Ограничение способности любить и гиперсексуальное поведение в их отношениях с психотиком и паранойей.

Introduction

Recent literature on psychoses increasingly supports the conceptualization of psychosis as a brain developmental disorder influenced by both polygenic heredity and environmental factors. 1 Research primarily aims to identify the polygenic components of psychosis and clarify their diverse phenotypic expressions. 2

Psychotic spectrum disorders and affective disorders with psychotic features are severe mental health conditions often accompanied by physical health comorbidities. 3 Individuals affected by psychiatric disorders frequently experience sexual dysfunctions, sometimes due to pharmacological treatments. 4 However, sexual dysfunctions can also precede the onset of mental illness, alongside subclinical psychotic symptoms that constitute high-risk indicators for psychosis. 5

The concept of ultra-high-risk (UHR) refers to a subclinical phase characterized by the presence of one of the following criteria: attenuated psychotic symptoms, brief intermittent psychotic symptoms, and genetic risk and functional decline. 6 Researchers and clinicians regard the UHR phase as an opportunity to intervene and potentially prevent the onset of full-blown psychosis. 7

Screening tools like the Symptom Checklist-90-R (SCL-90-R) and its shorter version, the Brief Symptom Inventory (BSI), can provide normative data to assess mental functioning across various domains. 8 These instruments are particularly useful for identifying pathology within non-clinical populations. 8 Notably, the BSI includes subscales for assessing paranoid ideation and psychoticism, which are critical areas for clinicians to explore when elevated scores are identified in non-clinical contexts. 8

Understanding comorbidities and the interplay between various symptoms can help clinicians anticipate and address early predispositions to clinically significant disorders. 5 Within this framework, sexuality and relational functioning represent important, though often neglected, areas of investigation. 5 , 9 These areas can sometimes be the reason why people seek help and exploring them with their potential pathology connection in mind, without prejudice, is essential for holistic and preventive care.

Compulsive sexuality, insecure attachment styles, and a limited Capacity to Love (CTL) are increasingly recognized as potential markers for the development of mental illness. 9-12

Compulsive Sexual Behavior Disorder (also known as "hypersexual disorder" or "sex addiction") is characterized by a strong urge to engage in sexual behaviors, using sexual behaviors as a way to cope with adverse emotional states, previous unsuccessful attempts to control these impulses, and repeated engagement in sexual behaviors despite negative consequences. 13 This behavior includes masturbation, frequent pornography use, cybersex or phone sex, sexual interactions with consenting adults, visiting brothels, or engaging in prostitution. 14 , 15 Hypersexual behaviors are often employed as maladaptive coping mechanisms to manage depressive or anxious states, attachment-related difficulties, relational problems, or emotional dysregulation. 16 , 17

Hypersexuality disorder has recently gained recognition in the ICD-11 (International Classification of Diseases for Mortality and Morbidity Statistics), such as Compulsive Sexual Behavior Disorder (CSBD), where it is categorized separately from paraphilias under impulse control disorders. The World Health Organization describes CSBD as a condition marked by a consistent failure to manage intense, recurring sexual urges or compulsions, leading to repetitive sexual actions. 18

In contrast, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders by the American Psychiatric Association does not list hypersexuality disorder as a formal diagnosis. This omission stems from ongoing debates in the scientific community about the potential risks of over-medicalizing personal behaviors and preferences. 18

Studies have explored the relationship between hypersexuality and attachment styles, 12 with recent research extending to examine the CTL 11 —a construct primarily developed by Otto Kernberg. 19 Kernberg conceptualized the CTL as a core aspect of psychological functioning and personality. In clinical practice, it is often applied to individuals with personality disorders. According to Kernberg, CTL encompasses the ability to form deep object relations, experience sexual pleasure, and share personal values with a significant other. This dimension reflects mature psychological development, whereas a limited CTL is often observed in individuals with paranoid, narcissistic, or masochistic traits. 19

A limited CTL can lead to problematic sexual behaviors, such as hypersexuality, particularly in individuals with vulnerable personality traits. 11 The quality of primary attachment relationships significantly influences CTL development, 19 in particular, according to Kernberg, the attachment that develops during childhood with the maternal object influences the dimension of basic trust, which is characteristic of the CTL. 19 Understood as empathy of the partner towards oneself and in the goodwill of the other. After all, this capacity implies the inner security of depending on a loving maternal introject, even when Oedipal guilt complicates this deep sense of secure attachment. 19

