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Reviews of the Literature & Commentaries:

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Despite a lack of longitudinal studies, it is plausible that the observed characteristics in men with sexual addiction are the results not the causes of excessive pornography consumption. Most of the studies report stronger cue reactivity in the reward circuit toward sexual material in excessive pornography users than in control subjects, which mirrors the findings of substance-related addictions.

The results concerning a reduced prefrontal-striatal-connectivity in subjects with pornography addiction can be interpreted as a sign of an impaired cognitive control over the addictive behavior. Potenza et al. Compulsive sexual behaviour disorder operationalised as hypersexual disorder was considered for inclusion in DSM-5 but ultimately excluded, despite the generation of formal criteria and field trial testing.

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This exclusion has hindered prevention, research, and treatment efforts, and left clinicians without a formal diagnosis for compulsive sexual behaviour disorder. Research into the neurobiology of compulsive sexual behaviour disorder has generated findings relating to attentional biases, incentive salience attributions, and brain-based cue reactivity that suggest substantial similarities with addictions.

Compulsive sexual behaviour disorder is being proposed as an impulse-control disorder in ICD, consistent with a proposed view that craving, continued engagement despite adverse consequences, compulsive engagement, and diminished control represent core features of impulse-control disorders.

This view might have been appropriate for some DSM-IV impulse-control disorders, specifically pathological gambling. However, these elements have long been considered central to addictions, and in the transition from DSM-IV to DSM-5, the category of Impulse Control Disorders Not Elsewhere Classified was restructured, with pathological gambling renamed and reclassified as an addictive disorder.

At present, the ICD beta draft site lists the impulse-control disorders, and includes compulsive sexual behaviour disorder, pyromania, kleptomania, and intermittent explosive disorder.

Compulsive sexual behaviour disorder seems to fit well with non-substance addictive disorders proposed for ICD, consistent with the narrower term of sex addiction currently proposed for compulsive sexual behaviour disorder on the ICD draft website. We believe that classification of compulsive sexual behaviour disorder as an addictive disorder is consistent with recent data and might benefit clinicians, researchers, and individuals suffering from and personally affected by this disorder.

The review first looks at the basic neurobiology of addiction with the basic reward circuit and structures involved generally in any addiction. The focus then shifts to pornography addiction and studies done on the neurobiology of the condition are reviewed. The role of dopamine in pornography addiction is reviewed along with the role of certain brain structures as seen on MRI studies. The effect of pornography addiction on higher order cognitive functions and executive function is also stressed.

In total, 59 articles were identified which included reviews, mini reviews and original research papers on the issues of pornography usage, addiction and neurobiology. The research papers reviewed here were centered on those that elucidated a neurobiological basis for pornography addiction. We included studies that had decent sample size and sound methodology with appropriate statistical analysis.

There were some studies with fewer participants, case series, case reports and qualitative studies that were also analyzed for this paper. Both the authors reviewed all the papers and the most relevant ones were chosen for this review.

This was further supplemented with the personal clinical experience of both the authors who work regularly with patients where pornography addiction and viewing is a distressing symptom.

The authors also have psychotherapeutic experience with these patients that have added value to the neurobiological understanding. A similar approach should be applied to CSB, which is currently being considered for inclusion as an impulse-control disorder in ICD Grant et al. Among the domains that may suggest similarities between CSB and addictive disorders are neuroimaging studies, with several recent studies omitted by Walton et al.

Such reactions may relate to activations of brain regions implicated in reward processing, including the ventral striatum. Tasks assessing cue reactivity and reward processing may be modified to investigate the specificity of cues e. We found that individuals seeking treatment for problematic pornography use and masturbation, when compared to matched by age, gender, income, religiosity, amount of sexual contacts with partners, sexual arousability healthy control subjects, showed increased ventral striatal reactivity for cues of erotic rewards, but not for associated rewards and not for monetary cues and rewards.

