Sexual addiction

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Sexual addiction, also known as sex addiction, is a state characterized by compulsive participation or engagement in sexual activity, particularly sexual intercourse, despite negative consequences. [1]

Contents

Proponents of a diagnostic model for sexual addiction consider it to be one of several sex-related disorders within hypersexual disorder. [2] The term sexual dependence is also used to refer to people who report being unable to control their sexual urges, behaviors, or thoughts. Related or synonymous models of pathological sexual behavior include hypersexuality (nymphomania and satyriasis), erotomania, Don Juanism (or Don Juanitaism), and paraphilia-related disorders. [3] [4] [5]

The concept of sexual addiction is contentious. [6] [7] There is considerable debate among psychiatrists, psychologists, sexologists, and other specialists whether compulsive sexual behavior constitutes an addiction, and therefore its classification and possible diagnosis. Animal research has established that compulsive sexual behavior arises from the same transcriptional and epigenetic mechanisms that mediate drug addiction in laboratory animals; however, as of 2018, sexual addiction is not a clinical diagnosis in either the DSM or ICD medical classifications of diseases and medical disorders. Some argue that applying such concepts to normal behaviors such as sex can be problematic, and suggest that applying medical models such as addiction to human sexuality can serve to pathologise normal behavior and cause harm. [8]

The ICD-11 created a new condition classification, compulsive sexual behavior, to cover "a persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behaviour". [9] [10]

Classification

Addiction and dependence glossary [11] [12] [13] [14]
  • addiction – a biopsychosocial disorder characterized by persistent use of drugs (including alcohol) despite substantial harm and adverse consequences
  • addictive behavior – a behavior that is both rewarding and reinforcing
  • addictive drug – a drug that is both rewarding and reinforcing
  • dependence – an adaptive state associated with a withdrawal syndrome upon cessation of repeated exposure to a stimulus (e.g., drug intake)
  • drug sensitization or reverse tolerance – the escalating effect of a drug resulting from repeated administration at a given dose
  • drug withdrawal – symptoms that occur upon cessation of repeated drug use
  • physical dependence – dependence that involves persistent physical–somatic withdrawal symptoms (e.g., fatigue and delirium tremens)
  • psychological dependence – dependence that involves emotional–motivational withdrawal symptoms (e.g., dysphoria and anhedonia)
  • reinforcing stimuli – stimuli that increase the probability of repeating behaviors paired with them
  • rewarding stimuli – stimuli that the brain interprets as intrinsically positive and desirable or as something to approach
  • sensitization – an amplified response to a stimulus resulting from repeated exposure to it
  • substance use disorder – a condition in which the use of substances leads to clinically and functionally significant impairment or distress
  • tolerance – the diminishing effect of a drug resulting from repeated administration at a given dose

None of the official diagnostic classification frameworks list "sexual addiction" as a distinct disorder.

DSM

The American Psychiatric Association (APA) publishes and periodically updates the Diagnostic and Statistical Manual of Mental Disorders (DSM), a widely recognized compendium of mental health diagnostics. [15]

The version published in 1987 (DSM-III-R), referred to "distress about a pattern of repeated sexual conquests or other forms of nonparaphilic sexual addiction, involving a succession of people who exist only as things to be used." [16] The reference to sexual addiction was subsequently removed. [17] The DSM-IV-TR, published in 2000 (DSM-IV-TR), did not include sexual addiction as a mental disorder. [18]

Some authors suggested that sexual addiction should be re-introduced into the DSM system; [19] however, sexual addiction was rejected for inclusion in the DSM-5, which was published in 2013. [20] Darrel Regier, vice-chair of the DSM-5 task force, said that "[A]lthough 'hypersexuality' is a proposed new addition...[the phenomenon] was not at the point where we were ready to call it an addiction." The proposed diagnosis does not make the cut as an official diagnosis due to a lack of research into diagnostic criteria for compulsive sexual behavior, according to the APA. [21] [22]

ICD

The World Health Organization produces the International Classification of Diseases (ICD), which is not limited to mental disorders. The most recent approved version of that document, ICD-10, includes "excessive sexual drive" as a diagnosis (code F52.7), subdividing it into satyriasis (for males) and nymphomania (for females). However, the ICD categorizes these diagnoses as compulsive behaviors or impulse control disorders and not addiction. [23] The most recent (yet unapproved) version of that document, ICD-11, includes "compulsive sexual behavior disorder" [24] as a diagnosis (code 6C72)—it does not use the addiction model. [25]

CCMD

The Chinese Society of Psychiatry produces the Chinese Classification of Mental Disorders (CCMD), which is currently in its third edition  the CCMD-3 does not include sexual addiction as a diagnosis.

Other

Some mental health providers have proposed various, but similar, criteria for diagnosing sexual addiction, including Patrick Carnes, [26] Aviel Goodman, [27] and the late Jonathan Marsh. [28] Carnes authored the first clinical book about sex addiction in 1983, based on his own empirical research. His diagnostic model is still largely utilized by the thousands of certified sex addiction therapists (CSATs) trained by the organization he founded. [29] No diagnostic proposal for sex addiction has been adopted into any official government diagnostic manual, however.

