Evidence-Based Reviews

Compulsive sexual behavior: A nonjudgmental approach

Current Psychiatry. 2018 February;17(2):34,38-40,45-46

References

1. Grant JE, Levine L, Kim D, et al. Impulse control disorders in adult psychiatric inpatients. Am J Psychiatry. 2005;162(11):2184-2188.
2. Odlaug BL, Lust K, Schreiber LR, et al. Compulsive sexual behavior in young adults. Ann Clin Psychiatry. 2013;25(3):193-200.
3. Black DW. Compulsive sexual behavior: a review. J Psychiatr Pract. 1998;4(4):219-229.
4. Coleman E. Is your patient suffering from compulsive sexual behavior? Psychiatr Ann. 1992;22(6):320-325.
5. Kaplan MS, Krueger RB. Diagnosis, assessment, and treatment of hypersexuality. J Sex Res. 2010;47(2):181-198.
6. Black DW, Kehrberg LL, Flumerfelt DL, et al. Characteristics of 36 subjects reporting compulsive sexual behavior. Am J Psychiatry. 1997;154(2):243-249.
7. McElroy SL, Phillips KA, Keck PE Jr. Obsessive compulsive spectrum disorder. J Clin Psychiatry. 1994;(suppl 55):33-51; discussion 52-53.
8. McElroy SL, Pope HG Jr, Keck PE Jr, et al. Are impulse-control disorders related to bipolar disorder? Compr Psychiatry. 1996;37(4):229-240.
9. Kafka MP. Hypersexual disorder: a proposed diagnosis for DSM-V. Arch Sex Behav. 2010;39(2):377-400.
10. Levine SB. What is sexual addiction? J Sex Marital Ther. 2010;36(3):261-275.
11. Christenson GA, Faber RJ, de Zwaan M, et al. Compulsive buying: descriptive characteristics and psychiatric comorbidity. J Clin Psychiatry. 1994;55(1):5-11.
12. Grant JE. Impulse control disorders: a clinician’s guide to understanding and treating behavioral addictions. New York, NY: W.W. Norton & Company, Inc.; 2008.
13. Frohmader KS, Lehman MN, Laviolette SR, et al. Concurrent exposure to methamphetamine and sexual behavior enhances subsequent drug reward and causes compulsive sexual behavior in male rats. J Neurosci. 2011;31(45):16473-16482.
14. Grant JE, Pinto A, Gunnip M, et al. Sexual obsessions and clinical correlates in adults with obsessive-compulsive disorder. Compr Psychiatry. 2006;47(5):325-329.
15. Mété D, Dafreville C, Paitel V, et al. Aripiprazole, gambling disorder and compulsive sexuality [in French]. Encephale. 2016;42(3):281-283.
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17. Kraus SW, Meshberg-Cohen S, Martino S, et al. Treatment of compulsive pornography use with naltrexone: a case report. Am J Psychiatry. 2015;172(12):1260-1261.
18. Derbyshire KL, Grant JE. Compulsive sexual behavior: a review of the literature. J Behav Addict. 2015;4(2):37-43.
19. Levine SB, Scott DL. Sexual education for psychiatric residents. Acad Psychiatry. 2010;34(5):349-352.
20. Alsughier N. Compulsive masturbation treated with selective serotonin reuptake inhibitors. African J Psychiatry (Johannesbg). 2015;18:299.
21. Elmore JL. SSRI reduction of nonparaphilic sexual addiction. CNS Spectr. 2000;5(11);53-56.
22. Stein DJ, Hollander E, Anthony DT, et al. Serotonergic medications for sexual obsessions, sexual addictions, and paraphilias. J Clinical Psychiatry. 1992;53(8):267-271.
23. Kafka M. Psychopharmacologic treatments for nonparaphilic compulsive sexual behaviors. CNS Spectr. 200;5(1):49-59.
24. Wainberg ML, Muench F, Morgenstern J, et al. A double-blind study of citalopram versus placebo in the treatment of compulsive sexual behaviors in gay and bisexual men. J Clin Psychiatry. 2006;67(12):1968-1973.
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Neuroimaging and cognition

One imaging study that compared participants with and without CSB found that participants with CSB had higher activity in the ventral striatum, anterior cingulate cortex, and amygdala relative to controls during a cue-reactivity functional MRI task.¹⁸ These findings show notable similarities to the patterns of activation seen in patients addicted to drugs when assessed using drug-craving paradigms. An additional neuroimaging study assessing patients with hypersexuality using diffusion tensor imaging noted that diffusivity in a prefrontal white matter tract within a superior frontal region was greater in patients with CSB.¹⁸ This study also indicated that there was a negative correlation between observed diffusion in the noted location and overall severity score for CSB symptoms such as frequency of urges or behaviors.

