Marc N. Potenza, MD, PhD

SPECIAL REPORT: CHILD & ADOLESCENT PSYCHIATRY

Spending time watching television, engrossed in a game on a tablet, glued to a gaming console, or messaging friends with a smartphone have become quintessential recreational activities of children and adolescents.

 activity (SMA) consumes about 40% to 60% of after-school time,

 and nearly 97% of US youth have at least 1 electronic item in their bedroom.

 However, SMA is highly diverse and continues to change over time.

 For example, over the past 4 years, the percentage of young individuals who say they watch online videos “every day” has more than doubled from 24% to 56% among 8- to 12-year-olds, and increased from 34% to 69% among 13- to 18-year-olds. Moreover, 70% of boys (aged 8 to 18 years) say they enjoy playing video games “a lot,” compared with 23% of girls aged 8 to 18; while 73% of girls say they enjoy listening to music “a lot,” compared with 59% of boys.

Considerable debate has emerged regarding the relationships between SMA and psychological and social problems.

 symptoms are important aspects of youth mental health that signal the potential emergence or presence of significant psychiatric concerns. Internalizing problems are characterized by withdrawal and may include depression, anxiety, and somatization. Externalizing problems refer to behavioral issues such as impulsiveness, rule-breaking, and aggressiveness.

Reviewing the literature, Zink and colleagues

 reported that some types of SMA were associated with internalizing symptoms but not others, such as watching television. Others reported that 

 was associated with more depressive features, panic symptomatology, delinquent behaviors, and family conflict, and lower levels of family and friend support,

 which is consistent with the observation that using social media for more than 3 hours per day was associated with internalizing problems.

 Greater SMA has been associated with decreased sleep duration, increased sleep onset latency, excessive sleepiness, insomnia, and overall sleep disturbance symptom severity.

 In a recent systematic review of reviews, those individuals who engaged in more SMA, and especially television-related SMA, reported higher energy intake, poor diet, obesity and adiposity, and poorer quality of life (

 In the same review, general SMA was moderately related to 

, except for social media use, which demonstrated a weak association.

Internalizing Symptoms Associated With SMA

At the same time, there was weak evidence for relationships between SMA and behavioral problems, anxiety, hyperactivity, inattention, low self-esteem, poor well-being, and psychosocial health. Authors found that there was insufficient evidence for associations between SMA and eating disorders, suicidal ideation, cardiovascular risk factors, asthma, or pain. The investigators concluded that there is limited (ie, weak) evidence that small amounts of daily screen time are not harmful and may have some benefits.

Supporting Youth: New Findings in Youth Depression and Beyond

Incorporating Well-Being Into Child and Adolescent Psychiatry

Jeff Q. Bostic, MD, EdD; Sean Pustilnik, MD; Alison Neuwirth; and Dominique Charlot-Swilley, PhD

A recent meta-analysis found that while overall SMA was not associated with academic performance, youth reporting more television viewing and gaming had poorer composite academic performance, whereas adolescents viewing more television had lower language and mathematics scores.

 Taken together, these recent studies seem to arrive at conflicting conclusions regarding the effects of SMA on mental or physical health and academic performance. So what is SMA, friend or fiend?

In considering these studies, it is important to step back and ask what we know and how we know it. To date, most research focused on SMA utilizes surveys or cross-sectional study designs, which provide some interesting information but cannot resolve causality or the directionality of relationships. In other words, we do not know whether mental and physical health issues precede and drive SMA-related behaviors, or if SMA behaviors result in mental and physical symptoms. Moreover, SMA among youth is not isolated behaviorally; it occurs in the context of other ongoing activities, experiences, and conflicts, and within a particular scaffold of relationships with family members, peers, and friends.

To truly determine whether SMA leads to any adverse mental health consequences, a controlled trial that randomizes youth into groups allowed to engage in SMA vs those not allowed would be needed. Obviously, such a study is impossible to do ethically and practically. Thus, we rely on data that can only approximate whether SMA is causally related to mental health problems.

The Adolescent Brain Cognitive Development (ABCD) study is a diverse, multisite, multilevel assessment cohort of 11,878 participants aged 9 to 10 years at entry that may provide such insight; the study is now in its 5th year. Given the diverse group of young participants and the longitudinal study design, it is possible to begin to examine the impact of SMA over time. However, the publicly available data are currently providing only a 2-year follow-up window and include participants aged 12 and younger, which limits the inferences one can draw currently about long-term influences of SMA.

