DSM-5 Attempts to Sweep Porn Addiction Under the Rug (2011)

Finally, the American Society of Addiction Medicine has acted, since the DSM would not.

Sweeping neuroscience under the rugThe Sexual and Gender Identity Disorders work group for the upcoming Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is currently discussing whether to demote the proposed “Hypersexual Disorder” (which addresses compulsive porn use, among other behaviors) from Sexual Dysfunctions to the appendix. Further, a member of the work group advises that “Hypersexual Disorder” may be banished altogether, offering no explanation.

The DSM is psychiatry’s bible. If a disorder isn’t in there, insurance companies won’t reimburse treatment costs for it, so psychiatrists don’t diagnose patients as having it. In the health care world, “Reality is what the DSM says it is.”

So, if you fall into compulsive Internet porn use…tough luck. Your condition doesn’t exist and you will be treated, if at all, for the unpleasant symptoms of addiction (such as anxiety, ED, depression, concentration problems) on the assumption that these conditions predated, and are unrelated to, your excessive porn use. No one will breathe a word to you about your actual pathology: addiction-related brain changes. It’s the equivalent of giving you Vicodin for the pain of your leg fracture instead of setting it—while allowing you to continue limping along on it without a cast.

This move comes just as the DSM’s pathological-gambling work group has determined that another highly stimulating, non-substance compulsion, gambling, will be upgraded to the renamed category: Addiction and Related Disorders—so that they can treat such patients for addiction. How, in the name of science, can one compulsion (gambling) be recognized an addiction risk while the other (compulsive sexual behavior) is casually dismissed?

All addiction is a matter of science

In recent years, the DSM has been taking a lot of heat for generating new mental health pathologies, some of which have resulted in over-diagnosis and over-medication. We understand its desire not to stick out its collective neck just because people chase booty or look at raunchy videos to excess.

However, as the gambling revision indicates, behavioral addictions are now verifiable pathologies “characterized by a loss of rational control, as well as significant and measurable changes in the neurochemistry of the brain.” The same physiological mechanisms and anatomical pathways are at work in gambling, video gaming, overeating, drug use and excessive sexual behavior. We now have the tools to measure (across populations) brain changes associated with all addiction. As a neurologist Max Wiznitzer  explained,

We already know what the [brain] imaging profile is for addictive behavior and what the profile is for the reward system, which is the dopamine system. …[T]his is a nonspecific activation pattern that is not stimulus sensitive. No matter what the addiction, it’s going to affect the same areas.

Similarly, Stanford University psychologist Brian Knutson observed:

It stands to reason if you can derange [brain circuits that evolved to reward survival-enhancing behavior] with pharmacology, you can do it with natural rewards too.

In short, rather than demoting or removing “Hypersexual Disorder” from the DSM, the work group should move it to the new Addiction and Related Disorders. Already the DSM acknowledges that pathological gamblers and those suffering from compulsive sexual behaviors often show similar symptoms, such as inability to control use despite negative consequences and escalation to more extreme stimulation. (Compare criteria here and here.)

There are oodles of comforting studies on gamblers’ brains using scans and tests, all of which show clearly that excessive gambling can cause physiological changes that are very like the brain changes in substance abusers. In contrast, there are only a couple studies on the brain effects of excessive Internet porn use or sex addiction. However, they do reveal the kinds of ominous changes observed in gamblers’ brains.

These lopsided databases don’t indicate that today’s hyperstimulating porn/chat can’t cause addiction—as some sexologists assert. They mean that desperately needed research hasn’t been done—and isn’t likely to be done very promptly—for reasons we’ll get to in a moment.

Gambling researchers have already developed blood tests, cognitive tests and, of course, brain scans that measure key addiction characteristics objectively. While such tests are impractical for individual use, they have helped to establish the diagnostic criteria for addiction-related disorders. It may be that the DSM criteria for diagnosis of hypersexual addiction could already be honed to detect even more accurately the presence (or absence) of addiction-related changes: dopamine dysregulation (numbed pleasure response), sensitization and hypofrontality.

