Sexual Addiction & Compulsivity, 8:241251, 2001

Copyright 2001 Brunner-Routledge

1072-0162 /01 $12.00 + .00

The Differential Diagnosis

of Problematic Hypersexuality
A. J. REID FINLAYSON
Vanderbilt University School of Medicine, Nashville, Tennessee, USA

JOHN SEALY
Del Amo Hospital, UCLA School of Medicine, Torrance, California, USA

PETER R. MARTIN

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Vanderbilt University School of Medicine, Nashville, Tennessee, USA

In this article, we review the diagnosis, classification, and differential diagnosis of problematic hypersexuality. The estimated frequency, morbidity, comorbidity, mortality, and the associated societal issues underscore the necessity for improved recognition, better
understanding, and more effective treatment for this disorder. In
general, hypersexual behavior does not seem to be evaluated, classified, or monitored in the same manner as other innate behaviors
like feeling, thinking, sleep, or eating, despite the fact that hypersexual behavior is among the criteria for several psychiatric disorders. More widespread clinical use of acceptable diagnostic criteria for problematic hypersexuality would further elucidate the
relationships among problematic hypersexuality and other psychiatric disorders.

Classification systems reflect a consensus of current formulations of evolving

knowledge in our field. They do not encompass, however, all the conditions for which people may be treated or that may be appropriate topics
for research efforts. (American Psychiatric Association, 1994, Cautionary
Statement, p. xxvii)

The purpose of this article is to support the inclusion of specific diagnostic

criteria for problematic hypersexual behavior into the mainstream of clinical
psychiatric practice. We outline the historical evolution of the disorder and
Fred S. Berlin, MD, PhD, and Jennifer J. Schneider, MD, PhD, provided critical reviews;
Heather A. Finlayson and Mitchell Parks, MD, provided valuable editorial suggestions.
Address correspondence to A. J. Reid Finlayson, MD, Vanderbilt University School of
Medicine, Vanderbilt Addiction Center, AA-2206 Medical Center North, Nashville, TN 372322647, USA. E-mail: Reid.Finlayson@mcmail.Vanderbilt.ed u
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diagnostic criteria and suggest a differential diagnostic decision tree, emphasizing the need to focus on the behavioral description and to avoid prejudicial and premature theoretical bias.

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HISTORICAL PERSPECTIVE
Sexual excess and debauchery have been described and catalogued from
antiquity. Nymphomania, a term derived from the Greek, has been used in
the past to describe female sexual excess. Don Juanism, after Don Juan
(Gordon; Lord Byron, 1819/1986), the infamous Spanish nobleman, immortalized as Don Giovanni, (Mozart & daPonte, 1787/1997) has denoted male
hypersexuality.
In his chapter titled Morbid States of the Sexual Appetite (1812/1988),
Dr. Benjamin Rush, a signatory to the United States Declaration of Independence and considered by many to be the father of American psychiatry,
described, among other similar cases, a man, who although he feels disgusted with his venereal propensities, he cannot resist them (p. 348).
Krafft-Ebbing (1886/1965) described a case of abnormally increased sexual
appetite, 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.
Many others (Carnes 1983, 1989; Coleman, 1995; Goodman, 1993, 1998;
Irons & Schneider, 1999; Kafka & Hennon, 1999; Money, 1986; Orford, 1978;
Schneider, 1991; Schneider & Irons, 1996) have described problematic hypersexuality and, as Goodman (1992) observed, there is general agreement
that the pattern of behavior exists, but considerable controversy surrounds
the issue of how it should be designated.
Earlier versions of the Diagnostic and Statistical Manual (American Psychiatric Association [APA], 1952, 1968) contained sparse descriptions of sexual
disorders. DSM-III (APA, 1980) included, under Sexual Behavior Not Elsewhere Classified (302.89), Distress about a pattern of repeated sexual conquests with a succession of individuals who exist only as things to be used
and added, parenthetically, (Don Juanism and Nymphomania) (p. 283,
302.89). DSM-III-R (APA, 1985) did not use the terms Don Juanism and Nymphomania. The description changed to Sexual Disorder Not Otherwise Specified (302.90), Distress about a pattern of repeated sexual conquests or other
forms of nonparaphilic sexual addiction (emphasis added) involving a succession of people who exist only as things to be used (p. 296).
Problematic hypersexuality, variously described as having addictive,
compulsive, impulsive, and paraphilic features is beginning to be recognized as a hidden dimension of many significant problems facing society.
The disorder is often associated with severe negative consequences, which

