In recent years there has been tremendous controversy about sexually compulsive behaviour. Researchers and clinicians alike have argued about the best terminology to use, diagnostic criteria, and treatment approaches. In this presentation, Dr. Carnes discusses the concerns about labelling out control sexual behaviour and examines the new research and the controversy surrounding the diagnosis. Different perspectives on conceptualisation of the disorder and treatment will be discussed.

1. Sex Addiction and
Compulsivity: Diagnostic
Challenges and New Research
Stefanie Carnes, Ph.D., CSAT-S
Clinical Sexologist
Certified Sex Therapist
AAMFT Approved Supervisor

2. Full
Disclosure
Dr. Stefanie Carnes is a Senior Fellow at the
Meadows Behavioral Health and the
President of the International Institute for
Trauma and Addiction Professionals.

3. Can Sex be an
Addiction? A
compulsion?
ICD – 11 includes sexual compulsivity under
impulse control disorders
Criteria across these different conceptualizations
are similar
Various authors have argued for different terms
- "Compulsive" (OCD,
Coleman, 2003)
- "Addictive" (Carnes,
1983)
- "Impulsive" (Barth
and Kinder, 1987)
- "Hypersexual"
(Stein et al., 2000,
Reid/ Kafka)
DSM III-R contained a category called "non-
paraphilic sexual addiction"

5. World Psychiatry – WHO
Committee April 2018
Currently, there is an active scientific discussion about
whether compulsive sexual behaviour disorder can
constitute the manifestation of a behavioural addiction.
For ICD-11, a relatively conservative position has been
recommended, recognizing that we do not yet have
definitive information on whether the processes involved
in the development and maintenance of the disorder are
equivalent to those observed in substance use disorders,
gambling and gaming. For this reason, compulsive sexual
behaviour disorder is not included in the ICD-11 grouping
of disorders due to substance use and addictive
behaviours, but rather in that of impulse control
disorders. The understanding of compulsive sexual
behaviour disorder will evolve as research elucidates the
phenomenology and neurobiological underpinnings of
the condition.

6. Sex Addiction
Defined
A pathological relationship to a
mood altering experience (sex)
that the individual continues to
engage in despite adverse
consequences.

7. Addiction Criteria

8. Loss of Control
CLEAR BEHAVIOR IN WHICH YOU DO MORE THAN
YOU INTEND OR WANT.

11. Compulsive
Behavior
A PATTERN OF OUT OF CONTROL BEHAVIOR OVER
TIME USED TO REDUCE ANXIETY AND SELF
MEDICATE NEGATIVE FEELINGS.

15. Efforts to Stop
REPEATED SPECIFIC ATTEMPTS TO STOP THE
BEHAVIOR WHICH FAIL.

19. Loss of Time
SIGNIFICANT AMOUNTS OF TIME LOST DOING
AND/OR RECOVERING FROM THE BEHAVIOR

22. Preoccupation
OBSESSING ABOUT OR BECAUSE OF THE BEHAVIOR

25. Inability to Fulfill
Obligations
THE BEHAVIOR INTERFERES WITH WORK, SCHOOL,
FAMILY, AND FRIENDS.

28. Continuation
Despite
Consequences
FAILURE TO STOP THE BEHAVIOR EVEN THOUGH
YOU HAVE PROBLEMS BECAUSE OF IT (SOCIAL,
LEGAL, FINANCIAL, PHYSICAL, WORK.)

32. Escalation
NEED TO MAKE THE BEHAVIOR MORE INTENSE,
MORE FREQUENT, OR MORE RISKY.

36. Losses
LOSING, LIMITING, OR SACRIFICING VALUED PARTS
OF LIFE SUCH AS HOBBIES, FAMILY,
RELATIONSHIPS, AND WORK

41. Withdrawal
STOPPING BEHAVIOR CAUSES CONSIDERABLE
DISTRESS, ANXIETY, RESTLESSNESS, IRRITABILITY,
OR PHYSICAL DISCOMFORT

44. Addiction Criteria
Tolerance
Withdrawal

45. DSM-5 Field Study Report for
Hypersexual Disorder

46. DSM-5 Hypersexual Disorder
Field Trial Report
Reid, R. , Carpenter, B.N., Hook, J.N., Garos, S., Manning, J.C., Gilliand, R., Cooper, E.B., McKittrick, H.,
Davitan, M., & Fong, T. (2012). Report of findings in a DSM-5 Field Trial for Hypersexual Disorder.
Goal was to examine the inter-rater reliability
of clinicians attempting to diagnose HD.
Reid et al. (2012) conducted a field study to
investigate the “clinical utility, reliability and validity
of diagnostic validity of [hypersexual disorder (HD)]
criteria in clinical settings” for possible inclusion in
the DSM-5.

