Randomized Controlled Trial of a Cognitive Behavioral Therapeutic Treatment for Hypersexual Disorder

Full text

ORIGINAL RESEARCH
INTERVENTIONS
A Cognitive-Behavioral Therapy Group Intervention for Hypersexual
Disorder: A Feasibility Study
Jonas Hallberg, MSc,
1,2
Viktor Kaldo, PhD,
3
Stefan Arver, MD, PhD,
1,2
Cecilia Dhejne, MD, PhD,
2,3
and
Katarina Görts Öberg, PhD
1,2
ABSTRACT
Background: The proposed criteria of the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition
for hypersexual disorder (HD) included symptoms reported by patients seeking help for excessive and out-
of-control non-paraphilic sexual behavior, including sexual behaviors in response to dysphoric mood
states, impulsivity, and risk taking. Although no prior studies of cognitive-behavioral therapy (CBT) for the
treatment of HD have been performed, CBT has been found effective for dysphoric mood states and impulsivity.
Aim: To investigate the feasibility of a CBT manual developed for HD explored through symptom decrease,
treatment attendance, and clients’treatment satisfaction.
Methods: Ten men with a diagnosis of HD took part in the CBT group program. Measurements were taken
before, during, and at the end of treatment and 3 and 6 months after treatment.
Outcomes: The primary outcome was the Hypersexual Disorder: Current Assessment Scale (HD:CAS) score
that measured the severity of problematic hypersexual symptoms and secondary outcomes were the Hypersexual
Disorder Screening Inventory (HDSI) score, the proportion of attended sessions, and the Client Satisfaction
Questionnaire (CSQ-8) score.
Results: Main results were significant decreases of HD symptoms from before to after treatment on HD:CAS
and HDSI scores and a decrease in the number of problematic sexual behaviors during the course of therapy. A
high attendance rate of 93% and a high treatment satisfaction score on CSQ-8 also were found.
Clinical Implications: The CBT program seemed to ameliorate the symptoms of HD and therefore might be a
feasible treatment option.
Strengths and Limitations: This study provides data from a CBT program for the treatment of the specific
proposed criteria of HD. Because of the small sample and lack of a control group, the results can be considered
only preliminary.
Conclusion: Although participants reported decreased HD symptoms after attending the CBT program, future
studies should evaluate the treatment program with a larger sample and a randomized controlled procedure to
ensure treatment effectiveness. Hallberg J, Kaldo V, Arver S, et al. A Cognitive-Behavioral Therapy Group
Intervention for Hypersexual Disorder: A Feasibility Study. J Sex Med 2017;14:950e958.
Copyright 2017, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.
Key Words: Hypersexual Disorder; Sexual Addiction; Cognitive-Behavioral Therapy; Hypersexual Disorder
Screening Inventory; Hypersexual Disorder: Current Assessment Scale; Client Satisfaction Questionnaire;
Treatment Satisfaction
INTRODUCTION
Hypersexual disorder (HD) is defined as a non-paraphilic
sexual desire disorder, including excessive sexual behaviors, in
relation to various depression, anxiety, and stress-oriented mood
states, combined with a sexual impulsivity component and loss of
control. The proposed diagnostic criteria (Table 1)
1
have
demonstrated high reliability and validity in multicenter field
Received February 6, 2017. Accepted May 1, 2017.
1
Department of Medicine, Karolinska Institute, Stockholm, Sweden;
2
ANOVA, Karolinska University Hospital, Stockholm, Sweden;
3
Center for Psychiatry Research, Department of Clinical Neuroscience,
Karolinska Institute, Stockholm, Sweden
Copyright ª2017, International Society for Sexual Medicine. Published by
Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jsxm.2017.05.004
950 J Sex Med 2017;14:950e958

trials.
2,3
HD is associated with an increased risk of sexually
transmitted infections, unwanted pregnancy, and psychiatric
comorbidity. It also has been found to be a predictor of sexual
crime recidivism.
4
Presented with subjective distress and
impairment in everyday life,
1,5,6
hypersexuality is seen in an
increasing number of help-seeking patients.
To our knowledge, no studies on treatment approaches for the
specific criteria of HD
1
have been performed. However, in line
with a review by Hook et al,
7
we found 14 studies on psycho-
logical treatment for conditions resembling HD, such as sexual
dysregulation, sexual addiction, and compulsive sexual behavior.
Of these, only one study was performed as a randomized
controlled trial.
