The terms compulsivity and impulsivity are often used interchangeably in clinical settings. However, this is incorrect. The American Psychological Association defines these concepts as [3]:

While the DSM-5-TR does include a category of Substance-Related Disorders, it generally does not use the term addiction in its descriptions of individual disorders. The DSM-5-TR uses the label substance use disorder to identify chemical addiction [5]. Gambling addiction is referred to simply as gambling disorder, and other conditions that are often referred to as addiction could be labeled as impulse control disorders. However, addiction is used widely as an all-inclusive clinical term, and the term appears in the names of many professional associations, such as the American Society of Addiction Medicine, the National Association for Addiction Professionals, and the National Institute on Drug Addiction. For the purposes of this course, the term "addiction" will be used to describe continuing a behavior (e.g., drinking alcohol, smoking cigarettes, gambling, engaging in sexual activity) even when the activity causes repeated pain and consequences [7]. Addiction usually implies a holistic impact on an individual as a result of continuing to engage in the harmful behavior. Carnes defines sexual addiction as an entire pattern of maladaptive behaviors, cognitions, belief systems, and consequences; the behavior alone can be identified as sexual compulsivity [1]. A simple way to identify addiction compared to compulsivity is to recognize that addiction involves how compulsive behaviors impact (or are impacted by) the rest of a person's functioning.

While the DSM-5-TR does include a category of Substance-Related Disorders, it generally does not use the term addiction in its descriptions of individual disorders. The DSM-5-TR uses the label substance use disorder to identify chemical addiction [5]. Gambling addiction is referred to simply as gambling disorder, and other conditions that are often referred to as addiction could be labeled as impulse control disorders. However, addiction is used widely as an all-inclusive clinical term, and the term appears in the names of many professional associations, such as the American Society of Addiction Medicine, the National Association for Addiction Professionals, and the National Institute on Drug Addiction. For the purposes of this course, the term "addiction" will be used to describe continuing a behavior (e.g., drinking alcohol, smoking cigarettes, gambling, engaging in sexual activity) even when the activity causes repeated pain and consequences [7]. Addiction usually implies a holistic impact on an individual as a result of continuing to engage in the harmful behavior. Carnes defines sexual addiction as an entire pattern of maladaptive behaviors, cognitions, belief systems, and consequences; the behavior alone can be identified as sexual compulsivity [1]. A simple way to identify addiction compared to compulsivity is to recognize that addiction involves how compulsive behaviors impact (or are impacted by) the rest of a person's functioning.

According to this model, preoccupation is commensurate to the mental obsession. That obsession could be about using a drug or alcohol, past resentments or abuse, or simply the ruminations of a bad day. The only thing that will bring relief to the mental noise of the obsession is to begin the chase toward feeling good, defined in stage 2 as ritualization. Ritualization may be defined as the routine or the "chase" that a person engages in to obtain their addictive substance or behavior. This could be driving to a certain bar or getting ready for a night out. Many addicts describe the ritualization prior to obtaining the substance or engaging the behavior as more of a rush than engaging in the behaviors themselves.

The word anorexia is generally defined as being without appetite. Nelson has described sexual anorexia as an obsessive state in which the physical, mental, and emotional task of avoiding sex dominates one's life [6]. Sexual addiction and sexual anorexia can exist in the same person or same family at one time; extremes are the common theme. Often, a cycle of binging on sexual compulsions then abstaining entirely becomes apparent. Both conditions (addiction and anorexia) consist of an obsession with sex, but the object or manifestation of the obsession is different. In many cases, this anorexic behavior is a response to recognized addictive behavior or trauma [11].

The idea of sexual anorexia and the addiction/anorexia cycle may be difficult to understand. However, clients who present for clinical attention are often plagued by all-or-nothing thinking—in this case, engaging in as much sexual activity as possible or none at all. Sexual anorexia is quite parallel to "dry drunk syndrome" seen in some chemical addicts [65]. Simply put, these individuals are abstinent but have not addressed any of the emotional issues that motivate their problem drinking or drug use (e.g., no recovery). "Dry drunks" are often impatient, depressed, irritable, impulsive, and difficult to be around as a result of the removal of their coping mechanism (e.g., drinking) without replacement with healthier coping strategies. Sexual anorexia is similar. If the core motivating issues are not addressed, a sex addict may evolve into a sexual anorectic who is depressed and difficult to be around. As such, sexual anorexia can lead to its own level of interpersonal problems. Furthermore, those who stop any addictive behavior but do not address the underlying issue(s) are at greater risk of relapse.

