“The concept of sex addiction has been developed over the past two decades to refer to persons who compulsively seek out sexual experiences and whose behavior becomes impaired if they are unable to gratify their sexual impulses” (Saddock &Saddock, 2008, p. 325)“Hypersexual Disorder” as was proposed as a new psychiatric disorder to be added to DSM-5, and was rejected by the American Psychiatric Association (APA) “because the current body of literature failed to provide adequate empirical support for the construct” (Moser, 2013, p. 63). There has been much controversy in the psychiatric world in regards to this topic, and the also the reliability and validity of much of the research regarding hypersexual disorder. While DSM-5 does not recognize “Hypersexual Disorder” or certain other compulsive sexual behaviors, there are ICD (International Classification of Diseases) codes pertaining to this disorder, recognized and use by the World Health Organization (WHO, 2013).
In terms of DSM-5, sexual behaviors are categorized into 3 classification groups: sexual dysfunctions, paraphilic disorders, and gender dysphoria (covered in a later chapter).
Sexual dysfunctions “are a heterogeneous groups of disorders that are typically characterized by a clinically significant disturbance in a person’s ability to respond sexually or to experience sexual pleasure” (APA, 2013, p. 423). Patients can suffer from more than one of these disorders at a time. When considering these disorders, the NP or provider needs to rule out any other medical problems or medications that could possibly be causing the dysfunction. In this presentation, we will discuss some of the more prevalent dysfunctions such as erectile disorder and female orgasmic disorder.
-Erectile disorder is “defined as the inability to attain or maintain an erection sufficient for satisfactory penetration or sexual performance” (Mutambirwa & Segone, 2013 ).-DSM-5 Diagnostic Criteria as listed above. Disorder can further be classified into further subtypes such as: lifelong or acquired, generalized or situational, and mild, moderate, or severe.- An estimated 10-20 percent of all men have reported suffering from acquired erectile disorder, while occurrences of lifelong ED are very rare (Saddock& Saddock, 2008, p. 308).
-Organic causes such as diabetes, multiple sclerosis, atherosclerosis, neuropathy, and endocrine problems should be ruled out as cause of ED. Some psychological factors that can contributed to ED include depression, anxiety, guilt, and religious inhibitions. The patient may have a combination of factors from both categories contributing to their ED. The provider must get a detailed medical history, perform a physical exam, and order lab tests in order identify any potential underlying causes.-Normal psychogenic erectile function is caused by an increase in nitric oxide in the blood in response to sexual stimulation, in turn causing dilation of blood vessels in the corpus cavernosum of the penis. When these vessels dilate, they fill with blood to create an erection. Signals from this process come from subcortical and cortical regions of the brain. “As ED is a neurovascular event, the nerves and their vascular-modulating transmitters can not be described in isolation” (Mutambirwa & Segone, 2013). Reflexogenic erections occur from direct stimulation of genitals or in patients with spinal cord injuries. Nocturnal erections occur during the REM stage of sleep. (Mutambirwa & Segone, 2013). -Pharmacological interventions for ED include oral and injectable medications that belong to a drug class called phosphodiesterase inhibitors. PDE5 inhibitors work by blocking certain enzymes which work by increasing and enhancing levels of nitric oxide in the blood, thereby facilitating blood flood to the penis. PDE 5 inhibitors are the first line therapy in ED. These are oral drugs that include Viagra (Slidenafil), Cialis (Tadalafil), Levitra (Vardenafil), and Stendra (Avanafil). Prostaglandin E1 agonists are considered after failed therapy of oral medications This drug class works by increasing systemic vasodilation. Alprostadil can be administered as an injection into the shaft of the penis or as an urethral suppository. Any underlying causes such as depression, anxiety, or medical conditions should be treated accordingly before starting mainline therapy for ED.
