Treatment of Compulsive Sexual Behaviour Disorder (CSBD): A Gestalt Therapy approach

Introduction

Out-of-control sexual behaviour was documented as early as the 3rd century by St Augustine and later from the mid-18th century by medical pioneers such as Benjamin Rush (1745–1813) and sexologist Richard von Krafft-Ebing (1840–1902). Krafft-Ebing observed one patient suffering:

To such an extent that permeates all his thoughts and feelings, allowing no other aims in life, tumultuously, and in a rut-like fashion demanding gratification and resolving itself into an impulsive, insatiable succession of sexual enjoyments. This pathological sexuality is a dreadful scourge for its victim, for he is in constant danger of violating the laws of the state and of morality, of losing his honor, his freedom, and even his life. (Krafft-Ebing, 1886) (in McKinney, 2014)

Definition of Compulsive Sexual Behaviour Disorder (ICD-11)

Compulsive sexual behaviour disorder (CSBD) is characterised in the ICD-11 (International Classification of Diseases, 11th Revision, World Health Organization, 2018) as,

“a persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behaviour. Symptoms may include repetitive sexual activities becoming a central focus of the person’s life to the point of neglecting health and personal care or other interests, activities and responsibilities; numerous unsuccessful efforts to significantly reduce repetitive sexual behaviour; and continued repetitive sexual behaviour despite adverse consequences or deriving little or no satisfaction from it. The pattern of failure to control intense, sexual impulses or urges and resulting repetitive sexual behaviour is manifested over an extended period of time (e.g., 6 months or more), and causes marked distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. Distress that is entirely related to moral judgments and disapproval about sexual impulses, urges, or behaviours is not sufficient to meet this requirement.”

The classification of Compulsive sexual behaviour disorder as an impulse control disorder is being debated. Some in the DSM camp, that has not classified this disorder, argue that hypersexuality is more related to addiction than compulsion. We can consider both arguments to be true.

Diagnostic requirements (ICD 11) are as follows:

A persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behaviour, manifested in one or more of the following:
- Engaging in repetitive sexual behaviour has become a central focus of the individual’s life to the point of neglecting health and personal care or other interests, activities and responsibilities.
- The individual has made numerous unsuccessful efforts to control or significantly reduce repetitive sexual behaviour.
- The individual continues to engage in repetitive sexual behaviour despite adverse consequences (e.g., marital conflict due to sexual behaviour, financial or legal consequences, negative impact on health).
- The person continues to engage in repetitive sexual behaviour even when the individual derives little or no satisfaction from it.
The pattern of failure to control intense, repetitive sexual impulses or urges and resulting repetitive sexual behaviour is manifested over an extended period of time (e.g., 6 months or more).

The patient is not considered to be diagnosed with CSBD if:

There is another mental disorder that can better explain the behaviour, e.g. mania, or if the patient’s behaviour is due to drug use or medications.
The personal and relational distress experienced is due to moral judgement and societal disapprovements.

Variations of Compulsive Sexual Behaviours and Sex Addiction

There are controversies surrounding labelling behaviours as CSBD and debate over whether the behaviour should be considered a disorder or a moral judgment. Sexual habits become disordered when the relationship to the behaviour becomes a problem to the individual’s life. Compulsive sexual behaviours include dysfunctional pornography use, excessive use of sexual services, chem sex, and sexual acts done indiscriminately with consenting or non-consenting others.

Life Consequences caused by CSBD

Patients who arrive to therapy seeking help to overcome CSBD reveal how seriously their compulsive sexual habits affect their personal lives. They seek therapeutic intervention on their own accord or through the advice or demands from loved ones.

Loss of jobs due to porn use at work
Legal issues
Damaged intimate relationships
Negatively affected social standing
Diminished libido
Sexually transmitted diseases
Sexual dysfunction
Escort /sex-worker engagement
Substance abuse
Physiological issues, e.g. insomnia
Social isolation, anxiety, depression, self-harming behaviours.

Who are at risk of developing CSBD?

Many individuals with CSBD report having experiences of acting out during pre-adolescence or adolescence, engaging in risky sexual behaviour, masturbation and using explicit material to cope with emotional challenges.

Other factors that have been found to increase the risk of developing CSBD are:

Early exposure to sexually explicit material.
Early onset of internet use.
Childhood sexual abuse.

There are gender differences associated with CSBD:

Most clients who report having CSBD are men of all sexual orientations.
Women with CSBD usually label themselves as “love addicts”. They are more likely to report having experienced sexual abuse at an early age.

