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hypersexulaity

  1. 1. HYPERSEXUALITY: A CASE STUDY Karen Abernathy Christina Kim
  2. 2. Chief Complaint • JK is a 45 year old single Caucasian male • Self referred for assessment of his “sex addiction” – National Institute for the Study, Prevention and Treatment of Sexual Trauma Recent • 6 day binge of watching pornography, compulsive masturbation, and medication non-compliance. • Seeking an evaluation for Androgen deprivation treatment (ADT)
  3. 3. HPI • No psychiatric or medical hospitalization for 2 years. • Sexaholics and Sex Addicts Anonymous 2 times per week. • Sees medical and psychiatric providers regularly. • Recently cancelled his internet at his apartment so that he would not be tempted to watch pornography. • No physical contact with another human being for 1 year • “Sober” in last 3 months : – Defined as: no pornography, masturbation 2-3 times per day (not public), and no sexual contact with males or females.
  4. 4. HPI (cont’d) • Binge started after SA group which emphasized healthy masturbation • "out of control" 6 day binge: – smoked marijuana joint, and immediately bought pornography and went to his parents’ home to make use of the internet. – First night masturbated 7 hours straight – 10-12 hours cataloguing pornography, which includes organizing in special ways like using hair color and body type as categories and inventing stories about each woman that he watches. – Left his parents’ home and spent all of the money he had for his monthly bills on a hotel room, pornography, and marijuana. – Stopped taking his psychiatric medications because he believes that they were interfering with his ability to climax. – 24 hours during this binge, in a frustrating cycle of watching pornography and masturbating without orgasm.
  5. 5. HPI (cont’d) Called his sponsor prior to seeking sex with an escort. • Afraid "addiction was triggered so easily” Requests evaluation for Lupron • Wants to continue current psychiatric medications
  6. 6. Family History • Father is “very prosperous businessman” – Undiagnosed Bipolar disorder and “extreme pornography consumption”. – First discovered pornography from his father’s wide- ranging collection. • Mother and two sisters have no history of psychiatric illness including substance abuse. • Maternal grandmother had a history of BPAD with multiple psychiatric hospitalizations and his maternal grandfather had a history of alcohol dependence. • No family history of suicides.
  7. 7. Educational History • Senior year of high school 1982 : – First manic episode, onset of his “sexual promiscuity.” – Hospitalized for several months. • Unable to complete undergraduate degree due to his psychiatric illness. • He is currently unemployed.
  8. 8. Relational • 3 significant relationships with women: – 1985-1991: sex worker and that he met her first as a client. – 1998-1999: engaged – 2011-2012: “trial marriage” sex worker • Relationships all ended – Sexual addiction continued throughout these relationship – Multiple partners, both male and female – Combined addictions • No relationship since 2012 – engaged in sexual activity with only females since then ,not more than once a day and only 3-4 times , as he has been working toward "sobriety". • He has no children.
  9. 9. Social • Sobriety has enabled him to have social interactions • Male friends that he is emotionally connected to from both of the 12 step programs that he attends. • Engages in social activities and enjoys movies, music concerts, playing the drums, and hiking.
  10. 10. Medical • HIV diagnosed in 1987(CD4=416 in 2/15) • Antiretroviral toxic neuropathy • Irritable bowel syndrome • Hypertriglyceridemia • Hypothyroidism • History of recurrent c. difficile • History of pneumonia (4 times) • History of Varicella zoster virus
  11. 11. Current Medications • Abacavir/ Lamivudine (Epzicom)1 tablet PO q daily • Raltegravir 400 mg bid • Neurontin 800 mg PO tid • Seroquel 600 mg PO qhs • Lamictal 450 mg PO daily • Tricor 145 mg PO qhs • Singulair 10 mg PO daily • Synthroid 200 mcg PO daily
  12. 12. Psychiatric History • Bipolar 1 Disorder – Hospitalized 8 times for “manic episodes.” – Involuntary certified three times. – Longest hospitalization has been 3 months. – Trials of Lithium, Depakote, Zyprexa, and Risperdal with little efficacy.
