We have in previous blogs discussed how substance addiction seems to have emotional processing and regulation deficits at the heart of their manifestation and act as pathomechanisms in propelling these disorders to eventual  chronicity.

In the next series of blogs we will be discussing whether fundamental emotional processing and regulation deficits are common to (or intrinsic to the aetiology of) other addictive disorders too).

First up, we discuss emotional (or otherwise known in research as affective) dysregulation in those with Hypersexual Disorder or more commonly know to lay persons as sexual addiction.

Hypersexual Disorder – the proposed diagnostic criteria that were given consideration for the Diagnostic and Statistical Manual of Mental Disorder Fifth Edition (DSM-5) characterize hypersexual disorder (HD) (1) which is commonly known as sexual addiction.

This study (1) states that HD is a phenomenon involving repetitive and intense preoccupation with sexual fantasies, urges, and behaviors, leading to adverse consequences and clinically significant distress or impairment in social, occupational, or other important areas of functioning (Bancroft, 2008; Kafka, 2010; Kaplan & Krueger, 2010; Marshall & Briken, 2010; Reid, Garos, & Fong, 2012).

Patients seeking help for HD typically experience multiple unsuccessful attempts to control or diminish the amount of time spent engaging in sexual fantasies, urges, and behaviors in response to dysphoric mood states or stressful life events (Kafka, 2010).

Personality characteristics such as proneness to boredom (Chaney
& Blalock, 2006), impulsivity and shame (Reid, Garos, & Carpenter, 2011), interpersonal sensitivity, alexithymia, loneliness, and low self-esteem also have been observed in association with hypersexual behavior (Reid, Dhuffar, Parhami, & Fong, 2012; Reid, Stein, et al., 2011; Reid, Carpenter, Spackman, & Willes, 2008). Collectively, these  characteristics create significant challenges for hypersexual patients.

The importance of finding effective treatments for HD cannot be underestimated given the gravity of its consequences (Reid, Garos, et al., 2012): Hypersexual patients are at increased risk for loss of employment, legal problems, social isolation, higher rates of divorce (Reid & Woolley, 2006; Reid, Carpenter, Draper, & Manning, 2010; Zapf, Greiner, & Carroll, 2008),
and sexually transmitted infections (Coleman et al., 2010; Dodge, Reece, Cole, & Sandfort, 2004; Rinehart & McCabe, 1997, 1998).

This study found (1) significant associations between unpleasant emotions, impulsivity, stress proneness, and hypersexuality replicating findings
noted in other studies (Reid et al., 2008; Reid, 2010). The findings in this study also offer some support for the DSM-5 proposed classification
criteria for HD (Kafka, 2010). Specifically, stress and emotional dysregulation have been hypothesized as precipitating and perpetuating risk factors for hypersexuality, and, accordingly,  correlations to reflect this relationship, were consistent with findings of this study (1).

Another study (2) looked at  investigating alexithymia, emotional instability, and vulnerability to stress proneness among individual seeking help for hypersexual behavior. Findings (2) provide evidence for the hypothesis that individuals who manifest symptoms of hypersexual behavior are more likely to experience deficits in affect regulation and negative affect (including
alexithymia,  depression, and vulnerability to stress).

An increasing number of individuals are seeking help for hypersexual behavior related to a constellation of symptoms that reflect difficulties in regulating sexual thoughts, feelings, and behaviors.

This study’s (2) conceptualization of this phenomenon keys on behavior dysregulation as manifest through exaggerated frequency and focus on sexual behavior (from sexual activity with partners, to use of pornography, sexual fantasy, or other erotic stimuli, to excessive masturbation).

Hypersexual behavior may include a sense of being out of control or a history of failed attempts at increased control, and it encompasses elements common to other psychiatric dysfunctions, such as impaired functioning in aspects of daily living, subjective distress, and deficits in coping strategies for addressing uncomfortable affective experiences (e.g., anxiety reduction), usually because of over reliance on sexual behavior as a means of affective regulation and relief. Many patients presenting with hypersexual behavior also report incongruence between their values and beliefs and their sexual behavior.

This study, used the definition of Reid and Woolley (2006) was used
to operationalize hypersexual behavior as: difficulty in regulating (e.g., diminishing or inhibiting) sexual thoughts, feelings, or behavior to the extent that negative consequences are experienced by self or others. The behavior causes significant levels of personal or interpersonal distress and may include activities that are incongruent with personal values, beliefs, or desired goals. The behavior may function as a maladaptive coping mechanism (e.g., used to avoid emotional pain or used as a tension-reduction activity)…. (p. 220)

“It may be that such persons possess deficits in affective regulation similar to those encompassed by the constructs of alexithymia and neuroticism. . It
is plausible that such deficits would influence exaggerated sexual behavior
in some persons (e.g., in the absence of other coping strategies for successful affective monitoring and regulation, the stress-reduction aspects of sexual behavior as a substitute may be powerfully reinforced).

