Two kinds of pharmacological treatment may be used to treat addiction: endocrinological agents and affect-regulating agents.3 Endocrinological agents decrease the intensity of the sexual drive; thus, the person is more in control and less likely to act on paraphilic interests. These agents do not change the direction of the sexual interest, however. Their primary therapeutic function is to reduce sex drive to manageable levels in those individuals whose ability to control their behavioral impulses is so impaired as to put them at risk either to injure themselves or others, or to render them unresponsive to psychological interventions.
Endocrinological agents can lower the risk of problematic sexual behavior during the interval between the initiation of treatment and the consolidation of the changes that affect-regulating agents, behavior modification, group therapy, or psychotherapy can induce. Those currently in use include anti-androgenic agents and gonadotropin-releasing hormone (GnRH) agonists. However, of the 2 anti-androgenic agents, one is fraught with unpleasant or dangerous adverse effects, and the other is not commercially available in the United States.
Analogues of GnRH have been developed that have higher potency and longer duration of action than does naturally occurring GnRH. Triptorelin(Drug information on triptorelin) is injected once a month, and leuprolide is injected once every 3 months. Initial administration of these agents raises serum testosterone levels. However, continuous administration produces down-regulation of GnRH receptors on the pituitary gonadotropes, which leads to a decrease in secretion of leutinizing hormone and follicle-stimulating hormone, and a consequent decrease in the synthesis of testosterone.
Several reports of uncontrolled, open-label trials of GnRH agonists in the treatment of paraphilias and hypersexual disorders have all demonstrated significant positive effects.22-27 The main adverse effects were erectile dysfunction, hot flashes, and a decrease in bone density. These results suggest that GnRH agonists could prove to be a more effective, safer, and less noxious alternative to the direct anti-androgenic agents.
A number of case reports and open-label studies have provided evidence for the efficacy of affect-regulating agents (primarily antidepressants) in the treatment of paraphilias and nonparaphilic sexual addictions, even in patients who did not have a major affective disorder.28,29 While symptoms of paraphilic and nonparaphilic sexual addiction improved with antidepressant treatment in the absence of major depression, some studies found that paraphilic patients with comorbid depression showed a concurrent decrease in paraphilic behavior when their depressive symptoms improved.30,31
Agents that have been found to be effective include fluoxetine, sertraline, citalopram, paroxetine, fluvoxamine(Drug information on fluvoxamine), venlafaxine, nefazodone(Drug information on nefazodone), imipramine(Drug information on imipramine), desipramine, clomipramine(Drug information on clomipramine), lithium, carbamazepine(Drug information on carbamazepine), topiramate(Drug information on topiramate), lamotrigine(Drug information on lamotrigine), divalproex, risperidone(Drug information on risperidone), buspirone(Drug information on buspirone).13-16,30,32-51 Electroconvulsive therapy has also been shown to be effective.52 Most of these studies reported a positive response rate in the range of 50% to 90%. Antidepressants, especially the serotonin reuptake inhibitors (SRIs), can produce diminished libido, but a number of the studies noted that antidepressants reduced the drive for symptomatic sexual behavior without decreasing the drive for healthy sexual behavior.
Augmentation of a 5-hydroxytryptamine reuptake inhibitor with bupropion or with a psychostimulant can further reduce sexual fantasies, urges, and behavior, particularly when concurrent depressive symptoms have not responded adequately to the SRI or when symptoms of attention-deficit disorder are present.53 I also have found that divalproex or lamotrigine can be helpful for sexual addiction symptoms that arise in the context of atypical manic-depressive conditions or “emotionally unstable character disorders,” and that gabapentin(Drug information on gabapentin) can alleviate accompanying irritability and feelings of being overwhelmed.
Psychiatric pharmacotherapy is direct intervention to enhance emotional and behavioral self-regulation; it also addresses other symptoms of comorbid psychiatric disorders. In sexual addiction, craving and urges to act out are expressions of dysregulated emotional states, and such urges are more likely to be acted out when behavioral regulation is impaired. Consequently, enhancement of affect regulation tends to diminish the frequency and intensity of addictive urges, while enhanced behavioral regulation reduces the likelihood that urges will lead to acting out.
A number of studies have indicated that antidepressant medications, particularly the SRIs, can reduce the frequency of addictive sexual behavior and the intensity of urges to engage in addictive sexual behavior, even when the patient does not have major depression.43 As may be imagined, the boundary between psychiatric pharmacotherapy and affect-regulating agents is indistinct and has to do more with the symptoms that the agents are intended to target than with the nature of the agents themselves.