Pornographic addiction: Is it a distinct entity? (2017)

Adnan Kadiani, Ekram Goyal, Spandana Devabhaktuni, Brig Daniel Saldanha, Bhushan Chaudhari
Department of Psychiatry, Dr DY Patil Medical College, Hospital and Research Centre, Pune, Maharashtra, India

Correspondence Address:
Brig Daniel Saldanha
Department of Psychiatry, Dr D. Y. Patil Medical College, Pimpri, Pune – 411 018, Maharashtra
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/MJDRDYPU.MJDRDYPU_303_16

Among all the different types of behavioral addictions, the one related to sexual activity is probably the most difficult to treat as we are reluctant to discuss issues related to sex. From innocuous viewing of pornographic content in adolescence, a 34-year-old married male for 6 years becomes addicted to it. The case highlights the importance of recognizing pornographic addiction as a disorder and the difficulties encountered in its management.

Keywords: Cognitive behavioral therapy, porn-watching behavior, pornographic addiction

The exponential growth of the internet in recent times shows the extent of people, who view pornography, i.e., there are over 4.2 million pornographic websites with 68 million daily pornographic search engine requests. Nearly 42.7% internet viewers view pornography and 72 million view adult sites worldwide per month. Almost 28% of China’s and South Korea’s porn revenue amounts to over $27.40 billion each that is enough to feed 62% of the world’s hungry population for the entire year.^[1] Given the above facts, internet addiction though not listed in the mental disorders in International Classification of Disease 10 or Diagnostic and Statistical Manual of Mental Disorder-5 (DSM-5), its presence is a matter of debate though many claim themselves to be addicted to pornography and seek help.^[2] Some researchers have tried to compare it with criteria for other established addictions such as substance abuse.^[3] The closest behavioral addiction that could be compared to it is perhaps “gambling” which is referred to as an addiction without a drug. The rationale of including gambling as an addictive diorder along with substance use disorders is based on evidence from clinical studies indicating that gamblers do share brain abnormalities and behavioral abnormalities commonly seen in individuals with substance use disorders.^[3],[4]

The study of behavioral addictions i.e. gambling, internet surfing, gaming, shopping, food, work, sex, etc., has gained increasing popularity in recent years.^[4] Sexual addiction is a state of persistent behavior acted out despite increasingly negative consequences to self and distress to others. Sexual addiction has many different forms: compulsive masturbation, sex with prostitutes, anonymous sex with multiple partners, multiple affairs outside a committed relationship, habitual exhibitionism, habitual voyeurism, inappropriate sexual touching, repeated sexual abuse of children, and episodes of rape. Sometimes, addiction may not involve acting out of sexual activity in public, instead, it may involve hours of reading and watching pornography.^[5] 20%–60% college-going males reported viewing pornography problematic depending on their domain of interest. There have been a few scientific cases reports documenting pornographic addiction and its adverse consequences.^[2],[6] We present one such case that came to our attention.

A 34-year-old male married since 6 years came to the outpatient department along with his wife with the intention to resolve marital issues mainly concerning husband’s disinterest in sex and his relative preoccupation with pornography for the past 3 years. The current problem had risen 3 years ago when his wife was pregnant, and they could not indulge in sex more often which they were used to because of the restrictions due to pregnancy.

