Сравнение эффекта диалектической терапии поведения и арипипразола на эмоциональную разводню в пациентах с гиперсексуальностью.

I NTRODUCTION

Sexual desires and needs are among the natural human needs. If not appropriately satisfied, they might cause various sexual disorders, including hypersexuality, which can affect individuals’ behaviors, emotions, jobs, social relationships, etc.[ 1 ] Hypersexuality disorder is also known as hypersexual disorder (HD), sexual addiction, compulsive sexual behavior disorder (CSBD), hypersexual behavior, or sexual compulsivity.[ 2 , 3 ] The prevalence of hypersexuality is almost the same among men and women, reaching its highest prevalence among those aged between 25 and 55.[ 3 ]

Hypersexuality is proposed in the International Classification of Diseases 11 th revision (ICD-11) as an impulse control disorder with the code “6C72.” In this study, the hypersexuality diagnosis was based on the definition and clinical instructions of the ICD-11.[ 4 ] It is notable that the participants of this study were those with non‐paraphilic hypersexual behavior (known as hypersexual).[ 3 ]

Difficulty in interpersonal or social relationships (e.g., marital conflicts) is a major problem for couples with hypersexuality[ 3 ] and might lead to emotional divorce. As a result, the couples become despair and disappointed and show reduced affection toward each other. After a long period of conflict, they feel hatred and behave indifferently, which is the last stage of the emotional relationship and ultimately ends in an emotional divorce. It is noteworthy that emotional divorce does not necessarily lead to divorce, and the couple might live in one house for some reason.[ 5 ] Although the exact rate and prevalence of emotional divorce are not known, this trend is increasing in the UK, Sweden, and generally worldwide.[ 6 ] The prevalence rate of emotional divorce is 40.9% among Iranian couples, indicating its alarming escalation.[ 7 ]

Due to the unique nature of many paraphiliae, treatment methods might range from pharmacological and psychotherapeutic interventions to more serious interventions (e.g., chemical castration, isolation, and incarceration) that can be sexually harmful or illegal.[ 3 ] Therefore, this study focused on treating hypersexuality (non-paraphilic HD), which does not require the abovementioned serious interventions. Pharmacological and psychotherapeutic interventions, that is, aripiprazole and dialectical behavior therapy (DBT), were conducted for this purpose.

The use of serotonin reuptake inhibitor drugs (SSRIs), antiandrogens, and other well-known standard and common psychiatric drugs are some of the medical interventions that are used for these disorders, which have also had relative effectiveness.[ 8 , 9 ] Aripiprazole is a partial agonist of the D2 dopamine receptor and an antipsychotic drug, which rarely has sexual side effects (decreased libido). By increasing prolactin levels, aripiprazole relieves side effects and impulsive behaviors, including hypersexuality, excessive shopping, and pathological gambling. However, sexual dysfunctions, such as hypersexuality, are sometimes the major reason for nonadherence to antipsychotic treatment in mental health disorder patients.[ 10 ]

Among the psychological treatments designed to solve the problems of couples with hypersexuality, we can refer to psychoanalytical treatments and couple and behavioral therapy.[ 11 , 12 ] DBT is one of the therapeutic approaches with long-term effects and enhances patients’ skills through cognitive, emotional, and behavioral intervention.[ 13 ] Considering the role of hypersexuality in emotional divorce, treatments that emphasize resolving conflicts and disagreements and obtaining social support can play a decisive role in treating and preventing hypersexuality-related complications. In psychology, DBT is one of the innovative treatments that emphasizes both skill training and emotion regulation skills. It includes four intervention components in its group format: mindfulness and distress tolerance as “acceptance-oriented components” and emotional regulation and interpersonal effectiveness as “change-oriented components.” Studies confirmed the effectiveness of DBT in reducing couples’ conflicts, increasing emotion regulation and marital satisfaction in couples on improving interpersonal relationships, brink of divorce, and reducing violent behaviors and sexual impulsivity.[ 14 ]

