in chronic drug abuse (i.e., the alterations mediated by ΔFosB).[10]

ΔFosB also plays an important role in regulating behavioral responses to natural rewards, such as palatable food, sex, and exercise.[8][10] Natural rewards, like drugs of abuse, induce ΔFosB in the nucleus accumbens, and chronic acquisition of these rewards can result in a similar pathological addictive state.[7][8] Thus, ΔFosB is also the key transcription factor involved in addictions to natural rewards as well,[7][9] and sex addictions in particular, since ΔFosB in the nucleus accumbens is critical for the reinforcing effects of sexual reward.[8] Research on the interaction between natural and drug rewards suggests that psychostimulants and sexual reward possess cross-sensitization effects and act on common biomolecular mechanisms of addiction-related neuroplasticity which are mediated through ΔFosB.[7][9]

ΔFosB inhibitors (drugs[which?] or treatments[which?] that oppose its action) may be an effective treatment for addiction and addictive disorders.[12]

Summary of addiction-related plasticity
Form of neural or behavioral plasticity Type of reinforcer Sources
Opiates Psychostimulants High fat or sugar food Sexual intercourse Physical exercise
(aerobic)
Environmental
enrichment
ΔFosB expression in
nucleus accumbens D1-type MSNs
[7]
Behavioral plasticity
Escalation of intake Yes Yes Yes [7]
Psychostimulant
cross-sensitization
Yes Not applicable Yes Yes Attenuated Attenuated [7]
Psychostimulant
self-administration
[7]
Psychostimulant
conditioned place preference
[7]
Reinstatement of drug-seeking behavior [7]
Neurochemical plasticity
CREB phosphorylation
in the nucleus accumbens
[7]
Sensitized dopamine response
in the nucleus accumbens
No Yes No Yes [7]
Altered striatal dopamine signaling DRD2, ↑DRD3 DRD1, ↓DRD2, ↑DRD3 DRD1, ↓DRD2, ↑DRD3 DRD2 DRD2 [7]
Altered striatal opioid signaling μ-opioid receptors μ-opioid receptors
κ-opioid receptors
μ-opioid receptors μ-opioid receptors No change No change [7]
Changes in striatal opioid peptides dynorphin dynorphin enkephalin dynorphin dynorphin [7]
Mesocorticolimbic synaptic plasticity
Number of dendrites in the nucleus accumbens [7]
Dendritic spine density in
the nucleus accumbens
[7]

Diagnosis

DSM

The American Psychiatric Association publishes and periodically updates the Diagnostic and Statistical Manual of Mental Disorders (DSM), a widely recognized compendium of mental health diagnostics.[6]

The version published in 1987 (DSM-III-R), referred to "distress about a pattern of repeated sexual conquests or other forms of nonparaphilic sexual addiction, involving a succession of people who exist only as things to be used."[13] The reference to sexual addiction was subsequently removed.[14] The DSM-IV-TR, published in 2000 (DSM-IV-TR), did not include sexual addiction as a mental disorder.[15] The DSM-IV-TR included a miscellaneous diagnosis called Sexual Disorders Not Otherwise Specified, stating : "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.)[15]

Some authors suggested that sexual addiction should be re-introduced into the DSM system;[16] however, sexual addiction was rejected for inclusion in the DSM-5, which was published in 2013.[17] 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 proposed diagnosis does not make the cut as an official diagnosis due to a lack of research into diagnostic criteria for compulsive sexual behavior, according to the American Psychiatric Association.[18][19]

