Sexual Addiction: Diagnosis and Treatment

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(This is the second of a two-part series on sexual addiction. Part I appeared in the July issue and presented a theory of sexual addiction-Ed.)

The diagnostic criteria for sexual addiction are derived from the behaviorally nonspecific criteria for addictive disorder that were presented in Part 1 (Goodman, 1998b), by replacing "behavior" with "sexual behavior" (see Table). A definition of sexual addiction, which facilitates preliminary diagnosis of the disorder, can similarly be derived from the simple definition of addiction.

Accordingly, sexual addiction is defined as a condition in which some form of sexual behavior is employed in a pattern that is characterized by two key features: 1) recurrent failure to control the sexual behavior, and 2) continuation of the sexual behavior despite significant harmful consequences. Consequently, sexual addiction is a syndrome in which some form of sexual behavior relates to and affects an individual's life in such a manner as to accord with the simple definition of addiction or to meet the diagnostic criteria for addictive disorder.

Significantly, no form of sexual behavior in itself constitutes sexual addiction. Whether a pattern of sexual behavior qualifies as sexual addiction is determined not by the type of behavior, its object, its frequency or its social acceptability, but by the relationship between this behavior pattern and an individual's life, as indicated in the definition and specified in the diagnostic criteria. The key features that distinguish sexual addiction from other patterns of sexual behavior are: 1) the individual is not reliably able to control the sexual behavior, and 2) the sexual behavior has significant harmful consequences and continues despite these consequences.

Differential Diagnosis

The paraphilic and hypersexual behaviors that characterize sexual addiction also can occur as manifestations of underlying organic pathology. Paraphilic or hypersexual behavior can be a symptom of a brain lesion, a side effect of medication or a symptom of endocrine abnormality.

The differential diagnosis is usually facilitated by the presence of additional symptoms or circumstances that suggest the underlying etiology. Clues that invite an organic evaluation include: onset in middle age or later, regression from previously normal sexuality, excessive aggression, report of auras or seizure-like symptoms prior to or during the sexual behavior, abnormal body habitus and presence of soft neurological signs.

Also of value in determining whether a case of paraphilia or hypersexuality represents sexual addiction are the diagnostic criteria for sexual addiction. Tolerance, psychophysiological withdrawal symptoms on discontinuation of the sexual behavior (usually affective discomfort, irritability or restlessness), and a persistent desire to cut down or control the behavior are generally not observed in patterns of paraphilic or hypersexual behavior that are not part of the sexual addiction syndrome.

The diagnostic criteria for sexual addiction are also useful in distinguishing sexual addiction from nonaddictive patterns of exploitative or aggressive sexual behavior that can occur with antisocial personality disorder.

Obsessions and compulsions with sexual content can occur in obsessive-compulsive disorder (OCD). Sexual obsessions are fairly common in OCD, and were reported in 32% of the patients who were studied by Rasmussen and Tsuang (1986). The content of these obsessions, however, consisted most often not of sexual fantasies, but of fears of acting on sexual impulses or fears of being a pervert. More generally, symptoms of sexual addiction differ from sexual obsessions and compulsions in that the former are associated with sexual arousal and sexual pleasure, while the latter typically are not.

A syndrome that meets the diagnostic criteria for sexual addiction can occur in the context of other psychiatric disorders, including manic-depressive conditions, schizophrenia, personality disorders and substance dependence.

When the diagnostic criteria for both sexual addiction and another psychiatric disorder are met, both diagnoses are warranted, regardless of whether sexual addiction might be secondary to the other psychiatric disorder. The diagnosis of sexual addiction is a descriptive designation of how a pattern of sexual behavior relates to and affects an individual's life. It does not presume a particular etiology, nor is it precluded by the presence of other conditions that may be etiologically relevant.

Clinical Examples

To illustrate the considerations that are involved in diagnosing sexual addiction, three clinical examples are presented.

Case 1: Harold. An executive in his mid-30s, Harold would say with a smile that his Achilles' heel was his "weakness for the fair sex." When an attractive woman indicated to Harold that she was interested in him sexually, he found himself unable to resist, or more accurately, he found himself unable to want to resist. He experienced himself almost as a victim, sexually drawn to women against his will. Harold's fiance ended their engagement after he repeatedly broke promises to her that he would stop sleeping with other women. When Harold began to use his apartment in the city for midday sexual liaisons, his lunch breaks stretched longer and longer. His formerly superior work performance began to slacken and he did not receive an expected promotion. Harold's boss warned him that he could lose his job if he was unable to keep business and pleasure separate in his life.