This pattern of brain reactivity is in line with the incentive salience theory and suggests that a key feature of CSB may involve cue reactivity or craving induced by initially neutral cues associated with sexual activity and sexual stimuli.

Additional data suggest that other brain circuits and mechanisms may be involved in CSB, and these may include anterior cingulate, hippocampus and amygdala Banca et al. For many individuals who experience persistent patterns of difficulty or failures in controlling intense, repetitive sexual impulses or urges that result in sexual behavior associated with marked distress or impairment in personal, family, social, educational, occupational, or other important areas of functioning, it is very important to be able to name and identify their problem.

It is also important that care providers i. Patients report that clinicians may avoid the topic, state that such problems do not exist, or suggest that one has a high sexual drive, and should accept it instead of treating despite that for these individuals, the CSBs may feel ego-dystonic and lead to multiple negative consequences.

We believe that well-defined criteria for CSB disorder will promote educational efforts including development of training programs on how to assess and treat individuals with symptoms of CSB disorder.

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We hope that such programs will become a part of clinical training for psychologists, psychiatrists, and other providers of mental health care services, as well as other care providers including primary care providers, such as generalist physicians. Basic questions on how best to conceptualize CSB disorder and provide effective treatments should be addressed.

However, CSB has been slow to be recognized clinically as a diagnosable disorder. CSB is co-morbid with affective disorders as well as substance use disorders, and recent neuroimaging studies have demonstrated shared or overlapping neural pathologies disorders, especially in brain regions controlling motivational salience and inhibitory control. A preclinical model to study the neural underpinnings of CSB in male rats is discussed consisting of a conditioned aversion procedure to examine seeking of sexual behavior despite known negative consequences.

Because CSB shares characteristics with other compulsive disorders, namely, drug addiction, comparisons of findings in CSB, and drug-addicted subjects, may be valuable to identify common neural pathologies mediating comorbidity of these disorders. Indeed, many studies have shown similar patterns of neural activity and connectivity within limbic structures that are involved in both CSB and chronic drug use []. In conclusion, this review summarized the behavioral and neuroimaging studies on human CSB and comorbidity with other disorders, including substance abuse.

Together, these studies indicate that CSB is associated with functional alterations in dorsal anterior cingulate and prefrontal cortex, amygdala, striatum, and thalamus, in addition to decreased connectivity between amygdala and prefrontal cortex.

Moreover, a preclinical model for CSB in male rats was described, including new evidence of neural alterations in mPFC and OFC that are correlated with loss of inhibitory control of sexual behavior.

This preclinical model offers a unique opportunity to test key hypotheses to identify predispositions and underlying causes of CSB and comorbidity with other disorders. Low sexual desire, reduced satisfaction in sexual intercourse, and erectile dysfunction ED are increasingly common in young population. At the same time, prevalence of unhealthy lifestyles associated with organic ED has not changed significantly or has decreased in the last decades, suggesting that psychogenic ED is on the rise [3].

Recent investigation has suggested the role of behavioral addiction in sexual dysfunctions: alterations in neurobiological pathways involved in sexual response might be a consequence of repeated, supernormal stimuli of various origins. Among behavioral addictions, problematic Internet use and online pornography consumption are often cited as possible risk factors for sexual dysfunction, often with no definite boundary between the two phenomena. In literature, researchers are discordant about positive and negative function of online pornography.

From the negative perspective, it represents the principal cause of compulsive masturbatory behavior, cybersex addiction, and even erectile dysfunction. To date, most neuroimaging research on compulsive sexual behavior has provided evidence of overlapping mechanisms underlying compulsive sexual behavior and non-sexual addictions.

Compulsive sexual behavior is associated with altered functioning in brain regions and networks implicated in sensitization, habituation, impulse dyscontrol, and reward processing in patterns like substance, gambling, and gaming addictions.

