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