Borderline personality disorder

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The American Psychiatric Association uses the Diagnostic and Statistical Manual of Mental Disorders (DSM) to define and classify mental illnesses and in the DSM-IV version of the document, it lists borderline personality disorder (BPD) as an Axis II – Cluster B personality disorder with the code 301.83. The DSM-5 dropped the multiaxial system, but BPD still retains the same numerical code of 301.83.[18] The World Health Organization's produces the International Classification of Diseases (ICD) and lists BPD under the name "Emotionally unstable personality disorder". The latest version of the document (ICD-10) lists the disorder in Chapter X which is reserved for "Disorders of adult personality and behaviour" and has the code F60.3.[20] The Chinese Society of Psychiatry uses the Chinese Classification of Mental Disorders (CCMD), which is in its third edition (CCMD-3) and has a diagnosis of "Nonorganic sexual dysfunction" (numerical code 52.9), of which sexual promiscuity may be a symptom. Personality disorders, Habit and impulse disorders, Psychosexual disorders in the CCMD-3 fall in Chapter 6 and under code 6.60 are listed the personality disorders. The CCMD-3 lists "impulsive personality disorder" (numerical code 60.4),[21] which is equivalent to what the DSM refers to as "borderline personality disorder" and what the ICD-10 refers to as "emotionally unstable personality disorder". All three classification manuals and documents list sexual promiscuity as a prevalent and problematic symptom for patients with this particular pathology. Hypersexuality along with high-risk sexual behaviour, seductive behaviour, and promiscuity are an often due to the marked impulsivity common to this group of patients. Individuals with borderline personality disorder (emotionally unstable personality disorder or impulsive personality disorder) not only are prone to promiscuity, but in many cases, co-morbid paraphilias and fetishistic behaviour are commonly associated with their sexual behaviours. Common paraphilic compulsions among individuals with this diagnosis include urolagnia ("golden showers"), sadomasochism, voyeurism autassassinophilia, partialism, biastophilia, and in some cases paraphilic drives may be more extreme and dangerous – such as erotophonophilia, necrophilia, pedophilia, and even anthropophagy. Both males and females with this personality disorder often have a strong desire and compulsion to get involved in illicit sex, affairs, and relationships with married or otherwise pre-attached individuals. Consequently, individuals with borderline personality disorder often experience love and sexuality in perverse and violent qualities which they cannot integrate with the tender, intimate side of relationships.[22][23]

ICD

The World Health Organization produces the International Classification of Diseases (ICD), which 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).[24]

CCMD

The Chinese Society of Psychiatry produces the Chinese Classification of Mental Disorders (CCMD), which is currently in its third edition – the CCMD-3 and Chapter 5 of the document lists "Physiological disorders related to psychological factors" and under code 52 are disorders that are "Nonorganic sexual dysfuction," and within that category are listed a number of disorders, one of which is "Other or unspecified sexual dysfunction" (numerical code 52.9).[25] This is roughly equivalent to the ICD-10 diagnosis of "Excessive sexual drive" (F52.7), "Other sexual dysfunction, not caused by organic disorder or disease" (F52.8) and "Unspecified sexual dysfunction, not caused by organic disorder or disease" (F52.9).[26]

Diagnostic criteria

Several mental health providers have proposed various, but similar, criteria for diagnosing sexual addiction, including Patrick Carnes,[27] and Aviel Goodman.[28] Dr. Carnes authored the first clinical book about sex addiction in 1983 based on his own empirical research. His diagnostic model is still largely utilized by the thousands of certified sex addiction therapists (CSATs) trained by the organization he founded.[29] No diagnostic proposal for sex addiction has been adopted into any official government diagnostic manual, however.

During the update of the Diagnostic and Statistical Manual to version 5 (DSM-5), the American Psychiatric Association rejected two independent proposals for inclusion.[citation needed]

The International Classification of Diseases (ICD-10) of the World Health Organization, however, does include an entry for "Excessive Masturbation"[30] and another for "Excessive Sexual Drive."[31]

In 2011, the American Society of Addiction Medicine (ASAM), the largest medical consensus of physicians dedicated to treating and preventing addiction,[32] redefined addiction as a chronic brain disorder[33] which for the first time broadened the definition of addiction from substances to include addictive behaviors and reward-seeking, such as gambling and sex.[34]

