Hypersexual disorder and preoccupation with internet pornography

Current Understanding of Compulsive Sexual Behavior Disorder and Co-occurring Conditions: What Clinicians Should Know about Pharmacological Options

Compulsive sexual behavior disorder (CSBD) has recently been recognized as a psychiatric disorder. Pharmacological treatments for CSBD have received little study and thus have limited empirical support. The main objective of the present work is to review existing literature on the efficacy of different drugs on the symptomatology of CSBD, including the subtype of problematic pornography use (PPU). The main pharmacological approaches to treating CSBD have included opioid antagonists (naltrexone and nalmefene), selective serotonin reuptake inhibitors (paroxetine, citalopram, fluoxetine, and sertraline), mood stabilizers (topiramate), tricyclic antidepressants (clomipramine), serotonin antagonist and reuptake inhibitors (nefazodone), and N-acetylcysteine. Since people with CSBD may experience different co-occurring disorders, these should be considered when choosing the best pharmacological treatment. Pharmacological therapy for CSBD/PPU has been suggested as an adjunct to psychological therapies, which, for the moment, have the most empirical evidence. However, to evaluate the efficacy of most of the drugs presented in this narrative review, data to date have only been available from case studies. Thus, empirical support is scant and generalizability of results is limited, highlighting the need for more research in this area.

Pharmacological Treatment for Pedophilic Disorder and Compulsive Sexual Behavior Disorder: A Review

Guidelines for the pharmacological treatment of paraphilic disorders have historically been based on data from forensic settings and on risk levels for sexual crime. However, emerging treatment options are being evaluated for individuals experiencing distress because of their sexual urges and preferences, targeting both paraphilic disorders such as pedophilic disorder (PeD) and the new diagnosis of compulsive sexual behavior disorder (CSBD) included in the International Classification of Diseases, 11th Revision (ICD-11). As in other mental disorders, this may enable individualized pharmacological treatment plans, taking into account components of sexuality (e.g. high libido, compulsivity, anxiety-driven/sex as coping), medical and psychiatric comorbidity, adverse effects and patient preferences. In order to expand on previous reviews, we conducted a literature search focusing on randomized controlled trials of pharmacological treatment for persons likely to have PeD or CSBD. Our search was not restricted to studies involving forensic or criminal samples. Twelve studies conducted between 1974 and 2021 were identified regardless of setting (outpatient or inpatient), with only one study conducted during the last decade. Of a total of 213 participants included in these studies, 122 (57%) were likely to have PeD, 34 (16%) were likely to have a CSBD, and the remainder had unspecified paraphilias (40, 21%) or sexual offense (17, 8%) as the treatment indication. The diagnostic procedure for PeD and/or CSBD, as well as comorbid psychiatric symptoms, has been described in seven studies. The studies provide some empirical evidence that testosterone-lowering drugs reduce sexual activity for patients with PeD or CSBD, but the body of evidence is meager. There is a need for studies using larger samples, specific criteria for inclusion, longer follow-up periods, and standardized outcome measures with adherence to international reporting guidelines.

Off-label Uses of Selective Serotonin Reuptake Inhibitors (SSRIs)

Psychiatric drugs have primacy for off-label prescribing. Among those, selective serotonin reuptake inhibitors (SSRIs) are highly versatile and, therefore, widely prescribed. Moreover, they are commonly considered as having a better safety profile compared to other antidepressants. Thus, when it comes to off-label prescribing, SSRIs rank among the top positions. In this review, we present the state of the art of off-label applications of selective serotonin reuptake inhibitors, ranging from migraine prophylaxis to SARS-CoV-2 antiviral properties. Research on SSRIs provided significant evidence in the treatment of premature ejaculation, both with the on-label dapoxetine 30 mg and the off-label paroxetine 20 mg. However, other than a serotoninergic syndrome, serious conditions like increased bleeding rates, hyponatremia, hepatoxicity, and post-SSRIs sexual dysfunctions, are consistently more prominent when using such compounds. These insidious side effects might be frequently underestimated during common clinical practice, especially by nonpsychiatrists. Thus, some points must be addressed when using SSRIs. Among these, a psychiatric evaluation before every administration that falls outside the regulatory agencies-approved guidelines has to be considered mandatory. For these reasons, we aim with the present article to identify the risks of inappropriate uses and to advocate the need to actively boost research encouraging future clinical trials on this topic.

Sex and Its Discontents: How Moral Incongruence Connects Same-Sex and Non-Marital Sexual Activity with Unhappiness

A growing body of research has demonstrated how the link between pornography use and various manifestations of psychological distress and dissatisfaction is explained by moral incongruence-the experience of violating one's deeply held moral values. The predictive power of moral incongruence, however, has yet to be applied to other sexual activities. Drawing on data from available waves of the General Social Surveys (1988-2018: n_men = 6590, n_women = 7047; 1989-2018: n_men = 3558, n_women = 4841), this study extended moral incongruence theory by testing whether engaging in same-sex or non-marital sexual activity when one rejects either as morally wrong is associated with a greater likelihood of reporting unhappiness. Analyses demonstrated that American men (but not women) who reported engaging in same-sex sex in the previous year were more likely than other men to say they were unhappy, but only if they viewed homosexuality as "always wrong." Analyses also showed that American women (not men) who reported higher frequencies of non-marital sex in the previous year were more likely than other women to report being unhappy, but only if they viewed non-marital sex as "always wrong." Though nuanced by gender, findings affirmed expectations from moral incongruence research: Sexual behavior per se is not associated with unhappiness, but moral inconsistency or conflict regarding one's sexual behavior is.

