Report of findings in a DSM-5 field trial for hypersexual disorder.

INTRODUCTION: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for hypersexual disorder (HD) have been proposed to capture symptoms reported by patients seeking help for out-of-control sexual behavior. The proposed criteria created by the DSM-5 Work Group on Sexual and Gender Identity Disorders require evaluation in a formal field trial. AIM: This DSM-5 Field Trial was designed to assess the reliability and validity of the criteria for HD in a sample of patients seeking treatment for hypersexual behavior, a general psychiatric condition, or a substance-related disorder. METHOD: Patients (N = 207) were assessed for psychopathology and HD by blinded raters to determine inter-rater reliability of the HD criteria and following a 2-week interval by a third rater to evaluate the stability of the HD criteria over time. Patients also completed a number of self-report measures to assess the validity of the HD criteria. MAIN OUTCOME MEASURES: HD and psychopathology were measured by structured diagnostic interviews, the Hypersexual Behavior Inventory, Sexual Compulsivity Scale, and Hypersexual Behavior Consequences Scale. Emotional dysregulation and stress proneness were measured by facets on the NEO Personality Inventory-Revised. RESULTS: Inter-rater reliability was high and the HD criteria showed good stability over time. Sensitivity and specificity indices showed that the criteria for HD accurately reflected the presenting problem among patients. The diagnostic criteria for HD showed good validity with theoretically related measures of hypersexuality, impulsivity, emotional dysregulation, and stress proneness, as well as good internal consistency. Patients assessed for HD also reported a vast array of consequences for hypersexual behavior that were significantly greater than those diagnosed with a general psychiatric condition or substance-related disorder. CONCLUSIONS: The HD criteria proposed by the DSM-5 Work Group on Sexual and Gender Identity Disorders appear to demonstrate high reliability and validity when applied to patients in a clinical setting among a group of raters with modest training on assessing HD.

Problems of self-concept in a patient sample of hypersexual men with attention-deficit disorder.

OBJECTIVES: Earlier evidence suggests comorbid attention-deficit disorder (ADHD) among those seeking treatment for hypersexual behavior. This article examines which facets of ADHD symptoms are most strongly associated with hypersexual behavior among a patient sample of men (N = 81). METHODS: ADHD diagnosis was made by 2 clinicians, and symptom characteristics were measured using the Conners' Adult ADHD Rating Scale and the Sexual Compulsivity Scale. RESULTS: Among ADHD symptoms, inattentive features were most prevalent. A stepwise regression analysis revealed that the Problems with Self-Concept subscale of the Conners' Adult ADHD Rating Scale was the strongest predictor of scores on the Sexual Compulsivity Scale. Surprisingly, subscales that measured traits of impulsivity, inattention, memory problems, and hyperactive restlessness did not contribute additional predictive variance in the statistical model. CONCLUSIONS: The results of these findings suggest that clinicians should exercise caution in assuming that common characteristics of ADHD, such as impulsivity and hyperactivity, exert the strongest influence on hypersexual behavior. Rather, our results provide evidence that the associated features of ADHD, such as problems with low self-esteem, might be more salient factors in influencing hypersexuality severity among patients with comorbid hypersexual behavior and ADHD.

A surprising finding related to executive control in a patient sample of hypersexual men.

INTRODUCTION: Patients seeking help for hypersexual behavior often exhibit features of impulsivity, cognitive rigidity, and poor judgment as well as deficits in emotion regulation and excessive preoccupation with sex. Some of these characteristics are also common among patients presenting with neurological pathology associated with executive dysfunction. Exploring relationships between dysregulated sexual behavior and executive deficits will enhance our understanding of hypersexuality. AIM: This study sought to assess whether patients seeking help for hypersexual behavior exhibit executive deficits as measured by standardized neuropsychological tests of executive functioning when compared with healthy controls. METHODS: Executive deficits were assessed in a sample of male patients (N = 30) seeking help for hypersexual behavior compared with a nonhypersexual community sample of men (N = 30) using neuropsychological tests of executive functioning. Using multivariate statistics, differences between the groups were examined. MAIN OUTCOME MEASURES: Sexual activity measured by the Hypersexual Behavior Inventory and the Compulsive Sexual Behavior Inventory. Executive functions measured through neuropsychological testing using several subtests of Delis-Kaplan Executive Function System: Color-Word Interference Test, the Tower Test, the Trail Making Test, the Verbal Fluency Test, as well as the Wisconsin Card Sorting Test. Psychopathology was assessed using the Mini International Neuropsychiatric Interview, and cognitive ability was assessed using the Wechsler Adult Intelligence Scale. RESULTS: Significant differences on measures of hypersexuality were observed. However, the groups failed to exhibit significant differences across neuropsychological tests of executive functioning even after controlling for cognitive ability. CONCLUSIONS: These results contradict a previous finding of executive deficits among hypersexual men measured by self-report. The lack of executive deficits suggests that this population may exhibit domain-specific aspects of impulsivity, poor judgment, and risky behavior that are not generalizable to other domains of life. Furthermore, our findings fail to support a conceptualization of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, proposed hypersexual disorder based on models of executive dysfunction. .

Understanding the roles of shame and neuroticism in a patient sample of hypersexual men.

