The APA, the DSM-5, and Sexual Addiction

In the spring of last year the American Psychiatric Association published the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders, commonly referred to as the DSM-5. Prior to publication, the APA carefully considered Hypersexual Disorder (aka, sexual addiction) for inclusion as an official diagnosis. Noted psychiatrist and Harvard Medical School instructor Dr. Martin Kafka prepared the proposed diagnosis for examination by the APA. In doing so, Dr. Kafka reviewed the entire body of sex addiction focused scientific research and literature, both epidemiological and clinical, concluding:

The data reviewed from these varying theoretical perspectives is compatible with the formulation that Hypersexual Disorder is a sexual desire disorder characterized by an increased frequency and intensity of sexually motivated fantasies, arousal, urges, and enacted behavior in association with an impulsivity component—a maladaptive behavioral response with adverse consequences. Hypersexual Disorder can be associated with vulnerability to dysphoric affects and the use of sexual behavior in response to dysphoric affects and/or life stressors associated with such affects. … Hypersexual Disorder is associated with increased time engaging in sexual fantasies and behaviors (sexual preoccupation/sexual obsession) and a significant degree of volitional impairment or “loss of control” characterized as disinhibition, impulsivity, compulsivity, or behavioral addiction. … [Hypersexual Disorder] can be accompanied by both clinically significant personal distress and social and medical morbidity.

In short, after reviewing decades of scientific research, analysis, and commentary, Dr. Kafka concluded that sexual addiction very definitely exists. Furthermore, he noted that sex addicts engage in their addictive fantasies and behaviors as a way to self-soothe emotional discomfort brought on by life stressors and/or the dysphoria associated with depression, anxiety, unresolved early-life trauma, and the like. (These are the exact same reasons that alcoholics drink and drug addicts get high.) Lastly, Dr. Kafka noted that sexual addiction typically results in significant distress and morbidity.

So basically he confirmed what sex addiction treatment specialists like Dr. Patrick Carnes and I have been saying for years—that there are three main elements to sexual addiction:

Sexual obsession
Loss of control
Negative consequences

The APA—inexplicably and without explanation—chose to disregard Dr. Kafka’s presentation of the facts and to exclude Hypersexual Disorder from the DSM-5.-Robert Weiss
Amazingly, the APA—inexplicably and without explanation—chose to disregard Dr. Kafka’s presentation of the facts and to exclude Hypersexual Disorder from the DSM-5. Certainly I have theories as to why the APA has adopted this untenable stance. The kindest of these notions is that the organization feels there is not yet enough scientific evidence proving that sex can indeed become an addiction. I suspect that several other not-so-noble factors are in also play, but for purposes of this article I’ll push my somewhat unkind opinions aside and address only the “lack of research” angle.

And, in truth, we actually do need more research on the causation, formation, nature, consequences, and effective treatment of sexual addiction. Dr. Kafka notes this in his paper, especially in regard to female sex addicts, and I quite agree with his assessment. This should not, however, prevent sexual addiction (or Hypersexual Disorder) from being included in the DSM-5.

Dr. Kafka states the matter rather clearly, writing “the number of cases of Hypersexual Disorder reported in the peer reviewed journals greatly exceeds the number of cases of some of the codified paraphilic disorders such as Fetishism and Frotteurism.” So why leave it out? And let’s be perfectly honest here: We also need more research on depression, anxiety, and pretty much every other DSM-sanctioned diagnosis, but that hasn’t precluded APA endorsement. If absolute certainty was the standard for APA approval, the DSM would be a very thin book.

If absolute certainty was the standard for APA approval, the DSM would be a very thin book.-Robert Weiss

New Research

If the APA actually did exclude Hypersexual Disorder from the DSM-5 based on lack of scientific evidence, they won’t be able to do so much longer, as new and powerful research is now emerging in support of this behavioral disorder. Two notable studies have been published post-Kafka, one looking at the efficacy of Dr. Kafka’s proposed diagnostic criteria, the second examining the effects of sexual stimuli on the brain.