Spotlight on Compulsive Sexual Behavior Disorder: A Systematic Review of Research on Women

PURPOSE OF REVIEW

World Health Organization recently included compulsive sexual behavior disorder (CSBD) to the upcoming 11th edition of International Classification of Diseases (6C72). Despite the potential benefits of this decision (eg, the acceleration of research in the field will allow the development of effective treatments), previous research focused mainly on men, and as a result, we do not have an accurate clinical picture of compulsive sexual behavior (CSB) among women. Therefore, in this systematic review, we aim to present available knowledge on this topical subject. Literature search was conducted in the guideline of PRISMA methodology. Studies were identified from multiple databases including Academic Search Ultimate, SocINDEX, PsycARTICLES, PsycINFO, PubMed, and MEDLINE. Out of a total of 10,531 articles identified and screened, 58 were included in this review. Included studies covered the following topics: prevalence and etiology of CSB, behavioral and cognitive processes involved, comorbidities, personality traits, psychosocial and interpersonal difficulties, traumatic experiences, and treatments.

RECENT FINDINGS

Available studies indicate that CSB symptom severity is lower in women than in men. Overall, women reported consuming pornography less often than men and exhibit lower rates of feeling urges to these materials. CSB symptoms (including problematic pornography use) have been found to be positively related to trait psychopathy, impulsivity, sensation seeking, attention-deficit/hyperactivity disorder symptoms, obsessive-compulsive disorder, pathological buying, sexual dysfunctions, general psychopathology, child sexual abuse, while negatively related to dispositional mindfulness.

SUMMARY

Conclusions that can be drawn from prior studies are considerably limited. There are no accurate estimates of the CSB prevalence or severity among women, and studies have been mostly conducted on non-clinical populations, which has limited application for women diagnosed with CSBD.

Is the Link Between Pornography Use and Relational Happiness Really More About Masturbation? Results From Two National Surveys

Numerous studies have observed a persistent and most often negative association between pornography use and romantic relationship quality. While various theories have been suggested to explain this association, studies have yet to empirically examine whether the observed link between pornography consumption and relationship outcomes has more to do with solo masturbation than actually watching pornography. The current study drew on two nationally representative data sets with nearly identical measures to test whether taking masturbation practice into account reduces or nullifies the association between pornography use and relational happiness. Controls are included for sex frequency and satisfaction, depressive symptoms, and other relevant correlates. Results from both the 2012 New Family Structures Study (NFSS; N = 1,977) and the 2014 Relationships in America survey (RIA; Ng = 10,106) show that masturbation is negatively associated with relational happiness for men and women, while pornography use is either unassociated or becomes unassociated with relational happiness once masturbation is included. Indeed, evidence points to a slight positive association between pornography use and relational happiness once masturbation and gender differences are accounted for. Findings suggest that future studies on this topic should include measures of masturbation practice along with pornography use and that modifications to theories connecting pornography use to relationship outcomes should be considered.

Pornography Problems Due to Moral Incongruence: An Integrative Model with a Systematic Review and Meta-Analysis

The notion of problematic pornography use remains contentious in both academic and popular literature. Although the mental health community at large is divided as to the addictive versus non-addictive nature of Internet pornography, substantial numbers of individuals report "feeling" as if their use of Internet pornography is problematic. The present work seeks to construct a model related to problematic pornography use that is clearly derived from empirical literature and that provides directions to be tested in future research. The focus of the present work is on those perceptions as they relate to the overarching experience of moral incongruence in pornography use, which is generally thought of as the experience of having one's behaviors be inconsistent with one's beliefs. To this end, we put forth a model of pornography problems due to moral incongruence. Within this model, we describe how pornography-related problems-particularly feelings of addiction to pornography-may be, in many cases, better construed as functions of discrepancies-moral incongruence-between pornography-related beliefs and pornography-related behaviors. A systematic review of literature and meta-analysis is conducted in order to evaluate support for this model, and the implications of this model for research and clinical practice are discussed.

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.

"Pornographic binges" as a key characteristic of males seeking treatment for compulsive sexual behaviors: Qualitative and quantitative 10-week-long diary assessment

Background and aims Compulsive sexual behaviors (CSBs) are an important clinical and social issue. Despite the increasing number of studies, some of CSB's aspects remain under-investigated. Here, we explore the nature of CSB, such as binge pornography use and masturbation (PuM), and verify the correspondence between self-perceived factors leading to such behavior with its measures obtained in a diary assessment. Methods Semi-structuralized interviews with nine treatment-seeking males aged 22-37 years (M = 31.7, SD = 4.85) were followed by a questionnaire and a 10-week-long diary assessment, allowing us to acquire real-life daily patterns of CSB. Results Six out of nine subjects experienced binge (multiple hours or times a day) PuM. All subjects presented a high level of anxiety and perceived PuM as a way to regulate mood and stress. Data collected in the diary assessment uncovered a high diversity in the patterns of sexual behaviors (such as frequency of regular and binge PuM) and its correlates. Binge PuM was related to decreased mood and/or increased stress or anxiety. The causal relation between these correlates remains undetermined. Discussion and conclusions Binge PuM seems to be one of the most characteristic behavior among males who are seeking treatment for CSB and is related to the feeling of losing control over one's sexual activity. CSB individuals indicate a variety of binge triggers. Also, diary assessment data indicate that specific correlates of binge PuM (decreased mood, increased stress, and anxiety) differ between subjects. It suggests the existence of significant individual differences in binge PuM behaviors, and a need to study these differences, as it may help guide personalized treatment.

