Classification of Sexually Addictive/Compulsive Behaviours

Eoin Stephens, M.A. Director of Education & Training PCI College & Centre for Sexual Addictions

Introduction The question of classification is not a trivial one in the case of Sexual Addiction (also known as Sexual Compulsivity, Sex and Love Addiction, and Compulsive Sexual Behaviour). There is still much controversy over the nature, and even the existence, of such a syndrome. According to Goodman (1998a), the term sexual addiction was first used by Fenichel in 1945: In severe cases of "sexual addictions", sexuality loses its specific function and becomes an unsuccessful nonspecific protection against stimuli. However, Krafft-Ebbing had already described the condition in 1886, and in 1897 Freud had referred to masturbation as the primal addiction (Goodman, 1998a). Goodman himself (ibid., p. 8) offers the following working definition: Some form of sexual behavior in a pattern that was characterised by recurrent failure to control the behavior and continuation of the behavior despite significant harmful consequences. It was with the rise, in 1970s America, of Twelve Step groups for sexual addiction based on the Alcoholics Anonymous model (Alcoholics Anonymous, 1976), that sexual addiction began to be taken seriously as a problem requiring treatment. These groups include Sex and Love Addicts Anonymous, Sexaholics Anonymous, Sexual Compulsives Anonymous and Sexual Addicts Anonymous (Carnes, 1997; Johnson, 2000, Sex and Love Addicts Anonymous, 1986). In the field of twelve-step-based addiction treatment, the work of Carnes in particular (1983, 1991, 1997) did a lot to make the concept more widely known, along with Coleman (1988), Peele & Brodsky (1991) and others. However, so many Twelve Step groups came into existence in the decades following the founding of AA that many clinicians and therapists began to feel that the whole concept of addiction was being stretched and diluted beyond usefulness (e.g. Arterburn, 1991; Peele, 1998). From the evolutionary standpoint which I would take (Carnes, 2001; Gilbert & Bailey, 2000), food and sex addictions are in fact the most fundamental human addictions, drugs being a more recent way of providing intensely mood-altering experiences.

It is, of course possible to become confused about the concept of sexual addiction; someone can be guilty and ashamed of perfectly healthy sexual behaviour, and this may lead him or her to consult a psychotherapist. However, as can be seen in Goodmans definition above, compulsive sexuality is characterised by loss of control of some sexual behaviours despite their leading to serious negative consequences (Carnes, 1983, 1989, 1991; Goodman, 1998a,b,c), as well as by the analgesic role described by Weissberg and Levay (also by Coleman, 1988; Hardiman, 1998; Quadland, 1985). Carnes, (1991, p. 11-12) outlines the following signs of sexual addiction: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. A pattern of out-of-control sexual behavior Severe consequences due to sexual behavior Inability to stop despite adverse consequences Persistent pursuit of self-destructive or high-risk behavior Ongoing desire or effort to limit sexual behavior Sexual obsession and fantasy as a primary coping strategy Increasing amounts of sexual experience because the current level of activity is no longer sufficient Severe mood changes around sexual activity Inordinate amounts of time spent in obtaining sex, being sexual, or recovering from sexual experience Neglect of important social, occupational, or recreational activities because of sexual behavior

Carnes (1983, p. 9) also describes a ' sexual addiction cycle' , suggesting that for sexual addicts an addictive experience progresses through a four-step cycle, which intensifies with each repetition. 1. Preoccupation - the trance or mood wherein the addicts minds is completely engrossed with thoughts of sex. The mental state creates an obsessive search for sexual stimulation. 2. Ritualization - the addicts own special routines, which lead up to sexual behaviour. The ritual intensifies preoccupation, adding arousal and excitement. 3. Compulsive sexual behaviour - the actual sexual act, which is the goal of preoccupation and ritualization. Addicts are unable to control/stop this behaviour. 4. Despair - the feeling of utter hopelessness addicts have about their behaviour and powerlessness. The pain the addict feels at the end of the cycle can be numbed or obscured by sexual preoccupation, which re-engages the addiction cycle.