During the update of the Diagnostic and Statistical Manual to version 5 (DSM-5), the APA rejected two independent proposals for inclusion.[ citation needed ]

In 2011, the American Society of Addiction Medicine (ASAM), the largest medical consensus of physicians dedicated to treating and preventing addiction, [30] redefined addiction as a chronic brain disorder, [31] which for the first time broadened the definition of addiction from substances to include addictive behaviors and reward-seeking, such as gambling and sex. [32]

Borderline personality disorder

The ICD, DSM and CCMD list promiscuity as a prevalent and problematic symptom for Borderline Personality Disorder. Individuals with this diagnosis sometimes engage in sexual behaviors that can appear out of control, distressing the individual or attracting negative reactions from others. [33] There is therefore a risk that a person presenting with sex addiction, may in fact be suffering from Borderline Personality Disorder. This may lead to inappropriate or incomplete treatment. [34]

Medical reviews and position statements

In November 2016, the American Association of Sexuality Educators, Counselors and Therapists (AASECT), the official body for sex and relationship therapy in the United States, issued a position statement on Sex Addiction that states that AASECT, "...does not find sufficient empirical evidence to support the classification of sex addiction or porn addiction as a mental health disorder, and does not find the sexual addiction training and treatment methods and educational pedagogies to be adequately informed by accurate human sexuality knowledge. Therefore, it is the position of AASECT that linking problems related to sexual urges, thoughts or behaviors to a porn/sexual addiction process cannot be advanced by AASECT as a standard of practice for sexuality education delivery, counseling or therapy." [35]

In 2017, three new USA sexual health organizations found no support for the idea that sex or adult films were addictive in their position statement. [36]

In 16 November 2017 the Association for the Treatment of Sexual Abusers (ATSA) published a position against sending sex offenders to sex addiction treatment facilities. [37] Those centers argued that "illegal" behaviors were symptoms of sex addiction, which ATSA challenged they had no scientific evidence to support.

Possible mechanisms

Animal research involving rats that exhibit compulsive sexual behavior has identified that this behavior is mediated through the same molecular mechanisms in the brain that mediate drug addiction. [38] [39] [40] Sexual activity is an intrinsic reward that has been shown to act as a positive reinforcer, [41] strongly activate the reward system, and induce the accumulation of ΔFosB in part of the striatum (specifically, the nucleus accumbens). [38] [39] [40] Chronic and excessive activation of certain pathways within the reward system and the accumulation of ΔFosB in a specific group of neurons within the nucleus accumbens has been directly implicated in the development of the compulsive behavior that characterizes addiction. [39] [42] [43] [44]

In humans, a dopamine dysregulation syndrome, characterized by drug-induced compulsive engagement in sexual activity or gambling, has also been observed in some individuals taking dopaminergic medications. [38] Current experimental models of addiction to natural rewards and drug reward demonstrate common alterations in gene expression in the mesocorticolimbic projection. [38] [45] ΔFosB is the most significant gene transcription factor involved in addiction, since its viral or genetic overexpression in the nucleus accumbens is necessary and sufficient for most of the neural adaptations and plasticity that occur; [45] it has been implicated in addictions to alcohol, cannabinoids, cocaine, nicotine, opioids, phenylcyclidine, and substituted amphetamines. [38] [45] [46] ΔJunD is the transcription factor which directly opposes ΔFosB. [45] Increases in nucleus accumbens ΔJunD expression can reduce or, with a large increase, even block most of the neural alterations seen in chronic drug abuse (i.e., the alterations mediated by ΔFosB). [45]

ΔFosB also plays an important role in regulating behavioral responses to natural rewards, such as palatable food, sex, and exercise. [39] [45] Natural rewards, like drugs of abuse, induce ΔFosB in the nucleus accumbens, and chronic acquisition of these rewards can result in a similar pathological addictive state. [38] [39] Thus, ΔFosB is also the key transcription factor involved in addictions to natural rewards as well, [38] [40] and sexual addictions in particular, since ΔFosB in the nucleus accumbens is critical for the reinforcing effects of sexual reward. [39] Research on the interaction between natural and drug rewards suggests that psychostimulants and sexual reward possess cross-sensitization effects and act on common biomolecular mechanisms of addiction-related neuroplasticity which are mediated through ΔFosB. [38] [40]

Summary of addiction-related plasticity
Form of neuroplasticity
or behavioral plasticity
Type of reinforcer Sources
OpiatesPsychostimulantsHigh fat or sugar food Sexual intercourse Physical exercise
(aerobic)
Environmental
enrichment
ΔFosB expression in
nucleus accumbens D1-type MSNs
[38]
Behavioral plasticity
Escalation of intakeYesYesYes [38]
Psychostimulant
cross-sensitization
YesNot applicableYesYesAttenuatedAttenuated [38]
Psychostimulant
self-administration
[38]
Psychostimulant
conditioned place preference
[38]
Reinstatement of drug-seeking behavior [38]
Neurochemical plasticity
CREB phosphorylation
in the nucleus accumbens
[38]
Sensitized dopamine response
in the nucleus accumbens
NoYesNoYes [38]
Altered striatal dopamine signaling DRD2, ↑DRD3 DRD1, ↓DRD2, ↑DRD3 DRD1, ↓DRD2, ↑DRD3 DRD2 DRD2 [38]
Altered striatal opioid signaling No change or
μ-opioid receptors
μ-opioid receptors
κ-opioid receptors
μ-opioid receptors μ-opioid receptors No changeNo change [38]
Changes in striatal opioid peptides dynorphin
No change: enkephalin
dynorphin enkephalin dynorphin dynorphin [38]
Mesocorticolimbic synaptic plasticity
Number of dendrites in the nucleus accumbens [38]
Dendritic spine density in
the nucleus accumbens
[38]

