Another failure of the latent disease model? The case of compulsive sexual behavior disorder •

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 absurdity of the latent disease model in mental health: 10,130,814 ways to have a DSM-5-TR psychological disorder

BACKGROUND

Latent disease classification is currently the accepted approach to mental illness diagnosis. In the United States, this takes the form of the Diagnostic and Statistical Manual of Mental Disorders-5-Text Revision (DSM-5-TR). Latent disease classification has been criticized for reliability and validity problems, particularly regarding diagnostic heterogeneity. No authors have calculated the scope of the heterogeneity problem of the entire DSM-5-TR.

AIMS

We addressed this issue by calculating the unique diagnostic profiles that exist for every DSM-5-TR diagnosis.

METHODS

We did this by applying formulas previously used in smaller heterogeneity analyses to all diagnoses within the DSM-5-TR.

RESULTS

We found that there are 10,130,814 ways to be diagnosed with a mental illness using DSM-5-TR criteria. When specifiers are considered, this number balloons to over 161 septillion unique diagnostic presentations (driven mainly by bipolar II disorder). Additionally, there are 1,951,065 ways to present with psychiatric symptoms, yet not meet diagnostic criteria.

CONCLUSIONS

Latent disease classification leads to considerable heterogeneity in possible presentations. We provide examples of how latent disease classification harms research and treatment programs. We echo recommendations for the dismissal of latent disease classification as a mental illness diagnostic program.

Multicultural Considerations for the Psychometrics of the Brief Pornography Screen

Problematic pornography use (PPU) is a burgeoning area of clinical interest. The Brief Pornography Screen (BPS) is a new PPU measure. The BPS has not been psychometrically studied within specific race/cultural groups. We sought to broaden the PPU literature by examining the confirmatory factor analysis (CFA) fit, measurement invariance, and structural invariance of the BPS across eight identity groups. Participants came from a survey administered at three U.S. universities. In total, n = 2,475 participants were analyzed, with the following identity group breakdowns: Asian American/Pacific Islander (AAPI) male = 268, AAPI female = 303, Black male = 101, Black female = 189, Latin male = 208, Latin female = 372, White male = 432, and White female = 602. BPS CFA fit was good across all groups. Measurement invariance analyses suggested metric, but not scalar invariance across all groups. We then split participants by sex assignment, full residual invariance was evident across groups for male participants and partial residual invariance was evident for female participants. Structural invariance analyses indicated anxiety as a weak positive BPS correlate in AAPI, Latin, and White male participants (β's = 0.25-0.27), but not meaningfully related in the other groups. Pornography viewing frequency was positively correlated with BPS scores across most groups with a wide range (β's = 0.29-0.52), except for Black male participants (β = 0.15). Our results suggest that the BPS is an appropriate PPU measure across the tested identity groups. While between-group measurement is relatively accurate within sex assignment groups, correlates differed in strength, meaning different variables likely predict PPU for different groups of people.

Compulsive sexual behavior disorder in an inpatient sample with substance use disorder

Background

Several studies indicate that compulsive sexual behavior disorder (CSBD) shares core elements with substance use disorder (SUD). These findings support the assumption of common mechanisms in addiction, which may lead to a higher tendency in patients with SUD to have comorbid CSBD. Nevertheless, this relationship between CSBD and SUD is poorly understood to date.

Aim

This study aimed to compare the prevalence of CSBD and its subtype pornography use disorder (PUD) between a SUD group and a matched control group. Herein, we aimed to test whether patients with SUD are more likely to have a comorbid CSBD/PUD. We further hypothesized that a higher CSBD/PUD prevalence in patients with SUD is accompanied by more pronounced CSBD- and PUD-related personal characteristics.

Methods

We assessed CSBD, PUD, and related personal characteristics in an inpatient SUD sample (N = 92) and a healthy control sample matched by age, gender, and educational level.

Outcomes

Primary outcomes were the diagnoses of CSBD/PUD as assessed by questionnaires. CSBD/PUD-related personal characteristics were the early onset of problematic pornography consumption, relationship status as a single person, a high sexual motivation, a high level of time spent watching pornography, and a high degree of problematic pornography consumption (Problematic Pornography Consumption Scale, short version).