Despite the beneficial effects of DBT and aripiprazole, no study has yet been conducted comparing the effects of these two treatments on disorders, such as hypersexuality. The rationale for including these two treatments is that hypersexuality is caused by dopamine regulation problems followed by emotional problems. Therefore, according to the research background,[ 3 , 10 ] prescribing a medication with the least sexual side effects and evidence-based psychotherapy can facilitate dopamine regulation. It is noteworthy that the present study researchers did not aim to treat the sexual side effects, that is, decrease in libido, of antipsychotic drugs. Yet, they meant to investigate the changes in the dopamine neurotransmitter because it is assumed that dopamine dysregulation, or high levels of this neurotransmitter, can cause hypersexuality. Therefore, the treatment is not to reduce sexual desire due to the side effects of drug use but to regulate dopamine, which regulates sexual behaviors.

The novelty of the current research is that it simultaneously examines two independent variables, aripiprazole and DBT, and the dependent variable, emotional divorce, which influences the mental and physical health of patients with hypersexuality. DBT, an emotion-focused treatment, and aripiprazole, a dopamine “regulating” medication with the least sexual side effects (decrease in libido), significantly help with hypersexuality treatment.

Scant attention has been paid to the issue of emotional divorce, and previous studies mainly focused on postdivorce problems.[ 15 ] In addition to investigating the effect of DBT and aripiprazole on emotional divorce in hypersexual patients, the debate on whether drug therapy and psychotherapy have different or similar effects in such cases is scientifically significant. Meanwhile, including two therapeutic approaches in a study can probably strengthen its findings and make it more valuable for the scientific community and practical use. Therefore, this study aimed to compare the effect of DBT and aripiprazole on emotional divorce in patients with hypersexuality, and the main research question was “Is there a difference between the effect of DBT and aripiprazole on the emotional divorce of hypersexual patients?”

M ATERIALS AND M ETHODS

This study was quasi-experimental, with two experimental groups, a control group, a pretest, a posttest, and a follow-up phase. The statistical population of this study included patients with hypersexuality who were referred to four hospitals and psychiatric centers in Isfahan, Iran.

Based on the test power of 80%, error of 5%, and standard deviation of 0.9, and due to the specificity of the target sample, 60 patients were selected purposively and, after the initial assessment, were randomly divided into a control and two experimental groups, each comprising 20 patients. Finally, 54 patients (due to attrition) were equally divided into three groups of 54 patients, and the Emotional Divorce Questionnaire was administered at the pretest stage.

The first experimental group underwent DBT intervention during eight sessions of 90 minutes by an experienced therapist [ Table 1 ]. Regarding the second experimental group, aripiprazole was given at an initial dose of 5 mg daily; however, the dose was increased if required (approved by a psychiatrist). It was prescribed once a week until the final increase in the daily dose of 20 mg (if tolerated) for 2 months. After the end of the treatments, the Emotional Divorce Questionnaire was administered as the posttest, and a follow-up phase was conducted 5 months after the treatments. To stabilize the drug therapy period after 2 months of medication administration, the participants continued to take aripiprazole for 6 months with a certain dose until the follow-up stage, whose aim was to investigate the possible late side effects, including tardive dyskinesia, which usually occurs 3 to 6 months after taking the medication. Besides, changes in the recurrence of symptoms, mood changes, etc., were also checked in the follow-up stage. In the end, the participants were appreciated for participating in the study.

