Treatment of compulsive sexual behaviour with naltrexone and serotonin reuptake inhibitors: two case studies

Current Understanding of Compulsive Sexual Behavior Disorder and Co-occurring Conditions: What Clinicians Should Know about Pharmacological Options

Compulsive sexual behavior disorder (CSBD) has recently been recognized as a psychiatric disorder. Pharmacological treatments for CSBD have received little study and thus have limited empirical support. The main objective of the present work is to review existing literature on the efficacy of different drugs on the symptomatology of CSBD, including the subtype of problematic pornography use (PPU). The main pharmacological approaches to treating CSBD have included opioid antagonists (naltrexone and nalmefene), selective serotonin reuptake inhibitors (paroxetine, citalopram, fluoxetine, and sertraline), mood stabilizers (topiramate), tricyclic antidepressants (clomipramine), serotonin antagonist and reuptake inhibitors (nefazodone), and N-acetylcysteine. Since people with CSBD may experience different co-occurring disorders, these should be considered when choosing the best pharmacological treatment. Pharmacological therapy for CSBD/PPU has been suggested as an adjunct to psychological therapies, which, for the moment, have the most empirical evidence. However, to evaluate the efficacy of most of the drugs presented in this narrative review, data to date have only been available from case studies. Thus, empirical support is scant and generalizability of results is limited, highlighting the need for more research in this area.

No Magic Pill: A Systematic Review of the Pharmacological Treatments for Compulsive Sexual Behavior Disorder

Compulsive sexual behavior disorder (CSBD) is a burgeoning diagnostic construct. No systematic reviews of CSBD pharmacotherapy interventions have been conducted. We addressed this gap using a three-aim approach. We reviewed researchers' theoretical arguments for various pharmacotherapies, outcomes from pharmacotherapy trials, and the generalizability of the extant findings. Our review included k = 13 studies, with n = 141 participants. An opioid model of reward seeking was the most popular framework, though inconsistently specified. A serotonin model was also documented, though with few details. Naltrexone was the most prominently examined pharmacotherapy and the only medication that reliably demonstrated a therapeutic effect for some (but not all) indicators compared to placebo. Paroxetine and citalopram were also documented in placebo-controlled trials, though their incremental benefit compared to placebo is suspect. Several additional pharmacotherapies have been documented in case series contexts. Across studies, only one female participant was identified. All trials were conducted in developed nations, and race was rarely assessed. We conclude that the case for pharmacotherapy for CSBD is limited and should preferably not occur outside of clinical trial contexts. Naltrexone offers the best evidence for a potential research program, though new theoretically informed approaches are welcome. Finally, we call for additional pharmacotherapy research in women and non-White populations.

The World Federation of Societies of Biological Psychiatry guidelines on the assessment and pharmacological treatment of compulsive sexual behaviour disorder

OBJECTIVES

The current guidelines aim to evaluate the role of pharmacological agents in the treatment of patients with compulsive sexual behaviour disorder (CSBD). They are intended for use in clinical practice by clinicians who treat patients with CSBD.

METHODS

An extensive literature search was conducted using the English-language-literature indexed on PubMed and Google Scholar without time limit, supplemented by other sources, including published reviews.

RESULTS

Each treatment recommendation was evaluated with respect to the strength of evidence for its efficacy, safety, tolerability, and feasibility. Psychoeducation and psychotherapy are first-choice treatments and should always be conducted. The type of medication recommended depended mainly on the intensity of CSBD and comorbid sexual and psychiatric disorders. There are few randomised controlled trials. Although no medications carry formal indications for CSBD, selective-serotonin-reuptake-inhibitors and naltrexone currently constitute the most relevant pharmacological treatments for the treatment of CSBD. In cases of CSBD with comorbid paraphilic disorders, hormonal agents may be indicated, and one should refer to previously published guidelines on the treatment of adults with paraphilic disorders. Specific recommendations are also proposed in case of chemsex behaviour associated with CSBD.

CONCLUSIONS

An algorithm is proposed with different levels of treatment for different categories of patients with CSBD.

A randomised controlled trial of fluoxetine versus naltrexone in compulsive sexual behaviour disorder: presentation of the study protocol

BACKGROUND

Compulsive sexual behaviour disorder is a new disorder in the International Classification of Diseases (ICD-11), and is associated with negative consequences in different areas of life. Evidence for pharmacological treatment of compulsive sexual behaviour disorder is weak and treatment options are limited. This proposed study will be the largest and the first randomised controlled trial comparing the efficacy and tolerability of two active drugs in compulsive sexual behaviour disorder.

METHODS AND ANALYSIS

Eighty adult participants with compulsive sexual behaviour disorder according to ICD-11 will be randomised to receive either naltrexone 25-50 mg or fluoxetine 20-40 mg for 8 weeks, followed by 6 weeks without treatment. The study will be conducted in a subspecialised outpatient sexual medicine unit at Karolinska University Hospital, Stockholm, Sweden. The study is financed by grants and entirely independent of the manufacturers.Exclusion criteria include severe psychiatric or psychical illness, changes to concurrent medication and non-compatible factors contraindicating the use of either drug. The primary outcome measure is the Hypersexual Disorder: Current Assessment Scale (HD: CAS), and tolerability will be assessed by the Udvalg for Kliniske Undersogelser side effect rating scale (UKU), drug accountability, adherence to treatment and drop-out rate. Participants will complete questionnaires at regular intervals, with the main endpoint for efficacy after 8 weeks (end of treatment) and after 14 weeks (follow-up). Blood chemistry will be repeatedly collected as a safety precaution and for research purposes. The results will be analysed using an appropriate analysis of variance model or a mixed model, depending on the distribution of HD: CAS and the extent of missing data.