47. DSM-5 Proposed
Criteria for
Hypersexual
Disorder
(Reid et al. (2012)

48. Method
Instruments:
Participants completed the Mini-International Neuropsychiatric
Interview (MINI 6.0) a structured diagnostic interview at intake to
rule out any other psychopathology that could account for HD
symptoms.
They also completed the HD Diagnostic Clinical Interview, the HD
Questionnaire (HDQ), the HD Course Questionnaire (HDCQ),
Hypersexual Behavior Inventory (HBI); Sexual Compulsivity Scale
(SCS), NEO Personality Inventory-Revised (NEO-PI-R), the
Hypersexual Behavior Consequences (HBCS) and the Erotic
Preferences Examination Scheme (EPES).
Included 13 raters from a variety of fields (psychiatry,
psychology, social work, marriage and family therapy,
etc) practicing in outpatient settings

49. Procedures
Raters were trained on how to
complete the structured
diagnostic interviews correctly and
to assess for the proposed HD
criteria
One rater completed and scored
the initial interviews of the MINI
6.0 and HD-DCI and another rater
scored it as well
• A third rater blind to the initial ratings
administered and scored the HD-DCI two
weeks later

50. Results
Inter-rater reliability: kappa
coefficient of .93 among the
clinicians
Indicates the diagnostic criteria
can be reliably used in patients
Test-Retest Reliability: “high” for
the HD criteria after the two
week follow-up p<0.001)
Suggests reliability of the
diagnostic criteria over time
Sensitivity=.88, Specificity=.93,
Positive Predictive Power=.97,
Negative Predictive Power=.74
Results suggested the proposed
HD criteria reflected the
presenting problems well.
High Concurrent Validity
HDQ scores were highly
correlated with HBI (r=.911) and
SCS scores (r=.829)

51. Results Continued
•Participants reporting having sex while experiencing negative
emotions had higher Neuroticism scores on the NEO-PI-R.
•There was a significant positive correlation between the
number of consequences people reported as a result of their
sexual behaviors and higher levels of hypersexual behaviors.
Concurrent Validity
•82% endorsed a gradual progression of HD symptoms lasting
months to years
•48.6% reported a continuous course, while 51.4% reported
episodic symptoms
Clinical Course: 54% of
participants reported
“dysregulated sexual fantasies,
urges and behaviors prior to
adulthood,” 30% indicated
these issues started in their
college years.

52. Conclusions
However, HD was not ultimately included
in the DSM-5.
The researchers suggested the proposed HD
diagnostic criteria could be reliably applied to
people presenting with hypersexual behaviors
and was measuring a valid construct

53. Why Wasn’t
HD Included
in the DSM-5?
REID AND KAFKA (2014) POSITED A NUMBER
OF REASONS WHY HYPERSEXUAL DISORDER
WAS NOT INCLUDED IN THE DSM-5

54. Reid, R.C. & Kafka, M.P. (2014). Controversies about Hypersexual Disorder and the DSM-
Some contended the HD diagnosis “confused
social disapproval and morality with issues of
health and disorder” (Wakefield, 2012)
Some members of the Sexual and Gender Identity
Disorders DSM-5 Task Force Committee were
specifically targeted in the media
Previous DSM editors openly criticized the DSM-5
Task Force and Workgroups before its publication
Politics

55. Potential
Legal
Implications
& Problems
Concerns about
potential misuse
in the forensic
community
• For example, using
an HD diagnosis as
mitigating factor in
cases of child
molestation
• No evidence a
pedophilia
diagnosis has ever
resulted in a
reduced sentence
Authors note a
recent field
study of HD
diagnosis in sex
offenders
resulted in very
few diagnoses
of HD

56. Criticisms of
the
Diagnostic
Criteria
Some argued hypersexual behaviors could
be better accounted for by another
already existing psychological disorder
Reid and Kafka suggested individual criterion
were “dissected” and rejected while
neglecting the fact that a constellation of at
least four of the five symptoms over 6 months
would need to be present for a diagnosis
Belief that the diagnostic criteria did not
differentiate between high sex drives and
pathological levels and activities

57. Empirical
Identification
of
Psychological
Symptom
Subgroups of
Sex Addicts:
An
Application of
Latent Profile
Analysis (Nino
De Guzman
et al. 2015)
There is a sizeable group (38%) of sex addicts that
probably do not have other comorbid disorders
(Class 1 and 2).
This provides further evidence for the existence of
sex addiction as a discrete disorder, as opposed to
merely being symptomatic of other psychological
disorders.
At the same time, about 24% of the sample (Class
4 and Class 5) likely do have other diagnosable
conditions (i.e., mood disorders and anxiety
disorders), and thus highlights the importance of
broad-band psychological assessment to facilitate
treatment planning for sex addicts.

