Monday October 15 2012
Sexual disorders cause distress to those affected
"Sex addiction IS a real disorder," claims the Daily Mail. The newspaper's story is based on a study assessing the accuracy of a proposed new medical diagnosis, called hypersexual disorder.
Hypersexual disorder (HD) is a term used to describe a number of related symptoms. These include spending excessive time engaged in sexual fantasies and urges or in planning for and engaging in sexual behaviour. This preoccupation then causes significant personal distress or impairment to social life or occupation.
While this model was well received, it has not yet been formally established as a psychiatric disorder. Specifically, hypersexual disorder has not yet been added to the proposed text of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). This is the definitive work listing all recognised mental health conditions. DSM-5 is due to be published in 2013.
In the study, researchers interviewed more than 200 patients who were referred to mental health clinics for a number of conditions including HD. The interviewers were not aware why patients had been referred, but their interviews were designed to reflect the proposed new criteria for HD. The study found that the interviewers were generally in agreement about which patients had HD, and that the proposed new criteria accurately reflected the problems patients reported. The study suggests that the proposed ‘symptoms checklist’ for HD is a useful tool.
These sorts of reality checks are important parts of research into sexual problems, which, despite sniggering in some sections of the media, can cause considerable distress to those affected.
Where did the story come from?
The study was carried out by researchers from the University of California, Brigham Young University, the University of North Texas, Texas Tech University and Temple University. There is no information about external funding.
The study was published in the peer-reviewed Journal of Sexual Medicine.
Predictably, the Mail sexed up its story using a photo of self-confessed “sex addict” Russell Brand and a description of sex addiction as something that has “traditionally been written off as an ‘excuse’ for philandering celebrities”.
The paper is incorrect to call hypersexual disorder an addiction. It has not been classified as such. The definition of addiction normally includes an element of physiological dependence.
It would be more accurate to describe hypersexual disorder as a type of personality disorder. Personality disorders are conditions in which distorted patterns of thinking can lead to unusual, and often self-destructive, behaviour.
What kind of research was this?
This was a field trial, which means research conducted in a “real” situation, in this case psychiatric clinics. The researchers say that patients seeking help for HD are typically unable to control the amount of time they spend engaging in sexual fantasies, urges and behaviours, including masturbation, pornography, cybersex, telephone sex and strip clubs.
Hypersexual disorder, the researchers say, causes significant personal distress and impairs patients socially and professionally. Although descriptions of hypersexual behaviour have existed for a long time, psychiatrists have only recently acknowledged it may be a clinical disorder rather than a normal variant of sexual expression.
A new diagnosis for hypersexual disorder has been proposed for the Diagnostic and Statistical Manual of Mental Disorders, the comprehensive classification of mental health disorders, published by the American Psychiatric Association. Updated at regular intervals, the DSM is used by mental health professionals worldwide. Some doctors have proposed that hypersexual disorder be included as a new diagnosis in the next edition (DSM-5).
What did the research involve?
The research included 207 patients aged 18 and over, randomly selected from various psychiatric clinics in the US that provide treatment for hypersexual disorder, psychiatric conditions and substance-related disorders. Of these patients, 152 were referred for hypersexual disorder.
The interviewers were 13 individuals from a broad range of backgrounds including psychiatrists, psychologists, social workers, marriage and family therapists, and postgraduate clinical psychology students. This diversity, say the researchers, was designed to reflect the broad range of professionals who use the DSM in their clinical practice. About half the team had not worked with hypersexual patients before the trial.
None of the team knew what the patients had been referred for. They all received training in conducting a diagnostic psychiatric interview and also listened to several recorded interviews where questions were designed to reflect the new criteria for hypersexual disorder (called the HD diagnostic clinical interview or HD-DCI).
All patients first underwent a standard psychiatric interview and each then had a detailed interview with one of the team, aimed at assessing whether they had hypersexual disorder. The questions were phrased to mirror closely the proposed new diagnostic criteria. During the first week of the study, patients also completed a number of self-report measures also designed to reflect the new criteria, to help assess their validity.
For each interview, two “raters” were usually present who were blinded to each other’s ratings. One rater conducted the interview while the other observed.
Two weeks after the initial interviews, a third rater repeated the HD-DCI interview with each patient.
Researchers then looked at how far the different raters agreed with each other on the diagnosis of hypersexual disorder and, in a subset of 32 patients, they also looked at whether diagnoses from the second test, two weeks later, matched the original diagnoses. They applied various standard statistical tests to assess whether the diagnostic criteria were valid and reliable.
What were the basic results?
The researchers say that:
- Inter-rater reliability (IRR) was high, at 93%. This means that interviewers mostly agreed on whether patients met the diagnostic criteria for hypersexual disorder (0.93, 95% confidence interval 0.78 to 1).
- The test–retest reliability was high, with 29 of 32 cases resulting in agreement.
- Sensitivity (the proportion of patients referred for hypersexual disorder who were correctly identified) and specificity (the proportion of patients referred for something else other than hypersexual disorder who were correctly identified) showed the new criteria for hypersexual disorder accurately reflected the problems patients had been referred for.
- Patients assessed for hypersexual disorder also reported a “vast array” of negative consequences for hypersexual behaviour that were “significantly greater” than those diagnosed with either a general psychiatric condition or a substance-related disorder. These included job loss, loss of a romantic relationship, legal and financial problems.
How did the researchers interpret the results?
The researchers point out that this is the first publication of a DSM-5 field trial for the proposed new diagnosis of hypersexual disorder. It found that the new criteria appear to demonstrate high reliability and validity when applied to patients in a clinical setting, using a group of raters with modest training on assessing hypersexual disorder.
The study of hypersexual disorder is an area of growing interest within the field of mental health and sexual medicine (and of course will be of interest to the press). This study seems to show that the proposed diagnostic criteria reflect the problems patients have in this area and also that they are workable in practice. Further research is needed to confirm these criteria and also on the issue of how hypersexual disorder might best be treated.
One potential weakness of the study is the use of self-report measures and diagnostic structured interviews, which may lack the reliability of more objective measures. Ideally, these sorts of studies are repeated in populations where the disorder is uncommon so that the extent of any false positives or wrong diagnoses can be assessed in a sample more typical of an un-referred healthy community.
If you are concerned that you may have an obsessive and unhealthy attitude towards sex that is adversely affecting your life, there are several treatments available, such as the talking therapy cognitive behavioural therapy. Read more about treating sex addiction.
Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on twitter.