Table 1 Summary of DBT sessions based on Linehan[ 16 ] Session Summary First session: mindfulness (1) Familiarity with the concept of mindfulness and three mental states (logical mind, emotional mind, and rational mind) Second session: mindfulness (2) Teaching two sets of skills to achieve mindfulness; the first category is “what” skills (including observing, describing, and participating), and the second category includes “how” skills (including a nonjudgmental stance, comprehensive self-awareness, and effective functioning) Third session: distress tolerance (1) Teaching distraction strategies and diverting the mind with Activities, Contributing, Comparisons, Emotions, Pushing away, Thoughts and Sensations (ACCEPTS) skills Fourth session: distress tolerance (2) Teaching self-soothing with the five senses Fifth session: emotion regulation (1) Teaching how to identify and label emotions enhances emotional control Sixth session: emotion regulation (2) Teaching to create positive emotional experiences through creating short-term positive emotional experiences Seventh session: effective communication and interpersonal efficiency (1) Situations for effective communication and interpersonal efficiency (congruency between one’s own desires and those of others; the ratio of desires to needs) Eighth session: effective communication and interpersonal efficiency (2) The goals of effective communication and interpersonal efficiency (achieving goals in a situation and dealing with resistance and conflict)

Summary of DBT sessions based on Linehan[ 16 ]

The inclusion criteria were as follows: age above 20, hypersexuality as a separate diagnosis based on ICD-11 classification, having at least a diploma, not undergoing any other training program before and during DBT, and being married. The exclusion criteria were as follows: suffering from a severe psychiatric illness and hypersexuality and using psychiatric drugs. Furthermore, patients who took levodopa, those who used substances, schizophrenia, or those with frontal lobe disorders, nursing mothers, pregnant women, and those at risk for suicide were excluded from the study. All possible side effects were also considered, recorded, and evaluated in the clinical interview and periodical examinations of patients, and aripiprazole side effects, especially cardiac ones, were carefully monitored.

Instruments

Researcher-made demographics questionnaire: It was designed to collect information about gender, age, marital status, education level, number of current family members, and employment and economic status. Data analysis revealed that none of these variables significantly influenced the dependent variables.

Emotional Divorce Questionnaire: [ 17 , 18 ] It is a 36-item questionnaire that includes nine subscales: criticism and blame, silence and confrontation, lack of emotional response, lack of emotional interaction, power and resources, loss, depression and frustration, the third angle, limiting, and sexual problems each comprising four items. The responses are rated on a five-point Likert scale ranging, from 0 (never) to 4 (always). The total score of each subscale ranges between 0 and 36. A score above 18 (on average) for each subscale indicates a higher-than-average emotional divorce. The reliability of the questionnaire assessed by Cronbach’s alpha was.95. The reliability of the questionnaire, estimated for this study, was.89.

R ESULTS

The data were analyzed by multivariate analysis of covariance (MANCOVA) using Statistical Package for the Social Sciences (SPSS) version 24, and its assumptions were checked before performing this analysis.

Tables 2 and 3 , respectively, present the results of the analysis of covariance for comparing two groups (the DBT and the control group; the aripiprazole and the control group) regarding emotional divorce, and Table 4 demonstrates the results of comparing the three groups in terms of emotional divorce.