ETHICS AND DISSEMINATION

The Swedish Ethical Review Authority and the Swedish Medical Products Agency have approved the study on 27 May 2020 and 4 June 2020, respectively (ref. no. 2020-02069 and ref. no. 5.1-2020-48282). Findings will be published in peer-reviewed journals and presented at relevant conferences.

TRIAL REGISTRATION NUMBER

2019-004255-36.

Compulsive Sexual Behavior and Alcohol Use Disorder Treated With Naltrexone: A Case Report and Literature Review

Compulsive sexual behavior (CSB) or sexual addiction is a term that generally indicates excessive and uncontrolled sexual behavior. This may lead to subjective distress, social and occupational impairment, or legal and financial consequences. Often, this condition is underreported and untreated. Until now there are no FDA-approved medications for sexual addiction or compulsive sexual behaviors. However, the therapeutic benefits of selective serotonin reuptake inhibitors (SSRIs) and naltrexone are known. This is a case of a 53-year-old male with a history of extensive alcohol use, alcohol withdrawal seizure, and delirium tremens. The patient was treated with naltrexone 50 mg/day for alcohol use disorder. The patient reported that his “sexual compulsion” also reduced after the medication and there was an improvement in both alcohol addiction and self-reported compulsive sexual behavior. This case report also includes a literature review of pharmacotherapy, especially naltrexone, for the treatment of sexual addiction/compulsive sexual behavior. The literature review has shown that patients’ symptoms were improved in different doses without side effects, and based on this and our experience, it can be said that naltrexone is effective in the reduction and remission of the symptoms of CSB or sexual addiction.

Off-label Uses of Selective Serotonin Reuptake Inhibitors (SSRIs)

Psychiatric drugs have primacy for off-label prescribing. Among those, selective serotonin reuptake inhibitors (SSRIs) are highly versatile and, therefore, widely prescribed. Moreover, they are commonly considered as having a better safety profile compared to other antidepressants. Thus, when it comes to off-label prescribing, SSRIs rank among the top positions. In this review, we present the state of the art of off-label applications of selective serotonin reuptake inhibitors, ranging from migraine prophylaxis to SARS-CoV-2 antiviral properties. Research on SSRIs provided significant evidence in the treatment of premature ejaculation, both with the on-label dapoxetine 30 mg and the off-label paroxetine 20 mg. However, other than a serotoninergic syndrome, serious conditions like increased bleeding rates, hyponatremia, hepatoxicity, and post-SSRIs sexual dysfunctions, are consistently more prominent when using such compounds. These insidious side effects might be frequently underestimated during common clinical practice, especially by nonpsychiatrists. Thus, some points must be addressed when using SSRIs. Among these, a psychiatric evaluation before every administration that falls outside the regulatory agencies-approved guidelines has to be considered mandatory. For these reasons, we aim with the present article to identify the risks of inappropriate uses and to advocate the need to actively boost research encouraging future clinical trials on this topic.

Neurochemical and Hormonal Contributors to Compulsive Sexual Behavior Disorder

Purpose of Review

Compulsive sexual behavior disorder has been recently included in the 11th revision of the International Classification of Diseases (ICD-11), and the possible contribution of neurochemical and hormonal factors have been reported. However, relatively little is known concerning the neurobiology underlying this disorder. The aim of this article is to review and discuss published findings in the area.

Recent Findings

Evidence suggests that the neuroendocrine systems are involved in the pathophysiology of compulsive sexual behavior. The hypothalamus-pituitary adrenal axis, the hypothalamus-pituitary–gonadal axis, and the oxytocinergic system have been implicated.

Summary

Further studies are needed to elucidate the exact involvement of neuroendocrine and hormonal systems in compulsive sexual behavior disorder. Prospective longitudinal studies are particularly needed, especially those considering co-occurring psychiatric disorders and obtaining hormonal assessments in experimental circumstances with appropriate control groups.

Assessment and treatment of hypersexuality: a review

Hypersexuality is defined under various terms in the DSM and ICD diagnostic classifications. However, it can be challenging to differentiate between hypersexuality as one of the symptoms of a mental disorder and hypersexual disorder as a primary diagnosis. In this article, we explore the physiology, assessment and treatment of hypersexual disorder, and consider its aetiology and epidemiology. In addition, we highlight the paucity of evidence in the literature about licensed or specific pharmacological recommendations for its treatment and the poor awareness of hypersexuality in clinical and research practice. Further research is recommended to identify more precise guidance for the pharmacological management of hypersexuality.

Sexual Responsivity and the Effects of Negative Mood on Sexual Arousal in Hypersexual Men Who Have Sex With Men (MSM)

BACKGROUND

A number of studies have found that hypersexuality is associated with a high propensity for sexual excitation. In comparison, less is known about the relationship between hypersexuality and sexual arousal at the state level. Also, previous research has revealed a relationship between hypersexuality and negative mood. However, the possibility that sexual response might not be as negatively impacted by negative mood in hypersexual individuals has, as yet, not been tested.

AIM

The purpose of this study was to investigate sexual responsivity and the effects of negative mood on sexual arousal in hypersexual men who have sex with men (MSM).

METHODS

A total of 211 MSM were assigned to a hypersexuality (N = 81) or a control (N = 130) group using an interview patterned with a semi-structured Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders format. Participants filled out questionnaires and were shown neutral, sexual, and anxiety- and sadness-inducing films.

OUTCOMES

Changes in penile circumference and self-reported sexual arousal were the primary outcomes analyzed in this study.

RESULTS

Controlling for age and HIV status, no differences were found in genital response between hypersexual and non-hypersexual men. Also, the 2 groups did not differ in subjective sexual arousal. Moreover, no effects of negative mood were found. Time series clustering analyses revealed 3 groups-low responders and slow and fast high responders. Sexual excitation, but not sexual compulsivity or pornography use, predicted cluster membership.