' Sexual activity' and ' sexual behaviour' in the above may refer to adult sexual intercourse, either heterosexual or homosexual, paid-for or mutual, consenting or otherwise, anonymous or as part of an ongoing relationship. However, it can also refer to a wide variety of other sexual practices e.g. sexual fantasy, masturbation, pornography of various kinds (including on the Internet), telephone sex, voyeurism, exhibitionism, fetishism, child molestation etc. Many of these sexual activities are not equally common amongst men and women (Ragan and Martin, 2000), and are therefore not found equally among sexually addicted men and women (Carnes, 1991; Goodman, 1998a). Some theorists (e.g. Arterburn, 1991; Peele and Brodsky, 1991) see sexual addiction as being part of a broader phenomenon which includes ' love addiction' , suggesting that sex/love addiction can express itself in any or all of three areas, namely romance, relationships, and sex.

Sexual Addiction and the DSM-IV Sexual addiction as a syndrome is not to be found in the DSM-IV (Carnes, 2000b; Goodman, 1998a,b; Mercer, 1998), although Carnes (1996) points out that there are two references to it in the DSM-III-R. Schneider and Irons (1996) note that The descriptive term "sexual addiction" does not appear in DSM-IV. Addiction professionals who encounter both compulsive and impulsive sexual acting-out behaviors in their patients have experienced paradigm and nomenclature communication difficulties with mental health professionals and managed care organizations that utilize DSM terminology and diagnostic criteria. This difficulty in communication has fueled skepticism among some psychiatrists and other mental health professionals regarding the case for including sexual addiction as a mental disorder (p. 8; quoted in Mercer, 1998). However, this must be seen in the context that the term addiction is not used in the DSMIV (Goodman, 1998a,b,). To what extent are we dealing with a real clinical entity here? Just what, if anything, is sexual addiction? One useful question in this regard would be whether the symptom cluster described above is already addressed within existing DSM-IV classifications. Likely candidates are discussed as follows:

1. Sexual dysfunction. Since the symptomatology we are talking about is seen as dysfunctional, and refers to the area of sexuality, it might be most appropriately classified under Sexual Dysfunctions (a sub-heading of the chapter entitled Sexual and Gender Identity Disorders). These are defined as being characterised by a disturbance in the processes that characterise the sexual response cycle or by pain associated with sexual intercourse. (APA, 1994, p. 493, italics added). It goes on to describe the sexual response cycle as being divided into four phases, Desire, Excitement, Orgasm, and Resolution, and suggests that disorders of sexual response may occur at one or more of these phases. (ibid, p. 494). In the light of the Sexual Addiction Cycle described above this sounds promising, or at least the italicised part does. However, while Sexual Desire Disorders and Sexual Arousal Disorders are then described in further detail (along with Orgasmic Disorders, Sexual Pain Disorders, and Sexual Dysfunction Due to a General Medical Condition), they are all presented as dysfunctional in the direction of barriers to sexual performance rather than in the direction of excessive sexual performance (excess being a central criterion for any addictive behaviour; see e.g. Orford, 1985). The disorders described are: Hypoactive Sexual Desire Disorder, Sexual Aversion Disorder, Female Sexual Arousal Disorder, and Male Erectile Disorder.1 If a classification of ' Hyperactive Sexual Desire Disorder' was added (the phenomenon is briefly discussed in e.g. Wincze and Carey, 1991, under the heading Excessive Sexual Desire) it might seem to capture some of the characteristics of sexually compulsive behaviour described above (e.g. Increasing amounts of sexual experience because the current level of activity is no longer sufficient; Severe mood changes around sexual activity; Inordinate amounts of time spent in obtaining sex, being sexual, or recovering from sexual experience). However, other characteristics of sexual addiction go beyond the concept of excessiveness alone (Inability to stop despite adverse consequences; Persistent pursuit of self-destructive or high-risk behavior; Ongoing desire or effort to limit sexual behavior). Another promising sub-heading in this particular chapter of the DSM-IV is that entitled Paraphilias; The essential features of a Paraphilia are recurrent, intense sexually arousing fantasies, sexual urges, or behaviours generally involving 1) nonhuman objects, 2) the suffering or humiliation of oneself or one' s partner, or 3) children or other nonconsenting persons (APA, 1994, pp. 522-3, italics added). Again, the italicized part seems relevant. However, criteria 1, 2 and 3, while sometimes present in sexual addicts, are not necessarily so. In other words, some sexual addicts may act out their addiction in areas such as Exhibitionism, Fetishism, Frotteurism, Pedophilia, Sexual Masochism, Sexual Sadism, Transvestic Fetishism or Voyeurism. Others will primarily be involved in non-paraphilic sexual activities such as pornography, masturbation, prostitution, multiple affairs etc.
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While sexual aversion may usefully be seen as the other side of the coin of sexual compulsivity (e.g. Carnes, 1997, who uses the term sexual anorexia), this is beyond the scope of the present article.

