Sexual Impulsivity Disorders: Psychiatric "Orphans"

Paraphilias (PAs) and paraphilia-related disorders (PRDs) (nonparaphilic sexual compulsivity or sexual addiction) are sexual disorders that predominantly afflict men. Psychiatry in the United States, in particular, has neglected to pay significant clinical or research attention to these commonly overlooked but very serious conditions. Although many clinicians might think that these conditions are merely uncommon, exotic, or of questionable diagnostic validity, the lack of systematic clinical and research attention paid to these conditions is more related to severe sociocultural and moral stigmatization, clinician discomfort to assertively inquire about these conditions, and severe shame and guilt among persons with these disorders.

Frequently, these conditions are acknowledged by men and women under the duress of a clinical emergency, such as an impending marital separation or divorce, or arrest and legal charges associated with inappropriate sexual behaviors. In addition, even when PAs or PRDs have been identified, the specific psychiatric Axis I disorders associated with sexual impulsivity can still elude astute, forensically trained clinicians, thus diminishing the perceived value of psychiatric consultation and treatment.

PAs are intense, recurring expressions of socially deviant or anomalous sexual arousal that cause individual distress and/or clinically significant adverse consequences (typically related to repetitive enactment). The most common paraphilic disorders described in DSM-IV are exhibitionism, voyeurism, fetishism and transvestic fetishism, frotteurism, sexual sadism and sexual masochism, and pedophilia.

Because several PAs are associated with sexual offenses, persons with these serious disorders are not likely to discuss their sexual impulses with intimate partners, friends, or clinicians. Currently, the social consequences that are associated with being a sexual offender can include incarceration, limitations and restrictions on personal liberty (eg, lengthy probation or parole, residency restrictions, global positioning surveillance, or employment limitations), and personal endangerment and bodily harm by vigilantes.

Treatment

Treatments that empirically have been shown to reduce sexual offender recidivism include medication and cognitive-behavioral therapy that is typically performed in a group-therapy paradigm.¹ Typical medications prescribed for men with PAs might include antiandrogens (eg, injection and oral medroxyprogesterone acetate), gonadotropin-releasing hormone agonists (eg, leuprolide), or SSRIs.²

Based on published data, PRDs such as compulsive masturbation, pornography dependence or addiction (including print, computer, and telephone), protracted promiscuity, and severe sexual desire incompatibility are more common than PAs but have no specific diagnostic designation in current DSM nosology. Fortunately, these latter conditions are being considered for DSM-V classification, pending further research and field trials that include diagnostic questionnaires.

PRDs may be common in persons with current PAs, but they can occur as stand-alone conditions. PRDs are time-consuming, are associated with medical comorbidities, such as venereal disease and unplanned pregnancy, and place severe strain on the basic trust necessary for a functional intimate partnership.

Currently, PRDs are most commonly considered compulsive disorders or behavioral addictions. As such, 12-step, self-help groups based on the Alcoholics Anonymous model are widely recommended, as is concurrent individual psychotherapy. Unfortunately, consistent empirical validation of any specific psychotherapeutic treatment modality is lacking.³

A recent, small, placebo-controlled study suggested partial support for the prescription of citalopram in men with protracted promiscuity.⁴ Other proserotonergic antidepressants have been reported to ameliorate both PAs and PRDs in open prospective (but not controlled) trials and retrospective reports.^5-7 As is the case with psychotherapy for PRDs, a robust empirical validation of the role of pharmacotherapy is suggestive but requires additional clinical trials.

Stigma

The reticence of persons seeking help from clinicians to recognize and acknowledge sexual impulsivity and clinician hesitance to inquire or raise an adequate index of suspicion with new patients is analogous to the "don't ask, don't tell" policy of the US military toward homosexuality. For example, while clinicians routinely inquire about changes (either notable increases or decreases) in sleep, psychomotor behavior, and eating during an initial clinical evaluation, most clinicians do not ask questions related to a person's sexual behavior (such as those listed in the Table).

TABLEScreening questions for sexual impulsivity disorders

Has your sexual behavior ever caused you persistent personal distress, medical problems (such as sexually transmitted disease or unwanted pregnancy), and/or legal difficulties?

Has your sexual behavior been associated with the loss of a job or has it caused significant problems in an important romantic relationship?

Have you ever engaged in repetitive sexual behaviors that you felt needed to be kept a secret (including affairs)?

