Hypersexuality in neurological diseases: do we see only the tip of the iceberg?

Abstract

The purpose of this commentary is to investigate the pathophysiological mechanisms underlying hypersexuality and its manifestation in neurological diseases through a meta-analysis. Studies were identified by searching on PubMed, Web of Science and Cochrane databases. All results of each database between 2014 and 2020 were evaluated for possible inclusion. After an accurate revision of complete manuscripts, forty articles satisfied the inclusion/exclusion criteria. Data from our meta-analysis indicated hypersexuality to be a frequent sexual disorder in patients with neurological disorders, especially neurodegenerative ones. Hypersexuality could negatively affect a patient's management and outcomes. This commentary discusses studies that are often incomplete for evaluation measures or sample selection. In our opinion, it is necessary to consider hypersexuality with particular attention, so more extensive sample studies are needed to find the most appropriate treatment to improve the quality of life for both the patient and the caregiver.

The Concept of “Hypersexuality” in the Boundary Between Physiological and Pathological Sexuality

“…Today, the majority position seems to reasonably lean toward the secondary hypothesis, as it appears to be a dysfunctional adaptation to a primary fact that secondarily induces the onset of the hypersexual condition. In fact, all etiological hypotheses underlying hypersexuality confirm this reasoning: a) neurological syndromes [9][10][11][12][13][14][15][16][17][18][19][20], such as Klüver-Bucy syndrome (consisting of a bilateral lesion of the amygdala), typical and atypical dementias with temporo-frontal involvement, Pick's dementia, Kleine-Levin syndrome (or recurrent hypersomnia), autism, and attention-deficit/hyperactivity disorder (ADHD); b) psychiatric forms [21][22][23][24][25][26][27][28][29][30][31][32], such as bipolarism and borderline disorder (in their euphoric/subeuphoric components typical of manic and/or hypomanic), sub-obsessive forms, sexually oriented behavioral addictions, and high-functioning personality disorders, such as covert-type narcissism; c) traumas of the encephalon [33], in the regions used for rationality and impulse control (temporofrontal and limbic system in general); d) implications arising from the use of excitatory drugs (such as methamphetamine, cocaine, synthetic drugs, and hallucinatory drugs) and from the therapeutic use of certain drugs, such as the use of L-dopa and prolactin inhibitors in Parkinson's dementia (indeed, dopaminergic drugs have been shown to influence conscious processing of rewarding stimuli and are associated with impulsive-compulsive behaviors, such as hypersexuality, by going on to activate the nucleus accumbens and dorsal anterior cingulate when shown subliminal sexual stimuli), anabolic drugs, and testosterone and other sex hormone products. [34].…”

The Concept of “Hypersexuality” in the Boundary between Physiological and Pathological Sexuality

“…Today, the majority position seems to reasonably lean towards the secondary hypothesis, as it appears to be a dysfunctional adaptation to a primary fact that secondarily induces the onset of the hypersexual condition. In fact, all etiological hypotheses underlying hypersexuality confirm this reasoning: (a) neurological syndromes [7,8,10,13,16,20,23,[30][31][32][33][34], such as Klüver-Bucy syndrome (consisting of a bilateral lesion of the amygdala), typical and atypical dementias with temporo-frontal involvement, Pick's dementia, Kleine-Levin syndrome (or recurrent hypersomnia), autism, and attention-deficit/hyperactivity disorder (ADHD); (b) psychiatric forms [9,11,12,21,24,25,27,[35][36][37][38][39], such as bipolar disorder and borderline disorder (in their euphoric/sub-euphoric components typical of manic and/or hypomanic), sub-obsessive forms, sexually oriented behavioural addictions, and high-functioning personality disorders, such as covert-type narcissism; (c) traumas of the encephalon [40], in the regions used for rationality and impulse control (temporofrontal and limbic system in general); (d) implications arising from the use of excitatory drugs (such as methamphetamine, cocaine, synthetic drugs, and hallucinatory drugs) and from the therapeutic use of certain drugs, such as the use of L-dopa and prolactin inhibitors in Parkinson's dementia (indeed, dopaminergic drugs have been shown to influence conscious processing of rewarding stimuli and are associated with impulsive-compulsive behaviours, such as hypersexuality, by going on to activate the nucleus accumbens and dorsal anterior cingulate when shown subliminal sexual stimuli), anabolic drugs, and testosterone and other sex hormone products [17]. It is precisely in the presence, therefore, of the fulfilment of generally accepted diagnostic criteria, out of any other physiological condition (albeit deviating from the statistical mean of the reference population) that the diagnosis of sexual conduct dysfunction due to hypersexuality is reached, resulting in the evaluation of a multidisciplinary therapeutic approach considering individual and/or group psychotherapy, mainly of cognitive-behavioural or constru...…”

Hypersexuality in neurological disorders: A systematic review

“…7 Understanding the mechanisms by which putative brain lesions or dysfunction results in sexual overactivity remains in its early stages. 1 Consequently, HS categorisation schemes are heterogeneous; qualitative descriptors range from ambiguous 'disinhibited sexuality' to ostensibly pathologising 'sexual addiction' used interchangeably, and the diagnostic criteria for hypersexual disorders, even among ostensibly healthy individuals, remain disputed. 11 Empirical findings on HS-related phenomena have emerged across various conditions from dementia [12][13][14][15] to traumatic brain injury.…”

“…Hypersexuality (HS) is a complex and poorly understood condition characterised by excessive sexual thoughts, urges and behaviours that can lead to significant distress and impairment in personal, social and occupational functioning. 1 Despite its association with various neurological disorders, such as Parkinson's disease (PD), Alzheimer's disease and traumatic brain injury, the definition, diagnostic criteria and psychopathological features of HS remain a topic of ongoing debate and controversy. [2][3][4][5] Pathological forms of sexual behaviour, also known as problematic or compulsive sexual behaviour, refer to sexual thoughts, urges or behaviours that are excessive, persistent and cause significant distress or impairment in personal, social or occupational functioning.…”

“…7 However, despite the historical recognition and profound personal and societal implications of such disinhibited and deviant behaviours, the scientific study of abnormal sexuality secondary to neuropathology has received relatively limited attention compared with other neuropsychiatric domains. 1 The inherent complexity surrounding human sexuality, spanning biological, psychological, interpersonal, sociocultural and moral dimensions, poses conceptual challenges for pathological characterisation. 8 In recent decades, issues surrounding excessive, intrusive sexual drive, termed 'HS', have gained prominence in mainstream neuropsychiatric models.…”