How Addiction to the Compulsive Sexual Behaviour Starts

Hall (2018) categorized broadly the processes in which sexual addictive behaviours are induced in individuals. We can consider that the individual may be influenced through one or more induction processes.

Opportunity-induced: with internet pornography accessible with just a mouse click, it becomes the cheapest, lowest-hanging self-soothing treatment choice. Several clients who are addicted to hiring escorts or sex workers report having lived in proximity to brothels and within sex districts as children.
The Trauma-induced: children and pre-adolescents discover masturbation as a means of self-soothing and coping with anxiety-triggering home environments.
The Attachment-induced: the child learns to cope with loneliness due to percieved neglect or abandonment by primary care-givers by self-gratifying and living in their sexual fantasies. These children are also more likely targets of grooming by sexually-predatory adults.

The psychotherapeutic approach to CSBD treatment needs to be holistic since the source of addictive sexual behaviour is multi-factorial.

How Addictive Behaviour is Reinforced

Psychotherapy with clients dealing with addictions is primarily about getting roadblocks out of the way. These roadblocks impede the client’s ability to break the cycles of addiction. If the client cannot break the cycle, the addiction is reinforced.

Addictive behaviours oscillate between the individual’s need for control or release, in a flip-flop between extreme states of euphoria and despair, avoidance and surrender, self-punishing (guilt) and exhaustion (shame).

Hall (2018) also introduced the six-phase cycle.

The Compulsive Sexual Behaviour Disorder cycle is repetitive, rendering the patient helpless to stop the habit.

This is the compulsion cycle.

There lies in going through this cycle repeatedly, painful feelings of deep-seated guilt and shame. The individual with CSBD is particularly likely to suffer this intensely and alone, keeping the habit out of the scrutiny of others for fear of persecution or being made to halt the habit.

The way out of this psychological pain is for the psyche to form cognitive distortions, like rationalizing, justifying, minimizing the impact, magnifying the need, blaming others and situations for causing them to be addicted, and feeling entitled/deserving of the pleasure, denying the gravity of the behaviour and its potential dangers.

Comorbidity with other Psychiatric Disorders

A recent study in Spain showed that over 90% of CSBD participants met the criteria for at least one Axis I disorder, compared to 66% of non-CSBD participants. CSBD participants were more likely to report an increased prevalence of alcohol dependence (16.2%), alcohol abuse (44%), major depressive disorder (39.7%), bulimia nervosa (5.9%), adjustment disorders (20.6%), and other substances –mainly cannabis and cocaine– abuse or dependence (22.1%). The prevalence of borderline personality disorder was significantly higher in CSBD participants (5.9%). (Ballester-Arnal et al., 2020).

Neural Correlates of Compulsive Sexual Behaviours

Voon et al. (2014) provide a study of the neurobiology of CSBD in this article.

Through fMRI brain imaging comparison studies of CSBD and healthy subjects, they were able to draw the following confirmation and conclusions:

That the neural circuits that govern the reward processing in compulsive sexual behaviour and substance dependency overlap.
That the CSBD group, compared to healthy individuals, had higher “desire” but similar “liking” scores when exposed to explicit sexual material.
Exposure to sexually explicit cues in CSB compared to non-CSB subjects was associated with activation of the dorsal anterior cingulate, ventral striatum and amygdala.
Functional connectivity of the dorsal anterior cingulate-ventral striatum-amygdala network was associated with subjective sexual desire (but not liking) to a greater degree in CSB than non-CSB subjects.

In CSBD subjects, there is evidence of a dissociation between desire (or wanting) and liking towards sexually explicit material. This split is a consistent phenomenon associated with drug addictions.

“Sex and porn addiction are not driven by the physical essence of libido but by the psychological need to satisfy a deeper subconscious urge, or to satisfy the biological craving in the brain” and is not correlated with high sex drive (Hall, 2018, p. 7). The motivation for such behaviour is to dissociate oneself from reality and the painful feelings that are present in it.

This demonstrates the splitting that exists in subjects with CSBD.

Gestalt Therapy for Treatment of Compulsive Sexual Behaviour Disorder

Considering the conditions and phenomena around CSBD, Gestalt therapy is arguably a model psychotherapeutic method for treating CSBD. Gestalt therapy, more evident than other modalities, directly addresses intra-psychic splitting mentioned in the above section. Therapeutic work revolves around integration. Integrative Gestalt therapists adopt a holistic approach when working with clients.

Gestalt Awareness Continuum approach and Contact Interruption in CSBD

Dissociation points us to realise the impact of trauma, particularly childhood trauma, on clients.