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include failed marriages, teen pregnancies, sexual harassment, exploitation

of women and children, the spread of sexually transmitted diseases, loss of
professional standing, and legal charges. The result is shame, secrecy, alienation from friends, social isolation, depression, and despair.
Sexual behaviors may involve autoeroticism, technology-based sexual
interactions (Cooper, Delmonico, & Burg, 2000) (various media, e.g., print,
film, video, Internet cybersex) or engaging in sexual activity with a series of
casual or unknown (anonymous) sexual partners and often with inattention
to safe sexual practices. Recent data (Benotsch, in press; Kalichman et al.,
1997) indicate a robust relationship between problematic (compulsive) hypersexuality and increased risk for HIV transmission.
Estimates of the prevalence of problematic hypersexuality are as high as
36% (Carnes, 1989, Coleman et al., 2001) of the general population.
It is important to emphasize that problematic hypersexuality refers neither to specific sexual orientation nor to sexual object choice. Nor should
nosological acceptance be an attempt to impose interpersonal, moral, or
social values.
Problematic hypersexuality is not a variant of paraphilia. The diagnostic
term paraphilia more accurately describes abnormal forms of sexual expression. The essential features of a Paraphilia are recurrent, intense sexually arousing fantasies, sexual urges or behaviors generally involving 1) nonhuman objects, 2) the suffering or humiliation of oneself or ones partner, or
3) children or other nonconsenting persons, that occur over a period of at
least six months (Criterion A) (APA, 1994, p. 522)
Some paraphilic behaviors may have a hypersexual dimension, but problematic hypersexuality can occur within or outside paraphilic categories.

DESCRIPTION AND DIAGNOSTIC CRITERIA

Problematic hypersexuality may be described as sexual fantasy, sexual urges,
or sexual behaviors that continue in spite of clinically significant distress or
impairment in social, educational, occupational, or other important areas of
functioning. The purpose of the hypersexuality appears to be the relief of
various unpleasant feelings, however this remains to be proven (Schneider
& Irons, 1996).
Problematic hypersexuality may involve three major features, which are
analogous to criteria for Substance Use Disorders (Carnes, 1983,1989;
Goodman, 1992, 1998; Irons & Schneider, 1999; Schneider & Irons, 1996):
1. The person is more preoccupied with sexual thoughts, sexual feelings,
sexual fantasies, and sexual behaviors than he or she would prefer, and
2. The person cannot control his or her sexual behavior the way he or she
wants to. He or she is continually unable to keep the promises made to
him- or herself about sexual behavior or to stick to his or her personal
standards, and

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3. The problematic hypersexual behavior continues, even after resulting in

significant problems in the persons life (e.g., health, relationship, or financial and legal consequences).
The recognition, study, and treatment of patients with problematic hypersexuality are limited by the absence of clearly accepted nomenclature
and diagnostic criteria. For example, the symptoms may most often meet
DSM-IV criteria for Sexual Disorder Not Otherwise Specified, 302.9 (Subsection 2.) Distress about a pattern of repeated sexual relationships involving a
succession of lovers who are experienced by the individual only as things to
be used (APA, 1994, p. 538). This sentence is the only suggestion in the
DSM-IV classification system of Sexual and Gender Identity Disorders, that
hypersexual behavior, which does not involve paraphilia, may be problematic.
Hypersexuality may be associated with excessive fantasy or preoccupation with sexual themes. Sexual fantasy or behavior, when engaged in excessively may be described as obsessive or compulsive, however sexual
fantasy and behavior is specifically excluded from Obsessive-Compulsive
Disorder, in particular when paraphilia is present (APA, 1994, p. 495)
An Impulse Control Disorder is defined as the failure to resist an impulse, drive, or temptation to perform an act that is harmful to the person or
others. (APA, 1994, p. 609) Usually, tension or arousal precedes the impulsive act and pleasure or gratification follows. Regret, self-reproach, and guilt
may result. Kleptomania, fire setting, and pathologic gambling are considered Impulse Control Disorders not otherwise classified. It is not clear whether
Problematic Hypersexuality could be considered an Impulse Control Disorder.
The general symptom description of Pathologic Gambling, an Impulse
Control Disorder, has been closely compared to the criteria proposed for the
diagnosis of problematic hypersexuality (Schneider & Irons, 1996). The
paraphilia disorders may have impulsive features but are considered separately from Impulse Control Disorders (not elsewhere classified) in DMS-IV.
Problematic hypersexuality has been variously ascribed to poor impulse control, high sex drive, dependency, addiction, and compulsive behavior, due
to the absence of clear criteria.
Other innate human behaviors such as eating and sleeping have been
considered abnormal in conditions of over- and underactivity, but this is not
the case at present for sexual behavior in many systems of diagnostic classification, including DSM-IV. Information about sexual behavior may be relatively neglected in clinical practice despite the prominence of sexual symptoms among the diagnostic criteria for psychiatric disorders.

