Psychosocial intervention for sexual addiction – A Review. (2018)

George, Manju, Shreemit Maheshwari, Suhas Chandran, Suman S. Rao, J. Shivanand Manohar, and TS Sathyanarayana Rao.

Indian Journal of Psychiatry 60, no. 8 (2018): 510.

Abstract

Addiction is the term employed not only for excess consumption of substances, but also for problem behaviours like eating disorders, pathological gambling, computer addiction and pathological preoccupation with video games and sexual acts. No clear diagnostic criterion has been established with validity for behavioral addictions. Sexual addiction, including addiction to pornography is not included as a separate entity because of a lack of strong empirical evidence in this area. Different scales can be used for assessment of sexual addiction. Since there is an absence of established diagnostic criteria, the significance of validity of these scales is doubted. Several of the questions in these scales do not yield information about whether the diagnostic criteria are met or not. Pharmacotherapy, together with psychotherapy proves to have a better outcome in such patients as it helps to synthesize the role of developmental antecedents, reduce current anxiety, depression, guilt and to improve social adjustment.

Keywords: Behavioural addiction, Sexual addiction, Internet addiction, psychosocial interventions

Introduction

Addiction is defined as a primary and chronic condition of the brain which stimulates the reward, motivation and memory related circuitry. The American Society of Addiction Medicine gave this definition in 2011 to include both substances and behaviours.^[1] The term “addiction” is commonly applied to uncontrolled intake of substances like drugs or alcohol, sexual addictions, problem behaviours such as eating disorders, pathological gambling, computer addiction and pathological preoccupation with video games. Besides this, another emerging addiction which has captured much attention is addiction to pornography, which is associated with significant socio-functional and psychological impairment.^[2] An individual who pathologically pursues reward and/or relief either by substance use or other behaviours reflects dysfunction in the brain reward circuitry. Behaviours potentially affecting the reward circuitry in human brains lead to a loss of control and other symptoms of addiction, in at least some individuals. Studies have shown that in behavioural addiction, underlying neural processes are similar to substance addiction.^[3] Present literature and research emphasize that in order to make a diagnosis of behavioural addiction, significant impairments must be present at work, in social relationships, or in other social situations. A number of experts believe that behavioural addictions can be passive (e.g. television) or active (e.g. computer games), and usually contain inducing and reinforcing features which may contribute to the promotion of addictive tendencies.^[4]

The existence of internet addiction was first proposed by Ivan Goldberg, a New York psychiatrist in 1995 and the term as such was coined by Kimberly Young of the University of Pittsburgh. Internet dependency has most commonly been conceptualised as a behavioural addiction, which operates on a modified principle of classic addiction models.^[5] The labels ‘Internet Addiction’, ‘Internet Addiction Disorder’, ‘Pathological Internet Use’ and ‘Compulsive Internet Use’ have all been used to describe by and large a similar concept. Two camps have formed in the area of Internet research – 1. Internet addiction is, or should be, established as a psychiatric disorder in its own right. 2. Internet addiction sufferers are actually dependent on some rewarding aspect or function of behaviour associated with Internet use that could exist in the ‘real’ world, such as dependent or addictive behavioural patterns related to money or sex. Few researchers have questioned the existence of Internet addiction as a separate entity as it is still unclear whether it develops of its own accord, or it is triggered by an underlying co-morbid psychiatric illness.^[6]

Pornography is also considered as another form of behavioural addiction. It is said to be the first place boys get to know about sex and achieve an understanding of their own whims and desires. A survey conducted in 2004 by MSNBC.com and Elle magazine studied 15,246 men and women. They found that three-fourth of the men said they had downloaded erotic films and videos from the internet and 41% of the female population did as well. Pornography is considered as straight forward and easy. It provides a refuge from the tangle of sexual hassles that teenagers face in the real world. With women also turning towards pornography, the way the construct their fantasies in their actual sex lives is fundamentally shifting.^[7] Many studies have been conducted across the world with regard to adolescents and pornography addiction.