-Various non-pharmacological treatment options exist, dependent up the patient’s underlying cause of ED. Vacuum pump or vacuum erection devices is a mechanical device that draws blood into the penis. Surgical options include implanting a penile prostheses device or vascular surgery to repair any blocked vessels. Cognitive behavioral therapy can be of the traditional kind or new research has indicated that internet based therapy in effective in the treatment of ED. Evaluation of a study by Leusink and Aarts proved the efficacy of a computer program named Rekindle. The program “consisted of three main treatment components, including sensate focus, communication exercises, and email contact with a therapist”(McCabe et al., 2008, p. 326). Sex therapy and group therapy allows the individual to evaluate any interpersonal problems through therapeutic talk or exercises with their partner or in a group environment.Gene transfer therapy is currently in research stages. If approved this therapy will be utilized in ED patients due to affects of aging, diabetes, and vascular injury that are unresponsive to other medications (Yoshimura, Kato, Chancellor, Nelson, & Glorioso, 2010).
-Issues that could cause difficulty in caring for these patients may include lack of reporting of symptoms of ED, multiple co-morbidities, or suffering for ED that has combination of organic and psychological origin. Follow-up care is essential, especially for patients who are placed on medications to treat ED. The provider should emphasize the importance of follow-up for management and adjustment of any medication therapies. Patients undergoing any behavioral therapies would follow-up with the provider providing that specific treatment.Patient education should be provided to the patient in regards to all types of therapies, side effects of treatment, and alternative treatment options. The patient’s partner should be included in therapy, informed of treatment plans (especially if considering sex therapy), and the importance of communication, encouragement, and support be stressed as vital roles of the partner.
-The source of origin of this disorder can have many different etiologies, or can be a combination of multiple origins. -Psychological factors include “anxiety, fear of impregnation, rejection by a sex partner, or damage to the vagina; hostility towards men, and feelings of guilt about sexual impulse” (Saddock &Saddock, 2008, p. 309)-Environmental factors include relationship factors, religious norms, and gender role expectations.Physiological factors include medical conditions (multiple sclerosis, nerve damage, and spinal cord injury), medications, hormonal imbalances, and imbalances of dopamine (too little) and serotonin (too much) in the brain. (Saddock & Saddock, 2008). -Pharmacological treatment can include hormonal therapy (estrogen, androgens, or testosterone) which as shown to increase libido in both men and women. PDE5 inhibitors (discussed earlier) have shown to increase vaginal lubrication in females, and some studies even show a reported increase in intensity and excitement during sexual activity. Medications to treat any underlying causes such as depression and anxiety should also be considered if warranted. - Non-pharmacological interventions would not be appropriate in the primary care setting. Referrals to a specialist for various types of therapy would be offered to the patient. Cognitive-behavioral therapy and sex therapy would be administered as previously described with focus on the patient’s particular disorder. Studies have shown that both directed masturbation and mechanical devices similar to vibrators and vacuum pumps such as ‘EROS’, ‘Slightest Touch’ and ‘Vielle’ have all been shown to improve orgasmic ability in women diagnosed with FOD (IsHak, Bokarius, Jeffrey, Davis, & Bakhta, 2010).
-Diagnosis of the disorder is made entirely based on the self-report of the patient. This creates difficulty in proper diagnosis and treatment of the patient. Follow-up care provided by the FNP would be in regards to monitoring medications efficacy, management, and adjusting medication dosage or regimen if needed. Patient education for this disorder would follow those as outline for ED for both the patient and the patient’s partner.
-Delayed ejaculation is described by the marked delay in or inability to achieve ejaculation, despite the presence of adequate sexual stimulation and the desire to ejaculate. -Female Sexual Interest/Arousal Disorder involves absent or reduced interest in sexual activity, sexual thoughts or fantasies, and reduced or absent initiation of sexual activity. -Genito-Pelvic Pain/Penetration Disorder is characterized by difficulty with vaginal penetration during intercourse, vulvovaginal pain or pelvic pain during intercourse or penetration attempts, fear and anxiety about pain from penetration/intercourse, and tightening of pelvic floor muscles during vaginal penetration attempts. Male Hypoactive Disorder is a lack of desire for sex and deficient or absent erotic thoughts/fantasies over at least a six month period. (American Psychiatric Association, 2013)
-Premature ejaculation is another common sexual dysfunction in men. It is defined by ejaculation occurring within approximately 1 minute following vaginal penetration and before it is desired during partnered activity and occurring over a period of at least 6 months.-Substance/Medication Induced Sexual Dysfunction is related to intoxication, withdrawal, or exposure to a medication or substance. This symptoms must occur over at least a one month period and can not be attributed to any other sexual dysfunction and not occurring during a period of delirium (American Psychiatric Association, 2013).