The husband gave history of watching pornography since the age of 16 years. Although infrequently then, he now resorted watching more frequently followed by masturbation. He confessed that he started spending more time watching pornography to achieve his desired level of pleasure. At the time of reporting, he spent 4–5 h/day or even more at times on viewing pornographic material. He watched the films even after he had finished masturbating and reported getting gratification only on viewing those films. If his time was cut short or he was interrupted by someone, he developed distress and became irritable. At work, he was warned for improper conduct after an internet virus had led to system failure and was traced down to the pornographic websites he had visited. Later, after no longer being able to view sexually explicit sites at the workplace, the patient took pornographic magazines with him and spent most of his time reading them. These practices had significantly decreased his ability in concentration and work efficiency. He started spending less time with his daughter and wife and more time alone in front of his computer or mobile phone. His wife noticed a change in his behavior and spending more time on the internet. On getting unsatisfactory answers to her queries and disinterest in her and his daughter, she confronted him and became aware of his problem of internet pornography viewing to satisfy his libido. He accepted that he was unable to control his urges and desire for viewing pornographic material even though he loved his wife and knew that this had put his marriage at stake. He, however, told her that he will not seek professional help as he felt he can give it up. His wife, however, was not convinced, and she brought him for consultation.

Mental status examination revealed low mood and depressed affect. His thought process showed the feeling of helplessness and hopelessness regarding his inability to control his behavior. On Hamilton Depression Rating Scale (HAM-D) he scored 9. There were no delusions or hallucinations. His judgment and insight were intact. We ruled out, Obsessive Compulsive Disorder (OCD), depression and personality disorder through serial and separate interviews of the patient and the wife. This was done independently by two psychiatrists, and a final diagnosis of internet addiction was made after due diligence keeping in mind the diagnosable criteria as applicable to substance use disorders. There was no history of paraphilias of any kind. We created a therapeutic milieu to tackle his problem and addressed three problematic areas in his life, namely, (a) personal, (b) family, and (c) occupational.

Personal

The patient was screened for other coexisting factors associated with the development of addiction. The patient falsely assumed that mild improvement is enough to say, “I have control over my urges.” Denial of the problem had to be contained. He was explained that complete recovery meant investigating the underlying issues that led up to the behavior and resolving those issues in a healthy manner; otherwise, relapse was the likely outcome.

He was educated about how such behavioral patterns could stem from other emotional or situational problems such as depression, anxiety, stress, relationship troubles, marital problems, and/or career difficulties. He rationalized his behavior by saying, “I am not harming anyone by watching porn,” “and I am not cheating on my wife by visiting sex worker.” With his growing preoccupation with pornography, he was not only missing important deadlines at work but spent less time with his family.

The early stage of therapy was behavioral, focusing on specific behaviors and situations where the impulse control disorder caused the greatest difficulty. Behavior therapy took into consideration all the portals through which the patient accesses pornographic content including gadgets and pictorials such as magazines. He was also explained that mobile phones and other gadgets have become an important part of our lives and that did not mean that we have to be addicted to them, but we can maximize their usefulness in better ways. One of the initial goals of behavioral therapy was to begin managing time spent on pornographic content and developing a clear and structured recovery program.

In this case, cognitive behavioral therapy (CBT) was applied to reduce symptoms, improve impulse control, challenge cognitive distortions, and address personal and situational factors specifically associated with the compulsive use of the Internet and to deal with maladaptive thoughts often associated with it.

Harm reduction therapy and maintaining the daily content viewing log

A particular pornographic site, a certain time of day or a patient’s mood just before watching serve as triggers that can lead to inappropriate conduct and abuse. To help pinpoint and determine these triggers, he was asked to maintain a daily content log to keep track of when and how he watched and to record the date and time of each activity, the antecedent events leading up to watching porn, and the means of accessing the content. Next, he was asked to keep track of how long each session lasted, specifically recording the number of minutes or hours per se ssion. He described the outcome of each session in terms of what actions were completed, what activities were interrupted while watching porn, or the feelings he experienced after each session. Keeping such a detailed log served as a baseline to identify high-risk situations that lead to excessive use. This helped us to set goals in treatment planning.

In the next step, the client was advised to delete bookmarks or favorite files on the computer and to discard the paraphernalia which he used while watching or reading pornographic content.

Few sessions focused on the cognitive restructuring of the client. Cognitive restructuring involved systematic identification of the problematic thought patterns which contributed to the onset and maintenance of his problematic porn viewing. This helped in re-evaluating the rationale of his behavior toward his wife and child.