Criteria for Defining Sex Addiction

The term addiction does not appear in Diagnostic and Statistical Manual of Mental Disorders (DSM) Fourth Edition, Text Revision or International Classification for Diseases 10 (ICD10): A broader terminology of “sexual addiction” has been described, but there is inconsistency in the criteria provided by different researchers.^[1] One of the main reasons DSM-5 has not included sex addiction is that empirical research is not strong in this area. There have been no nationally representative prevalence surveys using validated criteria. Similar to Internet Gaming Disorder which is now included in the appendix of DSM-5, sex addiction cannot be included until significant data have been obtained about the defining features, reliability and validity of the criteria and prevalence rates across the world. Researchers hence believe that even if sex addiction does eventually make into future editions of DSM, it will be one of the sub-categories of Internet Addiction Disorders rather than a separate entity.^[8]

Sexual Addiction diagnostic Criteria^[9]

A. A minimum of three criteria met during a 12-month period:

1. Recurrent failure to resist impulses to engage in specific sexual behaviour.
2. Frequently engaging in these behaviours to a greater extent or longer duration than intended.
3. Persistent desire or unsuccessful efforts to stop, to reduce, or to control behaviours.
4. Inordinate amount of time spent in obtaining sex, being sexual, or recovering from sexual experiences.
5. Preoccupation with the behaviour or preparatory activities.
6. Frequently engaging in the behaviour when expected to fulfill occupational, academic, domestic, or social obligations.
7. Continuation of the behaviour despite knowledge of having a persistent or recurrent social, financial, psychological, or physical problem that is caused or exacerbated by the behaviour.
8. Need to increase intensity, frequency, number, or risk of behaviours to achieve the desired effect or diminished effect with continued behaviours at the same level of intensity, frequency, number, or risk.
9. Giving up or limiting social, occupational, or recreational activities.
10. Distress, anxiety, restlessness, or irritability if unable to engage in the behaviors.

B. Has significant personal and social consequences (such as loss of partner, occupation, or legal implications).

Diagnostic criteria for behavioral addiction as proposed by Goodman 1990 in a format similar to DSM III R:^[10]

1. Recurrent failure to resist impulses to engage in a specified behaviour.
2. Increasing sense of tension immediately prior to initiating the behaviour.
3. Pleasure or relief at the time of engaging in the behaviour.
4. A feeling of lack of control while engaging in the behaviour.
5. At least five of the following: (1) frequent preoccupation with the behaviour or with activity that is preparatory to the behaviour (2) frequent engaging in the behaviour to a greater extent or over a longer period than intended (3) repeated efforts to reduce, control or stop the behaviour (4) a great deal of time spent in activities necessary for the behaviour, engaging in the behaviour or recovering from its effects (5) frequent engaging in the behaviour when expected to fulfill occupational, academic, domestic or social obligations (6) important social, occupational or recreational activities given up or reduced because of the behaviour (7) continuation of the behaviour despite knowledge of having a persistent or recurrent social, financial, psychological or physical problem that is caused or exacerbated by the behaviour (8) tolerance: need to increase the intensity or frequency of the behaviour in order to achieve the desired effect or diminished effect with continued behavior of the same intensity (9) restlessness or irritability if unable to engage in the behaviour.
6. (F) Some symptoms of the disturbance have persisted for at least 1 month, or have occurred repeatedly over a longer period of time.

The physical signs of drug addiction are absent in behavioural addiction. One of the precursors of behavioural addiction is the presence of psychopathologies such as depression, substance dependence or withdrawal, and social anxiety as well as a lack of social support.^[11]

Magnitude of the Problem

In 2007, China began restricting computer game use: current laws discourage more than 3 hours of daily game use. Using data from 2006, the South Korean government estimates that 210,000 children in the age group of 6-19 years are affected and need treatment. 80% of those needing treatment may need psychotropic medications, and perhaps 20-24% require hospitalization. Since the average South Korean high school student spends about 23 hours each week gaming, another 1.2 million are believed to be at risk for addiction and to require basic counselling.^[12] Therapists worry about the increasing number of individuals dropping out from school, work to spend time on computers or get in to legal troubles. As of June 2007, South Korea has trained 1,043 counsellors in the treatment of Internet addiction and enlisted over 190 hospitals and treatment centres. Many of these addicts get into cyber relationships and cybersex.^[13] According to studies carried out among the US population, it was found that Sex addiction was present in 3%, exercise-addiction in 3%, and shopping addiction in 6% among the total population. In India, an ICMR funded survey identified food addiction (1.6%; 2% male and 1.2%female), Shopping addiction (4%; male-3.2% and female-4.8%), Sex addiction (2%; 0.3%male and 0.1% female) and Exercise addiction (5.6%; 7.5% males and 3.8% females).^[14]