Results

There was no significant difference between groups regarding CSBD prevalence (SUD sample, 3.3%; control sample, 7.6%) and PUD prevalence (SUD sample, 2.2%; control sample, 6.5%). We found relationship status as a single person and the sexual motivation dimension of importance of sex to be the only CSBD-related personal characteristics that were more pronounced in the SUD sample than the matched control group.

Clinical Implications

Results indicate no higher tendency for patients with SUD to develop comorbid CSBD/PUD, yet important vulnerabilities (eg, emotional dysregulation) should be considered when treating addictive disorder to prevent possible symptom displacement.

Strengths and Limitations

A strength of the study is that we compared a sample of patients with SUD with a matched control sample and used an instrument based on ICD-11 criteria for CSBD. Possible limitations are significant differences between the groups because of the restrictions in an inpatient clinic that may have influenced responses (eg, roommates) and that the control group was not screened for SUD. Therefore, the results should be interpreted with some caution.

Conclusion

We found no evidence of an overcomorbidity of SUD and CSBD/PUD. However, a higher rate of vulnerability factors for CSBD/PUD in the SUD sample might suggest some similarities between SUD and CSBD/PUD.

Two subtypes of compulsive sexual behavior disorder

Models explaining addictive behaviors such as the Interaction of Person-Affect-Cognition-Execution (I-PACE) model emphasize the importance of reinforcement mechanisms for developing and maintaining these behaviors, including compulsive sexual behavior disorder (CSBD) as well as personal characteristics as vulnerability factors. This study aimed to determine whether there are CSBD subtypes distinguished by reinforcement sensitivity. We hypothesize that one subtype is sensitive to positive reinforcement (C+subtype) and one is sensitive to negative reinforcement (Ȼ-subtype). We calculated a cluster analysis with data from 62 patients with CSBD and tested differences between the identified clusters by t-test. The sample consisted only of men. Cluster variables were: the sensitivity to the Behavioral Inhibition and Approach System (BIS/BAS), the severity of depressive symptoms (BDI-II), the severity of Trait Anxiety (STAI-T), Sexual Sensation Seeking (SSSS), Thrill- and Adventure-Seeking (SSS-V subscale), Disinhibition (SSS-V subscale), Experience Seeking (SSS-V subscale), and Boredom Susceptibility (SSS-V subscale). Between-cluster differences were analyzed for Trait Sexual Motivation (TSMQ) and Sexual Compulsivity (SCS). The results showed a two-cluster solution with cluster 1 representing patients sensitive to negative reinforcement (Ȼ-subtype) and cluster 2 representing patients sensitive to positive reinforcement (C+subtype). No significant difference in symptom severity of Sexual Compulsivity between clusters was found. Cluster 2 showed higher Importance of Sex and a higher motivation to seek sexual encounters than cluster 2. We found a two-cluster solution regarding reinforcement sensitivity in patients with CSBD. This may have clinical implications regarding individual therapy by focusing on the underlying maintenance mechanisms.

Clarifying and extending our understanding of problematic pornography use through descriptions of the lived experience

Problematic pornography use (PPU) is a complex and growing area of research. However, knowledge of the PPU lived experience is limited. To address this gap, we conducted an online qualitative study with 67 individuals who self-identified as having problematic pornography use (76% male; Mage = 24.70 years, SD = 8.54). Results indicated several dimensions that have not been fully explored in the literature. These included various mental and physical complaints following periods of heavy pornography use, sexual functioning deficits with real partners, and a subjectively altered state of sexual arousal while using pornography. Moreover, we expanded on current knowledge regarding the inner conflict associated with PPU and clarified the ways that users can progress to increasingly intensified patterns of pornography use, such as tolerance/escalation and pornographic binges. Our study highlights the complex and nuanced nature of PPU and provides suggestions for future research and clinical practice.

Behavioral addictions in the ICD-11: An important debate that is anticipated to continue for some time

The Journal of Behavioral Addictions featured a debate on the topic of "behavioral addictions in ICD-11" in 2022. Three main debate papers were published and a total of eleven commentaries. One main topic of considerations in the three debate papers and in the majority of commentaries was compulsive sexual behavior disorder. The debate was balanced, collegial and conducted at a high scientific level. Although there are some disagreements regarding specific details, all authors consider more research on behavioral addictions as important. This scientific debate has been and continues to be enormously important to behavioral addiction research and clinical practice.