Hypersexual Disorder: A Proposed Diagnosis for DSM-V (2009)
Here are some excerpts from this article by Martin P. Kafka, MD:
"Hypersexual Desire" Defined
[Page 5] An operational definition for ‘‘hypersexual desire’’ based on a lifetime assessment of the frequency of sexual behavior as well as current measurements of time spent in PA and PRD associated sexual fantasies, urges, and behavior was derived from 220 consecutively evaluated males with PAs and PRDs (Kafka, 1997b, 2003a; Kafka & Hennen, 2003). From these clinically derived data, hypersexual desire in adult males was defined as a persistent TSO of 7 or more orgasms/week for at least 6 consecutive months after the age of 15 years.
Kafka’s proposed operational definition for hypersexual desire was formulated to reflect Kinsey et al. (1948), Atwood and Gagnon (1987), Janus and Janus (1993), and Laumann et al.’s (1994) normative data on the range of sexual behavior in American males as well as their data characterizing the most sexually active 5–10% of their samples.
A longitudinal history of hypersexual desire, as operationally defined above, was identified in 72–80% of males seeking treatment for paraphilias and paraphilia-related disorders (Kafka, 1997b, 2003a; Kafka & Hennen, 2003). If the TSO/week threshold for hypersexual desire were reduced to 59/week for a minimum duration of 6 months, this would have included 90% of the sample.
The most commonly enacted lifetime sexual behavior in these clinically derived samples was masturbation, not partnered sex, as was similarly reported by Kinsey et al. (1948, p. 197) and La°ngstro¨mand Hanson (2006) in men who were the most sexually active in their samples. The mean age of onset of persistent hypersexual behavior was 18.7±7.2 years, the age range of onset of hypersexual behavior was age 7–46, and the mean duration of this highest consistently maintained frequency of sexual appetitive behavior was 12.3±10.1 years. In contrast, the mean age of this group when they sought treatment was 37±9 years. Periods of persistent hypersexual behavior were continuous or episodic.
Sexual Addiction and Sexual Dependence
[Pages 7-8] In the peer-reviewed literature, there is some empirical support for sex as a behavioral addiction or dependency syndrome.
The neurobiology associated with psychoactive substance dependency has been elucidated in animal models. The negative emotional state that drives ‘‘compulsive’’ drug use is hypothesized to derive from dysregulation of key neurotransmitters involved in distinct reward and stress-associated neural circuits within the basal forebrain structures, particularly the ventral striatum (including the nucleus accumbens) and extended amygdala. Specific neurochemical elements in these structures associated with psychoactive substance dependence can include decreases in dopamine, serotonin, and opioid peptides in the ventral striatum, but also recruitment of brain stress neurohormones, such as corticotrophin-releasing factor in the extended amygdala (Koob, 2008).
In humans, the orbital prefrontal cortex and ventral anterior cingulate cortex are functionally associated with motivation, reward appraisal, and mediation/inhibition of impulsive aggression (Best, Williams, & Coccaro, 2002; Horn, Dolan, Elliott, Deakin,&Woodruff, 2003; New et al., 2002). The dysregulation in these brain circuits in their relationship with limbic structures, particularly the amygdala, have been detected by fMRI and neuroimaging procedures as well as sophisticated neuropsychological testing in impulsivity disorders, including substance abuse disorders and behavioral addictions (Bechara, 2005; Cavedini, Riboldi, Keller, D’Annucci, & Bellodi, 2002; London, Ernst, Grant, Bonson, & Weinstein, 2000; Volkow&Fowler, 2000).The application of neurobiological studies to putative human sexual addiction would be helpful to clarify whether a similar neurobiology and neural pathways are applicable.
Sexual Addiction or Impulsive–Compulsive Sexual
[page 15] The designation of nonparaphilic sexual behavior disorders as a behavioral addiction or admixture of compulsive/impulsive behavior merits further study. Several criteria proposed for Hypersexual Disorder are consistent with a behavioral addiction model as applied to the impulsity-associated component of Hypersexual Disorder. Examining a larger and community-based sample of men and women who could be solicited by advertisement or survey methodology, identified as having problematic sexual behaviors, and then applying the full criteria for psychoactive substance abuse modified to diagnose behavioral excesses of sexual behaviors would be very helpful in clarifying the comparative prevalence of sexual addiction/dependence among men and women reporting both paraphilic and nonparaphilic hypersexual behaviors. In addition, neuropsychological studies and neuroimaging studies of males and females with Hypersexual Disorder are needed to delineate whether there are common pathways that are associated with these disorders and other behavioral addictions or impulsivity disorders. At present, the published literature is lacking to firmly support a specific‘‘withdrawal’’ state associated with the abrupt cessation of Hypersexual Behavior. I also did not find sufficient empirical evidence of ‘‘tolerance’’ although progressive risk-taking in association with hypersexual behaviors could be analogous to drug tolerance. This is not to state that withdrawal and tolerance do not exist in hypersexual conditions but, rather, that further studies are necessary to support their clinical presence and relevance. (emphasis added) Full article