Harold resolved that he would turn over a new leaf and for six weeks he kept his sexual behavior in check. Then, when he was out of town on business and had just finished dinner with his work team, he commented that his neck and back were tight. His secretary offered to give him a back rub, and he accepted the offer without a moment's thought. The back rub resulted in a sexual encounter. Upon returning to his office, Harold continued to engage in sexual activity with his secretary. Soon, she began to pressure him for an exclusive relationship. When he rebuffed her, she filed a suit against him for sexual harassment. He was fired immediately.

Case 2: Joe. An electrician in his mid-20s, Joe had masturbated nearly every night before going to sleep since his middle teens. When he quit using alcohol and other drugs in his early 20s, his sexual fantasies and urges became more frequent and more intense. He began to experience strong urges to masturbate in the morning, and he found that if he did not act on these urges, he would feel "horny" all day, which for him was associated with being restless, distracted and irritable. Consequently, he started to masturbate before work, even though he would sometimes arrive late as a result. Some months later, Joe began to masturbate at work as well.

No longer sufficiently excited by his fantasies, Joe began to purchase pornography and pornographic videos. He received a second warning about tardiness and inattentiveness at work, and he felt disgusted with himself; but each time he tried to stop masturbating, he would fail. Sexual fantasies accompanied by arousal would intrude into his consciousness throughout the day, and he would feel as though he was going to explode.

When he began a new romantic relationship, he threw away his collection of pornography and resolved to quit masturbating. Within a few months, though, he lost control of his masturbation and the relationship soon fell apart. He started using telephone sex services, and before long had "maxed-out" his credit cards. Socially isolated, deeply in debt and about to lose his job, Joe realized that his preoccupation with masturbation and pornography was ruining his life, but he felt powerless.

Case 3: Steve. Steve was a neurologist in his 40s who sought treatment for depression, anxiety and marital difficulties. Sex was among the sources of tension in his marriage. Steve wanted to have sex with his wife every day, sometimes two or three times a day. Steve's wife wondered if he were a sex addict.

When she declined to have sex with Steve, he felt desperate and feared that she did not love him, that he was not good enough for her, that she was tired of him and was preparing to leave him. On such occasions, he usually withdrew to his study and immersed himself in work. He rarely masturbated, and did not seek sex elsewhere. When his wife's inflammatory bowel disease flared up, Steve cared for her sensitively, and she expressed her appreciation and gratitude. At such times, Steve felt needed and valued, and he rarely thought of sex. Steve's desire for sex occasionally offended his wife, who felt then that he would rather have sex than talk with her. Sometimes, when Steve's wife complied with his requests for sex, she resented him. Further inquiry did not reveal other harmful consequences from Steve's sexual behavior nor did it suggest that Steve had any difficulty controlling his sexual behavior.

The first two clinical examples, Harold and Joe, meet 4, 5 and 7 of the diagnostic criteria for sexual addiction and perhaps also criterion 6. Joe, in addition, meets criteria 1, 3 and probably 2. The third example, Steve, might meet criterion 5, but does not seem to meet any of the other criteria. Hence, Harold and Joe merit diagnoses of sexual addiction, according to the diagnostic criteria, while Steve does not.

An informal assessment that is based on the definition of sexual addiction reaches the same conclusions. Harold and Joe demonstrate patterns of sexual behavior that are characterized by recurrent failure to control and continuation of such behavior despite significant harmful consequences, while Steve does not. (Five detailed clinical vignettes, which include each patient's personal history, case formulations and course of treatment are presented in Goodman, 1998a.)

Treatment Approaches

Treatment for sexual addiction is most likely to be effective when it emerges from an integrated approach that brings together a range of therapeutic modalities, is individually tailored and evolves as the patient progresses.

The approach to treatment described here was developed (Goodman, 1997, 1998a) in the context of the theory that sexual addiction represents an expression through sexual behavior of the addictive process: an enduring, inordinately strong tendency to engage in some form of pleasure-producing behavior as a means of regulating affects or self-states that are painful and potentially overwhelming due to impaired self-regulation. Consequently, treatment for sexual addiction should address both the addictive sexual behavior and the underlying addictive process.

Addictive sexual behavior is addressed through behavioral symptom management, which consists primarily of relapse prevention and other cognitive-behavioral techniques. Meanwhile, the addictive process is addressed primarily through psychodynamic psychotherapy, therapeutic groups and psychiatric pharmacotherapy. Relapse prevention strategies help individuals who use sexual behavior addictively to recognize factors and situations that are associated with an increased risk of acting out sexually, to cope more effectively with sexual urges, to recover rapidly from episodes of symptomatic behavior and to use such "slips" as opportunities to learn about how their recovery plans can be improved.

