Hitting the Target: Considerations for Differential Diagnosis When Treating Individuals for Problematic Use of Pornography (2018). (Analysis of the Grubbs moral incongruence model)

The hallmark of CSBD is repeated failed attempts to control or suppress one’s sexual behavior that causes marked distress and impairment in functioning, and “psychological distress due to sexual behavior by itself does not warrant a diagnosis of CSBD” (Kraus et al., 2018, p. 109). These are important points to consider in clinical practice where the key ingredients for any successful case conceptualization and treatment plan begin with a thorough assessment and appropriate differential diagnosis. We have developed the algorithm in Fig. 1 to help clinicians conceptualize diagnosis and treatment approaches for clients presenting with problematic use of pornography.

To aid understanding, we will now discuss three examples of real clients who sought treatment for problematic use of pornography in an Department of Veterans Affairs (VA) outpatient mental health specialty clinic. The examples have all been de-identified in order to protect the confidentiality of the clients.

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During the clinic’s intake, Mr. S’s responses to the assessment process followed the trajectory of the middle pathway in Fig. 1. He endorsed PPMI since his sexual behaviors did not align with his religious beliefs. By his history and report of current problems, he also met full criteria for CSBD. Unfortunately, Mr. S did not engage in subsequent treatment with our clinic given his interest in seeking help solely through his church. Prior to premature termination, the treatment recommendations for Mr. S included prescribing medication (naltrexone) to address his craving and providing cognitive behavioral therapy to address underlying beliefs and behaviors that resulted in his compulsive use of pornography.

During the clinic’s intake, Mr. D did not endorse experiencing distress due to PPMI but did experience difficulties controlling his pornography use. He was assessed and found to meet full ICD-11 criteria for CSBD as depicted in Fig. 1. Mr. D was prescribed medication (naltrexone, 50 mg/day), and he also participated in individual sessions of cognitive behavioral therapy for substance use disorders that were adapted to address his problematic pornography use. Over the course of treatment, Mr. D decreased his pornography use and coped effectively with his cravings. He also reported an increase in engaging in pleasurable activities with his wife and friends such as hiking and traveling.

During the clinic’s intake, Mr. Z stated that he has never sought treatment for this issue before. He endorsed subjective experiences of distress due to PPMI and met diagnostic criteria for both depression and anxiety disorders but not CSBD as represented in Fig. 1. Individual therapy focused on reducing Mr. Z’s anxiety regarding initiation of sexual intercourse with his wife. Mr. Z and his wife also participated in couples therapy where the therapist assigned non-sexual pleasurable activities for the couple to do while also increasing their communication. Mr. Z reported a decrease in pornography use when he and his wife resumed physical intimacy. He also reported increased communication with his wife as well as decreased depression and anxiety which subsequently led him to discontinue treatment.

Our intention with this Commentary is to continue the needed dialogue about diagnostic considerations for clients seeking treatment for problematic use of pornography. As discussed by Grubbs et al. (2018a), the topic of moral incongruence is relevant when determining whether a client with problematic pornography use meets ICD-11 criteria for CSBD. Evidence suggests that some individuals report significant issues moderating and/or controlling their use of pornography leading to marked distress and impairment in many areas of psychosocial functioning (Kraus, Potenza, Martino, & Grant, 2015b). With the possible inclusion of CSBD in ICD-11 and high prevalence of pornography use in many Western countries, we anticipate that more people will seek treatment for problematic pornography use in the future. However, not all who seek treatment for problematic pornography use of pornography will meet criteria for CSBD. As discussed earlier, understanding the reasons behind clients’ decisions for seeking help for problematic use of pornography will be crucial in order to appropriately determine accurate diagnosis and treatment planning for clients.

As highlighted by our client examples, it is necessary to tease apart the nature of problematic pornography use for diagnostic clarification and appropriate treatment recommendations to be offered. Several treatments have been already developed and piloted for CSB, including problematic use of pornography. Preliminary evidence supports the use of cognitive behavioral therapy (Hallberg, Kaldo, Arver, Dhejne, & Öberg, 2017), acceptance commitment therapy (Crosby & Twohig, 2016) or mindfulness-based approaches (Brem, Shorey, Anderson, & Stuart, 2017; Reid, Bramen, Anderson, & Cohen, 2014). Additionally, there is some evidence to support pharmacological interventions (Gola & Potenza, 2016; Klein, Rettenberger, & Briken, 2014; Kraus, Meshberg-Cohen, Martino, Quinones, & Potenza, 2015a; Raymond, Grant, & Coleman, 2010). As shown in our client examples and Fig. 1, clients with problematic pornography use have diverse clinical presentations and reasons for seeking help. Therefore, future research is needed to develop treatments that appropriately address the complexity and nuances of issues underlying problematic use of pornography.