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10/14/2009
Cutting Edge
Pharmacology for Sex
Addiction
D Reef
Dr.
R fK
Karim
i
Assistant Clinical Professor, UCLA Semel Institute for Neuroscience
Director, The Control Center
www.thecontrolcenter.org
[email protected]
Office: (310) 271-8700
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What is Sex Addiction?
Compulsive Sexual Behavior; Hypersexual Disorder
Diagnostic & Treatment Implications
6
What is a typical sex addict?
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What is a typical sex addict?
What is a typical sex addict?
Process Addictions
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Sex addiction, sexual anorexia, pathologic gambling,
financial disorders,, compulsive
p
shopping
pp g and
disordered eating are all behavioral, impulse control
or process addictions
6
While they involve a chemical process in our brains,
they are not the same as alcohol or drug addiction
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Process addictions provide unique challenges in
sobriety given that the client is faced with them each
day
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Controversial Topic
6 What is normative sexual behavior?
6 Views on sex change over time?
6 DSM History with Homosexuality?
6 Is Sex Addiction a true measurable disorder?
6 Sex’ting
Terminology
6 Sex Addiction
6 Compulsive Sexual Behavior
6 Sexual Compulsivity
6 Hypersexual Behavior
6 Impulse Control Disorder
Definition
6 Compulsive sexual behavior is characterized by
inappropriate or excessive sexual behaviors or thoughts that
lead to subjective distress or impaired functioning.
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Epidemiology
6 COMPULSIVE SEXUAL BEHAVIOR:
6 Prevalence - 3% to 6% of the population
6 The
Th private
i
nature off sex and
d associated
i d stigma
i
may cause
underreporting
6 Psychiatric patients 4.9% prevalence CSB (Grant)
6 Preponderance of males - roughly 80% (Black)
6 However, since women often focus more on the romantic
or emotional aspects of sexual behavior, they may
underreport physical compulsive sexual behavior
Diagnostic Criteria
6 Data on the frequency of orgasm has been used
to correlate with compulsive sexual behavior
prevalence (Kinsey) (Total Sexual Outlet)
6 7.6% men up to age 30 - >7 orgasms/week
6 Men ages 18-25: 34% masturbated once per
week 15% 2-6 times/wk; 2% daily
6 >7 orgasms per week for at least 6 months could
be used to define hypersexual behavior (Kafka)
6 (This doesn’t take into account subjective distress
and psychological dysfunction.
Co-Morbidities with Sexual
Compulsivity
6 60-80 % Axis I Psychiatric Disorders -
(Depression, ADHD, Bipolar Disorder, Anxiety
Disorders, Other Impulse CD’s, Eating Disorders
(Kafka) (Black)
6 64-80 % Substance Use Disorders (Black)
(Raymond)
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So… Is Sex Addiction Really
About The Sex?
NO!!!!!!!!!
6 It’s about WHY you have the sex…
6 Emotional Pain/Trauma
6 Loneliness
6 Escape
6 Mood Instability
6 Anxiety
6 Other Co-Morbidities - ADHD, Bipolar,etc.
Sexual Compulsivity
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1) The brain categorizes and processes sexual stimuli 20% faster than other stimuli
(Anakhin, Golosheykin)
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2) Sexual Impulses tap into the same neural circuitry as other addictions.
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3) Cybersex has worsened the problem
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4) Hidden, Secretive, Self-Destructive Behavior
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5) Shame & Deception, Fantasy Preoccupation
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6) Executive Function Deficits
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7) Associations With Head Trauma (pedophilia)
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8) Health Consequences - STD’s, HIV, etc.