Table 2 Results of repeated-measures analysis of variance for within-group and between-group effect for the DBT group Scale Source Sum of squares df Mean square
F
Sig. Partial eta-squared Statistical power Criticism and blame Within groups Test 5.14 1.64 3.13 2.09 0.15 0.11 0.35 Test and group interaction 33.59 1.64 20.46 13.69 0.00 0.46 0.98 Between groups Group 78.24 1 78.24 7.86 0.01 0.33 0.75 Silence and confrontation Within groups Test 3.11 3 1.55 3.05 0.06 0.16 0.55 Test and group interaction 4.59 2 2.29 4.5 0.01 0.22 0.72 Between groups Group 75.85 1 75.85 16.51 0.00 0.5 0.96 Lack of emotional response Within groups Test 26.70 1.31 20.3 8.38 0.00 0.34 0.85 Test and group interaction 44.33 1.31 33.7 13.91 0.00 0.46 0.97 Between groups Group 80.66 1 80.66 5.16 0.03 0.24 0.57 Lack of emotional interaction Within groups Test 26.92 1.4 19.16 6.04 0.01 0.27 0.74 Test and group interaction 69.14 1.4 49.22 15.52 0.00 0.49 0.98 Between groups Group 133.79 1 133.79 11.3 0.00 0.41 0.88 Power and resources Within groups Test 10.33 2 5.16 1.62 0.21 0.09 0.31 Test and group interaction 62.92 2 31.46 9.86 0.00 0.38 0.97 Between groups Group 109.79 1 109.79 23.2 0.00 0.59 0.99 Loss, depression, and frustration Within groups Test 7.81 2 3.9 8.48 0.00 0.34 0.95 Test and group interaction 7.44 2 3.72 8.08 0.00 0.33 0.93 Between groups Group 24 1 24 2.63 0.12 0.14 0.33 Third angle Within groups Test 20.11 2 10.05 20.58 0.00 0.56 1 Test and group interaction 8.92 2 4.46 9.13 0.00 0.36 0.96 Between groups Group 21.4 1 21.4 3.52 0.07 0.18 0.42 Limiting Within groups Test 7.14 1.67 4.26 5.27 0.01 0.24 0.74 Test and group interaction 20.48 1.67 12.23 15.09 0.00 0.48 0.99 Between groups Group 167.13 1 167.13 32.23 0.00 0.66 1 Sexual problems Within groups Test 16.59 2 8.29 18.47 0.00 0.53 1 Test and group interaction 18.37 2 9.18 20.45 0.00 0.56 0.95 Between groups Group 58.07 1 58.07 7.8 0.01 0.32 0.96 Emotional divorce Within groups Test 926.77 2 463.38 49.57 0.00 0.75 1 Test and group interaction 2060.11 2 1030.05 110.19 0.00 0.87 1 Between groups Group 6337.5 1 6337.5 34.68 0.00 0.68 1

Results of repeated-measures analysis of variance for within-group and between-group effect for the DBT group

Table 3 Results of repeated-measures analysis of variance for within-group and between-group effects for the aripiprazole group Scale Source Sum of squares df Mean square
F
Sig. Partial eta-squared Statistical power Criticism and blame Within groups Test 3.37 2 1.68 2.36 0.11 0.12 0.43 Test and group interaction 6.48 2 3.24 4.54 0.01 0.22 0.73 Between groups Group 0.46 1 0.46 0.03 0.85 0.00 0.05 Silence and confrontation Within groups Test 2.25 2 1.13 2.56 0.09 0.13 0.47 Test and group interaction 1 2 0.5 1.13 0.33 0.06 0.23 Between groups Group 24 1 24 2.94 0.1 0.15 0.36 Lack of emotional response Within groups Test 2.81 2 1.4 3.08 0.05 0.16 0.55 Test and group interaction 1.92 2 0.96 2.11 0.13 0.11 0.4 Between groups Group 1.18 1 1.18 0.05 0.8 0.00 0.05 Lack of emotional interaction Within groups Test 9.33 2 4.66 4.36 0.02 0.21 0.71 Test and group interaction 13.77 2 6.88 6.44 0.00 0.28 0.87 Between groups Group 4.16 1 4.16 0.31 0.58 0.01 0.08 Power and resources Within groups Test 4.03 2 2.01 0.51 0.6 0.03 0.12 Test and group interaction 11.44 2 5.72 1.47 0.24 0.08 0.29 Between groups Group 4.16 1 4.16 0.5 0.48 0.03 0.1 Loss, depression, and frustration Within groups Test 20.25 1.48 13.61 8.39 0.00 0.34 0.88 Test and group interaction 24.48 1.48 16.44 10.15 0.00 0.38 0.93 Between groups Group 40.9 1 40.9 5.29 0.03 0.24 0.58 Third angle Within groups Test 36.59 2 18.29 32.21 0.00 0.67 1 Test and group interaction 19.11 2 9.55 17.34 0.00 0.52 1 Between groups Group 24 1 24 3.46 0.08 0.17 0.41 Limiting Within groups Test 1.44 2 0.72 1.03 0.36 0.06 0.21 Test and group interaction 4.11 2 2.05 2.93 0.06 0.15 0.53 Between groups Group 48.16 1 48.16 4 0.06 0.2 0.46 Sexual problems Within groups Test 44.77 2 22.38 30.32 0.00 0.65 1 Test and group interaction 46.25 2 23.13 31.32 0.00 0.66 1 Between groups Group 83.13 1 83.13 11.3 0.00 0.41 0.88 Emotional divorce Within groups Test 392.92 2 196.46 15.27 0.00 0.48 0.99 Test and group interaction 583.37 2 426.68 33.16 0.00 0.67 1 Between groups Group 1546.68 1 1546.68 6.47 0.02 0.28 0.66

Results of repeated-measures analysis of variance for within-group and between-group effects for the aripiprazole group

Table 4 Results of repeated-measures analysis of variance for within-group and between-group effects comparing the two experimental groups Scale Source Sum of squares df Mean square
F
Sig. Partial eta-squared Statistical power Criticism and blame Within groups Test 6.09 1.81 3.35 2.91 0.07 0.1 0.51 Test and group interaction 36.27 3.63 9.98 8.65 0.00 0.41 0.99 Between groups Group 96.91 2 48.45 4.45 0.02 0.27 0.7 Silence and confrontation Within groups Test 5.21 2 2.6 5.86 0.00 0.19 0.85 Test and group interaction 4.79 4 1.19 2.69 0.04 0.18 0.7 Between groups Group 76.24 2 38.12 5.91 0.00 0.33 0.83 Lack of emotional response Within groups Test 23.72 1.38 17.16 9.44 0.00 0.28 0.91 Test and group interaction 49.97 2.76 18.07 9.94 0.00 0.45 0.99 Between groups Group 96.06 2 48.04 3.13 0.06 0.2 0.54 Lack of emotional interaction Within groups Test 38.54 1.48 25.93 10.62 0.00 0.3 0.95 Test and group interaction 74.42 2.97 25.03 10.26 0.00 0.46 0.99 Between groups Group 152.46 2 76.23 7.39 0.00 0.38 0.9 Power and resources Within groups Test 8.91 2 4.45 1.33 0.27 0.05 0.27 Test and group interaction 65.3 4 16.32 4.9 0.00 0.29 0.94 Between groups Group 123.43 2 61.71 9.24 0.00 0.43 0.95 Loss, depression, and frustration Within groups Test 33.28 1.64 20.27 18.49 0.00 0.43 0.99 Test and group interaction 26.19 3.28 7.98 7.28 0.00 0.37 0.98 Between groups Group 44.76 2 22.38 2.74 0.08 0.18 0.49 Third angle Within groups Test 60.37 2 30.16 52.69 0.00 0.68 1 Test and group interaction 23.01 4 5.75 10.10 0.00 0.45 1 Between groups Group 30.32 2 15.16 2.33 0.11 0.16 0.42 Limiting Within groups Test 20.64 4 5.16 9.63 0.00 0.45 0.95 Test and group interaction 20.64 4 5.16 9.63 0.00 0.45 0.99 Between groups Group 167.43 2 83.71 9.17 0.00 0.43 0.95 Sexual problems Within groups Test 77.85 2 38.92 63.06 0.00 0.72 1 Test and group interaction 47.85 4 11.96 19.38 0.00 0.61 1 Between groups Group 95.63 2 47.81 6.95 0.00 0.36 0.88 Emotional divorce Within groups Test 1875.13 2 56/937 88.44 0.00 0.78 1 Test and group interaction 2219.38 4 554.84 52.34 0.00 0.81 1 Between groups Group 6637.8 2 3168.9 16.39 0.00 0.57 0.99

Results of repeated-measures analysis of variance for within-group and between-group effects comparing the two experimental groups

Emotional divorce and the components of silence and confrontation, lack of emotional response, lack of emotional interaction, loss, depression and frustration, the third angle, limiting, and sexual problems significantly altered over time ( P < 0.05). Therefore, it can be concluded that the pretest, posttest, and follow-up scores of the abovementioned variable and components significantly differed due to the treatment [ Table 2 ]. However, the component of criticism and blame did not significantly change over time ( P < 0.05). Bonferroni’s post hoc test was run to find the differences. Regarding test and group interaction for emotional divorce and its components ( P < 0.05), a significant difference was found among the pretest, posttest, and follow-up scores of the experimental group and control group.

The group effect was also significant; that is, there was a significant difference between DBT and the control group in terms of the emotional divorce and its components, namely criticism and blame, silence and confrontation, lack of emotional response, lack of emotional interaction, power and resources, limiting, and sexual problems ( P < 0.05). Between the two groups regarding loss, depression and frustration, and the third angle, there was no significant difference ( P < 0.05). The effect sizes (partial eta-squared values) reported in Table 2 (emotional divorce (68%), criticism and blame (33%), silence and confrontation (50%), lack of emotional response (24%), lack of emotional interaction (41%), power and resources (59%), limiting (66%), and sexual problems (32%)) reveal the effect of treatment on emotional divorce and its components.

As shown in Table 3 , emotional divorce and the components of lack of emotional interaction, loss, depression and frustration, the third angle, and sexual problems significantly altered over time ( P < 0.05). Therefore, it can be concluded that the pretest, posttest, and follow-up scores of this variable and its components significantly differed due to the treatment. However, blame and criticism, silence and confrontation, lack of emotional response, power and resources, and limiting did not significantly change over time ( P < 0.05). Bonferroni’s post hoc test was run to find the differences.

The group effect was also significant; that is, there was a significant difference between the aripiprazole group and the control group in terms of the emotional divorce and the components of loss, depression and frustration, and sexual problems ( P < 0.05). There was no significant difference between the two groups regarding blame and criticism, silence and confrontation, lack of emotional response, lack of emotional interaction, power and resources, the third angle, and limiting ( P < 0.05). The effect sizes (partial eta-squared values) reported in Table 3 (emotional divorce (28%), loss, depression, and frustration (24%), and sexual problems (41%)) reveal the effect of aripiprazole on emotional divorce and its components.

The variable of emotional divorce and its components (except for criticism and blame, and power and resources) significantly altered over time ( P < 0.05), and among pretest, posttest, and follow-up scores of the experimental and control groups in this variable and its components (except for power and resources), there was a significant difference [ Table 4 ]. Regarding test and group interaction for emotional divorce and its components ( P < 0.05), the pretest, posttest, and follow-up scores of the two experimental groups were significantly different. Given the group effect and F- and P values, there was a significant difference between the two experimental groups (DBT and aripiprazole) and among the two experimental and control groups in terms of the emotional divorce and its components (except for lack of emotional response, loss, depression and frustration, and third angle) ( P < 0.05).

D ISCUSSION

In explicating the effectiveness of DBT on emotional divorce, it can be stated that DBT at all stages attempts to show the two poles of action to couples in the process of forming emotional divorce and how emotion, thought, or behavior can improve or destroy a relationship. Given the significant and positive relationship between emotional divorce and dysfunctional communication patterns,[ 19 ] couples learn how to communicate effectively, express their wishes, and make simple request in DBT sessions, significantly reducing communication problems. The interpersonal relationships of the couples improve as a result of knowing each other better.

Through mindfulness training, that is, teaching awareness techniques and different mental states, especially the rational mental state, DBT deals with unpleasant thoughts and ineffective communication beliefs, resolves the communication conflict of couples, increases their marital satisfaction, and reduces emotional divorce. Furthermore, negative emotions result from marital conflicts, leading to emotional divorce. By enhancing emotion regulation skills and focusing on techniques, such as observing, describing emotional states, and not having a judgmental viewpoint, DBT makes couples accept negative emotions and express them. Conflicts are reduced when positive emotions increase. Thus, reducing emotional divorce in the DBT group can be related to acquiring these skills.

Aripiprazole is a Food and Drug Administration (FDA)-approved atypical antipsychotic. Studies demonstrated that short-term aripiprazole use reduces irritability, repetitiveness, hyperactivity, and aimless actions (stereotyped behaviors).[ 10 ] Moreover, aripiprazole improves cognitive function, modifies sexual function, and reduces the desire for sex in addicted patients and desire for alcohol.[ 20 ] Therefore, it can be stated that when patients with hypersexuality take aripiprazole, they show less irritability, impulsive behaviors, and less aimless actions and repetition; their cognitive functions improve, and sexual activities moderate, which can compensate for their hypersexuality. The positive changes caused by aripiprazole positively affect the patients and their partners so that they live more hopefully and expect improvements in their marital relations and quality of life, leading to stable relationships.

In a meta-analysis of sexual dysfunction of psychiatric patients taking antipsychotic medications, aripiprazole was associated with a relatively low rate of sexual dysfunction (27%), which was further reduced to zero by restricting the analysis to those studies that controlled for the effect of concomitant medications.[ 21 ] Besides, as a 5-hydroxy-tryptamine (5-HT)2A antagonist, aripiprazole acts on serotonin receptors and is a 5-HT1A partial agonist. Serotonergic transmission can also be related to sexual behaviors. It has been suggested that the antagonizing 5-HT2A and 5-HT2C receptors play a role in sexual arousal.[ 22 ] Antipsychotic drugs, in general, cause a decrease in libido due to dopamine receptor antagonism and increased prolactin levels.

As aripiprazole acts as a partial agonist of dopamine D3 receptors, which play a vital role in reward, stimulating D3 receptors in limbic areas by aripiprazole may cause behavioral changes (sexual impulsive behaviors and sexual hyperactivity) in patients with hypersexuality and their spouses. As a result, the intimate relationships damaged due to this disorder increase, and the emotional divorce rate reduces. Besides, some studies reported that aripiprazole stabilizes and balances individuals’ moods, reduces impulsive and aggressive behaviors of individuals with hypersexuality, and makes them less affected by their sexual impulses;[ 10 , 23 ] as a result, the rate of emotional divorce declines.

Marital relationships face difficulties and threats when couples show their emotions impulsively, or have no insight into their behaviors.[ 5 ] In addition, age-related problems, certain diseases, and hormonal problems in men and women, including hypersexuality, can negatively affect the sexual orientation, or function of couples, and reduce the stability of their lives.[ 15 ] Therefore, couples who undergo psychological treatments, such as DBT, or take psychiatric drugs, such as aripiprazole, rarely report relational, psychological, and especially sexual problems in their marital relationships, especially in the case of patients with hypersexuality. As a result, they experience more emotional stability.

The findings of case studies indicated that aripiprazole could reduce the hypersexuality and sexual impulses of affected patients.[ 10 ] However, there is an increasing number of reports on pathological behavioral changes, including hypersexuality and excessive shopping, associated with dopamine agonists, which occur during the treatment of a dopamine regulation-related disease.[ 23 ] Aripiprazole is known as an antipsychotic or antimanic agent.[ 24 ]

In explaining the effect of aripiprazole on various life problems of patients with hypersexuality, it can stimulate dopamine receptors in specific areas of the brain related to addiction and impulse control, similar to the way dopamine agonists stimulate the same areas. The limbic dopaminergic projection from the ventral tegmental area is involved in addiction and rewarding experiences, such as sex, addictive drugs, and food. The dopamine neurotransmission pattern consists of two different components, phasic and tonic. As aripiprazole with D2 receptors has a high affinity, about 90% of D2 receptors are occupied, and phasic and tonic dopamine transmission is blocked. However, its intrinsic activity and long half-life add to its dopaminergic potency. This unique effect of aripiprazole on dopaminergic transmission may be one of the reasons for reducing and changing the impulsive behaviors of these patients, resulting in the stability of their married life.

Regarding DBT, mindfulness and distress tolerance are “acceptance-oriented components,” and emotional regulation and interpersonal effectiveness are “change-oriented components,” which bring about cognitive and behavioral change.[ 13 ] By developing effective coping mechanisms, DBT skills reduce maladaptive behaviors, and due to affecting the conscious thought pattern of patients with hypersexuality, this treatment corrects their thoughts and actions.[ 14 ] Besides, the behaviors and actions prompted by emotional divorce, for example, anger, sadness, blaming the spouse, and not forgiving the spouse, are associated with a decrease in the dynamics of relationships and an increase in hostile relations between couples. Therefore, each blames the other for emotional divorce, separation, hostility, and violence and has a pessimistic attitude toward their spouse, themselves, and the future.[ 19 ]

DBT positively affects the cognitive regulation of emotions, helps individuals better understand and interpret emotions in interpersonal relationships, and reduces cognitive biases. It helps individuals develop more effective relationships with others and reduces dysfunctional and self-destructive behaviors.[ 25 ] As a result, married people can better understand the emotions and feelings of their spouses and others and replace dysfunctional behaviors and emotions with efficient ones, thereby improving interpersonal and marital relationships.

Consistent with the theory of choice, regulation of negative emotions, self-awareness, and awareness of negative emotions promote responsible behaviors, reduce self-centeredness, and balance the demands. Negative emotions, such as conflict, are reduced due to enhanced emotional recognition and awareness. Accordingly, individuals more realistically resolve their conflicts.[ 26 ] Individuals refrain from engaging in behaviors, such as hurting, blaming, aggressiveness, and extreme arguments; therefore, they find a more positive and pleasant perception of themselves, others, and their marital relationship. Psychotherapy is expected to be more influential than drug therapy due to the training the patients receive.

Reducing physical and sexual vulnerability was one of the major DBT techniques for regulating maladaptive emotions in the current research.[ 14 ] In addition, considering other harmful behaviors, such as sexual promiscuity and dysfunctional interpersonal relationships (such as sexual abuse and emotional exploitation by sexual partners in and out of the family context, substance abuse, eating disorders, depression, homelessness, and long periods of unemployment), emotion regulation training can help clarify the importance of identifying and treating inefficient behaviors, which is one of the DBT aims. Therefore, the DBT effect on some components of emotional divorce was more than aripiprazole for patients with hypersexuality.

The present research findings imply that DBT and aripiprazole can improve mental health and resolve the psychological problems of hypersexual patients. Therefore, urologists, gynecologists, and obstetricians, in cooperation with health psychologists, clinical psychologists, and psychiatrists, can help reduce the mental and physical complications and also side effects of this disease and make it more tolerable for patients. It is noteworthy that this study was conducted in Isfahan, Iran; care should be exercised in generalizing its findings to other similar hospitals, clinics, and research institutes. Last but not least, aripiprazole should be prescribed to prevent the disorder-related problems for those at a high risk of hypersexuality disorder.

Ethics approval and consent to participate

To comply with research ethics, following the principles of ethical character, five sessions of DBT were also conducted for the control group after the test sessions and the follow-up period. It should be noted that this study was presented in the form of a plan in the Research Council Commission for Research Development Management, Research Evaluation and Coordination of Research Centers of Isfahan University of Medical Sciences and was accepted on September 1, 2021, and succeeded in receiving the IR ethical code: MUI.MED. REC.1400.421, Isfahan University of Medical Sciences.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.

R EFERENCES