A Surprising Finding Related to Executive Control in a Patient Sample of Hypersexual Men

ArticleinJournal of Sexual Medicine 8(8):2227 - 2236 · August 2011with 177 Reads
Abstract
Introduction. Patients seeking help for hypersexual behavior often exhibit features of impulsivity, cognitive rigidity, and poor judgment as well as deficits in emotion regulation and excessive preoccupation with sex. Some of these characteristics are also common among patients presenting with neurological pathology associated with executive dysfunction. Exploring relationships between dysregulated sexual behavior and executive deficits will enhance our understanding of hypersexuality. Aim. This study sought to assess whether patients seeking help for hypersexual behavior exhibit executive deficits as measured by standardized neuropsychological tests of executive functioning when compared with healthy controls. Methods. Executive deficits were assessed in a sample of male patients (N = 30) seeking help for hypersexual behavior compared with a nonhypersexual community sample of men (N = 30) using neuropsychological tests of executive functioning. Using multivariate statistics, differences between the groups were examined. Main Outcome Measures. Sexual activity measured by the Hypersexual Behavior Inventory and the Compulsive Sexual Behavior Inventory. Executive functions measured through neuropsychological testing using several subtests of Delis–Kaplan Executive Function System: Color–Word Interference Test, the Tower Test, the Trail Making Test, the Verbal Fluency Test, as well as the Wisconsin Card Sorting Test. Psychopathology was assessed using the Mini International Neuropsychiatric Interview, and cognitive ability was assessed using the Wechsler Adult Intelligence Scale. Results. Significant differences on measures of hypersexuality were observed. However, the groups failed to exhibit significant differences across neuropsychological tests of executive functioning even after controlling for cognitive ability. Conclusions. These results contradict a previous finding of executive deficits among hypersexual men measured by self-report. The lack of executive deficits suggests that this population may exhibit domain-specific aspects of impulsivity, poor judgment, and risky behavior that are not generalizable to other domains of life. Furthermore, our findings fail to support a conceptualization of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, proposed hypersexual disorder based on models of executive dysfunction. Reid RC, Garos S, Carpenter BN, and Coleman E. A surprising finding related to executive control in a patient sample of hypersexual men. J Sex Med 2011;8:2227–2236.

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  • ... Although there has been a consistent interest in impulse control deficits as a possible link between beliefs and behavior in hypersexuality, emotion dysregulation has only recently attracted research interest (Reid & Carpenter, 2009; Reid, Garos, Carpenter, & Coleman, 2011; Simonelli, Bonanno, Michetti, & Rossi, 2008). Emotion dysregulation may provide a useful framework for considering sexual behaviors which are inappropriate, but not impulsive or " hypersexual " in a strict sense. ...
    ... It should also be noted that ER is considered an embodied À or partly embodied À characteristic , taking place, at least in part, outside of awareness and conscious control (Siegel, 1999). The multidimensional nature of ER strategies, the possibility of selective impairment or improvement in specific self-regulation processes (Reid et al., 2011), and the evidence for associations between specific ER deficits and various psychiatric disorders (Giromini, Velotti, de Campora, Bonalume, & Zavattini, 2012; Velotti et al., 2013) make it important to decompose the ER construct in order to relate specific ER processes to different outcomes . If one assumes that specific deficits in one or more ER processes underlie or even cause various kinds and degrees of hypersexual behavior, then understanding ER has important implications for the treatment of hypersexuality. ...
    ... Therefore, a treatment that does not take into account the emotional component underlying the hypersexual behavior in such cases is likely to fail. A second example of the importance of understanding the psychological processes underlying pathological behaviors is provided by Reid et al. (2011), who reported that patients with symptoms of hypersexual behavior had a domain-specific impairment in impulse control, but not a more general deficit in executive control. This is consistent with the assumption that sexuality-related emotions are likely to be particularly difficult to manage (Diamond, Blatt, & Lichtenberg, 2007) and we therefore suggest that ER impairments may trigger hypersexual behavior (when an individual experiences sexually related emotions and impulses) but not general behavioral disinhibition. ...
    Article
    There is long and varied history of research on hypersexuality, but no consensus on either etiology or therapeutic interventions. In an effort to advance understanding of hypersexuality we review the largely separate literatures on hypersexuality and emotion dysregulation, which has recently been suggested to be a critical factor in the development and maintenance of mental health problems. Unfortunately, there is also a lack of consensus on the various primary and intervening factors involved in development of emotion regulation or emotion dysregulation. First, we review theories and empirical evidence to try to explain how emotion dysregulation could contribute to the onset of hypersexuality or other inappropriate sexual behavior. Next, an attachment-theory perspective is used to develop a common etiological model for both emotion dysregulation and hypersexuality. Finally, we address the issue of hypersexual behavior in the context of couple relationships, taking an interpersonal perspective on emotion and emotion regulation. We refer to different age categories, ranging from adolescence to elderly, as emotion regulation skills are likely to change throughout the lifespan.
  • ... The Sexual Addiction Screening Test-R (SAST) (28) and the Hypersexual Behavior Inventory (HBI) (30) were used to examine PHB severity in each participant and to identify any relationship between PHB severity and neural responses to the Stroop interference task. The reliability of the SAST-R and HBI have been previously calculated as Cronbach's α = 0.91 and 0.96, respectively (28,30). ...
    ... The Sexual Addiction Screening Test-R (SAST) (28) and the Hypersexual Behavior Inventory (HBI) (30) were used to examine PHB severity in each participant and to identify any relationship between PHB severity and neural responses to the Stroop interference task. The reliability of the SAST-R and HBI have been previously calculated as Cronbach's α = 0.91 and 0.96, respectively (28,30). The SAST-R contains 20 questions designed to assess sexual addiction tendencies; total scores range from 0 to 20 points, with higher scores indicating more severe addiction. ...
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    Accumulating evidence suggests a relationship between problematic hypersexual behavior (PHB) and diminished executive control. Clinical studies have demonstrated that individuals with PHB exhibit high levels of impulsivity; however, relatively little is known regarding the neural mechanisms underlying impaired executive control in PHB. This study investigated the neural correlates of executive control in individuals with PHB and healthy controls using event-related functional magnetic resonance imaging (fMRI). Twenty-three individuals with PHB and 22 healthy control participants underwent fMRI while performing a Stroop task. Response time and error rates were measured as surrogate indicators of executive control. Individuals with PHB exhibited impaired task performance and lower activation in the right dorsolateral prefrontal cortex (DLPFC) and inferior parietal cortex relative to healthy controls during the Stroop task. In addition, blood oxygen level-dependent responses in these areas were negatively associated with PHB severity. The right DLPFC and inferior parietal cortex are associated with higher-order cognitive control and visual attention, respectively. Our findings suggest that individuals with PHB have diminished executive control and impaired functionality in the right DLPFC and inferior parietal cortex, providing a neural basis for PHB.
  • ... Patients seeking help for hypersexual behavior often exhibit features of impulsivity , cognitive rigidity, and poor judgment as well as deficits in emotion regulation and excessive preoccupation with sex. These characteristics are also common among patients presenting with neurological pathology associated with executive dysfunction, which has led some investigators, including our group, to question whether brain pathology might be linked to hypersexuality (Miner, Raymond, Mueller, Lloyd, & Lim, 2009; Reid, Garos, Carpenter, & Coleman, 2011; Reid, Karim, McCrory, & Carpenter, 2010). First, there has only been one study looking at brain pathology in hypersexual patients using neuroimaging, and it employed a cross-sectional design limiting inferences about causality. ...
    ... In one study, using neuropsychological self-report measures in a sample of hypersexual men, we found some evidence that executive deficits may exist in this population (Reid, Karim, McCrory, & Carpenter, 2010 ). However, when actual performance was assessed on neuropsychological tests sensitive to frontal deficits common in executive dysfunction, no differences were found between hypersexual patients and healthy controls (Reid, Garos, Carpenter, & Coleman, 2011). As we have noted elsewhere (Reid, Carpenter, & Fong, 2011), we interpreted these findings to support our theory that hypersexuality is a context-specific phenomenon which is expressed when triggered by a sexual cue or another stimulus, that when activated, is paired with sexual behavior (e.g., a learned behavior arising in response to dysphoric mood or stress such as been proposed in the current DSM-5 criteria for HD). ...
    Article
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    Review of the current state with respect to DSM-5 proposal for hypersexual disorder.
  • ... Data suggest differences between individuals with and without CSB on self-report and task-based measures of impulsivity [100][101][102][103]. Furthermore, impulsivity and craving seem to be associated with the severity of symptoms of dysregulated pornography use, such as loss of control [64,104]. ...
    ... minutes) did not differ on self-reported (UPPS-P Scale) or task-based (Stop Signal Task) measures of impulsivity [110]. Further, Reid and colleagues did not observe differences between individuals with CSB and healthy controls on neuropsychological tests of executive functioning (i.e., response inhibition, motor speed, selective attention, vigilance, cognitive flexibility, concept formation, set shifting), even after adjusting for cognitive ability in analyses [103]. Together, findings suggest that impulsivity may link most strongly to hypersexuality but not to specific forms of CSB like problematic pornography use. ...