In the diagnostic criteria field trial, researchers examined 207 patients at mental health clinics across the country. Psychological testing and interviews were conducted with each of the subjects, all of whom had sought treatment for hypersexual behavior, substance abuse, or another psychiatric condition (such as depression or anxiety). The aim of the research was to learn if people who’d entered treatment for sexual addiction would be accurately identified by the Hypersexual Disorder criteria, and to make sure those who did not enter treatment seeking help with out-of-control sexual activity would not be misidentified as hypersexual.

The study found that Dr. Kafka’s criteria are indeed well constructed. The proposed diagnosis correctly identified 88 percent of the self-identified sexual addicts. More importantly, the diagnosis was 93 percent accurate in terms of negative results. Notably, many of the people seeking treatment for substance abuse issues reported also engaging in problematic sexual activity, but only when drunk or high, and the proposed diagnosis identified only one of these individuals as hypersexual. For the rest, the primary disorder was recognized as substance abuse. This level of accuracy is actually quite high in comparison to most other psychiatric diagnoses.

The researchers found that when sex addicts are shown pornographic imagery their brains “light up” in three specific areas—the ventral striatum, the dorsal anterior cingulate, and the amygdala—while the brains of non-sex addicts do not.-Robert Weiss

The diagnostic field trial, while useful, is hardly definitive in proving the existence of sexual addiction. What we’ve really needed is scientific evidence that sexual addiction affects the brain in the same ways as other addictions. And recently this proof arrived in the form of a detailed fMRI study conducted by researchers at Cambridge University (UK). This study compared the brain activity of self-identified sex addicts to the brain activity of non-sex addicts, and also to brain activity of drug addicts. The researchers found that when sex addicts are shown pornographic imagery their brains “light up” in three specific areas—the ventral striatum, the dorsal anterior cingulate, and the amygdala—while the brains of non-sex addicts do not. Furthermore, when sex addicts’ brains light up they do so in the same places and to the same degree as the brains of drug addicts when they are exposed to drug-related stimuli. In short, the parts of the brain in charge of things like anticipatory pleasure, mood, memory, and decision-making are activated in sex addicts exactly as they are with drug addicts. Other variables in this study also linked sex addiction with other forms of addiction, though brain reactivity was by far the most important measure.

The Future of Sexual Addiction as a Diagnosis

Despite the APA’s current unwillingness to accept sexual addiction as a very real and devastating disorder, other organizations, most notably the American Society of Addiction Medicine, have opted for a much more forward-thinking stance. ASAM writes:

Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. [Emphasis added.] Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response.

The studies discussed above, in particular the recent fMRI study, are significant proof that ASAM has it right when it comes to process (behavioral) addictions, recognizing that process addictions are in most respects no different than substance use disorders. Additionally, the World Health Organization, publishers of the ICD-10 (the international version of the DSM-5), has long recognized hypersexuality as a disorder with its Excessive Sexual Drive diagnosis. However, the ICD-10 is not the favored diagnostic manual in the United States, the DSM-5 is.

So will the APA leap forward when they make their first set of addendums to the DSM-5, legitimizing sexual addiction? Probably not. But even they won’t be able to hold out forever. In fact, Dr. Richard Krueger of Columbia University, who served on the physician committee that considered and ultimately rejected Hypersexual Disorder for inclusion in the DSM-5, recently told ABC News that the Cambridge fMRI research is a “seminal study” supporting the notion that sexual addiction is indeed an identifiable and diagnosable disorder.

Eventually, it seems, the APA will be forced to accept the mounting proof that sexual addiction is a real, debilitating, diagnosable, and treatable disorder. Until that time, of course, nothing much changes; meaning clinicians who diagnose and treat sexual addiction will continue to do so in the ways they know best, with or without APA recognition.

Photo Source: istock