Sex Addiction: Neuroscience

Etiology and Treatment

Stefanie Carnes, Ph.D., CSAT-S

AAMFT Approved Supervisor
Rates of Sex Addiction Among CD
Patients (Deneke et al. 2014)
 Rates of Sex Addiction in Chemical Dependency
Patients
 Residential -18 %
 Relapse Unit - 19 %
 Extended Care Unit – 29 %

“Failure to complete a comprehensive screening for

behavioral addiction may compromise substance use
disorder treatment and maintain a revolving pattern
of substance abstinence and relapse”
Is Sex an Addiction?
 DSM III-R contained a category called "non-
paraphilic sexual addiction"
 Various authors have argued for different terms
- "Compulsive" (OCD, Coleman, 2003)
 - "Addictive" (Fenicehel, 1945, 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 draft includes “sexual compulsivity” –
Narrower term “sexual addiction”
American Society of Addiction
Medicine
 “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, alcohol 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
DSM-5 Field Study Report for
Hypersexual Disorder
 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, cybersex, 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)
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
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: Pornography (81.1%) Masturbation (78.3%),
Phone Sex (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
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
 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
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
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
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 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.
 Class 1: No comorbid psychopathology (22.7%)
Clinical Profile External Correlates:
Non-significant levels of Some alcohol and drug use
psychopathology symptoms, with Small but positive correlations with negative
average or below average scores on legal consequences
PAI scales Negative correlation with alcohol and drug-
Low levels of distress and related consequences.
psychological disturbance Negative correlation with sex-related
arrests.
Negative correlation with fantasy, pain,
voyeuristic anonymous sex by SDI.
Negative correlations with Core,
Preoccupation, and Affect Disturbance-SAST.
 Class 2: Dysfunctional Negative Emotions (14.9%)
Clinical Profile External Correlates:
Mildly elevated cognitive and Positive correlations with drug and
affective symptoms of anxiety chemical use.
Mildly elevated cognitive and Some legal consequences related to drug
affective symptoms of depression and chemical use in general
Mildly elevated levels of traumatic Positive correlation with intrusive-f sex by
stress reaction SDI.
Mild elevation in irritability
Isolation, social withdrawal
Disruptions in thought processes,
difficulties in concentration and
decision-making
Mild elevations in alcohol and
drug use
 Class 3: Mild Depression and Substance-Related
Problems (38.1%)
Clinical Profile External Correlates
Mild depression Negative correlations with fantasy-f,
Mildly disturbed concentration and intrusive-f and intrusive-p, and voyeuristic-
decision-making. p sex by SDI.
Mild elevation on drug and
alcohol use problems.
 Class 4: Clinical Depression and Anxiety (18.8%)

Clinical Profile External Correlates

Clinically significant cognitive and Some legal implications
affective symptoms of depression Sexual-related convictions.
Clinically significant cognitive and Positive and high correlation with fantasy-
affective symptoms of anxiety f, intrusive-p, voyeuristic-f and voyeuristic-
Clinically significant suicidal p, exhibitionistic –p, trade-p, and
ideation anonymous-p sex by SDI.
Clinically significant symptoms of Positive correlations with core,
traumatic stress preoccupation, loss of control, and
Mildly elevated somatization negative affect sexual behaviors, by
Problems with concentration and SAST.
decision-making
Social withdrawal
 Class 5: Severe Psychopathology (5.6%)

Clinical Profile External Correlates:

Highest levels of psychopathology Positive correlations with seductive-f,
Severe levels of anxiety intrusive-f; exhibitionistic-p sex by SDI.
Severe levels of depression Positive and highest sexual preoccupation
Severe levels of traumatic stress and negative relationship disturbance by
reaction symptoms SAST.
Severe levels of suicidal ideation
Clinically significant symptoms of
conversion, somatization, and
health concerns
Clinically significant elevations for
irritability and paranoia
Clinically significant levels of
social detachment and
concentration difficulties
Diagnosis
Differential Diagnosis
 DSM-5 - Possibilities:
 Other Specified Disruptive, Impulse Control and Conduct Disorder
 Other Specified Sexual Dysfunction
 Unspecified Paraphilic Disorder

 Rule out/ or in:

 Antisocial / Narcissistic personality disorder
 Paraphilia
 Bipolar affective disorder
 PTSD
 ADHD
 Substance induced disorder
 Dissociative disorder
 Delusional disorder
 OCD
 Delirium, dementia, or other cognitive disorder or organic condition
Krueger, 2016
 “Diagnoses that could refer to compulsive sexual behavior have
been included in the DSM and ICD for years and can now be
diagnosed legitimately in the United States using both DSM-5
and the recently mandated ICD-10 diagnostic coding.
Compulsive sexual behavior disorder is being considered for
ICD-11”
 The recommended code, according to the ICD-10-CM index, is
F52.8, which is the code for ‘other sexual dysfunction not due
to substance or known physiological condition’; the inclusion
terms of ‘excessive sexual drive’, ‘nymphomania’ and
‘satyriasis’ are listed under F52.8. DSM-5 also lists ‘other
specified sexual dysfunction’ 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.13366/full
Differential Diagnosis
 Antisocials (especially w/ sex offenders) w/out
addiction
 - History of physical abuse
 - Lacking remorse an shame
 - More force/ violence in the offense
 - History of other types of offenses
 - More impulsive (not as many sexual urges)
 - Distortions and denial
 - Decreased amenability for treatment
Differential Diagnosis Continued
 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
Paraphilias are not 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”
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.
Etiology
The making of a sex addict
Etiology
 Biology/ Neuroscience/ Sexual Conditioning
 Family Dynamics/ Attachment
 Trauma and abuse
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, reinforcement learning & impulsivity
Amygdala:
 Positive & negative emotional memory
Hippocampus:
 Processing & retrieval of long-term memories
Prefrontal Cortex:
 Coordinates & determines judgment & behavior
Evolutionary Function of Reward
System
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

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
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
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”
inhibitory control, increasing impulsivity and motivating further
action to seek out the source of pleasure.
 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 Down-Regulation is a Well-Established Finding in
Addiction Research
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.” (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
 Effects of Drugs on Dopamine Levels
1100 Accumbens AMPHETAMINE Accumbens
COCAINE
1000 400
% of Basal Release

900

% of Basal Release
800 DA
DA 300 DOPAC
700 DOPAC HVA
600 HVA
500 200
400
300
200 100
100
0
0 1 2 3 4 5 hr 0
0 1 2 3 4 5 hr
Time After Amphetamine Time After Cocaine

250 250
NICOTINE Accumbens ETHANOL
% of Basal Release

200 Accumbens Dose (g/kg ip)

200

% of Basal Release
Caudate
0.25
150 0.5
1
150 2.5
100

100
0
0 1 2 3 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

DA Concentration (% Baseline)
NAc shell

150 150
% of Basal DA Output

100 100

Copulation Frequency
15

Empty 10
50
Box Feeding
5

0 0
0 60 120 180 Scr Scr Scr Scr
BasFemale 1 Present Female 2 Present
Time (min) Sample 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Number
Mounts
Intromissions
Ejaculations

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

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

2014
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
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.”
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 behavioral addiction
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.
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.
Hypofrontality
 Cognitive problems such as forgetting responsibilities
 Problems with working memory
 Increased impulsivity
 Decreased cognitive flexibility
 Decreased ability to multi-task
 Difficulties with sustaining attention
 Slower learning
 Difficulties making decisions
 Decreased emotional regulation
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 30 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
Porn 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
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.
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
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
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
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
Families & Attachment
Circumplex

Copyright D.H. Olson

Measure Flexibility

Copyright D.H. Olson

Measure Cohesion

Copyright D.H. Olson

Families of Sex Addicts

77%
RIGID
87%
DISENGAGED
Copyright D.H. Olson
Significant differences in Attachment
Styles of Sex Addicts
Attachment varies by gender and sexual
orientation
 Anxious

Avoidant
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
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.
 “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
Recent Research
 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.
Assessment
Assessment Tools
 SAST-R 2.0
 PATHOS
 SDI-R
PATHOS
 1) Do you often find yourself preoccupied with sexual thoughts?
(Preoccupied)
 2) Do you hide some of your sexual behavior from others? (Ashamed)
 3) Have you ever sought help for sexual behavior you did not like?
(Treatment)
 4) Has anyone been hurt emotionally because of your sexual
behavior? (Hurt)
 5) Do you feel controlled by you sexual desire? (Out of control)
 6) When you have sex, do you feel depressed afterwards? (Sad)
SDI
 Comprehensive battery of tests
 SAST

 Diagnostic Criteria, Anorexia, Collateral Indicators

 Co-morbid Addiction screen

 Financial Costs

 Consistency, exaggeration

 Attachment Style

 Readiness for Change

MULTIPLE ADDICTIONS
Binge / Purge Cycle

Acting Out
Extreme Control Out of Control
 Dieting  Eating
 Sex Avoidance  Sex & Romance
 Saving / Hoarding  Alcohol
 Drugs
 Risk Aversion
 Spending / Debting
 Compulsive Athleticism  Risk-taking
 Work
 Gambling

Acting In
Treatment
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
 Programmatic care
 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
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
Question and Answer

Thank you!