This is the second and last of a two-part series that discusses the differences between sex addiction and Obsessive-Compulsive Disorder (OCD).
In part 1 of this series, we discussed the growing interest in sex addiction in the wake of recent revelations that Tiger Woods has had a wealth of mistresses. We also discussed how many people, including professional psychotherapists, inappropriately conceive of sex addiction as a form of Obsessive Compulsive Disorder (OCD). Finally, we reviewed the inherent experiential differences between these two conditions, as well as the innate problem of trying to treat sex addiction using therapeutic techniques known to be effective for the treatment of OCD.
In light of the significant differences between these two conditions, it seems clear that sex addiction is not OCD. So what is it?
Sex Addiction as a Diagnosis
The Diagnostic and Statistical Manual – 4th Edition, (DSM-IV), which is published by the American Psychiatric Association (APA), currently has no specific diagnosis for sex addiction. However, in its recent proposal for revisions planned for the upcoming DSM-5, the APA has suggested that “Hypersexual Disorder” be included in the category of Sexual and Gender Identity Disorders. This would put it on par with other sexual disorders currently listed in the DSM-IV, including Erectile Dysfunction, Premature Ejaculation, Hypoactive Sexual Disorder, Dyspareunia, and Vaginismus, all of which are disorders of functioning. In other words, these conditions tend to be descriptive of specific ways in which sexual organs or processes are not functioning properly, resulting in limited, difficult, or even impossible sexual activity. In fact, most (not all) of the sexual disorders listed in the DSM-IV are disorders of functioning. Taking that into consideration, Hypersexual Disorder may not really fit here.
So if sex addiction is not a sexual disorder, is it an addiction? The APA has suggested renaming the category of what are currently called Substance-Related Disorders as Addiction and Related Disorders, specifically to allow for the inclusion of “behavioral addictions” such as Pathological Gambling. A reasonable argument could be made that sex addiction is more of a behavioral addiction than a disorder of sexual functioning, and as such, belongs in this category.
In fact, the very concept of a behavioral addiction seems predicated on the idea that normal, pleasurable activity can become problematic. For example, one could argue that compulsive overeating is essentially a behavioral addiction, rather than an eating disorder. (For more on that issue, see our November 2009 article on Compulsive Overeating.)
At the same time, one could also argue that there are significant differences between addictions to mind-altering substances (i.e., alcohol, drugs) and addictions to behaviors (i.e., gambling, sex, eating), most notably the fact that substances can and often do lead to physical dependence, and that those addicted to substances can and often do experience physical withdrawal symptoms. Can the same be said for behavioral addictions?
An argument could also be made that sex addiction would perhaps be more appropriately classified as an impulse control disorder. This is an existing diagnostic category that currently covers wildly varying conditions, including Trichotillomania, Skin Picking Disorder, Pathological Gambling, Pyromania, and Intermittent Explosive Disorder. There seems little dispute that sex is an impulse, and that in those with sexual addiction, the impulse is not well controlled.
Does Excessive Sexual Activity Warrant a Diagnosis?
And then there is the simple question of whether or not sex addiction is a legitimate disorder at all. Many contend that sex addiction is really just another example of the APA stretching the bounds of mental illness to include normal variations of human experience. Others see the very idea of sex addiction as little more than a convenient excuse for bad behavior. Along these lines, one recent article on LinkedIn was posted under the rather pithy title of “Tiger Woods: Sex Addict or Scumbag.
And then there are those who say compulsive sexuality is not even bad behavior, but rather people (usually men) doing what they like to do for the very simple reason that they can. Some might even argue that one of the primary reasons men like Tiger Woods seek fame and fortune is for the unfettered access to multiple sex partners that comes with success and power. Many men in the public eye have been described as sex addicts, including professional athletes (Tiger Woods, Wilt Chamberlain), movie stars (Warren Beatty, Michael Douglas), and politicians (Bill Clinton, Eliot Spitzer). Are they and others like them sex addicts, or merely men fully enjoying the fruits of their labors?
So, the question remains: is sex addiction a sexual disorder, an addiction disorder, an impulse control disorder, bad behavior, or just people enjoying the benefits of their stature? There may be no easy answer for how, if at all, to diagnose and classify sex addiction. Simply put, the human psyche isn’t so easily divided into discrete categories, and our attempts to create an ever-expanding taxonomy sometimes seem more a function of a human need for order rather than any legitimate neuropsychiatric distinctions. The only thing that is certain in this discussion is that sexual addiction is not OCD.
•Tom Corboy, MFT, is the director of the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related conditions. In addition to individual therapy, the center offers six weekly therapy groups, as well as online therapy, telephone therapy, and intensive outpatient treatment. To contact the OCD Center of Los Angeles, click here.
I wholeheartedly agree with your thesis that sex addiction is not OCD. I’m disappointed, however, that you cast such doubt on whether process addictions are addictions at all. I work primarily with sex addicts, and it could not be clearer to me that behaviors (e.g., gambling, sex, shopping) can produce the same kind of brain “high” and withdrawal and tolerance that substances chemically induce. The disease model of addiction (both chemical and process addictions) was only a theory for years, but is now scientifically accepted (see the work of researchers like Dr. Kevin McCauley [Center for Addiction Study] or Dr. Harry Hartounian [Betty Ford Center]).
Thanks for addressing this OCD/Sex Addiction issue!
Thank you for your comments.
I think you may have misunderstood my position on process addictions (which I refer to as “behavioral addictions”). I totally agree that behaviors can become addictive. As I noted in the article:
“A reasonable argument could be made that sex addiction is more of a behavioral addiction than a disorder of sexual functioning, and as such, belongs in this category.”
My goal with the article was to address the issue of sex addiction with more nuance than the media, which clearly prefer to focus on the more sensationalistic aspects of the the story (Sex!!! Tiger Woods!!!). My description of the differences between substance addictions and behavioral addictions was meant to bring attention to differences that I think are noteworthy – namely physical dependence and physical withdrawal. We may disagree about this part of the issue, but I completely agree with you that excessive sex, gambling and shopping can be addictive, and would add food, shoplifting, and internet gaming to that list.
Thanks again for contributing your thoughts.
I totally concur that if sex addiction is a disorder it is more a behavioral addiction. I understand that the definition of an addiction is a “brain high”, withdrawal and compulsive behavior but that can possibly be stated about regular people who enjoy frequent sex. I could also make a case for anxiety being redirected into sexual behavior and the problem having nothing to do with addiction or sex.
You’re forgetting one major componenent in your last paragraphy summary: Expanding the scope of “mental illness” to include “sex addiction” also can be seen as a SOCIAL phenomenon where we, as a society, demonize frequent sex in a “sex negative” way that perhaps we would not have done in the more “sex positive” 60s and 70s. And, it’s also a COMMERCIAL phenomenon, where there is much MONEY to be made by therapists and “addiction treatment centers” if we pathologize frequent sex, where often the CLINICIANS are pointing at the frequent-sex client and saying “BAD, BAD!” as opposed to the client seeking help himself. Therapists who play into the current sex-negative society (see “America’s War on Sex” by Marty Klein, Ph.D) and who play into individuals’ sexual guilt, can make a FORTUNE in these rather tough times for therapists who face insurance reimbursement difficulties, or new therapists nearly desperate to build a practice. In short, “sex addiction” is a “popular” trend, almost a “fad”, and a real money-maker, and we shouldn’t forget that commercial aspect of it as well, that has nothing to do with its clinical diagnosis.