Bonus Chapter for Therapists: The Unofficial Diagnosis of Sexual Addiction
In the spring of 2013, the American Psychiatric Association (APA) published the latest edition of its Diagnostic and Statistical Manual of Mental Disorders (the DSM-5) without listing sexual addiction as an official diagnosis. Because the DSM-5 is the unofficial “diagnostic bible” used by the vast majority of treatment providers and insurance companies, this exclusion is significant. Yes, sex addicts can still be self-identified and/or clinically diagnosed as sexually addicted, but when they seek insurance-funded professional help they often run into problems because insurance companies typically won’t pay for treatment without an officially sanctioned DSM-5 diagnosis. As a result, sex addicts and those who treat them must sometimes work around the APA’s currently flawed system, usually by listing a related or a co-occurring issue—depression, anxiety, substance abuse, an eating disorder, etc.—as the primary reason for treatment. Needless to say, this is less than ideal.
Amazingly, sexual addiction (sometimes referred to as Hypersexual Disorder) was omitted from the DSM-5, despite an APA-commissioned position paper prepared by Dr. Martin Kafka of Harvard Medical School that recommended inclusion. Dr. Kafka wrote:
The data reviewed from these varying theoretical perspectives is compatible with the formulation that Hypersexual Disorder is a sexual desire disorder characterized by an increased frequency and intensity of sexually motivated fantasies, arousal, urges, and enacted behavior in association with an impulsivity component—a maladaptive behavioral response with adverse consequences. Hypersexual Disorder can be associated with vulnerability to dysphoric affects and the use of sexual behavior in response to dysphoric affects and/or life stressors associated with such affects. . . . Hypersexual Disorder is associated with increased time engaging in sexual fantasies and behaviors (sexual preoccupation/sexual obsession) and a significant degree of volitional impairment or “loss of control” characterized as disinhibition, impulsivity, compulsivity, or behavioral addiction. . . . [Hypersexual Disorder] can be accompanied by both clinically significant personal distress and social and medical morbidity.1
Though Dr. Kafka’s language is somewhat technical, his message is clear: sexual addiction is a very real and debilitating psychiatric condition. Recognizing this, Dr. Kafka proposed specific diagnostic criteria for adoption by the APA. Essentially, his suggested criteria are as follows:
Hypersexual Disorder occurs when, over a period of at least six months, sexual fantasies, urges, and behaviors occur in association with three or more of the following:
√ Interference with other important (nonsexual) goals, activities, and obligations
√ mood states (anxiety, depression, irritability, etc.)
√ Use as a coping mechanism (to avoid/not feel stress, emotional discomfort, physical discomfort, etc.)
√ Repeated but unsuccessful efforts to control the fantasies, urges and behaviors
√ Continued fantasies, urges and behaviors despite negative consequences
With his position paper, Dr. Kafka confirmed what sex addicts and sexual addiction treatment specialists have known for decades: Sexual addiction is an obsessive, out-of-control pattern of sexual fantasy and behaviors that creates directly related negative life consequences, including relationship problems, trouble at work or in school, loss of interest in other activities/obligations, isolation, decreased self-esteem, financial woes, legal issues, etc. Dr. Kafka also noted that sexual addiction, like other addictions, is typically a maladaptive attempt to self-soothe and/or self-medicate stress and other forms of emotional discomfort, including the pain of unresolved psychiatric conditions like depression, anxiety, attachment disorders, and early-life or severe adult trauma.
So why did the APA exclude sexual addiction from the DSM-5? In the introduction to the Addictive Disorders section they write:
Other excessive behavioral patterns, such as Internet gaming, have also been described, but the research on these and other behavioral syndromes is less clear. Thus, groups of repetitive behaviors, which some term behavioral addictions, with such subcategories as “sex addiction,” “exercise addiction,” or “shopping addiction,” are not included because at this time there is insufficient peer-reviewed evidence to establish the diagnostic criteria and course descriptions needed to identify these behaviors as mental disorders.2
In reality, as Dr. Kafka rather eloquently detailed in his position paper, there is more than enough evidence for the APA to officially recognize Hypersexual Disorder. In fact, many of the disorders currently included in the DSM-5 (particularly the sex-related disorders) have significantly less supportive evidence. On this topic Dr. Kafka wrote: “The number of cases of Hypersexual Disorder reported in the peer reviewed journals greatly exceeds the number of cases of some of the codified paraphilic disorders, such as Fetishism and Frotteurism.”3 Nevertheless, the APA opted for “lack of research” as support for its obstinate, behind-the-times refusal to acknowledge sexual addiction.
Happily, new research on sex addiction emerges on a relatively regular basis. Of the studies published post-Kafka, three are especially important.
First we have a diagnostic criteria field trial.4 The goal of this research was to find out if people who seek treatment for sexual addiction are accurately identified by Dr. Kafka’s proposed diagnosis, and, at the same time, to make sure those who do not seek treatment for hypersexuality are not misidentified as sex addicts. According to the study, the proposed diagnostic criteria are well-constructed, accurately identifying self-identified sex addicts while not misdiagnosing non-sex addicts. Most notable is the fact that many of the study’s subjects who sought treatment for substance abuse also reported problematic sexual activity, but only when drinking or using, and the proposed diagnosis identified only one of those individuals as sexually addicted. For the others, the primary diagnosis was substance addiction.