In Gestalt Therapy, we stay in contact with the client by being attentive to the interruptions in the contact cycle. This therapeutic philosophy is more effective than trying to get the client out of or breaking the compulsion cycle. This is the way to therapeutic change, even though the client who is desperate to break the cycle may not appreciate this.

The Therapeutic Contact begins before the Beginning.

This is also known as the pre-contact phase.

Clients approaching us for therapy may or may not pose CSBD as a presenting issue. There are possible reasons for this:

There are more pressing issues that are at the forefront of their minds,
The client is in denial that the habit causes dysfunction,
The shame of revealing the habit.
Fear of persecution.

As therapists, we can be alert to the possibility of CSBD being presented to us later in therapy, which happens when the client feels secure enough in the therapeutic alliance.

The first meeting is very important even though its significance is often overlooked or overshadowed by intake matters. This is the point when the therapist encounters the field of the client. It is like the moment we touch a bucket of cold water. The moment before our organism adjusts to the differences. In this pre-contact phase, we sense the client’s existence most acutely as foreign to ours. The fertile void lies amidst this differentiation.

The Paradoxical Theory of Change in the Treatment of CSBD

We acknowledge the sense of urgency when clients approach psychotherapy to “fix” their addictions. The therapist often feels drawn to this strife. Our first instinct is to yearn for a solution, knowing that diving to “solve the problem” is not the solution. Beisser’s (1970) Paradoxical Theory of Change, a cornerstone of Gestalt therapy theory, becomes an invaluable resource. Biesser adds, “(b)y rejecting the role of change agent, we make meaningful and orderly change possible.”

This does not mean therapists do not care if the client overcomes the addiction. We do, as that is the working contract. It means that therapists do not position themselves as the “maker of change”.

The client overcomes an addiction, and in this case CSBD, in a therapeutic change process of self-actualization. Self-actualization is the holistic embodied shift a person experiences almost unconsciously, sometimes spontaneously. This phenomenon happens with clients in therapy for a period of time. Perls explains that we cannot make ourselves self-actualize as it is not an active process:

[W]e realize that we cannot deliberately bring about changes in ourselves or in others. This is a very decisive point: Many people dedicate their lives to actualize a concept of what they should be like, rather than to actualize themselves. This difference between self-actualizing and self-image actualizing is very important. Most people only live for their image. Where some people have a self, most people have a void, because they are so busy projecting themselves as this or that. This is again the curse of the ideal. The curse that you should not be what you are. (Perls, 1969 p.39)

As Gestalt therapists, we are aware of this change process. Our work is to support change through working with the client. The client self-actualizes within the field of the therapeutic relationship. Changes in the field actualize the field, bringing about change to the individuals within it.

Psychopathology is a Phenomenological Process in Gestalt Therapy

Psychopathology is a process. It is not the same as using a diagnostic manual and questionnaires to diagnose a patient and then telling the patient what ailment they suffer from.

Psychopathology is process.

Psychopathology relies upon the following:

Observing while avoiding theoretical explanations, presuppositions and prejudices, confining ourselves to the presenting phenomenon in the therapeutic encounter, and
The attempt to use empathy as a clinical instrument ‘to recreate in the psychopathologist the subjective experience of a patient to obtain a valid and reliable description of his experience.’ (Stanghellini & Fuchs, 2013, p. xviii)

Psychopathology is conceptualised as a process in psychotherapy of bringing to light and making palpable the essence of the suffering of the client. It is through this “en-lightening” or illumination process that therapeutic change can be effected. This process is integral to therapy. It is the therapeutic contract, exists in the therapeutic alliance, and is responsible for therapeutic change.

Gestalt therapy engagement in the phenomenological field persuades the therapist to focus on the process of psychopathology and to perceive the atmosphere of the co-created field of the therapy situation. Through this process, we uncover pathos and painful emotions from trauma while being present with the clients in the here and now. In working with clients with CSBD, this process is crucial for understanding/validating the underlying triggers and suffering the client avoids through addiction.

Shame, Guilt, Despair and Helplessness in the Co-created field

CSBD suffer the pain of shame due to their condition more than any other addicts. Working through shame is fundamental to therapeutic work and is even more crucial when clients struggle with CSBD.

Working with shame in therapy, there needs (Yontef, 1996),

Empathic understanding of the patient’s experience with shame
Assist the client in understanding this experience fully.
Showing warm understanding, acceptance and respect.
To heal shame, the therapist must understand shame. The therapist must understand this in the context of the patient.
The therapist must be committed to dialogue (Buber, 1970/1936).
Hold the client in unconditional positive regard.