Sexual Aggressors Against Women's Sexual Lives: A Latent Class Analysis

This study investigated the day-to-day deviant and nondeviant sexuality of a sample of Canadian sexual aggressors against women ( N = 160). Using latent class analysis, three latent classes were identified: internalized deviant (ID), low sexual problem (LSP), and hypersexual deviant (HD). Following the latent class analysis, the developmental, physiological, cognitive, and criminological correlates of these lifestyles were analyzed. ID ( n = 31) aggressors were characterized by sexual dissatisfaction, sexual deviance, and a bland sexual life. LSP ( n = 116) aggressors were characterized by the absence of sexual deviance or hypersexuality. HD ( n = 13) aggressors were characterized by hypersexuality and sexual deviance. Our exploratory study suggests that the day-to-day nondeviant and deviant sexual life of sexual aggressors against women appear to affect their modus operandi. Furthermore, the adult sexual lifestyles of sexual aggressors against women appear to be extensions of their adolescent sexual lifestyles. The results of this study thus suggest avenues for research-notably, the specific influence of sexual behaviours and internalized psychosexual problems on modus operandi-that could improve the clinical management of sexual aggressors against women.

Ventral Striatal Reactivity in Compulsive Sexual Behaviors

Compulsive Sexual Behaviors (CSB) are a reason to seek treatment. Given this reality, the number of studies on CSB has increased substantially in the last decade and the World Health Organization (WHO) included CSB in its proposal for the upcoming ICD-11. Sixty percent of the neuroimaging studies on CSB published since 2014 aimed to examine similarities and differences between brain mechanisms underlying CSB, gambling disorder, and substance use disorders. One of the crucial brain circuits involved in addiction is the reward system involving the ventral striatum (including nucleus accumbens). There are two distinct theories describing ventral striatal activity in addictions: Incentive Salience Theory (IST) and Reward Deficiency Syndrome (RDS). IST describes increased ventral striatal activations during the anticipation of addiction-related reward, while RDS describes decreased ventral striatal reactivity both during the anticipation of the reward and during the reward processing. Here, we aim to investigate how the findings on ventral striatal reactivity in CSB support each of these two addiction frameworks. For this purpose, we conducted a systematic review of neuroimaging studies on CSB available in Pubmed, EBSCO, and Google Scholar between 2005 and 2018. We found nine relevant research papers. Only four of these studies directly investigated processing of erotic cues and/or rewards and reported findings related to ventral striatum activations. Three of these studies indicate increased ventral striatal reactivity for erotic stimuli, which is consistent with IST and does not support predictions based on RDS. Therefore, the current state of this data suggest that CSB is related to increased ventral striatal reactivity during the anticipation of erotic stimuli.

Is Social Status Related to Internet Pornography Use? Evidence from the Early 2000s in the United States

While most studies on Internet pornography focus on individual's psychological characteristics, few have explored how social status itself is associated with Internet pornography use. As the Internet is becoming increasingly prevalent, online behaviors may have started to reflect the inequalities of the offline world. This study tested whether lower social status was associated with fewer sexual intercourse opportunities, and whether this led to higher likelihood of using Internet pornography as an alternative means of sexual release. To test the theory, I used the nationally representative sample of the General Social Survey of the U.S. between 2000 and 2004, with missing data handled by chained multiple imputation. The analyses found that lower income, longer working length, being unemployed, or a laborer in the social class strata were associated with fewer sexual intercourse opportunities as measured by three variables: marital status, the number of sex partners, and sex frequency. Lower income, less education, and longer working length were also associated with higher odds of using Internet pornography in the past 30 days, but only income was partially mediated by marital status. Social status was associated with Internet pornography use and sexual intercourse opportunities independently. The comparison of Internet pornography with the traditional X-rated movie found the unique features of Internet pornography use absent for X-rated movie.

Clinical relevance of the proposed sexual addiction diagnostic criteria: relation to the Sexual Addiction Screening Test-Revised

The present article examines and compares the various diagnostic rubrics proposed to codify symptoms of sexual addiction, and then briefly summarizes the ongoing controversy on whether sexual addiction is a valid construct. Using the diagnostic criteria proposed by , the prevalence rate of each criterion is examined in terms of scores on the Sexual Addiction Screening Test-Revised scales (). Differences in diagnostic criteria endorsement associated with sex, sexual orientation, and setting were also explored. Results from a clinical sample of men and women seeking treatment for sexual addiction demonstrated clinical relevance of the criteria, in that all but 3 criteria are endorsed at more than 50% of participants screening positive for sexual addiction on the Sexual Addiction Screening Test-Revised. Sex differences were also noted for endorsement rates of several of the criteria. Finally, several proposed criteria may pose a higher clinical threshold and thus be utilized by clinicians to identify patients with increased pathology. Results are discussed in the context of existing diagnostic frameworks across etiological perspectives.