The American Psychiatric Association defines paraphilia as “any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners. “A paraphilic disorder is defined as “a paraphilia that is currently causing distress or impairment to the individual or a paraphilia whose satisfaction has entailed personal harm, or risk of harm, to others. (APA, 2010, p. 685-686). An individual can have a paraphilia, but it does not necessarily mean that the individual is suffering from a paraphilic disorder. An individual suffering from two or more paraphilias is also common. This presentation will discuss two of the more prevalent paraphilic disorders: pedophilic disorder and fetishistic disorder.
DSM-5 lists different subcategories for this disorder including exclusive type (attracted to only children) or nonexclusive type. Another is whether the individual is attracted to males, females, or both or if the paraphilia is limited to incest.
Prevalence of this disorder is unknown, although it is assumed the prevalence in the male population is 3%-5%. There is no certainty about the prevalence in the female population.Many individuals with pedophilic disorder have shown antisocial personality traits, so it is stated that “antisocial personality disorder may be considered a risk factor for pedophilic disorder in males with pedophilia” An environmental factor with relation to this disorder is sexual abuse during childhood. Physiological factors related to neuropathophysiology are not well known but there “is some evidence that neurodevelopment perturbation in utero increases the probability of of developmental of a pedophilic orientation (APA, 2013, p. 698-699). Chemical castration is a term used describe the administration of medications that reduce libido or sexual activity. This topic is very controversial, especially in the United States, but the use of this treatment as been gradually increasing in other countries. Administration of an anti-androgen medication (Depo-Provera is widely used) is administered which decreases testosterone levels, thereby reducing libido in males and controlling compulsive sexual behaviors. Medications such as SSRIs and anti-psychotics are administered to help with other underlying conditions such as depression or schizophrenia.
Prison or incarceration is viewed as an external control for individuals with this disorder, although treatment elements are usually not available to the individual. Cognitive-behavioral therapy includes imaginal desensitization, learning what triggers paraphilic impulses, and learning how to modify their behaviors. Psychotherapy for these individuals involves understanding how the paraphilia developed, and how to deal with both internal and external stressors. A study conducted by John Corson studied sex offenders who were taught hyperventilation techniques to response to thoughts and images related to their illegal sexual behavior. Hyperventilation was used to prevent or abort unwanted sexual arousal. In the follow-up of the study, only 2 out of 21 participants reoffended after a three month period. Participants were under constant surveillance by law enforcement, family members, or community members during this time (Courson, 2010). Issues that could occur in regards to difficulty in care would be lack of reporting of inappropriate sexual thoughts or behaviors due to shame and fear of imprisonment. Many of these individuals may currently be incarcerated which would also make care difficult.
Follow-up care for these patients would predominately take place with specialists or psychiatrists. Education should focus on the individual being able to recognize triggers, coping strategies to control impulses, compliance with medication and treatment therapy, and the potential consequences of non-compliance. Family education should be focused on feelings that may possibly be experienced such as shame, guilt, anxiety, and anger. They should be provided information regarding therapeutic treatment and counseling for members of the family. Family members should also be aware of the individual’s triggers so that they may help the individual avoid and deal with these situations as needed.