Perhaps even more exciting, ABCD participants undergo both structural and functional magnetic resonance imaging, which—for the first time—enables determination of whether SMA affects brain development. The underlying premise is that brain structure and function are highly adaptable and change in response to the types of activities in which individuals engage. Evidence from several recent studies is consistent with the hypothesis that changes in brain structure are correlated across areas with similar function that recapitulate functional networks,

 which has been termed maturational coupling or structural correlation networks (SCNs).

Recent ABCD study data suggest that cortical surface characteristics, such as thickness or gray matter volume in youth, are organized such that they form a SCN and are related to levels of cognitive function.

 We conducted an analysis to determine the relationship between brain structure and SMA.

 The SMA-related latent variables were most strongly associated with visual brain structures, such that those individuals with significant exposure to activities that engage the visual system (television or video watching, 

, and social network activities) showed structural patterns suggestive of greater maturation in the visual system (ie, thinner cortex, reduced volume, and a more complex pattern of changes in sulcal depth). We found little evidence that SMA-related brain structure differences were associated with internalizing pathology (ie, increases in anxiety, depression, or other avoidance or withdrawal behaviors).

On the other hand, those ABCD participants with thinner occipital cortices and smaller orbitofrontal volumes, as well as thinner hippocampi and smaller inferior-temporal cortical volumes, showed greater levels of externalizing psychopathology. Based on our interpretation of these findings, SMA might be problematic for some, but not all youth, and a pattern of inadequate top-down control might be contributing to this association. However, these conclusions are far from certain, and the strictly cross-sectional nature of these analyses does not permit causal inferences. Therefore, more research will be necessary to better link SMA to brain structure or function and to delineate whether such changes are beneficial or problematic.

Given that the behavioral research findings relating SMA to mental health problems are somewhat inconsistent, mostly associative, and at an early stage, what should the take-home message be for the mental health practitioner? First, SMA is an important activity among youth; it is diverse regarding modes and methods of exposure, and technologies enabling SMA are constantly evolving. These changes in use are due in part to individual development and maturation as well as innovations in technology fields. Thus, one should assess the nature and extent of SMA use including 1) television and video watching (eg, streaming), 2) social media and related social networking activities, and 3) gaming (“On a typical day, how much time do you spend…?”). Additionally, many adolescents view pornography,

 with much viewing done on the internet, and the content of pornography on the internet has become more extreme over time.

 Therefore, it is essential that developmentally appropriate inquiries into pornography viewing should be done as part of youth assessment. Changes in SMA use should result in asking specific questions about the reasons and contexts regarding changes in modes, methods, and patterns of use.

Second, while SMA grossly assessed may have small effects on youth, individual impacts can be substantial given differences in types, patterns, and contexts of SMA consumption. Therefore, it is important to assess emotional impact and behavioral changes, and to evaluate whether changes have resulted in problems (“Have you noticed that you feel different after …?”). Although there may be little evidence for the displacement hypothesis (ie, that SMA outcompetes other recreational activities and/or 

 SMA may interfere with other important activities such as school, relationships, and/or recreational activities for some individuals. As a result, gaming disorder has been introduced into the eleventh revision of the ICD-11. Other forms of problematic SMA may be considered as “other specified disorders due to addictive behaviors” in ICD-11.

Third, SMA can also be helpful by providing virtual support, maintaining a social network even during time of physical distancing, and yielding access to information that helps develop coping behaviors in difficult situations or honing skills (“In what way has…been helpful to you?”).

Assessing the evolving landscape between SMA and mental health is becoming increasingly important.

 Taken together, a thoughtful assessment of SMA should be part of a mental assessment as much as any other aspect of social or developmental history. Only then can mental health practitioners make educated decisions about whether SMA is a friend, fiend, or both for their young patients.

is the scientific director and president of the Laureate Institute for Brain Research and a professor in the Department of Psychiatry at the University of California San Diego.

is a professor of psychiatry in the Child Study Center and of Neuroscience; director of the Division of Addictions Research; director of the Center of Excellence in Gambling Research; and director of the Yale Program for Research on Impulsivity and Impulse Control Disorders.

is an assistant professor in the Departments of Psychiatry and Pediatrics at the Icahn School of Medicine at Mount Sinai, New York, New York; and deputy medical director of mental health, Mount Sinai Adolescent Health Center.

1. United Nations. #YouthStats: information and communication technology. Accessed August 30, 2021. 

https://www.un.org/youthenvoy/information-communication-technology/

2. Arundell L, Fletcher E, Salmon J, et al. 

A systematic review of the prevalence of sedentary behavior during the after-school period among children aged 5-18 years.

Screen time and sleep among school-aged children and adolescents: a systematic literature review.

