Return Home. "Differential Diagnosis of Addictive Sexual Disorders Using the DSM-IV" Sexual Addiction & Compulsivity 1996, Volume 3, pp 7-21, 1996.

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1 Return Home ABSTRACT "Differential Diagnosis of Addictive Sexual Disorders Using the DSM-IV" Sexual Addiction & Compulsivity 1996, Volume 3, pp 7-21, by Richard Irons, M. D. and Jennifer P. Schneider, M.D., Ph.D. The current Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) describes certain sexual disorders which are characterized by, or include among their features, excessive and/or unusual sexual urges or behaviors. Common disorders in the differential diagnosis include paraphilias, impulse disorder not otherwise specified (NOS), sexual disorder NOS, bipolar affective disorder, cyclothymic disorder, post-traumatic stress disorder, and adjustment disorder. Infrequent disorders in the differential diagnosis consist of substance-induced anxiety disorder, substance-induced mood disorder, dissociative disorder, delusional disorder (erotomania), obsessive-compulsive disorder, gender identity disorder, and delirium, dementia, or other cognitive disorder. Addictive sexual disorders which do not fit into standard DSM-IV categories can best be diagnosed using an adaptation of the DSM-IV criteria for substance dependence. The need for a classification of mental disorders has been clear throughout the history of medicine, but there has been little agreement on which disorders should be included and the optimal method for the organization. The many nomenclatures that have been developed during the past two millennia have differed in their relative emphasis on phenomenology, etiology, and course as defining features (DSM- IV, Introduction, p. xvi).the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III, 1980) represented a major advance in the diagnosis of mental disorders and greatly facilitated empirical research. The development of DSM-IV (1994) benefitted from the substantial increase in research on diagnosis that was generated in part by DSM-III and DSM-III-R. In DSM-IV, each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e. impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom. In addition, this syndrome must not be merely an expected and culturally sanctioned response to a particular event. Neither deviant behavior (e.g. political, religious, or sexual), nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual, as described above (DSM-IV, Introduction, p. xxi). When the DSM-IV categories, criteria, and textual descriptions are employed for forensic purposes, there are significant risks that diagnostic information will be misused or misunderstood. In most situations, the clinical diagnosis of a DSM-IV mental disorder is not sufficient to establish the existence for legal purposes of a "mental disorder," "mental disability," or "mental disease." In determining whether an individual meets a specified legal standard (e.g. for criminal responsibility or disability), additional information is usually required beyond that contained in the DSM-IV diagnosis. Even when diminished control over one's behavior is a feature of the disorder, having the diagnosis in itself does not demonstrate that a particular individual is (or was) unable to control his or her behavior at a particular time. The use of DSM-IV in forensic settings should be informed by an awareness of the risks and

2 limitations discussed above (DSM-IV, Introduction, pg xxiii). The descriptive term "sexual addiction" does not appear in the current Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Addiction professionals who encounter both compulsive and impulsive sexual acting-out behaviors in their patients have experienced paradigm and nomenclature communication difficulties with mental health professionals and managed care organizations who utilize DSM terminology and diagnostic criteria. This difficulty in communication has fueled skepticism among some psychiatrists and other mental health professionals regarding the case for including sexual addiction as a mental disorder. The goal of this paper is to familiarize addiction practitioners and counselors with how sexual behaviors involving sexual excesses, improprieties, and/or urges are categorized in the DSM-IV. It is our hope that this will encourage and permit more rigorous diagnostic classification of sexually troubled individuals by addiction professionals, demonstrate to mental health professionals that addictive sexual behaviors are indeed subsumed in various categories of the DSM-IV, and facilitate communication between all concerned parties. Current DSM Nosology The DSM-IV is written in clear language and easily understood by non-psychiatrists. For each disorder it provides a detailed description of its diagnostic features, subtypes if any, associated features and disorders, course of the illness, and differential diagnosis."differential diagnosis" refers to a list of all other disorders which might cause the same symptoms. After the detailed description of each disorder, there