Input: Could not generate response.

Response:
The algorithm in Figure 12.1 illustrating the potential process of assessment and associated treatments is based on our clinical experience. As far as we are aware, there are no empirically validated diagnostic criteria or treatment algorithms for PGAD. Thus we cannot as yet define how long genital symptoms must last or the degree of distress necessary; this must be left to clinician judgment. It is not yet known in which order treatments should be tried or whether they should be tried simultaneously. It is logical that if PGAD symptoms started with the initiation of a particular medication or life 250

event, then this should be carefully investigated. Because of this lack of knowledge, it seems crucial for one clinician to monitor and coordinate the assessment and treatment process.

Unless there is a simple remediable medical cause, mindfulness-based cognitive-behavior therapy (CBT) is recommended as a treatment for most patients. As a result, we highlight the role of the psychologist/sex therapist.

**TREATMENT BY A SEX THERAPIST/PSYCHOLOGIST**

**Mindfulness-Based CBT**

For the majority of women with PGAD, the role of the clinical psychologist/sex therapist is to help the patient manage and cope with symptoms of PGAD rather than finding a cure. CBT is a useful tool for women with genital pain and therefore likely to be useful for PGAD (Lofrisco, 2011). PGAD can easily rule over all other aspects of the patients life so that the womans thinking becomes very negative. Explaining to the woman that she likely has a subtle derangement of her pudendal nerve that wont cause damage but can be exacerbated by anxiety is very important. Reassuring her that she is neither a sex maniac nor insane is also crucial. Women suffering from PGAD often think catastrophically (e.g., "this problem rules my whole life," "my genitals must be grossly abnormal," or " this must be due to masturbating too much as a teenager"). Such thinking should be challenged point by point.

There is often an understandable urge to masturbate to orgasm to relieve symptoms.

This can take on features of a compulsion. Many women find that refraining from masturbation leads to an overall lessening of their symptoms, as well as to freeing up the women from spending a lot of her time trying to relieve their symptoms. Other women find that their PGAD builds up to a crescendo over days and that a session of repeated masturbation and orgasm over hours can bring some degree of relief. Working with the patient to explore extending periods of masturbation abstinence may guide therapist and patient. So, for instance, an exacerbation of physical symptoms with little anxiety might suggest that masturbation at intervals would be useful. However, if the major theme is an increase in anxiety at abstinence, then exploring and managing this may be more beneficial than repeated masturbation.

Mindfulness is now seen by many psychologists as an important additional therapy to be used in conjunction with CBT (Kabat-Zinn, 2005). There is reasonable evidence that its regular use decreases anxiety, depression, and the suffering aspect of pain, as well as altering brain structure, function, and immune responses (Goldmeier & Mears, 2010).

The practice of mindfulness requires that the patient focus on the breath and also observe distractions such as thoughts or physical discomforts. One way that mindfulness may work is by increasing focus on any event or situation, with distractions becoming increasingly peripheral. Thus one can learn to observe the sensations of PGAD rather than experiencing them with negative thoughts ("Will this ever stop?" "I can take this no 251

longer," "When will I have to masturbate next?"). Focusing on the "naked" PGAD

symptoms, that is, observing the exact site and quality of the PGAD sensations for 10–20

minutes a day, alongside mindfully observing the minds reaction to it, has had very useful outcomes in some of our patients. After some weeks of mindfulness training, which might include 20 minutes of focusing on the breath and 20 minutes focusing on the PGAD itself, patients may feel they can more easily live alongside the PGAD

symptoms and can learn to recognize thoughts and emotions secondary to these and gently put those on one side. In effect, the patient comes to be more accepting of her PGAD symptoms. Such acceptance has been shown to help pain and therefore likely to help PGAD symptoms (Vowles, McCracken, & OBrien, 2011). Our own patients who are motivated to do regular mindfulness exercises anecdotally report significant improvement in their quality of life. In light of the associated psychological aspects of PGAD described before, it should not be surprising that management of anxiety and depression has yielded good results in some of our patients. Those who have been sexually assaulted may derive great benefit from specific therapies such as revisiting and reconstructing these events under carefully controlled conditions (Littrell, 1998).

**Enhancing Sexual Functioning in the Patient with PGAD**

Most women with PGAD are highly focused on alleviating their symptoms rather than being sexual. They find that genital touching or sexual arousal precipitates or exacerbates their symptoms, at least in certain trigger areas (Leiblum et al., 2005; Waldinger, Venema, et al., 2009). Our experience is that being sexual and being sexually stimulated are very far from their minds. The prescribed pharmacotherapy may also cause problems with desire, subjective and genital arousal, and orgasm. It is only a minority of women with PGAD who are able to respond to sexual desire in relation to a partner and then proceed to arousal that is pleasurable. Many women may find pleasure in nongenital stimulation, but find that once sexual arousal is present, so is the PGAD.

Women who have intermittent symptoms are often sexual between exacerbations, and women whose symptoms are controlled want to return to intercourse in order to keep their relationships going. Most women with PGAD find that connecting emotionally rather than sexually is what they want to achieve.

The clinician should broach the topic of sexual functioning in all women suffering from PGAD. We feel we are on a learning curve in regard to addressing this issue, so we stress the importance of a thorough assessment. We suggest asking the patient for details of how her PGAD affects sex with her partner, including the following: 1. Does sexual arousal with her partner always trigger PGAD? If not, when does the PGAD get triggered and when does it not?

2\. Are there certain places on her body where she can enjoy sexual stimulation or sexual/sensual touch that does not trigger PGAD? Similarly, are there certain sexual activities that do or do not become triggers?

3\. If all sexual arousal causes an exacerbation of the PGAD, does stimulating her 252

partner also result in an increase in symptomatology? Is the idea or thought of sex problematic?

Input from the partner is important. However, we recommend interviewing the patient privately, as in a conjoint session she may hide the extent of her symptoms in order not to hurt or upset her partner. A later interview with the couple will allow for the partners perceptions to be included in the assessment and may also help the patient understand how the PGAD affects him or her. Many partners are perplexed regarding the fact that sexual activity is avoided, even though it reliably results in orgasm. The partners need or desire for sex, as well as the patients own sexual problems or dysfunctions, should be part of the assessment, as these issues will inform treatment decisions.

Treatment directed toward the couples sexual relationship focuses on the same issues that individual treatment does: managing and coping with the symptoms of PGAD, rather than "curing" them. Reassurance is also important. Sharing the diagnosis and the results of the assessment with the couple can alleviate tensions built on misconceptions regarding the nature and origin of the problem. It is important to distinguish PGAD from hypersexuality or sexual aversion and also to dispel the notion that somehow the partner is responsible for the problem. Treatment options for patient and partner will depend on their interest in having sex, as well as the way that PGAD

manifests in the sexual relationship. These options range from no sexual activity to sexual stimulation only for the partner (or limited sexual or sensual stimulation for the PGAD sufferer) to sex between exacerbations of PGAD to sexual activity knowing that the symptoms of PGAD will likely worsen. In the latter scenario, the patient should be encouraged to engage in mindfulness during sex, noticing the genital sensations but focusing on the emotional connection. After sex, masturbation, mindfulness, yoga, or cold compresses may help to control the symptoms.

**CONTEMPORANEOUS TREATMENT BY A PHYSICIAN**

Based on the findings of the medical assessment, the physicians major role may be to prescribe or adjust medication (see Facelle, Sadeghi-Nejad, & Goldmeier, 2012, for a review). SSRIs, SNRIs, and tricyclic antidepressants have been reported to have useful effects as anxiolytics, antidepressants, analgesics, and in some cases antiobsessionals.

Other drugs with which success has been reported are antipsychotics (e.g., quetiapine), dopaminergic agents (e.g., varenicline), benzodiazepines (e.g., clonazepam; however, continuous use may lead to dependence), and atypical opiates (e.g., tramadol). The composite clinical picture and its spectrum of symptoms should help dictate the medication choice. The final decision should be taken after consultation with all the health care workers involved plus the patient. For example, if the major symptomatology is PGAD in the absence of psychiatric features, then gabapentin might be the initial drug of choice; if it is PGAD associated with anxiety, then a low-dose 253

antipsychotic might be appropriate; if it is PGAD associated with depression, then tricyclics or SSRI antidepressants might be most appropriate.

