CU-MA-PSY-SEM-IV-Clinical Disorders II (1) Revised

suggests that if you are suffering from Internet Addiction Disorder, your brain makeup is similar to those that suffer from a chemical dependency, such as drugs or alcohol. Interestingly, some studies link Internet Addiction Disorder to physically changing the brain structure – specifically affecting the amount of gray and white matter in regions of the prefrontal brain. This area of the brain is associated with remembering details, attention, planning, and prioritizing tasks. It is suggested one of the causes of Internet Addiction Disorder is structural changes to the prefrontal region of the brain are detrimental to your capability to prioritize tasks in your life, rendering you unable to prioritize your life, i.e., the Internet takes precedence to necessary life tasks. Internet Addiction Disorder, in addition to other dependency disorders, seem to affect the pleasure center of the brain. The addictive behavior triggers a release of dopamine to promote the pleasurable experience activating the release of this chemical. Over time, more and more of the activity is needed to induce the same pleasurable response, creating a dependency. That is, if you find online gaming or online shopping a pleasurable activity and you suffer from an addiction to the Internet, you will need to engage in more and more of the behavior to institute the same pleasurable feeling prior to your dependency. The variable reinforcement effects of Internet addiction is another cause of this behavior. According to the Variable Ratio Reinforcement Schedule (VRRS) theory, the reason why you might be so addicted to Internet activity (e.g., gaming, gambling, shopping, pornography, etc.), is because it provides multiple layers of rewards. That is, your constant surfing of the Internet leads to multiple rewards that are unpredictable. Perhaps your addiction to Facebook provides a multiple and unpredictable layer of rewards in the sense that every time you sign on to read your updates, you get repeated and unexpected good news. Maybe you found out one of your great friends just got engaged. The next time you sign on, you learn another friend just had a baby! Or, perhaps the man you are really interested in just posted an update that he and his longtime girlfriend just broke up. Each sign on gives you unpredictable results that keep you entertained and coming back for more. Certain games, such as MMROPGs (massively multiplayer online roleplaying games) – including World of Warcraft and Ever quest may lead to Internet addiction because, in effect, they never end. Biological predispositions to Internet Addiction Disorder may also be a contributing factor to the disorder. If you suffer from this disorder, your levels of dopamine and serotonin may be deficient compared to the general population. This chemical deficiency may require you to engage in more behaviors to receive the same pleasurable response compared to individuals not suffering from addictive Internet behaviors. To achieve this pleasure, individuals may engage in more behavior to the general public, increasing their chances for addiction. Predispositions of Internet addiction are also related to anxiety and depression. Oftentimes, if you are already suffering from anxiety or depression, you may turn to the Internet to relieve 151 CU IDOL SELF LEARNING MATERIAL (SLM)

your suffering from these conditions. Similarly, shy individuals and those with social awkwardness might also be at a higher risk of suffering from Internet addiction. If you suffer from anxiety and depression, you might turn to the Internet to fill a void. If you are shy or socially awkward, you may turn to the Internet because it does not require interpersonal interaction and it is emotionally rewarding. 7.9 PROGNOSIS OF INTERNET ADDICTION Internet addiction is believed to be a largely treatable condition. When the addiction is acknowledged, a therapist or other mental health professional can help an individual take steps to address the behavior and regain the ability to use the Internet in a healthy way. Internet addiction differs from some other types of addiction in that some level of Internet use is generally necessary for function in society. Thus, the goal of treatment is usually not complete abstinence. However, when a person is addicted to online porn, for example, treatment goals may involve using the internet without attempting to seek out pornography. 7.10 TREATMENT OF INTERNET ADDICTION Because of the lack of consistency and cross-cultural aspects of Internet Addiction, interventional studies are often difficult to compare with each other. Nevertheless, the prevalence and potential degree of dysfunction have prompted a number of treatment studies. These studies evaluated a range treatment options, but they are often derived from distinct theoretical foundations. Currently, there is no consensus-based clinical guideline available for the treatment of Internet Addiction, and there are no pharmacotherapy agents approved by the U.S. Food and Drug Administration for Internet Addiction. Treatment is therefore primarily symptom-focused, with the goal of recovery being the improvement of the critical cognitive and psychosocial functioning that was significantly impaired by the behavioral disturbances. Some high-profile addiction treatment facilities have begun to enter the market for inpatient private-pay Internet Addiction services. The first step in treatment is the recognition that a problem exists. If you do not believe you have a problem, you are not likely to seek treatment. One of the overarching problems with the Internet is that there is often no accountability and no limits. You are hidden behind a screen – and some things that you may say or do online are things you would never do in person. There is debate in the literature whether treatment is necessary in the first place. Some believe Internet Addiction Disorder to be a “fad illness” and suggest that it usually resolves itself on its own. Studies have shown that self-corrective behavior can be achieved and successful. Corrective behaviors include software that controls the Internet use and types of sites that can be visited – with the majority of professionals in agreement that total abstinence from the computer is not an effective method of correction. 152 CU IDOL SELF LEARNING MATERIAL (SLM)

Some professionals argue that medications are effective in the treatment of Internet Addiction Disorder – because if you are suffering from this condition, it is likely that you are also suffering from an underlying condition of anxiety and depression. It is generally thought that if you treat the anxiety or depression, the Internet Addiction may resolve in step with this treatment approach. Studies have shown that anti-anxiety and anti-depressant medications have had a profound effect on the amount of time spent on the Internet – in some cases decreasing rates from 35+ hours a week to 16 hours a week. Physical activity has also been indicative of effective in increasing serotonin levels and decreasing dependency on the Internet. 7.10.1 Pharmacological Treatment In order to identify pharmacological agents efficacious in modifying thoughts and behavior, the underlying circuit-level abnormalities should first be reviewed. Functional magnetic resonance imaging studies of Internet Addiction subjects in China revealed a number of changes in these patients, including increased synchronization between the cerebellum, brainstem, limbic areas, and frontal cortex, indicating a potential role in the reward- processing pathways. Medications that potentially target reward and reinforcement may therefore have some effect on Internet use patterns. At the same time, because of the high degree of comorbidity, treating coexisting disorders may also improve the patient’s Internet Addiction symptoms. Antidepressants Antidepressant medications, particularly selective serotonin reuptake inhibitors, have a potential role in the treatment of Internet Addiction, because the episodic comorbidity between IA and depression is high. Early case studies using escitalopram in the treatment of IA have resulted in anecdotal reports of improvement in mood and a reduction of craving for Internet use. In an open-label study of 19 patients with 10 weeks at a uniform dose of 20 mg/day of escitalopram, 11 patients (64.7% of the sample, factoring in dropouts) had a significant decrease in weekly hours spent online and improvements in global functioning. At the end of the 10 weeks, participants were randomized to either continue escitalopram or receive a placebo. Clinical improvement remained in the second phase of the study, but no significant differences were observed between those who continued taking the drug and those who were switched to placebo. Long-term effects of antidepressants in patients with mild to moderate depression and Internet Addiction have not been evaluated, and clinicians need to be especially vigilant in monitoring for activation and manic-switching side effects during antidepressant treatments, which can worsen Internet Addiction behavior. Opioid Receptor Antagonists The possible overlap between Internet Addiction, substance use disorders, pathological gambling, and sexual compulsions suggests that a common circuit-level abnormality may be 153 CU IDOL SELF LEARNING MATERIAL (SLM)

involved. An especially attractive candidate circuit may be the prefrontal-limbic-striatal circuit that is prominently involved in the recognition and modulation of reward and reinforcement behaviors. Dopamine is the central neurotransmitter that has several putative roles in this circuit, from indicating reward itself to measuring error in estimated reward. Several agents have been developed to target the dopaminergic pathway in both the striatum and the cortex to treat substance use disorders. Opioid receptor antagonists inhibit dopamine release in the nucleus accumbent and ventral pallidum, they have been shown to be efficacious for opioid and alcohol use disorders, and they may have a potential role in the treatment of Internet Addiction. The medical literature is currently limited to a single case report of successful treatment with naltrexone (150 mg/ day) added to a stable dose of sertraline, which induced a 3-year remission. Mood Stabilizers Mood stabilizers may be efficacious in Internet Addiction in targeting the potential overlap between symptoms in mania and Internet Addiction. Some mood stabilizers, such as topiramate, may have a generalized anti-reinforcement effect, and they have been used in alcohol-dependent patients with varying clinical effect. Other mood stabilizers, such as lithium and valproate, may theoretically have some utility in treating pathological gambling. However, at present, the effectiveness of mood stabilizers in Internet Addiction treatment has not been investigated in controlled studies. Antipsychotics Because atypical antipsychotics, similar to selective serotonin reuptake inhibitors, also target the serotonergic circuit, they have been investigated, especially as an augmenting agent in treating compulsive-impulsive spectrum psychopathologies, such as OCD. Several atypical antipsychotics have been shown to be effective in trichotillomania, skin picking, and borderline personality disorder. A single case study revealed that quetiapine (200 mg/day), gradually added to citalopram, improved Internet Addiction symptoms in a 23-year-old patient. These improvements were maintained at a 4-month follow-up. The possible role of antipsychotics in the treatment of IA symptoms requires additional studies. Psychostimulants and Other Medications Because of a significant comorbidity between ADHD and IA, psychostimulants have been proposed as a possible treatment, especially for children and adolescents. A recent open-label trial of osmotic release oral-formulation (mean daily dose 30.5 mg) methylphenidate in 62 medication-naïve children with comorbid ADHD and Internet video game addiction reported a significant improvement in both ADHD symptoms and Internet use after 8 weeks of treatment. Medications that indirectly act on ADHD symptoms, such as α2-agonists (guanfacine, clonidine) may also have an effect on IA symptoms, although there is currently no controlled evidence supporting their use. Finally, emerging glutamatergic agents may have a role in targeting impulsive behaviors. 154 CU IDOL SELF LEARNING MATERIAL (SLM)

7.10.2 Psychological Treatment A number of studies and reviews for the psychosocial treatment of IA have been published. For the most part, psychotherapy for these patients involves developing and maintaining skills important in self-limiting Internet use, as well as strategies for coping with cravings and social isolation. Some of the more common psychological treatments of Internet Addiction Disorder include:  Individual, group, or family therapy  Behavior modification  Dialectical Behavioral Therapy (DBT)  Cognitive Behavioral Therapy (CBT)  Equine Therapy  Art Therapy  Recreation Therapy  Reality Therapy Because of the prevalence of the disorder in the general population, treatment centers and programs have started to pop up in the US and across the globe. In some cases, electro-shock therapy was used to wean individuals off the Internet – this method has since been banned. The ReSTART residential treatment facility was started in 2009 in Seattle, WA for pathological computer use. In 2013, a USB-connected keyboard device was created to provide a very low voltage shock to users who visited particular websites. In other places nationwide and internationally, de-addiction centers have been started to aid individuals suffering from Internet Addiction Disorder. In many instances, multimodal treatments have been employed to treat Internet Addiction Disorder. In this method of treatment, if you are suffering from this condition, you might be prescribed both medications and psychotherapy to treat your addiction to the Internet. Cognitive-Behavioral Therapy At present, cognitive-behavioral therapy (CBT) is the mainstay of psychotherapy treatment for IA, and almost all existing trials include some component ofCBT in their treatment program. CBT relies on recognition of maladaptive patterns and modification and reconstruction of distorted thoughts and behaviors. Skills often acquired as part of the CBT program include time managementstrategies, a more balanced view of the benefits and potential harms of the Internet, increased self-awareness and awareness of others and one’s surroundings, identifying “triggers” of Internet “binge behavior,” and increased capacityfor managing emotions and cravings. In a trial of online 155 CU IDOL SELF LEARNING MATERIAL (SLM)

