You are on page 1of 93

Sexual Compulsivity and Addiction With

Drs. Pat Carnes and Ken Rosenberg

Directors: Ken Rosenberg, M.D.
Patrick Carnes, Ph.D.
Date: Saturday, May 3, 2014
Time: 1 PM - 5 PM
Location: New York Hilton Midtown
Mercury Ballroom

Seminar 3
American Psychiatric Association New York, NY, May 3 - 7, 2014 167th Annual Meeting

Agenda
The materials contained in this packet were submitted
and reviewed by the course /seminar director(s) and
were correct at the time of print. Any changes to the
material that were made after the review deadline
are the responsibility of the course/seminar director(s).

Sex Addiction Assessment and Treatment

AGENDA:

Patrick Carnes, PhD (80 mins.)
Break (15 mins.)
Ken Rosenberg, MD: Presentation and Videotape Cases (25 mins.)
Open Discussion about Cases and General Q & A (60 mins.)

 

. Any changes to the material that were made after the review deadline are the responsibility of the course/seminar director(s). Outline The materials contained in this packet were submitted and reviewed by the course /seminar director(s) and were correct at the time of print.

* Discuss the substantial similarities between substances of abuse disorders and the behavioral addictions of pathological gambling and internet addiction. individuals will learn about theoretical changes in the DSM V. Identifying the danger signs. Rosenberg’s presentation. assessment of the 10 types of sex addiction. while end-stage addiction results primarily from anterior cingulate and orbitofrontal glutamatergic projections to the nucleus accumbens. * Discuss how environmental cues previously paired with morphine. intervention. . and treatment methods are outlined. consequences of addiction and dependency. Session Objectives: * To introduce diagnostic criteria for sexual addiction * To understand the evolution and research of the Sexual Addiction Screening Test-Revised (SAST-R) * To utilize the SAST-R in a clinical setting * To describe the PATHOS. and boundaries are examined. PhD In this session. protein kinase M zeta (PKMzeta). Rosenberg will also review the neurobiological and theoretical bases for sexual compulsivity and addiction. Session Objectives: * Discuss proposals for DSM V diagnoses related to sexual compulsivity and addiction. in the nucleus accumbens core of rats. a sexual addiction screening test being developed for physician use * To introduce the Sexual Dependency Inventory – Revised (SDI-R) * To describe gender differences and co-occurring patterns of sexual anorexia * To provide overview of Cybersex and Internet pornography * To provide overview of sex addiction treatment * To describe evidenced-based data about recovery * To introduce the concept of task-centered therapy * To specify the research and conceptual foundations of a task centered approach to therapy * To understand task one including performables and therapist competencies Outline .Outline .Ken Rosenberg. and discuss how this theory may apply to behavioral addictions. bonding.Patrick Carnes. MD In Dr. Family structures. * Review the theory of how dopamine is critical for acute reward and initiation of addiction. cocaine or high-fat food (but not opiate withdrawal symptoms) were abolished by inhibition of the protein kinase C isoform. individuals will learn about the history and a general overview of sexual addiction. Dr. which will add the subcategory of behavioral addictions.

* Review how the practices of addiction psychiatry may be adapted to treat sexual compulsivity and behavioral addictions.   .* To describe SPECT and f-MRI scans of human subjects during sexual excitement suggest that similar structures are involved in sexual compulsivity and addiction.

Any changes to the material that were made after the review deadline are the responsibility of the course/seminar director(s). Slides The materials contained in this packet were submitted and reviewed by the course /seminar director(s) and were correct at the time of print. .

Sexual Addiction,
Assessment & Treatment
Patrick J. Carnes, PhD
& Ken Rosenberg, MD

©2010 Patrick J. Carnes, PhD

The Family Component
Most
addicts
come from
families with
addicts and
most have
less than
optimum
attachment
styles
© 2010

Circumplex Model by David Olsen

© 2010
Copyright D.H. Olson

Abuse/Early Trauma Most addicts report some type of abuse during childhood. © 2010 . Teicher’s work has shown us how this abuse changes the brain and how it works forever.

Sexual Addiction Criteria This is how we define a problem area…it has nothing to do with “amount” or “number of times” a person has sex or masturbates. © 2010 .

Carnes. PhD .10 Diagnostic Criteria for Addiction ©2010 Patrick J.

Loss of Control Clear behavior in which you do more than you intend or want. PhD . Carnes. ©2010 Patrick J.

Carnes. PhD . ©2010 Patrick J.Compulsive Behavior A pattern of out of control behavior over time.

PhD . Efforts to Stop Repeated specific attempts to stop the behavior which fail. Carnes. ©2010 Patrick J.

PhD . ©2010 Patrick J. Loss of Time Significant amounts of time lost doing and/or recovering from the behavior. Carnes.

Carnes. Preoccupation Obsessing about or because of the behavior. PhD . ©2010 Patrick J.

and friends. PhD . Inability to Fulfill Obligations The behavior interferes with work. family. Carnes. school. ©2010 Patrick J.

physical). ©2010 Patrick J. legal. Carnes. PhD . financial. Continuation Despite Consequences Failure to stop the behavior even though you have problems because of it (social.

©2010 Patrick J. Carnes. more frequent. Escalation Need to make behavior more intense. or more risky. PhD .

Carnes. ©2010 Patrick J. limiting. relationships. family. and work. or sacrificing valued parts of life such as hobbies. Losses Losing. PhD .

anxiety. or physical discomfort. PhD . irritability. Carnes. Withdrawal Stopping behavior causes considerable distress. restlessness. ©2010 Patrick J.

The Addictive Cycle Belief System Unmanageability Impaired Thinking Addictive Cycle Preoccupation Shame Despair Ritualization Guilt Compulsive Behavior © 2008 © 2010 .

Trauma Factors These are some of the factors that therapists look at when looking for the etiology of the problem… © 2010 .

© 2010 . Sexual Behaviors Here are ways in which people act out when having a problem with sexual addiction.