Relationship Attachment Styles in a Sample of Hypersexual Patients

Some authors theorize that relationship attachment difficulties play an etiological role in the development of hypersexual behavior. The research in support of this theory is plagued by small sample sizes and analyses that are limited to averages within 4 forced-choice categories of attachment. The present study seeks to further the understanding of relationship attachment styles and hypersexual behavior by analyzing both categorical and dimensional measures of attachment among a large sample of men (N = 136) seeking treatment for excessive sexual behaviors. Many, but not all, subjects reported attachment difficulties. Using cluster analysis, 4 distinct clusters appeared to be unique on measures of attachment, demographics, and shame proneness. The utility of the categorical versus the dimensional model of attachment, as well as the assessment and treatment implications for hypersexual behavior, are discussed.

A Humanistic Approach to Problematic Online Sexual Behavior

Problematic Internet use for sexual activity is often explained by some combination of unique features of the Internet and user characteristics. Disease models of addiction are also often used. Experiential personal construct psychology offers an alternative, humanistic, nondisease diagnostic conceptualization of problematic online sexual activity. A detailed case example demonstrates an experiential personal construct psychology conceptualization. The article concludes with reflective comments provided by the client described in the case example.

Theorising sexual media and sexual violence in a forensic setting: men's talk about pornography and offending

This article reports findings from a discourse analytic study which critically explored the language of mental health nurses, and detained sexual offenders, in relation to pornography in one high-security hospital. It recognised previous empirical investigation, and pro-feminist theorising, into mediated representations and male sexual violence, but situated the research process in a forensic nursing context. Decision-making about access to, or restriction of, commercial sexual literature, as a component of therapeutic intervention and offender management, reveals tensions between service-user rights and treatment goals. The aim was to access nurse and patient talk in a specific culture. Semi-structured interviews with eighteen nursing staff, and nine patients, were used to co-construct accounts of pornography, sexual offending, and treatment. Analysis and data collection were undertaken concurrently. Interviews were audio-taped and transcribed. Data was coded to identify theoretical/conceptual themes and sub-themes representing discursive repertoires. Attention was given to how textual variation positioned respondents in relation to each other and the institution. Findings suggested collective male talk textured the environment, promoted gendered inequality, marginalised female nurses, and undermined rehabilitation. Shared discourse enabled male staff and patients to relate to each other as men, while maintaining distance through constructions of otherness. Discussion focuses on discriminatory discursive-practices, where men's talk about pornography and sexual violence embodied gendered knowledge/experience and contributed to a toxic culture. Consideration is given to ways of resisting institutional impediments and promoting positive therapeutic relations.

Seeking insights about cycling mood disorders via anonymized search logs

Background

Mood disorders affect a significant portion of the general population. Cycling mood disorders are characterized by intermittent episodes (or events) of the disease.

Objective

Using anonymized Web search logs, we identify a population of people with significant interest in mood stabilizing drugs (MSD) and seek evidence of mood swings in this population.

Methods

We extracted queries to the Microsoft Bing search engine made by 20,046 Web searchers over six months, separately explored searcher demographics using data from a large external panel of users, and sought supporting information from people with mood disorders via a survey. We analyzed changes in information needs over time relative to searches on MSD.

Results

Queries for MSD focused on side effects and their relation to the disease. We found evidence of significant changes in search behavior and interests coinciding with days that MSD queries are made. These include large increases (>100%) in the access of nutrition information, commercial information, and adult materials. A survey of patients diagnosed with mood disorders provided evidence that repeated queries on MSD may come with exacerbations of mood disorder. A classifier predicting the occurrence of such queries one day before they are observed obtains strong performance (AUC=0.78).

Conclusions

Observed patterns in search behavior align with known behaviors and those highlighted by survey respondents. These observations suggest that searchers showing intensive interest in MSD may be patients who have been prescribed these drugs. Given behavioral dynamics, we surmise that the days on which MSD queries are made may coincide with commencement of mania or depression. Although we do not have data on mood changes and whether users have been diagnosed with bipolar illness, we see evidence of cycling in people who show interest in MSD and further show that we can predict impending shifts in behavior and interest.

Clinical correlates of nucleus accumbens volume in drug-naive, adult patients with obsessive-compulsive disorder

BACKGROUND

Reward-processing deficits have been demonstrated in obsessive-compulsive disorder (OCD) and this has been linked to ventral striatal abnormalities. However, volumetric abnormalities of the nucleus accumbens (NAcc), a key structure in the reward pathway, have not been examined in OCD. We report on the volumetric abnormalities of NAcc and its correlation with illness severity in drug-naïve, adult patients with OCD.

METHOD

In this cross-sectional study of case-control design, the magnetic resonance imaging (MRI) 1.5-T (1-mm) volume of NAcc was measured using 3D Slicer software in drug-naïve OCD patients (n = 44) and age, sex and handedness-matched healthy controls (HCs) (n = 36) using a valid and reliable method. OCD symptoms were assessed using the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) Symptom checklist and severity and the Clinical Global Impression-Severity (CGI-S) scale.

RESULTS

There was no significant difference in NAcc volumes on either side between OCD patients and HCs (F = 3.45, p = 0.07). However, there was significant negative correlation between the right NAcc volume and Y-BOCS compulsion score (r = -0.48, p = 0.001).

CONCLUSIONS

Study observations suggest involvement of the NAcc in the pathogenesis of OCD, indicating potential reward-processing deficits. Correlation between the right NAcc volume deficit and severity of compulsions offers further support for this region as a candidate for deep brain stimulation treatment in OCD.

