Compulsive Sexual Behavior: Clinical Characteristics and Treatment

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

4. Current Prevalence of ICDs among Adolescent Psychiatric Inpatients

5. 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% ICDs in Adolescent Psychiatric Inpatients

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 StillDeveloping • 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!

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

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

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

16. Adulthood

17. 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, ... Neural Systems and Addiction

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