________________________________________________________________________ Behavioral Addictions
DIAGNOSIS Variously worded diagnostic entities describing addictive sexual behavior have appeared in the iterations of the DSM and the ICD [181]. Diagnostic criteria for hypersexual disorder were created and proposed for the DSM-5. These criteria are [140; 182]: • Over a period of at least six months, recurrent and intense sexual fantasies, urges, or behaviors (specify if masturbation, pornography, sexual behavior with con- senting adults, cybersex, phone sex, or strip clubs) in the context of three or more of the following criteria: - Excessive time consumed by sexual fantasies and urges, and planning for and engaging in sexual behaviors, repetitively interferes with other impor- tant (non-sexual) goals, activities, and obligations - Repetitive engagement in such sexual activity as a means to regulate dysphoric mood states of anxiety, depression, boredom, or irritability - Repetitively engaging in such sexual activity in response to stressful life events - Repeated but unsuccessful efforts to control or significantly reduce these sexual fantasies, urges, or behaviors - Repetitive engagement in sexual behaviors while disregarding the risk for physical or emotional harm to self or others • Presence of clinically significant personal distress or impairment in social, occupational, or other important areas of functioning associated with the frequency and intensity of these sexual fantasies, urges, or behaviors • Sexual activities not due to the direct physiologic effects of a recreational drug or medication, a co-occurring general medical condition, or to manic episodes • Age of at least 18 years Not included in the diagnostic criteria, Kafka also proposed that seven sexual outlets (i.e., orgasms) per week represented a cutoff point for excessive sexual activity, based on his review of published research [182]. The APA rejected the recommendation of its own Sexual and Gender Identity Disorders Work Group to include hypersexual disorder in the DSM-5. The APA stated an objection to the implicit normative reference to the “right amount” of sexuality (e.g., the cutoff of seven sexual outlets per week suggested in the supporting review but not in the diagnostic criteria) [183]. The DSM-5 task force also stated there were insufficient data to support inclusion of hypersexual disorder [76]. An evaluation of various proposed diagnostic criteria for sexual addiction found common core domains [76]: • Excessive sexual behavior, generally outside the context of sustained intimate relationships
• Intense and persistent urges to perform such sexual behavior, similar to drug craving in substance addiction • Continuation of sexual behavior despite the potential to cause significant personal, occupational, or financial consequences and/or harm to physical health • Difficulty stopping the behavior despite repeated attempts or significant negative consequences The ICD-10-CM was introduced to the U.S. healthcare system in 2015. It is the most widely used mental disorders classifica- tion worldwide and permits a hypersexual disorder diagnosis for coding and reimbursement. In the United States and other countries, ICD diagnostic codes are mandated by international treaty, unlike the DSM-5-TR, which lacks such mandate. As such, a diagnosis of hypersexual disorder can be used even though it is not included in the DSM-5-TR [181]. Diagnostic criteria for compulsive sexual behavior disorder also appear in the ICD-11, published in 2018. These diagnostic criteria are [109]: • A persistent pattern of failure to control intense, repeti- tive sexual impulses or urges resulting in repetitive sexual behavior. Symptoms may include: • Repetitive sexual activities become a central focus to the point of neglecting health, personal care, or other interests, activities, and responsibilities • Numerous unsuccessful efforts to control or signifi- cantly reduce repetitive sexual behaviors • Continued engagement in sexual behaviors despite adverse consequences • Continued engagement in sexual behaviors even when the individual derives little or no satisfaction from it • Pattern evident for at least six months • Pattern leads to marked distress or significant impair- ment in personal, family, social, educational, occupa- tional, or other important areas of functioning Distress that is entirely related to moral judgments and disap- proval about sexual impulses, urges, or behaviors does not fulfill these criteria. Behaviors better categorized as a paraphilic disorder (e.g., exhibitionistic disorder, voyeuristic disorder, pedophilic disorder) also do not qualify. TREATMENT Standard approaches for the treatment of sexual addiction include a variety of psychological and pharmacologic options ( Table 2 ). Understanding the characteristics of persons seeking help for out-of-control sexual behavior and differences among patients can help guide clinician decision-making for better patient-treatment matching.
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