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Fantasy Sex
Noticing Attraction: Emails
Noticing,
Emails, Chat Rooms
Rooms, Instant Messaging
Messaging, Fantasy Stories
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Paying For Sex
Intimacy Individuation,
Intimacy,
Individuation Touching,
Touching Foreplay,
Foreplay Intercourse,
Intercourse Commitment,
Commitment Renewal:
Online Strippers, Phone Sex Contacts, Booking Prostitution
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Anonymous Sex
Intimacy Individuation,
Intimacy,
Individuation Touching,
Touching Foreplay,
Foreplay Intercourse,
Intercourse Commitment,
Commitment Renewal:
Chat Rooms, Screen Name Contacts, E-mail Cruising
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Internet Surprises
40 % of them are women
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Sexual Behavior List
6 Masturbation (Excessive)
6 Sexual Obsession or Fantasy
6 Affairs / Multiple Relationships
6 Multiple One Night Stands
6 Pornography (Cybersex, Internet, Other)
6 Strip Bars/Shows
6 Exhibitionism / Voyeurism
6 Prostitution / Use of Prostitutes / Escorts
6 Massage Parlors
Sexual Behavior List
6 Inappropriate Touching (Frotteurism, etc)
6 Sado-Masochism
6 1
1-900
900 Line Obsession
6 Violent / Dangerous Sex
6 Cross Dressing
6 Fetishistic Sex
6 Sexual Asphyxiation
6 Trading Sex for Drugs / Other
6 Inappropriate Sex Partners (family, work, animals)
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Criteria Summaries
Sexual Addiction (Impulsive)
Sexual Anorexia (Obsessive)
Compulsive Behavior
Loss of Control
Efforts to Stop
Loss of Time
Preoccupation
Affects Obligations
Continuation Despite Consequences
Escalation
Social, Occupational, Recreational
Losses
Distress, Anxiety, Restlessness
Irritability
Compulsive Behavior
Excessive Control
Efforts to Avoid
Rigid, Judgmental Attitudes
Preoccupation
Affects Obligations
Extreme Shame
Despair
Avoidance of Intimacy and
Relationships
Distress, Anxiety, Restlessness
Irritability
Internet Certainties
There are people who now struggle with sexual compulsion that would never have
gotten there had it not been for the internet. Dr. Al Cooper
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Cybersex and Pornography
6 Over 100,000 sites
6 200 new pornography
h websites
b it every day
d
6 95,000,000 unique visitors a month to not for pay sites
6 15,000,000 users of pay sites per month
6 Over a billion dollars in annual revenue
6 Most downloads between 9 and 5
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Fantasy
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For most sex addicts and anorexics, the process of fantasy is
extraordinarily powerful
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Fantasy allows
F
ll
the
h client
li
to have
h
a complete
l process in
i their
h i
minds regarding sexual acting out/in that no one else can see
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Thus, the client can be in full relapse sitting in here in
treatment
Factors In Escalation
6 Anonymity
6 Ease of use
6 Stimulation
S i l i beyond
b
d original
i i l design
d i
6 Access to the unresolved
6 Marketing loops
6 Computer trance bypasses logic
6 New technology for old obsessions
Specific Immediate Strategies
6 Confront Denial and Rationalization
6 Reduce Access
6 Reduce Anonymity
6 Introduce Specific Accountability
6 Develop Healthy On-Line Habits
6 Use Support Network
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Treatment
6 Non Pharmacologic
6 12 Step Groups
6 Cognitive Behavioral Therapy
6 Psychodynamic Psychotherapy
6 Psychopharmacology
Sobriety Statement
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A sobriety statement has three components
1.
Abstinence list-These are the behaviors, that
are part of the addiction
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Part of the client’s sobriety then is to abstain
from these behaviors
Sobriety Statement
2.
Boundaries List-Here are the things the client does not do
because they
y create a hazard to their recovery.
y It is best if
these are very concrete
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Sobriety Statement
3.
Sex and relationship plan-asks what the client
is working toward sexually.
sexually
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Sobriety does not mean anorexia. It means to
explore sexuality in healthy ways
6
Yet the plan is not intended to be restrictive.