In due course, challenging this type of negative and faulty interpretation of his behavior and active cooperation of his wife helped the individual to gradually overcome the compulsive viewing of internet pornography. The client was encouraged to give a list of major problems caused by addiction and to come up with major benefits of cutting down or abstaining from pornographic use. The patient was given 12 sessions of CBT over a period of 3 months of 45–60 min each. And to contain his anxiety, distress, and mild depressed affect we started on a suitable selective serotonin reuptake inhibitor (SSRI) tablet sertraline in the dose of 50 mg initially once a day and gradually increased to 150 mg a day.

Family and occupation

As the patient was having relationship trouble with his wife, couples counseling was suggested instead of turning to cybersex to address those intimacy issues. Also as he was caught watching porn at work, he was taught progressive muscle relaxation and distraction techniques for effective stress management to help him relax instead of relying on porn. He was encouraged to distract himself whenever he had the urge to watch pornographic material by taking a stroll through the office or to go and see what the family member is doing in the next room. These techniques helped him to wean himself from the problematic use and focus on ways to disrupt old patterns of addictive behavior. Gradual inclusion of his wife in the sessions, effective communication and behavior exchange technique strengthened their relationship. After serial outpatient reviews once he was found to have resolved his marital issues to a great extent we tapered of the SSRI tablet sertraline in 3-month time. The patient reported a significant decrease in the frequency of porn watching behavior and improved intimate relationship with his wife. During the last review, the wife reported improvement in her husband’s behavior and marital bond that existed between them in their early part of marital life.

There are innumerable opportunities for anyone to explore the sexual content on the internet for self-gratification of one’s inner urges. A 1-year longitudinal study of Internet applications by Meerkerk et al. revealed Internet pornography to have the highest potential for addiction.^[7] DSM in its 5^th edition included gambling disorder as a nonsubstance-related addiction disorder. The criteria to diagnose gambling addiction were modeled along the general characteristics of substance addiction, namely compulsive consumption, withdrawal, tolerance, unable to cut back even after socio-occupational impairment. However, it refrained from adding sexual behavioral disorder because there was not enough literature to establish diagnostic criteria for hypersexuality and its subtype excessive pornographic viewing.^[8],[9] A functional magnetic resonance imaging study of men seeking treatment for problematic pornographic use (PPU) Gola et al.^[10] found increased activation of a brain reward region (the ventral striatum) specifically for erotic pictures than for monetary gains. This brain activation was accompanied by increased behavioral motivation to view erotic images (higher “wanting”). Ventral striatal reactivity significantly related to the severity of PPU, the amount of pornography use per week and number of weekly masturbations. These were similar to substance use and gambling disorders. These findings suggest that PPU may represent a behavioral addiction suggesting thereby interventions in targeting behavioral and substance addictions may help men with PPU.^[11],[12] Studies also suggest that gamblers’ risk-taking behavior have an underlying neurological cause, i.e., subnormal 3 methoxy-4 hydroxyphenylglycol (MHPG) concentration in plasma and increased MHPG concentration in cerebrospinal fluid. There is also evidence to suggest serotonergic regulatory dysfunction in pathological gamblers.^[13] Hence, the usefulness of SSRI in cases such as internet addiction which is akin to gambling disorder is worthwhile, and we did find it useful in our case to break his initial reluctance to accept professional help.

The patient’s reluctance in accepting professional help in the beginning and willingness later, his wife’s timely intervention and cooperation throughout helped this case in ameliorating the symptoms to restore his family life.

The criteria for calling our case as a pornographic addiction seem to meet the general criteria for behavioral addiction. In that, he had tolerance, withdrawal, salience, and socio-occupational impairment related to his porn-watching behavior.

Pornographic addiction is difficult to manage without full cooperation of the patient as well as those affected. With more number of cases coming to light and further work may strengthen it as a case for inclusion as an addictive disorder.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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