8
When treated with acceptance and commitment
therapy (ACT), a 93% decrease in compulsive pornography use
was found in the ACT group compared with a 21% decrease in
the control group. In another study, the frequency of pornog-
raphy engagement decreased by 85% in six men after ACT
treatment.
9
Klontz et al
10
conducted a trial of a brief multimodal
experiential therapy for sexual addiction. On average, the 38
participants reported significant decreases in anxiety, intrapsychic
conflict regarding sexual desire, and shame as a result of acting
out on sexual desires after 6 months. In general, cognitive-
behavioral therapy (CBT) interventions have been proved
effective for the proposed core HD criteria
1
(eg, behavioral
activation for depression,
11
exposure and problem-solving stra-
tegies for anxiety,
12
and mindfulness practice for impulse control
disorders and stress
13,14
).
Further, Naficy et al
15
reported attenuated hypersexual
problems as a result of pharmacologic treatment but concluded
that the results should be interpreted with caution because of the
use of un-validated measuring instruments.
The aim of this study was to evaluate the feasibility of a CBT
program for HD. Feasibility in the present study was defined by
the participants’decreased HD symptoms, their attendance rate,
and their satisfaction with treatment.
METHODS
Setting
The study took place at the ANOVA at Karolinska University
Hospital (Karolinska, Sweden), a multidisciplinary clinic for
research, assessment, and treatment in andrology, sexual medi-
cine, and trans-medicine.
Procedure
Participants were recruited through advertisements in a daily
national newspaper. The target sample was composed of women
and men with self-identified problematic “hypersexual behavior”
and “out-of-control sexual behaviors”who were interested in
participating in a group CBT intervention at the ANOVA.
Potential participants for the treatment program submitted
their applications on a secure internet platform and provided
their informed consent and contact information (Figure 1). A
screening battery containing the introductory part of the study
was administered on the platform. The introductory internet
survey included 14 structured questionnaires on sociodemo-
graphics, paraphilic interests, and psychiatric well-being and
included the Hypersexual Disorder Screening Inventory (HDSI).
Of 71 participants contacted, 43 were assessed in a clinical
interview at the ANOVA and a final group of 15 participants
were included in the treatment program. HD was preliminarily
assessed with the HDSI and then verified through the clinical
assessment conducted by a psychiatrist and a psychologist and
licensed sexologist. Inclusion criteria for the treatment program
were (i) age older than 18 years, (ii) fulfillment of the proposed
criteria for HD according to Kafka
1
and the American Psychi-
atric Association
16
and the clinical assessment, and (iii) willing-
ness to take part in the group treatment. Exclusion criteria were
(i) paraphilias of pedophilia, voyeurism, exhibitionism, and
frotteurism; (ii) severe depression, anxiety, or other contra-
indicating psychiatric conditions as assessed by a psychiatrist
Table 1. Diagnostic criteria for hypersexual disorder proposed for inclusion in the Diagnostic and Statistical Manual of Mental Disorders,
Fifth Edition
A Over a period of 6 mo, recurrent and intense sexual fantasies, sexual urges, or sexual behaviors in association
with 4 of the following 5 criteria:
A1 Time consumed by sexual fantasies, urges, or behaviors repetitively interferes with other important (non-sexual) goals,
activities, and obligations
A2 Repetitively engaging in sexual fantasies, urges, or behaviors in response to dysphoric mood states (eg, anxiety,
depression, boredom, irritability)
A3 Repetitively engaging in sexual fantasies, urges, or behaviors in response to stressful life events
A4 Repetitive but unsuccessful efforts to control or significantly decrease these sexual fantasies, urges, or behaviors
A5 Repetitively engaging in sexual behaviors while disregarding the risk for physical or emotional harm to self or others
B1 There is clinically significant personal distress or impairment in social, occupational, or other important areas of
functioning associated with the frequency and intensity of these sexual fantasies, urges, or behaviors
B2 These sexual fantasies, urges, or behaviors are not due to the direct physiologic effect of an exogenous substance
(eg, a drug of abuse or a medication)
Specify Masturbation, pornography, sexual behavior with consenting adults, cybersex, telephone sex, venues for sexual
entertainment, other
J Sex Med 2017;14:950e958
CBT for Hypersexual Disorder 951

with the Mini-International Neuropsychiatric Interview
17
; (iii)
ongoing psychotherapy; and (iv) contraindicating factors (eg,
poor personal hygiene, therapy-obstructing behavior). Excluded
participants were offered treatment at the ANOVA or, if more
appropriate, referred to suitable health care services.