© 2010 . Ph.D. Origins of the Ten Types A total of 10 “types” of sexually compulsive behavior emerged in the sex addicts surveyed by Patrick Carnes.

Carnes. PhD . The Ten Types of Sex Addiction ©2010 Patrick J.

a series of 114 sexual behaviors was statistically analyzed. PhD . Carnes. A total of 10 “types” of sexually compulsive behavior emerged in the sex addicts surveyed. ©2010 Patrick J.Research of the 10 Types In the original research conducted for Don’t Call It Love.

PhD . and situations. relationships. Fantasy Sex Sexually charged fantasies. Arousal depends on sexual possibility. ©2010 Patrick J. Carnes.

PhD . Seductive Role Sex Seduction of partners. Arousal is based on conquest and diminishes rapidly after initial contact. Carnes. ©2010 Patrick J.

PhD . ©2010 Patrick J. Voyeuristic Sex Visual arousal. The use of visual stimulation to escape into obsessive trance. Carnes.

Sexual arousal stems from reaction of viewer whether shock or interest. Carnes. PhD . ©2010 Patrick J. Exhibitionistic Sex Attracting attention to body or sexual parts of the body.

Paying for Sex Purchasing of sexual services. ©2010 Patrick J. PhD . Arousal is connected to payment for sex. Carnes. and with time the arousal actually becomes connected to the money itself.

Arousal is based on gaining control of others by using sex as leverage. PhD . Carnes. Trading Sex Selling or bartering sex for power. ©2010 Patrick J.

Sexual arousal occurs by violating boundaries with no repercussions. ©2010 Patrick J. PhD . Carnes. Intrusive Sex Boundary violation without discovery.

Carnes. Anonymous Sex High-risk sex with unknown persons. Arousal involves no seduction or cost and is immediate. ©2010 Patrick J. PhD .

Pain Exchange Sex Being humiliated or hurt as part of sexual arousal. ©2010 Patrick J. or sadistic hurting or degrading another sexually. PhD . Carnes. or both.

Carnes. Arousal patterns are based on target “types” of vulnerability. ©2010 Patrick J. PhD . Exploitive Sex Exploitation of the vulnerable.

© 2010 . Other Addictions Co-morbid or co- occurring addictions are very high.

Sex Addiction
Co-morbidity

©2010 Patrick J. Carnes, PhD

Gambling (N=103)

100% 83%

48%

50% 31%

0%

Sexual Addiction Sexual Anorexia Both

© 2010

Alcoholism (N=740)

100%
80%

52%

50% 33%

0%

Sexual Addiction Sexual Anorexia Both

© 2010

Substance Abuse (N=664) 100% 82% 49% 50% 33% 0% Sexual Addiction Sexual Anorexia Both © 2010 .

Eating Disorder (N=213) 100% 65% 66% 50% 33% 0% Sexual Addiction Sexual Anorexia Both © 2010 .

Addiction Interaction Gambling Eating Disorder 100% 100% 50% 50% 0% 0% Sexual Addiction Sexual Anorexia Both Sexual Addiction Sexual Anorexia Both Alcoholism Substance Abuse 100% 100% 50% 50% 0% 0% Sexual Addiction Sexual Anorexia Both Sexual Addiction Sexual Anorexia Both © 2010 .

Addiction Interaction It is important to treat all of the addictions and to understand how they are linked together © 2010 .

Carnes. PhD .Sexual Addiction Assessment ©2010 Patrick J.

and community groups. the SAST-R provides a profile of responses which help to discriminate between addictive and non-addictive behavior.SexHelp. treatment programs. © 2010 . Developed in cooperation with hospitals. private therapists.com. Initial Assessment Sexual Addiction Screening Test – Revised (SAST-R) available on www. Comprised of 45 yes or no questions. Designed to assist in the assessment of sexually compulsive behavior which may indicate the presence of sex addiction.

SDI-R Categories Outline Demographics Sexual Addiction Screening Test (SAST) The Ten Sexual Addiction Types Scales Consequences Scales  Family/Friends  Financial/Business  Legal  Preoccupation/Loss of Control • Motivation for Change Scale © 2010 .

dynamic issues. E – Score = Ever or historical problem behaviors. © 2010 . SDI-R Scoring C – Score = Current problem behaviors. static issues.

Presentation of Sexual Issues Diagnosis & Treatment Pattern for Compulsive In-depth Sexual History Date from Sexual Behavior Family/Employer Pattern Situational Compulsive Other Mental Issues • Repetitive cycles • Mood disorders • Efforts to stop • Anxiety disorders • Resulting life problems • Abnormal personality traits • Other addictions Inpatient Outpatient • Suicidality • Commitment to therapy • Failure to stop • Support of family • Risk to self or others • Periods of abstinence from self-destructive sexual behavior Task-Centered Therapy © 2010 .

Carnes.Sexual Addiction Treatment Using the Task Centered Approach ©2010 Patrick J. PhD .

4 Sexual Addiction in Reference Manual) Type of Treatment Helpful Not Helpful Inpatient Treatment 35% 2% Outpatient Group 27% 7% After Care (Hospital) 9% 5% Individual Therapy 65% 12% Family Therapy 11% 3% Couples Therapy 21% 11% 12-Step Group (SA based) 85% 4% 12-Step Group (Other) 55% 8% Sponsor 61% 6% Partner Support 36% 6% Higher Power 87% 3% Friends’ Support 69% 4% Celibacy Period 64% 10% © 2010 Exercise/Nutrition 58% 4% . Treatment Choices (Refer to article 18.

The Stages of Recovery © 2010 .

Recovery Over Time WORSE BETTER BETTER 2ND 6 MONTHS 2ND/3RD YEARS 3 YEARS PLUS Sex addiction relapse Financial situation* Healthy sexuality Health Status Coping with stress* Primary relationship Spirituality Relationship w/ family of origin Career Status* Relationship w/ children Friendships* Life satisfaction * Continue to improve three-years plus © 2010 .

