Paraphilia

Compulsive sexual behavior, while not an official diagnosis in the psychiatric and psychological fields, is a well-recognized clinical problem. A better understanding of the etiology of compulsive sexual behavior would be helpful in understanding the disorder and directing treatment. In the meantime, clinicians must rely on case reports, a few openlabel trials, clinical experience, and clinical judgment to make recommendations to their patients with this disorder.

Certainly clinicians in the area report marked improvement with adequate pharmotherapy for compulsive sexual behavior. Adequate treatment and improvement of symptoms can lead to improvement in psychosocial functioning and decreased risk of contracting sexually transmitted diseases.

COMORBID DISORDERS

Psychiatrists treating patients with compulsive sexual behavior must remember that as a group, these individuals usually have a high prevalence of other mood, anxiety, and substance use disorders.1 It is difficult, if not impossible, to treat the sexual disorder without also addressing these related disorders.

The literature indicates that mood disorders, primarily depression, are common in patients with compulsive sexual behavior.2,3,4 Studies indicate that approximately 70 percent of these patients are diagnosed with mood disorders at some point in their lives. Estimates of anxiety disorders range from about 50 to 90 percent.

Substance use disorders also affect at least half of the individuals, particularly alcohol and marijuana abuse or dependence. These are often best addressed by treatment programs specifically designed to support sobriety.

Sobriety is an important prerequisite to psychotherapy or medications directed at treating compulsive sexual behavior or the comorbid psychiatric disorders. Active substance abuse decreases the efficacy of attempts at treatment.

USE OF SRIs

Antidepressants that increase the brain neurotransmitter serotonin are often the first choice for psychiatrists treating individuals with compulsive sexual behavior.

Neurotransmitters are the naturally occurring substances produced by brain cells to communicate with other brain cells. Serotonin has consistently been found to be low in individuals with depression. Low serotonin levels are associated with impulsive and aggressive behaviors in individuals.5

When patients with impulse control problems are treated with serotonin reuptake inhibitors (SRIs), they often report decreased frequency and intensity of urges to engage in the impulsive behavior. They also report increased ability to exercise conscious control over a response to an urge.

Individuals with compulsive sexual behavior have reported similar benefits from SRIs.6 In addition, they also report that relief from the moods and anxiety symptoms that often accompany their sexual problem enables them to exercise more control over their sexual urges and behaviors.

Many patients also suffer from preoccupation with thoughts of sexual activities or sexually arousing fantasies. SRIs have also been found to be useful in decreasing obsessive thinking in a number of different psychiatric disorders.

Therefore, the SRI antidepressants can be used to accomplish several goals: (1) improve depressed mood; (2) decrease anxiety; (3) decrease urges; (4) increase control over urges to engage in compulsive sexual behavior; and (5) decrease obsession and ruminative thinking patterns.

SIDE EFFECTS OF SRIs

SRIs are well known to have sexual side effects, particularly decreased libido and delayed orgasm. It has been suggested that these side effects may be responsible for the efficacy of these medications in the treatment of compulsive sexual behavior. However, we have found the opposite to be true.

Instead of reducing the preoccupation with their sexual behavior, we have found that the medications that have sexual side effects often make this worse. For example, if patients with compulsive sexual behavior experience delayed ejaculation, they report that they spend even more time engaging in sexual behavior or sexual fantasy in order to experience climax. For this reason, we most often prescribe an SRI that is less likely to cause sexual side effects such as: es-citalopram (Lexapro(TM)), sertraline (Zoloft(TM)), or citalopram (Celexa(TM)).

Adding medication such as nafazodone or buproprion to an SRI can reduce the sexual side effects of the SRI. These medications may be used in addition to or instead of an SRI to avoid the sexual side effects. However, used alone these medications may not have the same efficacy as an SRI in reducing impulsive or obsessive behavior.

NEW TREATMENTS

Recently, our research group at the University of Minnesota has published two case reports on the use of an opiate antagonist, naltrexone (Revia(TM)) in reducing urges to engage in compulsive sexual behavior.7,8

The theory regarding the use of this medication in impulse control disorders was based on work by S.W. Kim, who suggested that the neuro-anatomical pathway that subserves urges to engage in impulsive behaviors may be the same pathway that subserves drug cravings and the rewarding property of substances of abuse.9 Activity in this pathway is reduced by use of the opiate antagonist naltrexone (Revia(TM)).

Our research group has seen marked reductions in urges to masturbate compulsively, to engage in anonymous sex, and to engage in computer pornography in patients with severe compulsive sexual behavior. Caution should be used with the use of naltrexone, as higher dosages that are often needed to treat compulsive sexual behaviors can be harmful to the liver.10 Liver damage is much more likely to occur if naltrexone is taken with pain medications such as ibuprofen (Motrin(TM)), acetaminophen (Tylenol(TM)), or aspirin. Liver function tests must be performed regularly to ensure no damage is occurring.

