Sex : Diagnostic Challenges and New Research Stefanie Carnes, Ph.D., CSAT-S Clinical Sexologist AAMFT Approved Supervisor

Is Sex an Addiction?

 DSM III-R contained a category called "non- paraphilic "  Various authors have argued for different terms  - "Compulsive" (OCD, Coleman, 2003)  -"Addictive" (Carnes, 1983)  - "Impulsive" (Barth and Kinder, 1987)  -"Hypersexual" (Stein et al., 2000, Reid/ Kafka)  Criteria across these different conceptualizations are similar  Is not in DSM-5  ICD – 11 includes sexual compulsivity under impulse control disorders

1 World Psychiatry – WHO Committee April 2018

 Currently, there is an active scientific discussion about whether compulsive sexual behaviour disorder can constitute the manifestation of a behavioural addiction. For ICD-11, a relatively conservative position has been recommended, recognizing that we do not yet have definitive information on whether the processes involved in the development and maintenance of the disorder are equivalent to those observed in substance use disorders, gambling and gaming. For this reason, compulsive sexual behaviour disorder is not included in the ICD-11 grouping of disorders due to substance use and addictive behaviours, but rather in that of impulse control disorders. The understanding of compulsive sexual behaviour disorder will evolve as research elucidates the phenomenology and neurobiological underpinnings of the condition.

2 American Society of

 “Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.”  “Addiction also affects neurotransmission and interactions between cortical and hippocampal circuits and brain reward structures, such that the memory of previous exposures to rewards (such as food, sex, and other drugs) leads to a biological and behavioral response to external cues, in turn triggering craving and/or engagement in addictive behaviors.”  4 years – 80 neuroscientists

Taken from: http://www.asam.org/advocacy/find-a-policy-statement/view-policy-statement/public-policy- statements/2011/12/15/the-definition-of-addiction on 9/25/12

3 Sex Addiction Defined

A pathological relationship to a mood altering experience (sex) that the individual continues to engage in despite adverse consequences.

Addiction Criteria

4 Loss of Control

Clear Behavior in which you do more than you intend or want.

Compulsive Behavior

A pattern of out of control behavior over time.

5 Efforts to Stop

Repeated specific attempts to stop the behavior which fail.

Loss of Time

Significant amounts of time lost doing and/or recovering from the behavior

6 Preoccupation

Obsessing about or because of the behavior

Inability to Fulfill Obligations

The behavior interferes with work, school, family, and friends.

7 Continuation Despite Consequences

Failure to stop the behavior even though you have problems because of it (social, legal, financial, physical, work.)

Escalation

Need to make the behavior more intense, more frequent, or more risky.

8 Losses

Losing, limiting, or sacrificing valued parts of life such as hobbies, family, relationships, and work

Withdrawal

Stopping behavior causes considerable distress, anxiety, restlessness, irritability, or physical discomfort

9 Addiction Criteria

 Tolerance

 Withdrawal

DSM-5 Field Study Report for Hypersexual Disorder

10 DSM-5 Hypersexual Disorder Field Trial Report

 Reid et al. (2012) conducted a field study to investigate the “clinical utility, reliability and validity of diagnostic validity of [hypersexual disorder (HD)] criteria in clinical settings” for possible inclusion in the DSM-5.  Also explored proposed HD specifiers and their consequences  Sexual behavior with consenting adults, , telephone sex and going to strip clubs  Examined the clinical course of HD  Goal was to examine the inter-rater reliability of clinicians attempting to diagnose HD.

Reid, R. , Carpenter, B.N., Hook, J.N., Garos, S., Manning, J.C., Gilliand, R., Cooper, E.B., McKittrick, H., Davitan, M., & Fong, T. (2012). Report of findings in a DSM-5 Field Trial for Hypersexual Disorder. Journal of Sexual Medicine, 9, 2868-2877. DOI: 10.111/j.1743-6109.2012-02936.x

DSM-5 Proposed Criteria for Hypersexual Disorder (Reid et al. (2012)

11 Method

 Included 13 raters from a variety of fields (psychiatry, psychology, social work, marriage and family therapy, etc) practicing in outpatient settings  Participants completed the Mini-International Neuropsychiatric Interview (MINI 6.0) a structured diagnostic interview at intake to rule out any other psychopathology that could account for HD symptoms  They also completed the HD Diagnostic Clinical Interview, the HD Questionnaire (HDQ), the HD Course Questionnaire (HDCQ), Hypersexual Behavior Inventory (HBI); Sexual Compulsivity Scale (SCS), NEO Personality Inventory-Revised (NEO-PI-R), the Hypersexual Behavior Consequences (HBCS) and the Erotic Preferences Examination Scheme (EPES)

Procedures

 Raters were trained on how to complete the structured diagnostic interviews correctly and to assess for the proposed HD criteria

 One rater completed and scored the initial interviews of the MINI 6.0 and HD-DCI and another rater scored it as well  A third rater blind to the initial ratings administered and scored the HD-DCI two weeks later

12 Results

 Inter-rater reliability: kappa coefficient of .93 among the clinicians  Indicates the diagnostic criteria can be reliably used in patients  Test-Retest Reliability: “high” for the HD criteria after the two week follow-up (ϕ=.81, p<0.001)  Suggests reliability of the diagnostic criteria over time  Sensitivity=.88, Specificity=.93, Positive Predictive Power=.97, Negative Predictive Power=.74  Results suggested the proposed HD criteria reflected the presenting problems well.  Specifiers for HD: (81.1%) (78.3%), (7.9%), Cybersex (18.1%), Strip Clubs (9.4%), Sex with Consenting Adults (44.9%)  Diagnostic Validity of HD criteria  High Concurrent Validity-HDQ scores were highly correlated with HBI (r=.911) and SCS scores (r=.829)

Results Continued

 Concurrent Validity  Participants reporting having sex while experiencing negative emotions had higher Neuroticism scores on the NEO-PI-R.  There was a significant positive correlation between the number of consequences people reported as a result of their sexual behaviors and higher levels of hypersexual behaviors.  Clinical Course: 54% of participants reported “dysregulated sexual fantasies, urges and behaviors prior to adulthood,” 30% indicated these issues started in their college years.  82% endorsed a gradual progression of HD symptoms lasting months to years  48.6% reported a continuous course, while 51.4% reported episodic symptoms

13 Conclusions

 The researchers suggested the proposed HD diagnostic criteria could be reliably applied to people presenting with hypersexual behaviors and was measuring a valid construct

 However, HD was not ultimately included in the DSM-5.