Treatment

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Behavioral therapy

Cognitive behavioral therapy is a common form of behavioral treatment for addictions and maladaptive behaviors in general.[medical citation needed] Dialectical behavior therapy has been shown to improve treatment outcomes as well. Certified Sex Addiction Therapists (CSAT) – a group of sexual addiction therapists certified by the International Institute for Trauma and Addiction Professionals – offer specialized behavioral therapy designed specifically for sexual addiction.[29][35]

Intensive outpatient programs for sexual addiction provide intensive treatment for individuals over the course of several weeks or months. An intensive outpatient program can help stabilize an individual who may be in crisis, but may not need inpatient treatment. Individuals who successfully complete an intensive outpatient program may then continue with less frequent treatment services such as individual counseling, group counseling, and couples counseling to help continue work toward and maintenance of their recovery. Intensive outpatient programs can help clients address, understand and overcome triggers in their everyday lives that may be contributing to compulsive sexual behavior and acting out.

Twelve-step programs

Involvement in twelve-step programs for sex addiction can also serve as an adjunct therapy to supplement clinical treatment. Self-help groups exist in most of the developed world. Such programs include Sexaholics Anonymous, Sex Addicts Anonymous, Sex and Love Addicts Anonymous, and others.

Epidemiology

According to a systematic review from 2014, prevalence rates of sexual addiction and related sexual disorders ranges from 3% to 6%.[1]

History

Sex addiction as a term first emerged in the mid-1970s when various members of Alcoholics Anonymous sought to apply the principles of 12-Steps toward sexual recovery from serial infidelity and other unmanageable compulsive sex behaviors that were similar to the powerlessness and un-manageability they experienced with alcoholism.[36] Multiple 12-step style self-help groups now exist for people who identify as sex addicts, including Sex Addicts Anonymous, Sexaholics Anonymous, Sex and Love Addicts Anonymous, and Sexual Compulsives Anonymous.

Society and culture

Controversy

External media
Images
image icon The History and Rise of Sex and Love Addiction (INFOGRAPHIC)
Audio
audio icon Robert Weiss & David Ley. Is sex addiction a myth? // KPCC (25 April 2012, 9:29 am)
Video
video icon Nicole Prause, Ph.D. (sexual physiologist). [1] CBS (18 July 2013)

The controversy surrounding sexual addiction is centered around its identification, through a diagnostic model, in a clinical setting. As noted in current medical literature reviews, compulsive sexual behavior has been observed in humans;[7][8] drug-induced compulsive sexual behavior has also been noted clinically in some individuals taking dopaminergic drugs.[7] Moreover, current medical research involving neuropsychological models has identified sexual addictions (i.e., the compulsive engagement in sexual behavior despite negative consequences) as a true form of addiction (i.e., it possesses all the necessary characteristics to classify it as one) in animal models.[7][8] Since current diagnostic models use drug-related concepts as diagnostic criteria for addictions,[6] these are ill-suited for modelling compulsive behaviors in a clinical setting.[7] Consequently, diagnostic classification systems, such the DSM, do not include sexual addiction as a diagnosis because there is currently "insufficient peer-reviewed evidence to establish the diagnostic criteria and course descriptions needed to identify these behaviors as mental disorders".[18] A 2014 systematic review on sexual addiction indicated that the "lack of empirical evidence on sexual addiction is the result of the disease's complete absence from versions of the Diagnostic and Statistical Manual of Mental Disorders."[1]

There have been debates regarding the definition and existence of sexual addictions for decades, as the issue was covered in a 1994 journal article.[37][38] According to a 2014 systematic review, sexual addiction (including excessive masturbation and pornography addiction) a diagnosable behavioral addiction with estimable prevalence rates.[1] The Mayo Clinic considers sexual addiction to be a form of obsessive compulsive disorder and refer to it as sexual compulsivity (note that by definition, an addiction is a compulsion toward rewarding stimuli).[39] A paper dating back to 1988 and a journal comment letter published in 2006 asserted that sex addiction is itself a myth, a by-product of cultural and other influences.[40][41] The 1988 paper argued that the condition is instead a way of projecting social stigma onto patients.[40]