Although shame and facets of neuroticism have independently been linked to hypersexuality, the present study extends these findings by exploring pathways among these variables, using structural equation modeling in a patient sample of hypersexual adult men (N = 95). Results suggested that the domain of neuroticism, as represented by the NEO Personality Inventory-Revised, was a significant direct predictor of hypersexuality, with specific variance from the facet of impulsivity adding additional predictive power. Shame's bivariate association with hypersexuality was also significant, but in a predictive path model the effect of shame on hypersexuality was indirectly mediated through neuroticism and was not an independently significant predictor. Implications for treatment suggest that clinicians working with this population should evaluate precipitating risk factors to consider whether shame is activating neurotic coping or if other stressors might be influencing emotional instability that can trigger hypersexuality. Independent of the general distress associated with neuroticism, the literature on impulsivity might provide other valuable insights and direction for working with hypersexual men.

Disputing the notion of psychopathology among women married to hypersexual men using the MMPI-2-RF.

This article offers a report disputing the notion that women who are married to hypersexual men exhibit a constellation of pathological symptoms, although it is likely they experience marital distress. The authors measured psychopathology using the Minnesota Multiphasic Personality Inventory-2-Restructured Form and marital satisfaction using the Revised Dyadic Adjustment Scale. The authors failed to find evidence supporting a common belief that wives of hypersexual men have their own pathology. Wives of hypersexual men, however, were significantly more distressed about their marriages compared with the controls in this study. Overall, these findings contradict a characterization of wives of hypersexual men as being more depressed, anxious, chemically dependent, or otherwise dysfunctional.

Self-reported differences on measures of executive function and hypersexual behavior in a patient and community sample of men.

Patients seeking help for hypersexual behavior often exhibit features of impulsivity, cognitive rigidity, poor judgment, deficits in emotion regulation, and excessive preoccupation with sex. Some of these characteristics are also common among patients presenting with neurological pathology associated with executive dysfunction. These observations led to the current investigation of differences between a group of hypersexual patients (n = 87) and a non-hypersexual community sample (n = 92) of men using the Behavior Rating Inventory of Executive Function-Adult Version (BRIEF-A) and the Hypersexual Behavior Inventory (HBI). Significant differences between the groups emerged on eight subscales and all of the general indices of executive functioning with the most dramatic differences on BRIEF-A's Shift, Emotional Control, Initiate, and Plan/Organize subscales. Hypersexual behavior was positively correlated (r = .37, p < .01) with global indices of executive dysfunction and several subscales of the BRIEF-A. These findings provide preliminary evidence supporting the hypothesis that executive dysfunction may be implicated in hypersexual behavior.

Exploring relationships of psychopathology in hypersexual patients using the MMPI-2.

This article reports the findings of a study investigating relationships among Minnesota Multiphasic Personality Inventory-2 (MMPI-2) scales as they pertain to a group of individuals seeking help for hypersexual behavior (N = 152). A number of MMPI-2 scale elevations were prevalent with this group, suggesting that some of these patients experience symptoms associated with psychopathology and interference or impairment in important areas of personal and interpersonal functioning. We failed to find any evidence in our data supporting the notion that hypersexual patients experience addictive tendencies. For a significant portion of the group, however, there were few-to-minimal elevations, reflecting normal psychological profiles. An overall important finding in our data suggests that patients presenting with hypersexual behavior are a diverse group, sufficiently so that studying subsamples of this group may lead to a clearer understanding of this behavior. Models that promote a homogenous conceptualization and treatment of hypersexuality likely miss important differences that provide valuable insight when working with this population.

Measuring work productivity with a mental health self-report measure.

OBJECTIVE: To determine whether the Social Role (SR) Scale of the Outcome Questionnaire (OQ) can predict work productivity. METHODS: Employees at Utah State Hospital completed the OQ and the Work Productivity and Activity Impairment Scale (WPAI) once monthly for four months. RESULTS: The SR predicted the WPAI Presenteeism and Activity Impairment scales. CONCLUSIONS: The SR can be used to estimate work productivity using tools like the Productivity Calculator. Specific relationships among measures and suggestions for future research are discussed.

Alexithymia, emotional instability, and vulnerability to stress proneness in patients seeking help for hypersexual behavior.

This article reports the findings of a study investigating alexithymia, emotional instability, and vulnerability to stress proneness among individuals (N = 120) seeking help for hypersexual behavior. At the onset of treatment at an outpatient community clinic, subjects completed the Sexual Compulsivity Scale (SCS), the 20-item Toronto Alexithymia Scale (TAS-20), and the NEO Personality Inventory Revised (NEO-PI-R). The results of a hierarchical regression analysis revealed the best model in predicting severity of hypersexual behavior included the facets of depression and vulnerability to stress from the NEO and the Difficulty Identifying Feelings (DIF) factor of the TAS-20. Although the NEO domain of neuroticism appeared to capture the majority of variance in hypersexual behavior, the difficulty identifying feelings factor of the TAS-20 did make some modest, but significant, contribution to the severity of hypersexual behavior after controlling for depression and vulnerability to stress. These data 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). Possible reasons for these results are suggested and future recommendations for research are offered.