Why Wasn’t HD Included in the DSM-5?

Reid and Kafka (2014) posited a number of reasons why Hypersexual Disorder was not included in the DSM-5

14 Politics

 Previous DSM editors openly criticized the DSM-5 Task Force and Workgroups before its publication

 Some members of the Sexual and Gender Identity Disorders DSM-5 Task Force Committee were specifically targeted in the media

 Some contended the HD diagnosis “confused social disapproval and morality with issues of health and disorder” (Wakefield, 2012)

Reid, R.C. & Kafka, M.P. (2014). Controversies about Hypersexual Disorder and the DSM- 5. Current Sexual Health Reports, 6, 259-264. DOI:10.1007/s11930-014-0031-9

Potential Legal Implications & Problems

 Concerns about potential misuse in the forensic community  For example, using an HD diagnosis as mitigating factor in cases of child molestation  No evidence a pedophilia diagnosis has ever resulted in a reduced sentence

 Authors note a recent field study of HD diagnosis in sex offenders resulted in very few diagnoses of HD

15 Criticisms of the Diagnostic Criteria

 Belief that the diagnostic criteria did not differentiate between high sex drives and pathological levels and activities

 Reid and Kafka suggested individual criterion were “dissected” and rejected while neglecting the fact that a constellation of at least four of the five symptoms over 6 months would need to be present for a diagnosis

 Some argued hypersexual behaviors could be better accounted for by another already existing psychological disorder

Pathologizing Normal behavior?

 Some researchers and clinicians argue hypersexual behaviors are simply variants of normal sexual behavior that an HD diagnosis is pathologizing

 There are also concerns regarding increasing the number of people diagnosed with a mental illness, the number of false positives and the number of people on unnecessary psychotropic medications

16 Insufficient Empirical Research on HD

 Concerns about adding new disorders without sufficient scientific research

 There is a definite lack of epidemiological studies

 More studies with objective data (“e.g., genetic abnormality, deficits in brain function, etc) are needed as well

ICD DX – Considers the criticisms

 Early critics were concerned that any formal diagnosis would be used to pathologise sexual minorities and alternative sexual practices. However, to meet the diagnostic criteria for CSBD, the problematic behavior must cause persistent marked distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. In other words, the new diagnosis doesn’t diagnose patients based on what sexual behavior they freely engage in. It diagnoses patients based on persistent impairment and distress. If sexual behavior, whatever form it takes, results in neither, the new diagnosis will not apply.

17 ICD DX – Considers the criticisms

 Other critics warned that a CSBD diagnosis might result in mistaken diagnosis by patients whose behavior was not, in fact, compulsive, and whose distress was due to moral judgment by patient or professional. To prevent such outcomes, the new diagnosis provides that, “Distress that is entirely related to moral judgments and disapproval about sexual impulses, urges, or behaviours is not sufficient.” In other words, a patient must actually be unable to control impulses and be engaging in repetitive sexual behavior that has become problematic.

Diagnosis

18 Appropriate Diagnostic Categories

 DSM-5 also lists ‘other specified ’ as F52.8 [13]. This diagnosis may thus be used for hypersexual disorder.

 Krueger, R (2016) Society for the Study of Addiction. http://onlinelibrary.wiley.com/doi/10.1111/add.1 3366/full

 The recommended code for the ICD 11 index is 6C72 - “Compulsive Sexual Behavior Disorder”

Differential Diagnosis

 DSM-5 - Possibilities:  Other Specified Sexual Dysfunction  Other Specified Disruptive, Impulse Control and Conduct Disorder  Unspecified Paraphilic Disorder

 Common Co-morbidities:  Antisocial / Narcissistic personality disorder  Paraphilia  ADHD  Bipolar affective disorder  PTSD  Substance induced disorder  OCD  Delirium, dementia, or other cognitive disorder or organic condition

19 Just because someone has had affairs, used prostitutes, attended a strip club, uses porn recreationally…does not mean they are a sex addict… It is just as important to determine who is NOT a sex addict as it is to determine who is.

Differential Diagnosis Continued

 Carpenter et al. (2013) found that 92% of their sample of men seeking treatment for Hypersexual Disorder (HD) screened positive for potential Personality Disorders when using the SCID-II Personality Questionnaire  However, only 17% of the sample met full criteria for a Personality Disorder when assessed with the SCID-II Structured Interview  Suggests people with HD may have some pathological personality traits but do not have a diagnosable Personality Disorder

Carpenter, B.N., Reid, R.C., Garos, S. & Najavits, L.M. (2013). Personality Disorder comorbidity in treatment-seeking men with Hypersexual Disorder. Sexual Addiction & Compulsivity, 20, 79- 90. DOI: 10.1080/10720162.2013.772873

20 Results

Students screening positive on the SAST-R are twice as likely to screen positive for ADHD than students who do not screen positive on the SAST-R.

Results

Students screening positive on the ASRS V1.1 are twice as likely to screen positive for Sexual Addiction than students who do not screen positive on the ASRS V1.1.

21 Empirical Identification of Psychological Symptom Subgroups of Sex Addicts: An Application of Latent Profile Analysis (Nino De Guzman et al. 2015)

 There is a sizeable group (38%) of sex addicts that probably do not have other comorbid disorders (Class 1 and 2).

 This provides further evidence for the existence of sex addiction as a discrete disorder, as opposed to merely being symptomatic of other psychological disorders.

 At the same time, about 24% of the sample (Class 4 and Class 5) likely do have other diagnosable conditions (i.e., mood disorders and anxiety disorders), and thus highlights the importance of broad-band psychological assessment to facilitate treatment planning for sex addicts.