In this study, CTL is operationalized as an indicator of attachment quality—specifically, the ability to form secure, mature, and reciprocal emotional bonds—and is measured by the CTL Inventory. 19

Furthermore, insecure attachment patterns, depression, and interpersonal sensitivity appear to contribute to symptoms like paranoid ideation and psychoticism. 10

In line with preventive and holistic care approaches, the literature underscores the importance of addressing multiple health outcomes—physical, mental, and sexual—within an integrated framework. 20 While subthreshold psychotic symptoms are commonly studied in high-risk groups, fewer studies have examined how relational and sexual functioning may serve as early indicators of psychopathological distress in the general population. Addressing this gap is particularly relevant in light of current priorities in mental health research, which emphasize early identification and preventive care strategies.

The present study focuses specifically on testing the hypothesis that higher levels of hypersexuality, in conjunction with a limited CTL, are associated with increased scores in paranoid ideation and psychoticism.

Therefore, the research question was: Can a limited CTL and hypersexual tendencies be considered early indicators of psychopathological vulnerability, specifically in the symptom dimensions of paranoid ideation and psychoticism, in a non-clinical population?

Building on these considerations, we aim to explore the relationships between CTL, hypersexuality, and the symptom dimensions of psychoticism and paranoid ideation, in a non-clinical population.

Materials and methods

Recruitment

Using an online platform promoted via major social networks, a convenience sample of 521 young adults was gathered, consisting of 390 women and 131 men, with a mean age of 26.46 years (SD = 5.89). Participants were required to be between 18 and 60 years old and proficient in Italian. Each individual filled out a sociodemographic questionnaire and completed three psychometric assessments to evaluate hypersexuality, the CTL, psychological problems and symptoms of psychopathology. Participants were fully informed about the research and did not receive monetary compensation for their involvement. This work is based on a previously conducted dataset investigating CTL and sociosexuality. 21 The study was conducted anonymously, and the protocol received approval from the Institutional Review Board of Sapienza University of Rome (protocol number 293). Consent to participate was obtained through a dedicated item on the online platform.

Measures

Sociodemographic characteristics

Basic sociodemographic data were collected, including participants' gender, age, educational level, nationality, and relationship status.

Capacity to love

The CTL was assessed using the Italian adaptation of the Capacity to Love Inventory (CTL-I). 22 , 23 This tool consists of 41 items rated on a 4-point Likert scale (1 = strongly disagree to 4 = strongly agree) and evaluates six dimensions: interest in the partner's life project, basic trust, gratitude, shared ego-ideal, permanence of sexual passion, and aspects related to loss, jealousy, love, and mourning. The total score (CTL-I Total) was calculated using the mean method. Cronbach’s α for the total scale was .94, with subscale values ranging from .83 to .87.

Hypersexuality

Hypersexuality was measured with the Italian version of the Hypersexual Behavior Inventory (HBI). 24 The HBI includes 19 items rated on a 5-point Likert scale (1 = never to 5 = very often) and assesses hypersexual behavior through three factors: the coping factor (seven items), which evaluates the use of sex and sexual behavior to manage emotional distress such as sadness or anxiety; the control factor (eight items), which examines difficulties in regulating sexual behavior and failed attempts to change it; and the consequences factor (four items), which assesses negative outcomes of sexual thoughts or actions, such as interference with academic or work responsibilities. A total score (HBI Total) is calculated, with higher scores indicating a greater tendency toward hypersexual behavior. Following the cutoff score established by Reid et al., 25 scores of 53 or higher were considered indicative of problematic hypersexuality. Cronbach’s α values ranged from .81 to .92 across the total scale and subscales.

