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Hypersexual Disorder: A proposed diagnosis for DSM-V

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Abstract

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.
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... There has been ongoing debate about nosology and diagnostic criteria of compulsive sexual behavior (CSB) for many years (Coleman et al., 2018;Grubbs et al., 2020;Kafka, 2010). Most recently, Hypersexual Disorder (HD) was proposed for the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) of the American Psychiatric Association (APA) (2013). ...
... When HD was proposed, hypersexual disorder was conceptualized as a nonparaphilic sexual desire disorder that attempted to integrate various pathophysiological perspectives, including dysregulation of sexual arousal and desire, sexual impulsivity, sexual addiction, and sexual compulsivity. This included recognizing that HD was also conceptualized as a response to dysphoric mood states (i.e., anxiety, depression, boredom, irritability) and/or stressful life events (Kafka, 2010). The proposed diagnosis therefore acknowledged the inability of individuals with HD to appropriately regulate their affective state in response to negative internal or external stimuli. ...
... Individuals with CSB also experience negative emotions to a greater extent than individuals without CSB symptoms (Janssen et al., 2020;Miner, Dickenson, & Coleman, 2019;Miner et al., 2016). From an etiological standpoint, CSB may develop as a coping mechanism to manage these negative affective states (Coleman et al., 2018;Kafka, 2010;Reid, Carpenter, Spackman, & Willes, 2008;Reid & Kafka, 2014). For example, a daily diary study found that men with CSB were more likely to regulate affective arousal through sexual behavior than controls (Miner et al., 2019). ...
Article
Affect regulation is associated with compulsive sexual behavior (CSB) despite ongoing debate about its inclusion in diagnostic criteria. Previous studies on two specific affect regulation constructs - boredom proneness and attachment styles - suggest that affect regulation is associated with CSB. We tested a moderation model of the effects of attachment anxiety and attachment avoidance on the relationship between boredom proneness and CSB. Results indicate that the relationship between boredom proneness and CSB is stronger at higher levels of attachment anxiety, with no interaction between boredom proneness and attachment avoidance. Overall findings support the importance of affect regulation in conceptualizing and treating CSB.
... A psychiatrist will obtain a medical and psychiatric history, perform a physical examination including blood pressure and heart and pulmonary auscultation, as well as perform interviews with the Mini International Neuropsychiatric Interview (MINI) 18 and Columbia Suicide Severity Rating Scale (C-SSRS). 19 The study psychologist will focus on sexual behaviours by conducting a structured interview addressing the ICD-11 criteria for CSBD and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for hypersexual disorder as originally proposed for inclusion 20 and paraphilia(s). The separate psychiatrist and psychologist interviews aim Open access to determine eligibility criteria in an unbiased manner. ...
... The main outcome is symptom relief as assessed with HD: CAS, which measures symptom severity during the previous 2 weeks according to the suggested conceptualisation of Hypersexual Disorder to the DSM-5. 20 Corresponding scales for the ICD-11 diagnosis have not yet been developed. We chose a scale that is sensitive to changes and participants will be asked to fill it in at baseline, every second week during the treatment phase and at end of study. ...
Article
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Background Compulsive sexual behaviour disorder is a new disorder in the International Classification of Diseases (ICD-11), and is associated with negative consequences in different areas of life. Evidence for pharmacological treatment of compulsive sexual behaviour disorder is weak and treatment options are limited. This proposed study will be the largest and the first randomised controlled trial comparing the efficacy and tolerability of two active drugs in compulsive sexual behaviour disorder. Methods and analysis Eighty adult participants with compulsive sexual behaviour disorder according to ICD-11 will be randomised to receive either naltrexone 25–50 mg or fluoxetine 20–40 mg for 8 weeks, followed