How to treat sex addictions?

[Symmetry11]

What is the process of treating a sex/porn addiction? Is it any different from treating drug addictions? Do you guys have any informative articles on the subject?

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[splik]

some people engage in compulsive sexual behaviors to an extent that it completely dominates and destroys their lives. Whether this is an addiction is an area of debate. the process or behavioral addictions are still somewhat controversial, and to some extent the use of the term addiction was really metaphorical and has been reified. Other formulations would be these behaviors are impulse control disorders, or obsessive compulsive spectrum disorders, bipolar spectrum disorders, or a symptom of a cluster B personality disorder.

I have evaluated many and treated a few patients with compulsive sexual behavior. In DSM-5 there isn't an adequate way of coding for it (luckily i don't use DSM-5 and in ICD-10 there is - ut unfortunately the terms "satyriasis" and"nymphomania" are used which are not patient friendly terms..). Hypersexual disorder was proposed for DSM-5 but didn't make it in. The field of psychosexual medicine has tended to focus on sexual dysfunctions (like ED, hyposexuality, painful sex, premature ejaculation) rather than hypersexuality. Hypersexuality has a large differential diagnosis and is seen in various neurogenetic/neurodevelopmental disorders, dementias including bvFTD, mania, substance use disorder, character disorders, and occassionally psychosis. coarse brain disease (for example frontal lobe tumors, strokes) can sometimes lead to compulsive sexual behaviors or sexual disinhibition. In my experience, all the the patients I saw met criteria for either borderline or narcissistic personality disorder, sometimes both. One patient was a psychopath.

Some models of treating it are based on an addictions model - for example twelve step facilitation - like sex and love addicts anonymous, or sexaholics anonymous. Personally I can't think of anything worse than this. Also these treatments re abstinence based. Now one can live without drugs and alcohol and be all the healthier for it. I suppose one could live without sex but it would ill-advised. naltrexone is sometimes used to curb sexual urges. I haven't found it all that helpful but worth a try. I had one patient who responded very well to depakote (which was quite surprising as I've never really seen depakote be good for anything other than epilepsy). SSRIs at high doses are used, either to treat impulsivity-compulsivity, or to suppress sexual urges. For paraphilic compulsive sexual behaviors GnRH analogues or medroxyprogesterone are used but have significant risks and raise ethical issues. Cognitive behavioral therapies are of course used as they are with everything. A motivational enhancement approach may be used to explore ambivalence to change. Motivated patients may benefit from DBT, mentalization-based treatment, or adaptive forms of psychoanalytic based treatment (relational, not your freudian stuff which these patients would not be able to cope with).

 

[HarryMTieboutMD]

SLAA doesn't demand complete abstinence from sex- it demands abstinence from high risk sexual behaviour (ie, outside of a monogamous relationship), etc. I agree that most people who I have seen claim to have "sex addiction" are pathological narcissists or other cluster Bs, and most of these people have a co morbid substance use disorder (Tiger Woods loved his vicodin...). I think it is SOMETIMES helpful for the patient in recovery to concept his/her behaviour as addictive in nature; other times it can reinforce narcissistic traits ("I'm going to go to SLAA and share my sexalogues..."). Splik hit the main points for pharmacotherapy- limited evidence for SSRIs and case reports for naltrexone; mood stabilizers are worth a try as well. Sometimes lithium can do amazing things in people with a family history of bipolar. THe central problem, however, as splik said, is an operational problem- this is the most controversial of all of the process addictions, and one must keep in mind a broad differential dx when addressing these patients.

Here is a nice overview of the subject from Marc Potenza, who is the leading authority in process addictions: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3836191/

 

[deleted343839]

The concept of sex addiction has little face validity from a clinical perspective. However, labeling oneself as a "sex addict" serves an important function for most patients. It's up to you to help the patient gain insight into that function, and propose alternatives for addressing the underlying problem (shame about sexual interests or orientation, social incompetence, anxiety, personality disorder, etc.).

 

[Doctor Bagel]

My understanding is that 12 step programs have a goal of monogamy not abstinence, but they're historically (and maybe still) not considered to be particularly friendly to non-straight folk.

I agree that every patient I've seen who endorsed having a sexual addiction has significant Cluster B traits. I haven't seen a ton, though, so I can't extrapolate too much from that. I'm also very dubious of expensive sex addiction treatment centers.

 

[smalltownpsych]

The concept of sex addiction has little face validity from a clinical perspective. However, labeling oneself as a "sex addict" serves an important function for most patients. It's up to you to help the patient gain insight into that function, and propose alternatives for addressing the underlying problem (shame about sexual interests or orientation, social incompetence, anxiety, personality disorder, etc.).

Maybe for patients who are involved and committed to a recovery program this is true, but many of the patients who I have seen who label themselves as sex addicts tend to not be involved in recovery and other diagnoses seem to account for the sex issue as other posters alluded to and in those cases, I really question how useful the label is.

 

[deleted343839]

Maybe for patients who are involved and committed to a recovery program this is true, but many of the patients who I have seen who label themselves as sex addicts tend to not be involved in recovery and other diagnoses seem to account for the sex issue as other posters alluded to and in those cases, I really question how useful the label is.

I agree with you. All I was saying is that people who are invested in the sex addict label are usually getting something from it, such as not having to address a more distressing issue within themselves or in their relationships.

