Obsessions, Compulsions, Addictions and Personality flaws
The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), published in 2013 after decades of intense debate remains confusing to many as some of the listings have similar names, but refer to a different set of behaviours. E.g. Obsessive Compulsive Disorder (OCD) (300.3) is different from Obsessive Compulsive Personality Disorder (OCPD) (301.4).
The DSM-5 (2013) states that Obsessive Compulsive Disorders (OCD) are characterised by the presence of obsessions and/or compulsions. Obsessions are recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted, whereas compulsions are repetitive behaviours and mental acts that an individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
Although a behaviour can be perceived as obsessive compulsive in many ways due to a pre-occupation with the behaviour or the intent (fantasy) to engage in the behaviour, it would not fall under the classic OCD label when pleasure is derived from these behaviours and the wish to stop engaging in these behaviours is directly related to the deleterious consequences (see p. 242).
Most people who have obsessive compulsive behaviours also suffer from anxiety and depression.
Obsessive Compulsive Personality Disorder (OCPD) is different from OCD in many ways. First of all, personality disorders are subject to intense debate among clinicians. Many perceive PDs as a human condition and that only the extent and the hurt that is done to self or others differentiates the person from having either a disorder or from being flawed as any human being. The DSM-5 has proposed an alternative model to the personality disorders listed in the same volume. OCPD remains listed (see p. 768). As explained above, PDs are different from other “disorders” listed in the DSM, as PDs are traits; and with this is meant that they are pervasive and enduring. The characteristics often surface during adolescence or early adulthood and lead to distress to self or others or both. The Alternative model has brought the number of listed PDs from 10 to 6 and the DSM clearly states as many clinicians have found that patterns do not clearly correspond with just one listing.
OCPDs are characterised by “rigid perfectionism, negative affectivity, an avoidance of intimacy including intimate sexual relationships, and a constricted emotional experience and expression (indifference and coldness)” (DSM-5, p. 768-769).
Compulsive Sexual Behaviour (CSB)
Many clinicians refer to the pattern of Compulsive Sexual Behaviour as SEXUAL ADDICTION. I am not in agreement with the use of sex addiction as it is overused and does not take into account the different types and root causes of the behaviours.
Some people are NOT CAPABLE to tolerate emotional and psychological intimacy. When they talk about the issues they experience, they often state that they care about the person they live with but that they cannot commit or they state that they are not deeply in love with the person they live with. What they might mean is that they have a fear of vulnerability and as a result they avoid becoming emotionally intimate with another person. It has been found that these people are not often aware of the root causes of their behaviours. Men with CSB might state that they have told their partner that they do not want to get married and that they do not want to have children, but as the relationship on the surface seems a committed relationship, many female partners will perceive it as such and have the expectations that “he will change once the baby is born” and that they have a “normal” and healthy relationship. Females with CSB often have stated to their partner at some time that they fear that they might not be able to stop having affairs.
The inability to develop a deep emotional connection is hurtful to partners of men (and women) with CSB and many partners might not understand the behaviour. They might perceive their partner as an adulterer. The people with the behaviours discussed in this post need treatment when they are ready and it might require long-term therapy. Even if therapy is helpful, a relapse is not unlikely. This can be understood from a therapeutic point of view, but the partner will feel very hurt. It might not be possible for a man with CSB to remain in a relationship or the partner of a man with these behaviours might not be capable to accept the reality of the problem and work with him. This is fully understandable as she too needs a loving and respectful relationship and she might not find that with her current partner.
CSB is not just related to a strong sex drive. If this was the case, medication, an understanding partner and self-help groups should be helpful, but it is hardly ever enough. This does not mean that all need lengthy therapy. Some people benefit from brief counselling. Although attending meetings based on the principles a 12-step program can be helpful, for some it is not enough as it does not deal with the root causes. Sexaholics Anonymous (SA) requires of attendees to have a desire to stop lusting and become “sexually sober”. This is a problem as physical intimacy is a basic human need. What attendees want to achieve is a sense of being in control of their behaviour. This is no different for people who identify themselves as overeaters. We need food, what we do not want is that food becomes an obsession and controls us. Unfortunately, to many in our society food is an obsession.
Therapists who are working with clients with CSB need to assess the client for mood disorders, ADD/ADHD and a history of trauma based in childhood which has affected parental attachment. If the client is in a relationship, couple therapy can be helpful as well. Further, it is important to ask many questions and to ask for clarifications when issues are not clear. A psychodynamic approach might be helpful in combination with a 12-step program or Cognitive Behavioural Therapy. I mentioned a psychodynamic approach, but other approaches can be equally helpful as long as the therapist spends time on family of origin, attachment and family relationships.
Some men state that they feel empty and when they are asked about their sexual encounters they rate them as not satisfying. This becomes clear when looking at the core issue: “…in inability to internally soothe themselves [leading to] seeking external means, such as sex to modulate their emotions” (Marcus, 2010, p. 385).