counseling in 114 clients diagnosed with IA (Young 2007), most patients showed significant improvement by the eighth session, and symptomatic control was sustained at the6-month follow-up. Motivational Interviewing Motivational Interviewing (MI) is a patient-centered and directive counselingapproach for eliciting behavioral change. It assumes that the patient ultimatelyhas the responsibility to change. The physician’s role is to provide guidance andrealistically assess the pros and cons of different choices; the physician engagesthe patient’s intrinsic motivation for changing behavior. This approach hasbeen demonstrated to be effective for a number of substance use disorders, andanalogies drawn between illicit substance use and problematic Internet use canbe made such that MI can be used effectively as a psychotherapy modality. Orzack et al. (2006) used a combination of CBT and Motivational Interviewing in treating patients who engage in excessive Internet use and found that whereas the effect on total use time is not apparent, there is improvement in overall quality of life and symptoms of depression. Whereas the Internet allows him to have a risk-free social life, his desires for relationships in real life and success in his employment can be used to self-motivate a potential change in behavioral patterns. Psychodynamic Psychotherapy Although there are no published controlled studies on the efficacy of psychodynamic psychotherapy in Internet Addiction, this phenomenon can be conceptualized within thepsychodynamic framework to design a customized therapeutic program for individual patients. In our case, Henry’s main complaints about control, entrapment, and subsequent dysfunction can be explained and understood throughrecognition of a repeated pattern of behavior that may have an origin in hischildhood, with his attachment response modeled specifically to patterns of hisparents. The goal of this type of therapy is to engage the patient in understanding these difficult interpersonal patterns and to view Internet Addiction as a manifestation of theirown inability to deal with intimate relationships because of their earlier life experiences. Psychodynamic approaches may be especially helpful in exploring hissexual feelings associated with using the Internet and his Internet use as a meansof relieving tension and as a substitute for his lack of romantic partnership. Integrative Approaches Integrative psychotherapy attempts to use elements of different therapeutic approaches in a flexible, solution-focused way to help patients achieve their individual goals. Patients with substance use disorders often benefit from a flexibletreatment program because treatment goals and directions change as treatmentprogresses. Often individual patients are not interested in changing at the outset, or he or she has a psychopathology such as depression 156 CU IDOL SELF LEARNING MATERIAL (SLM)

that makes it too difficult to address the other problematic behavioral patterns. The initial approachmay be pharmacologic, and as the patient’s depressive symptoms begin to lift,he or she becomes more amenable to considering changing patterns of behaviorthat he or she often relies on for self-soothing. Motivational Interviewing engages these patients andenhances this motivation and subsequently can improve the efficacy of CBT,which is most helpful when patients are fully committed to change and need aprogram to specifically adopt change in their lives and to monitor the progressthat they have made. A randomized trial studied the effect ofmultimodal intervention in 56 adolescents with Internet Addiction, comparing an eight-sessiongroup CBT intervention plus family sessions and psychoeducation workshopswith a wait list control. Although Internet use decreased in both groups, symptomatic improvement was more pronounced in the treatment group. Group Therapy Group therapy is commonly used in substance us disorders. Its effectiveness intreating Internet Addiction has been mixed in controlled studies. The advantage of group therapy lies in the ability of the individual to acquire socialskills in a real-world context and the possibility of improving and resolvingshame, guilt, and isolation through sharing with others with similar experiences. There is no formal controlled study for 12-step facilitation treatment forInternet Addiction, although these groups do exist in the community, often intermingling withgroups for other behavioral addictions, such as sex addictions. In clinical practice, group therapy can often be an important and practical adjunct treatmentmodality for patients with Internet Addiction symptoms. Family Therapy Family therapy and network therapy are likely an important aspect of treatmentfor IA. The approach is both informative and interventional. First, family members may be relieved to know that the symptoms that they recognized in theirloved ones may be alleviated by becoming aware that Internet Addiction is partially mediatedby a causal loop that involves depression and anxiety, abnormalities that may beaddressed through pharmacotherapy. Second, a powerful message of hope canbe communicated: even persistent, dysfunctional patterns of behavior can bechanged through commitment and treatment with psychotherapy. Twelve-step programs and social skills training Twelve-step programs and social skills training may also be treatment options for some individuals. When a mental health concern such as stress, depression, or anxiety has led a person to turn to the internet for support, a therapist may work to treat the addiction by first addressing this mental health condition. Similarly, any other underlying conditions are often exposed through work in therapy, and treating these concerns can often help facilitate recovery from the addiction. 157 CU IDOL SELF LEARNING MATERIAL (SLM)

7.11 SUMMARY  Internet addiction is when a person has a compulsive need to spend a great deal of time on the Internet, to the point where other areas of life (such as relationships, work or health) are allowed to suffer.  The person becomes dependent on using the Internet and needs to spend more and more time online to achieve the same ‘high’.  There is a range of behaviour that can be referred to as Internet addiction. Other terms for this addiction include Internet addiction disorder (IAD) and net addiction.  Generally speaking, surveys suggest that males who are addicted to spending time online tend to prefer viewing pornographic websites, while females are attracted to chat rooms for making platonic and cyber-sexual relationships.  Whenever Internet addicts feel overwhelmed, stressed, depressed, lonely or anxious, they use the Internet to seek solace and escape.  Studies from the University of Iowa show that Internet addiction is quite common among males ages 20 to 30 years old who are suffering from depression.  Certain people are predisposed to having a computer or Internet addiction, such as those who suffer from anxiety and depression.  Their lack of emotional support means they turn to the Internet to fill this need. There are also those who have a history of other types of addiction, such as addictions to alcohol, drugs, sex and gambling.  The short-term effects of an online addiction include unfinished tasks, forgotten responsibilities and weight gain.  Long-term effects are seen more in the physical symptoms such as backache, neck pain, carpal tunnel syndrome, and vision problems from staring at the screen.  It can also lead to bankruptcy, especially if the time spent online is focused on shopping, gambling and gaming.  It isn’t necessary to quit using the Internet altogether. Professional treatment aims to allow the person to use the Internet positively rather than compulsively.  Internet addiction seems to respond well to cognitive behaviour therapy (CBT). This type of therapy focuses on changing patterns of thinking and beliefs that are associated with and trigger anxiety.  The basis of cognitive behaviour therapy is that beliefs trigger thoughts, which then trigger feelings and produce behaviour. 158 CU IDOL SELF LEARNING MATERIAL (SLM)

7.12 KEY WORDS  Addiction: According to the American Society of Addiction Medicine (ASAM), addiction is a primary, chronic, neurobiological disease with genetic, psychosocial, and environmental factors influencing its development and manifestation.  Behavioral addictions: A form of addiction that involves a compulsion to engage in a rewarding non-drug-related behavior – sometimes called a natural reward – despite experiencing negative harmful consequences due to the compulsive behavior (e.g., sex, gambling, food, shopping, internet).  Behavioral medicine: An interdisciplinary field that integrates knowledge across disciplines to study the behavioral and social aspects of medical conditions and illness.  Biological model of addiction: A conceptual understanding of addiction that focuses on the genetic or other biological pre-determinants or risks for developing and/or maintaining a substance use disorder.  Case management: The collaborative process of assessment, planning, care coordination, evaluation, and advocacy for options and services to facilitate disease management (e.g. connecting individuals to mutual help organizations, peer & family support services and counseling, employment, housing, basic healthcare, childcare, etc.).  Coping strategies: The specific efforts, both behavioral & psychological, utilized to master, tolerate, reduce, or minimize the effects of stressful events.  Dependence: The state in which metabolic status and functioning is maintained through the sustained presence of a drug; manifested as a mental or physical disturbance or withdrawal upon removal of the substance.  Disease model of addiction: Classifies addiction as a disease. There are several “disease models,” but addiction is widely considered a complex disease with biological, neurobiological, genetic, and environmental influences among clinical scientists.  Peer support group: Also known as mutual help organizations, peer support groups are structured non-clinical relationships, in which individuals participate in activities that engage, educate, and support patients recovering from substance use disorder.  Problem-behavioral theory: Proposed by Richard Jessor in 1991, Problem Behavior Theory is a conceptual framework that examines factors leading to adolescent substance use. 159 CU IDOL SELF LEARNING MATERIAL (SLM)

7.13 LEARNING ACTIVITY 1. Do you believe internet addiction is a reality? What makes you draw this conclusion? ___________________________________________________________________________ ___________________________________________________________________________ 2. How is internet addiction different from substance related addiction? ___________________________________________________________________________ ___________________________________________________________________________ 7.14 UNIT END QUESTIONS A. Descriptive Questions Short Questions 1. Define Internet addiction. 2. What is cyber-sex addiction? 3. What is inline gaming addiction? 4. What is the DSM criteria for internet addiction? 5. What is the incidence of internet addiction? Long Questions 1. Write in detail about the causes of internet addiction. 2. What is the prevalence of internet addiction? 3. Explain in detail the different types of internet addiction. 4. What are the comorbidities of internet addiction? 5. Write in detail any one therapy used for internet addiction. B. Multiple Choice Questions 1. In kids, internet can lead to ____________ addiction a. gaming b. shopping c. chatting d. surfing 160 CU IDOL SELF LEARNING MATERIAL (SLM)

2. In women, internet can lead to ____________ addiction a. gaming b. shopping c. chatting d. surfing 3. Internet addiction is _____________________ a. emotional b. behavioral c. substance related d. All of these 4. What is the main purpose of motivational interviewing? a. The main purpose is to resolve the client's conflicting feelings. b. There is no main purpose. c. Asking open-ended questions is the main purpose. d. An actively engaged client who makes quality choices to change is the main purpose. 5. Many individuals use _____ to deal with their problems, which can lead to more problems requiring counseling. a. addiction b. hobby c. counselling d. distraction Answers 1-a, 2-b, 3-b, 4-d, 5-a 161 CU IDOL SELF LEARNING MATERIAL (SLM)

7.15 REFERENCES Textbooks  Ahuja N (2002). A short text book of Psychiatry. (5th edn). New Delhi: Jaypee Brothers Medical. Publishers (pvt) Ltd.  American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders, Fourth Edition, Text Revision: DSM-IV-TR. Washington, DC: American Psychiatric Publishing, Inc.  Clifford Morgan, Richard King, John Weisz, John Schopler (2004) Introduction to Psychology, McGraw-Hill, New Delhi  Domjan Michael (2010). The Principles of Learning and Behavior (6th Edt) Wadsworth, Cengage Learning.  Hergenhahn B R (2008). An introduction to the history of psychology, Wadsworth, Cengage Learning.  Robert S. Feldman (2011) Understanding Psychology, McGraw-Hill, New Delhi.  Robert. A. Baron, Psychology, (2008) Prentice Hall India. Reference books  American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders, Fourth Edition, Text Revision: DSM-IV-TR. Washington, DC: American Psychiatric Publishing, Inc.  Carson, R. C., Butcher, J. N., & Mineka, S. (2002).Abnormal psychology over time. In Fundamentals of abnormal psychology and modern life. New York: Allyn & Bacon.  Emery, R.E., &Oltmans, T.F. (1998). Abnormal Psychology (2nd ed.). Upper Saddle River, NJ: Prentice-Hall, Inc.  Kay J, Tasman A. (2006) Essentials of Psychiatry, Chichester, John R. Wiley and Sons.  Orzack MH, Voluse AC, Wolf D, et al: An ongoing study of group treatment for men involved in problematic Internet-enabled sexual behavior. Cyberpsychology Behave 9(3):348–360, 2006 16780403  Sadock, Benjamin, J., & Virginia A. (2002). Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry (9th ed.). Lippincott Williams &Wilkins. 162 CU IDOL SELF LEARNING MATERIAL (SLM)

 Sarason I., G & Sarason B. R. (2005).Abnormal psychology: The problem of maladaptive behavior. (11th edn). PHI Learning Private limited.  World Health Organization (1993). The ICD-10 Classification of Mental and Behavioral Disorders Websites  www.simplypsychology.com  http://www.human-memory.net  www.simplypsychology.org  https://psychcentral.com  https://courses.lumenlearning.com  https://www.sparknotes.com 163 CU IDOL SELF LEARNING MATERIAL (SLM)