A cross-sectional study sample comprising of 987 students of various disciplines across the city of Mumbai was conducted and the students were assessed with a specially constructed semi-structured proforma and The Internet Addiction Test (IAT; Young, 1998). Of the 987 adolescents who took part in the study, 681 (68.9%) were female and 306 (31.1%) were males. Of the total, about 74.5% were moderate (average) users. Using Young’s original criteria, 0.7% were found to be addicts. Those with excessive use internet had high scores on anxiety, depression, and anxiety depression^[15]

Screening instruments

The different scales which can be used for assessment of sexual addiction include:

θ The sexual addiction screening test

θ The sexual compulsivity scale

θ The sexual dependency inventory – revised

θ The sex addicts anonymous questionnaire

θ Compulsive sexual behaviour inventory

Since there is an absence of established diagnostic criteria, the significance of validity of these scales is doubted. Several of the questions in these scales do not yield information about whether the diagnostic criteria are met or not.

The Sexual compulsivity scale is most commonly used for gauging the presence of sexual addiction. It includes both the key features of addiction (impaired control and harmful consequences). It is a 10 item scale which scores from 1-4. The cut off value is 24.^[16]

Management

Pharmacological treatment has modest and short-lasting benefit. Current expert opinion is that a combination of pharmacotherapy and psychotherapy is optimal management strategy for any sort of behavioural addiction.

θ Pharmacotherapy includes 1. Endocrinological agents: Anti androgenslike Medroxy progesterone acetate which acts by inhibiting testosterone reductase. This is used in Paraphilias also. In addition these drugs reduce sex drive and aggressive sexual behavior. Other pharmacological agents include Cyproterone acetate, Analogues of GNRH (leuprolide acetate) and affectregulation agents likeSSRI’s, TCA’s, lithium, carbamazepine, buspirone. These agents have a positive response rate of 50-90%. Theydecrease the drive for excessive sexual behaviour without decreasing the drive for healthy behaviour. They also cause a decrease in the frequency of addicted individual’s symptomatic sexual urges, masturbation, and the use of pornography, while having no significant effect on partnered sexual behaviours.^[17]

Non Pharmacological:

Psychodynamic psychotherapy helps to synthesize the role of developmental antecedents, reduce current anxiety, depression, guilt and to improve social adjustment. There is no evidence for this as a solitary treatment. Referral to a self- help group is another most commonly adopted therapy associated with successful outcome. It is elaborated into 12-Steps and has a profound effect on the process of recovery.^[18] The relapse prevention model and accompanying cognitive-behavioural and social learning techniques are commonly employed in specialized sex offender treatment programmes in the United States and Canada. There is no published data on this comprehensive approach to the treatment of sexual addiction.

Young describes seven possible ways of dealing with the internet addiction, of which the first three are basically time management strategies. These methods have been addressed in detail in the article on technology addiction.^[19]

Orzack and Orzack have suggested two strategies for the treatment. 1) Cognitive Behavioural Therapy which includes cognitive restructuring about the internet applications an individual uses most often, behavioural exercisesand exposure therapy in which the individual stays offline forprogressively increasing durations. 2) Motivational Enhancement Therapy: It allows the addicts and their therapists to collaborate on treatment plans and set attainable goals. It needs a rather non confrontational approach and is considered more innovative.^[20]

There are multiple psychological interventions like Multi-level Counselling Program (MLC), Social competence training (SoCo), Solution-focused Brief Therapy (SFBT), Cognitive Therapy (CT) and Reality Therapy (RT) that have used for the treatment of behavioural addictions.^[21]

Conclusion

Increased access to the internet by adolescents has created unprecedented opportunities for sexual education, learning, and growth. Conversely, it has also lead to the emergence of various behaviors which are repeatedly reinforcing the reward; motivation and memory circuitry are all part of the disease of addiction. One such behavioral addiction is involves pornography Research suggests that adolescents who use pornography, especially that found on the internet, have lower degrees of social integration, increase in conduct problems, higher levels of delinquent behaviour, higher incidence of depressive symptoms, and decreased emotional bonding with caregivers. The treatment of sex addiction has its own unique challenges that many general addiction and mental health specialists may overlook if they have not had much hands-on experience treating the disorder. Though there is a deficiency in the number of studies regarding the treatment outcomes, it is seen that a combination of pharmacotherapy together with psychotherapy has a better outcome in preventing relapse for these patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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