Prior to the advent of Alcoholics Anonymous in 1935 and the American Medical Association's recognition of alcoholism as a disease in 1952, alcoholism and addiction were largely viewed as sin problems [14]. This perspective is referred to as the moral model. According to this view, alcoholics and addicts are morally flawed, and repentance, conversion, or total commitment to a religious program will address the sin and solve the problem. Interestingly, this moral model view still abounds in many circles today.

In addiction treatment, the moral model views addicts as weak-willed and essentially faulty. Many religious groups, specifically those with more fundamentalist or conservative beliefs, approach addiction as a sin problem, not a treatable disease. Compulsive behaviors are best addressed through dedication to the spiritual pursuits as defined by the tenets of that religion. Examples of such cure-through-religion courses or counseling include Blazing Grace and Reformers Unanimous International Ministries, which address addiction problems primarily through the use of biblical passages, and Comunità Cenacolo, a conservative Catholic movement that rejects the idea of therapeutic intervention and advocates addicts living together as a religious community to overcome addiction problems [15,16,17]. These three programs are a few of the many faith-based programs that still operate from the moral model. In most cases, these extreme faith-based programs reject, and often condemn, the necessity of therapeutic intervention. However, it is important to note that not all faith-based recovery programs are as extreme in their moral model stance as the programs listed here.

On the other end of the spectrum from the moral model is the notion that sexual addiction does not exist at all. Some professionals argue that sex addiction is a pseudoscientific cover-up to promote puritanical moral values by the mainstream establishment. One such critic contends that "sex addiction has also been used as a political justification for censorship, eliminating sex education and birth control clinics, and opposing equal rights for gays and lesbians" [18]. Others in the general public believe sex addicts just enjoy sex; the addiction label is only used when they face consequences of their sexual behaviors. Indeed, using addiction as an excuse for poor behavior is not a new concept.

Several theorists suggest that ingestion or reliance on a physical substance is needed to truly justify addiction or dependence. These theorists argue that forms of sexual activities are interactions, not substances [1]. In response, Weiss notes that "acting out sexually becomes the primary way to meet the chemical needs of the brain" [9]. Indeed, anyone who takes an introductory course in addiction learns that it is the dopaminergic response in the brain that makes an experience addicting. Sexual arousal can trigger the release of dopamine and other hormones, including endorphins, which are neurotransmitters in the brain with properties similar to morphine. Some studies have indicated that viewing sexually explicit images can induce the same dopamine response as heroin in addicts [19]. However, a study published in 2013 found that neural responsivity to visual sexual stimuli did not significantly differ in persons with hypersexuality issues compared to healthy controls [85]. Some argue that this lack of verifiable biologic response (as seen in persons with substance dependence) is evidence that sexual addiction is not a real clinical entity.

High comorbidity exists between substance use disorders and sexual addiction. Hagedorn and Juhnke contend that those trained to treat chemical dependency should also be trained to treat the commonly comorbid sexual addiction [1]. Part of meeting this challenge is recognizing the reality of process addictions. Process addictions are often referred to as behavioral addictions and include such addictions as sex, gambling, shopping, Internet use, sports, and eating. The term suggests that the behavioral act, or process, is the most addictive aspect, not necessarily the result of engaging in that activity. O'Brien has suggested that a good starting point for conducting assessments is the exploration of out-of-control behaviors and their consequences, even more so than physical tolerance and withdrawal [1]. O'Brien's contention stems from the idea that any substance and any behavior can become addictive as long as it has the potential to create debilitating behavioral consequences.

