Dr Dan Riddle

Specialist Relationship/Individual Psychologist-Occupational Coach

Corporate Consulting Group Aust ABN: 91103380436 P.O Box 75 Vermont Vic 3133 fax: 03-8711-4982 mob: 0412 142 504

Normophillic sexual disorders in private practice: diagnostic changes, prevalence & treatment
Sexual Disorders defined by DSM-4
Normophilic sexual activities conform to the dictates of custom, religion, and law. These include Sexual Behavior with Consenting Adults, Masturbation, Pornography, Cybersex, Telephone Sex, Strip Clubs. Normophillic sexual behaviors represent one of the core avenues for human satisfaction, however in excess these behaviours can of course lead to harm. DSM-4 accounted for excesses of Normophillic behaviours under the category Sexual Disorder Not Otherwise Specified (NOS). See table over page. Paraphillic sexual activities by contrast do NOT conform to the dictates of custom, religion, and law and generally include sexually deviant types of behavior. See table over page for Paraphillic disorders.

Diagnostic changes for the Sexual Disorders in DSM-5

There have been five revisions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) since it was first published in 1952, gradually including more mental disorders, although some have been removed and are no longer considered to be mental disorders, most notably homosexuality. Last edition DSM-4 published (1994) with minor revisions 2000. Next edition DSM-5 to be released 2013. Notable changes in DSM-5 that relate to Sexual Disorders are: Acceptance that some paraphillic (sexual deviant) behaviours are NOT necessarily disorders since some people engage consensually in paraphillias without causing themselves or others distress/disturbance e.g BDSM, fetishism. Sexual Disorder Not Otherwise Specified (NOS) in DSM-4 which was previously the best category to place sex addiction or excessive sexual drive (subdivided into nymphomania (for females) and satyriasis (for males)) will now give way to a broader category Hypersexual Disorder,( see over page) encompassing excessive normophillic or accepted sexual behaviors.

Trying to understand the prevalence of disordered normophillic sexual activities

Langstrom and Hanson (2006), definition for impersonal sex (in a Swedish community sample of >2000 even gender split) operationalised as the Total Sexual Outlet/month (TSO) that included six specific enacted behaviors (frequency of masturbation/month, frequency of pornography use/year, number of sexual partners in past year and per active year, having extra-partnered sex while in a stable partnered relationship, ever participating in group sex and preferring a casual sexual lifestyle). They defined Hypersexual as the top 5-10% of sexually active subjects in their sample. This group had an average TSO/month of 17.5 (more than 4 times per week). Despite acknowledging a higher frequency of sexual behavior, they were less likely to feel satisfied with their sexual life, had more relationship-associated problems, more STDs, and were more likely to have consulted professional help for sexuality-related issues. See article Hypersexual Disorder: A Proposed Diagnosis for DSM-V Martin P. Kafka _ American Psychiatric Association 2009

Sexual and Gender Identity Disorders in DSM 4. The sexual disorders are further subdivided into 4 categories
DSM-IV Sexual Disorder Categories 1. Sexual Dysfunctions Broad Description Examples

disturbance in sexual desire and in the psychophysiological changes that constitute the sexual response cycle.

Low Sexual Desire Disorders (Hypoactive Sexual Desire Disorder and Sexual Aversion Disorder), Sexual Arousal Disorders (Female Sexual Arousal Disorder and Male Erectile Disorder), Orgasmic Disorders (Female Orgasmic Disorder, Male Orgasmic Disorder, and Premature Ejaculation), Sexual Pain Disorders (Dyspareunia-painful intercourse, Vaginismus-vaginal spasm during penetration). Secondary and Other Sexual Dysfunctions, which include Sexual Dysfunction Due to a General Medical Condition, Substance-Induced Sexual Dysfunction

2. Paraphillic disorders,

recurrent, intense sexual urges, fantasies, or behaviors that involve unusual objects, activities, or situations that occur over a period of at least six months and cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Paraphilias are commonly associated with increased sexual activity, often with compulsive and/or impulsive features

The DSM provides clinical criteria for these paraphilias:

Exhibitionism: the recurrent urge or behavior to expose one's genitals to an unsuspecting person, or to perform sexual acts that can be watched by others.Fetishism: the use of inanimate objects to gain sexual excitement. Partialism refers to fetishes specifically involving nonsexual parts of the body.Frotteurism: recurrent urges of behavior of touching or rubbing against a nonconsenting person.Pedophilia: strong sexual attraction to prepubescent children, Sexual Masochism: the recurrent urge or behavior of wanting to be humiliated, beaten, bound, or otherwise made to suffer for sexual pleasure.Sexual Sadism: the recurrent urge or behavior involving acts in which the pain or humiliation of a person is sexually exciting.Transvestic fetishism: arousal from wearing "clothing associated with members of the opposite sex."Voyeurism: the recurrent urge or behavior to observe an unsuspecting person who is naked, disrobing, or engaging in sexual activities, or who is engaging in activities usually considered to be of a private nature.Under Paraphilia NOS, the DSM mentions telephone scatalogia (obscene phone calls), necrophilia (corpses), partialism (exclusive focus on one part of the body), zoophilia (animals), coprophilia (feces), klismaphilia (enemas), urophilia (urine), emetophilia (vomit). cross-dress to look like the other sex, not specifically for sexual stimulation. They may be sexually attracted to males, females, both, or neither

3. Gender Identity Disorders

strong and persistent cross-gender identification accompanied by persistent discomfort with one's assigned sex disorders of sexual functioning that are not classifiable in any of the specific categories

4. Sexual Disorder Not Otherwise Specified (NOS).

"Distress about a pattern of repeated sexual relationships involving a succession of lovers who are experienced by the individual only as things to be used" (DSM-IV . 638). This diagnosis has historically been the most common one to be used for patients identified as sexual addicts.