**CONTEMPORANEOUS TREATMENT WITH PELVIC FLOOR**

**PHYSICAL THERAPY**

The pudendal nerve can become "entrapped" or compressed, usually causing vulval/clitoral pain that is worse on sitting and relieved on standing. Rosenbaum (2010) has described a case of a pregnant woman in whom the PGAD symptoms were immediately relieved on massaging and manipulating one of the pelvic floor muscles (the obturator internus), which in this womans case was overcontracted. The patient reported "that something had been released." Rosenbaum (2010) theorizes that the pelvic floor tonicity may have compressed the pudendal nerve in Alcocks canal, leading to her symptoms, and that the soft tissue mobilization released this tension

TENS (transcutaneous electrical nerve stimulation) produces its effects by activation of opioid receptors in the central nervous system. Some of our patients have found it very helpful. Similar anecdotal successes have been described in the literature (Waldinger, de Lint, et al., 2010).

In principle, pelvic floor physical therapy should be very useful when there is sensory disruption of the pelvic floor musculature. There has been little systematic work reported to date, and it is not clear whether biofeedback or the full range of manual techniques used by pelvic floor physical therapists will be useful. In our clinical experience, physical therapy has been helpful in only a very few cases.

**CASE DISCUSSION**

**Development of Symptoms**

Belinda was a 52-year-old primary school teacher. Two years ago she became depressed after her father died of lung cancer. The grief reaction of the first 6 months after his passing seemed to exacerbate after the onset of her menopause at that time. Her family practitioner diagnosed a mixed affective disorder in that she displayed quite high levels of anxiety as well as depression. She suffered morbid thoughts but no active suicidal ideation. Along with the depression, she began to develop disturbing sensations in her genital area. These included a sensation as if she were sexually aroused. She found these feelings highly distressing inasmuch as she had had no sexual interest since her father died. Belinda was at this stage too ashamed to reveal or discuss this issue with anyone.

The sensations "rippled" up and down her genital area all day long and kept her awake much of the night. Although she found it difficult to precisely describe the sensations, they included a "tingling" and almost "pain-like congestion" quality. At times, she felt 254

she was very close to orgasm, so she tried clitoral stimulation to see if that would help.

Orgasm relieved the uncomfortable sensations for 1–2 minutes but seemed to initiate muscle "twitching" just inside the outer genital area that was equally distressing. Two to 3 minutes after orgasm, Belinda found herself back with both the distressing genital sensations and the muscle twitchings. Many days she masturbated up to 30 times in a row.

Belinda felt that these sensations "hounded " her and that her genitals were about to explode. She felt that they had taken over her thoughts and her life and often thought of nothing else. The more tense she got, the worse they became.

Her general practitioner prescribed sertraline at this point. Her depression gradually improved over 8–10 weeks. However, her genital sensations continued with the same frequency and intensity. She eventually discussed her symptoms with one of the doctors in her general practice, who was sympathetic but confessed she did not know what the cause of her problem might be. At this point she came to see one of us, having looked up what her condition might be on the Internet.

**Belindas Background**

Belinda was born and brought up in northern England. Her parents were Catholic but had very broadminded and liberal views on most matters, including sex and sex education. She had no significant physical illness in childhood but suffered from enuresis till age 9. Looking back over her adolescent and teenage years, she felt she was very shy and thought she might have had panic attacks in her early 20s. She went to a Catholic school where she was very happy and achieved high marks, studying art at a university and then going on to teachers training college, where she met her first husband, Tom, also a teacher. She describes him as very attractive and very sexually needy, from the outset having to have sex every night when possible. In the first 2 years of their relationship, she mostly enjoyed this, but once the children came along and she

"had two jobs—one at work and the other at home," she began to dread sex. In many other respects, he was a caring father and husband but seemed to "thoughtlessly and selfishly demand sex"—although when he did so it was not rough but rather an emotionless event for Belinda. This went on for 20 years, at which time she was 43 and felt she could no longer live with him. Her three children had by this time all grown up and left home.

At age 45 she met Joe, her second husband, who was a year younger than she. She said she was emotionally very close to him and that their sexual life was consensual, although for Belinda intercourse was more of an emotional than a sexual event.

However, at times when she made love with Joe she found herself thinking about sex with Tom and "froze up." She told Joe about this, and he reacted in a "very understanding way."

**Assessment**

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On direct questioning Belinda still reported high anxiety levels with occasional panic attacks. She had a somewhat perfectionistic personality (e.g., she liked the house very tidy) but no overt obsessional–compulsive illness and had no features of depression.

Her genital symptoms were continuously present in the background but became worse at night, preventing and interrupting sleep. Once every week or so the symptoms reached a peak, when she had to clitorally stimulate herself to orgasm repeatedly over a period that lasted up to 5 hours (her "sorting out"), after which she was exhausted but symptomatically much improved. Because of her genital symptoms, she had to take a long-term sick leave from schoolteaching.

Belinda did not have restless legs or urinary symptoms, had no other illnesses, and had sustained no pelvic or head trauma. External genital examination appeared normal apart from a small patch of psoriasis on the left labium majus. There was no allodynia in the vulvar vestibule but definite hypersensitivity on cotton bud testing of the periclitoral and suprapubic area. Digital palpation of the left pubococcygeus muscle showed it to be hypertonic and tender.

Pelvic ultrasound was normal, as was a gadolinium-enhanced MRI scan of the pelvis

—no incompetent veins, pelvic masses, or visible pathology along the path of the pudendal nerve. An MRI of the brain and spinal cord, as well as an EEG, were normal. A full blood count, thyroid, renal, and liver function tests were normal. Hormonally she presented a postmenopausal picture.

**Therapy**

The patients dose of sertraline was increased to 40 mg per day. This and adding, in sequence, amitriptyline, nortriptyline, and quetiapine did not help and caused major side effects, so none of these medications were continued. Varenicline was not given because of her history of depression. Gabapentin (300 mg at night) was well tolerated but caused somnolence, which was a therapeutic advantage. TENS also proved unhelpful. Hormone replacement therapy given for 6 months was also unhelpful. She had sessions with a pelvic floor physiotherapist but did not find these helpful.

Belinda also undertook sessions in CBT. The likely pathology of PGAD was explained insomuch as it might be seen as a pudendal/clitoral nerve neuralgia that was exacerbated by stress and fear of the condition itself. The sensations coming from the genital area, it was explained, could be modified by a positive emotional and affective outlook on the issue. Pleasant imagery was taught for her to use when the PGAD

symptoms became very severe. Cognitive restructuring was also initiated, so that negative cognitions (e.g., "PGAD is taking over my life") were replaced with more positive ones (i.e., "I can have a productive and enjoyable life in spite of having PGAD").

During therapy she was taught to use this type of thinking over increasingly large parts of the day.

She was also taught mindfulness meditation in the clinic, as well as by book and CD

(Williams, Teasdale, Segal, & Kabat-Zinn, 2007), and practiced it for 30 minutes a day.

This was done by learning to focus on both her breath and other parts of her body.

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Distracting thoughts and feelings were to be seen as important in that they were to be observed, followed by a gentle return to the focus of the meditation. Belinda also spent 15 minutes a day mindfully looking at the PGAD itself—examining its exact site, texture, and radiation. Once again, she was taught to observe the thought that came with the PGAD (e.g., "PGAD is so awful—can I cope?") and to observe these cognitions for 1–2 minutes and then compassionately and gently return to the focus of the meditation.

In terms of the unwanted sex with her first husband, she did 10 sessions of revisiting, reexperiencing, and reprocessing these events with an expert in psychological trauma therapy (Littrell, 1998). Six months later Belinda was back at work teaching and was, on the whole, enjoying life. She was much better at coping with the PGAD during the day and slept well by night. She reported being much less anxious and had not had a panic attack. However, she still had to spend up to 5 hours about once a week "sorting out."