Relapse prevention conceptualizes urges to engage in addictive sexual behavior as signals of disruptive affect states, for which the addict needs to develop healthier, more adaptive management. In thus shifting the focus from controlling the behavior to understanding the affects, relapse prevention provides a natural bridge from behavior management to psychodynamic psychotherapy.

Cognitive-behavioral techniques other than relapse prevention comprise directive, didactic procedures that focus not on symptomatic sexual behavior, but on other aspects of a person's life that predispose him or her to rely on symptomatic behavior to cope with distressful affects and unmet needs. Applicable cognitive-behavioral techniques may be divided into two groups: skills training, which helps patients to learn thoughts and behaviors that will result in more effective management of their affects and meeting of their needs (e.g., anger management, assertiveness training); and lifestyle regeneration, which helps patients learn to achieve and maintain a healthy, balanced lifestyle.

The primary goals of psychodynamic psychotherapy in the treatment of sexual addiction are to enhance individuals' self-regulation and to foster their capacity for meaningful interpersonal connections. The fabric of psychodynamic psychotherapy is woven from three strands: understanding, integration and internalization.

Three Strands of Psychodynamics

Understanding focuses on the relationship between addictive sexual behavior and impaired self-regulation. When we understand that addictive behaviors typically are patients' attempts to regulate their affective states, which threaten to overwhelm them because their built-in regulation systems are impaired, our focus shifts from behavior to affect. Affects then guide our explorations: What affects are emerging? What events triggered the affects? What core beliefs, inner conflicts and personal history are involved?

Integration refers to the patient's personality. Automatically, without conscious intent or awareness, we engage in a variety of mental processes that function to protect us from emotional trauma. Most of these self-protective processes can be understood as ways of keeping out of our awareness material that we unconsciously imagine would be overwhelmingly painful or dangerous if we were to become aware of it.

The cornerstone of integration in psychotherapy is the fostering of patients' awareness of such material: their affects, needs, wishes, fears, inner conflicts, core beliefs and automatic ways of protecting themselves from emotional pain. Psychotherapeutic work tends to be most effective when it addresses issues in the here-and-now. In psychotherapy, the most here-and-now issues are those that concern the relationship between the patient and the therapist. Hence, these often are the most productive issues to address.

As a significant relationship develops between the patient and the therapist, the patient's basic inner models become activated, and the psychological factors that influence the patient's other significant relationships begin to affect how the patient perceives, experiences and acts toward the therapist. The therapeutic relationship then provides a safe environment in which the patient and the therapist together can explore the patient's basic inner models in "real time."

Bringing together in consciousness the various disintegrated aspects of a person's psychic processes gradually heals the personality and enables it increasingly to function as an integrated whole. The result is more conscious choice, more flexibility and more freedom.

Internalization is the process through which the self-regulation system-the built-in system that regulates our affects and sense of self-develops in early life. Through interactions between the maturing child and his or her responsive caregivers, regulatory functions that had been provided for the child by the caregivers gradually become integrated into the child's autonomous functional system. The capacity for such developmental internalization is greatest during early childhood, but it continues throughout life.

The function of internalization in psychotherapy derives from its role in the development of self-regulation. A primary means by which psychotherapy promotes the healing of impaired self-regulation is by providing new opportunities for patients to internalize self-regulatory functions that were not adequately internalized during childhood.

Therapeutic groups, including 12-step groups, can facilitate the development of abilities to make meaningful connections with others and to turn to people in times of need instead of turning to addictive behavior. Some therapeutic processes may be more likely to occur in groups than in individual psychotherapy.

Psychiatric Pharmacotherapy

Psychiatric pharmacotherapy is direct intervention to enhance affect regulation, to stabilize psychobiological functioning or to modulate psychotic symptoms, and to treat other symptoms of comorbid psychiatric disorders.

A number of studies have indicated that antidepressant medications, particularly the serotonin reuptake inhibitors, can reduce the frequency of addictive sexual behavior and the intensity of urges to engage in addictive sexual behavior, even when the patient is not suffering from major depression (Kafka, 1991; Kafka and Prentky, 1992; Kruesi et al., 1992; Stein et al., 1992).