Shame is an emotion that holds together the therapeutic alliance when brought into the open. It becomes part of the co-created field. Despair, on the other hand, threatens to break the alliance. This is especially so in work with addictions. Despair is the feeling of resignation and disappointment, especially when relapses happen. Resignation is the sense that there is no hope of resolving the problem, followed by disappointment in the therapy. Recognizing the possibility of despair early in the therapeutic process is helpful.

Creative Indifference as Central Attitude when working with CSBD

Salomo Friedlaender’s “Creative Indifference,” also known as “Schöpferische Indifferenz,” was published in 1918 and is considered a seminal philosophy of Gestalt therapy. Creative Indifference incorporates philosophical values that serve as the bedrock for humanistic psychotherapy approaches like Gestalt therapy:

“Creative” = to make something exist out of a void.
“Indifference” = to be unbiased, to be present without agenda.
Holism = to perceive wholes as more than the sum of parts.
Inter-subjectivity = the co-creation of the field.
Intentionality (including creative will and decision-making), and
Nondualism (emphasising exemption from isolation).
The Creative pathos.
Creative relatedness.
Authentic self.

Polarities as depicted in Zinker (1977).

These values ground the therapist working with CSBD clients. The nature of the pathos in CSBD is compulsivity, guilt and shame, alternating with bouts of despair and helplessness. These feelings exist within the co-created therapeutic field. The therapist will experience these feelings. It is the work of the therapist to willfully attune to the phenomenon of the field and to grasp the feelings that exist in the atmosphere of the therapeutic situation. Creative indifference acknowledges a fertile middle point between polarities (and differences) where contact exists.

Conclusion

CSBD is a complex psychological and physiological challenge to work with clients through in psychotherapy. Shame is an individual’s predominant experience with the disorder, leading many clients to avoid the subject at the beginning of therapy. A contactful therapeutic alliance built on solid footing initiates the treatment process.

The therapeutic change process is organic and progressive. Focussing the work on the abstinence of behaviour alone does not promise a positive outcome of treatment. Therapeutic change depends on the ability of both client and therapist to stay with the process and have the patience and faith to see through cyclical moments of complicated feelings of shame, guilt, and despair. This involves trauma work as well. Feelings of despair usually cause either party in the alliance to give up on the work. The client may despair upon relapse, and the therapist may feel helpless when confluent with the client.

CSBD is a diagnosis categorized only recently in the ICD-11. Having CSBD defined in diagnostics is crucial to recognising and treating the disorder. Clinical diagnosis alone, however, is useless to the therapist. The therapeutic process involves the unearthing of the pathos /or suffering/ trauma that underlie the symptoms. This is the process of psychopathology, which requires sensitivity to uncover and make graspable these feelings, or pathos. Following which, something shifts in the system.

Gestalt therapy engages the phenomenon of the co-created field. This is an ideal philosophy for treatment as it is in the field that the psychopathology in the field comes to the foreground and is witnessed. This works best in the treatment of CSBD, since the behaviour is a dissociative, self-soothing mechanism, which can be “unlocked” only when the client is able to grasp the mental suffering from which they are soothing themselves with the behaviour.

Case Study of “John”

Case study of “Businessman John” 40, was presented in the talk on 4 Mar 23 to DRM (Derimu) Psychological Education, 德瑞姆无形完形俱乐部, China (https://www.deruimu.com/).

References

Ballester-Arnal, R., Castro-Calvo, J., Giménez-García, C., Gil-Juliá, B., & Gil-Llario, M. D. (2020). Psychiatric comorbidity in compulsive sexual behavior disorder (CSBD). Addictive behaviors, 107, 106384

Beisser, A. (1970). The paradoxical theory of change. Gestalt therapy now, 1(1), 77-80.

Buber, M. (1936/70). I and Thou. Kindle ed. (W. Kaufman, Trans.) Charles Scribner’s Sons.

Frambach, L. (2015). Philosophie, Mystik, Psychotherapie. Die Bedeutung Salomo
Friedlaenders für die Gestalttherapie. In D. T. L. Frambach (Ed.), Friedlaender /
Mynona und die Gestalttherapie. Das Prinzip “Schöpferische Indifferenz. EHP.

Hall, P. (2018). Understanding and Treating Sex and Pornography Addiction: a comprehensive guide for people who struggle with sex addiction and those who want to help them. Routledge.

Lee, R. G., & Wheeler, G. (2013). The voice of shame: Silence and connection in psychotherapy. Gestalt Press.

McKinney, F. (2014). A relational model of therapists’ experience of affect regulation in psychological therapy with female sex addiction (Doctoral dissertation, Middlesex University/Metanoia Institute).