Treatment

Counseling

As of 2017, none of the official regulatory bodies for Psycho-sexual Counseling or Sex and Relationship therapy, have accepted sex addiction as a distinct entity with associated treatment protocols. Indeed, some practitioners regard sex addiction as a potentially harmful diagnosis and draw parallels with gay conversion therapy. [35] As a result, treatment for sex addiction is more often provided by addiction professionals in the counseling field than psychosexual specialists. These counseling professionals typically hold advanced degrees of education including Master's degrees or Doctorates in counseling or a related field like psychology. These counselors can also hold certifications like Licensed Professional Counselors (LPC-S) who are required to hold a Master's degree or higher level of education. Therapists and Psychologists usually also hold a Master's in a related field of study. [47]

Cognitive behavioral therapy is a common form of behavioral treatment for addictions and maladaptive behaviors in general. [48] Dialectical behavior therapy has been shown to improve treatment outcomes as well. Certified Sex Addiction Therapists (CSAT)  a group of sexual addiction therapists certified by the International Institute for Trauma and Addiction Professionals   offer specialized behavioral therapy designed specifically for sexual addiction. [29] [49] Their treatments have yet to be subject to peer-review, so it is unclear if they help or harm patients.

Support groups

Online support groups

NoFap is an online community founded in 2011. [50] It serves as a support group for those who wish to avoid the use of pornography, masturbation, and/or sexual intercourse. [51] [52]

In-person support groups

In-person support groups are available in most of the developed world. None yet have any scientific evidence to show whether or not they are helpful, so attendees do so at their own risk.

The groups include:

  • Sex Addicts Anonymous: For those who want to reduce or eliminate their use of pornography, masturbation, and/or unwanted sexual activity.
  • Sex and Love Addicts Anonymous: Similar to the above.
  • Sexaholics Anonymous: For those who want to eliminate their use of pornography, masturbation, unwanted sexual activity, and/or sex outside of marriage. Has a stricter definition of sexual sobriety than its competitors.
  • SMART Recovery.

In places where none of the above are available, open meetings of Alcoholics Anonymous or Narcotics Anonymous may be a second-best option. At open AA and NA meetings, non-alcoholics/non-addicts are welcome to observe but not participate.

Support groups may be useful for uninsured or under-insured individuals. (See also: Alcoholics Anonymous § Health-care costs.) They may also be useful as an adjunct to professional treatment. In addition, they may be useful in places where professional practices are full (i.e. not accepting new patients), scarce, or nonexistent, or where these practices have waiting lists. Finally, they may be useful for patients who are reluctant to spend money on professional treatment.

Medications

Antiviral drugs

The term "pre-exposure prophylaxis" (PrEP) generally refers to the use of antiviral drugs to help prevent AIDS. PrEP is an optional treatment for people who are HIV-negative, but have a substantial risk of getting an HIV infection.

In the US, most insurance plans cover these drugs. [53]

Epidemiology

According to a systematic review from 2014, observed prevalence rates of sexual addiction/hypersexual disorder range from 3% to 6%. [2] Some studies suggest that sex addicts are disproportionately male, at 80%. [54]

History

Sex addiction as a term first emerged in the mid-1970s when various members of Alcoholics Anonymous sought to apply the principles of 12-steps toward sexual recovery from serial infidelity and other unmanageable compulsive sex behaviors that were similar to the powerlessness and un-manageability they experienced with alcoholism. [55] Multiple 12-step style self-help groups now exist for people who identify as sex addicts, including Sex Addicts Anonymous, Sexaholics Anonymous, Sex and Love Addicts Anonymous, and Sexual Compulsives Anonymous.

Society and culture

Controversy

"Nonconsensual sexual activity is sexual abuse. Treatment for sexual addiction generally will not address the factors that lead people to sexually abuse others."— Association for the Treatment of Sexual Abusers [56]

The controversy surrounding sexual addiction is centered around its identification, through a diagnostic model, in a clinical setting. As noted in current medical literature reviews, compulsive sexual behavior has been observed in humans; drug-induced compulsive sexual behavior has also been noted clinically in some individuals taking dopaminergic drugs. [38] Moreover, some research suggests compulsive engagement in sexual behavior despite negative consequences in animal models. Since current diagnostic models use drug-related concepts as diagnostic criteria for addictions, [15] these are ill-suited for modelling compulsive behaviors in a clinical setting. [38] Consequently, diagnostic classification systems, such as the DSM, do not include sexual addiction as a diagnosis because there is currently "insufficient peer-reviewed evidence to establish the diagnostic criteria and course descriptions needed to identify these behaviors as mental disorders". [21] A 2014 systematic review on sexual addiction indicated that the "lack of empirical evidence on sexual addiction is the result of the disease's complete absence from versions of the Diagnostic and Statistical Manual of Mental Disorders." [2]

External media
Audio
Nuvola apps arts.svg Robert Weiss & David Ley. Is sex addiction a myth? // KPCC (25 April 2012, 9:29 am)
Video
Nuvola apps kaboodle.svg Nicole Prause, Ph.D. (sexual physiologist). CBS (18 July 2013)

There have been debates regarding the definition and existence of sexual addictions for decades, as the issue was covered in a 1994 journal article. [57] [58] The Mayo Clinic considers sexual addiction a form of obsessive compulsive disorder and refer to it as sexual compulsivity (note that by definition, an addiction is a compulsion toward rewarding stimuli). [59] A paper dating back to 1988 and a journal comment letter published in 2006 asserted that sex addiction is itself a myth, a by-product of cultural and other influences. [60] [61] The 1988 paper argued that the condition is instead a way of projecting social stigma onto patients. [60] "Love addiction" falls into the same controversial area as well since it refers to a frequent pattern of intimate relationships which can be a by product of cultural norms and commonly accepted morals. [62]