is a summary of the diagnostic criteria and sometimes a statement about how mlisted criteria must be present in order to make the diagnosis. The DSM-IV defines a mental disorder as "a clinically important collection of symptoms (these can be behavioral or psychological) that causes an individual distress, disability, or the increased risk of suffering pain, disability, death, or the loss of freedom." The DSM-IV follows the medical model of illness, meaning that it is a descriptive work derived from scientific studies of groups of patients who appear to have a great deal in common, including symptoms, signs, and life course of their disease (Morrison, p.8) Complete assessment of a patient according to the DSM-IV involves evaluation along five axes. Axis I diagnoses are clinical disorders, including cognitive disorders (such as delirium, dementia, and amnesia), mood disorders (such as depression or bipolar illness), anxiety disorders, schizophrenia and other psychotic disorders, substance-related disorders, dissociative disorders, sexual and gender identity disorders, eating disorders, sleep disorders, and impulse-control disorders. Axis II codes personality disorders and mental retardation. The former includes characterologic disorders and prominent maladaptive personality features. Disorders in this Axis may be considered the principal diagnosis. Axis III describes general medical conditions that are potentially relevant to the understanding or management of the individual's mental disorder. Axis IV is for reporting psychosocial and environmental problems that may affect the treatment and prognosis of mental disorders (such as financial, legal, and relationship problems), and Axis V scores the patient's current overall occupational, psychological, and social functioning, recorded as a single number on a scale from 1 to 100. Patients may have one or more diagnoses from any of the first three axes. The use of the multiaxial system facilitates comprehensive and systematic evaluation with attention to the entire person and their biopsychosocial environment, including the level of functioning which might be overlooked if the focus were on assessing a single presenting problem. A multiaxial system provides a comprehensive format for organizing and communicating clinical information, for capturing the complexity of clinical situations, and for describing the heterogeneity of individuals presenting with the same diagnosis. (DSM-IV, p.25)

3 It is important to note that notions of deviance, standards of sexual performance, and concepts of appropriate gender role can vary from culture to culture. The DSM-IV was extensively validated on American populations, and cannot be indiscriminately applied to other cultures. The provision of a culture-specific section in the DSM-IV text, the inclusion of a glossary of culture bound syndromes, and the provision of an outline for cultural formulation are designed to enhance the cross-cultural applicability of DSM-IV (DSM-IV, p.xxv). The DSM-IV mental disorders are grouped into sixteen major diagnostic classes, one of which is entitled Sexual and Gender Identity Disorders. The sexual disorders are subdivided into three categories, Sexual Dysfunctions, Paraphilias, and Gender Identity Disorders, as well as a catch-all category called Sexual Disorder Not Otherwise Specified (NOS). The Sexual Dysfunctions are characterized by disturbance in sexual desire and in the psychophysiological changes that constitute the sexual response cycle. These disturbances result in decreased sexual desire and/or performance and cause marked distress and interpersonal difficulty. Sexual Dysfunctions include Low Sexual Desire Disorders (Hypoactive Sexual Desire Disorder and Sexual Aversion Disorder), Sexual Arousal Disorders (Female Sexual Arousal Disorder and Male Erectile Disorder), Orgasmic Disorders (Female Orgasmic Disorder, Male Orgasmic Disorder, and Premature Ejaculation), and Sexual Pain Disorders (Dyspareunia, or genital pain during intercourse, and Vaginismus, or severe vaginal spasm which causes pain for a woman and interferes with penetration). There is also a group of Secondary and Other Sexual Dysfunctions, which include Sexual Dysfunction Due to a General Medical Condition, Substance-Induced Sexual Dysfunction, and a residual category, Sexual Dysfunction Not Otherwise Specified (NOS). The paraphilias are characterized by recurrent, intense sexual urges, fantasies, or behaviors that involve unusual objects, activities, or situations that occur over a period of at least six months and cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. For some individuals, paraphilic fantasies or stimuli are obligatory for erotic arousal and are always included in sexual activity; in other cases, the paraphilic preferences occur only episodically, while at other times the person is able to function sexually without paraphilic fantasies or stimuli. In contrast to the Dysfunctions, which are associated with decreased sexual functioning, the Paraphilias are commonly associated with increased sexual