The World Federation of Societies of Biological Psychiatry guidelines on the assessment and pharmacological treatment of compulsive sexual behaviour disorder

Current Advances in Behavioral Addictions: From Fundamental Research to Clinical Practice

Gambling disorder is the only behavioral addiction recognized as a clinical disorder in DSM-5, and Internet gaming disorder is included as a condition requiring further research. ICD-11 categorizes gambling and gaming disorders as disorders due to addictive behaviors. Additional behavioral addictions may include compulsive sexual behavior disorder, compulsive buying-shopping disorder, and problematic use of social media. This narrative review summarizes the current state of knowledge regarding these five (potential) disorders due to addictive behaviors. All five (potential) disorders are clinically relevant and prevalent. Behavioral addictions frequently co-occur with other mental and behavioral problems, such as depression, anxiety, and attention deficit hyperactivity disorder. Validated diagnostic instruments exist, with empirical support varying across conditions. No medications have approved indications from regulatory bodies for behavioral addictions, and cognitive-behavioral therapy has the most empirical support for efficacious treatment. Given that behavioral addictions are prevalent, frequently co-occur with psychiatric disorders, may often go undiagnosed and untreated, and have been linked to poorer treatment outcomes, active screening and treatment are indicated. Public health considerations should be expanded, and impacts of modern technologies should be investigated more intensively. Treatment optimization involving pharmacotherapy, psychotherapy, neuromodulation, and their combination warrants additional investigation.

No Magic Pill: A Systematic Review of the Pharmacological Treatments for Compulsive Sexual Behavior Disorder

Compulsive sexual behavior disorder (CSBD) is a burgeoning diagnostic construct. No systematic reviews of CSBD pharmacotherapy interventions have been conducted. We addressed this gap using a three-aim approach. We reviewed researchers' theoretical arguments for various pharmacotherapies, outcomes from pharmacotherapy trials, and the generalizability of the extant findings. Our review included k = 13 studies, with n = 141 participants. An opioid model of reward seeking was the most popular framework, though inconsistently specified. A serotonin model was also documented, though with few details. Naltrexone was the most prominently examined pharmacotherapy and the only medication that reliably demonstrated a therapeutic effect for some (but not all) indicators compared to placebo. Paroxetine and citalopram were also documented in placebo-controlled trials, though their incremental benefit compared to placebo is suspect. Several additional pharmacotherapies have been documented in case series contexts. Across studies, only one female participant was identified. All trials were conducted in developed nations, and race was rarely assessed. We conclude that the case for pharmacotherapy for CSBD is limited and should preferably not occur outside of clinical trial contexts. Naltrexone offers the best evidence for a potential research program, though new theoretically informed approaches are welcome. Finally, we call for additional pharmacotherapy research in women and non-White populations.

The PornLoS Treatment Program: Study protocol of a new psychotherapeutic approach for treating pornography use disorder

Background

The introduction of Compulsive Sexual Behavior Disorder (CSBD) into the 11th International Classification of Diseases has raised expectations for better treatment options for CSBD. Furthermore, the treatment demand has increased, particularly for pornography use disorder (PUD), a subtype of CSBD. Presumably due to the easy access to Internet pornography an increasing prevalence of PUD is observed. Consequently, providing tailored and effective treatment is essential.

Methods

This article provides an overview of the manualized short-term PornLoS Treatment Program (Pornografienutzungsstörung effektiv behandeln- Leben ohne Suchtdruck; translation: Treating pornography use disorder effectively - life without craving). The program combines 24 individual and 6 group psychotherapy sessions with an interdisciplinary approach by offering a novel treatment framework. This includes, e.g., a mobile app, establishment of self-help groups, and access to other social services such as couple counseling. The cognitive-behavioral treatment program contains interventions addressing psychoeducation, cue exposure, impulse control, cognitive restructuring, emotional regulation, and relapse management.We here also describe the study protocol of an ongoing four-arm randomized controlled trial. The aim is to test two variants of the PornLoS Treatment Program differing with respect to their treatment goal (abstinence or reduced pornography use) against cognitive-behavioral treatment as usual and against a waitlist control group. The primary outcome is the absence of a PUD diagnosis at the end of therapy. The total target sample size will comprise n = 316 patients with PUD across eight study sites.