Have you ever thought of yourself as someone who was either blessed or cursed with a high sex drive?³

Diagnosis and comorbidities

Clinicians are well acquainted with diminished sexual interest in mood disorders, especially in major depression. What is still novel to the clinical and forensic community, however, is that increased sexual behavior, including persistent hypersexual behavior, may also be associated with anxious and depressive affect^8,9 as well as anxiety and mood disorders.¹⁰

Studies of nonsexual impulsivity disorders frequently reveal that such conditions rarely occur as solitary disorders and, in fact, tend to cluster with each other (eg, pathological gambling with substance abuse) or with certain Axis I psychiatric disorders that are associated with behavioral disinhibition.

Regarding sexual impulsivity disorders, PAs and PRDs have been reported as comorbid with mood disorders^10-14; attention-deficit/hyperactivity disorder (ADHD)^10,15-17; substance use disorders^10,12,16,17; fetal alcohol-spectrum disorders^18,19; schizophrenic disorders; degenerative neurological disorders or head injuries^20,21; and other, less common Axis I neurodevelopmental conditions, such as autism-spectrum disorders²² and Tourette disorder.²³Dysthymia

In my clinical experience, the aforementioned Axis I disorders, particularly chronic mood disorders, substance use disorders, adult ADHD, and fetal alcohol-spectrum disorders, understandably are overlooked by mental health professionals who assess adults. It is not that clinicians do not assess for symptoms of major depression or a clearly defined hypomanic episode (as in bipolar II disorder), but rather that dysthymic disorder (arguably a more common unipolar comorbid condition with sexual impulsivity than major depression) and bipolar-spectrum disorders (during which hypomanic phase symptoms may manifest for only 1 to 2 days) are more difficult to differentiate in patients than complex, repetitive, behavioral sexual impulsivity and its psychosocial consequences.

Dysthymic disorder can be characterized by an early age of onset (eg, before 21 years); a waxing and waning clinical course; and a comorbid association with other, more florid clinical syndromes, such as anxiety, substance abuse, and personality disorders. The common vegetative features associated with a major depressive episode are less likely to be associated with chronic or low-grade depressive conditions. Externalizing behavior disorders, including sexual impulsivity and eating disorders, can mislead clinicians to overlook this chronic mood disorder that has been reported to have a lifetime prevalence of 6% in the United States and can be addressed effectively with antidepressant pharmacotherapy and specific psychotherapies.²⁴

Bipolar disorder

The changing concept and threshold of hypomania for bipolar-spectrum conditions also presents clinical challenges. Although the gold standard for hypomania in bipolar II disorder is an episode lasting "4 or more days" according to DSM-IV, recent research has shown that the mean duration of hypomanic episodes in outpatient samples is 1 to 2 days.²⁵ Episodic nonsubstance abuse-induced euphoric mood, while pathognomonic of hypomania, is no longer considered the primary mood that characterizes hypomania, since irritable or agitated, anxious, and mixed moods may be associated with hypomania as well. The nonpsychiatric mental health or primary care practitioner may not yet appreciate these important clinical findings.

Within a broader-spectrum concept for bipolar disorder, which includes bipolar I, bipolar II, mixed states, cyclothymia, and bipolar not otherwise specified, the incidence rate may be 4% to 6% of the adult population.²⁶ Because increased sexual motivation and excessive involvement in pleasurable activities, including sexual indiscretions, are recognized as possible cardinal manifestations of hypomania, a broader and less exclusive boundary for hypomania should alert clinicians that sexual impulsivity disorders may be found in both poles of bipolar mood disorders.

Drug and alcohol abuse

There is a well-known comorbidity between sexual offending and alcohol abuse. Less commonly reported, however, are associations between sexual impulsivity disorders and marijuana dependence and cocaine abuse. Cocaine (including "crack" cocaine) and very high doses of psychostimulants, such as methylphenidate, dextroamphetamine, and methamphetamine, may specifically disinhibit sexual behavior, most likely in association with dopaminergic overstimulation. Patients with a current substance use disorder may deny or minimize their drug abuse, obscuring the common comorbidity between impulsivity disorders and sexual impulsivity.