There may, for example, be a marked difference in the brain of someone presenting Tiger Woods-type behavior compared with someone hooked on today’s Internet porn and struggling to quit. Consider this young recovering porn user’s subjective experience:

After a couple weeks of no PMO (porn/masturbation/orgasm), I tried something completely different – M and O without P – something I’ve never considered. Two days later, I added the P to the MO on a whim and relapsed. The two experiences were vastly different. Just MO was almost shocking, because I had no uncomfortable buzz afterward, no shift of perception. It turned out to be a sweet, invigorating feeling. In contrast, the full PMO session felt like I was totally on a DRUG. Every picture turned my body into a searing blast of tension, each new one more powerful than the last. I felt almost like a “dope surge” run from my brain through my body. Suddenly I could hear and feel EVERYTHING more intensely. Then it was like a cloud of idiocy swept over me, and everything went numb. That feeling lasted two days at least. Enlightening.

It would be unwise to wait

No doubt the DSM work group would like to see more research before taking action to help those who prove susceptible to pathological brain changes due to today’s extremely sexual environment. We would, too. Here, however, delay would be negligent, and especially dangerous for those who fall into compulsive porn use early in life. (Unlike gambling, which is largely confined to adults with funds, Internet porn is free and available to all ages.) Without correct diagnosis, youngsters who start long before their brains are fully developed and slip into a spiral of mind-bending escalation may never discover what balance feels like.

The DSM should act now. Here’s why:

1.            Unlike gambling, today’s porn use isn’t confined to a relatively small minority of the population. 2008 statistics revealed that 87 percent of male, and 31 percent of female, computer users already viewed porn. This means that if the DSM work group is guessing wrong about porn’s harmlessness, there is potential for many to suffer needlessly until some future DSM work group changes course. A new survey of 2000 young Swedes  using the Internet for sex reveals that 5% of women and 13% of men report problems with their use. A 2009 study of US college males found even higher percentages of users acknowledging porn-related problems. These data are significant given that younger porn/chat users are unlikely to see excessive sexual behavior as a problem. In fact, many troubled users, especially those who slide into erectile dysfunction, do not recognize that Internet porn use was the source of their addiction-related symptoms until weeks after they quit, and experience improvements in mood, desire to socialize, and sexual responsiveness. If you know your peers have been masturbating to Internet porn since they started, and experts insist there’s no such thing as “too much,” your symptoms have to get pretty bad before you rethink cause with effect. Italian urologists, however, are starting to make the impotence-porn connection.

2.            More research would be ideal, but is unnecessary to recognize compulsive porn use as an addiction-related disorder. Evidence of the last 10 years now firmly supports the addictive potential of natural rewards. Chairman of neuroscience at Mount Sinai Medical Center Eric Nestler says, “Growing evidence indicates that the VTA-NAc pathway and the other limbic regions … mediate, at least in part, the acute positive emotional effects of natural rewards, such as food, sex and social interactions. These same regions have also been implicated in the so-called ‘natural addictions’ (that is, compulsive consumption of natural rewards) such as pathological overeating, pathological gambling and sexual addictions.” In short, today’s hyperstimulating porn has the power to dysregulate dopamine in some users’ brains—whether or not scientists ever research Internet porn’s effects on the brain.

3.            Scientists have also isolated various factors that increase the risk of addiction, such as ease of access (unlimited porn is available 24/7 at a click) and novelty-on-demand. In other words, there are solid, scientific reasons to conclude that today’s porn has the potential to cause brain changes that can tamper with free will, dampen responsiveness to pleasure, and bloom into full-fledged addiction. Sexologists currently place all porn in the same “harmless” category, but, in fact, Internet porn is far more potentially addictive than static erotica, or even rented DVDs of the past. It’s unlikely one would develop ED masturbating to Playboy or a rental of the pizza boy doing a customer. In contrast, clicking effortlessly to endless novelty and variety and seeking out ideal, hotter, or more tension-producing material all release the dopamine that can override natural satiety and lead to dysregulation. Novelty can, in fact, serve as its own neurochemical reward quite apart from orgasm. You may not want another bite of burger…but you’ll eat three times the calories for dessert in the form of cheesecake. Squirts of dopamine in your brain override satiety.

