Hypersexual disorder : clinical presentation and treatment

Abstract

Background: Persistent hypersexual behavior (HB) leading to negative consequences is a phenomenon that has lacked a recognized diagnosis in the psychiatric nomenclature, despite extensive study. Due to differences in the means of assessment and conceptualization of the phenomenon, it has been difficult to compare and generalize from the results of treatment studies. Hypersexual Disorder (HD) was proposed for the 5th edition of the Diagnostic and Statistical Manual (DSM-5) as an atheoretical formulation of HB. However, it was rejected despite receiving empirical support in a field trial and studies in clinical and forensic sample populations. However, the HD and its proposed criteria enabled targeted treatment studies based on uniform, albeit preliminary diagnostic, categorization.

Aims: The overall aim of the thesis was to investigate the validity of the HD criteria for categorizing HB and develop a cognitive behavioral therapy (CBT) treatment protocol based on the findings, and subsequently evaluate the feasibility and efficacy of the protocol and implement its administration via the Internet. The specific research questions were • Is the HD diagnosis and its criteria suitable means to categorize a group of men and women who engage in excessive sexual behavior to a degree that leads to personal distress and impairment? • Is a newly developed CBT intervention protocol efficacious for amelioration of the symptoms associated with HD if administered in group settings? • If the CBT intervention protocol is efficacious in treatment of HD symptoms, can it be administered via the Internet?

Methods: In Study I, the validity of the HD criteria was examined in a sample of self-identified hypersexual individuals using the Hypersexual Disorder Screening Inventory (HDSI). Subsequently in Study II, the feasibility of a newly developed CBGT treatment for HD was examined in a sample of hypersexual men recruited through Study I. Measurements were made pre-, mid-, and post-treatment as well as 3 and 6 months after the end of treatment. Study III was a larger RCT, comparing 7 sessions of CBGT treatment with a waitlist. Measurements were performed pre-, mid- and post-treatment during the comparative study period. The waitlist participants subsequently underwent CBGT and were measured at the same relative time points. Both groups were also measured at 3 and 6 months after their respective treatment period. Data from both groups were pooled and analyzed for intragroup effects. Study IV investigated the feasibility and intragroup effects of a 12-week ICBT program for HD, with or without paraphilia(s)/paraphilic disorder(s). Participants were assessed according to the procedures used in Study II and III and after inclusion were assigned a therapist for feedback, support, and clarifications during treatment. Measurements were performed weekly, with focus on pre-, mid-, and post-treatment, as well as 3 months after cessation of treatment. Participants were also offered a follow-up assessment interview.

Results: In Study I, 50% of the sample met the criteria for HD. Some gender differences were noted regarding the overall symptom severity and types of exhibited sexual behaviors. The HD criteria were found to be valid for both men and women, although the proposed interpretation of HDSI appeared to be too restrictive. Study II found the CBGT treatment for HD to be feasible. Substantial reductions in HD symptoms were noted at the end of treatment and were maintained at the 3- and 6-month follow-ups. The main findings from Study III suggested moderate post-treatment intergroup effects on the primary outcome. Similar effects were found for the secondary outcomes. The results from the pooled data analyses revealed moderate decreases in hypersexual symptoms at post-treatment and at follow up. Participants’ overall psychiatric wellbeing also improved significantly, albeit to a lesser degree. In Study IV, considerable effects were observed as a result of ICBT treatment of HD, with or without paraphilia(s)/paraphilic disorder(s). Moderate effects were noted for paraphilia(s)/paraphilic disorder(s). Psychiatric wellbeing also improved, but to a lesser extent.

Conclusions: The HD criteria were found useful for categorizing patients with hypersexual behavior even though the recently recognized diagnose compulsive sexual behavior disorder (CSBD) is more applicable today. Study II and III showed that CBGT is a feasible treatment that relieves HD symptoms. The results from Study IV suggests that the treatment can be administered via the internet and efficaciously reduces HD and its associated symptoms. Further development of the interventions may have the potential to prevent unwanted sexual behavior, including sexual offending.