58. Pathologizing
Normal
behavior?
Some researchers and clinicians
argue hypersexual behaviors are
simply variants of normal sexual
behavior that an HD diagnosis is
pathologizing
There are also concerns regarding
increasing the number of people
diagnosed with a mental illness, the
number of false positives and the
number of people on unnecessary
psychotropic medications

59. Insufficient Empirical Research
on HD
Concerns about adding new disorders without sufficient
scientific research
There is a definite lack of epidemiological studies
More studies with objective data (“e.g., genetic
abnormality, deficits in brain function, etc) are needed as
well

60. ICD DX – Considers the
criticisms
Early critics were concerned that any
formal diagnosis would be used to
pathologise sexual minorities and
alternative sexual practices. However, to
meet the diagnostic criteria for CSBD,
the problematic behavior must cause
persistent marked distress or significant
impairment in personal, family, social,
educational, occupational, or other
important areas of functioning. In other
words, the new diagnosis doesn’t
diagnose patients based on what sexual
behavior they freely engage in. It
diagnoses patients based on persistent
impairment and distress. If sexual
behavior, whatever form it takes, results
in neither, the new diagnosis will not
apply.

61. ICD DX – Considers the
criticisms
Other critics warned that a CSBD diagnosis
might result in mistaken diagnosis by
patients whose behavior was not, in fact,
compulsive, and whose distress was due to
moral judgment by patient or professional.
To prevent such outcomes, the new
diagnosis provides that, “Distress that is
entirely related to moral judgments and
disapproval about sexual impulses, urges,
or behaviours is not sufficient.” In other
words, a patient must actually be unable to
control impulses and be engaging in
repetitive sexual behavior that has become
problematic.

62. Diagnosis

63. Appropriate Diagnostic Categories
DSM-5 also lists
‘other specified
sexual dysfunction’ as
F52.8. This diagnosis
may thus be used for
hypersexual disorder.
(Krueger, 2016)
The recommended
code for the ICD 11
index is 6C72 -
“Compulsive Sexual
Behavior Disorder”

64. /
Differential Diagnosis
DSM-5 - Possibilities:
Other Specified Sexual Dysfunction
Other Specified Disruptive, Impulse Control and Conduct Disorder
Unspecified Paraphilic Disorder
Common Co-morbidities:
Antisocial / Narcissistic personality disorder
Paraphilia
ADHD
Mood and Anxiety Disorders
PTSD
Substance induced disorder
OCD
Delirium, dementia, or other cognitive disorder or organic condition

65. Differential Diagnosis
Continued
Carpenter, B.N., Reid, R.C., Garos, S. & Najavits, L.M. (2013). Personality Disorder comorbidity
Suggests people with HD may have some pathological
personality traits but do not have a diagnosable Personality
Disorder
However, only 17% of the sample met full criteria for a
Personality Disorder when assessed with the SCID-II
Structured Interview
Carpenter et al. (2013) found that 92% of their sample of
men seeking treatment for Hypersexual Disorder (HD)
screened positive for potential Personality Disorders
when using the SCID-II Personality Questionnaire

66. SAST-R Positive
ASRS V1.1
Positive
(40.5%)
SAST-R
Negative
ASRS V1.1
Positive
(19.04%)
Students screening positive on the SAST-R are twice as likely to screen positive for
ADHD than students who do not screen positive on the SAST-R.
ADHD - Results

67. ASRS V1.1
Positive
SAST-R
Positive
(21.32%)
ASRS V1.1
Negative
SAST-R
Positive
(8.56%)
Students screening positive on the ASRS V1.1 are twice as likely to screen positive
for Sexual Addiction than students who do not screen positive on the ASRS V1.1.
ADHD - Results

68. Multiple
Addictions

69. Frequencies
of Multiple
Addictions
(N = 1604)
Alcohol was the most frequently co-
occurring addiction in both males and
females at 46%, however in gay males
drug abuse was most frequent 54%.
Gay males also scored higher on high
risk/ dangerous behaviors
Women scored higher on compulsive
spending, compulsive eating, and
compulsive cleaning

73. Differential
Diagnosis –
Typical
Presentation
Compulsive
Sexual
Behavior
- High shame
- Emotional and
sexual abuse in
background
- Highly sexualized
(lots of
preoccupation)
- Multi-addicted
- Less defenses
- High potential
for suicide
- Increased
amenability for
treatment

75. Just because someone has had affairs,
used prostitutes, attended a strip club,
uses porn recreationally…does not
mean they are a sex addict… It is just as
important to determine who is NOT a
sex addict as it is to determine who is.