Perls, F. (1969/1992). Gestalt Therapy Verbatim. The Gestalt Journal Press. Kindle Edition. (p. 93)

Stanghellini, G., & Fuchs, T. (2013). One century of Karl Jaspers’ general psychopathology. (G. Stanghellini, & T. T. Fuchs, Eds.) Oxford University Press.

Voon, V., Mole, T. B., Banca, P., Porter, L., Morris, L., Mitchell, S., … & Irvine, M. (2014). Neural correlates of sexual cue reactivity in individuals with and without compulsive sexual behaviours. PloS one, 9(7), e102419.

World Health Organization. (2018). International Classification of Diseases, 11th Revision. URL: https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f334423054

Yontef, G. (1996) Shame and guilt in Gestalt Therapy. In R. Lee & G. Wheeler (Eds) The Voice of Shame. San Francisco: 390. pp. 370-371.

Zinker, J. (1977). Creative process in Gestalt therapy. Brunner/Mazel.

Compulsive Sexual Behaviour Disorder in Psychotherapy

Compulsive Sexual Behaviour Disorder (CSBD) is also known as hypersexual disorder, and sexual addiction has been included in the World Health Organization’s International Classification of Diseases (ICD-11) #6C72, which indicates the awareness and perhaps the increased prevalence (current estimate is about 5%, and it could be higher) of this condition in today’s society.

Definition of Compulsive Sexual Behaviour Disorder

Classified as a subset of impulse control disorders, CSBD is described in ICD-11 as: characterised by a persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behaviour. Symptoms may include repetitive sexual activities becoming a central focus of the person’s life to the point of neglecting health and personal care or other interests, activities and responsibilities; numerous unsuccessful efforts to significantly reduce repetitive sexual behaviour; and continued repetitive sexual behaviour despite adverse consequences or deriving little or no satisfaction from it. The pattern of failure to control intense, sexual impulses or urges and resulting repetitive sexual behaviour is manifested over an extended period of time (e.g., 6 months or more), and causes marked distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. Distress that is entirely related to moral judgments and disapproval about sexual impulses, urges, or behaviours is not sufficient to meet this requirement.

Behaviours associated with CSBD include repetitive sexual behaviour with others or alone, masturbation, the use of sexual services, pornography and cybersex, telephone sex, chemsex and deviant sexual behaviour like voyeurism and taking upskirt pictures, which often gets the sufferer in trouble with law enforcement. The sexual urges are intense, rendering the sufferer helpless at controlling them. The sexual arousal, sexual fantasies and encounters are addictive, taking control of the lives of the person. It is important to note that the behaviours alone do not constitute a problem or an addiction, but the relationship to these behaviours.

Many sufferers report an early onset of impulsive or risky sexual behaviour, beginning during pre-adolescence or adolescence, with a number reporting having stumbled onto and having used porn from an early age. The behaviour often starts off hedonistic, but later on functions as a self-soothing mechanism against mental pain, negative affect, anxiety and depression. The individuals use the high to anaesthetise themselves from feeling negative emotions and emotional pain. The typical porn addict, for example, spends hours online scanning porn sites in an effort to escape reality while keeping themselves in an aroused mental state.

CSBD has consequences for its sufferers and the people close to them. The ramifications range from financial and career failure, breakdown of relationships, sexually transmitted infection and even incarceration. These consequences add to the emotional toll. The shame of having these urges and the potential toll on intimate relationships lead the person to live a parallel secret life, alienating them and crystallising the addiction to the behaviours.

CSBD happens in men and women. While men may report CSBD, women tend to frame the condition as love addiction, often reporting childhood sexual abuse trauma.

Practitioners need to differentiate CSBD from other patients who have feelings of shame and guilt about sexual activity due to moral or religious conditioning, or those who experience fear of consequences resulting from sexual activity. These individuals may inadvertently label themselves inaccurately. It is important for the practitioner to find out if the self-diagnosis is the result of self-judgement, or if there is an impairment.

Some sexual impulses and behaviours are transient. Life transitions and experiences may trigger sexual urges. CSBD should not be diagnosed in individuals who experience only brief episodes of increased sexual activity. One needs to take into account the context in which the person is living before making such a diagnosis.

Practitioners also need to take cultural and religious differences into account when considering this diagnosis.

Differentiation of Compulsive Sexual Behaviour from Sexual Desires and Libido

Patients who suffer CSBD generally complain about suffering sexual dysfunction. We may be able to explain this by considering the dissociative state in which the individual falls into or is on the edge of during the triggers. “Sex and porn addiction are not driven by the physical essence of libido but by the psychological need to satisfy a deeper subconscious urge, or to satisfy biological craving in the brain.” (Hall, 2018) The clients whom I have seen generally encounter sexual dysfunction and low libido.

