Response to Moser’s (2010) Critique of Hypersexual Disorder for DSM-5

Abstract

Moser (2001) has long been a consistent critic of the empirical basisof the inclusionofparaphilicdisorders in the APA’s diagnostic manuals and has, to date, already published two Letters to the Editor of this Journal critical of the Paraphilias Subworkgroup’s DSM-5 proposals (Moser, 2009, 2010b). InMoser’s (2010a)current lettercriticizingourproposal for Hypersexual Disorder as ‘‘just more muddled thinking,’’he restates many of the general criticisms that he has previously raised about paraphilic disorders. Interestingly, he agrees that ‘‘there are people who have difficulty controlling their sexual fantasies, urges, and behaviors’’and that‘‘these individuals may benefit frompsychiatric intervention’’butonlyasserts‘‘Thepresent formulationofHypersexualDisorderdoesnotdescribe these individuals.’’He offers no counter proposal as to how to better define such a condition. Many of his specific criticisms of Hypersexual Disorder reflect a combination of misunderstanding, omissions, dichotomous reductionism or an incomplete reading of the review which identifies the sources for the specific criteria for this proposed condition (Kafka, 2010). In addition, Moser applies an interpretation of each suggested criterion in a manner that overlooks the greater context of the forest for its trees. Moser asserts that‘‘Kafka’s proposed diagnostic criteria do not indicate that the sexual interest must be either non-paraphilic or have an impulsivity component.’’ In fact, all of the required behavioral specifiers (Kafka, 2010, Table 1, p. 379) associated with the operational definition of Hypersexual Disorder were deliberately chosen as non-paraphilic behaviors. Despite these specifiers being intrinsic to the diagnosis, he did not acknowledge them. In addition, when an enduring sexual behavior repetitively occurs in response to dysphoric affects (A2), stressful events (A3), include repetitive volitional impairment (A4), and persistent risk-taking behavior (A5), aren’t these characteristicsasufficient representationofan impulsivitycomponent? Pathological Gambling, a prototypical impulse control disorder in DSM-IV-TR, includes these same impulsivity-associated components (and others) as well (American Psychiatric Association, 2000). By isolating and criticizing the wording of each A criterion item, Moser completely misses the broader context required by the proposed diagnosis: it is not merely any single specific behavioral criterion that defines this syndrome, but that it is a polythetic mixture of four or more of these five behavioral descriptors of sexual behavior, a minimum persistence of at least6 months,and,most importantly, clinically significantdistress and/or role impairment (B criterion). It is the composite that constitutes a psychiatric disorder, not an isolated criterion item. Each selected criterion item has been selected from multiple published rating scales (Kafka, 2010, pp. 380–386). By analogy, isolating and then criticizing the relativity or inexactness of a single behavioral criterion, such as‘‘often has difficulty organizing tasks and activities,’’would misconstrue the polythetic contextuality and required degree of impairment requiredassociatedwiththediagnosisofAttentionDeficitHyperactivity Disorder, Inattentive Subtype. When discussing the B criterion for Hypersexual Disorder (significant distress and social role impairment), Moser’s M. P. Kafka (&) Harvard Medical School, Boston, MA, USA e-mail: mpkafka@rcn.com