Psychiatric comorbidity and compulsive/impulsive traits in compulsive sexual behavior

Same Same but Different: A Clinical Characterization of Men with Hypersexual Disorder in the Sex@Brain Study

Problems arising from hypersexual behavior are often seen in clinical settings. We aimed to extend the knowledge about the clinical characteristics of individuals with hypersexual disorder (HD). A group of people who fulfilled the proposed diagnostic criteria for HD (men with HD, n = 50) was compared to a group of healthy controls (n = 40). We investigated differences in sociodemographic, neurodevelopmental, and family factors based on self-report questionnaires and clinical interviews. Men with HD reported elevated rates of sexual activity, paraphilias, consumption of child abusive images, and sexual coercive behavior compared to healthy controls. Moreover, rates of affective disorders, attachment difficulties, impulsivity, and dysfunctional emotion regulation strategies were higher in men with HD. Men with HD seem to have experienced various forms of adverse childhood experiences, but there were no further differences in sociodemographic, neurodevelopmental factors, and family factors. Regression analyses indicated that attachment-related avoidance and early onset of masturbation differentiated between men with HD and healthy controls. In conclusion, men with HD appear to have the same neurodevelopment, intelligence levels, sociodemographic background, and family factors compared to healthy controls, but they report different and adverse experiences in childhood, problematic sexual behavior, and psychological difficulties.

Behavioral addictions in bipolar disorders: A systematic review

Clinical and epidemiological research suggests that behavioral addictions (BA) are associated with a wide range of psychiatric disorders. However, the relationship between BA and bipolar disorders (BD) has not been thoroughly explored. The aim of this systematic review was to critically summarize and evaluate the current available evidence regarding a possible association between BA and BD. A systematic review of major electronic databases according to PRISMA guidelines was conducted from inception to 31st December 2017. We sought quantitative studies data concerning prevalence of comorbidity, features and treatment related to BA-BD comorbidity. Data were narratively synthesized. Of the 1250 studies returned from the search, a total of 28 articles were included in this review. BA may be overrepresented in BD samples, and the other way around. Pathological gambling and kleptomania were the most prevalent conditions followed by compulsive buying, compulsive sexual behavior and internet addiction. BA was also associated with other mood disorders, anxiety disorders and substance use disorder. BD-BA comorbidity was related with more severe course of illness. Studies on treatment strategies for BD-BA comorbidity are rather limited; only one randomized controlled trial that fulfilled inclusion criteria was identified. Methodological heterogeneity in terms of design and results among studies was found. BD-BA commonly co-occurs although there is a need for rigorous studies. Routine screening and adequate assessment may be helpful in BD patients to identify individuals at risk for BA and to effectively manage the complex consequences associated with BA-BD comorbidity.

Where the Mind Cannot Dare: A Case of Addictive Use of Online Pornography and Its Relationship With Childhood Trauma

Dysfunctional use of cybersex has often been conceptualized as a "behavioral addiction" sharing common traits with substance addiction. We describe the case of a treatment-seeking man, who displayed addictive use of pornography. The case is presented from two perspectives: (1) a symptom-based approach inspired by the addiction model of excessive sexual behaviors and (2) a process-based approach aimed to identify the psychological processes and risk factors that may foster the development of addiction-like symptoms. This article shows how case conceptualization according to a process-based approach is likely to result in psychological intervention that targets the specific processes and risk factors involved in addictive cybersex use.

Quality of life of young adults with non-paraphilic problematic sexual behaviors: An exploratory study

Introduction

Many young adults are unable to control their sexual behavior despite distress or negative consequences created by these activities—a clinical phenomenon described as non-paraphilic problematic sexual behavior (PSB). Little is known about clinical features associated with quality of life in PSB.

Methods

54 participants affected by PSB (ages 18–29 years) were recruited for a study on impulsivity in young adults. PSB was defined as the experience of sexual urges, fantasies, or behaviors that feel overwhelming or out of control. Participants were assessed using the Quality of Life Inventory (QOLI), other validated instruments, and questions examining aspects of health and well-being. Clinical measures associated with variation in quality of life were identified using the statistical technique of partial least squares (PLS).

Results

Lower quality of life in PSB was associated with greater behavioral and self-report measures of impulsivity (specifically, Barratt attentional impulsiveness, lower age at first alcohol use), emotional dysregulation, problematic use of the internet, current suicidality, higher state anxiety and depression, and lower self-esteem.

Conclusions

Impulsivity and affective problems are correlated with lower quality of life in PSB. These associations may provide a means to distinguish PSB from healthy sexual behavior.

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Quality of life is understudied in adults with problematic sexual behaviors.

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Lower quality of life was associated with affective problems and impulsivity.

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Higher quality of life was predicted by better self-esteem.

