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Brain Structure and Functional Connectivity Associated With Pornography Consumption
Kühn, S., & Gallinat, J. JAMA psychiatry 71.7 (2014): 827-834.
Importance  Since pornography appeared on the Internet, the accessibility, affordability, and anonymity of consuming visual sexual stimuli have increased andRead More...

Importance  Since pornography appeared on the Internet, the accessibility, affordability, and anonymity of consuming visual sexual stimuli have increased and attracted millions of users. Based on the assumption that pornography consumption bears resemblance with reward-seeking behavior, novelty-seeking behavior, and addictive behavior, we hypothesized alterations of the frontostriatal network in frequent users.

Objective  To determine whether frequent pornography consumption is associated with the frontostriatal network.

Design, Setting, and Participants  In a study conducted at the Max Planck Institute for Human Development in Berlin, Germany, 64 healthy male adults covering a wide range of pornography consumption reported hours of pornography consumption per week. Pornography consumption was associated with neural structure, task-related activation, and functional resting-state connectivity.

Main Outcomes and Measures  Gray matter volume of the brain was measured by voxel-based morphometry and resting state functional connectivity was measured on 3-T magnetic resonance imaging scans.

Results  We found a significant negative association between reported pornography hours per week and gray matter volume in the right caudate (P < .001, corrected for multiple comparisons) as well as with functional activity during a sexual cue–reactivity paradigm in the left putamen (P < .001). Functional connectivity of the right caudate to the left dorsolateral prefrontal cortex was negatively associated with hours of pornography consumption.

Conclusions and Relevance  The negative association of self-reported pornography consumption with the right striatum (caudate) volume, left striatum (putamen) activation during cue reactivity, and lower functional connectivity of the right caudate to the left dorsolateral prefrontal cortex could reflect change in neural plasticity as a consequence of an intense stimulation of the reward system, together with a lower top-down modulation of prefrontal cortical areas. Alternatively, it could be a precondition that makes pornography consumption more rewarding.

Depictions of sexual content in films, music videos, and the Internet have increased in recent years.1 Because the Internet is not subject to regulations, it has emerged as a vehicle for circulation of pornography. Pornographic images are available for consumption in the privacy of one’s home via the Internet rather than in public adult bookstores or movie theaters. Therefore, the accessibility, affordability, and anonymity have attracted a wider audience. Research in the United States has shown that 66% of men and 41% of women consume pornography on a monthly basis. An estimated 50% of all Internet traffic is related to sex. These percentages illustrate that pornography is no longer an issue of minority populations but a mass phenomenon that influences our society. Interestingly, the phenomenon is not restricted to humans; a recent study found that male macaque monkeys gave up juice rewards to watch pictures of female monkeys’ bottoms.

The frequency of pornography consumption has been shown to predict various negative outcome measures in humans. A representative Swedish study on adolescent boys has shown that boys with daily consumption showed more interest in deviant and illegal types of pornography and more frequently reported the wish to actualize what was seen in real life. In partnerships, a decrease in sexual satisfaction and a tendency to adopt pornographic scripts have been associated with frequent Internet pornography consumption. A longitudinal study following Internet users has found that accessing pornography online was predictive of compulsive computer use after 1 year. Taken together, the aforementioned findings support the assumption that pornography has an impact on the behavior and social cognition of its consumers. Therefore, we assume that pornography consumption, even on a nonaddicted level, may have an impact on brain structure and function. However, to our knowledge, the brain correlates associated with frequent pornography consumption have not been investigated so far.

Similar to theories taken from addiction research, it has been speculated in popular science literature that pornography constitutes a prewired, naturally rewarding stimulus and that high levels of exposure result in a downregulation or habituation of the neural response in the reward network. This is assumed to elicit adaptive processes in which the brain is hijacked, becoming less responsive to pornography. There is common agreement that the neural substrates of addiction consist of brain areas that are part of the reward network such as midbrain dopamine neurons, the striatum, and the prefrontal cortex. The striatum is assumed to be involved in habit formation when drug use progresses towards compulsive behavior. The ventral striatum in particular has been shown to be involved in cue-reactivity processing of various drugs of abuse but also in processing of novelty. Compromised prefrontal cortex function is among the major neurobiological modifications discussed in the research on substance abuse disorders common in humans and animals. In studies on pharmacological addiction in humans, volumetric alterations have been shown in the striatum and prefrontal cortex.

