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Compulsive Sexual Behavior: Clinical Characteristics and Treatment Jon E. Grant, JD, MD, MPH University of Minnesota School of Medicine Minneapolis, MN Impulse Control Disorders Pathological gambling Kleptomania Compulsive sexual behavior Compulsive buying Pyromania

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compulsive sexual behavior clinical characteristics and treatment

Compulsive Sexual Behavior: Clinical Characteristics and Treatment

Jon E. Grant, JD, MD, MPH

University of Minnesota

School of Medicine

Minneapolis, MN

impulse control disorders
Impulse Control Disorders
  • Pathological gambling
  • Kleptomania
  • Compulsive sexual behavior
  • Compulsive buying
  • Pyromania
icds in adolescent psychiatric inpatients
Overall Girls Boys

Int. Explosive Disorder 12.7% 12.5% 13.0%

Pathological Skin Picking 11.8% 16.1% 6.5%

Kleptomania 8.8% 7.1% 10.9%

Pyromania 6.9% 12.5% 0%

Compulsive Buying 6.9% 10.7% 2.2%

Compulsive Sex 4.9% 8.9% 0%

Pathological Gambling 4.9% 1.8% 8.7%

Trichotillomania 3.9% 5.4% 2.2%

ICDs in Adolescent Psychiatric Inpatients
core features of impulse control disorders
Core Features of Impulse Control Disorders
  • Repetitive or compulsive engagement in a behavior despite adverse consequences
  • Diminished control over the problematic behavior
  • An appetitive urge or craving state prior to engagement in the problematic behavior
  • A hedonic quality during the performance of the problematic behavior.
common core features of impulse control disorders
Common Core Features of Impulse Control Disorders
  • Tolerance
  • Withdrawal
  • Repeated unsuccessful attempts to cut back or stop
  • Impairment in major areas of life functioning
developmental biology
Developmental Biology
  • High rates of co-occurrence of ICDs and SUDs start in young adulthood.
  • Environmental and genetic influences - vulnerability to and expression of addictive disorders
  • Changes in brain structure and function during adolescence might influence the motivation to engage in risk-taking behaviors like gambling.

Youth Problem Gambling as a

Component of Problem Behaviors











emerging science teen brains are still developing
Emerging Science: Teen Brains Are StillDeveloping
  • New insights about:
    • Why teenagers take risks and show poor judgment
    • How teenagers may be highly vulnerable to drug abuse
  • These findings can help parents!





Physical coordination

Prefrontal Cortex

Nucleus Accumbens


Notice: Judgment is last to develop!


Age 24



Physical coordination, sensory processing




In the presence of stress…

I hate school; I am going to skip classes and look at pornography



neural systems and addiction
Mesocorticolimbic Dopamine System (“Overactive Motor”)

-Ventral Tegmental Area, Nucleus Accumbens

Frontal Serotonin Systems (“Bad Brakes”)

-Frontal/Prefrontal Cortical Function

Role for Neurotransmitter Systems Modulating DA, 5HT Function

- GABA, Glutamate, Opioids, ...

Neural Systems and Addiction
motivational neural circuits
Motivational Neural Circuits
  • Multiple brain structures underlying motivated behaviors.
  • Motivated behavior involves integrating information regarding internal state (e.g., hunger, sexual desire, pain), environmental factors (e.g., resource or reproductive opportunities, the presence of danger), and personal experiences (e.g., recollections of events deemed similar in nature).
neurochemistry of impulsivity
Neurochemistry of Impulsivity





