Report of Findings in a DSM-5 Field Trial for Hypersexual Disorder. (2012)

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COMMENTS: The upcoming DSM-5 is trying to decide if hypersexual disorder should be included. The conclusion is that hypersexual disoder does exist as those with modest training can accurately diagnose the condition. See the article below the study describe the findings.


J Sex Med. 2012 Oct 4. doi: 10.1111/j.1743-6109.2012.02936.x.

Source

UCLA Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, USA Department of Psychology, Brigham Young University, Provo, UT, USA Department of Psychology, University of North Texas, Denton, TX, USA Department of Psychology, Texas Tech University, Lubbock, TX, USA Private Practice, Denver, CO, USA Department of Psychology, Temple University, Philadelphia, PA, USA.

Abstract

Introduction.  

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for hypersexual disorder (HD) have been proposed to capture symptoms reported by patients seeking help for out-of-control sexual behavior. The proposed criteria created by the DSM-5 Work Group on Sexual and Gender Identity Disorders require evaluation in a formal field trial.

Aim. 

This DSM-5 Field Trial was designed to assess the reliability and validity of the criteria for HD in a sample of patients seeking treatment for hypersexual behavior, a general psychiatric condition, or a substance-related disorder. Method.  Patients (N = 207) were assessed for psychopathology and HD by blinded raters to determine inter-rater reliability of the HD criteria and following a 2-week interval by a third rater to evaluate the stability of the HD criteria over time. Patients also completed a number of self-report measures to assess the validity of the HD criteria.

Main Outcome Measures. 

HD and psychopathology were measured by structured diagnostic interviews, the Hypersexual Behavior Inventory, Sexual Compulsivity Scale, and Hypersexual Behavior Consequences Scale. Emotional dysregulation and stress proneness were measured by facets on the NEO Personality Inventory-Revised. Results.  Inter-rater reliability was high and the HD criteria showed good stability over time. Sensitivity and specificity indices showed that the criteria for HD accurately reflected the presenting problem among patients. The diagnostic criteria for HD showed good validity with theoretically related measures of hypersexuality, impulsivity, emotional dysregulation, and stress proneness, as well as good internal consistency. Patients assessed for HD also reported a vast array of consequences for hypersexual behavior that were significantly greater than those diagnosed with a general psychiatric condition or substance-related disorder.

Conclusions. 

The HD criteria proposed by the DSM-5 Work Group on Sexual and Gender Identity Disorders appear to demonstrate high reliability and validity when applied to patients in a clinical setting among a group of raters with modest training on assessing HD.

Reid RC, Carpenter BN, Hook JN, Garos S, Manning JC, Gilliland R, Cooper EB, McKittrick H, Davtian M, and Fong T. Report of findings in a DSM-5 Field Trial for hypersexual disorder. J Sex Med **;**:**-**.

© 2012 International Society for Sexual Medicine.


Media claims 'sex addiction' is real

"Sex addiction IS a real disorder," claims the Daily Mail. The newspaper's story is based on a study assessing the accuracy of a proposed new medical diagnosis, called hypersexual disorder.

Hypersexual disorder (HD) is a term used to describe a number of related symptoms. These include spending excessive time engaged in sexual fantasies and urges or in planning for and engaging in sexual behaviour. This preoccupation then causes significant personal distress or impairment to social life or occupation.

While this model was well received, it has not yet been formally established as a psychiatric disorder. Specifically, hypersexual disorder has not yet been added to the proposed text of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). This is the definitive work listing all recognised mental health conditions. DSM-5 is due to be published in 2013.

In the study, researchers interviewed more than 200 patients who were referred to mental health clinics for a number of conditions including HD. The interviewers were not aware why patients had been referred, but their interviews were designed to reflect the proposed new criteria for HD. The study found that the interviewers were generally in agreement about which patients had HD, and that the proposed new criteria accurately reflected the problems patients reported. The study suggests that the proposed ‘symptoms checklist’ for HD is a useful tool. 

These sorts of reality checks are important parts of research into sexual problems, which, despite sniggering in some sections of the media, can cause considerable distress to those affected. 

Hypersexual disorder

The criteria (or ‘symptom checklist’) for hypersexual disorder are based on three main factors. 

A. Over a period of at least six months, experiencing recurrent and intense sexual fantasies, sexual urges and sexual behaviour in association with four or more of the following five criteria:

  • excessive time is consumed by sexual fantasies and urges, and by planning for and engaging in sexual behaviour
  • repetitively engaging in these sexual fantasies, urges and behaviour in response to negative mood states (for example, anxiety, depression, boredom and irritability)
  • repetitively engaging in sexual fantasies, urges and behaviour in response to stressful life events
  • repetitive but unsuccessful efforts to control or significantly reduce these sexual fantasies, urges and behaviour
  • repetitively engaging in sexual behaviour while disregarding the risk of physical or emotional harm to self or others

B. There is clinically significant personal distress or impairment in social, occupational or other important areas associated with these sexual fantasies, urges and behaviour.

C. Sexual fantasies, urges and behaviour are not due to the direct physiological effects of external substances (for example, drugs or abuse of medications), another medical condition or manic episodes.

Where did the story come from?

