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Psychosocial intervention for sexual addiction

Article in Indian Journal of Psychiatry · February 2018

DOI: 10.4103/psychiatry.IndianJPsychiatry_38_18

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REVIEW ARTICLE

Psychosocial intervention for sexual addiction

Manju George, Shreemit Maheshwari, Suhas Chandran, Suman S Rao1, Shivanand Manohar J2,
T.S.Sathyanarayana Rao2
Department of Psychiatry, J.S.S Medical College and Hospital, J.S.S University, Mysore, 1Department of Psychiatry,
Vydehi Institue of Medical Sciences and Research Centre, Bengaluru, 2Department of Psychiatry, J.S.S Medical College and
Hospital, J.S.S University, Mysore, Karnataka, India

ABSTRACT

Addiction is the term employed not only for excess consumption of substances, but also for problem behaviours like
eating disorders, pathological gambling, computer addiction and pathological preoccupation with video games and
sexual acts. No clear diagnostic criterion has been established with validity for behavioral addictions. Sexual addiction,
including addiction to pornography is not included as a separate entity because of a lack of strong empirical evidence
in this area. Different scales can be used for assessment of sexual addiction. Since there is an absence of established
diagnostic criteria, the significance of validity of these scales is doubted. Several of the questions in these scales do not
yield information about whether the diagnostic criteria are met or not. Pharmacotherapy, together with psychotherapy
proves to have a better outcome in such patients as it helps to synthesize the role of developmental antecedents, reduce
current anxiety, depression, guilt and to improve social adjustment.

Key words: Behavioural addiction, Sexual addiction, Internet addiction, psychosocial interventions

INTRODUCTION significant socio‑functional and psychological impairment.[2]

Addiction is defined as a primary and chronic condition of the
brain which stimulates the reward, motivation and memory
related circuitry. The American Society of Addiction Medicine
gave this definition in 2011 to include both substances and
behaviours.[1] The term “addiction” is commonly applied to
uncontrolled intake of substances like drugs or alcohol, sexual
addictions, problem behaviours such as eating disorders,
pathological gambling, computer addiction and pathological
preoccupation with video games. Besides this, another
emerging addiction which has captured much attention
is addiction to pornography, which is associated with
Address for correspondence: T.S.Sathyanarayana Rao,
Professor and Head, Department of Psychiatry, J.S.S Medical
College and Hospital, J.S.S University, Mysore, Karnataka, India.
E-mail: tssrao19@yahoo.com
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Website:
www.indianjpsychiatry.org
An individual who pathologically pursues reward and/or
relief either by substance use or other behaviours reflects
dysfunction in the brain reward circuitry. Behaviours
potentially affecting the reward circuitry in human brains
lead to a loss of control and other symptoms of addiction,
in at least some individuals. Studies have shown that in
behavioural addiction, underlying neural processes are similar
to substance addiction.[3] Present literature and research
emphasize that in order to make a diagnosis of behavioural
addiction, significant impairments must be present at work,
in social relationships, or in other social situations. A number
of experts believe that behavioural addictions can be
passive (e.g. television) or active (e.g. computer games), and
usually contain inducing and reinforcing features which may
contribute to the promotion of addictive tendencies.[4]
This is an open access article distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially, as long as the
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For reprints contact: reprints@medknow.com

How to cite this article: George M, Maheshwari S,

DOI:
Chandran S, Rao SS, Shivanand MJ, Sathyanarayana Rao TS.
Psychosocial intervention for sexual addiction. Indian J
10.4103/psychiatry.IndianJPsychiatry_38_18
Psychiatry 2018;60:510-3.