    Article
    Full-text available
    Purpose of Review The current review summarizes the latest findings concerning neurobiological mechanisms of compulsive sexual behavior disorder (CSBD) and provides recommendations for future research specific to the diagnostic classification of the condition. Recent Findings To date, most neuroimaging research on compulsive sexual behavior has provided evidence of overlapping mechanisms underlying compulsive sexual behavior and non-sexual addictions. Compulsive sexual behavior is associated with altered functioning in brain regions and networks implicated in sensitization, habituation, impulse dyscontrol, and reward processing in patterns like substance, gambling, and gaming addictions. Key brain regions linked to compulsive sexual behavior features include the frontal and temporal cortices, amygdala, and striatum, including the nucleus accumbens. Summary Despite much neuroscience research finding many similarities between CSBD and substance and behavioral addictions, the World Health Organization included CSBD in the ICD-11 as an impulse-control disorder. Although previous research has helped to highlight some underlying mechanisms of the condition, additional investigations are needed to fully understand this phenomenon and resolve classification issues surrounding CSBD.
  • ... Notably, sexual risk-taking has been linked to reduced performance across multiple indices of executive function (Joyal, Plante- Beaulieu, de Chanterac, 2014). However, results have been mixed regarding the WCST (Adjorlolo & Egbenya, 2016;Cohen et al., 2010;Joyal, Black, & Dassylva, 2007;Reid, Garos, Carpenter, & Coleman, 2011). Adjorlolo and Egbenya (2016) have proposed that deficits in cognitive inhibition (i.e., impulsivity), in tandem with cognitive inflexibility, contribute to sexual misconduct. ...
    Article
    Objective: Among patients with brain damage, executive function deficits and impulsivity correspond with propensity to engage in risky behaviors. Less research has addressed this issue in healthy adults, and fewer still have simultaneously evaluated the importance of executive function and impulsive personality. Additionally, most research has focused exclusively on substance use while ignoring other domains of risky behavior such as sexual activity and antisocial practices. Toward this end, we examined the association of risky behaviors with executive function and self-reported impulsivity. Method: Healthy undergraduates ( n = 56) were administered the Iowa Gambling Task (IGT), Wisconsin Card Sorting Test (WCST), and UPPS-P impulsivity questionnaire. A self-report questionnaire assessed risky sexual activities, drug use, and antisocial behaviors over a 2-month interval. Results: After accounting for social desirability and performance effort, multiple regression analyses revealed a robust relationship between executive function and risk-taking. Specifically, WCST performance correlated with risky sexual and substance use behavior, whereas the IGT was uniquely linked with antisocial acts. Trait impulsivity was positively associated with sexual behavior. Conclusions: Extending previous research, executive function accounted for more variance in risky behaviors than self-reported impulsivity, but this was mediated by facet of executive function. Decision-making under risk seemed to better account for antisocial acts, whereas perseveration was more strongly linked to sexual activity and substance misuse. These data imply that poor executive function increases the likelihood that healthy young adults will engage in risky and potentially dangerous acts, extending the ecological validity of the WCST and IGT.
  • ... Based upon these observations, the model of specific internet addiction proposed by Brand et al. [15] has recently been specified for cybersex use (including IP) [289]. Reid, Karim, McCrory and Carpenter [290] found greater self-reported executive dysfunction in a sample of hypersexual patients, another study found no general impairments of executive functions observed using neuropsychological tests [291]. However, several studies reported an interference of the processing of sexual cues and sexual arousal with executive functions. ...
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    Many recognize that several behaviors potentially affecting the reward circuitry in human brains lead to a loss of control and other symptoms of addiction in at least some individuals. Regarding Internet addiction, neuroscientific research supports the assumption that underlying neural processes are similar to substance addiction. The American Psychiatric Association (APA) has recognized one such Internet related behavior, Internet gaming, as a potential addictive disorder warranting further study, in the 2013 revision of their Diagnostic and Statistical Manual. Other Internet related behaviors, e.g., Internet pornography use, were not covered. Within this review, we give a summary of the concepts proposed underlying addiction and give an overview about neuroscientific studies on Internet addiction and Internet gaming disorder. Moreover, we reviewed available neuroscientific literature on Internet pornography addiction and connect the results to the addiction model. The review leads to the conclusion that Internet pornography addiction fits into the addiction framework and shares similar basic mechanisms with substance addiction. Together with studies on Internet addiction and Internet Gaming Disorder we see strong evidence for considering addictive Internet behaviors as behavioral addiction. Future research needs to address whether or not there are specific differences between substance and behavioral addiction.
  • ... A previous study initially reported executive functioning problems that were described as indicative of emotion dysregulation (Reid, Karim, McCrory, & Carpenter, 2010). When later assessed by neuropsychological tests, no actual difference on a large number of executive functioning measures was identified (Reid, Garos, Carpenter, & Coleman, 2011 ). The selfreport assessment of executive functioning used in the original study was unusual and has been demonstrated not to correspond with actual executive measures in other populations (Bakar, Taner, Soysal, Karakas, & Turgay, 2011). ...
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    Full-text available
    People who report distress due to their frequent use of visual sexual stimuli (VSS) may experience primarily negative affect, primarily positive affect, or coactivation of positive and negative affect when consuming VSS. Theories of sexual addiction suggest that these individuals regulate their emotions poorly, as evidenced by coactivation of positive and negative emotions during sexual stimulation. Men and women who either reported problems down-regulating their use of VSS (VSS-P, N = 71) or no problem regulating use of VSS (VSS-C, N = 49) watched a neutral film and a sexual film. They reported their positive and negative feelings after each film. Unexpectedly, the VSS-P group exhibited significantly less coactivation of positive and negative affect to the sexual film than VSS-C. This is inconsistent with emotion dysregulation, supposedly a key feature of “hypersexual disorder.” Affect regulation could be failing at a different stage of sexual stimulus processing not studied. Theories about hypersexuality could be more specific regarding when and how affect dysregulation is thought to occur to allow in hypersexuality to allow testing.
  • ... This finding was recently extended to demonstrate that sexual desire levels, not hypersexual problems, predict how well a person up-and down-regulates their sexual responses to VSS [77]. Similarly, sex addiction patients report dysexecutive problems [78], but do not actually exhibit them when tested [79]. If there is not actually any evidence for dysregulation, what might explain their reports of problems regulating VSS use? ...
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    Full-text available
    The addiction model is rarely used to describe high frequency use of Visual Sexual Stimulus (VSS) in research, yet it is commonly used in media and clinical practice. The theory and research behind “pornography addiction” is hindered by poor experimental designs, limited methodological rigor, and lack of model specification. The history and limitations of addiction models are reviewed, including how VSS fail to meet standards of addiction. These include how VSS use can reduce health risk behaviors. Proposed negative effects, including erectile problems, difficulty regulating sexual feelings, and neuroadaptations are discussed as non-pathological evidence of learning. Individuals reporting “addictive” use of VSS could be better conceptualized by considering issues such as gender, sexual orientation, libido, desire for sensation, with internal and external conflicts influenced by religiosity and desire discrepancy. Since a large, lucrative industry has promised treatments of pornography addiction despite this poor evidence, scientific psychologists are called to declare the emperor (treatment industry) has no clothes (supporting evidence). When faced with such complaints, clinicians are encouraged to address behaviors without conjuring addiction labels.
  • ... Higher scores on self-report measures of executive functions also were positively related to hypersexual behavior. However, when executive deficits in hypersexual patients have been assessed through objective neuropsychological tests, hypersexual patients failed to exhibit executive deficits when compared to healthy controls (Reid, Garos, Carpenter, & Coleman, 2011). Collectively, these mixed findings suggest that further research is needed to determine whether brain-behavior relationships and executive deficits observed among individuals with SUDs generalize to hypersexual individuals. ...
    Article
    Full-text available
    Hypersexual behavior has been documented within clinical and research settings over the past decade. Despite recent research on hypersexuality and its associated features, many questions remain how best to define and classify hypersexual behavior. Proposed diagnostic criteria for Hypersexual Disorder (HD) have been proposed for the DSM-5 and a preliminary field trial has lent some support to the reliability and validity of the HD diagnosis. However, debate exists with respect to the extent to which the disorder might be categorized as a non-substance or behavioral addiction. In this article, we will discuss this debate in the context of data citing similarities and differences between hypersexual disorder, drug addictions, and pathological gambling. The authors of this paper conclude that despite many similarities between the features of hypersexual behavior and substance-related disorders, the research on HD at this time is in its infancy and much remains to be learned before definitively characterizing HD as an addiction at this time.
  • ... Given that a lack of control over strong sexual urges is cited as a primary feature of hypersexuality , it was surprising that neither of two scales measuring hypersexual problems were related to the self-regulation of sexual arousal. Other studies have been unable to find relationships between hypersexuality and executive dysfunction (Reid, Garos, Carpenter, & Coleman, 2011), affect dysregulation () or responsivity to sexual cues (Steele, Staley, Fong, & Prause, 2013). If high sexual desire is primarily responsible for a failure to control sexual urges, as these data suggest, it may be useful to consider addressing this underlying construct directly. ...