  13. 13. Substance Abuse History • Detailed history of substance use, including alcohol, marijuana, cocaine, hallucinogens, PCP, and ecstasy in 1980-1990s – No history of detox • Current : – Had not smoked marijuana for 1 year prior to the 6-day binge – Smoked heavily during this "binge", estimating that he consumed about an ounce of marijuana at this time.
  14. 14. THC: Mechanism of Action Marijuana contains THC, indirectly increasing the amount of dopamine, “the feel good” neurotrasmitter responsible for feelings of pleasure and reward.
  15. 15. Sexual History • Age 11 : began masturbating to father’s pornography collection and pictures of adult females. • Age 13: first sexual contact, oral sex with a 14-year-old male neighbor. • Age 15, masturbating several times a day, acquiring his own pornography, and having paid phone sex. • Age 18, sex with prostitutes both male and female, – strip clubs – pornography – massage parlors – adult bookstores - casual sex with males – Stole money from his family to finance activites.
  16. 16. Sexual History • Rarely felt sexually satisfied and craved sexual physical contact. • Identifies as heterosexual and masturbates to female images and fantasizes about women. • Sex w/ males : less expensive, more readily available to him, and when cravings for sex are " out of control” • Sex many times without protection and without telling the person that he is HIV positive. – remorse : blog about his personal struggles with "sex addiction and HIV” – No unprotected sex in the last two years
  17. 17. Mental Status Exam • Appearance: Normal development, normal nutrition, normal habitus, no deformities. • Level of consciousness: Alert • Orientation: MMSE 30/30 • Dress/grooming: Neatly groomed • Eye contact: Appropriate • Attitude: Good self-attitude • Motor: Normal strength, normal tone, normal muscle mass, normal movements • Speech: Increased rate, normal rhythm, normal volume, normal tone, normal articulation, normal coherent speech, normal spontaneity • Mood: States mood is "up and down" • Affect: Full range • Thought Process: Normal processing, normal computation • Thought Content: goal directed • Insight: Poor • Judgment: Poor • Intellect: Above average • Memory: 3/3 recall MMSE • Concentration: 5/5 attention and calculation • Language: fluent
  18. 18. Formulation • 46 year old Caucasian, single, unemployed male – Bipolar Disorder I – Unspecified Paraphilic Disorder – Cannabis Use Disorder • Multiple medical Comorbidities
  19. 19. Disease Perspective • Bipolar 1 Disorder – As evidenced by distinct periods of manic episodes – Family HX of untreated Bipolar disorder – Maintained on mood stabilizers and anti- psychotics • Recurrent sexual arousal and cravings AND increased sexually driven behaviors PERSIST in the absence of an exacerbation of his bipolar illness
  20. 20. Life Circumstances • Stable home, not close to his father, sees mother once a week • Completed two years of college • Minimal professional success • Multiple relationship failures • Sexual development began early at age 11, looking at pornography obsessively • First psychiatric admission at age 17 for mania • Multiple psychiatric admissions over the course of his life
  21. 21. Dimension Perspective • Obsessive-compulsive personality disorder – As evidenced by obsession and preoccupation of sexual thoughts, interfering with activities and maintaining jobs.
