A biopsychosocial view of sex addiction – Part 1

As readers may be well aware now we advocate a biopsychosocial view of all addictions and addictive behaviours and our  biopsychosocial theory of addictve behaviour is briefly covered here  About.Paul Henry and in the footer section at the bottom  of this blogsite page.

Given this, we were thus interested and glad to see find this biopsychosocial view of sex addiction from a couple of years ago.

There are not enough  biopsychosocial views of addiction out there which means theories of addiction are usually too narrow in their scope, either too narrow in concentrating purely on neurobiology or neural mechanisms or too purely psychological or with too much emphasis on social factors which seems to have come into vogue again. When alcoholism is at least 50% genetic inheritance it is obviously too simplistic, if not naive to say societal factors are the sole reasons for addiction.

We believe that theories of addiction, which rely on impaired neurobiological explanation and not on how these impairments are mediated by stress/emotion dysregulation and resultant cognitive distortions are limited.

These affective difficulties, we believe,  by prompting distress based impulsivity, heighten reward sensitivity to certain behaviours, and shape the decision making impairments that set in motion and sustain the addiction cycle.

We also incorporated both psychological and psycho-analytic views of addiction, as has the article we cite below (1),  such as those which suggest addiction is partly caused by insecure attachment to primary caregivers and environmental issues such as child maltreatment in families into a bio-psycho-social approach.

We believe societal/cultural factors also play an important role (and in recovery too).

We combine these models into a unified model of addiction which posits that impaired genetic expression in the fertile ground of maltreatment creates deleterious effects on the stress/emotional circuitry of the brain, emotion processing and regulation, which result in persistent errors of thinking and the heightened reward sensitivity.

Initially the majority of people with addictive behaviours use substances/behaviour to regulate emotion, distorted thinking and to escape negative self schemata.

This perpetuates the addiction cycle via substance abuse, to cope with increasingly negative emotions and thoughts, to the endpoint of addiction, characterized by chronic emotional dysregulation whereby emotional distress acts as a stimulus to automatic responding of compulsive addictive behaviours; to relieve chronic distress not to induce pleasure.

Anyway that is our model and here is another ( 1)

“The biopsychosocial model, first theorized by psychiatrist George L. Engel at the University of Rochester in 1977, has been a useful paradigm for exploring a number of different psychosexual difficulties. The key advantages are that it allows us to expand our thinking beyond the traditional medical model into psychological considerations and further into the societal context and construct of the perceived problem. Another advantage is that it enables us, as therapists and clinicians, to focus on the client as an individual, rather than on our preferred theoretical model or personal understanding.

As Watson and Vidall (2011) rightly said in a previous issue of this journal, ‘‘it is very likely that a client will not stop buying sex or using drugs for that matter, if they are unaware of the underlying relational mechanisms driving such behaviours’’ (p. 65). In addition, I would add that it’s unlikely that a client will change their behaviour without having explored and understood why it is a problem to them…

When looking at addiction generally, it is important to note that there are many different theories from a variety of perspectives including medical, psychological and sociocultural. Biopsychosocial views have increased in popularity (DiClemente, 2003; Perkinson, 1997; Ray & Ksir, 2004) and these new views allow addiction to be understood and treated in a more holistic way with regard to how the person becomes involved in addictive behaviour, stays involved in addictive behaviour and stops the addictive behaviour. Sex addiction has also been viewed through this lens before by Charles Samenow (2010), whose recent paper was published in the American journal, Sexual Addiction & Compulsivity.

The biology of sex addiction Exploring the biological components of any problem may be construed as medicalising or falling into the trap of biological reductionism. Therefore it is important to stress that highlighting the physiological aspects of a problem does not necessarily undermine any other essential elements. Indeed, given the neuroplasticity of the brain, biology is inseparable from psychosocial aspects of life anyway, as we will see when we consider the ways in which our development and experience impact on brain chemistry and physiology. For many clients and clinicians, an understanding of the biology, and especially the neurobiology, of sex addiction can provide legitimacy for the psychological and emotional components. In my experience, sharing our biological understanding of sex addiction with clients can considerably reduce feelings of shame and confusion.

…there are a number of circulating hypotheses that are currently under investigation.

Dopamine dysregulation

It is now clinically understood that the common denominator in all addictions is dopamine (Robbins & Everitt, 2010). Dopamine is the neurochemical responsible for the experience of reward and pleasure and is naturally stimulated by eating, drinking and having sex. From an evolutionary point of view, dopamine is essential for our survival as it motivates us to continue to feed and reproduce. Dopamine can be similarly heightened through cognitive anticipation and fantasy, which is perhaps why so many of us enjoy cookery programmes as well as pornography!

Brain development There is growing evidence from neuroscience that deprivation of empathic care in early childhood creates a growth-inhibiting environment that produces immature,  physiologically undifferentiated orbitofrontal affect regulatory systems (Schore, 2003). A child who does not receive its needs for attention, soothing, stimulation, affection and validation may find the consequences structurally written into their developing brain. The altered prefrontal function is associated with high risk of drug and alcohol addiction (Bechara & Damasio, 2002; Franklin et al., 2002; Goldstein, Volkow, Wang, Fowler, & Rajaram, 2001) and research from Carnes (1991) also found a high amount of neglect in his sample of sex addicts. Hudson Allez (2009) proposes an explanation for this, saying that the insecure attachment template is not able to produce its own endogenous opiates and therefore individuals will reach for external opiates to stimulate their dopamine pathways in order to stimulate the pleasure centres and reduce the pain. Additionally, for the insecurely attached individual, the orbitofrontal area of the cortex may no longer produce sufficient dopamine or noradrenaline to facilitate sexual excitation and inhibition and, therefore, an external source may become increasingly relied upon for something that the brain has not learnt to manufacture for itself.

When a sex addict has experienced childhood trauma, it has been suggested that the addiction is not necessarily a pleasure seeking strategy but a survival strategy (Fisher, 2007). Van der Kolk (1996) found that the imprint of the trauma is located in the limbic system and in the brainstem – in our animal brains, not our thinking brains – and the amygdala, responsible for ‘‘fight and flight’’ may remain hypersensitive long after the trauma has passed. And indeed, long after any conscious memory of the trauma has passed. This hypersensitive amygdala may be triggered by any number of external sources throwing the body’s sympathetic nervous system into hyper-arousal, or the parasympathetic system into hypo-arousal and temporarily by-passing the thinking part of the brain. Sexual behaviour may become a way for a trauma sufferer to numb feelings of hyper-arousal such as hyperactivity, obsessive thinking, rage and panic and also alleviate feelings of disassociation, numbness, depression and exhaustion experienced in hypo-arousal. In short, it is thought that addictive behaviours can become an effective technique to regulate the nervous system (Fisher, 2007).

The psychology of sex addiction

There are numerous psychological factors that feed into addiction processes and into the development and continuation of sexual addiction. An understanding and exploration of the emotional and cognitive influences are important for ensuring that treatment moves beyond biological symptom relief and change, to the deeper psychological processes that can both cause and drive the unwanted behaviours. I hope that grouping the most common psychological experiences under the main therapeutic approaches will be a helpful way of presenting these issues, although inevitably there are crossovers. One notable common denominator throughout each theory is the role of shame in sexual addiction. Shame has been highlighted by many clinicians from varying viewpoints as a key influence in sex addiction and it is likely to arise in every modality since it may be experienced and endorsed personally, relationally and societally. The latter is explored under social influences.

Part 2 tomorrow!

TBC

References

1. Hall, P. (2011). A biopsychosocial view of sex addiction. Sexual and Relationship Therapy, 26(3), 217-228.