It is designed to map out sexual and
relational areas to explore
3-Circle Method
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Inner circle relates to the bottom line behaviors the addict
avoids from their abstinence list
6
Middle circle relates to the boundaries list of warning signs
and slippery behaviors that alert the addict they are in danger
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Outside circle is the sex and relationship plan that enhances
healthy sexuality
Attachment Theory
)
The child’s first intimate relationship is with their maternal
care giver
)
Thi relational
This
l ti
l ttemplate
l t sett th
the stage
t
ffor all
ll future
f t
intimate
i ti t
relationships.
)
Dysfunction in that early attachment process makes the
person vulnerable to seeking attachment and approval from
external behaviors and/or people (DenDooven, 2000).
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Three Stages of Separation
)
)
Protest State-where infant would recognize the absence of a caregiver and
their own neediness (distress, fear or loneliness) and would begin calling,
crying, seeking, attempting to make physical contact.
The protest state is designed to bring the adults into close proximity and meet
their core needs.
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Three Stages of Separation
)
Despair Stage-where infant would begin to lose hope that their needs would be met
y would start to fall into lethargy,
gy fearfulness,
f f
ppassivity,
y and withdrawal.
and they
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Three Stages of Separation
)
Detachment Stage-where infant lost all hope and was without a response to
most environmental stimuli (Bowlby, 1973).
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Object Constancy
In the healthy family, the protest state brought the maternal care giver to
consistently meet the child’s needs.
)
)
Over time, the child developed object constancy and a secure attachment style
based on numerous repetitions of the MCG meeting their core needs.
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Attachment & Family of Origin
)
Sex addicts and co-addicts often did not experience secure attachment
with their maternal care givers.
givers
)
This impairs their ability to have successful bonding and separation in
subsequent relationships during adolescent and adult life (Laaser,
1996).
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12 Step Recovery
Groups
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12-Step Recovery Groups
•
Sexaholics Anonymous (SA)-Started in Simi
Valley. Started because sexual offenders were sent
there to live.
live Most conservative and evangelical of
all.
•
They have the sobriety imperative. The only
acceptable forms of sexuality are in the form of
sanctified (married) relationships.
•
Homosexuals and singles can’t be sexual by their
standards.
12-Step Recovery Groups
•
Sex Addicts Anonymous (SAA)-started in the Midwest.
Home office in Houston. More clear about the bottom line
behaviors less clear on anorexia.
12-Step Recovery Groups
•
Sex and Love Addicts Anonymous (SLAA)-by
far the largest of the fellowships-first to identify
sexuall anorexia
i and
d the
th love
l
addict.
ddi t
•
Loosest in term of their bottom line behaviors.
Not much structure there.
•
Most inclusive of the fellowships. Place where
most women are comfortable.
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So is it really an
Addiction?
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Withdrawal Symptoms
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Fatigue
6
Nervousness
6
Insomnia
6
H d h
Headaches
6
Body Aches
6
Low or High Sexual Arousal
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Impulsivity
6
Diaphoresis
6
Nausea
6
Tachycardia
6
Shortness of Breath
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Research - Executive Function
Deficits in Hypersexual
Individuals
6 Research has shown that hypersexual behavior is positively
correlated with global indices of executive dysfunction
including features of impulsivity, cognitive rigidity, poor
judgment, deficits in emotional regulation, deficits in
initiate, shift, plan and organize. (Reid, Karim 2009)
Neurobiology - Compulsive
Sexual Behaviors
6 Occipital Cortex - Visual Processing
6 Anterior Cingulate Gyrus - Repetitive Behavior,
Behavior
Shifting Attention
6 Striatum - Dopaminergic Tone, Reward
6 Claustrum - Somatosensory Processing,
Heightened Arousal
6 Right Insula
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Psychotropic Medications
6 Are they a “Cure”?
6 Symptom Reduction?
6 Cognitive Enhancer?
6 Dull Affect?
6 Enhance Affect?
6 Control Agitation?
6 Decrease Impulsivity?
Sex Addiction Treatment
6 To best understand treatment options including
which clients should be started on medications
and which specific medications should be
initiated, we must investigate the diagnostic
categories associated with sex addiction.