76. /
Paraphilias are not always Sex
Addiction
DSM-5 Paraphilias include
•Exhibitionism
•Fetishism
•Frotteurism
•Pedophilia
•Sexual masochism
•Sexual sadism
•Voyeurism
•Transvestic fetishism.
In DSM -5– new definition
must include “psychological
distress” or “distress, injury or
death of unwilling persons – or
those not of legal age”

77. Sex Addiction Paraphilia
Sex Addiction
With Paraphilic
Thoughts and
Behaviors
Overlap of Sex Addiction and Paraphilic Thoughts and Behaviors

78. Recent Headlines…

79. Abuse of
power
Politicians
Media Moguls
Sports Figures
Religious Leaders
CEOs, Business Executives
Specialized Knowledge
Extremely Wealthy
Abuse
of
Power

80. Common Questions….
Are these men “Sex
Addicts”? Is that
really a “diagnoses”?
Is this just an excuse
for bad behavior?
How is a sex addict
different from
individuals with a
more sinister profile?
What’s the difference
between sex
addiction and sex
offending?
What is the
prognosis for these
individuals?
What is the best
course of treatment?

81. Significant Overlap
Sex
Addiction
Sex
Offending
Paraphilias

82. Common
Features
Behavior is
distressful to
self or others
Support their
behavior with
cognitive
distortions
Secret double
life
Serious life
consequences

83. Sex offending is not sex addiction
Research shows that about
10 % - 30 % of sex
offenders are sex addicts
Sex offending is a legal
term – must be adjudicated
in the legal system
Most common sex crimes –
sexual assault, sexual
battery, statutory rape,
rape, child enticement and
endangerment, child sexual
abuse
Includes a victim/
exploitation/ lack of
consent
Prostitution – is a sex
crime, but in most states
does not require
registration as a sex
offender
Sometimes clients with
offending history may be
recommended to
participate in offender
treatment if indicated

84. Sexual harassment and
abuse of power is an
offending behavior
because it includes a
victim, lack of consent
and exploitation
IT’S NOT “JUST SEX ADDICTION”!

85. Non-
Adjudicated
Sex Offender
Paraphilic
Behavior w/
non consenting
victims
Compulsive
Sexual
Behavior
With non
consenting
victims
Non Consensual Sexual Behaviors
(Predatory/ Offending)
“I’m a sex addict!”

87. Sex addiction therapists and clinics need
to be very good at differential diagnosis
and triage

88. Are there times
when someone with
abuse of power
legitimately struggles
with addictive or
compulsive sexual
behavior?

90. Paulhus & Williams,
2002

92. Cycle of Narcissistic Sexual
Exploitation
1 – Narcissist
experiences ego
degradation
2 – Core sense of
shame and
unworthiness
3 – Thought
Distortions =
Entitlement
4 – Sexual Acting
out
5 – Shame and
Guilt

93. Sex offenders – 73%
personality disorder
McElroy et al.
Sex addicts
17% personality
disorders
Reid et al.

94. /
Poor prognostic indicators
Dark Triad
Personality
Characteristics
Forced or coerced
into treatment
Lacking remorse,
shame and
empathy
History of other
types of offenses –
or assaultive violent
tendencies
Other types of
unethical behavior
History of other
types of impulsive
behaviors
Lack of openness,
lots of defenses
Evasion of
consequences

95. Referral to
Sex
Offender
Program is
often
necessary
IF AVAILABLE!

96. We need to
eliminate
the silo
mentality in
sexual
health
treatment

97. Prevalence and
Etiology

98. Dickenson, J. A.,
Gleason, N.,
Coleman, E., &
Miner, M. H.
(2018). Prevalence
of Distress
Associated With
Difficulty
Controlling Sexual
Urges, Feelings,
and Behaviors in
the United
States. JAMA
Network Open,1(7).
doi:10.1001/jamanet
workopen.2018.446
8
Results: “Among men, 10.3% endorsed clinically relevant
levels of distress and/or impairment associated with
difficulty controlling sexual feelings, urges, and behaviors,
in comparison with 7.0% of women.“
Conclusion: "This study was the first we know of to
document the US national prevalence of distress
associated with difficulty controlling one’s sexual
thoughts, feelings, and behaviors—the key feature of
CSBD. The high prevalence of this sexual symptom
has major public health relevance as a sociocultural
problem and indicates a significant clinical problem
that warrants attention from health care professionals.
Moreover, gender, sexual orientation, race/ethnicity,
and income differences suggest potential health
disparities, point to the salience of sociocultural
context of CSBD, and argue for a treatment approach
that accounts for minority health, gender ideology, and
sociocultural norms and values surrounding sexuality
and gender."

99. Etiology
Trauma and abuse
Biology/
Neuroscience/ Sexual
Conditioning
Family Dynamics/
Attachment

100. Trauma

101. Trauma and
Abuse History
Most came from families were
abuse and trauma were present.
72% experienced physical abuse
81% experienced sexual abuse
97% experienced emotional abuse
In addition, they came from
families where shame was present.