activity, often with compulsive and/or impulsive features. Paraphilic sexual activity revolves around fantasies, urges, or behaviors that are considered unusual or frankly deviant by society and generally involve (a) nonhuman objects or animals; (b) humiliation or suffering of the patient or partner, or (c) nonconsenting persons, including children. Even when such urges or fantasies are not acted upon, the level of distress may be sufficient to warrant a diagnosis; far more commonly, paraphiliacs have acted upon their desires many times before a diagnosis is made (Morrison, 1995, p. 360). Gender Identity Disorders (transsexualism), a third type of sexual disorder, are characterized by strong and persistent cross-gender identification accompanied by persistent discomfort with one's assigned sex. Transsexuals cross-dress to look like the other sex, not specifically for sexual stimulation. They may be sexually attracted to males, females, both, or neither. Sexual Disorder Not Otherwise Specified (NOS) is included for coding disorders of sexual functioning that are not classifiable in any of the specific categories. One of the three examples given for this disorder is "Distress about a pattern o repeated sexual relationships involving a succession of lovers who are experienced by the individual only as things to be used" (DSM-IV. 638). This diagnosis has historically been the most common one to be used for patients identified as sexual addicts. Addictive Sexual Disorders The range of fantasies, urges, and behaviors which can be considered addictive sexual disorders may be

4 appreciated by reviewing the ten categories developed by Carnes (1991): Table 1: Patterns and Themes of Sexual Addiction 1. Fantasy sex: Items focused on sexual fantasy life and consequences due to obsession. Themes include denial, delusion, and problems due to preoccupation. 2. Seductive role sex: Items focused on seductive behavior for conquest. Multiple relationships, affairs, and unsuccessful serial relationships. 3. Anonymous sex: engaging in sex with anonymous partners, having one-night stands. 4. Paying for sex: paying prostitutes for sex, paying for sexually explicit phone calls. 5. Trading sex: receiving money or drugs for sex or using sex as a business. Highly correlated were swapping partners and using nudist clubs to find sex partners. 6. Voyeuristic sex: Items focused on forms of visual sex, including pornography, window peeping, and secret observation. Highly correlated with excessive masturbation, even to the point of injury. 7. Exhibitionist sex: exposing oneself in public places or from the home or car; wearing clothes designed to expose. 8. Intrusive sex: touching others without permission, using position or power (e.g. professional, religious) to sexually exploit another person; rape. 9. Pain exchange: causing or receiving pain to enhance sexual pleasure. Use of dramatic roles, sexual aids, and animals were common themes. 10.Exploitive Sex: Use of force or partner vulnerability to gain sexual access. Five of Carnes' categories can be readily identified in the DSM-IV as specific paraphilias. These include voyeuristic sex, exhibitionistic sex, pain exchange (sexual sadism, sexual masochism), as well as some types of intrusive sex (frotteurism), and exploitive sex (pedophilia). Four of the remaining categories may be correlated with paraphilias: fantasy sex may be associated with paraphilic urges not acted upon, anonymous sex may be used to permit expression of paraphilic behavior with decreased risk of consequences, and paying for sex or trading sex are means by which a partner who may permit paraphilic activity may be purchased. Sexual improprieties and excesses that are considered addictive in nature can usually be classified into one of three major DSM-IV categories: Paraphilia (either one or more specifically identified in the DSM-IV or Paraphilia NOS), Impulse Control Disorder NOS, or Sexual disorder NOS. When the behavior does not fit easily into one of these categories, and is not considered a manifestation of some other DSM IV Axis I diagnosis, then it can be diagnosed a work-related problem or a relational problem, utilizing a V code on Axis I. Impulse-Control Disorders is another DSM-IV category which may include sexual behaviors. Some authors have considered compulsive sexual behavior to be essentially an impulse control disorder (e.g., Barth and Kinder (1987)). In our opinion, some cases of sexual excess represent an impulse-control disorder, whereas most cases are attributable to other DSM diagnoses which embrace the predominant compulsive features associated with sexual acting out. The essential feature of Impulse-Control Disorders is the failure to resist an impulse, drive, or temptation to perform an act that is harmful to the person or to others. The individual feels an increasing sense of tension or arousal before committing the act and then experiences pleasure, gratification, or relief associated with the activity. Following the sexual acting out, there may or may not be regret, self-reproach, or guilt.