UNIT 8 – SEX ADDICTION 164 STRUCTURE 8.0 Learning Objectives 8.1 Introduction 8.2 Sex Addiction 8.3 Types of Sex Addiction 8.4 DSM Criteria for Sex Addiction 8.5 Incidence of Sex Addiction 8.6 Prevalence of Sex Addiction 8.7 Co-morbidity of Sex Addiction 8.8 Causes of Sex Addiction 8.9 Prognosis of Sex Addiction 8.10 Treatment of Sex Addiction 8.11 Summary 8.12 Key Words 8.13 Learning Activity 8.14 Unit End Questions 8.15 References 8.0 LEARNING OBJECTIVES After studying this unit, you will be able to,  Explain the nature and symptoms of Sex Addiction  Describe the incidence and prevalence of Sex Addiction  Explain the co-morbidity of Sex Addiction  State the causes of Sex Addiction  Explain the prognosis of Sex Addiction  State the treatment for Sex Addiction CU IDOL SELF LEARNING MATERIAL (SLM)

8.1 INTRODUCTION Ami, 26, enters therapy, reporting a depressed mood and suicidal thoughts. She tells the therapist that she has not been happy since her boyfriend of four years left her three months earlier. In order to combat loneliness, she has been meeting people in bars and having one- night stands nearly every night. She says she enjoys the act of sex but feels worse after her partner leaves. Ami also tells the therapist that she often becomes very intoxicated and engages in exhibitionistic acts. Though she often regrets the behavior, Ami finds it difficult to keep herself from repeating her actions, stating that she longs to feel wanted and loved. In therapy, Ami comes to realize her sexual activity is helping her to cope with the breakup, which she never fully grieved or got over. The therapist helps her to realize that while it is all right to feel sadness for the loss of the relationship, engaging in risky, promiscuous behavior will not help her to recover from the loss. Ami makes a goal of abstaining from sexual activity until she begins to date again. She also decides that she will no longer visit bars on her own to prevent herself from being triggered and repeating the pattern of one-night stands. Ami continues in therapy for depression and begins to learn healthier coping mechanisms. 8.2 SEX ADDICTION Sex addiction is defined as a lack of control over sexual thoughts, urges, and impulses. While sexual impulses are natural, sex addiction only refers to behaviors that are done in excess and significantly impact one’s life in a negative way.Although sex addiction isn’t listed as a diagnosable condition in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), research indicates that excess sexual behavior can develop, like a chemical addiction. Sexual addiction, also called hypersexuality, hypersexual disorder, and sexual compulsivity, is a behavioral addiction focused on sex and sexual fantasy. More specifically, sex addiction is a dysfunctional preoccupation with sexual urges, fantasies, and behaviors, often involving the obsessive pursuit of objectified non-intimate sexuality: pornography, casual/anonymous sex, prostitution, etc. This adult pattern of sexual urges, fantasies, and behaviors must continue for a period of at least six months, despite both related negative life consequences and (failed) attempts to either stop or curtail the pleasurable, but problem-inducing behaviors. In short, sex addiction is an ongoing, out-of-control pattern of compulsive sexual fantasies and behaviors that causes problems in the addict’s life. A person with sex addiction may have a compulsive need to be sexually stimulated. This desire often interferes with their ability to live their daily life. Sexual addictions can come in many different forms, including addiction to:  Sexual acts 165 CU IDOL SELF LEARNING MATERIAL (SLM)

 Prostitution  Watching or consuming pornography  Masturbation or sexual fantasy  Exhibition or voyeurism Like other addicts, sex addicts typically abuse both fantasy and behavior as ways to “numb out” and escape from stress and emotional (and sometimes physical) discomfort—including the pain of underlying emotional and/or psychological issues like depression, anxiety, early- life trauma abandonment fears and the like. In other words, sex addicts don’t use compulsive sexual fantasies and behaviors to feel better, they use them to distract themselves from what they are feeling in that moment. As such, sexual addiction is not about having fun, no matter how good the sex itself, it’s about controlling (by escaping) what one feels. In sum, sex addicts are hooked on the dissociative euphoria produced by intense sexual fantasies and directly related patterns of sexual behavior (including their “endless” search for sex). They typically find as much excitement and escape in fantasizing about and searching for their next sexual encounter as in the sex act itself. Thus they can spend hours, sometimes even days, in this elevated emotional state—high on the goal/idea of having sex—before actually engaging in any concrete sexual act. Because of this, sex addicts spend much more time engaged in the fantasy and ritualized pursuit of sex than in the sex act itself. Sex addicts may alter their activities to perform sexual acts persistently, unable to control their behavior despite any consequences. This compulsive sexual behavior can have serious personal consequences. Like drug or alcohol addiction, sex addiction can impact physical health, mental health, personal relationships, and quality of life.Sex addiction is any compulsive, sexually motivated behavior that is acted out despite the negative consequences. It is also known as sexual compulsion or sexual dependency. Estimates suggest between 12 to 30 million Americans experience some kind of sexual compulsion.Sex addiction can interfere with one’s social life, physical health, and emotional well-being. It generally does not improve until the person receives treatment. A compassionate therapist can help individuals develop a healthier relationship with sex and intimacy. Patterns of problematic fantasy-driven behavior typically exhibited by sex addicts often include:  Compulsive use of pornography, with or without masturbation  Compulsive use of one or more digital “sexnologies,” i.e., webcams, sexting, dating/hookup websites and hook-up apps, virtual reality sex games, sexual devices, etc.  Consistently being “on the hunt” for sexual activity 166 CU IDOL SELF LEARNING MATERIAL (SLM)

 Multiple affairs or brief “serial” relationships  Consistent involvement with strip clubs, adult bookstores, adult movie theaters, sex clubs, and other sex-focused environments  Ongoing involvement with prostitution and/or sensual massage (hiring or providing)  A pattern of anonymous and/or casual sexual hookups with people met online via apps, websites or in person  Repeatedly engaging in unprotected sex  Repeatedly engaging in sex with potentially dangerous people or in potentially dangerous places  Seeking sexual experiences without regard to immediate or long-term potential consequences  In some, repeated patterns of minor sexual offenses such as voyeurism, exhibitionism, frotteurism, etc. Symptoms of Sex Addiction Most people enjoy sex and seek it out from time to time. In sex addiction, however, this enjoyment becomes an obsession. An individual’s thoughts can be consumed by intense sexual fantasies. They may consistently prioritize sex over family, friends, and work. Over time, an individual may need to engage in increasing amounts of sex (or more unusual forms of sexual gratification) in order to get the same “high” as before. Common signs of sex addiction include  Prolonged periods of promiscuity with multiple partners or one-night stands.  Compulsive pornography.  Excessive masturbation (sometimes to the point of physical injury).  Excessive cybersex or sexting.  Prostitution or use of prostitutes.  Multiple acts of marital infidelity.  Frequent unsafe sex.  Exhibitionism.  Voyeurism. Sexual addiction can manifest itself in many different ways, both physical and emotional. It takes a healthcare professional to make a clear diagnosis, but here are some signs that can point to a potential sex addiction: 167 CU IDOL SELF LEARNING MATERIAL (SLM)

Obsessive Sexual Thoughts Someone dealing with sex addiction may find themselves thinking persistently about sex. These chronic thoughts of sex or sexual fantasies may become obsessive or interfere with other responsibilities. Spending Excessive Time on Sex While seeking out sexual partners isn’t necessarily a sign of sexual addiction, if someone is spending excessive amounts of time and energy on sex, it might be a red flag. This can include spending time attempting to acquire sex, having sex, being sexual, or recovering from sexual experiences. Feeling Shame or Depression If a need for sex crosses over into an addiction, someone’s sexual feelings might also be interspersed with feelings of anxiety, shame, depression, or regret. The individual may feel shame about their sexual urges and their difficulty controlling those urges. They may even show signs of clinical depression or suicide ideation. Research shows that it isn't uncommon for people who are sexually compulsive to also show signs of depression, anxiety, and social anxiety. One study found that, among sexually compulsive men, 28% showed signs of depression, compared to 12% of the general population. Excluding Other Activities A sex addict may fixate on sex to the point where they have difficulty engaging in their other activities. They may fall behind on responsibilities in school, work, or their personal lives or become socially withdrawn. They may also prioritize sexual behavior over other forms of relaxation or hobbies. Relationships with friends, families, and partners may suffer because of this. Masturbating Excessively While masturbation can be a healthy way to explore sexuality and express sexual drive, excessive masturbation can be a sign of sexual addiction. This might look like compulsive masturbation, masturbation during inappropriate times, or even masturbation to the point of causing physical discomfort or pain. Engaging in Risky or Inappropriate Behaviors In some cases, sexual addiction can lead to inappropriate and/or risky sexual behaviors. This can include exhibitionism, public sex, sex without protection, and sex with prostitutes. In some cases, this can lead someone to develop sexually transmitted diseases. Studies have shown that those who identify as sexually compulsive are more likely to develop sexually transmitted diseases like HIV. 168 CU IDOL SELF LEARNING MATERIAL (SLM)

Cheating on Partners Someone with a sexual addiction may feel compelled to seek out sex with new partners, even if this means cheating on a partner or having an extramarital affair. They may seek out one- night stands on a regular basis or even cheat multiple times with different partners. Committing Criminal Sex Offenses In some extreme cases, people may engage in criminal activities like stalking, rape, or child molestation. While some sexual offenders may also be sex addicts, there is no evidence that sexual addiction can lead someone to commit sexual offenses. For the most part, the core signs and symptoms of sexual addiction are the same regardless of age, race, gender, social history, and psychological underpinnings. In fact, nearly all sex addicts report, in some form, the following:  Obsessive Sexual Fantasy and Preoccupation: Sex addicts obsess about romance and sex. They spend hours, sometimes even days, fantasizing about it, planning for it, pursuing it, and engaging in it. The majority of their decisions revolve around sex, including what they wear, which gym they go to, the car they drive, their relationships, and perhaps even the career path they choose.  Loss of Control: Sex addicts lose control over their ability to choose to not engage in sexual fantasies and behaviors. They try to quit or cut back, making promises to themselves and/or others, but they repeatedly fail in these efforts.  Related Adverse Consequences: Sex addicts eventually experience the same basic negative life consequences that alcoholics, drug addicts, compulsive gamblers, compulsive spenders, and all other addicts deal with, such as job loss, trouble in school, financial woes, ruined relationships, declining physical and/or emotional health, loss of interest in previously enjoyable activities, loss of time, isolation, arrest, etc.  Tolerance and Escalation: With substance addiction, tolerance and escalation manifest when the addict must take more of a substance or a stronger substance to achieve and maintain the same high that he or she seeks. With sexual addiction, tolerance and escalation occur when the addict spends increasing amounts of time engaging in the addiction, or when the intensity level of his/her sexual fantasies and activities increases. Over time, thanks to tolerance and escalation, many sex addicts find themselves engaging in sexual behaviors that hadn’t even occurred to them early in the addictive process. Some act out in ways that violate their personal moral code, their spiritual beliefs, and perhaps even the law. Some escalate to viewing illicit or bizarre images, and others simply lose increasing amounts of valuable time and energy to sex. 169 CU IDOL SELF LEARNING MATERIAL (SLM)