102. “CSB (Compulsive Sexual Behavior) has
been strongly linked to early childhood
trauma or abuse, highly restricted
environments regarding sexuality,
dysfunctional attitudes about sex and
intimacy, low self-esteem, anxiety, and
depression.”
- Eli Coleman
“Sexual addiction is strongly anchored
in shame and trauma. Research
conducted over the last fifteen years
has consistently shown the prevalence
of emotional, physical, and sexual
abuse in this population.”
Cox et al (2007)
Coleman, E. (1992). Is your patient suffering from compulsive sexual behavior? Psychiatric Annals , 22(6),
320-325. Cox, R. P., & Howard, M. D. (2007). Utilization of EMDR in the treatment of sexual addiction: A
case study. Sexual Addiction & Compulsivity, 14(1), 1-20. doi: 10.1080/10720160601011299

103. Blain, L. M., Muench, F., Morgenstern, J., & Parsons, J. T. (2012). Exploring the role of child sexual abuse and
posttraumatic stress disorder symptoms in gay and bisexual men reporting compulsive sexual behavior. Child
This finding is in line with Briere and Runtz’s (1990) report
that childhood sexual abuse was uniquely associated with
maladaptive sexual behavior, and with previous literature
supporting childhood sexual abuse as a possible etiological
factor in CSB development (Perera et al., 2009) (p.419).”
These findings are “largely consistent with previously
studied self-identified community samples of individuals
with CSB (Black et al., 1997; Kafka & Prentky, 1992)
Recent Study (2012) found 39% of gay and bisexual men
with compulsive sexual behavior had experienced
childhood sexual abuse

109. Contemporary VS. Classic SA
Reimersma & Sytsma (2013)
Classic Typology:
History of
abuse
Insecure
attachment
Poor impulse
control
Cross
Addictions
Co-morbid
mood
disorders
Used to
soothe toxic
emotions

110. Contemporary
Rapid onset
Due to explosive growth
of internet technology
Chronic exposure to
graphic content online
Content – unique,
intense, graphic,
limitless novelty
Culture – trending
towards virtual and non-
relational sex
Early exposure to
graphic sexual material
Sexual conditioning
Less trauma history/
attachment problems
May not be having sex
(or may never have had
sex)
May not be able to
perform – can include
performance anxiety,
unrealistic performance
standards

111. New Research in
Neuroscience

112. Voon – Neural Mechanisms Underlying CSB
Similar to Those in Found in CD
2014

113. Neural
Correlates of
Sexual Cue
Reactivity in
Individuals
with and
Without
Compulsive
Sexual
Behaviors
(2014 – Voon
et al.
Cambridge
University)
Compulsive porn users react to porn cues in
the same way that drug addicts react to
drug cues
Compulsive porn users craved porn (greater
wanting), but did not have higher sexual
desire (liking) than controls. This finding
aligns perfectly with the current model of
addiction.
Over 50% of subjects (average age: 25) had
difficulty achieving erections with real
partners, yet could achieve erections with
porn

114. Enhanced
Attentional Bias
towards
Sexually Explicit
Cues in
Individuals with
and without
Compulsive
Sexual
Behaviors –
Voon et al.
2014
“Our findings of enhanced attentional bias in CSB
subjects suggest possible overlaps with
enhanced attentional bias observed in studies of
drug cues in disorders of addictions. These
findings converge with recent findings of neural
reactivity to sexually explicit cues in CSB in a
network similar to that implicated in drug-cue-
reactivity studies and provide support for
incentive motivation theories of addiction
underlying the aberrant response to sexual cues
in CSB.”

116. Kuhn – High Porn Consumption Associated w/Grey
Matter Volume Reduction
2014

117. Brain Structure and Functional Connectivity Associated With
Pornography Consumption: The Brain on Porn (2014)
Simone Kühn continued - "We assume that subjects with a
high porn consumption need increasing stimulation to
receive the same amount of reward.”
Simone Kühn - "That could mean that regular consumption
of pornography more or less wears out your reward system.“
Higher hours per week/more years of porn viewing
correlated with a reduction in grey matter in sections of the
reward circuitry (translates into sluggish reward activity, or a
numbed pleasure response – desensitization)

