Professional Documents
Culture Documents
March20
th
,2014
HYPERSEXUALITYANDHYPERSEXUAL
DISORDER:
AGUIDEFORCLINICIANS
MartinKafkaMD
ClinicalAssociateProfessor
DepartmentofPsychiatry
HarvardMedicalSchool
mpkafka@rcn.com
Disclaimer
Thecontentofthispresentationwillpromote
qualityand/orimprovementsinhealthcare
andwillnotpromoteaproprietarybusinessor
commercialinterest.Thecontentofthis
presentationwillbewellbalanced,evidence
basedandunbiased.
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Cingulate cortex
Para-olfactory
area
Hypothalamus
Uncus
Amygdala
Para-hippocampal
gyrus
Hippocampus
Mamillary bodies of
hypothalamus
Fornix
Thalamus
Anterior nucleus of
thalamus
Orbitofrontal cortex
Corpus callosum
Medial
Prefrontal
cortex
HumanSexualDesire
The presence of sexual fantasies, urges or
behaviors accompanied by the subjective
conscious motivation to engage in sexual
behavior in response to relevant internal
or external social cues.
Lieblum, 1988; American Psychiatric Association, 1994; Everaerd, 2001; Levine 2002
GenderandtheBrain
Thesexhormones,especiallytestosterone
andestrogenareassociatedwithdistinct
patternsofbothbraindifferentiationand
sexualbehavioraldifferencesinmenand
women
Fetalbrainismasculinized bytestosterone
Testosteroneinmammalianbrainstructurallyaffects
limbicforebrainandprefrontalcortex
Postpubertalmalesareblessed/cursedwithtentimesas
muchtestosteroneasfemales
Testosterone
Adultfemaleshaveonetenththeamountofcirculating
testosterone(thesameamountasaprepubertalmale)
Decreasesinserumtestosteroneareassociatedwithfemalesexual
dysfunction,especiallydiminishedsexualdesireandarousal
Athresholdeffectfortestosteronetoestablishandmaintainsexual
motivation,arousalandperformanceispresentinbothmalesand
females
Inmales,exceptforextremevalues,moretestosteroneisnot
directlyassociatedwithgreatersexualarousalorbehavior
SexualoffenderstypicallydoNOThaveabnormaltestosterone
levels
Hypothalamus Pituitary
Hypothalamusandtestosterone
Whatisanormalsexualappetite
in
males
KinseyandTotalSexualOutletinmales
Genderdifferencesandsexual
behavior
Adultmalesreport:
moresexualfantasies
morediversesexualfantasies
initiatesexualbehaviormorefrequently
masturbatemorefrequently
reportmorelifetimepartnersthanadultfemales
morereadilysexuallyarousedbyvisualstimuli
moresexualdeviancy
Femalesexualarousalismorecontextually
dependent
Oliver,1993;Baumeister,2000
Sexualimpulsivityandgender
ParaphilicDisordersarealmostexclusively
malegenderdisorders
HypersexualDisordersaremarkedlyand
predominantlymalegenderdisorders
Exceptions(butstillpredominantlymale)
Sexualmasochism
Protractedpromiscuity,compulsivemasturbation
DSM5ParaphilicDisordertemplate
Duration:6monthsormore
Sexualdesire:
Recurrentandintensesexualarousal
Anomalousobjectofdesire
Manifestedasfantasies,urgesorbehaviors
Distress/impairmentmustbepresent
Paraphiliavs.ParaphilicDisorder
NewtoDSM5
CourseSpecifiers
Inacontrolledenvironment
i.e.institutionalsetting
Inremission
Nodistressorimpairmentinsocialfunctioningforat
least5yearswhileinanuncontrolledenvironment
DSM5ParaphilicDisorders
PedophilicDisorder
SexualSadismDisorder
SexualMasochismDisorder
TransvesticDisorder
VoyeuristicDisorder
FrotteuristicDisorder
ExhibitionisticDisorder