Key brain regions linked to CSB features include the frontal and temporal cortices, amygdala, and striatum, including the nucleus accumbens. Current findings raise important questions regarding the classification of CSBD. Many disorders characterized by impaired impulse-control are classified elsewhere in the ICD for example, gambling, gaming, and substance-use disorders are classified as being addictive disorders. Recent neurobiological studies have revealed that compulsive sexual behaviors are associated with altered processing of sexual material and differences in brain structure and function.

The findings summarized in our overview suggest relevant similarities with behavioral and substance-related addictions, which share many abnormalities found for CSBD as reviewed in [ ].

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Although beyond the scope of the present report, substance and behavioral addictions are characterized by altered cue reactivity indexed by subjective, behavioral, and neurobiological measures overviews and reviews: [,]; alcohol: []; cocaine: []; tobacco: []; gambling: []; gaming: []. Results concerning resting-state functional connectivity show similarities between CSBD and other addictions [].

Although few neurobiological studies of CSBD have been conducted to date, existing data suggest neurobiological abnormalities share communalities with other additions such as substance use and gambling disorders.

Thus, existing data suggest that its classification may be better suited as a behavioral addiction rather than an impulse-control disorder. Given this reality, the number of studies on CSB has increased substantially in the last decade and the World Health Organization WHO included CSB in its proposal for the upcoming ICD From our point of view, it is worth investigating whether CSB can be distinguished into two subtypes characterized by: 1 dominant interpersonal sexual behaviors, and 2 dominant solitary sexual behaviors and pornography watching 48 The amount of available studies on CSB and sub-clinical populations of frequent pornography users is constantly increasing.

Among currently available studies, we were able to find nine publications Table 1 which utilized functional magnetic resonance imaging.

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Three studies indicate increased ventral striatal reactivity for erotic stimuli 36 - 39 or cues predicting such stimuli 36 - These findings are consistent with Incentive Salience Theory IST 28one of the most prominent frameworks describing brain functioning in addiction.

The only support for another theoretical framework which predicts hypoactivation of the ventral striatum in addiction, RDS theory 2930comes partially from one study 37where individuals with CSB presented lower ventral striatal activation for exciting stimuli when compared to controls.

In the last few years, there has been a wave of articles related to behavioral addictions; some of them have a focus on online pornography addiction. However, despite all efforts, we are still unable to profile when engaging in this behavior becomes pathological. Common problems include: sample bias, the search for diagnostic instrumentals, opposing approximations to the matter, and the fact that this entity may be encompassed inside a greater pathology i.

Behavioral addictions form a largely unexplored field of study, and usually exhibit a problematic consumption model: loss of control, impairment, and risky use. Hypersexual disorder fits this model and may be composed of several sexual behaviors, like problematic use of online pornography POPU.

This problematic use might have adverse effects in sexual development and sexual functioning, especially among the young population. As far as we know, a number of recent studies support this entity as an addiction with important clinical manifestations such as sexual dysfunction and psychosexual dissatisfaction.

However, concepts like tolerance and abstinence are not yet clearly established enough to merit the labeling of addiction, and thus constitute a crucial part of future research. For the moment, a diagnostic entity encompassing out of control sexual behavior has been included in the ICD due to its current clinical relevance, and it will surely be of use to address patients with these symptoms that ask clinicians for help.

Initiation and development of cybersex addiction have two stages with classical conditioning and operant conditioning. Firstly, individuals use cybersex occasionally out of entertainment and curiosity. On this stage, use of internet devices is paired with sexual arousal and The results in classical conditioning, further leads to sensitization of cybersex-related cues which trigger intense craving.

Individual vulnerabilities also facilitate sensitization of cybersex-related cues.

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On the second stage, individuals make use of cybersex frequently to satisfy their sexual desires or During this process, cybersex-related cognitive bias like positive expectation of cybersex and coping mechanism like using it to deal with negative emotions are positively reinforced, those personal traits associated with cybersex addiction such as narcissism, sexual sensation seeking, sexual excitability, dysfunction use of sex are also positively reinforced, while common personality disorders like nervousness, low self-esteem and psychopathologies like depression, anxiety are negatively reinforced.