Results

The results will be presented at international conferences and published in a scientific peer-reviewed journal.

Magnetoencephalographic correlates of pornography consumption: Associations with indicators of compulsive sexual behaviors

Pornography consumption is highly prevalent but can develop into problematic sexual behavior with severe negative emotional consequences. Neurobiological studies indicate that compulsive sexual behaviors (CSB) are associated with altered brain structure and function in processing pornography. This study investigated the neuroaffective mechanisms underlying exposure to erotic and explicit pornographic images and their relationship to CSB-relevant symptoms. Whole-head magnetoencephalography (MEG) assessed brain activity during passive viewing of opposite- and same-sex erotic and pornographic images in healthy heterosexual and homosexual women and men (N = 50). Correlations of estimated event-related neural activity with indicators of CSB (hypersexuality, sexual sensation seeking, problematic pornography use, and time spent on pornography use), mood and anxiety, as well as with subjective picture ratings of hedonic valence and emotional arousal were analyzed. Responses of brain regions to sexual content revealed hyper- and hypoactivation and were related to problematic pornography consumption, hypersexuality, time spent on pornography use, and perceived subjective arousal. The neural activation towards erotic and pornographic content revealed further significant associations with depression and anxiety scores. The findings suggest an involvement of prefrontal and temporo-parietal cortex regions in the divergent processing of sexual content in relation to indicators of CSBD. Insight into the neurobiological factors underlying CSB can contribute to a more precise clinical conceptualization of this problem and may promote the development of more effective therapeutic interventions.

Assessment and treatment of compulsive sexual behavior disorder: a sexual medicine perspective

INTRODUCTION

The addition of compulsive sexual behavior disorder (CSBD) into the ICD-11 chapter on mental, behavioral, or neurodevelopmental disorders has greatly stimulated research and controversy around compulsive sexual behavior, or what has been termed "hypersexual disorder," "sexual addiction," "porn addiction," "sexual compulsivity," and "out-of-control sexual behavior."

OBJECTIVES

To identify where concerns exist from the perspective of sexual medicine and what can be done to resolve them.

METHODS

A scientific review committee convened by the International Society for Sexual Medicine reviewed pertinent literature and discussed clinical research and experience related to CSBD diagnoses and misdiagnoses, pathologizing nonheteronormative sexual behavior, basic research on potential underlying causes of CSBD, its relationship to paraphilic disorder, and its potential sexual health consequences. The panel used a modified Delphi method to reach consensus on these issues.

RESULTS

CSBD was differentiated from other sexual activity on the basis of the ICD-11 diagnostic criteria, and issues regarding sexual medicine and sexual health were identified. Concerns were raised about self-labeling processes, attitudes hostile to sexual pleasure, pathologizing of nonheteronormative sexual behavior and high sexual desire, mixing of normative attitudes with clinical distress, and the belief that masturbation and pornography use represent "unhealthy" sexual behavior. A guide to CSBD case formulation and care/treatment recommendations was proposed.

CONCLUSIONS

Clinical sexologic and sexual medicine expertise for the diagnosis and treatment of CSBD in the psychiatric-psychotherapeutic context is imperative to differentiate and understand the determinants and impact of CSBD and related "out-of-control sexual behaviors" on mental and sexual well-being, to detect forensically relevant and nonrelevant forms, and to refine best practices in care and treatment. Evidence-based, sexual medicine-informed therapies should be offered to achieve a positive and respectful approach to sexuality and the possibility of having pleasurable and safe sexual experiences.

Reducing problematic pornography use with imaginal retraining-A randomized controlled trial

Background and aim

Problematic pornography use (PPU) can be a manifestation of compulsive sexual behavior disorder (CSBD). Studies investigating PPU confirm approach-avoidance tendencies in response to pornographic stimuli in this population. This study show indications of the significance of the efficacy of imaginal retraining, a variant of approach bias modification, as an intervention for PPU.