Intercourse continued as an emotional but not a sexual event for her. However, there were no longer psychological "freeze ups."

This case history reflects many of the typical features of the cases of PGAD that we have treated. The range of comorbid problems and reactions to different therapies is, however, very wide. Some women suffering with PGAD do not have antecedent or current psychiatric problems or past unwanted sex. Others are similar to Belinda. Some respond remarkably well to simple mindfulness-based CBT; others refuse all psychological therapies and demand medication. A few of our patients have done so well that they no longer require our care. However, the majority continue to see us, albeit with some degree of improvement in the quality of their lives.

**CONCLUSIONS**

Without the groundbreaking work of Sandra Leiblum and Sharon Nathan (2001), we probably would not have a label for the problem of PGAD, and this chapter would not exist. Although it is still not clear whether PGAD is a unitary syndrome, we are now in a position to investigate this issue and some of the explanatory mechanisms that have been proposed. It is hoped that the chapter on PGAD in the next edition of Principles and Practice of Sex Therapy will report significant therapeutic advances.

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**CHAPTER 13**

Nonparaphilic Hypersexuality Disorders

Martin P. Kafka

**I** n recent years, there has been a veritable explosion in therapeutic approaches, self-help books, and groups aimed at the treatment of "sexual addiction." In this chapter, Kafka uses the term "nonparaphilic hypersexuality disorder" to describe this phenomenon, while leaving aside the issue of cause. Hypersexual disorders (HDs) feature

"disinhibited or exaggerated expressions of human sexual arousal and appetites. . . . involving sexual behaviors that are culturally considered within the range of normal or conventional." According to Kafka, HDs and paraphilias are

"arguably the most shame- and guilt-inducing contemporary psychiatric conditions." HDs are often kept secret from the persons partner and friends, and its clinical presentation is often masked, appearing paradoxically as low desire. Kafka describes how the symptom constellation of HDs is actually quite complex and that these problems are often accompanied by paraphilias, severe relationship distress, and comorbid psychiatric conditions, such as bipolar disorder, depression, anxiety, and attention-deficit/hyperactivity disorder (ADHD). Given this complexity, treatment cannot be a prepackaged in a one-size-fits-all approach. Sex therapy will often be the point of entry for an individual or couple struggling with HD, but medication, self-help support groups, behavior therapy techniques, couple therapy, and individual psychotherapy will often be part of the treatment armamentarium.

**Martin P. Kafka, MD,** is a Clinical Associate Professor of Psychiatry at Harvard Medical School in Boston, Massachusetts, a Senior Clinical Associate at McLean Hospital, Belmont, Massachusetts, and a Distinguished Life Fellow of the American Psychiatric Association. He was a member of the DSM-5 Sexual and Gender Disorders Work Group. In 2010, Dr. Kafka was awarded the Carnes Award for achievement by the Society for Sexual Health.

**HISTORICAL OVERVIEW**

Nonparaphilic hypersexuality disorders are disinhibited or exaggerated expressions of human sexual arousal and appetites. In contrast to paraphilic disorders, a group characterized by unconventional or even "deviant" sexual arousal, nonparaphilic hypersexuality disorders are "normophilic," that is, involving sexual behaviors that are culturally considered within the range of normal or conventional. The modern clinical view of these disorders dates from the late 19th century, with the pioneering work in Europe of Richard von Krafft-Ebing (1886/1965), Havelock Ellis (1905), and Magnus Hirschfeld (1948). These investigators observed a spectrum of persistent, socially deviant sexual behaviors that we now call paraphilias (PAs). They further noted clinical examples of males and females whose nonparaphilic sexual appetites, including compulsive masturbation, appeared insatiable. Their clinical characterizations were amplified in the 20th century with other disorders, such as protracted promiscuity, identified as "Don Juanism" or satyriasis in men and nymphomania in women.

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**CONTEMPORARY CLINICAL CONCEPTUALIZATIONS OF**

**NONPARAPHILIC HYPERSEXUALITY**

In 1978, Orford suggested that excessive sexual appetites and activities, including promiscuity, could be understood as a syndrome with many resemblances to addiction, even in the absence of an actual substance being abused (Orford, 1978, 1985). The clinical concept of "sexual addiction" was further popularized by the publication of Carness descriptive book Out of the Shadows: Understanding Sexual Addiction (Carnes, 1983) and other publications (Carnes, 1989, 1990, 1991). The clinical term has been enthusiastically embraced by the popular press. It has particularly struck a chord with people who feel themselves subject to either repetitive paraphilic or nonparaphilic hypersexual behaviors that they find difficult to control and that lead to undesirable and significant psychosocial consequences.

The term "sexual compulsivity" was introduced by Quadland (1985) around the time of Carness first publication. He suggested this term to describe volitional impairment associated with nonparaphilic hypersexual behavior. His term has subsequently been taken up as a descriptor for both paraphilic and nonparaphilic sexual behavior disorders by a number of investigators (Coleman, 1986, 1987; Anthony & Hollander, 1993; Black, 1998; Black, Kehrberg, Flumerfelt, & Schlosser, 1997). The applicability to both paraphilic and nonparaphilic disorders has been the subject of some debate (Coleman, 1986), with the upshot that a hybrid term, "sexual compulsivity/addiction" (or the reverse), is now used to cover both cases (Shaffer, 1994).

Kinsey Institute researchers have outlined a theoretical model for sexual appetite and have illustrated its applicability to nonparaphilic "out-of-control" sexual behaviors (Bancroft & Vukadinovic, 2004). Bancroft and associates put forward a dual-control model of sexual arousal (Bancroft & Janssen, 2000) that postulates a centrally mediated homeostasis between sexual excitation and sexual inhibition in males and females. They have developed a validated scale of proneness to excitation and inhibition to assess how social or clinical groups might differ in these regards. In this view, "sexual risk takers"

would show low inhibition or high excitation or both and would thus tend in particular toward promiscuous behavior. They concur with other investigators (Carnes, 1989; Coleman, 1987; Kafka, 1991) that "negative" mood states, especially anxiety and depression, can be associated with both sexual promiscuity and increased masturbation (Bancroft, Janssen, Strong, Carnes, et al., 2003; Bancroft, Janssen, Strong, & Vukadinovic, 2003). They have applied their model and rating instruments to a small group of "sexual addicts" and found that those self-identified persons had low sexual inhibition and high sexual excitation and that these characteristics were associated with anxious/depressive mood states (Bancroft & Vukadinovic, 2004).

I have suggested the term "paraphilia-related disorder" (PRD; Kafka & Hennen, 1999; Kafka & Prentky, 1994, 1998) for specific nonparaphilic hypersexual conditions.

Unlike "impulsivity," "compulsivity," or "addiction," this term is not bound to explanatory models for these specific actions and behaviors. Nevertheless, it acknowledges that such behaviors, although not socially deviant, may share many of the 260

same clinical characteristics as the family of paraphilic disorders.

Following the DSM nosology (American Psychiatric Association, 2000), PRDs like PAs, persist for at least 6 months, are manifested by intense and arousing sexual fantasies, urges, and activities, and produce personal distress or significant psychosocial impairment (Kafka, 2007).

In organized American psychiatry, sexual deviations were recognized as personality disorders in the second edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-II; American Psychiatric Association, 1968), but that document made no mention of nonparaphilic hypersexuality disorders. By 1980, however, DSM-III (American Psychiatric Association, 1980) had subclassified paraphilic disorders as distinct pathologies, that is, as sexual disorders. Don Juanism and nymphomania were included as psychosexual disorders not otherwise specified. In DSM-IV (American Psychiatric Association, 1994) and DSM-IV-TR (American Psychiatric Association, 2000), there were no specific designations describing paraphilia-related disorders, although sexual disorders not otherwise specified (302.9) includes a condition described as "distress about a pattern of repeated sexual relationships involving a succession of lovers who are experienced by the individual only as things to be used" (American Psychiatric Association, 2000, p. 582)

Over the past 30 years, sufficient empirical data have been published from these aforementioned clinical perspectives to allow the formulation of a composite diagnostic entity, hypersexual disorder (HD) (Kafka, 2010), which was proposed for but not included in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013). The most current formulation for HD is presented in Table 13.1.