Component Model of Addiction Treatment: A Pragmatic Transdiagnostic Treatment Model of Behavioral and Substance Addictions

Behavioral addictions such as gambling, video games, sex, and shopping share many clinical features with substance use addictions including etiology, course, and neurobiology. Yet, the treatment of behavioral and substance use addictions tends to be separated. However, we argue that a more effective and efficient treatment approach is to conceptualize behavioral and substance use addictions as different expressions of a common underlying disorder and, in treatment, to address the underlying mechanisms common to both. To this end, the article presents a developing transdiagnostic treatment model of addictions that targets underlying similarities between behavioral and substance use addictions, called the component model of addiction treatment (CMAT). The CMAT is transdiagnostic in that it can be used in the treatment of both behavioral and substance use addictions. It is pragmatic in that it targets component vulnerabilities, which are enduring, yet malleable, individual psychological, cognitive, and neurobiological characteristics that are common to all addictive disorders and have been demonstrated to be modifiable. A working model of CMAT is presented, including proposed component vulnerabilities: lack of motivation, urgency, maladaptive expectancies, deficits in self-control, deficits in social support, and compulsivity, as well as their potential intervention possibilities. Future directions and potential implications of the CMAT are discussed.

Trait and state impulsivity in males with tendency towards Internet-pornography-use disorder

INTRODUCTION

Impulsivity has been identified to be involved in the development and maintenance of specific Internet-use disorders (IUD). It can be differentiated between relatively stable trait impulsivity and state impulsivity which is dependent on environmental and affective factors such as craving. Following the I-PACE (Interaction of Person-Affect-Cognition-Execution) model, both trait and state impulsivity may play an interactive role in IUD. The present study aimed to investigate the relationship between trait and state impulsivity and symptom severity of Internet-pornography-use disorder (IPD) as one form of IUD.

METHODS

Fifty heterosexual males participated in this study. State impulsivity was measured with reaction times in a modified stop-signal task. Each participant conducted two blocks of this task which included neutral and pornographic pictures. Moreover, current subjective craving, trait impulsivity, and symptom severity of IPD were assessed using several questionnaires.

RESULTS

Results indicate that trait impulsivity was associated with higher symptom severity of IPD. Especially those males with higher trait impulsivity and state impulsivity in the pornographic condition of the stop-signal task as well as those with high craving reactions showed severe symptoms of IPD.

CONCLUSION

The results indicate that both trait and state impulsivity play a crucial role in the development of IPD. In accordance with dual-process models of addiction, the results may be indicative of an imbalance between the impulsive and reflective systems which might be triggered by pornographic material. This may result in loss of control over the Internet-pornography use albeit experiencing negative consequences.

The Development and Validation of the Bergen-Yale Sex Addiction Scale With a Large National Sample

The view that problematic excessive sexual behavior ("sex addiction") is a form of behavioral addiction has gained more credence in recent years, but there is still considerable controversy regarding operationalization of the concept. Furthermore, most previous studies have relied on small clinical samples. The present study presents a new method for assessing sex addiction-the Bergen-Yale Sex Addiction Scale (BYSAS)-based on established addiction components (i.e., salience/craving, mood modification, tolerance, withdrawal, conflict/problems, and relapse/loss of control). Using a cross-sectional survey, the BYSAS was administered to a broad national sample of 23,533 Norwegian adults [aged 16-88 years; mean (± SD) age = 35.8 ± 13.3 years], together with validated measures of the Big Five personality traits, narcissism, self-esteem, and a measure of sexual addictive behavior. Both an exploratory and a confirmatory factor analysis (RMSEA = 0.046, CFI = 0.998, TLI = 0.996) supported a one-factor solution, although a local dependence between two items (Items 1 and 2) was detected. Furthermore, the scale had good internal consistency (Cronbach's α = 0.83). The BYSAS correlated significantly with the reference scale (r = 0.52), and demonstrated similar patterns of convergent and discriminant validity. The BYSAS was positively related to extroversion, neuroticism, intellect/imagination, and narcissism, and negatively related to conscientiousness, agreeableness, and self-esteem. High scores on the BYSAS were more prevalent among those who were men, single, of younger age, and with higher education. The BYSAS is a brief, and psychometrically reliable and valid measure for assessing sex addiction. However, further validation of the BYSAS is needed in other countries and contexts.

Emotionally laden impulsivity interacts with affect in predicting addictive use of online sexual activity in men

The interest in studying addictive use of online sexual activities (OSA) has grown sharply over the last decade. Despite the burgeoning number of studies conceptualizing the excessive use of OSA as an addictive disorder, few have tested its relations to impulsivity, which is known to constitute a hallmark of addictive behaviors. To address this missing gap in the literature, we tested the relationships between addictive OSA use, impulsivity traits, and affect among a convenience sample of men (N=182; age, M=29.17, SD = 9.34), building upon a theoretically driven model that distinguishes the various facets of impulsivity. Results showed that negative urgency (an impulsivity trait reflecting the tendency to act rashly in negative emotional states) and negative affect interact in predicting addictive OSA use. These results highlight the pivotal role played by negative urgency and negative affect in addictive OSA use, supporting the relevance of psychological interventions that focus on improving emotional regulation (e.g., to reduce negative affect and learn healthier coping strategies) to mitigate excessive use of OSA.

Associations Between Personality Disorder Characteristics, Psychological Symptoms, and Sexual Functioning in Young Women

BACKGROUND

Recently, the etiology of sexual dysfunctions in women has been approached from different angles. In clinical practice and in previous studies, it has been observed that women with sexual problems experience anxiety problems and express more rigid and perfectionistic personality traits than women without these problems.