Differential Diagnosis Continued

 Typical Sex Addicts

 -High shame

 - Emotional and sexual abuse in background

 - Highly sexualized (lots of preoccupation)

 - Multi-addicted

 - Less defenses

 - High potential for suicide

 - Increased amenability for treatment

22 Paraphilias are not always Sex Addiction

 DSM-5 Paraphilias include: exhibitionism, fetishism, frotteurism, pedophilia, sexual masochism, sexual sadism, voyeurism, and transvestic fetishism.  In DSM -5– new definition must include “psychological distress” or “distress, injury or death of unwilling persons – or those not of legal age”

Clemente et al. 2017 – Prevalence of paraphilic thoughts and behaviors and sex addiction in a sample of people who use drugs

 RESULTS:  The sample comprised 134 persons who use drug, predominantly men (76.1%), 39.6% were aged between 18 and 29 years, and 54.9% were single. Most were persons who use polydrug, 73.9% were alcohol and cocaine users, 63.4% marijuana users, 81.1% tobacco users, and 5.2% steroid users. Prevalence of paraphilic thoughts/behaviors (including paraphilic disorders) with and without sexual addiction was 47%. Paraphilic and nonparaphilic thoughts/behaviors were associated to the presence of childhood physical neglect, low educational level, heterosexuality and youth.  CONCLUSIONS:  The high prevalence of paraphilic thoughts/behaviors with or without sex addiction in persons who use drugs may be related to the experience of physical and emotional neglect during childhood and this possibility should routinely be investigated in clinical practice

23 Overlap of Sex Addiction and Paraphilic Thoughts and Behaviors

Sex Addiction Sex AddictionWith Paraphilic Paraphilia Thoughts and Behaviors

Sex offending

 Research shows that about 10 % - 30 % of sex offenders are sex addicts  Sex offending is a legal term – must be adjudicated in the legal system  Most common sex crimes – lewd conduct, sexual assault, sexual battery, statutory rape, rape, child enticement and endangerment, child sexual abuse  Includes a victim/ exploitation/ lack of consent  Prostitution – is a sex crime, but in most states does not require registration as a sex offender  Sometimes clients with offending history may be recommended to participate in offender treatment if indicated

24 Recent Headlines…

Abuse of power

 Politicians

 Media Moguls

 Sports Figures

 Religious Leaders

 CEOs, Business Executives

 Specialized Knowledge

 Extremely Wealthy

25 Paulhus & Williams, 2002

26 Poor prognostic indicators

 Dark Triad Personality Characteristics

 Forced or coerced into treatment

 Lacking remorse, shame and empathy

 History of other types of offenses – or assaultive violent tendencies

 Other types of unethical behavior

 History of other types of impulsive behaviors

 Lack of openness, lots of defenses

 Evasion of consequences

Prevalence and Etiology

27 Prevalence – Grant 2018

 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%,1 while a university-based survey estimated the prevalence of CSB at approximately 2%.2 Others have estimated that the prevalence is between 3% to 6% of adults in the United States,3,4 with males comprising the majority (≥80%) of affected individuals.5

Etiology

 Trauma and abuse

 Biology/ Neuroscience/ Sexual Conditioning

 Family Dynamics/ Attachment

28 Trauma

Trauma and Abuse History

 Most came from families were abuse and trauma were present.

 72% experienced physical abuse

 81% experienced sexual abuse

 97% experienced emotional abuse

 In addition, they came from families where shame was present.

29  “CSB (Compulsive Sexual Behavior) has been strongly linked to early childhood trauma or abuse, highly restricted environments regarding sexuality, dysfunctional attitudes about sex and intimacy, low self-esteem, anxiety, and depression.”

Coleman, E. (1992). Is your patient suffering from compulsive sexual behavior? Psychiatric Annals , 22(6), 320-325.

 “Sexual addiction is strongly anchored in shame and trauma. Research conducted over the last fifteen years has consistently shown the prevalence of emotional, physical, and sexual abuse in this population.”

Cox, R. P., & Howard, M. D. (2007). Utilization of EMDR in the treatment of sexual addiction: A case study. Sexual Addiction & Compulsivity, 14(1), 1-20. doi: 10.1080/10720160601011299

30  Recent Study (2012) found 39% of gay and bisexual men with compulsive sexual behavior had experienced childhood sexual abuse  These findings are “largely consistent with previously studied self-identified community samples of individuals with CSB (Black et al., 1997; Kafka & Prentky, 1992)  This finding is in line with Briere and Runtz’s (1990) report that childhood sexual abuse was uniquely associated with maladaptive sexual behavior, and with previous literature supporting childhood sexual abuse as a possible etiological factor in CSB development (Perera et al., 2009) (p.419).” Blain, L. M., Muench, F., Morgenstern, J., & Parsons, J. T. (2012). Exploring the role of child sexual abuse and posttraumatic stress disorder symptoms in gay and bisexual men reporting compulsive sexual behavior. Child Abuse & Neglect, 36(5), 413-422.

Sex addicts have dysfunctional stress circuits

 This study found that sex addicts have dysfunctional stress systems - a key neuro-endocrine change caused by addiction. The current study found epigenetic changes on genes central to the human stress response and closely associated with addiction. With epigenetic changes, The DNA sequence isn’t altered (as happens with a mutation). Instead, the gene is tagged and its expression is turned up or down. The epigenetic changes reported in this study resulted in altered CRF gene activity. CRF is a neurotransmitter and hormone that drives addictive behaviors such as cravings, and is a major player in many of the withdrawal symptoms experienced in connection with substance and behavioral , including porn addiction.

 Andreas Chatzittofis, Stefan Arver, Katarina Öberg, Jonas Hallberg, Peter Nordström, Jussi Jokinen. HPA axis dysregulation in men with hypersexual disorder. Psychoneuroendocrinology, 2016; 63: 247 DOI:

31 Neuroscience & Sexual Conditioning

Brain Regions Involved in Addiction

Mesolimbic Dopamine (DA) Pathway:

 Connects the ventral tegmental area to the nucleus accumbens (NAc)

 “Reward Center” tied to pleasure, learning & impulsivity Amygdala:

 Positive & negative emotional memory Hippocampus:

 Processing & retrieval of long-term memories Prefrontal Cortex:

 Coordinates & determines judgment & behavior

32 Evolutionary Function of

 Mesolimbic Dopamine Pathway is activated by salient survival-based stimuli (sex, food, nurturing, etc.).