The Course of Recovery Over Time PRERECOVERY YEAR 1 YEAR 2 YEAR 3 YEAR 4 YEAR 5 DEVELOPING STAGE Up to 2 years © 2010 .

Sub-Stages of the Developing Stage Ambivalence Recognition Despair © 2010 .

© 2010 . The Course of Recovery Over Time PRERECOVERY YEAR 1 YEAR 2 YEAR 3 YEAR 4 YEAR 5 DEVELOPING STAGE Up to 2 years CRISIS/DECISION STAGE 1 day to 3 months SHOCK STAGE About 8 months GRIEF STAGE 4 to 8 months REPAIR STAGE 18 to 36 months GROWTH STAGE 2 years and cont.

Fifth Year Repair 5 6 Growth © 2010 . Third Year Repair 5 6 Growth Developing 1 2 Crisis/Decision Stage Mix in Recovery 3 Shock 4 Grief 3. Developing 1 2 Crisis/Decision 3 Shock 4 Grief Repair 5 1. Early First Year 6 Growth 1 Developing 2 Crisis/Decision 3 Shock 4 Grief 2.

Using the Tasks Individual Therapy Group Therapy Twelve Step Meeting Sponsor Steps One through Nine Family Participation Family Recovery Couples Recovery Exercise/Nutrition © 2010 .

urges. Sexual Behavior Wit h Consent ing Ad ult s. [ 16 ] ( 3 ) R epet iti vely engagin g in sexual f antas ies. bor edom. Specif y if: Mastu rbatio n. Telephone Sex. Fifth Edition (DSM V) . and behavior are n ot d ue to direct physiolog ical effe ct s of e xogenous substa nces (e . No S igns or S ym pto ms of th e Disord er Were Present ) In a Cont ro lled Env ironment (Kafka. urges. irritabi lity ). [ 18 ] ( 5 ) R epet iti vely engagin g in sexual b ehavior while disregard ing t he risk f or phy sical or em ot ional harm t o self or o th ers. St rip Clubs. sexual urges. d epression. 2010) Sexual and Gender Identity Disorders Working Group for the Diagnostic and Statistical Manual of Mental Disorders. recurr ent and i nt ense sexual f anta sies.g. Jour Sex and Marital Therapy. Over a period of at least six month s.Hyp ersexual Disorder A. These sexual f anta sies. [ 21 ] D. M P. Pornogra phy . and behavior. There is c linically signif icant perso nal dist ress or imp airment in social. T he person is at least 18 years of age. [ 15 ] ( 2 ) R epet iti vely engagin g in th ese sexual f antas ies. [ 20 ] C.. Ot her: Specif y if : In Remission (During th e Past S ix Month s. drugs of abuse or med icat ions) or t o Manic Episodes.. and sexual behavior in associat ion wit h f our or mor e of t he f ollowing f ive crit eria: (1) Excessive t ime is consumed by sexual f antas ies and urges. [ 19 ] B. urg es. oc cupati onal or o th er imp orta nt areas of fu nctio ning associat ed w it h t he fr equency and int ensity of t hese sexual f antas ies. 36:276-281. anxiety . and behavior i n response to str essf ul lif e eve nt s. and b ehavior i n respo nse t o dysphoric mood st at es (e . Cyb ersex. and b ehavior . urges. urges. MP Arch Sex Behav (2010) 39:377-400) (Kafka. [ 17 ] ( 4 ) R epet iti ve but unsuccessf ul eff ort s to c ontrol or signif icantl y reduce t hese sexual f antas ies. and by planning f or a nd engagi ng in sexual behavior.g.

has jeopardized or lost a significant relationship. is restless or irritable when attempting to cut down or stop gambling 5. depression) 6. gambles as a way of escaping from problems or of relieving a dysphoric mood (e. preoccupied with reliving past gambling experiences.. or thinking of ways to get money with which to gamble 2. is preoccupied with gambling (e. or others to conceal the extent of involvement with gambling 8. relies on other to provide money to relieve a desperate financial situation caused by gambling .g. after losing money gambling. Persistent and recurrent maladaptive gambling behavior as indicated by five (or more) of the following: 1. job. or stop gambling 4. feelings of helplessness.Disordered Gambling A. guilt. anxiety. needs to gamble with increasing amounts of money in order to achieve the desired excitement 3. has repeated unsuccessful efforts to control. cut back. often returns another day to get even (“chasing” one’s losses) 7. or educational or career opportunity because of gambling 9. handicapping or planning the next venture. therapist. lies to family members.g..

Concep t ually. t he diagnosis is a comp ulsive-im pulsive spect rum disorder t hat involves online and/ or of f line compute r usage and con sist s of at l east t hree subt ypes: exces sive gaming. poo r achievement . lying. including fee lings of anger. and f at igue Editor ial. and/ or depression when t he compute r is inacce ssible. or more hours of use. t ension.07101556 © 2008 American Psychiatri c Associati on . sexual preoccu pat ions. 3 ) t olerance. and e-m ail/t ext messaging. and 4 ) negat ive reperc ussions. 2 ) wit hdrawal. All of t he variant s share t he fo llowing fo ur component s: 1 ) exces sive use. more sof t ware.ajp.Inte rnet addict ion appears t o be a comm on disorder t hat merits inclusion in DSM-V. Am J Psychiatry 165 :306-307 . of t en assoc iat ed wit h a loss of sense of t ime or a neglect of basic drives. including arg ument s. soc ial isolat ion. including t he need fo r bet t er compute r equipm ent.1176 / appi.2007. Marc h 2008 doi: 10.