4. Rideout VJ, Robb MB. The Common Sense Census: media use by tweens and teens, 2019. Common Sense Media Incorporated; 2019. Accessed August 30, 2021. 

https://www.commonsensemedia.org/sites/default/files/uploads/research/2019-census-8-to-18-full-report-updated.pdf

Everything in moderation: moderate use of screens unassociated with child behavior problems.

6. Twenge JM, Joiner TE, Rogers ML, Martin GN. 

Increases in depressive symptoms, suicide-related outcomes, and suicide rates among US adolescents after 2010 and links to increased new media screen time.

The Achenbach System of Empirically Based Assessment (ASEBA): Development, Findings, Theory and Applications.

 University of Vermont Research Center for Children, Youth, and Families; 2009.

8. Zink J, Belcher BR, Imm K, Leventhal AM. 

The relationship between screen-based sedentary behaviors and symptoms of depression and anxiety in youth: a systematic review of moderating variables. 

Social media use subgroups differentially predict psychosocial well-being during early adolescence.

10. Riehm KE, Feder KA, Tormohlen KN, et al. 

Associations between time spent using social media and internalizing and externalizing problems among US youth.

11. Hisler GC, Hasler BP, Franzen PL, et al. 

Screen media use and sleep disturbance symptom severity in children.

Effects of screentime on the health and well-being of children and adolescents: a systematic review of reviews.

13. Adelantado-Renau M, Moliner-Urdiales D, Cavero-Redondo I, et al. 

Association between screen media use and academic performance among children and adolescents: a systematic review and meta-analysis.

Structural and maturational covariance in early childhood brain development.

15. Palmer CE, Zhao W, Loughnan R, et al. 

Distinct regionalization patterns of cortical morphology are associated with cognitive performance across different domains.

16. Paulus MP, Squeglia LM, Bagot K, et al. 

Screen media activity and brain structure in youth: evidence for diverse structural correlation networks from the ABCD study.

Prevalence, patterns and self-perceived effects of pornography consumption in Polish university students: a cross-sectional study.

18. Bridges AJ, Wosnitzer R, Scharrer E, et al. 

Aggression and sexual behavior in best-selling pornography videos: a content analysis update.

19. Rothman EF, Kaczmarsky C, Burke N, et al. 

“Without porn ... I wouldn’t know half the things I know now”: a qualitative study of pornography use among a sample of urban, low-income, Black and Hispanic youth.

20. Fritz N, Malic V, Paul B, Zhou Y. Worse than objects: the depiction of Black women and men and their sexual relationship in pornography. 

21. Lees B, Squeglia LM, Breslin FJ, et al. 

Screen media activity does not displace other recreational activities among 9-10 year-old youth: a cross-sectional ABCD study.

22. Brand M, Rumpf HJ, Demetrovics Z, et al. 

Which conditions should be considered as disorders in the International Classification of Diseases (ICD-11) designation of “other specified disorders due to addictive behaviors”?

The Oxford Handbook of Digital Technologies and Mental Health.

Articles

Television, tablets, gaming, phones: how are they impacting child and adolescent mental health? 

Screen Media Activity in Youth: Friend or Fiend?

All other clinicians either will receive a CME Attendance Certificate or may choose any of the types of CE credit being offered.

The goal of this activity is to provide an understanding of problematic pornography use and how it relates to compulsive sexual behavior disorder.

At the end of this CE activity, participants should be able to:

• Discuss the classification of and diagnostic criteria for compulsive sexual behavior disorder;

• Define the potential risk factors for problematic pornography use;

• Identify the proposed psychological and neurobiological mechanisms involved in problematic pornography use;

• Recognize the dichotomy of problematic behavior and moral incongruence.

This continuing medical education activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.

 This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of CME Outfitters, LLC, and 

. CME Outfitters, LLC, is accredited by the ACCME to provide continuing medical education for physicians.

CME Outfitters designates this enduring material for a maximum of 1.5 

™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Note to Nurse Practitioners and Physician Assistants:

 AANPCP and AAPA accept certificates of participation for educational activities certified for 

It is the policy of CME Outfitters, LLC, to ensure independence, balance, objectivity, and scientific rigor and integrity in all of their CME/CE activities. Faculty must disclose to the participants any relationships with commercial companies whose products or devices may be mentioned in faculty presentations, or with the commercial supporter of this CME/CE activity. CME Outfitters, LLC, has evaluated, identified, and attempted to resolve any potential conflicts of interest through a rigorous content validation procedure, use of evidence-based data/research, and a multidisciplinary peer-review process.

The following information is for participant information only. It is not assumed that these relationships will have a negative impact on the presentations.