 This system evolved to reward and encourage the organism to seek out activities necessary for survival.

Addiction in the brain

Evolutionary Adaptive System Hijacked

33 How does Dopamine Down Regulation Work?

Learning, Memory & Motivation “Wanting”

 Dopamine interacts with glutamate to produce a hyper-excitable state that enhances the responsiveness of the mesolimbic dopamine reward system.

 Hippocampus records memories of intense reward.

 Amygdala records memories of environmental cues associated with the intense reward.

 Brain mistakenly treats the highly rewarding substance or behavior as necessary for survival, reducing “top down” , increasing impulsivity and motivating further action to seek out the source of pleasure.

34 Tolerance Reduces “Liking”

 Repeated use over time leads to over-stimulation of the dopamine reward system.

 To maintain homeostatic balance, the brain eventually down- regulates dopamine receptor availability in the striatum, producing an altered set point for pleasure.

 Substance or behavior no longer produces the intense pleasure that it did originally (tolerance).

 Other "normal" sources of pleasure don't produce a noticeable impact on the down-regulated reward system, leaving the individual feeling anxious, depressed, dysphoric & irritable (withdrawal).

Dopamine’s Normal Action

Based on Time, May 5, 1997

1. After being released into the synapse (the gap between nerve endings and receiver cells), dopamine binds to receptors on the next neuron 2. The dopamine is either quickly reabsorbed or broken down by the enzyme monoamine oxidase (MAO)

35 How Drugs Affect Dopamine Levels

Based on Time, May 5, 1997

Cocaine blocks Amphetamin the normal es stimulate stimulates the absorption of excess release release of dopamine. As a of dopamine, dopamine, result, overwhelmin while another dopamine g the substance in accumulates in processes of cigarette smoke the synapse, reuptake and blocks the where is enzyme action of MAO. stimulates the breakdown. receiver cell.

Dopamine Down-Regulation is a Well-Established Finding in Addiction Research

36 Nucleus Accumbens—Brain’s Reward Center

Red indicates high number of receptors Normal Obese for dopamine

Hans Breiter, director of the Motivation and Emotion Neuroscience Center at Massachusetts General Hospital Alcoholic Cocaine

People short of dopamine have difficulty feeling joy.

 “An orgasm is the primary natural blast of dopamine available to all of us. Accordingly, J.R. Georgiadis (2006) scanned the brains of people having orgasm. He said they resembled scans of heroin rushes. These individuals experienced one of the most addictive substance ever produced: dopamine. Orgasms and addictive substances or behaviors have two things in common. They produce an initial pleasurable experience, and both are followed by neurochemical fluctuations that appear to continue for a week or two (p.137).”

Blum, K., Chen, A., Giordano, J., Borsten, J., Chen, T., Hauser, M., Simpatico, T., Femino, J., Braverman, E. R., & Barh, D. (2012). The addictive brain: All roads lead to dopamine. Journal of Psychoactive Drugs, 44 (2), 134– 143. DOI: 10.1080/02791072.2012.685407

37 Effects of Drugs on Dopamine Levels

Accumbens 1100 Accumbens COCAINE 1000 400 900 800 DA DA 300 700 DOPAC DOPAC HVA 600 HVA 500 200 400 % of Basal Release

300 Release Basal % of 200 100 100 0 001122334455 hr 0 001122334455 hr Time After Amphetamine Time After Cocaine

250 250 NICOTINE Accumbens ETHANOL

200 Accumbens 200 Dose (g/kg ip) Caudate 0.25 150 0.5 1 150 2.5 100 % of Basal Release

% of Basal Release 100 0 00112233 hr 0 0 1 2 3 4hr Time After Nicotine Time After Ethanol Source: Di Chiara and Imperato

Natural Rewards Elevate Dopamine Levels

FOOD SEX 200 200 NAc shell

150 150

100 Copulation Frequency 100 15

Empty 10 50 Box Feeding DA Concentration (% Baseline) (% DA Concentration % of Basal DA Output of Basal % 5

0 0 006060120 180 Scr Scr Scr Scr BasFemale 1 Present Female 2 Present Time (min) Sample 1122334455667788 99101011 12 13 14 15 16 17 Number Mounts Intromissions Ejaculations

Source: Di Chiara et al. Source: Fiorino and Phillips

38 Koob: “The dark side of addiction”

 When the reward center can no longer be returned to it’s homeostatic set point it enters an “allostatic” state

 Reward system has an altered set point

 Leaves the individual susceptible to dependence and relapse

 Withdrawal is not about the physiological effects of a specific substance – it is the negative affect resulting from this allostatic state

Cue-Induced Craving & “Wanting” Persist

 Now the drug or behavior produces less pleasure than before (and MORE negative consequences).

 But the hippocampus and amygdala stored strong memories of reward and produce intense conditioned cravings to environmental cues.

 Inaccurate encoding of negative consequences leaves “wanting” in tact.

39 Intense Persistent Cue Conditioned Cravings Increased Impulsivity / Reduced Inhibitory Control Hyper-sensitized Anticipation of Reward Reduced Experience of Consummatory Reward Dysphoric Mood States in Withdrawal + Inaccurate Encoding of Negative Consequences ______= Addicted Response I WANT MORE!!!

Dr. David Linden – Professor of Neuroscience, John Hopkins School of Medicine

 "The truth is that just liking sex a lot doesn't make you a sex addict, and just cheating or engaging with prostitutes or other anti-social behavior doesn't make you a sex addict. If you are a sex addict, just like a heroin addict ... you are at the point where you are having sex not because you are deriving pleasure from it, but because you need to do that just to fall asleep at night and face the day, and not have withdrawal symptoms. So while true sex addiction is rare, it is one of many very real addictions that stem from the way the human brain feels - or doesn't feel - pleasure.“  - The Compass of Pleasure: How Our Brains Make Fatty Foods, Orgasm, Exercise, Marijuana, Generosity, Vodka, Learning, and Gambling Feel So Good

40 Addiction is a Brain Disease – Volkow et al. 2016

 Three re-occurring phases (called the “addiction circle”):

 1 – Binge and Intoxication

 2 – Withdrawal and Negative Affect

 3 - Anticipation and Craving

Binge and Intoxication

 Dopamine released in reward system (nucleaus accumbens )

 Repeated exposure to rewards leads to cue responsivity over time – which predicts increased intake of the substance/ behavior (classical conditioning)

 Leads to “Incentive Sensitization” – Robinson and Berridge (1993) – stimuli associated with the reward become “cues” that trigger enhanced dopamine release signaling incentive salience and induced “wanting” (clinically described as craving).