th e wo rk grou p is addr essing th e disorder patho logical gambling. o pioids. Finally. wh ich is current ly list ed und er th e diagno st ic cat ego ry I mpulse-Cont rol Disord ers Not Elsewh ere Classif ied.The Subst ance-Relat ed D isord ers Wor k Gro up… h as pro posed to t ent at ively re-t it le t he c at egory. o ut -of -cont rol drug u se has been p rob lem at ic. ( APA WEB SITE) . Th e wo rk grou p had ext ensive d iscussions on t he u se of th e word “ add ict ion. The pr esence o f t olerance and w ithdr awal sympt oms are not c ount ed as sym pto ms t o be count ed f or th e diagnosis of su bst ance u se d isord er wh en oc curr ing in th e cont ext of app ropr iat e medical t reat ment wit h pr escr ibed me dicat ions. It has been confu sing to ph ysicians and h as r esult ed in pat ient s wit h normal to lerance and wi t hdr awal being labeled a s “ addicts. a nt i-anxiet y agent s and oth er d rugs. ” This has also result ed in pat ients s uf f ering f rom severe p ain having a dequat e do ses of o pioids withh eld because of fe ar of pro ducing “ addict ion. wh ich is a normal response to r epeat ed d oses of many medicat ions including beta - blockers. Add ict ion and Relat ed Disorders.” Th ere w as general agreem ent t hat “ dependence” as a label f or co mpulsive. th e w ord “ dependence” is now limit ed to physiological dependence. ant idepr essants. ” Acc ord ingly.

ÓAm J Psychiatry 2005. diminishing cognitive control (choice) and enhancing glutamatergic drive in response to drug-associated stimuli.Kenneth Paul Rosenberg. MD Neurobiology Review: 1. Dopamine (from the ventral tegmental area to the nucleus accumbens) is critical for acute reward and initiation of addiction. (Kaliva PW. end-stage addiction results primarily from cellular adaptations in anterior cingulate and orbitofrontal glutamatergic projections to the nucleus accumbens. Volkow ND ÒThe Neural Basis of Addiction: A Pathology of Motivation and Choice. 162:1403-1413) . by decreasing the value of nautural rewards.

ÒShould addictive disorders include non-substance related conditions?ÓAPA Journal compilation. There are substantial similarities between the behavioral addiction of pathological gambling and substances of abuse disorders. 2006 Society of the Study of Addiction. Addiction 101. MD Neurobiology Review: 2. a reward deficiency model of lower normal activation of this area: the D2A1 allele of the D2 dopmaine receptor gene (DRD2)Ó has been implicated in pathological gambling.Kenneth Paul Rosenberg.. (Potenza.(Suppl 1) 142-151) . M N. Naltrexone and longer acting Nalmefene (with less liver toxicity) indirectly affect the mesolimibc dopamine system. helping both alcohol addiction and pathological gambling. In chromosomal linkage studies.

et al. cocaine or high-fat food (but not opiate withdrawal symptoms) were abolished by inhibition of the protein kinase C isoform. ÒInhibition of PKMzeta in nucleus accumbens core abolishes long-term drug reward memoryÓIn submission. (Li. protein kinase M zeta (PKMzeta). Environmental cues previously paired with morphine. PKMzeta activity in the accumbens core is a critical cellular substrate for the maintenance of memories of reward cues. PKM Zeta is a molecule that is sufficient and necessary for the consolidation of memories Ğ a process known as long-term potentiation (or LTP. MD Neurobiology Review: 3. 2007).) (Sacktor. in the nucleus accumbens core of rats.) . Interfering with this memory molecule causes rats to ÒforgetÓlongĞterm addiction-related cues. Kenneth Paul Rosenberg.

Kenneth Paul Rosenberg. J Sex Marital Ther 2003. while women respond more thoughtfully.differences between male and female brains-. Numerous studies demonstrated that lesions of the lateral orbitofrontal cortex cause impulsive tendencies. concordance of womenÕs genital and subjective sexual arousal. Gizewski found increased brain activation in females during midluteal phase.. aiding in the person experiencing a Ôloss of controlÕduring orgasm. van Lunsen RH. to the point of orgasm. In fact. Giorgiadis found men are more responsive than women to sexually explicit material in the activation of the lower brain systems.29:15Ğ23. Laan E. relates to the degree of sexual control. and especially the orbitofrontal cortex. 2. Sexual dimorphism -.may account for differences in sexual compulsivity. Concordance between womenÕs physiological and subjective sexual arousal is associated with consistency of orgasm during intercourse but not other sexual behavior. women show more activation of the left frontoparietal regions.33: 31Ğ9. and erotic stimulus presentation sequence. During orgasm. areas involved in mental representations. 1. During arousal. Giogiadis found blood flow in the prefrontal cortex. There is also less concordance between subjective arousal and the objection signs of arousal in females such as lubrication and engorgement (Brody S. namely the amygdala and possibly hypothalamus. SPECT and f-MRI scans of human subjects during sexual excitement suggest that similar structures are involved in sex and addiction. the female brain reacts similarly to the male.) Gender similarities are greater than the differences. MD Neurobiology Review: 4. The suggests that males are more reactive to sexually arousing material. Orbitofrontal cortex is also the key area cited by Volkow as critical in modulating craving and decision-making in chemical addiction. Brody S. empathy and prespective. Intercourse orgasm consistency. Giorgiadis found that the frontal lobe blood flow is decreased. Once sex proc eeds beyond arousal. . including hypersexuality. J Sex Marital Ther 2007.