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    Full-text available
    A person’s ability to control their own sexual arousal is important both to reduce the risks associated with some sexual behaviors and to respond sexually with intimate partners. A lack of control over sexual urges is a proposed feature of “Hypersexual Disorder”, though some evidence suggests that sexual desire predicts the self-regulation of sexual arousal better than hypersexuality. In the current study, a sample (N=116) of men and women recruited from community ads viewed a series of 20-second neutral and sexual films. Before each sexual film participants were instructed to increase their sexual arousal, decrease their sexual arousal, or respond as usual. Higher levels of desire for sex with a partner consistently predicted failures to downregulate sexual arousal. Hypersexuality was unrelated. These findings replicate Winters et al. (2009) and extend their findings by including upregulation, including women, using a new measure of hypersexuality, and a higher-trial design.
  • ... T. entsprechende Defizite berichteten [57], z. T. jedoch auch keine signifikanten Unterschiede in den testleistungen hypersexueller Patienten einerseits und gesunder Kontrollprobanden andererseits feststellten [59]. ...
    Article
    Der vorliegende Beitrag befasst sich mit Ausdrucksformen sexuellen Verhaltens und Erlebens, die durch ihren exzessiven Charakter und Leidensdruck und/oder Fremdgefährdung charakterisiert sind. Zunächst wird die historische Entwicklung des gegenwärtig im klinisch-diagnostischen Bereich überwiegend als Hypersexualität bezeichneten Konstrukts dargestellt – von der fallgeschichtlichen Darstellung bei Krafft-Ebing bis hin zur aktuellen Diskussion um die Aufnahme der hypersexuellen Störung in das Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5). Anschließend werden unterschiedliche Diagnoseformen und -ansätze für hypersexuelles Verhalten vorgestellt sowie ein kurzer Überblick über Epidemiologie, ätiologische Modelle und Hypothesen gegeben. Es wird die forensische Relevanz des Konstrukts für die gutachterliche Tätigkeit diskutiert; hierbei steht der mögliche Einfluss hypersexuellen Verhaltens auf die Schuldfähigkeit bzw. die Kriminalprognose im Mittelpunkt. Abstract The present article deals with hypersexual behavior and experience which is characterized by excessive sexual activity and a high degree of psychological strain and/or endangerment for others. Initially, the historical developments of different conceptualizations of the construct which is currently predominantly denominated hypersexuality are illustrated from the beginning in terms of the famous case studies presented by Krafft-Ebing up to the current discussion about the inclusion of hypersexual disorder in the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5). Different diagnostical methods and approaches for hypersexual behavior are presented as well as a brief overview about the epidemiology and different etiological models and hypotheses. Finally, the forensic relevance of the construct for expert witness activity is discussed by focusing on the potential impact of hypersexual behavior on criminal responsibility and recidivism risk assessment.
  • ... executive deficits) or a problem of generalized impulse control does not appear to be supported in well-designed studies. [34, 35]. Where questions of self-control are central to a legal case, research and theory regarding " sex addiction " may not be as helpful to the courts, as research and diagnoses related to impulse control disorders or other diagnoses where there is a greater body of empirical research. ...
    Article
    Full-text available
    The term “sex addiction” has been popularized in recent years to describe a range of different problematic sexual behaviors which are assumed to be similar to being addicted to substances and lend themselves to similar treatment approaches. Other terms such as sexual compulsivity, sexual impulsivity, erotomania, hyperphilia, and hypersexuality have been proposed in the literature which assumes different mechanisms and treatment approaches. However, the term “sex addiction” remains the most widely used and recognized label, particularly in public parlance. The current paper presents several case examples to illustrate how the concept of “sex addiction” is having a significant impact in US legal proceedings. The authors offer some commentary about the relevance of these cases as they pertain to matters of criminal, civil, and administrative law.
  • ... As noted above, non-neurological samples of "sex- ually addicted" patients also rate themselves as having general problems with impulsivity and self-control, 52 but, curiously, do not show objective executive function impairments. 112 Finally, the high rate of comorbidity between anxiety disor- ders and HS, also observed in PD, 88 may suggest an obsessive- compulsive pathology, which is postulated to be a form of compulsive fantasizing used to relieve anxiety, which is gradu- ally positively reinforced by the relief from anxiety. However, phenomenologically, there does seem to be discrepancy between the ego-syntonic nature of sexual thoughts in hyper- sexual disorder, and the more ego-dystonic obsessions of OCD. ...
    Article
    Hypersexuality (HS) was one of the earliest examples of an impulse control disorder (ICD) or behavior to be associated with treatment for Parkinson's disease (PD), with an estimated prevalence of approximately 3.5%. Here, we report on a systematic review of the published literature of HS in PD with a view to uncovering evidence as to whether it is distinct from other ICDs. In addition, we report on 7 new cases that had broad neuropsychological testing, including a gambling test, which taps into reward and inhibitory mechanisms. The review uncovered a number of case series and cohorts that comment on the prevalence of HS, but very few made systematic comparisons with other ICDs, although younger onset and male sex are usually noted. A few studies have begun to map out a neuropsychological profile for HS, and our own cases show particular deficits in learning from negative outcomes, but, overall, there are insufficient data to draw firm conclusions. Functional imaging has shown patterns of increased content-specific activation in response to sexual material and this might relate to increased dopamine release. We conclude with a brief survey of the neurobiology of sexuality, which suggests possible avenues for further research and treatment of HS.
  • ... Future studies may also investigate the role of executive functions in controlling cybersex use. In hypersexuality, no differences in general executive functions were reported (Reid, Garos, Carpenter & Coleman, 2011), but the authors hypothesize that executive functions might be affected when individuals are confronted with addiction associated cues. It was shown that sexual cues interfere with inhibition, cognitive flexibility, working memory, and decision making (Laier, Pawlikowski & Brand, accepted pending minor revision; Laier et al., 2012; Macapagal, Janssen, Fridberg, Finn & Heiman, 2011), which could be related to the loss of control and the neglect of negative consequences reported by cybersex addicted individuals. ...
    Article
    Full-text available
    Background and aims: Cybersex addiction is discussed controversially, while empirical evidence is widely missing. With respect to its mechanisms of development and maintenance Brand et al. (2011) assume that reinforcement due to cybersex should lead to the development of cue-reactivity and craving explaining recurrent cybersex use in the face of growing but neglected negative consequences. To support this hypothesis, two experimental studies were conducted. Methods: In a cue-reactivity paradigm 100 pornographic cues were presented to participants and indicators of sexual arousal and craving were assessed. The first study aimed at identifying predictors of cybersex addiction in a freely recruited sample of 171 heterosexual males. The aim of the second study was to verify the findings of the first study by comparing healthy (n = 25) and problematic (n = 25) cybersex users. Results: The results show that indicators of sexual arousal and craving to Internet pornographic cues predicted tendencies towards cybersex addiction in the first study. Moreover, it was shown that problematic cybersex users report greater sexual arousal and craving reactions resulting from pornographic cue presentation. In both studies, the number and subjective quality of real-life sexual contacts were not associated to cybersex addiction. Discussion: The results support the gratification hypothesis, which assumes reinforcement, learning mechanisms, and craving to be relevant processes in the development and maintenance of cybersex addiction. Poor or unsatisfying sexual real-life contacts cannot sufficiently explain cybersex addiction. Conclusions: Positive reinforcement in terms of gratification plays a major role in cybersex addiction.
  • ... This study appears to add to a list of studies that have not been able to identify pathology consistent with substance addiction models. First, hypersexuals report neuropsychological problems ( Reid, Karim, McCrory, & Carpenter, 2010), but neuropsychological testing does not suggest problems ( Reid, Garos, Carpenter, & Coleman, 2011). Second, hypersexuals report using VSS to regulate negative mood, but show few, small differences in positive or negative emotions when viewing VSS relative to controls ( Prause et al., 2013). ...
  • ... Expanding the CA findings, CFA suggested that a two-factor solution (with sexual desire/activity and the per- ceived lack of control/negative consequences as separate latent dimensions) fits the collected data. In addition, the small size of the cluster represent- ing problematic sexuality (6% of men and 3% of women) is in line with the current hypersexuality estimates and prevalence rates [34,35]. Overall, the presented findings inform the debate about hypersexuality in several ways. ...