The study was carried out by researchers from the University of California, Brigham Young University, the University of North Texas, Texas Tech University and Temple University. There is no information about external funding.

The study was published in the peer-reviewed Journal of Sexual Medicine.

Predictably, the Mail sexed up its story using a photo of self-confessed “sex addict” Russell Brand and a description of sex addiction as something that has “traditionally been written off as an ‘excuse’ for philandering celebrities”.

The paper is incorrect to call hypersexual disorder an addiction. It has not been classified as such. The definition of addiction normally includes an element of physiological dependence.

It would be more accurate to describe hypersexual disorder as a type of personality disorder. Personality disorders are conditions in which distorted patterns of thinking can lead to unusual, and often self-destructive, behaviour.

What kind of research was this?

This was a field trial, which means research conducted in a “real” situation, in this case psychiatric clinics. The researchers say that patients seeking help for HD are typically unable to control the amount of time they spend engaging in sexual fantasies, urges and behaviours, including masturbation, pornography, cybersex, telephone sex and strip clubs.

Hypersexual disorder, the researchers say, causes significant personal distress and impairs patients socially and professionally. Although descriptions of hypersexual behaviour have existed for a long time, psychiatrists have only recently acknowledged it may be a clinical disorder rather than a normal variant of sexual expression.

A new diagnosis for hypersexual disorder has been proposed for the Diagnostic and Statistical Manual of Mental Disorders, the comprehensive classification of mental health disorders, published by the American Psychiatric Association. Updated at regular intervals, the DSM is used by mental health professionals worldwide. Some doctors have proposed that hypersexual disorder be included as a new diagnosis in the next edition (DSM-5).

What did the research involve?

The research included 207 patients aged 18 and over, randomly selected from various psychiatric clinics in the US that provide treatment for hypersexual disorder, psychiatric conditions and substance-related disorders. Of these patients, 152 were referred for hypersexual disorder.

The interviewers were 13 individuals from a broad range of backgrounds including psychiatrists, psychologists, social workers, marriage and family therapists, and postgraduate clinical psychology students. This diversity, say the researchers, was designed to reflect the broad range of professionals who use the DSM in their clinical practice. About half the team had not worked with hypersexual patients before the trial.

None of the team knew what the patients had been referred for. They all received training in conducting a diagnostic psychiatric interview and also listened to several recorded interviews where questions were designed to reflect the new criteria for hypersexual disorder (called the HD diagnostic clinical interview or HD-DCI).

All patients first underwent a standard psychiatric interview and each then had a detailed interview with one of the team, aimed at assessing whether they had hypersexual disorder. The questions were phrased to mirror closely the proposed new diagnostic criteria. During the first week of the study, patients also completed a number of self-report measures also designed to reflect the new criteria, to help assess their validity.

For each interview, two “raters” were usually present who were blinded to each other’s ratings. One rater conducted the interview while the other observed.

Two weeks after the initial interviews, a third rater repeated the HD-DCI interview with each patient.

Researchers then looked at how far the different raters agreed with each other on the diagnosis of hypersexual disorder and, in a subset of 32 patients, they also looked at whether diagnoses from the second test, two weeks later, matched the original diagnoses. They applied various standard statistical tests to assess whether the diagnostic criteria were valid and reliable.

What were the basic results?

The researchers say that: 

  • Inter-rater reliability (IRR) was high, at 93%. This means that interviewers mostly agreed on whether patients met the diagnostic criteria for hypersexual disorder (0.93, 95% confidence interval 0.78 to 1).
  • The test–retest reliability was high, with 29 of 32 cases resulting in agreement.
  • Sensitivity (the proportion of patients referred for hypersexual disorder who were correctly identified) and specificity (the proportion of patients referred for something else other than hypersexual disorder who were correctly identified) showed the new criteria for hypersexual disorder accurately reflected the problems patients had been referred for.
  • Patients assessed for hypersexual disorder also reported a “vast array” of negative consequences for hypersexual behaviour that were “significantly greater” than those diagnosed with either a general psychiatric condition or a substance-related disorder. These included job loss, loss of a romantic relationship, legal and financial problems.

How did the researchers interpret the results?

The researchers point out that this is the first publication of a DSM-5 field trial for the proposed new diagnosis of hypersexual disorder. It found that the new criteria appear to demonstrate high reliability and validity when applied to patients in a clinical setting, using a group of raters with modest training on assessing hypersexual disorder.

Conclusion

The study of hypersexual disorder is an area of growing interest within the field of mental health and sexual medicine (and of course will be of interest to the press). This study seems to show that the proposed diagnostic criteria reflect the problems patients have in this area and also that they are workable in practice. Further research is needed to confirm these criteria and also on the issue of how hypersexual disorder might best be treated.

One potential weakness of the study is the use of self-report measures and diagnostic structured interviews, which may lack the reliability of more objective measures. Ideally, these sorts of studies are repeated in populations where the disorder is uncommon so that the extent of any false positives or wrong diagnoses can be assessed in a sample more typical of an un-referred healthy community.

If you are concerned that you may have an obsessive and unhealthy attitude towards sex that is adversely affecting your life, there are several treatments available, such as the talking therapy cognitive behavioural therapy. Read more about treating sex addiction.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on twitter.