Executive function deficits occur due to long-term cybersex use. Interaction of executive function deficits and intense craving promotes development and maintenance Of cybersex addiction. Researches using electrophysiological and brain imaging tools mainly to study cybersex addiction found that cybersex addicts may develop more and more robust craving for cybersex when facing cybersex-related cues, but they feel less and less pleasant when using it. Studies provide evidence for intense craving triggered by cybersex-related cues and impaired executive function.

Once they reduce cybersex use or just quit it, they would suffer from a series of adverse effects like depression, anxiety, erection dysfunction, lack of sexual arousal. Compulsive sexual behavior disorder, including problematic pornography use, has been included in the ICD as impulse control disorder.

Many researchers and clinicians also argue that problematic pornography use can be considered a behavioral addiction. Cue-reactivity and craving in combination with reduced inhibitory control, implicit cognitions e.

Neuroscientific studies confirm the involvement of addiction-related brain circuits, including the ventral striatum and other parts of fronto-striatal loops, in the development and maintenance of problematic pornography use. Case reports and proof-of-concept studies suggest the efficacy of pharmacological interventions, for example the opioid antagonist naltrexone, for treating individuals with pornography-use disorder and compulsive sexual behavior disorder.

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Theoretical considerations and empirical evidence suggest that the psychological and neurobiological mechanisms involved in addictive disorders are also valid for pornography-use disorder. Self-perceived problematic pornography use seems to be related to multiple units of analysis and different systems in the organism.

Based on the findings within the RDoC paradigm described above, it is possible to create a cohesive model in which different units of analysis impact each other Fig. It appears that elevated levels of dopamine, present in the natural activation of the reward system related to sexual activity and orgasm, interfere with the regulation of the VTA-NAc system in people who report SPPPU.

This dysregulation leads to greater activation of the reward system and increased conditioning related to the use of pornography, fostering approach behavior to pornographic material due to the increase in dopamine in the nucleus accumbens. Continued exposure to immediate and easily available pornographic material seems to create an imbalance in the mesolimbic dopaminergic system.

This excess dopamine activates GABA output pathways, producing dynorphin as a byproduct, which inhibits dopamine neurons. When dopamine decreases, acetylcholine is released and can generate an aversive state Hoebel et al. This imbalance is also correlated to the shift from approach to avoidance behavior, seen in people who report problematic pornography use.

These changes in internal and behavioral mechanisms among people with SPPPU are similar to those observed in people with substance addictions, and map into models of addiction Love et al.

Results for : studies

The neurological studies below are categorized in two ways: 1 by the addiction-related brain changes each reported, and 2 by the date of publication. Koob and Nora D. Volkow in their landmark review. The paper describes the major brain changes involved with both drug and behavioral addictions, while stating in its opening paragraph that sex addiction exists:.

Neuroscience research in this area not only offers new opportunities for the prevention and treatment of substance addictions and related behavioral addictions e. All 4 of these brain changes have been identified among the many neurological studies listed on this page:. Each study listed below is accompanied by a description or excerpt, and indicates which of the 4 addiction-related brain change s just discussed its findings endorse:. Brain scans revealed that sex addicts had disorganized prefrontal cortex white matter compared to controls.

The data presented in this paper are consistent with the assumption that CSB has much in common with impulse control disorders, such as kleptomania, compulsive gambling, and eating disorders.

Specifically, we found that individuals who meet diagnostic criteria for compulsive sexual behavior score higher on self report measures of impulsivity, including measures of overall impulsivity and the personality factor, Constraint.

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In addition to the above self-report measures, CSB patients also showed significantly more impulsivity on a behavioral task, the Go-No Go procedure.