In a report from 2003, Marty Klein, stated that "the concept of sex addiction provides an excellent example of a model that is both sex-negative and politically disastrous." [63] :8 Klein singled out a number of features that he considered crucial limitations of the sex addiction model [63] :8 and stated that the diagnostic criteria for sexual addiction are easy to find on the internet. [63] :9 Drawing on the Sexual Addiction Screening Test , he stated that "the sexual addiction diagnostic criteria make problems of nonproblematic experiences, and as a result pathologize a majority of people." [63] :10

Sexual addiction has been the main theme in a variety of films including Diary of a Sex Addict , I Am a Sex Addict , Black Snake Moan , Confessions of a Porn Addict , Shame , Thanks for Sharing , Don Jon , and Choke .

See also

Related Research Articles

Hypersexuality is extremely frequent or suddenly increased libido. It is currently controversial whether it should be included as a clinical diagnosis used by mental healthcare professionals. Nymphomania and Satyriasis were terms previously used for the condition in women and men, respectively.

Pornography addiction is an addiction model of compulsive sexual activity with concurrent use of pornographic material, despite negative consequences to one's physical, mental, social, or financial well-being. Neither the DSM-5 nor the ICD-11 classify pornography as a mental disorder or addiction.

The mesolimbic pathway, sometimes referred to as the reward pathway, is a dopaminergic pathway in the brain. The pathway connects the ventral tegmental area in the midbrain to the ventral striatum of the basal ganglia in the forebrain. The ventral striatum includes the nucleus accumbens and the olfactory tubercle.

Drug withdrawal, drug withdrawal syndrome, or substance withdrawal syndrome, is the group of symptoms that occur upon the abrupt discontinuation or decrease in the intake of medicational or recreational drugs.

Nucleus accumbens Region of the basal forebrain

The nucleus accumbens is a region in the basal forebrain rostral to the preoptic area of the hypothalamus. The nucleus accumbens and the olfactory tubercle collectively form the ventral striatum. The ventral striatum and dorsal striatum collectively form the striatum, which is the main component of the basal ganglia. The dopaminergic neurons of the mesolimbic pathway project onto the GABAergic medium spiny neurons of the nucleus accumbens and olfactory tubercle. Each cerebral hemisphere has its own nucleus accumbens, which can be divided into two structures: the nucleus accumbens core and the nucleus accumbens shell. These substructures have different morphology and functions.

Alcohol dependence is a previous psychiatric diagnosis in which an individual is physically or psychologically dependent upon alcohol.

Dexmethylphenidate

Dexmethylphenidate, sold under the brand name Focalin among others, is a medication used to treat attention deficit hyperactivity disorder (ADHD) in those over the age of 5 years. If no benefit is seen after 4 weeks it is reasonable to discontinue its use. It is taken by mouth. The immediate release formulation lasts up to 5 hours while the extended release formulation lasts up to 12 hours.

Motivational salience is a cognitive process and a form of attention that motivates or propels an individual's behavior towards or away from a particular object, perceived event or outcome. Motivational salience regulates the intensity of behaviors that facilitate the attainment of a particular goal, the amount of time and energy that an individual is willing to expend to attain a particular goal, and the amount of risk that an individual is willing to accept while working to attain a particular goal.

Substance dependence, also known as drug dependence, is an adaptive state that develops from repeated drug administration, and which results in withdrawal upon cessation of drug use. A drug addiction, a distinct concept from substance dependence, is defined as compulsive, out-of-control drug use, despite negative consequences. An addictive drug is a drug which is both rewarding and reinforcing. ΔFosB, a gene transcription factor, is now known to be a critical component and common factor in the development of virtually all forms of behavioral and drug addictions, but not dependence.

Sensitization is a non-associative learning process in which repeated administration of a stimulus results in the progressive amplification of a response. Sensitization often is characterized by an enhancement of response to a whole class of stimuli in addition to the one that is repeated. For example, repetition of a painful stimulus may make one more responsive to a loud noise.

Patrick Carnes is an American proponent of the viewpoint that some sexual behavior is an addiction. According to CBS News, he popularized the term sex addiction. He created the International Institute for Trauma and Addiction Professionals (IITAP), as well as numerous addiction treatment facilities, and created the CSAT certification.

An addictive behavior is a behavior, or a stimulus related to a behavior, that is both rewarding and reinforcing, and is associated with the development of an addiction. Addictions involving addictive behaviors are normally referred to as behavioral addictions.

Reverse tolerance or drug sensitization is a pharmacological concept describing subjects' increased reaction to a drug following its repeated use. Not all drugs are subject to reverse tolerance.

Reward system Group of neural structures responsible for motivation and desire

The reward system is a group of neural structures responsible for incentive salience, associative learning, and positively-valenced emotions, particularly ones involving pleasure as a core component. Reward is the attractive and motivational property of a stimulus that induces appetitive behavior, also known as approach or consummatory behavior. A rewarding stimulus has been described as "any stimulus, object, event, activity, or situation that has the potential to make us approach and consume it is by definition a reward". In operant conditioning, rewarding stimuli function as positive reinforcers; however, the converse statement also holds true: positive reinforcers are rewarding.