    Article
    Full-text available
    IntroductionThe concept of hypersexuality has been accompanied by fierce debates and conflicting conclusions about its nature. One of the central questions under the discussion is a potential overlap between hypersexuality and high sexual desire. With the relevant research in its early phase, the structure of hypersexuality remains largely unknown.AimThe aim of the present study was to systematically explore the overlap between problematic sexuality and high sexual desire.MethodsA community online survey was carried out in Croatia in 2014. The data were first cluster analyzed (by gender) based on sexual desire, sexual activity, perceived lack of control over one's sexuality, and negative behavioral consequences. Participants in the meaningful clusters were then compared for psychosocial characteristics. To complement cluster analysis (CA), multigroup confirmatory factor analysis (CFA) of the same four constructs was carried out.Main Outcome MeasuresIndicators representing the proposed structure of hypersexuality were included: sexual desire, frequency of sexual activity, lack of control over one's sexuality, and negative behavioral outcomes. Psychosocial characteristics such as religiosity, attitudes toward pornography, and general psychopathology were also evaluated.ResultsCA pointed to the existence of two meaningful clusters, one representing problematic sexuality, that is, lack of control over one's sexuality and negative outcomes (control/consequences cluster), and the other reflecting high sexual desire and frequent sexual activity (desire/activity cluster). Compared with the desire/activity cluster, individuals from the control/consequences cluster reported more psychopathology and were characterized by more traditional attitudes. Complementing the CA findings, CFA pointed to two distinct latent dimensions—problematic sexuality and high sexual desire/activity.Conclusion Our study supports the distinctiveness of hypersexuality and high sexual desire/activity, suggesting that problematic sexuality might be more associated with the perceived lack of personal control over sexuality and moralistic attitudes than with high levels of sexual desire and activity. Carvalho J, Štulhofer A, Vieira AL, and Jurin T. Hypersexuality and high sexual desire: Exploring the structure of problematic sexuality. J Sex Med **;**:**–**.
  • ... Hypersexual individuals may have propensities to experience more negative than positive emotions, and self-critical affect (e.g., shame, self-hostility) may contribute to the maintenance of CSB (32). Given limited studies and mixed results, it is unclear whether CSB is associated with deficits in impaired decision- making/executive functioning (33)(34)(35)(36). ...
    Article
    Full-text available
    Aims: To review the evidence base for classifying compulsive sexual behavior (CSB) as a non-substance or 'behavioral' addiction. Methods: Data from multiple domains (e.g. epidemiological, phenomenological, clinical, biological) are reviewed and considered with respect to data from substance and gambling addictions. Results: Overlapping features exist between CSB and substance use disorders. Common neurotransmitter systems may contribute to CSB and substance use disorders, and recent neuroimaging studies highlight similarities relating to craving and attentional biases. Similar pharmacological and psychotherapeutic treatments may be applicable to CSB and substance addictions, although considerable gaps in knowledge currently exist. Conclusions: Despite the growing body of research linking compulsive sexual behavior (CSB) to substance addictions, significant gaps in understanding continue to complicate classification of CSB as an addiction.
  • ... However, evi- dence of expected frontal/executive dysfunction is not always evident in hypersexuality, leading to speculation that impulsivity, poor judgment, and risky behaviors may be "domain specific." 223 Many other personality and emo- tional factors have been related to hypersexuality, such as impulsivity, emotional dysregulation, shame, neuroticism, stress-proneness, and a tendency to distrust others. 186,187,189 I. INTRODUCTION Further research in lesion-induced hypersexuality will be required to clarify the potency of such phenomena, indi- vidually or collectively, in producing hypersexuality. ...
    Book
    Neuroimaging Personality, Social Cognition, and Character covers the science of combining brain imaging with other analytical techniques for use in understanding cognition, behavior, consciousness, memory, language, visual perception, emotional control, and other human attributes. Multidimensional brain imaging research has led to a greater understanding of character traits such as honesty, generosity, truthfulness, and foresight previously unachieved by quantitative mapping. This book summarizes the latest brain imaging research pertaining to character with structural and functional human brain imaging in both normal individuals and those with brain disease or disorder, including psychiatric disorders. By reviewing and synthesizing the latest structural and functional brain imaging research related to character, this book situates itself into the larger framework of cognitive neuroscience, psychiatric neuroimaging, related fields of research, and a wide range of academic fields, such as politics, psychology, medicine, education, law, and religion. Provides a novel innovative reference on the emerging use of neuroimaging to reveal the biological substrates of character, such as optimism, honesty, generosity, and others Features chapters from leading physicians and researchers in the field Contains full-color text that includes both an overview of multiple disciplines and a detailed review of modern neuroimaging tools as they are applied to study human character Presents an integrative volume with far-reaching implications for guiding future imaging research in the social, psychological and medical sciences, and for applying these findings to a wide range of non-clinical disciplines such as law, politics, and religion Connects brain structure and function to human character and integrates modern neuroimaging techniques and other research methods for this purpose.
  • ... The growing interest in "sex addiction" both conceptually and empirically has been accompanied with a rapid development of instruments such as the Sexual Addiction Screening Test (SAST;Carnes, 1989) and SAST-Revised (SAST-R; Carnes et al., 2010), the Shorter PROMIS Questionnaire-sex subscale (SPQ- S; Christo et al., 2003), PATHOS 1 ( Carnes et al., 2012), and the Short Internet Addiction Test (Young, 1998) adapted to online sexual activities (s-IAT-sex; Laier et al., 2013;Pawlikowski et al., 2013;Wéry et al., 2016a). While other validated scales have been developed, they assess and conceptualize "hypersexuality" as a compulsive, impulsive, and/or sexual dysregulation disorder (e.g., Kalichman and Rompa, 1995;Coleman et al., 2001;Reid et al., 2011). ...
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    The view that problematic excessive sexual behavior ("sex addiction") is a form of behavioral addiction has gained more credence in recent years, but there is still considerable controversy regarding operationalization of the concept. Furthermore, most previous studies have relied on small clinical samples. The present study presents a new method for assessing sex addiction-the Bergen-Yale Sex Addiction Scale (BYSAS)-based on established addiction components (i.e., salience/craving, mood modification, tolerance, withdrawal, conflict/problems, and relapse/loss of control). Using a cross-sectional survey, the BYSAS was administered to a broad national sample of 23,533 Norwegian adults [aged 16-88 years; mean (± SD) age = 35.8 ± 13.3 years], together with validated measures of the Big Five personality traits, narcissism, self-esteem, and a measure of sexual addictive behavior. Both an exploratory and a confirmatory factor analysis (RMSEA = 0.046, CFI = 0.998, TLI = 0.996) supported a one-factor solution, although a local dependence between two items (Items 1 and 2) was detected. Furthermore, the scale had good internal consistency (Cronbach's α = 0.83). The BYSAS correlated significantly with the reference scale (r = 0.52), and demonstrated similar patterns of convergent and discriminant validity. The BYSAS was positively related to extroversion, neuroticism, intellect/imagination, and narcissism, and negatively related to conscientiousness, agreeableness, and self-esteem. High scores on the BYSAS were more prevalent among those who were men, single, of younger age, and with higher education. The BYSAS is a brief, and psychometrically reliable and valid measure for assessing sex addiction. However, further validation of the BYSAS is needed in other countries and contexts.
  • ... To the best of our knowledge, there is no study which investigated trait and state impulsivity in individuals with tendency towards IPD. Studies which investigated impulsivity in hypersexual individuals re- ported higher trait impulsivity compared to controls (Raymond, Coleman, & Miner, 2003;Rettenberger, Klein, & Briken, 2016) and, similarly to specific IUDs, mixed results were found for state impulsivity (Miner, Raymond, Mueller, Lloyd, & Lim, 2009;Reid, Garos, Carpenter, & Coleman, 2011). Few studies examined the effects of Internet-por- nographic-cues on individuals with IPD tendencies. ...
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    Criteria for hypersexual disorder were proposed for consideration for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), but ultimately rejected by the American Psychiatric Association despite a field trial suggesting the criteria were valid and reliable. This article highlights the vast array of controversial issues surrounding the proposal for hypersexual disorder. While some criticisms covered a broader scope of general concerns about the field of psychiatric mental illness, many of these often extended to the proposal for hypersexual disorder. It is important to discuss both general concerns about psychiatric disorders and those specifically focused on hypersexuality in order to understand the challenges encountered in advancing the criteria for hypersexual disorder. This article attempts to place the controversies, criticisms, and issues about hypersexuality in context from leading experts in the field.
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    Hypersexual Disorder, often termed colloquially as sex addiction, does not appear as a diagnosis in the most recent edition of the DSM, as there was insufficient empirical support for the putative cluster of symptoms involving preoccupation with sexual thoughts, feelings, and behaviours. Despite the lack of scientific evidence for a sex addiction diagnosis, the popular media continue to discuss sex addiction, and individuals continue to present clinically seeking assistance with their out-of-control sexual behaviours. Importantly, ''sex addiction'' is being led as a defence in criminal and civil matters in several jurisdictions. Building on a recent American case law review, the current research systematically sampled Canadian court, tribunal, and arbitral case law to query how these venues are addressing the concept of sex addiction. Case law was identified using the comprehensive Canadian legal database, Quicklaw, using an exhaustive list of key terms. Of the 111 cases identified and screened, 63 were excluded, and 48 were included in the review. Results indicate sex addiction is being used most commonly in criminal law and family law matters but is also used at arbitral and professional disciplinary hearings, as well as in administrative proceedings (including employment, human rights and immigration hearings). The current article presents examples of how sex addiction is being used in these venues and offers commentary on the ways in which legal and scientific epistemologies differ.
