Download Proposed Criteria for Hypersexual Disorder in the DSM-5

Proposed Criteria for Hypersexual Disorder
in the DSM-5: Mindfulness Applications to
Attenuate Symptoms of Hypersexuality
RORY C. REID, Ph.D., LCSW
Research Psychologist / Neuropsychology
Semel Institute for Neuroscience & Human Behavior
Department of Psychiatry and Biobehavioral Sciences
Terminology
Hypersexual impulsivity, sexual
compulsivity, sexual addiction, sexual
dependence, unrestrained sexual
desire, sexual disinhibition,
hypersexuality, sexual torridity, sexual
sensation seeking, sexual desire
disorders, excessive sexual desire
disorder, hyperlibido, hyperactive
sexual behavior, uninhibited sexual
desire, paraphilia-related disorders,
non-paraphilic sexual disorders, Don
Juanism, erotomania, nymphomania,
and satyriasis.
.
What Hypersexual Disorder is NOT!
1. HD is not a label to pathologize people’s right to an freedom of
their sexual expression.
2. HD is not a synonym for people with high sexual desire.
3. HD is not an extension of other psychopathology such as bipolar
disorder or substance abuse.
4. HD is not synonymous with persistent sexual arousal syndrome
in which an individual experiences persistent sexual arousal in
the absence of desire.
5. HD is not a manifestation of behavior caused by neurological
pathology or cortical atrophy in the brain (e.g., TBI; KlüverBucy syndrome).
DSM‐5 Proposed Classification Criteria
A. Over a period of at least six months, recurrent and
intense sexual fantasies, sexual urges, and sexual behavior
in association with four or more of the following five
criteria:
1. Excessive time is consumed by sexual fantasies and
urges, and by planning for and engaging in sexual
behavior.
2. Repetitively engaging in these sexual fantasies, urges,
and behavior in response to dysphoric mood states
(e.g., anxiety, depression, boredom, irritability).
3. Repetitively engaging in sexual fantasies, urges, and
behavior in response to stressful life events.
Model:
Tension Reduction / Affect Regulation
Affect Regulation / Tension Reduction Model
Unpleasant Affective State
Action Tendency
SHAME, ANXIETY,
DEPRESSION
AVOID / ESCAPE
DISSASOCIATE
Tension Reduction
Affect Regulation
SEX USED TO SOOTHE
TRANQUILIZE
DSM‐5 Proposed Classification Criteria
Continued:
4. Repetitive but unsuccessful efforts to control or
significantly reduce these sexual fantasies, urges, and
behavior.
5. Repetitively engaging in sexual behavior while
disregarding the risk for physical or emotional harm to self
or others.
DSM‐5 Proposed Classification Criteria
B. There is clinically significant personal distress or
impairment in social, occupational or other important
areas of functioning associated with the frequency and
intensity of these sexual fantasies, urges, and behavior.:
C. These sexual fantasies, urges,
and behavior are not due to direct
physiological effects of exogenous
substances (e.g., drugs of abuse or
medications) or to Manic Episodes.
D. Person is at least 18 years of age.
Let’s Keep a Secret…At Least for a While Longer!!
Highlights from the
DSM-5 Field Trial:
Hypersexual Disorder
Note: Some of these data are being
presented for the first time. Please do
not publish or present this information
elsewhere until results are officially
published, etc…
Reliability of Proposed DSM‐5 HD Criteria Inter-rater reliability. The magnitude of agreement between raters
was calculated for a randomly selected subset of patients (n = 50) at
the initial interview for HD. Kappa coefficient of .93, p < .001, 95%
CI (.78 – 1.0), among clinicians with an intraclass correlation of .95.
Krippendorff’s alpha was α = .92, 95% CI (.86 – .98).
Test-retest reliability. The overall HD criteria test-retest reliability
by clinical interview was high (r = .81, p < .001) based on a subset
of patients (n = 32) who received a second interview after a twoweek interval.