DIFFERENTIAL DIAGNOSIS
The term diagnosis is derived from Greek and literally means from knowledge. Diagnosis refers to distinguishing or discerning the disorder, by which

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the patients symptoms are most accurately classified, in order to effect understanding, research, and treatment. The use of diagnostic criteria for problematic hypersexuality will not only enhance the study of sexual behavior, as
part of the sexual and gender identity disorders, but will advance knowledge
about the association of problematic hypersexuality (Black, Kehrberg,
Flumerfelt, & Schlosser, 1997) with other psychiatric disorders that have sexual
behavioral symptoms. A proposed diagnostic decision tree as outlined in
Figure 1 is suggested.
The first branch on the decision tree is to rule out general medical
disorders known to be associated with problematic hypersexuality (see Figure
2). DSM-IV (APA, 1994, p. 495) outlines the diagnostic process required to
attribute sexual symptoms to a general medical condition, although the focus is solely on sexual dysfunction. General medical conditions, which may
be associated with problematic hypersexuality, include neurological conditions (e.g., temporal lobe lesions, post brain injury states [Finlayson, 2000], and
a wide variety of other neurological conditions which may result in cortical
disinhibition ) and endocrine conditions (e.g., hypergonadal states, pituitary
dysfunction ).
The associated physical examination findings, laboratory findings, and
patterns of prevalence or onset, reflect the etiological general medical condition. The possibility of an independent or coexisting problematic hypersexual disorder should be reconsidered if the hypersexual behavior persists
after resolution or stabilization of the identified general medical condition.
The next branch in the differential diagnosis decision tree would lead to

Decision Tree
Problematic Hypersexual Behavior
Due to direct physiologic
effect of general medical
condition?
No

If Yes

Problematic Hypersexuality
due to general medical condition

Due to the direct physiologic

effect of a substance medication,
or toxin?
No

If Yes

Substandt-Induced
Problematic Hypersexuality

Due to Psychotic illness or

Bipolar disorder
No

If Yes

Functional Psychosis with

Problematic Hypersexuality

Due to Axis II pathology

No

If Yes

Axis II Disorder with

Problematic
Hypersexuality

Problematic Hypersexuality
FIGURE 1. Differential diagnosis of problematic hypersexuality.

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Disinhibition of cortical controldelirium, dementia, brain injury, or

lesion (e.g., medial basal frontal, septal, diencephalon, and other
neurological conditions)
Alzheimer, Huntington, Pick, Tourette
Seizure disorder
Hyper-testosteroinism

Reconsider an independent diagnosis of problematic hypersexuality if symptoms

persist after resolution or stabilization of the identified medical condition.