In terms of cognition, a preliminary assessment of young adults with CSB compared with healthy controls did not find any differences between groups across several tasks, although the previously mentioned diffusion tensor imaging study reported elevated impulsivity in CSB.¹⁸

Approaches to treatment

Most people with CSB are reluctant to mention it to their health care providers, and most physicians are generally uncomfortable talking about sex with their patients, in part, because of a lack of training.¹⁹ Patients are more likely to bring up the topic when they are receiving treatment for anxiety, depression, or substance abuse. Therefore, clinicians must consider that sexual behavior might be associated with a coping mechanism, distressing outcome, or comorbid condition in these patients.

Pharmacologic treatment

Evidence for the pharmacologic treatment of CSB consists primarily of small, open-label studies, case series, or retrospective analyses, except for 1 double-blind, placebo-controlled study. Based on this evidence, there may be several pharmacologic treatment options for patients with CSB; however, there are no FDA-approved medications for CSB.

Antidepressants. One of the most thoroughly documented categories of pharmacologic treatment for CSB is selective serotonin reuptake inhibitors (SSRIs). Several retrospective analyses and case series have reported on the general efficacy of SSRIs in reducing symptoms of CSB.^20-23 Citalopram, the only treatment for CSB that has been assessed using a double-blind, placebo-controlled methodology, was associated with significant decreases in CSB symptoms, including sexual desire/drive, frequency of masturbation, and pornography use.²⁴

In addition to SSRIs, several additional case reports have suggested that other classes of antidepressants, such as serotonin-norepinephrine reuptake inhibitors and tricyclic antidepressants, or stimulants may be beneficial when treating CSB.²⁵ Several case reports have indicated significant improvement of CSB symptoms using clomipramine.²² A retrospective study of nefazodone also has suggested that it may be an option for treating CSB. Patients reported notable reductions in the frequency of sexual obsessions/compulsions while taking nefazodone and reported no notable sexual adverse effects.²⁶ One branded version of nefazodone, Serzone, was associated with rare but severe liver problems and was withdrawn from the U.S. market in 2004.

Although some initial evidence regarding antidepressant use, particularly SSRIs, to treat CSB has suggested that these medications may be potentially beneficial, the findings are far from conclusive, with only 1 controlled trial and only single-subject case reports for many of the medications studied.

Naltrexone, an opioid antagonist, has received support from available cases, open-label studies, and retrospective analyses.^17,27 Although evidence for the use of naltrexone in CSB is limited to case reports and retrospective analyses, results have been positive. Naltrexone has shown notable decreases in CSB symptom severity when used as monotherapy and when used in combination with other treatments.

Anticonvulsants. Several case reports have suggested that certain anticonvulsants may be beneficial for treating CSB. Topiramate may be a particularly useful option.²⁸ Other anticonvulsants showing benefit for CSB in case reports include valproic acid, lamotrigine, and levetiracetam.¹⁸

Psychotherapy

Evidence supporting specific types of psychotherapy for CSB is limited and largely drawn from uncontrolled studies and case reports.

Cognitive-behavioral therapy (CBT) is one of the more common psychotherapeutic options used for CSB. Several uncontrolled studies and case reports have found that CBT is beneficial for CSB, although methodologies have varied.

Several cases found that combining CBT with motivational interviewing was associated with significant reductions in sexual behaviors, such as frequency of sexual partners and amount of time spent online during work hours.^29,30 Group CBT also has been shown to be effective for CSB.³¹

Acceptance and commitment therapy (ACT) has received some initial support, with 1 uncontrolled study and 1 controlled study.^32,33 The controlled study used 12 sessions of individual ACT compared with a wait-list condition.³² Improvements in CSB symptoms were maintained for 3 months. The overall reduction in problematic Internet pornography use was reported as 92% immediately after the study ended, and 86% after 3 months.

Marital/relationship therapy has been used successfully in several case series and case reports, although no studies have assessed its efficacy in treating CSB using a randomized protocol. In 1 case report, the researcher found that participation in marital sex therapy elicited notable improvements over the course of 1 year and 20 sessions.³⁴

Bottom Line

Limited research and a lack of standardized criteria can make compulsive sexual behavior (CSB) challenging to properly diagnose and treat. Initial evidence suggests that certain antidepressants and psychotherapeutic treatments can reduce symptoms of CSB.

Related Resource

Carnes PJ. Out of the shadows: understanding sexual addiction. 3rd ed. Center City, MN: Hazelden Publishing; 2001.

Drug Brand Names

Aripiprazole • Abilify
Citalopram • Celexa
Clomipramine • Anafranil
Lamotrigine • Lamictal
Levetiracetam • Keppra
Naltrexone • Revia
Topiramate • Topamax
Valproic acid • Valproic