________________________________________________________________________ Behavioral Addictions
The Designated Patient Romantic partners of designated patients demand they get help and instigate sex disorder clinical assessments. These demands may reflect highly restrictive sexual beliefs with zero-tolerance for masturbation, pornography, or non-procreative sex. Desig- nated patients may self-label as sex addicts (or a similar term) but lack the sexual behavioral patterns. These patients state their partners explicitly believe the problem is theirs to solve. Designated patients are best helped by including the partner in psychoeducation on healthy masturbation and pornography use and communication and assertiveness training. Sex-positive clinicians quickly see partner demands as unnecessarily restric- tive. Some patients know this, but agree to the restrictions for the benefit of the relationship. Better Accounted for as a Symptom of Another Condition Hypersexuality can be a symptom or sequelae of several non-sexual diagnoses, including some personality disorders, hypomania, developmental delay, disinhibiting brain injuries, neurologic disease, and medication side effects. Borderline personality disorder is the most common associated syndrome and can present as any hypersexuality subtype. In general, personality disorders are distinguished from hypersexualities by the presence of other personality disorder symptoms and not by differences in sexual behaviors.
Avoidance and procrastination motives drive the masturbation. In the gay male community, avoidance may be expressed as excessive time frequenting bathhouses, perusing online hook- up sites, or engaging in anonymous sex with large numbers of partners. With avoidance motivation, treatment is more productive when it addresses avoidance and procrastination instead of masturbation. Motivational interviewing can be very beneficial [138]. Chronic Adultery In clinical settings, patients with chronic adultery are almost always male and outliers in the frequency of extramarital sexual activities involving one-time hook-ups, on-going relationships, or sex workers. Extreme time involvement seeking or engaging in sex is usually absent [138]. Chronic adulterers frequently state their wives or partners have a condition or history that inhibits sexual enjoyment, such as coital pain disorders (i.e., dyspareunia), low libido, sexual abuse history, or conservative/religious backgrounds. When partners present for therapy, their histories and libido levels usually match their husband’s description. Patients may seek treatment motivated by secondary gains from appearing sincere about changing their behavior, without an actual desire to change. In practice, this is less common than assumed; chronic adulterers are generally motivated to change by the time they present for help [138]. Marital distress may be a consequence of most other hyper- sexuality subtypes, but it is antecedent to chronic adulterer behaviors. While couples therapy is strongly indicated, because many marital issues are unresolvable without partner engage- ment, spouses often instruct the chronic adulterer to go fix his problem and are unwilling to participate. Mismatching atypically high and low sex drives often predate the marriage; the sex drive discrepancy goes unaddressed, and the high libido is chronically expressed outside the marriage. Demanding the adulterer fix his problem in therapy also serves to distract from or excuse unaddressed issues of the spouse [138]. Sexual Guilt Patients with sexual guilt self-label as hypersexual or sex addicted and express intense distress, but lack evidence of sexual behavior that exceeds peer group norms. Highly con- servative (usually religious) family environments are typically reported; some willfully adopt moralistic standards in adult- hood that exceed the dictates of their religious. Initially presenting with hypersexuality complaints, further assessment will identify sexual guilt and broadly expressed anxiety over sexual urges or interests. Among these patients are androphilic men who reject or resist their sexual orienta- tion and seek treatment for their perception of addiction or compulsion to have sex with men. Psychoeducation and permission-giving is beneficial, and several therapy approaches can address inaccurate beliefs about sexuality and peer norms. These beliefs may reflect explicit religious involvement or other deeply held ideologies, such as gender roles.
Psychological Interventions Cognitive-Behavioral Therapy
CBT can help the patient identify and work through triggers of sexually addictive behavior, permission-giving thoughts that weaken inhibition of the behavior, and the negative consequences of the behavior. Specific CBT approaches have been modified to treat sexually addictive behavior [185; 186]. Motivational Interviewing Motivational interviewing serves to help the patient consider the pros and cons of maintaining the addiction in the context of their overall goals and priorities [187]. Motivational inter- viewing is less focused on actual behavior change than on bolstering motivation to enter the change process. Advantages of motivational interviewing include the non-confrontational and nondirective nature, which can be more effective in those with low motivation to change [76]. Psychodynamic Therapy Psychodynamic therapy has relatively few published clini- cal studies in sexual addiction treatment, but it appears to offer unique advantages [186]. Specifically, psychodynamic treatment can address the factors related to the individual’s unique personal history and personality organization and can clarify the specific meaning the addictive behavior holds for the patient. For instance, sexual addiction can reflect a rebel- lion against a puritanical and authoritarian parent; a form of self-soothing in the context of parental abandonment; a
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