4.            The risk of compulsive porn use may be growing as youthful viewers start out with increasingly stimulating material. (Young brains produce more dopamine and are more plastic.) Despite the mainstream belief that porn is innocuous, porn recovery websites are springing up all over the web. Visitors to such sites and visitors to Q&A sites like Medhelp and Yahoo Answers report compulsive use and other symptoms common to all addicts: withdrawal, tolerance (need for increasing stimulation), greater anxiety, altered priorities, and so forth. Some develop uncharacteristic social anxiety, concentration problems, and delayed ejaculation/ED. Brain research suggests that all of these symptoms may best be explained by dopamine dysregulation in the brain—a fundamental characteristic of all addictions.

5.            Finally, if the DSM dismisses compulsive porn use from the upcoming manual, who is likely to fund attempts at further brain research? The DSM is not proactive in demanding research. Sexology researchers aren’t encouraging it because most have not been trained to understand (and therefore dismiss) its relevance. Behavioral addiction researchers understand its relevance, but tend to focus their efforts elsewhere (obesity, gambling, video gaming)—in part to avoid strident accusations of “moralizing” by the uninformed. Moreover, there’s little point in waiting for the perfect research because researchers will remain hampered in their efforts to measure Internet porn’s actual effects. Mere surveys won’t get at the full scope of brain effects. Correctly designed studies face a serious hurdle: It’s hard to find control groups of porn “virgins.” Even if they could be found, it’s unlikely that ethics committees would sanction exposing naïve subjects to the kinds of extreme, and potentially brain-altering, material casually viewed by many of today’s users.

In short, if the DSM doesn’t act, we may be waiting a very long time for some future DSM work group to sort things out. Meanwhile, health care providers are left with no way to diagnose and effectively treat patients’ compulsive porn use because it doesn’t officially exist. Indeed, it’s likely that many clinicians (with clients desperate to stop porn use) would be outraged if they were fully aware of the work group’s intention to quietly move or remove “Hypersexual Disorder.”

Empowering the client

Contrary to the medical model, which declares all of us normal until we cross an imaginary line into pathology, use of hyperstimuli is a slippery slope for many. If the DSM were to acknowledge that excessive porn use is an addiction-related disorder, it would indirectly help to educate porn users about the symptoms that signal addiction processes at work before they become addicts.

For example, it would quickly become common knowledge that decreasing sexual responsiveness in porn users is not “normal,” but rather evidence of tolerance; that symptoms will recede if users stop and give their brains time to restore normal sensitivity; that withdrawal can be painful and anxiety-producing, depending upon the degree of dysregulation; and that full recovery can take months.

A clear understanding of what is going on in his/her brain, and how his behavior impacts those brain changes, empowers the patient/client. He can gauge his progress and his setbacks as he restores his brain’s natural sensitivity. He soon feels a sense of optimism, and even relapse is educational. Here are comments of four men who have applied the recent behavioral-addiction brain science to their heavy porn use:

I experienced a no-libido period for weeks right after I quit, but now I seem to walk around with a boner all day and feel like an animal I have to tame when around women. Not surprisingly, I have no trouble achieving and maintaining a solid erection during sex. This is opposed to sitting in front of the computer stroking a half-erect penis to hardcore pornography like I was 1-2 months ago.

This time around [13 days of abstinence from porn/masturbation] also assuaged some of my fears [about my attraction to transexual porn] and helped reinforce the fact that if I do quit this addiction, I will be completely able to have healthy sex with women. Yes, I binged, but along with the binge came a silver lining. Those first few times masturbating were very exciting and it was to very vanilla softcore porn. It showed me that without binging, my sexual tastes will begin to normalize and that was very, very reassuring. This vanilla stuff wouldn’t even have been a blip on my radar four weeks ago, but now it drove me wild. Of course, as I continued the binge I progressed onto more extreme material, again making all too clear how the addiction works on my tastes. I had to escalate to get that same rush.

It’s now been 34 days since I engaged in the full PMO cocktail I was using, and the longer I go, the more I can feel my willpower growing. I find myself more positive and productive and that’s helping a ton. I’ve got a couple of prospects on the online dating front – one that should lead to a date this week. I’ve also noticed myself appreciating the beauty of real women more, which is just awesome.

