Brian is an investment banker in his early forties. In graduate school, he first began to visit prostitutes, spend money on phone sex, masturbate compulsively and spend as much as five to 10 hours a day looking at Internet porn. When sexually acting out, he would feel that someone had turned on his brain for the first time. On the net, he would suddenly feel alive. He had energy and felt the euphoria that sexual immersion seductively provides. His mind slowed down; he didn’t need to keep moving.

Since his teens, he had masturbated nearly every night before going to sleep and sometimes once or twice during the day as well. He was shy in school and dated infrequently, partly from his feelings of inadequacy — from the persistent inability to concentrate, multiple failures, disapproval from parents, teachers and peers and the subsequent demoralization that contributed to low self-esteem.

College had been difficult for him. Complex mathematical formulations from his economics courses were tape-recorded while he fantasized about looking under the shirt of the girl who sat next to him. He was chronically late to classes, his dorm was messy and his clothes were disheveled. He seemed to live in another world.

Once on the job, he loved the thrill, excitement and risk of being a trader, but when he had to sit in boardrooms to listen to his bosses talk about strategy, his eyes glazed over and he entered into an “erotic haze.” He would fantasize about the escort he had been with the night before and anticipate getting home after a long day to get on the chat rooms and look at pornography on the internet.

His days were the usual business of forgetting assignments and people’s names, of losing things and being chastised by bosses, as he had been by parents, for being unable to sit still or follow directions. At home, he felt empty, depressed and lonely. He was unable to focus on a book or a movie. He often felt different than others. It was as though others were given a chip at birth that allowed them to remember simple things, to process information accurately, to complete tasks in an orderly fashion, to moderate their impulses and calm their bodies and mind when they wanted to.

But Brian knew he was “different” from them. His girlfriend complained that he interrupted their conversations and that he always put his needs first; he could never finish a task that wasn’t engrossing for him. He would lose his temper over trivial things and he didn’t know why. On the Internet, however, looking at a montage of erotic images, he finally felt not scattered — instead, he felt soothed, whole and unafraid.

However, he soon found himself in poor job performance because of his obsession. He went to a 12-step “S” program and learned to stay away from compulsive sex. He married and got a promotion at work. Time passed as he worked his 12-step program and settled in to marriage. However, the impulse to call an escort or make an erotic phone call never went away.

One day, after two years of abstinence, he ran across an escort in a hotel who offered him her services and he could not think of a reason to refrain. He had realized that his fantasies had taken on a distinct sadomasochist flavor and he had been curious about acting them out with this woman. He had been involved in a deal at work that went wrong and he felt inferior and somewhat ashamed. Memories of shaming and humiliating remarks about his conduct and learning skills from teachers and parents came flooding back, precipitating his masochistic sexual fantasies. His sense of self was completely destabilized.