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Compulsive Sexual Behavior: Clinical Characteristics and Treatment Jon E. Grant, JD, MD, MPH University of Minnesota School of Medicine Minneapolis, MN.

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Presentation on theme: "Compulsive Sexual Behavior: Clinical Characteristics and Treatment Jon E. Grant, JD, MD, MPH University of Minnesota School of Medicine Minneapolis, MN."— Presentation transcript:

1 Compulsive Sexual Behavior: Clinical Characteristics and Treatment Jon E. Grant, JD, MD, MPH University of Minnesota School of Medicine Minneapolis, MN Jon E. Grant, JD, MD, MPH University of Minnesota School of Medicine Minneapolis, MN

2 Impulse Control Disorders Pathological gambling Pathological gambling Kleptomania Kleptomania Compulsive sexual behavior Compulsive sexual behavior Compulsive buying Compulsive buying Pyromania Pyromania

3 Current and Lifetime Prevalence of ICDs among Psychiatric Inpatients Impulse Control Disorder Current Prevalence Lifetime Prevalence Compulsive Buying 19 (9.3%) Kleptomania 16 (7.8%) 19 (9.3%) Pathological Gambling 14 (6.9%) Intermittent Explosive Disorder 13 (6.4%) 14 (6.9%) Compulsive Sexual Behavior 9 (4.4%) 10 (4.9%) Pyromania 7 (3.4%) 12 (5.9%) Trichotillomania 7 (3.4%) 9 (4.4%)

4 Impulse Control DisorderCurrent Prevalence Pathologic Skin Picking12 (11.8%) Kleptomania9 (8.8%) Pyromania7 (6.9%) Compulsive Buying7 (6.9%) Compulsive Sexual Behavior5 (4.9%) Pathological Gambling5 (4.9%) Trichotillomania4 (3.9%) Current Prevalence of ICDs among Adolescent Psychiatric Inpatients

5 ICDs in Adolescent Psychiatric Inpatients Overall Girls Boys Overall Girls Boys Int. Explosive Disorder 12.7% 12.5% 13.0% Pathological Skin Picking 11.8% 16.1% 6.5% Kleptomania 8.8% 7.1% 10.9% Pyromania 6.9% 12.5% 0% Compulsive Buying 6.9% 10.7% 2.2% Compulsive Sex 4.9% 8.9% 0% Pathological Gambling 4.9% 1.8% 8.7% Trichotillomania 3.9% 5.4% 2.2%

6 Impulse Control DisorderLifetime Prevalence Trichotillomania3.91% Trichotillomania without tension/gratification1.39% Compulsive Sexual Behavior3.66% Sub-clinical Compulsive Sexual Behavior7.82% Compulsive Buying1.89% Sub-clinical Compulsive Buying10.59% Pathological Gambling1.13% Problem gambling1.39% Pyromania1.01% Sub-clinical Pyromania1.26% Intermittent Explosive Disorder0.50% Sub-clinical Intermittent Explosive Disorder3.53% Kleptomania0.38% Sub-clinical Kleptomania0.50%

7 Core Features of Impulse Control Disorders Repetitive or compulsive engagement in a behavior despite adverse consequences Repetitive or compulsive engagement in a behavior despite adverse consequences Diminished control over the problematic behavior Diminished control over the problematic behavior An appetitive urge or craving state prior to engagement in the problematic behavior An appetitive urge or craving state prior to engagement in the problematic behavior A hedonic quality during the performance of the problematic behavior. A hedonic quality during the performance of the problematic behavior.

8 Common Core Features of Impulse Control Disorders Tolerance Tolerance Withdrawal Withdrawal Repeated unsuccessful attempts to cut back or stop Repeated unsuccessful attempts to cut back or stop Impairment in major areas of life functioning Impairment in major areas of life functioning

9 The Brain

10 Developmental Biology High rates of co-occurrence of ICDs and SUDs start in young adulthood. High rates of co-occurrence of ICDs and SUDs start in young adulthood. Environmental and genetic influences - vulnerability to and expression of addictive disorders Environmental and genetic influences - vulnerability to and expression of addictive disorders Changes in brain structure and function during adolescence might influence the motivation to engage in risk-taking behaviors like gambling. Changes in brain structure and function during adolescence might influence the motivation to engage in risk-taking behaviors like gambling.