by 6 weeks without treatment. The study will be conducted in a subspecialised outpatient sexual medicine unit at Karolinska University Hospital, Stockholm, Sweden. The study is financed by grants and entirely independent of the manufacturers. Exclusion criteria include severe psychiatric or psychical illness, changes to concurrent medication and non-compatible factors contraindicating the use of either drug. The primary outcome measure is the Hypersexual Disorder: Current Assessment Scale (HD: CAS), and tolerability will be assessed by the Udvalg for Kliniske Undersogelser side effect rating scale (UKU), drug accountability, adherence to treatment and drop-out rate. Participants will complete questionnaires at regular intervals, with the main endpoint for efficacy after 8 weeks (end of treatment) and after 14 weeks (follow-up). Blood chemistry will be repeatedly collected as a safety precaution and for research purposes. The results will be analysed using an appropriate analysis of variance model or a mixed model, depending on the distribution of HD: CAS and the extent of missing data. Ethics and dissemination The Swedish Ethical Review Authority and the Swedish Medical Products Agency have approved the study on 27 May 2020 and 4 June 2020, respectively (ref. no. 2020-02069 and ref. no. 5.1-2020-48282). Findings will be published in peer-reviewed journals and presented at relevant conferences. Trial registration number 2019-004255-36
... Esta enfermedad se ha clasificado como una alteración de control de impulsos (Brewer y Potenza, 2008;Miner y Coleman, 2013), que además se presenta de forma simultánea con otros trastornos, como el trabajo compulsivo (28%), los trastornos alimenta-rios (38%) y la dependencia de sustancias químicas (42%) (Schneider, 2004). En el actual DSM-V (Diagnostic Statistical Manual of Mental Diseases, Fifth Edition, 2013) no se incluye esta enfermedad, sin embargo, durante los trabajos de desarrollo del manual se consideró incorporar en la sección de trastornos sexuales el de hipersexualidad, conceptualizado como un trastorno del deseo sexual no parafílico con un componente de impulsividad (Kafka, 2010). Se propusieron como criterios diagnósticos que al menos durante seis meses se presentaran fantasías sexuales recurrentes e intensas y un deseo sexual apremiante, así como conductas sexuales asociadas a una cantidad de tiempo excesiva invertida en fantasías y deseos sexuales; también, la planificación y realización de conductas sexuales; fantasías, deseos y conductas sexuales repetidas en respuesta a estados de ánimo disfóricos (como ansiedad, depresión, aburrimiento, irritabilidad); fantasías, deseos y conductas sexuales repetidas en respuesta a situaciones vitales estresantes; intentos persistentes pero infructuosos para controlar o reducir significativamente las fantasías, deseos y conductas sexuales; implicación repetida en conductas sexuales ignorando el riesgo físico, psíquico o emocional que puedan suponer para sí mismo o para otros; todo lo anterior acompañado de malestar clínicamente significativo o deterioro social, laboral o de otras áreas importantes (Echeburúa, 2012;Kafka, 2010). ...
... En el actual DSM-V (Diagnostic Statistical Manual of Mental Diseases, Fifth Edition, 2013) no se incluye esta enfermedad, sin embargo, durante los trabajos de desarrollo del manual se consideró incorporar en la sección de trastornos sexuales el de hipersexualidad, conceptualizado como un trastorno del deseo sexual no parafílico con un componente de impulsividad (Kafka, 2010). Se propusieron como criterios diagnósticos que al menos durante seis meses se presentaran fantasías sexuales recurrentes e intensas y un deseo sexual apremiante, así como conductas sexuales asociadas a una cantidad de tiempo excesiva invertida en fantasías y deseos sexuales; también, la planificación y realización de conductas sexuales; fantasías, deseos y conductas sexuales repetidas en respuesta a estados de ánimo disfóricos (como ansiedad, depresión, aburrimiento, irritabilidad); fantasías, deseos y conductas sexuales repetidas en respuesta a situaciones vitales estresantes; intentos persistentes pero infructuosos para controlar o reducir significativamente las fantasías, deseos y conductas sexuales; implicación repetida en conductas sexuales ignorando el riesgo físico, psíquico o emocional que puedan suponer para sí mismo o para otros; todo lo anterior acompañado de malestar clínicamente significativo o deterioro social, laboral o de otras áreas importantes (Echeburúa, 2012;Kafka, 2010). ...