Methods

A total of 274 participants (86.5% male; mean age = 30.65, SD = 10.13) with self-reported PPU were randomized to imaginal retraining (instruction video) or a waitlist control group. Assessments were conducted online at baseline and after the six-week intervention period. The primary outcome was a reduction in problematic pornography use. Compulsive sexual behavior, sexual desire, depressiveness, and satisfaction with the intervention served as secondary outcomes.

Results

Retention was low (51.7%), but comparable between groups. The retraining was performed at least once a week (the per-protocol [PP] criterion) by 51.4% of participants. The PP analyses of 111 participants showed a significant reduction in problematic pornography use (primary outcome) in the intervention compared to the control group. The intention-to-treat analyses (ITT), however, did not corroborate this result. Despite low adherence, participants rated their satisfaction with the intervention positively.

Discussion and Conclusion

Imaginal retraining can function as a low-threshold self-help intervention for PPU to overcome help-seeking barriers and may reduce PPU in a subgroup of users. Low adherence limits the results of this trial. Given the need for low-threshold interventions for PPU and/or CSBD, further research should focus on increasing adherence and should evaluate retraining for clinical groups. Modifications to augment efficacy are suggested.

Why Do People Watch Pornography? Cross-Cultural Validation of the Pornography Use Motivations Scale (PUMS) and Its Short Form (PUMS-8)

Motivations for pornography use may vary across gender identities, sexual orientations, and geographical regions, warranting examination to promote individual and public health. The aims of this study were to validate the Pornography Use Motivations Scale (PUMS) in a diverse, multicultural sample, and develop a short form (PUMS-8) that can assess a wide range of pornography use motivations. Using data from 42 countries (N = 75,117; Mage = 32.07; SDage = 12.37), enabled us to thoroughly evaluate the dimensionality, validity, and reliability of the Pornography Use Motivations Scale (PUMS), leading to the development of the more concise PUMS-8 short scale. Additionally, language-, nationality-, gender-, and sexual-orientation-based measurement invariance tests were conducted to test the comparability across groups. Both the PUMS and the PUMS-8 assess eight pornography use motivations, and both demonstrated excellent psychometric properties. Sexual Pleasure emerged as the most frequent motivation for pornography use across countries, genders, and sexual orientations, while differences were observed concerning other motivations (e.g. self-exploration was more prevalent among gender-diverse individuals than men or women). The motivational background of pornography use showed high similarity in the examined countries. Both the PUMS and the PUMS-8 are reliable and valid measurement tools to assess different types of motivations for pornography use across countries, genders, and sexual orientations. Both scales are recommended for use in research and clinical settings.

Paraphilic fantasies and behavior in attention deficit/hyperactivity disorder and their association with hypersexuality

Previous research has found some peculiarities in sexual functioning of adults with attention deficit/hyperactivity disorder (ADHD). Using a set of questionnaires that had to be answered online, we assessed the prevalence of paraphilic fantasies and behaviors in a sample of 160 adults with ADHD in comparison to 75 adults without ADHD and evaluated the association between paraphilias and hypersexuality in the ADHD group. Both groups reported high rates of paraphilic fantasies and behaviors. ADHD individuals were more likely to report about very sexually arousing paraphilic fantasies (ADHD: 58.2% vs. non-ADHD: 40.5%; χ2 = 6.323, p = 0.01) and behaviors (ADHD: 44.9% vs. non-ADHD: 28.4%; χ2 = 5.774, p = 0.02). Furthermore, ADHD individuals reported on average about more very sexually arousing paraphilic behaviors compared to non-ADHD individuals (ADHD: M = 1.28, SD = 0.10 vs. non-ADHD: M = 0.81, SD = 0.09; T = 2.68, p < 0.01). Furthermore, in ADHD individuals both very sexually arousing paraphilic interests in masturbation fantasies (r(158) = 0.17, p = 0.03) and in sexual behaviors (r(158) =0.19, p = 0.02) showed a significant correlation with hypersexuality. In non-ADHD individuals no such significant correlation could be found. Altogether, it can be concluded that individuals with ADHD seem to be more prone to develop and act out paraphilic sexuality than those without ADHD, however, found differences were rather small. The results of the present study add to the current trend to depathologize paraphilic sexuality in the general as well as in clinical populations.