11 Problem Behaviors smoking delinquency male drug use gambling sexual behavior Youth Problem Gambling as a Component of Problem Behaviors

12 Emerging Science: Teen Brains Are Still Developing New insights about: New insights about: Why teenagers take risks and show poor judgmentWhy teenagers take risks and show poor judgment How teenagers may be highly vulnerable to drug abuseHow teenagers may be highly vulnerable to drug abuse These findings can help parents! These findings can help parents!

13 Motivation Emotion Judgment Cerebellum Amygdala Nucleus Accumbens Prefrontal Cortex Physical coordination Notice: Judgment is last to develop !

14 Motivation Emotion Judgment Age 24 Physical coordinatio n, sensory processing Balance

15 PFC amygdala In the presence of stress… I hate school; I am going to skip classes and look at pornography

16 Adulthood

17 Neural Systems and Addiction Mesocorticolimbic Dopamine System (Overactive Motor) Mesocorticolimbic Dopamine System (Overactive Motor) -Ventral Tegmental Area, Nucleus Accumbens -Ventral Tegmental Area, Nucleus Accumbens Frontal Serotonin Systems (Bad Brakes) Frontal Serotonin Systems (Bad Brakes) -Frontal/Prefrontal Cortical Function -Frontal/Prefrontal Cortical Function Role for Neurotransmitter Systems Modulating DA, 5HT Function Role for Neurotransmitter Systems Modulating DA, 5HT Function -GABA, Glutamate, Opioids,... -GABA, Glutamate, Opioids,...

18 Motivational Neural Circuits Multiple brain structures underlying motivated behaviors. Multiple brain structures underlying motivated behaviors. Motivated behavior involves integrating information regarding internal state (e.g., hunger, sexual desire, pain), environmental factors (e.g., resource or reproductive opportunities, the presence of danger), and personal experiences (e.g., recollections of events deemed similar in nature). Motivated behavior involves integrating information regarding internal state (e.g., hunger, sexual desire, pain), environmental factors (e.g., resource or reproductive opportunities, the presence of danger), and personal experiences (e.g., recollections of events deemed similar in nature).

19 Neurochemistry of Impulsivity Impulsivity GLUTAMATE DOPAMINE SEROTONIN

20 Role of Serotonin Decreased serotonin associated with adult risk-taking behaviors. Decreased serotonin associated with adult risk-taking behaviors. Blunted serotonergic responses in the ventromedial prefrontal cortex - in individuals with impulsivity Blunted serotonergic responses in the ventromedial prefrontal cortex - in individuals with impulsivity Implicated in disadvantageous decision- making. Implicated in disadvantageous decision- making.

21 Role of Dopamine Dopamine release into the nucleus accumbens - translates motivated drive into action - a go signal Dopamine release into the nucleus accumbens - translates motivated drive into action - a go signal Dopamine release associated with rewards and reinforcing Dopamine release associated with rewards and reinforcing Dopamine release - maximal when reward is most uncertain, suggesting it plays a central role in guiding behavior during risk-taking situations. Dopamine release - maximal when reward is most uncertain, suggesting it plays a central role in guiding behavior during risk-taking situations.

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23 Opioid System The endogenous opioid system influences the experiencing of pleasure. The endogenous opioid system influences the experiencing of pleasure. Opioids modulate mesolimbic dopamine pathways via disinhibition of GABA input in the ventral tegmental area. Opioids modulate mesolimbic dopamine pathways via disinhibition of GABA input in the ventral tegmental area.

