Status Quo (For Now). In mid-July I published a blog discussing a recently released fMRI (brain imaging) study showing that the brain activity of sex addicts, when they are shown pornography, mirrors the brain activity of drug addicts when they are exposed to drug-related imagery.
That research strongly suggested that sexual addiction not only exists, but that it manifests in the brain in profoundly similar ways to more readily accepted forms of addiction like alcoholism, drug addiction, and gambling addiction. Publication of this study was highly significant in light of the American Psychiatric Association’s unexplained and unexpected refusal to include Hypersexual Disorder (aka, sexual addiction) in the DSM-5 last year. This despite Harvard Professor Dr. Martin Kafka’s well-researched and elegantly presented argument, commissioned by the APA, in favor of such a diagnosis.
It has been hypothesized that the APA may have rejected Dr. Kafka’s proposed hypersexual disorder diagnosis due to a lack of scientific evidence proving that sex can indeed become an addiction. In truth, Dr. Kafka noted the need for more research in his paper, especially in regard to female sexual addicts, and I quite agree with his assessment. This should not, however, have kept sexual addiction (or hypersexual disorder, as Dr. Kafka prefers to call it) out of the DSM. After all, as Dr. Kafka rather eloquently explained, “[The] number of cases of Hypersexual Disorder reported in the peer reviewed journals greatly exceeds the number of cases of some of the already codified paraphilic disorders such as Fetishism and Frotteurism.” So why leave it out? And do we not also need more research on depression, anxiety, posttraumatic stress disorder, and every other DSM-approved diagnosis? Let’s be real here: If absolute certainty was the standard for inclusion in the DSM, the book would be a pamphlet.
Nevertheless, it does appear that “lack of research” is what the APA is leaning on as support for its untenable stance regarding sexual addiction. If so, they’re going to need a new crutch. Since the publication of Dr. Kafka’s already definitive paper, three important studies supporting the diagnosis of sexual addiction have been released – the fMRI study mentioned above, a UCLA study showing that Dr. Kafka’s proposed diagnostic criteria are accurately constructed and eminently usable, and a new study looking at attentional bias toward sexually explicit cues.
The New Research in Detail
“Attentional bias” is the tendency of a person to focus a higher than normal portion of his or her attention toward a specific stimulus or sensory cue. This may lead to poor judgment and/or an incomplete (or slowed) recollection of a certain event or memory. For instance, a person with an attentional bias toward drugs will, when exposed to drug-related stimuli, have an incomplete or slowed memory of surrounding, non-drug related stimuli. In other words, if you put a drug addict in a room and there are drugs and paraphernalia on the coffee table, it is likely that the addict will be able to later recall the drugs, the paraphernalia, and the coffee table with alacrity and clarity. However, he or she may not remember the color of the couch at all.
Numerous studies have linked attentional bias toward drug cues with drug addiction. This new sex addiction-focused research, conducted at Cambridge University (UK), looks at whether sex addicts display a similar attentional bias, but in regard to sexual rather than drug-related cues. In the study, researchers compared a group of self-identified sex addicts to healthy test subjects using a dot probe task (explained momentarily). Addictively sexual and healthy test subjects were age-matched, heterosexual males. Exclusionary criteria included: being less than 18 years old, having a substance use disorder or a behavioral addiction (other than sexual addiction), and serious psychiatric disorders. The study tested two healthy subjects for each compulsively sexual subject.
The dot probe task utilized was relatively simple. Subjects sat at a computer with their left and right index fingers over the “s” and “l” letters on the keyboard. A central fixation image (a plus sign) appeared on the screen for between half a second and a second. Then two photos appeared on the screen, one on either side, for .15 seconds, followed by the central fixation image for between .1 and .3 seconds, followed by a green dot on either the left or the right side of the screen. When the green dot appeared, the test subjects pressed either the “s” or the “l” key, depending on which side of the computer screen the dot showed up on. Reactions were timed to see if the photos displayed prior to the dot were more or less distracting for sex addicts versus healthy subjects.
There were four types of photos – explicit sexual images (heterosexual intercourse), erotic images (nude women), neutral images (clothed women), and control images (chairs). In similar studies looking at drug addiction, addicts have shown an attentional bias toward drug-related images, meaning they have a slower reaction time after viewing a drug-related image versus a neutral or control image. The hypothesis here was that compulsively sexual test subjects would display the same basic attentional bias, only in regard to sexual rather than drug cues. And that is exactly what occurred.
As with drug studies, one possible explanation for attentional bias involves incentive learning theory. Much like the process of classical conditioning, with repeated pairing of cues and pleasurable neurochemical reactions (as occurs with drug abuse, alcohol abuse, compulsive gambling, repetitive porn use, etc.), biased cues develop an incentive value and acquire incentive-motivational properties – meaning the cues become more attractive and thus grab attention, distracting the person from other tasks. In plain addiction language: addicts can be “triggered” by visual cues.
The Future DSM
Whenever new research emerges in support of sexual addiction as an identifiable and treatable disorder, I can’t help but wonder when the APA will wake up and take action. That said, I am not hopeful this will occur anytime soon. The organization simply lacks the political will to implement a sexual addiction diagnosis, especially when they’re actively and inexplicably eliminating the word “addiction” from the DSM. Even drug and alcohol addictions have been renamed. Now they are called “Substance Use Disorders.” Why the change? In truth, I don’t know, and I wish the APA would reverse its stance. After all, addiction is the term that almost every treatment specialist utilizes (despite the APA’s semantic antics), and it’s also the term that makes the most sense to addicts themselves.
At some point the APA will have to join the 21st century and approve sexual addiction (or hypersexual disorder, or compulsive sexual behavior, or whatever else people want to call this) as an official DSM diagnosis. Until then, nothing much changes. Clinicians who treat sexual addiction will continue to do so in the ways they know best, more research will emerge, and people like Stefanie Carnes, Ken Adams, and I will continue in our efforts to educate and enlighten clinicians, the general public, sex addicts themselves, and their loved ones about the nature and treatment of this chronic, debilitating, and progressive neurobiological disorder.
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