Pornography, Relationship Alternatives, and Intimate Extradyadic Behavior

Two studies tested the hypothesis that exposure to pornography among romantically committed individuals would increase the likelihood of intimate extradyadic behavior and that this effect would be mediated by heightened perceptions of romantic alternatives. Study 1 ( n = 74) found that participants primed with sexually explicit material reported having higher quality romantic alternatives. Study 2 ( n = 291) showed that initial pornography consumption predicted intimate extradyadic behavior 12 weeks later even after controlling for initial extradyadic behavior, sociosexuality, relationship length, baseline relationship satisfaction, social desirability, and participant gender and race. The relationship between pornography and intimate extradyadic behavior was mediated by perceptions of the quality of romantic alternatives. These results suggest that sexually explicit material can provoke intimate extradyadic behavior via its effect on perceptions of alternative partners.

The use of sexually explicit internet material and its antecedents: a longitudinal comparison of adolescents and adults

An implicit assumption in research on adolescents' use of sexually explicit internet material (SEIM) is that they may feel more attracted to such material than adults, given the "forbidden" character of SEIM for minors. However, systematic comparisons between adolescents' and adults' SEIM use and of its antecedents are missing. We conducted a two-wave panel survey among a nationally representative sample of 1,445 Dutch adolescents and a nationally representative sample of 833 Dutch adults. Adolescents' and adults' SEIM use was similar. When significant differences in the SEIM use occurred, they indicated that adults used SEIM more often than adolescents. Male adults were the most frequent users of SEIM. No difference in the antecedent structure of SEIM use emerged between adolescents and adults. In both groups, males, sensation seekers, as well as people with a not exclusively heterosexual orientation used SEIM more often. Among adolescents and adults, lower life satisfaction increased SEIM use. Our findings suggest that the frequency of SEIM use and its antecedents are largely the same among adolescents and adults.

Hypersexual disorder: a proposed diagnosis for DSM-V

Hypersexual Disorder is proposed as a new psychiatric disorder for consideration in the Sexual Disorders section for DSM-V. Historical precedents describing hypersexual behaviors as well as the antecedent representations and proposals for inclusion of such a condition in the previous DSM manuals are reviewed. Epidemiological as well as clinical evidence is presented suggesting that non-paraphilic "excesses" of sexual behavior (i.e., hypersexual behaviors and disorders) can be accompanied by both clinically significant personal distress and social and medical morbidity. The research literature describing comorbid Axis I and Axis II psychiatric disorders and a purported relationship between Axis I disorders and Hypersexual Disorder is discussed. Based on an extensive review of the literature, Hypersexual Disorder is conceptualized as primarily a nonparaphilic sexual desire disorder with an impulsivity component. Specific polythetic diagnostic criteria, as well as behavioral specifiers, are proposed, intended to integrate empirically based contributions from various putative pathophysiological perspectives, including dysregulation of sexual arousal and desire, sexual impulsivity, sexual addiction, and sexual compulsivity.

Volitional disorders: a proposal for DSM-V

In the DSM-IV-TR, specific impulse control disorders not elsewhere classified (ICD) have been designated following four principles: (1) through the addition of an adjective that emphasizes the aberrant character of an otherwise normal behaviour (e.g., pathological gambling); (2) by means of metaphors (such as in intermittent explosive disorder); (3) according to the presumably quintessential nature of their main signs and symptoms, such as impulsive (e.g., impulse control disorders not elsewhere classified), compulsive (e.g., compulsive shopping), or addictive (e.g., internet addiction); or (4) using Greek suffix mania (e.g., kleptomania, pyromania, and trichotillomania). Given this flagrant inconsistency, we argue that time has come to adopt a less arbitrary way of describing these disorders, at least until it becomes clearer whether they are really impulsive, compulsive or addictive or if the preoccupation with this distinction is valid. In keeping with DSM's emphasis on descriptive phenomenology rather than on unsupported theory, a less biased terminology is in order. Therefore, we would like to suggest: (1) the substitution of the term ICD by the more neutral expression 'volitional disorders not elsewhere classified'; (2) the use of the classical Greek suffix mania, already present in some DSM-IV-TR ICDs, as the main naming principle to be adopted in the DSM-V; and (3) the creation of compulsive, impulsive, and mixed subtypes of the 'volitional disorders not elsewhere classified', since they are beginning to be validated by treatment trials.

Optimal waist-to-hip ratios in women activate neural reward centers in men

Secondary sexual characteristics convey information about reproductive potential. In the same way that facial symmetry and masculinity, and shoulder-to-hip ratio convey information about reproductive/genetic quality in males, waist-to-hip-ratio (WHR) is a phenotypic cue to fertility, fecundity, neurodevelopmental resources in offspring, and overall health, and is indicative of "good genes" in women. Here, using fMRI, we found that males show activation in brain reward centers in response to naked female bodies when surgically altered to express an optimal (approximately 0.7) WHR with redistributed body fat, but relatively unaffected body mass index (BMI). Relative to presurgical bodies, brain activation to postsurgical bodies was observed in bilateral orbital frontal cortex. While changes in BMI only revealed activation in visual brain substrates, changes in WHR revealed activation in the anterior cingulate cortex, an area associated with reward processing and decision-making. When regressing ratings of attractiveness on brain activation, we observed activation in forebrain substrates, notably the nucleus accumbens, a forebrain nucleus highly involved in reward processes. These findings suggest that an hourglass figure (i.e., an optimal WHR) activates brain centers that drive appetitive sociality/attention toward females that represent the highest-quality reproductive partners. This is the first description of a neural correlate implicating WHR as a putative honest biological signal of female reproductive viability and its effects on men's neurological processing.