Current Understanding of Compulsive Sexual Behavior Disorder and Co-occurring Conditions: What Clinicians Should Know about Pharmacological Options

Compulsive sexual behavior disorder (CSBD) has recently been recognized as a psychiatric disorder. Pharmacological treatments for CSBD have received little study and thus have limited empirical support. The main objective of the present work is to review existing literature on the efficacy of different drugs on the symptomatology of CSBD, including the subtype of problematic pornography use (PPU). The main pharmacological approaches to treating CSBD have included opioid antagonists (naltrexone and nalmefene), selective serotonin reuptake inhibitors (paroxetine, citalopram, fluoxetine, and sertraline), mood stabilizers (topiramate), tricyclic antidepressants (clomipramine), serotonin antagonist and reuptake inhibitors (nefazodone), and N-acetylcysteine. Since people with CSBD may experience different co-occurring disorders, these should be considered when choosing the best pharmacological treatment. Pharmacological therapy for CSBD/PPU has been suggested as an adjunct to psychological therapies, which, for the moment, have the most empirical evidence. However, to evaluate the efficacy of most of the drugs presented in this narrative review, data to date have only been available from case studies. Thus, empirical support is scant and generalizability of results is limited, highlighting the need for more research in this area.

Disorders of impulsivity in trichotillomania and skin picking disorder

Trichotillomania and skin picking disorder are often classified as body-focused repetitive behaviors (BFRBs) as they are characterized by repetitive hair-pulling and skin picking, respectively. They were initially considered to be impulse control disorders despite little research scrutiny. The objective of this study was to examine the relationship of these two conditions to other disorders with impulsive features. Adults with trichotillomania (n = 104) and skin picking (n = 178) or both (n = 96) were recruited from the general community using advertisements and online support groups and completed an online survey. Participants undertook a structured clinical interview and completion of self-report instruments to characterize clinical profiles and associated characteristics. In addition, each participant completed the Minnesota Impulse Disorders Interview to screen for disorders with impulsive features. Of the 378 adults with BFRBs, 134 (35.4%) screened positive for at least one disorder with features of impulsivity with the most common being compulsive buying (18.3%) and problematic use of the internet (17.5%). Participants with a co-occurring disorder of impulsivity reported significantly worse pulling and picking symptoms (p < .001), were more likely to have co-occurring alcohol problems (p < .001) and PTSD (p < .001), and scored higher regarding dissociative symptoms (p < .001). BFRBs are associated with a range of impulsive disorders and the comorbidity may have important treatment implications.

Taking Another Look at the Pornography Problems Due to Moral Incongruence Model: Does Gender Play a Role?

The pornography problems due to moral incongruence (PPMI) model is a premier framework for understanding problematic pornography use (PPU). However, past studies have generally examined men or entered gender as a covariate in primary analyses. Such approaches mask between-gender differences. Additionally, dysregulation constructs are also thought to be relevant to PPU, yet it is unclear the degree to which they incrementally predict PPU beyond moral incongruence constructs in non-pathological populations. We addressed these gaps by gathering a large sample of college students (n = 295 men, n = 838 women). Analyses with pornography users (n = 251 men, n = 407 women) were consistent with the PPMI model, adjusted for pornography use frequency. Findings did not change when dysregulation constructs of impulsivity and emotional resilience were added to the model. No paths significantly differed between genders. Altogether, among college student pornography users, religiosity was strongly positively correlated with moral disapproval (β = .65 men, β = .62 women), moral disapproval was moderately positively correlated with PPU (β = .41 men, β = .29 women), religiosity was initially moderately positively correlated with PPU (r = .21 men, r = .22 women), but became non-significant in the full model (β = - .21 men, β = - .04 women), and indirect effects of religiosity to PPU through moral disapproval were significant (indirect β = .27 men, β = .18 women). None of the dysregulation constructs significantly predicted PPU. The full model accounted for 23-22% of the PPU variance in men and women, respectively. Implications, future directions, and limitations are discussed.