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    Known since ancient times, sexual excess has been referred to as 'sexual addiction,for three decades. DSM-5 has proposed a new category of 'hypersexual disorder' to bring together disturbing situations of masturbation, pornography use, strip club attendance, multiple affairs, internet procurement of partners, prostitution use, unprotected sex with multiple partners and other sexually arousing behaviors. The conditions under which patients come for assessment differ between single and married, heterosexual and homosexual, paraphilic and nonparaphilic, and sex criminals and law-abiding patients. Treatment depends on apparent causes, comorbidities and the patient's capacities. While questions have been raised about the validity of hypersexual disorder, the numerous requests for assistance from patients should remind the field of psychiatry that utility also drives the employment of a diagnosis.
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    Introduction: Despite the serious behavioral consequences faced by individuals with sexual compulsivity, related neuropsychological studies are sparse. Aim: To compare decision making and cognitive flexibility at baseline and after exposure to an erotic video in sexually compulsive participants and non-sexually compulsive controls. Methods: The sample consisted of 30 sexually compulsive men and 30 controls. Cognitive flexibility was investigated through the Wisconsin Card Sorting Test and decision making was examined through the Iowa Gambling Task. Main outcome measures: Wisconsin Card Sorting Test categories, correct responses, and perseverative errors and Iowa Gambling Task general trends and blocks. Results: Sexually compulsive subjects and controls performed similarly at baseline. After watching an erotic video, controls performed better in block 1 of the Iowa Gambling Task (P = .01) and had more correct responses on the Wisconsin Card Sorting Test (P = .01). Conclusions: The controls presented fewer impulsive initial choices and better cognitive flexibility after exposure to erotic stimuli. Messina B, Fuentes D, Tavares H, et al. Executive Functioning of Sexually Compulsive and Non-Sexually Compulsive Men Before and After Watching an Erotic Video. J Sex Med 2017;XX:X-XX.
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    Introduction: Despite the rejection of hypersexual disorder (HD) as a new diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), clinical and research interest in HD continues. Aim: To systematically review the existing scientific literature on the conceptualization and assessment of HD and out-of-control sexual behavior. Methods: Studies were identified from PsychInfo, PubMed, JSTOR, Google Scholar, and Scholar's Portal using an exhaustive list of key terms. Of 299 total articles identified and screened, 252 were excluded, and 47 are included in this review. Main outcome measures: To review two categories of articles: HD conceptualization and HD psychometric assessment. Results: First, results of the review of theoretical conceptualizations of HD reflected a large proportion of the peer-reviewed literature devoted to discussing conceptualizations of HD without reaching consensus. Second, results of the review of HD psychometric assessments were analyzed using Hunsley and Mash's (2008) criteria to evaluate psychometric adequacy of evidence-based assessment measurements. The six most researched measurements of HD were evaluated, including the Hypersexual Disorder Screening Inventory, the Hypersexual Behavior Inventory, the Sexual Compulsivity Scale, the Sexual Addiction Screening Test, the Sexual Addiction Screening Test-Revised, and the Compulsive Sexual Behavior Inventory. Psychometric properties of the scales are reviewed, evaluated, and discussed. Conclusion: The Hypersexual Disorder Screening Inventory, the measurement proposed for the clinical screening of HD by the DSM-5 workgroup, currently has the strongest psychometric support. Future research and clinical directions are discussed in light of findings after the literature review and synthesis. Montgomery-Graham S. Conceptualization and Assessment of Hypersexual Disorder: A Systematic Review of the Literature. Sex Med Rev 2017;5:146-162.
  • Chapter
    An overview of the complexities of neuroimaging of personality, social cognition, and character (NPSCC) is provided, using hypersexuality (HS) as an example. In Section 1, many questions are posed for which there are no easy answers. Definitions are introduced and the issue of HS is described to provide an organizing construct that facilitates the discussion. In Section 2, a selective review of HS is presented, covering both non-brain-lesion and lesion-induced hypersexuality. The main brain areas likely to relate to HS are summarized. Localizationist and network/associationist theories of brain organization are presented to explain current models of HS in relation to three key brain networks implicated by the research. Finally, in Section 3, the lesion method and newer neuroimaging tools are briefly introduced. Many of the well-known challenges to conclusive NPSCC research are summarized. The goal of these sections is not to provide a definitive review of HS or the many conceptual and methodologic challenges faced in the study of HS. Instead, a major goal of these sections is to reveal stumbling blocks encountered in the study of one clinical phenomenon (hypersexuality) that might be considered in future NPSCC research.
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    Hypersexual behavior can have a devastating impact on attachments between partners in committed couple relationships. An array of emotions is activated by these attachment ruptures, including feelings of betrayal, confusion, frustration, hopelessness, and abandonment. Repairing these ruptures can be a delicate and challenging part of helping couples restore trust and forgiveness in their relationships. This article describes the process of using Emotionally Focused Therapy for couples as an intervention to facilitate the process of repairing the damage caused by hypersexual behavior.
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    As the problem of sexual addiction and co-addiction surfaces among women within Christian circles, more of these strugglers will seek treatment. They are most likely first to turn for help within their community of faith by seeking counsel from a clergy person or Christian therapist. Unfortunately, these resources typically fail to provide an adequate response. This article, based on the author s experience as a Christian counselor who works with Christian sex addicts and co-addicts, outlines the common treatment errors made by faith-based clinicians and suggests ways secular practitioners can understand and help this specialized population.
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    This article reports the findings of a study investigating psy-chopathology, personality traits, and marital distress among a sample of women married to hypersexual men (n = 85) com-pared with a control group (n = 85) drawn from a combined college and community sample. Psychopathology and personality traits were measured using the NEO Personality Inventory—Revised (NEO–PI–R), and martial satisfaction was measured using the Re-vised Dyadic Adjustment Scale (RDAS). A multivariate analysis of variance (MANOVA) of between-group differences was significant. However, although there were a few minor differences with mod-est effect sizes, examination of post-hoc univariate tests revealed that generally, the wives did not show any more psychopathol-ogy or problematic personality traits than would be found within a community sample. In contrast, wives were significantly more distressed about their marriages compared with the controls. Over-all, these findings contradict much of the existing research that characterizes wives of hypersexual men as being more depressed, anxious, and chemically dependent, as well as emotionally needy.
  • Article
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    Psychometric properties of the Hypersexual Behavior Inventory (HBI) are reported using treatment-seeking samples of hypersexual men. Study 1 details item reduction and exploratory factor analysis of the HBI. Study 2 provides results of a confirmatory factor anal-ysis yielding a 3-factor model measuring Control, Consequences, and Coping associated with sexual thoughts, feelings, and behav-iors. Concurrent and discriminant validity was established with measures of theoretically related and dissimilar constructs. The psychometric properties of the HBI suggest it reflects the proposed DSM-V classification criteria for hypersexual disorder and has both the clinical and research utility to advance a more comprehensive understanding of hypersexuality. The proposed diagnostic criteria for Hypersexual Disorder (HD) in the DSM-V characterize this phenomenon as a repetitive and intense preoccupation with sexual fantasies, urges, and behaviors, leading to adverse consequences and clinically significant distress or impairment in social, occupational, or other important areas of functioning (Kafka, 2010; Kaplan & Krueger, 2010; Address correspondence to Rory C. Reid, Ph.D.
  • Article
    Hypersexuality is a difficult problem to manage in the elderly, especially in nursing home residents and people with dementia being cared for at home. The present study reports the case of a 70-year-old man who suffered from hypersexuality following a frontal lobe injury, and was successfully treated with haloperidol. There is no previously reported evidence of the efficacy of haloperidol for the treatment of hypersexuality, however, we consider that it might be worthwhile trailing this drug for this condition, as long as there are no serious adverse effects.
  • Article
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    This article reports the psychometric evaluation of the Pornography Consumption Inventory (PCI), which was developed to assess motivations for pornography use among hypersexual men. Initial factor structure and item analysis were conducted in a sample of men (N = 105) seeking to reduce their pornography consumption (Study 1), yielding a 4-factor solution. In a second sample of treatment-seeking hypersexual men (N = 107), the authors further investigated the properties of the PCI using confirmatory factor analytic procedures, reliability indices, and explored PCI associations with several other constructs to establish convergent and discriminant validity. These studies demonstrate psychometric evidence for the PCI items that measure tendencies of hypersexual men to use pornography (a) for sexual pleasure; (b) to escape, cope, or avoid uncomfortable emotional experiences or stress; (c) to satisfy sexual curiosity; and (d) to satisfy desires for excitement, novelty, and variety.