These packages can be unbundled and each addiction approached separately.. with ulnerabilities such as the need to maintain constant set points (homeostasis) and constant specific levels of critical biological parameters (allostasis). CarneÕs clinically-based Addiction Interaction Disorder allows for multiple addictive behaviors to exist as part of a single illness. 2008 31 415-487) 6. In Mihaly Csiksz entmihalyÕ s 1990 book ÒFlow: The Psychology of Optimal Experience. Yet equally important is that they can approached as a whole. Computational theory supports the potential for behavioral addictions. MD Neurobiology Review: 5.Ó Carnes notes that addiction is a Òphantom optimal experienceÓand a Òperversion of flowÓ. Murray. PJ. reinforce and become part of one another. ÒA unified framewarok for addiction: Vulnerabilities in the decision processÓ Behavioral and Brain Sciences. Charpentier. which is the current level of practice. Johnson A.Ó (ÒBargains with Chaos: Sex Addicts and Addiction Interaction Disorder. R E. They in fact. Carnes writes. interact.Óthe ultimate Attention Deficit Disorder. RedishÕ computational model accounts for ÒvulnerabilitiesÓin the planning or habit systemsÊof the brain. as well as vulnerabilities in assessment and searching functions of the brains which can be linked to those anatomical centers which receive dopaminertic input from the ventral tegmental areas and input from the opioid systems.ÓCarnes. (Redish. L) . he writes that the addict becomes a Òcaptive of a certain order. AD. Kenneth Paul Rosenberg. become packages. ÒWhat it means is that addictions do more than co-exist. Jensen S.Ó 7. in effect. They.

Grant and Steinberg found that 19. Sexual behavior and gambling. 40% of heterosexual women.685. 69% of men.05 and avoidance F(1. 79% of women and 80% of gay men with sex addiction fit the diagnostic criteria for other addictions. 70. p < . and 60% of homosexual men engage in sexual acting out while simultaneously involved in other addictions. (Grant. Chemical addictions are incorporated into sex addiction behaviors. 38) = 6.122.05 in their romantic relationships. 37) = 4.) . Kenneth Paul Rosenberg. There was no association with chemical addiction. Among 225 male and female outpatients who met American Psychiatric Association criteria for pathological gambling. p < . Among the subjects with both conditions. Sex addiction co-occurs with sexual disorders such as sexual aversion or sexual anorexia. Sexual Addiction and Compulsivity 12:235-244.6% also met criteria for compulsive sexual behavior. Further evidence for Addiction Interaction Disorder: 1. JE Steinberg MA. 4. 2. 40% of heterosexual men.5 % developed compulsive sexual behavior first. 2005. 3. Sexually addicted men were found to have higher anxiety F(1. MD Neurobiology Review: 8.

MD Clinical Associ at e Profe ssor. Psyc hiat ry Cornell Medical College/ New Yor k Presbyt erian Hospit al . Kennet h Paul Rosenberg.

(2) Repetitively engaging in these sexual fantasies. C. Cybersex. and sexual behavior in association with four or more of the following five criteria: (1) Excessive time is consumed by sexual fantasies and urges.ÊThere is clinically significant personal distress or impairment in social. No Signs or Symptoms of the Disorder Were Present) In a Controlled Environment Kafka. anxiety. urges. urges. and behavior in response to dysphoric mood states (e.ÊThese sexual fantasies.ÊThe person is at least 18 years of age. depression. (4)ÊRepetitive but unsuccessful efforts to control or significantly reduce these sexual fantasies. 2010 Sexual and Gender Identity Disorders Working Group for the Diagnostic and Statistical Manual of Mental Disorders.. Telephone Sex. (5)ÊRepetitively engaging in sexual behavior while disregarding the risk for physical or emotional harm to self or others. and behavior are not due to direct physiological effects of exogenous substances (e. M P. urges. and behavior. boredom. urges. Other:Ê Specify if: InÊRemission (During the Past Six Months. Strip Clubs.g. irritability). Jour Sex and Marital Therapy.Hypersexual Disorder A. drugs of abuse or medications) or to Manic Episodes. D. MP Arch Sex Behav (2010) 39:377-400) (Kafka. occupational or other important areas of functioning associated with the frequency and intensity of these sexual fantasies. and behavior in response to stressful life events. Specify if: Masturbation. sexual urges. 36:276-281. and behavior.g. and by planning for and engaging in sexual behavior.. Sexual Behavior With Consenting Adults. (3) Repetitively engaging in sexual fantasies. B. recurrent and intense sexual fantasies.ÊÊÊOver a period of at least six months. Fifth Edition (DSM V) . Pornography. urges.

therapist. or educational or career opportunity because of gambling 9. lies to family members.Disordered Gambling A. or others to conceal the extent of involvement with gambling 8.. has jeopardized or lost a significant relationship. anxiety. needs to gamble with increasing amounts of money in order to achieve the desired excitement 3. guilt.g. gambles as a way of escaping from problems or of relieving a dysphoric mood (e. after losing money gambling. preoccupied with reliving past gambling experiences. or thinking of ways to get money with which to gamble 2.Êis preoccupied with gambling (e.. feelings of helplessness. often returns another day to get even (ÒchasingÓoneÕsosses) l 7. is restless or irritable when attempting to cut down or stop gambling 5. cut back.g. job. has repeated unsuccessful efforts to control. depression) 6. or stop gambling 4.ÊÊÊPersistent and recurrent maladaptive gambling behavior as indicated by five (or more) of the following: 1. relies on other to provide money to relieve a desperate financial situation caused by gambling . handicapping or planning the next venture.

including arg ument s. soc ial isolat ion.Inte rnet addict ion appears t o be a comm on disorder t hat merits inclusion in DSM-V. or more hours of use. Concep t ually. 2 ) wit hdrawal.1176 / appi.ajp. t ension. including fee lings of anger. and e-m ail/t ext messaging. and 4 ) negat ive reperc ussions. Marc h 2008 doi: 10. 3 ) t olerance. sexual preoccu pat ions. All of t he variant s share t he fo llowing fo ur component s: 1 ) exces sive use. t he diagnosis is a comp ulsive-im pulsive spect rum disorder t hat involves online and/ or of f line compute r usage and con sist s of at l east t hree subt ypes: exces sive gaming. including t he need fo r bet t er compute r equipm ent.07101556 © 2008 American Psychiatri c Associati on .2007. Am J Psychiatry 165 :306-307 . poo r achievement . more sof t ware. lying. of t en assoc iat ed wit h a loss of sense of t ime or a neglect of basic drives. and f at igue Editor ial. and/ or depression when t he compute r is inacce ssible.