AIM

To investigate whether personality disorder characteristics according to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) and psychological symptoms are associated with sexual problems in women.

METHODS

188 women 18 to 25 years old participated in this cross-sectional study. Questionnaires measuring sexual functioning (Female Sexual Function Index), personality disorder characteristics (Assessment of DSM-IV-TR Personality Disorders Questionnaire), and psychological symptoms (Brief Symptom Inventory and Center for Epidemiological Studies Depression Scale) were used.

OUTCOME

The main outcome measure used was sexual functioning assessed by self-report.

RESULTS

Results, using analysis of variance, indicated that women with sexual problems report significantly more cluster A (specifically schizoid) and C (specifically avoidant and obsessive-compulsive) personality disorder characteristics than women without sexual problems. Furthermore, using multiple regression analyses, higher cluster A (specifically schizoid) and lower cluster B (specifically borderline and antisocial) personality disorder characteristics indicated lower levels of sexual functioning. Psychological symptoms partly mediated the effect of cluster A personality disorder characteristics on sexual functioning.

CLINICAL IMPLICATIONS

The results of this study indicate that clinical practice should extend its scope by focusing more on improving adaptive personality characteristics, such as extraversion and individualism seen in cluster B personality characteristics, and decreasing the perfectionistic, introvert, and self-doubting characteristics seen in cluster C personality characteristics.

STRENGTHS AND LIMITATIONS

Because of the correlational design and use of self-report measures, causal relations cannot be established between personality disorder characteristics and sexual functioning.

CONCLUSION

Overall, the results indicate that personality disorder characteristics can play an important associative role in the development and maintenance of sexual functioning problems in women. Grauvogl A, Pelzer B, Radder V, van Lankveld J. Associations Between Personality Disorder Characteristics, Psychological Symptoms, and Sexual Functioning in Young Women. J Sex Med 2018;15:192-200.

Marijuana Use, Marijuana Expectancies, and Hypersexuality among College Students

Research supports links between marijuana effect expectancies and risky sexual behaviors among marijuana users, but associations between marijuana expectancies and hypersexuality have yet to be investigated. The current study examined links between marijuana lifetime use and hypersexuality among university students. A hierarchical regression adjusting for gender and alcohol use was used to determine the degree to which marijuana use and expectancies accounted for variance in hypersexuality. Marijuana lifetime use and hypersexuality were significantly and positive related. After adjusting for covariates, perceptual and cognitive enhancement expectancies positively correlated with hypersexuality, while tension reduction and relaxation expectancies negatively correlated with hypersexuality.

Hypersexuality: A Critical Review and Introduction to the "Sexhavior Cycle"

An empirical review of hypersexuality is timely as "compulsive sexual behavior" is being considered as an impulse control disorder for inclusion in the forthcoming International Classification of Diseases, 11th ed. Specifically, hypersexuality has been conceptualized in the literature as the inability to regulate one's sexual behavior that is a source of significant personal distress. Various theoretical models have been posited in an attempt to understand the occurrence of hypersexuality, although disagreement about these divergent conceptualizations of the condition has made assessment and treatment of hypersexual clients more challenging. Theories of sexual compulsivity, sexual impulsivity, dual control (sexual inhibition/excitation), and sex addiction are critically examined, as are the diagnostic criteria for clinically assessing hypersexuality as a sexual disorder. Our discussion of hypersexuality covers a diversity of research and clinical perspectives. We also address various challenges associated with reliably defining, psychometrically measuring, and diagnosing hypersexuality. Furthermore, literature is reviewed that expresses concerns regarding whether hypersexuality (conceptualized as a disorder) exists, whether it is simply normophilic behavior at the extreme end of sexual functioning, or alternatively is a presenting problem that requires treatment rather than a clinical diagnosis. Following our literature review, we developed the "sexhavior cycle of hypersexuality" to potentially explain the neuropsychology and maintenance cycle of hypersexuality. The sexhavior cycle suggests that, for some hypersexual persons, high sexual arousal may temporarily and adversely impact cognitive processing (cognitive abeyance) and explain a repeated pattern of psychological distress when interpreting one's sexual behavior (sexual incongruence). We also suggest that further research is required to validate whether hypersexuality is a behavioral disorder (such as gambling), although some presentations of the condition appear to be symptomatic of a heterogeneous psychological problem that requires treatment.

Investigating Clinically and Scientifically Useful Cut Points on the Compulsive Sexual Behavior Inventory

INTRODUCTION

One of the major obstacles to conducting epidemiologic research and determining the incidence and prevalence of compulsive sexual behavior (CSB) has been the lack of relevant empirically derived cut points on the various instruments that have been used to measure the concept.

AIM

To further develop the Compulsive Sexual Behavior Inventory (CSBI) through exploring predictive validity and developing an empirically determined and clinically useful cut point for defining CSB.

METHODS

A sample of 242 men who have sex with men was recruited from various sites in a moderate-size Midwestern city. Participants were assigned to a CSB group or a control group using an interview for the diagnosis that was patterned after the Structured Clinical Interview for the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition. The 22-item CSBI was administered as part of a larger battery of self-report inventories.

