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

2. Impulse Control Disorders
Pathological gambling
Kleptomania
Compulsive sexual behavior
Compulsive buying
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%)
Pathological Gambling
14 (6.9%)
Intermittent Explosive Disorder
13 (6.4%)
Compulsive Sexual Behavior
9 (4.4%)
10 (4.9%)
Pyromania
7 (3.4%)
12 (5.9%)
Trichotillomania

4. Current Prevalence of ICDs among Adolescent Psychiatric Inpatients
Impulse Control Disorder
Current Prevalence
Pathologic Skin Picking
12 (11.8%)
Kleptomania
9 (8.8%)
Pyromania
7 (6.9%)
Compulsive Buying
Compulsive Sexual Behavior
5 (4.9%)
Pathological Gambling
Trichotillomania
4 (3.9%)

5. ICDs in Adolescent Psychiatric Inpatients
Overall Girls Boys
Int. Explosive Disorder % % %
Pathological Skin Picking % % %
Kleptomania % % %
Pyromania % % %
Compulsive Buying % % %
Compulsive Sex % % %
Pathological Gambling % % %
Trichotillomania % % %

6. Impulse Control Disorder
Lifetime Prevalence
Trichotillomania
3.91%
Trichotillomania without tension/gratification
1.39%
Compulsive Sexual Behavior
3.66%
Sub-clinical Compulsive Sexual Behavior
7.82%
Compulsive Buying
1.89%
Sub-clinical Compulsive Buying
10.59%
Pathological Gambling
1.13%
Problem gambling
Pyromania
1.01%
Sub-clinical Pyromania
1.26%
Intermittent Explosive Disorder
0.50%
Sub-clinical Intermittent Explosive Disorder
3.53%
Kleptomania
0.38%
Sub-clinical Kleptomania

7. Core Features of Impulse Control Disorders
Repetitive or compulsive engagement in a behavior despite adverse consequences
Diminished control over 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.

8. Common Core Features of Impulse Control Disorders
Tolerance
Withdrawal
Repeated unsuccessful attempts to cut back or stop
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.
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.

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

12. Emerging Science: Teen Brains Are Still Developing
New insights about:
Why teenagers take risks and show poor judgment
How teenagers may be highly vulnerable to drug abuse
These findings can help parents!
New scientific discoveries are altering out perspective on how to understand adolescent behavior. Now, research into the adolescent brain suggests that the human brain is still maturing during the adolescent years, with changes continuing into the early 20s.
The immature brain of the teenage years may provide clues as to why adolescents are prone to take risks and why teenagers are at elevated risk to the effects of drugs. These new scientific discoveries provide valuable lessons for parents and adults that work with youth. They reinforce the importance that teenagers need guidance from adults, and that careful and regular monitoring of their behavior can not be over-stated.

13. Notice: Judgment is last to develop!
Amygdala
Judgment
Emotion
Motivation
Physical coordination
Prefrontal Cortex
Nucleus Accumbens
The pruning of brain structures generally occurs from the back of the brain to the front. Thus, structures at the back of brain finish the pruning first, making these structures the first to mature. Structures at the front of the brain finish pruning last, and it is these structures that do not complete maturation until about age 24.
There are four primary brain structures from the back to the front of the brain – cerebellum, nucleus accumbens, amygdala and prefrontal cortex – that are noteworthy in terms of how their differential development may impact adolescent behavior.
The first area to be finished with pruning is the cerebellum. Located at the back of the brain , this structure controls physical or motor coordination.
Next are the nucleus accumbens, which is responsible for motivation, and the amygdala, which identifies and controls emotion. The nucleus accumbens is responsible for how much effort the organism will expend in order to seek rewards. A developing nucleus accumbens is believed to contribute to the often-observed tendency that teenagers prefer activities that require low effort yet produce high excitement. Real-world observations bear this out: teenagers tend to favor activities such as playing video-games, skate boarding and, unfortunately, substance use. The amygdala is responsible for integrating how to emotionally react to pleasurable and aversive experiences. It is hypothesized that a developing amygdala contributes to two behavioral effects: the tendency for adolescents to react to situations with “hot” emotions rather than more controlled and “cool” emotions, and the propensity for youth to mis-read neutral or inquisitive facial expressions from other individuals as a sign of anger. (Instruct parents: “Smile as you ask your teenager ‘How was school today?’”)
And one of the last areas to mature is the structure named the prefrontal cortex, located just behind the forehead. Sometimes referred to as “the seat of sober second thought,” it’s the area of the brain responsible for the complex processing of information, ranging from making judgments, to controlling impulses, foreseeing the consequences of ones’ actions, and setting goals and plans. An immature prefrontal cortex is thought to be the neurobiological explanation for why teenagers show poor judgment and too often act before they think.
Cerebellum
Notice: Judgment is last to develop!

14. Age 24 Balance Emotion Motivation Judgment
Physical coordination, sensory processing
Judgment
Balance by 24.
Balance

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

16. Adulthood

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

18. Motivational Neural Circuits
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).

19. Neurochemistry of Impulsivity
SEROTONIN
Impulsivity
GLUTAMATE
DOPAMINE

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

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

24. Compulsive Sexual Behavior

25. Compulsive Sexual Behavior
Sexual thoughts, urges and behaviors that are normative
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:
(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
(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)
(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

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).
(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

29. (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
(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

30. CSB Behaviors Compulsive masturbation 85% Phone sex dependence 31%
Pornography dependence 73%
Ego-dystonic promiscuity 50%
Sexual chat room dependence 40%

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

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

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

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

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

37. Case Example
Content of sexual obsessions:
thoughts of and urges to sexually molest children
doubting if committed sexual acts, fear of being alone around children
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

38. How are OCD and CSB Alike?
Propensity of individuals with CSB to engage in excessive,
Possibly harmful behavior
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
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.

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

41. 225 Pathological Gamblers
27 (12%) current co-morbid CSB
44 (19.5%) lifetime CSB
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%
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 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
Alternating: Cycling from one addiction to another in a patterned, systematic way
Masking: Using denial around one addiction to cover up for another
Ritualizing: one addiction is part of the ritualizing for another
*Patrick J. Carnes, Ph.D.

45. Dynamics of Multiple Addictions (con’t.)
Intensifying: Using addictive patterns simultaneously to intensify the overall experience
Numbing: using addiction to medicate shame and pain due to another addiction
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
Often takes the form of compulsive exercise
Steroid abuse

48. Self-Harm and Suicide Gay men 7x more likely to have attempted suicide
Gay youth comprise 30% of completed suicides annually
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 rates for methamphetamine use in the previous 6 months among MSM in San Francisco range between 11%–17%
Associated with high rates of HIV
13-25% experience psychosis; 11x the population
90% of gay men using meth also use other drugs

50. Treatment

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

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

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

54. Citalopram 28 gay/bisexual men; mean age 37yrs
10% HIV positive; 77% with STDs
12 weeks; medication vs. placebo
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

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

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

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

58. Summary

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