Methamphetamine Stimulant drug, trade name Desoxyn, street name “meth”

Methamphetamine is a potent central nervous system (CNS) stimulant that is mainly used as a recreational drug and less commonly as a second-line treatment for attention deficit hyperactivity disorder and obesity. Methamphetamine was discovered in 1893 and exists as two enantiomers: levo-methamphetamine and dextro-methamphetamine. Methamphetamine properly refers to a specific chemical, the racemic free base, which is an equal mixture of levomethamphetamine and dextromethamphetamine in their pure amine forms. It is rarely prescribed over concerns involving human neurotoxicity and potential for recreational use as an aphrodisiac and euphoriant, among other concerns, as well as the availability of safer substitute drugs with comparable treatment efficacy. Dextromethamphetamine is a stronger CNS stimulant than levomethamphetamine.

FOSB

Protein fosB, also known as FosB and G0/G1 switch regulatory protein 3 (G0S3), is a protein that in humans is encoded by the FBJ murine osteosarcoma viral oncogene homolog B (FOSB) gene.

Behavioral addiction is a form of addiction that involves a compulsion to engage in a rewarding non-substance-related behavior – sometimes called a natural reward – despite any negative consequences to the person's physical, mental, social or financial well-being. Addiction canonically refers to substance abuse; however, the term connotation has been expanded to include behaviors that may lead to a reward since the 1990s. A gene transcription factor known as ΔFosB has been identified as a necessary common factor involved in both behavioral and drug addictions, which are associated with the same set of neural adaptations in the reward system.

Substance use disorder Continual use of drugs (including alcohol) despite detrimental consequences

Substance use disorder (SUD) is the persistent use of drugs despite substantial harm and adverse consequences. Substance use disorders are characterized by an array of mental/emotional, physical, and behavioral problems such as chronic guilt; an inability to reduce or stop consuming the substance(s) despite repeated attempts; driving while intoxicated; and physiological withdrawal symptoms. Drug classes that are involved in SUD include: alcohol; caffeine; cannabis; phencyclidine and other hallucinogens, such as arylcyclohexylamines; inhalants; opioids; sedatives, hypnotics, or anxiolytics; stimulants; tobacco; and other or unknown substances.

Addiction Compulsive engagement in rewarding stimuli despite adverse consequences

Addiction is a brain disorder characterized by compulsive engagement in rewarding stimuli despite adverse consequences. Despite the involvement of a number of psychosocial factors, a biological process—one that is induced by repeated exposure to an addictive stimulus—is the core pathology that drives the development and maintenance of an addiction, according to the "brain disease model" of addiction. However, many scholars who study addiction argue that the brain disease model is incomplete and misleading.

Sexual masochism disorder (SMD) is the condition of experiencing recurring and intense sexual arousal in response to enduring moderate or extreme pain, suffering, or humiliation. The Diagnostic and Statistical Manual (DSM-5) of the American Psychiatric Association indicates that a person may have a masochistic sexual interest but that the diagnosis of sexual masochism disorder would only apply to individuals who also report psychosocial difficulties because of it.