MAIN OUTCOME MEASURES

Receiver operating characteristic analyses were used to compute area-under-the-curve measurements to ascertain the predictive validity of the total scale, the control subscale, and the violence subscale. Cut points were determined through consensus of experts balancing sensitivity and specificity as determined by receiver operating characteristic curves.

RESULTS

Analyses indicated that the 22-item CSBI was a good predictor of group membership, as was the 13-item control subscale. The violence subscale added little to the predictive accuracy of the instrument; thus, it likely measures something other than CSB. Two relevant cut points were found, one that minimized false negatives and another, more conservative cut point that minimized false positives.

CONCLUSION

The CSBI as currently configured measures two different constructions and only the control subscale is helpful in diagnosing CSB. Therefore, we decided to eliminate the violence subscale and move forward with a 13-item scale that we have named the CSBI-13. Two cut points were developed from this revised scale, one that is useful as a clinical screening tool and the other, more conservative measurement that is useful for etiologic and epidemiologic research. Miner MH, Raymond N, Coleman E, Swinburne Romine R. Investigating Clinically and Scientifically Useful Cut Points on the Compulsive Sexual Behavior Inventory. J Sex Med 2017;14:715-720.

Hypersexual Disorder According to the Hypersexual Disorder Screening Inventory in Help-Seeking Swedish Men and Women With Self-Identified Hypersexual Behavior

Introduction

The Hypersexual Disorder Screening Inventory (HDSI) was developed by the American Psychiatric Association for clinical screening of hypersexual disorder (HD).

Aims

To examine the distribution of the proposed diagnostic entity HD according to the HDSI in a sample of men and women seeking help for problematic hypersexuality and evaluate some psychometric properties.

Methods

Data on sociodemographics, the HDSI, the Sexual Compulsivity Scale (SCS), and the Cognitive and Behavioral Outcomes of Sexual Behavior were collected online from 16 women and 64 men who self-identified as hypersexual. Respondents were recruited by advertisements offering psychological treatment for hypersexual behavior.

Main Outcome Measures

The HDSI, covering the proposed criteria for HD.

Results

Of the entire sample, 50% fulfilled the criteria for HD. Compared with men, women scored higher on the HDSI, engaged more often in risky sexual behavior, and worried more about physical injuries and pain. Men primarily used pornography, whereas women had sexual encounters. The HD group reported a larger number of sexual specifiers, higher scores on the SCS, more negative effects of sexual behavior, and more concerns about consequences compared with the non-HD group. Sociodemographics had no influence on HD. The HDSI’s core diagnostic criteria showed high internal reliability for men (α = 0.80) and women (α = 0.81). A moderate correlation between the HDSI and the SCS was found (0.51). The vast majority of the entire sample (76 of 80, 95%) fulfilled the criteria for sexual compulsivity according to the SCS.

Conclusion

The HDSI could be used as a screening tool for HD, although further explorations of the empirical implications regarding criteria are needed, as are refinements of cutoff scores and specific sexual behaviors. Hypersexual problematic behavior causes distress and impairment and, although not included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, HD should be endorsed as a diagnosis to develop evidence-based treatment and future studies on its etiology.

Öberg KG, Hallberg J, Kaldo V, et al. Hypersexual Disorder According to the Hypersexual Disorder Screening Inventory in Help-Seeking Swedish Men and Women With Self-Identified Hypersexual Behavior. Sex Med 2017;5:e229–e236.

Interpersonal violence, early life adversity, and suicidal behavior in hypersexual men

Background and aims There are significant gaps in knowledge regarding the role of childhood adversity, interpersonal violence, and suicidal behavior in hypersexual disorder (HD). The aim of this study was to investigate interpersonal violence in hypersexual men compared with healthy volunteers and the experience of violence in relation to suicidal behavior. Methods This case-control study includes 67 male patients with HD and 40 healthy male volunteers. The Childhood Trauma Questionnaire - Short Form (CTQ-SF) and the Karolinska Interpersonal Violence Scale (KIVS) were used for assessing early life adversity and interpersonal violence in childhood and in adult life. Suicidal behavior (attempts and ideation) was assessed with the Mini-International Neuropsychiatric Interview (version 6.0) and the Montgomery-Åsberg Depression Rating Scale - Self-rating. Results Hypersexual men reported more exposure to violence in childhood and more violent behavior as adults compared with healthy volunteers. Suicide attempters (n = 8, 12%) reported higher KIVS total score, more used violence as a child, more exposure to violence as an adult as well as higher score on CTQ-SF subscale measuring sexual abuse (SA) compared with hypersexual men without suicide attempt. Discussion Hypersexuality was associated with interpersonal violence with higher total scores in patients with a history of suicide attempt. The KIVS subscale exposure to interpersonal violence as a child was validated using the CTQ-SF but can be complemented with questions focusing on SA for full assessment of early life adversity. Conclusion Childhood adversity is an important factor in HD and interpersonal violence might be related to suicidal behavior in hypersexual men.