5 The premier example of an Impulse-control disorder listed in the DSM-IV is Pathological Gambling (DSM-IV, p.618): Table 2: Diagnostic criteria for Pathologic Gambling A persistent and recurrent maladaptive gambling behavior as indicated by five (or more) of the following: (1) is preoccupied with gambling (preoccupation). (2) needs to gamble with increasing amounts of money in order to achieve the desired excitement. (tolerance) (3) has repeated unsuccessful efforts to control, cut back, or stop gambling (loss of control). (4) is restless or irritable when attempting to cut down or stop gambling (withdrawal symptoms). (5) gambles as a way of escaping from problems or of relieving a dysphoric mood (preoccupation). (6) after losing money gambling, often returns another day to get even ["chasing" one's losses] (loss of control) (7) lies to family members, therapist, or others to conceal the extent of involvement with gambling (continues despite adverse consequences) (8) has committed illegal acts such as forgery, fraud, theft, or embezzlement to finance gambling (adverse consequences). (9) has jeopardized or loss a significant relationship, job, or educational or career opportunity because of gambling (adverse consequences). (10) relies on others to provide money to relieve a desperate financial situation caused by gambling (adverse consequences). After each criterion we have appended what we consider the essential element which may be associated with an addictive disorder. It is instructive to compare this list with the DSM-IV criteria for a substancerelated disorder (DSM-IV, p.181): Table 3: Diagnostic Criteria for Substance Dependence A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period: (1) Tolerance, as defined by either of the following: a. A need for markedly increased amounts of the substance to achieve intoxication or desired effect. b. Markedly diminished effect with continued use of the same amount of the substance. (2) Withdrawal, as manifested by either of the following: a. The characteristic withdrawal syndrome for the substance b. The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms.

6 (3) The substance is often taken in larger amounts or over a longer period than was intended (loss of control). (4) There is a persistent desire or unsuccessful efforts to cut down or control substance use (loss of control). (5) A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects (preoccupation). (6) Important social, occupational, or recreational activities are given up or reduced because of substance use (continuation despite adverse consequences). (7) The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance. (adverse consequences). Note that although pathological gambling is classed as an Impulse-Control Disorder whereas Substance Dependence is an addiction, the criteria are in fact very similar. Both sets of criteria involve preoccupation, loss of control, continuation despite adverse consequences, development of tolerance with prolonged use, and withdrawal symptoms when use is stopped. Such overlap is also seen elsewhere in the DSM-IV, and accounts for some of the difficulty and disagreements clinicians sometimes have in diagnosing particular disorders. As stated above, the DSM-IV category of Sexual Disorder NOS specifically cites as an example the person who experiences a series of lovers only as things to be used. This category may therefore be correlated with addictive sexual behavior identified in the Carnes categories of anonymous sex, paying for sex, trading sex, and certainly seductive-role sex. What of other compulsive sexual behaviors which don't clearly fit into these categories, such as fantasy sex, seductive role sex, and compulsive masturbation? If they cause distress to the person, they can be diagnosed as Sexual Disorder NOS, which is defined as "a sexual disturbance that does not meet the criteria for any specific Sexual Disorder and is neither a Sexual Dysfunction nor a Paraphilia." It is, however, instructional to see how such behaviors fit the diagnostic criteria for substance-related disorder as shown in Table 3. Based on his observation of patients with compulsive sexual behavior as well as on the similarities between pathological gambling and addictive use of a substance, Goodman (1990) suggested a list of criteria for any addictive disorder: Table 4: Criteria for Addictive Disorder A. Recurrent failure to resist impulses to engage in a specified behavior. B. Increasing sense of tension immediately prior to initiating the behavior. C. Pleasure or relief at the time of engaging in the behavior. D. At least five of the following: 1. Frequent preoccupation with the behavior or with activity that is preparatory to the behavior. 2.Frequent engaging in the behavior to a greater extent or over a longer period than intended. 3. Repeated efforts to reduce, control, or stop the behavior.