I have noticed that men with CSB only come to therapy when they feel deeply stuck. This happens when they are in a relationship and their partner demands a deeper commitment. It often involves pregnancy or the birth of a baby. Although many men feel deeply ashamed and even express disgust when talking about their multiple short-term sexual encounters, they seem to lack the notion that they hurt many people. In the first place, their partner and the mother of their children, but they also hurt those they have sex with as these people might have expected some sort of relationship or at least some emotional connection.
Researchers have written about this and Marcus (2010) in “Men who are Not in Control of their Sexual Behaviour” writes that he prefers the term SEXUAL COMPULSIVITY and the SEXUALLY ACTING OUT as a “relationship disorder”. I agree with Marcus that CSB can be better described as a RELATIONSHIP “DISORDER” than as a sex addiction.
According to the DSM-5 Hypersexual Behaviour is not an official psychiatric disorder, as evidence is lacking to include the behaviour in the handbook. This is in my opinion a positive decision as if we would include all behaviours that are excessive and that have a negative impact on daily functioning and relationships we could include about all human behaviours in the DSM-5 as most “normal” behaviours can be exercised in excess and therefore will have a negative impact on oneself and on others.
Hypersexual behaviour may include: excessive masturbating, excessive viewing of pornography and frequently engaging in cybersex, among other behaviours. Those who come forward with the problem experience shame and guilt. We have to be aware that what has been historically seen as paraphilia (and disordered behaviour) might be seen as perfectly acceptable in current times. Of course, cultural differences also play a role in what is seen either as excessive and abnormal or as an accepted preference. Needless to state that some screening tests are no longer valid.
Jonnides (2012) in “The Challenging Landscape of Problematic Sexual Behaviours, Including “Hyper-sexuality”, refers to three published research studies. He found that the prevalence of hyper-sexuality varies from 5 to 6%. A large study undertaken by Skegg and colleagues in 2010, found that 14% of men and 7% of women perceived their sexual fantasies and urges “out of control”. More importantly, less than 1% of the total sample of 1,037 men and women reported that their sexual behaviours had interfered with their lives.
This means we are talking about a small group of people who experience negative effects from their sexual behaviours. Many studies focused more on male versus female behaviours. It might be that females experience their “out of control” sexual behaviours in different ways. More studies are needed to find out whether there is a difference and whether this effects how therapists can be helpful to females.
Many enjoy their active sex life and as long as people are honest about the nature of the interaction and practice as-safe-as possible-sex, it is entirely their business as it is personal and with clear boundaries and honesty and openness others are not hurt by in the process.
Those who frequently use porn without a partner might find difficulties in reaching satisfying sexual pleasure and orgasm with a real life partner. Porn has negative side effects on some people (who use it to compensate for a lack of offline sexual intimacy) and it can develop into an obsessive compulsive behaviour that is difficult to stop due to the activated reward systems in the brain. More recent research shows an increase in Erectile Dysfunction in men under 40, and a correlation to frequent porn use.
However, there is a lack of research evidence to demonstrate that porn addiction is an addiction with similar characteristics to chemical addictions (e.g. see Prause, Steele, Staley, Sabatinelli and Hajcak (2015) in their article in Biomedical Psychology, 108, 1192-199).
Infidelity: Non-consensual Extra Dyadic Sex (EDS)
To add infidelity as a common aspect of hypersexual behaviour is not correct, as infidelity has an additional component. This is deception, and doing HARM to others. Hypersexual behaviours are not necessarily harmful to others. This section is about those who are capable of developing emotional and psychological intimacy with a partner.
It is interesting that the term Sex Addiction is used AFTER an adulterer is caught and facing the consequences. Although I use the term porn addiction when relevant, I do not use the term sex addiction and not when discussing affairs as there is so much more to affairs than sex. First of all, there is the issue of a definition of an affair as it can be related to sex only, “romance” (an emotional affair) or both. It could be short term or long term. What affairs have in common is that they involve deception of the person’s significant other. This means that affairs are non-consensual interactions as those affected by it (the partners of the persons having an affair) have not been informed and have not consented to the interaction.
Affairs happen for a variety of reasons. The most important one is opportunity which is defined as money, status and an opportunity to have a secret rendezvous, which often means travel as most elicit affairs happen in hotel rooms. When those who have had affairs are asked why they did it, they often list egoistic reasons such as opportunity, feeling flattered, feeling wanted and excitement and the thrill of the “hunt” and the reward of the attention. Family life can be exhausting and having the responsibility of having a partner and children and the chores that goes with all of it can be a bit much for the selfish person who might find an escape under the disguise of “work” an attractive option to escape their responsibilities. That they leave their partner with all of it to deal on their own seems to be less of a concern to a person who lacks empathy and insight. This, however, is not an illness…this is a personality shortcoming!
At the time of their interaction with the affair partner, they do not consider the consequences and the hurt done to their partner and family. This means that rather than piling affairs under the heading “addiction”, we have to consider personality “disorders” that have as a commonality a lack of empathy and a tendency to be self-centered as well as a lack of insight in the harm their behaviour is causing their families. The one most frequently mentioned in relation to infidelity is a Narcissistic Personality Disorder (NPD). That the feeling of being wanted, desired and flattered might be addictive is a no brainer, but this is not enough to label the behaviour an addiction.