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FIGURE 2. Rule out: General Medical conditions.

consideration of whether the hypersexual behavior occurs as a result of the

effects of a substance or medication (see Figure 3). Substance-Induced Sexual
Dysfunction (APA, 1994) considers only Impaired Desire, Impaired Arousal,
Impaired Orgasm, and Sexual Pain (specifically, pain that is experienced by
the patient and not perpetrated by the patient) associated with intoxication.
Sexual disinhibition or hypersexuality has been associated with many
substances of abuse (Washton & Boundy, 2000). Alcohol, amphetamines
(particularly methamphetamine crystal-meth), cocaine, and marijuana use
or abuse are frequently associated with increased sexual behavior.
Drug use affects sexual behavior by several mechanisms. Sexual behavior may be altered by disinhibition of the normal pathways that inhibit sexual
arousal and allow social interaction. Substances that are abused may influence sexual behavior via their actions in the dopamine reward pathways of
the median forebrain bundle. Drugs such as alcohol and sedatives may influence sexual behavior by disinhibition, whereas stimulant drugs may affect
the sexual arousal circuits. Opiates do not appear to increase sexual behavior.
Although hundreds of compounds exert positive and negative effects
on sexual behavior, more research into mechanisms of action and adequate
clinical treatment trials are needed (Crenshaw & Goldberg, 1996). Problematic hypersexuality persisting, following resolution or stabilization of the
Substance Use Disorder, warrants reconsideration of problematic hypersexuality as an independent disorder.
Bipolar and psychotic disorders are associated with sexual hyperactivity

Cocaine
Methamphetamine Crystal Meth
Alcohol
Marijuana
Halucinogens
Others

Reconsider an independent diagnosis of

problematic hypersexuality if symptoms
persist after resolution or stabilization of
the identified substance use disorder.
FIGURE 3. Rule out: Substance-related disorder.

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247

Mood Disorders
Sparce literature on sexual behavior in bipolar patients
Functional Psychosis
Schizophrenia
Delusional Disorder (Erotomania)
Other Psychotic Disorder
Reconsider an independent diagnosis of problematic
hypersexuality if symptoms persist after resolution or
stabilization of the identified mood disorder or psychosis.

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FIGURE 4. Rule out: Biopolar or psychotic disorder.

(see Figure 4). Delusional disorder is the presence of one or more nonbizarre
delusions that persist for at least a month. Apart from the direct impact of the
delusion, the persons behavior appears normal and their psychosocial functioning is not markedly impaired. The delusion may be of being a prominent
person or having a special relationship with such a person, or that the patients
spouse or lover is unfaithful, or is being conspired against, or that the patient
has an infestation of insects on the skin or a bad odor.
In the erotomanic type of delusional disorder the central theme of the
delusion is that another person is in love with the individual (APA, 1994).
The delusion often concerns idealized romantic love and spiritual union
rather than sexual attraction. The person about whom this conviction is
held is usually of higher status, but can be a complete stranger (APA, 1994,
p. 297).
Variations in the frequency and intensity of hypersexual behaviors have
been identified in hypersexual patients (Carnes & Moriarity, 1997). The periodicity has been compared to the cycles of binging and anorexia in eating
disorders, but also is reminiscent of cycloid states.
The literature describing sexual behavior in relation to mood disorders
is surprisingly sparse. Spalt (1975) questioned 154 consecutive mood (affective) disorder patients about prostitution, promiscuity, and extramarital affairs. He found no differences in prostitution rates or number of extramarital
partners between unipolar and bipolar patients and found that personality
factors and alcoholism were more related to the incidence of extramarital
affairs than was the diagnosis of affective (mood) disorder. Further study of
the relationship of problematic hypersexuality to mood disorders is clearly
needed.
The criteria for Manic Episode include B (6) increase in goal-directed
activity (either socially, at work or school, or sexually) or psychomotor agitation (APA, 1994, p. 332). Two more symptoms from group B (three more if
the mood is only irritable) are required for diagnosis of mania or hypomania,
and mood must be abnormally and persistently elevated, expansive, or irritable (mania) or clearly different (hypomania) from the usual nondepressed
mood (APA, 1994, p. 338).

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A. J. Finlayson et al.

