How to prove a sexual addiction: Criteria for diagnosing 'hypersexual disorder' tested

Yet psychiatrists have been reluctant to accept the idea of out-of-control sexual behavior as a mental health disorder because of the lack of scientific evidence.

Now a UCLA-led team of experts has tested a proposed set of criteria to define "hypersexual disorder," also known as sexual addiction, as a new mental health condition.

Rory Reid, a research psychologist and assistant professor of psychiatry at the Semel Institute of Neuroscience and Human Behavior at UCLA, led a team of psychiatrists, psychologists, social workers, and marriage and family therapists that found the proposed criteria to be reliable and valid in helping mental health professionals accurately diagnose hypersexual disorder.

The results of this study -- reported in the current edition of the Journal of Sexual Medicine -- will influence whether hypersexual disorder should be included in the forthcoming revised fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), considered the "bible" of psychiatry.

The importance of the study, Reid said, is that it suggests evidence in support of hypersexual disorder as a legitimate mental health condition.

"The criteria for hypersexual disorder that have been proposed, and now tested, will allow researchers and clinicians to study, treat and develop prevention strategies for individuals at risk for developing hypersexual behavior," he said.

The criteria, developed by a DSM-5 sexual and gender identity disorders work group for the revised manual, establish a number of symptoms that must be present. These include a recurring pattern of sexual fantasies, urges and behaviors lasting a period of six months or longer that are not caused by other issues, such as substance abuse, another medical condition or manic episodes associated with bipolar disorder. Also, individuals who might be diagnosed with this disorder must show a pattern of sexual activity in response to unpleasant mood states, such as feeling depressed, or a pattern of repeatedly using sex as a way of coping with stress.

Part of the criteria also states that individuals must be unsuccessful in their attempts to reduce or stop sexual activities they believe are problematic.

"As with many other mental health disorders," said Reid, "there must also be evidence of personal distress caused by the sexual behaviors that interfere with relationships, work or other important aspects of life."

In order to evaluate the criteria for hypersexual disorder, Reid and his colleagues conducted psychological testing and interviews with 207 patients in several mental health clinics around the country. All of the patients were seeking help for out-of-control sexual behavior, a substance-abuse disorder or another psychiatric condition, such as depression or anxiety.

The researchers found that the proposed criteria for hypersexual disorder accurately classified 88 percent of hypersexual patients as having the disorder; the criteria were also accurate in identifying negative results 93 percent of the time. In other words, the criteria appear to do a good job of discriminating between patients who experience hypersexual behavior and those who don't, such as patients seeking help for other mental health conditions like anxiety, depression or substance abuse.

"The results lead us to believe that the proposed criteria tend not to identify patients who don't have problems with their sexual behavior," Reid said. "This is a significant finding, since many had expressed concerns that the proposal would falsely classify individuals."

Reid also noted that the ability of the criteria to accurately identify hypersexual disorder in these patients was quite high and compared favorably to other psychiatric diagnoses.

Another significant finding of the study, he said, was that patients who met the criteria for hypersexual disorder experienced significantly greater consequences for their sexual activities, compared with individuals with a substance-abuse diagnosis or a general medical condition. Of the 207 patients they examined, 17 percent had lost a job at least once, 39 percent had a relationship end, 28 percent contracted a sexually transmitted infection and 78 percent had interference with healthy sex.

"So an individual meeting the criteria for hypersexual disorder can experience significant challenges and consequences in their life," Reid said. "Our study showed increased hypersexual behavior was related to greater emotional disturbance, impulsivity and an inability to manage stress."

Interestingly, the researchers found that 54 percent of the hypersexual patients felt their sexual behavior began to be problematic before the age of 18. Another 30 percent reported that their sexual behavior began to be problematic during their college-aged years, from 18 to 25.

"This appears to be a disorder that emerges in adolescence and young adulthood, which has ramifications for early intervention and prevention strategies," Reid said.

The study also examined the types of sexual behavior that hypersexual patients reported. The most common included masturbation and excessive use of pornography, followed by sex with another consenting adult and cybersex. The study noted that hypersexual patients had sex with commercial sex workers, had repeated affairs or had multiple anonymous partners -- amounting to an average of 15 sex partners in the previous 12-month period.

"It's not that a lot of people don't take sexual risks from time to time or use sex on occasion to cope with stress or just escape, but for these patients, it's a constant pattern that escalates until their desire for sex is controlling every aspect of their lives and they feel powerless in their efforts to change," Reid noted.

Other authors on the study included Heather McKittrick, Margarit Davtian, and senior author Dr. Timothy Fong, all of UCLA; Bruce N. Carpenter and Randy Gilliland of Brigham Young University; Joshua N. Hook of the University of North Texas; Sheila Garos of Texas Tech University; Jill C. Manning, in private practice; and Erin B. Cooper of Temple University. Dr. Fong has the following relationships: speaker's bureau for Reckitt Benckiser, Pfizer Pharmaceuticals, and grant support from Psyadon Pharmaceuticals. The other authors report no conflict of interest.

Most of the study was unfunded; researchers donated their time. Some travel expense was funded internally through the UCLA Department of Psychiatry.