Within the present study, we set out to investigate the neural correlates associated with frequent—not necessarily addictive—pornography use in a healthy population to explore whether this common behavior is associated with the structure and function of certain brain regions.

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Technological change and sexual disorder
Keane, H. Addiction 111.12 (2016): 2108-2109.
Commentary to: Should compulsive sexual behavior be considered an addiction? Sexual practices are profoundly influenced and shaped by social change, includingRead More...

Commentary to: Should compulsive sexual behavior be considered an addiction?

Sexual practices are profoundly influenced and shaped by social change, including technological change. The impact of the digital revolution further complicates the classification of sexual behavioir as normal or pathological.

In their final paragraph, Kraus et al. mention the impact technological changes are having on sexual behaviour and the possible implications for the diagnosis of compulsive sexual behaviour (CSB) . This commentary discusses technological change and compulsive sexuality further, linking it to Kraus et al.'s observation about the difficulty of determining the threshold between normal and pathological in relation to sexuality.

Digital technologies have permeated social, economic, political and cultural life, transforming social relations, identities and patterns of production and consumption. Sexual practices and sexual culture have been impacted profoundly by this change, whether through the development of novel forms such as ‘sexting’ or the transformation of existing fields such as pornography and sex work . In the psychological and therapeutic literature on sex addiction, this technological change is interpreted as an escalation and expansion of risk. Cybersex is seen as producing a particularly virulent form of sexual compulsivity, providing new outlets for established addicts as well as tempting people who would not have been exposed previously to addictive forms of sexual imagery and fantasy . Online sexual activity is constituted as unnatural and perverse, a threat to ‘real‐life’ relationships and responsibilities.

However, this account of cybersex ignores the way in which sexuality is shaped by social and cultural forces, including technological change. Individual lived experiences of sexuality cannot be separated from social contexts . What is regarded as normal shifts depending on cultural and historical location, for example behaviour that is now classified as healthy female sexuality, could have attracted a diagnosis of nymphomania before the liberalization which took place in the mid‐20th century .

Contemporary social science research is revealing the way in which online sociability is now part of, rather than in competition with, everyday life, undermining the real/virtual distinction . Sites and apps such as OKcupid, Tinder and Grindr are used by a wide range of people seeking relationships as well as casual encounters . Social media networks are changing patterns of sexual practice, just as earlier technologies such as the contraceptive pill and the car expanded sexual opportunities and altered norms.

As Kraus et al. suggest, issues of validity remain troubling in relation to CSB . The social perspective outlined above suggests that identifying sexual normality and pathology inevitably involves value judgements about forms of desire and relationships. The use of the term ‘risk’ can mask these judgments without necessarily undermining them. For example, is a practice such as ‘multiple sexual partners on one occasion’ inevitably risky, or is it rather constituted as risky because it is non‐normative?

The enormous heterogeneity of sexuality as a realm of experience has always been a challenge to models of sex addiction, as they attempt to incorporate practices ranging from solitary fantasizing to sexual violence into a single diagnostic category . The rise of the internet complicates the diagnosis of individual sexual disorder further because it has produced new possibilities for erotic imagining and sexual consumption. The conceptualization of CSB within the framework of ‘problematic hypersexuality’ exacerbates this problem, as it is unclear how to define what is excessive or ‘hyper’ in relation to sexuality. Kafka mentions a threshold of seven orgasms a week in his model of hypersexual disorder, but it is unclear why this level represents dysfunction . As Wakefield has argued, the availability of stimuli such as internet pornography could well increase the sexual activity of individuals without being associated with pathology . Given the abundance and accessibility of online pornography, what are the parameters of normality in relation to its use? Masturbation might become tied more commonly and routinely to the consumption of images than it has been in the past, but this is not necessarily a sign of increased pathology.