 Withdrawal: With sexual addiction, withdrawal tends to manifest not so much physically, as often occurs with substance abuse (i.e., delirium tremens when detoxing from alcohol), but emotionally and psychologically. Sex addicts in withdrawal tend to become either depressive or restless, lonely, irritable, and discontented. As with tolerance, withdrawal is not a necessary element of the sex addiction diagnosis, but most sex addicts do experience the feeling of it.  Denial: Denial keeps sex addicts out of touch with the process, costs, and reality of their addiction. They routinely ignore the kinds of warning signs that would be obvious to a healthier person. Often, they externalize blame onto people or situations for the consequences of their sexual acting out. In short, they are often unable or unwilling to see the destructive effects wrought by their sexual behavior until a related crisis shows up at the door. The Cycle of Sexual Addiction All addictions are cyclical in nature, with no clear beginning or end andone stage leading to the next (and then the next, and the next, and thenext), leaving the addict stuck in an endless, downwardly spiraling loop.With sexual addiction, various models of the addictive cycle have beenproposed, modified, and expanded upon, and there are now manyversions, each with merit.9 I generally prefer and utilize a six-stage modelthat follows. 170 CU IDOL SELF LEARNING MATERIAL (SLM)

Fig 8.1 Stage One–Triggers (Shame/Blame/Guilt/Other StrongEmotions): Triggers are catalysts that create a need/desire to act outsexually. Most often triggers are some sort of “pain agent.” Pain agentsinclude both emotional/psychological and physical discomfort, eithershort-term or long-term. Depression, anxiety, loneliness, boredom,stress, shame, anger, and any other uncomfortable feeling can easilytrigger a sex addict’s desire to escape, avoid, and dissociate. Positiveagents can also serve as triggers like the icing on a cake. So if a sexaddict gets fired from his or her job, he or she will want to act outsexually; and if that same addict gets a great new job, he or she willwant act out sexually. Triggers can also be visual (seeing a sexy imageon a billboard), auditory (hearing a noise that reminds the addict ofsexual activity), olfactory (smelling the perfume of a past sexualpartner), or even touch or taste related. If such triggers are notrecognized early and dealt with in a healthy way (dissipated via ahealthy, nonaddictive coping mechanism like talking to supportivefriends, family members, or a therapist), then the cycle inevitablyslides forward into stage two. Stage Two–Fantasy: After being triggered and therefore needing toemotionally escape and dissociate, sex addicts often unconsciouslyturn to their primary coping mechanism: sexual fantasy. They startthinking about how much they enjoyed past sexual encounters andhow much they would enjoy a sexual encounter either right now or inthe near future. At this point, the addict is preoccupied to the point ofobsession with his or her sexual fantasies. On this day they might flirtwith the grocery clerk that they barely noticed just a day or two prior. Every person encountered by the addict (both in person and online) isviewed as a sexual object or simply “in the way.” The addict’s fantasiesdo not involve memories of prior bad experiences or related negativeconsequences. Once the addict’s mind is mired in fantasy, it is verydifficult to stop the addictive cycle without some sort of outsideintervention. Stage Three–Ritualization: Ritualization is where fantasy movestoward reality. This stage adds excitement, intensity, and arousal. Forexample, the addict logs on to the computer and goes to his or herfavorite porn site, or hops in the car and drives to a place where sexworkers congregate, or begins the process of booking an out-of-townbusiness trip on which he or she can act out sexually without restraint,or simply opens up their favorite “adult friend finder” app. This stageof the cycle is also known as the bubble or the trance because theaddict is psychologically and emotionally lost to it. Real-worldconcerns disappear as the addict focuses more and more intently onhis or her sexual fantasies. This stage of the addiction (rather than thesex act itself) evokes the escapist neurochemical high that (sex) addictsseek. As such, sex addicts typically try to stretch this stage out for aslong as possible—looking at porn, cruising for casual sex, chatting viawebcams, losing hours on a sex app, and the like for many hours (oreven days) before moving to the next stage. 171 CU IDOL SELF LEARNING MATERIAL (SLM)

Stage Four–Sexual Acting Out: Most non-sex addicts think thatthis stage, is the ultimate goal of sexual addiction, because this iswhere actual sex and orgasm takes place (either solo or with others).However, as stated above, the fantasy-fueled escape and dissociationof this stage is the real objective. In fact, many will try to put off actualsex and orgasm for as long as possible because orgasm ends thefantasy driven escapist high and tosses the addict back into the realworld with all of its issues and problems. In other words, sex addictsare seeking more to escape emotional discomfort, than to experiencethe pleasure of orgasm. Orgasm brings their high to an abrupt,screeching halt. Stage Five–Numbing: After acting out, sex addicts attempt toemotionally distance themselves emotionally from what they’ve justdone. They justify their behaviors, telling themselves, if my spousewas nicer to me, I wouldn’t need to do this. They minimize theirbehaviors, telling themselves, nobody knows that I just spent sixhours looking at and masturbating to pornography, and nobody gothurt by what I did, so it’s no big deal. They rationalize their behaviors,telling themselves, Hooking up with people online for mutualmasturbation isn’t really cheating because I don’t actually touch theother person and I don’t even give that person my real name, etc. Inother words, in this stage of the cycle the addict’s denial kicks in fullforce as a way to temporarily protect him or her from the next stage. Stage Six–Despair (Shame/Anxiety/Depression): Eventually,numbing will dissipate for most sex addicts. And when it does, manywill start to feel ashamed and remorseful. Exacerbating theseunwanted emotions is the fact that they also feel powerless to stop thecycle of their addiction. Plus, whatever reality it was that they weretrying to escape in the first place returns, bringing with it whateverself-loathing, anxiety, and depression they were already experiencing. And, as you may recall, this is exactly the sort of emotional discomfortthat triggers sexual addiction in the first place. As such, over time,stage six spins the self-perpetuating cycle right back to stage one.Where it starts all over again.Repeating the Cycle Builds Tolerance AND Trains the Brain. The sexual addiction cycle typically intensifies with each repetition,requiring more of the same behavior or more intense behavior to reach ormaintain the same neurochemical high over time. This transforms from arepetitive loop into a downward spiral—one characteristic of all forms ofaddiction—leading to relationship, work, health, financial, legal, andother crises. And all of these crises also qualify as emotional triggers,which can set the same process in motion yet again. How Can the Cycle Be Stopped? 172 CU IDOL SELF LEARNING MATERIAL (SLM)

The cycle of sexual addiction is best interrupted in the early portion ofstage one, when the addict’s emotional triggers (the experiences andemotions that activate a desire to sexually act out) first arise. If and whenthe addict learns to recognize the early signs of emotional discomfort likestress, certain types of imagery, people, situations, places, then he or shecan engage in contrary actions designed to: A: Stop the escalating fantasies before they lead into ritualization andacting out B: Deal with the unwanted uncomfortable feelings or triggers in anemotionally healthy way and not act them out 8.3 TYPES OF SEX ADDICTION 8.3.1 Biological sex addicts A biological sex addict is someone whose excessive masturbation and pornography viewing has hijacked the sexual response to attaching to images and fantasy. This person may have challenges with relational sex. Although most people have the biological type as one component of their addiction, only about 15 percent (in Dr. Weiss’s experience) are solely biologically based. Warning signs  This addiction is a masturbation and pornography based sexual addiction.  Your brain is condition to seek neurological highs from the addictive behavior.  Increased endorphin releases lead to repeat patterns of behavior. Treatment Biological sex addiction is treatable through changing your behavior and by retraining your brain to accept a new “normal” by remapping your brain’s neural networks. They are self- treatable if you understand your biological triggers and how to manage and control them. However, professional help is needed in severe cases or if addicts continually relapse into their old behavior patterns. 8.3.2 Psychological sex addicts Research shows that most sexual addicts have suffered some form of past abuse or neglect. This person finds the combination of the messages in the fantasy world and the sexual chemical cocktail to the brain to be a salve for their hurting soul. Simply put, they medicate the past pain in their souls with sexual acting out, which is their form of medicine. In our clinical experience, 80 percent or more of those who struggle with sex addiction have abandonment, abuse or neglect issues of some type in their past. These painful events will ultimately need to be addressed for them to fully heal. 173 CU IDOL SELF LEARNING MATERIAL (SLM)

Warning signs  This addiction is associated with fantasy and relies on building your self-image and value through the sexual behavior.  You use it to self-medicate past issues of abandonment, abuse or neglect.  Your brain elevates your self-image, personal value and perceived worth because of the endorphin highs. Treatment Psychological sex addiction is treated through first realizing that you are dependent on the sexual behavior to treat your past issues. Once you are aware of this, you must address the abandonment, abuse or neglect at the source and not continue to self-medicate your emotional pain. You can then rebuild your self-image and value through other healthy ways. This treatment is best accomplished with the help of a professional such as a licensed counselor or psychologist. 8.3.3 Spiritual sex addicts The person with this type is looking for a spiritual connection in all the wrong places. In recovery, we talk about our spiritual hole. This person tries sex for this spiritual void and finds it doesn’t scratch the itch over time. Warning signs  This addiction is associated with fantasy and relies on building your self-image and value through the sexual behavior.  You use it to self-medicate past issues of abandonment, abuse or neglect.  Your brain elevates your self-image, personal value and perceived worth because of the endorphin highs. Treatment Spiritual sex addiction is treated through understanding that you are a spiritual being and that your spirituality must be nurtured in the right way. You must understand that the love, acceptance and enlightening experience is not found in the sexual behavior, but in accepting that you are a human being with an inner spirit that is tied to the spiritual world with a power greater than yourself. You will have the best chance of recovery by working with professionals like spiritual leaders who understand this sex addiction and licensed counselors. 8.3.4 Trauma based sex addicts The person with the trauma-based type has experienced sexual trauma(s) as a child or adolescent. This trauma becomes the major repetitive behavior in their addiction. 174 CU IDOL SELF LEARNING MATERIAL (SLM)

For the trauma-based, the trauma determines the flavor of the sexual addiction. Here trauma work will need to be addressed for the addict to heal. Warning signs  This addiction comes from past sexual trauma that you experienced as a child or adolescent.  Your predominant fantasy comes from and is very similar to the trauma.  This trauma becomes the major repetitive behavior in the addiction. Treatment Trauma-based sex addiction is treated through a several step plan. First, you need to realize your addiction is coming from trauma and stop acting out. Second, you need to identify what the trauma was and how it affected you. There is a good chance your feelings and emotions surrounding the trauma are “frozen” or suppressed, so you may need to work with licensed counselors for the best chance of recovery. Finally, you can start the recovery and healing process. 8.3.5 Intimacy anorexia sex addicts In earlier research we determined 29% of addicts fit into the category of intimacy anorexia in addition to other areas. This subject is covered in great detail in the Intimacy Anorexia DVD and book. There is a list of the characteristics of intimacy anorexia below. Answer these the way your spouse or partner would answer them about you. Many addicts who have been trying to get sober but keep having what I call “flat tire” recovery (relapsing regularly) often are identified as intimacy anorexics. If you have been sober from acting out behaviors for a year but your wife wants to leave you now because “nothing’s changed” you might also be a sexual/emotional anorexic. Warning signs This addiction is related to withholding intimacy causing the spouse or partner to often feel like a roommate. If five or more of the below criteria apply to you, then you are probably dealing with intimacy anorexia.  Withhold love  Withhold praise or appreciation  Control by silence/anger  Criticism causing isolation  Withholding sex 175 CU IDOL SELF LEARNING MATERIAL (SLM)