role of serotonin
Role of Serotonin
  • Decreased serotonin associated with adult risk-taking behaviors.
  • Blunted serotonergic responses in the ventromedial prefrontal cortex - in individuals with impulsivity
  • Implicated in disadvantageous decision-making.
role of dopamine
Role of Dopamine
  • Dopamine release into the nucleus accumbens - translates motivated drive into action - a “go” signal
  • Dopamine release associated with rewards and reinforcing
  • Dopamine release - maximal when reward is most uncertain, suggesting it plays a central role in guiding behavior during risk-taking situations.
opioid system
Opioid System
  • The endogenous opioid system influences the experiencing of pleasure.
  • Opioids modulate mesolimbic dopamine pathways via disinhibition of GABA input in the ventral tegmental area.
compulsive sexual behavior25
Compulsive Sexual Behavior
  • Sexual thoughts, urges and behaviors that are normative
  • Engaged in with a frequency or intensity that leads to distress or impairment
csb diagnostic criteria
CSB Diagnostic Criteria
  • Persistent and recurrent maladaptive behavior as indicated by the following:
  • (1) Difficulty controlling sexual behavior as indicated by engaging in sexual behavior for longer periods than intended
  • (2) Repeated unsuccessful efforts to control, cut back, or stop excessive sexual behavior
  • (3) Becomes restless or irritable when attempting to cut down or stop the sexual behavior
(4) Needs to engage in the sexual behavior for increasing amounts of time or intensity in order to achieve the desired feelings (e.g., stimulation, excitement, pleasure, gratification)
  • (5) Is preoccupied with the sexual behavior (e.g., fantasizing about the behavior or planning the next future sexual activities
  • (6) Has sexual impulses that are experienced as uncontrollable, intrusive, and/or senseless
(7) Sexual behavior is continued despite knowledge of possible health, safety, economic, or legal problems (e.g. sexually transmitted diseases, injuries, illnesses, use of prostitutes, sexual offenses).
  • (8) Engages in excessive sexual behavior as a way of escaping from problems or of relieving a dysphoric mood (e.g., feelings of helplessness, guilt, anxiety, depression)
  • (9) Important social, occupational, or recreational activities given up or reduced because of excessive sexual behavior
(10) Repeatedly engages in excessive sexual behavior despite feeling guilty about it
  • (11) Lies to family members, friends, therapist, or others to conceal the extent of sexual behavior
  • (12) Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of excessive sexual behavior
  • (13) sexual behavior causes clinically significant distress
csb behaviors
CSB Behaviors
  • Compulsive masturbation 85%
  • Phone sex dependence 31%
  • Pornography dependence 73%
  • Ego-dystonic promiscuity 50%
  • Sexual chat room dependence 40%
  • Begins in late adolescence
  • Peaks between ages 20 and 30
  • Ratio of males to females is 3:1
  • Minimum TSO of 7/week for at least 6 months
  • Exhibitionism
  • Fetishism
  • Frotteurism
  • Pedophilia
  • Masochism
  • Sadism
  • Transvestic Fetishism
  • Voyeurism
different from paraphilias
Different from Paraphilias?
  • Same TSO
  • Paraphilias more likely to have ADHD
  • More criminal histories
  • More trouble in school
  • More likely to have been abused
health concerns
Health Concerns
  • HIV and AIDS
  • Hepatitis
  • Syphilis
  • STDs
  • Self-Esteem
  • Nicotine dependence
case example
Case Example
  • 30 years old and seeking treatment for first time
  • Onset at 15 years old
  • Male
  • Business
  • Wax and wane in intensity depending on external stressors
case example37
Case Example

Content of sexual obsessions:

  • thoughts of and urges to sexually molest children
  • doubting if committed sexual acts, fear of being alone around children
  • thoughts of inappropriate sexual acts towards coworkers and family members
  • fear of being aroused by thoughts and checking for arousal, avoidance of people associated with thoughts
how are ocd and csb alike
How are OCD and CSB Alike?
  • Propensity of individuals with CSB to engage in excessive,
  • Possibly harmful behavior
  • Leads to significant impairment in social or occupational functioning and causes personal distress.
how are csb and ocd different
How are CSB and OCD Different?
  • People with CSB may report an urge or craving state prior to engaging in the problematic behavior and
  • A hedonic quality during the performance of the behavior.
  • Individuals with OCD are generally harm avoidant with a compulsive risk-aversive endpoint to their behaviors.
problem gambling and compulsive sexual behavior unrecognized co occurring disorders