24 Compulsive Sexual Behavior

25 Sexual thoughts, urges and behaviors that are normative Sexual thoughts, urges and behaviors that are normative Engaged in with a frequency or intensity that leads to distress or impairment Engaged in with a frequency or intensity that leads to distress or impairment

26 CSB Diagnostic Criteria Persistent and recurrent maladaptive behavior as indicated by the following: Persistent and recurrent maladaptive behavior as indicated by the following: (1) Difficulty controlling sexual behavior as indicated by engaging in sexual behavior for longer periods than intended (1) Difficulty controlling sexual behavior as indicated by engaging in sexual behavior for longer periods than intended (2) Repeated unsuccessful efforts to control, cut back, or stop excessive sexual behavior (2) Repeated unsuccessful efforts to control, cut back, or stop excessive sexual behavior (3) Becomes restless or irritable when attempting to cut down or stop the sexual behavior (3) Becomes restless or irritable when attempting to cut down or stop the sexual behavior

27 (4) Needs to engage in the sexual behavior for increasing amounts of time or intensity in order to achieve the desired feelings (e.g., stimulation, excitement, pleasure, gratification) (4) Needs to engage in the sexual behavior for increasing amounts of time or intensity in order to achieve the desired feelings (e.g., stimulation, excitement, pleasure, gratification) (5) Is preoccupied with the sexual behavior (e.g., fantasizing about the behavior or planning the next future sexual activities (5) Is preoccupied with the sexual behavior (e.g., fantasizing about the behavior or planning the next future sexual activities (6) Has sexual impulses that are experienced as uncontrollable, intrusive, and/or senseless (6) Has sexual impulses that are experienced as uncontrollable, intrusive, and/or senseless

28 (7) Sexual behavior is continued despite knowledge of possible health, safety, economic, or legal problems (e.g. sexually transmitted diseases, injuries, illnesses, use of prostitutes, sexual offenses). (7) Sexual behavior is continued despite knowledge of possible health, safety, economic, or legal problems (e.g. sexually transmitted diseases, injuries, illnesses, use of prostitutes, sexual offenses). (8) Engages in excessive sexual behavior as a way of escaping from problems or of relieving a dysphoric mood (e.g., feelings of helplessness, guilt, anxiety, depression) (8) Engages in excessive sexual behavior as a way of escaping from problems or of relieving a dysphoric mood (e.g., feelings of helplessness, guilt, anxiety, depression) (9) Important social, occupational, or recreational activities given up or reduced because of excessive sexual behavior (9) Important social, occupational, or recreational activities given up or reduced because of excessive sexual behavior

29 (10) Repeatedly engages in excessive sexual behavior despite feeling guilty about it (10) Repeatedly engages in excessive sexual behavior despite feeling guilty about it (11) Lies to family members, friends, therapist, or others to conceal the extent of sexual behavior (11) Lies to family members, friends, therapist, or others to conceal the extent of sexual behavior (12) Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of excessive sexual behavior (12) Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of excessive sexual behavior (13) sexual behavior causes clinically significant distress (13) sexual behavior causes clinically significant distress

30 CSB Behaviors Compulsive masturbation85% Compulsive masturbation85% Phone sex dependence31% Phone sex dependence31% Pornography dependence73% Pornography dependence73% Ego-dystonic promiscuity50% Ego-dystonic promiscuity50% Sexual chat room dependence40% Sexual chat room dependence40%

31 Characteristics Begins in late adolescence Begins in late adolescence Peaks between ages 20 and 30 Peaks between ages 20 and 30 Ratio of males to females is 3:1 Ratio of males to females is 3:1 Minimum TSO of 7/week for at least 6 months Minimum TSO of 7/week for at least 6 months

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33 Paraphilias Exhibitionism Exhibitionism Fetishism Fetishism Frotteurism Frotteurism Pedophilia Pedophilia Masochism Masochism Sadism Sadism Transvestic Fetishism Transvestic Fetishism Voyeurism Voyeurism