Matthias Brand, PhD, reports that he has received grants (to University of Duisburg-Essen) from the German Research Foundation (DFG), the German Federal Ministry for Research and Education, the German Federal Ministry for Health, and the European Union; he has performed grant reviews for several agencies; he has edited journal sections and articles; he has given academic lectures in clinical or scientific venues; and has generated books or book chapters for publishers of mental health texts.

Gretchen R. Blycker, LMHC, has no disclosure to report.

Mark N. Potenza, MD, PhD, reports that he receives support from NIH (R01 DA039136, R01 DA042911, R01 DA026437, R03 DA045289, R21 DA042911, and P50 DA09241), the Connecticut Department of Mental Health and Addiction Services, the Connecticut Council on Problem Gambling and the National Center for Responsible Gaming; he has consulted for and advised Rivermend Health, Game Day Data, Addiction Policy Forum, and Opiant Therapeutics; he received research support from the Mohegan Sun Casino and the National Center for Responsible Gaming; he has consulted for or advised legal and gambling entities on issues related to impulse control and addictive behaviors; provided clinical care related to impulse control and addictive behaviors; performed grant reviews; edited journals/journal sections; given academic lectures in grand rounds, CME events and other clinical/scientific venues; and he has generated books or chapters for publishers of mental health texts.

Vernon Rosario, MD, has no disclosures to report.

 staff and CME Outfitters staff have no disclosures to report.

Faculty of this CME/CE activity may include discussion of products or devices that are not currently labeled for use by the FDA. The faculty have been informed of their responsibility to disclose to the audience if they will be discussing off-label or investigational uses (any uses not approved by the FDA) of products or devices. CME Outfitters, LLC, and the faculty do not endorse the use of any product outside of the FDA-labeled indications. Medical professionals should not utilize the procedures, products, or diagnosis techniques discussed during this activity without evaluation of their patient for contraindications or dangers of use.

Although both internet and non-internet pornography may share features, the availability of pornography on the internet has altered consumption patterns, which may have a significant effect on psychiatric and physical health, intimate relationships, and other aspects of functioning. The contributing factors include convenience and perceived anonymity of pornography use on the internet, affordability, accessibility, and the opportunity to escape from reality. Practically speaking, the seemingly endless and diverse sexual material may fit with all sorts of sexual fantasies. The material can be accessed anonymously, irrespective of time and place-this ease of use may become problematic for individuals who have characteristics that put them at increased risk for addiction.

Compulsive sexual behavior disorder (CSBD), including problematic pornography use, is included in ICD-11 as an impulse-control disorder. As such, problematic pornography use may be considered a form of CSBD. Although CSBD is classified as an impulse-control disorder, the diagnostic criteria for the disorder are very similar to those for disorders due to addictive behaviors. A comparison of diagnostic criteria for CSBD and disorders due to addictive behaviors (using gaming disorder as an example) is provided in 

Based on extant data, problematic pornography use may be considered a behavioral addiction. A more detailed discussion of classification and diagnostic procedures can be found in a recent systematic 

of literature related to problematic pornography use.

 Prevalence estimates for CSBD have not been systematically evaluated, but may be roughly between 5% and 12%, with males being twice as likely to experience features of CSBD or related phenomena.

Prevalence estimates are currently imprecise because different scales have been used across studies; moreover, most studies do not distinguish problematic pornography use from other (hyper)sexual behaviors. However, one national 

showed “clinically relevant levels of distress and/or impairment associated with difficulty controlling sexual feelings, urges, and behaviors” in 8.6% of individuals (10.3% of men and 7.0% of women).

 In another report sexual impulsivity was acknowledged by 

 These data suggest that a large proportion of US adults are experiencing clinically relevant features of CSBD.

Problematic internet pornography use can also be a concern in individuals with normal/average socio-sexual behaviors, which means that these individuals have a specific problem in controlling their internet pornography consumption, but not hypersexual behaviors in other domains. It is therefore important to define whether problems related to pornography are only one component of CSBD that may co-exist with compulsive sexual behaviors offline (eg, frequent sexual intercourse with multiple partners, going to prostitutes, anonymous sexual contacts). When making treatment decisions, it is important to consider potentially addictive aspects of the behavior, such as experiencing gratification and cravings (eg, responses to triggers or pornography-related stimuli) as well as impaired control of pornography consumption despite adverse consequences.

Specific socio-demographic variables may represent risk factors for problematic pornography use, with males more likely to be affected. Co-occurring depression, anxiety, and substance-use disorders exist in individuals with problematic pornography use. Another factor that has been linked to problematic pornography use is hypersexuality, which may include high general sexual excitability and high trait sexual motivation.