Looking at comorbid conditions can also help us identify other potential treatments. For example, in his comorbidity studies, Martin Kafka has found a high prevalence of adult attention deficit disorder in his patients with compulsive sexual behavior.11 He advocates treatment of the attention deficit disorder to help control impulsive sexual behavior. While stimulants such as methylphenadate (Ritalin(TM)) and dextroamphetamine still remain the most common treatments for attention deficit disorder, new medications such as the recently released atomoxetine (Stratera(TM)) may be effective while avoiding the potentially addictive properties of the stimulants.

Other potential medications include the antidepressant buproprion (Wellbutrin(TM)) and the medication modafanil (Provigil(TM)) that is approved for treatment of narcolepsy. Mood stabilizers such as valproic acid (Depakote(TM)) and lithium can be particularly useful in patients with mood instability or comorbid manic-depressive spectrum disorders. Both of these medications have also been used with success in various disorders where patients exhibit problems with impulse control. For the patient that exhibits comorbid thought disorders or psychotic disorders, one of the newer atypical antipsychotics such as rispiridone (Risperdal(TM)), olanzapine (Zyprexa(TM)), or quitiapine (Seroquel(TM)) can be added to the regimen.

CONCLUSION

Ultimately, much more research is needed in the way of controlled treatment trials to determine the efficacy of any of these medications in the treatment of compulsive sexual behavior. In order to conduct rigorous treatment trials, we need to come to a consensus on specific diagnostic criteria for compulsive sexual behavior and on a uniform method to operationalize its definition.

It should be noted that many clinicians in this field, while finding medications useful in the treatment of compulsive sexual behavior, think that concurrent psychotherapy is often needed for the individual to develop healthy sexual behavior and attitudes. At the same time, patients in concurrent psychotherapy often report that they are able to make more rapid progress in therapy once their compulsive sexual behavior and comorbid disorders are adequately treated.

References

1. N. C. Raymond, E. Coleman, C. Benefield, and M. Miner, "Psychiatric Comorbidity and Compulsive/Impulsive Traits in Compulsive Sexual Behavior," Comprehensive Psychiatry, in press.

2. Ibid.

3. M. P. Kafka and R. A. Prentky, "Preliminary Observations of DSM-III-R Axis I Comorbidity in Men with Paraphilias and Paraphilia-Related Disorders," Journal of Clinical Psychiatry, 1994, vol. 55, pp. 481-487.

4. D. W. Black, L. L. D. Kehrberg, D. L. Flumerfelt and S. S. Schlosser, "Characteristics of 36 Subjects Reporting Compulsive Sexual Behavior," American Journal of Psychiatry, 1997, vol. 154, pp. 243-249.

5. E. F. Cocarro and R. J. Kavoussi, "Fluoxetine and Impulsive Aggressive Behavior in Personality-Disordered Subjects," Archives of General Psychiatry, 1998, vol. 54, pp. 1081-1088.

6. M. P. Kafka, "Sertraline Pharmacotherapy for Paraphilias and Paraphilia-Related Disorders: An Open Trial," Annals of Clinical Psychiatry, 1994, vol. 6, no. 3, pp. 189-195.

7. N. C. Raymond, J. E. Grant, S. W. Kim and E. Coleman, "Treatment of Compulsive Sexual Behavior with Naltrexone and Serotonin Reuptake Inhibitors: Two Case Studies," International Clinical Psychopharmacology, 2002, vol. 17, pp. 201-205.

8. J. E.Grant and S. W. Kim, "A Case of Kleptomania and Compulsive Sexual Behavior Treated with Naltrexone," Annals of Clinical Psychiatry, 2001, vol. 13, pp. 229-231.

9. G. F. Koob, "Drugs of Abuse: Anatomy, Pharmacology and Function of Reward Pathways," Trends in Pharmacologic Science, 1989, vol. 13, pp. 177-184.

10. S. W. Kim, J. E. Grant, D.E. Adson and R. P. Remmel, "A Preliminary Report on Possible Naltrexone and Nonsteroidal Analgesic Interactions," Journal of Clinical Psychopharmacology, 2001, vol. 21, pp. 632-634.

11. M. P. Kafka and R. A. Prentky, "Attention-Deficit/Hyperactivity Disorder in Males with Paraphilias and Paraphilia-Related Disorders: A Comorbidity Study," Journal of Clinical Psychiatry, 1998, vol. 59, no. 7, pp. 388-396.

Nancy C. Raymond, M.D.

Associate Professor

Department of Psychiatry and Family Practice

University of Minnesota

Minneapolis, MN

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