Psychopathological symptoms

Psychopathological symptoms were evaluated using the BSI, a validated 53-item self-report questionnaire derived from the Symptom Checklist-90. 26 The BSI identifies a wide range of psychological problems experienced over the previous 7 days. It measures nine primary symptom dimensions (somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation [PAR], and psychoticism [PSY]) and three indices of global symptom severity (Global Severity Index, designed to measure overall psychological distress, Positive Symptom Distress Index, which measures the intensity of symptoms, and Positive Symptom Total, which records the number of self-reported symptoms). Cronbach’s α ranged from .68 to .91 for this measure. As in other studies 27 , 28 we mainly considered the SCL-90 subscales “psychoticism” and “paranoid ideation” to test our hypothesis.

Statistical analysis

Continuous variables were expressed as means and SD, while dichotomous variables were reported as absolute frequencies and percentages. Pearson’s bivariate correlations were conducted to examine relationships between variables assessed through psychometric tests and their subscales. Two linear regressions were performed to analyse the influence of CTL and HBI on psychoticism in one model and paranoid ideation in another. A mediation model was also conducted to assess the direct and indirect effects of HBI (predictor) and CTL (mediator) on psychoticism and paranoid ideation. All variables were treated as continuous, and effects were considered significant if their confidence intervals excluded 0. Statistical significance was set at an alpha level of less than 5%. Data analysis was performed using JASP 0.14.

Results

The sociodemographic characteristics of the sample, along with the mean scores and standard deviations for the psychometric measures, are presented in Table 1 .

Table 1 Demographics and psychometric characteristics of sample (n = 521). Variables n;%/mean ± SD
Gender
Women 390;74.9 Men 131;25.1
Relational status
Single 237;45.5 In a relationship 284;54.5 Age 26.46 ± 5.89 PARANOID IDEATION 1.317 ± 0.988 PSYCHOTICISM 1.170 ± 0.925 CTL 19.096 ± 2.313 HBI 31.355 ± 12.503

Demographics and psychometric characteristics of sample (n = 521).

Analysis of the sociodemographic data revealed that the sample was predominantly composed of women (74.9%).

A pairwise correlation matrix indicated that all psychometric variables analysed were statistically significant. The CTL showed a significant negative correlation with paranoid ideation, psychoticism, and hypersexuality (HBI), whereas paranoid ideation and psychoticism were both positively correlated with HBI ( Table 2 ).

Table 2 Correlation among the psychometric variables. Variable CTL PARANOID IDEATION PSYCHOTICISM CTL / PARANOID IDEATION -0.269; <.001 / PSYCHOTICISM -0.385; <.001 0.765; <.001 / HBI -0.246; <.001 0.302; <.001 0.320; <.001

Correlation among the psychometric variables.

Table 3 displays the results of the linear regression analysis with psychoticism as the dependent variable. The analysis showed that CTL ( β = -0.326; P  < .001) was associated with lower levels of psychoticism, while HBI ( β = 0.239; P  < .001) was associated with higher levels of psychoticism. Similarly, Table 4 outlines the linear regression analysis with paranoid ideation as the dependent variable. In this case, CTL ( β = -0.207; P  < .001) was associated with lower levels of paranoid ideation, and HBI ( β = 0.251; P  < .001) was associated with higher levels of paranoid ideation.

Table 3 Linear regression assuming Psychoticism as dependent variable. Coefficients Model Unstandardized Standard Error Standardized t
P
CTL -0.130 0.016 -0.326 -8.048 <.001 HBI 0.018 0.003 0.239 5.914 <.001 R 2  = 0.20

Linear regression assuming Psychoticism as dependent variable.

R 2  = 0.20

Table 4 Linear regression assuming Paranoid Ideation as dependent variable. Coefficients Model Unstandardized Standard Error Standardized t
P
CTL -0.088 0.018 -0.207 -4.908 <.001 HBI 0.020 0.003 0.251 5.951 <.001 R 2  = 0.13

Linear regression assuming Paranoid Ideation as dependent variable.

R 2  = 0.13

Finally, Table 5 and Figure 1 summarize the mediation analysis, which demonstrated that CTL significantly mediated the indirect relationships between hypersexuality and both paranoid ideation and psychoticism. Hypersexuality also showed significant associations with both paranoid ideation and psychoticism in both the direct and total pathways.