Sexual focus can be on objects such as shoes, gloves, women’s underwear, and pantyhose or body parts such as feet, toes, and hair. Subcategories of this disorder include body part(s), non-living object(s), and other. Also included is in a controlled environment or in full remission. Controlled environment is used to describe institutions or facilities where these behaviors are restricted. In full remission is specified if the individual has had no distress or impairment (social or occupational) for at least five years while in an uncontrolled environment.(APA, 2013, p. 700)
Fetishistic behaviors can develop while in childhood and carry on throughout life while fluctuating in intensity and frequency of urges or behavior. The particular fetish usually linked to someone closely involved in the individual’s childhood and “has a quality associated with this love, needed, or traumatizing person” (Saddock & Saddock, 2008, p. 320).There are currently no FDA approved pharmacological treatments for fetishism. Studies in this disorder are lacking due to activities are usually not illegal, and treatment is not forced. Certain studies have experimented with the use of SSRIs, anti-androgens, and topiramate to reduce fetish-related compulsive behavior. A study that treated an individual with certain foot fetish behaviors was treated with 200 mg of topiramate daily. After six months, he reported a resolution of his fetishism (Shiah, Chao, Mao, & Chuang, 2006).
Modified aversive behavior rehearsal involves the individual acting out their paraphilia with a mannequin while on camera. The individual then sits down with a group and a therapist and communication is engaged regarding thoughts, feelings, and motives regarding the act (Saddock & Saddock, 2008, p. 324). Group therapy and psychotherapy are followed as described earlier to develop understanding of potential underlying causing and any other conditions that need to be treated. Care may be difficult because most of these individuals will not seek out help for their disorder due to feelings of shame or embarrassment. Many times these behaviors are not associated with illegal activities so reporting of behaviors falls primarily on the individual.The NP will more than likely not be involved in follow-up care, as most treatment is associated with therapies that would be done with a specialist. Education would be very similar to that in pedophilic disorder, in regards to treatment and therapy compliance, and educating the family in regards to possibly feelings that may be experienced and therapies/counseling available.
-Voyeuristic Disorder is characterized by sexual arousal from watching unsuspecting person who is naked, disrobing, or engaging in sexual activity. The individual experiencing the arousal must be at least 18 years old. Masturbation with orgasm usually accompanies the event.-Exhibitionistic Disorder describes sexual arousal from exposing one’s genitals to unsuspecting person. This can involve pre-pubertal children, mature adults, or both. -Frotteuristic Disorder describes sexual arousal from touching or rubbing against a non-consenting person. This act usually occurs in crowded places such as subways and buses. Orgasm is the goal of the act and usually this act is their only source of sexual gratification.-Sexual Masochism describes sexual arousal from the act of being humiliated, beaten, bound, or otherwise made to suffer. This condition can specify with or without asphyxiophilia (restriction of breathing). These individuals often feel “pain is a prerequisite for sexual pleasure” (Saddock & Saddock, 2008, p. 321)
Sexual sadism disorder involves sexual arousal from the physical or psychological suffering of another person. The individual has acted on these urges with a non-consenting person or it has caused significant distress and impairment in their life. This disorder can be related to rape. Transvestic disorder involves sexual arousal from cross-dressing and these thoughts and behaviors have caused significant distress or impairment in their life. Subcategories can include with fetishism and with autogynephilia (sexually aroused by thoughts or images of self as a female).
-Telephone scatologia involves obscene phone calls with an unsuspecting person. -Necrophilia involves obtaining sexual gratification from cadavers. -Zoophilia involves sexual arousal or activities with animals, where the animals may be trained to participate. -Coprophilia is sexual pleasure from the desire to defecate on a partner, to be defecated on, or to eat feces. -Klismaphilia is the use of enemas as part of sexual stimulation.-Urophilia is sexual pleasure from the desire to urinate on a partner or to be urinated on.
Gambling addiction is newly recognized by the APA as an addictive behavior and was just added in with the new publication of the DSM-5.
-Early remission- individual has not met criteria for disorder for period of 3-12 months after having met all criteria previously.-Sustained remission- individual has not met criteria for disorder for 12 months or longer after having met all criteria previously.-Mild – 4-5 criteria met.-Moderate- 6-7 criteria met.-Severe- 8-9 criteria met.