Chapter
A lo largo de la historia y de las diferentes culturas se han descrito y documentado las manifes-taciones de la sexualidad humana. La vida sexual es regulada por diversas normas, en particular biológicas, aunque en las sociedades también intervienen varias cuestiones morales y religio-sas de la época. Estas normas derivan en creencias dogmáticas que, sin embargo, se basan en "verdades" del momento histórico específico y algunas veces carecen de fundamentos lógi-cos. Por un lado, se ha estigmatizado la práctica sexual que no conduce a la reproducción, sobre todo por instituciones religiosas, como la Iglesia católica, cuyo auge oscila entre poco antes de la caída del Imperio romano de occidente en el año 476 d. C., hasta comienzos del Renacimiento alrededor del año 1400. Durante la reforma protestante del siglo XVI, Martín Lutero reconoció el valor del sexo dentro del matrimonio, mientras que Juan Calvino (teólogo francés) argumentó que el sexo marital era permisible si tenía como finalidad aligerar y faci-litar los cuidados y tristezas de los deberes hogareños (Taylor, 1970). Estos movimientos ideológicos llevaron a la apertura del pensamiento con respecto al coito con fines lúdicos, permitiendo el desarrollo de una gran diversidad de prácticas sexuales. Es claro que el fin último de la conducta sexual es la reproducción. Sin embargo, para que los animales (incluyendo a los humanos) tengan sexo, la evolución misma ha propiciado que se experimente placer durante su práctica, de tal forma que los organismos sexuales buscan este acercamiento para obtener placer. Al experimentar placer durante el sexo, los animales incre-mentan la búsqueda de parejas sexuales y a su vez la satisfacción del deseo sexual durante la ejecución del acto mismo. Por lo anterior, se puede notar con claridad que la conducta sexual tiene dos fases, una apetitiva y otra consumatoria. La primera involucra aspectos motivacio-nales e incluye todas aquellas conductas de búsqueda de pareja sexual, predisposición e inicio de la interacción con la pareja; la segunda es de índole más ejecutivo, con conductas como caricias, besos, penetración, entre otras, que culminan con la eyaculación y, en su caso, el or-gasmo. A diferencia de otras especies, entre las que la conducta sexual no tiene otro significado más que sexo (Agmo, 1999), en el ser humano subyace un complejo sistema que incluye un com-ponente neurobiológico, uno cognoscitivo-psicológico y uno sociocultural, que derivan en desen-volvimiento del impulso sexual, es decir, aquella motivación por búsqueda del placer sexual.
... La hipersexualidad es la expresión desinhibida de conductas sexuales culturalmente adaptadas que provoca consecuencias adversas importantes (Kafka, 2010), e incluye una combinación de deseo sexual excesivo e incapacidad para controlarlo (Ballester-Arnal et al., 2019). La primera conceptualización de hipersexualidad como una adicción fue propuesta por Orford (1978), quien hizo hincapié en las consecuencias negativas que conlleva, el tiempo que se invierte en pensar en el "consumo", las dificultades de autocontrol, así como en la conciencia sobre lo inapropiado que resulta. ...
Article
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Se presenta el caso de un varón gay VIH positivo con problemas en el control de impulsos sexuales, con frecuentes conductas sexuales sin protección asociadas al chemsex, que afectan al ámbito social, familiar y laboral. El objetivo fue evaluar la utilidad de un protocolo de 8 semanas basado en ACT para tratar la hipersexualidad y valorar su aplicabilidad. Los cambios fueron medidos mediante autorregistros y cuestionarios estandarizados. El índice de cambio clínicamente significativo de Jacobson-Truax reveló mejoras en hipersexualidad y flexibilidad psicológica. El tratamiento fue seguido de una reducción de hipersexualidad del 90% (t=-0,9, p=0,0) y una drástica reducción mantenida a los tres meses en tiempo empleado en buscar citas, número de encuentros y parejas y frecuencia de consumo de sustancias. Los resultados aportaron evidencia de que la aplicación de ACT fue seguida de una mejora en la conducta sexual impulsiva y justificaron su uso en futuros ensayos clínicos.
... Although sexual addiction disorder or hypersexuality was proposed as a distinct disorder in the latest Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, it was subsequently not included (Table 1). 1 Conversely, World Health Organization 2 has planned to include excessive sexual behaviors within the latest version of the International Classification of Diseases (ICD-11) as a disorder of sexual compulsive behavior ( Table 2). Important attributes that distinguish sexual addiction disorder from other patterns of sexual behavior are (a) failure to control sexual behavior and (b) the sexual behavior has significant harmful consequences and (c) continues despite these consequences. ...
Article
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Sexual addiction, hypersexuality, sexual compulsivity, and sexual impulsivity are all terms that describe a psychological disorder that is characterized by a person's inability to control his or her sexual behavior. This spectrum of symptoms are often referred to as sexual addiction disorder. Whether excessive sexual behavior should be regarded as an addiction, or a compulsion, or an impulse control disorder is arguable, as each label indicates a specific etiological model and treatment plan. Sexual addiction disorder has been largely ignored by the clinicians, although it causes significant emotional and behavioral problems among the patients. Fortunately, in the recent years, this disorder is gaining recognition, and attempts have been made to understand it through research. The present article aims to systematically review and summarize the recent understanding and research on phenomenology, clinical characteristics, etiology, assessment, and management of sexual addiction disorder.
