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Date: Mon, 5 Jun 1995 19:36:09 -0700 (PDT)
From: Ivan Goldberg <psydoc@psycom.net>
Subject: SSRIs for sexual addiction
Every year I am consulted by a number of "sexual addicts" who request that I prescribe high doses of one or another of the SSRIs to control their uncomfortable, and frequently dangerous, sexual behavior. Any of the SSRIs, if prescribed in high enough doses, will cause loss of libido usually followed by decreased sexual behavior.
One has to be willing to use, on occasion, the same high doses sometines needed to treat pholks with "borderline personality disorder," namely, a few hundred mg/day of fluoxetine or sertraline or over 400 mg/day of venlafaxine.
Date: Tue, 26 Dec 1995 19:32:02 -0500
From: vicka corey <vicka@u.washington.edu>
Subject: Other drugs for sexual addiction
SSRIs are not the only drugs used in such cases. Both LHRH antagonists and antiandrogens have been usefully prescribed (usually along with counselling, at least in cases where the behavior in question was dangerous or criminal). There have not been too many well-controlled studies done in this area (I think John Money may have done one at Johns Hopkins Hospital), but anyway SSRIs are not the only tool available.
Date: Tue, 23 Jan 1996 17:41:47 -0800
From: "Jim Ellison" <jellison@interserv.com>
Subject: Sexual addiction
To me, this hypothesized mechanism of SSRI treatment of "sexual addicts" is researchable but currently unproven -- i.e., lowering the libido is not a consistent SSRI effect, this effect may not be entirely dose-related, and the anti-"sexual-addiction" effect may relate to treatment of an obsession (e.g., pathological jealousy) or compulsion rather than simply lowering libido -- so I find Dr. Corey's comment opens a number of interesting questions about what "sexual addiction" is and how any medication might affect it...
Date: Wed, 24 Jan 1996 01:12:39 -0500
From: "Paul Luisada, M.D." <pvl2@cornell.edu>
Subject: Fluoxetine for sexual addiction
I also had my doubts about what this "sexual addiction" thing was -- until a 40-ish man came to my office complaining of it. In his case, it boiled down to compulsively having affairs with women, married or not, and changing partners every few months, despite being on his own second or third marriage. He had read about "sexual addiction" in the popular press and was referred by another patient with whom he was currently having an affair.
The family history was negative for any psychiatric problems except for OCD in a parent. The past history was devoid of symptoms suggestive of manic or hypomanic states or depressive episodes of any significance. No significant energy or sleep disturbances, either up or down. No drugs or alcohol. He worked in an executive position with the federal government, with stable employment for over 15 years. He had a number of other, less disruptive OCD behaviors, such as checking and hoarding.
The bottom line was that the history and presentation suggested that the "sexual addiction" was a compulsive behavior which relieved anxiety, and not a manifestation of an episodic or cyclical mood change. Hence, fluoxetine.
At 60 mg per day it worked. His libido was slightly diminished but he lost no sexual functioning despite the high dose. The compulsion to start yet another affair diminished to the point where he could control it. He remained in that relationship for the next 3.5 years (twice as long as any prior one), until he moved away due to job reassignment. The problem remains under control, according to his most recent letter.
While I'm still not sure what "sexual addiction" is, I think this man's diagnosis was OCD. His improvement seemed to result from relief of the anxiety he had previously relieved through sexual behavior, not due to the abolition of his sexual drive itself. So this case is a vote in favor of the SSRI's effectiveness being via an anti-OCD rather than an anti-sex mechanism.
However, until we have an agreed-upon working definition of "sexual addiction" itself, we won't really know if he met the criteria for that "diagnosis" or not.
From: Judith Lipton <jlipton@forest.net>
Subject: Sexual addiction
On Wed, 24 Jan 1996 evb@YKnet.YK.CA wrote:
My concern is that social values of monogamy lead the therapist to prescribe medication to decrease libido in an individual for whom variety is the spice of life when it comes to sexual partners. I guess his subjective distress and seeking of help must be respected, but I know of others whose behaviour is not significantly different and for whom having a different partner each time is not viewed as a source of distress, but rather a confirmation of their self image as a successful sexual partner.Curiously enough, the Internet and other online services have apparently produced a new form of compulsive sexual behavior that is expensive, dangerous, ego-dystonic, and frightening.One could call them "promiscuous", but that is a value judgment. Alfred Kinsey is said to have defined a promiscuous person as "one who has a greater number of sex partners than I do." Thus promiscuity, like beauty, may be in the eye of the beholder.
