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ICD-11 for Mortality and Morbidity Statistics: 6C72 Compulsive sexual behaviour disorder
Compulsive sexual behaviour disorder is characterized by a persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behaviour. Symptoms may include repetitive sexual activities becoming a central focus of the person’s life to the point of neglecting health and personal care or other interests, activities and responsibilities; numerous unsuccessful efforts to significantly reduce repetitive sexual behaviour; and continued repetitive sexual behaviour despite adverse consequences or deriving little or no satisfaction from it. The pattern of failure to control intense, sexual impulses or urges and resulting repetitive sexual behaviour is manifested over an extended period of time (e.g., 6 months or more), and causes marked distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. Distress that is entirely related to moral judgments and disapproval about sexual impulses, urges, or behaviours is not sufficient to meet this requirement.
Neurocognitive Mechanisms in Compulsive Sexual Behavior Disorder (2018)
SUMMARY: Despite much neuroscience research finding many similarities between CSBD and substance and behavioral addictions, the World Health Organization included CSBD in the ICD-11 as an impulse-control disorder. Although previous research has helped to highlight some underlying mechanisms of the condition, additional investigations are needed to fully understand this phenomenon and resolve classification issues surrounding CSBD. KEY FINDINGS: Due to the associated distress and impairment reported by men and women with CSB, the World Health Organization (WHO) has recommended including compulsive sexual behavior disorder (CSBD) in the forthcoming 11th edition of the International Classification of Diseases. This inclusion should help increase access to treatment for unserved populations, reduce stigma and shame associated with help-seeking, promote concerted research efforts, and increase international attention on this condition. Over the last 20 years, there have been varying definitions used to describe dysregulated sexual behaviors often characterized by excessive engagement in nonparaphilic sexual activities (e.g., frequent casual/anonymous sex and problematic use of pornography). For the current review, we will use the term CSB as an overarching term for describing problematic, excessive sexual behavior.
A Current Understanding of the Behavioral Neuroscience of Compulsive Sexual Behavior Disorder and Problematic Pornography Use (2018)
PURPOSE OF REVIEW: In the recently released eleventh edition of the International Classification of Diseases (ICD-11), compulsive sexual behavior disorder (CSBD) was for the first time included and classified as an impulse control disorder. The present report aims at summarizing the empirical results concerning the neurobiological underpinnings of CSBD, including problematic pornography use. Insight into mechanistic factors underlying CSBD may promote the development of more effective therapeutic interventions for people affected. RECENT FINDINGS: Recent neurobiological studies have revealed that compulsive sexual behaviors are associated with altered processing of sexual material and differences in brain structure and function. SUMMARY: Although few neurobiological studies of CSBD have been conducted to date, existing data suggest neurobiological abnormalities share communalities with other additions such as substance use and gambling disorders. Thus, existing data suggest that its classification may be better suited as a behavioral addiction rather than an impulse-control disorder.
Ventral Striatal Reactivity in Compulsive Sexual Behaviors (2018)
INTRODUCTION: Compulsive Sexual Behaviors (CSB) are a reason to seek treatment. Given this reality, the number of studies on CSB has increased substantially in the last decade and the World Health Organization (WHO) included CSB in its proposal for the upcoming ICD-11. Sixty percent of the neuroimaging studies on CSB published since 2014 aimed to examine similarities and differences between brain mechanisms underlying CSB, gambling disorder, and substance use disorders. One of the crucial brain circuits involved in addiction is the reward system involving the ventral striatum (including nucleus accumbens). There are two distinct theories describing ventral striatal activity in addictions: Incentive Salience Theory (IST) and Reward Deficiency Syndrome (RDS). IST describes increased ventral striatal activations during the anticipation of addiction-related reward, while RDS describes decreased ventral striatal reactivity both during the anticipation of the reward and during the reward processing. Here, we aim to investigate how the findings on ventral striatal reactivity in CSB support each of these two addiction frameworks. For this purpose, we conducted a systematic review of neuroimaging studies on CSB available in Pubmed, EBSCO, and Google Scholar between 2005 and 2018. We found nine relevant research papers. Only four of these studies directly investigated processing of erotic cues and/or rewards and reported findings related to ventral striatum activations. Three of these studies indicate increased ventral striatal reactivity for erotic stimuli, which is consistent with IST and does not support predictions based on RDS. Therefore, the current state of this data suggest that CSB is related to increased ventral striatal reactivity during the anticipation of erotic stimuli. HIGHLIGHTS: Compulsive Sexual Behaviors (CSB) are a reason to seek treatment for both males and females. The most commonly reported symptoms of CSB concern time spent viewing pornography (mainly on the Internet) and excessive masturbation. Other reported types of behaviors include risky casual sexual relations, anonymous sex, and use of paid sexual services.