Neuroscience of Compulsive Sexual Behaviour Disorder

Impulse control disorders as well as addictions appear in brain fMRI scans. In the brains of a sample of individuals who experience CSBD, there appears to be a greater left amygdala grey matter volume and reduced resting state functional connectivity between the left amygdala see and bilateral dorsolateral prefrontal cortex compared to healthy volunteer samples (Schmidt et al, 2017).

Psychotherapeutic Approach to Compulsive Sexual Behaviour Disorder Diagnosis

My therapeutic approach to treating Compulsive Sexual Behaviour Disorder involves a 3-pronged attitude at viewing psychopathology:

The mono-personal paradigm of diagnosing follows the dominant paradigm of clinical psychotherapy and psychiatry. It views the client’s suffering in isolation and uses third-person descriptive diagnosis and clinical work. This paradigm relies on the client to change independently. The mono-personal approach involves facilitating emotional and sensory awareness, and trauma therapy.
The bi-personal or relational paradigm sees the relationship co-created by the therapist and client, who jointly produce change through their alliance. The therapeutic alliance provides a safe setting for clients to process feelings of shame and guilt experienced.
The field-based paradigm is unique to Gestalt therapy. This paradigm attunes to the atmosphere, sensing the aesthetics of the therapy situation and looking beyond the individuals. Suffering is perceived, and change is co-created. The field-based paradigm requires the therapist to put attention to the “vibe” of the therapeutic alliance. In the atmosphere of the field, the pathos or suffering is felt and brought to the surface.

Figure 1. the three paradigms of psychotherapy and diagnosis

All three paradigms are relevant to the work. Psychotherapeutic work with CSBD involves ongoing psychopathology. Psychotherapeutic work with CSBD involves ongoing psychopathology. Psychopathology is the study of the suffering that is the basis of the client’s symptoms. This process is continuing even though a clinical diagnosis has already been made.

Gestalt Therapy understanding of CSBD

CSBD and most compulsive behaviours can be explained as contact interruption due to dissociation. Below is a schematic diagram of the awareness cycle:

An explanation of this concept of the contact cycle of awareness can be found in this article.

In CSBD, the interruption seems to happen as a deflection from sensing, just as the trigger of stimulus is about to be sensed. The individual who is not able to tolerate sensing the stimulus dissociates and the awareness is interrupted.

The dissociation triggers hyperarousal which is a physiological reaction that leads to intense stress which leads to a need for release, which is the compulsive behaviour.

Whenever dissociation is identified, we become aware of trauma, in particular childhood trauma, which the client would need to be worked through in therapy. The effect of dissociating can be described in Gestalt therapy terms as the loss of ground, or being on shaky ground where figural experiences fail to form.

At the heart of the treatment of CSBD is ultimately trauma therapy. To support the process, the client is supported through experiments in awareness and accessing core beliefs. The premise of the therapeutic process is to guide the client out of dissociation and facilitate their awareness in the continuum.

References

Hall, P. (2018). Understanding and Treating Sex and Pornography Addiction: a comprehensive guide for people who struggle with sex addiction and those who want to help them. Routledge.

Schmidt, C., Morris, L. S., Kvamme, T. L., Hall, P., Birchard, T., & Voon, V. (2017). Compulsive sexual behavior: Prefrontal and limbic volume and interactions. Human brain mapping, 38(3), 1182-1190.

Zinker, J. (1977). Creative process in Gestalt therapy. Brunner/Mazel.

Nicotine Addiction: the bio-psycho-social viewpoint of the smoking habit

This article is a reflection on the lecture series on the topic of addiction. The focus here is that of nicotine addiction.

Why Smoking?

Nicotine addiction seems less serious to law enforcers than addiction to other “hard substances” like opioids, for example. However, for the many persons who need to quit the cigarette for health reasons, addiction is an important issue. This short paper addresses some of the different aspects of nicotine addiction that warrant attention. Through this overview, we can appreciate how one “habit” transcends over many fields of science, and how psychotherapy, within these fields that can support cessation.

The Social Norms of Smoking Initiation

The habit of cigarette smoking is observed to be most often developed during adolescence. Qualitative studies were thus conducted by Peters, et al. (2005) involving high school students who are smokers, regarding the latter’s beliefs in smoking initiation and nicotine addiction.

Questions posed to the subjects were like, “who was with you the first time you smoked?”, to which the answers were largely peers and family members of the same age-group like cousins. Smokers from both genders regard “curiosity” and “peer pressure” as motivation for starting the habit, while for boys, the added motivation is for “cool / image”.