 Blaming partner for everything  Staying very busy to avoid partner time  Control/Shame with money issues  Unable to share feelings  Withholding spiritual connection  Feel more like a roommate Treatment Intimacy anorexia is treated by developing your emotional capacity which allows you to open up to deeper emotions and be able to share your heart. Your partner or spouse most likely wants intimacy, but you have to be able to realize that and share the deepest parts of yourself with them. Lies you tell yourself also tend to be part this addiction when you tell yourself that, “if you knew me, you wouldn’t love me.” Once you overcome these false truths, you can practice intimacy and get better at it over time. It is best to get professional help from licensed counselors when dealing with intimacy anorexia because it is very hard to successfully breakout of the realization and relapse cycle by yourself. 8.3.6 Mood disorder sex addicts In a journal article Dr. Weiss wrote called The Prevalence of Depression in Male Sex Addicts Residing in the United States, Weiss discovered that 28% of male sex addicts suffered from depression. People with depression have chemical imbalances in adolescence or young adulthood. This young person finds the sexual release as a way to medicate or alter their present chemical imbalance. They then use this sexual response regularly and over time unexpectedly create an addiction. Warning signs  This addiction deals with chemical imbalances and using the sexual addiction to medicate that imbalance.  You experience mood shifts and changes daily or weekly.  You use the sexual addiction as a “release” to balance the mood disorder. Treatment Mood disorder sex addiction is treated through professional help with licensed counselors and psychologists and possibly prescribed medications. The chances of successful recovery are low if you try fighting through your depression and addiction on your own. This is because your rapidly changing mood swings and depression create a potent mix when combined with the sexual addiction. 176 CU IDOL SELF LEARNING MATERIAL (SLM)

8.4 DSM CRITERIA FOR SEX ADDICTION The scientific community has long debated whether sex addiction is a “real” diagnosis. The World Health Organization recognizes sex addiction as its own mental health condition, while the American Psychological Association does not. Some individuals claim that behaviors we classify as sex addiction are likely symptoms of other conditions. For example, people with bipolar can develop hypersexuality during a manic episode. They may have trouble controlling their sexual behaviors during this period. Others argue that sexual compulsions can and do occur independently of other diagnoses. Stigma is also large concern in the debate. In the past, women, people in the LGBTQ+ community, and other marginalized identities have been censured for displaying “too much” sexuality. Clinicians diagnosed overtly sexual women with nymphomania and “cured” the condition by removing the labia or cutting the clitoris. Some gay men, including the famous codebreaker Alan Turing, were chemically castrated to reduce their libidos. As such, many people are wary that a diagnosis of “sex addiction” will be used to pathologize marginalized communities or people with naturally high sex drives. Proponents of the diagnosis believe sex addiction can be distinguished from cultural expectations. According to the current framework, sex addiction is characterized not by the amount or type of sex a person has, but by how these sexual activities affect a person’s well- being. Casual sexual encounters, consensual BDSM, or responsible pornography use do not indicate sexual addiction. It’s only when these behaviors grow out of the person’s control and sabotage their emotional health that they can be called sexual compulsions. Within the DSM, distress as a result of sexual behavior was first proposed in the DSM-III, under the diagnostic category “Psychosexual Disorder Not Otherwise Specified”. This referred to “distress about a pattern of repeated sexual conquests with a succession of individuals who exist only as things to be used”. This category was revised in the DSM-III-R to include the concept of non-paraphilic sexual addiction and renamed “Sexual Disorders Not Otherwise Specified”. However, due to a lack of empirical evidence, sexual addiction was removed from the DSM-IV and DSM-IV-TR, and the DSM-III diagnostic criteria for “Psychosexual Disorder Not Otherwise Specified” were re-established. During the DSM-5 revision process, hypersexual disorder was proposed as a new diagnostic category (Kafka, 2010). The DSM-5 Sexual Disorders Workgroup defined hypersexual disorder as a “sexual desire disorder characterized by an increased frequency and intensity of sexually motivated fantasies, arousal, urges, and enacted behavior in association with an impulsivity component—a maladaptive behavioral response with adverse consequences” resulting in clinically significant personal distress or social, occupational, or other impairment and not due to the physiological effect of an exogenous substance (e.g., drug of abuse or medication). 177 CU IDOL SELF LEARNING MATERIAL (SLM)

Initially proposed diagnostic criteria included at least three of the following experienced over a 6-month period (Kafka, 2010): 1. Time consumed by sexual fantasies, urges, or behaviors that repetitively interfere with other important (nonsexual) goals, activities, and obligations 2. Repetitive engaging in sexual fantasies, urges, or behaviors in response to dysphoric mood states (e.g., anxiety, depression, boredom, and irritability) 3. Repetitive engaging in sexual fantasies, urges, or behaviors in response to stressful life events 4. Repetitive but unsuccessful efforts to control or significantly reduce these sexual fantasies, urges, or behaviors 5. Repetitive engaging in these sexual behaviors while disregarding the risk for physical or emotional harm to self or others Proposed specifiers included excessive masturbation, pornography use, sexual behavior with consenting adults, cybersex, telephone sex, strip clubs, and other. A DSM-5 field trial evaluated the reliability, validity, and clinical utility of the proposed hypersexual disorder diagnostic criteria in a sample of 207 outpatients seeking treatment for hypersexual disorder, substance use disorders, or general psychiatric conditions. The study used structured diagnostic interviews and self-report inventories. Findings demonstrated good internal consistency and good stability over time for these proposed criteria. The criteria demonstrated validity in comparison with theoretically related measures of stress, impulsivity, and emotional dysregulation, and sensitivity and specificity indicators suggested that the criteria accurately reflected the disorder among the patients sampled. Masturbation, pornography use, and sexual behavior with consenting adults were the most commonly endorsed specifiers. In summary, the diagnosis of hypersexual disorder is not currently included in the DSM or the ICD, but compulsive sexuality is currently being considered for inclusion in the ICD-11. If agreement is achieved regarding the inclusion of this diagnosis in a major diagnostic manual, it will pave the way for additional research on the etiology and treatment of the condition. The DSM-5 did not include the disorder in part due to a lack of expert consensus on models for conceptualizing the disorder. In the following section, dominant models of conceptualizing hypersexual disorder are discussed. 8.5INCIDENCE OF SEX ADDICTION Currently, researchers are only able to roughly estimate how common sex addiction is. First, sex addiction is not currently recognized as a true psychological disorder. Part of this is because sex itself is a normal, healthy human behavior like eating and sleeping. It becomes a problem, however, when the need for sex interferes with one’s daily life, creates relationship 178 CU IDOL SELF LEARNING MATERIAL (SLM)

issues or causes harm to others. People with a sex addiction frequently try, unsuccessfully, to curb their sexual behaviors on their own. Second, the stigma against people with sex addictions makes such individuals reluctant to speak about it or seek help. Dispelling myths about the disorder and making the benefits of treatment more well-known are essential for reducing its prevalence. 8.6 PREVALENCE OF SEX ADDICTION When the disorder was first discussed, researchers estimated that between 3–5% of the adult population had some form of addictive sexual behavior. While it can be challenging to assess current rates of sex addiction, many believe that the prevalence of the condition has increased in recent years. Though it can impact anybody, sex addiction tends to affect certain populations more often than others. The number of people in the United States living with sex addiction is currently estimated at 12–30 million. Both men and women can be affected, though little research exists on female sex addiction. Men with sex addiction have an average of 32 sexual partners, while females have an average of 22 sexual partners. A strong correlation exists between sex addiction and childhood trauma. Surveys of people with sex addictions show that during childhood:  72% were physically abused  81% were sexually abused  97% were emotionally abused 8.7 CO-MORBIDITY OF SEX ADDICTION People with sex addictions are likely to struggle with other mental disorders and illnesses. Some of these may be related to past abuse that many people with sex addiction have experienced. Although the prevalence rate of hypersexual disorder is not well understood, data from treatment-seeking samples suggest that it is highly associated with other psychiatric conditions. Common co-occurring disorders include:  Asperger’s or autism spectrum disorder  Depression  Anxiety  Substance abuse  Other forms of addiction 179 CU IDOL SELF LEARNING MATERIAL (SLM)

 Obsessive-compulsive disorder  Bipolar disorder  Borderline personality disorder  Eating disorders  Sexually-transmitted infections  Erectile dysfunction 8.8 CAUSES OF SEX ADDICTION Although the causes of compulsive sexual behavior are unclear, they may include: 8.8.1 Biological Causes An imbalance of natural brain chemicals. Certain chemicals in your brain (neurotransmitters) such as serotonin, dopamine and norepinephrine help regulate your mood. High levels may be related to compulsive sexual behavior. Changes in brain pathways. Compulsive sexual behavior may be an addiction that, over time, might cause changes in the brain's neural circuits, especially in the reinforcement centers of the brain. Like other addictions, more-intensive sexual content and stimulation are typically required over time in order to gain satisfaction or relief. Conditions that affect the brain. Certain diseases or health problems, such as epilepsy and dementia, may cause damage to parts of the brain that affect sexual behavior. In addition, treatment of Parkinson's disease with some dopamine agonist medications may cause compulsive sexual behavior. 8.8.2 Psychological Causes Environmental influences: Early-life environmental factors, including adverse events like abuse or exposure to sexual content, can contribute to some of the underlying characteristics that drive hypersexual behavior. Mental health: Anxiety, depression, personality disorders, poor impulse control, and performance anxiety might be simultaneous issues that one struggles with alongside sex addiction. Those that have been diagnosed with Bipolar Disorder, or have a tendency toward “manic” states, are much more likely to engage in excessive or risky sexual behavior. 8.8.3 Social Causes Rejection: Rejection in relationships and social circles can lead to other, less healthy ways to find sexual gratification. 180 CU IDOL SELF LEARNING MATERIAL (SLM)

Social isolation: Not only does social isolation increase one’s likelihood of seeking inappropriate ways of being sexually gratified, it also leads to a host of other problems–like depression and physical maladies–that can contribute to sex addictions or unhealthy sex behaviors. Social learning: Watching others perform a behavior, or “modeling,” is one way to learn something new–especially when you “like” or “identify” with that person. So having a friend, or a group of friends, who engage in excessive sexual activities or porn viewing can influence you in a very subtle, yet powerful, way. 8.8.4 Risk factors Compulsive sexual behavior can occur in both men and women, though it may be more common in men. It can also affect anyone, regardless of sexual orientation. Factors that may increase risk of compulsive sexual behavior include: Ease of access to sexual content. Advances in technology and social media allow access to increasingly intensive sexual imagery and information. Privacy. Secrecy and privacy of compulsive sexual activities tend to allow these problems to worsen over time. Also, an increased risk of compulsive sexual behavior may occur in people who have:  Alcohol or drug abuse problems  Another mental health condition, such as a mood disorder (such as depression or anxiety), or a gambling addiction  Family conflicts or family members with problems such as addiction  A history of physical or sexual abuse 8.9 PROGNOSIS OF SEX ADDICTION Therapy for sex addiction differs from the treatment of other addictions in that complete abstinence is not the goal, as it often is with, for example, drug and alcohol addictions. Instead, the person in therapy will generally work with the therapist to identify specific behaviors they want to quit. For example, a person may set a goal to stop soliciting sex from strangers and to only be intimate with people they know personally. A therapist can help the person identify potential triggers that may facilitate addictive behavior and develop a plan to avoid these “danger zones.” The success of sexual addiction treatment can depend on several factors, including:  Which behaviors the person is trying to quit.  Whether the person has a history of sex offenses. 181 CU IDOL SELF LEARNING MATERIAL (SLM)