 These and other potential risk factors are summarized in 

. (For a systematic review of risk factors, please see WÃ©ry and Billieux.

Psychological and neurobiological mechanisms

The psychological and neurobiological mechanisms underlying problematic pornography use show similarities with substance-use disorders as well as gambling and gaming disorders. The mechanisms have been summarized in the updated theoretical Interaction of Person-Affect-Cognition-Execution (I-PACE) model of addictive behaviors.

 Cue-reactivity and craving in combination with reduced inhibitory control, implicit cognitions (eg, approach tendencies), and gratification are linked to pornography use. Furthermore, compensatory mechanisms over time may underlie problematic pornography use and other internet-use behaviors. Neuroscientific studies suggest the involvement of addiction-related brain circuits, including the ventral striatum and other parts of fronto-striatal loops, in the development and maintenance of problematic pornography use.

Problems related to pornography use may involve feelings of moral incongruence related to pornography and may not represent excessive or real addictive use.8 Moral incongruence may be defined as feelings or thoughts related to specific behaviors (eg, using pornography) that are in opposition to one’s core set of beliefs or values. Questions remain whether the processes underlying problematic pornography use as an addictive behavior and problems related to pornography use due to moral incongruence are alike or different.9 ICD-11, however, states in the criteria for CSBD that “distress that is entirely related to moral judgments and disapproval about sexual impulses, urges, or behaviors is not sufficient to meet this [CSBD] requirement.”

For clinical practice, it is important to consider both pornography-related problems in the contexts of compulsive or addictive use and moral incongruence. In working with patients, psychiatrists should examine explicitly patterns of pornography use, diminished control over pornography use, and, importantly, distress and impairment related to pornography use in considering addictive use and moral incongruence.

In treating individuals with problematic pornography use and CSBD, case reports and proof-of-concept studies suggest the efficacy of pharmacological interventions. Drugs targeting dopamine, norepinephrine, serotonin, and opioidergic systems have shown efficacy to varying degrees. An open-label case report indicates that cognitive-behavioral therapy may help reduce pornography consumption. However, in this setting of reduced consumption craving increased, which decreased with 50 mg naltrexone administration daily.

Data from an open-label case series of 20 mg paroxetine daily show that paroxetine treatment was associated with reductions in pornography consumption and anxiety.11 However, new problematic sexual concerns emerged relating to paying for sex or engaging in extra-marital affairs.

Assessing for multiple possible outlets for CSBD is important in treating individuals with problematic pornography use. Furthermore, randomized placebo-controlled clinical trials are needed to demonstrate potential short- and long-term efficacies and tolerabilities of pharmacological interventions, given that many studies of problematic pornography use have methodological limitations.

 Currently there are no medications with an approved Food and Drug Administration indication for CSBD.

Psychotherapeutic options warrant consideration. Cognitive-behavioral therapy and mindfulness-based interventions, perhaps accompanied by acceptance and commitment therapy, may be effective in reducing pornography use and increasing quality of life.

 Systematic studies are scarce, and clinicians should consider treatment motivations and individual goals of those seeking treatment for problematic pornography use. Among male pornography viewers, approximately one in seven has reported interest in seeking treatment for pornography use, and those interested in treatment reported more pornography use and hypersexuality.

These findings are in line with those indicating that slightly more than 80% of men in treatment for hypersexuality have reported problems with pornography use.16 Specific situations or emotional states have been reported to link to perceived difficulties in controlling pornography use (eg, when using the internet and experiencing stress or negative mood states), and decreased self-efficacy in these situations has been linked to pornography use frequency and hypersexuality; as such, they may represent treatment targets in therapy.17 Other treatment options include online forums: NoFap and Reboot Nation were founded to help young males quit pornography viewing, with some men experiencing erectile dysfunction, which they attributed to altered sexual arousal altered resulting from use of pornography.

Systematic studies on the efficacies of prevention and treatment efforts for problematic pornography use are an important topic for future research and practice. Referral to therapists who focus on sexual and relational health may be indicated. Several programs (eg, the American Association of Sexuality Educators, Counselors [AASECT], International Institute for Trauma and Addiction Professionals [IITAP], and Society for the Advancement of Sexual Health [SASH]) provide training and certification for therapists who treat individuals with CSBD and other sexual and relational concerns. However, before making referrals, psychiatrists and other clinicians should identify concerns that are often not disclosed without direct questioning because of shame, guilt, or ambivalence.

