Presentation on theme: "Compulsive Sexual Behavior: Clinical Characteristics and Treatment"— Presentation transcript:
1 Compulsive Sexual Behavior: Clinical Characteristics and Treatment Jon E. Grant, JD, MD, MPHUniversity of MinnesotaSchool of MedicineMinneapolis, MN
2 Impulse Control Disorders Pathological gamblingKleptomaniaCompulsive sexual behaviorCompulsive buyingPyromania
3 Current and Lifetime Prevalence of ICDs among Psychiatric Inpatients Impulse Control DisorderCurrent PrevalenceLifetime PrevalenceCompulsive Buying19 (9.3%)Kleptomania16 (7.8%)Pathological Gambling14 (6.9%)Intermittent Explosive Disorder13 (6.4%)Compulsive Sexual Behavior9 (4.4%)10 (4.9%)Pyromania7 (3.4%)12 (5.9%)Trichotillomania
4 Current Prevalence of ICDs among Adolescent Psychiatric Inpatients Impulse Control DisorderCurrent PrevalencePathologic Skin Picking12 (11.8%)Kleptomania9 (8.8%)Pyromania7 (6.9%)Compulsive BuyingCompulsive Sexual Behavior5 (4.9%)Pathological GamblingTrichotillomania4 (3.9%)
6 Impulse Control Disorder Lifetime PrevalenceTrichotillomania3.91%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 gamblingPyromania1.01%Sub-clinical Pyromania1.26%Intermittent Explosive Disorder0.50%Sub-clinical Intermittent Explosive Disorder3.53%Kleptomania0.38%Sub-clinical Kleptomania
7 Core Features of Impulse Control Disorders Repetitive or compulsive engagement in a behavior despite adverse consequencesDiminished control over the problematic behaviorAn appetitive urge or craving state prior to engagement in the problematic behaviorA hedonic quality during the performance of the problematic behavior.
8 Common Core Features of Impulse Control Disorders ToleranceWithdrawalRepeated unsuccessful attempts to cut back or stopImpairment in major areas of life functioning
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 disordersChanges 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 sexualbehaviordelinquencysmokingProblemBehaviorsgamblingmaledruguse
12 Emerging Science: Teen Brains Are Still Developing New insights about:Why teenagers take risks and show poor judgmentHow teenagers may be highly vulnerable to drug abuseThese 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! AmygdalaJudgmentEmotionMotivationPhysical coordinationPrefrontal CortexNucleus AccumbensThe 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.CerebellumNotice: Judgment is last to develop!
14 Age 24 Balance Emotion Motivation Judgment Physical coordination, sensory processingJudgmentBalance 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 pornographyPFCamygdala
17 Neural Systems and Addiction Mesocorticolimbic Dopamine System (“Overactive Motor”)-Ventral Tegmental Area, Nucleus AccumbensFrontal Serotonin Systems (“Bad Brakes”)-Frontal/Prefrontal Cortical FunctionRole 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 SEROTONINImpulsivityGLUTAMATEDOPAMINE
20 Role of SerotoninDecreased serotonin associated with adult risk-taking behaviors.Blunted serotonergic responses in the ventromedial prefrontal cortex - in individuals with impulsivityImplicated in disadvantageous decision-making.
21 Role of DopamineDopamine release into the nucleus accumbens - translates motivated drive into action - a “go” signalDopamine release associated with rewards and reinforcingDopamine release - maximal when reward is most uncertain, suggesting it plays a central role in guiding behavior during risk-taking situations.
25 Compulsive Sexual Behavior Sexual thoughts, urges and behaviors that are normativeEngaged 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
34 Different from Paraphilias? Same TSOParaphilias more likely to have ADHDMore criminal historiesMore trouble in schoolMore likely to have been abused
35 Health Concerns HIV and AIDS Hepatitis Syphilis STDs Self-Esteem Nicotine dependence
36 Case Example30 years old and seeking treatment for first timeOnset at 15 years oldMaleBusinessWax and wane in intensity depending on external stressors
37 Case ExampleContent of sexual obsessions:thoughts of and urges to sexually molest childrendoubting if committed sexual acts, fear of being alone around childrenthoughts of inappropriate sexual acts towards coworkers and family membersfear 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 behaviorLeads 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 andA 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 CSB44 (19.5%) lifetime CSBRates 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 alonePG + CSB subjects more likely (82%)than PG subjects (65%) to smokePG + 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 anotherAlternating: Cycling from one addiction to another in a patterned, systematic wayMasking: Using denial around one addiction to cover up for anotherRitualizing: 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 experienceNumbing: using addiction to medicate shame and pain due to another addictionDisinhibiting: Using one addiction to lower inhibitions for other addictive acting out
47 Eating DisordersGay men 3x more likely than heterosexual men to have an eating disorderOften takes the form of compulsive exerciseSteroid abuse
48 Self-Harm and Suicide Gay men 7x more likely to have attempted suicide Gay youth comprise 30% of completed suicides annuallyGay and bisexual men have higher rates of deliberate self-harm
49 MethamphetaminePrevalence 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 HIV13-25% experience psychosis; 11x the population90% of gay men using meth also use other drugs
51 Treatment of CSB Medical causes excluded Assess comorbid disorders Assess motivation for treatmentExamine what starts behavior or maintains behaviorDifferential diagnosisFamily involvementOther assistance - e.g. financial planning
52 Heterogeneity of CSB Anxiety driven Affective driven Urges/cravings drivenImpulsive/inattentive
53 Psychotherapy Cognitive therapy Exposure and response prevention Habit reversal with relaxation techniquesCovert sensitizationImaginal desensitizationFamily/couples therapy
54 Citalopram 28 gay/bisexual men; mean age 37yrs 10% HIV positive; 77% with STDs12 weeks; medication vs. placeboDecrease in sexual drive, frequency of masturbation, and pornography useSexual risk did not change between groups – number of partners, number of risky oral and anal sex acts54
59 Conclusions CSB appears to be fairly common Frequently co-occur with other disordersResult in significant distress as well as social and functional impairment.Emerging data suggest they may respond well to pharmacological and psychotherapeutic interventions.