ant idepr essants. wh ich is a normal response to r epeat ed d oses of many medicat ions including beta - blockers. Finally.The Subst ance-Relat ed D isord ers Wor k Gro up… h as pro posed to t ent at ively re-t it le t he c at egory. Add ict ion and Relat ed Disorders. ” Acc ord ingly. Th e wo rk grou p had ext ensive d iscussions on t he u se of th e word “ add ict ion. th e w ord “ dependence” is now limit ed to physiological dependence. wh ich is current ly list ed und er th e diagno st ic cat ego ry I mpulse-Cont rol Disord ers Not Elsewh ere Classif ied. o pioids. ” This has also result ed in pat ients s uf f ering f rom severe p ain having a dequat e do ses of o pioids withh eld because of fe ar of pro ducing “ addict ion. The pr esence o f t olerance and w ithdr awal sympt oms are not c ount ed as sym pto ms t o be count ed f or th e diagnosis of su bst ance u se d isord er wh en oc curr ing in th e cont ext of app ropr iat e medical t reat ment wit h pr escr ibed me dicat ions. a nt i-anxiet y agent s and oth er d rugs.” Th ere w as general agreem ent t hat “ dependence” as a label f or co mpulsive. It has been confu sing to ph ysicians and h as r esult ed in pat ient s wit h normal to lerance and wi t hdr awal being labeled a s “ addicts. ( APA WEB SITE) . th e wo rk grou p is addr essing th e disorder patho logical gambling. o ut -of -cont rol drug u se has been p rob lem at ic.

Kenneth Paul Rosenberg. diminishing cognitive control (choice) and enhancing glutamatergic drive in response to drug-associated stimuli. Volkow ND ÒThe Neural Basis of Addiction: A Pathology of Motivation and Choice. MD Neurobiology Review: 1. 162:1403-1413) . (Kaliva PW. Dopamine (from the ventral tegmental area to the nucleus accumbens) is critical for acute reward and initiation of addiction. by decreasing the value of nautural rewards.ÓAm J Psychiatry 2005. end-stage addiction results primarily from cellular adaptations in anterior cingulate and orbitofrontal glutamatergic projections to the nucleus accumbens.

. ÒShould addictive disorders include non-substance related conditions?ÓAPA Journal compilation. Addiction 101.Kenneth Paul Rosenberg. There are substantial similarities between the behavioral addiction of pathological gambling and substances of abuse disorders. Naltrexone and longer acting Nalmefene (with less liver toxicity) indirectly affect the mesolimibc dopamine system. M N. MD Neurobiology Review: 2. 2006 Society of the Study of Addiction.(Suppl 1) 142-151) . (Potenza. a reward deficiency model of lower normal activation of this area: the D2A1 allele of the D2 dopmaine receptor gene (DRD2)Ó has been implicated in pathological gambling. In chromosomal linkage studies. helping both alcohol addiction and pathological gambling.

2007).Kenneth Paul Rosenberg. in the nucleus accumbens core of rats.) . MD Neurobiology Review: 3. PKMzeta activity in the accumbens core is a critical cellular substrate for the maintenance of memories of reward cues. PKM Zeta is a molecule that is sufficient and necessary for the consolidation of memories Ğ a process known as long-term potentiation (or LTP. ÒInhibition of PKMzeta in nucleus accumbens core abolishes long-term drug reward memoryÓIn submission. protein kinase M zeta (PKMzeta). Interfering with this memory molecule causes rats to ÒforgetÓlongĞterm addiction-related cues. et al. Environmental cues previously paired with morphine.) (Sacktor. (Li. cocaine or high-fat food (but not opiate withdrawal symptoms) were abolished by inhibition of the protein kinase C isoform.

During orgasm. 1. During arousal. 3. relates to the degree of sexual control. SPECT and f-MRI scans of human subjects during sexual excitement suggest that similar structures are involved in sex and addiction.. Orbitofrontal cortex is also the key area cited by Volkow as critical in modulating craving and decision-making in chemical addiction. and especially the orbitofrontal cortex. aiding in the person experiencing a Ôloss of controlÕduring orgasm. MD Neurobiology Review: 4.may account for differences in sexual compulsivity. 2. including hypersexuality. . The suggests that males are more reactive to sexually arousing material. to the point of orgasm. Sexual dimorphism -. the female brain reacts similarly to the male. Once sex proceeds beyond arousal. while women respond more thoughtfully. women show more activation of the left frontoparietal regions. Gizewski found increased brain activation in females during midluteal phase. Giorgiadis found that the frontal lobe blood flow is decreased. Gender similarities are greater than the differences.Kenneth Paul Rosenberg. In fact. namely the amygdala and possibly hypothalamus. Giogiadis found blood flow in the prefrontal cortex. empathy and prespective. There is also less concordance between subjective arousal and the objection signs of arousal in females such as lubrication and engorgement.differences between male and female brains-. Giorgiadis found men are more responsive than women to sexually explicit material in the activation of the lower brain systems. Numerous studies demonstrated that lesions of the lateral orbitofrontal cortex cause impulsive tendencies. areas involved in mental representations.

Óthe ultimate Attention Deficit Disorder. Murray. (Redish. which is the current level of practice. ÒA unified framewarok for addiction: Vulnerabilities in the decision processÓ Behavioral and Brain Sciences.Ó Carnes notes that addiction is a Òphantom optimal experienceÓand a Òperversion of flowÓ. CarneÕs clinically-based Addiction Interaction Disorder allows for multiple addictive behaviors to exist as part of a single illness. he writes that the addict becomes a Òcaptive of a certain order. They. ÒWhat it means is that addictions do more than co-exist. Yet equally important is that they can approached as a whole. They in fact. L) .Kenneth Paul Rosenberg. Johnson A. reinforce and become part of one another. R E. interact. as well as vulnerabilities in assessment and searching functions of the brains which can be linked to those anatomical centers which receive dopaminertic input from the ventral tegmental areas and input from the opioid systems. Charpentier.Ó 7. Carnes writes. PJ.. Jensen S. 2008 31 415-487) 6.ÓCarnes. with ulnerabilities such as the need to maintain constant set points (homeostasis) and constant specific levels of critical biological parameters (allostasis). In Mihaly Csiksz entmihalyÕ s 1990 book ÒFlow: The Psychology of Optimal Experience. These packages can be unbundled and each addiction approached separately. RedishÕ computational model accounts for ÒvulnerabilitiesÓin the planning or habit systemsÊof the brain.Ó (ÒBargains with Chaos: Sex Addicts and Addiction Interaction Disorder. AD. in effect. Computational theory supports the potential for behavioral addictions. become packages. MD Neurobiology Review: 5.