Additionally, numerous case reports have described the effectiveness of antidepressants for symptoms of sexual addiction, and a few have reported successful treatment with lithium. In my experience, divalproex (Depakote) also can be helpful for sexual addiction symptoms that arise in the context of atypical manic-depressive conditions or "emotionally unstable character disorders."

Such findings make sense when the biopsychological process that underlies addictive disorders is understood to originate in impaired affect regulation, impaired behavioral inhibition and aberrant motivational-reward function. Addictive craving and addictive urges are then recognized to be both expressions of dysregulated affect, and conditioned stimuli for coping responses (responses to cope with dysregulated affect) that have been learned in the context of impaired behavioral inhibition and aberrant motivational-reward function.

Accordingly, to the extent that affect regulation is enhanced, the frequency and intensity of addictive urges are likely to diminish. Meanwhile, greater stability of psychobiological functioning is associated with better behavioral control and improved assessment of reality. Interventions that enhance affect regulation and behavioral inhibition can thus be expected to reduce the symptomatic expression of sexual addiction.

Tailoring and Timing

The specific functional impairments, needs and inner resources that individuals who use sexual behavior addictively bring to the treatment situation vary from individual to individual. Functional impairments also vary within the same individual from one point during treatment to another. Treatment for sexual addiction is most likely to be effective when the treatment plan for each patient is individually tailored and evolves as the patient progresses through recovery.

Recovery from sexual addiction is a developmental process that can be understood to proceed in four overlapping stages:

• Stage I, Initial Behavior Modulation
   
• Stage II, Stabilization (of behavior and affect)
   
• Stage III, Character Healing
   
• Stage IV, Self-Renewal

Certainly, these stages constitute a heuristic device that oversimplifies the picture. Behavior, affect, character and self can be considered also as dimensions of a person, which are concurrent and interrelated. At different times in treatment, one dimension or another may be the most prominent, or may receive the most therapeutic attention, but all the dimensions are involved at all points in the developmental process. This multidimensional understanding applies also to the therapeutic modalities.

During Stage I, most individuals who use sexual behavior addictively can begin to modulate their addictive behavior by means of a combination of inner motivation, psychological support and affect-regulating medication. Many sex addicts do not require affect- regulating medication; but some who are able to modulate their behavior without medication may still benefit from the medication's attenuation of addictive urges and from its alleviation of the affective distress that often accompanies the initial modulation of addictive behavior.

While the core of treatment for sexual addiction is constituted by relapse prevention and psychodynamic psychotherapy, the benefit that sex addicts derive from these treatment modalities is likely to be limited until they have achieved some control over their addictive sexual behavior. For some individuals who use sexual behavior addictively, the combination of inner motivation, psychological support and affect-regulating medication may be insufficient to enable achievement of behavioral control. In such cases, behavior modification and/or antiandrogen pharmacotherapy may be necessary before comprehensive treatment can proceed.

The progressive modulation of addictive sexual behavior marks the transition from Stage I to Stage II. At this point, the therapeutic focus can shift to relapse prevention as the primary modality for stabilizing abstinence from addictive behavior. Supportive psychotherapy may be helpful at this time, but exploratory-expressive psychotherapy is likely to be more beneficial in most cases if it is deferred until the latter part of Stage II, when behavior and affect are more stable. Meanwhile, psychodynamically oriented interventions may be needed during Stages I and II to address psychodynamically based resistances to pharmacological, behavioral and cognitive-behavioral interventions, lest the entire treatment be disrupted.

Moreover, unlike psychoactive substance addictions, sexual addiction involves the addictive use of a behavior that is part of normal living. Consequently, recovery from sexual addiction is not a matter of complete abstinence from sexual behavior, but of learning 1) to distinguish between those forms of sexual behavior that are high-risk and those that are low-risk, and to refrain from engaging in high-risk forms of sexual behavior; and 2) learning to engage in sexual behavior in ways that are healthy rather than pathological. Learning the first type can usually be addressed in relapse prevention, but learning the second type often requires psychodynamic psychotherapy.

Early in recovery, when the sex addict's judgment is still significantly distorted by a combination of denial, rationalization, vague or fragmented identity, and superego pathology, distinguishing healthy from pathological sexual behavior can be exceedingly difficult. During this initial period, some patients might benefit from total abstinence from any kind of sexual behavior.

The rationale for initial abstinence is that, early in recovery, individuals who have been using sexual behavior addictively may be incapable of selectively eliminating the self-regulatory functions from their sexual behavior; and, to the extent that they continue to use sexual behavior to regulate their affects and/or self-states, they are less likely to benefit from treatment.

