Sexual Addiction Update Assessment, Diagnosis, and Treatment: Page 2 of 3
Sexual Addiction Update Assessment, Diagnosis, and Treatment: Page 2 of 3
In the first vignette, Stan meets criteria 4, 5, and 7 of the diagnostic criteria for sexual addiction, and perhaps also criterion 6. The third example, Jolene, meets criteria 4, 5, 6, 7, and probably 2. In the fourth vignette, Dale seems to meet all of the criteria except 3. The second example, Steve, might meet criterion 5, but he does not seem to meet any of the other criteria. Charla, the fifth example, probably meets criterion 5. She might or might not meet criterion 6, depending on the importance (to her) of the activities with Mike that she gives up to have sex with other men.
According to the diagnostic criteria, Stan, Dale, and Jolene merit diagnoses of sexual addiction. Steve and Charla do not. An informal assessment based on the definition of sexual addiction reaches the same conclusions. Stan, Jolene, and Dale demonstrate patterns of sexual behavior that are characterized by recurrent failure to control their sexual behavior, which they continue despite significant harmful consequences. Steve and Charla do not.
A number of inventories or questionnaires have been developed for use as instruments to screen for sexual addiction or sexual compulsivity: the Sexual Addiction Screening Test, the Sexual Compulsivity Scale, the Sexual Dependency Inventory-Revised, the Sex Addicts Anonymous Questionnaire, and the Compulsive Sexual Behavior Inventory.4-8 Each of these questionnaires has high test-retest reliability, high internal consistency, modest criterion validity, and modest construct (convergent and divergent) validity.
In the absence of a standard set of diagnostic criteria, however, the significance of a report of criterion validity or construct validity is hard to evaluate. Moreover, most of the inventories include a significant number of questions that are not diagnostically relevant (ie, they do not yield information about whether diagnostic criteria are or are not met). Among these instruments, the one that is most likely to be useful for gauging the presence of sexual addiction is the Sexual Compulsivity Scale.5 It addresses both of the key features of addiction—impaired control and harmful consequences—and every question is relevant for assessing these features. In general, yes/no questionnaires of this kind can be helpful when used for screening and self-assessment. But for diagnostic evaluation, they cannot substitute for face-to-face interviews that use open-ended questions.
The addictive process
The most comprehensive and exciting new developments that concern sexual addiction have occurred in the neurobiological understanding of the addictive process, the underlying biopsychological process that all addictive disorders share. The addictive process can be understood to involve impairments in 3 interrelated functional systems: motivation-reward, affect regulation, and behavioral inhibition. An impaired motivation-reward system exposes addicts to unsatisfied states of irritable tension, emptiness, and restless anhedonia.
In the context of impaired motivation-reward function, behaviors that are associated with activation of the reward system are more strongly reinforced (via both positive and negative reinforcement) than they otherwise would have been. Impaired affect regulation renders addicts chronically vulnerable to painful affects and emotional instability.
In the context of impaired affect regulation, behaviors that are associated with escape from or avoidance of painful affects are more strongly reinforced (via negative reinforcement) than they otherwise would have been. Impaired behavioral inhibition increases the likelihood that urges for some form of reinforcement (negative, positive, or both) in the short term will override consideration of longer-term consequences, both negative and positive.
When motivation-reward and affect regulation are impaired, impaired behavioral inhibition means that urges to engage in behaviors that are associated with both (a) activation of the reward system, and (b) escape from or avoidance of painful affects, are extraordinarily difficult to resist, despite the harmful consequences that they might entail. Neuroscience research during the past decade has expanded and deepened our understanding of the neurochemistry, neuroanatomy, and developmental neurobiology of all 3 components of the addictive process.9
While this body of research does not mention sexual addiction, its relevance for sexual addiction is considerable. It illuminates a neurobiological process that underlies addictive patterns of behavior; that is not specific to drugs but can involve any behavior that is associated with activation of the brain reward system; and that develops through the interaction of genetic, prenatal, neonatal, and childhood influences on motivation-reward, affect regulation, and behavioral inhibition functions, and not as a result of exposure to a psychoactive substance or behavior.
Many arguments against the concept of sexual addiction were grounded in a drug-oriented neurobiology of addiction that is being supplanted by a brain-oriented neurobiology of addiction. The latter readily accommodates the addictive use of sexual behavior, much as it accommodates the addictive use of food or eating: a naturally rewarding behavior that is part of normal life but that can come to be used in self-harming ways when motivation-reward, affect regulation, and behavioral inhibition functions are impaired.
Little research on the management of sexual addiction has been published. Most of the treatment-related articles published during the past decade are case reports: 2 on psychodynamic psychotherapy, 1 on eye movement desensitization and reprocessing, and 4 on pharmacotherapy.10-16 One double-blind, placebo-controlled study and 3 case series, 1 on pharmacotherapy and 2 on inpatient treatment programs, have also been published.17-20 Psychotherapy case reports seem to be most meaningful when they focus on describing the process and conveying understanding.
A case report by Chirban10 in which he used an integrative treatment that was centered in psychodynamic therapy with cognitive-behavioral modalities performs both functions well, and it illustrates how diverse modalities of treatment can be provided together as a flexible and coherent system. A notable feature of the pharmacotherapy case reports is that all of the patients were treated with 2 or more medications concurrently, including 1 stabilizer and 1 antidepressant.13-16 The treatment that is described in the pharmacotherapy case series also involves prescription of 2 medications concurrently.18 However, in this study, a psychostimulant was added to the antidepressant.
The double-blind, placebo-controlled study found that in sex addicts, citalopram reduced the frequency of symptomatic sexual urges, masturbation, and use of pornography, but it had no significant effect on partnered sexual behaviors.17 The large number of positive findings is encouraging, but confidence in drawing conclusions is limited by the paucity of controlled studies.
A comprehensive critical review of treatment for paraphilias also is instructive, despite the substantial areas of the categories sexual addiction and paraphilia that do not overlap.21 Three of the review’s conclusions seem to be particularly relevant:
1. Treatment programs that were most effective at reducing recidivism were predominantly cognitive-behavioral. Programs that did not employ a cognitive-behavioral approach to treatment were ineffective. The conclusion is based on the results of 112 studies with almost 23,000 convicted sex offenders—a group that at first glance might not seem to be ideal for cognitive-behavioral treatment.
2. Treatment effectiveness was greater for individual treatment (odds ratio, 2.88) than for group treatment (odds ratio, 1.71).
3. Attainment of treatment goals with sex offenders is highly dependent on process issues. More specifically, the therapist’s genuine expression of personal qualities—such as empathy, warmth, directiveness, and encouragement—is predictive of the clients’ attainment of the goals of treatment. A proviso is that unless the expression of these qualities is authentic, treatment is unlikely to be successful.