Problem Gambling and Compulsive Sexual Behavior: Unrecognized Co-Occurring Disorders

225 pathological gamblers
225 Pathological Gamblers
  • 27 (12%) current co-morbid CSB
  • 44 (19.5%) lifetime CSB
  • Rates of CSB 3X in study of psychiatric patients (12%-19.5% compared to 4.4%)
clinical characteristics
Clinical Characteristics
  • Age of onset: CSB preceded PG for 70.3%
  • PG with CSB were significantly more often male than PG alone
  • PG + CSB subjects more likely (82%)than PG subjects (65%) to smoke
  • PG + CSB score higher on Eysenck impulsivity scale than PG subjects or CSB subjects
dynamics of multiple addictions
Dynamics of Multiple Addictions*
  • Switching: Replacing on addiction with another
  • Alternating: Cycling from one addiction to another in a patterned, systematic way
  • Masking: Using denial around one addiction to cover up for another
  • Ritualizing: one addiction is part of the ritualizing for another

*Patrick J. Carnes, Ph.D.

dynamics of multiple addictions con t
Dynamics of Multiple Addictions (con’t.)
  • Intensifying: Using addictive patterns simultaneously to intensify the overall experience
  • Numbing: using addiction to medicate shame and pain due to another addiction
  • Disinhibiting: Using one addiction to lower inhibitions for other addictive acting out
eating disorders
Eating Disorders
  • Gay men 3x more likely than heterosexual men to have an eating disorder
  • Often takes the form of compulsive exercise
  • Steroid abuse
self harm and suicide
Self-Harm and Suicide
  • Gay men 7x more likely to have attempted suicide
  • Gay youth comprise 30% of completed suicides annually
  • Gay and bisexual men have higher rates of deliberate self-harm
  • Prevalence of people who have used within the past 12 months is 0.6%
  • Prevalence rates for methamphetamine use in the previous 6 months among MSM in San Francisco range between 11%–17%
  • Associated with high rates of HIV
  • 13-25% experience psychosis; 11x the population
  • 90% of gay men using meth also use other drugs
treatment of csb
Treatment of CSB
  • Medical causes excluded
  • Assess comorbid disorders
  • Assess motivation for treatment
  • Examine what starts behavior or maintains behavior
  • Differential diagnosis
  • Family involvement
  • Other assistance - e.g. financial planning
heterogeneity of csb
Heterogeneity of CSB
  • Anxiety driven
  • Affective driven
  • Urges/cravings driven
  • Impulsive/inattentive
  • Cognitive therapy
  • Exposure and response prevention
  • Habit reversal with relaxation techniques
  • Covert sensitization
  • Imaginal desensitization
  • Family/couples therapy
  • 28 gay/bisexual men; mean age 37yrs
  • 10% HIV positive; 77% with STDs
  • 12 weeks; medication vs. placebo
  • Decrease in sexual drive, frequency of masturbation, and pornography use
  • Sexual risk did not change between groups – number of partners, number of risky oral and anal sex acts54
  • Antidepressants
  • Antiepileptics/lithium
  • Opioid antagonists
  • Stimulants
  • Baclofen
  • Isradipine
  • Ondansetron
  • Antabuse
  • Psychodynamic psychotherapy, IPT
  • Group CBT therapy
  • CBT: Social skills, assertiveness, anger management; cognitive restructuring, reconditioning techniques of arousal, relapse prevention; imaginal desensitization
12 step programs
12-Step Programs
  • Sexaholics Anonymous
  • Sex and Love Addicts Anonymous
  • CSB appears to be fairly common
  • Frequently co-occur with other disorders
  • Result in significant distress as well as social and functional impairment.
  • Emerging data suggest they may respond well to pharmacological and psychotherapeutic interventions.