Pharmacotherapy
6 So… how do you treat sex addiction using medications?
6 Do you treat the primary co-morbidity?
6 Do you treat the impulsivity?
6 Do you treat the obsessional quality?
6 Do you treat the anxiety and/or mood instability?
6 Do you treat all of the above?
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Diagnostic Categories
1) Impulsive (Reward, Substance/Addiction Like)
2) Obsessive (Pre-Occupation,
(Pre-Occupation Ritual)
3) Trauma & Attachment (Development, Intimacy)
4) Axis II (Narcissistic, Borderline, Dependent, Histrionic)
5) Co-Morbidity (ADHD, Bipolar, Depression, Anxiety,
Impulse Control Disorders, Eating Disorders, Substance
Abuse/Dependence)
Pharmacology of Sex Addiction
6 Currently, there are no U.S. Food and Drug Administration
(
(FDA)
) approved
pp
medications for compulsive
p
sexual
behaviors.
6 Not much research data – particularly randomized, double
blind placebo controlled trials
Pharmacology of Sex Addiction
Medication Classes:
6 SSRI’s (Prozac, Celexa, Paxil, Zoloft, Lexapro, Luvox)
6 SNRI’s (Effexor, Cymbalta, Pristiq)
6 Opiate Antagonists
6 Mood Stabilizers
6 Stimulants
6 Anti-Androgens
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The Evolution of
Antidepressants
1950s
1980s
1970s
1960s
Imipramine Clomipramine
Nortriptyline
(1957)
1990s
Maprotiline Bupropion
Nefazodone
Amoxapine
Mirtazapine
Amitriptyline
Fluoxetine
Desipramine
Sertraline
Venlafaxine
Paroxetine
Phenelzine
Fluvoxamine
Isocarboxazid
Citalopram
Tranylcypromine
Kaplan HI, Sadock BJ. In: Synopsis of Psychiatry: Behavioral Sciences, Clinical
Psychiatry. 8th ed. 1998:932-933.
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SSRI’s for Sex Addiction
6 Selective Serotonin Reuptake Inhibitors:
6 (SSRI
(SSRI’s)
s) (Prozac,
(Prozac Celexa
Celexa, Paxil,
Paxil Luvox,
Luvox Lexapro,
Lexapro Zoloft)
6 SSRI’s block the reabsorption (reuptake) of serotonin by certain
nerve cells in the brain. The leaves more serotonin in the brain.
Increased serotonin enhances neurotransmission.
6 SSRI’s used to treat major depression, obsessive compulsive
disorder, generalized anxiety disorder, panic disorder, posttraumatic stress disorder, bulemia, pre-menstrual dysphoric
disorder.
6 Choice of SSRI often based on side effect profile as well as
efficacy.
Pharmacokinetic Profiles of
Select Antidepressants
Half-life
Metabolite
half-life
Metabolite
activity
relative to
parent
compound
Pharmacokinet
ics
(parent
compound)
Sertraline
Citalopram
Escitalopra
m
Fluoxeti
ne
Paroxetine/
paroxetine
controlledrelease
Venlafaxine/
venlafaxine
extendedrelease
26 hours
≈ 35 hours
27-32
hours
96-144
hours*
21 hours
(15-20
hours for
controlledrelease)
5±2 hours
62-104
hours
N/A
N/A
96-384
hours
N/A
11±2 hours
Equal
potency
≤1/50 as
potent
Approximat
ely
equiactive
and
equipotent
Nonlinea
r
Nonlinear
4
Substantial
Substantia
metabolites
ly less
lly
, ≤1/8 as
active
less active
potent
Linear†
Manufacturers’ product information 2003.