118. Gola et al. (2017)
Gave fMRIs to 28 men in treatment for problematic pornography use (PPU) and 28 men without
PPU to examine ventral striatal responses to “erotic and monetary stimuli”
Wanted to differentiate “cue-related ‘wanting’ from reward-related ‘liking’”
Participants completed an incentive delay task during the fMRI and were given “erotic or
monetary rewards preceded by predictive cues”
PPU group had higher activation in the ventral striatum for cues that predicted erotic stimuli
but not for cues that predicted monetary reward or to the actual erotic pictures
◦ Authors argued this is “consistent with the incentive salience theory of addiction”
Sensitivity to erotic stimuli cues was related to increased motivation to see the erotic stimuli
(suggests “higher wanting”), higher pornography use, severity level of PPU and more frequent
masturbation
Gola, M., Wordecha, M., Sescousse, G., Lew-Starowicz, M., Kossowski, B., Wypych, M., ... & Marchewka, A. (2017). Can pornography be
addictive? An fMRI study of men seeking treatment for problematic pornography use. bioRxiv, 057083.
“Findings congruent with research on gambling and substance
addictions suggesting PPU may be a behavioral addiction”

119. Ji-Woo Seok
and Jin-Hun
Sohn of the
Brain
Research
Institute at
Chungnam
National
University in
South Korea
Sex addicts focus a higher-than-normal share of their
attention on addiction related cues (i.e., pornography), doing
so in the same basic ways and to the same basic degree as
other addicts.
The brain response of sex addicts exposed to sexual stimuli
(i.e., pornography) mirrors the brain response of drug
addicts when exposed to drug-related stimuli. For example,
the dorsal orbital prefrontal cortex lights up just as it does
with substance addicts. Equally important is the fact that this
region goes below baseline for neutral stimuli, the same as
with substance abusers. In other words, the dorsal orbital
prefrontal cortex overreacts to addiction cues and
underreacts to neutral cues in all forms of addiction,
including sexual addiction.

120. Banca et al. (2016)
Examined whether men with CSB showed more of a preference for “sexual novelty and stimuli conditioned sexual rewards”
compared to a healthy control group
CSB group:
◦ Had a stronger preference for novel sexual images in comparison to control images
◦ Demonstrated a preference for cues that had been conditioned to sexual and monetary rewards over neutral
outcomes
This result was not observed in the control group
◦ Had higher levels of dorsal cingulate habituation during an fMRI when presented with repeated sexual images
compared to monetary images
◦ Level of habituation to sexual images was positively correlated with self-reported preference for sexual novelty
◦ Had an early attentional bias to sexual cues compared to control group that significantly correlated with higher levels
of approach behaviors towards cues conditioned to sexual images
Authors concluded the CSB participants had a “dysfunctional enhanced preference for sexual novelty possibly mediated by
greater cingulate habituation” as well as an overall enhanced reaction to rewards
Banca, P., Morris, L. S., Mitchell, S., Harrison, N. A., Potenza, M. N., & Voon, V. (2016). Novelty, conditioning
and attentional bias to sexual rewards. Journal of psychiatric research, 72, 91-101.
“The novelty seeking and cue conditioning found in CSB participants
is similar to results seen in studies on substance addictions”

121. Ventral Striatum Activity Correlated with
Porn Addiction (Brand et al. 2016)
Reward center activity (ventral striatum) was higher for
preferred pornographic pictures.
Ventral striatum reactivity correlated with the internet sex
addiction score.
Both findings indicate sensitization and align with the
addiction model. The authors state that the "Neural basis
of Internet pornography addiction is comparable to other
addictions."

122. Soek & Sohn
2018
The caudate nucleus is the main subregion of the striatum,
and is important for reward-based behavioral learning,
intricately associated with pleasure and motivation, and
related to the maintenance of addiction.
Compared to healthy subjects, individuals with PHB had
significantly decreased functional connectivity between the
Superior Temporal Gyrus and the caudate nucleus.
This fMRI study compared carefully screened sex addicts
("problematic hypersexual behavior") to healthy control
subjects. Sex addicts had reduced gray matter in the
temporal lobes - regions the authors say are associated
with inhibition of sexual impulses.

123. Examples of
Hypofrontality
IMPAIRMENT IN EXECUTIVE FUNCTION

124. Executive function
– Reid et al. 2010
Patients seeking help for hypersexual behavior
often exhibit features of impulsivity, cognitive
rigidity, poor judgment, deficits in emotion
regulation, and excessive preoccupation with
sex. Some of these characteristics are also
common among patients presenting with
neurological pathology associated with
executive dysfunction. These observations led
to the current investigation of differences
between a group of hypersexual patients (n =
87) and a non-hypersexual community sample
(n = 92) of men

125. Pornographic Picture Processing Interferes with
Working Memory Performance
Laier, Schulte and Brand (2013) examined the effect of sexual arousal
during internet sex on Working Memory (WM)
Found worse performance of WM for pornographic pictures compared
to neutral, negative and positive stimuli
◦ Results moderated by need to masturbate and sexual arousal suggesting this
arousal interferes with working memory processes
Laier, C., Schulte, F.P. & Brand, M. (2013). Pornographic picture processing interferes with
working memory performance. Journal of Sex Research, 50(7), 642-652. DOI:
Authors concluded that the cognitive problems often
reported by people with sexual addiction following
pornography consumption (forgetfulness, neglecting
responsibilities, missing appointment, etc.) may be
accounted for by the interference with WM related to
pornographic material