The concept of technological affordance is useful here, as it highlights the way in which new tools can provide users with expanded possibilities for social action, including the construction of new sexual identities and repertoires . This is not to deny that online sexuality can produce harms and predicaments, including problems of excess and compulsivity. Rather, it is to emphasize that technological change alters the sexual landscape in multiple ways. In this kind of dynamic environment, the questions of what counts as good, normal and/or healthy sex and who is authorized to define it become more complex than ever.

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Compulsive sexual behaviour as a behavioural addiction: the impact of the internet and other issues
Griffiths, M. D. Addiction 111.12 (2016): 2107-2108.
The issue of sex addiction as a behavioural addiction has been much debated. However, there is little face validity for co-occurringRead More...

The issue of sex addiction as a behavioural addiction has been much debated. However, there is little face validity for

co-occurring behavioural addictions, and more emphasis is needed on the characteristics of the internet as these may

facilitate problematic sexual behaviour.

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Neuroscience of Internet Pornography Addiction: A Review and Update
Love, T., Laier, C., Brand, M., Hatch, L., & Hajela, R. Behavioral sciences 5.3 (2015): 388-433.
Many recognize that several behaviors potentially affecting the reward circuitry in human brains lead to a loss of control andRead More...

Many recognize that several behaviors potentially affecting the reward circuitry in human brains lead to a loss of control and other symptoms of addiction in at least some individuals. Regarding Internet addiction, neuroscientific research supports the assumption that underlying neural processes are similar to substance addiction. The American Psychiatric Association (APA) has recognized one such Internet related behavior, Internet gaming, as a potential addictive disorder warranting further study, in the 2013 revision of their Diagnostic and Statistical Manual. Other Internet related behaviors, e.g., Internet pornography use, were not covered. Within this review, we give a summary of the concepts proposed underlying addiction and give an overview about neuroscientific studies on Internet addiction and Internet gaming disorder. Moreover, we reviewed available neuroscientific literature on Internet pornography addiction and connect the results to the addiction model. The review leads to the conclusion that Internet pornography addiction fits into the addiction framework and shares similar basic mechanisms with substance addiction. Together with studies on Internet addiction and Internet Gaming Disorder we see strong evidence for considering addictive Internet behaviors as behavioral addiction. Future research needs to address whether or not there are specific differences between substance and behavioral addiction.

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Psychometric development of the Problematic Pornography Use Scale
Kor, A., Zilcha-Mano, S., Fogel, Y. A., Mikulincer, M., Reid, R. C., & Potenza, M. N. Addictive behaviors 39.5 (2014): 861-868.
Despite the increased social acceptance and widespread use of pornography over the past few decades, reliable and valid instruments assessingRead More...

Despite the increased social acceptance and widespread use of pornography over the past few decades, reliable and valid instruments assessing problematic use of pornography are lacking. This paper reports the findings of three studies aimed at developing and validating a new scale measuring problematic pornography use. The Problematic Pornography Use Scale (PPUS) items showed high internal consistency, convergent validity, and construct validity. Exploratory and confirmatory factor analyses revealed four core factors relating to proposed domains of problematic pornography use. High PPUS scores were positively correlated with measures of psychopathology, low self-esteem and poor attachment. Although PPUS scores were related to other behavioral addictions, problematic pornography use as operationalized in the current paper appears to be uniquely distinguished from features of behavioral addictions relating to gambling and Internet use. Findings highlight the potential use of the PPUS for future research and possible clinical applications by defining problematic pornography use as a behavioral addiction.

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Should Hypersexual Disorder be Classified as an Addiction?
Kor, A., Fogel, Y. A., Reid, R. C., & Potenza, M. N. Sexual addiction & compulsivity 20.1-2 (2013): 27-47.
Hypersexual behavior has been documented within clinical and research settings over the past decade. Despite recent research on hypersexuality andRead More...

