LAS VEGAS – A growing body of evidence suggests that a high proportion of men with hypersexual disorder have an axis I psychiatric comorbidity such as attention-deficit/hyperactivity disorder, an association that can easily fly under a clinician’s radar.
"ADHD is very prominent in men with hypersexual disorder who come to see me now, occurring about 45% of the time," Dr. Martin Kafka said at the annual psychopharmacology update held by the Nevada Psychiatric Association. "I spend half of my time trying to get authorizations for them to be prescribed stimulants."
Men with ADHD tend to "look for something novel when they’re feeling dysphoric affect like boredom or when they’re depressed," continued Dr. Kafka, clinical associate professor of psychiatry at Harvard Medical School, Boston, and an authority on hypersexual disorder (HD). "They procrastinate, so when they’re facing stressful events they escape through their sexual behavior. Pornography is very tempting, because it can be viewed with just the click of a button."
Dr. Martin Kafka
He based his remarks on an analysis of medical records from about 150 HD patients he’s treated in recent years, with a goal of expanding that data set to at least 300. Previous studies he published from 1994 to 2002 suggested that the association between HD and ADHD ranged from 17% to 19%. Those studies also found that dysthymia was the most common coexisting axis I disorder in HD patients, occurring 61%-62% of the time, followed by alcohol abuse (25%-39%) and social phobia (22%-25%).
In Dr. Kafka’s current clinical practice, about 26% of men with HD that he counsels also have bipolar spectrum disorder. "What’s interesting is that this tends to occur in patients with cyclothymic disorder or bipolar disorder not otherwise specified," he said. "It’s the ones who have hypomanias lasting 1-2 days, but repetitively, who have a family history of the illness. In community samples, about 5% of the population meets criteria for hypomania if you shorten the duration to 1-2 days. We really need to be sensitive about brief, recurrent hypomanias and things like cyclothymic disorder, where you’re not depressed for that long."
Though one hallmark symptom of major depressive disorder (MDD) is decreased sexual interest, a small body of literature suggests that the opposite might be true. "This sounds counterintuitive, but subgroups of patients with MDD can have increased sexual behavior," Dr. Kafka said. "Some can have chronically increased sexual behavior." In one 1993 study of cognitive therapy in 40 subjects who were having problems with sexual arousal, 28 got better. The 12 who didn’t get better had chronic low-grade depression" (Arch. Gen. Psychiatry 1993;50:24-30).
Other investigators have reported that when men are depressed, they are more likely to respond to dysphoric affect through action and impulsivity (Arch. Sexual Behav. 2003; 32:217-30). "So even though it’s counterintuitive, depressive disorders can be associated with hypersexuality," Dr. Kafka said.
Treatment of axis I disorders, when executed properly, can positively affect outcomes for patients with HD. "Consider doing a thorough diagnostic evaluation," Dr. Kafka advised. "If they’re not getting better with nonpharmacological treatments, or their behavior is endangering them, then medications could be indicated." He went on to note that the medical model "goes a long way to destigmatize behavior in patients with HD. Yes, there are people who do immoral acts. Promiscuous behavior is an immoral act. But it could be embedded in a psychiatric disorder, which makes it much more complex. It makes it much more understandable; it can destigmatize the person. The person is not just a philanderer; the person is somebody who has an affliction, whose symptom is philandering. They will connect with you if you say this is a medical psychiatric disorder and not just a moral issue."
Though no controlled studies exist on treatment strategies for HD, Dr. Kafka recommended integrating psychiatric diagnosis into the treatment of HD. He also recommended proactive communication with other mental health professionals in helping derive "a good diagnostic picture" of certain patients and educating them about subthreshold adult manifestations of psychiatric diagnoses. "Of course, they can’t really help you with identifying bipolar spectrum disorder or ADHD unless they’re educated about it, but it’s helpful when a psychotherapist tells you that a patient looked hypomanic to him," Dr. Kafka explained. "The next time you see that patient, you might want to ask about that."
He also recommended educating HD patients as much as possible about their illness from resources such as the Society for the Advancement of Sexual Health (www.sash.net) "because these are chronic, early-onset disorders. They’re going to have them for the rest of their lives. Unless they understand them, they’re going to use medication inappropriately, they’re not going to be as treatment compliant and collaborative, and they’re going to relapse."