7 4. A great deal to time spent in activities necessary for the behavior, engaging in the behavior, or recovering from its effects. 5. Frequent engaging in the behavior when expected to fulfill occupational, academic, domestic or social obligations. 6. Important social, occupational, or recreational activities given up or reduced because of the behavior. 7. Continuation of the behavior despite knowledge of having a persistent or recurrent social, financial, psychological, or physical problem that is caused or exacerbated by the behavior. 8. Tolerance: need to increase the intensity or frequency of the behavior in order to achieve the desired effect, or diminished effect with continued behavior of the same intensity. 9. Restlessness or irritability if unable to engage in the behavior. E. Some symptoms of the disturbance have persisted for at least one month, or have occurred repeatedly over a longer period of time. According to Goodman's definition, any behavior that is used to produce gratification and to escape internal discomfort can be engaged in compulsively and can constitute an addictive disorder. Substance dependence, Impulse-Control Disorder, and Obsessive-Compulsive Disorder all include these elements. Schneider (1994) summarized the key elements of any addictive disorder as loss of control, continuation despite adverse consequences, and preoccupation or obsession. As stated above, there is significant overlap among DSM-IV diagnostic criteria, so it is possible for a single disorder to fit more than one diagnostic category. Some cases of compulsive sexual behavior may fit into the Impulse-Control Disorder NOS and Sexual Disorder NOS, as well as fulfill the criteria for an addictive disorder. To remain within DSM terminology, Irons and Schneider (1994) code the results of Irons' assessments using Paraphilia (either one or more specifically identified in the DSM-IV, or Paraphilia NOS), Impulse Control Disorder NOS, or Sexual Disorder NOS, but always with the inclusion of appropriate and relevant descriptors. Frequently addictive features are present. Other descriptors used include assaultive, compulsive, dissociative, ego dystonic, ego syntonic, exploitive, paraphþ꺫þ Ðtandard for diagnostic criteria and the classification of mental disorders which may result in out-ofcontrol sexual thoughts and acting out. Rather than attempting to fit all cases into one model, addiction treatment professionals need to be know þ꺫þ ÐÆ[YW ø ÿá D Ygn W e TÉ Ç<Ù} bé B 0e Ö`ñÊ ŽÆ[ W 0e Ö ŽÆ[ Wªª Oÿÿ öù " )Úledgeable about the spectrum of mental disorders that may be associated with sexuaor addictive disorder. The complete differential diagnosis is presented in Table 5; some of the disorders will be discussed below. Table 5: Axis I Differential diagnosis of excessive sexual behaviors Common: Paraphilias Sexual disorder NOS Impulse control disorder NOS Bipolar affective disorder (type I or II) Cyclothymic disorder

8 Post-traumatic stress disorder Adjustment disorder [disturbance of conduct] Infrequent: Substance-induced anxiety disorder [obsessive-compulsive symptoms] Substance-induced mood disorder [manic features] Dissociative disorder Delusional disorder [erotomania] Obsessive-compulsive disorder Gender identity disorder Delirium, dementia, or other cognitive disorder. Among the common diagnoses we have not yet discussed, manic-depressive illness, now called bipolar affective disorder, is frequently characterized by sexual excesses in the manic phase. According to the DSM-IV (p ), "The expansive quality of the mood is characterized by unceasing and indiscriminate enthusiasm for interpersonal, sexual, or occupational interactions...the increase in goaldirected activity often involves excessive planning of, and excessive participation in, multiple activities (e.g. sexual...) Increased sexual drive, fantasies, and behavior are often present." Cyclothymic disorder can be viewed as a scaled-down version of bipolar illness. Its essential feature is a chronic, fluctuating mood disturbance involving numerous periods of hypomanic symptoms and numerous periods of depressive symptoms. Hypersexuality may be seen during the hypomanic