Toss Your Textbooks: Docs Redefine Sexual Behavior Addictions

American Society of Addiction Medicine
UPDATES on this American Association of Addiction Medicine announcement:

The American Society of Addiction Medicine states that sexual behavior addictions are as real as drug addictions

A major event has occurred in the realm of addiction science and treatment. America’s top addiction experts at The American Society of Addiction Medicine (ASAM) have just released their sweeping new definition of addiction. This new definition ends the debate over whether sex and porn addictions are “real addictions.” They are.

From the ASAM press release:

The new definition resulted from an intensive, four‐year process with more than 80 experts actively working on it, including top addiction authorities, addiction medicine clinicians and leading neuroscience researchers from across the country. … Two decades of advancements in neurosciences convinced ASAM that addiction needed to be redefined by what’s going on in the brain.

It’s likely ASAM acted, in part, because the psychiatrists who are revising the DSM (the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders) have been dragging their feet in bringing the upcoming DSM-5 into alignment with advances in behavioral addiction research. Traditionally, the DSM offers diagnoses based not on underlying disease, but on lists of behaviors. Since DSM authors can’t agree on a list of sexual behaviors that constitute “Hypersexuality Disorder” (which addresses compulsive porn use), they are hamstrung. In fact, they may banish the disorder to the appendix—right as Internet porn use among adolescent boys is becoming nearly universal. (NOTE: This was written before the upcoming DSM-5 decided to create a “behavioral addiction category“.)

ASAM Definition

In contrast, the ASAM definition, “looks at the role of the brain in the etiology of addiction—what is happening with brain functioning and specific brain circuitry that can explain the outward behaviors seen in addiction.” It is an acknowledgement that a sexual behavior (e.g., viewing Internet porn daily) may be evidence of pathology in one person’s brain without reflecting pathology in another’s.

Research shows that both behavioral and chemical addictions entail the same major alterations in brain anatomy and physiology. An ASAM spokesman explained:

The new definition leaves no doubt that all addictions—whether to alcohol, heroin or sex, say—are fundamentally the same. Dr. Raju Haleja, former president of the Canadian Society for Addiction Medicine and the chair of the ASAM committee that crafted the new definition, told The Fix, “We are looking at addiction as one disease, as opposed to those who see them as separate diseases. Addiction is addiction. It doesn’t matter what cranks your brain in that direction, once it has changed direction, you’re vulnerable to all addiction.” …Sex or gambling or food addiction [are] every bit as medically valid as addiction to alcohol or heroin or crystal meth.

Here is a brief summary of  the American Society of Addiction Medicine’s major points:

  1. Addiction reflects the same brain changes whether it arises in response to chemicals or behaviors.
  2. Addiction is a primary illness. It’s not necessarily caused by mental health issues such as mood or personality disorders. This puts to rest the popular notion that addictive behaviors are always a form of “self-medication” to ease other disorders.
  3. Both behavioral and substance addictions cause the same major changes in the same neural circuitry: Hypofrontality, sensitization, desensitization, altered stress circuits, etc. .
  4. Engagement in chronic “addictive behaviors” indicates the above brain changes have occurred. Addictive behaviors then become unconscious and habitual.
  5. The new definition eradicates the old “addiction vs. compulsion” distinction, which was often used to deny the existence of behavioral addictions, including Internet porn addiction.

Unlike the brains of gambling, food, videogame addicts, the brains of sex/porn addicts have not yet been scanned. Yet the brain mechanics of behavioral addiction are already so well defined, that experts can say with confidence that sexual behaviors are also potentially addictive. In other words, it’s not the form or quantity of a stimulus, but rather the resulting brain changes, which matter. These excerpts from ASAM’s FAQs explain the science common to all addiction:

QUESTION: What’s different about this new definition?

ANSWER: The focus in the past has been generally on substances associated with addiction, such as alcohol, heroin, marijuana, or cocaine. This new definition makes clear that addiction is not about drugs, it’s about brains. It is not the substances a person uses that make them an addict; it is not even the quantity or frequency of use. Addiction is about what happens in a person’s brain when they are exposed to rewarding substances or rewarding behaviors, and it is more about reward circuitry in the brain and related brain structures than it is about the external chemicals or behavior that “turn on” that reward circuitry.(Emphasis added.)