CLINICAL TRANSLATION

Hypersexual MSM may benefit more from an exploration of motivational and behavioral, as compared to psychophysiological, mechanisms underlying possible links between (negative) mood and sexual behavior.

STRENGTHS & LIMITATIONS

Strengths of the study include its sample size, making it one of the larger psychophysiological sex studies; the use of clinical interviews for group assignment; the inclusion of genital response measures; and the application of time series clustering to examine differences among participants. Limitations include possible sample heterogeneity and the reliance on researcher-selected stimuli.

CONCLUSION

Given the lack of any effects of negative mood on sexual response in hypersexual MSM, future studies could explore in more depth possible motivational and behavioral effects, including, for example, the impact of negative mood on the tendency to seek out sex as a form of distraction or for validation or emotional support. Janssen E, Prause N, Romine RS, et al. Sexual Responsivity and the Effects of Negative Mood on Sexual Arousal in Hypersexual Men Who Have Sex With Men (MSM). J Sex Med 2020;17:1751-1760.

Dialectical behaviour therapy skills training for the treatment of addictive behaviours among individuals with alcohol use disorder: the effect of emotion regulation and experiential avoidance

BACKGROUNDS

Dialectical behavior therapy skills training (DBT-ST) is an effective treatment for alcohol use disorder (AUD). AUD frequently co-occurs with other addictive behaviors.

OBJECTIVE

s: These secondary analyses of prior studies on the effectiveness of a 3-month DBT-ST program for AUD investigated pre- post-treatment changes in the severity of concurrent addictive behaviors. The study hypothesized that emotion regulation and experiential avoidance should be the key therapeutic mechanisms involved in the treatment of addictive behaviors.

METHODS

The research included 186 individuals (110 males; 76 females) with a primary diagnosis of AUD. Mediational models were performed considering shorter PROMIS questionnaire subscales (i.e., gambling, sex, shopping, food binging, and starvation) as dependent variables. The difficulties in emotion regulation scale and acceptance and action questionnaire-II total scores were independent and mediator variables, respectively.

RESULTS

Clinical variables significantly improved during the treatment, independent of baseline levels. Changes in emotion regulation showed significant total effects on improvements in addictive behaviors. Significant indirect effects of changes in experiential avoidance were detected considering compulsive buying and dysfunctional eating behaviors.

CONCLUSION

The DBT-ST was a feasible treatment for several addictive behaviors frequently reported by individuals with AUD. The improvements in emotion regulation and experiential avoidance were relevant therapeutic mechanisms involved in the treatment of these conditions. Future controlled trials and follow-up studies are recommended to support the efficacy of DBT-ST as a stand-alone intervention for the treatment of different classes of addictive behaviors.

Extended-release naltrexone for methamphetamine dependence among men who have sex with men: a randomized placebo-controlled trial

BACKGROUND AND AIMS

Methamphetamine use is increasingly prevalent and associated with HIV transmission. Early-phase human studies suggested naltrexone reduced amphetamine use among dependent individuals. We tested if extended-release naltrexone (XRNTX) reduces methamphetamine use and associated sexual risk behaviors among high-risk methamphetamine-dependent men who have sex with men (MSM).

DESIGN

Double-blind, placebo-controlled, randomized trial of XRTNX versus placebo over 12 weeks from 2012 to 2015.

SETTING

San Francisco Department of Public Health, California, USA.

PARTICIPANTS

One hundred community-recruited, sexually-active, actively-using methamphetamine-dependent MSM. Mean age was 43.2 years; 96% were male, 3% transfemale, and 1% transmale; 55.0% were white, 19.0% African American, and 18.0% Latino.

INTERVENTIONS

XRNTX 380 mg (n = 50) or matched placebo (n = 50) administered by gluteal injection at 4-week intervals.

MEASUREMENTS

Regression estimated average level and change in level of positive urines during the period 2-12 weeks (primary outcomes) and sexual risk behaviors (secondary outcome).

FINDINGS

Ninety per cent of visits were completed. By intent-to-treat, participants assigned to XRNTX had similar differences during 2-12 weeks in methamphetamine-positive urines as participants assigned to placebo [incidence rate ratio (IRR) = 0.95, 95% confidence interval (CI) = 0.76-1.20; Bayes factor < 0.3]. Observed urine positivity declined from 78 to 70% in the XRNTX arm and 74 to 64% in the placebo arm. Adherence to injections was 96.7% in the XRNTX arm and 91.3% in the placebo arm. Sexual risk behaviors declined similarly among participants in both arms (all P > 0.05). There were no serious adverse events related to study drug and no differences in frequency of adverse events by treatment arm.

CONCLUSIONS

Notwithstanding very high medication adherence for this study, extended-release naltrexone does not appear to reduce methamphetamine use or sexual risk behaviors among methamphetamine-dependent men who have sex with men compared with placebo.

Investigating Clinically and Scientifically Useful Cut Points on the Compulsive Sexual Behavior Inventory

INTRODUCTION

One of the major obstacles to conducting epidemiologic research and determining the incidence and prevalence of compulsive sexual behavior (CSB) has been the lack of relevant empirically derived cut points on the various instruments that have been used to measure the concept.

AIM

To further develop the Compulsive Sexual Behavior Inventory (CSBI) through exploring predictive validity and developing an empirically determined and clinically useful cut point for defining CSB.

METHODS

A sample of 242 men who have sex with men was recruited from various sites in a moderate-size Midwestern city. Participants were assigned to a CSB group or a control group using an interview for the diagnosis that was patterned after the Structured Clinical Interview for the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition. The 22-item CSBI was administered as part of a larger battery of self-report inventories.

MAIN OUTCOME MEASURES

Receiver operating characteristic analyses were used to compute area-under-the-curve measurements to ascertain the predictive validity of the total scale, the control subscale, and the violence subscale. Cut points were determined through consensus of experts balancing sensitivity and specificity as determined by receiver operating characteristic curves.