**TABLE 13.1.** **Proposed Diagnostic Criteria for Hypersexual Disorder** A. Over a period of at least 6 months, recurrent and intense sexual fantasies, sexual urges, and sexual behavior in association with four or more of the following five criteria:

1\. Excessive time is consumed by sexual fantasies and urges, and by planning for and engaging in sexual behavior.

2\. Repetitively engaging in these sexual fantasies, urges, and behavior in response to dysphoric mood states (e.g., anxiety, depression, boredom, irritability).

3\. Repetitively engaging in sexual fantasies, urges, and behavior in response to stressful life events.

4\. Repetitive but unsuccessful efforts to control or significantly reduce these sexual fantasies, urges, and behavior.

5\. Repetitively engaging in sexual behavior while disregarding the risk for physical or emotional harm to self or others.

B. 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, and behavior.

C. These sexual fantasies, urges, and behavior are not due to direct physiological effects of exogenous substances (e.g., drugs of abuse or medications), a co-occurring medical condition, or to manic episodes.

D. The person is at least 18 years of age.

Specify if:

Masturbation

Pornography

Sexual behavior with consenting adults

Cybersex

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Telephone Sex

Adult entertainment venues/clubs

Other:

Specify if:

In remission (no distress, impairment, or recurring behavior for 5 years and in an uncontrolled environment) In a controlled environment

Note. Copyright 2013 by the American Psychiatric Association. Reprinted by permission.

The diagnosis of HD was constructed from the in-common core factors derived from the most rigorously validated and reliable rating scales published in refereed Journals.

Rating scales included the Sexual Compulsivity Scale (Kalichman & Rompa, 1995), the Sexual Addiction Screening Test (Carnes, 1991), the Kinsey Institutes rating scales (Janssen, Vorst, Finn, & Bancroft, 2002a, 2002b ), the Compulsive Sexual Behavior Inventory (Coleman, Miner, Ohlerking, & Raymond, 2001), and, most recently, the Hypersexual Behavior Inventory (Reid, Ganes, & Carpenter, 2011). In an independent multicenter field trial testing how well these proposed criteria "fit" persons seeking treatment for "sexual addiction" or "hypersexual behavior," Rory Reid and associates reported robust reliability and discriminative validity administering a rating scale devised directly from the specific HD criteria and administered to men seeking such treatment (N = 152) in comparison with those with nonsexual psychiatric disorders (N

= 35), as well as substance abuse disorders (N = 20; Reid et al., 2012). The diagnostic criteria for HD also were significantly associated with theoretically related measures of hypersexuality, impulsivity, emotional dysregulation, and stress proneness. Patients assessed for HD also reported a vast array of consequences for hypersexual behavior that were significantly greater than for those diagnosed with a general psychiatric condition or substance-related disorder. The behavioral specifiers that would accompany the diagnosis of HD are also behaviors described in the sexual addiction, sexual compulsivity, paraphilia-related disorders, and other hypersexual behavior empirical literatures.

There has been recent controversy as to whether HD is really just "sexual addiction"

but with a new appellation. DSM-5 is intended as an "atheoretical" text, listing disorders in broad categories until the etiology of a specific disorder has been clearly elaborated.

At present, the etiologies of paraphilias or HD are unknown. It should be noted, however, that the five proposed "A criteria" for HD (see Table 13.1) are all compatible with the definition of a dependence syndrome or a behavioral addiction (e.g., as in psychoactive substance dependence in DSM-IV). The rating instruments reviewed to synthesize HD, however, do not sufficiently measure important domains associated with addictions, such as behavioral tolerance (e.g., escalation of behaviors or increased risk taking) and withdrawal phenomenology. This does not mean that these phenomena do not clinically exist; we need carefully constructed rating scales to look at these phenomena to see how frequently they can accompany HD behaviors and how to best operationalize these phenomena. There are both similarities and differences between pathological gambling and HD and whether HD behavioral addiction requires further research (Kor, Fogel, Reid, & Potenza, 2013).

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Although HD was considered for placement in the section of DSM-5 saved for newly proposed psychiatric disorders that require more empirical research, it was ultimately rejected for such placement. Researchers and clinicians should further explore the clinical utility of the proposed diagnostic criteria, as well as investigate aspects such as family history, specific developmental vicissitudes, and neurobiological components. It would also be important to obtain larger epidemiological studies to assess whether the proposed criteria for HD adequately discriminate prospective patients from those who do not have a nonparaphilic sexual impulsivity disorder. For example, would there be a high false-positive diagnosis of HD among adolescents in a large nonpatient community sample? As has been stated so commonly in published journal articles, "more research is needed" to establish the diagnostic reliability and validity of HD. This adage is particularly true when constructing a psychiatric disorder characterizing sexual behavior in general and normophilic sexual behaviors specifically.

The failure of HD to achieve any designated placement in DSM-5 leaves clinicians in a quandary of how to adequately diagnose or categorize persons who would otherwise have been designated by sexual disorder not otherwise specified, a residual diagnostic category, in Prior DSM editions. While HD is not a sexual dysfunction nor a paraphilia, it can be considered an impulsivity disorder and thus can be diagnosed as "Other Specified Disruptive, Impulse-Control, and Conduct Disorder: hypersexual disorder"

(ICD 312.89) (American Psychiatric Association, 2013, p. 479). For physicians who favor other designations for nonparaphilic sexual behavior disorders requiring clinical assessment and treatment or who have patients who do not meet criteria for HD, the ICD 312.89 code can be followed by other clinical descriptors, such as, but not limited to, sexual addiction/compulsivity, or nonparaphilic hypersexual behavior.

In the following sections of this chapter, I use the term HD when its use would appear consistent with the rejected DSM-5 proposal.

In men (and presumably in women), HD shares some clinical characteristics that are also associated with paraphilic disorders. First, although the male–female prevalence ratio of HD, estimated at 5:1 (Black et al., 1997; Carnes & Delmonico, 1996), is not as high as the estimated ratio for paraphilias (20:1; American Psychiatric Association, 1987, 1994), HD and PAs are still predominantly male disorders. Second, PAs and HD

both show themselves during adolescence (Abel, Mittleman, & Becker, 1985; Black et al., 1997; Kafka, 1997). Third, several empirical studies have reported that people presenting for treatment of sexual impulsivity disorders (Abel, Becker, Cunningham-Rathner, Mittelman, & Rouleau, 1988; Freund, Sher, & Hucker, 1983; Carnes, 1983, 1989, 1991) commonly report having multiple rather than single hypersexual outlets over their lifetimes. These studies reveal a general diathesis or vulnerability to PAs and/or HD.


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Response:
Fourth, although many studies of paraphilic sex offenders do not systematically assess HD, nevertheless HD may be common among males with PA (Anthony & Hollander, 1993; Black et al., 1997; Kafka & Hennen, 2003; Kafka & Prentky, 1998; Levine, Risen, & Althof, 1990). Fifth, men and women with HD, as well as those with PAs, describe their sexual behavior as obligatory, repetitive, and stereotyped at times. In addition, sexually arousing fantasies, urges, and behaviors can be time-consuming, often occupying several hours per day (Black et al., 1997; Carnes, 1983; Kafka, 1997). Sixth, like paraphilic 263

arousal (American Psychiatric Association, 2000), HD can wax and wane, be either ego-syntonic or ego-dystonic, and is more likely to occur or intensify during periods of

"stress" (Black et al., 1997; Reid, Carpenter, Spackmen, & Willes, 2008). Seventh, men with PAs or PRDs (HD) are equally likely to report periods of persistently heightened sexual behaviors leading to orgasm, compared with the general population (Kafka, 1997; Kafka & Hennen, 2003). Last, as with PAs, people with HD may come to prefer unconventional sexual activities to sex with a partner. This may lead to extramarital activity, reliance on masturbation, and /or severe relationship problems.

