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SEX, DRUGS AND NO CONTROL: SEX AS ADDICTION AND THE TREATMENT THEREOF.
By Shaun Shelly
Introduction
According to the DSM-V Sex Addiction is not a diagnosable condition. Sexual addiction was mentioned in the DSM-III-R, but disappeared in the DSM-IV, threatened a come-back in the DSM-V but has now been discarded. Sex, however, has long been described as addictive. In the late 1800s Freud described masturbation as the original addiction. Rado in the 20s described addiction as compulsive and made the reward/pleasure/sex link. We saw words such as nymphomania (Ellis) and the clumsy Don Juanism(Stoller). In the 70s Mac Dougall spoke of addictive sexuality. It was originally proposed that sex be included under the heading of addiction in the DSM-V, and then that was discarded and the idea of hyper-sexuality was introduced as a possibility. Eventually none of these proposals was accepted, and so sexual addiction has ceased to exist, according to the DSM, that is.
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The bottom line is that with anything of a sexual nature, society has both a fascination and avoidance. There are few topics that are so tainted by personal experience and upbringing.
So, what behaviours characterise sexual addiction? I would argue it is foolish to try and list specifics of behaviour and quantify these behaviours to try and diagnose sex addiction. It is not the behaviour, but rather the pattern and consequences of the behaviour. It is here that I would differ with Carnes considered by many to be the spokesman of sex addiction after the publishing of his 1983 book Out of the Shadows - who describes levels of addictions. He starts with Level 1 behaviours, which include what many would classify as normal sexual behaviours: Masturbation, homo and heterosexual relationships, pornography, strip shows, prostitution. He then describes Level 2 behaviours as exhibitionism, voyeurism and indecent phonecalls, while Level 3 is reserved for the behaviours most of us would classify as abhorrent paedophilia, rape and the like. I would argue that the paraphilias have nothing to do with sexual addiction, but would rather be a cooccurring disorder co-existing with sex addiction in some cases. If addiction is a pathological relationship with a substance or activity at the expense of more beneficial relationships or activities, then sex addiction is when our relationship with sex is more important than our relationship with the person with whom we are (or are not) having sex.
of these areas, and that in turn amplifies the effects on each plane individually and collectively. Therefore, for something to be an addiction it must be demonstrated to some or other degree in each of these planes.
Neurology
This tragic photo shows Didier Jambert with his wife Christine at a press conference after he was awarded damages because his ReQuip tablets turned him into a hypersexual, gay, cross-dressing gambling addict. The apparent cause of this sudden and unprecedented change in behaviour was dopamine. Dopamine is certainly one of the usual suspects when it comes to drug addiction, and similarly it has been shown to have a role in behavioural addictions. There certainly seems to be significant correlation between dopamine levels and behavioural addictions, including sex addiction. However, the reward system is not enough to explain addiction.
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One of the more useful theories of addiction is the iRISA theory of Goldstein and Volkow (Goldstein, 2002). Basically this says that addiction can be considered an impairment of inhibition and/or an over exaggerated drive or motivation. During drug use there is a repetitive cycle of salience attribution, craving, bingeing and withdrawal. Each of these phases involves different brain regions and neurotransmitters and neuropeptides. Similarly Carnes describes a cycle of sexual behaviour in the addict, although I found earlier references of this process in the work of Reed and Blaine from a 1988 paper. I would like to propose that these could possibly be corresponding and that the underlying neurology may be similar: iRISA Salience Attribution Drug Expectation Carnes/Reed & Blain Pre-occupation Ritualisation Possible underlying Neurobiological processes DA levels in limbic brain regions particularly NAcc, evidence of DA levels in frontal regions. Likely involvement of Amygdala, PFC and Hippocampus. Activation of Thalamoorbitofrontal circuit and anterior cinculate. Loss of top down control DA, 5-HT & Glutamate play active role Disruption of frontal cortical circuits. DA 5-HT
Like drug addiction, sex addiction breeds tolerance, and like drug addiction real-life becomes less rewarding neurologically and experientially. There is evidence that low levels of pre-addiction serotonin are also linked, like in other addiction, with behavioural and sexual addictions (Grant, Brewer, & Potenza, 2006). Also, what must be noted, is that addiction-like sexual behaviours, as well as paraphilias, can be the result of brain lesions or underlying organic conditions. This, I believe, shows us that addiction is a lot more than a simple choice process, and that brain dysfunction has a significant role to play.
The System
The Micro-environment A study by Carnes in 1991 suggested that 82% of the sex-addict subjects had experienced childhood sexual abuse. This figure is incredibly high, but is supported to some degree by other studies. Not only does this point to the psychology of the sex addict, but also to the biology. We know that early childhood abuse has major effects on the pre-frontal cortex circuitry, and we see reduced size in the left-hippocampus and a corresponding set of dissociative symptoms in adulthood. It should also be noted that these abnormalities were seen in cocaine addicts (Ersche, Jones, Williams, Smith, & Bulmore, 2012). We also see less left-right brain integration with corresponding opposing views of the world in which they live, and to further complicate this we see alterations in oxytocin and vasopressin mediated sexual arousal. There has long been the proposed link between the lack of early attachment and addictive disorders. It may be that the corresponding drop in dopamine and noradrenaline may drive the individual to seek behaviours or drugs that boost levels just so they can feel normal. What means they choose may have a lot to do with the broader eco-system in which they find themselves, rather than with direct conscious choice. We also see the imprint of childhood trauma on the limbic system, leading to a hypersensitive amygdala, which may contribute to impulsivity and this adds credence to the idea that for the sex addict, sex is not merely pleasure seeking, but survival seeking.
