Addictive Sexual Behaviors

Written by Jennifer P. Schneider, MD, PhD, and Richard Irons, MD

sexual problems

Addictive Sexual Disorders: Differential Diagnosis and Treatment
Jennifer P. Schneider, MD, PhD, and Richard Irons, MD

Educational Objectives:
Visualize where addictive sexual disorders fit into the DSM-IV.
Obtain an overview of the spectrum of addictive sexual disorders.
Understand the principles of treatment of sex addiction and have access to resources for recovery.

Introduction: Patients who present with excessive and/or unusual sexual urges or behaviors are often a source of confusion to clinicians. In some cases, the diagnosis appears clear-cut: The young man who has a history of arrests for exposing his genitals to unsuspecting strangers has a paraphilia known as exhibitionism (pp525); a young woman's obsessive, intrusive, and very disturbing sexual thoughts may be one aspect of her obsessive-compulsive disorder (pp417); the 70-year-old nursing home patient who gropes any female staff member who gets within touching distance may be exhibiting a loss of judgment secondary to his Alzheimers disease (pp139); and another hypersexual patient exhibits pressured speech and grandiosity typical of the manic phase of bipolar type I or II psychosis. (pp356)

In a larger number of cases, the etiology is less obvious, and therefore the therapeutic approach is less clear. Some examples are: The computer programmer whose job and marriage suffer because he spends many hours daily viewing internet pornography and communicating online with women who have similar interests; the married woman who has multiple affairs despite her fears that the marriage will end; the gay man who has had thousands of anonymous sexual encounters in restrooms and parks with other menusually without giving any thought to "safe sex" practices until panic sets in after the encounter is over; the clinician who uses his professional practice to engage in sexual encounters with women; and the isolated consumer of home and bookstore pornography whose multiple daily episodes of masturbation have cost him excessive time, money, and injuries to his genitalia.

To complicate the picture, many people who engage in excessive sexual behavior are also pathologically indulgent in other behaviors and activities.

1. They are most commonly found to have a concurrent substance use disorder, such as alcohol dependence, an impulse control disorder such as pathological gambling, or an eating disorder.

2 The majority of people with cocaine dependence engage in compulsive sexual behavior as part of their cocaine-using lifestyle.

3 Professionals who treat chemical dependency are learning that in order to avoid relapse in chemical use among recovering addicts, all compulsive behaviors must be identified and addressed. Assessment and treatment of addictive sexual behaviors must be an integral part of chemical dependency treatment.

The goal of this article is to help the psychiatrist and the primary care physician to understand the various disease processes underlying excessive sexual behaviors and to understand the various treatment approaches which are helpful. Slide #PP4:16

Differential Diagnosis of Excessive Sexual Behaviors
Common
- Paraphilias
- Sexual disorder NOS
- Impulse control disorder NOS
- Bipolar disorder (I or II)
- Cyclothymic disorder
- Posttraumatic stress disorder
- Adjustment disorder [disturbance of conduct]

Source: Schneider JP, Irons RR. Sexual Addiction Compulsivity. 1996; 3:721.
Schneider JP, Irons RR. Primary Psychiatry. Vol. 5. No. 4. 1998.
Slide #PP4:17

Differential Diagnosis of Excessive Sexual Behaviors

Infrequent
- Substance-induced anxiety disorder [obsessive-compulsive symptoms]
- Substance-induced mood disorder [manic features]
- Dissociative disorder
- Delusional disorder [erotomania]
- Obsessive-compulsive disorders
- Gender identity disorder
- Delirium, dementia, or other cognitive disorder
Source: Schneider JP, Irons RR. Sexual Addiction Compulsivity. 1996; 3:721.
Schneider JP, Irons RR. Primary Psychiatry. Vol. 5. No. 4. 1998.