Hypersexual behavior has been documented within clinical and research settings over the past decade. Despite recent research on hypersexuality and its associated features, many questions remain around how best to define and classify hypersexual behavior. Diagnostic criteria for Hypersexual Disorder (HD) have been proposed for the DSM-5 and a preliminary field trial has lent some support to the reliability and validity of the HD diagnosis. However, debate exists with respect to the extent to which the disorder might be categorized as a non-substance or behavioral addiction. In this article, we will discuss this debate in the context of data citing similarities and differences among hypersexual disorder, drug addictions, and pathological gambling. The authors of this article conclude that despite many similarities between the features of hypersexual behavior and substance-related disorders, the research on HD at this time is in its infancy and much remains to be learned before definitively characterizing HD as an addiction.

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Should compulsive sexual behavior be considered an addiction?
Kraus, S. W., Voon, V., & Potenza, M. N. Addiction, 111(12), 2097-2106.
Aims To review the evidence base for classifying compulsive sexual behavior (CSB) as a non‐substance or ‘behavioral’ addiction. Methods DataRead More...

Aims

To review the evidence base for classifying compulsive sexual behavior (CSB) as a non‐substance or ‘behavioral’ addiction.

Methods

Data from multiple domains (e.g. epidemiological, phenomenological, clinical, biological) are reviewed and considered with respect to data from substance and gambling addictions.

Results

Overlapping features exist between CSB and substance use disorders. Common neurotransmitter systems may contribute to CSB and substance use disorders, and recent neuroimaging studies highlight similarities relating to craving and attentional biases. Similar pharmacological and psychotherapeutic treatments may be applicable to CSB and substance addictions, although considerable gaps in knowledge currently exist.

Conclusions

Despite the growing body of research linking compulsive sexual behavior (CSB) to substance addictions, significant gaps in understanding continue to complicate classification of CSB as an addiction.

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Neurobiology of Compulsive Sexual Behavior: Emerging Science
Kraus, S. W., Voon, V., & Potenza, M. N. Neuropsychopharmacology 41.1 (2016): 385.
Compulsive sexual behavior (CSB) is characterized by craving, impulsivity, social/occupational impairment, and psychiatric comorbidity. Prevalence of CSB is estimated aroundRead More...

Compulsive sexual behavior (CSB) is characterized by craving, impulsivity, social/occupational impairment, and psychiatric comorbidity. Prevalence of CSB is estimated around 3–6%, with a male predominance. Although not included in DSM-5, CSB can be diagnosed in ICD-10 as an impulse-control disorder. However, debate exists about CSB’s classification (eg, as an impulsive-compulsive disorder, a feature of hypersexual disorder, an addiction, or along a continuum of normative sexual behavior).

Preliminary evidence suggests that dopamine may contribute to CSB. In Parkinson’s disease (PD), dopamine replacement therapies (Levo-dopa, dopamine agonists) have been associated with CSB and other impulse-control disorders (Weintraub et al, 2010). A small number of case studies using naltrexone support its effectiveness at reducing urges and behaviors associated with CSB (Raymond et al, 2010), consistent with the possible opioidergic modification of mesolimbic dopamine function in reducing CSB. Currently, larger, adequately powered, neurochemical investigations and medication trials are needed to further understand CSB.

Incentive motivational processes relate to sexual cue reactivity. CSB vsnon-CSB men had greater sex-cue-related activation of the anterior cingulate, ventral striatum, and amygdala (Voon et al, 2014). In CSB subjects, functional connectivity of this network associated with cue-related sexual desire, thus resonating with findings in drug addictions (Voon et al, 2014). 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.