RESULTS

Analyses indicated that the 22-item CSBI was a good predictor of group membership, as was the 13-item control subscale. The violence subscale added little to the predictive accuracy of the instrument; thus, it likely measures something other than CSB. Two relevant cut points were found, one that minimized false negatives and another, more conservative cut point that minimized false positives.

CONCLUSION

The CSBI as currently configured measures two different constructions and only the control subscale is helpful in diagnosing CSB. Therefore, we decided to eliminate the violence subscale and move forward with a 13-item scale that we have named the CSBI-13. Two cut points were developed from this revised scale, one that is useful as a clinical screening tool and the other, more conservative measurement that is useful for etiologic and epidemiologic research. Miner MH, Raymond N, Coleman E, Swinburne Romine R. Investigating Clinically and Scientifically Useful Cut Points on the Compulsive Sexual Behavior Inventory. J Sex Med 2017;14:715-720.

Should compulsive sexual behavior be considered an addiction?

AIMS

To review the evidence base for classifying compulsive sexual behavior (CSB) as a non-substance or 'behavioral' addiction.

METHODS

Data from multiple domains (e.g. epidemiological, phenomenological, clinical, biological) are reviewed and considered with respect to data from substance and gambling addictions.

RESULTS

Overlapping features exist between CSB and substance use disorders. Common neurotransmitter systems may contribute to CSB and substance use disorders, and recent neuroimaging studies highlight similarities relating to craving and attentional biases. Similar pharmacological and psychotherapeutic treatments may be applicable to CSB and substance addictions, although considerable gaps in knowledge currently exist.

CONCLUSIONS

Despite the growing body of research linking compulsive sexual behavior (CSB) to substance addictions, significant gaps in understanding continue to complicate classification of CSB as an addiction.

Clinicians' Beliefs, Observations, and Treatment Effectiveness Regarding Clients' Sexual Addiction and Internet Pornography Use

This study addressed how sex addiction and problematic IP use present to mental health professionals (MHPs), and how MHPs conceptualize and treat these issues. MHPs (N = 183) reported on beliefs about, experiences with, and treatment of problematic sexual behaviors (PBS). Most MHPs saw clients with PBS, but most do not feel competent to treat PBS. Specialized MHPs endorsed seeing more clients with PBS and feeling more effective than nonspecialists. Sexual addiction and problematic IP use share similarities, but differ in etiology and co-occurring problems. Diagnostic ambiguity, insufficient knowledge, and limited dissemination may hinder MHPs ability to assess and treat PBSs.

Feasibility, Acceptability, and Tolerability of Targeted Naltrexone for Nondependent Methamphetamine-Using and Binge-Drinking Men Who Have Sex with Men

BACKGROUND

There are no effective pharmacologic strategies for nondependent methamphetamine (meth)-using and binge-drinking men who have sex with men (MSM) at high-risk for HIV. We sought to determine the feasibility of enrolling and retaining this population in a pharmacologic trial; the acceptability of pharmacotherapy study procedures; and the tolerability of targeted naltrexone versus placebo.

METHODS

Thirty meth-using and binge-drinking MSM were randomly assigned 1:1 to 50 mg naltrexone or placebo for 8 weeks for targeted administration (ie, during craving or in anticipation of meth or alcohol use). Substance use counseling and behavioral assessments were conducted every 2 weeks. Medication use was measured using WisePill dispensers.

RESULTS

Trial completion was 93%; visit completion rate was 95%. Mean weekly number of medication pills taken was 2.1 and was similar between arms. Participant satisfaction rate was 96%. There were neither serious adverse events nor differences in adverse event rates between arms. In exploratory intention-to-treat analyses, there were no differences in meth use and drinking. Naltrexone participants had greater reductions in serodiscordant receptive anal intercourse [incident rate ratio (IRR) = 0.15; 95% CI = 0.05 to 0.42] and serodiscordant condomless receptive anal intercourse (IRR = 0.11; 95% CI = 0.03 to 0.37), compared with placebo. In subgroup analyses among frequent meth users, naltrexone participants had greater reductions in meth-using days (IRR = 0.78; 95% CI = 0.62 to 0.99). In as-treated analyses, frequent study medication users in the naltrexone arm had greater reductions in binge drinking days (IRR = 0.72; 95% CI = 0.54 to 0.97).

CONCLUSIONS

Targeted naltrexone is a feasible, acceptable, and tolerable intervention strategy for nondependent meth-using and binge-drinking MSM. Naltrexone was associated with significant sexual risk reductions; and for some individuals, naltrexone was associated with meth and binge-drinking reductions.

Understanding the Personality and Behavioral Mechanisms Defining Hypersexuality in Men Who Have Sex With Men

INTRODUCTION

Hypersexuality has been conceptualized as sexual addiction, compulsivity, and impulsivity, among others, in the absence of strong empirical data in support of any specific conceptualization.

AIM

To investigate personality factors and behavioral mechanisms that are relevant to hypersexuality in men who have sex with men.

METHODS

A sample of 242 men who have sex with men was recruited from various sites in a moderate-size mid-western city. Participants were assigned to a hypersexuality group or a control group using an interview similar to the Structured Clinical Interview for the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition. Self-report inventories were administered that measured the broad personality constructs of positive emotionality, negative emotionality, and constraint and more narrow constructs related to sexual behavioral control, behavioral activation, behavioral inhibition, sexual excitation, sexual inhibition, impulsivity, attention-deficit/hyperactivity disorder, and sexual behavior.

MAIN OUTCOME MEASURES

Hierarchical logistic regression was used to determine the relation between these personality and behavioral variables and group membership.