The frequency distribution of HD in females is less thoroughly studied, although compulsive masturbation, protracted promiscuity (including prostitution), and the paraphilia of sexual masochism have been reported. Carnes, Coleman, and others describe pathological "crushes," "obsessional fixations," or "love addictions" (Carnes, 1991; Kasl, 1989; Schaef, 1989) as predominant female expressions of sexual compulsivity/addiction. Currently, however, there is a substantial lack of empirical data on these conditions. For example, it is not evident whether these are primarily genital/sexual behavior disorders or, perhaps, attachment disorders or obsessional symptoms not primarily mediated by sexual appetitive behavior.

**CLINICAL AND DIAGNOSTIC ASSESSMENT OF HD**

**General Principles**

Several principles are of particular relevance in the evaluation and treatment of HD.

First, PA and HD behaviors are secretive because they engender considerably more shame, guilt, and blame than other sexual disorders. Indeed, these sexuality disorders are arguably the most shame- and guilt-inducing contemporary psychiatric conditions.

Sometimes it may take years before a person with these conditions acknowledges them to a professional or is "caught" by a spouse or significant other engaging in an unconventional sexual behavior. Thus the first principle for the evaluation of HD (or paraphilias) is to ask specific clinically relevant questions and to inquire without a spouse or significant other present. In this regard, I always inform patients that when I ask them personal questions about sexual behavior, it is because sexual disorders are highly misunderstood by the lay public and are, in fact, readily treatable conditions. I suggest that the failure to address and diagnose these conditions during the early part of evaluation and treatment can lead to misdiagnosis, costly and unproductive psychotherapy, and an incomplete understanding of the causes of a persons suffering.

This helps to establish a rationale for self-disclosure early in the process of evaluation or treatment of both PAs and HD. A clinician can inquire about problematic sexual behavior by referring to the proposed criteria for HD in a safe, clinical context. For a full assessment and treatment algorithm, see Figure 13.1.

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**FIGURE 13.1.**Assessment–treatment algorithm for hypersexuality disorder.

**The Importance of Assessing Comorbidity**

In the few studies that systematically evaluated psychopathology-related diagnoses in

"sexually compulsive" males and females (Black et al., 1997, Morgenstern et al., 2011), paraphilia-related disorders (Kafka & Hennen, 2002; Kafka & Prentky, 1994, 1998), or nonparaphilic HD (Reid, Carpenter, et al., 2011), one of the major findings is that most individuals with these disorders have multiple lifetime comorbid disorders, especially mood, anxiety, and psychoactive substance abuse disorders and ADHD. Anxious and depressive affect (as opposed to specific clinical disorders) can be associated with sexual risk-taking behaviors and "out-of-control" sexual behaviors in both heterosexual and homosexual men (Bancroft, Janssen, Strong, Carnes, et al., 2003; Bancroft, Janssen, Strong, & Vukadinovic, 2003; Bancroft & Vukadinovic, 2004).

The clinical implications of these reports are significant for several reasons. First, these findings strongly suggest that all persons, male or female, who seek evaluation for 265

a sexual behavior disorder should be systematically questioned about symptoms consistent with dysthymic disorder, bipolar spectrum disorders such as cyclothymia and bipolar disorder—not otherwise specified, and social anxiety disorder, as well as ADHD.

The appropriate assessment of these conditions requires retrospective as well as current symptom ascertainment. In addition, many persons with current psychoactive substance abuse may deny the severity of their use of these substances. Thus the concurrent presence of these clinically significant and common comorbid psychiatric conditions may be undetected and thus untreated. Comorbid psychiatric conditions may be risk factors that substantially contribute to the onset, severity, escalation, and social deviance of hypersexual behaviors (Kafka & Prentky, 1998).

**Comorbidity with Other Sexual Disorders**

The coassociation of PAs with HD has already been mentioned. In addition, both males and females with HD commonly report reduced sexual arousal to "conventional"

partnered sex, especially when the initial infatuation phase of a relationship has passed.

In these circumstances, patients with HD may present to psychotherapists and sex therapists with apparent hypoactive sexual desire disorder, acquired and situational subtypes. In addition, diminished sexual arousal in a current relational context could present as female arousal disorder, male erectile disorder, and, perhaps, sexual aversion.

Thus it is imperative to take a full sexual history of patients who present with these sexual dysfunctions as a primary complaint to rule out the presence of paraphilic or nonparaphilic hypersexuality disorders.

**HD, General Medical Conditions, and Drugs/Medications**

When it can be clearly established that hypersexual behaviors or HD are temporally associated with another concurrent medical or neurological condition, the diagnosis of HD should not be made independently of the medical condition or medication. Medical conditions that may be associated with hypersexual behavior can include, but are not limited to, brain injury, dementias, Huntingtons disease, and Kleine–Levin syndrome.

Medications or drugs that increase dopamine in the brain can be associated with hypersexual behavior. For example, amphetamine stimulants, cocaine, and medications associated with the treatment of Parkinsons disease can be associated with sexual disinhibition.

**The Pair Bond**

Although there are no compelling data showing that contemporary relationship dysfunction is a primary etiological factor for HD, the presence of a meaningful pair bond can have profound effects on the clinical course and outcome of treatment. Both 266

PAs (Marshall, 1989) and HD have been described as intimacy dysfunctions by many clinicians (Carnes, 1991; Coleman, 1995; Schneider & Schneider, 1991). At least some significant others, characterized as "codependents," suffer from low self-esteem, depression, overly dependent behavior, "enabling behaviors" (e.g., protecting the identified patient from the brunt of the consequences of his or her behavior), and comorbid impulse-control disorders (Schneider & Schneider, 1991) prior to the disclosure or discovery of a PRD in their partners.

Certainly, the sudden personal disclosure or unexpected discovery of a nonparaphilic (or paraphilic) disorder in a partner during a stable pair-bonded relationship can have devastating consequences because mutual trust has been severely breached. It is clinically helpful, whenever possible, to include the significant other during the assessment process and/or early treatment phases to assess the impact of disclosure on the pair bond and to attempt to contain the relationship crisis that invariably follows disclosure. It may be helpful to send the affected partner for individual or group therapy if conjoint treatment is not feasible. In particular, when protracted sexual promiscuity (sexual behavior with consenting adults) is an identified HD, assessment for sexually transmitted diseases should be prescribed for the identified patient and, if indicated, for the significant other, especially if identified problematic behaviors included unprotected sex. There may be certain clinical situations, however, in which the identified patient is unwilling to include the significant other. For example, he or she may still be unaware of the sexual disorder or too emotionally unstable to tolerate disclosure, or imminent disclosure would almost certainly be followed by divorce or its equivalent.

The extent and timing of disclosure of nonparaphilic hypersexual behaviors in an intimate partnership should be subject to joint negotiation. Both Schneider (Schneider

& Schneider, 1991) and Corley (Corley & Schneider, 2002) reported that the honesty that follows full disclosure is most likely to lead to the best marital outcome but that the reestablishment of trust might take years.

**TREATMENT MODALITIES FOR HD**

Some general principles associated with the evaluation and treatment of HD are enumerated in Table 13.2.