Linear
Linear
Linear
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Anti-depressant Tx SSRI’s
6 Sexual Side Effects
6 Weight Gain
6 Discontinuation Syndrome
6 Gastro-Intestinal Difficulties
6 Rebound Anxiety
6 Headaches, Light-headedness
6 Others
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SSRI’s for Sex Addiction
6 The use of SSRI’s as a treatment for sexual addiction is based on the theorized
mechanism of serotonergic dysfunction. Preclinical data shows that serotonin
depletion in the presence of testosterone greatly potentiates sexual behavior in
laboratory animals.
animals (Gessa,
(Gessa 1970)
6 Theoretically, SSRI’s may decrease the preoccupation, obsessional thinking,
emotional reactivity, urges and cravings associated with the behavior.
6 Attempting to use SSRI’s to create sexual dysfunction through their side effect
profile and thus to reduce compulsive sexual behaviors has not been reported as
being that effective.
6 SSRI’s have shown to be most effective when the sex addiction symptomatology
is co-morbid with depression, anxiety or obsessive compulsive disorder.
SSRI’s for Sex Addiction
6
Research Studies:
6
“Fluoxetine Treatment of Nonparaphilic Sexual Addictions and Paraphilias in
Men” (Kafka, Journal Clin Psych, 1992) Results showed Prozac
g
y reduced depressive
p
symptoms
y p
and mitigating
g
g paraphilias
p p
and
significantly
nonparaphilic behaviors but did not affect sexual interest.
6
“Serotonergic medications for sexual obsessions, sexual addictions and
paraphilias” (Stein, Journal Clin Psych, 1992) Results showed that
serotonin reuptake blockade improved sexual obsessions but not
paraphilias.
6
“A Double-Blind Study of Citalopram Versus Placebo in the Treatment of
Compulsive Sexual Behaviors in Gay and Bisexula Men” (Wainberg, J Clin
Psych, 2006) Results showed reductions in drive/desire for sex, frequency
of masturbation and for the compulsive use of pornography.
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Dual Serotonin &
Norepinephrine Reuptake
Inhibitors (SNRI’s)
6 Antidepressants that affect both
serotonergic and noradrenergic systems
(dual reuptake inhibition) may:
6 Have a broader spectrum of action
6 Be effective in bringing more patients
to remission
6 Be useful for refractory patients
Frazer A. J Clin Psychiatry. 2000;61(suppl 10):25-30.
Rush AJ, Thase ME. J Clin Psychiatry. 1997;58(suppl
13):14-22.
61
SNRI’s for Sex Addiction
6
Selective Serotonin and Norepinephrine Reuptake Inhibitors
(SNRI’s): (Effexor, Cymbalta, Pristiq)
6
Used on label for major depressive disorder, generalized anxiety disorder.
6
Effexor also indicated for social anxiety disorder and panic disorder and also blocks the
dopamine transporter (mildly) which can increase dopamine transmission.
6
Since dopamine is inactivated by norepinephrine reuptake in the frontal cortex, Effexor
can increase dopamine neurotransmission in this part of the brain
6
Cymbalta also approved to treat fibromyalgia and diabetic pain.
6
Works by restoring the balance of serotonin and norephinephrine in the brain by
inhibiting their reabsorption (reuptake) into cells in the brain. (Dual reuptake inhibtion)
6
Case Reports of improvement of Axis II and Eating Disorder dysfunction with SNRI’s
Naltrexone for Sex Addiction
6 Opiate Antagonists: (Naltrexone, Vivitrol)
6 Naltrexone has been effective in treating urge-driven disorders
such as pathological gambling, alcoholism, borderline personality
disorder with self-injurious behavior and cocaine abuse. The
primary pharmacological action of naltrexone within the central
nervous system is the antagonism of the opioid system that
processes pleasure and pain.
6 Naltrexone blocks the opiate’s capacity to augment dopamine
release thereby decreasing dopamine and reducing the euphoric
properties of fantasy and tension buildup which are often the
initial steps in CSB.