S510 © 2018 Indian Journal of Psychiatry | Published by Wolters Kluwer - Medknow

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George, et al.: Psychosocial interventions for sexual addiction
The existence of internet addiction was first proposed
by Ivan Goldberg, a New York psychiatrist in 1995 and
the term as such was coined by Kimberly Young of the
University of Pittsburgh. Internet dependency has most
commonly been conceptualised as a behavioural addiction,
which operates on a modified principle of classic addiction
models.[5] The labels ‘Internet Addiction’, ‘Internet Addiction
Disorder’, ‘Pathological Internet Use’ and ‘Compulsive
Internet Use’ have all been used to describe by and large
a similar concept. Two camps have formed in the area of
Internet research – 1. Internet addiction is, or should be,
established as a psychiatric disorder in its own right. 2.
Internet addiction sufferers are actually dependent on
some rewarding aspect or function of behaviour associated
with Internet use that could exist in the ‘real’ world, such
as dependent or addictive behavioural patterns related
to money or sex. Few researchers have questioned the
existence of Internet addiction as a separate entity as it is
still unclear whether it develops of its own accord, or it is
triggered by an underlying co‑morbid psychiatric illness.[6]
Pornography is also considered as another form of behavioural
addiction. It is said to be the first place boys get to know about
sex and achieve an understanding of their own whims and
desires. A survey conducted in 2004 by MSNBC.com and Elle
magazine studied 15,246 men and women. They found that
three‑fourth of the men said they had downloaded erotic films
and videos from the internet and 41% of the female population
did as well. Pornography is considered as straight forward and
easy.It provides a refuge from the tangle of sexual hassles that
teenagers face in the real world. With women also turning
towards pornography, the way the construct their fantasies
in their actual sex lives is fundamentally shifting.[7] Many
studies have been conducted across the world with regard to
adolescents and pornography addiction.
CRITERIA FOR DEFINING SEX ADDICTION
The term addiction does not appear in Diagnostic and
Statistical Manual of Mental Disorders (DSM) Fourth Edition,
Text Revision or International Classification for Diseases
10 (ICD10): A broader terminology of “sexual addiction” has
been described, but there is inconsistency in the criteria
provided by different researchers.[1] One of the main reasons
DSM‑5 has not included sex addiction is that empirical
research is not strong in this area. There have been no
nationally representative prevalence surveys using validated
criteria. Similar to Internet Gaming Disorder which is now
included in the appendix of DSM‑5, sex addiction cannot
be included until significant data have been obtained about
the defining features, reliability and validity of the criteria
and prevalence rates across the world. Researchers hence
believe that even if sex addiction does eventually make into
future editions of DSM, it will be one of the sub‑categories
of Internet Addiction Disorders rather than a separate
entity.[8]
Indian Journal of Psychiatry Volume 60 (Supplement 4), February 2018
Sexual Addiction diagnostic Criteria[9]
A. A minimum of three criteria met during a 12‑month
period:
1) Recurrent failure to resist impulses to engage in specific
sexual behaviour.
2) Frequently engaging in these behaviours to a greater
extent or longer duration than intended.
3) Persistent desire or unsuccessful efforts to stop, to
reduce, or to control behaviours.
4) Inordinate amount of time spent in obtaining sex, being
sexual, or recovering from sexual experiences.
5) Preoccupation with the behaviour or preparatory
activities.
6) Frequently engaging in the behaviour when expected
to fulfill occupational, academic, domestic, or social
obligations.
7) Continuation of the behaviour despite knowledge
of having a persistent or recurrent social, financial,
psychological, or physical problem that is caused or
exacerbated by the behaviour.
8) Need to increase intensity, frequency, number, or risk of
behaviours to achieve the desired effect or diminished
effect with continued behaviours at the same level of
intensity, frequency, number, or risk.
9) Giving up or limiting social, occupational, or recreational
activities.
10) Distress, anxiety, restlessness, or irritability if unable to
engage in the behaviors.
B. Has significant personal and social consequences (such as
loss of partner, occupation, or legal implications).
Diagnostic criteria for behavioral addiction as proposed by
Goodman 1990 in a format similar to DSM III R:[10]
A) Recurrent failure to resist impulses to engage in a
specified behaviour.
(B) Increasing sense of tension immediately prior to
initiating the behaviour.
(C) Pleasure or relief at the time of engaging in the
behaviour.
(D) A feeling of lack of control while engaging in the
behaviour.
(E) At least five of the following: (1) frequent preoccupation
with the behaviour or with activity that is preparatory
to the behaviour (2) frequent engaging in the behaviour
to a greater extent or over a longer period than
intended (3) repeated efforts to reduce, control or stop
the behaviour (4) a great deal of time spent in activities
necessary for the behaviour, engaging in the behaviour
or recovering from its effects (5) frequent engaging in
the behaviour when expected to fulfill occupational,
academic, domestic or social obligations (6) important
social, occupational or recreational activities given up
or reduced because of the behaviour (7) continuation of
the behaviour despite knowledge of having a persistent
or recurrent social, financial, psychological or
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George, et al.: Psychosocial interventions for sexual addiction
physical problem that is caused or exacerbated by the
behaviour (8) tolerance: need to increase the intensity
or frequency of the behaviour in order to achieve the
desired effect or diminished effect with continued
behavior of the same intensity (9) restlessness or
irritability if unable to engage in the behaviour.
(F) Some symptoms of the disturbance have persisted for
at least 1 month, or have occurred repeatedly over a
longer period of time.
The physical signs of drug addiction are absent in behavioural
addiction.One of the precursors of behavioural addiction
is the presence of psychopathologies such as depression,
substance dependence or withdrawal, and social anxiety as
well as a lack of social support.[11]
Magnitude of the Problem
In 2007, China began restricting computer game use: current
laws discourage more than 3 hours of daily game use. Using
data from 2006, the South Korean government estimates