I am currently treating a woman who has become "addicted" to online sex talk. Her online bills are over $300 monthly, her marriage is in jeopardy, her real telephone bills are mounting, and she fears that soon she will meet men for anonymous sex. The computer gave her freedom that she had never known before, popularity beyond her wildest belief. Although she is ... fifty, she feels like a nymphet.
We've talked about Prozac, but it would be simpler to stop her computer serivce, or donate the computer to a good cause.
Let us not gloss over the huge costs of compulsive behaviors.
Particularly online, there is no such thing as free love.
From: NoleDoc@aol.com (Paul Kelley)
Date: Thu, 25 Jan 1996 22:22:23 -0500
Subject: Sexual addiction
I believe we must be careful not to let our diagnostic-psychopathologic mindset as physicians nudge us into a subtle arrogance about behavior which may cause no harm, provide lots of pleasure, and, even if it resides in the outskirts (so to speak) of human sexual behavior, may not be a disease. Just a thought.
Date: Sat, 23 Mar 1996 06:57:30 EST
From: MWKR59A@prodigy.com (Dr Frederick C Goggans)
Subject: Fluoxetine for sexual impulse disorder
I have had success in treating some cases of sexual impulse disorder with fluoxetine. In one case, the patient was a software engineer in his 30s who had a compulsion to drive alongside or follow women in their automobiles and often to masturbate while doing so. He came from a foreign culture where women tended to be more wrapped up in public. At 60 mg per day, the behavior has been eliminated, but the patient enjoys a normal sexual life with his wife. So however this works, it does not do so by direct reduction of libido per se, but by a different effect. I have also had good effect in a couple of other cases of sexual compulsive behaviors involving otherwise well functioning individuals with fluoxetine in this dose range (similar to that used in OCD).
Date: Sat, 23 Mar 1996 19:31:21 -0500 (EST)
From: "William B. Strek" <wstrek@athens.net>
Subject: Sexual acting out in dementia
I've had elderly adults in nursing homes who sexually harass female patients. I had had positive results with SSRIs, usually paroxetine, to dampen the sexual response, starting at 10 mg PO qam and increasing to 20 mg PO qam. It's important to discontinue any anticholinergic medications as sometimes just doing that will eliminate the behavior.
Date: Sun, 24 Mar 1996 13:09:57 -0500 (EST)
From: Alan Eppel <eppela@fhs.csu.mcmaster.ca>
Subject: Hormones for sexual addiction
In Canada, hormone treatment is used for individuals who have an abnormally high sex drive that leads to problem behavior: medroxyprogesterone (Provera), cyproterone acetate (Androcur).
Date: Tue, 26 Mar 1996 10:43:04 +1200
From: david.menkes@stonebow.otago.ac.nz (David Menkes)
Subject: Sexual addiction
SSRIs seem helpful in some cases, especially if there is an "impulse dyscontrol" flavour to it. My strategy is different if there is evidence of hypersexuality (degree of sex drive, frequency of masturbation, possibly androgen levels) in which case I would consider cyproterone -- very effective in some folks, but go gently as there is a window of response without too much effect on "normal" sexuality.
These oral medication strategies obviously depend on a degree of insight and compliance, so the psychological profile of the patient is important in this respect, too. If compliance is doubtful, and if hypersexuality is likely, medroxyprogesterone given as a depot could be considered as a "public health" maneouvre.
Date: Fri, 12 Apr 96 21:11:00 UT
From: "Gary Galambos" <Gary_Galambos@msn.com>
Subject: Sexual addiction
I was involved in the management of a patient in his late teens incarcerated in a medium-security forensic unit for impulsive paedophilic acts, whom we believed suffered from Asperger's disorder and some psychopathic personality traits. He had penile erections that went off the scale on penile plethysmography when exposed to pictures of naked children which persisted for over an hour despite removal of the stimulus pictures. Graduated exposure failed to assist because he undermined the therapy. Interestingly, his whole profile of responsiveness to pictures of children and adults altered on treatment with Androcur -- his responses to children reduced to brief blips and increased to moderate (more "usual" levels) to young women. Unfortunately, we assessed his dangerousness to continue to be sky-high because of his exploitiveness, lack of empathy, immaturity and barren possibilities of acquiring non-child sexual gratification due to his paucity of social skills. But we thought he was "safer" on the Androcur.