Feasibility of an Emotion Regulation Intervention to Improve Mental Health and Reduce HIV Transmission Risk Behaviors for HIV-Positive Gay and Bisexual Men with Sexual Compulsivity

Gay and bisexual men (GBM) report high rates of sexual compulsivity (SC), yet no empirically based treatments exist. An intervention based on the Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders was pilot tested in a sample of 13 HIV-positive GBM with SC. Participants completed a baseline interview, and were offered up to ten intervention sessions. Of those, 11 completed a 3-month follow-up assessment. Despite problems with session attendance (only 4 men completed all 10 sessions), improvements were observed in all psychological outcomes, including SC, depression, and anxiety. Decreases were observed in drug use and HIV risk. The Unified Protocol may be useful in improving the health of HIV-positive GBM, however challenges with session attendance must be addressed. Future work should consider if fewer sessions produce similar results, whether barriers to attending all sessions could be alleviated, and how the intervention would perform compared to treatments.

Mating Strategies and Sexual Functioning in Personality Disorders: A Comprehensive Review of Literature

INTRODUCTION

Personality disorders impair several aspects of intrapsychic and interpersonal life. In particular, mating strategies and sexual functioning could manifest in different and/or dysfunctional ways in people with personality disorders.

AIM

To describe, through a comprehensive review of the literature, the mating strategies and sexual functioning in patients with personality disorders.

METHODS

We listed and discussed the principal studies on the relation between mating strategies and sexual functioning in personality disorders. The search strategy used search terms in PubMed for the main studies published from January 2000 to December 2016.

MAIN OUTCOME MEASURES

We considered two main sections for our selection according to the aim of the present review: mating and sexuality.

RESULTS

Interesting evidence on mating strategies in personality disorders was found. In particular, the major items were found in the dramatic-unpredictable cluster, with borderline personality disorder being the most studied. In contrast, the bizarre-eccentric cluster had fewer items, with the schizoid personality disorder being the least studied. For sexual behavior, borderline personality seems to be the unique disorder sufficiently studied, with evidence of major histories of child sexual abuse, the presence of sexual dysfunctions, and paraphilic interests.

CONCLUSION

A large spectrum of mating strategies characterizes different personality disorders, although an inconsistent knowledge about the relation between sexual function and personality disorders emerged from our analysis of the literature. Hence, we invite clinicians and researchers to integrate psychodiagnostic and sexual assessments in psychiatric disciplines for people with personality disorders. Collazzoni A, Ciocca G, Limoncin E, et al. Mating Strategies and Sexual Functioning in Personality Disorders: A Comprehensive Review of Literature. Sex Med Rev 2017;5:414-428.

An Online Assessment of Personality, Psychological, and Sexuality Trait Variables Associated with Self-Reported Hypersexual Behavior

"Hypersexual" behavior represents a perceived inability to control one's sexual behavior. To investigate hypersexual behavior, an international sample of 510 self-identified heterosexual, bisexual, and homosexual men and women completed an anonymous online self-report questionnaire battery. In addition to age and sex (male), hypersexual behavior was related to higher scores on measures of sexual excitation, sexual inhibition due to the threat of performance failure, trait impulsivity, and both depressed mood and anxiety. In contrast, hypersexual behavior was related to lower scores on sexual inhibition due to the threat of performance consequences. Higher neuroticism and extraversion, as well as lower agreeableness and conscientiousness, also predicted hypersexual behavior. Interestingly, interactions among the variables assessed did not significantly predict hypersexual behavior, suggesting the possible existence of multiple and predominantly independent taxa for various persons reporting hypersexual behavior. Core personality features may also be present in persons with hypersexual behavior. Clinical implications and future research directions are discussed.

Executive Functioning of Sexually Compulsive and Non-Sexually Compulsive Men Before and After Watching an Erotic Video

INTRODUCTION

Despite the serious behavioral consequences faced by individuals with sexual compulsivity, related neuropsychological studies are sparse.

AIM

To compare decision making and cognitive flexibility at baseline and after exposure to an erotic video in sexually compulsive participants and non-sexually compulsive controls.

METHODS

The sample consisted of 30 sexually compulsive men and 30 controls. Cognitive flexibility was investigated through the Wisconsin Card Sorting Test and decision making was examined through the Iowa Gambling Task.

MAIN OUTCOME MEASURES

Wisconsin Card Sorting Test categories, correct responses, and perseverative errors and Iowa Gambling Task general trends and blocks.

RESULTS

Sexually compulsive subjects and controls performed similarly at baseline. After watching an erotic video, controls performed better in block 1 of the Iowa Gambling Task (P = .01) and had more correct responses on the Wisconsin Card Sorting Test (P = .01).

CONCLUSIONS

The controls presented fewer impulsive initial choices and better cognitive flexibility after exposure to erotic stimuli. Messina B, Fuentes D, Tavares H, et al. Executive Functioning of Sexually Compulsive and Non-Sexually Compulsive Men Before and After Watching an Erotic Video. J Sex Med 2017;14:347-354.

Relationships between Behavioural Addictions and Psychiatric Disorders: What Is Known and What Is Yet to Be Learned?