Although recent neuroimaging studies have suggested some possible neurobiological mechanisms of CSB, these results should be treated as tentative given methodological limitations (eg, small sample sizes, cross-sectional designs, solely male subjects, and so on). Current gaps in research exist complicating definitive determination whether CSB is best considered as an addiction or not. Additional research is needed to understand how neurobiological features relate to clinically relevant measures like treatment outcomes for CSB. Classifying CSB as a ‘behavioral addiction’ would have significant implications for policy, prevention and treatment efforts; however, at this time, research is in its infancy. Given some similarities between CSB and drug addictions, interventions effective for addictions may hold promise for CSB, thus providing insight into future research directions to investigate this possibility directly.

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Compulsive sexual behavior: A review of the literature
Derbyshire, K. L., & Grant, J. E. Journal of behavioral addictions 4.2 (2015): 37-43.
Background and aims Compulsive sexual behavior (CSB) is a common disorder featuring repetitive, intrusive and distressing sexual thoughts, urges andRead More...

Compulsive sexual behavior (CSB) is a common disorder featuring repetitive, intrusive and distressing sexual thoughts, urges and behaviors that negatively affect many aspects of an individual’s life. This article reviews the clinical characteristics of CSB, cognitive aspects of the behaviors, and treatment options.

Methods

Results

Conclusions

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Compulsive sexual behaviour disorder in the ICD‐11
Kraus, S. W., Krueger, R. B., Briken, P., First, M. B., Stein, D. J., Kaplan, M. S.,& Reed, G. M. World Psychiatry 17.1 (2018): 109-110.
During the last decade, there has been heated debate regarding whether compulsive sexual behaviour should be classified as a mental/behaviouralRead More...

During the last decade, there has been heated debate regarding whether compulsive sexual behaviour should be classified as a mental/behavioural disorder. Compulsive sexual behaviour disorder has been proposed for inclusion as an impulse control disorder in the ICD‐11. It is characterized by a persistent pattern of failure to control intense, repetitive sexual impulses or urges, resulting in repetitive sexual behaviour over an extended period (e.g., six months or more) that causes marked distress or impairment in personal, family, social, educational, occupational or other important areas of functioning.

The pattern is manifested in one or more of the following: a) engaging in repetitive sexual activities has become a central focus of the person's life to the point of neglecting health and personal care or other interests, activities and responsibilities; b) the person has made numerous unsuccessful efforts to control or significantly reduce repetitive sexual behaviour; c) the person continues to engage in repetitive sexual behaviour despite adverse consequences (e.g., repeated relationship disruption, occupational consequences, negative impact on health); or d) the person continues to engage in repetitive sexual behaviour even when he/she derives little or no satisfaction from it.

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Searching for clarity in muddy water: future considerations for classifying compulsive sexual behavior as an addiction
Kraus, S. W., Voon, V., Kor, A., & Potenza, M. N. Addiction (Abingdon, England) 111.12 (2016): 2113.
Abstract Commentary to: Should compulsive sexual behavior be considered an addiction? The debate about whether to classify compulsive sexual behavior asRead More...

Abstract

Commentary to: Should compulsive sexual behavior be considered an addiction?

The debate about whether to classify compulsive sexual behavior as an addiction continues to evolve. Additional research is needed to clarify the terminology and diagnostic criteria used for classification purposes. Data assessing prevalence and other comorbidities are needed to further policy, prevention, diagnosis, and treatment efforts.

We recently considered evidence for classifying compulsive sexual behavior (CSB) as a non‐substance (behavioral) addiction . Our review found that CSB shared clinical, neurobiological and phenomenological parallels with substance‐use disorders; however, we concluded that more research is needed in order to address current shortcomings.

The responding commentaries highlight important issues regarding classification efforts including the lack of a consensus definition for CSB and disagreement about proposed criteria central to defining CSB . More research should examine which proposed criteria – whether those relating more closely to sexual addiction or hypersexual disorder – accurately reflect CSB in clinical contexts. Although the two diagnostic categories may conceptually differentiate between addiction and excessive drive, the criteria overlap and stress and negative emotionality as triggers apply to both . More research is needed to better understand in CSB how central features of addiction (e.g. tolerance, withdrawal) relate to CSB and its treatment. Additional concerns included improving research methodologies and minimizing possible confounds that may limit generalizability of studies . Although data suggest that other behavioral addictions are comorbid with other psychiatric disorders , additional research is needed to determine the prevalence of co‐occurring disorders with CSB . Co‐occurring behavioral addictions with CSB should be considered, particularly if the behaviors are intertwined (e.g. traveling to resort casinos to engage in sex and gamble). Further, additional research is needed to better understand the prevalence of CSB among the general population.