... In fact, Stinson et al. (2008) found that self-control deficits predict paraphilias and antisocial behaviors in men adjudicated for sex offenses. Finally, impulsiveness is linked with sexual excitation and inhibition, as individuals may engage in more sexual activities because they are both impulsive and have low sexual inhibition (Kafka, 2010). For example, Joyal and colleagues (2007) found that paraphilias were associated with deficits in areas relating to impulsive control, with pedophiles consistently reporting the highest level of deficits when compared to individuals with other paraphilias. ...
Article
Little is known about distinct factors linked with acting on paraphilic interests or refraining from engaging in paraphilic behaviors. Participants from Canada and the United States ( N = 744), aged 19–42 years ( M = 29.2; SD = 3.18), were recruited through Amazon’s Mechanical Turk. Participants completed questionnaires about their paraphilic interests and behaviors, as well as potential key factors linked to behavioral engagement (i.e., perceptions of consent, sexual excitation/inhibition, impulsivity, moral disengagement, empathy). Results indicated that higher moral disengagement and impulsivity, lower sexual control (i.e., high sexual excitation, low sexual inhibition), and maladaptive understandings of consent were best able to differentiate individuals who reported highly stigmatized (e.g., hebephilia, pedophilia, coprophilia) or Bondage and Dicipline, Dominance and Submission, Sadism and Masochism(BDSM)/Fetish paraphilic interests and engagement in the paraphilic behaviours associated with these interests relative to individuals who did not report such paraphilic interests or behaviors. Moreover, higher moral disengagement, impulsivity, and maladaptive perceptions of consent were best able to differentiate non-consensual paraphilic interests and behaviours (e.g., voyeurism, exhibitionism) compared to individuals who did not report these paraphilic interests or behaviours. These results provide future directions for the exploration of mechanisms that may contribute to engagement in paraphilic behaviors and may be targets for intervention aimed at preventing engagement in potentially harmful paraphilias.
... Overall, we found that a group of women who had not sought treatment for CSB in the past (68.2% of the whole sample) obtained a mean SAST-PL score that exceed a cut-off value proposed by Carnes. 10 This finding is in line with an analysis by Kraus and colleagues 29 showing that 29% of men in their sample who met or exceed the Hypersexual Behavior Inventory (HBI) 30 total clinical cutoff score, suggesting the presence of a possible Hypersexual Disorder (HD), 6 were disinterested in seeking treatment for pornography use. However, preliminary data suggests that the probability of seeking treatment for PPU in women is 7 times lower than in men, 31 though factors that may uniquely contribute to this possible difference have yet to be explored. ...
Article
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Background Compulsive Sexual Behavior Disorder is currently included in the forthcoming eleventh revision of the International Classification of Diseases (ICD-11); however, prior studies have been conducted mostly on heterosexual, White/European male samples. Aim To examine the correlates of compulsive sexual behaviors (CSB) with sociodemographic and sexual history characteristics, as well as predictors of CSB in a sample of treatment-seeking Polish women. Methods Six hundred seventy-four (674) Polish women aged 18–66 completed an online-based survey. Outcomes Polish adaptation of the Sexual Addiction Screening Test-Revised (SAST-PL) was used to assess the severity of CSB symptoms. Brief Pornography Screen was used to measure problematic pornography use. The bivariate associations between SAST-PL scores and demographic and sexual history characteristics were also examined. A linear regression analysis was performed to identify variables related to the severity of CSB symptoms. Results Thirty one percent (31.8%) of women in the studied sample reported treatment seeking for CSB in the past. Problematic pornography use was the strongest predictor of CSB symptoms. Higher severity of CSB symptoms were observed among divorced/separated and single women compared to those who were married or in informal relation. Severity of CSB was positively related to the number of sexual partners during the last year, number of dyadic sexual intercourse during the last 7 days, and negatively associated with age of first sexual intercourse. Clinical Implications Our results suggest that CSB is a significant concern among women and more research is needed to identify protective (eg, relationship status) and risk (eg, problematic pornography use, number of past year sexual partners, frequency of past week masturbation) factors associated with CSB symptom severity among treatment-seeking women. Strengths & Limitations Our study is one of very few investigating predictors of CSB among women. Given the lack of precise estimates of the prevalence, as well as lack of psychometrically validated instruments measuring CSB in women, present findings should not be considered indicative of CSB prevalence among Polish women. Conclusion The lack of clinical data on women reporting issues with CSB remains an important target for future clinical research exploration. Kowalewska E, Gola M, Lew-Starowicz M, et al. Predictors of Compulsive Sexual Behavior Among Treatment-Seeking Women. Sex Med 2022;XX:XXXXXX.