Addicts share common brain changes, which show up in behavior as unsuccessful attempts to control use, cravings during abstinence periods, and withdrawal symptoms. To date, the underlying brain changes seen in all addicts (desensitization, sensitization, and hypofrontality) have already been observed in the brains of compulsive gamblers, overeaters, videogamers. It’s likely they are present in today’s compulsive porn users as well. If it walks, talks and acts like a duck, it’s a duck. (Update: Cambridge University: Brain scans find porn addiction)

Another implication of ASAM’s statement is that one cannot define “porn addiction” by time spent viewing or genres watched. Porn addiction exists only if the relevant brain changes have occurred in the viewer. Since brain scans are impractical, ASAM has created a 5-part assessment to help people figure out if their brains have changed. This is similar to assessing diabetes markers in patients complaining of telltale symptoms.

These next two questions from ASAM address sex and food addictions specifically:

QUESTION: This new definition of addiction refers to addiction involving gambling, food, and sexual behaviors. Does ASAM really believe that food and sex are addicting?

ANSWER: Addiction to gambling has been well described in the scientific literature for several decades. In fact, the latest edition of the DSM (DSM-5) will list gambling disorder in the same section with substance use disorders.

The new ASAM definition makes a departure from equating addiction with just substance dependence, by describing how addiction is also related to behaviors that are rewarding. This the first time that ASAM has taken an official position that addiction is not solely “substance dependence.”

This definition says that addiction is about functioning and brain circuitry and how the structure and function of the brains of persons with addiction differ from the structure and function of the brains of persons who do not have addiction. It talks about reward circuitry in the brain and related circuitry, but the emphasis is not on the external rewards that act on the reward system. Food and sexual behaviors and gambling behaviors can be associated with the “pathological pursuit of rewards” described in this new definition of addiction. (Emphasis added.)

QUESTION: Who has food addiction or sex addiction?

ANSWER: We all have the brain reward circuitry that makes food and sex rewarding. This is a survival mechanism. In a healthy brain, these rewards have feedback mechanisms for satiety or ‘enough.’  For someone with addiction, the circuitry becomes dysfunctional such that the message to the individual becomes ‘more’, which leads to the pathological pursuit of rewards and/or relief through the use of substances and behaviors.

In short, sex addiction exists, and it is caused by the same basic alterations in brain structure and physiology as drug addictions. This makes perfect sense. After all, addictive drugs do nothing but increase or decrease normal biological functions. They hijack neural circuits for natural rewards, so it should be evident that extreme versions of natural rewards (junk food, Internet porn) can also hijack those circuits.

What about porn addicts?

Today’s healthcare providers and popular advice columnists are often misled about the risks of Internet porn use—in part because they know that masturbation (without porn) seldom results in addiction. Trouble is, Internet porn is not mere masturbation. The belief that masturbation and Internet porn are the same demonstrates a lack of understanding of the potential brain effects of constant novelty. Normally, masturbation leads to feelings of satiety. In contrast, Internet porn can override natural satiety. In some brains, overriding natural satiety with extreme stimulation is the slippery slope to addiction-related brain changes. This misunderstanding results in poor advice to patients/clients/readers.

Research challenges

When researchers someday look into the brains of Internet porn addicts, they are sure to see the changes already observed in other kinds of Internet addicts. Alas, porn-addiction research faces daunting challenges:

1.   Control groups of male, non-Internet porn users can no longer be found, and even if they could, review boards would certainly not approve protocols that call for them to watch the kinds of porn for as many hours a day as many of today’s young guys are watching.

2.   Vague questionnaires (unlike brain scans) make it tough for porn users to connect sexual performance problems (or social anxiety, depression or concentration problems) with Internet porn use. After all, porn seems like the world’s most reliable aphrodisiac, and users always feel better while using. How could it be causing the very problems it temporarily cures?

Only with broader knowledge of addiction, its symptoms, and its etiology can researchers and their subjects correctly connect cause with effect. The ASAM statement supports researchers in investigating porn use through the lens of brain changes.

Therapists have new responsibilities

ASAM’s declaration is a step forward in helping to reeducate therapists and their clients. Many were erroneously taught that sexual behavior addictions could not arise from overstimulation of the brain via behavior. Instead, they were trained to assure clients that addiction to sexual behavior was never a risk—unless the client had other (often genetic) disorders.

Yet ASAM authors estimate that genetics only make up about half the cause of addiction. This means that addiction can develop in the absence of pre-existing conditions. In other words, porn-related symptoms such as depression, social anxiety, youthful sexual performance issues and concentration problems need to be viewed as possible consequences of addiction, instead of being presumed always to be their cause.

The new statement on addiction medicine thus places responsibility on therapists to help sex and porn-addicted clients make fundamental changes to their behavior. At the moment, many counselors simply refer clients to a doctor for psychotropic and sexual-enhancement drugs. At the same time they are assuring them that their sexual behavior is typical and harmless.

The ASAM statement is a big step in a sound direction. In this post, we consider the specific symptoms porn users report, which may indicate addiction-related brain changes.