Addict Behav Rep. 2018 Oct 18;8:164-169. doi: 10.1016/j.abrep.2018.10.003.
Blum AW1, Chamberlain SR2,3, Grant JE1.
Abstract
Introduction:
Many young adults are unable to control their sexual behavior despite distress or negative consequences created by these activities-a clinical phenomenon described as non-paraphilic problematic sexual behavior (PSB). Little is known about clinical features associated with quality of life in PSB.
Methods:
54 participants affected by PSB (ages 18-29 years) were recruited for a study on impulsivity in young adults. PSB was defined as the experience of sexual urges, fantasies, or behaviors that feel overwhelming or out of control. Participants were assessed using the Quality of Life Inventory (QOLI), other validated instruments, and questions examining aspects of health and well-being. Clinical measures associated with variation in quality of life were identified using the statistical technique of partial least squares (PLS).
Results:
Lower quality of life in PSB was associated with greater behavioral and self-report measures of impulsivity (specifically, Barratt attentional impulsiveness, lower age at first alcohol use), emotional dysregulation, problematic use of the internet, current suicidality, higher state anxiety and depression, and lower self-esteem.
Conclusions:
Impulsivity and affective problems are correlated with lower quality of life in PSB. These associations may provide a means to distinguish PSB from healthy sexual behavior.
KEYWORDS: Compulsivity; Hypersexuality; Impulsivity; Sexual behavior; Young adult
PMID: 30386816
PMCID: PMC6205335
DOI: 10.1016/j.abrep.2018.10.003
Discussion
To our knowledge, this is the most detailed study of quality of life in young adults affected by PSB. Using the statistical technique of PLS, we found that the covariance between quality of life and other clinical characteristics in our sample was best explained by a single latent factor. Lower quality of life in PSB was significantly and positively associated with emotional dysregulation, suicidality, problematic use of the internet, lower self-esteem, and elevated state (i.e., situational) symptoms of anxiety and depression. Aspects of impulsivity (specifically, attentional impulsiveness on the BIS-11 and lower age at first alcohol use) were also significantly associated with lower quality of life. These findings may have implications for the health and well-being of people with PSB.
Notably, we found that lower quality of life was associated with a specific measure of impulsivity: attentional impulsiveness on the BIS-11. Attentional impulsiveness is defined as the inability to concentrate or focus attention on a given task (for example, “I don’t ‘pay attention’” [Stanford et al., 2009]). Other evidence implicating impaired attention in PSB comes from studies of compulsive sexual behavior (hypersexuality). Approximately 23%–27% of hypersexual men meet diagnostic criteria for attention-deficit/hyperactivity disorder (ADHD)—arguably the archetypal disorder of impulsivity—with the overwhelming majority meeting criteria for the inattentive subtype (Reid, 2007; Reid, Carpenter, Gilliland, & Karim, 2011). Hypersexual behavior (in men) has also been linked with proneness to boredom (Chaney & Blalock, 2006), a personality trait closely related to attentional impulsivity. Furthermore, heightened attentional impulsivity may be linked to emotional dysregulation in PSB, reflected by attempts to use sex to cope with stress or negative affect. Such a hypothesis is consistent with psychological studies showing that people often find it difficult to exert self-control in times of emotional distress, when immediate affect regulation is prioritized over long-term goals (Tice, Bratslavsky, & Baumeister, 2001). Thus, our results suggest that impulsivity could give rise to a range of problems affecting quality of life in people with PSB.
Although attentional impulsivity was associated with lower quality of life, other self-control processes previously implicated in PSB—including motor response inhibition (Leppink et al., 2016)—did not show such an association. Therefore, our analysis suggests that attentional problems may be more clinically relevant than deficits in other impulsivity constructs. More generally, these divergent findings illustrate the importance of fractionating impulsivity into its constituent domains. It is also worth noting one particular area requiring further study: whether impulsivity plays a global role in forms of PSB, or if it is expressed only in domain-specific contexts (such as in response to sexual stimuli; Reid, Berlin, & Kingston, 2015).