Other means of modelling and encouragement given to teenagers as motivation for initiation of smoking are:

Self medication and coping: “My parents were arguing so I went in her car and saw her cigarettes there, I wanted it to calm me down” and “Because I was having problems at my house and my friend told me if you want to feel better you should start doing it.”
Peer Pressure: “Because someone asked me if I have ever done it”, “because he (boyfriend) kept telling me try it, try it” and “because everybody was smoking one at the bus stop.”
Curiosity: “We were just curious”, “something to try” or “I was curious to see if it was an effect.”
Other Modeling Recurrence: “Because I saw my friends doing it”, and “Because everybody else was doing it, so I wanted one.”

The majority of the subjects revealed that the next time they smoked after the initiation is within 48 hours of the first smoke. This recurrence of smoking crystallizes the behavior into an addiction:

Craving/Withdrawal: “I was craving it and I wanted to be with my friends”, “I had to have another cigarette”, “When they are shaking.”

When asked “how long does someone have to smoke before they are hooked?” The first 3 times emerged as the most frequent response from the subjects. Most subjects also say that one pack or less is all it took for them to get hooked on the smoking habit. This is also the topic of question for Birge, et al. (2017), “What proportion of people who try one cigarette become daily smokers?”.

At the mention of “being hooked on the habit” or eventually “becoming daily smokers”, it is interesting to also note that it may not necessarily mean that the subjects were actually spontaneous addicted to the substance, nicotine, per se. This would have only been clearer had the subjects who were just initiated, were induced to try to “quit” after the 2^nd,3^rd(and so on) smoke after initiation.

Smoking Regularity and Nicotine Addiction in Adolescence

Selya et al. (2013) worked on the little-known time-varying effects of smoking quantity and nicotine dependence on the regularity of adolescent smoking behavior. The findings indicated that, in adults, smoking quantity and extent of nicotine dependence is significantly related to regularity of smoking during adolescence. Nicotine dependence is found to increase over time as the effects from regularity of smoking decreased with time. This indicates implicitly also that the initial phases of smoking have more significance in causing nicotine addiction.

A Brief Neurobiology of Nicotine Addiction

From the above studies alone, one gets the impression that, for adolescents at least, smoking is an addictive habit from the beginning. What is not so clear is to what extent, and which time frame does the biological effects of nicotine take over the psychological need to light up a cigarette. The students cite mainly psychological factors (e.g. image and peer pressure), rather than physical factors (e.g. pain management) in getting initiated to smoking.

Nicotine molecules target neuronal nicotinic acetylcholine receptor (AChRs) of cells, in particular neurons. Activation of these receptors is involved in a chain reaction that regulates the system related to dopamine (the dopaminergic system). Consuming of Nicotine regularly causes an “up-regulation” of these receptors. This means that the cells are genetically stimulated to produce more or more effective AChRs receptors. This change in biological structure in neuronal cells changes the normal homeostasis of the intercellular environment of the brain. This process of up-regulation is known to be responsible for the initiation of nicotine dependence (Ortells & Arias, 2010).

The motivation for smoking, like other drugs and addictive behaviors, relies on neurons in the brain’s reward system, based in a brain region called the ventral tegmental area (VTA). Obtaining a reward leads to excitation of these neurons and the release of a neurotransmitter, dopamine. Dopamine transmission from the VTA is critical for controlling both rewarding and aversive behaviors. The degree to which the reward system can be activated is normally tightly controlled by a neurotransmitter called GABA which inhibits excitatory signaling in neurons and keeps the system in balance. Figure one pictorially represents how the main neurotransmitters are held in homeostasis in living cells (in particularly the brain). When a substance like nicotine affects the effects of a neurotransmitter— in this case, Acetycholine— the system would adjust itself to regain balance. Chronic exposure to nicotine leads to the cells adjusting permanently to the imbalances. Such changes are adaptations that occur at a genetic level (since it involves receptors, which are proteins). When the addictive substance is no longer in the system, the imbalance caused by the adaptation would be felt.

Figure 1: (Tretter, 2018)

Researchers have also discovered enzymes that disinhibits dopamine neuron action with chronic nicotine exposure (Buczynski, et al., 2016). Pointing further to the biochemical action of nicotine that leads to the addictive phenomenon.

Nicotine Effect on Metabolism

The negative side-effect of smoking caused by tar and “smoke pollution” (figure 2) that causes lung damage is well known and quite easily grasped. However, the effects of nicotine in itself on the biological system – especially on the metabolic system— is relatively not well understood by the general public. This has likely given rise to the misconception that chewing nicotine or smoking nicotine vapors are the answer to countering the negative health effects of smoking. In fact consuming nicotine only adds to the metabolic issues in the body.