Treatment Approaches for Problematic Pornography Use: A Systematic Review

Problematic pornography use (PPU) is an emerging condition associated with several negative psychological and sexual outcomes. This study aimed to systematically review treatment approaches for PPU. Potentially eligible studies were searched for in PubMed/MEDLINE, Embase, PsycINFO, and Web of Science up to April 1, 2023. The quality of the evidence was assessed with the use of the Joanna Briggs Institute's checklists, the Cochrane risk-of-bias tools, and the GRADE approach. A total of 8936 references were retrieved, and 28 studies were included in the systematic review (n = 500 participants). Included studies were case reports (k = 16), case series (k = 1), quasi-experimental investigations (k = 7), and randomized clinical trials (k = 4). The majority of included studies presented overall low quality and significant risk of bias, with all interventions receiving a low or very low rating according to the GRADE approach. Most studies investigated psychological interventions, with the predominance of second and third wave cognitive behavioral therapy interventions. Pharmacological treatments included opioid antagonists (naltrexone in most cases) and antidepressants, while one study investigated a protocol that included rTMS. Several investigations described the combination of psychological and pharmacological approaches. Most studies did not report on side effects, with online and self-help interventions presenting significant issues in terms of treatment adherence. Even though there are promising options that may have efficacy for the treatment of patients with PPU, the literature in the topic still presents significant limitations that compromise the reaching of more definitive conclusions.

Withdrawal-like Symptoms in Problematic Pornography Use: A Scoping Review

OBJECTIVES

There is still debate whether problematic pornography use (PPU) can be understood as an addictive disorder, and little is known about withdrawal-like symptoms in these patients. Therefore, our aim was to summarize the existing scientific literature about this topic in the format of a scoping review.

METHODS

Potentially eligible references were retrieved from 6 databases (MEDLINE/PubMed, Web of Science, Embase, PsycINFO, LILACS, and SciELO) up to February 7, 2023. Studies were included if they reported original data about withdrawal-like symptoms in individuals with PPU. Studies investigating child pornography use, or in which it was not possible to extract data of interest were excluded. Data extracted from included studies and their quality assessment were described narratively.

RESULTS

A total of 937 references were retrieved, and 14 studies were included (n = 31,009 participants). According to our results, cravings were intense in most cases and frequent reasons for relapse. The proportion of participants experiencing other withdrawal-like symptoms (mental, sexual, and physical symptoms) reached up to 72.2% in the cross-sectional studies with this information available. Severity of withdrawal symptoms was associated with severity of PPU and frequency of pornography use. In some studies, measures of withdrawal symptoms were considered central symptoms of PPU and were significantly higher in individuals considering treatment. Masturbation was reported to alleviate withdrawal-like symptoms in some cases.

CONCLUSIONS

There is preliminary evidence for the existence of withdrawal-like symptoms in PPU. Future studies should investigate onset, characteristics, duration, and proportion of withdrawal-like symptoms in PPU with robust methodology, also investigating potential confounding variables.

Identifying Relationships Between Difficulties with Emotion Regulation and Compulsive Sexual Behavior

Emotion dysregulation is an associated feature of compulsive sexual behavior disorder (CSBD), now recognized by the World Health Organization. Previous studies have identified associations between trait emotion dysregulation and CSBD. Given that difficulties with emotion regulation (DERS) is comprised of several facets (e.g., difficulty with impulse control and lacking awareness of one's feelings when upset), and that these facets differentially relate to other mental health concerns, the present study aimed to examine how DERS facets relate to compulsive sexual behavior (CSB). The present study also considered interpersonal emotion regulation via attachment avoidance and attachment anxiety. Hierarchical regression was conducted, first accounting for demographic covariates, then adding attachment styles, and finally all DERS subscales. Results indicated that, among a large, diverse, online U.S. sample (N = 915; Mage = 39.21, SD = 0.81; 54.3% men), difficulty controlling impulses when upset, difficulty with clarity of emotions, and non-acceptance of emotions were significantly positively associated with CSB (small to moderate effects). Attachment anxiety and avoidance were also significantly positively associated with CSB, although their effects were minimal when adding DERS facets. Overall, this study supports the theorized impact of emotion dysregulation on CSB. Assessment of individual differences in DERS and intervening on these concerns are important for treating CSB.