Twenty years ago I had an enjoyable dinner with Patrick Carnes, PhD. He is the foremost authority on Sexual Addiction. Patrick J. Carnes is a nationally-known speaker on addiction and recovery issues. He is the author of Out of the Shadows, Contrary to Love, A Gentle Path Through the 12 Steps, and Don't Call It Love. He is the clinical director for sexual disorder services at The Meadows in Wickenburg, Arizona. Carnes is the editor-in-chief of Sexual Addiction and Compulsivity: The Journal of Treatment and Prevention, the official journal of the National Council of Sexual Addiction/Compulsivity, an organization for which he also serves as a board member. He also serves on the national advisory board of the American Academy of Health Care Providers in the Addictive Disorders.
He started a program at the Meadows Treatment Center noting that this was indeed an addiction that was being overlooked and undertreated. As most of you probably know he was right. He wanted to meet with me because he was trying to understand the biologic components of this addiction. He heard about my work with ADHD patients over the life cycle and wanted to understand how ADHD could be a contributing factor. We both agreed that that indeed we were both seeing this phenomenon. Patients with ADHD had more addictions in general and that sexual addiction was a real problem. We also discussed that the Internet would create a major stimulus for Pornography Addiction. We predicted that the Internet now brought pornography into the home and that adolescents would now be able to access any perversion or sexual act they could think of and many they never dreamed of. Suddenly this media blossomed. Today the number 1 Internet search is for pornography. It is the biggest business on the Internet. So now we have Pornography Addiction as well as Video game addiction.
Patients with ADHD have a higher incidence of drug addiction also. Cigarette smoking is twice the risk with ADHD and individuals start a younger age as well as have greater difficulty stopping. This association is found with all substance abuse disorders. Dr. Kafka, Clinical Associate Professor at Harvard, research shows that Hypersexual Disorder and ADHD have a 17-19% association. Dysthymia was the most common co-existing axis I disorder n Hypersexual Disorder patients, occurring 61-62% of the time, followed by alcohol abuse(25-39%) and Social Phobia(22-25%). Bipolar Spectrum Disorder is also highly associated (26%) with Hypersexual Disorder.
The reason that ADHD and Sexual Addiction are associated is multifactorial. ADHD is always seeking something novel when they are bored or depressed. They also use sex as a way to relieve stress, which they often create in their lives by procrastinating doing important tasks that they find tedious.
From a biological perspective, we must understand the ADHD brain. People with ADHD have abnormal reward centers in the brain. They do not produce enough Dopamine. That is why stimulants help. Stimulants increase the release of Dopamine and also interfere with its breakdown. Therefore there is more Dopamine in the reward center. People with ADHD need higher levels of stimulation to get rewarded. Therefore anything that is highly stimulating helps them feel better. So the riskier the behavior the greater the stimulation and thereby the greater the Dopamine release, thus the greater the reward.
The problem I see is that therapists who treat addictions do not think about their patients having ADHD. The diagnosis is missed and treatment fails. Dr. Carnes and I noted that patients who fail addiction treatments often have untreated ADHD. This is also complicated because addiction programs do not like using medications at all. So my experience shows that adult therapists and Psychiatrists need to think about this disorder and be willing to treat it with medication. In my experience, patients with Sexual Addiction have more severe ADHD and require some type of medication to change their behavior. I have used Strattera( atomoxetine) and Intuniv(guanfacine) for this problem without the risk of stimulant abuse. I clearly do not believe that medicine should be the only treatment for this disorder. But my experience has shown me that is an important component along with a 12 Step Program as well as treating any other Psychiatric Axis I Disorders.