Behavioral Addictions _ _______________________________________________________________________
narcissistic need for constant affirmation of one’s attractive- ness; or a desperate attempt to stave off feelings of emptiness. In most cases, sexually addictive behavior is thought to reflect a disturbance in the core self-concept and/or the capacity for intimate relationships [76]. Psychodynamic psychotherapists recognize the inherent human need for close intimate relationships to help regulate negative and positive emotions, and how this need must be reconciled with feeling dependent on people who remain, in large part, outside of one’s control [188; 189]. For those with less ability or an inability to tolerate this dilemma, often resulting from maladaptive early attachment, an addictive object can provide a convenient end-run around the vulnerability and relative powerlessness inherent in intimate relationships. In this way, sexually addictive behavior can serve as a transitional object [76]. According to psychodynamic theory, sexually addictive behavior serves as a self-soothing and emotionally regulating “other” that remains under the individual’s near-total control. The sexual partners in sexually addictive behavior are rarely experienced as “subjects”—three-dimensional people who can make an emotional impact on the sexually addicted individual outside of his or her control. Instead, they are fleeting “objects,” used to gratify an urge and then discarded. Paradoxically, by insisting on total control over the attachment object, the sexu- ally addicted individual loses control and ends up controlled by their addiction. Psychodynamic therapy can help the patient to understand how these dynamics play out in his or her life and to subsequently develop healthier relational patterns [76]. Group Psychotherapy Group psychotherapy can be highly effective in the treatment of substance and behavioral addictions and, in some cases, is more effective than individual therapy alone [186]. Group therapy serves multiple purposes and probably works through a combination of mechanisms. It provides social support during the difficult change process, information about other group members’ experiences and coping strategies, support for a positive new group identity, and confrontation of the denial and rationalizations associated with sexually addictive behavior [76]. Group therapy helps individuals feel less isolated and reduces feelings of shame [145]. Couples Therapy Due to the negative impact of sex addiction on intimate rela- tionships, couples therapy may offer both the patient and their partner guidance on dealing with this disorder [140]. Pharmacologic Interventions Few pharmacotherapy studies in sex addiction have been published. The research that has been published focuses on male patients. Clinical experience indicates close monitoring is needed in treating compulsive sexual behavior, as some individuals may increase risky sexual behavior to compensate for the dampening effects of medication on sex drive [85].
In a study of gay and bisexual men with complaints of com- pulsive sexual behaviors, 12 weeks of citalopram led to greater reductions in desire for sex, frequency of masturbation, and hours of pornography use per week compared with placebo. However, the number of sexual partners during treatment did not differ [190]. Naltrexone was evaluated over eight weeks in non-addicted, methamphetamine-using, binge-drinking men who have sex with men at high risk for HIV. Naltrexone led to significantly greater reductions in overall and condom-less receptive anal intercourse than placebo. Among frequent methamphetamine users, naltrexone led to greater reductions in methamphet- amine-using days. Higher naltrexone adherence also led to greater reductions in binge drinking days [191]. The importance of close patient monitoring is underscored by a case report of three heterosexual men (24 to 35 years of age) who developed new-onset problematic sex behaviors during paroxetine (an SSRI) treatment for pathologic pornography use and masturbation. After 10 weeks of paroxetine, all showed marked reductions in anxiety and pathologic pornography use and masturbation and return of normal sexual function. However, by three months, all had new-onset sexual behaviors; none had histories of risky sexual behaviors, affairs, paying for sex, or mania/hypomania symptoms during treatment [192]. Two were in long-term relationships (one married); one was single. All described pride in overcoming inhibitions to take sexual risks with success and felt strongly motivated to con- tinue. Both patients in relationships felt guilt but also elation over new sexual frontiers as both had remained with their first and only sex partner. None wanted to phase-out paid sexual services by increasing pornography and masturbation, which they described as isolating, time-consuming, and humiliating [192]. In this study, the authors explain that an imbalance in reward reactivity and threat reactivity promoted sexual risk-taking; problematic behaviors resulted from increased impulsivity or increased anxiety [192; 193]. All three patients regulated their high pretreatment anxiety levels with pathologic pornography use and masturbation. Paroxetine helped decrease amygdala reactivity, which decreased anxiety and subsequently decreased pathologic pornography use and masturbation, with new com- pulsive sexual behaviors potentially emerging from diminished anxiety [192]. When sexually disordered behavior presents a grave risk to the individual or society, such as persistent uncontrolled pedo- philia, anti-androgen therapy has been effective for drastically reducing sexual drive. The side effects with this drug class are notable, and such medications are rarely used outside of seri- ous circumstances in a forensic context [76]. Twelve-Step Programs Sex Addicts Anonymous (SAA) is a support group with a purpose of helping others with sex addiction find recovery. This organization operates similarly to AA and uses the 12-step
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