Online Porn Addiction: What We Know and What We Don’t—A Systematic Review (2019)
ABSTRACT: In the last few years, there has been a wave of articles related to behavioral addictions; some of them have a focus on online pornography addiction. However, despite all efforts, we are still unable to profile when engaging in this behavior becomes pathological. Common problems include: sample bias, the search for diagnostic instrumentals, opposing approximations to the matter, and the fact that this entity may be encompassed inside a greater pathology (i.e., sex addiction) that may present itself with very diverse symptomatology. Behavioral addictions form a largely unexplored field of study, and usually exhibit a problematic consumption model: loss of control, impairment, and risky use. Hypersexual disorder fits this model and may be composed of several sexual behaviors, like problematic use of online pornography (POPU). Online pornography use is on the rise, with a potential for addiction considering the “triple A” influence (accessibility, affordability, anonymity). This problematic use might have adverse effects in sexual development and sexual functioning, especially among the young population. We aim to gather existing knowledge on problematic online pornography use as a pathological entity. Here we try to summarize what we know about this entity and outline some areas worthy of further research. HIGHLIGHTS: The inclusion of this category in the ICD-11 may be a response to the relevance of this issue and attest to its clinical utility, whereas the growing but yet inconclusive data prevents us from properly categorizing it as a mental health disorder. It is believed to provide a better tool (yet in refinement process) for addressing the needs of treatment seeking patients and the possible guilt associated, and also may reflect the ongoing debates regarding the most appropriate classification of CSB and its limited amount of data in some areas. This inclusion could be the first step towards recognizing this issue and expanding on it, one key point being undoubtedly its online pornography subtype.
Compulsive Sexual Behaviour as a Behavioural Addiction: The Impact of the Internet and Other Issues (2016)
This paper provides a commentary to: Should compulsive sexual behavior be considered an addiction? by Kraus et al. HIGHLIGHTS: Arguably the most important development in the field of CSB and sex addiction is how the internet is changing and facilitating CSB. This was not mentioned until the concluding paragraph, yet research into online sex addiction (while comprising a small empirical base) has existed since the late 1990s, including sample sizes of up to almost 10 000 individuals. In fact, there have been recent reviews of empirical data concerning online sex addiction and treatment. These have outlined the many specific features of the internet that may facilitate and stimulate addictive tendencies in relation to sexual behaviour (accessibility, affordability, anonymity, convenience, escape, disinhibition, etc.).
Neurobiology of Compulsive Sexual Behavior: Emerging Science (2016)
HIGHLIGHTS: CSB men further show enhanced attentional bias to pornographic cues, implicating early attentional orienting responses as in addictions (Mechelmans et al, 2014). In CSB vs non-CSB PD patients, exposure to pornographic cues increased activation in the ventral striatum, cingulate and orbitofrontal cortex, linking also to sexual desire (Politis et al, 2013). A small diffusion-tensor-imaging study implicates prefrontal abnormalities in CSB vs non-CSB men (Miner et al, 2009). In contrast, studies in healthy individuals suggest a role for enhanced habituation with excessive use of pornography. In healthy men, increased time spent watching pornography correlated with lower left putaminal activity to pornographic pictures (Kühn and Gallinat, 2014). Lower late-positive-potential activity to pornographic pictures was observed in subjects with problematic pornography use. These findings, while contrasting, are not incompatible. Habituation to picture cues relative to video cues may be enhanced in healthy individuals with excessive use; whereas, CSB subjects with more severe/pathological use may have enhanced cue reactivity.
Promoting educational, classification, treatment, and policy initiatives (2018)
ABSTRACT: Here, we discuss the potential impact of including CSB disorder in ICD-11 for four areas: educational efforts related to CSB (for both clinicians and patients), investigation of underlying mechanisms and subtypes, development of personalized treatment frameworks, and answering socially important questions and advancing important prevention efforts and effective policies. Each of these four areas has their own challenges that should be addressed, and we briefly describe and discuss them. We hope that this information will help continue a dialog and provide a framework for moving forward in this area. HIGHLIGHTS: In an era of unfettered Internet access on mobile devices, such behaviors as pornography use, searching for paid sexual services, and casual sexual encounters (so called hook-ups) appear to have become more prevalent. Everyday common and clinical observations indicate that for some individuals, these new forms of sexual behaviors have become problematic and prompted treatment seeking (Gola, Lewczuk, & Skorko, 2016). Given such cases, terms such as “sex addiction” exist in the mass media and public discussion. However, despite the high social importance and interest in this phenomenon, compulsive sexual behaviors (CSBs) for years have arguably remained at the margin of systematic scientific investigation and psychiatric classification (Kafka, 2014; Kraus, Voon, & Potenza, 2016; Potenza, Gola, Voon, Kor, & Kraus, 2017).