Our study also found a link between poor quality of life in PSB and problematic use of the internet. For some people, excessive or compulsive use of the internet—especially for purposes of sexual gratification—may lead to shame about the behavior (resulting in loss of self-esteem), relationship difficulties, or workplace problems (including loss of employment), with clear negative consequences for one’s quality of life (Griffiths, 2012). Alternatively, online sexual behaviors may provide a short-term escape from various problems contributing to poor quality of life (Griffiths, 2012).
Consistent with previous studies, poor quality of life in PSB was associated with several emotional or psychological problems. One parsimonious explanation for these findings is that PSB and emotional difficulties may share a common antecedent: a lack of appropriate emotional regulation. From this perspective, inappropriate or excessive sexual behavior could be characterized as a maladaptive coping strategy for stress or dysphoric moods (e.g., anxiety, depression; see Black et al., 1997; Coleman, 1992; Raymond et al., 2003; Reid et al., 2008). Several findings from our study support this characterization, particularly the strong, negative association between emotional dysregulation (as measured by the DERS) and quality of life. One possibility is that people who struggle to regulate their emotions are prone to stress and rumination (Reid et al., 2008; Reid, Bramen, Anderson, & Cohen, 2014; Reid, Temko, Moghaddam, & Fong, 2014), which may make them more vulnerable to depression or anxiety interfering with quality of life. In response to these negative emotions, some people may use sex as a compensatory behavior. Some people, in fact, show paradoxically increased sexual desire and behavior when depressed or anxious, and this association appears to be especially robust in forms of disordered sexual behavior (Bancroft & Vukadinovic, 2004; Lykins, Janssen, & Graham, 2006). These behaviors offer only temporary relief from negative emotions, however, and problems resulting from PSB (such as shame [Reid, 2010; Reid, Harper, & Anderson, 2009]) may invite even more maladaptive sexual behavior in a misguided attempt to manage worsening distress. Taken together, these findings suggest that therapy focusing on cognition and emotion (i.e., cognitive–behavioral therapy and/or dialectical behavior therapy) may improve psychological well-being (and therefore quality of life) in people affected by PSB.
The present study has several limitations. Our sample included only young adults, and the clinical associations identified here may not generalize to people with PSB across a broader age range. We also note three limitations related to our clinical assessments. First, as in other studies, our analysis did not include a dimensional measure of clinical severity, as it is currently unclear how severity in PSB should be defined and measured (Reid, 2015). Second, the QOLI is a self-report assessment and may therefore under- or over-report difficulties with various life domains. Third, the BIS-11 was not specifically adapted for PSB. As noted by a previous study, using an alternative factor structure of the BIS-11 may permit a more disorder-specific assessment of impulsivity in certain clinical populations, including those affected by PSB (Reid, Cyders, Moghaddam, & Fong, 2014). Even so, we elected to use the traditional factor structure given the high rates of psychiatric comorbidity in our sample. In terms of data analysis, our use of bootstrap methods to identify statistically significant measures in the PLS model was quite conservative and may have resulted in some variables being overlooked (false negatives). Our approach does, however, provide a high degree of statistical confidence in the significant results. In addition, this study used a cross-sectional analysis and therefore cannot establish causal relationships between sexual behavior, quality of life, and other clinical variables. Despite this limitation, our analysis provides robust measures of association. Finally, the proportion of variance explained by the model was relatively modest, and other unmeasured variables are likely to be important. Future studies may wish to consider other risk factors for hypersexual behavior, such as loneliness, interpersonal sensitivity (Reid, Bramen, et al., 2014), or trauma (Howard, 2007). Sex hormone levels are also known to influence sexual behavior, though we are aware of no controlled studies examining hormonal factors in hypersexuality (Kaplan & Krueger, 2010). How these factors may influence quality of life merits further investigation.
To our knowledge, the present study is the only to examine quality of life in young adults with PSB. We found that low quality of life in PSB was associated with selective deficits in self-control—specifically, in attention and emotional regulation. Our findings therefore support the hypothesis that loss of control over sex may have pronounced effects on psychological well-being and quality of life, even among people not meeting all proposed diagnostic criteria for compulsive sexual behavior. These findings may have implications for our understanding and treatment of sexual behaviors that affect quality of life.
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