Psychiatry has a long tradition of believing that too much sex is a bad thing. The classical literature provides detailed accounts of men and women who demonstrated apparently pathological sexual appetites. Since Freud, psychoanalytic authors have held that masturbation is unhealthy, and psychodynamically oriented thinkers have written on Don Juanism and nymphomania.

Compulsive sexual behavior (CSB) is characterized by inappropriate or excessive sexual behaviors or cognitions that lead to subjective distress or impaired functioning. Both abnormal (paraphilic) and conventional (nonparaphilic) forms of sexual behavior are usually included in the definition. CSB is reported to affect 3% to 6% of the general population in the United States, occurring more frequently in men. It typically begins in the late teens or early twenties and is chronic or intermittent. The disorder has been described as a progression through four stages: preoccupation, ritualization, gratification, and despair. Men with CSB typically focus on physical sexual gratification; women focus on romantic or emotional aspects of sexuality. Psychiatric comorbidity is common, particularly substance use, mood, anxiety, and personality disorders. CSB can lead to medical complications. Risk factors are thought to include family history and childhood abuse.

Relatively few studies of the psychobiology of hypersexuality have been undertaken. Nevertheless, the literature does suggest the possibility of a neurobiology of hypersexuality. Three cases of hypersexual behavior are presented in the context of neuropsychiatric disorders, and the literature on this phenomenon is briefly reviewed. These case studies and the literature provide evidence that different brain systems may play a role in this disorder. Frontal lesions may be accompanied by disinhibition, including impulsive hypersexual response to external cues, while striatal lesions may be accompanied by repetitive triggering of internally generated response patterns. Temporal-limbic lesions may be accompanied by disturbances in sexual appetite itself, including change in the direction of sexual drive. These case studies demonstrate that a neurobiology of hypersexuality may prove of some heuristic value in the clinic. However, further research is required to consolidate the literature in this area.

This article reviews the use of pharmacologic agents to treat nonparaphilic compulsive sexual behaviors (paraphilia-related disorders). Recent data suggest that serotonergic antidepressants, especially serotonin reuptake inhibitors (SRIs), may be effective in treating nonparaphilic sexual behaviors characterized by hypersexuality. The rationale, prescriptive use, and limitations of SRIs are reviewed, as are the proposed mechanisms of action, prescriptive use, and side effects of medications that lower serum testosterone (including triptorelin and the antiandrogens medroxyprogesterone acetate and cyproterone acetate). The potential use of psychostimulants, mood stabilizers, and atypical antipsychotics for paraphilia-related disorders in specific clinical situations is discussed. Practical guidelines, augmentation strategies with adjunctive psychopharmacologic agents, and indications regarding pharmacologic combinations of the above medications are suggested.

Paraphilias are recurrent and intense sexually arousing fantasies, sexual urges, or behaviors generally involving nonhuman objects. These paraphilias cause the suffering or humiliation of the patient or patient's partner, or children, or other nonconsenting persons. However, in many patients symptoms involve more culturally acceptable patterns (eg, repetitive masturbation, Internet pornography); such hypersexual symptoms have been labeled as compulsive, addictive, or impulsive. Growing evidence supports the existence of a discrete syndrome characterized by recurrent and intense sexually arousing fantasies, sexual urges, or behaviors involving patterns that fall outside the definition of paraphilia. There is, however, high comorbidity with paraphilia. While such symptoms have been labeled as sexual compulsion or addiction, these terms are problematic in this context. Modern nosology has neglected this entity, although the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), category of sexual disorders not otherwise specified includes hypersexual behaviors as an example. We suggest that the DSM-IV category of sexual disorders be modified to include explicitly diagnostic criteria for a disorder characterized by hypersexual symptoms involving patterns that fall outside of the current definition of paraphilia. The disorder might be classified as one of the paraphilias, or as paraphilia-related. In the absence of a comprehensive understanding of the pathogenesis of this disorder, we suggest that it simply be termed hypersexual disorder.