Theories, prevention, and treatment of pornography-use disorder (2019)
INTRODUCTION: Compulsive sexual behavior disorder, including problematic pornography use, has been included in the ICD-11 as impulse control disorder. The diagnostic criteria for this disorder, however, are very similar to the criteria for disorders due to addictive behaviors, for example repetitive sexual activities becoming a central focus of the personʼs life, unsuccessful efforts to significantly reduce repetitive sexual behaviors and continued repetitive sexual behaviors despite experiencing negative consequences (WHO, 2019). Many researchers and clinicians also argue that problematic pornography use can be considered a behavioral addiction. METHODS: Based on theoretical considerations, empirical studies are evaluated considering the question if the main characteristics and processes involved in addictive behaviors can also be observed in problematic pornography use. RESULTS: Cue-reactivity and craving in combination with reduced inhibitory control, implicit cognitions (e.g. approach tendencies) and experiencing gratification and compensation linked to pornography use have been demonstrated in individuals with symptoms of pornography-use disorder. Neuroscientific studies confirm 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. Case reports and proof-of-concept studies suggest the efficacy of pharmacological interventions, for example the opioid antagonist naltrexone, for treating individuals with pornography-use disorder and compulsive sexual behavior disorder. Randomized placebo-controlled clinical trials are needed to demonstrate the potential long-term effects of pharmacological interventions. Systematic studies on the efficacy of prevention methods for problematic pornography use are still missing, but a very important topic for future research and practice. CONCLUSION: Theoretical considerations and empirical evidence suggest that the psychological and neurobiological mechanisms involved in addictive disorders are also valid for pornography-use disorder. Systematic studies addressing potential intervention strategies are one of the main challenges for future research providing data for evidence-based prevention and treatment of pornography-use disorder.
Pornography addiction – a supranormal stimulus considered in the context of neuroplasticity (2013)
ABSTRACT: Addiction has been a divisive term when applied to various compulsive sexual behaviors (CSBs), including obsessive use of pornography. Despite a growing acceptance of the existence of natural or process addictions based on an increased understanding of the function of the mesolimbic dopaminergic reward systems, there has been a reticence to label CSBs as potentially addictive. While pathological gambling (PG) and obesity have received greater attention in functional and behavioral studies, evidence increasingly supports the description of CSBs as an addiction. This evidence is multifaceted and is based on an evolving understanding of the role of the neuronal receptor in addiction-related neuroplasticity, supported by the historical behavioral perspective. This addictive effect may be amplified by the accelerated novelty and the ‘supranormal stimulus’ (a phrase coined by Nikolaas Tinbergen) factor afforded by Internet pornography.
Is Internet Pornography Causing Sexual Dysfunctions? A Review with Clinical Reports (2016)
ABSTRACT: Traditional factors that once explained men’s sexual difficulties appear insufficient to account for the sharp rise in erectile dysfunction, delayed ejaculation, decreased sexual satisfaction, and diminished libido during partnered sex in men under 40. This review (1) considers data from multiple domains, e.g., clinical, biological (addiction/urology), psychological (sexual conditioning), sociological; and (2) presents a series of clinical reports, all with the aim of proposing a possible direction for future research of this phenomenon. Alterations to the brain's motivational system are explored as a possible etiology underlying pornography-related sexual dysfunctions. This review also considers evidence that Internet pornography’s unique properties (limitless novelty, potential for easy escalation to more extreme material, video format, etc.) may be potent enough to condition sexual arousal to aspects of Internet pornography use that do not readily transition to real-life partners, such that sex with desired partners may not register as meeting expectations and arousal declines. Clinical reports suggest that terminating Internet pornography use is sometimes sufficient to reverse negative effects, underscoring the need for extensive investigation using methodologies that have subjects remove the variable of Internet pornography use. In the interim, a simple diagnostic protocol for assessing patients with porn-induced sexual dysfunction is put forth.
The relationship between frequent pornography consumption, behaviours, and sexual preoccupancy among male adolescents in Sweden (2017)
KEY FINDINGS: Frequent users watched hard core pornography and violent pornography to a higher extent. Frequent users were more likely to have engaged in a wider range of sexual activities. Frequent users fantasised about trying sexual activities seen in hard core pornography. Frequent users showed signs of sexual preoccupancy and problematic pornography use.