RESULTS

A hierarchical logistic regression controlling for age showed a significant positive relation between hypersexuality and negative emotionality and a negative relation with constraint. None of the behavioral mechanism variables entered this equation. However, a hierarchical multiple regression analysis predicting sexual behavioral control indicated that lack of such control was positively related to sexual excitation and sexual inhibition owing to the threat of performance failure and negatively related to sexual inhibition owing to the threat of performance consequences and general behavioral inhibition

CONCLUSION

Hypersexuality was found to be related to two broad personality factors that are characterized by emotional reactivity, risk taking, and impulsivity. The associated lack of sexual behavior control is influenced by sexual excitatory and inhibitory mechanisms, but not by general behavioral activation and inhibitory mechanisms.

Opioid antagonists in broadly defined behavioral addictions: a narrative review

INTRODUCTION

Naltrexone (NTX), a mu-opioid receptor antagonist, has been approved for the treatment of alcoholism and opioid dependence. More recently, however, NTX and a related drug, nalmefene (NMF), have also shown positive results for the treatment of gambling disorders.

AREAS COVERED

In this study, we reviewed the trials testing the effect of opioid antagonists (OA) in gambling disorders and in other broadly defined behavioral addictions, including selected DSM-5 disruptive, impulse-control, and conduct disorders, obsessive-compulsive and related disorders, eating disorders, and other conditions not currently recognized by official classification schemes. We found six randomized controlled trials (RCTs) of OA in gambling disorder, two RCTs of OA in trichotillomania (hair pulling disorder), two RCTs of OA in binge eating disorder, and one RCT of OA for kleptomania. We also reviewed case reports on hypersexual disorder, compulsive buying and skin picking disorders.

EXPERT OPINION

The reviewed data supported the use of OA, namely NTX and NMF, in gambling disorder (both) and kleptomania (NTX). We did not find enough evidence to support the use of NTX or NMF in trichotillomania (hair pulling disorder), excoriation (skin-picking) disorder, compulsive buying disorder, hypersexual disorder, or binge eating disorder.

Dimensionality of Cognitions in Behavioral Addiction

Cognitive constructs provide conceptual frameworks for transpathological characterization and improved phenotyping of apparently disparate psychiatric groups. This dimensional approach can be applied to the examination of individuals with behavioral addictions, for example, towards gambling, video-games, the internet, food, and sex, allowing operationalization of core deficits. We use this approach to review constructs such as impulsivity, compulsivity, and attention regulation, which may be most relevant, applicable, and successful for the understanding and subsequent treatment of the addictions.

Possible role of a dysregulation of the endogenous opioid system in antisocial personality disorder

Around half the inmates in prison institutions have antisocial personality disorder (ASPD). A recent theory has proposed that a dysfunction of the endogenous opioid system (EOS) underlies the neurobiology of borderline personality disorder (BPD). In the present theoretical paper, based on a comprehensive database and hand search of the relevant literature, this hypothesis is extended to ASPD, which may be the predominant expression of EOS dysfunction in men, while the same pathology underlies BPD in women. According to evidence from human and animal studies, the problematic behaviours of persons with antisocial, callous, or psychopathic traits may be seen as desperate, unconscious attempts to stimulate their deficient EOS, which plays a key role in brain reward circuits. If the needs of this system are not being met, the affected persons experience dysphoric mood, discomfort, or irritability, and strive to increase binding of endogenous opioids to receptors by using the rewarding effects of aggression by exertion of physical or manipulative power on others, by abusing alcohol or substances that have the reward system as target, by creating an "endorphin rush" by self-harm, by increasing the frequency of their sexual contacts, or by impulsive actions and sensation seeking. Symptoms associated with ASPD can be treated with opioid antagonists like naltrexone, naloxone, or nalmefene.

Alleviating waiting impulsivity and perseverative responding by μ-opioid receptor antagonism in two inbred mouse strains

RATIONALE

Recent evidence has implicated the opioid system in exaggerated ethanol consumption and impulsivity deficits. The opioid receptor antagonist naltrexone (NTX) has proven efficient in reducing alcohol consumption; however, its role on impulsive behaviour is not fully characterised.

OBJECTIVE

The aim of this study was to investigate the effects of NTX on two measures of impulsive behaviour in two inbred mouse strains that differ in ethanol preference and impulsive phenotype.

METHODS

Two separate groups of C57BL/6J (B6, n = 24) and DBA2/J (D2, n = 24) male mice were exposed to intermittent ethanol (IEE; 2 g/kg) during early (PND 30-45, IEE_Early) or late (PND 45-60, IEE_Late) adolescence or the respective saline control. The ability of NTX (10 mg/kg) alone, or co-administered with ethanol (0.5 g/kg), to diminish waiting impulsivity in the five-choice serial reaction time task (5-CSRTT), or improve decision-making in a mouse version of the Iowa Gambling Task (mIGT), was examined in adulthood.

RESULTS

In the 5-CSRTT, NTX diminished impulsivity in both strains of mice, irrespective of previous ethanol experience. In the mIGT, NTX failed to alter risky decision-making but decreased perseverative responding.

CONCLUSIONS

Blocking the actions of endogenous opioids may attenuate waiting impulsivity, in addition to alleviating perseverative responding. In a broader context, μ-opiate antagonism may be of potential interest for impulse-control disorders.

Gambling disorder and other behavioral addictions: recognition and treatment

Addiction professionals and the public are recognizing that certain nonsubstance behaviors--such as gambling, Internet use, video-game playing, sex, eating, and shopping--bear resemblance to alcohol and drug dependence. Growing evidence suggests that these behaviors warrant consideration as nonsubstance or "behavioral" addictions and has led to the newly introduced diagnostic category "Substance-Related and Addictive Disorders" in DSM-5. At present, only gambling disorder has been placed in this category, with insufficient data for other proposed behavioral addictions to justify their inclusion. This review summarizes recent advances in our understanding of behavioral addictions, describes treatment considerations, and addresses future directions. Current evidence points to overlaps between behavioral and substance-related addictions in phenomenology, epidemiology, comorbidity, neurobiological mechanisms, genetic contributions, responses to treatments, and prevention efforts. Differences also exist. Recognizing behavioral addictions and developing appropriate diagnostic criteria are important in order to increase awareness of these disorders and to further prevention and treatment strategies.