FetishisticDisorder
OtherSpecifiedParaphilicDisorder
OtherUnspecifiedParaphilicDisorder
HistoricalPrecursorsofHypersexualityand
HypersexualDisorder
Excessivesexualbehaviors
withadverse
consequences
BenjaminRush(17451813)
R.vonKrafftEbbing(19401902)
H.Ellis(18591939)
M.Hirshfeld(18681935)
DSMManuals:DonJuanism,satyriasis,
nymphomaniaandnonparaphilicsexual
addiction
Epidemiologyofhypersexuality
Hypersexualityandsexualoffending
RayKnight:Assessmentsoftheproclivityforsexualaggression
MultidimensionalAssessmentofSexandAggression(MASA;1994,1999)
Administeredtoover3000individuals
candiscriminatesexuallydeviantsamplefromcontrols(Zakireh,
RonisandKnight2008)
Demonstrateddimensionalhypersexualityassociatedwith
rape(Knight2003,2004)and
childmolestation(DaversaandKnight,2007)
Developedanempiricallyderivedscalesforsexualization,including
hypersexuality
Hypersexualityandsexualoffending
MultidimensionalInventoryofDevelopment,SexandAggression
(MIDSA;Knight,2008)
SexualizationandHypersexualityScales(derivedfromMASA)
Appliedin2largesamples(Walters,KnightandLangstom,2011)
Langstromsepidemiologialsample(5250menandwomen)
and716malesexoffenderstodemonstratethelatentdimensional
natureof
hypersexuality
Cautionedaboutneedformoreresearchtodelineateacategoricaldiagnosis
fromadimensionalcontinuousvariable
ManyDSMdiagnosesaredimensional,includingparaphilias,attention
deficithyperactivitydisorderandpersonalitydisorders
Fromdimensionalhypersexualityto
HypersexualDisorder
Constructinganewpsychiatricdisorder
Constructinganewdiagnosis:
HypersexualDisorder
Derivedfromextensiveliteraturereview(Kafka2010)
Findingcommonfactorsamongstratingscales
whosereliabilityandvalidityhavebeenpublished
andtestedinmultiplesamples
SexualCompulsivityScale(Kalichman1995,2001)
SexualAddictionScale(Carnes1989,Nelson2008)
CompulsiveSexualBehaviorInventory(Coleman2001,2007)
SexualInhibition/SexualExcitationScales(Bancroft1999,2003,2004)
HYPERSEXUALDISORDER(HD)
A.
Atleastsixmonths,recurrentandintensesexual
fantasies,sexualurges,andsexualbehaviorinassociation
withfourormore:
(1)excessivetimeconsumed
Repetitivelyengaginginsexualbehaviorinresponseto:
(2)dysphoricmoodstates(e.g.,anxiety,depression,boredom,irritability).
(3)
stressfullifeevents.
(4)
Repetitive,unsuccessfuleffortstocontrolor
significantlyreducesexualbehavior.
(5)
Disregardingtheriskforphysicaloremotionalharmto
selforothers.
ReprintedwithpermissionfromtheAmericanPsychiatricAssociation.All
RightsReserved.
HYPERSEXUALDISORDER
B.
Clinicallysignificantpersonaldistressor
impairmentinimportantareasoffunctioning
C.
notduetodirectphysiologicaleffectsof
exogenoussubstances(e.g.,drugsofabuseor
medications),acooccurringmedicalconditionor
toManicEpisodes.
D.
Thepersonisatleast18yearsofage.
ReprintedwithpermissionfromtheAmericanPsychiatricAssociation.AllRights
Reserved2013
HYPERSEXUALDISORDER:
behavioralspecifiers
Masturbation
Pornography
SexualBehaviorWithConsentingAdults
Cybersex
TelephoneSex
AdultEntertainmentVenues/Clubs
Other:
ReprintedwithpermissionfromtheAmericanPsychiatricAssociation.AllRightsReserved
2013
Whatabouthypersexualdisorderandsexual
offending?
Insampleof220consecutivelyassessedmales111(50.4%)were
paraphilicsexualoffenders.