References

  1. Malenka RC, Nestler EJ, Hyman SE (2009). "Chapter 15: Reinforcement and Addictive Disorders". In Sydor A, Brown RY (eds.). Molecular Neuropharmacology: A Foundation for Clinical Neuroscience (2nd ed.). New York: McGraw-Hill Medical. pp. 364–365, 375. ISBN   9780071481274. The defining feature of addiction is compulsive, out-of-control drug use, despite negative consequences. ...
    compulsive eating, shopping, gambling, and sex–so-called "natural addictions"– ... Indeed, addiction to both drugs and behavioral rewards may arise from similar dysregulation of the mesolimbic dopamine system.
  2. 1 2 3 Karila L, Wéry A, Weinstein A, Cottencin O, Petit A, Reynaud M, Billieux J (2014). "Sexual addiction or hypersexual disorder: different terms for the same problem? A review of the literature". Curr. Pharm. Des. 20 (25): 4012–20. doi:10.2174/13816128113199990619. PMID   24001295. Sexual addiction, which is also known as hypersexual disorder, has largely been ignored by psychiatrists, even though the condition causes serious psychosocial problems for many people. A lack of empirical evidence on sexual addiction is the result of the disease's complete absence from versions of the Diagnostic and Statistical Manual of Mental Disorders. ... Existing prevalence rates of sexual addiction-related disorders range from 3% to 6%. Sexual addiction/hypersexual disorder is used as an umbrella construct to encompass various types of problematic behaviors, including excessive masturbation, cybersex, pornography use, sexual behavior with consenting adults, telephone sex, strip club visitation, and other behaviors. The adverse consequences of sexual addiction are similar to the consequences of other addictive disorders. Addictive, somatic and psychiatric disorders coexist with sexual addiction. In recent years, research on sexual addiction has proliferated, and screening instruments have increasingly been developed to diagnose or quantify sexual addiction disorders. In our systematic review of the existing measures, 22 questionnaires were identified. As with other behavioral addictions, the appropriate treatment of sexual addiction should combine pharmacological and psychological approaches.
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  12. Nestler EJ (December 2013). "Cellular basis of memory for addiction". Dialogues in Clinical Neuroscience. 15 (4): 431–443. PMC   3898681 . PMID   24459410. Despite the importance of numerous psychosocial factors, at its core, drug addiction involves a biological process: the ability of repeated exposure to a drug of abuse to induce changes in a vulnerable brain that drive the compulsive seeking and taking of drugs, and loss of control over drug use, that define a state of addiction. ... A large body of literature has demonstrated that such ΔFosB induction in D1-type [nucleus accumbens] neurons increases an animal's sensitivity to drug as well as natural rewards and promotes drug self-administration, presumably through a process of positive reinforcement ... Another ΔFosB target is cFos: as ΔFosB accumulates with repeated drug exposure it represses c-Fos and contributes to the molecular switch whereby ΔFosB is selectively induced in the chronic drug-treated state.41. ... Moreover, there is increasing evidence that, despite a range of genetic risks for addiction across the population, exposure to sufficiently high doses of a drug for long periods of time can transform someone who has relatively lower genetic loading into an addict.
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    Addiction: A term used to indicate the most severe, chronic stage of substance-use disorder, in which there is a substantial loss of self-control, as indicated by compulsive drug taking despite the desire to stop taking the drug. In the DSM-5, the term addiction is synonymous with the classification of severe substance-use disorder.
  15. 1 2 Malenka RC, Nestler EJ, Hyman SE (2009). "Chapter 15: Reinforcement and Addictive Disorders". In Sydor A, Brown RY (eds.). Molecular Neuropharmacology: A Foundation for Clinical Neuroscience (2nd ed.). New York: McGraw-Hill Medical. pp. 364–368. ISBN   9780071481274. The defining feature of addiction is compulsive, out-of-control drug use, despite negative consequences. ...Addictive drugs are both rewarding and reinforcing. A reward is a stimulus that the brain interprets as intrinsically positive. A reinforcing stimulus is one that increases the probability that behaviors paired with it will be repeated. Not all reinforcers are rewarding—for example, a negative or punishing stimulus might reinforce avoidance behaviors. ... Familiar pharmacologic terms such as tolerance, dependence, and sensitization are useful in describing some of the time-dependent processes that underlie addiction. ...
    Dependence is defined as an adaptive state that develops in response to repeated drug administration, and is unmasked during withdrawal, which occurs when drug taking stops. Dependence from long-term drug use may have both a somatic component, manifested by physical symptoms, and an emotional–motivation component, manifested by dysphoria. While physical dependence and withdrawal occur with some drugs of abuse (opiates, ethanol), these phenomena are not useful in the diagnosis of addiction because they do not occur with other drugs of abuse (cocaine, amphetamine) and can occur with many drugs that are not abused (propranolol, clonidine). The official diagnosis of drug addiction by the Diagnostic and Statistic Manual of Mental Disorders (2000), which makes distinctions between drug use, abuse, and substance dependence, is flawed. First, diagnosis of drug use versus abuse can be arbitrary and reflect cultural norms, not medical phenomena. Second, the term substance dependence implies that dependence is the primary pharmacologic phenomenon underlying addiction, which is likely not true, as tolerance, sensitization, and learning and memory also play central roles. It is ironic and unfortunate that the Manual avoids use of the term addiction, which provides the best description of the clinical syndrome.
  16. American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., rev.). Washington, DC: Author.
  17. Kafka, M. P. (2010). "Hypersexual Disorder: A proposed diagnosis for DSM-V" (PDF). Archives of Sexual Behavior . 39 (2): 377–400. doi:10.1007/s10508-009-9574-7. PMID   19937105. S2CID   2190694.
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  20. Psychiatry's bible: Autism, binge-eating updates proposed for 'DSM' USA Today.
  21. 1 2 American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (Fifth ed.). Arlington, VA: American Psychiatric Publishing. pp.  481, 797–798. ISBN   978-0-89042-555-8. Thus, groups of repetitive behaviors, which some term behavioral addictions, with such subcategories as "sex addiction," "exercise addiction," or "shopping addiction," are not included because at this time there is insufficient peer-reviewed evidence to establish the diagnostic criteria and course descriptions needed to identify these behaviors as mental disorders.
  22. Rachael Rettner (6 December 2012). "'Sex Addiction' Still Not Official Disorder". LiveScience . Retrieved 2 January 2013.
  23. "2017/18 ICD-10-CM Diagnosis Code F52.8: Other sexual dysfunction not due to a substance or known physiological condition". Icd10data.com. Retrieved 28 December 2017.
  24. "compulsive sexual behavior disorder"."
  25. Ley, David J. (24 January 2018). "Compulsive Sexual Behavior Disorder in ICD-11". Psychology Today. Retrieved 28 November 2018.
  26. Patrick Carnes; David Delmonico; Elizabeth Griffin (2001). In the Shadows of the Net . p.  31. ISBN   1-59285-149-5.
  27. Goodman, Aviel (1998). Sexual Addiction: An Integrated Approach. Madison, Connecticut: International Universities Press. pp. 233–234. ISBN   978-0-8236-6063-6.
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  34. Hull J. W.; Clarkin J. F.; Yeomans F. (1993). "Borderline personality disorder and impulsive sexual behavior". Psychiatric Services. 44 (10): 1000–1001. doi:10.1176/ps.44.10.1000. PMID   8225264.
  35. 1 2 "AASECT Position on Sex Addiction – AASECT:: American Association of Sexuality Educators, Counselors and Therapists". Aasect.org. Retrieved 28 December 2017.