 Whether the person has an additional mental health diagnosis. In general, treatment works best when the individual wants improvement for themselves, as opposed to receiving outside pressure to get help. 8.10 TREATMENT OF SEX ADDICTION Sex addiction occurs when an individual’s preoccupation with sex negatively impacts their daily life. Sex addiction can have many social consequences, sabotaging one’s intimate relationships, friendships, and career. It can also increase one’s risk of unplanned pregnancies and sexually transmitted infections. Sex addiction is a treatable condition. A compassionate therapist can help individuals understand and manage their sexual compulsions. Some individuals also benefit from medication and support groups. In severe cases, rehab for sex addiction may be necessary. 8.10.1 Therapy for sex addiction Perhaps one of the first things a mental health professional will do is make sure a person’s sexual disinhibition truly stems from an addiction. Someone whose hypersexuality is a result of mania or Alzheimer’s will require different treatment than someone with a sex addiction. It is important to understand the cause of the behavior to determine the best treatment strategies. Different psychotherapy approaches have been suggested for the support and treatment of hypersexual disorder, placing emphasis on different aspects of the patient’s presenting problem. A mental health professional might then assist with the exploration of a person’s sexual history. Together, they may examine any patterns and rituals in the person's life that may contribute to the addiction. If neglect or sexual abuse was experienced in childhood, the person can also discuss these in therapy, as past abuse may have an influence on current behavior. Research has identified several effective therapies for sex addiction.  Cognitive behavioral therapy (CBT) can help a person identify automatic negative thoughts that may lead to undesired sexual behaviors. A person can then learn to counter these thoughts and stop the behavior. More specifically, CBT can help the individual identify and better attend to the triggers of the sexually addictive behavior, the permission-giving thoughts that weaken inhibition of the behavior, and the negative consequences of the behavior. Specific modes of CBT that have been developed to treat chemical addictions have been modified to treat sexually addictive behavior.  Psychodynamic therapy would address how a person’s childhood experiences influenced their emotional development and attachment styles, especially in regards to intimate relationships.It can clarify the specific meaning the addictive behavior holds 182 CU IDOL SELF LEARNING MATERIAL (SLM)

for the patient. Does sexual addiction reflect a rebellion against a puritanical and authoritarian parent? Is it a form of self-soothing in the context of parental abandonment, as with Sam? Does it assuage a narcissistic need for constant affirmation of one’s attractiveness? Or is it used in a desperate attempt to stave off feelings of emptiness? In almost all cases, however, sexually addictive behavior reflects a disturbance in the core self-concept and/or the capacity for intimate relationships. As deeply social animals with lifelong attachment needs, it is inherent in the human condition to need close intimate relationships, which serve to regulate both negative and positive emotions.  Motivational enhancement therapy (MET) can help individuals increase and maintain their motivation to change their sexual behaviors, even when cravings are strong. Motivational interviewing is often used with chemical addictions and serves to help the patient consider the pros and cons of maintaining the addiction in the context of their overall goals and priorities. Motivational interviewing is aimed less at actually changing the behavior than in shoring up motivation to enter the change process. The advantage of this approach is its nonconfrontational and nondirective nature, which is seen to be more effective with those patients with low motivation to change.  Couples therapy can be especially helpful when sexual addiction has sabotaged a romantic relationship.  Relapse prevention techniques have been suggested to treat paraphilic disorders and sexual addictions; psychodynamic psychotherapy has been suggested to assist patients in exploring family-of-origin, trauma, self-esteem, and identity issues; and couples therapy has been recommended to manage the interpersonal conflicts and effects of hypersexual disorder on the patient’s partner and their relationship. In many cases, sex addiction co-occurs with another mental health issues such as depression. These additional issues can make sex addiction symptoms worse. As such, a therapist will likely work on treating the diagnoses in tandem. 8.10.2 Group Psychotherapy Group treatment has been highly effective in the treatment of chemical andother behavioral addictions, and in some cases, it is more effective than individual therapy alone. Group therapy serves multiple purposesand probably works through a combination of mechanisms. More specifically,group therapy provides social support for the difficult change process, information about other group members’ experiences and coping strategies, support fora positive new group identity, and confrontation of the all-too-common denialand rationalizations associated with addictive behavior. 183 CU IDOL SELF LEARNING MATERIAL (SLM)

8.10.3 Twelve-step programs Twelve-step programs constitute a specific form of group therapy, the firstand best known being AA. These are member-led groups composed of peoplewith similar addictions who are committed to helping each other achieve andmaintain sobriety. The 12 steps refer to a specific therapeutic plan to acknowledge the extent of the addiction and powerlessness over the addiction, to makeamends for past behavior, and to commit to a lifetime of usefulness to other people. Since the first incarnation of AA in the early 20th century, a plethora of new12- step programs have arisen, adapted for such problems as pathological gambling (Gamblers Anonymous) and overeating (Overeaters Anonymous). The Twelve Steps of Alcoholics Anonymous Adapted for Sexual Addicts Twelve-step programs have been suggested as supplements to psychotherapy interventions in supporting patients through the recovery process and keeping them accountable for their behaviors. 1. We admitted we were powerless over our sexual addiction that our lives had become unmanageable. 2. Came to believe that a Power greater than ourselves could restore us to sanity. 3. Made a decision to turn our will and our lives over to the care of God as we understood Him. 4. Made a searching and fearless moral inventory of ourselves. 5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs. 6. Were entirely ready to have God remove all these defects of character. 7. Humbly asked Him to remove our shortcomings. 8. Made a list of all persons we had harmed, and became willing to make amends to them all. 9. Made direct amends to such people wherever possible, except when to do so would injure them or others. 10. Continued to take personal inventory and when we were wrong promptly admitted it. 11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out. 12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to others and to practice these principles in all our affairs. Anumber of 12-step programs for people with sexually addictive behavior arealso available, including Sex Addicts Anonymous, Sexual Recovery Anonymous, and Sex and Love Addicts Anonymous. 184 CU IDOL SELF LEARNING MATERIAL (SLM)

The Twelve Steps can fundamentally interrupt and alter the addictive system. The Steps can restore the capacity for meaningful relationships by developing in addicts and co-addicts new beliefs to replace dysfunctional or faulty beliefs. Recovering persons who use the Twelve Steps can say to themselves: 1. I am a worthwhile person deserving of pride. 2. I am loved and accepted by people who know me as I am. 3. My needs can be met by others if I let them know what I need. 4. Sex is but one expression of my need and care for others. Each of the Twelve Steps contributes to the new beliefs. Some Steps, however, are more key to some core beliefs than others. Without losing sight of the interdependency of each Step in the Twelve Step Program, the role of key Steps in the change of each core belief can be shown. By examining each core belief separately, the Twelve Step process emerges as a clear path for addicts and co-addicts to have healthy relationships. When they admit their need by joining a Twelve Step Program, addicts and their family members have their first experience in the care of the fellowship. The Program has no conditions or restrictions. Addicts and their families receive affirmation simply through admitting their needs. The care they experience provides a basic experience which allows addicts and co-addicts to trust a Higher Power and the human community to supply the care they need and to discard the old self-destructive behaviors they had used to feel better. When addicts and co-addicts depended on their sexual \"connections,\" they found their lives empty and still unsatisfied. Depending on others does bring the fundamental affirmation of themselves as persons. Almost like children, both the addicts and co-addicts have to be taught (or to relearn) how to let others know about their needs. As they learn to ask, they discover a new belief: My needs can be met by others if I let them know what I need. A man opens up during a support group for sex addiction. In addition to therapy, support groups can also be helpful during the process of sex addiction recovery. A support group is a small collection of people who help each other stick to recovery goals. Some support groups use a 12-step program similar to that of Alcoholics Anonymous. If an addiction has a severe negative effect on a person’s life and outpatient treatment is not effective, then they may need to get inpatient treatment. A person doing inpatient therapy will likely take up temporary residence at a rehab center. Trained staff will monitor the person and provide them with intensive therapy. The length and cost of sex addiction rehab varies widely between individual cases. A mental health professional can help individuals pick the most appropriate program. 185 CU IDOL SELF LEARNING MATERIAL (SLM)

8.10.4 Medications for sex addiction The Food and Drug Administration has not approved any specific drug therapy for sex addiction. However, there are some medicines which can help with symptoms.Studies suggest SSRIs (selective serotonin reuptake inhibitors) and mood stabilizers can help reduce some of the urges to engage in sexual behaviors. They can reduce both impulsive and compulsive urges. SSRIs can also treat depressive symptoms, which commonly coexist with sex addiction.Naltrexone is often used to treat impulse control issues such as pathological gambling or kleptomania. Research shows it can also treat sexual addiction, especially when paired with an SSRI. Although medication is not the first-line treatment for sexually addictive behavior, psychotropic medications are available for the treatment of such problems. To the extent that the problematic behavior is an outgrowth of or exacerbated by other psychiatric problems, such as mania, depression, anxiety, affective lability, and general impulsivity, medications shown to be efficacious with these conditions, such as mood stabilizers, antidepressants, antianxiety medications, and second-generation antipsychotics, may be indicated. Selective serotonin reuptake inhibitors (SSRIs) have also been investigated for their specific efficacy with sexually disordered behavior, but data from controlled trials are lacking. SSRIs may work to reduce compulsive thoughts because of their anti-obsessional effects. Selective serotonin reuptake inhibitors (SSRIs) and serotonin/norepinephrine reuptake inhibitors, which are typically used as antidepressants, appear to reduce desire, arousal, and orgasm. Additionally, the otherwise undesirable side effect of reduced sexual drive and function might be considered beneficial for individuals with hypersexuality. Mood stabilizers and anti-impulsive medications have been suggested for managing patients presenting with manic or impulsive features or promiscuity, whereas stimulants have been suggested for highly distractible and thrill-seeking individuals. When sexually disordered behavior offers grave risk to the individual or to society, for example, as in the case of persistent and uncontrolled pedophilia, antiandrogen therapy has been found effective in drastically reducing sexual drive. The side effects with this class of medication are notable, however, so it is unlikely that such medication will be used except in very grave circumstances. More recent treatments include gonadotropin-releasing hormone analogues, including leuprorelin and triptorelin, which provide a more advantageous side effect profile than older antiandrogen medications. Still, significant problems with bone mineral loss suggest the use of these medications is indicated only in high-risk situations. Sex addiction and accountability Many celebrities have used a sex addiction diagnosis to justify having an affair. However, there is little to no research suggesting that sex addiction causes infidelity. Currently 16% of Americans engage in marital infidelity, while only 3-6% of people experience sex addiction. 186 CU IDOL SELF LEARNING MATERIAL (SLM)

Even if most individuals with sex addiction had affairs (which they do not), the majority of people who cheat on their partners do not have a sex compulsion. The same is true of sexual harassment, sexual assault, and so on. While sex offenders do have higher rates of sex addiction, most sex offenders do not have the condition. Sexual assault is generally more about power than sex itself. Sex addiction does cause cravings for sex which are hard to resist. However, sex addiction does not force a person to pursue sex in a way that hurts others. In fact, studies show the most common sexual compulsions are masturbation, pornography, and consensual promiscuity. Having a sex addiction in no way erases a person’s responsibility to get consent. 8.11 SUMMARY  Sex addiction is the active use of a sexual behavior, whether it is masturbation, an internet porn addiction, fetishes and/or behavior with self or others in a compulsive life-destroying pattern. When you are addicted to sex it is called a sex addiction.  It is important to understand that although sex and porn addiction are not “formally” diagnosable, these conditions exist and often present with very adverse consequences and high levels of distress, guilt, and emotional turmoil.  If you can relate to the symptoms mentioned above, or know somebody who meets these criteria, do not hesitate to ask for help. Call to speak to a treatment support specialist who can provide you with more information.  According to Departmental Management of the USDA, about 38% of men and 45% of women with sex addictions have a venereal disease as a result of their behavior.  Pregnancy is also a common side effect that can occur due to risky behavior. In one survey, nearly 70% of women with sex addictions reported they’d experienced at least one unwanted pregnancy as a result of their addiction.  There are a number of theories as to why a sexual addiction occurs. Some of these involve conceptualizing a sex addiction as a form of impulse control, obsessive- compulsive or relationship disorder.  They also include the idea that in some individuals sexual addictions emerge as a consequence and way of coping with early traumas, including sexual trauma.  In some forms of mental illness (such as bipolar disorder), hypersexuality may be a symptom.  In certain instances, neurological disorders (such as epilepsy, head injury, or dementia), have been known to cause hypersexual behaviors.  Certain drugs that impact dopamine may also rarely do the same. 187 CU IDOL SELF LEARNING MATERIAL (SLM)