Theories suggest that individuals with this addiction have” subnormal MHPG concentrations in plasma, increased MHPG concentrations in cerebrospinal fluid, and increased urinary output of norepinephrine” (Saddock & Saddock, 2008, p. 366). Chronic gamblers have also been shown to have low MAO and serotonin activity. -Pharmacological interventions are lacking in research. Certain studies have shown that fluvoxamine (SSRI) ,clomipramine (tricyclic antidepressant), and lithium (anti-psychotic) have been effective in treatment by correcting serotonin activity in the brain, treating obsessive-compulsive behavior, and stabilizing the individual’s mood. Any underlying medical conditions such as anxiety, depression, or mania should be treated accordingly. (Saddock & Saddock, 2008).Non-pharmacological interventions for gambling addiction are treated much like substance addictions. Gamblers Anonymous is framed after Alcoholics Anonymous and is a step- based group therapy. Dropout rate for GA is found to be high. Inpatient treatment at a facility would be modeled much like substance addiction in-patient treatment. This helps by removing the individual from their environment so that they can better focus on treatment (Saddock & Saddock, 2008). Cognitive-behavioral therapies is the most widely used in regards to gambling addiction and may include relaxation techniques, desensitization , and cognitive restructuring. Internet based help is a treatment avenue that is in it’s infancy, but certain studies have shown that it has proven effective in some chronic gamblers. This program uses an 8 week internet based program with information and exercises for the individual to do on their own, weekly discussion board assignments on-line, and a weekly telephone conversation with a therapist. This type of therapy would be very beneficial due to ease of availability and access to the treatment (Carlbring & Smit, 2008).
-Difficulty often arises when caring for these patients because they seldom seek treatment for their addiction. Many types these individuals also have multiple co-morbidities with their gambling addiction such as substance addiction, depression, ADHD, and impulse control disorders. Follow-up care for the individual would very much mimic that someone being treated for substance abuse. Pharmacological therapies and their effectiveness should be assessed during follow-up. The individual should follow up with a specialist if undergoing any other therapeutic treatments.Education for the patient should include being able to identify triggers for the behavior, identifying a support group, coping strategies to deal with triggers, and compliance in regards to medication and therapy.Education for the family should include possible signs and symptoms of relapse (depression, irritability, hiding or asking for money, irregular eating habits, etc.) and supports groups that can help with dealing with the family member’s addiction such as Gam-Anon.
Sex&gambling addiction ppt
Sex & Gambling Addiction
Georgia Southern University
“Sex addiction”- not a universally recognized or
“Hypersexual Disorder” - proposed for DSM-5 and
ICD-9-CM Code –Other Specified Psychosexual
ICD-10 Codes: Excessive Sexual Drive (F52.7)
Excessive Masturbation (F98.8)
DSM-5 – Sexual Behavior Classification
• 10 disorders
Gender Dysphoria (not covered in this
Sexual Dysfunctions (DSM-5)
Female Orgasmic Disorder
Female Sexual Interest/Arousal Disorder
Genito-Pelvic Pain/Penetration Disorder
Male Hypoactive Sexual Disorder
Premature (Early) Ejaculation Disorder
Substance/Medication Induced Sexual Dysfunction
Other Specified Sexual Dysfunction
Unspecified Sexual Dysfunction
Erectile Disorder (ED)
Must experience at least one of three following
symptoms 75%-100% of time during sexual activity
Difficulty in obtaining an erection
Difficulty in maintain erection until completion of sexual activity
Decrease in erectile rigidity
Minimum of 6 months
Clinically significant distress
Can not be attributed to another mental disorder,
stressor, medical problem, or substance/medication use
Erectile Disorder (ED)
Origin of erectile disorder
Combination of both
Normal Erectile function
PDE5 Inhibitors (Viagra, Cialis, Levitra)
PGE1 agonist (Caverject, Edex, Muse)
Medications to treat underlying causes
Erectile Disorder (ED)
Cognitive Behavioral Therapy
Internet based or traditional
Gene Transfer Therapy (Currently being
Erectile Disorder (ED)
Difficulties in care
Lack of reporting
Combined nature of origin
Female Orgasmic Disorder
Presence of at least one of the following symptoms
occurring in 75%-100% of occasions of sexual
Delay in, infrequency of, or absence of orgasm.