 This causes neural and molecular changes in reward system (neuroplasticity) in many brain regions

 Results in the “down-regulation” of dopamine resulting in tolerance

41 Withdrawal and Negative Affect

 Withdrawal symptoms and negative affect are consequences of the brains natural compensatory response to excessive dopamine

 Brain is trying to maintain homeostasis

 Natural rewards are experienced as less rewarding by addicted subjects than healthy subjects

 Motivates further reward seeking behavior to stop negative affect (negative reinforcement)

Preoccupation and Anticipation Phase

 Preoccupation with obtaining the reward

 Craving

 Changes in pre-frontal regulatory circuits that leads to impaired response inhibition

42 Addiction Involves….

 Sensitization – repeated administrations of a stimulus results in cue reactivity  Cues create cravings  The addiction becomes more compelling than other areas of life

 Desensitization – The more consumed – the less activity in the reward circuit  Less sensitive to pleasure  Tolerance develops after desensitization

 Hypofrontality – Decreased executive control functioning

Kuhn – High Porn Consumption Associated w/Grey Matter Volume Reduction

2014

43 Brain Structure and Functional Connectivity Associated With Pornography Consumption: The Brain on Porn (2014)

 Higher hours per week/more years of porn viewing correlated with a reduction in grey matter in sections of the reward circuitry (translates into sluggish reward activity, or a numbed pleasure response – desensitization)

 Simone Kühn - "That could mean that regular consumption of pornography more or less wears out your reward system.“

 Simone Kühn continued - "We assume that subjects with a high porn consumption need increasing stimulation to receive the same amount of reward.”

Voon – Neural Mechanisms Underlying CSB Similar to Those in Found in CD

2014

44 Neural Correlates of Sexual Cue Reactivity in Individuals with and Without Compulsive Sexual Behaviors (2014 – Voon et al. Cambridge University)

 Compulsive porn users react to porn cues in the same way that drug addicts react to drug cues  Compulsive porn users craved porn (greater wanting), but did not have higher sexual desire (liking) than controls. This finding aligns perfectly with the current model of addiction.  Over 50% of subjects (average age: 25) had difficulty achieving erections with real partners, yet could achieve erections with porn

Enhanced Attentional Bias towards Sexually Explicit Cues in Individuals with and without Compulsive Sexual Behaviors – Voon et al. 2014

 “Our findings of enhanced attentional bias in CSB subjects suggest possible overlaps with enhanced attentional bias observed in studies of drug cues in disorders of addictions. These findings converge with recent findings of neural reactivity to sexually explicit cues in CSB in a network similar to that implicated in drug-cue-reactivity studies and provide support for incentive motivation theories of addiction underlying the aberrant response to sexual cues in CSB.”

45 Gola et al. (2017)

 Gave fMRIs to 28 men in treatment for problematic pornography use (PPU) and 28 men without PPU to examine ventral striatal responses to “erotic and monetary stimuli”  Wanted to differentiate “cue-related ‘wanting’ from reward-related ‘liking’”  Participants completed an incentive delay task during the fMRI and were given “erotic or monetary rewards preceded by predictive cues”  PPU group had higher activation in the ventral striatum for cues that predicted erotic stimuli but not for cues that predicted monetary reward or to the actual erotic pictures  Authors argued this is “consistent with the incentive salience theory of addiction”  Sensitivity to erotic stimuli cues was related to increased motivation to see the erotic stimuli (suggests “higher wanting”), higher pornography use, severity level of PPU and more frequent masturbation  Findings congruent with research on gambling and substance addictions suggesting PPU may be a

Gola, M., Wordecha, M., Sescousse, G., Lew-Starowicz, M., Kossowski, B., Wypych, M., ... & Marchewka, A. (2017). Can pornography be addictive? An fMRI study of men seeking treatment for problematic pornography use. bioRxiv, 057083.

Ji-Woo Seok and Jin-Hun Sohn of the Brain Research Institute at Chungnam National University in South Korea

 Sex addicts focus a higher-than-normal share of their attention on addiction related cues (i.e., pornography), doing so in the same basic ways and to the same basic degree as other addicts.  The brain response of sex addicts exposed to sexual stimuli (i.e., pornography) mirrors the brain response of drug addicts when exposed to drug-related stimuli. For example, the dorsal orbital prefrontal cortex lights up just as it does with substance addicts. Equally important is the fact that this region goes below baseline for neutral stimuli, the same as with substance abusers. In other words, the dorsal orbital prefrontal cortex overreacts to addiction cues and underreacts to neutral cues in all forms of addiction, including sexual addiction.

46 Banca et al. (2016)

 Examined whether men with CSB showed more of a preference for “sexual novelty and stimuli conditioned sexual rewards” compared to a healthy control group

 CSB group:

 Had a stronger preference for novel sexual images in comparison to control images

 Demonstrated a preference for cues that had been conditioned to sexual and monetary rewards over neutral outcomes This result was not observed in the control group

 Had higher levels of dorsal cingulate habituation during an fMRI when presented with repeated sexual images compared to monetary images  Level of habituation to sexual images was positively correlated with self-reported preference for sexual novelty

 Had an early attentional bias to sexual cues compared to control group that significantly correlated with higher levels of approach behaviors towards cues conditioned to sexual images

 Authors concluded the CSB participants had a “dysfunctional enhanced preference for sexual novelty possibly mediated by greater cingulate habituation” as well as an overall enhanced reaction to rewards

 The novelty seeking and cue conditioning found in CSB participants is similar to results seen in studies on substance addictions

Banca, P., Morris, L. S., Mitchell, S., Harrison, N. A., Potenza, M. N., & Voon, V. (2016). Novelty, conditioning and attentional bias to sexual rewards. Journal of psychiatric research, 72, 91-101.

Ventral Striatum Activity Correlated with Porn Addiction (Brand et al. 2016)

 Reward center activity (ventral striatum) was higher for preferred pornographic pictures.