Additional points were raised regarding the language used to describe CSB, with ‘risky’ or ‘excessive’ terminology being potentially misleading. ‘Excessive’ sex may not be problematic . Instead, sexual behavior leading to significant functional impairment or psychological distress may more likely reflect important clinical hallmarks of CSB. Applying a more objective approach to developing a diagnostic framework for CSB may promote advancement. Objective indicators of distress (e.g. repeated attempts to quit, craving, etc.) rather than frequency of sexual behaviors should be a focus , particularly as frequency of sexual behaviors may not be a strong predictor of CSB

The pathologizing of sexual behaviors falling outside normative standards or ranges and the evolution of sexual practices and societal values over time were also discussed . Notably, changes in usage of digital technologies have altered sexual behaviors, particularly amongst youth and young adults. Internet pornography is thriving, casual sex (‘hook‐up’) websites are widely popular, and social media may act as a sexual conduit for many individuals. These developments are accompanied by many unanswered questions . Future longitudinal research is needed to examine how digital technologies are related to the development and maintenance of CSB over the lifespan.

Although the American Psychiatric Association rejected hypersexual disorder  from DSM‐5, a diagnosis of CSB (excessive sex drive) can be made using ICD‐10 . CSB is also being considered by ICD‐11 , although its ultimate inclusion is not certain. Future research should continue to build knowledge and strengthen a framework for better understanding CSB and translating this information into improved policy, prevention, diagnosis, and treatment efforts to minimize the negative impacts of CSB.

Funding sources

This study was funded by support from the Department of Veterans Affairs, VISN 1 Mental Illness Research Education and Clinical Center, the National Center for Responsible Gaming, and the National Center on Addiction and Substance Abuse. SWK is a full‐time employee of the Department of Veterans Affairs. The content of this manuscript does not necessarily reflect the views of the funding agencies and reflects the views of the authors.

Declaration of interests

The authors report no conflicts of interest with respect to the content of this manuscript. Dr. Potenza has consulted for and advised Ironwood, Lundbeck, INSYS, Shire, RiverMend Health and Opiant/Lakelight Therapuetics; has received research support from Mohegan Sun Casino, the National Center for Responsible Gaming, and Pfizer; has participated in surveys, mailings or telephone consultations related to drug addiction, impulse‐control disorders or other health topics; has consulted for gambling and legal entities on issues related to impulse‐control and addictive disorders; provides clinical care in the Connecticut Department of Mental Health and Addiction Services Problem Gambling Services Program; has performed grant reviews for the National Institutes of Health and other agencies; has edited journals or journal sections; has given academic lectures in grand rounds, CME events and other clinical or scientific venues; and has generated books or book chapters for publishers of mental health texts

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Neurocognitive Mechanisms in Compulsive Sexual Behavior Disorder
Kowalewska, E., Grubbs, J. B., Potenza, M. N., Gola, M., Draps, M., & Kraus, S. W. Current Sexual Health Reports 10.4 (2018): 255-264.
Purpose of Review The current review summarizes the latest findings concerning neurobiological mechanisms of compulsive sexual behavior disorder (CSBD) andRead More...

Purpose of Review

The current review summarizes the latest findings concerning neurobiological mechanisms of compulsive sexual behavior disorder (CSBD) and provides recommendations for future research specific to the diagnostic classification of the condition.