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Naltrexone for Sex Addiction
6 Research:
6 “A Case of Kleptomania and Compulsive Sexual Behavior Treated
With
Wi
hN
Naltrexone”
l
” (Grant,
(G
2002) The
Th use off hi
high
hd
dose
naltrexone (150mg) led to remission of a patient’s sexual
urges.
6 “Naltrexone in the Treatment of Adolescent Sexual Offenders”
(Ryback, 2003) Results showed naltrexone at dosages of
100mg to 200mg per day helped decrease sexual fantasies
and masturbation. Open label trial 15/21 patients noted
reductions in sexual impulses and arousal.
Mood Stabilizers for
Sex Addiction
6 Mood Stabilizers (Depakote, Lithium, Lamictal, Tegretol,
Trileptal, Topamax)
6 Used
U d primarily
i
il for
f bipolar
bi l disorder
di d and
d bipolar
bi l depression
d
i
6 Most of the mood stabilizers potentiate the activity of
gamma-aminobutyric acid (GABA) in the brain and inhibit
glutamate transmission.
6 Unknown whether the mood stabilizer is having an
independent effect on reducing compulsive sexual behaviors
or is treating the co-morbidity mood disorder.
Stimulants for Sex Addiction
6 “Psychostimulant Augmentation During Treatment With Selective
Serotonin Reuptake Inhibitors in Men With Paraphilias and
Paraphilia-Related Disorders: A Case Series.” (Kafka, J Clin Psych,
2000) Open
O
trial
i l off psychostimulants
h i l
(Ritalin
(Ri li SR) added
dd d to
SSRI’s (Prozac) to treat men with paraphilias and paraphilasrelated disorders showed the synergistic effect of these two
medications helped diminish sexual impulsivity.
6 Noradrenergic/Dopaminergic medications have been found to
enhance both sexual appetitive behavior and performance in
Humans. But, may be useful in ADHD co-morbid subgroup.
6 Treating ADHD and Hypersexual Behavior? Abuse?
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Anti-Androgens for Sex
Addiction
6 Altering Sexual Hormone Function…
6 Medroxyprogesterone Acetate (300-500mg per week IM)
6 Cyproterone Acetate (300-600mg per week IM)
6 Both lower serum testosterone levels and subsequently
diminish sexual drive and desire.
Psychopharmacology
Wrap Up
6 SSRI’s: May help with sexual side effects with anorgasmia, reduced
libido but primary effect more consistent with diminishing obsessive
thinking, compulsions, anxiety, mood instability. Celexa study in gay
men; Sertraline Study,
Study Prozac Study (Kafka)
6 Opiate Antagonist - Dampening dopamine release may help reduce
impulsivity as well as the buildup of fantasies
6 Dopamine Agonists - Preliminary research shows ADHD like
subgroup that responds well and DA agonists may help to augment
the SSRI response
6 Anti-Androgens - Medroxyprogesterone and Cyproterone (Androgen
receptor blocker); LHRH - Leutinizing Hormone Releasing Hormone
Chemical Castration
DSM V ?
DSM5 - Compulsive-Impulsive Sexual Behavior ?
The Diagnostic Category reflects the central feature of
“The
compulsive sexual behaviors due to impaired impulse
inhibition.”
DSM 5 – Hypersexual Disorder?
Fantasies, Urges, Behaviors that are recurrent in nature,
excessive time consumed, mood instability and
social/occupational dysfunction.
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Future Research Studies
6 UCLA Sexual Addiction/Compulsivity Research
6 Dr. Reef Karim, Dr. Steve Shoptaw, Rory Reid
6 1) Diagnostic - Criteria, Classification
6 2) Medication Trials
6 3) Neuroimaging
Cutting Edge
Pharmacology for Sex
Addiction
Dr. Reef Karim
Assistant Clinical Professor, UCLA Semel Institute for Neuroscience
Director, The Control Center
www.thecontrolcenter.org
[email protected]
Office: (310) 271-8700
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