126. Messina et al. (2017)
Compared cognitive flexibility and decision making in 30 men
with CSB and 30 control subjects before and after viewing an
erotic video
No significant differences in cognitive flexibility and decision
making between the groups prior to viewing the erotic video
Messina, B., Fuentes, D., Tavares, H., Abdo, C. H., & Scanavino, M. D. T. (2017). Executive Functioning of
Sexually Compulsive and Non-Sexually Compulsive Men Before and After Watching an Erotic Video. The
Journal of Sexual Medicine, 14(3), 347-354.
“The control group members made fewer impulsive
choices and demonstrated higher levels of cognitive
flexibility than CSB participants”

127. Schiebener, Laier & Brand (2015)
Studied relation between executive functioning and cybersex addiction in
104 heterosexual men
Subjects completed an executive multitasking paradigm with two subsets of
pictures (humans & pornography) they had to classify on certain criteria
◦ Subjects were supposed to work on all tasks in equal amounts which required
switching between the two subsets in a balanced way
Individuals with more symptoms of cybersex addiction had less balanced
performances in the multitasking paradigm
◦ These individuals “often either overused or neglected working on the
pornographic pictures”
◦ Suggested tendency towards approach/avoidance of pornography similar to motivational models of
addiction
Schiebener, J., Laier, C., & Brand, M. (2015). Getting stuck with pornography? Overuse or neglect of cybersex
cues in a multitasking situation is related to symptoms of cybersex addiction. Journal of behavioral
Indicated lower levels of executive control in multitasking performance when
viewing pornography may “contribute to dysfunctional behaviors and negative
consequences resulting from cybersex addiction”

128. Banca, Harrison & Voon (2016)
Studied two facets of compulsivity (reversal learning and attentional set
shifting) in participants with CSB vs healthy control group
No significant differences between the groups in set shifting or reversal
learning.
Banca, P., Harrison, N. A., & Voon, V. (2016). Compulsivity across the pathological misuse
of drug and non-drug rewards. Frontiers in Behavioral Neuroscience, 10.
CSB group learned faster from rewards and slower from
losses than control group
Suggests perseveration and enhanced sensitivity to
rewards in CSB

129. Sexual Picture Processing Interferes
with Decision-Making Under Ambiguity
Sexual arousal might interfere with the decision-making process and
should therefore lead to disadvantageous decision-making in the long
run.
Results demonstrated an increase of sexual arousal following the
sexual picture presentation. Decision-making performance was worse
when sexual pictures were associated with disadvantageous card
decks compared to performance when the sexual pictures were linked
to the advantageous decks. Subjective sexual arousal moderated the
relationship between task condition and decision-making
performance.
Laier, C., Pawlikowski, M., & Brand, M. (2014). Sexual picture processing interferes
with decision-making under ambiguity. Archives of sexual behavior,43(3), 473-482.
This study emphasized that sexual arousal interfered with decision-making,
which may explain why some individuals experience negative
consequences in the context of cybersex use.

130. Schmidt et al. (2017)
Compared brain volumes and resting state functional connectivity
between men with CSB and healthy men
Results suggested CSB is related to higher volumes in parts of the
limbic system that are associated with processing emotions and
motivation
◦ Unknown whether increased amygdala volumes pre-exists CSB and
is a risk factor or is the result of CSB
Schmidt, C., Morris, L. S., Kvamme, T. L., Hall, P., Birchard, T., & Voon, V. (2017). Compulsive sexual behavior:
Prefrontal and limbic volume and interactions. Human brain mapping, 38(3), 1182-1190.
Also found reduced connectivity between the amygdala and the bilateral
dorsolateral prefrontal cortex (DLPFC) in CSB group which is associated with
higher levels of impulsivity and lower levels of emotional regulation.
Authors argued the dysfunction in these brain systems in people engaging
in CSB is similar to incentive motivation theory research on substance
addictions