Compulsive sexual behavior among male military veterans: prevalence and associated clinical factors

BACKGROUND AND AIMS

Compulsive sexual behavior (CSB) is highly prevalent among men, often co-occurring with psychiatric disorders and traumatic experiences. Psychiatric disorders and trauma are highly prevalent among military veterans, yet there is a paucity of research on CSB among military samples. The aim of this study was to examine the prevalence of and factors associated with CSB among male military veterans.

METHODS

Surveys were administered to veterans of Operations Iraqi Freedom, Enduring Freedom, or New Dawn at baseline (n = 258), 3 months(n = 194), and 6 months (n = 136). Bivariate analyses and Generalized Estimating Equations were utilized to estimate associations between CSB and the following variables: psychiatric co-morbidity, childhood physical or sexual trauma, pre- and post-deployment experiences, TV/ Internet usage, and sociodemographics. Associations between CSB and specific PTSD symptom clusters were also examined.

RESULTS

CSB was reported by 16.7% of the sample at baseline. Several variables were associated with CSB in bivariate analyses; however, only PTSD severity, childhood sexual trauma, and age remained significant in multivariable GEE models. The PTSD symptom cluster re-experiencing was most strongly associated with CSB.

DISCUSSION

This exploratory study suggests that CSB is prevalent amongst veterans returning from combat and is associated with childhood trauma and PTSD, particularly re-experiencing.

CONCLUSIONS

Further study is needed to identify the mechanisms linking PTSD and CSB, define the context and severity of CSB in veterans, and examine the best ways to assess and treat CSB in VA clinical settings.

Behavioral addictions: a novel challenge for psychopharmacology

Although addictive syndromes have been traditionally related to substance-use disorders, during the last few decades a novel addictive group, including the so-called "behavioral or no-drug addictions," has been recognized and has attracted increasing attention for its relevant social impact. This group includes pathological gambling, compulsive shopping, TV/Internet/social network/videogame addictions, workaholism, sex and relationship addictions, orthorexia, and overtraining syndrome. Substance and behavioral addictions show similar phenomenological features, such as craving, dependence, tolerance, and abstinence, and perhaps they share a common possible pathophysiology. It is, however, controversial whether all or at least some of them should be considered real disorders or just normal, albeit extreme, behaviors. The aim of this article is to review current data on pharmacological treatment of behavioral addictions. As no specific and validated treatment algorithms are currently available, only an improved knowledge on their psychopathological, clinical, and neurobiological features may have relevant implications for more focused preventive and therapeutic strategies.

Effects of systemic opioid receptor ligands on ethanol- and sucrose seeking and drinking in alcohol-preferring (P) and Long Evans rats

The endogenous opioid system has been implicated in mediating the reinforcing effects of ethanol (EtOH). Naltrexone (NTX), an opioid antagonist with concentration-dependent selectivity for the mu receptor, naltrindole (NTI), a selective delta receptor antagonist, and U50,488H, a selective kappa receptor agonist were examined in both alcohol-preferring (P) and nonselected (Long Evans (LE)) rats to determine whether they differentially affected the seeking and consumption of EtOH and sucrose. Using the sipper-tube model, rats reinforced with either 2% sucrose or 10% EtOH were injected with vehicle and either NTI (2.5, 5.0, or 10.0 mg/kg), U50 (2.5, 5.0, or 10.0 mg/kg), low-dose NTX (0.1, 0.3, or 1.0 mg/kg), or high-dose NTX (1.0, 3.0, or 10.0 mg/kg). Subsequent intakes (consummatory) or lever responses (seeking) were assessed. Overall, NTI, U50, and NTX attenuated intake and responding for sucrose and EtOH, with EtOH-reinforced P rats being the most sensitive to the effects of NTI on intake and seeking. U50 treatment decreased intake and seeking in both P and LE rats but did not selectively reduce EtOH intake or seeking in either line. P rats were more sensitive than LE rats to lower doses of NTX, and these doses more selectively attenuated responding for EtOH than sucrose. Higher doses of NTX suppressed intake and responding across both lines and reinforcers. These results suggest that drugs selective for the opioid receptors may be good pharmacotherapeutic targets, particularly in those with an underlying genetic predisposition for greater EtOH preference/intake.

Treatment of fetishism with naltrexone: a case report

Fetishism is a paraphilic sexual disorder characterized by recurrent, intense sexually arousing fantasies, sexual urges or behaviors involving the use of nonliving objects. We describe a case of fetishism with comorbid alcohol and cannabis dependence. A 40-year-old man was presented with sexual fantasies and urges toward women's undergarments since the age of 25 years. He had fetish behavior even during prolonged period of abstinence from substance use. Our case remitted from fetishism and cannabis and alcohol use on treatment with naltrexone and maintains remission for the last 11 months. Experience with our patient suggests that naltrexone may be effective to treat fetishism with comorbid substance use. Our case is reported as it is the first reported case of successful use of naltrexone in fetishism comorbid with cannabis and alcohol dependence.