 Ventral striatum reactivity correlated with the internet sex addiction score.

 Both findings indicate sensitization and align with the addiction model. The authors state that the "Neural basis of addiction is comparable to other addictions."

47 Soek & Sohn 2018

 This fMRI study compared carefully screened sex addicts ("problematic hypersexual behavior") to healthy control subjects. Sex addicts had reduced gray matter in the temporal lobes - regions the authors say are associated with inhibition of sexual impulses.  Compared to healthy subjects, individuals with PHB had significantly decreased functional connectivity between the Superior Temporal Gyrus and the caudate nucleus.  The caudate nucleus is the main subregion of the striatum, and is important for reward-based behavioral learning, intricately associated with pleasure and motivation, and related to the maintenance of addiction.

Examples of Hypofrontality

48 Executive function – Reid et al. 2010

 Patients seeking help for hypersexual behavior often exhibit features of impulsivity, cognitive rigidity, poor judgment, deficits in emotion regulation, and excessive preoccupation with sex. Some of these characteristics are also common among patients presenting with neurological pathology associated with executive dysfunction. These observations led to the current investigation of differences between a group of hypersexual patients (n = 87) and a non- hypersexual community sample (n = 92) of men

Pornographic Picture Processing Interferes with Working Memory Performance

 Laier, Schulte and Brand (2013) examined the effect of during internet sex on Working Memory (WM)  Found worse performance of WM for pornographic pictures compared to neutral, negative and positive stimuli  Results moderated by need to masturbate and sexual arousal suggesting this arousal interferes with working memory processes  Authors concluded that the cognitive problems often reported by people with sexual addiction following pornography consumption (forgetfulness, neglecting responsibilities, missing appointment, etc.) may be accounted for by the interference with WM related to pornographic material

Laier, C., Schulte, F.P. & Brand, M. (2013). Pornographic picture processing interferes with working memory performance. Journal of Sex Research, 50(7), 642-652. DOI: 10.1080/00224499.2012.716873

49 Messina et al. (2017)

 Compared cognitive flexibility and decision making in 30 men with CSB and 30 control subjects before and after viewing an erotic video  No significant differences in cognitive flexibility and decision making between the groups prior to viewing the erotic video  After viewing the erotic video the control group members made fewer impulsive choices and demonstrated higher levels of cognitive flexibility than CSB participants

Messina, B., Fuentes, D., Tavares, H., Abdo, C. H., & Scanavino, M. D. T. (2017). Executive Functioning of Sexually Compulsive and Non-Sexually Compulsive Men Before and After Watching an Erotic Video. The Journal of Sexual Medicine, 14(3), 347-354.

Schiebener, Laier & Brand (2015)  Studied relation between executive functioning and cybersex addiction in 104 heterosexual men  Subjects completed an executive multitasking paradigm with two subsets of pictures (humans & pornography) they had to classify on certain criteria  Subjects were supposed to work on all tasks in equal amounts which required switching between the two subsets in a balanced way  Individuals with more symptoms of cybersex addiction had less balanced performances in the multitasking paradigm  These individuals “often either overused or neglected working on the pornographic pictures”  Suggested tendency towards approach/avoidance of pornography similar to motivational models of addiction  Indicated lower levels of executive control in multitasking performance when viewing pornography may “contribute to dysfunctional behaviors and negative consequences resulting from cybersex addiction”

Schiebener, J., Laier, C., & Brand, M. (2015). Getting stuck with pornography? Overuse or neglect of cybersex cues in a multitasking situation is related to symptoms of cybersex addiction. Journal of behavioral addictions, 4(1), 14-21.

50 Banca, Harrison & Voon (2016)

 Studied two facets of compulsivity (reversal learning and attentional set shifting) in participants with CSB vs healthy control group

 CSB group learned faster from rewards and slower from losses than control group  Suggests perseveration and enhanced sensitivity to rewards in CSB

 No significant differences between the groups in set shifting or reversal learning.

Banca, P., Harrison, N. A., & Voon, V. (2016). Compulsivity across the pathological misuse of drug and non-drug rewards. Frontiers in Behavioral Neuroscience, 10.

Sexual Picture Processing Interferes with Decision-Making Under Ambiguity

 Sexual arousal might interfere with the decision-making process and should therefore lead to disadvantageous decision-making in the long run.

 Results demonstrated an increase of sexual arousal following the sexual picture presentation. Decision-making performance was worse when sexual pictures were associated with disadvantageous card decks compared to performance when the sexual pictures were linked to the advantageous decks. Subjective sexual arousal moderated the relationship between task condition and decision- making performance.

 This study emphasized that sexual arousal interfered with decision- making, which may explain why some individuals experience negative consequences in the context of cybersex use.

Laier, C., Pawlikowski, M., & Brand, M. (2014). Sexual picture processing interferes with decision-making under ambiguity. Archives of sexual behavior,43(3), 473-482.

51 Schmidt et al. (2017)

 Compared brain volumes and resting state functional connectivity between men with CSB and healthy men  Results suggested CSB is related to higher volumes in parts of the limbic system that are associated with processing emotions and motivation  Unknown whether increased amygdala volumes pre- exists CSB and is a risk factor or is the result of CSB  Also found reduced connectivity between the amygdala and the bilateral dorsolateral prefrontal cortex (DLPFC) in CSB group which is associated with higher levels of impulsivity and lower levels of emotional regulation  Authors argued the dysfunction in these brain systems in people engaging in CSB is similar to incentive motivation theory research on substance addictions

Schmidt, C., Morris, L. S., Kvamme, T. L., Hall, P., Birchard, T., & Voon, V. (2017). Compulsive sexual behavior: Prefrontal and limbic volume and interactions. Human brain mapping, 38(3), 1182-1190.