Recent Findings

To date, most neuroimaging research on compulsive sexual behavior has provided evidence of overlapping mechanisms underlying compulsive sexual behavior and non-sexual addictions. Compulsive sexual behavior is associated with altered functioning in brain regions and networks implicated in sensitization, habituation, impulse dyscontrol, and reward processing in patterns like substance, gambling, and gaming addictions. Key brain regions linked to compulsive sexual behavior features include the frontal and temporal cortices, amygdala, and striatum, including the nucleus accumbens.

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.

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Behavioral and Pharmacological Treatment of Compulsive Sexual Behavior/Problematic Hypersexuality
Leppink, E. W., & Grant, J. E. Current Addiction Reports 3.4 (2016): 406-413.
Purpose of the Review The present article summarizes the available evidence to date on the pharmacological and behavioral treatment ofRead More...

Purpose of the Review

The present article summarizes the available evidence to date on the pharmacological and behavioral treatment of compulsive sexual behavior/problematic hypersexuality and provides two case vignettes to illustrate potential approaches to treating different presentations of problematic sexual behavior in patients.

Recent Findings

To date, some evidence supports the use of several medications, such as selective serotonin reuptake inhibitors and naltrexone, as well as certain therapy techniques, including marital therapy, acceptance and commitment therapy, and cognitive behavioral therapy.

Summary

Unfortunately, little controlled research has been conducted or reported on optimal treatments for patients struggling to manage their problematic sexual behavior. Limited evidence for some options has been reported, but additional controlled, blinded research will be necessary to improve the specificity and quality of available care.

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Compulsive sexual behavior: A nonjudgmental approach
Grant, J. E. Current Psychiatry 17.2 (2018): 34-40.
Compulsive sexual behavior (CSB), also referred to as sexual addiction or hypersexuality, is characterized by repetitive and intense preoccupations withRead More...

Compulsive sexual behavior (CSB), also referred to as sexual addiction or hypersexuality, is characterized by repetitive and intense preoccupations with sexual fantasies, urges, and behaviors that are distressing to the individual and/or result in psychosocial impairment. Individuals with CSB often perceive their sexual behavior to be excessive but are unable to control it. CSB can involve fantasies and urges in addition to or in place of the behavior but must cause clinically significant distress and interference in daily life to qualify as a disorder.

Because of the lack of large-scale, population-based epidemiological studies assessing CSB, its true prevalence among adults is unknown. A study of 204 psychiatric inpatients found a current prevalence of 4.4%,  while a university-based survey estimated the prevalence of CSB at approximately 2%.  Others have estimated that the prevalence is between 3% to 6% of adults in the United States,  with males comprising the majority ([greater than or equal to] 80%) of affected individuals.

CSB usually develops during late adolescence/early adulthood, and most who present for treatment are male.  Mood states, including depression, happiness, and loneliness, may trigger CSB. Many individuals report feelings of dissociation while engaging in CSB-related behaviors, whereas others report feeling important, powerful, excited, or gratified.

Why CSB is difficult to diagnose

Although CSB may be common, it usually goes undiagnosed. This potentially problematic behavior often is not diagnosed because of:

* Shame and secrecy. Embarrassment and shame, which are fundamental to CSB, appear to explain, in part, why few patients volunteer information regarding this behavior unless specifically asked.

* Patient lack of knowledge. Patients often do not know that their behavior can be successfully treated.

* Clinician lack of knowledge. Few health care professionals have education or training in CSB. A lack of recognition of CSB also may be due to our limited understanding regarding the limits of sexual normality. In addition, the classification of CSB is unclear and not agreed upon , and moral judgments often are involved in understanding sexual behaviors.

No consensus on diagnostic criteria

Accurately diagnosing CSB is difficult because of a lack of consensus about the diagnostic criteria for the disorder. Christenson et al  developed an early set of criteria for CSB as part of a larger survey of impulse control disorders. They used the following 2 criteria to diagnose CSB: (1) excessive or uncontrolled sexual behavior(s) or sexual thoughts/urges to engage in behavior, and (2) these behaviors or thoughts/urges lead to significant distress, social or occupational impairment, or legal and financial consequences.