 Sexual addiction requires treatment from a medical professional experienced in the field, such as a psychologist, psychiatrist, or sex therapist.  Treatment can vary based on the underlying cause, but will typically be conducted on an outpatient basis with counseling and behavioral therapies.  If the sex addiction is associated with an anxiety disorder or mood disorder, medications may be prescribed as part of the treatment plan.  There are currently no established recommendations on the appropriate use of medications to treat a sex addiction outside of the realm of these clinically classified disorders. 8.12 KEY WORDS  Acceptance And Commitment Therapy (ACT): A person who exhibits impaired control over engaging in substance use (or other reward-seeking behavior, such as gambling) despite suffering severe harms caused by such activity.  In-patient treatment: Admission to a hospital or facility for treatment that requires at least one overnight stay and typically requires medical management.  Intensive outpatient treatment: A time limited, intensive, non-residential clinical treatment that often involves participation in several hours of clinical services several days per week. It is a step below partial hospitalization in intensity.  Medical model: An addiction theory that considers addiction a medical, rather than social issue.  Outpatient treatment: A professionally delivered substance use disorder treatment modality that requires daily to weekly attendance at a clinic or facility, allowing the patient to return home or to other living arrangements during non-treatment hours.  Risk factors: Attributes (e.g., genetics), characteristics (e.g., impulsivity) or exposures (e.g., to prescription opioids) that increases the likelihood of developing a disease or injury.  Treatment: The management and care of a patient to combat a disease or disorder. Can take the form of medicines, procedures, or counseling and psychotherapy.  Trigger: A specific stimulus that sets off a memory or flashback, transporting the individual back to a feeling, experience, or event which may increase susceptibility to psychological or physical symptom recurrence and reinstatement of substance use disorder. 188 CU IDOL SELF LEARNING MATERIAL (SLM)

 Twelve step facilitation (TSF): An evidence-based clinical approach to substance use disorder treatment that is grounded in the principles of Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) 8.13 LEARNING ACTIVITY 1. Explain the types of addiction along with their symptoms and treatment? ___________________________________________________________________________ ___________________________________________________________________________ 2. How does support group help a person with addiction? ___________________________________________________________________________ ___________________________________________________________________________ 8.14 UNIT END QUESTIONS A. Descriptive Questions Short Questions 1. Define Sex Addiction? 2. What do you mean by biological sex addiction? 3. What do you mean by psychological sex addiction? 4. What do you mean by spiritual sex addiction? 5. What is the prognosis of sex addiction? Long Questions 1. What are the symptoms of Sex addiction? 2. What is the relationship between trauma and sex addiction? 3. Explain the different types of sex addictions in detail. 4. What are some of the causes of sex addiction? 5. How does group therapy help in sex addiction? B. Multiple Choice Questions 1. Which of the following is not a strategy used in motivational interviewing a. Expressing empathy b. Rolling with resistance 189 CU IDOL SELF LEARNING MATERIAL (SLM)

c. Avoiding arguments d. None of these 2. Sex addiction occurs when a person is preoccupied with ___________ a. sex b. porn c. internet d. drugs 3. Sex addiction is _____________________ a. emotional b. behavioral c. substance related d. All of these 4. Sex addiction can have many ________________ consequences a. social b. legal c. economical d. None of these 5. Sex addiction can have many ________________ consequences a. obsession b. guilt c. permanent d. temporary Answers 1-d, 2-a, 3-a, 4-b, 5-a 8.15 REFERENCES Textbooks  Ahuja N (2002). A short text book of Psychiatry. (5th edn). New Delhi: Jaypee Brothers Medical. Publishers (pvt) Ltd. 190 CU IDOL SELF LEARNING MATERIAL (SLM)

 American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders, Fourth Edition, Text Revision: DSM-IV-TR. Washington, DC: American Psychiatric Publishing, Inc.  Clifford Morgan, Richard King, John Weisz, John Schopler (2004) Introduction to Psychology, McGraw-Hill, New Delhi  Domjan Michael (2010). The Principles of Learning and Behavior (6th Edt) Wadsworth, Cengage Learning.  Hergenhahn B R (2008). An introduction to the history of psychology, Wadsworth, Cengage Learning.  Robert S. Feldman (2011) Understanding Psychology, McGraw-Hill, New Delhi.  Robert. A. Baron, Psychology, (2008) Prentice Hall India. Reference books  American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders, Fourth Edition, Text Revision: DSM-IV-TR. Washington, DC: American Psychiatric Publishing, Inc.  Carson, R. C., Butcher, J. N., & Mineka, S. (2002).Abnormal psychology over time. In Fundamentals of abnormal psychology and modern life. New York: Allyn & Bacon.  Emery, R.E., &Oltmans, T.F. (1998). Abnormal Psychology (2nd ed.). Upper Saddle River, NJ: Prentice-Hall, Inc.  Kay J, Tasman A. (2006) Essentials of Psychiatry, Chichester, John R. Wiley and Sons.  Sadock, Benjamin, J., & Virginia A. (2002). Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry (9th ed.). Lippincott Williams &Wilkins.  Sarason I., G & Sarason B. R. (2005).Abnormal psychology: The problem of maladaptive behavior. (11th edn). PHI Learning Private limited.  World Health Organization (1993). The ICD-10 Classification of Mental and Behavioral Disorders Websites  www.simplypsychology.com  http://www.human-memory.net  www.simplypsychology.org  https://psychcentral.com 191 CU IDOL SELF LEARNING MATERIAL (SLM)

 https://courses.lumenlearning.com  https://www.sparknotes.com 192 CU IDOL SELF LEARNING MATERIAL (SLM)

UNIT 9 – CASE STUDIES STRUCTURE 9.0 Learning Objectives 9.1 Introduction 9.2 Case of Ginger 9.3 Case of James 9.4 Case of Sam 9.5 Case of Henry 9.6 Case of Del 9.7 Summary 9.8 Key Words 9.9 Learning Activity 9.10 Unit End Questions 9.11 References 9.0 LEARNING OBJECTIVES After studying this unit, you will be able to,  Describe the symptoms and clinical presentation of Food Addiction  Describe the symptoms and clinical presentation of Internet Addiction  Describe the symptoms and clinical presentation of Sex Addiction 9.1 INTRODUCTION Even though behavioral addictions are in most respects similar to substance addictions, they are often more difficult to identify. After all, they’re easier to hide, they’re (usually) more socially acceptable, and outside observers (even therapists) don’t always recognize the behaviors as potentially addictive. As such, behavioral addicts will typically experience serious directly related consequences before being found out, confronted and/or seeking help. Sometimes behavioral addictions are only uncovered during treatment for a substance use disorder or some other psychiatric condition. For instance, a woman in treatment for depression and alcohol abuse may find herself flirting or acting out sexually with other patients or even staff, leading to an evaluation for sex and love addiction, or a man attending 193 CU IDOL SELF LEARNING MATERIAL (SLM)

Alcoholics Anonymous may find himself continually relapsing at the local casino, leading to a realization that he has an intertwined alcohol and gambling addiction. Another major obstacle in the identification and treatment of behavioral addictions is the fact that most people view them as being less serious than “real” addictions (i.e., substance addictions). In fact, nothing could be further from the truth. Behavioral addictions create the same types and degree of havoc as substance use disorders: relationship trouble, issues at work or in school, declining physical and/or emotional health (depression, anxiety, loss of self-esteem, etc.), isolation, financial woes, loss of interest in previously enjoyable activities, legal trouble, and worse; addiction is addiction. Case management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the client's health and human service needs. It is characterized by advocacy, communication, and resource management and promotes quality and cost-effective interventions and outcomes. Case management is an area of specialty practice within the health and human services professions. Its underlying premise is that everyone benefits when clients (1) reach their optimum level of wellness, self-management, and functional capability. The stakeholders include the clients being served; their support systems; the health care delivery systems, including the providers of care; the employers; and the various payer sources. Case management facilitates the achievement of client wellness and autonomy through advocacy, assessment, planning, communication, education, resource management, and service facilitation. Based on the needs and values of the client, and in collaboration with all service providers, the case manager links clients with appropriate providers and resources throughout the continuum of health and human services and care settings, while ensuring that the care provided is safe, effective, client-centered, timely, efficient, and equitable. This approach achieves optimum value and desirable outcomes for all stakeholders. Case management services are optimized best if offered in a climate that allows direct communication among the case manager, the client, the payer, the primary care provider, and other service delivery professionals. The case manager is able to enhance these services by maintaining the client's privacy, confidentiality, health, and safety through advocacy and adherence to ethical, legal, accreditation, certification, and regulatory standards or guidelines. 9.2 CASE OF GINGER Ginger is a 62-year-old married white woman of Italian descent. She works as a hospital administrator at a local, large-volume hospital and presents to the outpatient psychiatry clinic for concerns related to her overeating and multiple diet failures. She was referred by her primary care provider, who has recommended a diet of 1,600 calories per day and has prescribed phentermine and Topamax for the patient to help suppress appetite and cravings, respectively. In the past 3 months since initiation of this regimen, Ginger has lost 2 lb. in the 194 CU IDOL SELF LEARNING MATERIAL (SLM)

first month and gained 4 lb. in the past 2 months, for a total net gain of 2 lb. Today she expresses frustration at her lack of progress but adds, “I’m not surprised.” She notes her weight has steadily risen and that in the past 40 years, she has gained 70 lb. to achieve her current weight of 271 lb. Her body mass index (BMI) today is 47. Ginger wonders if she may be addicted to food because she has tried multiple diets over her lifetime, and whereas she often loses weight initially, she has not been able to lose more than 15 lb. or keep it off for more than 1 month. She states that her eating habits are poor and that while she likes fruits and vegetables and a variety of meats, she prefers carbohydrates. She also enjoys sweets and often feels a loss of control when it comes to sugary foods. Most of her eating of sugary foods is done in private. She rarely orders dessert in a restaurant but admits she will often buy cookies or cake from a grocery store and eat the entire thing on her drive home, stopping to discard the containers and receipts before arriving home. While her portions of carbohydrates are often larger than intended, her intake of sweets is “out of control.” She finds it difficult to have just one cookie or one slice of cake and notes that when she starts to eat these foods, she finds herself consuming far more than intended and will even go out of her way to secure the desserts she wants from far-away bakeries or grocery stores. When her husband is away from the house, she has mixed sugar, flour, salt, and butter in a bowl and consumed the entire amount without baking it. She describes often feeling physically sick and nauseous and has eaten to the point of vomiting, but she insists that she has never intentionally purged after a binge episode. At work, she has periodically shut the door to her office to consume large amounts of desserts, and she will not answer the phone or door while she is eating these foods. Ginger describes these times as being “like a fog” and denies that she is making the decision to eat the entire portion but rather says that the food is simply gone quickly. She denies the use of laxatives, compulsive exercise, or other attempts to undo the intake of sweets. She reports that her episodes of binge eating occur 3–5 times weekly, and she cannot often predict when they will happen. While shopping for clothes this week, she stood in line to check out and purchased a large box of gift chocolates (approximately 40 pieces) and ate the entire box before arriving home. She stopped at a gas station to throw away the box and receipt before arriving home. After an incident like this, she describes feeling depressed, disgusted, discouraged, and hopeless. She also experiences increased cravings for sweets and carbohydrates following these episodes. She notes that the medications prescribed by her primary care provider have helped somewhat by reducing her appetite, but she adds, “I really don’t need to be hungry to eat anyway.” Past attempts at weight loss have included Weight Watchers, the Atkins diet, low-carbohydrate diets, Medifast, Slim Fast, calorie restriction, and over-the-counter supplements. 195 CU IDOL SELF LEARNING MATERIAL (SLM)

