Sexual Impulsivity Disorders: Psychiatric "Orphans"

The changing concept and threshold of hypomania for bipolar-spectrum conditions also presents clinical challenges. Although the gold standard for hypomania in bipolar II disorder is an episode lasting "4 or more days" according to DSM-IV, recent research has shown that the mean duration of hypomanic episodes in outpatient samples is 1 to 2 days.²⁵ Episodic nonsubstance abuse-induced euphoric mood, while pathognomonic of hypomania, is no longer considered the primary mood that characterizes hypomania, since irritable or agitated, anxious, and mixed moods may be associated with hypomania as well. The nonpsychiatric mental health or primary care practitioner may not yet appreciate these important clinical findings.

Within a broader-spectrum concept for bipolar disorder, which includes bipolar I, bipolar II, mixed states, cyclothymia, and bipolar not otherwise specified, the incidence rate may be 4% to 6% of the adult population.²⁶ Because increased sexual motivation and excessive involvement in pleasurable activities, including sexual indiscretions, are recognized as possible cardinal manifestations of hypomania, a broader and less exclusive boundary for hypomania should alert clinicians that sexual impulsivity disorders may be found in both poles of bipolar mood disorders.

There is a well-known comorbidity between sexual offending and alcohol abuse. Less commonly reported, however, are associations between sexual impulsivity disorders and marijuana dependence and cocaine abuse. Cocaine (including "crack" cocaine) and very high doses of psychostimulants, such as methylphenidate(Drug information on methylphenidate), dextroamphetamine, and methamphetamine, may specifically disinhibit sexual behavior, most likely in association with dopaminergic overstimulation. Patients with a current substance use disorder may deny or minimize their drug abuse, obscuring the common comorbidity between impulsivity disorders and sexual impulsivity.

Adult ADHD has recently received considerable research and clinical attention and is less likely to be overlooked than, say, a decade ago. In incarcerated populations, however, where adult ADHD-combined subtype would have a higher prevalence because of its comorbidity with antisocial behaviors, this diagnosis is frequently not assessed.²⁷ In adult sexual offenders who are incarcerated, ADHD assessment is over-looked in preference to an Axis II diagnosis, most commonly antisocial personality disorder.²⁸

While the former diagnosis is readily treatable with medication, such as a psychostimulant, the latter diagnosis implies a poorer prognosis. Unfortunately, prescribing psychostimulants in a correctional setting is discouraged because of their misuse potential, so this condition remains undertreated in men and women whose antisocial impulsivity may be embedded in residual symptoms associated with childhood ADHD. There is some research suggesting that while the combined subtype of ADHD may be more predictive of paraphilic sexual offending, the inattentive subtype of adult ADHD may be more likely associated with PRDs.¹⁰

Fetal alcohol syndrome (FAS) and the more broadly defined fetal alcohol effects (FAE) are not specific diagnoses in DSM-IV despite recent evidence that fetal alcohol exposure may be the leading preventable cause of mental retarda- tion in the United States.²⁹ Although the population prevalence of fetal alcohol-associated disorders may be less than that of mood disorders, substance abuse, and ADHD, severe sexual disinhibition, including sexual offending and antisocial impulsivity, is strikingly common in samples of adolescents and adult men (eg, 40% to 50%) with this severe neurodevelopmental condition.^18,19

Many persons with a history of alcohol-related teratogenic effects are hospitalized or clustered in structured residential settings. While clinicians may look for specific and observable congenital facial characteristics in children when they suspect FAS, such observable signs may not be present in children with FAE and may be less readily observed in postpubertal adolescents and adults with FAS. If an infant with FAS or FAE was adopted at birth, maternal medical and psychiatric records that could be critical for diagnostic assessment of the child may not be available. The adolescent or adult with FAE may present with mental retardation, social and learning disabilities, and severe impulsivity and affective lability.

The sexual impulsivity of patients with FAE or FAS is less likely to be coherently organized or planned, as might be the case for persons with PAs. For example, an adolescent or adult with FAE might receive an incorrect diagnosis of frotteurism or exhibitionism because his or her sexually disinhibited behavior is indiscriminate, and he would more likely repetitively target nearby peers or adults, not strangers as those with paraphilia would stealthily seek. At present, in contrast to unipolar or bipolar disorder or ADHD, there is no uniform psychotherapeutic or psychopharmacological treatment algorithm for FAS or FAE. Given the likely prevalence of this condition and its co-association with antisocial impulsivity, more research is needed for effective treatments for this potentially preventable neurodevelopmental disorder.

Clinicians need to have a higher index of suspicion for sexual impulsivity disorders in patients and bring a finer diagnostic lens to the psychiatric comorbidities associated with PAs and PRDs. Persons with diagnoses of mood disorders, ADHD, substance use disorders, and/or developmental disabilities are particularly vulnerable to sexual disinhibition. Men, in particular, are more vulnerable than women. Establishing a therapeutic alliance and then inquiring nonjudgmentally about sexual behavior history (as suggested in the Table) may improve our ability to identify PAs and nonparaphilic expressions of sexual disinhibition such as PRDs.

Pharmacological treatment reports suggest that ameliorating comorbid Axis I psychopathologies or markedly diminishing the testosterone signal effect can diminish sexual impulsivity. Therefore, the correct identification of these conditions and their associated comorbidities would help ameliorate the human suffering and victimization associated with these stigmatized and misunderstood conditions.