that 210,000 children in the age group of 6‑19 years are
affected and need treatment. 80% of those needing treatment
may need psychotropic medications, and perhaps 20‑24%
require hospitalization. Since the average South Korean
high school student spends about 23 hours each week
gaming, another 1.2 million are believed to be at risk for
addiction and to require basic counselling.[12] Therapists
worry about the increasing number of individuals dropping
out from school, work to spend time on computers or get in
to legal troubles. As of June 2007, South Korea has trained
1,043 counsellors in the treatment of Internet addiction
and enlisted over 190 hospitals and treatment centres.
Many of these addicts get into cyber relationships and
cybersex.[13] According to studies carried out among the US
population, it was found that Sex addiction was present in
3%, exercise‑addiction in 3%, and shopping addiction in 6%
among the total population. In India, an ICMR funded survey
identified food addiction (1.6%; 2% male and 1.2%female),
Shopping addiction (4%; male‑3.2% and female‑4.8%), Sex
addiction (2%; 0.3%male and 0.1% female) and Exercise
addiction (5.6%; 7.5% males and 3.8% females).[14]
A cross‑sectional study sample comprising of 987 students of
various disciplines across the city of Mumbai was conducted
and the students were assessed with a specially constructed
semi‑structured proforma and The Internet Addiction
Test (IAT; Young, 1998). Of the 987 adolescents who took part
in the study, 681 (68.9%) were female and 306 (31.1%) were
males. Of the total, about 74.5% were moderate (average)
users. Using Young’s original criteria, 0.7% were found to be
addicts. Those with excessive use internet had high scores on
anxiety, depression, and anxiety depression[15]
Screening instruments
The different scales which can be used for assessment of
sexual addiction include:
S512
q The sexual addiction screening test
q The sexual compulsivity scale
q The sexual dependency inventory – revised
q The sex addicts anonymous questionnaire
q Compulsive sexual behaviour inventory
Since there is an absence of established diagnostic criteria,
the significance of validity of these scales is doubted. Several
of the questions in these scales do not yield information
about whether the diagnostic criteria are met or not.
The Sexual compulsivity scale is most commonly used for
gauging the presence of sexual addiction. It includes both
the key features of addiction (impaired control and harmful
consequences). It is a 10 item scale which scores from 1‑4.
The cut off value is 24.[16]
Management
Pharmacological treatment has modest and short‑lasting
benefit. Current expert opinion is that a combination
of pharmacotherapy and psychotherapy is optimal
management strategy for any sort of behavioural addiction.
q Pharmacotherapy includes 1.Endocrinological
agents: Anti androgenslike Medroxy progesterone acetate
which acts by inhibiting testosterone reductase. This is used
in Paraphilias also. In addition these drugs reduce sex drive
and aggressive sexual behavior. Other pharmacological
agents include Cyproterone acetate, Analogues of
GNRH (leuprolide acetate) and affectregulation agents
likeSSRI’s, TCA’s, lithium, carbamazepine, buspirone. These
agents have a positive response rate of 50‑90%. Theydecrease
the drive for excessive sexual behaviour without decreasing
the drive for healthy behaviour. They also cause a decrease
in the frequency of addicted individual’s symptomatic
sexual urges, masturbation, and the use of pornography,
while having no significant effect on partnered sexual
behaviours.[17]
Non Pharmacological:
Psychodynamic psychotherapy helps to synthesize the role
of developmental antecedents, reduce current anxiety,
depression, guilt and to improve social adjustment.
There is no evidence for this as a solitary treatment.
Referral to a self‑ help group is another most commonly
adopted therapy associated with successful outcome. It is
elaborated into 12‑Steps and has a profound effect on the
process of recovery.[18] The relapse prevention model and
accompanying cognitive‑behavioural and social learning
techniques are commonly employed in specialized sex
offender treatment programmes in the United States and
Canada. There is no published data on this comprehensive
approach to the treatment of sexual addiction.
Young describes seven possible ways of dealing with the
internet addiction, of which the first three are basically
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George, et al.: Psychosocial interventions for sexual addiction
time management strategies. These methods have
been addressed in detail in the article on technology
addiction.[19]
Orzack and Orzack have suggested two strategies for the
treatment. 1) Cognitive Behavioural Therapy which includes
cognitive restructuring about the internet applications
an individual uses most often, behavioural exercisesand
exposure therapy in which the individual stays offline
forprogressively increasing durations. 2) Motivational
Enhancement Therapy: It allows the addicts and their
therapists to collaborate on treatment plans and set
attainable goals. It needs a rather non confrontational
approach and is considered more innovative.[20]
There are multiple psychological interventions like
Multi‑level Counselling Program (MLC), Social competence
training (SoCo), Solution‑focused Brief Therapy (SFBT),
Cognitive Therapy (CT) and Reality Therapy (RT) that have
used for the treatment of behavioural addictions.[21]
CONCLUSION
Increased access to the internet by adolescents has
created unprecedented opportunities for sexual
education, learning, and growth. Conversely, it has
also lead to the emergence of various behaviors which
are repeatedly reinforcing the reward; motivation
and memory circuitry are all part of the disease of
addiction. One such behavioral addiction is involves
pornography Research suggests that adolescents who
use pornography, especially that found on the internet,
have lower degrees of social integration, increase in
conduct problems, higher levels of delinquent behaviour,
higher incidence of depressive symptoms, and decreased
emotional bonding with caregivers. The treatment of
sex addiction has its own unique challenges that many
general addiction and mental health specialists may
overlook if they have not had much hands‑on experience
treating the disorder. Though there is a deficiency in the
number of studies regarding the treatment outcomes, it
is seen that a combination of pharmacotherapy together
with psychotherapy has a better outcome in preventing
relapse for these patients.
Indian Journal of Psychiatry Volume 60 (Supplement 4), February 2018
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Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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