**TABLE 13.2.** **Selected Pertinent Psychological or Behavioral Domains to Be Addressed during the Evaluation** **and Treatment of HD**

A. Gaining control over hypersexual symptomatology:

Psychoeducation about what we know and what we dont know about these conditions and their psychiatric and developmental comorbidities

Discussion of the range of available therapeutic strategies and selective referral to cognitive and behavior therapies, support groups, marital therapy, and/or pharmacotherapy

Collaborative limit setting to establish a "bottom line" to hypersexual behavior that the patient can work toward

Negotiating the use of phone blocks; discarding paraphernalia such as pornography; canceling 267

subscriptions for pornography;installing password protection pornography blocking software; holding or discontinuing credit cards; using an Internet censor with password controlled by partner, family member, or therapist; moving a computer out of a private setting; consider eliminating Internet access completely Facilitating decisions about self-disclosure/trust in revealing the details of hypersexual activities to a significant other, involvement of partner if indicated

Psychotherapeutic interventions that specifically target current sexual symptoms in preference to early developmental conflicts

Encouraging involvement in 12-step recovery programs

B. Here-and-now issues

Destigmatization: discussing the paradigm shift from "badness" to "illness" to diminish blame, shame, and guilt

Clarification of thoughts, affects, behaviors, and common precipitating stressors that might precede hypersexual behaviors

Developing alternative response strategies for managing dysphoric affects that precede both covert and overt problematic sexual behaviors

Maintenance of interpersonal boundaries to reduce stressors: assertiveness training, social skills training, relaxation/meditation, recognition and modulation of stressful affects

If involved in a 12-step group program: establishing a sponsor, monitoring attendance and a bottom line, encouraging and reviewing progress with the 12-step methodology

Consideration of 6 months of celibacy as a personal growth experience

Psychoeducation regarding a "healthy" sexual relationship: how to develop and maintain intimacy, how to remain single but not be depressed or lonely, what healthy sexuality is

Mourning a lifestyle of hypersexual behaviors: the role of suffering, pleasure, and escape from painful affects

If referred for pharmacotherapy: monitor changes in sexual arousal and impulse control, assess concurrent depressive and anxious symptoms, collaboration with other treaters

C. Developmental factors (issues preferably managed after symptom stabilization) Coming to terms with family dysfunction; identification of the role of psychiatric illness in family members Events that may have shaped early sexual behaviors, including emotional, physical or sexual abuse or neglect, premature sexualization in relationships

The development and elaboration of the "false self" or "double life" to compartmentalize nonparaphilic hypersexuality and manage painful affects

Possible psychodynamic or behavioral contexts for the meaning and perpetuation of sexual symptom formation

Assessing the developmental effects of concurrent psychiatric diagnoses

**Psychodynamic Psychotherapy**

At present, there is no compelling empirically derived evidence to suggest that individual psychodynamic therapy as the solitary treatment modality is effective for either PAs or HD. Psychodynamic psychotherapy, however, may help to synthesize the role of developmental antecedents; reduce current anxiety, depression, guilt, and shame; and improve social adjustment. As is commonly the case for the treatment of PAs, multimodal treatment approaches utilizing behavioral, psychodynamic, group, psychoeducational, and pharmacological treatments are commonly prescribed and tailored to the specific needs of the patient or couple. The informed individual psychotherapist, regardless of theoretical persuasion, may function as the person to select and integrate different therapeutic interventions, akin to the model of "primary-care therapist" advocated by Khantzian (1986) for the recovering substance abuser. In 268

the sexual addiction literature, the most commonly prescribed combination of therapies associated with successful outcome are 12-step group therapy (see the following section) and individual psychotherapy with a clinician familiar with sexual addiction as a conceptual framework (Carnes, 2004).

**Group Psychotherapies**

Men with HD have been treated with therapist-led group psychotherapy. Quadland (1985) reported favorable outcome in 30 gay or bisexual men enrolled in a semistructured 20-week group therapy program with a goal of controlling protracted promiscuity. Earle and Crow (1989) and Turner (1990) report the use of outpatient group psychotherapy with "sexual addicts," but no outcome was included. A model for outpatient group therapy combining psychodynamic and cognitive-behavioral techniques has been reported as well (Line & Cooper, 2002).

**Case 1: Sam**

Sam was a 33-year-old married man who was referred by an experienced psychotherapist after many years of sexual addiction treatment, including active participation in 12-step programs. Although Sam was "better" and "understood some of my triggers," he episodically continued to engage in promiscuous behaviors with women. His wife was aware of his problem and history of treatment and stayed married because "I am a good father." Their relationship, although still affectionate, no longer included sexual relations.

Sam grew up in a household in which there was significant interpersonal turmoil. His mother was likely depressed, and his father had unpredictable moods, punctuated by bouts of alcohol intoxication. At times, his father unleashed harsh and undeserved criticism, especially at Sam, such that Sam withdrew from his dad but also felt little support from his mother. The father eventually sobered up but was characterized as a

"dry drunk" by Sam and his younger sister.

Sams escape from his dysfunctional family was his ability to do well in school and have active friendships. Known for his creativity and general high energy, Sam graduated from a distinguished business school, joined a start-up technology group, and was financially successful. At business meetings he was described as a natural leader, although he could be narcissistic and argumentative when he perceived that his peers were "not as bright."

Sams promiscuous behavior started in college and had included one-night stands with peer females, progressing to escort services once he was in business. Typically he planned and looked forward to having sex with women, sometimes staying up the night before checking out ads on the Internet for sexual services. When he traveled for business, he almost always looked to hook up with either women he met through business or escort services. His addiction could cost over $2,000 some months, but he 269

used a separate credit card until his wife discovered some of his receipts. He rarely sought out pornography and was not an enthusiast for masturbation, either.

A careful psychiatric evaluation of Sams developmental and behavioral symptoms revealed that he had had two past episodes of major depression. His promiscuous behavior appeared associated with either an anxious/depressive mood state or bursts of increased energy, increased talkativeness, and "racing thoughts" lasting 1–2 days. It was hard to sort out whether these "energy bursts" were caused by his anticipated sexual trysts, but he also recalled other such periods when he was working on business plans and could get by with less sleep for up to 3 days in a row.

Sams DSM-5 Diagnoses

Other specified bipolar and related disorders: short-duration hypomanic episodes and major depressive episodes

Other specified disruptive, impulse-control, and conduct disorder: hypersexual disorder, sexual behavior with consenting adults

TREATMENT

Sams treatment with me was limited to pharmacological management of a bipolar mood disorder associated with the bipolar spectrum. He was prescribed lamotrigine, a limbic anticonvulsant mood stabilizer. He began to notice a calming effect on lamotrigine 100 mg/day but the optimal effect when a daily dose of 200 mg/day was reached. He described improved emotional resilience and greatly improved ability to think before he made plans, whether it was at business meetings or fantasizing about having a sexual liaison. Unexpectedly, with the help of his individual psychotherapist, he was better able to emotionally process how much damage he had perpetrated on his wife over the years through his persistent philandering. He was ready to join a therapist-led group with other men who had similar sexual impulsivity disorders. Both psychotherapies contributed to his ability to address issues associated with narcissism, self-esteem, and the compartmentalization of his emotional life. In 1 year at follow-up he reported only one slip—while away on a business trip.

After 6 months of abstinence from sexual impulsivity, Sam wanted to taper lamotrigine. He did so slowly with check-ins to my office. He noticed increased emotional lability, and he self-monitored his emotional states, made sure he had regular and sound sleep, and learned to moderate his mood swings with mindfulness techniques. After an additional year of follow-up, he had not had a recurrence of promiscuous sexual behavior, and his marriage was substantially mended. He continued in both individual and group therapy.

**Self-Help Groups**

Since the formation of Alcoholics Anonymous and the articulation of the 12-step 270

recovery program, self-help groups based on 12-step methodology have been formed for many forms of impulsive/addictive behaviors, including behavior involving drugs, sex, and food, as well as gambling, kleptomania, and others. These programs can have a profound effect on the process of recovery, especially if the program is zealously adhered to. For example, 12-step recovery programs commonly require daily attendance at a 12-step meeting for the first 3 months of recovery from alcoholism (Galanter, Talbott, & Gallegos, 1990), and recovery from bulimia nervosa (Malenbaum, Herzog, & Eisenthal, 1988) was associated with five or more 12-step meetings per week for at least 3 years.

Although HD does not meet the criteria necessary to qualify as a behavioral addiction, the primary resources available for the treatment of this condition are based in the addiction model. There are now several different 12-step programs for recovering

"sex addicts," some of which are distinguished by geographic location or differing philosophies as to what constitutes "recovery," "abstinence," and "bottom line" in the context of normalizing sexual behaviors (Salmon, 1995). Naditch and Barton (1990) and Carnes (1991) noted a positive long-term outcome associated with 12-step sexual addiction programs in conjunction with individual psychotherapy in a retrospective survey of men and women recovering from both nonviolent PAs and HD. Resources for locating such groups are available via the Internet (e.g., Sexaholics Anonymous, www.sa.org; Sex Addicts Anonymous, http://saa-recovery.org; Sex and Love Addicts Anonymous, www.slaafws.org).