Exhibitionism
(n=57)
51.8%
Voyeurism
(n=34)
30.9%
Pedophilia
(n=32)
29.0%
Thelifetimeprevalenceofparaphiliarelateddisordersintheoffender
groupwas:
Compulsivemasturbation(n=75)
67.5%
Pornographydependence(n=47)
42.3%
Protractedpromiscuity(n=36)
32.4%
Phonesexdependence(n=7)
6.3%
LifetimePRDsareprevalentinmalesexualoffenders
(n=220:Kafka,1997,2003,2003)Briken2006
DSM5FieldTrialdata:
SexualoffendersandHD
Clinicalsamplesofhypersexual
disorder
Malesaremarkedlypredominant
45:1ratio??
Myclinicalpractice35/14002.5%arefemale
Femalesmorelikelytohavebeensexuallyabused
Ageofonset
adolescence
Ageofhelpseeking
mid30s
early40s
MultipleHDbehaviorsarecommon
simultaneous,serially
HDincidenceinmenwithPAand/or
HD
masturbation,promiscuity,pornography
(Kafka,1997)n=100
masturbation,pornography,promiscuity
(Kafka,2002)n=120
pornography(76%),masturbation(71%),
promiscuity(51%)
(Kafka,2014unpub)n=150,Reidetal2012
IsHypersexualDisorderabehavioral
addiction?
GamblingDisorder HypersexualDisorder
preoccupation preoccupation
tolerance inadequateempiricalbutpresent
withdrawal inadequateempirical,likelypresent
lossofcontrol lossofcontrol
responsetodysphoricaffect responsetodysphoricaffectandevents
1yearormore 6monthsormore
significantadverseconsequences
Maniaexcluded
significantadverseconsequences
Maniaexcluded
Lying Notincludedincriteriabutwho
wouldnt?
Masturbation
primarysexualoutletevenduringastableintimate
relationship
atleastonce/day
Maystartofforendnearlyeveryday
sometimesatwork
Maybeassociatedwithselfabrasionorinjury
Commonlycoassociatedwithothernonpartnered
HDbehaviors
Associatedwiththeleast distress
butcanbetime
consuming
AdultPornography
25%33%ofinternetsiteshavesexuallyrelated
content
4%classifiedaspornography
>2.5millionwebsites
Websites,filesharing,Usenetgroups
NewmaterialsEVERYDAY
malesprefervisualporn,thesexact
womenpreferromanceanderoticfiction
dominanceandsubmissionthemes
Pornographyspamadsmayfloodtheuserandalert
aspouseorpartner
OgasandGaddam,2011
(Child)pornography
BIGPROBLEM:
MENFINDPOSTPUBESCENTFEMALESHIGHLYSEXUALLY
AROUSING
Imagesofminors
belowage18
Possessionofand/ortransmissionofchildoradolescent
pornographyimages
Stateoffense
adjudicationmorevariable
Federaloffense
minimum5yearprisonsentence.
Childpornimagesmaybetagged
foreasier
recognitionbylawenforcement
(Child)pornography
USAisalargeconsumerofchildporn
Since2003,depictingmoreviolence/rape
adultpornography
escalationtoview/receivechildandadolescent
images
FTP:purposeful/inadvertentdissemination
(Child)pornography
Manymaleswhopossesschildpornarenotclassicalpedophiles
mosthavenopriorcriminalhistory
manymarried,middleclass,morehighlyeducated
1in8havehandsonvictims(Seto,Hansenetal.2011)
somemeetcriteriaforpedophiliabasedsolelyonviewinghistory
verylowrecidivismrateunless:
pedophilicfixation
priorhandsonvictims
antisocialpersonality
Sexualbehaviorwithconsenting
adults
A persistentpatternofsexualconquests
Caninclude onenightstands repetitiveuseof
prostitutes,escortservices, massageparlors ,
cruising ,repetitivebrieforlengthyaffairs,serial
polygamy,swinging,etc.
HookupsviatheInternetbecomingmorecommon
Grindr,Tinder,GetPure
findsexualpartnersquickly,safelyandwithout
commitment".
