• loss of control of sexual impulses
• engaging in sexual activity despite it no longer feeling pleasurable
• using sex as escape
• continuing to have sex despite having legal, health, or relationship problems
• inability to establish emotional close relationship
• having multiple sexual partners
• engaging in high risk sexual behavior (anonymous, unsafe, exchanging money or drugs)
• escalation in behaviors
  • pornography
  • chat/phone
  • escorts
  • sex clubs

• not currently recognized in DSM
• is it OCD?
• is it impulse control?
• is it substance dependence?
• is it primary disease or symptom of other diseases?

• repetitive behavior or mental acts that the person feels drive to perform in response to obsession
• behaviors aimed at preventing or reducing distress or preventing some dreaded event or situation

problem: not involved with reduction in distress or anxiety

• failure to resist an impulsive at or behavior that may be harmful to self or others
• is not premeditated or not considerd in advance and one over which the individual has little or no sexual control
• problem: sexual addiction often involves well planned out behaviors

• look at tolerance and withdrawal
• problem: sex is NOT a substance (I can't say increase amounts to achieve intoxication)

• repetitive and intense preoccupations with sexual thoughts, urges, behaviors
• multiple unsuccessful attempts at controlling sexual thoughts, urges, and behaviors
• adverse consequences causing clinically significant distress or impairment in occupational, interpersonal, or social areas of functioning
• symptoms cannot occur exclusively in context of another axis I disorder (ex: mania), be substance induced (esp. cocaine, amphetamines), or occur in relation to a general medical condition
• symptoms can include solo or relational activities
• can occur co-morbidly with paraphilias

1. low serotonin, ADH, OT
2. leads to increase testosterone
3. increased sexual drive and aggression

• behaviors lead to increased dopamine release in limbic forebrain
• when aroised, if behavior is not acted upon, leads to tension and excitement aka addiction

• increased rate of pedophilia in familes with other pedophiles compared to controles
• higher rate of family members with other forms of addiction
  • substance abuse
  • sex disorder
  • eating disorder
  • some gambling

• amygdala- responsible for affective dysregulation
  • in addiction, usually comorbid with mood disorders
• ventral striatal circuits and NA- behavior reward
  • in sex addiction, preoccupation, dysphoria when trying to cut back
• prefrontal cortex- impaired cognitive/ executive control
  • in sex addiction, continued behaviors despite negative consequences

• orbitofrontal tumors
• decreased gray matter volumes
• increase LH release

• thalamic stroke
• traumatic brain injury
• dopamine agonists
• alzheimer's dementia

• functional MRI
  • amygdala and hypothalamus activation in men much greater in women when viewing stimulating materials
• PET
  • increase activity in mesodiencephalic transitional area
  • increased internal opiate release during sexual arousal

• naltrexone successful
• SSRI lower libido
• testosterone lowering agents decrease recidivism rates in sexual offenders

• inhibited children have acting in behaviors (compulsive)
• uncontrolled children seem to have acting out behaviors (impulsive)
• temperment serves as predisposing factor that paired with other biological and envir. factors can lead to sexual compulsive behaviors

• difficulties with pair bonding, courtship, attraction, love, affection, and intimacy
• avoidant attachment- sex w/o affection or emotion, so prostitutes, pornography
• disorganized- needing/fearing wants closeness but fears rejection, leads to objectivication, leads to paraphilia
• preoccupied- leads to emotional neediness with multiple partners
• sexual acting out may serve to temper negative affective states

• self constancy (or self object) developed at age 3
• neglected children may not form self object
• sexual compulsivity may be a form of needing to constantly feel affirmed/desired

• ID with aggressor
• large number of sexual criminals were molested as children (but we dont have data of ALL people with that predisposing factor)
• pairing of sexaul arousal with terror violence lead to continual return to the trauma to try to master/comprehend it
• dissociation which is protective during trauma plays itself out later in life

• religious fundamentalism
  • Hasidic Jews more sexual compulsion than controls
• internet
  • affordable, anonymous, accessible
• sexualization of children
  • earlier age of puberty
  • more exposure to sex in media
• changes in parenting
  • absent parenting leads to needy children who seek out dependent relationships
  • leads to premature sexuality

• sexual compulsivity scale
• sexual addiction screening tool
• hypersexual behavior inventory

Ones in bold have been validated

• bipolar d/o (hypomania/mania)
• MDD
• substance induced
• organic brain injury
  • traumatic brain injury
  • seizure d/o
  • Kluver Bucy syndrome
  • Kleine Levin syndrome
• endocrin pathology
  • hyperadrenalism
  • pancreatic tumor
  • ovarian CA

• onset of middle age or later
• excessive aggression or personality changes
• reports of auras or seizure like symptoms prior to or during the sexual behavior
• abnormal body habitus
• presence of soft neurological signs

• mood d/o
• anxiety d/o
• personality d/o
• substance use
• other compuslive behaviors
• ADHD
• paraphilias

• unwanted pregnancy*
• legal problems*
• STI
• physical trauma
• isolation, depression, suicide?*

*this means theoretical, not studied

• SSRI's
• naltrexone
• mood stabilizers
• stimulants
• anti androgens

1. opiate antagonist to block pain and pleasure
2. mediates affects on DA involved in reward pathway
3. leads to decrease sexual fantasy and masturbation

Used in alcoholism

• ADHD tx can reduce sexual behavior
• indirect effect
• Straterra can be used if addiction concerns

• psychodynamic (understand, integration, internalization)
• cognitive (skills training, lifestyle regeneration, relapse prevention)
• behavioral (aversion therapy)

Usually we use cognitive approach. Psychodynamic NOT as good.