The self-help fellowships for treatment of HD can offer several important advantages.

First, these groups have become increasingly prevalent in many parts of the country, so they are generally readily accessible, especially in metropolitan areas. Second, there is no financial burden associated with this form of treatment. Third, these groups are very helpful in lessening the shame, secrecy, stigmatization, and blame that accompanies nonparaphilic hypersexuality. Fourth, there can be a sense of "healing community" that includes fellowship, spiritual values, association with other persons in recovery, self-help support groups for the "coaddict," and the provision of a sponsor relationship that can include daily check-in phone calls and crisis management. Fifth, in many respects, the program offered by zealous adherence to the 12-step recovery model for sexual addiction or HD bears some resemblance to a relapse prevention program based on cognitive-behavioral therapy (CBT), a model of psychological treatment prevalent for the treatment of sex offenders with PAs (Carnes, 1991; Laws, 1989).

On the other hand, 12-step programs such as Sex and Love Addicts Anonymous (SLAA), Sexaholics Anonymous, and Sexual Compulsives Anonymous require an intensive evening-and-weekend time commitment, a sponsor, the regional availability of appropriate groups, and, most important, a person who is willing to work in an intensive recovery program over a period of several years.

Note that self-help resources are also available for partners of individuals with HD

(e.g., COSA, www.cosa-recovery.org; Recovering Couples Anonymous, www.recovering-couples.org; S-Anon International Family Groups, www.sanon.org). For additional resources for clinicians and patients with HD, please consult the books and websites included in this chapters reference list (e.g., Society for the Advancement of Sexual Health, 2012; Edwards, Delmonico, & Griffin, 2011; Delmonico, Griffin, & Moriarity, 271

2001; Carnes, Delmonico, Griffin, & Moriarity, 2007; Maltz & Maltz, 2008).

**Case 2: Alan**

Alan was a 33-year-old single male who was self-referred after he received a threatening e-mail from a man he had encountered online. They had engaged in cybersex repetitively using web cameras, and the e-mailer threatened to "out" him in his work setting using recordings he surreptitiously kept of Alan masturbating. He demanded $1,000.

Alan was an avid user of cybersex chatrooms and cybertechnology (most typically webcams). He had engaged in these behaviors several times per week for about 5 years.

He stated that he had a high sexual drive but was typically too anxious to meet men in person if his intent was to develop an intimate relationship. Cybersex allowed him to maintain anonymity and reduce his social anxiety but, at least with some men he encountered online, fantasize that he could meet them eventually and have already

"gotten through the preliminaries" of a romantic relationship.

Alan had discovered the world of online sex through lifestyle websites that encouraged him to develop an alternative personality with an avatar. He could build a lifestyle, acquire a home, money, and friends, and engage in sex. Although he was gainfully employed, outside of the work setting he had very few friendships, had only a single former romantic partner, and described feeling anxious and depressed when he

"stepped outside my safety zone." Alan had unsuccessfully tried to meet men at bars and in gay cruising areas, but he was too reticent to come out to his family or work colleagues.

When Alan was unable to meet someone for cybersex chat, he would view gay pornography and masturbate. These were his primary evening activities, sometimes extending into the late-night hours. He was also increasingly concerned because he noted that the pornography that turned him on the most seemed to involve younger males, some perhaps under age 18.

Alan already had an individual psychotherapist, who had counseled him to retain an attorney but to have no contact whatsoever with the man who had threatened him. After beginning to psychologically process the blackmail threat that had been made against him, it dawned on Alan that he had never revealed where he was employed to this particular male and had no Facebook page or other simple means by which his workplace could be readily identified. His DSM-5 psychiatric diagnoses were as follows: persistent depressive disorder: late onset, with pure dysthymic syndrome; mild social anxiety disorder; and other specified, disruptive, impulse-control, and conduct disorder: hypersexual disorder; cybersex, pornography, and masturbation.

TREATMENT

Alan needed "connection" as a primary modality for his treatment. He felt safely 272

connected to his therapist, who had specialized skills with gay men who had sexual addiction. Both his therapist and I made a strong case for his attending local 12-step groups, as he lived in an urban environment and these were readily available. Alan balked at first, but when I asked whether he would begin attending if he were accompanied by another patient in my practice, he agreed. This turned out to be a crucial turning point for Alan, as he was able to attend multiple 12-step groups with many gay males and, especially because this was to be deliberately "unromantic," he began to establish a broader network of platonic friendships. He established his "bottom line" behaviors and was able to abstain from cybersex. One year later he was able to abstain from pornography, except for occasional use.

Eventually the 12 steps and the strong fellowship that the groups fostered became central to his lifestyle. Over a 2- to 3-year period, Alan matured socially and eventually came out to his family and then to some work colleagues. As his social anxiety decreased, so did his low self-esteem and other depressive symptoms. He did not return to cybersex.

**Cognitive-Behavioral Therapies**

Relapse prevention is an integrated cognitive-behavioral and group therapy treatment approach that originally evolved from a theoretical understanding of and treatment for addictive disorders such as alcohol abuse, nicotine dependence, and compulsive overeating (Marlatt & Gordon, 1980). Several different techniques are used: (1) identifying and modifying cognitive distortions and beliefs that rationalize hypersexual behavior, (2) helping the patient to recognize and then anticipate high-risk situations, (3) identifying specific behavioral-affective-cognitive precursors to relapse, and (4) extensive behavior rehearsal of new comprehensive problem-solving techniques, as well as social and sexual skills training.

The relapse prevention model and accompanying cognitive-behavioral and social learning techniques are now becoming commonly employed in specialized sex offender treatment programs in the United States and Canada. To my knowledge, there are no published data on this comprehensive approach to the treatment of HD.

**Behavioral Therapy Techniques**

Behavioral therapy techniques are used frequently in treatment centers specializing in the assessment and treatment of sexually aggressive persons with PAs. These techniques appear to be applicable to nonviolent PAs and HD as well. Aversive techniques, for example, can be applied to a wide range of human behaviors, including sexual behaviors, when accompanied by the voluntary consent and understanding of the patient.

McConaghy and Armstrong (1985) reported that imaginal desensitization was as effective as covert sensitization in reducing compulsive sexual behaviors in a group of 20

273

men with PAs and HD (promiscuity) at both 1-month and 1-year follow-up.

Olfactory aversion was designed to reduce unconventional sexual arousal with aversive smells, such as ammonia (Colson, 1972). The advantage of olfactory aversion is the immediacy of a powerful noxious odor that can be rapidly introduced during the repetition of specific sexually arousing fantasies. Ammonia aversion utilizes encapsulated ammonia ampoules that are portable and can be broken and inhaled in conjunction with both behavioral homework and in vivo practice in situations that trigger sexual urges. As is the case for any conditioning therapy, aversion therapy requires persistent and repetitive practice involving specific self-identified precursor situations that are sexually arousing.

**Psychopharmacology**

As is the case for the previously mentioned psychological treatment modalities, published data supporting a pharmacological approach for the amelioration of nonparaphilic hypersexuality disorders are scant but encouraging. A persuasive rationale for the use of psychopharmacological agents for these conditions can be based on the clinical evidence of psychiatric comorbidity. There are pharmacological treatments that target specific disorders, such as chronic mood and anxiety disorders and ADHD and nonparaphilic hypersexuality disorders (see the section on comorbidity earlier in this chapter).

In my clinical experience with the pharmacological treatment of more than 500 males with HD who have failed a panoply of psychological treatments, the use of mood stabilizers, antidepressants, atypical neuroleptics, psychostimulants, opiate antagonists, and an orally administered anti-androgen, medroxyprogesterone, alone or in various combinations, can have profound effects in ameliorating nonparaphilic as well as paraphilic hypersexuality disorders (Kafka, 2008) . We do not currently have sufficient outcome data to determine whether these agents need to be prescribed for the short term (e.g., 1 year) while other psychological therapies are ongoing or whether pharmacological therapy requires longer term prescription for the successful continued management of nonparaphilic hypersexuality disorders.

