2. Chief Complaint
• JK is a 45 year old single
Caucasian male
• Self referred for assessment of
his “sex addiction”
– National Institute for the Study,
Prevention and Treatment of
Sexual Trauma Recent
• 6 day binge of watching
pornography, compulsive
masturbation, and medication
non-compliance.
• Seeking an evaluation for
Androgen deprivation
treatment (ADT)
3. HPI
• No psychiatric or medical hospitalization for 2 years.
• Sexaholics and Sex Addicts Anonymous 2 times per week.
• Sees medical and psychiatric providers regularly.
• Recently cancelled his internet at his apartment so that he
would not be tempted to watch pornography.
• No physical contact with another human being for 1 year
• “Sober” in last 3 months :
– Defined as: no pornography, masturbation 2-3 times per day (not
public), and no sexual contact with males or females.
4. HPI (cont’d)
• Binge started after SA group which emphasized healthy
masturbation
• "out of control" 6 day binge:
– smoked marijuana joint, and immediately bought pornography and went
to his parents’ home to make use of the internet.
– First night masturbated 7 hours straight
– 10-12 hours cataloguing pornography, which includes organizing in
special ways like using hair color and body type as categories and
inventing stories about each woman that he watches.
– Left his parents’ home and spent all of the money he had for his monthly
bills on a hotel room, pornography, and marijuana.
– Stopped taking his psychiatric medications because he believes that they
were interfering with his ability to climax.
– 24 hours during this binge, in a frustrating cycle of watching pornography
and masturbating without orgasm.
5. HPI (cont’d)
Called his sponsor prior
to seeking sex with an
escort.
• Afraid "addiction
was triggered so
easily”
Requests evaluation for
Lupron
• Wants to continue
current psychiatric
medications
6. Family History
• Father is “very prosperous businessman”
– Undiagnosed Bipolar disorder and “extreme
pornography consumption”.
– First discovered pornography from his father’s wide-
ranging collection.
• Mother and two sisters have no history of
psychiatric illness including substance abuse.
• Maternal grandmother had a history of BPAD with
multiple psychiatric hospitalizations and his
maternal grandfather had a history of alcohol
dependence.
• No family history of suicides.
7. Educational History
• Senior year of high school 1982 :
– First manic episode, onset of his “sexual
promiscuity.”
– Hospitalized for several months.
• Unable to complete undergraduate
degree due to his psychiatric illness.
• He is currently unemployed.
8. Relational
• 3 significant relationships with women:
– 1985-1991: sex worker and that he met her first as a client.
– 1998-1999: engaged
– 2011-2012: “trial marriage” sex worker
• Relationships all ended
– Sexual addiction continued throughout these relationship
– Multiple partners, both male and female
– Combined addictions
• No relationship since 2012
– engaged in sexual activity with only females since then ,not more
than once a day and only 3-4 times , as he has been working
toward "sobriety".
• He has no children.
9. Social
• Sobriety has enabled him to have social
interactions
• Male friends that he is emotionally
connected to from both of the 12 step
programs that he attends.
• Engages in social activities and enjoys
movies, music concerts, playing the
drums, and hiking.
10. Medical
• HIV diagnosed in 1987(CD4=416 in 2/15)
• Antiretroviral toxic neuropathy
• Irritable bowel syndrome
• Hypertriglyceridemia
• Hypothyroidism
• History of recurrent c. difficile
• History of pneumonia (4 times)
• History of Varicella zoster virus
11. Current Medications
• Abacavir/ Lamivudine (Epzicom)1 tablet PO q
daily
• Raltegravir 400 mg bid
• Neurontin 800 mg PO tid
• Seroquel 600 mg PO qhs
• Lamictal 450 mg PO daily
• Tricor 145 mg PO qhs
• Singulair 10 mg PO daily
• Synthroid 200 mcg PO daily
12. Psychiatric History
• Bipolar 1 Disorder
– Hospitalized 8 times for “manic episodes.”