In differentiating problematic hypersexuality from hypomania, the presence of additional manic symptoms other than sexual hyperactivity and positive
family history of bipolar illness are more suggestive of an association with
mood disorder. Persisting problematic hypersexuality following resolution
or stabilization of the mood disorder symptoms should lead to reconsideration of problematic hypersexuality as an independent disorder.
Substance Induced Mood Disorder is a category in which problematic
hypersexuality, substance use disorders, and concurrent mood symptoms
may be readily categorized (APA, 1994). Study of this particularly complex
and difficult diagnostic area would be greatly assisted by clear and accepted
criteria for problematic hypersexuality.
The last branch in the schema considers Axis II disorders (see Figure 5).
Personality Disorder or Pervasive Developmental Disorder may explain problematic sexual hyperactivity. Coleman and Montaldi (in press), have pointed
out that problematic sexual hyperactivity diagnosed on Axis I is usually troublesome to the patient, whereas problematic sexual behavior ascribed to Axis II
is more often disturbing to those around the patient.
Of all the criteria for Personality Disorder diagnosis, cognitive, affective,
and interpersonal patterns that deviate from cultural expectations most closely
align with the behavioral symptoms of problematic hypersexuality. All personality disorders may be associated with interpersonal and sexual difficulties, however those grouped in Cluster B are most likely to be associated
with hypersexual behavior.
Antisocial Personality Disorder criteria include a pervasive pattern of
disregard for and violation of the rights of others, failure to conform to social
norms, deceitfulness, impulsivity, consistent irresponsibility, and lack of remorse (APA, 1994).
The diagnosis of Borderline Personality Disorder requires, among other
things, a pervasive pattern of instability of interpersonal relationships, a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation, and self-damaging impulsivity in two areas such as for example, spending, sex, substance
abuse, reckless driving, or binge eating (APA, 1994).
Among the criteria for Histrionic Personality Disorder, interaction with
others is often characterized by inappropriate sexually seductive or provocative behavior (APA, 1994, p. 657). Narcissistic Personality Disorder criteria

Sociopathic Personality Disorder

Narcissistic Personality Disorder
Borderline Personality Disorder
Other Personality Disorder
Mental Retardation
Pervasive Developmental Disorder

FIGURE 5. Rule out: Significant Axis II pathology.

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249

Adjustment Disorder
Attention Disorders: ADD/ADHD
Depressive (Spectrum) Disorder
Dissociative Disorder
Impulse-Control Disorder/Intermittent Eplosive Disorder
Obsessive-Compulsive Disorder
Paraphilia(s)
Posttraumatic Stress Disorder
Process Addictions (e.g., eating, gambling, working, spending, risk taking)

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FIGURE 6. Common concurrent disorders which do not override an independent diagnosis

of Problematic Hypersexuality.

include interpersonal exploitation, that is the individual takes advantage of

others to achieve his or her own ends (APA, 1994).
Even with clear and distinct criteria for problematic hypersexuality, the
accurate differentiation from personality disorder will require considerable
knowledge, training, and, particularly, clinical experience. It is important to
avoid tendencies to moralize sexual behaviors. There is a distinction between someone who is more promiscuous as a lifestyle choice and another
whose behavior is characterized by preoccupation and loss of control and
continues in spite of negative consequences. Further study is important in
order to advance knowledge and patient care.
Figure 6 lists a number of conditions that are known to occur concurrently with problematic sexual hyperactivity. These disorders do not override an independent diagnosis problematic hypersexuality. Although in certain types of paraphilia (e.g., pedophilia), any person who succumbs to their
unacceptable sexual temptations might be considered problematically hypersexual.
The general convention in DSM-IV is to allow multiple diagnoses to be
assigned for those presentations that meet criteria for more than one DSM-IV
disorder (APA, 1994, p. 6).

REFERENCES
American Psychiatric Association. (1952). Diagnostic and statistics manual of mental disorders. Washington, DC: Author.
American Psychiatric Association. (1968). Diagnostic and statistics manual of mental disorders (DSM-II, 2nd ed.). Washington, DC: Author.
American Psychiatric Association. (1980). Diagnostic and statistics manual of mental disorders (DSM-III, 3rd ed.). Washington, DC: Author.
American Psychiatric Association. (1987). Diagnostic and statistics manual of mental disorders (DSM-III-R, 3rd ed., rev.). Washington, DC: Author.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (DSM-IV, 4th ed.). Washington, DC: Author.