2. Organic pathology. Goodman (1998c. p. 1) points out that ' Paraphilic or hypersexual behavior can be a symptom of a brain lesion, a side effect of medication or a symptom of endocrine abnormality.' He suggests that differential diagnosis in such cases can be facilitated by the presence of various neurological and physiological symptoms. 3. Borderline Personality Disorder (BPD). Another possible candidate for a current DSM classification into which the clinical picture described here might fit is Borderline Personality Disorder, defined as A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity (APA, 1994, p. 654). In particular, criterion 4 seems relevant: Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating) (Italics added). However, other criteria are either not relevant (identity disturbance; paranoid ideation or dissociative symptoms) or not necessarily relevant (recurrent suicidal behaviour; chronic feelings of emptiness), although they may of course be present. The connections and differences between BPD and sexual addiction are of particular interest because of the fact that the etiology of BPD (like that of sexual addiction) is frequently found to involve childhood abuse (e.g. Layden et al, 1993). Rickards and Laaser (1999, p. 34), for instance, suggest that ' it is clear that borderline personality disorder has a powerful relationship with a history of childhood abuse.' They go on to say that Although less frequently researched, a significant relationship has been shown to exist between sexual abuse and sexual addiction/compulsivity as well. In his landmark study, Carnes (1991) found that 82% of the sexually addictive/compulsives in his sample had been sexually abused in childhood. Other authors have discovered a similar relationship between childhood sexual trauma and subsequent sexual addiction/compulsivity in adulthood (e.g., Anderson & Coleman, 1991; Tedesco & Bola, 1997). Rickards and Laaser suggest that three distinct populations can be described: ' sexually addictive/compulsives, sexually addictive/compulsive borderlines, and borderlines who may act-out sexually but who are not sexually addictive/compulsive' (1999, p. 32). Also on the subject of Personality Disorders, Goodman (1998c, p.1) suggests that sexual addiction can be distinguished from ' nonaddictive patterns of exploitative or aggressive sexual behavior that can occur with Antisocial Personality Disorder.'

4. Obsessive-Compulsive Disorder (OCD). Our next candidate is Obsessive-Compulsive Disorder, whose essential features are said to be recurrent obsessions or compulsions (Criterion A) that are severe enough to be time consuming or cause marked distress or significant impairment (Criterion C). At some point during the course of the disorder, the person has recognised that the obsessions or compulsions are excessive or unreasonable (Criterion B). (p. 417). All of this seems relevant to our clinical picture. However, Criterion D specifies that the content of the obsessions not be restricted to another Axis I disorder (e.g. food, in the case of an Eating Disorder; drugs, in the case of a Substance Use Disorder; sexual urges or fantasies, in the case of a Paraphilia). For similar reasons Sexual Addiction should surely be excluded, despite the fact that it is not (yet) defined as an Axis I disorder. Furthermore, obsessions are defined in the DSM-IV as persistent ideas, thoughts, impulses or images that are experienced as intrusive and inappropriate and that cause marked anxiety or distress. (APA, 1994, p. 418). While, especially in the later stage of addiction, sexual addicts will partly experience sexual thoughts/fantasies in this negative way, their initial experience is a positive one, with such thoughts being fostered and encouraged rather than resisted. This is the nature of all addictive behaviour (Liese and Franz, 1996; Thombs, 1999). Similarly, while Quadland (1985) and Weissberg & Levay (1986) have pointed out that the sexual activity of sexual addicts operates to reduce anxiety and other painful affects (Goodman, 1998a, p. 12), which is the goal of compulsions as defined in the DSM-IV, it also serves to provide pleasure or gratification, a goal which is specifically excluded under the DSM definition (APA, 1994, p. 418). 5. Impulse disorders. The DSM-IV chapter entitled Impulse-Control Disorders Not Elsewhere Classified also appears to provide the possibility of a suitable home for the syndrome of Sexual Addiction. This is argued by, for example, Barth and Kinder (1987), who suggest that ' ..the sexually impulsive individual' s promiscuity is due to a lack of impulse control rather than to exaggerated desire' (p. 17). This chapter contains, amongst other disorders, Pathological Gambling, a disorder with immediately obvious structural similarities to Sexual Addiction. Its criteria include: Preoccupation with the activity; Need for increasing amounts of the activity to achieve the desired excitement; Repeated unsuccessful efforts at control; Restlessness or irritability when attempting control; Use of the activity to escape problems or negative feelings (APA, 1994). The essential feature of Impulse-Control Disorders is the failure to resist an impulse, drive, or temptation to perform an act that is harmful to the person or to others. For