If you can manage at least 3 weeks, you’ll see how powerful all of this is. The clarity and lack of depression for me was extremely noticeable and I felt like a different person. It gave me some hope that there is nothing fundamentally wrong with me. I see myself having a spice of life again. Just with everybody. Honestly my life, socially speaking, is changing, and I see it even when I have an occasional relapse.

If the DSM sweeps porn problems under the rug, then these (mostly younger) people are left with no way to comprehend their circumstances accurately. They may easily end up on psychotropic drugs for life—in error.

This dismal outcome is the result of half a century of misguided dogma about hypersexuality. Academic sexologists presume that, unlike other addictions, hypersexuality arises from “pre-existing conditions” such as ADHD, OCD, depression or anxiety/shame. They presume this, in part, because of their rigid convictions that porn use cannot cause pathology. While it is true that genetics and childhood trauma can predispose some people toward addiction, it is rash to presume that this is always the case in hypersexuality, and that excess itself cannot dysregulate dopamine.

In fact, recovering porn users consistently report improvements in the very symptoms of those conditions, whether or not they supposedly had such a condition. In other words, whatever their starting point, changing their behavior is therapeutic. Indeed, for all we know, research might someday show that medications for commonly diagnosed conditions such as ADHD, depression and anxiety are less effective than simply stopping Internet porn use—much as antidepressants are less effective than exercise.

Probably the most distressing porn-related symptom for which young men now seek medical treatment is ED. They fear they are ruined for life, that nothing can be done, that they will never be able to sustain a relationship. Some are even suicidal. Yet if they think to ask their doctors about ED and excess, they inquire about “masturbation,” and are swiftly assured that masturbation can’t cause ED (probably true). However, nearly every younger guy who says “masturbation,” actually means “masturbation to Internet porn.” Thus, the message he takes away is that masturbation to Internet porn cannot be causing his ED (false).

Conflating today’s porn with masturbation confuses both patients and medical professionals. It’s hyperstimulation that overrides natural satiety and triggers pathological brain changes, not masturbation—or rather the combination of the two—that causes problems. Meanwhile, when doctors test their young ED patients’ hormones, etc., and don’t find anything wrong, they give them the pat answer, required by the deficient DSM, that their problems are “due to anxiety.” Small comfort indeed for a desperate young man whose problem is reversible if he is properly diagnosed and educated.

Let’s do the right thing

It’s time for the DSM to face the science of behavioral addiction squarely with respect to sexual compulsivity. Sexual compulsives need help understanding the changes in their brains so they can restore them to normal sensitivity. Pills and counseling for “pre-existing conditions” don’t do the job.

Academic sexologists traditionally shrink from modifying anyone’s sexual proclivities. However today’s “normal” (i.e., typical) porn use is giving rise to symptoms in some users that are very abnormal from a physiological standpoint. As a society, we need to get very clear about the effects of sexual superstimuli on the brain by employing recent addiction-science discoveries and diagnostic tools rather than historical academic presumptions.

Even academic sexologists may one day be glad if the DSM jumpstarts their awareness of the profound link between sex and recent brain science. Addiction research is revealing important information about the very brain circuitry most relevant to their profession. The reward circuitry governs/facilitates libido, erections and orgasm in addition to addiction. Better education about this circuitry of the brain would, in fact, foster a more enlightened understanding of critical aspects of human sexuality and pair bonding.

Meanwhile, nearly every computer savvy young man is finding his way to Internet porn/chat. Girls’ use is growing, too. Porn’s effects on their brains won’t go away because the DSM officially ignores them. For too long the key work group has been lulled into inertia by its unsupportable conviction that “All porn is harmless.” If these academics could just replace the word “porn” with “stimuli,” they would instantly see the weakness in their position.

Treating sexual compulsion as an addiction-related disorder because of its effects on the brain would align with the trend in psychiatry as a whole:

The intellectual basis of [psychiatry] is shifting from one discipline, based on subjective ‘mental’ phenomena, to another, neuroscience.” Thomas Insel 

Unless the DSM reconsiders its recent decision, those who become hooked on today’s synthetic erotica will continue to be misdiagnosed and discouraged from making the changes that can reverse their pathology. If instead the authors of the new DSM act to underscore the connection between the brain’s reward circuitry and hypersexual disorders, they could do much to help protect everyone’s free will and appetite for sexual pleasure.

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