This article provides a narrative review of the relationships between several behavioural addictions [pathological gambling, problematic Internet use (PIU), problematic online gaming, compulsive sexual behaviour disorder, compulsive buying, and exercise addiction] and psychiatric disorders. Associations between most behavioural addictions and depressive and anxiety disorders are strong and seem relatively non-specific. Strong links with substance use disorders may support the notion that some people are more prone to addictive behaviours, regardless of whether these involve substances or problematic activities. Other associations seem relatively specific, for example, those between PIU/online gaming and attention-deficit/hyperactivity disorder, between compulsive buying on the one hand and eating disorders and hoarding on the other hand and between exercise addiction and eating disorders. The quality of the research varies, but most studies suffer from methodological limitations, including a cross-sectional or correlational design, non-representative study populations, small sample sizes, reliance on self-report assessment instruments, diverse diagnostic criteria, and conceptual heterogeneity of most behavioural addictions. Due to these limitations, generalisability of the findings is questionable and the direction of causality, if any, is unknown in the relationships between behavioural addictions and psychiatric disorders. Regardless of the aetiological uncertainty, these relationships often call for a modified treatment approach. Prospective studies are needed to clarify the longitudinal relationships between behavioural addictions and psychiatric disorders.

Should compulsive sexual behavior be considered an addiction?

AIMS

To review the evidence base for classifying compulsive sexual behavior (CSB) as a non-substance or 'behavioral' addiction.

METHODS

Data from multiple domains (e.g. epidemiological, phenomenological, clinical, biological) are reviewed and considered with respect to data from substance and gambling addictions.

RESULTS

Overlapping features exist between CSB and substance use disorders. Common neurotransmitter systems may contribute to CSB and substance use disorders, and recent neuroimaging studies highlight similarities relating to craving and attentional biases. Similar pharmacological and psychotherapeutic treatments may be applicable to CSB and substance addictions, although considerable gaps in knowledge currently exist.

CONCLUSIONS

Despite the growing body of research linking compulsive sexual behavior (CSB) to substance addictions, significant gaps in understanding continue to complicate classification of CSB as an addiction.

Understanding the Personality and Behavioral Mechanisms Defining Hypersexuality in Men Who Have Sex With Men

INTRODUCTION

Hypersexuality has been conceptualized as sexual addiction, compulsivity, and impulsivity, among others, in the absence of strong empirical data in support of any specific conceptualization.

AIM

To investigate personality factors and behavioral mechanisms that are relevant to hypersexuality in men who have sex with men.

METHODS

A sample of 242 men who have sex with men was recruited from various sites in a moderate-size mid-western city. Participants were assigned to a hypersexuality group or a control group using an interview similar to the Structured Clinical Interview for the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition. Self-report inventories were administered that measured the broad personality constructs of positive emotionality, negative emotionality, and constraint and more narrow constructs related to sexual behavioral control, behavioral activation, behavioral inhibition, sexual excitation, sexual inhibition, impulsivity, attention-deficit/hyperactivity disorder, and sexual behavior.

MAIN OUTCOME MEASURES

Hierarchical logistic regression was used to determine the relation between these personality and behavioral variables and group membership.

RESULTS

A hierarchical logistic regression controlling for age showed a significant positive relation between hypersexuality and negative emotionality and a negative relation with constraint. None of the behavioral mechanism variables entered this equation. However, a hierarchical multiple regression analysis predicting sexual behavioral control indicated that lack of such control was positively related to sexual excitation and sexual inhibition owing to the threat of performance failure and negatively related to sexual inhibition owing to the threat of performance consequences and general behavioral inhibition

CONCLUSION

Hypersexuality was found to be related to two broad personality factors that are characterized by emotional reactivity, risk taking, and impulsivity. The associated lack of sexual behavior control is influenced by sexual excitatory and inhibitory mechanisms, but not by general behavioral activation and inhibitory mechanisms.

Psychological, Relational, and Biological Correlates of Ego-Dystonic Masturbation in a Clinical Setting

INTRODUCTION

Attitudes toward masturbation are extremely varied, and this practice is often perceived with a sense of guilt.

AIM

To evaluate the prevalence of ego-dystonic masturbation (EM), defined as masturbation activity followed by a sense of guilt, in a clinical setting of sexual medicine and the impact of EM on psychological and relational well-being.

METHODS

A series of 4,211 men attending an andrology and sexual medicine outpatient clinic was studied retrospectively. The presence and severity of EM were defined according to ANDROTEST items related to masturbation, determined by the mathematical product of the frequency of masturbation and the sense of guilt after masturbation.

MAIN OUTCOME MEASURES

Clinical, biochemical, and psychological parameters were studied using the Structured Interview on Erectile Dysfunction, ANDROTEST, and modified Middlesex Hospital Questionnaire.