Psychopharmacological treatment for HD should not be reserved only for situations in which other therapeutic endeavors have either failed or been only partially successful.

If an individual is still struggling with strong urges or acting out repetitively despite involvement in therapies to help him stop his destructive sexual behaviors, a psychopharmacological consultation should be considered. The careful diagnosis of chronic psychiatric disorders that have been empirically demonstrated to have a genetic/biological component should be followed by a discussion of all available treatment modalities, both psychological and biological. Since the last edition of this text, my clinical practice has been shaped significantly by referrals of individuals with HD or sexual addiction who have "spectrum" manifestations of bipolar mood disorders in particular. The thorough assessment of such patients requires a clinician to understand that hypomania, the pathognomonic mood state distinguishing bipolar 274

from unipolar mood disorders, is not always easy to detect and has its own spectrum.

Recurrent hypomania can be of brief duration (1–3 days) and is not necessarily associated with elevated mood or euphoria (e.g., it can include irritability and anxiety instead); hypomanic symptoms can co-occur even while a person is dysthymic or having a major depressive episode. Recent research suggests that the hallmark of hypomania is increased energy and activity accompanied by racing or "crowded" thoughts, rather than a specific "elevated" mood state (Judd & Akiskal, 2003; Judd et al., 2003; Benazzi, 2001).

I have noticed several clinical situations in which the apparent mitigating effect of medication is less robust for HD. This outcome can be noted in psychological treatments as well. On closer inspection of patients whose outcomes are less robust, I have repeatedly observed several common clinical concomitants. First, such patients no longer feel as intense an urgency to their sexual desire after pharmacotherapy in combination with psychologival treatments. For example, many are able to willfully control themselves when requested to do so for a period of several weeks. Second, many patients with HD may continue to maintain a reduced frequency of a nonparaphilic sexual behavior when they have no current or regular sexual partners, when the financial cost of the specific outlet is modest, when a sexual dysfunction in a partner precludes sexual intimacy, or when pair-bond intimacy dysfunction that affects sexual relations is apparent. In these situations, the sexual behavior no longer is described as ego-dystonic and therefore may not meet criteria for a "disorder." I see this most commonly with continued pornography use.

**Case 3: Ted**

Ted was a 37-year-old married male whose Internet pornography viewing while at work was discovered when the companys computer operating system was upgraded. He had planned to delete his Internet browsers viewing history, but he had not done so. There was sufficient evidence, along with his general work underperformance, that led to his being asked to take a "medical leave" or be fired. Choosing the former option, Ted was panicked when he called for an appointment. A married man with two young children, he was the family breadwinner and desperately wanted help. He had noted that even after a few weeks of his taking leave, he could not help himself to resist urges at home to view pornography and masturbate while smelling and stroking his wifes underpants.

Ted started masturbating (without ejaculation) while smelling or stroking his older sisters undergarments when he was about age 8. He had viewed his sister scantily clad on only a few occasions but felt an intense urge to steal her underpants. During adolescence and into adulthood, Ted had collected womens panties from girlfriends or by sneaking into the bedrooms of adults when he visited them as an adolescent with his family and he had amassed a small collection. He had intermittently tried to discard them but then would collect others. He was highly aroused by smelling or stroking these underpants, not by wearing them.

During his courtship, Ted had mentioned to his fiancée that he enjoyed viewing 275

pornography and had done so starting in early adolescence. He did not tell her, however, about his fetishistic attraction to female lingerie. Although the majority of his pornography viewing was of adult heterosexuals engaging in diverse sexual activities, he enjoyed looking at and masturbating while viewing female underwear sites online. He denied promiscuous behavior or persistent visits to strip clubs.

Ted was criticized by his father during childhood and adolescence because he underperformed at schoolwork, procrastinated with his homework, and seemed more at ease with action games than interacting with family members. There was no overt abuse or neglect in his family, but an older brother had similar school underachievement problems and barely graduated high school. He had some close male friends and dated girls during high school but "always loved my pornography," at times masturbating at least one to three times a day and sometimes spending 3–5 hours viewing pornography, especially as he had Internet access.

Ted tried college but found the workload too demanding, handed in his assignments and papers at the last moment, and never finished college. His school underperformance was further compromised by smoking marijuana, eventually on a daily basis "to help me concentrate better." Even while married, Ted enjoyed getting stoned on weekends, even though it upset his wife.

Teds marriage had been troubled because, from his wifes perspective, he was self-centered and a poor communicator. She had noted his distractibility and procrastination but attributed those characteristics to his marijuana smoking. She also described increasing social withdrawal, pessimism, irritability, and passivity during the past 3 years. As well, he took to overeating when stressed, so she felt he was less and less physically attractive.

Teds primary DSM-5 psychiatric diagnoses included: attention-deficit/hyperactivity disorder (ADHD), predominantly inattentive type; cannabis use disorder; persistent depressive disorder: late onset, with pure dysthymic syndrome, moderate; fetishistic disorder, nonliving object; other specified disruptive, impulse control, and conduct disorderL hypersexual disorder; pornography and masturbation.

TREATMENT

Ted agreed to attend 12-step support groups (SLAA) but was unable to maintain the bottom line of abstinence from viewing pornography or masturbating while stroking stolen womens undergarments. He stopped using marijuana, to the relief of his wife. He was encouraged to purchase pornography-blocking software, and his wife placed a password on his home laptop computer. He confided with me that he was using his smartphone to access pornography, however, and just couldnt stop himself. He started psychotherapy with an experienced sexual addiction–trained therapist, but he never agreed to give up his smartphone for one without Internet access. He was referred back to me to "treat my ADD." Prescription of a long-acting psychostimulant and a serotonergic antidepressant, sertraline, had substantial effects on improving his emotional resilience and his executive functions. He experienced sufficient relief that he 276

was able to agree to give up a smartphone and redouble his efforts in psychotherapy and 12-step group participation. He called his sponsor to check in regularly. After an additional year of treatment, he was able to use a smartphone without accessing pornography except during unusual stress points in his life. He told me that he had discarded almost all of the underpants he had stashed, although he kept "a few pairs."

He returned to work in another company.

**CONCLUSIONS**

When persons afflicted with HD are effectively relieved of their target symptoms by medications, self-help groups, and/or psychotherapies, it is rare that they miss their sexually impulsive behaviors. They are most often relieved to be more productive, feel less sexually preoccupied, and have more emotional resilience. There is generally no

"symptom substitution" but, rather, a sense of feeling unburdened, perhaps for the first time in many, many years.

In contrast to other disturbances of human sexuality, the status of HD remains controversial because we lack sufficient empirical studies of these behaviors and their treatment outcomes. As a result, these serious conditions are only cursorily addressed in most textbooks and academic courses teaching about human sexuality disorders.

Despite the lack of empirical information regarding nonparaphilic hypersexuality disorders, there is certainly clinical lore evidencing that they are prevalent conditions that may remain hidden from spouses and family members.

It is imperative to form a trusting and collaborative therapeutic alliance and to offer hope and effective treatment modalities to persons impaired by these conditions. As demonstrated by the case examples in this chapter, the successful treatment of these conditions commonly requires more than one type of mental health intervention. As clinicians, then, it behooves us to sustain collegial relationships with a collaborative network of resources and specialized clinicians who may share differing competencies but can work collaboratively.

The healing and recovery period that is necessary when HD has disrupted the pair bond should be measured in years, not months. Marriages and other intimate partnerships need time to heal and reestablish a trusting bond, even if problematic sexual behavior ceases early in treatment. In most cases, especially during the first few years of treatment, we need to speak about "effective treatment" or "control" rather than

"cure" as an outcome measure. In kind, we can analogously think of the successful amelioration of other chronic medical conditions, such as psychoactive substance abuse, obsessive–compulsive disorder, diabetes mellitus, atherosclerotic vascular disease, and hypertension in similar terms.

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