The functional anatomy of impulse control disorders

Impulsive–compulsive disorders such as pathological gambling, hypersexuality, compulsive eating, and shopping are side effects of the dopaminergic therapy for Parkinson’s disease. With a lower prevalence, these disorders also appear in the general population. Research in the last few years has discovered that these pathological behaviors share features similar to those of substance use disorders (SUD), which has led to the term “behavioral addictions”. As in SUDs, the behaviors are marked by a compulsive drive toward and impaired control over the behavior. Furthermore, animal and medication studies, research in the Parkinson’s disease population, and neuroimaging findings indicate a common neurobiology of addictive behaviors. Changes associated with addictions are mainly seen in the dopaminergic system of a mesocorticolimbic circuit, the so-called reward system. Here we outline neurobiological findings regarding behavioral addictions with a focus on dopaminergic systems, relate them to SUD theories, and try to build a tentative concept integrating genetics, neuroimaging, and behavioral results.

Effect of opioid antagonists on sex hormone secretion

BACKGROUND

Endogenous opioids have roles in various functions in different parts of the body, including intestinal motility, suppression of pain, reinforcement of behavior, and regulation of the hypothalamic-pituitary-gonadal axis. The endogenous opioid system is also recognized to be involved in the negative-feedback regulation of the release of LH and testosterone.

AIM

The reviewed articles herein show the development of the current model of this regulation, the evidence supporting it, and also the observed effects of opioid antagonist (naloxone, naltrexone, and nalmefene) on the system.

MATERIALS AND METHODS

Review of the studies published during the years 1979-1996 (no significant studies made after that). Search from databases Pubmed, SciFinder, and Medline with search words opioid antagonists, hormones, LH, testosterone, and GnRH, in different combinations.

RESULTS/CONCLUSIONS

Opioid antagonists seem to increase the secretion of GnRH in the hypothalamus which then causes a pulsatile release of LH in the pituitary and secretion of testosterone. According to the experiments, the frequency of pulses and concentration of LH and testosterone in plasma seem to increase. These effects are seen in both men and women (at early follicular phase). More research is needed to investigate the consequences of these effects in general.

Oxycodone lengthens reproductions of suprasecond time intervals in human research volunteers

Oxycodone, a popularly used opioid for treating pain, is widely abused. Other drugs of abuse have been shown to affect time perception, which, in turn, may affect sensitivity to future consequences. This may contribute to continued use. This study evaluated the effect of oxycodone on time perception in normal healthy volunteers. For this within-subject, double-blind design study, participants performed a temporal reproduction task before and after receiving placebo or oxycodone (15 mg, orally) over six outpatient sessions. Participants were first trained with feedback to reproduce three standard intervals (1.1, 2.2, and 3.3 s) in separate blocks by matching response latency from a start signal to the duration of that block's standard interval. During testing, participants were instructed to reproduce the three intervals from memory without feedback before and after drug administration. Oxycodone significantly lengthened time estimations for the two longer intervals relative to placebo. These results suggest that opioids alter temporal processing for intervals greater than 1 s, raising questions about the effect of these drugs on the valuation of future consequences.

Introduction to behavioral addictions

BACKGROUND

Several behaviors, besides psychoactive substance ingestion, produce short-term reward that may engender persistent behavior, despite knowledge of adverse consequences, i.e., diminished control over the behavior. These disorders have historically been conceptualized in several ways. One view posits these disorders as lying along an impulsive-compulsive spectrum, with some classified as impulse control disorders. An alternate, but not mutually exclusive, conceptualization considers the disorders as non-substance or "behavioral" addictions.

OBJECTIVES

Inform the discussion on the relationship between psychoactive substance and behavioral addictions.

METHODS

We review data illustrating similarities and differences between impulse control disorders or behavioral addictions and substance addictions. This topic is particularly relevant to the optimal classification of these disorders in the forthcoming fifth edition of the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (DSM-V).

RESULTS

Growing evidence suggests that behavioral addictions resemble substance addictions in many domains, including natural history, phenomenology, tolerance, comorbidity, overlapping genetic contribution, neurobiological mechanisms, and response to treatment, supporting the DSM-V Task Force proposed new category of Addiction and Related Disorders encompassing both substance use disorders and non-substance addictions. Current data suggest that this combined category may be appropriate for pathological gambling and a few other better studied behavioral addictions, e.g., Internet addiction. There is currently insufficient data to justify any classification of other proposed behavioral addictions.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Proper categorization of behavioral addictions or impulse control disorders has substantial implications for the development of improved prevention and treatment strategies.

Volitional disorders: a proposal for DSM-V

In the DSM-IV-TR, specific impulse control disorders not elsewhere classified (ICD) have been designated following four principles: (1) through the addition of an adjective that emphasizes the aberrant character of an otherwise normal behaviour (e.g., pathological gambling); (2) by means of metaphors (such as in intermittent explosive disorder); (3) according to the presumably quintessential nature of their main signs and symptoms, such as impulsive (e.g., impulse control disorders not elsewhere classified), compulsive (e.g., compulsive shopping), or addictive (e.g., internet addiction); or (4) using Greek suffix mania (e.g., kleptomania, pyromania, and trichotillomania). Given this flagrant inconsistency, we argue that time has come to adopt a less arbitrary way of describing these disorders, at least until it becomes clearer whether they are really impulsive, compulsive or addictive or if the preoccupation with this distinction is valid. In keeping with DSM's emphasis on descriptive phenomenology rather than on unsupported theory, a less biased terminology is in order. Therefore, we would like to suggest: (1) the substitution of the term ICD by the more neutral expression 'volitional disorders not elsewhere classified'; (2) the use of the classical Greek suffix mania, already present in some DSM-IV-TR ICDs, as the main naming principle to be adopted in the DSM-V; and (3) the creation of compulsive, impulsive, and mixed subtypes of the 'volitional disorders not elsewhere classified', since they are beginning to be validated by treatment trials.

Diagnosis, assessment, and treatment of hypersexuality

This article reviews the current evidence base for the diagnosis, assessment, and treatment of hypersexual conditions. Controversy concerning this diagnosis is discussed. Terminology and diagnostic criteria, as well as psychological, psychopharmacological, and other treatment approaches, are presented.