most of the disorders in this section, the individual feels an increasing sense of tension or arousal before committing the act and then experiences pleasure, gratification, or relief at the time of committing the act. Following the act there may or may not be regret, self-reproach, or guilt (ibid, p. 609). According to Goodman (1998, p. 16), this description does indeed seem to accurately characterise this sexual syndrome. However, he goes on to add that At the same time, the description of impulse-control disorders not only fits this sexual syndrome; it seems to characterize substance dependence equally well. If substance dependence, which is readily acknowledged to be an addictive disorder, is also an impulse-control disorder, then a condition that meets the diagnostic criteria for impulse-control disorder is not thereby precluded from classification also as an addictive disorder (ibid.). This seems to point to some confusion on the part of the DSM-IV classification system.

We now turn to the category of Substance Dependence. 6. Substance-Related Disorders. This is the chapter in which can be found the classification Substance Dependence. This is defined separately from Substance Abuse, a distinction which does not seem to be clearly madein many approaches, including Cognitive Therapy (e.g. Beck et al, 1993; Liese and Franz, 1996). Substance Dependence (equivalent to the term ' chemical dependency' , commonly used in the addiction treatment field) is defined as a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues use of the substance despite significant substance-related problems. There is a pattern of repeated selfadministration that usually results in tolerance, withdrawal, and compulsive drug-taking behavior (APA, 1994, p. 176). Box 1 displays the full criteria for this disorder. The DSM-IV adds Although not specifically listed as a criterion item, "craving" (a strong subjective drive to use the substance) is likely to be experienced (ibid, p. 176).2

The criteria for Substance Abuse, in contrast, ' do not include tolerance, withdrawal, or a pattern of compulsive use and instead include only the harmful consequences of repeated use (ibid., p. 182).

Diagnostic Criteria for Substance Dependence (Box 1) A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period: 1) tolerance, as defined by either of the following: (a) a need for markedly increased amounts of the substance to achieve intoxication or desired effect (b) markedly diminished effect with continued use of the same amount of the substance withdrawal, as manifested by either of the following: (a) the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances) (b) the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms the substance is often taken in larger amounts or over a longer period than was intended there is a persistent desire or unsuccessful efforts to cut down or control substance use a great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects important social, occupational, or recreational activities are given up or reduced because of substance use the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption)

2)

3) 4) 5) 6) 7)

These criteria come closest to describing (specifically for drugs in this case) the more general phenomenon known to many counselors, therapists and clinicians as ' addiction' . Goodman (1998a,b,c) has therefore suggested both a general set of criteria for ' Addictive Disorder' as a syndrome (Box 2) and a specific set for Sexual Addiction (Box 3), based on the above. He suggests that: While DSM-IV does not include a behaviorally nonspecific definition of addiction, a provisional set of diagnostic criteria for addictive disorder can be derived from the DSM-IV criteria for substance dependence, which is the prototypal addictive disorder (Goodman, 1998b, p.22).

Diagnostic Criteria for Addictive Disorder (Box 2) Addictive disorder is characterized by a maladaptive pattern of behavior, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period: 1) tolerance, as defined by either of the following: a) a need for markedly increased amount or intensity of the behavior to achieve the desired effect; or b) markedly diminished effect with continued involvement in the behavior at the same level of intensity; 2) withdrawal, as manifested by either of the following: a) characteristic psychophysiological withdrawal syndrome of physiologically described changes and/or psychologically described changes upon discontinuation of the behavior; or b) the same (or a closely related) behavior is engaged in to relieve or avoid withdrawal symptoms; 3) the behavior is often engaged in over a longer period, in greater quantity or at a higher level of intensity than was intended; 4) there is a persistent desire or unsuccessful efforts to cut down or control the behavior; 5) a great deal of time is spent in activities necessary to prepare for the behavior, to engage in the behavior or to recover from its effects; 6) important social, occupational or recreational activities are given up or reduced because of the behavior; 7) the behavior continues despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the behavior.