Lower Psychological Well-Being and Excessive Sexual Interest Predict Symptoms of Compulsive Use of Sexually Explicit Internet Material Among Adolescent Boys (2016)
ABSTRACT: Although a growing body of literature addresses the effects of young people's use of sexually explicit Internet material, research on the compulsive use of this type of online content among adolescents and its associated factors is largely lacking. This study investigated whether factors from three distinct psychosocial domains (i.e., psychological well-being, sexual interests/behaviors, and impulsive-psychopathic personality) predicted symptoms of compulsive use of sexually explicit Internet material among adolescent boys. Links between psychosocial factors and boys' compulsive use symptoms were analyzed both cross-sectionally and longitudinally with compulsive use symptoms measured 6 months later (T2). Data were used from 331 Dutch boys (M age = 15.16 years, range 11-17) who indicated that they used sexually explicit Internet material. The results from negative binomial regression analyses indicated that lower levels of global self-esteem and higher levels of excessive sexual interest concurrently predicted boys' symptoms of compulsive use of sexually explicit Internet material. Longitudinally, higher levels of depressive feelings and, again, excessive sexual interest predicted relative increases in compulsive use symptoms 6 months later. Impulsive and psychopathic personality traits were not uniquely related to boys' symptoms of compulsive use of sexually explicit Internet material. Our findings, while preliminary, suggest that both psychological well-being factors and sexual interests/behaviors are involved in the development of compulsive use of sexually explicit Internet material among adolescent boys. Such knowledge is important for prevention and intervention efforts that target the needs of specific problematic users of sexually explicit Internet material.
Pornographic Picture Processing Interferes with Working Memory Performance (2013)
ABSTRACT: Some individuals report problems during and after Internet sex engagement, such as missing sleep and forgetting appointments, which are associated with negative life consequences. One mechanism potentially leading to these kinds of problems is that sexual arousal during Internet sex might interfere with working memory (WM) capacity, resulting in a neglect of relevant environmental information and therefore disadvantageous decision making. In this study, 28 healthy individuals performed 4 experimental manipulations of a pictorial 4-back WM task with neutral, negative, positive, or pornographic stimuli. Participants also rated 100 pornographic pictures with respect to sexual arousal and indicated masturbation urges previous to and following pornographic picture presentation. Results revealed worse WM performance in the pornographic picture condition of the 4-back task compared with the three remaining picture conditions. Furthermore, hierarchical regression analysis indicated an explanation of variance of the sensitivity in the pornographic picture condition by the subjective rating of the pornographic pictures as well as by a moderation effect of masturbation urges. Results contribute to the view that indicators of sexual arousal due to pornographic picture processing interfere with WM performance. Findings are discussed with respect to Internet sex addiction because WM interference by addiction-related cues is well known from substance dependencies.
Adolescents and web porn: a new era of sexuality (2016)
BACKGROUND: Pornography can affect the lifestyles of adolescents, especially in terms of their sexual habits and porn consumption, and may have a significant influence on their sexual attitudes and behaviors. RESULTS: All young people, on an almost daily basis, have access to Internet. Among those surveyed, 1163 (77.9%) of Internet users admit to the consumption of pornographic material, and of these, 93 (8%) access pornographic websites daily, 686 (59%) boys accessing these sites perceive the consumption of pornography as always stimulating, 255 (21.9%) define it as habitual, 116 (10%) report that it reduces sexual interest towards potential real-life partners, and the remaining 106 (9.1%) report a kind of addiction. In addition, 19% of overall pornography consumers report an abnormal sexual response, while the percentage rose to 25.1% among regular consumers. CONCLUSION: It is necessary to educate web users, especially young users, to a safe and responsible use of the Internet and of its contents. Moreover, public education campaigns should be increased in number and frequency to help improve knowledge of Internet-related sexual issues both by adolescents and by parents.
Addiction and mindfulness; pornography addiction and mindfulness-based therapy (ACT) (2019)
ABSTRACT: Mindfulness, more specifically acceptance and commitment therapy (ACT) may be the most optimal form of therapy to be used in treating problematic pornography use—use that may qualify as addiction, which falls within the realm of sex addiction. ACT would be beneficial to apply in a clinical setting for 1-on-1 therapy, coaching and sexuality workshops using the ACT model. Though some ambiguity exists on whether pornography addiction falls within the realm of sex addiction, there is sufficient theoretical framework to apply addiction identifiers to problematic pornography use, which further has implications to the benefits of using ACT in treating perceived problematic or addictive pornography use.

ACTIVITY GOAL

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

LEARNING OBJECTIVES

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.

TARGET AUDIENCE

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.