Our clients experience

 Powerful sexual conditioning and learning  Neuroplastic change  Structural changes in the brain  Deficits in areas of functioning (e.g. memory, decision making)

 Over 40 articles on the neuroscience of sex addiction…  Embedded in a large body of research on behavioral addictions (130 behavioral addiction articles - e.g. 70 brain articles on internet addiction)  Longitudinal research in other areas

52 Reward deficiency syndrome – K. Blum

 Genetic pre-disposition to addiction

 Carriers of the DRD2-A1 gene have fewer dopamine receptors

 More likely to have disruption in mesolimbic reward system

 Results in hypodopamergic state that yields a predisposition to addiction

 Congenital chemical imbalance

 Over-represented in samples of drug and alcohol addiction, gambling, CSB, compulsive gaming, work and shopping

Poster Presented at ACNP 2017: Analysis of the DAT1 3’ VNTR in Sexual Addiction Lapetina D.L.1*, Hu X. 1*, Lee D. 1,Roper L. 1, Aryal G. 1, Wallace K. 1, Yu M. 1, Henriques Carvalho B. 1, Lodhi R.J. 1, Carnes P. 2, Isenberg R. 2, Green B. 3 , Carnes P. 2**, Aitchison, K. J. 1** 1 Departments of Psychiatry and Medical Genetics, University of Alberta, Edmonton, Canada 2 American Foundation for Addiction Research, U.S.A. 3 Psychology Clinic, University of Southern Mississippi, U.S.A. * joint co-authors and **joint senior authors

Sexual addiction has been relatively understudied in terms of its biological basis. We herein aim to investigate genes associated with sexual addiction and related phenotypes. One of our candidate genes is the dopamine transporter (DAT1, SLC6A3). Polymorphism in exon 15 of the gene encoding the 3’ VNTR has been suggested to be associated with conditions relevant to reward deficiency syndrome, such as attention deficit hyperactivity disorder (ADHD) (Uhl et al., 2003; Faraone et al., 2014). Exon 15 encodes the 3’UTR region, and includes multiple copies of a 40 bp tandem repeat (VNTR). The most common alleles are 9 or 10 copies (Kang et al., 1999). There is marked interethnic variation in 10 repeat allele frequency, with the lowest being seen in the African Mbuti (36%), and the highest in the Brazilian indigenous tribe Karitiana (100%).

53 Pornography and the Brain

Novelty and the “Coolidge” Effect Gary Wilson

 Presentation of a new potential mate creates a surge of dopamine in the brain  Becomes harder to mate with the same old partner (less dopamine is released)  Gary Wilson “Endless online mates keep dopamine surging”  “Males need time to recover their potency and vigor after overriding their sexual satiation mechanisms with dopamine/novelty.”  “Porn Induced” Erectile Dysfunction – due to desensitized dopamine system in the brain – as opposed to blood flow in penis as in natural later onset

54 Hilton – Pornography Potentially Addictive

2013

Supernormal Stimulus

 A supernormal stimulus or superstimulus is an exaggerated version of a stimulus to which there is an existing response tendency, or any stimulus that elicits a response more strongly than the stimulus for which it evolved.

 Nickolaas Tinbergen discovered animals (birds, gypsy moths etc) could be fooled into preferring fake mates and eggs.

55 It’s not how much time is spent that leads to problematic use….

 Important findings in this study are that neither time spent viewing porn on the Internet nor personality factors were associated the level of reported problems with Internet porn use

 Instead, it was intensity of the experience and amount of novelty (different applications opened)

 “It has generally been assumed that predisposing personality problems are what make porn addiction possible, but it may be dopamine levels, quite apart from personality.”

 As it turns out, the level of reported psychological problems (e.g., social anxiety, depression, and compulsivity) appears to be related to how intense the arousal produced, and the number of applications used (degree of novelty).

 "Although we did not examine brain correlates of watching Internet pornographic pictures in our study, we found the first experimental evidence for the potential link between subjective reactivity on Internet pornographic stimuli and a tendency toward cybersex addiction.“

Brand, M., Laier, C., Pawlikowski, M., Schächtle, U., Schöler, T., & Altstötter-Gleich, C. (2011). Watching pornographic pictures on the internet: Role of sexual arousal ratings and psychological–psychiatric symptoms for using internet sex sites excessively. Cyberpsychology, Behavior, and Social Networking, 14(6), 371-377.

Sexual Conditioning

 “Erections may become conditioned to aspects of VSS [porn] that do not transition easily to real-life partner situations. Sexual arousal may be conditioned to novel stimuli, including particular sexual images, specific sexual films or even non-sexual images. It is conceivable that experiencing the majority of sexual arousal within the context of VSS may result in a diminished erectile response during partnered sexual interactions. Similarly, young men who view VSS expect that partnered sex will occur with themes similar to what they view in VSS. Accordingly, when high stimulation expectations are not met, partnered sexual stimulation may not produce an erection.”

Prause & Pfaus, 2015 Veiwing sexual stimuli associated with greater sexual responsiveness not erectile dysfunction

56 Contemporary Vs. Classic SA Reimersma & Sytsma (2013)

 Classic:  History of abuse  Insecure attachment  Poor impulse control  Cross Addictions  Co-morbid mood disorders  Used to soothe toxic emotions

Contemporary

 Rapid onset  Due to explosive growth of internet technology  Chronic exposure to graphic content online  Content – unique, intense, graphic, limitless novelty  Culture – trending towards virtual and non-relational sex  Early exposure to graphic sexual material  Sexual conditioning  Less trauma history/ attachment problems  May not be having sex (or may never have had sex)  May not be able to perform – can include performance anxiety, unrealistic performance standards

57 Giordana and Cashwell Prevalence study 2017

 339 college students surveyed and found that 10.3% scored in the clinical range for cybersex addiction. Further, we found significant gender differences among the clinical and non-clinical range groups as males were more likely to score in the clinical range for cybersex addiction.