Table 5 Mediation Analysis assuming Paranoid Ideation and Psychoticism as dependent variable.
Direct effects
95% Confidence Interval Estimate Std. Error z-value
P
Lower Upper HBI ➔ PARANOID IDEATION 0.020 0.003 5.968 <.001 0.013 0.026 HBI ➔ PSYCHOTICISM 0.018 0.003 5.931 <.001 0.012 0.024
Indirect effects
95% Confidence Interval Estimate Std. Error z-value
P
Lower Upper HBI ➔ CTL ➔ PARANOID IDEATION 0.004 0.001 3.749 <.001 0.002 0.006 HBI ➔ CTL ➔ PSYCHOTICISM 0.006 0.001 4.702 <.001 0.003 0.008
Total effects
95% Confidence Interval Estimate Std. Error z-value
P
Lower Upper HBI ➔ PARANOID IDEATION 0.024 0.003 7.237 <.001 0.017 0.030 HBI ➔ PSYCHOTICISM 0.024 0.003 7.697 <.001 0.018 0.030
Residual covariances
95% Confidence Interval Estimate Std. Error z-value
P
Lower Upper PARANOID IDEATION ↔ PSYCHOTICISM 0.551 0.041 13.414 <.001 0.471 0.632

Mediation Analysis assuming Paranoid Ideation and Psychoticism as dependent variable.

Path plot for the pathway between hypersexual behavior and psychopathology Figure 1 . Path graph indicates the direct and indirect effect of Hypersexuality (TOTHBI) on the PAR and PSY, through the mediation of CTL.

Discussion

The findings of this study underscore the association between problematic sexual behaviors and mental health symptoms such as paranoid ideation and psychoticism. Several studies have highlighted the intrinsic influence of psychosis itself on sexual functioning, suggesting that neurobiological mechanisms common to both sexual problems and schizophrenia may play a crucial role. 5

Our study aligns with previous findings, indicating that problematic sexual behaviors, such as hypersexuality, can serve as markers of psychosocial distress, particularly in young adults and adolescents. 29 , 30 These behaviors are often observed in individuals with fragile personalities and could indicate underlying psychopathological issues. 30

Moreover, the role of the CTL is emerged as a significant factor in our research, revealing how a central existential element of the human life, play a fundamental role also for the psychological and sexological health. The CTL, encompassing components such as interest in others, basic trust, and gratitude, was inversely correlated with hypersexuality, paranoid ideation, and psychoticism in Pearson's analysis, reaffirming its protective role against these dysfunctional behaviors. 11 In particular, as in previous studies, the psychopathological symptoms as paranoid ideation, psychoticism or both these psychotic prodromes, are found in correlation with dysregulated sexuality in several forms. Paranoia, for example, was also discussed with sexual violence and discriminatory behavior. 31

In our non-clinical sample, the subscale of Paranoid Ideation showed a mean score of 1.317 (SD = 0.988) and Psychoticism a mean of 1.170 (SD = 0.925), with both scales covering the full theoretical range (0–4). The relatively low means and moderate dispersion suggest that most participants report subclinical levels of these symptoms. By contrast, studies conducted in clinical samples 8 , 32 generally report higher mean scores and greater variability on these subscales, reflecting the presence of more pronounced psychopathological features. This qualitative difference underscores that while the entire score range is theoretically possible in both clinical and non-clinical groups, in non-clinical populations high scores are less frequent, thereby supporting the sensitivity of these measures as early indicators of potential psychopathological distress.

This finding supports the hypothesis that a well-developed CTL may buffer individuals against the development of severe mental health conditions, including those characterized by problematic sexuality. It, in fact, could be related to functional relational patterns in the positive or negative relationship with problematic sexuality and psychopathological suffering. 21

Interestingly, other studies have suggested that hypersexual behavior often stems from post-traumatic events, proposing a link between the inability to love and trauma. 30 This could indicate that coping with trauma and improving the CTL could be crucial in preventing and treating psychopathological conditions.

In a recent study, a correlation between sexual issues, the ability to love and insecure attachment is also emerged, 11 revealing once again the consolidate role of primary relationship and related relational patterns for sexual behavior and for the psychosexological health. 33

Insecure attachment is highly prevalent among patients with schizophrenia and other schizophrenia spectrum disorders 34 , 35 as well as in the premorbid stages. 10 The strong correlation existing in the literature between insecure attachment and limited CTL, explored in this study in the sexual context, with a strong link between problematic sexuality, limited CTL, and high paranoid ideation and psychoticism calls for future studies in at-risk populations, including individuals at clinical high risk for psychosis, which could inform holistic early intervention strategies.