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  37. "Association for the Treatment of Sexual Abusers : Statement about sexual addiction, sexual abuse, and effective treatment" (PDF). Atsa.com. 16 November 2017. Retrieved 28 December 2017.
  38. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Olsen CM (December 2011). "Natural rewards, neuroplasticity, and non-drug addictions". Neuropharmacology. 61 (7): 1109–1122. doi:10.1016/j.neuropharm.2011.03.010. PMC   3139704 . PMID   21459101. Cross-sensitization is also bidirectional, as a history of amphetamine administration facilitates sexual behavior and enhances the associated increase in NAc DA ... As described for food reward, sexual experience can also lead to activation of plasticity-related signaling cascades. The transcription factor delta FosB is increased in the NAc, PFC, dorsal striatum, and VTA following repeated sexual behavior (Wallace et al., 2008; Pitchers et al., 2010b). This natural increase in delta FosB or viral overexpression of delta FosB within the NAc modulates sexual performance, and NAc blockade of delta FosB attenuates this behavior (Hedges et al, 2009; Pitchers et al., 2010b). Further, viral overexpression of delta FosB enhances the conditioned place preference for an environment paired with sexual experience (Hedges et al., 2009). ... In some people, there is a transition from "normal" to compulsive engagement in natural rewards (such as food or sex), a condition that some have termed behavioral or non-drug addictions (Holden, 2001; Grant et al., 2006a). ... In humans, the role of dopamine signaling in incentive-sensitization processes has recently been highlighted by the observation of a dopamine dysregulation syndrome in some patients taking dopaminergic drugs. This syndrome is characterized by a medication-induced increase in (or compulsive) engagement in non-drug rewards such as gambling, shopping, or sex (Evans et al, 2006; Aiken, 2007; Lader, 2008)." Table 1"
  39. 1 2 3 4 5 6 Blum K, Werner T, Carnes S, Carnes P, Bowirrat A, Giordano J, Oscar-Berman M, Gold M (2012). "Sex, drugs, and rock 'n' roll: hypothesizing common mesolimbic activation as a function of reward gene polymorphisms". Journal of Psychoactive Drugs. 44 (1): 38–55. doi:10.1080/02791072.2012.662112. PMC   4040958 . PMID   22641964. It has been found that deltaFosB gene in the NAc is critical for reinforcing effects of sexual reward. Pitchers and colleagues (2010) reported that sexual experience was shown to cause DeltaFosB accumulation in several limbic brain regions including the NAc, medial pre-frontal cortex, VTA, caudate, and putamen, but not the medial preoptic nucleus. Next, the induction of c-Fos, a downstream (repressed) target of DeltaFosB, was measured in sexually experienced and naive animals. The number of mating-induced c-Fos-IR cells was significantly decreased in sexually experienced animals compared to sexually naive controls. Finally, DeltaFosB levels and its activity in the NAc were manipulated using viral-mediated gene transfer to study its potential role in mediating sexual experience and experience-induced facilitation of sexual performance. Animals with DeltaFosB overexpression displayed enhanced facilitation of sexual performance with sexual experience relative to controls. In contrast, the expression of DeltaJunD, a dominant-negative binding partner of DeltaFosB, attenuated sexual experience-induced facilitation of sexual performance, and stunted long-term maintenance of facilitation compared to DeltaFosB overexpressing group. Together, these findings support a critical role for DeltaFosB expression in the NAc in the reinforcing effects of sexual behavior and sexual experience-induced facilitation of sexual performance. ... both drug addiction and sexual addiction represent pathological forms of neuroplasticity along with the emergence of aberrant behaviors involving a cascade of neurochemical changes mainly in the brain's rewarding circuitry.
  40. 1 2 3 4 Pitchers KK, Vialou V, Nestler EJ, Laviolette SR, Lehman MN, Coolen LM (February 2013). "Natural and drug rewards act on common neural plasticity mechanisms with ΔFosB as a key mediator". J. Neurosci. 33 (8): 3434–3442. doi:10.1523/JNEUROSCI.4881-12.2013. PMC   3865508 . PMID   23426671. Drugs of abuse induce neuroplasticity in the natural reward pathway, specifically the nucleus accumbens (NAc), thereby causing development and expression of addictive behavior. ... Together, these findings demonstrate that drugs of abuse and natural reward behaviors act on common molecular and cellular mechanisms of plasticity that control vulnerability to drug addiction, and that this increased vulnerability is mediated by ΔFosB and its downstream transcriptional targets. ... Sexual behavior is highly rewarding (Tenk et al., 2009), and sexual experience causes sensitized drug-related behaviors, including cross-sensitization to amphetamine (Amph)-induced locomotor activity (Bradley and Meisel, 2001; Pitchers et al., 2010a) and enhanced Amph reward (Pitchers et al., 2010a). Moreover, sexual experience induces neural plasticity in the NAc similar to that induced by psychostimulant exposure, including increased dendritic spine density (Meisel and Mullins, 2006; Pitchers et al., 2010a), altered glutamate receptor trafficking, and decreased synaptic strength in prefrontal cortex-responding NAc shell neurons (Pitchers et al., 2012). Finally, periods of abstinence from sexual experience were found to be critical for enhanced Amph reward, NAc spinogenesis (Pitchers et al., 2010a), and glutamate receptor trafficking (Pitchers et al., 2012). These findings suggest that natural and drug reward experiences share common mechanisms of neural plasticity
  41. "What is a Sex Addict". Understanding Sexual Addiction. Retrieved 17 October 2020.
  42. Koob GF, Volkow ND (August 2016). "Neurobiology of addiction: a neurocircuitry analysis". Lancet Psychiatry. 3 (8): 760–773. doi:10.1016/S2215-0366(16)00104-8. PMC   6135092 . PMID   27475769. Drug addiction represents a dramatic dysregulation of motivational circuits that is caused by a combination of exaggerated incentive salience and habit formation, reward deficits and stress surfeits, and compromised executive function in three stages. The rewarding effects of drugs of abuse, development of incentive salience, and development of drug-seeking habits in the binge/intoxication stage involve changes in dopamine and opioid peptides in the basal ganglia. The increases in negative emotional states and dysphoric and stress-like responses in the withdrawal/negative affect stage involve decreases in the function of the dopamine component of the reward system and recruitment of brain stress neurotransmitters, such as corticotropin-releasing factor and dynorphin, in the neurocircuitry of the extended amygdala. The craving and deficits in executive function in the so-called preoccupation/anticipation stage involve the dysregulation of key afferent projections from the prefrontal cortex and insula, including glutamate, to the basal ganglia and extended amygdala. Molecular genetic studies have identified transduction and transcription factors that act in neurocircuitry associated with the development and maintenance of addiction that might mediate initial vulnerability, maintenance, and relapse associated with addiction. ... Substance-induced changes in transcription factors can also produce competing effects on reward function.141 For example, repeated substance use activates accumulating levels of ΔFosB, and animals with elevated ΔFosB exhibit exaggerated sensitivity to the rewarding effects of drugs of abuse, leading to the hypothesis that ΔFosB might be a sustained molecular trigger or switch that helps initiate and maintain a state of addiction.141,142
  43. Ruffle JK (November 2014). "Molecular neurobiology of addiction: what's all the (Δ)FosB about?". Am. J. Drug Alcohol Abuse. 40 (6): 428–437. doi:10.3109/00952990.2014.933840. PMID   25083822. S2CID   19157711.
    The strong correlation between chronic drug exposure and ΔFosB provides novel opportunities for targeted therapies in addiction (118), and suggests methods to analyze their efficacy (119). Over the past two decades, research has progressed from identifying ΔFosB induction to investigating its subsequent action (38). It is likely that ΔFosB research will now progress into a new era – the use of ΔFosB as a biomarker. ...