 From Table 1 in the full paper (which is available in the SASH journal Sexual Addiction & Compulsivity)

 Percentage of men in the clinical range - 19%

 Percentage of women in the clinical range - 4%

Psychological Correlates of Internet Porn Use

 Levin, Lillis and Hayes (2012) found the following correlates of increased porn use in college males:  Depression  Anxiety  Stress  Poor social functioning

Lam, C.B. & Chan, D.K.S. (2007). The use of cyberpornography by young men in Hong Kong: Some psychosocial correlates. Archives of Sexual Behavior, 36, 588-598 Levin, M.E., Lillis, J. & Hayes, S.C. (2012). When is online pornography viewing problematic in college males? Examaning the moderating role of experiential avoidance. Sexual Addiction & Compulsivity, 19, 168-180

58 Porn Use & Erectile Dysfunction in Young Men

 Foresta and colleagues (2011) studied 28,000 Italian men and found higher levels of porn use was associated with higher levels of erectile dysfuction in young men  Landripet and Stulhofer (2015) found that moderate (but not high) levels of porn consumption were related to higher chances of young Croatian men having erectile difficulties  Voon (2014) found that over half (11 of 19) men with compulsive porn use reported erectile dysfunction  First time in history – widespread youthful ED in young men

Rebooting for PIED

 General recovery after 2 months of no porn or masturbation

 Older guys are recovering faster than those that wired their brains to internet porn during adolescence

 Fapstronauts / “No Fap” community on Reddit

 Rebootnation.org

 Yourbrainonporn.com

59 Correlates of Porn Use in Young Men 2014

 Szymanski and Stewart-Richardson (2014)

 Higher frequencies of pornography use and problematic porn use were related to: Avoidant attachment style Anxious attachment style Decreased sexual satisfaction Increased relational problems

Szymanski, D.M. & Stewart-Richardson, D.N. (2014). Psychological, relational, and sexual correlates of pornography use on young adult heterosexual men in romantic relationships. The Journal of Men’s Studies, 22(1), 64-82

Families & Attachment

60 Circumplex

Copyright D.H. Olson

Measure Flexibility

Copyright D.H. Olson

61 Measure Cohesion

Copyright D.H. Olson

Families of Sex Addicts 77% RIGID 87% DISENGAGED

Copyright D.H. Olson

62 Significant differences in Attachment Styles of Sex Addicts

Attachment varies by gender and sexual orientation

Anxious Avoidant

63 MULTIPLE ADDICTIONS

Frequencies of Multiple Addictions (N = 1604)

 Alcohol was the most frequently co-occurring addiction in both males and females at 46%, however in gay males drug abuse was most frequent 54%.

 Gay males also scored higher on high risk/ dangerous behaviors

 Women scored higher on compulsive spending, compulsive eating, and compulsive cleaning

64 Collateral Indicators (N = 1604)

Heterosexual Heterosexual Homosexual Males Females Males

Meets diagnostic 69% 79% 80% criteria for another addictive disorder Simultaneously uses 40% 40% 60% sexual behavior in concert with other addictions Reports other family 48% 63% 55% members are addicts

65 When Substance Addiction is Present…

 Chronology of treatment is vital…  Client must be carefully detoxed and stabilized  Clients may be initially screened and assessed to see if sex addiction is present  Therapeutic alliance and supportive community established  After client is stable and is not at risk of elopement and has increased capacity for emotional regulation  Proceed slowly on sexual issues  Sexual issues may be associated with trauma and shame  Manage triggers, cues  Provide support

Treatment

66 Evidence Based Pharmacological Interventions

 SSRIs  SNRIs  Naltrexone  Anticonvulsants (Topiramate, valproic acid, lamotrigine, and levetiracetam)

 Grant (2018) Compulsive Sexual Behavior: A Nonjudgemental Approach. Current Psychiatry. February;17(2):34,38-40,45-46

Evidence Based Approaches to Treatment

 Cognitive Behavioral Therapy

 Motivational Interviewing

 Del Giudice MJ, Kutinsky J. Applying motivational interviewing to the treatment of sexual compulsivity and addiction. Sex Addict Comp. 2007;14(4):303-319.

 Shepherd L. Cognitive behavior therapy for sexually . Clin Case Stud. 2010;9(1):18-27.

 Sadiza J, Varma R, Jena SPK, et al. Group cognitive behaviour therapy in the management of compulsive sex behaviour. International Journal of Criminal Justice Sciences. 2011;6(1-2):309- 325.

67 Evidence Based Approaches to Treatment

 Acceptance Commitment Therapy  The overall reduction in problematic Internet pornography use was reported as 92% immediately after the study ended, and 86% after 3 months.

 Crosby JM, Twohig MP. Acceptance and commitment therapy for problematic Internet pornography use: a randomized trial. Behav Ther. 2016;47(3):355- 366.

 Twohig MP, Crosby JM. Acceptance and commitment therapy as a treatment for problematic internet pornography viewing. Behav Ther. 2010;41(3):285-295.

Evidence Based Approaches to Treatment

 12 Step Group Participation

 Yaniv & Gola (2018) Compulsive Sexual Behavior: A 12 Step Based Therapuetic Approach. Journal of Behavioral Addictions.

 Sevcikova et al. (2018) Excessive Internet use for Sexual Purposes Among Members of Sexaholics Anonymous and Sex Addicts Anonymous.

68 Treatment

 Programmatic care – Long term treatment  Group  12 step support  Educational component  Celibacy agreement  Sexual health plan  Task methodology  12 step  Mindfulness, CBT  IFS, Trauma treatment, EMDR, SE  Family / Couple treatment  Partner Trauma Treatment  Disclosure

69 Task Methodology: The Process

For Healing…Three Legged Stool

 Addict’s therapist  Individual therapy  Support Groups/ 12 step support

 Partner’s therapist  Individual therapy  Support Groups

 Couples therapist

70 Family therapy

 Treatment for sex addiction induced trauma for whole family and betrayal trauma for partners

 Treatment from a relational paradigm

 Effective and well orchestrated disclosure to partner

 Long term couples therapy

Betrayal Trauma Symptoms

 Emotional Instability

 Hypervigilance

 Trauma Symptoms: Intrusive thinking, Nightmares

 Cognitive Problems

 Damaged Self Esteem

 Shame

 Morbid Preoccupation

 Health Problems

71 SA Couples need effective disclosure

 Empowers the partner

 Is thoughtfully planned and prepared

 Is well organized and structured

 Includes extensive support for both parties

 Includes an impact letter and Emotional Restitution Process

The Basics…

 Disclosure is for repair of a committed couple

 Disclosure is done after addict has some traction in and commitment to recovery

 Disclosure is done with tremendous support for both parties

 Disclosure is guided by partners need and desire to know

 Disclosure shares important facts and clear information, not painful details

 Disclosure is followed up with trauma treatment and couples therapy

72 Questions?

Thank you!

73