Primary Outcome Measurement
The Hypersexual Disorder: Current Assessment Scale
(HD:CAS)
18
measures the severity of the problematic hyper-
sexual symptoms during the preceding 2 weeks according to the
proposed criteria for HD (Table 1; the website cited for
the American Psychiatric Association is no longer active).
1,16
The
scale consists of seven items: A1 is a multi-option item for six
different sexual behavior specifiers (Table 1); A2 is the number of
times the respondent has had orgasm from any of the specified
sexual behaviors; A3 is the amount of time spent on problematic
sexual fantasies, urges, or behaviors; A4 concerns whether the
respondent used sexual behaviors or fantasies to cope with
dysphoric feelings (anxiety, depression, boredom, frustration,
guilt, or shame); A5 concerns whether the respondent used
sexual fantasies and behaviors to postpone or handle stressful life
events or other problems or obligations in his or her life; A6
concerns the experienced level of control over the respondent’s
sexual fantasies, urges, or behaviors; and A7 concerns whether
the respondent participated in behaviors that were risky, harmful,
or even dangerous to the respondent, the respondent’s partner, or
other persons. A five-point scale (0e4) is applied and total sum
Figure 1. Participant flow and reasons for dropping out throughout the pilot study. m ¼men; w ¼women.
J Sex Med 2017;14:950e958
952 Hallberg et al

scores range from 0 to 24 points. Measurements were adminis-
tered at the beginning of the first, fourth, and last sessions of the
CBT program and at 3- and 6-month follow-ups.
Secondary Outcomes
The HDSI was developed by the American Psychiatric Asso-
ciation
1,19
for clinical screening of HD and follows the proposed
diagnostic criteria for HD as described by the Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (Table 1).
For confirmation of the HD diagnosis, the HDSI measures the
experienced hypersexual symptoms (five A criteria and distress
and impairment in two B criteria) during the past 6 months. A
five-point scale (0e4), ranging from “never true”to “almost al-
ways true,”is applied. Six different “sexual specifiers”are
examined on a yes-or-no scale and a seventh option is to check
“other.”In the present study, the total HDSI score was used to
examine changes in the participants’experienced problems by
applying a polythetic and a quantitative cutoff. First, a score of
three or four points on a minimum of four of five A criteria items
and three or four points of one of the two B criteria items is
applied as suggested by Kafka.
19
Second, Parsons et al
20
pro-
posed a quantitative cutoff at a sum score of 20 points for a
possible HD diagnosis. The HDSI fits a single-factor solution
and shows strong reliability across the continuum of hypersex-
uality. However, two items, A2 and A3, can measure sex as a
form of coping.
20
Measurements were administered at the
beginning of the first and last sessions of the program and at 3-
and 6-month follow-ups.
Treatment Satisfaction
A post-treatment measurement was performed at the last
session of the CBT program with the Client Satisfaction Ques-
tionnaire (CSQ-8),
21
an eight-item questionnaire on various
aspects of satisfaction. Items are scored with one to four points
(range ¼1e32).
22
The questionnaire has shown high internal
consistency (Cronbach arange ¼0.83e0.93, aweighted
mean ¼0.88); scores correlate with changes in self-reported
symptoms.
23
In the present study, the scoring procedure pro-
posed by Smith et al
23
was used: “poor”(score ¼8e13), “fair”
(score ¼14e19), “good”(score ¼20e25), and “excellent”
(score ¼26e32).
Attendance
Attendance rate was measured by the number of sessions
attended by each participant and the proportion of total sessions
attended.
Treatment Procedure and Components
During the course of the study, two treatment groups were
formed. The first (n ¼6) took part in the treatment from August
26 through October 28 2010 over seven sessions of 2 hours 30
minutes per session. In the second group, four individuals were
treated over 10 sessions from December 6, 2010 through March
7, 2011. The two treatment groups were offered 3- and 6-month
follow-up sessions. The two different treatment lengths aimed to
evaluate any major impact of the number of sessions and total
hours in treatment. Two licensed CBT psychologists (one of
whom is a licensed sexologist) conducted the treatment program
together and used similar treatment material in the two groups.
To ensure integrity, the material was supplied in written form
and consisted of detailed self-help oriented texts with appending
exercises and homework assignments. It was presented during the
group sessions by the CBT psychologists and discussed and
elaborated in relation to the participants’specific situations and
problems. The treatment program consisted of seven modules
targeting the different criteria of HD. Modules 1 to 3 presented
HD from cognitive, behavioral, and functional perspectives.
Information was given on the condition of HD in general and
how various factors can contribute to the maintenance of the
problematic sexual behavior by means of basic behavioral prin-
ciples (eg, classic and operant conditioning). Assignments were
provided on behavior and functional analysis and management of
urges and impulses by urge-surfing and impulse-control skills
and mindfulness practice. Behavioral activation, exposure, and
development of problem-solving skills were assigned for
dysphoric mood states, depression, anxiety, and boredom.
Stimulation on motivation to work toward behavioral change
and to abstain from hypersexual behavior was performed.
Modules 4 to 6 consisted of stress and time management tech-
niques, cognitive restructuring and diffusion techniques
addressing negative thoughts and beliefs, and identification of
values as a way to identify future goal-directed behaviors,
behavioral experiments, and activation. The treatment program
further assigned participants to a weekly registration of the
amount of time spent on problematic sexual (inner and overt)
behavior (ie, actions, thoughts, impulses, planning). The last
module consisted of relapse prevention, development of an in-
dividual maintenance program, and a summary of the treatment.
Statistics
The data did not meet the requirements for normal distri-
bution according to the Kolmogorov-Smirnov test, so the Wil-
coxon signed rank test was used to determine whether there were
any differences regarding the experienced HD symptoms among
measurement points. Effect sizes of differences in the instruments
HD:CAS and HDSI also were calculated. Spearman correlation
analysis was conducted between treatment gains and the pro-
portion of attended sessions. HD:CAS items A4, A5, and A6 at
the end-treatment measurement of three respondents were lost
and therefore imputed using the last-observation-carried-forward
procedure.
24
All Pvalues less than .05 were considered statisti-
cally significant. Statistical analyses were carried out using SPSS
15.0, 19.0, and 20 (SPSS, Inc, Chicago, IL, USA).
Ethics
The study was approved by the regional ethical review board
in Stockholm, Sweden (registration ID 2010/5:3).
J Sex Med 2017;14:950e958
CBT for Hypersexual Disorder 953

RESULTS
Participants
Ten men participated in the CBT program. Their mean age
was 38.9 years (range ¼27e51, SD ¼8.1). Two were single,
one had a non-cohabiting relationship, and seven were married
or cohabiting. Nine were employed or self-employed and one
was a student. Seven had at least university experience and three
of those also had a university degree. The other three had
completed upper secondary school.
Primary Outcome (HD:CAS Score)
The pre- and post-treatment median response and inter-
quartile range (IQR) for each item of the HD:CAS are presented
in Table 2. Hypersexual symptoms showed a median pre-
treatment score of 12 (IQR ¼4; Figure 2), which decreased
significantly at mid-treatment (median ¼7.5, IQR ¼5,
z¼2.71, P<.01), after treatment (median ¼7.5, IQR ¼7,
z¼2.35, P<.05), at 3-month follow-up (median ¼8,
IQR ¼7, z ¼2.68, P<.01), and at 6-month follow-up
(median ¼10.5, IQR ¼5, z ¼2.21, P<.05) compared
with pre-treatment scores. The effect sizes were large (r ¼
0.53e0.61). There was no significant difference between the 7-
and 10-session groups on HD:CAS score after treatment.
Secondary Outcomes
HD:CAS Specifiers
The number of hypersexual specifiers according to the
HD:CAS score decreased during the course of therapy. The
mean number of specifiers before treatment was 1.9, which
decreased to 1.3 at mid-treatment and post-treatment. At the 3-
and 6-month follow-ups, the mean numbers of specifiers were
0.9 (three participants reported no specifier at all) and 1.3,
respectively. However, these changes did not significantly differ
from the pre-treatment measurement according to the Wilcoxon
signed rank test (Table 3).
Table 2. HDSI and HD:CAS item responses before and after treatment (N ¼10)
HDSI item HDSI, median (IQR) HD:CAS item HD:CAS, median (IQR)
A1. Time A2. Number of orgasms
Before treatment 3.00 (1) Before treatment 2.00 (1)
After treatment 2.00 (1) After treatment 1.00 (1)
A2. Dysphoric feelings A3. Time
Before treatment 3.00 (1) Before treatment 2.00 (1)
After treatment 3.00 (1) After treatment 1.50 (1)
A3. Stress A4. Dysphoric feelings
Before treatment 3.00 (1) Before treatment 2.00 (1)
After treatment 2.00 (1) After treatment 1.50 (2)
A4. Control A5. Avoid/Postpone
Before treatment 3.00 (1) Before treatment 2.50 (1)
After treatment 1.00 (1) After treatment 1.50 (2)
A5. Risk-taking A6. Control
Before treatment 2.50 (2) Before treatment 2.00 (1)
After treatment 0.50 (2) After treatment 2.00 (1)
B1. Distress A7. Risk-taking
Before treatment 3.00 (2) Before treatment 0.00 (1)
After treatment 2.00 (1) After treatment 0.00 (0)
B2. Impairment
Before treatment 2.00 (2)
After treatment 1.00 (1)
HD:CAS ¼Hypersexual Disorder: Current Assessment Scale; HDSI ¼Hypersexual Disorder Screening Inventory; IQR ¼interquartile range.
Figure 2. HD:CAS median sum scores before, during, and after
treatment and at 3- and 6-month follow-ups. FU ¼follow-up;
HD:CAS ¼Hypersexual Disorder: Current Assessment Scale.
J Sex Med 2017;14:950e958
954 Hallberg et al

HDSI Score
The HDSI analysis showed a statistically significant decrease
in HD symptoms. Calculations (Figure 3) were based on HDSI
pre-treatment score (median ¼20, IQR ¼7) vs post-treatment
score (n ¼10; median ¼12.5, IQR ¼8, z ¼2.60, P<.01),
the 3-month follow-up score (n ¼5; median ¼13.0, IQR ¼4,
z¼2.03, P<.05), and the 6-month follow-up score (n ¼3;
median ¼8.0, IQR ¼not applicable, z ¼1.60, P¼not
significant). The effect sizes were large at the post-treatment
measurement (r ¼0.58) and at the 3-month follow-up (r ¼
0.52). At the pre-treatment measurement, eight participants
fulfilled the diagnostic criteria proposed by Kafka
1
and one ful-
filled the diagnostic criteria at the post-treatment measurement.
During the pre-treatment measurement, five participants reached
the cutoff score in concordance with the findings of Parsons
et al,
20
whereas none did at the end of treatment. At the 3-month
follow-up, none of the participants fulfilled the criteria for either
proposed diagnostic cutoff. The pre- and post-treatment median
response and IQR for each item of HDSI are presented in
Table 2. No significant difference was found between the 7- and
10-session groups on HDSI score after treatment.
Treatment Satisfaction (CSQ-8 Score)
The median sum scores of the CSQ-8 were high (median ¼
27.5, range ¼24e29). Seven of 10 scored within the “excellent”
span and three scored within the “good”span. No significant
differences regarding treatment satisfaction between the 7- and
10-session groups emerged.
Attendance
Four participants were absent from one session and one
participant was absent from two sessions. The mean attendance
in the 7-week group was 6.5 sessions (93%) and that in the
10-week group was 9.3 sessions (93% of total number of
sessions). The mean of the proportion of attended sessions did
not significantly differ between the 7- and 10-week groups.
Attendance was not significantly associated with treatment
outcome (Spearmen rank correlation analysis).
DISCUSSION
The main findings were that the CBT program for HD
demonstrated good feasibility with significant decreases of HD
symptoms from before to after treatment and a decrease in the
number of problematic sexual behaviors. These improvements
were maintained at the 3- and 6-month follow-ups. The results
are in line with those of psychosocial treatment studies reviewed
by Hook et al.
7
The CBT interventions in this particular program were
applied because of the previously demonstrated effect on the
proposed criteria of HD. As pointed out by Forsyth et al,
25
“functional behavior analysis is a potent intervention in itself”
and “behavioral activation”targets inactivity regarding valued
behaviors.
11
The latter also was in consensus with the value
identification process of ACT as presented by Hayes et al
26
and
as a central treatment component for compulsive or problematic
pornography use as described by Crosby
8
and Crosby and
Twohig.
27
Problem-solving strategies have been found useful to
handle stress and social interaction problems,
28
and exposure
effectively contributes to the treatment of anxiety disorders.
29
Experiencing sexual urges in an acceptance-based manner but
without engagement in the problematic behavior (eg, urge
surfing) combined with self-monitoring techniques could have
Table 3. Participants’hypersexual behavior specifiers during the course of therapy and at 3- and 6-month follow-ups according to the
Hypersexual Disorder: Current Assessment Scale (N ¼10)
Measurements
Participants
123 456 78910
Before treatment M, P M, P Cy M, P M, P M, P, C M, P M, P P M, P
During treatment M, P M, P M, Cy M, P M, P none none P P O
End of treatment M, P M, P Cy none M, P M, P none M, P M, P none
3-mo follow-up none none C M M, P —M, P P P none
6-mo follow-up ——none M M, P —M, P P —M, P
C¼sexual behaviors with consenting adults; Cy ¼cybersex behaviors; M ¼masturbation; O ¼other (sexual fantasies); P ¼pornography.
Figure 3. HDSI median sum scores before, during, and after
treatment and at 3- and 6-month follow-ups. FU ¼follow-up;
HDSI ¼Hypersexual Disorder Screening Inventory.
J Sex Med 2017;14:950e958
CBT for Hypersexual Disorder 955

contributed to participants’ability to abstain from problematic
sexual behaviors, which in turn could have increased their sense
of self-efficacy in accordance with the model described by
Bandura.
30
A strength of this study is that the treatment material was
administered to the participants in written form, which decreases
the risk of divergence from the intended treatment program as
reported by Andersson et al.
31
Furthermore, the material was
presented orally, which could have enhanced the participants’
understanding of the treatment components. Attendance at
treatment sessions is regarded as crucial, and Reardon et al
32
found a dose-response relation in a study of treatment of 74
outpatients with psychiatric conditions. In the present study, the
attendance was high, as was the effect size of the ameliorated
symptoms of HD at the post-treatment measurement and 3-
month follow-up. This is in line with other CBT efficacy
studies that have implied that the number of attended sessions
within a treatment protocol is correlated with a more propitious
treatment outcome.
33
Interestingly, attendance, treatment satis-
faction, and post-treatment outcome measurements were not
affected by the different numbers of sessions of the present
treatment program. Although the small sample has to be taken
into account when interpreting these results, the shorter seven-
session program is tentatively preferable in future trials.
By addressing relevant problem areas in the participants’lives,
a good problem-intervention match might have been obtained.
This could have led to the high treatment satisfaction (according
to CSQ-8 scores). Other explanations for the high treatment
satisfaction could be the relatively short treatment time and
presenting the treatment material in a comprehensible way.
In this study, the HDSI and HD:CAS were used exclusively
as measurements of hypersexual behavior; this restricts infor-
mation on respondents’degree of problematic sexual behavior.
AlthoughtheHDSIwasfoundtobeahighlyreliablescreening
tool for hypersexuality in highly sexually active men,
20
further
psychometric studies are necessary for test-retest reliability. The
implications of the HDSI as a possible screening tool for the
diagnosis of HD must be recognized. The HDSI sum score
decrease found in the present study, supported by the median
item decrease (Table 2), indicates the presence of participants
whonolongerfulfilled the diagnostic criteria or were in
remission at the end of treatment and follow-up. Diagnostic
remission is supported by the decrease in sexual specifiers found
in the present study and is in line with our findings from the
internet survey (cf Methods) that a significantly (P¼.018)
larger number of specifiers was found in a HD group (according
to HDSI score) compared with a non-HD group (unpublished
manuscript).
Some important methodologic considerations and limitations
of the study should be recognized. The absence of a control
group affects any inference of improvement owing solely to the
treatment program used. The participants were highly educated
and socially well-established compared with the general Swedish
population as previously mapped out
34
(ie, a selection bias
possibly influenced treatment comprehension and outcome
positively as described by Sole et al
35
).Thebiasinthissample
could be due to the initial recruitment procedure using a widely
circulated daily newspaper targeting a higher socioeconomic
subpopulation and emphasized by participants’proneness to
submit responses to the rather vast internet-administered
screening battery. Half (three of six) the dropouts were
women, leaving only men in the study. Turner
36
argued that
sexually compulsive women exhibit difficulties with bonding
with others, disclosure of intimate information, and handling
criticism, which could account for the included women drop-
ping out of group treatment. Thus, it remains unknown
whether these treatment interventions might be applicable to
women.
The lack of post-treatment face-to-face clinical assessment of
fulfillment of the HD diagnosis is an evident shortcoming.
Further, the timeframe of pre-treatment, post-treatment, and
follow-up measurements with the HDSI limits the interpretation
of the results for long-term effects, as does the high dropout rate
at 3- and 6-month follow-ups.
The last-observation-carried-forward procedure of the
missing HD:CAS item scores has to be considered. It is
reasonable to assume that the imputed scores would follow a
similar decreasing trend as the obtained item scores. This is
tentatively supported by the decrease in the number of sexual
specifiers we found and is emphasized by the suggestion that
“more sexual behaviors increase hypersexuality.”
5
In this study,
the number of sexual specifiers decreased from the start of
treatment to the conclusion of treatment and decreased further
at the 3-month follow-up.
CONCLUSION
Although the evaluated CBT program for HD was feasible,
further evaluations are needed in larger trials with a randomized
controlled design to explore the long-term effects and its efficacy
for women.
ACKNOWLEDGMENTS
We acknowledge the staff of the ANOVA for participating in
the logistics of the study and Tania Samuelsson for the linguistic
revision.
Corresponding Author: Katarina Görts Öberg, PhD, Depart-
ment of Medicine, Karolinska Institutet, Hälsovägen C2:94,
Stockholm 141 86, Sweden; E-mail: katarina.gorts-oberg@kar-
olinska.se
Conflicts of Interest: The authors report no conflicts of interest.
Funding: Swedish Prison and Probation Service (grant 2010-159,
Dnr 52-2010-013228).
J Sex Med 2017;14:950e958
956 Hallberg et al

STATEMENT OF AUTHORSHIP
Category 1
(a) Conception and Design
Jonas Hallberg; Viktor Kaldo; Stefan Arver; Cecilia Dhejne;
Katarina Görts Öberg
(b) Acquisition of Data
Jonas Hallberg; Katarina Görts Öberg
(c) Analysis and Interpretation of Data
Jonas Hallberg; Viktor Kaldo; Stefan Arver; Cecilia Dhejne;
Katarina Görts Öberg
Category 2
(a) Drafting the Article
Jonas Hallberg; Katarina Görts Öberg
(b) Revising It for Intellectual Content
Jonas Hallberg; Viktor Kaldo; Stefan Arver; Cecilia Dhejne;
Katarina Görts Öberg
Category 3
(a) Final Approval of the Completed Article
Jonas Hallberg; Viktor Kaldo; Stefan Arver; Cecilia Dhejne;
Katarina Görts Öberg
REFERENCES
1. Kafka MP. Hypersexual disorder: a proposed diagnosis for
DSM-V. Arch Sex Behav 2010;39:377-400.
2. Reid RC, Carpenter BN, Hook JN, et al. Report of findings in a
DSM-5 field trial for hypersexual disorder. J Sex Med 2012;
9:2868-2877.
3. Scanavino Mde T, Ventuneac A, Rendina HJ, et al. Sexual
compulsivity scale, compulsive sexual behavior inventory, and
hypersexual disorder screening inventory: translation, adap-
tation, and validation for use in Brazil. Arch Sex Behav 2016;
45:207-217.
4. Kingston DA, Bradford JM. Hypersexuality and recidivism
among sexual offenders. Sex Addict Compulsivity 2013;
20:91-105.
5. Kafka MP, Hennen J. The paraphilia-related disorders: an
empirical investigation of nonparaphilic hypersexuality disor-
ders in outpatient males. J Sex Marital Ther 1999;25:305-
319.
6. McBride KR, Reece M, Sanders SA. Using the Sexual
Compulsivity Scale to predict outcomes of sexual behavior in
young adults. Sex Addict Compulsivity 2008;15:97-115.
7. Hook JN, Reid RC, Penberthy JK, et al. Methodological review
of treatments for nonparaphilic hypersexual behavior. JSex
Marital Ther 2014;40:294-308.
8. Crosby JM. Acceptance and commitment therapy for the
treatment of compulsive pornography use: a randomized
clinical trial. Graduate thesis 999. Logan, Utah: Utah State
University; 2011.
9. Twohig MP, Crosby JM. Acceptance and commitment therapy
as a treatment for problematic Internet pornography viewing.
Behav Ther 2010;41:285-295.
10. Klontz BT, Garos S, Klontz PT. The effectiveness of brief
multimodal experiential therapy in the treatment of sexual
addiction. Sex Addict Compulsivity 2005;12:275-294.
11. Martell CR, Addis ME, Jacobsen NS. Depression in context:
strategies for guided action. New York: WW Norton & Co;
2001.
12. Dugas MJ, Robichaud M. Cognitive-behavioral treatment for
generalized anxiety disorder: from science to practice. New
York: Routledge/Taylor & Francis Group; 2009.
13. Reid RC, Temko J, Moghaddam JF, et al. Shame, rumination,
and self-compassion in men assessed for hypersexual disor-
der. J Psychiatr Pract 2014;20:260-268.
14. Reid RC, Bramen JE, Anderson A, et al. Mindfulness,
emotional dysregulation, impulsivity, and stress proneness
among hypersexual patients. J Clin Psychol 2014;70:313-321.
15. Naficy H, Samenow CP, Fong TW. A review of pharmacological
treatments for hypersexual disorder. Sex Addict Compulsivity
2013;20:139-153.