  • Article
    Earlier evidence suggests comorbid attention-deficit disorder (ADHD) among those seeking treatment for hypersexual behavior. This article examines which facets of ADHD symptoms are most strongly associated with hypersexual behavior among a patient sample of men (N = 81). ADHD diagnosis was made by 2 clinicians, and symptom characteristics were measured using the Conners' Adult ADHD Rating Scale and the Sexual Compulsivity Scale. Among ADHD symptoms, inattentive features were most prevalent. A stepwise regression analysis revealed that the Problems with Self-Concept subscale of the Conners' Adult ADHD Rating Scale was the strongest predictor of scores on the Sexual Compulsivity Scale. Surprisingly, subscales that measured traits of impulsivity, inattention, memory problems, and hyperactive restlessness did not contribute additional predictive variance in the statistical model. The results of these findings suggest that clinicians should exercise caution in assuming that common characteristics of ADHD, such as impulsivity and hyperactivity, exert the strongest influence on hypersexual behavior. Rather, our results provide evidence that the associated features of ADHD, such as problems with low self-esteem, might be more salient factors in influencing hypersexuality severity among patients with comorbid hypersexual behavior and ADHD.
  • Article
    New developments in understanding the nature, etiology and treatment of compulsive sexual behavior offer new hope for people suffering from these sexual disorders. There is considerable debate about terminology and these newer approaches to treatment. This paper reviews these new developments and the controversy which surround them. Compulsive sexual behavior can be divided into two types: paraphilic and nonparaphilic. While John Money (1986) has described the paraphilias at length, a specific attempt is made here to describe and classify nonparaphilic compulsive sexual behaviors. An obsessive-compulsive model for understanding paraphilic and nonparaphilic compulsive sexual behaviors is preferred by the author.
  • Article
    There is a severe lack of studies on male sexual desire and its biopsychosocial determinants. Most of the studies are focused on female sexual interest and are based on the contribution of single dimensions instead of the interaction between them. The aim of the present study was to test a conceptual model considering the interrelated role of biopsychosocial factors on male sexual desire. This model allowed us to test not only the unique impact of predictors that are traditionally related to sexual desire, but also how their interaction affects sexual desire in men. Two hundred and thirty seven men from the general population were assessed according to age (mean age = 35, standard deviation = 11), medical problems, psychopathology, dyadic adjustment, and cognitive-emotional factors. Psychopathology measured by the Brief Symptom Inventory, dysfunctional sexual beliefs measured by the Sexual Dysfunctional Beliefs Questionnaire, thoughts and emotions in sexual context measured by the Sexual Modes Questionnaire, dyadic adjustment measured by the Dyadic Adjustment Scale, medical condition measured by the Medical History Formulation, and sexual desire measured by the Sexual Desire subscale of the International Index of Erectile Function. Results showed that cognitive factors (sexual beliefs and automatic thoughts during sexual activity) were the best predictors of sexual desire in men. Specifically, beliefs related to restrictive attitudes toward sexuality, erection concerns, and lack of erotic thoughts in sexual context, had a significant direct effect on reduced sexual desire. Moreover, this set of cognitive-emotional factors also mediated the relationship between medical problems, age, and sexual desire. Results from this integrative approach highlighted the role of cognitive factors related to cultural values (dysfunctional sexual beliefs) and distraction mechanisms during sexual context (automatic thoughts) in male sexual interest. Findings support the need to include cognitive dimensions in the assessment and treatment of sexual desire problems, considering their involvement as vulnerability or resiliency factors for deficient sexual desire in men. Moreover, these factors surpassed the importance of the remaining factors (particularly, of medical factors and psychopathology), showing that, despite the lack of studies, male sexuality is better conceptualized from a biopsychosocial perspective.
  • Article
    Although studies of specific groups of individuals (e.g., adolescents, "high risk" samples) have examined sexual repertoire, little is known, at the population level, about the sexual behaviors that comprise a given sexual encounter. To assess the sexual behaviors that men and women report during their most recent sexual event; the age, partner and situational characteristics related to that event; and their association with participants' evaluation of the sexual event. During March-May 2009, data from a United States probability sample related to the most recent partnered sexual event reported by 3990 adults (ages 18-59) were analyzed. Measures included sexual behaviors during the most recent partnered sexual event, event characteristics (i.e., event location, alcohol use, marijuana use, and for men, erection medication use), and evaluations of the sexual experience (pleasure, arousal, erection/lubrication difficulty, orgasm). Great diversity exists in the behaviors that occur during a single sexual event by adults, with a total of 41 combinations of sexual behaviors represented across this sample. Orgasm was positively related to the number of behaviors that occurred and age was related to greater difficulty with erections and lubrication. Men whose most recent event was with a relationship partner indicated greater arousal, greater pleasure, fewer problems with erectile function, orgasm, and less pain during the event compared with men whose last event was with a nonrelationship partner. Findings demonstrate that adults ages 18 to 59 engage in a diverse range of behaviors during a sexual event and that greater behavior diversity is related to ease of orgasm for both women and men. Although both men and women experience sexual difficulties related to erectile function and lubrication with age, men's orgasm is facilitated by sex with a relationship partner whereas the likelihood of women's orgasm is related to varied sexual behaviors.
  • Article
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    Knowledge about the regulation of sexual emotion may add to the understanding of sexual problems such as diminished sexual desire and hypersexuality. To investigate the regulation of sexual arousal by means of attentional focus in healthy sexually functional men and women. Using a habituation design with attentional strategies, it was investigated whether a focus on hot, emotional information of sexual stimuli would sustain or amplify sexual responses, whereas a focus on cool, cognitive information would weaken sexual responses. Genital response (in women measured by vaginal photoplethysmography assessing vaginal pulse amplitude, and in men measured by mechanical penile strain gauge assessing penile circumference) and subjective report of sexual arousal and absorption. Attenuation of sexual feelings by attentional focus was observed, with stronger sexual feelings under the hot focus condition than under the cool focus condition. Also, sexual feelings diminished during repeated erotic stimulation, and increased with the introduction of novel stimulation, indicating habituation and novelty effects. Contrary to the expectations, the hot attentional focus did not preclude habituation of sexual arousal. Attentional focus has substantial regulatory effects on subjective sexual arousal. Taking a participant and emotion-oriented focus rather than a spectator and stimulus-oriented focus while viewing erotic stimuli, enhances feelings of sexual arousal. Implications for the treatment of hypoactive sexual desire, sexual arousal disorder, and hypersexuality are discussed, as well as future directions for studying regulation of sexual emotion.
  • Article
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    The main aim of the study was to examine blood oxygen level-dependent response during task switching in adults with attention-deficit/hyperactivity disorder (ADHD). Fifteen male adults with ADHD and 14 controls participated and performed a task-switching paradigm. Behaviorally, no specific executive control problems were observed in the ADHD participants, although they did display more errors in general. The neuroimaging data did show remarkable differences between the ADHD and control adults: Adults with ADHD engaged more strongly the dorsal anterior cingulate cortex, middle temporal gyrus, precuneus, lingual gyrus, precentral gyrus, and insula than did the healthy controls during task switching. Controls displayed more task-related activity in the putamen, posterior cingulate gyrus, medial frontal gyrus, thalamus, orbitofrontal cortex, and postcentral gyrus. ADHD adults did not display specific executive control problems at a behavioral level, but did engage different brain areas during task switching compared with healthy controls. The results are discussed in the framework of the executive frontostriatal circuitry, conflict detection, and attentional networks.
  • Article
    Attention deficit hyperactivity disorder (ADHD) is a common, genetically transmitted common childhood-onset disorder with a high rate of persistence in adulthood. Although many studies have shown anatomical and functional abnormalities in children and adolescents, studies with adult patients are rare. Nineteen adults with ADHD (11 ADHD, combined type; 8 ADHD, partially remitted) and 17 controls were included in this functional magnetic resonance imaging (fMRI) study. Brain activation was investigated with a continuous performance test (CPT). Impaired activation of a fronto-striatal and a parietal attentional network was observed during the NoGo condition in ADHD subjects. Correlations of reduced activity of the caudate nuclei, the anterior cingulate cortex, and parietal cortical structures, as well as increased activity in the insular cortex, with inattention and impulsivity symptom scores were found. The activation patterns were similar to those known from children and adolescents with ADHD. In conclusion we found not only a widespread dysfunction of brain regions that are involved in cognitive processing in adults with ADHD compared with controls, but also correlations between symptom severity and dysfunction of neuronal systems across adult subjects with a history of ADHD in childhood but whose symptoms did (persistent ADHD) and did not (not persistent ADHD) qualify for a full diagnosis of ADHD in adulthood.
  • Article
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    Department of Psychiatry, Harvard Medical School, Boston,MA, USAOnline publication date: 27 April 2010To cite this Article Kafka, Martin P.(2010) '“What is Sexual Addiction?” A Response to Stephen Levine', Journal of Sex &Marital Therapy, 36: 3, 276 — 281To link to this Article: DOI: 10.1080/00926231003719707URL: http://dx.doi.org/10.1080/00926231003719707
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    This article reviews the current evidence base for the diagnosis, assessment, and treatment of hypersexual conditions. Controversy concerning this diagnosis is discussed. Terminology and diagnostic criteria, as well as psychological, psychopharmacological, and other treatment approaches, are presented.