During the DSM-5 revision process, a second approach to the diagnostic criteria was proposed for hypersexuality disorder. Under the proposed criteria for hyper-sexuality, a person would meet the diagnosis if [greater than or equal to] 3 of the following were endorsed over a 6-month period: (a) time consumed by sexual fantasies, urges, or behaviors repetitively interferes with other important (non-sexual) goals, activities, and obligations; (b) repetitively engaging in sexual fantasies, urges, or behaviors in response to dysphoric mood states; (c) repetitively engaging in sexual fantasies, urges, or behaviors in response to stressful life events; (d) repetitive but unsuccessful efforts to control or significantly reduce these sexual fantasies, urges, or behaviors; and (e) repetitively engaging in sexual behaviors while disregarding the risk for physical or emotional harm to self or others.

These 2 proposed approaches to diagnosis are somewhat similar. Both suggest that the core underlying issues involve sexual urges or behaviors that are difficult to control and that lead to psychosocial dysfunction. …

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Is excessive sexual behaviour an addictive disorder?
Potenza, M. N., Gola, M., Voon, V., Kor, A., & Kraus, S. W. The Lancet Psychiatry 4.9 (2017): 663-664.
In their Comment in The Lancet Psychiatry, John B Saunders and colleagues  aptly described current debates regarding the consideration and classification ofRead More...

In their Comment in The Lancet Psychiatry, John B Saunders and colleagues  aptly described current debates regarding the consideration and classification of gambling and gaming disorders as addictive disorders, which occurred during the generation of DSM-5  and in anticipation of ICD-11.  Compulsive sexual behaviour disorder is being proposed as an impulse-control disorder for ICD-11.  However, we believe the logic applied by Saunders and colleagues  might also apply to compulsive sexual behaviour disorder. Compulsive sexual behaviour disorder (operationalised as hypersexual disorder) was considered for inclusion in DSM-5 but ultimately excluded, despite the generation of formal criteria and field trial testing.  This exclusion has hindered prevention, research, and treatment efforts, and left clinicians without a formal diagnosis for compulsive sexual behaviour disorder.

Research into the neurobiology of compulsive sexual behaviour disorder has generated findings relating to attentional biases, incentive salience attributions, and brain-based cue reactivity that suggest substantial similarities with addictions.  Compulsive sexual behaviour disorder is being proposed as an impulse-control disorder in ICD-11, consistent with a proposed view that craving, continued engagement despite adverse consequences, compulsive engagement, and diminished control represent core features of impulse-control disorders.  This view might have been appropriate for some DSM-IV impulse-control disorders, specifically pathological gambling. However, these elements have long been considered central to addictions, and in the transition from DSM-IV to DSM-5, the category of Impulse Control Disorders Not Elsewhere Classified was restructured, with pathological gambling renamed and reclassified as an addictive disorder.  At present, the ICD-11 beta draft site lists the impulse-control disorders, and includes compulsive sexual behaviour disorder, pyromania, kleptomania, and intermittent explosive disorder. There are both pros and cons regarding the classification of compulsive sexual behaviour disorder as an impulse-control disorder. On one hand, inclusion of compulsive sexual behaviour disorder in ICD-11 could improve consistency in diagnosis, treatment, and study of individuals with this disorder. On the other hand, classification of compulsive sexual behaviour disorder as an impulse-control disorder as opposed to an addictive disorder might negatively influence treatment and study by limiting treatment availability, treatment training, and research efforts. Compulsive sexual behaviour disorder seems to fit well with non-substance addictive disorders proposed for ICD-11, consistent with the narrower term of sex addiction currently proposed for compulsive sexual behaviour disorder on the ICD-11 draft website.

 We believe that classification of compulsive sexual behaviour disorder as an addictive disorder is consistent with recent data and might benefit clinicians, researchers, and individuals suffering from and personally affected by this disorder.  VV reports grants from the Medical Research Council. MNP reports grants and other support from the National Center for Responsible Gaming and the National Center on Addiction and Substance Abuse. All other authors declare no competing interests.

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