Given the high comorbidity of problematic pornography use with depression, anxiety, and other psychological disorders and given that some people feel ashamed of their pornography use, clinicians might overlook problems related to pornography use if they do not ask specific questions. To elicit information from patients, begin by acknowledging the interconnected nature of physical, mental, and sexual health. Since there are individual differences and variability in sexual orientation and expression as well as gender identity and expression, sexual health comprises multiple expressions. The following are some tips for beginning the conversation.

 Ask patients about any potential barriers to healthy sexual expression or experiences as well as potential excessive and risky behaviors, including pornography use.

 Ask patients about impairment related to pornography use, understanding that such impairment may be in relational, occupational, educational, or other domains. In order not to over-pathologize behaviors, it is important to assess functional impairment in everyday life related to pornography use (see ICD-11 criteria for CSBD and those for other disorders such as gaming disorder). The diagnosis is justified only if the pattern of sexual behaviors including pornography use results in significant impairment in personal, family, soci al, educational, occupational, or other important areas of functioning.

 Examine symptom severity of problematic pornography use including impairment, poor control, preoccupation, and continued use despite negative consequences instead of only asking for time and frequency of pornography use. Given that behavioral addictions are not defined by the objective amount of time spent with the behavior, it is important to consider the symptoms and distress and impairment, including those listed in ICD-11 criteria for CSBD.

 Examine potential conflicts between pornography use and moral values. Explore individuals’ personal perspectives and beliefs regarding what promotes their sexual health and support them in a process of their own harm assessment. It is important to distinguish between distress resulting from a conflict between pornography use and moral values and functional impairment due to addictive use of pornography, although these factors are not mutually exclusive.

 Examine individual goals and treatment motivation. Treatment goals may be different (eg, abstinence or reducing the behavior, gaining better control over the behavior, increasing acceptance of the [reduced] behavior). Consider these goals to provide individualized care and optimal treatment.

“Dr Jones” has a 26-year history of problematic pornography use, paying for sex during times of stress as well as untreated compulsive sexual behaviors that damaged trust, led to sexual disconnection, and contributed to a divorce.

In his 30s, Dr Jones sought treatment twice to address his concerns of problematic pornography use, about which he started to feel guilty and wondered whether it was interfering with situational sexual functioning during dyadic sex with his first wife. He met with therapists who minimized his distress and normalized his pornography use. Without his concerns being addressed, the negative consequences became more severe over the next three years.

At age 37 he was compelled to enter into couples therapy with his first wife. However, once again, his compulsive sexual behaviors were not addressed. The treatment represented another missed opportunity for a therapeutic behavioral intervention to address some of the underlying compulsive sexual behaviors that were contributing to the barriers to his sexual and emotional health.

By not identifying and addressing the problems, his treatment providers may have unwittingly enabled his growing denial of compulsive sexual behaviors. He did not take responsibility for his contributions to the sexual problems in the marriage for which he initially blamed his wife. At age 38, he was divorced; he remarried at age 42 to his current wife.

During this current marriage, he continued past patterns of behaviors that directed his sexual energy and attention to secret pornography use despite a commitment to himself and to his wife to stop. Because it was no longer as pleasurable or stimulating as it had been in the past, his use of pornography escalated to continually more extreme sexually explicit content. He engaged in risky sexual behaviors that included viewing pornography during work hours and sexting with a staff member at work, which crossed professional boundaries and resulted in a sexual misconduct violation.

At age 47, after the sexual misconduct violation and the relational and professional consequences he experienced from his compulsive sexual behaviors, Dr Jones entered mindfulness-based treatment for CSBD. He has engaged in this treatment for 1.5 years. The treatment plan included mindfulness-based therapy weekly meetings, attending weekly 12-step Sex and Love Addicts Anonymous (SLAA) meetings, building a relationship with a sponsor, and installing internet accountability software to his digital devices for one year.

Early in therapy, he created a working abstinence list that included identifying and detailing specific problematic behaviors with a comprehensive plan for avoidance of or non-engagement in the identified behaviors. Through self-awareness and mindfulness-based therapy, he integrated healthy boundary-promoting behaviors including a mindful and compassion practice that helped him manage the mental and physical effects of stress. He practiced healthy communication, honesty, and transparency with his wife and family and emotional vulnerability with trusted people. He utilized materials from a mindfulness-based relapse prevention program that included listening to Stop, Observe, Breath, Expand, Respond (SOBER)-breathing and urge-surfing guided meditations.18

Mindful inquiries were also utilized during treatment, which expanded the connection and integration of his mind, body, and emotions.13 Early in treatment when learning to be present while mindfully observing his inner experiences in the moment, he noted that “The thoughts and intense feelings change and go away.” He integrated this practice and habit of being present during his experiences of intense feelings, urges, and cravings, and this strengthened his tolerance of uncomfortable states without acting out to escape them.