Adams and Robinson (2001), as well as others (e.g., Schwartz & Masters,
1994; Wilson, 2000), have theoretically postulated that hypersexuality represents a compensatory behavior that attempts to alleviate symptom distress associated with problems of affect regulation. A similar theory among individuals with eating disorders was advanced by Heatherton and Baumeister (1991), who argued that motivation for binge eating emerged as an attempt to escape from negative appraisals associated with self-awareness and unpleasant mood states triggered by stressful events.
It can be reasonably argued that sexual activity provides a mood-altering experience enabling individuals to disassociate from uncomfortable, awkward, or unpleasant emotions (Quayle, Vaughan, & Taylor, 2006).

The power of sexual experience to shield one from negative emotions, then, probably arises from sexual arousal’s inherent ability to create intense focus on the competing state of pleasurable arousal, as well as the release of tension associated with orgasm. Furthermore, some individuals may find that fantasizing about sexual activity provides a greater distraction than partnered activity because it encourages—and maybe even requires— disconnect from relationships with their inherent problems, challenges, and complexities.

One plausible way to understand hypersexuality is seeing behaviors associated with reward, distraction, or soothing—such as overeating, exaggerated focus on somatic complaints, substance abuse, or hypersexuality—as being particularly likely in those for whom emotional distancing has high priority. This need for emotional distance can arise from increased stress proneness, negative affective states, emotional pain associated with unresolved trauma, or the inability to develop and form secure attachment bonds.

Our clinical impressions of patients displaying hypersexuality, as defined above, are consistent with those of other researchers who have suggested that alexithymic individuals seek tension reduction from uncomfortable or unpleasant emotions (Keltikangas-Jarvinen, 1982; Kroner & Forth,
1995; Zimmermann, Rossier, de Stadelhofen, & Gaillard, 2005), thereby contributing to their eating disorders (Corcos et al., 2000; Larsen, van Strien, & Eisinga, 2006), substance abuse (Haviland, Hendryx, Shaw, & Henry, 1994),
and the like. Our rationale for suggesting associations of stress vulnerability, emotional instability, and alexithymia with hypersexual behavior also stems, in part, from our own observations of poor affect regulation and deficits in stress management among these patients.

Research supports some associations between alexithymia and stress. For instance, high, as compared to low, alexithymic individuals show different cardiovascular response to stress (e.g., Linden, Lenz, & Stossel, 1996).

The findings  support our hypothesis that alexithymia, emotional instability,
and vulnerability to stress are associated with the severity of hypersexual
behavior. More specifically, it appears that patients who present with more
profound levels of hypersexual behavior are more depressed, alexithymic,
and prone to stress.

These findings are consistent with our theoretical conceptualization of
emotional instability among individuals with hypersexual behavior. Our clinical impressions suggest this population struggles with uncomfortable, awkward, or unpleasant affective states, and in fact, these data indicate that they also experience the prevalence of such emotions in greater proportions than those found in normal populations.

Many of the subjects in the present study displayed emotional deficits and a paucity of emotional awareness. Queries about feelings in therapy would often elicit a response such as “I don’t know” or “I’m not feeling anything.” – otherwise know as emotional differentiation and discussed recently in another blog. 

Our clinical impressions of hypersexual patients suggest that many of
these individuals habitually entertain negative self-appraisals that are likely
influenced by attention bias which seeks evidence in daily experiences to
confirm irrational beliefs (I’m unlovable, worthless, etc.). Additionally, many
of these patients devote time to maintaining facades and implementing strategies of impression management that may further disconnect them from their authentic self, including their genuine emotions. Patients desperately desire external validation by others and privilege such adulation while marginalizing subjective positive perceptions about the self. Unable to control and predict the reactions of others, patients vacillate along a continuum of emotional instability. Negative appraisals by others become threats to their sense of self-worth, and such criticisms often result in disavowing aspects of the self. Specifically, the patients disconnect from undesirable emotional states.

The function of sexual activity in these instances is stress reduction and escape from or avoidance of uncomfortable and unpleasant affective experiences attributable to difficulties in their interpersonal relationships and other challenges in daily living.

References

1.  Reid, R. C., Bramen, J. E., Anderson, A., & Cohen, M. S. (2014). Mindfulness, emotional dysregulation, impulsivity, and stress proneness among hypersexual patients. Journal of clinical psychology, 70(4), 313-321.

2.  Reid, R. C., Carpenter, B. N., Spackman, M., & Willes, D. L. (2008). Alexithymia, emotional instability, and vulnerability to stress proneness in patients seeking help for hypersexual behavior. Journal of Sex & Marital Therapy, 34(2), 133-149.