High comorbidity exists between substance use disorders and sexual addiction. Hagedorn and Juhnke contend that those trained to treat chemical dependency should also be trained to treat the commonly comorbid sexual addiction [1]. Part of meeting this challenge is recognizing the reality of process addictions. Process addictions are often referred to as behavioral addictions and include such addictions as sex, gambling, shopping, Internet use, sports, and eating. The term suggests that the behavioral act, or process, is the most addictive aspect, not necessarily the result of engaging in that activity. O'Brien has suggested that a good starting point for conducting assessments is the exploration of out-of-control behaviors and their consequences, even more so than physical tolerance and withdrawal [1]. O'Brien's contention stems from the idea that any substance and any behavior can become addictive as long as it has the potential to create debilitating behavioral consequences.

Many of these scales can be accessed online; others must be accessed through academic databases. As an example, the WASTE-Time screening tool consists of items organized into six areas: withdrawal, adverse consequences, inability to stop, tolerance, use of sex as an escape, and time spent on sexual activity (Table 1). The tool also allows for follow-up questions.

As previously discussed, the goal of recovery from sexual addiction is never the extreme of deprivation or sexual anorexia. Rather, the general guiding principle is to have recovering individuals put their sexuality into perspective and to learn how to use it in a way that respects themselves and others.

As noted, many who are addicted to both drugs/alcohol and sex have identified sexual addiction as the most difficult recovery [9]. When sex addicts attempt to control their disease by "white knuckling," they can be successful for various lengths of time, but this is in essence acting in rather than acting out [26]. Therefore, the basis of sex addiction treatment is similar to the traditional basis for treatment of chemical addictions; quitting "cold turkey," and without help, is never recommended. The Carnes model of sex addiction treatment is eclectic, incorporating educational, behavioral, and psychodynamic components. This will be the model discussed in this course.

Whereas total abstinence from the chemical is recommended in traditional chemical addiction treatment and certain behavioral addiction treatments (e.g., gambling), total abstinence from sex is not necessarily a part of the treatment of sexual addiction. The first part of a successful treatment program for sexual addiction is to cease the acting-out behaviors that are causing the most pervasive problems (e.g., compulsive masturbation, contact with prostitutes, voyeurism, affairs with people other than the spouse). These problems should, of course, be identified in the initial assessment or shortly thereafter. Contracts are often used as part of the treatment process [6]. This is a close parallel to chemical addiction treatment, in which the client is asked to abstain from mood/mind-altering drugs to optimize the effectiveness of the treatment.

Four basic components should be addressed in a treatment plan for sexual addiction. As long as these four components are included, the individualized aims for abstinence of problematic behaviors and resumption (or attainment) of healthy sexuality can be worked in. Clinical discretion regarding how these behaviors are addressed is a must. The four major goals of sex addiction treatment are [1,6]:

The importance of lifestyle change for the addict cannot be overestimated. In 12-step recovery, there is an axiom that an addict must change people, places, and things in order to recover. These are all facets of an individual's lifestyle. In much of the available research of treatment models for recovery (e.g., 12-step, religious, spiritual, rational), there is one major similarity: the necessity of lifestyle change.

For the purposes of this course, relapse refers to any resumption of the primary addictive behavior(s) that cause significant functional impairment in the individual's life. This concept has been defined in numerous ways in the published literature, which has often led to problems in studying the phenomenon [46]. Relapse prevention plans are often discussed as elements of addiction treatment and are essentially proactive steps identified by the client and counselor that the client will take to maintain gains in recovery. Some treatment professionals prefer to refer to these steps as recovery enhancement rather than relapse prevention. While the two terms are basically synonymous, the former reminds recovering individuals that the stronger the recovery system they have in place, the less likely that relapse will occur.

Graduate study in human sexuality is encouraged for counselors, and an understanding of healthy sexuality is vital for those treating sexual addiction. Sadly, most graduate programs do not include coursework on healthy sexuality or sexual addiction [1]. As Hagedorn and Juhnke cautioned, "If counselors do not receive the proper training in the treatment of sexual addiction, clients, and those affected by their addicted behaviors, will be the ones adversely affected" [1].

In addition to more extensive education, clinicians may benefit from networking with other professionals in the community. This networking is especially important for clinicians who make referrals for specific treatment. Colleagues who are comfortable treating sexual addiction and local treatment centers equipped to address sex addiction can be identified, allowing for better referral and education for clients.