In a non-academic opinion report from 2003, Marty Klein, stated that "the concept of sex addiction provides an excellent example of a model that is both sex-negative and politically disastrous."[42]:8 Klein singled out a number of features that he considered crucial limitations of the sex addiction model[42]:8 and stated that the diagnostic criteria for sexual addiction are easy to find on the internet.[42]:9 Drawing on the Sexual Addiction Screening Test, he stated that "the sexual addiction diagnostic criteria make problems of nonproblematic experiences, and as a result pathologize a majority of people."[42]:10

Popular culture

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Sexual addiction has been the main theme in films such as 2001 film Diary of a Sex Addict, 2005 film I Am a Sex Addict, 2006 film Black Snake Moan, 2008 film Confessions of a Porn Addict, 2011 film Shame, 2012 film Thanks for Sharing, and others.

See also

References

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  7. 7.00 7.01 7.02 7.03 7.04 7.05 7.06 7.07 7.08 7.09 7.10 7.11 7.12 7.13 7.14 7.15 7.16 7.17 7.18 7.19 7.20 7.21 7.22 7.23 7.24 7.25 7.26 Lua error in package.lua at line 80: module 'strict' not found.Table 1"
  8. 8.0 8.1 8.2 8.3 8.4 8.5 8.6 8.7 8.8 8.9 Lua error in package.lua at line 80: module 'strict' not found.
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  13. American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., rev.). Washington, DC: Author.
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  15. 15.0 15.1 American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (fourth edition, text revision). Washington, DC: Author.
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  17. Psychiatry's bible: Autism, binge-eating updates proposed for 'DSM' USA Today.
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  24. International Classification of Diseases, version 2007.
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  29. 29.0 29.1 IITAP Official Website
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  35. Stefanie Carnes. Mending a Shattered Heart: A Guide for Partners of Sex Addicts. Gentle Path Press; Second Edition. (4 October 2011) page 139 ISBN 978-0-9826505-9-2
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  37. Francoeur, R. T. (1994). Taking sides: Clashing views on controversial issues in human sexuality, p. 25. Dushkin Pub. Group.
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  39. Mayo Clinic Website
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Further reading

There are several books which offer overview history and treatment techniques for sexual addiction, including the following
There are also books focusing on partners of sex addicts
  • My Secret Life with a Sex Addict – from discovery to recovery by Emma Dawson. (Thornton Publishing, 2004) ISBN 978-1-932344-70-7
  • Hope After Betrayal: Healing When Sexual Addiction Invades Your Marriage by Meg Wilson. (Kregel Publications, 2007) ISBN 978-0-8254-3935-3
  • Deceived: Facing Sexual Betrayal Lies and Secrets by Claudia Black. (Hazelden, 2009) ISBN 978-1-59285-698-5
  • Your Sexually Addicted Spouse: How Partners Can Cope and Heal by Barbara Steffens and Marsha Means. (New Horizon Press, 2009) ISBN 978-0-88282-309-6
  • Mending a Shattered Heart: A Guide for Partners of Sex Addicts by Stefanie Carnes. (Gentle Path Press, 2011) ISBN 978-0-9774400-6-1
  • Love You, Hate the Porn: Healing a Relationship Damaged by Virtual Infidelity by Mark Chamberlain. (Shadow Mountain; 2.7.2011 edition, 2011. ISBN 1606419366
  • A Couple's Guide to Sexual Addiction: A Step-by-Step Plan to Rebuild Trust and Restore Intimacy by Paldrom Collins and George Collins. (Adams Media, 2011) ISBN 978-1-4405-1221-6
  • Facing Heartbreak: Steps to Recovery for Partners of Sex Addicts by Stefanie Carnes. (Gentle Path Press, 2012) ISBN 978-0-98327-133-8
The interested reader can find discussions of the concept of sexual addiction in
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External links