RESULTS

Three hundred fifty-two subjects (8.4%) reported any sense of guilt after masturbation. Subjects with EM were younger than the remaining sample (mean age ± SD = 51.27 ± 13.43 vs 48.31 ± 12.04 years, P < .0001) and had more psychiatric comorbidities. EM severity was positively associated with higher free-floating (Wald = 35.94, P < .001) and depressive (Wald = 16.85, P < .001) symptoms, and subjects with a higher EM score reported less phobic anxiety (Wald = 4.02, P < .05) and obsessive-compulsive symptoms (Wald = 7.6, P < .01). A higher EM score was associated with a higher alcohol intake. Subjects with EM more often reported the partner's lower frequency of climax and more problems achieving an erection during sexual intercourse. EM severity was positively associated with worse relational and intrapsychic domain scores.

CONCLUSION

Clinicians should consider that some subjects seeking treatment in a sexual medicine setting might report compulsive sexual behaviors. EM represents a clinically relevant cause of disability, given the high level of psychological distress reported by subjects with this condition, and the severe impact on quality of life in interpersonal relationships.

Clinical Characteristics of Men Interested in Seeking Treatment for Use of Pornography

Background and aims This study examined the prevalence of, and factors associated with, men's interest in seeking treatment for use of pornography. Methods Using an Internet-based data-collection procedure, we recruited 1,298 male pornography users to complete questionnaires assessing demographic and sexual behaviors, hypersexuality, pornography-use characteristics, and current interest in seeking treatment for use of pornography. Results Approximately 14% of men reported an interest in seeking treatment for use of pornography, whereas only 6.4% of men had previously sought treatment for use of pornography. Treatment-interested men were 9.5 times more likely to report clinically significant levels of hypersexuality compared with treatment-disinterested men (OR = 9.52, 95% CI = 6.72-13.49). Bivariate analyses indicated that interest-in-seeking-treatment status was associated with being single/unmarried, viewing more pornography per week, engaging in more solitary masturbation in the past month, having had less dyadic oral sex in the past month, reporting a history of seeking treatment for use of pornography, and having had more past attempts to either "cut back" or quit using pornography completely. Results from a binary logistic regression analysis indicated that more frequent cut back/quit attempts with pornography and scores on the Hypersexual Behavior Inventory - Control subscale were significant predictors of interest-in-seeking-treatment status. Discussion and conclusions Study findings could be used to inform current screening practices aimed at identifying specific aspects of sexual self-control, impulsivity, and/or compulsivity associated with problematic use of pornography among treatment-seeking individuals.

Neurobiological Basis of Hypersexuality

Until now, hypersexuality has not found entry into the common diagnostic classification systems. However it is a frequently discussed phenomenon consisting of excessive sexual appetite that is maladaptive for the individual. Initial studies investigated the neurobiological underpinnings of hypersexuality, but current literature is still insufficient to draw unequivocal conclusions. In the present review, we summarize and discuss findings from various perspectives: neuroimaging and lesion studies, studies on other neurological disorders that are sometimes accompanied by hypersexuality, neuropharmacological evidence, genetic as well as animal studies. Taken together, the evidence seems to imply that alterations in the frontal lobe, amygdala, hippocampus, hypothalamus, septum, and brain regions that process reward play a prominent role in the emergence of hypersexuality. Genetic studies and neuropharmacological treatment approaches point at an involvement of the dopaminergic system.

The relationship between mindfulness and compulsive sexual behavior in a sample of men in treatment for substance use disorders

Substance use disorders (SUDs) are a serious worldwide problem. Despite years of research on the treatment of SUDs, relapse remains high. One factor that may complicate SUDs treatment for some patients is compulsive sexual behavior. Factors that are related to both SUDs and compulsive sexual behavior could be targeted in SUDs treatment. In the current study, we examined dispositional mindfulness, a protective factor for a range of mental health problems, and its relationship to compulsive sexual behavior in a SUDs treatment sample. This is the first study to examine this relationship in a SUDs sample. Medical records from men in residential SUDs treatment were reviewed for the current study (N = 271). Upon admission to treatment, men completed self-report measures on alcohol and drug use, dispositional mindfulness, and compulsive sexual behavior. Bivariate correlations demonstrated dispositional mindfulness to be negatively associated with a variety of indicators of compulsive sexual behavior. After controlling for alcohol and drug use and problems in hierarchical regression analyses, which were both associated with compulsive sexual behaviors, dispositional mindfulness remained negatively associated with all of the compulsive sexual behavior indicators. Our results provide the first empirical association between dispositional mindfulness and compulsive sexual behavior in a SUDs sample. Although continued research is needed in this area, our findings suggest that it may be beneficial for SUDs treatment to incorporate mindfulness-based interventions for individuals with comorbid compulsive sexual behavior.

Dimensionality of Cognitions in Behavioral Addiction

Cognitive constructs provide conceptual frameworks for transpathological characterization and improved phenotyping of apparently disparate psychiatric groups. This dimensional approach can be applied to the examination of individuals with behavioral addictions, for example, towards gambling, video-games, the internet, food, and sex, allowing operationalization of core deficits. We use this approach to review constructs such as impulsivity, compulsivity, and attention regulation, which may be most relevant, applicable, and successful for the understanding and subsequent treatment of the addictions.