The comprehensive assessment of sexual function and the inclusion of sexological expertise in clinical practice are crucial. This approach not only aids in early detection of potential mental health issues but also ensures holistic patient care, addressing both psychological and sexual well-being. 5

Therefore, our study reinforces the need to integrate sexual health assessments into psychiatric evaluations and emphasizes the protective role of the CTL in mitigating problematic sexual behaviors and, in this case, paranoid ideation and psychoticism. Future research should continue to explore these relationships, focusing on intervention strategies that enhance relational and sexual well-being to prevent the onset of severe mental health disorders.

It is important to emphasize that no formal diagnostic assessments were conducted; rather, our measures reflect the severity of specific symptom dimensions. Future research could benefit from a more detailed quantitative comparison of the variance in BSI subscale scores between non-clinical and clinical samples.

Limitations

The study design reflects a gender imbalance, which could affect the generalizability of the findings (especially considering that hypersexuality is more commonly observed in men, 36 while 75% of our sample consisted of women). Furthermore, the sample was predominantly made up of students and individuals from Italian cultural backgrounds. Another potential limitation lies in the use of online surveys, which are prone to sampling bias due to the non-representative nature of participants and the lack of control over survey conditions. Additionally, self-reported data may introduce inaccuracies and social desirability bias. To address these limitations, future research should include a more diverse sample and a larger proportion of individuals seeking treatment for sexual problems.

Conclusions

This research highlights the intricate relationship between problematic sexuality and psychosis traits in the general population, supporting the growing recognition of the link between dysregulated sexuality and mental health symptoms, including psychoticism and paranoid ideation.

Problematic sexual behaviors, such as hypersexuality, are significant markers of psychosocial distress, particularly in vulnerable populations like young adults and adolescents. CTL emerged as a protective factor against these behaviors, suggesting that enhancing CTL could help mitigate the risk of severe mental health issues.

Incorporating comprehensive sexual health assessments into clinical practice is essential for early detection and holistic patient care, addressing both psychological and sexual well-being. Future studies may adopt indicated prevention frameworks in help-seeking young people meeting clinical high risk for psychosis criteria, which could inform holistic intervention strategies targeting physical, sexual, and mental health outcomes.

Contributor Information

Giulia Origlia,
Department of Dynamic and Clinical Psychology, and Health Studies, Sapienza University of Rome, Rome 00185, Italy.

Davide Doroldi,
Department of Dynamic and Clinical Psychology, and Health Studies, Sapienza University of Rome, Rome 00185, Italy.

Gabriele Lo Buglio,
Department of Dynamic and Clinical Psychology, and Health Studies, Sapienza University of Rome, Rome 00185, Italy.

Tommaso Boldrini,
Department of Psychology and Health Science, Pegaso University, Naples 80143, Italy;
Department of Psychiatry, University of Ottawa, Ottawa, ON K1N 6N5, Canada.

Antonio Del Casale,
Department of Dynamic and Clinical Psychology, and Health Studies, Sapienza University of Rome, Rome 00185, Italy.

Grazia Spitoni,
Department of Dynamic and Clinical Psychology, and Health Studies, Sapienza University of Rome, Rome 00185, Italy.

Erika Limoncin,
Department of Dynamic and Clinical Psychology, and Health Studies, Sapienza University of Rome, Rome 00185, Italy.

Giacomo Ciocca,
Department of Dynamic and Clinical Psychology, and Health Studies, Sapienza University of Rome, Rome 00185, Italy.

Funding

This research is supported by PRIN 2022 (project number: 20224SX547), and PRIN 2022 PNRR (project number: P2022ARREH).

Conflicts of interest

The authors declare no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study protocol was approved by the Ethics Committee of the Department of Dynamic and Clinical Psychology and Health Studies of the Sapienza University.

Informed consent

Informed consent was obtained from all individual participants included in the study.

References