34 Different from Paraphilias? Same TSO Same TSO Paraphilias more likely to have ADHD Paraphilias more likely to have ADHD More criminal histories More criminal histories More trouble in school More trouble in school More likely to have been abused More likely to have been abused

35 Health Concerns HIV and AIDS HIV and AIDS Hepatitis Hepatitis Syphilis Syphilis STDs STDs Self-Esteem Self-Esteem Nicotine dependence Nicotine dependence

36 Case Example 30 years old and seeking treatment for first time 30 years old and seeking treatment for first time Onset at 15 years old Onset at 15 years old Male Male Business Business Wax and wane in intensity depending on external stressors Wax and wane in intensity depending on external stressors

37 Case Example Content of sexual obsessions: thoughts of and urges to sexually molest children thoughts of and urges to sexually molest children doubting if committed sexual acts, fear of being alone around children doubting if committed sexual acts, fear of being alone around children thoughts of inappropriate sexual acts towards coworkers and family members thoughts of inappropriate sexual acts towards coworkers and family members fear of being aroused by thoughts and checking for arousal, avoidance of people associated with thoughts fear of being aroused by thoughts and checking for arousal, avoidance of people associated with thoughts

38 How are OCD and CSB Alike? Propensity of individuals with CSB to engage in excessive, Propensity of individuals with CSB to engage in excessive, Possibly harmful behavior Possibly harmful behavior Leads to significant impairment in social or occupational functioning and causes personal distress. Leads to significant impairment in social or occupational functioning and causes personal distress.

39 How are CSB and OCD Different? People with CSB may report an urge or craving state prior to engaging in the problematic behavior and People with CSB may report an urge or craving state prior to engaging in the problematic behavior and A hedonic quality during the performance of the behavior. A hedonic quality during the performance of the behavior. Individuals with OCD are generally harm avoidant with a compulsive risk-aversive endpoint to their behaviors. Individuals with OCD are generally harm avoidant with a compulsive risk-aversive endpoint to their behaviors.

40 Problem Gambling and Compulsive Sexual Behavior: Unrecognized Co-Occurring Disorders

41 225 Pathological Gamblers 27 (12%) current co-morbid CSB 27 (12%) current co-morbid CSB 44 (19.5%) lifetime CSB 44 (19.5%) lifetime CSB Rates of CSB 3X in study of psychiatric patients (12%-19.5% compared to 4.4%) Rates of CSB 3X in study of psychiatric patients (12%-19.5% compared to 4.4%)

42 Clinical Characteristics Age of onset: CSB preceded PG for 70.3% Age of onset: CSB preceded PG for 70.3% PG with CSB were significantly more often male than PG alone PG with CSB were significantly more often male than PG alone PG + CSB subjects more likely (82%)than PG subjects (65%) to smoke PG + CSB subjects more likely (82%)than PG subjects (65%) to smoke PG + CSB score higher on Eysenck impulsivity scale than PG subjects or CSB subjects PG + CSB score higher on Eysenck impulsivity scale than PG subjects or CSB subjects

43 Independent Disorder or Should We Think Addiction with Multiple Behaviors?

44 Dynamics of Multiple Addictions* Switching: Replacing on addiction with another Switching: Replacing on addiction with another Alternating: Cycling from one addiction to another in a patterned, systematic way Alternating: Cycling from one addiction to another in a patterned, systematic way Masking: Using denial around one addiction to cover up for another Masking: Using denial around one addiction to cover up for another Ritualizing: one addiction is part of the ritualizing for another Ritualizing: one addiction is part of the ritualizing for another *Patrick J. Carnes, Ph.D.