  • Article
    To investigate the concurrent validity and reliability of the Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID), a short structured diagnostic interview for DSM-IV and ICD-10 psychiatric disorders in children and adolescents. Participants were 226 children and adolescents (190 outpatients and 36 controls) aged 6 to 17 years. To assess the concurrent validity of the MINI-KID, participants were administered the MINI-KID and the Schedule for Affective Disorders and Schizophrenia for School Aged Children-Present and Lifetime Version (K-SADS-PL) by blinded interviewers in a counterbalanced order on the same day. Participants also completed a self-rated measure of disability. In addition, interrater (n = 57) and test-retest (n = 83) reliability data (retest interval, 1-5 days) were collected, and agreement between the parent version of the MINI-KID and the standard MINI-KID (n = 140) was assessed. Data were collected between March 2004 and January 2008. Substantial to excellent MINI-KID to K-SADS-PL concordance was found for syndromal diagnoses of any mood disorder, any anxiety disorder, any substance use disorder, any ADHD or behavioral disorder, and any eating disorder (area under curve [AUC] = 0.81-0.96, kappa = 0.56-0.87). Results were more variable for psychotic disorder (AUC = 0.94, kappa = 0.41). Sensitivity was substantial (0.61-1.00) for 15/20 individual DSM-IV disorders. Specificity was excellent (0.81-1.00) for 18 disorders and substantial (> 0.73) for the remaining 2. The MINI-KID identified a median of 3 disorders per subject compared to 2 on the K-SADS-PL and took two-thirds less time to administer (34 vs 103 minutes). Interrater and test-retest kappas were substantial to almost perfect (0.64-1.00) for all individual MINI-KID disorders except dysthymia. Concordance of the parent version (MINI-KID-P) with the standard MINI-KID was good. The MINI-KID generates reliable and valid psychiatric diagnoses for children and adolescents and does so in a third of the time as the K-SADS-PL.
  • Article
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    Patients seeking help for hypersexual behavior often exhibit features of impulsivity, cognitive rigidity, poor judgment, deficits in emotion regulation, and excessive preoccupation with sex. Some of these characteristics are also common among patients presenting with neurological pathology associated with executive dysfunction. These observations led to the current investigation of differences between a group of hypersexual patients (n = 87) and a non-hypersexual community sample (n = 92) of men using the Behavior Rating Inventory of Executive Function-Adult Version (BRIEF-A) and the Hypersexual Behavior Inventory (HBI). Significant differences between the groups emerged on eight subscales and all of the general indices of executive functioning with the most dramatic differences on BRIEF-A's Shift, Emotional Control, Initiate, and Plan/Organize subscales. Hypersexual behavior was positively correlated (r = .37, p < .01) with global indices of executive dysfunction and several subscales of the BRIEF-A. These findings provide preliminary evidence supporting the hypothesis that executive dysfunction may be implicated in hypersexual behavior.
  • Article
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    Attention deficit hyperactivity disorder (ADHD) is associated with deficits in executive functioning (EF). ADHD in adults is also associated with impairments in major life activities, particularly occupational functioning. We investigated the extent to which EF deficits assessed by both tests and self-ratings contributed to the degree of impairment in 11 measures involving self-reported occupational problems, employer reported workplace adjustment, and clinician rated occupational adjustment. Three groups of adults were recruited as a function of their severity of ADHD: ADHD diagnosis (n = 146), clinical controls self-referring for ADHD but not diagnosed with it (n = 97), and community controls (n = 109). Groups were combined and regression analyses revealed that self-ratings of EF were significantly predictive of impairments in all 11 measures of occupational adjustment. Although several tests of EF also did so, they contributed substantially less than did the EF ratings, particularly when analyzed jointly with the ratings. We conclude that EF deficits contribute to the impairments in occupational functioning that occur in conjunction with adult ADHD. Ratings of EF in daily life contribute more to such impairments than do EF tests, perhaps because, as we hypothesize, each assesses a different level in the hierarchical organization of EF as a meta-construct.
  • Article
    To examine the association between psychological tests of executive functioning and functional outcomes among high-IQ adults with attention deficit hyperactivity disorder (ADHD). Subjects were high-IQ adults with (n=64) and without ADHD (n=53). Subjects were administered a battery of neuropsychological tests assessing executive functioning. High-IQ adults with ADHD performed less well than those without ADHD on several psychological tests of executive functioning, including the Wisconsin Card Sorting Test (WCST), Stroop Color and Word Test, Rey-Osterrieth Complex Figure Test (ROCF), California Verbal Learning Test (CVLT) and an auditory continuous performance test (CPT). Test performance in the high-IQ adult ADHD group, however, was average. In the entire sample, performance on several tests of executive functioning including the ROCF and the CVLT were significant predictors of real-world functioning. High-IQ adults with ADHD perform less well on tests of executive functioning relative to high-IQ control participants. Performance on several tests of executive functioning was a significant predictor of functioning.
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    Hypersexual Disorder is proposed as a new psychiatric disorder for consideration in the Sexual Disorders section for DSM-V. Historical precedents describing hypersexual behaviors as well as the antecedent representations and proposals for inclusion of such a condition in the previous DSM manuals are reviewed. Epidemiological as well as clinical evidence is presented suggesting that non-paraphilic "excesses" of sexual behavior (i.e., hypersexual behaviors and disorders) can be accompanied by both clinically significant personal distress and social and medical morbidity. The research literature describing comorbid Axis I and Axis II psychiatric disorders and a purported relationship between Axis I disorders and Hypersexual Disorder is discussed. Based on an extensive review of the literature, Hypersexual Disorder is conceptualized as primarily a nonparaphilic sexual desire disorder with an impulsivity component. Specific polythetic diagnostic criteria, as well as behavioral specifiers, are proposed, intended to integrate empirically based contributions from various putative pathophysiological perspectives, including dysregulation of sexual arousal and desire, sexual impulsivity, sexual addiction, and sexual compulsivity.
  • Article
    In recent years, there has been increased interest in a clinical syndrome characterized by excessive sexual thoughts, sexual urges, and/or sexual behaviors that has many aspects in common with impulse control disorders. This study provides a preliminary examination of the impulsive aspects of this syndrome, compulsive sexual behavior (CSB). Sixteen male subjects, eight CSB patients and eight non-patient controls, completed psychometric measures of impulsivity and compulsive sexual behavior, performed a behavioral task designed to assess impulse control (Go-No Go task), and underwent diffusion tensor imaging (DTI) procedures. The results indicated that CSB patients were significantly more impulsive; whether measured by psychometric testing or the Go-No Go procedure, than controls. The results also indicate that CSB patients showed significantly higher superior frontal region mean diffusivity (MD) than controls. A correlational analysis indicated significant associations between impulsivity measures and inferior frontal region fractional anisotropy (FA) and MD, but no associations with superior frontal region measures. Similar analyses indicated a significant negative association between superior frontal lobe MD and the Compulsive Sexual Behavior Inventory. Thus, while CSB patients were more impulsive than controls, the DTI results were not consistent with impulse control disorders.
  • Article
    This article reports the findings of a study investigating relationships among Minnesota Multiphasic Personality Inventory-2 (MMPI-2) scales as they pertain to a group of individuals seeking help for hypersexual behavior (N = 152). A number of MMPI-2 scale elevations were prevalent with this group, suggesting that some of these patients experience symptoms associated with psychopathology and interference or impairment in important areas of personal and interpersonal functioning. We failed to find any evidence in our data supporting the notion that hypersexual patients experience addictive tendencies. For a significant portion of the group, however, there were few-to-minimal elevations, reflecting normal psychological profiles. An overall important finding in our data suggests that patients presenting with hypersexual behavior are a diverse group, sufficiently so that studying subsamples of this group may lead to a clearer understanding of this behavior. Models that promote a homogenous conceptualization and treatment of hypersexuality likely miss important differences that provide valuable insight when working with this population.
  • Article
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    Out of control sexual behavior, also known as compulsive sexual behavior or sexual addiction, has not been studied in a representative sample of the general population. At age 32 years, 940 (93%) of 1,015 members of the birth cohort of the Dunedin Multidisciplinary Health and Development Study responded to a series of questions about sexual behavior, administered by computer. We enquired about sexual fantasies, urges or behavior that participants regarded as out of control during the previous year, and defined such experiences as out of control sexual experiences (OCSE). Nearly 13% of men and 7% of women reported OCSE in the past year. Women who reported such experiences were more likely than other women to have reported (elsewhere in the interview) having had high numbers of opposite sex partners, concurrent sexual relationships, or sex with a partner met on the internet, as well as a higher likelihood of same-sex attraction or behavior. Among men reporting OCSE, there was an association with having paid for heterosexual sex and with same-sex attraction and behavior. Few believed that OCSE had interfered with their lives (3.8% of all men and 1.7% of all women in the cohort). Only 0.8% of men and 0.6% of women reported that their actual sexual behavior had interfered with their lives. OCSE were also analyzed in relation to certain personality traits and to childhood sexual abuse (CSA). Some evidence of a link with impulsivity (women only) and negative affectivity was found. CSA was associated with OCSE among men. In conclusion, this population-based study has provided the first empirical estimations of the occurrence of OCSE and its relationship to a range of sexual behaviors in a representative sample.