16. American Psychiatric Association. Hypersexual disorder.
American Psychiatric Association’s DSM-5 Workgroup on
Sexual and Gender Identity Disorders. Available at: http://
www.dsm5.org/ProposedRevisions/Pages/proposedrevision.
aspx?rid¼415. Published 2010. Accessed March 2010,
September 2011.
17. Sheehan DV, Lecrubier Y, Sheehan KH, et al. The Mini-
International Neuropsychiatric Interview (M.I.N.I.): the devel-
opment and validation of a structured diagnostic psychiatric
interview for DSM-IV and ICD-10. J Clin Psychiatry 1998;
59:22-33.
18. American Psychiatric Association. Hypersexual disorder: cur-
rent assessment scale. American Psychiatric Association’s
DSM-5 Workgroup on Sexual and Gender Identity Disorders.
Available at: http://www.dsm5.org/ProposedRevisions/Pages/
proposedrevision.aspx?rid¼415. Published 2010. Accessed
March 2010, September 2011.
19. American Psychiatric Association. Hypersexual Disorder
Screening Inventory. American Psychiatric Association’s
DSM-5 Workgroup on Sexual and Gender Identity Disorders.
Available at: http://www.dsm5.org/ProposedRevisions/Pages/
proposedrevision.aspx?rid¼415. Published 2010. Accessed
March 2010, September 2011.
20. Parsons JT, Rendina JH, Ventuanec A, et al. A psychometric
investigation of the Hypersexual Disorder Screening Inventory
among highly sexually active gay and bisexual men: an item
response theory analysis. J Sex Med 2013;10:3088-3101.
21. Attkisson CC, Zwick R. The client satisfaction questionnaire:
psychometric properties and correlations with service utiliza-
tion and psychotherapy outcome. Eval Program Plann 1982;
5:233-237.
22. Attkisson CC, Greenfield TK. Client Satisfaction Questionnaire-
8 and Service Satisfaction Scale-30. The use of psychological
testing for treatment, planning and outcome assessments.
Mahwah, NJ: Lawrence Erlbaum Associates; 1994.
23. Smith D, Roche E, O’Loughlin K, et al. Satisfaction with service
following voluntary and involuntary admission. J Ment Health
2014;23:38-45.
J Sex Med 2017;14:950e958
CBT for Hypersexual Disorder 957

24. Molnar FJ, Hutton B, Fergusson D. Does analysis using “last
observation carried forward”introduce bias in dementia
research? CMAJ 2008;179:751-753.
25. Forsyth JP, Eifert GH. “Cleaning-up cognition”in triple-
response fear assessment through individualized functional
behavior analysis. J Behav Ther Exp Psychiatry 1996;27:
87-98.
26. Hayes SC, Strosahl KD, Wilson KG. Acceptance and commit-
ment therapy: the process and practice of mindful change. 2nd
ed. New York: Guilford Press; 2011.
27. Crosby JM, Twohig MP. Acceptance and commitment therapy
for problematic Internet pornography use: a randomized trial.
Behav Ther 2016;47:355-366.
28. D’Zurilla TJ, Nezu AM. Problem-solving therapy: a social
competence approach to clinical intervention. New York:
Springer; 1999.
29. Deacon BJ, Abramowitz JS. Cognitive and behavioral treat-
ments for anxiety disorders: a review of meta-analytic find-
ings. J Clin Psychol 2004;60:429-441.
30. Bandura A. On the functional properties of perceived self-
efficacy revisited. J Manage 2012;38:9-36.
31. Andersson G, Bergström J, Buhrman M, et al. Development of
a new approach to guided self-help via the internet: the
Swedish experience. J Technol Hum Serv 2008;26:161-181.
32. Reardon ML, Cukrowicz KC, Reeves MD, et al. Duration and
regularity of therapy attendance as predictors of treatment
outcome in an adult outpatient population. Psychother Res
2002;12:273-285.
33. Chavira DA, Golinelli D, Sherbourne C, et al. Treatment
engagement and response to CBTamong Latinos with anxiety
disorders in primary care. J Consult Clin Psychol 2014;
82:392-403.
34. Lewin B. Sex in Sweden. Stockholm: National Institute of
Public Health; 2000 [English translation].
35. Sole JAR, Guarch J, Jorquera A, et al. Predictive variables of
the therapeutic outcome in the cognitive-behavioral treatment
of the social phobia. Rev Psiquiatr Fac Med Barc 2004;
31:185-193.
36. Turner M. Female sexual compulsivity: a new syndrome.
Psychiatr Clin North Am 2008;31:713-727.
J Sex Med 2017;14:950e958
958 Hallberg et al