Sexual and other axis I diagnoses of 60 males arrested for crimes against children involving the Internet

OBJECTIVE

This study was conducted to describe Axis I sexual diagnoses of 60 males arrested for possession of child pornography obtained via the Internet and/or attempting to meet children via the Internet.

METHODS

Data was obtained from a chart review of evaluations conducted on 60 males referred for a psychosexual evaluation following an arrest for possession of child pornography and/or attempting to meet children. All crimes involved use of the Internet. Information obtained from the chart review was entered into SAS. All diagnoses were made according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Simple descriptive statistics were computed and cross tabulations were tested for significance using chi2 or Fisher's Exact test.

RESULTS

Of the total sample, 40% had at least one paraphilia. Thirty-one percent had a diagnosis of pedophilia and 18% of a paraphilia not otherwise specified (NOS). Thirty-three percent had a sexual disorder NOS, characterized by hypersexuality. Seventy percent of the total sample had an Axis I disorder that antedated and was judged to be contributory to the behavior leading to their arrest.

CONCLUSIONS

This sample of men arrested for committing crimes against children and adolescents via the Internet has a high incidence of lifetime sexual and other psychopathology.

An integrative theoretical framework for understanding sexual motivation, arousal, and behavior

An integrative theoretical framework and model for understanding sexual motivation, arousal, and behavior is presented, combining the principles of incentive motivation theory and the hierarchical control of behavior. It is intended to stimulate discussion. The framework can serve as a "route map" in understanding the links between different component processes and their interactions, as well as the relations between different academic perspectives on understanding sexuality. It is suggested that both excitation and inhibition of sexual motivation, arousal, and behavior act at various levels in a hierarchical structure, and much confusion can be avoided by distinguishing these levels. The model integrates information from different branches of psychology: biological, evolutionary, clinical, cognitive, developmental, and social. It describes interactions between sexual behavior and anxiety, attachment, aggression, and drug taking; and it is applied to gender differences, evolutionary psychology, sexual deviancy, sexual addiction, and the biological bases of sexuality.

Classifying hypersexual disorders: compulsive, impulsive, and addictive models

In closing, we argue for two conclusions. First, there are advantages to using theoretically neutral terms (such as hypersexual disorder) that go beyond the compulsive-impulsive-addictive distinctions. Although the notion of theory-neutral observation cannot be defended, it is important not to rely on any particular theoretical framework before all the evidence is in. Our current nosology employs a range of contradictory terms and frameworks (eg, impulse control disorder, compulsive gambling and buying, trichotillomania, and kleptomania). In keeping with the approach taken in other DSM categories, it may be useful to find a more theory-neutral term that can cut across these conditions. Second, any conclusions drawn here about the nosology of hypersexual disorder must be tempered by the relative lack of rigorous psychobiological and systematic treatment data. A better understanding of the psychobiology of hypersexual disorder might provide greater confidence in one or the other theoretical model. The A-B-C model proposed here is tentative at best, given the relative absence of supporting data. Further, a richer assessment and treatment literature would allow clearer conclusions about the clinical utility of different nosological approaches. We emphasize the need for much additional work to characterize the phenomenology and psychobiology of hypersexual disorder and other conditions characterized by affective dysregulation, behavioral addiction, and cognitive dyscontrol, in the hope that such research would ultimately lead to improved assessment and management.

Internet addiction: definition, assessment, epidemiology and clinical management

Internet addiction is characterized by excessive or poorly controlled preoccupations, urges or behaviours regarding computer use and internet access that lead to impairment or distress. The condition has attracted increasing attention in the popular media and among researchers, and this attention has paralleled the growth in computer (and Internet) access. Prevalence estimates vary widely, although a recent random telephone survey of the general US population reported an estimate of 0.3-0.7%. The disorder occurs worldwide, but mainly in countries where computer access and technology are widespread. Clinical samples and a majority of relevant surveys report a male preponderance. Onset is reported to occur in the late 20s or early 30s age group, and there is often a lag of a decade or more from initial to problematic computer usage. Internet addiction has been associated with dimensionally measured depression and indicators of social isolation. Psychiatric co-morbidity is common, particularly mood, anxiety, impulse control and substance use disorders. Aetiology is unknown, but probably involves psychological, neurobiological and cultural factors. There are no evidence-based treatments for internet addiction. Cognitive behavioural approaches may be helpful. There is no proven role for psychotropic medication. Marital and family therapy may help in selected cases, and online self-help books and tapes are available. Lastly, a self-imposed ban on computer use and Internet access may be necessary in some cases.