Figure 2 (Ambrose & Barua, 2004)

The effects of cigarette smoking on metabolism is illustrated through a recent Japanese study by Kang, et al. (2009). Fasting blood insulin, glucose and lipid levels were measured in 2 groups of women. One group consisted of regular smokers and the other non-smokers. Fasting levels of these substances are indicative of the efficiency of the metabolic system. During fasting, insulin levels and glucose levels in the blood should ideally be low. Since there is no food entering the body during fasting, one would expect that glucose that had entered the blood from the previous meal to is already removed from the blood stream. The hormone, Insulin, is produced by the Islets of Langerhan cells of the pancreas immediately during food consumption to signal to the other cells in the body that glucose released into the blood from digested food needs to be quickly removed from the blood. High levels of glucose concentration in the blood is toxic to the body, and this process of insulin release is a form of homeostasis. During insulin release, fat cells convert glucose to fat, muscle cells convert glucose to glycogen, and cells stop releasing glucose (gluconeogenesis) into the blood stream. After a period of time, the blood glucose level is supposed to be lowered, and Insulin levels in the blood will drop to safe levels (Eckel, Grundy, & Zimmet, 2005).

As with the above study by Kang et al., when comparing the blood profiles of the group of cigarette smokers with the group of non-smokers, the results showed significantly higher mean Insulin and blood glucose levels while lower mean high-density lipoprotein (fats molecules) in smokers as compared with non-smokers. This indicates that nicotine affects the functionality of Insulin by making this hormone inefficient in reducing the glucose levels in the blood. With nicotine, fat cells do not respond as effectively to insulin by storing fat, muscle cells do not respond as effectively to storing glycogen, and cells do not respond to Insulin as effectively to inhibit gluconeogenesis. So blood glucose after meals take longer time to return to safe levels, causing more Insulin to be pumped into the blood. This conditions mimics that of type 2 diabetes or metabolic disorder.

There are many papers that have highlighted the link between smoking and cardiovascular-related illnesses. The above study is an example that explains to us that nicotine affects blood glucose regulation and the function of insulin. Impaired blood- glucose regulation is related to a pre-diabetic condition also known as insulin resistance.

Weight Gain and Smoking Cessation

A better-known cause of insulin resistance is not smoking, but high carbohydrates and/or alcohol in the diet coupled with sedentary lifestyle. However, cessation of smoking leads to a “similar” phenomenon of gaining weight. This phenomenon is unpleasant, and it is a signal that nicotine consumption messes up the function of insulin in glucose metabolism.

Figure 3 is an illustration from a paper by Nogueiras et al. (2015) that examines the biochemical link between insulin resistance and nicotine use. If more attention is paid to educating the general public (and doctors) on metabolism, the medical field can perhaps help people with smoking cessation.

During cessation, nicotine is suddenly “deprived” in the system, fat cells no longer become insulin resistant (which is a good thing). Fat cells start to “hear” the insulin signals, and mop up the glucose from the blood (also a good thing). Since there is excess insulin in the blood, blood sugar levels become very low and fat cells begin to hold on to the fat (which causes one to put on weight).

It could be, that one possible way out of this situation is to maintain a very controlled diet that does not cause more insulin to be released in blood. Since Insulin is mainly triggered when sugars enter the blood stream, it might just be that a very low intake of carbohydrates may be the answer. With time, the body would cope by producing less insulin. Less insulin means that the fat cells do not absorb more sugars but actually start to burn off the fat. This is how the biochemical aspect of metabolism becomes paradoxical and really interesting, but this is a big subject in itself.

Figure 3 (Nogueiras, Diéguez, & López, 2015)

Conclusion

Smoking addiction begins with the initiation at mainly adolescence, which opens up a whole potential field of education, and psycho-social influences. There is also biochemistry. Biochemistry is many-factorial and complex. There is the harmful effects of tar and other chemicals other than nicotine.

Nicotine, being known as the addictive substance is significant to the field of neurochemistry and pharmacology. What is interesting and important is nicotine on metabolism. This could be relevant in psychotherapy, since it involves lifestyle and effects of hyperinsulinemia or a diabetic-like situation. Hyperinsulinemia is incidentally linked to as well to depression (Löwe, Hochlehnert, & Nikendei, 2006) (Vogelzangs & Penninx, 2007).

For psychotherapists, this is a common addiction of functioning (and also paying) clients. Knowledge of the different aspects of this addiction lends itself to a multifaceted way of providing therapeutic support.

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