ADHD

Adult ADHD has recently received considerable research and clinical attention and is less likely to be overlooked than, say, a decade ago. In incarcerated populations, however, where adult ADHD-combined subtype would have a higher prevalence because of its comorbidity with antisocial behaviors, this diagnosis is frequently not assessed.²⁷ In adult sexual offenders who are incarcerated, ADHD assessment is over-looked in preference to an Axis II diagnosis, most commonly antisocial personality disorder.²⁸

While the former diagnosis is readily treatable with medication, such as a psychostimulant, the latter diagnosis implies a poorer prognosis. Unfortunately, prescribing psychostimulants in a correctional setting is discouraged because of their misuse potential, so this condition remains undertreated in men and women whose antisocial impulsivity may be embedded in residual symptoms associated with childhood ADHD. There is some research suggesting that while the combined subtype of ADHD may be more predictive of paraphilic sexual offending, the inattentive subtype of adult ADHD may be more likely associated with PRDs.¹⁰

Fetal alcohol syndrome and fetal alcohol effects

Fetal alcohol syndrome (FAS) and the more broadly defined fetal alcohol effects (FAE) are not specific diagnoses in DSM-IV despite recent evidence that fetal alcohol exposure may be the leading preventable cause of mental retarda- tion in the United States.²⁹ Although the population prevalence of fetal alcohol-associated disorders may be less than that of mood disorders, substance abuse, and ADHD, severe sexual disinhibition, including sexual offending and antisocial impulsivity, is strikingly common in samples of adolescents and adult men (eg, 40% to 50%) with this severe neurodevelopmental condition.^18,19

Many persons with a history of alcohol-related teratogenic effects are hospitalized or clustered in structured residential settings. While clinicians may look for specific and observable congenital facial characteristics in children when they suspect FAS, such observable signs may not be present in children with FAE and may be less readily observed in postpubertal adolescents and adults with FAS. If an infant with FAS or FAE was adopted at birth, maternal medical and psychiatric records that could be critical for diagnostic assessment of the child may not be available. The adolescent or adult with FAE may present with mental retardation, social and learning disabilities, and severe impulsivity and affective lability.

The sexual impulsivity of patients with FAE or FAS is less likely to be coherently organized or planned, as might be the case for persons with PAs. For example, an adolescent or adult with FAE might receive an incorrect diagnosis of frotteurism or exhibitionism because his or her sexually disinhibited behavior is indiscriminate, and he would more likely repetitively target nearby peers or adults, not strangers as those with paraphilia would stealthily seek. At present, in contrast to unipolar or bipolar disorder or ADHD, there is no uniform psychotherapeutic or psychopharmacological treatment algorithm for FAS or FAE. Given the likely prevalence of this condition and its co-association with antisocial impulsivity, more research is needed for effective treatments for this potentially preventable neurodevelopmental disorder.

Conclusion

Clinicians need to have a higher index of suspicion for sexual impulsivity disorders in patients and bring a finer diagnostic lens to the psychiatric comorbidities associated with PAs and PRDs. Persons with diagnoses of mood disorders, ADHD, substance use disorders, and/or developmental disabilities are particularly vulnerable to sexual disinhibition. Men, in particular, are more vulnerable than women. Establishing a therapeutic alliance and then inquiring nonjudgmentally about sexual behavior history (as suggested in the Table) may improve our ability to identify PAs and nonparaphilic expressions of sexual disinhibition such as PRDs.

Pharmacological treatment reports suggest that ameliorating comorbid Axis I psychopathologies or markedly diminishing the testosterone signal effect can diminish sexual impulsivity. Therefore, the correct identification of these conditions and their associated comorbidities would help ameliorate the human suffering and victimization associated with these stigmatized and misunderstood conditions.

References:

References1. Losel F, Schmucker M. The effectiveness of treatment for sexual offenders: a comprehensive meta-analysis. J Exp Criminol. 2005;1:117-146.
2. Hill A, Briken P, Kraus C, et al. Differential pharmacological treatment of paraphilias and sex offenders. Int J Offender Ther Comp Criminol. 2003;47:407-421.
3. Kafka MP. Paraphilia-related disorders: the evaluation and treatment of nonparaphilic hypersexuality. In: Lieblum S, ed. Principles and Practice of Sex Therapy. 4th ed. New York: Guilford Press; 2006:442-476.
4. Wainberg ML, Muench F, Morgenstern J, et al. A double-blind study of citalopram versus placebo in the treatment of compulsive sexual behaviors in gay and bi-
sexual men. J Clin Psychiatry. 2006;67:1968-1973.
5. Federoff JP. Serotonergic drug treatment of deviant sexual interests. Sex Abuse J Res Treatment. 1993;6: 105-121.
6. Greenberg DM, Bradford JM, Curry S, O'Rourke A. A comparison of treatment of paraphilias with three serotonin reuptake inhibitors: a retrospective study. Bull Am Acad Psychiatry Law. 1996;24:525-532.
7. Kafka MP. The role of medications in the treatment of paraphilia-related disorders. Sex Relationship Ther. 2001; 16:105-112.
8. Bancroft J, Janssen E, Strong D, et al. The relation between mood and sexuality in heterosexual men. Arch Sex Behav. 2003;32:217-230.
9. Bancroft J, Janssen E, Strong D, Vukadinovic Z. The relation between mood and sexuality in gay men. Arch Sex Behav. 2003;32:231-242.
10. Kafka MP, Hennen J. A DSM-IV Axis I comorbidity study of males (n = 120) with paraphilias and paraphilia-related disorders. Sex Abuse. 2002;14:349-366.
11. Raymond NC, Coleman E, Miner MH. Psychiatric comorbidity and compulsive/impulsive traits in compulsive sexual behavior. Compr Psychiatry. 2003;44:370-380.
12. Raymond NC, Coleman E, Ohlerking F, et al. Psychiatric comorbidity in pedophilic sex offenders. Am J Psychiatry. 1999;156:786-788.
13. Dunsieth NW, Nelson EB, Brusman-Lovins LA, et al. Psychiatric and legal features of 113 men convicted of sexual offenses. J Clin Psychiatry. 2004;65:293-300.
14. Grant JE. Clinical characteristics and psychiatric comorbidity in males with exhibitionism. J Clin Psychiatry. 2005;66:1367-1371.
15. Fago DP. Comorbidity of attention deficit hyperactivity disorder in sexually aggressive children and adolescents. In: Null GA, Schwartz BA, eds. The Sex Offender: Theoretical Advances, Treating Special Populations and Legal Developments. Vol 3. Kingston, NJ: Civic Research Institute; 1999:16.11-16.15.
16. Galli V, McElroy SL, Soutello CA, et al. The psychiatric diagnoses of twenty-two adolescents who have sexually molested other children. Compr Psychiatry. 1999;40: 85-88.
17. Kafka MP, Prentky RA. Attention-deficit/hyperactivity disorder in males with paraphilias and paraphilia- related disorders: a comorbidity study. J Clin Psychiatry. 1998;59:388-396.
18. Baumbach J. Some implications of prenatal alcohol exposure for the treatment of adolescents with sexual offending behaviors. Sex Abuse. 2002;14:313-327.
19. Mattson SN, Goodman AM, Caine C, et al. Executive functioning in children with heavy prenatal alcohol exposure. Alcohol Clin Exp Res. 1999;23:1808-1815.
20. Blanchard R, Christensen BK, Strong SM, et al. Retrospective self-reports of childhood accidents causing unconsciousness in phallometrically diagnosed pedophiles. Arch Sex Behav. 2002;31:511-526.
21. Blanchard R, Kuban ME, Klassen P, et al. Self-reported injuries before and after age 13 in pedophilic and nonpedophilic men referred for clinical assessment. Arch Sex Behav. 2003;32:573-581.
22. Kumagami T. Characteristics of juvenile court cases with pervasive developmental disorder [in Japanese]. Seishin Shinkeigaku Zasshi. 2006;108:327-336.
23. Comings DE. Role of genetic factors in human sexual behavior based on studies of Tourette syndrome and ADHD probands and their relatives. Am J Med Genet. 1994;54:227-241.
24. Klein DN, Santiago NJ. Dysthymia and chronic depression: introduction, classification, risk factors, and course. J Clin Psychol. 2003;59:807-816.
25. Judd LL, Akiskal HS, Schettler PJ, et al. A prospective investigation of the natural history of the long-term weekly symptomatic status of bipolar II disorder. Arch Gen Psychiatry. 2003;60:261-269.
26. Glick ID. Undiagnosed bipolar disorder: new syndromes and new treatments. Prim Care Companion J Clin Psychiatry. 2004;6:27-33.
27. James DJ, Glaze LE. Mental health problems of prison and jail inmates. Bureau of Justice Statistics Special Report. September 2006. Available at: http://www.ojp.usdoj.gov/bjs/pub/pdf/mhppji.pdf. Accessed June 12, 2007.
28. Zander TK. Civil commitment without psychosis: the law's reliance on the weakest link in psychodiagnosis. J Sex Offender Civil Commitment Sci Law. 2005;1:17-82.
29. Streissguth AP. Fetal alcohol syndrome and fetal alcohol effects: a clinical perspective of later developmental consequences. In: Zagon IS, Slotkin TA, eds. Maternal Substance Abuse and the Developing Nervous System. San Diego: Academic Press; 2006:5-24.