This CME activity provides an understanding of problematic pornography use and how it relates to compulsive sexual behavior disorder.
Table 1. Comparison of ICD-11 criteria for CSBD, gaming disorder, and the criteria for gaming disorder adopted to pornography-use disorder
Table 2. Potential risk factors for developing problematic pornography use
Table 3. Links between ICD-11 criteria for CSBD and case vignette
Premiere Date: December 20, 2019
Expiration Date: June 20, 2021
This activity offers CE credits for:
1. Physicians (CME)
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.
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 Psychiatric Times. 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 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
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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.
Applicable Psychiatric Times staff and CME Outfitters staff have no disclosures to report.
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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.
Classification and diagnostic criteria
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 Table 1.
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 review of literature related to problematic pornography use.1 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 sample 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).2 In another report sexual impulsivity was acknowledged by 14.7% of individuals (18.9% of men and 10.9% of women).3 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.4 These and other potential risk factors are summarized in Table 2. (For a systematic review of risk factors, please see WÃ©ry and Billieux.5)
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.6 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.7
A role for moral incongruence
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.10
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.12 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.13,14 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.15
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.
Clinical implications and tips
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.
1) Ask patients about any potential barriers to healthy sexual expression or experiences as well as potential excessive and risky behaviors, including pornography use.
2) 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.
3) 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.
4) 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.
5) 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.
Table 3 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.
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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