131. Seok & Sohn
(2018) Altered
Prefrontal and
Inferior
Parietal
Activity During
a Stroop Task
in Individuals
With
Problematic
Hypersexual
Behavior
Accumulating evidence suggests a relationship
between problematic hypersexual behavior (PHB)
and diminished executive control. Clinical studies
have demonstrated that individuals with PHB exhibit
high levels of impulsivity; however, relatively little is
known regarding the neural mechanisms underlying
impaired executive control in PHB. This study
investigated the neural correlates of executive control in
individuals with PHB and healthy controls using event-
related functional magnetic resonance imaging (fMRI).
Twenty-three individuals with PHB and 22 healthy
control participants underwent fMRI while performing a
Stroop task. Response time and error rates were
measured as surrogate indicators of executive control.
Individuals with PHB exhibited impaired task
performance and lower activation in the right
dorsolateral prefrontal cortex (DLPFC) and inferior
parietal cortex relative to healthy controls during the
Stroop task. In addition, blood oxygen level-dependent
responses in these areas were negatively associated with
PHB severity. The right DLPFC and inferior parietal
cortex are associated with higher-order cognitive control
and visual attention, respectively. Our findings suggest
that individuals with PHB have diminished executive
control and impaired functionality in the right DLPFC
and inferior parietal cortex, providing a neural basis for
PHB.

132. Our clients experience
Powerful sexual conditioning and learning
Neuroplastic change
Structural changes in the brain
Deficits in areas of functioning (e.g. memory, decision making)
Over 40 articles on the neuroscience
of sex addiction…
Embedded in a large body of research on behavioral
addictions (130 behavioral addiction articles - e.g. 70
brain articles on internet addiction)
Longitudinal research in other areas

133. Families &
Attachment

134. Circumplex
Copyright D.H. Olson

135. Copyright D.H. Olson
77%
RIGID
87%
DISENGAGED
Families of Sex Addicts

136. Significant
differences in
Attachment Styles
of Sex Addicts

137. Anxious
Avoidant

138. Treatment

139. Evidence Based
Pharmacological
Interventions
SSRIs
SNRIs
Naltrexone
Anticonvulsants
(Topiramate, valproic acid,
lamotrigine, and
levetiracetam)
Grant (2018) Compulsive
Sexual Behavior: A
Nonjudgemental Approach.
Current Psychiatry.
February;17(2):34,38-40,45-46

140. Some Evidence Based
Approaches to Treatment
Del Giudice MJ, Kutinsky J. Applying motivational interviewing to the treatment of sexual compulsivity and addiction. Sex
Addict Comp. 2007;14(4):303-319.
Shepherd L. Cognitive behavior therapy for sexually addictive behavior. Clin Case Stud. 2010;9(1):18-27.
Sadiza J, Varma R, Jena SPK, et al. Group cognitive behaviour therapy in the management of compulsive sex behaviour.
International Journal of Criminal Justice Sciences. 2011;6(1-2):309-325.
Motivational Interviewing
Cognitive Behavioral Therapy

141. Evidence Based Approaches to
Treatment
The overall reduction in problematic Internet pornography use was
reported as 92% immediately after the study ended, and 86% after 3
months.
Crosby JM, Twohig MP. Acceptance and commitment therapy for problematic Internet pornography use: a randomized
trial. Behav Ther. 2016;47(3):355-366.
Twohig MP, Crosby JM. Acceptance and commitment therapy as a treatment for problematic internet pornography
viewing. Behav Ther. 2010;41(3):285-295.
Acceptance Commitment Therapy

142. Evidence Based Approaches to
Treatment
Yaniv & Gola (2018) Compulsive Sexual Behavior: A 12 Step Based Therapuetic
Approach. Journal of Behavioral Addictions.
Sevcikova et al. (2018) Excessive Internet use for Sexual Purposes Among Members
of Sexaholics Anonymous and Sex Addicts Anonymous.
12 Step Group Participation

143. TASK 7: CULTURE OF SUPPORT
Maintains a healthy support system

144. Treatment
Programmatic care – Long term
treatment
Celibacy agreement
Sexual health plan
Task methodology
12 step
Mindfulness, CBT
IFS, Trauma treatment, EMDR, SE
Family / Couple treatment

145. Task Methodology: The Process

147. IITAP Core Beliefs–
Healthy Sexuality
•IITAP celebrates diversity, and our
ethical guidelines promote non-
discrimination by race, creed, color,
ethnicity, national origin, religion, sex,
sexual orientation, gender expression,
age, height, weight, physical or mental
ability, veteran status, military
obligations, and marital status.
•IITAP does not condone the practice of
Reparative Therapy. Homosexuality is
not pathological and is not a mental
illness.
•Sexual addiction is not defined by the
type of sexual act or the gender of the
sexual partner

148. For Healing…Three Legged
Stool
Addict’s therapist
◦ Individual therapy
◦ Support Groups/ 12 step support
Partner’s therapist
◦ Individual therapy
◦ Support Groups
Couples therapist

149. Family
therapy
Treatment for sex
addiction induced
trauma for whole family
and betrayal trauma for
partners
Treatment from a
relational paradigm
Effective and well
orchestrated disclosure
to partner
Long term couples
therapy

150. Questions?
THANK YOU!
STEFANIE@IITAP.COM