  • This article reports the findings of a study investigating coping strategies used by hypersexual patients (n = 71), compared with a control group (n = 73), in their attempts to defend against shame. Coping strategies were measured using the Compass of Shame Scale (CoSS) and hypersexual behaviour was measured by the Hypersexual Behavior Inventory (HBI). A multivariate analysis of variance of between-group differences was significant, and examination of post hoc univariate tests revealed that the sample of hypersexual patients defended against shame with higher levels of withdrawal and higher tendencies to attack self and others when compared with the control group. The effect sizes of these differences were moderate to large. A categorical analysis of the patient group indicated that the greatest percentages of elevated shame scores were clustered on the Withdrawal and Attack Self subscales of the CoSS. Between-group differences on the Avoidance subscale of the CoSS were not significant. The results of this study are discussed as they pertain to clinical practice, and future recommendations for research are offered.
  • Article
    The neural bases of inhibitory function are reviewed, covering data from paradigms assessing inhibition of motor responses (antisaccade, go/nogo, stop-signal), cognitive sets (e.g., Wisconsin Card Sort Test), and emotion (fear extinction). The frontal cortex supports performance on these paradigms, but the specific neural circuitry varies: response inhibition depends upon fronto-basal ganglia networks, inhibition of cognitive sets is supported by orbitofrontal cortex, and retention of fear extinction reflects ventromedial prefrontal cortexamygdala interactions. Inhibition is thus neurobiologically heterogeneous, although right ventrolateral prefrontal cortex may support a general inhibitory process. Dysfunctions in these circuits may contribute to psychopathological conditions marked by inhibitory deficits.
  • Article
    In closing, we argue for two conclusions. First, there are advantages to using theoretically neutral terms (such as hypersexual disorder) that go beyond the compulsive-impulsive-addictive distinctions. Although the notion of theory-neutral observation cannot be defended, it is important not to rely on any particular theoretical framework before all the evidence is in. Our current nosology employs a range of contradictory terms and frameworks (eg, impulse control disorder, compulsive gambling and buying, trichotillomania, and kleptomania). In keeping with the approach taken in other DSM categories, it may be useful to find a more theory-neutral term that can cut across these conditions. Second, any conclusions drawn here about the nosology of hypersexual disorder must be tempered by the relative lack of rigorous psychobiological and systematic treatment data. A better understanding of the psychobiology of hypersexual disorder might provide greater confidence in one or the other theoretical model. The A-B-C model proposed here is tentative at best, given the relative absence of supporting data. Further, a richer assessment and treatment literature would allow clearer conclusions about the clinical utility of different nosological approaches. We emphasize the need for much additional work to characterize the phenomenology and psychobiology of hypersexual disorder and other conditions characterized by affective dysregulation, behavioral addiction, and cognitive dyscontrol, in the hope that such research would ultimately lead to improved assessment and management.
  • Article
    In this paper the first case of Kluver-Bucy syndrome (KBS) in Huntington's chorea is reported. The patient, a 46-year-old man with advanced Huntington's disease, displayed prosopagnosia, oral tendencies, emotional changes, hypersexual behavior, and hyperphagia associated with severe dementia. Haloperidol in moderate doses controlled both the KBS and the chorea, suggesting a possible role for the dopaminergic system in the pathogenesis of KBS in Huntington's disease. The presence of profound dementia in our patient supports the previous assertion that human cases of KBS are invariably associated with severe cognitive dysfunction. Since KBS was established as an entity, a great deal of attention has been directed to its neuroanatomical basis. However, due to the multidetermined nature of human behavior, the role of physiological, psychological, and environmental factors should also be taken into consideration with regard to the pathogenesis of this syndrome.
  • Article
    Full-text available
    The longitudinal history and temporal stability of total sexual outlet (TSO) in a group of outpatient males with paraphilias (PA) and paraphilia-related disorders (PRD) was assessed. Based on extant normative data from contemporary population-based surveys of sexual behavior, it was hypothesized that a persistent TSO of 7 or more orgasms/week for a minimum duration of 6 months be considered as the lower boundary for hypersexual desire in males. In almost all statistical analyses, the PA (n = 65) and PRD (n = 35) groups were not statistically different. The mean current TSO (PA, 7.4 +/- 5.7; PRD, 8.0 +/- 4.2) as well as the current average time consumed in all unconventional sexual behaviors (1-2 hr/day) were not statistically different. Unconventional sexual behaviors (i.e., related to PAs or PRDs) leading to orgasm constituted 77% of current TSO. In the combined group (n = 100), 72% (n = 72) reported a hypersexual TSO of 7 or greater. Age of onset of hypersexual TSO in the PAs (19.2 +/- 6.8 years; range 10-43) and the PRDs (21.0 +/- 8.6; range 10-46) and the duration of hypersexual TSO (PA, 11.1 +/- 11.2 years; PRD, 10.5 +/- 9.1) were not significantly different. Fifty-seven males (57%) reported a TSO of 7 or more for a minimum duration of 5 years. Clinical implications of reconceptualizing PAs and PRD as sexual desire disorders are discussed.
  • Article
    Sexual function is among the many areas affected by traumatic brain injury. The most common change is decreased sexual performance and satisfaction, for the brain injured person and the sexual partner. Hypersexuality, especially inappropriate sexual comments and gestures, is also a common result of traumatic brain injury. A case of hypersexuality in a severely disabled brain injured man is presented. He was successfully treated with medroxyprogesterone acetate after failure of multiple other treatment strategies. The literature is reviewed. An evaluation and treatment strategy for sexual dysfunction post traumatic brain injury is presented.
  • Article
    The Mini-International Neuropsychiatric Interview (M.I.N.I.) is a short structured diagnostic interview, developed jointly by psychiatrists and clinicians in the United States and Europe, for DSM-IV and ICD-10 psychiatric disorders. With an administration time of approximately 15 minutes, it was designed to meet the need for a short but accurate structured psychiatric interview for multicenter clinical trials and epidemiology studies and to be used as a first step in outcome tracking in nonresearch clinical settings. The authors describe the development of the M.I.N.I. and its family of interviews: the M.I.N.I.-Screen, the M.I.N.I.-Plus, and the M.I.N.I.-Kid. They report on validation of the M.I.N.I. in relation to the Structured Clinical Interview for DSM-III-R, Patient Version, the Composite International Diagnostic Interview, and expert professional opinion, and they comment on potential applications for this interview.
  • Article
    The temporolimbic structures of the brain that subserve emotional representation are highly epileptogenic and play an important role in the modulation of hormonal secretion and mediation of hormonal feedback. Estrogen is highly epileptogenic and exerts energizing and antidepressant effects. Excessive estrogen influence produces anxiety, agitation, irritability, and lability. It can promote the development of anxiety manifestations (e.g., panic, phobias, and obsessive-compulsive disorder). Progesterone and its metabolites inhibit kindling and seizure activity. They have potent anxiolytic effects, possibly by virtue of their GABAergic activity. Excessive progesterone influence produces sedation and depression. Testosterone has two major metabolites: estradiol, which can exacerbate seizures, and dihydrotestosterone, which blocks NMDA-type glutamate transmission and may be responsible for antiseizure effects. Testosterone has energizing effects and increases sexual desire in both men and women. In excess, however, it may promote aggressive, impulsive, and hypersexual behavior. Hormonal effects tend to be exaggerated or idiosyncratic in the setting of an abnormal or anomalous temporolimbic substrate, especially temporolimbic epilepsy. This may reflect altered neuronal responsivity to hormonal exposure perhaps by virtue of changes in the number of dendritic spines and receptors.
  • Article
    Most persons aware of their HIV-positive serostatus refrain from sexual behavior that could transmit HIV infection to others. However, a minority of men who test HIV-seropositive continue to engage in transmission risk behavior. One factor that may play a role in high-risk sexual activity involves sexual behavior self-management. The present study investigated the role of sexual compulsivity as a contributing factor to high-risk sexual behavior in HIV seropositive men who have sex with men (N = 112). Participants also completed measures of factors known to be related to risky sexual behavior including: personal substance use, sexual partner substance use, pleasure associated with high-risk activities, beliefs about transmission risks, intentions to avoid future instances of risky behavior, and self-esteem. Men scoring high on sexual compulsivity reported engaging in more frequent unprotected sexual acts with more partners, reported greater use of cocaine in conjunction with sexual activity, rated high-risk sexual acts as more pleasurable, and reported lower self-esteem. Mediational analyses indicated that the relationship between sexual compulsivity and high-risk sexual behavior was partially mediated by both personal cocaine use and partner cocaine use in conjunction with sexual activity. The results suggest a need to integrate HIV risk-reduction services and substance use treatment for those persons living with HIV who have difficulty avoiding transmission risk behavior.