– Involuntary certified three times.
– Longest hospitalization has been 3 months.
– Trials of Lithium, Depakote, Zyprexa, and
Risperdal with little efficacy.
13. Substance Abuse History
• Detailed history of substance use, including
alcohol, marijuana, cocaine, hallucinogens,
PCP, and ecstasy in 1980-1990s
– No history of detox
• Current :
– Had not smoked marijuana for 1 year prior to the
6-day binge
– Smoked heavily during this "binge", estimating
that he consumed about an ounce of marijuana
at this time.
14. THC: Mechanism of Action
Marijuana contains THC, indirectly increasing the amount of
dopamine, “the feel good” neurotrasmitter responsible for
feelings of pleasure and reward.
15. Sexual History
• Age 11 : began masturbating to father’s pornography
collection and pictures of adult females.
• Age 13: first sexual contact, oral sex with a 14-year-old male
neighbor.
• Age 15, masturbating several times a day, acquiring his own
pornography, and having paid phone sex.
• Age 18, sex with prostitutes both male and female,
– strip clubs
– pornography
– massage parlors
– adult bookstores - casual sex with males
– Stole money from his family to finance activites.
16. Sexual History
• Rarely felt sexually satisfied and craved sexual
physical contact.
• Identifies as heterosexual and masturbates to female
images and fantasizes about women.
• Sex w/ males : less expensive, more readily available
to him, and when cravings for sex are " out of control”
• Sex many times without protection and without telling
the person that he is HIV positive.
– remorse : blog about his personal struggles with "sex
addiction and HIV”
– No unprotected sex in the last two years
17. Mental Status Exam
• Appearance: Normal development,
normal nutrition, normal habitus, no
deformities.
• Level of consciousness: Alert
• Orientation: MMSE 30/30
• Dress/grooming: Neatly groomed
• Eye contact: Appropriate
• Attitude: Good self-attitude
• Motor: Normal strength, normal
tone, normal muscle mass, normal
movements
• Speech: Increased rate, normal
rhythm, normal volume, normal
tone, normal articulation, normal
coherent speech, normal
spontaneity
• Mood: States mood is "up and
down"
• Affect: Full range
• Thought Process: Normal
processing, normal computation
• Thought Content: goal directed
• Insight: Poor
• Judgment: Poor
• Intellect: Above average
• Memory: 3/3 recall MMSE
• Concentration: 5/5 attention and
calculation
• Language: fluent
18. Formulation
• 46 year old Caucasian, single,
unemployed male
– Bipolar Disorder I
– Unspecified Paraphilic
Disorder
– Cannabis Use Disorder
• Multiple medical Comorbidities
19. Disease Perspective
• Bipolar 1 Disorder
– As evidenced by distinct periods of manic
episodes
– Family HX of untreated Bipolar disorder
– Maintained on mood stabilizers and anti-
psychotics
• Recurrent sexual arousal and cravings AND
increased sexually driven behaviors PERSIST
in the absence of an exacerbation of his
bipolar illness
20. Life Circumstances
• Stable home, not close to his father, sees mother
once a week
• Completed two years of college
• Minimal professional success
• Multiple relationship failures
• Sexual development began early at age 11,
looking at pornography obsessively
• First psychiatric admission at age 17 for mania
• Multiple psychiatric admissions over the course of
his life
22. Behavioral Perspective
• History of substance use disorder and may have
genetic loading as he reports alcohol abuse in his
grandparents.
• DSM V: Unspecified Paraphilic Disorder
• Drive
• Object goal
• Pursuit
• Procurement
• Consumptatory experience
• Satiety
• Rarely reaches satiety
23. DSM V: Paraphilic Disorder
• Experiences repeated and intense sexual
arousal as a result of the specified sexual
interest lasting for a period of longer than
six months
(APA, 2013; McManus, Hargreaves, Rainbow, and Alison, 2013)
24. Sexual behaviors result in:
significant distress
clinically impairment
decreased personal functioning
25. Hypersexuality and Addiction
• Hypersexuality disorder (HD) is not included in the DSM-V
– research indicates that HD may be viewed within the context of an
addiction framework
• Clinical manifestations of addiction and hypersexuality
disorder parallel in that they often involve chronic use and
relapse.