Sexualbehaviorwithconsenting
adults
Cybersex
Internetrelatedsexuallyoriented chatrooms ,messageboards,
webcams,instantmeetups,avatars
specificallyforsexualarousalandactivity,including
solicitation
Thisdoes
not
includevisualpornographyspecifier
Personsmayeithertalk,planormeetforsexor dosex
whileonline
Falseidentitiesarecommoninsexchatrooms
Stingoperations
Somecanbevictimizedandblackmailed
Malesmeetingmalesthroughcybersexmorelikelytohave
hadSTDsandprotractedpromiscuity(McFarlaneetal2000)
ClinicalAssessment
ClinicalAssessment
IFYouDONTASK
TheyDONTTELL!!
1.Haveyoueverhadpersistentorrepetitive
problemscontrollingyoursexualbehavior?
2.Hasyoursexualbehaviorevercausedyou
significantpersonaldistressorcausedsignificant
consequences
Medical
Interpersonal/pairbond
Legal
Workassociatedimpairment
ClinicalAssessment
3.Haveyoueverhadrepetitivesexual
activitiesthatyoufeltsoashamedofor
guiltyaboutthatyoukeptthemasecret?
4.Doyouthinkthatyouarespendingtoo
muchtimeengaginginsexualfantasy,
masturbationorothersexualbehaviors?
5.Haveyoueverfeltthatyoursexdrivewas
too strong ortoo high to control?
ClinicalAssessmentScales
Sexual Addiction Screening Test
(Carnes, 1989 n=191; 1991: Nelson, 2008 n=639 male veterans: Marshall, 2010 n=151; 74
male sex offenders and 77 community controls)
25 items, dichotomous, available for males and
females
www.sexhelp.com
Score > 13 indicative of sexual addiction
Sexual Compulsivity Scale (Kalichman,1995, 2004, Grov 2010)
Derived from characteristics of sexual addiction
Easy to administer, 10 items extensively tested,
established reliability and validity
www.personality-testing.info/tests/SCS.php
ClinicalAssessmentScales
HypersexualBehaviorInventory(HBI)
Reidet.al,2011;Reidetal2012;Kleinetal.2013
19item,3factor,selfreportmeasure
control,consequences,sexascoping
UsedinDSM5fieldtrial
Dimensional,notdiagnostic
HypersexualDisorderDiagnosticClinicalInterview
http://www.rory.net/tests.htm
PrevalenceofAxisIpsychiatric
comorbidity
inHDmales
MultipleAxisIcomorbidity
ispredominantinHD
Kafkaetal1994,1998,2002,
Dysthymia
6162%
Socialphobia
2225%
Alcoholabuse
2539%
ADHD1719%
ADHD
23,67%*
Bipolarspectrum0%
Blacketal,1997
Phobicdisorders 42%
MDD/Dysthymia
39%
Alcoholabuse
58%
*Reid,Carpenteretal2011,Blankenship&Laaser,2004
PrevalenceofAxisIpsychiatric
comorbidity
inHDmales
Kafka,2014unpublished
n=85
MINIPLUSv.6
AnyADHD
40%
Inattentivesubtype
27%
Combinedsubtype
13%
AdultADHD
30%
AnyBipolar
38%
BipolarII
19%
Cyclothymic/NOS
19%
Unipolar
MajorDepression
25%
Nonalcoholsubstanceabuse
22%
Alcohol,dysthymia,socialanxiety
20%each
AxisIcomorbidity:depression
MDDdiminishedsexualarousal,activityandpleasure,Hypoactive
SexualDesireDisorder
Subgroupsreportincreasedsexualbehavior
(Mathew,1979,1982;
Bancroft2003;Schultz,2013)
Malesresistanttocognitivetherapyfordepressionhaddysthymia
withincreasedTSO(Nofzinger,1993)
MaleswithPAs
andPRDs
haveincreasedTSOandmood
disorders(Kafka,1997,2002,2007,Schultz2013)
Malesrespondtodysphoric
affectthroughactionand
impulsivity
A selfmedication oraddictiondynamic(Carnes1983,Martinetal,2013)
AxisIcomorbidity:hypomania