Date: Fri, 19 Jul 1996 10:00:15 -0500
From: ner@box-n.nih.gov (Norman Rosenthal)
Subject: Sexual addiction
SSRIs are rather reliable in reducing libido -- Paxil has the most potent effect in this regard in my clinical experience. Yet, in dealing with a number of people with sexual addictions, I have found that, as with all addictions, they respond best if the medication is used as part of a general program. Sex and Love Addicts Anonymous (SLAA) can be very helpful in this regard.
Date: Fri, 19 Jul 1996 10:06:22 -0500
From: ner@box-n.nih.gov (Norman Rosenthal)
Subject: Sexual addiction
I would like to remind all those purists who decry medications for this condition that it can be fatal -- just as much as depression -- especially in the age of AIDS -- not only to the addict himself, but also to his loved ones. And even if it doesn't kill, it can destroy relationships, ruin careers and reputations, and result in untold misery. No strategy that can be applied to ameliorate the condition should be excluded out of hand. While family and individual therapy might be invaluable, medications can provide critical restraint to the impulsive acting out that is a cornerstone of the condition.
Date: Sat, 20 Jul 96 22:09:43 UT
From: "Jim Pfrommer" <jpfrommer@msn.com>
Subject: SSRIs for sexual addiction
The utility of the SSRIs in the treatment of sexual addiction is much more involved than simply reducing libido. "Sexual addiction is no more about libido than bulimia is about appetite."
The major role of the SSRIs in the treatment of sexual addiction is in treating the shame filled dysphoric state that drives the sexually "compulsive" behaviors. The SSRIs are often helpful in the sexual addictions even if the prescriber has no idea how they are actually helping the patient. When the chronic shame and dysphoria beneath the the addiction are recognized, the patient is able to helped even more.
The 12 step groups are a helpful adjunct in this treatment.
From: ckuttner@proaxis.com (Charles Kuttner)
Subject: Estrogen for acting out
I have a 95 year old male in an "old age home"... He has an "eye" for the young women working in the place... His daughter asked me if giving him a "chemical castration" would be an option (she works at the jail, and they have some inmates using this).To offer a distantly related weird anecdote: a muscular young man was known for having a bad temper and yelling a lot at home and work. He stopped seeing me after I tried a couple of SSRIs. Then he returned and told me he tried something on his own; knowing how irritable his wife was when she stopped her estrogen supplement, he started taking her pills (conjugated estrogens 1.25 mg, if I recall correctly).--Valorie Cunningham
He reported that everybody was delighted with the change in him after only a few days. The effect was sustained over two months. He noted no change in libido, muscle mass, etc., but felt his mood was a lot better.
I explained that I did not feel comfortable prescribing this drug for him, due to the lack of any knowledge of possible adverse effects. "No problem," he said. His wife now sees two different doctors to get two different prescriptions and has them filled at two different pharmacies. Her husband gets one of the bottles.
Date: Thu, 24 Oct 1996 23:08:16 -0700 (PDT)
From: ckuttner@proaxis.com (Charles Kuttner)
Subject: Hormones for sexual acting out in dementia
I found the following articles:
Cooper AJ. Medroxyprogesterone acetate (MPA) treatment of sexual acting out in men suffering from dementia. J Clin Psychiatry. 1987 Sep; 48 (9): 368-70.
Kyomen HH, Nobel KW, Wei JY. The use of estrogen to decrease aggressive physical behavior in elderly men with dementia. J Am Geriatr Soc. 1991 Nov; 39 (11): 1110-2.
From: "M Cevdet Tosyali" <TOSYALIM@child.cpmc.columbia.edu>
Date: Mon, 28 Oct 1996 13:08:06 EST
Subject: Antipsychotics for sexual acting out in dementia
I think the castration stuff may be pushing it a bit. I would not think of this as a sexual drive issue, but as an inappropriate aggression issue. Often in patients with dementia who have aggressive behavior, low doses of antipsychotics do the trick. Risperidone may be a good choice, but watch very carefully for orthostatic hypotension. Tiny doses of haloperidol may also work.