6% also met criteria for compulsive sexual behavior. Sexual behavior and gambling. Sexually addicted men were found to have higher anxiety F(1. 40% of heterosexual women. 37) = 4.Kenneth Paul Rosenberg.05 in their romantic relationships. 3. Among the subjects with both conditions. Grant and Steinberg found that 19. MD Neurobiology Review: 8.05 and avoidance F(1. p < . Further evidence for Addiction Interaction Disorder: 1.5 % developed compulsive sexual behavior first. Sex addiction co-occurs with sexual disorders such as sexual aversion or sexual anorexia. Among 225 male and female outpatients who met American Psychiatric Association criteria for pathological gambling. 4. 79% of women and 80% of gay men with sex addiction fit the diagnostic criteria for other addictions. 2.122. 70. Sexual Addiction and Compulsivity 12:235-244. and 60% of homosexual men engage in sexual acting out while simultaneously involved in other addictions. p < . 69% of men. 2005. Chemical addictions are incorporated into sex addiction behaviors. There was no association with chemical addiction.) . JE Steinberg MA. (Grant. 40% of heterosexual men.685. 38) = 6.

Dopamine (from the ventral tegmental area to the nucleus accumbens) is critical for acute reward and initiation of addiction. MD Neurobiology Review: 1. end-stage addiction results primarily from cellular adaptations in anterior cingulate and orbitofrontal glutamatergic projections to the nucleus accumbens. (Kaliva PW. Volkow ND ÒThe Neural Basis of Addiction: A Pathology of Motivation and Choice.ÓAm J Psychiatry 2005. 162:1403-1413) . diminishing cognitive control (choice) and enhancing glutamatergic drive in response to drug-associated stimuli. by decreasing the value of nautural rewards.Kenneth Paul Rosenberg.

(Potenza. Addiction 101.(Suppl 1) 142-151) . Naltrexone and longer acting Nalmefene (with less liver toxicity) indirectly affect the mesolimibc dopamine system. M N. There are substantial similarities between the behavioral addiction of pathological gambling and substances of abuse disorders. ÒShould addictive disorders include non-substance related conditions?ÓAPA Journal compilation. a reward deficiency model of lower normal activation of this area: the D2A1 allele of the D2 dopmaine receptor gene (DRD2)Ó has been implicated in pathological gambling. MD Neurobiology Review: 2. In chromosomal linkage studies..Kenneth Paul Rosenberg. 2006 Society of the Study of Addiction. helping both alcohol addiction and pathological gambling.

et al.) . PKMzeta activity in the accumbens core is a critical cellular substrate for the maintenance of memories of reward cues. ÒInhibition of PKMzeta in nucleus accumbens core abolishes long-term drug reward memoryÓIn submission. MD Neurobiology Review: 3. cocaine or high-fat food (but not opiate withdrawal symptoms) were abolished by inhibition of the protein kinase C isoform.) (Sacktor. Interfering with this memory molecule causes rats to ÒforgetÓlongĞterm addiction-related cues. PKM Zeta is a molecule that is sufficient and necessary for the consolidation of memories Ğ a process known as long-term potentiation (or LTP. Environmental cues previously paired with morphine. 2007). protein kinase M zeta (PKMzeta). (Li.Kenneth Paul Rosenberg. in the nucleus accumbens core of rats.

Giogiadis found blood flow in the prefrontal cortex. aiding in the person experiencing a Ôloss of controlÕduring orgasm. 1. to the point of orgasm.Kenneth Paul Rosenberg. Giorgiadis found that the frontal lobe blood flow is decreased. including hypersexuality. MD Neurobiology Review: 4. while women respond more thoughtfully. Sexual dimorphism -. There is also less concordance between subjective arousal and the objection signs of arousal in females such as lubrication and engorgement. In fact. . namely the amygdala and possibly hypothalamus. women show more activation of the left frontoparietal regions. and especially the orbitofrontal cortex. empathy and prespective. areas involved in mental representations. During orgasm. The suggests that males are more reactive to sexually arousing material. 2. SPECT and f-MRI scans of human subjects during sexual excitement suggest that similar structures are involved in sex and addiction. Orbitofrontal cortex is also the key area cited by Volkow as critical in modulating craving and decision-making in chemical addiction. relates to the degree of sexual control.differences between male and female brains-. Gender similarities are greater than the differences. 3. Giorgiadis found men are more responsive than women to sexually explicit material in the activation of the lower brain systems. During arousal. Once sex proceeds beyond arousal. Gizewski found increased brain activation in females during midluteal phase..may account for differences in sexual compulsivity. the female brain reacts similarly to the male. Numerous studies demonstrated that lesions of the lateral orbitofrontal cortex cause impulsive tendencies.