Increased/riskysexualbehaviorisassociatedwith
hypomaniasdiagnosticcriteria
Thebipolarspectrummayinclude6%oftheadult
population
Themeandurationofhypomanic
episodesis12days
Myclinicalexperiencepromiscuityisapredictorof
increasedlikelihoodofmooddisorders
esp.bipolarspectrum
Bipolars
typicallyhavesexualimpulsivityduringboth
phasesoftheirmooddysregulation
Cyclothymia
andOtherSpecifiedBipolarDisorderare
underdiagnosed
AxisIcomorbidity:ADHD
SexualproblemsandADHD
prevalenceinadultsinUSA4.4%(Kessleretal2006)
Sexualadjustmentproblems(20%)greaterthancontrols
(2.4%)
Sexatanearlierage
Moresexpartners
MoreS.T.D.s
(17%vs.4%)
highrisksexuallifestyle (Barkley,1998)
Moreunplannedpregnancy(Hosain
etal,2012)
ADHDCassociatedwithparaphilias,pornographydependence
andsexoffending
Kafka,2003,2007
TreatmentInterventions
Gooddataislacking
Hereandnowbeforethereandthen
externalinterventionstolimitaccess
Phoneblock,internetfilterswithkept
passwords,movethecomputertoamore
publiclocation,changeISPs,removecredit
cards
(Behun
etal
,2012)
Includespousetofacilitatedisclosure??
be
CAREFUL
Assessrelationshipstability,valuesand
religion,psychiatricstabilityandco
dependence
TreatmentInterventions
Frequent12stepmeetingswithadaily
contactwithsponsor
SLAA,SAA,SA
Differing bottomlines
612monthsof celibacy
Buildarecoverynetwork
Individualpsychotherapy,group+
meds
Manyuseaddictionmodel
SomeCBT
Nopublishedoutcomestudieswithcontrols
PharmacotherapyforHypersexual
Disorder
DiagnoseandthentreatAxisIcomorbidity
associatedwithimpulsivity
Oneplacebocontrolleddoubleblindstudy(n=21)
Citalopramforhomosexualpromiscuity(Wainbergetal
,2006)
Noeffectonhomosexualpromiscuity,highplacebo
responserate,decreasedTSO.12weektrial,
masturbationdecreased,pornographyusedecreased
PharmacotherapyforHD
Uncontrolledstudies(Kafka,1992,1994,2000)
Clinicalexperiencewith>250malestreatingAxisI
comorbidityassociatedwithHD
SSRIs,psychostimulantsormoodstabilizer
combinationseffectivelyamelioratesormarkedlyreduce
bothparaphilicandnonparaphilicsexualimpulsivity
Casesreportsbyotherinvestigators
PharmacotherapyforHypersexual
Disorder
Useincombinationwithindividualand/orpsychotherapyor
grouptherapy(including12stepprograms)
moodstabilizers.SSRIsorpsychostimulants
standarddoses
SSRIsexual dysfunction
maydissipate
lowerTSO/weekto13ifpossible
minimizemasturbationifanintactrelationshippersists
ordevelops
Lamotrigine,valproateandoxycarbamazepine
Naltrexoneandtopiramate
casereports
targetsxareurges
andcraving
DiagnosingHypersexualDisorderin
DSM5
HDcanbediagnosedas:
OtherSpecifiedDisruptive,ImpulseControl,
andConductDisorder:hypersexualdisorder
(orotherdescriptors,eg.recurrenthypersexualbehaviors,
sexualaddiction)312.89:F91.8
Additionaltreatmentconsiderations
Amedical/psychiatricmodel
basedonacomorbidityoranaddictionmodel
destigmatizebehaviorsfrom moral to medical
thespouseorpartnerisleftwiththemostdifficultdecisions
Outcomemaydependonrelationshipstatus
residualpornographyorotherformsofimpersonalsex
SocietyfortheAdvancementofSexualHealth
Resources/reading/workbooksathttp://www.sash.net/
and
SASHbookstore