From research methods to clinical practice in psychiatry: challenges and opportunities in the developing world

Psychiatric disorders are amongst the most prevalent, burdensome, and costly of all medical disorders. Several factors make this an exciting time for research on these conditions; these include relevant advances in (1) nosology and epidemiology; (2) neuroscience, including neurogenetics, molecular neurobiology, cognitive-affective neuroscience, and brain imaging; (3) psychopharmacological and psychotherapeutic interventions; (4) systems research in mental health, including evaluation of evidence and of costs; and (5) patient advocacy and mental health literacy. At the same time, there are important challenges facing psychiatry researchers; these include (1) limitations of current diagnostic systems; (2) problems in attracting talented researchers to neuroscience and in obtaining sufficient funding for the vast amount of needed work; (3) a relative lack of controlled pharmacotherapeutic and psychotherapeutic studies undertaken outside the context of tertiary centres in the developed world; (4) ongoing gaps in systems research, including a relative lack of research on the effects of mental health policy; and (5) stigmatization of mental illness and anti-scientific beliefs in the community. These opportunities and challenges exist in both the developed and the developing world, but their scope may differ qualitatively and quantitatively; here we present a perspective from the developing world. We conclude with a wish list for the way forwards.

[Pornography and sexual abuse in the Internet]

Internet pornography has been regarded as either stimulating sexual aggression and abuse or as serving as a safety valve. This controversy is an important issue in health, media and legal politics. According to empirical studies on pornography in general, soft-core pornography and nonviolent pornography can be regarded as harmless, whereas non-violent hard-core pornography and violent pornography may increase aggression. Individuals with a high risk for sexual aggression show more interest in violent pornography and are stimulated more strongly through such material. Two case histories illustrate the characteristics of internet pornography and "cybersex": easy access, anonymity, affordability, wide range and deviation of the material, unlimited market, blurring the borders between consumer and producer, interactive communication, space for experimenting between fantasy and in real-life behavior, virtual identities, easy contact between offender and victim or among offenders, and low risk of apprehension. The phenomenon of "sexual addiction" (or paraphilia- related disorder) is particularly relevant for the problematic use of internet pornography. Preventive measures to protect possible victims are presented as well as treatment strategies for offenders. Beside limiting access to the internet, these include therapy of comorbid psychiatric disorders and psychological problems (social isolation, bereavement, stress- and anger-management, guilt and shame, childhood traumata, cognitive distortion, victim empathy), psychopharmacotherapy and the enhancement of a more integrative and relationship-oriented sexuality.

Hypersexual behaviour, frotteurism and delusional jealousy in a young parkinsonian patient during dopaminergic therapy with pergolide: A rare case of iatrogenic paraphilia

Neuropsychological and psychopathological modifications induced by dopaminergic drugs in patients with Parkinson's disease (PD) are invariably not taken into sufficient consideration by the neurologist. Among the former, modifications of sexual urges and behaviours are of particular importance with regard to severity and variety of clinical pictures. Although rare, such modifications may assume the connotations of an aberrant sexual behaviour with criminal implications, in line with a diagnosis of paraphilia. The authors report the case of a 51-year-old male PD patient who, after a few years of dopaminergic treatment with pergolide, developed a paraphilic disorder, consistent with DSM-IV TR diagnosis of frotteurism, and delusional jealousy. The patient presented mild motor impairment and lack of or negligible cognitive deterioration, thus providing evidence that these disorders are not typical of advanced PD. Pergolide was reduced and quetiapine, an atypical neuroleptic, was introduced with subsequent subsiding of the paraphilic disorder and improvement of delusional jealousy.

Epidemiologic and clinical updates on impulse control disorders: a critical review

The article reviews the current knowledge about the impulse control disorders (ICDs) with specific emphasis on epidemiological and pharmacological advances. In addition to the traditional ICDs present in the DSM-IV-pathological gambling, trichotillomania, kleptomania, pyromania and intermittent explosive disorder-a brief description of the new proposed ICDs-compulsive-impulsive (C-I) Internet usage disorder, C-I sexual behaviors, C-I skin picking and C-I shopping-is provided. Specifically, the article summarizes the phenomenology, epidemiology and comorbidity of the ICDs. Particular attention is paid to the relationship between ICDs and obsessive-compulsive disorder (OCD). Finally, current pharmacological options for treating ICDs are presented and discussed.

Prescription of medroxyprogesterone acetate to a patient with pedophilia, resulting in Cushing's syndrome and adrenal insufficiency

This article provides a case report of a patient with pedophilia who was treated over a 4-year period with medroxyprogesterone acetate (MPA) at a dose of 300 mg/day and as a consequence developed Cushing's Syndrome and adrenal insufficiency, for which he was treated and from which he recovered. He also reported a hypersexual reaction to his own past cessation of MPA. Gonadotropin-releasing hormone agonists, which have a more benign side-effect profile than MPA, are suggested as an alternative to MPA.

High rates of sexual behavior in the general population: correlates and predictors

We studied 2450, 18-60-year-old men and women from a 1996 national survey of sexuality and health in Sweden to identify risk factors and correlates of elevated rates of sexual behavior (hypersexuality) in a representative, non-clinical population. Interviews and questionnaires measured various sexual behaviors, developmental risk factors, behavioral problems, and health indicators. The results suggested that correlates of high rates of intercourse were mostly positive, whereas the correlates of high rates of masturbation and impersonal sex were typically undesirable. For both men and women, high rates of impersonal sex were related to separation from parents during childhood, relationship instability, sexually transmitted disease, tobacco smoking, substance abuse, and dissatisfaction with life in general. The association between hypersexuality and paraphilic sexual interests (exhibitionism, voyeurism, masochism/sadism) was particularly and equally strong for both genders (odds ratios of 4.6-25.6). The results held, with a few exceptions, when controlling for age, being in a stable relationship, living in a major city, and same-sex sexual orientation. We conclude that elevated rates of impersonal sex are associated with a range of negative health indicators in the general population.