Goodman (1998b, p. 22) also proposes the following definition of addiction: A condition in which a behavior that can function both to produce pleasure and to relieve painful affects is employed in a pattern that is characterised by two key features: (1) recurrent failure to control the behavior; and (2) continuation of the behavior despite significant harmful consequences.

Diagnostic Criteria for Sexual Addiction (Box 3) A maladaptive pattern of sexual behavior, leading to clinically significant impairment or distress, as manifested by three (or more) of the following and occurring at any time in the same 12-month period, 1) Tolerance, as defined by either of the following: a) a need for markedly increased amount or intensity of the sexual behaviour to achieve the desired effect; b) markedly diminished effect with continued involvement in the sexual behaviour at the same level of intensity. 2) Withdrawal, as manifested by either of the following: a) characteristic psychophysiological withdrawal syndrome of physiologically described changes and/or psychologically described changes upon discontinuation of the sexual behavior. b) the same (or a closely related) sexual behavior is engaged in to relieve or avoid withdrawal symptoms, 3) The sexual behavior is often engaged in over a longer period, in greater quantity or at a higher level of intensity than was intended. 4) There is a persistent desire or unsuccessful efforts to cut down or control the sexual behavior. 5) A great deal of time is spent in activities necessary to prepare for the sexual behavior, to engage in the behavior or to recover from its effects. 6) Important social, occupational or recreational activities are given up or reduced because of the sexual behavior. 7) The sexual behavior continues despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the behaviour.

Ragan and Martin (2000, p. 162) suggest that this set of criteria ' appears to accurately describe the syndrome of sexual addictionand thus has some face validity.' They also argue (ibid., p. 172) that The advantage of viewing excessive or compulsive sexual behaviors as an addiction is heuristic. It provides one with a starting point and framework within which to understand these behaviors. Goodman (1998b, p.22) also suggests that ' some significant biopsychological characteristics are shared by alcoholism, drug addiction, bulimia, pathological gambling and sexual addiction.' Schneider (1999) agrees, and adds compulsive spending to the list.

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Conclusion There is of course a real danger in trying to explain too many problematic behaviours by classifying them as addictions. Indeed, it is clear from the above discussion that inappropriate/excessive sexual behaviour may also often fall into other diagnostic categories. Schneider, one of the leading researchers in the field of sexual addiction, remarks (2004, p. 221) that Before embarking on a treatment plan, the clinician must have formulated an explanation for the excessive or inappropriate sexual behavior. It is not always sexual addiction. However, an addiction model is still one useful and important tool in looking at the phenomenon of out-of-control sexual behaviour, and the term sexual addiction is highly relevant and useful in certain cases. Most important of all, some clients seem to find the concept usefully, even excitingly, relevant to some of their more serious problems. This provides them with both a map of the territory in which they find themselves lost, and a highly motivating sense of identification with others in a similar predicament. While most clients wont be interested in the details of definition explored in this article, they certainly need us to try to clarify our own thinking in this area, so that we can meet them with more confidence in their struggle with frighteningly damaging sexual behaviours.

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Schneider, J.P. (1999) How to Recognize the signs of sexual addiction. http://angelfire.com/mi/collateral/research4.html (accessed 20/9/00) Schneider, J.P. (2004) Understanding and Diagnosing Sex Addiction. In Coombs, R. H. (ed), Handbook of Addictive Disorders. New Jersey: John Wiley & Sons. Pp. 197-232. Schneider, J.P. and Irons, R.R. (1996) Differential diagnosis of addictive sexual disorders using the DSM-IV. Sexual Addiction and Compulsivity, 3(1), 7-21. Sex and Love Addicts Anonymous (1986) Sex and Love Addicts Anonymous. Boston: SLAA Fellowship-Wide Services. Tedesco, A. and Bola, J.R. (1997) A pilot study of the relationship between childhood sexual abuse and compulsive sexual behaviors in adults. Sexual Addiction and Compulsivity. 4: 147-157. Thombs, D.L. (1999) Introduction to Addictive Behaviours. 2nd edn. New York: Guilford Press. Weissberg, J.H. and Levay, A.N. (1986) Compulsive Sexual Behavior. Medical Aspects of Human Sexuality, 20:127-128. Wincze, J.P. & Carey, M.P. (1991) Sexual Dysfunction: a guide for assessment and treatment. New York: Guilford Press.

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