  22. 22. Behavioral Perspective • History of substance use disorder and may have genetic loading as he reports alcohol abuse in his grandparents. • DSM V: Unspecified Paraphilic Disorder • Drive • Object goal • Pursuit • Procurement • Consumptatory experience • Satiety • Rarely reaches satiety
  23. 23. DSM V: Paraphilic Disorder • Experiences repeated and intense sexual arousal as a result of the specified sexual interest lasting for a period of longer than six months (APA, 2013; McManus, Hargreaves, Rainbow, and Alison, 2013)
  24. 24. Sexual behaviors result in: significant distress clinically impairment decreased personal functioning
  25. 25. Hypersexuality and Addiction • Hypersexuality disorder (HD) is not included in the DSM-V – research indicates that HD may be viewed within the context of an addiction framework • Clinical manifestations of addiction and hypersexuality disorder parallel in that they often involve chronic use and relapse. • As the clinically significant behaviors endure with both hypersexuality disorder and substance abuse: – Decreased pleasure with the act itself – Increased cravings – Withdrawal – Rumination and guilt that interfere with functionin (Kor, Fogel, Reid, Potenza, 2013)
  26. 26. Evidence based Treatment • The gold standard for treatment, in conjunction with psychotherapy, remains androgen deprivation therapy (ADT), a pharmacological approach that lowers testosterone levels and therefore lowers the sex drive. • While there are side effects, ADT has been shown to significantly reduce recidivism rates in sex offenders and treats sex offenders who are considered to be sexually disordered or diagnosed with paraphilic disorder. (Berlin, 2009)
  27. 27. Pharmacological Interventions • ADT : oral or injectable • 2 major categories: – steroidal antiandrogens – gonadotropin-releasing hormone analogs or agonists (GnRHa) • GnRHa : desensitize pituitary receptors resulting in hypogonasism and very low serum levels of testosterone – administered IM monthly or every three months – Treatment initiation : augmentation with oral non-steroidal anti- androgen drug • first several weeks of therapy → block androgen production (due to surge of hormone production when first introduced) (Assumpcao et al, 2014)
  28. 28. Monitoring • Labs: – Prior to initiation of a GnRHa and at 6 months, – Testosterone, LH, FSH, prolactin, CBC, renal and liver function, fasting glucose, and lipids. – Yearly bone scans to monitor for osteopenia and osteoporosis.
  29. 29. Other Pharmacological Treatments • Serotoninergic reuptake inhibitors (SSRIs): – Side effect of these medications decrease libido and interfere with orgasm and ejaculation. – Studies have shown that the greatest efficacy is achieved with treatment of paraphilic disorders, specifically exhibitionism, compulsive masturbation and pedophilic urges not acted upon . • Currently, fluoxetine and sertraline have shown the most promise in the limited studies. (Assumpcao et al, 2014)
  30. 30. Other Recommendations • Continue with current psychiatric care. • Start Lupron injections to help reduce his sexual preoccupation, masturbation and compulsive use of pornography. – 7.5 mg IM monthly augmented with oral Flutamide 300 mg PO bid for the first month of the ADT initiation therapy. • Continue treatment with his therapist, outpatient psychiatrist, and the medical team who treats his HIV. • Continue Sexaholics, Sex Addicts Anonymous and this clinic for further stabilization of his sexual addiction.
  31. 31. References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association. Assumpcao, A.A., Garcia, F.D., Garcia, H.D., Bradford, J.M.W., & Thibaut, F. (2014). Pharmacologic treatment of paraphilias. The Psychiatric Clinics of North America, 37(2), 173-181. Berlin, F. S. (2009). Commentary: Risk/benefit ratio of androgen deprivation treatment for sex offenders. The Journal of the American Academy of Psychiatry and the Law, 37(1), 59-62. First, M.B. (2014). DSM-5 and paraphilic disorders. Journal of the American Academy of Psychiatry Law, 42(2), 191-200. Kor, A., Fogel, Y., Reid, R., Potenza, M. Should Hypersexual Disorder be Classified as an Addiction? Sex Addict Compulsivity, 20(1-2), 1-16. McManus, M., Hargreaves, P., Rainbow, L., Alison, L. Paraphilias: definition, diagnosis and treatment. F1000 Prime Reports 2013, 5(36), 1-6.
  • RajKumar2947

    Sep. 13, 2021
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    Jun. 17, 2018

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