 

[MacDonaldTriad]

Ever notice how the only people who talk about “sexual addiction” are the psychiatrists who are profiting from running sexual addiction treatment centers, and their customers who are celebrities caught cheating on spouses or physicians in legal trouble for boundary violations? Wanting to have sex is a compulsion that is relieved by partaking in sexual activity, but who is to say when this becomes pathological? How can we as professionals say that we can help beat back sexual drives from the abnormal into the normal when there is no definition of where this line is other than getting in trouble? This one smells worse than adult ADHD. It isn’t in DSM and there is a market for it because it provides a rational for bad behavior. I’m sure that I’m being a little extreme, and ADHD symptoms don’t evaporate magically when someone happens to turn 18. Still, no one is getting help for sexual addition who hasn’t been caught. Now, a subset of you are about ready to write posts condemning my opinion, but take note of the fellow members of this subset before you decide to join the club. I will stay on my side of this line thank you.

 

[deleted343839]

Ever notice how the only people who talk about “sexual addiction” are the psychiatrists who are profiting from running sexual addiction treatment centers, and their customers who are celebrities caught cheating on spouses or physicians in legal trouble for boundary violations?

Or they are "Christian counselors" with questionable training credentials who are all too willing to join patients in their shame about sexuality. I saw a member of a couple who were being counseled in parallel (but the partners were never actually in the room together -- WTH?) by someone like this.

 

[VA Hopeful Dr]

Wasn't there a South Park about this?

 

[Shikima]

So, the bottom line is - sexual addiction isn't real. Ok cool. What about those with sexual feelings for cross species and children? Based on the above discussions, these too are not considered pathological and do not need treatment.

 

[MacDonaldTriad]

Well those are illegal, or at least acting on them. I would argue that our attempts to treat them are questionably successful as well.

 

[deleted343839]

So, the bottom line is - sexual addiction isn't real. Ok cool. What about those with sexual feelings for cross species and children? Based on the above discussions, these too are not considered pathological and do not need treatment.

Read James Cantor.

And resist the allure of the slippery slope.

 

[Leo Aquarius]

So, the bottom line is - sexual addiction isn't real. Ok cool. What about those with sexual feelings for cross species and children? Based on the above discussions, these too are not considered pathological and do not need treatment.

Acting out on sexual impulses with a child is considered a paraphilic disorder, in addition to it being illegal.

Sex with animals is termed zoophilia and is also a paraphilic disorder.

Sex addiction? No official recognition of this in a psychiatry text book. Pick one up and try to find it. People are built to want sex. Tiger Woods and most other famous people didn't have a sex addiction. The dumb public wants to shame people. Some say it's completely normal, others call it cheating. Some call it listening to biological instinct in ways that conflict with social contracts that don't take into account human nature.

 

[Shikima]

You can call it a slippery slope, but no one talks about these fringe sexual preferences and urges. It is illegal, just like homosexual behaviors along with oral and anal sex currently are. We cannot deny that these are occurring and I agree that attempts to delineate "normal" spectrum is touch. At one time DSM said homosexuality needed to be fixed and this then went away. The process in which it went away remains for discussion.

People do not need to act out on them to struggle with these thoughts.

Moreover to the point, we have a problem with sex, discussing sex, and the over sexualization with each subsequent brave new world year. So, again, how do we treat what we have poorly defined?

Edit: I've been thinking about this further. I've been thinking, what are the cultural conceptions about sex and the meaning they place behind the act. Some are more conservative talking about procreation and bonding. Other believe it to be a 'normal' behavioral response and biologically speaking, the brain wanting to stimulate the pleasure center.

In a greater cultural context, who is correct and why do people feel the need to change that context based on poor studies and philosophies? Take APA vs Indonesia for example. The APA sent a letter saying how dare the Indonesian mental health community to consider homosexuality a disorder that needs treating. Who is correct? Who is more correct with this communication? What about faith healing? Who and what defines the status quo in this greater context?

Yes, I realized I used homosexuality as a topic for listing examples. But this can be applied to incest, rough sexual pleasures, bestiality.... It's the greater cultural context which has not been well defined nor accepted by anyone. As there isn't any one standard which everyone can based this off of, people are telling others through poorly drafted research on what ought to be accepted as we haven't fully comprehended the fully philosophy behind this subject matter.

 

[deleted343839]

You can call it a slippery slope, but no one talks about these fringe sexual preferences and urges.

I've seen quite a bit about paraphilias in the literature, especially since DSM-5 came out. But it's true that original data are in short supply because the work is difficult to carry out in this political climate (less so in Canada where some of the better research on paraphilias is being conducted).

It is illegal, just like homosexual behaviors along with oral and anal sex currently are.

No, this is not a safe general assumption. What is illegal depends on your jurisdiction. Preferences are not criminalized; behaviors are. So-called "sodomy laws" have been challenged over the past few decades and many of them are no longer in effect, including in conservative states like Texas. This is a global trend and has been the subject of much legal and sociological scholarship.

At one time DSM said homosexuality needed to be fixed and this then went away. The process in which it went away remains for discussion.

The process is pretty well documented.

 

[MarkAntony47]

What is the process of treating a sex/porn addiction? Is it any different from treating drug addictions? Do you guys have any informative articles on the subject?

As with other type of addictions, recovering porn addicts tend to do the best with the support of others who are also in the process of healing. Porn addiction and sex addiction are treated as two separate disorders. It is important to seek treatment or support if you feel that you are struggling with sex/porn addiction. There are many types of sex addiction treatments for this like the 12 step, couple's therapy, individual therapy etc.