Date: Tue, 17 Dec 1996 08:20:17 -0800 (PST)
From: Judith Lipton <jlipton@forest.net>
Subject: Sexual addiction
By the way, my patient responded to Effexor (venlafaxine) and Depakote (divalproex), plus education on borderline personality disorder, and is back to work full time, off line, and pretty happy.
Date: Sat, 21 Jun 1997 01:30:08 -0700
From: Frank Feiner <nfrank@pol.net>
Subject: Hormones for sexual addiction
The use of estrogen therapy for aggressive (usually sexually deviant) males, once common, has largely been replaced by progesterone therapy (medroxyprogesterone (Provera) in the USA and cyproterone in Europe), largely because of feminization -- especially gynecomastia, which, according to one source, almost always required surgical treatment -- but also because of GI side-effects and, rarely, breast cancer.
Date: Fri, 25 Jul 1997 23:37:02 -0400
From: William Braden <braden@brown.edu>
Subject: Medroxyprogesterone for sexual acting out in dementia
My geropsychiatric colleague suggested considering starting on oral medroxyprogesterone 10 mg a day; if this is satisfactory, switch to depot at 100 mg IM weekly, or higher. Common side effects: fatigue, weight gain, decreased libido; severe side effect: phlebitis.
From: MZSHRINK@aol.com (Victoria Codispoti,M.D.)
Date: Sat, 26 Jul 1997 10:13:09 -0400 (EDT)
Subject: Medroxyprogesterone for sexual acting out in mental retardation
I routinely use Depo-Provera in the mentally retarded or developmentally disabled population who are acting out impulsively or inappropriate sexually. I have had excellent results using the injections on a weekly basis, starting at 300 mg IM weekly and going as high as 800 if necessary. I find that with the assitance of the medications, the behavioral controls are much more effective. If the oral dose is used, you may need to use very high doses (60-100 mg) per day, a lot of pills, unfortunately.
From: MZSHRINK@aol.com (Victoria Codispoti,M.D.)
Date: Tue, 29 Jul 1997 00:24:21 -0400 (EDT)
Subject: Sexual acting out in mental retardation
For adolescents, one cannot use Depo-Provera until bone age x-rays show closure of the epiphyses. This is so that we do not affect the hormonal axis (which I can't recall the name of tonight)...
If the person does not show closure, then SSRIs would be the next choice... these may decrease obsessiveness as well as compulsiveness, and, with any luck, lower libido.
Date: Tue, 02 Dec 1997 08:54:02 -0500
From: Whit Garberson <jwgg@world.std.com>
Subject: Sexual acting out
The patient is a man in his 70s with two CVAs, a dense hemiparesis, [and multiple other medical problems reportedly including] seizures who now takes Dilantin (phenytoin), gabapentin, [other medications], Zoloft (sertraline), amitriptyline, and Premarin. He has been in a nursing home due to the hemiparesis. He scores 23 on the Mini-Mental State Examination.In similar situations in nursing homes:I am asked to see him for "sexual aggression", which according to relatives and staff is his making sexualized comments and attempting (sometimes successfully) to touch female staff inappropriately. The prior MD apparently started the Premarin for this. He and his relatives state in essence that he has always behaved in this manner, far predating any apparent neurological problems. It seems harder for me to see this behavior as a neurological or pharmacological issue in light of it being presented as his usual behavior over the years. Further, I might consider SSRIs or anticonvulsants for reduction of impulse control, etc., in the context of the neurological injury, but he is already taking them.
--Ken Wiesert, M.D.
From: MZSHRINK@aol.com (Victoria Codispoti,M.D.)
Date: Thu, 12 Feb 1998 20:48:35 EST
Subject: Hormones for sexual acting out in dementia
Depo-Provera should be started at 300 mg IM qweek and raised by 100 mg if there are no results in two weeks. You can continue to raise the dose to 800 mg if necessary, although with no more than 1 cc per arm or hip. The equivalent dose in po form is difficult to calculate... about the same amount per day orally as per week intramuscularly... which is a lot of pills!
You can also use Lupron Depot (leuprolide) 3.75 mg or 7.5 mg IM qmonth. That works just as well and causes less problems with injection sites.