Downloaded by [ ] at 13:03 12 August 2011

250

A. J. Finlayson et al.

Benotsch, E. (in press). Sexual compulsivity and risk of HIV-AIDS: Cause for concern or false alarm? Journal of Sexual Addiction and Compulsivity.
Black, D. W., Kehrberg, L. L. D., Flumerfelt, D. L., & Schlosser, S. S. (1997) Characteristics of 36 subjects reporting compulsive sexual behavior. American Journal of
Psychiatry, 154, 243249.
Carnes, P. (1983) Out of the shadows: Understanding sexual addiction. Minneapolis,
MN: CompCare.
Carnes, P. (1989) Dont call it love: Recovery from sexual addiction New York: Bantam.
Carnes, P., & Moriarity J. M. (1997). Sexual anorexia: overcoming sexual self-hatred.
Center City, MN: Hazelden.
Coleman, E. (1995). Treatment of compulsive sexual behavior. In R. C. Rosen & S. R.
Leiblum (Eds.), Case studies in dex therapy (pp. 33349). New York: Guilford Press.
Coleman, E., Miner, M., Ohlerking, F., & Raymond, N. (2001). Compulsive sexual
behavior inventory: Reliability and validity. Journal of Sexual and Marital
Therapy, 21, 325332.
Coleman, E., & Montaldi, D. (in press). Sexual compulsivity. Sex Addiction &
Compulsivity.
Cooper, A., Delmonico, D. L., & Burg, R. (2000). Cybersex users, abusers and
compulsives: new findings and implications. Sexual Addiction & Compulsivity,
7, 529.
Crenshaw T. L., & Goldberg, J. P. (1996). Sexual pharmacology: Drugs that affect
sexual function. New York: Norton & Co.
Finlayson M. A. J. (2000). Sexuality After Head Injury. Unpublished manuscript.
Goodman, A. (1992). Sexual addiction: Designation and treatment. Journal of Sex &
Marital Therapy, 18(4), 303314.
Goodman, A. (1993). Diagnosis and treatment of sexual addiction. Journal of Sex &
Marital Therapy 19(3), 225251.
Goodman, A. (1998). Sexual addiction: An integrated approach. Madison, CT: International Universities Press.
Gordon, G.; Lord Byron. (1819/1986). Don Juan. In The Norton anthology of english
literature (pp. 594660). New York: Norton.
Irons, R., & Schneider, J. P. (1999). The wounded healer: Addiction-sensitive approach to the sexually exploitative professional. Northvale, NJ: Aronson.
Kafka, M. P., & Hennon, J. (1999). The paraphilia-related disorders: an empirical
investigation of nonparaphilic hypersexuality disorders in outpatient males Journal of Sex & Marital Therapy 25:305-319.
Kalichman, S. C., Greenberg, J., & Abel, G. (1997). Sexual compulsivity among HIV
positive men who engage in high-risk sexual behavior with multiple partners:
An exploratory study. AIDS Care, 9(4), 94419450.
Krafft-Ebbing, R. (1886/1965). Psychopathia sexualis (F. J. Rebman, Translator). New
York: Paperback Library.
Money, J. (1986). Love maps. Buffalo, NY: Prometheus.
Mozart W. A., & daPonte, L. (1787/1997). Don Giovanni. In S. Sadie (Ed.), The new
grove book of operas (pp. 161165). New York: St Martins.
Orford, J. (1978). Hypersexuality: Implications for a theory of dependence. British
Journal of Addiction, 73, 299310.
Rush, B. (1812/1988). Medical inquiries and observations upon the diseases of the

The Differential Diagnosis

251

Downloaded by [ ] at 13:03 12 August 2011

mind. Philadelphia: Kimber & Richardson. Reproduced by The Classics of Psychiatry & Behavioral Sciences Library, Gryphon, Birmingham, AB.
Schneider, J. P. (1991). How to recognize the signs of sex addiction. Postgraduate
Medicine, 90(6), 171182.
Schneider, J. P. (1994). Sex addiction: Controversy. Sexual Addiction & Compulsivity,
1 (1), 1945.
Schneider, J. P., & Irons, R. (1996). Differential diagnosis of addictive sexual disorders using the DSM-IV. Sexual Addiction & Compulsivity, 3(1), 721.
Spalt, L. (1975). Sexual behavior and affective disorders. Diseases of the Nervous
System, 36(12), 644647.
Washton, A., & Boundy D. (2000). Willpowers not enough: Recovering from addictions of every kind. New York: HarperCollins.