A second study looked at attentional bias5—i.e., the tendency of addicts to focus a higher-than-normal share of their attention on an addiction-related cue, which typically creates a slowed reaction and/or an incomplete recollection of a certain event. For example, drug addicts will, when they see drug-related stimuli, manifest an incomplete or slowed memory of surrounding but non-drug-related items and events. So if you put a cocaine addict in a room and there is a pile of white powder on the coffee table, the addict will recall the powder and the table quickly and easily, but he or she might not remember the color of the carpet at all. Over the years, numerous studies have linked attentional bias with substance addiction, but this study was the first to look at whether sex addicts display similar attentional bias (with sexual stimuli). Unsurprisingly, they do.
While the diagnostic field trial and the attentional bias research are useful support for a sexual addiction diagnosis, they are probably not enough to change the APA’s stance. What has really been needed is definitive proof that sex addiction manifests in the brain in the same way as other addictions. And, with the third study, this proof recently arrived.6 Using fMRI (functional magnetic resonance imaging) scans, researchers compared the brain activity of sex addicts to the brain activity of non-sex addicts, and also to the brain activity of drug addicts. Unsurprisingly, they found significant differences in the brain response manifested by sex addicts and non-sex addicts, and striking similarities in the brain response manifested by sex addicts and drug addicts. Put simply, the research team found that when sex addicts are shown pornography their brains activate in three primary areas—the amygdala, the dorsal anterior cingulate, and the ventral striatum (regions of the brain in charge of things like mood, anticipatory pleasure, memory, and decision-making)—while the brains of non-sex addicts do not. They further concluded that this activation closely mirrors the brain activity of drug addicts when they are exposed to drug-related stimuli. Needless to say, these findings are significant.
So is the APA likely to move forward with an addendum to the DSM-5 that officially recognizes sexual addiction as an identifiable and treatable disorder? Probably not anytime soon. When it comes to making significant changes to the ways in which clinicians view psychiatric disorders, the APA is nearly always the last to arrive at the party. That said, they will have to concede at some point because significant research is piling up, most notably the fMRI study cited above. In fact, one member of the APA committee that considered but ultimately rejected Hypersexual Disorder for inclusion in the DSM-5, Dr. Richard Krueger of Columbia University, has called the fMRI research a “seminal study” supporting an eventual sex-addiction diagnosis.7 Until the APA alters its stance of willful ignorance, however, nothing much changes. Sex addicts hoping to heal will seek therapy and twelve-step recovery, and the clinicians who treat them will do so in the ways they know best, with or without APA recognition and support.
The Neurobiology of Limerence vs. Love
Sex and love addicts often want to know: what is the difference between limerence and love, and how are they related?
Happily, thanks to modern brain-imaging studies, this question is easily answered. Typically, these studies are conducted using fMRI (functional magnetic resonance imaging) technology, which allows researchers to measure brain activity in response to various stimuli. Essentially, when one portion of the brain is activated—by a thought, an emotion, a movement, or anything else—blood flow to and within that area increases, and fMRI scans clearly depict this. In this way, tracking what happens in the brain when an individual experiences things like sexual arousal and long-term love is a relatively straightforward task.
One rather extensive study combined and analyzed the results of twenty separate fMRI trials looking at brain reactivity in response to physical attraction, sexual arousal, and long-term love.8 After pooling this extensive data, scientists were able to “map” the ways in which both sexual desire and long-term love stimulate the brain. The two main findings were as follows:
1) Sexual desire and long-term love both stimulate the striatum, an area of the brain that includes the nucleus accumbens (the rewards center). This means that both sexual attraction and lasting love create the experience of pleasure.
2) Long-term love (but not sexual desire) also stimulates the insula, an area of the brain associated with motivation. In other words, the insula “gives value” to pleasurable and/or life-sustaining activities (to make sure we continue to engage in them). This means that lasting love has an inherent “value” that sexual attraction does not.
In short, the striatum (the home of the rewards center) is responsible for initial attraction and sexual desire, i.e., limerence, while the insula is responsible for transforming that desire into long-term love.
Interestingly, the striatum is the area of the brain most closely associated with the formation of addiction. In fact, addictive substances and activities all rather thoroughly stimulate this segment of the brain. As such, it is hardly surprising that some people (i.e., love addicts) might get hooked on the limerence stage of relationships. After all, limerence produces the same basic high (the same basic neurobiological stimulation) as cocaine, heroin, sexual activity, gambling, and other addictive substances and behaviors: the release of dopamine, adrenaline, oxytocin, serotonin, and various other endorphins.
One very interesting facet of the above findings is that the striatum, the portion of the brain most closely associated with addiction, must be stimulated if a person wishes to build and maintain long-term love. In fact, this neurobiological rush is what pushes couples toward the slow and steady development of mature intimacy and longer-term relationships. This means that limerence, the addiction-like stage of a romantic relationship, is a necessary step on the road to long-term love. As such, even healthy relationships can look a lot like love addiction in the early stages. Of course, the difference between love addicts and healthy people is that love addicts never make it past limerence; they never “assign value” to anything beyond the initial intensity they experience. Instead, they seek to continually stimulate their brain’s pleasure center with one new relationship after another, just as alcoholics stimulate their brains with one drink after another, and sex addicts repeatedly stimulate their brains with sexual fantasies, images, and encounters.