periods. Substance-induced mood changes such as anxiety or euphoria may result in sexual preoccupation and activity, which can be then considered secondary to the substance use rather than an independent diagnosis. The challenge often is to sort out the role of the chemical use in the sexual compulsivity. For example, Washton (1989) reported that 70% of patients enrolled in his outpatient cocaine addiction treatment center exhibited sexual compulsivity. He found that some of these patients had had no sexually addictive behaviors prior to cocaine use, and had no difficulty with sexual excess once cocaine use was stopped; clearly their sexual behaviors were secondary to cocaine abuse. Other patients, who showed evidence of an addictive sexual disorder antedating their cocaine use, clearly have two separate addictions. Still others found it difficult to stop their compulsive sexual behaviors after stopping cocaine use and form a gray area; their addictive sexual disorder may have originally been secondary to cocaine use, but seemed to have taken on a life of its own and needed to be treated in its own right. Just as mood-alteration by chemicals can affect a person's sexuality, so can cognitive disorders. Dementia and delirium result in loss of the ability to judge the appropriateness of various behaviors; public masturbation, inappropriate sexual touching, and uninhibited language may be expressions of the altered social awareness. Obsessive-Compulsive Disorder (OCD, which must be differentiated from a separate, Axis II, diagnosis of Obsessive-Compulsive Personality Disorder), has as its essential features (DSM IV, p ) "recurrent obsessions or compulsions that are severe enough to be time consuming or cause marked distress or significant impairment. At some point during the course of the disorder,the person has recognized that the obsessions or compulsions are excessive or unreasonable...the most common obsessions are repeated thoughts about contamination, repeated doubts... and sexual imagery (e.g. a

9 recurrent pornographic image... The individual with obsessions usually attempts to ignore or suppress such thoughts or impulses or to neutralize them with some other thought or action (i.e., compulsion... Compulsions are repetitive behaviors (e.g., handwashing, ordering, checking) or mental acts the goal of which is to prevent or reduce anxiety or distress, not to provide pleasure or gratification". Some sexologists, such as Eli Coleman (1990), consider sexual compulsivity to be a variant of OCD. We agree that sexual obsessions may be an aspect of OCD. However, when compulsive sexual behavior is the primary disorder, the DSM-IV (p ) specifically rules out the diagnosis of OCD. It says, "Some activities such as eating (e.g. Eating Disorders), sexual behavior (e.g. Paraphilias, gambling (e.g. Pathological Gambling), or substance use (e.g. Alcohol Dependence), when engaged in excessively, have been referred to as 'compulsive.' However, these activities are not considered to be compulsions as defined in this manual because the person usually derives pleasure from the activity and may wish to resist it only because of its deleterious consequences." When sexual or seductive (romantic) behavior is the focus of obsessive mental activity, is neither acted upon nor produces gratification, and is causing significant distress, then it may meet the criteria for OCD. In our experience, such rare cases are associated with nonsexual behavioral manifestations of OCD. Delusional disorder is the presence of one or more nonbizarre delusions that persist for at least a month. Apart from the direct impact of the delusion, the person's behavior appears normal and their psychosocial functioning is not markedly impaired. The delusion may be of being a prominent person or having a special relationship with such a person, or that the patient's spouse or lover is unfaithful, or that the patient is being conspired against, or that the patient has an infestation of insects on the skin or a bad odor. In the erotomanic type of delusional disorder (DSM-IV, p.197), "the central theme of the delusion is that another person is in love with the