Sexual Compulsivity Scale, Compulsive Sexual Behavior Inventory, and Hypersexual Disorder Screening Inventory: Translation, Adaptation, and Validation for Use in Brazil

Epidemiological, behavioral, and clinical data on sexual compulsivity in Brazil are very limited. This study sought to adapt and validate the Sexual Compulsivity Scale (SCS), the 22-item version of the Compulsive Sexual Behavior Inventory (CSBI-22), and the Hypersexual Disorder Screening Inventory (HDSI) for use in Brazil. A total of 153 participants underwent psychiatric assessment and completed self-reported measures. The adaptation process of the instruments from English to Portuguese followed the guidelines of the International Society for Pharmacoeconomics and Outcomes Research. The reliability and validity of the HDSI criteria were evaluated and the construct validity of all measures was examined. For the SCS and HDSI, factor analysis revealed one factor for each measure. For the CSBI-22, four factors were retained although we only calculated the scores of two factors (control and violence). All scores had good internal consistency (alpha >.75), presented high temporal stability (>.76), discriminated between patients and controls, and presented strong (ρ > .81) correlations with the Sexual Addiction Screening Test (except for the violence domain = .40) and moderate correlations with the Impulsive Sensation Seeking domain of the Zuckerman Kuhlman Personality Questionnaire (ρ between .43 and .55). The sensitivity of the HDSI was 71.93 % and the specificity was 100 %. All measures showed very good psychometric properties. The SCS, the HDSI, and the control domain of the CSBI-22 seemed to measure theoretically similar constructs, as they were highly correlated (ρ > .85). The findings support the conceptualization of hypersexuality as a cluster of problematic symptoms that are highly consistent across a variety of measures.

How should severity be determined for the DSM-5 proposed classification of Hypersexual Disorder?

BACKGROUND AND AIMS

The concept of severity among providers working with hypersexual behavior is frequently used despite a lack of consensus about how severity should be operationalized. The paucity of dialogue about severity for hypersexual behavior is disconcerting given its relevance in determining level of care, risk, allocation of resources, and measuring treatment outcomes in clinical practice and research trials. The aim of the current article is to highlight several considerations for assessing severity based on the proposed DSM-5 criteria for hypersexual disorder.

METHODS

A review of current conceptualizations for severity among substance-use disorders and gambling disorder in the DSM-5 were considered and challenged as lacking applicability or clinical utility for hypersexual behavior.

RESULTS AND CONCLUSIONS

The current research in the field of hypersexual behavior is in its infancy. No concrete approach currently exists to assess severity in hypersexual populations. Several factors in operationalizing severity are discussed and alternative approaches to defining severity are offered for readers to consider.

The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the treatment of adolescent sexual offenders with paraphilic disorders

The primary aim of these guidelines was to evaluate the role of pharmacological agents in the treatment of adolescents with paraphilic disorders who are also sexual offenders or at-risk of sexual offending. Psychotherapeutic and psychosocial treatments were also reviewed. Adolescents with paraphilic disorders specifically present a different therapeutic challenge as compared to adults. In part, the challenge relates to adolescents being in various stages of puberty and development, which may limit the use of certain pharmacological agents due to their potential side effects. In addition, most of the published treatment programmes have used cognitive behavioural interventions, family therapies and psychoeducational interventions. Psychological treatment is predicated in adolescents on the notion that sexually deviant behaviour can be controlled by the offender, and that more adaptive behaviours can be learned. The main purposes of these guidelines are to improve the quality of care and to aid physicians in their clinical decisions. These guidelines brought together different expert views and involved an extensive literature research. Each treatment recommendation was evaluated and discussed with respect to the strength of evidence for efficacy, safety, tolerability and feasibility. An algorithm is proposed for the treatment of paraphilic disorders in adolescent sexual offenders or those who are at risk.

Syndemic production and sexual compulsivity/hypersexuality in highly sexually active gay and bisexual men: further evidence for a three group conceptualization

Among gay and bisexual men (GBM), a syndemic describes a situation in which negative conditions (e.g., childhood sexual abuse, intimate partner violence, depression, polysubstance use) co-occur such to amplify HIV risk. Research has suggested that sexual compulsivity (SC) may also be a syndemic condition. Between 2011 and 2013, 368 highly sexually active (9+ male partners in 90 days) GBM completed a survey of syndemic factors as well as measures of sexual compulsivity (Sexual Compulsivity Scale [SCS]) and hypersexuality (hypersexual disorder screening inventory [HDSI]). Based on scores on the SCS and HDSI, participants were organized into three groups-negative on both ("Neither SC nor HD"); positive on the SCS only ("SC Only"), and positive on both the SCS and the HDSI ("Both SC and HD"). We found support for the utility of a three-group classification of sexual compulsivity/hypersexuality as one of the syndemic factors that contribute to HIV risk. The average number of syndemic factors experienced was lowest among those who experienced Neither SC nor HD and highest among the group that experienced Both SC and HD, with those experiencing SC Only falling between the two other groups. This study provided further evidence that sexual compulsivity/hypersexuality is a contributing factor to the syndemics model of HIV risk for GBM and that considering three levels of severity (i.e., SC along with HD) led to stronger model predictions than considering SC alone. SC/HD severity provides another modifiable target for HIV prevention intervention development.