Sensitivity and Specificity
Presenting Problem
Results of HD
Diagnostic
Interview
Current HD
Positive +
Current HD
Negative –
Referred for HD
Diagnosis
Referred for
General Psychiatric
Diagnosis
Referred for
Substance-Related
Diagnosis
134
3
1
(True Positive)
(False Positive)
(False Positive)
18
32
19
(False Negative)
(True Negative)
(True Negative)
152
35
20
138
69
207
Manifestations of Hypersexual Behavior
Specifiers:
Masturbation
Pornography
Sexual with
Consenting Adults
Cybersex
Telephone Sex
Strip Clubs
Other:
Manifestations of Hypersexual Behavior
Symptom Endorsement
Trajectories of Hypersexual Disorder
Onset
Before age 18
Age 18-25
After age 25
Rapid/Acute ≤ 90 days
Gradual, several months, years
Course
Continuous
Episodic
Escalation
Amount of time
Frequency or intensity
Venues / Manifestations
Associated Risk
54.1%
30.3%
15.6%
17.4%
82.6%
48.6%
51.4%
83.5%
81.7%
62.4%
60.6%
Group Differences on HD Scales and HBCS
Sample Items from the HBCS
High Prevalence of Comorbid Adult ADHD (23%)
Reid, R. C., Carpenter, B. N., Gilliland, R., & Karim, R. (2011). Problems of self-concept in a patient
sample of hypersexual men with attention-deficit disorder. Journal of Addiction Medicine, 5(2), 134–140.
Conflicting Evidence of Executive Deficits
Reid, R. C., Garos, S., Carpenter, B. N., & Coleman, E. (2011). A surprising finding related to executive
control in a patient sample of hypersexual men. Journal of Sexual Medicine, 8(8), 2227–2236.
Subtyping Hypersexuality on MMPI‐2 Profiles
Reid, R. C. & Carpenter, B. N. (2009). Exploring relationships of psychopathology in hypersexual
patients using the MMPI-2. Journal of Sex & Marital Therapy, 35(4), 294–310.
Using Mindfulness to Attenuate
Symptoms in Hypersexual Patients
A Feasibility Study Conducted at UCLA
Mindfulness Based Stress Reduction
Mindfulness is a philosophy and a practice of cultivating
increased awareness of our moment-to-moment experience
in a non-judgmental way. Mindfulness enhances selfcompassion, kindness, gratitude, awareness, openness, and
increased tolerance for suffering. It decreases reactivity as
we “lean into” the various moments in our lives.
Mindfulness is not about feeling a particular state or
“getting rid” of unwanted feelings. Mindfulness is about
expanding the breadth of experience whatever it might be
and learning to embrace the various moments in our lives.
Collectively, the practice of mindfulness helps us find
solitude, peace, and balance in our lives.
Treating Hypersexuality through Mindfulness
HYPERSEXUALITY
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Shame
Entitled/Ungrateful
Emotionally Reactive
Intolerance for Discomfort
Critical/Judgmental
Rumination
Anticipatory Anxiety
Tug of War with Cravings
Special Status to Thoughts
Thought Suppression
Disconnecting/Inattention
MINDFULNESS
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Self-Compassion
Gratitude/Humility
Emotionally Present / Aware
Being Present w/h Suffering
Curious/Non-Judgmental
Reflection
Present in the Present
Acceptance of Cravings
A Thought is Just a Thought
Noting, Curiosity, Present
Connecting / Attentive
Developing a New Relationship with Cravings
Dr. Hedy Kober, Assistant Professor
Yale University School of Medicine
Hypothesized Mechanisms of Action in MBSR
Attention Regulation [3 min exercise]
Necessary in Conflict Monitoring
Body Awareness
Attention to Somatic Experience, “What am I really craving?”
Emotion Regulation
Being present with uncomfortable / unpleasant emotions
Change in Self-Perception
Observing mental processes with increased clarity
Non-Judgmental Self-Appraisals
Feasibility Study MBSR
Frequency
Time
Baseline
8 week Mindfulness (n=15)
8 week Psycho-Education (n=10)
Frequency
Time
After 10 Weeks
In meditation, nothing
happens next. This is it!”
DSM‐5 Field Trial Team Members
UCLA Department of
Psychiatry and Biobehavioral Sciences
Rory C. Reid, Ph.D.
Margarit Davtian, M.A.
Heather McKittrick
Reef Karim, D. O.
Timothy Fong, MD
Affiliate Research Team Members
Desiree Li,
Stanford University School of Medicine
Erin B. Cooper, M.A.
Dept of Psychology, Temple University
Priya Chaudhri
Department of Psychology
University of California, San Diego
Affiliate Research Team Members
Sheila Garos, Ph.D., Psychologist,
Texas Tech, Dept of Psychology
Joshua Hook, Ph.D.
Department of Psychology,
University of North Texas
Bruce Carpenter, Ph.D., Psychologist
Randy Gilliland, M.S., Doctoral Student
BYU, Dept of Psychology
Heather Chapman, Ph.D., Psychologist
U.S. Department of Veterans Affairs
Jill C. Manning, Ph.D., MFT,
Marriage and Family Therapist
Private Practice, Denver, CO.