Article
Background and aims Compulsive sexual behavior disorder (CSBD) is characterized by persistent patterns of failure to control sexual impulses resulting in repetitive sexual behavior, pursued despite adverse consequences. Despite previous indications of addiction-like mechanisms and the recent impulse-control disorder classification in the International Classification of Diseases (ICD-11), the neurobiological processes underlying CSBD are unknown. Methods We designed and applied a behavioral paradigm aimed at disentangling processes related to anticipation and viewing of erotic stimuli. In 22 male CSBD patients (age: M = 38.7, SD = 11.7) and 20 healthy male controls (HC, age: M = 37.6, SD = 8.5), we measured behavioral responses and neural activity during functional magnetic resonance imaging (fMRI). The main outcomes were response time differences between erotic and non-erotic trials and ventral striatum (VS) activity during anticipation of visual stimuli. We related these outcomes with each other, to CSBD diagnosis, and symptom severity. Results We found robust case-control differences on behavioral level, where CSBD patients showed larger response time differences between erotic and non-erotic trials than HC. The task induced reliable main activations within each group. While we did not observe significant group differences in VS activity, VS activity during anticipation correlated with response time differences and self-ratings for anticipation of erotic stimuli. Discussion and Conclusions Our results support the validity and applicability of the developed task and suggest that CSBD is associated with altered behavioral correlates of anticipation, which were associated with ventral striatum activity during anticipation of erotic stimuli. This supports the idea that addiction-like mechanisms play a role in CSBD.
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We discuss the long‐standing “sex‐as‐drive‐or‐appetite” controversy—whether sexual desires may arise on their own, from internal states, or whether they only arise when attractive stimuli are presented. The issue is approached through integration of sexual motivation within an umbrella theory of motivational systems that closely follows currently dominant incentive motivation theories. In this formulation sexual motivation, like hunger or thirst, emerges from an interaction of external incentives and internal states. Deprivation acts to enhance the palatability of incentives but does not create an internal goad. That is, there is no aversive internal sensation associated with sexual deprivation. Through this perspective we integrate sex with findings from other motivational systems such as hunger or thirst and clarify otherwise puzzling phenomena: why orgasm and sexual motivation can be decoupled; how female sexual motivation arises and is similar to males'; how novel stimulation affects sexual motivation; and why measured sexual motivation seems to vary with experimental technique. Sexual self‐stimulation is accounted for under this model. Predictions are generated for the outcomes of both human and animal experiments. Finally, practical implications are discussed.
Book
'Why in this enlightened day would one choose to entitle a work Perversion, a term that is becoming passe? The great research published in the last decade or two has taught us that aberrant sexual behavior is found in other species, is ubiquitous in man, and is the product of brain and hormonal factors that can function independently of anything we might call psyche. Then too, their findings make researchers regret society's moral stance that sexual aberration is unnatural-sinful-and the repressive social action that follows. Thus, in ridding ourselves of the concept of perversion, we have the tempting combination of good research serving a humane cause. Yet it is the author's contention, explored in the body of this book, that perversion exists. The connotations of the word are unpleasant and have a flavor of morality and therefore of free will that is antiquated in these days of science and determinism. It is to avoid such connotations that the softer terms "variant", "deviation," or "aberration" are used.
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Prepared by one of the world's leading authorities, Human Sexuality and its Problems remains the foremost comprehensive reference in the field. Now available in a larger format, this classic volume continues to address the neurophysiological, psychological and socio-cultural aspects of human sexuality and how they interact. Fully updated throughout, the new edition places a greater emphasis on theory and its role in sex research and draws on the latest global research to review the clinical management of problematic sexuality providing clear, practical guidelines for clinical intervention. Clearly written, this highly accessible volume now includes a new chapter on the role of theory, and separate chapters on sexual differentiation and gender identity development, transgender and gender non-conformity, and HIV, AIDS and other sexually transmitted diseases. Human Sexuality and its Problems fills a gap in the literature for academics interested in human sexuality from an interdisciplinary perspective, as well as health professionals involved in the management of sexual problems.
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Impulsive-compulsive sexual behavior is a little studied clinical phenomenon which affects similar to 5% to 6% of the population. In the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision, it is classified as an impulse control disorder not otherwise specified or a sexual disorder not otherwise specified. It may be placed in a possible new category in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition called substance and behavioral addictions. This clinical entity is reviewed and the merit of classifying it as an addiction is assessed. Information is presented regarding its diagnostic criteria, epidemiology, types of behavior it can involve, relationship to hypersexuality, comorbidities, treatment, and etiology. The data regarding this disorder and its overlap with chemical addiction is limited. If the two disorders are to be grouped together, further data are needed.