Meanwhile, refraining from behaviors that could be used addictively pushes the individual into greater self-awareness. Therapeutic use of this enhanced self-awareness to undermine denial and rationalization, to stabilize identity and sense of self, and to integrate healthy superego functions then brings patients to a point where they are more capable of distinguishing healthy from pathological sexual behavior. Abstinence from sexual behavior, though not a goal of treatment for sexual addiction, can on occasion be a helpful therapeutic technique.

Treating Character Pathology

Stage III is the period during which the therapeutic focus can turn to psychodynamic psychotherapy as the therapeutic modality that is most effective in treating character pathology. Psychodynamic psychotherapy, however, is not equally effective in all cases. Both the need and the capacity for psychodynamic therapy vary among individuals who use sexual behavior addictively. In addition, the effectiveness of psychodynamic treatment often depends also on the "goodness of fit" between the patient and the therapist, and on the nature of their relationship. Initiation of psychodynamic psychotherapy does not, of course, mean that relapse prevention is no longer needed. Urges to engage in symptomatic sexual behavior can be evoked or exacerbated by affects that emerge in the course of psychodynamic therapy.

Relapse prevention skills not only help to limit undesirable behaviors, but also enhance the effectiveness of psychotherapy by increasing the likelihood that inner states will be communicated in words rather than actions. The therapist must thus be able to shift sensitively among exploratory and supportive psychodynamic therapy, and relapse prevention in response to the patients' changing needs.

Couples or family therapy, when it is indicated, is most likely to have positive results if it is deferred until Stage III. I consider couples and family therapy to be treatment not for sexual addiction per se, but for the interpersonal issues and dysfunctional relationship patterns associated with sexual addiction. Indications for couples or family therapy in the context of sexual addiction are not significantly different from what they are in the context of other psychiatric disorders, unless the addict's addictive sexual behavior directly involves the couple or members of the family. As is the case when treating individuals who suffer from psychiatric conditions other than sexual addiction, couples and family therapy is likely to help most after the individual's major disorder has stabilized and, if significant character pathology was part of the presenting picture, after character healing is underway.

The identified patient's mate or children often require time to stabilize and, occasionally, individual psychotherapy is necessary, before they can productively engage in conjoint therapy. However, couple or family intervention may be necessary earlier in treatment if the couple or family is in crisis. Self-help groups, such as 12-step groups, are typically most helpful during Stages I and II and early in Stage III. A good self-help group-one that is composed of relatively healthy, growing individuals with whom the patient fits well-can also be helpful in Stages III and IV.

To date, no studies have been conducted to evaluate the effectiveness of this integrated approach to treating sexual addiction. In fact, empirical research on almost every aspect of sexual addiction is sorely lacking: neurobiology, psychometrics, family history, diagnostic criteria (reliability, coverage and predictive validity) and response to treatments. This deficit may have been due to the unavailability, until recently, of clear and meaningful diagnostic criteria for sexual addiction. It also may have been due to a reluctance by many to consider sexual addiction as a fit subject for scientific study. Hopefully, this and the previous article will redress these conditions and stimulate the empirical research that this new field so desperately needs.

References:

References

Goodman A (1998a), Sexual Addiction: An Integrated Approach. Madison, Conn.: International Universities Press.

Goodman A (1998b), Sexual addiction: terminology and theory. Psychiatric Times 15(7):22-26.

Goodman A (1997), Sexual addiction: diagnosis, etiology and treatment. In: Substance Abuse: A Comprehensive Textbook, 3rd ed. Lowenstein JH, Millman RB, Ruiz P, Langrod JG, eds. Baltimore: Williams & Wilkins, pp 340-354.

Kafka MP (1991), Successful antidepressant treatment of nonparaphilic sexual addictions and paraphilias in men. J Clin Psychiatry 52(2):60-65.

Kafka MP, Prentky R (1992), Fluoxetine treatment of nonparaphilic sexual addictions and paraphilias in men. J Clin Psychiatry 53(10):351-358.

Kruesi MJP, Fine S, Valladares L et al. (1992), Paraphilias: a double-blind crossover comparison of clomipramine versus desipramine. Arch Sex Behav 21(6):587-593.

Rasmussen SA, Tsuang MT (1986), Clinical characteristics and family history in DSM-III obsessive-compulsive disorder. Am J Psychiatry 143(3):317-322.

Stein DJ, Hollander E, Anthony DT et al. (1992), Serotonergic medications for sexual obsessions, sexual addictions, and paraphilias. J Clin Psychiatry 53(8):267-271.