interact. Computational theory supports the potential for behavioral addictions.Ó (ÒBargains with Chaos: Sex Addicts and Addiction Interaction Disorder. They.ÓCarnes. (Redish. he writes that the addict becomes a Òcaptive of a certain order.Kenneth Paul Rosenberg. 2008 31 415-487) 6. PJ. become packages. in effect. Murray. L) . Johnson A. R E. reinforce and become part of one another. with ulnerabilities such as the need to maintain constant set points (homeostasis) and constant specific levels of critical biological parameters (allostasis). CarneÕs clinically-based Addiction Interaction Disorder allows for multiple addictive behaviors to exist as part of a single illness.. Carnes writes.Óthe ultimate Attention Deficit Disorder. They in fact. In Mihaly Csiksz entmihalyÕ s 1990 book ÒFlow: The Psychology of Optimal Experience. ÒA unified framewarok for addiction: Vulnerabilities in the decision processÓ Behavioral and Brain Sciences. Charpentier. ÒWhat it means is that addictions do more than co-exist.Ó 7. which is the current level of practice. as well as vulnerabilities in assessment and searching functions of the brains which can be linked to those anatomical centers which receive dopaminertic input from the ventral tegmental areas and input from the opioid systems. RedishÕ computational model accounts for ÒvulnerabilitiesÓin the planning or habit systemsÊof the brain.Ó Carnes notes that addiction is a Òphantom optimal experienceÓand a Òperversion of flowÓ. These packages can be unbundled and each addiction approached separately. AD. MD Neurobiology Review: 5. Jensen S. Yet equally important is that they can approached as a whole.

6% also met criteria for compulsive sexual behavior.122. Sexual Addiction and Compulsivity 12:235-244. Sexually addicted men were found to have higher anxiety F(1. 40% of heterosexual men. Sex addiction co-occurs with sexual disorders such as sexual aversion or sexual anorexia. 2.05 in their romantic relationships. 2005. (Grant.685. 69% of men. 3. There was no association with chemical addiction. 4.Kenneth Paul Rosenberg. Among the subjects with both conditions.5 % developed compulsive sexual behavior first.) . 37) = 4. p < . 70.05 and avoidance F(1. MD Neurobiology Review: 8. Among 225 male and female outpatients who met American Psychiatric Association criteria for pathological gambling. 40% of heterosexual women. and 60% of homosexual men engage in sexual acting out while simultaneously involved in other addictions. Grant and Steinberg found that 19. p < . Further evidence for Addiction Interaction Disorder: 1. Chemical addictions are incorporated into sex addiction behaviors. 79% of women and 80% of gay men with sex addiction fit the diagnostic criteria for other addictions. JE Steinberg MA. 38) = 6. Sexual behavior and gambling.

. Any changes to the material that were made after the review deadline are the responsibility of the course/seminar director(s).References The materials contained in this packet were submitted and reviewed by the course /seminar director(s) and were correct at the time of print.

” Am J Psychiatry 2005. Out of the Shadows: Understanding Sexual Addiction. D. Ken Rosenberg What’s in a Word? Addiction versus Dependence in DSM V. Sex and the Internet: A Guide for Clinicians.4. Pp.(Suppl 1) 142-151 Li. MN: Hazelden. MP Arch Sex Behav (2010) 39:377-400) (Kafka. J Sex Med 1743-6109. J. 2006 Society of the Study of Addiction. Sadock & Sadock. Carnes. editors. Volkow ND “The Neural Basis of Addiction: A Pathology of Motivation and Choice. Carnes. Center City. 113-140.References for Dr. PA: Lippincott.) Kafka. Williams & Wilkins.2010   . Delmonico. and Griffin. P. “Inhibition of PKMzeta in nucleus accumbens core abolishes long-term drug reward memory” In submission Salonia. R. edited by Al Cooper. 1. Carnes. Brunner-Routledge: PA. Don’t Call it Love: Recovering from Sexual Addiction. 36:276281. (1991). J. P. E. 2001). “Treatment of Internet Addiction” 2010 (in press. Sexually Addicted Families: Clinical Use of the Circumplex Model. (1989). References for Dr. “Should addictive disorders include non-substance related conditions?” APA Journal compilation. New York: Bantam Books. J. P. Sexual Addiction: Chapter 18. O’Brien.. 2010 Kaliva PW. Jour Sex and Marital Therapy. P. N. Addiction 101. M N. Philadelphia. (2001). (1983. May 2006 Tao. P. 162:1403-1413 Potenza. Volkow. A et al “Physiology of Women’s Sexual Function: Basic Knowledge and New Findings. 1992. Patrick Carnes Carnes. Comprehensive Textbook of Psychiatry. J. Vol. Carnes. (2005). Electron Ecstasy: When Cybersex Becomes the Drug of Choice. Circumplex Model: Systematic Assessment and Treatment of Families by David Olson. CP. M P. Li T-K Am J Psychiatry 163:5.

Self-Assessment The materials contained in this packet were submitted and reviewed by the course /seminar director(s) and were correct at the time of print. Any changes to the material that were made after the review deadline are the responsibility of the course/seminar director(s). .

a) 50 b) 60 c) 72 d) 81 6. a) 10 b) 20 c) 30 d) 40 4. In the task-centered approach. 1) . Exam for Sexual Addiction Dx & Tx 1. Please list the three diagnostic criteria of sexual addiction. In the original long-term study published in Don’t Call It Love _____% of addicts reported that they had been sexually abused. there are a total of _____ areas of competency that make for successful recovery. The addictive system includes: a) The belief system of the addict b) Impaired thinking c) The addictive cycle and unmanageability d) All of the above 5. a) Disengaged & Chaotic b) Rigid & Disengaged c) Separated & Flexible d) Structured & Enmeshed 2. Which of the following is not part of the stages of recovery? a) The developing stage b) The crisis/decision stage c) The repartitioning stage d) The shock stage and the grief stage e) The repair stage and the growth stage 3. The family systems of the sexual addiction are usually __________ and __________.

Please list the three “types” of sexual behavior often found in sexual addiction. DSM V is likely to include the following diagnoses a) Behavioral Addictions b) Pathological Gambling c) Hypersexual Disorder d) All of the above 10. Neurobiological theories that may account for addiction include the following: a) Nucleus Accumbens b) Orbitofrontal Cortex c) PKM Zeta d) All of the above . 1) 2) 9. 2) 3) 7. Please list the two assessments instruments that can aid with the diagnosis of sexual addiction. 1) 2) 3) 8.