45 Dynamics of Multiple Addictions (cont.) Intensifying: Using addictive patterns simultaneously to intensify the overall experience Intensifying: Using addictive patterns simultaneously to intensify the overall experience Numbing: using addiction to medicate shame and pain due to another addiction Numbing: using addiction to medicate shame and pain due to another addiction Disinhibiting: Using one addiction to lower inhibitions for other addictive acting out Disinhibiting: Using one addiction to lower inhibitions for other addictive acting out

46 Body Image and Self Harm

47 Eating Disorders Gay men 3x more likely than heterosexual men to have an eating disorder Gay men 3x more likely than heterosexual men to have an eating disorder Often takes the form of compulsive exercise Often takes the form of compulsive exercise Steroid abuse Steroid abuse

48 Self-Harm and Suicide Gay men 7x more likely to have attempted suicide Gay men 7x more likely to have attempted suicide Gay youth comprise 30% of completed suicides annually Gay youth comprise 30% of completed suicides annually Gay and bisexual men have higher rates of deliberate self-harm Gay and bisexual men have higher rates of deliberate self-harm

49 Methamphetamine Prevalence of people who have used within the past 12 months is 0.6% Prevalence of people who have used within the past 12 months is 0.6% Prevalence rates for methamphetamine use in the previous 6 months among MSM in San Francisco range between 11%–17% Prevalence rates for methamphetamine use in the previous 6 months among MSM in San Francisco range between 11%–17% Associated with high rates of HIV Associated with high rates of HIV 13-25% experience psychosis; 11x the population 13-25% experience psychosis; 11x the population 90% of gay men using meth also use other drugs 90% of gay men using meth also use other drugs

50 Treatment

51 Treatment of CSB Medical causes excluded Medical causes excluded Assess comorbid disorders Assess comorbid disorders Assess motivation for treatment Assess motivation for treatment Examine what starts behavior or maintains behavior Examine what starts behavior or maintains behavior Differential diagnosis Differential diagnosis Family involvement Family involvement Other assistance - e.g. financial planning Other assistance - e.g. financial planning

52 Heterogeneity of CSB Anxiety driven Anxiety driven Affective driven Affective driven Urges/cravings driven Urges/cravings driven Impulsive/inattentive Impulsive/inattentive

53 Psychotherapy Cognitive therapy Cognitive therapy Exposure and response prevention Exposure and response prevention Habit reversal with relaxation techniques Habit reversal with relaxation techniques Covert sensitization Covert sensitization Imaginal desensitization Imaginal desensitization Family/couples therapy Family/couples therapy

54 Citalopram 28 gay/bisexual men; mean age 37yrs 28 gay/bisexual men; mean age 37yrs 10% HIV positive; 77% with STDs 10% HIV positive; 77% with STDs 12 weeks; medication vs. placebo 12 weeks; medication vs. placebo Decrease in sexual drive, frequency of masturbation, and pornography use Decrease in sexual drive, frequency of masturbation, and pornography use Sexual risk did not change between groups – number of partners, number of risky oral and anal sex acts54 Sexual risk did not change between groups – number of partners, number of risky oral and anal sex acts54

55 Pharmacotherapy Antidepressants Antidepressants Antiepileptics/lithium Antiepileptics/lithium Opioid antagonists Opioid antagonists Stimulants Stimulants Baclofen Baclofen Isradipine Isradipine Ondansetron Ondansetron Antabuse Antabuse

56 Psychotherapy Psychodynamic psychotherapy, IPT Psychodynamic psychotherapy, IPT Group CBT therapy Group CBT therapy CBT: Social skills, assertiveness, anger management; cognitive restructuring, reconditioning techniques of arousal, relapse prevention; imaginal desensitization CBT: Social skills, assertiveness, anger management; cognitive restructuring, reconditioning techniques of arousal, relapse prevention; imaginal desensitization

57 12-Step Programs Sexaholics Anonymous Sexaholics Anonymous Sex and Love Addicts Anonymous Sex and Love Addicts Anonymous

58 Summary

59 Conclusions CSB appears to be fairly common CSB appears to be fairly common Frequently co-occur with other disorders Frequently co-occur with other disorders Result in significant distress as well as social and functional impairment. Result in significant distress as well as social and functional impairment. Emerging data suggest they may respond well to pharmacological and psychotherapeutic interventions. Emerging data suggest they may respond well to pharmacological and psychotherapeutic interventions.


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