Corrigendum to "gender in obsessive-compulsive disorder: clinical and genetic findings" [Eur. Neuropsychopharmacol. 14 (2004) 105-113]

BACKGROUND

There is increasing recognition that obsessive-compulsive disorder (OCD) is not a homogeneous entity. It has been suggested that gender may contribute to the clinical and biological heterogeneity of OCD.

METHODS

Two hundred and twenty patients (n=220; 107 male, 113 female) with DSM-IV OCD (age: 36.40 +/- 13.46) underwent structured interviews. A subset of Caucasian subjects (n=178), including subjects from the genetically homogeneous Afrikaner population (n=81), and of matched control subjects (n=161), was genotyped for polymorphisms in genes involved in monoamine function. Clinical and genetic data were statistically analyzed across gender.

RESULTS

Compared with females, males with OCD (1) had an earlier age of onset, and a trend toward having more tics and worse outcome, (2) had somewhat differing patterns of OCD symptomatology and axis I comorbidity, and (3) in the Caucasian group, were more likely to have the high activity T allele of the EcoRV variant of the monoamine oxidase A (MAO-A) gene compared to controls, and (4) in the Afrikaner subgroup, were more frequently homozygous for the G allele at the G861C variant of the 5HT1Dbeta gene than controls. Females with OCD (1) reported more sexual abuse during childhood than males, (2) often noted changes in obsessive-compulsive symptoms in the premenstrual/menstrual period as well as during/shortly after pregnancy, and with menopause, and (3) in the Caucasian subgroup, were more frequently homozygous for the low activity C allele of the EcoRV variant of the MAO-A gene compared to controls, with this allele also more frequent in female patients than controls.

CONCLUSION

This study supports the hypothesis that gender contributes to the clinical and biological heterogeneity of OCD. A sexually dimorphic pattern of genetic susceptibility to OCD may be present. Further work is, however, needed to delineate the mechanisms that are responsible for mediating the effects of gender.

Gender in obsessive-compulsive disorder: clinical and genetic findings

BACKGROUND

There is increasing recognition that obsessive-compulsive disorder (OCD) is not a homogeneous entity. It has been suggested that gender may contribute to the clinical and biological heterogeneity of OCD.

METHODS

Two hundred and twenty patients (n=220; 107 male, 113 female) with DSM-IV OCD (age: 36.40+/-13.46) underwent structured interviews. A subset of Caucasian subjects (n=178), including subjects from the genetically homogeneous Afrikaner population (n=81), and of matched control subjects (n=161), was genotyped for polymorphisms in genes involved in monoamine function. Clinical and genetic data were statistically analyzed across gender.

RESULTS

Compared with females, males with OCD (1) had an earlier age of onset, and a trend toward having more tics and worse outcome, (2) had somewhat differing patterns of OCD symptomatology and axis I comorbidity, and (3) in the Caucasian group, were more likely to have the high activity T allele of the EcoRV variant of the monoamine oxidase A (MAO-A) gene compared to controls, and (4) in the Afrikaner subgroup, were more frequently homozygous for the C allele at the G861C variant of the 5HT(1D beta) gene than controls. Females with OCD (1) reported more sexual abuse during childhood than males, (2) often noted changes in obsessive-compulsive symptoms in the premenstrual/menstrual period as well as during/shortly after pregnancy, and with menopause, and (3) in the Caucasian subgroup, were more frequently homozygous for the low activity C allele of the EcoRV variant of the MAO-A gene compared to controls, with this allele also more frequent in female patients than controls.

CONCLUSION

This study supports the hypothesis that gender contributes to the clinical and biological heterogeneity of OCD. A sexually dimorphic pattern of genetic susceptibility to OCD may be present. Further work is, however, needed to delineate the mechanisms that are responsible for mediating the effects of gender.

Problematic internet use: proposed classification and diagnostic criteria

Since the mid-1990s, there have been frequent reports of individuals whose use of the computer and internet is problematic. Given the recent expansion and the expected increase in internet availability and usage in the coming years, it is important that healthcare professionals be informed about this behavior and its associated problems. Recently, psychological and psychiatric literature has described individuals that exhibit problematic internet use who often suffer from other psychiatric disorders. In the face of this comorbidity, it is essential to evaluate whether these individuals represent a distinct class of disorder, or a manifestation/coping mechanism related to other underlying diagnosis. In either event, problematic internet use negatively impacts social and emotional functioning. Based on the current limited empirical evidence, problematic internet use may best be classified as an impulse control disorder. It is therefore imperative that problematic internet use be appropriately identified among symptomatic individuals. For these reasons, we propose specific diagnostic criteria that will allow for consistent identification and assist in further study of this behavior.

Model of problematic internet use in people with a sexual interest in children

Agencies working with sex offenders are starting to see the emergence of people with a sexual interest in children who meet some of their needs through the use of child pornography, or the seduction of children, through the Internet. While CBT models dominate our understanding of sex offenders, there has been little research into the role that such new technologies may play in offending behavior. Data from the COPINE project has been used to generate a model of such offending behavior that emphasizes the role of cognitions in both the etiology, engagement with and problematic use of the Internet for those with a sexual interest in children. Such a model seeks to incorporate contemporary thinking about the role of cognitions in Pathological Internet Use, but applies this from a nonpathological perspective. This model is a first step towards providing a conceptual framework for such offending that will help inform both assessment and therapy.