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Undoubtedly, like with other addictions, but more so, the neurological effects of childhood abuse and attachment issues move the individual towards a predisposition for sexual behaviour that presents as addiction. The Macro-Environment In the world of the internet we have what is referred to as the triple A-engine: affordability, accessibility and anonymity. The availability of sexual images at ever decreasing ages has certainly fuelled what Carnes calls the Tsunami of sexual addiction. The estimated first age of exposure to pornography is 11 in the United States (Bryant & Brown, Pornography: research advances and policy considerations). I alluded to the effect of this macro-system or ecosystem in that it may push the addiction prone individual towards a particular manifestation of the underlying condition or need. In a world where sex, drugs and rock and roll are the norm we will get more addicts of the drug and sex type than in a more conservative society, where we may get religious addicts which is arguably a more acceptable manifestation it doesnt mean the individual isnt sick, it just means that they arent being as harshly judged for their particular symptoms!
These should not be seen as hard and fast individual processes that happen independently of one another, but should rather be seen as interrelated aspects of the recovery process. The biggest challenge is that when it comes to sex addiction, all treatments, except in the case of a few co-occurring paraphilia, are essentially harm reduction and not abstinence based. It is important
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to help the patient define healthy sexual behaviours as opposed to unhealthy behaviours, and facilitate the move away from pathological behaviours. Having said this, many of those that treat sexual addiction may suggest an initial period of abstinence to help establish initial behavioural modification.
Psycho-social interventions:
Most searches on the internet when it comes to treatment for sex addiction invariably lead to 12 step programs. In the local context we see SLA Sex and Love Addicts anonymous. While many have described these groups as very helpful in overcoming the sense of shame and isolation that many sex addicts experience, these groups should not be seen as treatment, but rather as an adjunct to treatment. It should also be borne in mind that these groups are also filled with sex addicts, and as such can be a trigger for the recovering sex addict. Another problem with this approach, especially in the treatment setting, is that many 12-step based treatment plans are confrontational and expect the sharing of ones deepest and darkest secrets in the group setting. If we consider that the majority of sex addicts have a history of being sexually abused this could be extremely counterproductive. We need to tread carefully, and above all, nonjudgementally. For this reason, sexologists would immediately feel that the treatment of sexual addiction falls firmly into their field, however many of those seeking treatment for sex addiction feel that they need less therapy and more treatment. According to Robert Weiss, one of the major complaints received from patients is that therapists dont understand how destructive their behaviour is. Many may also misconstrue the source of the shame felt by sex addicts. While it may be caused by some of the activities they engage in, it is often more about the levels of salience they have attributed to the pursuit of their sexual behaviours (Hall, 2011) at the expense of the ones they love and the values they consider important. The types of psycho-interventions that have shown to benefit sex addicts are cognitive behavioural therapies, particularly in the stages of behaviour modification and stabilisation, and then a gradual move towards psycho-dynamic psychotherapy which is often essential to long-term recovery and the process of character healing. I would also like to see more research on the use of Dialectical Behavioural Therapy due to the similar aetiologies of Borderline Personality Disorder and Sex Addiction. In managing the environmental aspect of the addiction, it is also helpful to include the spouse, although this, I would suggest, be left till later in the process. Dealing with constant relapse within the couples therapy environment is difficult and can be damaging to the process, and until there has been some demonstrable changes in behaviour, the partner is more likely to be oppositional than reconciliatory.
Pharmacological Interventions
Most of the limited research revolves around the SSRIs. There have been limited successes, and a few double blind trials, which have tended to be focused on very specific target groups, and have had limited research value. Both Citalopram and Fluoxetine (Prozac) has also been shown to have some effect in the reduction of acting out with sexual behaviours (Garcia & Thibaut, 2010).
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Naltrexone, the opioid antagonist that has been used across a multitude of addictions, has also been shown to have some effect on compulsive sexual behaviour (Raymond & Grant, 2010) (Bostwick & Bucci, 2008). Topiramate, originally used as an anticonvulsant, and more recently approved for weight loss, has, in one case report (Khazaal & Zullino, 2006) shown to possibly mediate the cue effect in sexual addictions. Interestingly a 2010 Cochrane Review concluded that there was evidence supporting the use of Topiramate in the treatment of borderline personality disorder, which I have suggested earlier could have a similar origin to sex addiction. Topiramate has also shown some success in the treatment of cocaine addiction in clinical trials (Kampman KM, 2004) as well as alcohol (Johnson, 2005). Topiramate increases cerebral GABA levels and inhibits glutametergic activity. There is also literature regarding the use of antiandrogen medications for nonparaphilic sexual behaviour, but, personally, I have some unresolved ethical issues surrounding this and so wont discuss this here.
Conclusion
It is obvious that whether or not we buy into the term Sex Addiction there are significant similarities with addictive disorders when it comes to pathological non-paraphilic sex. We need to keep in mind that the only reason we seek to label is so that we can identify a treatment path. Certainly there needs to be a lot more research into what I have termed sex addiction: the neurobiology, chemistry, behaviours, and biopsychosocial interventions to bring some level of comfort to those who find themselves suffering from this particular manifestation of addictive disorders. Even once we have achieved some measure of clarity there will always remain the unanswered key question in the world of sex addiction: Is Tiger Woods a sex addict or not?
Bibliography
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