• As the clinically significant behaviors endure with both
hypersexuality disorder and substance abuse:
– Decreased pleasure with the act itself
– Increased cravings
– Withdrawal
– Rumination and guilt that interfere with functionin
(Kor, Fogel, Reid, Potenza, 2013)
26. Evidence based Treatment
• The gold standard for treatment, in conjunction
with psychotherapy, remains androgen
deprivation therapy (ADT), a pharmacological
approach that lowers testosterone levels and
therefore lowers the sex drive.
• While there are side effects, ADT has been shown
to significantly reduce recidivism rates in sex
offenders and treats sex offenders who are
considered to be sexually disordered or diagnosed
with paraphilic disorder.
(Berlin, 2009)
27. Pharmacological Interventions
• ADT : oral or injectable
• 2 major categories:
– steroidal antiandrogens
– gonadotropin-releasing hormone analogs or agonists (GnRHa)
• GnRHa : desensitize pituitary receptors resulting in
hypogonasism and very low serum levels of testosterone
– administered IM monthly or every three months
– Treatment initiation : augmentation with oral non-steroidal anti-
androgen drug
• first several weeks of therapy → block androgen production (due to
surge of hormone production when first introduced)
(Assumpcao et al, 2014)
28. Monitoring
• Labs:
– Prior to initiation of a GnRHa and at 6 months,
– Testosterone, LH, FSH, prolactin, CBC, renal
and liver function, fasting glucose, and lipids.
– Yearly bone scans to monitor for osteopenia
and osteoporosis.
29. Other Pharmacological Treatments
• Serotoninergic reuptake inhibitors (SSRIs):
– Side effect of these medications decrease libido and
interfere with orgasm and ejaculation.
– Studies have shown that the greatest efficacy is
achieved with treatment of paraphilic disorders,
specifically exhibitionism, compulsive masturbation
and pedophilic urges not acted upon .
• Currently, fluoxetine and sertraline have shown the
most promise in the limited studies.
(Assumpcao et al, 2014)
30. Other Recommendations
• Continue with current psychiatric care.
• Start Lupron injections to help reduce his sexual
preoccupation, masturbation and compulsive use of
pornography.
– 7.5 mg IM monthly augmented with oral Flutamide 300 mg
PO bid for the first month of the ADT initiation therapy.
• Continue treatment with his therapist, outpatient
psychiatrist, and the medical team who treats his HIV.
• Continue Sexaholics, Sex Addicts Anonymous and this
clinic for further stabilization of his sexual addiction.
31. References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5.
Washington, D.C: American Psychiatric Association.
Assumpcao, A.A., Garcia, F.D., Garcia, H.D., Bradford, J.M.W., & Thibaut, F. (2014). Pharmacologic treatment of
paraphilias. The Psychiatric Clinics of North America, 37(2), 173-181.
Berlin, F. S. (2009). Commentary: Risk/benefit ratio of androgen deprivation treatment for sex offenders. The
Journal of the American Academy of Psychiatry and the Law, 37(1), 59-62.
First, M.B. (2014). DSM-5 and paraphilic disorders. Journal of the American Academy of Psychiatry Law, 42(2),
191-200.
Kor, A., Fogel, Y., Reid, R., Potenza, M. Should Hypersexual Disorder be Classified as an Addiction? Sex Addict
Compulsivity, 20(1-2), 1-16.
McManus, M., Hargreaves, P., Rainbow, L., Alison, L. Paraphilias: definition, diagnosis and treatment. F1000
Prime Reports 2013, 5(36), 1-6.