None of these have been effective, per Ginger, because in the past year, she has not gone longer than 3 weeks without a binge episode. She describes her marriage as a happy one and says that she and her husband are “entirely food focused.” They both enjoy cooking, trying new recipes, watching cooking shows, eating out, and planning trips around meals. She loves pasta and potato dishes and notes that growing up in an Italian family, meals were often centered around numerous starchy carbohydrates. Her husband is also overweight, but she does not believe he secretly eats as she does. She has not shared with him her habit of eating secretly and eating large amounts of sweets at one sitting. Ginger describes herself as friendly, a leader, and agreeable overall. Few people know when she is upset, she states, and she often withholds her emotions from colleagues, friends, and even close family. She equates anger with screaming and yelling, and she therefore would rather deal with a situation independently or ignore it in hopes of it resolving on its own. Despite her 22-year marriage to a man whom she describes as “compassionate and loving,” she rarely expresses her displeasure with him, and oftentimes he does not know that she is upset about something. This is also true in her relationship with her two adult daughters. When situations arise at work that require her to advocate on behalf of her employees, she will do it but admits to significant anxiety and dread about being perceived as angry or unreasonable. She speaks openly of the discrepancy between the success she has achieved in other areas of her life as a high-ranking hospital administrator, a mother, and wife and the lack of control she feels when it comes to food. She describes herself as a “complete failure” in regard to her eating and admits to feelings of significant low self-worth despite her success professionally and interpersonally. She has never received any treatment for her overeating and has never before seen a therapist. She has no prior inpatient or outpatient psychiatric history. She believes there have been times in her life when she has felt “pretty depressed,” but she has never received any treatment, and these times gradually abated according to Ginger. She denies regular use of alcohol and drinks approximately one drink per month. She is negative for use of cocaine, marijuana, opioids, benzodiazepines, sedatives, hallucinogens, and other substances. Ginger was raised in a small town in northern Michigan and is the youngest of three children. She has two older brothers and describes her childhood as “happy” overall, although she notes that she was the only “fat one” in the family and that this was often a source of ridicule from her mother, brothers, and peers at school. She believes weight first became an issue for her around the age of 5, and she can recall early memories of her mother scolding her for eating large portions. She recalls an incident around age 7 that involved her mother bringing home a large cake and setting it on the table. Ginger was excited to see the cake and asked her mother to try a piece. Apparently disturbed by Ginger’s enthusiasm and desire for the cake, Ginger’s mother used her hand to wipe all of the icing off the top, and while putting her hand in Ginger’s face 196 CU IDOL SELF LEARNING MATERIAL (SLM)

asked, “Why do you like this so much? It’s all just fat and that’s why you’re fat.” Shortly after this incident, Ginger began to identify food, and sweets in particular, as a source of shame and guilt. She began taking her allowance money and riding her bike to the corner store to purchase large amounts of chocolate, which she would eat in one sitting before heading home. She recalls that her mother questioned where her money was being spent but that no one ever knew about her secret eating. In front of friends and family, Ginger became very aware of the importance of limiting her portions and not eating seconds. She remembers some family members wondering why her weight was continuing to rise when she simply ate what all of the other members of her family were eating; they were not aware of her secret binge episodes. As she aged, the tension in her family on the topic of her weight continued to worsen, with her brothers often teasing her and peers at school ridiculing her. She had friends but few boyfriends and was not particularly physically active in her youth, preferring reading and schoolwork. At age 22, she married her current husband and went on to have two daughters (now ages 30 and 27). She is close to them, although they both live several hours away. Her younger daughter “may also struggle with food”; she is over-weight and very focused on food according to Ginger. She remembers as a child hearing rumors that her mother had an eating disorder and describes her mother as very thin and a controlled eater. She also vaguely remembers hearing that her mother was institutionalized and received electroconvulsive therapy for a time before her marriage to Ginger’s father, but this fact was never discussed at home nor was her mother’s own relationship to food. Her mother passed away 6 months earlier at the age of 95. Ginger is pleasant and cooperative during the interview and makes good eye contact. She processes easily and is often tearful, particularly when discussing the relationship she had with her mother. While she readily admits that her mother often used control and shame in relation to Ginger’s food, she is reluctant to discuss any uncomfortable feelings associated with this and immediately follows up the stories of her childhood with “but she was a really good mom and a good woman.” The guilt and shame that Ginger feels following an episode of binge eating (which are characteristic of persons with binge-eating disorder [BED]) appear to have originated in early childhood as she began to identify her eating and food desires as shameful and out of the ordinary, resulting in her hiding these behaviors. She also is reluctant to discuss any hurt and anger she has toward her brothers, former classmates, current colleagues, or others, noting that anger serves “no purpose.” When asked to elaborate on what anger looks like, she describes scenes from her childhood of fights between her parents that involved yelling, screaming, slamming doors, and dramatic exits from the home of one or both of her parents for a short time. She relays that she avoids these type of altercations at all costs and generally avoids the expression of negative feelings on the 197 CU IDOL SELF LEARNING MATERIAL (SLM)

whole, as illustrated by her mentioning that her husband is rarely aware when she is upset or angry at him. While the therapist gathers information from Ginger about her initiation of treatment, she expresses concern that Ginger may be addicted to food. Food addiction, although increasingly supported in the scientific literature in the fields of psychology and medicine, remains a hypothesis because it has not been declared a diagnosis in DSM-5 (American Psychiatric Association 2013). The YFAS is currently the most accurate measurement available to evaluate for food addiction. This scale could be administered to determine if Ginger might be addicted to food. Another disorder that would be high on the list of differential diagnoses for Ginger is BED. BED has been added to the list of feeding and eating disorders and generally describes many of the signs and symptoms we associate with the food addiction hypothesis and many symptoms we see in Ginger. It is important to note, however, that distinctions do exist between the two. In particular, one study suggested that as many as 24% of persons who met criteria for food addiction did not meet the criteria for BED. Similarly, those who meet criteria according to the YFAS often present with a more depressed affect, reduced emotion regulation, lower self-esteem, and higher prevalence of mood disorders compared with those with BED. Ginger also denies purging, which helps to narrow the differential of eating disorders in her case. Additionally, whereas Ginger is considered morbidly obese with a BMI of 47, it is important to note that not all obese individuals are addicted to food or have BED, nor are all persons with food addiction obese. Therefore, this distinction can be made only through a detailed workup of the patient. Food itself also can have different effects on different populations. This is because patients can adopt different styles of interacting with food that are referred to as information gathering and sharing styles (IGS). These styles can be translated into different stimulation or inhibition patterns of the same neurotransmitters, and therefore, an understanding of the individual’s IGS style is critical to the successful treatment of disease. To summarize, Ginger presents with the following: eating larger portions than most others would consider normal in a discreet period of time, a sense of lack of control over eating during the episode, eating more rapidly than normal, eating until uncomfortably full, eating large amounts of food when not feeling hungry, eating alone because of the embarrassment of how much one is eating, feeling disgusted after an episode of binge eating, marked distress surrounding the binge-eating episodes, binge eating not associated with any compensatory behavior (like purging or exercise), and binge eating occurring at least once a week for 3 months (in Ginger’s case, the episodes have been occurring approximately 3–5 times weekly for at least 1 year). Although food addiction is a more novel hypothesis, the YFAS should be administered, and food addiction should be considered as a diagnosis in cases such as Ginger’s. 198 CU IDOL SELF LEARNING MATERIAL (SLM)

9.3 CASE OF JAMES James was always a bright student. His Korean parents fostered his education,perhaps at times excessively. Without effort, he was on the honor roll throughhigh school. Now a freshman in college, he was going to sleep at odd hours, beginning his online time innocently enough “to check e-mail” and ending upplaying World of Warcraft, an MMORPG, into the early morning hoursto thedetriment of morning classes. When his parents proudly inquired about hisgrades during winter break, they were surprised to find out that he had mustered only mediocre grades. He reluctantly revealed this out of concern that hemight lose his scholarship. This was not James’ first time running into troublewith computer gaming. Although he had been on the soccer team in middleschool, he was quick to get bored in high school and was regarded by his teacheras “not trying hard enough.” He did not naturally make friends, preferring solitude. Throughout his senior year in high school, he spent progressively moretime on the computer, dismissing his parents’ attempts to engage him in familylife, so he could “complete a mission with [his] clan and upgrade [his] avatar.” Before the end of his senior year, his parents heeded the advice of the school social worker and took James to a child and adolescent psychiatrist whom he recommended. She diagnosed James with social anxiety disorder, also recognizinghis excessive time spent gaming. Whether because of the individual sessions, theescitalopram that was prescribed for his anxiety, or the family sessions focusingon curbing his access to computers, James initially kept up with his schoolwork. Soon, though, he was skipping school, heading to Internet cafés to circumventthe move of his computer from his room to his parents’ room. Not ready to giveup, his parents enrolled James in “Rehab After School,” a group therapy programfor chemically addicted high school students. James was one of two in the groupwith Internet gaming problems. He eventually joined a church basketball teamand was able to finish his senior year, staying away from Internet games for the entire second semester. Away in college and without the watchful eyes of his parents, James driftedback to World of Warcraft, playing as many as 60 hours a week. James was notsurprised by his midterm grades. Most nights he did not go to bed until the earlymorning hours, attending only evening classes. He began skipping cafeteriameals, opting for unhealthy snacks, because he was often “in the middle of an intense quest.” He probably lost 10 pounds, he surmised. If it weren’t for his parents’ insistence, James was prepared not to go back home during the few shortschool breaks, preferring instead to stay in the dormitory. He, nevertheless,came home but made a point of planning his days there around his games. Seeing his preoccupation, his parents demanded some of his brief time at home, butthey were met with anger and irritability. Their son once again was consumed byonline games. James’ 199 CU IDOL SELF LEARNING MATERIAL (SLM)

parents stopped his gaming subscription payment. WhenJames attempted to surreptitiously reactivate his payments on his father’s creditcard, his father punished him by cutting basic cable and Internet service to thehouse, which brought James to the verge of physical confrontation. When his psychiatrist sees him after a hiatus, she finds him to be underweight and tired, if not also somewhat depressed. Speaking into his lap, he describes his mood as “okay.” While not overtly sad, he fails to brighten much. Hehas little rationale to explain his excessive gaming, other than to comment: “I amreally good at World of Warcraft, but if I don’t keep up, people will catch up to me!” The psychiatrist ascertains that James has not been using drugs or alcohol in college and that his Internet addiction does not involve pornography or gambling.James has continued taking escitalopram since starting college. He alsoagrees to individual therapy at the college’s student health clinic, but his attendance there is sporadic. Because of his failing grades, and at the behest of his parents, counselor, and psychiatrist, James decides to take a term off from schooland attend an inpatient Internet addiction program. 9.4 CASE OF SAM Sam is a 42-year-old married man with two children. He was referred for psychotherapy at the request of his wife, who was concerned about his capacity tocontrol his increasing urges for infidelity, which had precipitously increased after attending a party for his oldest child’s seventh birthday. Although the patientwas initially resistant to psychotherapy, he soon acknowledged that he was desperate to save his marriage and terrified at the thought of breaking up his family. He reported a long history of polysubstance abuse (primarily involving alcohol, ecstasy, and cocaine), starting in his late teens and ending 2 years into hisrelationship with his wife, whom he met 10 years prior to entering treatment. With the exception of a few small relapses, he had easily remained sober sincejoining Alcoholics Anonymous (AA) 8 years previously. However, in the contextof his substance abuse, he had chronically demonstrated compulsive sexual behavior, including promiscuous sex with women and some men, patronizing ofprostitutes, and compulsive masturbation to pornography. As a young man in his20s, he was a member of a fairly successful rock band and therefore had ample access to drugs and casual sex. Whereas discontinuing his drug abuse was relativelyeasy, refraining from compulsive sexual behavior was far more difficult. Although he later recognized an underlying shame at his out-of-control behavior,he had long seen his sexuality as ego-syntonic, a reflection of a free and honestspirit unconstrained by hypocritical societal conventions. He also viewed hissexual behavior as consistent with his philosophical opposition to monogamy. 200 CU IDOL SELF LEARNING MATERIAL (SLM)