From: "Kevin Gray, MD" <jahsteel@cyberramp.net>
Subject: Hormones for sexual acting out in dementia
Date: Mon, 16 Feb 1998 10:29:52 -0600
For our elderly, demented patients, we typically begin more gently with depot medroxyprogesterone acetate at 100-200 mg q 2wks, with good results. We reserve depot for those who are unreliable with PO dosing, otherwise 10 mg PO qd is a fine place to begin.
Leuprolide acetate is considerably more expensive, and we have not yet seen a need to resort to the use of this agent for behavioral symptoms.
Date: Wed, 27 Jan 1999 23:45:14 -0500
From: whit garberson <jwgg@earthlink.net>
Subject: Hormones for sexual acting out in dementia
I [don't want to be] guilty here of skipping over the competency issue. [I am] familiar [with] severely demented, verbally compromised men who have shown a pattern of repeated sexual aggression towards female nursing home residents. Where it's aggression and not assault only because nobody has filed any charges yet, this can constitute a true emergency.
That is a very different kettle of fish than, say, a male resident who keeps propositioning nursing assistants during personal care and is a pain in the neck, but is cognitively intact. This latter guy is typically dysphoric, angry, and bored, and his goal is to see how much of a stir he can cause -- or who knows, he might even get lucky. His behavior may well be manageable without any medications at all even if his mood cannot.
I haven't fully thought through how much more ethically loaded hormone treatment seems to be than other kinds of pharmacological interventions, even where the target symptom is identical. Personally, I would need to weigh whether administering estrogen to a demented and sexually assaultive man, presumably although not necessarily with his reproductive years behind him, is in fact more harmful than administering an antipsychotic or a mood stabilizer or a high dose of an antidepressant (or for that matter a Posey harness) for exactly the same symptom.
We talk a good deal on this list about minimizing sexual side effects in high-functioning patients whose illnesses fall in the mild to moderate range -- and with whose medications many of us probably have some passing personal familiarity. We spend almost no time, it seems to me, worrying about sexual side-effects in folks with major mental illness and the big gun medications they require. Interesting, no?
Date: Thu, 28 Jan 1999 01:23:54 -0500
From: "Phyllis B. Edelheit, MD" <edelheit@nassau.cv.net>
Subject: Hormones for sexual acting out in dementia
It is a while since I've looked at:
Herzog AG, Klein P, Jacobs AR. Testosterone versus testosterone and testolactone in treating reproductive and sexual dysfunction in men with epilepsy and hypogonadism. Neurology 1998 Mar; 50 (3): 782-4
but my recollection is that it gives several references on the effects of estrogen in men and also on its epileptic effects and potential to worsen behavior. More importantly, I believe the finding that men had better control of aggressive impulses when testolactone (Teslac, an aromatase inhibitor) was added to testosterone (in the treatment of reproductive endocrine disorders) was in this article.
Another reference is:
Hutchison JB. Aromatase: neuromodulator in the control of behavior. J Steroid Biochem Mol Biol 1993 Mar; 44 (4-6): 509-20.
Aromatase, the enzyme responsible for the estradiol <--> testosterone balance, plays an important role in behavior. Alterations of it may have strong effects. There is significant work on the epileptic effect of estrogen and some evidence that testosterone may be antiepileptogenic because of its action at the NMDA receptor. Therefore, aromatase may be pivotal as behavioral studies become more hormonally directed.
In another direction, a suggestion is to consider the use of melatonin 1-3 mg at 9 PM. I can't say I remember where I read this, but I believe it lessens hypersexual behavior. Here I would need to search for the reference, but I believe it can be considered a relatively safe intervention.
Date: Thu, 28 Jan 1999 13:56:28 -0500
From: "eric.fier" <eric.fier@MCI2000.com>
Subject: Amantadine for sexual acting out in dementia
I would consider amantadine for frontal lobe sexual disinhibition. It is much easier to utilize than hormonal treatments and has fewer side effects. The typical dose 100-300 mg/day, divided bid. It should improve impulse control associated with a hypodopaminergic frontal or prefrontal insult. See data by Marilyn Krause, MD, at the University of Pittsburgh.
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Dr. Bob is Robert Hsiung, MD,
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URL: http://www.dr-bob.org/tips/split/Sexual-addiction.html
Original tips copyright 1994-99 original authors.
Web page copyright 1995-99 Robert Hsiung.