individual. The delusion often concerns idealized romantic love and spiritual union rather than sexual attraction. The person about whom this conviction is held is usually of higher status, but can be a complete stranger." Completing the Diagnosis of Addictive Sexual Disorders Developing a systematic way of completing a comprehensive DSM diagnosis will facilitate communication with mental health professionals as well as third-party payors. It is helpful to complete the differential diagnosis on Axis I before considering Axes II and III. Sexual disorders, impulse control disorders and paraphilias, when identified, should be described as precisely as possible. If the NOS category is utilized, then it is important to use appropriate descriptors that define the features seen. For example, a lawyer who has exhibited a pattern of sexual involvement with his clients might be diagnosed with "Sexual Disorder NOS with Addictive and Exploitative Features." The severity of the disorder, duration, current level of activity, and amenability to treatment should also be recorded. In the differential diagnosis of sexual improprieties and excesses, Axis II characterologic disorders and traits are often contributory, or may be considered the primary etiology of paraphilic sexual behavior. For example, narcissistic personality disorder is associated with a person who has a grandiose sense of selfimportance, a sense of entitlement, requires excessive admiration, believes he or she is "special," unique, and can only be understood by other special people, is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love, is interpersonally exploitative, lacks empathy, is often envious of others or believes others are envious of them, and shows arrogant, haughty behaviors or attitudes. Such an individual may readily view another person as an object to be used for one's own sexual pleasure. Although these personality characteristics may be seen as defects of character than can be resolved over time through unconditional surrender and dedication to a twelve-step program of recovery, some individuals are "unfortunates" -- and remain naturally incapable of grasping and developing a manner of living which demands rigorous honesty (AA Big Book, p. 58). Such constitutional incapability is the essence of sexual excess that should be relegated to the primary diagnosis of a personality disorder. Conclusion

10 The DSM-IV is our current standard for diagnostic criteria and the classification of mental disorders which may result in out-of-control sexual thoughts and acting out. Rather than attempting to fit all cases into one model, addiction treatment professionals need to be knowledgeable about the spectrum of mental disorders that may be associated with sexual fantasy, urges, and behaviors. Even when the term sexual addiction is the most straightforward identification, and the one best received by the patient, the DSM-IV must be utilized for organizing, thinking about, and reporting the diagnosis. REFERENCES Alcoholics Anonymous, Third Edition, New York: Alcoholics Anonymous World Services, Inc. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Washington, D.C. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition, Washington, D.C. Barth, RJ and Kinder, BN, The mislabeling of sexual impulsivity. J. Sex Marital Therapy 13(1): Carnes, Patrick, Don't Call it Love. New York: Bantam. Coleman, Eli, The obsessive-compulsive model for describing compulsive sexual behavior. Amer. J. Prev. Psychiatr. Neurol 2:9-14. Goodman, Aviel, Addiction: Definition and implications. Brit J Psychiatry 85: Irons, Richard, and Schneider, Jennifer, Sexual addiction: Significant facor in sexual exploitation by health care professionals. Sexual Addiction Compulsivity 1(3): Morrison, James, DSM-IV Made Easy: The Clinician's Guide to Diagnosis. New York: Guilford Press. Schneider, Jennifer P., Sexual addiction: Controversy in mainstream addiction medicine, DSM-III- R diagnosis, and physician case histories. Sexual Addiction & Compulsivity 1(1): Washton, Arnold, Cocaine may trigger sexual compulsivity. US J Drug Alcohol Depend 13(6):8. Comments to jennifer@jenniferschneider.com