Proposed diagnostic criteria for Hypersexual Disorder

A. Over a period of at least 6 months, recurrent and intense sexual fantasies, sexual urges, or sexual behaviors in association with 3 or more of the following 5 criteria: A1. Time consumed by sexual fantasies, urges or behaviors repetitively interferes with other important (non-sexual) goals, activities and obligations. A2. Repetitively engaging in sexual fantasies, urges or behaviors in response to dysphoric mood states (e.g., anxiety, depression, boredom, irritability). A3. Repetitively engaging in sexual fantasies, urges or behaviors in response to stressful life events. A4. Repetitive but unsuccessful efforts to control or significantly reduce these sexual fantasies, urges or behaviors. A5. Repetitively engaging in sexual behaviors while disregarding the risk for physical or emotional harm to self or others. B. There is clinically significant personal distress or impairment in social, occupational or other important areas of functioning associated with the frequency and intensity of these sexual fantasies, urges or behaviors. C. These sexual fantasies, urges or behaviors are not due to the direct physiological effect of an exogenous substance (e.g., a drug of abuse or a medication)

Sexual fantasies, urges or behaviours may relate to: Masturbation Pornography Sexual Behavior with Consenting Adults Cybersex Telephone Sex Strip Clubs.

Case examples John 48 Michael 38

Presentation Using internet porn streaming videos & photo galleries as a self-soothing habit. Partner found evidence on his PC and demanded he address the issue. Marital breakdown. Porn usage was one factor. He used at work and at home to manage stress. His step daughter followed a URL address to porn site told her mother who confronted him. His wife answered late night call from unknown woman. Confronted partner who confessed he had met woman online in sex chat line and agreed to meet for liaison. Daughter revealed that father had touched her. When confronted he confessed masturbating in front of daughter. Presented with homicidal and suicidal ideation.CATT team called. Post hospitalization adopted BDSM as a stress management technique. Depressed. Grieving over having autistic son 4yrs old. Intimacy breakdown with wife. Using porn late at night when he cant sleep. He was concerned that he only wanted to watch 1980s simulated rape domination videos. Stress in marriage.flirting and chasing women. Compelled to have sex as a stress reliever rather than addressing his primary relationship problems. Frequent casual sex as a self soother for loneliness. Also as a defense against seeking men who treat her wellfear of being abandoned again. Struggling with parenting and marriage. Staying up late online chat and cyber sex.

Background Issues Extremely strict religious upbringing. Taboos about nudity and intimacy. Anxiety about having sex, never confident. Pressure from partner to have children. He came from very enmeshed family of origin, lacked adult confidence. Very devout Christian. Lacked confidence with women used porn from teens. Bullied, social anxiety teens. Fell into to gaming as an escape. Enjoyed going onto sex chat lines pretending to be older or different gender. Long history of being socially anxious, using internet porn. Had early sexual experiences aged 9 initiated by 12 yr old girl. Extremely devout Christian. Broke up from wife has 5 kids under 12. Significant drug user. Borderline PD. History of passionate relationship with more mature woman when he was 16. Then had partner into BDSM preferred aggressive sex. Current wife more sexually conservative. His own mother had extramarital affair and left his father when he was 8. Extreme work pressure, business owner, no work-life balance Sexually assaulted as a child. Borderline features. Recently abandoned by her husband of 1 yr. History of sexual abuse as a child, 2 failed marriages.

Matt 28 Peter 35 Daniel 34 Adam 38

Andrew 44 Jo L 38 Mary 48

DANS TREATMENT APPROACHES FOR HYPERSEXUAL DISORDER

Regardless of your particular kind of unwanted sexual behaviors, its important to understand that there is a logical, reasonable, brain science explanation behind how you got caught up in these behaviors. You are NOT a freak, loser or lost cause. You are a good and valuable human being who has simply developed a literal dependency on an extremely powerful brain-chemical-releasing activity for escape, self-medication and pleasure. This is not unlike anyone who chooses alcohol, drugs, food or any other personal drug-of-choice. The good news is, just as with any other unwanted behavior or addiction, there is logical way out. 3 educational keys to recovery: 1. Sexual outlets and behaviours can create chemical dependency on dopamine, nor-epinephrine and serotonin. Sexual outlets can become a drug of choice. 2. Avoidance and willpower are not enough to achieve recovery see model below. 3. Change is possible and is best achieved by a combined psycho-educational coaching oriented model rather than a punitive pathologising approach. Tools below have been very useful in my work with those managing hypersexual behaviours and urges: Brain science education: about impacts of neurochemicals helps diminish shame and guilt..freeing up motivation to look at the underlying imbalances in ones life. http://www.pornaddiction.com/; free itune podcast series candeo program download from itunes store. Orientation to cognitive behaviour tools such as www.Moodgym.anu.edu.au, and www.smartrecoveryaustralia.com.au, www.cci.health.wa.gov.au/resources/consumers.cfm, Group/self led education programs: e.g Valiant Man at Citylife church Knox & Mt Evelyn. Some do not like Christian basis of this. Other groups like sex anonymous using 12 step programs. Effective intimacy education variety of topics: Expanded lovemaking podcast series Itunes Life balance assessment and goal setting: Use of excel to create personalized charts depicting growth gaps from current to desired future in all life domains. Relationship Assessment in couples setting to identify healthier behaviours to develop as alternatives to hypersexual behaviours. Life Traps model: Championed by Cognitive Therapist Jeff Young. Reinventing your life and Schema assessment helps to identify childhood origins of ineffective selfsoothing behaviours.