Reduced intensity of orgasmic sensations
Minimum duration of 6 months
Clinically significant distress in individual
Not better explained by a nonsexual mental
disorder and can not be attributed to causes such
as relationship stressors, medical condition, or
Female Orgasmic Disorder
Difficulties in care
Diagnosis fully relies on self-report
Other Sexual Dysfunctions
Delayed Ejaculation – delay or inability to achieve
Female Sexual Interest/Arousal Disorderabsent/reduced interest in sexual activity
Genito-Pelvic Pain/Penetration Disorder- vulvovaginal or
pelvic pain during intercourse/tightening of pelvic floor
muscles during penetration attempt
Male Hypoactive Disorder- lack of desire for sex and
deficient/absent erotic thoughts/fantasies
Other Sexual Dysfunctions
Premature (Early) Ejaculation- Ejaculation occurring
within approximately 1 minute following vaginal
penetration and before it is desired
Substance/Medication Induced Sexual Dysfunctionrelated to intoxication, withdrawal, or exposure to a
medication or substance
DSM 5 Criteria:
Over a period of at least 6 months, recurrent, intense
sexually arousing fantasies, urges, or behaviors involving
sexual activity with a prepubescent child/children
Has acted on sexual urges or they have cause marked
distress or interpersonal difficulty
Individual is at least 16 years old and 5 years older than
Hyperventilation study (Courson, 2010)
Difficulties in care
Lack of self-reporting
Resources for family members
Recurrent and intense sexual arousal from either the
use of non-living objects or specific focus on non-genital
body part(s), as manifested by fantasies, urges, or
Occurs over period of at least 6 months
Fetish objects not limited to articles of clothing used in
cross-dressing or devices designed for purpose of tactile
genital stimulation (e.g. vibrator)
No FDA approved medications
Lack of research/studies
Modified aversive behavior rehearsal
Difficulty in care
Voyeuristic Disorder- sexual arousal from watching
unsuspecting person who is naked, disrobing, or
engaging in sexual activity
Exhibitionistic Disorder- sexual arousal from
exposing one’s genitals to unsuspecting person
Frotteuristic Disorder- sexual arousal from touching
or rubbing against a non-consenting person
Sexual Masochism- sexual arousal from the act of
being humiliated, beaten, bound, or otherwise
made to suffer
Sexual Sadism Disorder- sexual arousal from the
physical or psychological suffering of another
Transvestic Disorder- sexual arousal from crossdressing
Unspecified Paraphilic Disorder- does not meet
criteria for specific disorder, clinician chooses not
to specify reason
DSM-5 – Gambling Disorder- newly recognized
DSM-5 Diagnostic Criteria:
Persistent or recurrent problematic gambling indicated
by exhibiting four (or more) of the following:
Needs to gamble with increasing amount of money to
achieve desired excitement
Restless or irritable when attempting to cut back or
Repeated unsuccessful efforts to control, cut back, or
Often preoccupied with gambling
DSM-5 Diagnostic Criteria (Continued) :
Often gambles when feeling distressed
After losing money gambling, often returns
another day to “get even”
Lies to conceal extent of involvement with
Has jeopardized or lost a significant relationship,
job, or educational or career opportunity
because of gambling
Relies on others to provide money to relieve
desperate financial situations caused by gambling
DSM-5 Diagnostic Criteria (Continued):
All behavior within 12 month period
Behavior not better explained by manic episode
Episodic or Persistent
In early remission/in sustained remission
Mild, Moderate, or Severe
Difficulties in care
Seldom seek care
Symptoms of relapse
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Behavioral Therapy in the Treatment of Sex
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International Classification of Diseases (ICD). (n.d.). WHO.
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