He also proactively developed healthy ways to manage stress. Through mindful inquiries, he became aware of the part of himself that felt sad about letting go of the anticipation of engaging in the exhilarating pornography use and other compulsive sexual behaviors that were a part of his escape from stress. He realized that his coping habits of seeking intense excitement were short-term experiences that created more problems and led to growing feelings of shame. Letting go of compulsive sexual behaviors felt less like deprivation or loss when he identified how many healthy pleasures he had been integrating into his life during recovery.

He shared his new insights: “I notice my thoughts seeking to blame others. I see how this enables my feeling powerless and how this leads to feeling resentment.” This awareness allowed him to practice curiosity about this pattern in relational dynamics, and he was able to make positive changes that benefitted him and many of his personal and professional relationships.

Practicing mindful management of sexual desire and expression and exploring practices that contributed to health, balance, and boundaries helped him to change his patterns of seeking to engage in risky or problematic sexual behaviors when he experienced stress or frustration. In addition to reducing problematic and harmful behaviors, he engaged in a process of integrating healthy practices that provided tools to help promote mental and sexual wellness.

Throughout the course of treatment, he experienced more emotional stability, which led to avoiding problematic use of pornography for short-term pleasure at the cost of long-term harm. He is now able to manage healthy boundaries personally and professionally, and he continues on a shared path of exploration of mindful sexual connection with his wife.

 explores examples of the connections between ICD-11 criteria for CSBD and the Case Vignette.

Theoretical considerations and empirical evidence suggest that the psychological and neurobiological mechanisms involved in addictive disorders may apply to problematic pornography use. Systematic studies that address potential treatment strategies are a main area for future research. In addition, disentangling further the potential overlaps and differentiations between problematic pornography use that may or may not co-exist with other forms of CSBD, and other types of dysfunctional use of the internet for sexual purposes (eg, sexting, excessive use of dating apps, Instagram with sexual content) should be addressed in future studies. Such research could provide support for evidence-based prevention and treatment of problematic pornography use.

Post-tests, credit request forms, and activity evaluations must be completed online at 

 (requires free account activation), and participants can print their certificate or statement of credit immediately (80% pass rate required). This Web site supports all browsers except Internet Explorer for Mac. For complete technical requirements and privacy policy, visit 

PLEASE NOTE THAT THE POST-TEST IS AVAILABLE ONLINE ONLY ON THE 20TH OF THE MONTH OF ACTIVITY ISSUE AND FOR 18 MONTHS AFTER.

Dr Brand is Professor, General Psychology: Cognition and Center for Behavioral Addiction Research (CeBAR), University of Duisburg-Essen, and Erwin L. Hahn Institute for Magnetic Resonance Imaging, Essen, Germany. Ms Blycker is a Clinician and Educator, College of Nursing, University of Rhode Island, Kingston, RI, HÃ¤lsosam Therapy, Jamestown, RI, and Department of Psychiatry, Yale University School of Medicine, New Haven, CT. Dr Potenza is Professor, Department of Psychiatry, Yale University School of Medicine, Department of Neuroscience and Child Study Center, Yale University, Connecticut Council on Problem Gambling, Wethersfield, CT, and Connecticut Mental Health Center, New Haven, CT.

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 Blycker GR, Potenza MN. A mindful model of sexual health: A review and implications of the model for the treatment of individuals with compulsive sexual behavior disorder. 

 Crosby JM, Twohig MP. Acceptance and commitment therapy for problematic internet pornography use: a randomized trial. 

 Kraus SW, Martino S, Potenza MN. Clinical characteristics of men interested in seeking treatment for use of pornography. 

This CME activity provides an understanding of problematic pornography use and how it relates to compulsive sexual behavior disorder.

When Pornography Becomes a Problem: Clinical Insights

To differentiate binge eating disorder (BED) from other eating disorders and understand the mechanisms that may put BED into the realm of addiction disorders.

 Recognize the differences between BED and other eating disorders

 Understand how BED relates to addiciton disorders

 Recognize treatment approaches-pharmacological and psychotherapeutic

CME Credit (Physicians): This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of CME Outfitters, LLC, and 

CME Outfitters designates this enduring material for a maximum of 

. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Iris M. Balodis, PhD, has no disclosures to report.

Carlos M. Grilo, PhD, reports that he has received grants and research support from the National Institutes of Health, he is on the speakers bureau of Shire, and he is a consultant for Shire and Sunovion.

Marc N. Potenza, PhD, MD, reports that he is a consultant for Shire, INSYS, and RiverMend Health.