    Conclusions
    ΔFosB is an essential transcription factor implicated in the molecular and behavioral pathways of addiction following repeated drug exposure. The formation of ΔFosB in multiple brain regions, and the molecular pathway leading to the formation of AP-1 complexes is well understood. The establishment of a functional purpose for ΔFosB has allowed further determination as to some of the key aspects of its molecular cascades, involving effectors such as GluR2 (87,88), Cdk5 (93) and NFkB (100). Moreover, many of these molecular changes identified are now directly linked to the structural, physiological and behavioral changes observed following chronic drug exposure (60,95,97,102). New frontiers of research investigating the molecular roles of ΔFosB have been opened by epigenetic studies, and recent advances have illustrated the role of ΔFosB acting on DNA and histones, truly as a ‘‘molecular switch’’ (34). As a consequence of our improved understanding of ΔFosB in addiction, it is possible to evaluate the addictive potential of current medications (119), as well as use it as a biomarker for assessing the efficacy of therapeutic interventions (121,122,124). Some of these proposed interventions have limitations (125) or are in their infancy (75). However, it is hoped that some of these preliminary findings may lead to innovative treatments, which are much needed in addiction.
  44. Biliński P, Wojtyła A, Kapka-Skrzypczak L, Chwedorowicz R, Cyranka M, Studziński T (2012). "Epigenetic regulation in drug addiction". Ann. Agric. Environ. Med. 19 (3): 491–496. PMID   23020045. For these reasons, ΔFosB is considered a primary and causative transcription factor in creating new neural connections in the reward centre, prefrontal cortex, and other regions of the limbic system. This is reflected in the increased, stable and long-lasting level of sensitivity to cocaine and other drugs, and tendency to relapse even after long periods of abstinence. These newly constructed networks function very efficiently via new pathways as soon as drugs of abuse are further taken ... In this way, the induction of CDK5 gene expression occurs together with suppression of the G9A gene coding for dimethyltransferase acting on the histone H3. A feedback mechanism can be observed in the regulation of these 2 crucial factors that determine the adaptive epigenetic response to cocaine. This depends on ΔFosB inhibiting G9a gene expression, i.e. H3K9me2 synthesis which in turn inhibits transcription factors for ΔFosB. For this reason, the observed hyper-expression of G9a, which ensures high levels of the dimethylated form of histone H3, eliminates the neuronal structural and plasticity effects caused by cocaine by means of this feedback which blocks ΔFosB transcription
  45. 1 2 3 4 5 6 Nestler EJ (December 2012). "Transcriptional mechanisms of drug addiction". Clin. Psychopharmacol. Neurosci. 10 (3): 136–143. doi:10.9758/cpn.2012.10.3.136. PMC   3569166 . PMID   23430970. ΔFosB has been linked directly to several addiction-related behaviors ... Importantly, genetic or viral overexpression of ΔJunD, a dominant negative mutant of JunD which antagonizes ΔFosB- and other AP-1-mediated transcriptional activity, in the NAc or OFC blocks these key effects of drug exposure14,22–24. This indicates that ΔFosB is both necessary and sufficient for many of the changes wrought in the brain by chronic drug exposure. ΔFosB is also induced in D1-type NAc MSNs by chronic consumption of several natural rewards, including sucrose, high fat food, sex, wheel running, where it promotes that consumption14,26–30. This implicates ΔFosB in the regulation of natural rewards under normal conditions and perhaps during pathological addictive-like states.
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Further reading

Books that provide overview history and treatment techniques for sexual addiction include:

Books focusing on partners of sex addicts:

Discussions of the concept of sexual addiction: