Compulsive Sexual Behaviour Disorder

Key points (based on presentation by Briken):

• Impulse control disorder, not behavioral addiction - no clear information on whether the processes involved are equivalent to substance use disorders, gambling and gaming.
• Concerns about over pathologizing sexual behaviors are explicitly addressed
• Individuals with high levels of sexual interest and behavior who do not exhibit impaired (sexual self-)control and significant distress or impairment in functioning should not be diagnosed.
• Diagnosis should also not be assigned to describe high levels of sexual interest and behaviors (e.g. masturbation) that are common among adolescents
• Should not be diagnosed based on psychological distress related to moral judgments.

References

• Briken, P. (2020). An integrated model to assess and treat compulsive sexual behaviour disorder. Nature Reviews Urology, 17. https://doi.org/10.1038/s41585-020-0343-7
• Although the word ‘compulsive’ is included in the name because that is a very common way of referring to this phenomenon in the literature, sexual behaviour in CSBD is not considered a true compulsion that occurs in relation to intrusive, unwanted and typically anxiety provoking thoughts (obsessions) as in OCD. Rather, CSBD is a repetitive, typically initially rewarding behaviour pattern that the person feels unable to control, which appears to have both impulsive and compulsive elements [106]. Early in the development of the behaviour pattern, impulsivity and positive reinforcement (pleasure) are the most important elements. Later in the course of the disorder, compulsive aspects and negative reinforcement (e.g. temporary improvement of negative mood) are likely to become increasingly important in sustaining the behaviors [107]. The most thoroughly investigated theoretical model on the interplay between excitatory and inhibitory influences on sexual behaviour is the dual control model [108], according to which CS BD could be a problem when sexual self-control is relatively low and sexual responsiveness/excitability is relatively high [109, 110]. Clinically, the lack of self-control is often subjectively experienced as urgency, while sex in CSBD may fulfill a variety of different functions. Treatment therefore focuses on improvement of sexual self-control as well as coping with the underlying emotional states and motives. Briken in Stein, D. J., Szatmari, P., Gaebel, W., Berk, M., Vieta, E., Maj, M., de Vries, Y. A., Roest, A. M., de Jonge, P., Maercker, A., Brewin, C. R., Pike, K. M., Grilo, C. M., Fineberg, N. A., Briken, P., Cohen-Kettenis, P. T., & Reed, G. M. (2020). Mental, behavioral and neurodevelopmental disorders in the ICD-11: an international perspective on key changes and controversies. BMC Medicine, 18(1), 21. p. 17.
  • Available evidence suggests a prevalence of 10–12% for men and 7% for women for sexual compulsivity; however, the new CSBD guidelines are yet to be used in epidemiological studies (e.g. [111–113]). Ibid.
    • In the absence of consistent definitions and community based epidemiological data, determining accurate prevalence rates of compulsive sexual behaviour disorder has been difficult. Epidemiological estimates have ranged up to 3-6% in adults [8], though recent studies have produced somewhat lower estimates of 1 to 3% [9]. The more restrictive diagnostic requirements proposed for ICD-11 would be expected to produce lower prevalence rates. In Gola, M., Lewczuk, K., Potenza, M., Kingston, D., Grubbs, J., Stark, R., & Reid, R. (2020). What should be included in the criteria for compulsive sexual behavior disorder? Journal of Behavioral Addictions. https://doi.org/10.1556/2006.2020.00090
    • The results indicated that most participants had viewed pornography within their lifetimes (n = 1,461), with just over half reporting some use in the past year (n = 1,056). Moreover, roughly 11% of men and 3% of women reported some agreement with the statement “I am addicted to pornography.” Across all participants, such feelings were most strongly associated with male gender, younger age, greater religiousness, greater moral incongruence regarding pornography use, and greater use of pornography. Grubbs, J. B., Kraus, S. W., & Perry, S. L. (2019). Self-reported addiction to pornography in a nationally representative sample: The roles of use habits, religiousness, and moral incongruence. Journal of Behavioral Addictions, 8(1), 88–93. https://doi.org/10.1556/2006.7.2018.134

Treatment

• See First- step treatment goals and Second- step therapy goals in Briken, P. (2020). An integrated model to assess and treat compulsive sexual behaviour disorder. Nature Reviews Urology, 17. https://doi.org/10.1038/s41585-020-0343-7
  • The treatment goals and the development of a treatment plan vary but should consider the symptoms first and then the existing comorbidities and the under lying hypothesis for the development of the disorder. Thus, dividing the treatment goals and the treatment plan into different steps seems reasonable [38]. Ibid.

See also

• Leonhardt, N. D., Busby, D. M., & Willoughby, B. J. (2020). Do You Feel in Control? Sexual Desire, Sexual Passion Expression, and Associations with Perceived Compulsivity to Pornography and Pornography (t sexual drive is associated with higher pornography use, providing some support for Prause et al. hypothesis, namely, sexual drive, rather then addiction, leads to compulsive sexual behavior. )
• Kraus, S. W., Krueger, R. B., Briken, P., First, M. B., Stein, D. J., Kaplan, M. S., Voon, V., Abdo, C. H. N., Grant, J. E., Atalla, E., & Reed, G. M. (2018). Compulsive sexual behaviour disorder in the ICD-11. World Psychiatry, 17(1), 109–110. https://doi.org/https://doi.org/10.1002/wps.20499
  • Concerns about overpathologizing sexual behaviours are explicitly addressed in the diagnostic guidelines proposed for the disorder. Individuals with high levels of sexual interest and behaviour (e.g., due to a high sex drive) who do not exhibit impaired control over their sexual behaviour and significant distress or impairment in functioning should not be diagnosed with compulsive sexual behaviour disorder. The diagnosis should also not be assigned to describe high levels of sexual interest and behaviour (e.g., masturbation) that are common among adolescents, even when this is associated with distress. Ibid
  • Careful attention must be paid to the evaluation of individuals who self-identify as having the disorder (e.g., calling them selves “sex addicts” or “porn addicts”). Upon examination, such individuals may not actually exhibit the clinical characteristics of the disorder, although they might still be treated for other mental health problems (e.g., anxiety, depression). Additionally, individuals often experience feelings such as shame and guilt in relationship to their sexual behaviour [2], but these experiences are not reliably indicative of an underlying disorder.
• Gola, M., Lewczuk, K., Potenza, M., Kingston, D., Grubbs, J., Stark, R., & Reid, R. (2020). What should be included in the criteria for compulsive sexual behavior disorder? Journal of Behavioral Addictions. https://doi.org/10.1556/2006.2020.00090
  • Furthermore, researchers have raised questions about whether models dichotomizing CSB involving the presence or absence of moral incongruence are as distinct as proposed (Brand, Antons, Wegmann, & Potenza, 2019). Thus, although moral incongruence may have clinical relevance in what motivates individuals to seek treatment for CSB (Kraus & Sweeney, 2019), its role in the etiology of and definition of CSBD warrants additional understanding.