Ashley Gearhardt, PhD (peer/content reviewer), has no disclosures to report.

Obesity has been considered within an addiction framework with the term “food addiction” debated as a potential clinical entity. Certain core addiction characteristics, such as diminished control or loss of control while eating, food cravings, and continued behaviors despite negative consequences, appear pertinent to some patterns of disordered eating. Systematic investigations into neurobiological mechanisms underlying these features are ongoing in an effort to understand potential contributions to different patterns of overeating. It is likely that obesity is the result of multiple factors. Genetics, environment, various overeating behaviors (from excess snacking to overeating of nutrition-poor but calorie-dense foods to binge eating), insufficient lifestyle physical activity, and various metabolic conditions may all contribute in complex ways to obesity.

A central research goal is to define how different etiologies and pathways contribute to the many manifestations of overeating and obesity. Discussing obesity as a unitary disorder may obfuscate research findings that pertain to this complex problem; therefore, our focus is on binge eating disorder (BED).

The notion of food addiction has recently been applied to BED, which is defined by recurrent episodes of consuming unusually large amounts of food. It is important to note that persons with BED experience a subjective sense of loss of control during these episodes, but they do not perform the extreme weight compensatory behaviors that characterize bulimia nervosa. BED is the most prevalent eating disorder; it affects approximately 4% of the US population, occurs across all weight categories, and is strongly associated with severe obesity.

 It is linked with increased risk of psychiatric and medical comorbidities. Moreover, BED exhibits behavioral and psychological dimensions that are distinct from other eating disorders.

Although BED is currently categorized as an eating disorder in DSM-5, distinct parallels are noted in phenomenological/behavioral features between BED and addiction. Recurrent binging episodes, a lack of control, and personal distress/negative social consequences appear as core characteristics across both disorders. Understanding the neural systems underlying these features is particularly important because they contribute significantly to appetite regulation, weight, and treatment response.

Despite the prevalence and clinical impact of BED, functional and structural neuroanatomical studies specifically examining BED are only beginning to emerge. These neuroimaging studies are fundamental for demonstrating structural and functional brain characteristics supporting BED as a condition distinct from other forms of obesity or other forms of disordered eating (eg, anorexia nervosa, bulimia nervosa). In addition, these studies clarify the clinical relevance of specific features.

Given the frequent consumption of highly palatable foods during binge eating episodes, reward processing needs to be considered in BED. Several neuroimaging studies in BED demonstrate increased activity in prefrontal areas while viewing food stimuli.

 Specifically, food cues produce greater activity increases in the ventromedial prefrontal cortex/orbitofrontal cortex in individuals with BED than in healthy, overweight, or bulimic cohorts. This region not only processes multimodal information and encompasses the secondary taste cortex, but it also signals the motivational properties of food and other reinforcers, including drugs.

 Greater activity in the orbitofrontal cortex during food cue exposure relates to higher reward sensitivity, which supports the idea that individuals with BED are hypersensitive to the motivational and rewarding properties of food.

 Structural differences are also observed in persons with BED: gray matter volume differences have been identified in the medial prefrontal regions in these individuals; this is similar to gray matter volume differences detected in substance-dependent populations.

Palatable flavors (as compared with water) also stimulate greater responses in reward neurocircuitry, including the orbitofrontal cortex, insula, and striatum, in compulsive overeaters.

 Specifically, high-calorie foods (eg, chocolate milk) produce stronger connectivity between the ventral striatum and other reward regions, relative to water. Higher binge eating scores relate to stronger ventral striatal connections and provide mechanistic information on how BED features might relate to reward-related learning mechanisms.

A reward system that is hyperresponsive to food/taste cues is consistent with the incentive-sensitization hypothesis in addiction that posits that addiction-related cues stimulate and eventually hijack reward neurocircuitry. A large body of research demonstrates that the striatum (particularly the ventral component including the nucleus accumbens) signals reward anticipation.

 In persons with addictions, the striatum is involved with craving.

 Understanding whether similar parallels in craving occur in BED and how these may be altered across the course of the disorder is important for future directions.

This CME is intended to help differentiate binge eating disorder (BED) from other eating disorders and understand the mechanisms that may put BED into the realm of addiction disorders.

Marc N. Potenza, MD, PhD

Articles

Screen Media Activity in Youth: Friend or Fiend?

When Pornography Becomes a Problem: Clinical Insights

Neurobiological Underpinnings of Obesity and Addiction: A Focus on Binge Eating Disorder and Implications for Treatment

Young Adult Mental Health

Pathological Gambling: A Present Problem From the Past