Now or Later? An fMRI study of the effects of endogenous opioid blockade on a decision-making network

Previously, we found that distinct brain areas predict individual selection bias in decisions between small immediate ("Now") and larger delayed rewards ("Later"). Furthermore, such selection bias can be manipulated by endogenous opioid blockade. To test whether blocking endogenous opioids with naltrexone (NTX) alters brain activity during decision-making in areas predicting individual bias, we compared fMRI BOLD signal correlated with Now versus Later decision-making after acute administration of NTX (50 mg) or placebo. We tested abstinent alcoholics and control subjects in a double-blind two-session design. We defined regions of interest (ROIs) centered on activation peaks predicting Now versus Later selection bias. NTX administration significantly increased BOLD signal during decision-making in the right lateral orbital gyrus ROI, an area where enhanced activity during decision-making predicts Later bias. Exploratory analyses identified additional loci where BOLD signal during decision-making was enhanced (left orbitofrontal cortex, left inferior temporal gyrus, and cerebellum) or reduced (right superior temporal pole) by NTX. Additional analyses identified sites, including the right lateral orbital gyrus, in which NTX effects on BOLD signal predicted NTX effects on selection bias. These data agree with opioid receptor expression in human frontal and temporal cortices, and suggest possible mechanisms of NTX's therapeutic effects.

Internet sex addiction treated with naltrexone

Malfunctioning of the brain's reward center is increasingly understood to underlie all addictive behavior. Composed of mesolimbic incentive salience circuitry, the reward center governs all behavior in which motivation has a central role, including acquiring food, nurturing young, and having sex. To the detriment of normal functioning, basic survival activities can pale in importance when challenged by the allure of addictive substances or behaviors. Dopamine is the neurotransmitter driving both normal and addictive behavior. Other neurotransmitters modulate the amount of dopamine released in response to a stimulus, with the salience determined by the intensity of the dopamine pulse. Opiates (either endogenous or exogenous) exemplify such modulators. Prescribed for treating alcoholism, naltrexone blocks opiates' capacity to augment dopamine release. This article reviews naltrexone's mechanism of action in the reward center and describes a novel use for naltrexone in suppressing a euphorically compulsive and interpersonally devastating addiction to Internet pornography.

Pharmacological treatments for paraphilic patients and sexual offenders

PURPOSE OF REVIEW

This review addresses testosterone-lowering and other psychotropic medications for the treatment of paraphilic patients or sexual offenders.

RECENT FINDINGS

Randomized controlled studies are still lacking, and only a few new studies were reported during the past year. On the other hand, there is substantial scientific knowledge about the wide range of psychiatric comorbidity associated with paraphilias and in sexual offenders. Empirically based treatment of these patients, especially of impulsivity, anxiety and mood disorders, may also ameliorate sexual impulsivity.

SUMMARY

Medication interventions, either substantially lowering serum testosterone or treating axis I comorbidities, show definite promise as a significant component of the management of sexual offenders. Pharmacotherapy should be combined with other therapeutic treatment modalities, most commonly cognitive-behaviour based psychotherapy and intensive community supervision.

Neurobiology of addiction. An integrative review

Evidence that psychoactive substance use disorders, bulimia nervosa, pathological gambling, and sexual addiction share an underlying biopsychological process is summarized. Definitions are offered for addiction and addictive process, the latter being the proposed designation for the underlying biopsychological process that addictive disorders are hypothesized to share. The addictive process is introduced as an interaction of impairments in three functional systems: motivation-reward, affect regulation, and behavioral inhibition. An integrative review of the literature that addresses the neurobiology of addiction is then presented, organized according to the three functional systems that constitute the addictive process. The review is directed toward identifying candidate neurochemical substrates for the impairments in motivation-reward, affect regulation, and behavioral inhibition that could contribute to an addictive process.

The neurobiology and genetics of impulse control disorders: relationships to drug addictions

Impulse control disorders (ICDs), including pathological gambling, trichotillomania, kleptomania and others, have been conceptualized to lie along an impulsive-compulsive spectrum. Recent data have suggested that these disorders may be considered addictions. Here, we review the genetic and neuropathological bases of the impulse control disorders and consider the disorders within these non-mutually exclusive frameworks.

Endogenous opioid blockade and impulsive responding in alcoholics and healthy controls

The opioid receptor antagonist naltrexone (NTX) is one of few approved treatments for alcoholism, yet the mechanism by which it reduces drinking remains unclear. In rats, NTX reduces morphine-induced impulsive choice bias; however, nothing is known about the drug's effect on discrete aspects of impulsive behavior in humans, such as decision-making and inhibitory control. Here, we used a modified delay discounting procedure to investigate whether NTX improves decision-making or inhibitory control in humans. We measured the effect of acute NTX (50 mg) on choice between smaller sooner (SS) and larger later monetary rewards and on response errors (motor mismatch) in a high conflict condition in a group of abstinent alcoholics (AA) and healthy control subjects (CS). We previously reported that AA selected the SS option significantly more often than did CS in this paradigm. If the choice bias of AA is due to enhanced endogenous opioid signaling in response to potential reward, NTX should reduce such bias in the AA group. We found that NTX did not reliably reduce impulsive choice in the AA group; however, NTX's effect on choice bias across individuals was robustly predictable. NTX's effect on choice bias was significantly correlated with scores on Rotter's Locus of Control (LOC) scale; increasingly internal LOC scores predicted increasing likelihood of impulsive choices on NTX. In addition, we found that NTX significantly enhanced control of motor responses, particularly within the CS group. These results suggest that endogenous opioids may impair response selection during decision-making under conflict, and that NTX's effects on explicit decision-making are personality-dependent. Determining the biological basis of this dependence could have important implications for effective alcoholism treatment.