Results also indicate that CSB patients showed significantly higher superior frontal region mean diffusivity MD than controls. A correlational analysis indicated significant associations between impulsivity measures and inferior frontal region fractional anisotrophy FA and MD, but no associations with superior frontal region measures.

Similar analyses indicated a significant negative association between superior frontal lobe MD and the compulsive sexual behavior inventory. These data also indicate that CSB is likely characterized by impulsivity, but also includes other components, which may be related to the emotional reactivity and anxiety of OCD.

Patients seeking help for hypersexual behavior often exhibit features of impulsivity, cognitive rigidity, poor judgment, deficits in emotion regulation, and excessive preoccupation with sex.

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Some of these characteristics are also common among patients presenting with neurological pathology associated with executive dysfunction. These findings provide preliminary evidence supporting the hypothesis that executive dysfunction may be implicated in hypersexual behavior. Results indicate that self-reported problems in daily life linked to online sexual activities were predicted by subjective sexual arousal ratings of the pornographic material, global severity of psychological symptoms, and the number of sex applications used when being on Internet sex sites in daily life, while the time spent on Internet sex sites minutes per day did not significantly contribute to explanation of variance in IATsex score.

We see some parallels between cognitive and brain mechanisms potentially contributing to the maintenance of excessive cybersex and those described for individuals with substance dependence. Some individuals report problems during and after Internet sex engagement, such as missing sleep and forgetting appointments, which are associated with negative life consequences.

One mechanism potentially leading to these kinds of problems is that sexual arousal during Internet sex might interfere with working memory WM capacity, resulting in a neglect of relevant environmental information and therefore disadvantageous decision making.

Results revealed worse WM performance in the pornographic picture condition of the 4-back task compared with the three remaining picture conditions. Findings are discussed with respect to Internet addiction because WM interference by addiction-related cues is well known from substance dependencies. Decision-making performance was worse when sexual pictures were associated with disadvantageous card decks compared to performance when the sexual pictures were linked to the advantageous decks.

Subjective sexual arousal moderated the relationship between task condition and decision-making performance. This study emphasized that sexual arousal interfered with decision-making, which may explain why some individuals experience negative consequences in the context of cybersex use.

The results show that indicators of sexual arousal and craving to Internet pornographic cues predicted tendencies towards cybersex addiction in the first study. Moreover, it was shown that problematic cybersex users report greater sexual arousal and craving reactions resulting from pornographic cue presentation. In both studies, the number and the quality with real-life sexual contacts were not associated to cybersex addiction.

The results support the gratification hypothesis, which assumes reinforcement, learning mechanisms, and craving to be relevant processes in the development and maintenance of cybersex addiction.

Poor or unsatisfying sexual real life contacts cannot sufficiently explain cybersex addiction. Not so. Steele et al. How so?

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The study reported higher EEG readings relative to neutral pictures when subjects were briefly exposed to pornographic photos. Studies consistently show that an elevated P occurs when addicts are exposed to cues such as images related to their addiction.

In line with the Cambridge University brain scan studiesthis EEG study also reported greater cue-reactivity to porn correlating with less desire for partnered sex. To put it another way - individuals with greater brain activation to porn would rather masturbate to porn than have sex with a real person.

Together, these two Steele et al. Eight peer-reviewed papers explain the truth: Peer-reviewed critiques of Steele et al. Also see this extensive YBOP critique. Steele at al. This Max Planck Institute fMRI study reported 3 neurological findings correlating with higher levels of porn use: 1 less reward system grey matter dorsal striatum2 less reward circuit activation while briefly viewing sexual photos, 3 poorer functional connectivity between the dorsal striatum and dorsolateral prefrontal cortex.

The researchers interpreted the 3 findings as an indication of the effects of longer-term porn exposure. Said the study. This is in line with the hypothesis that intense exposure to pornographic stimuli results in a down-regulation of the natural neural response to sexual stimuli.

In describing the poorer functional connectivity between the PFC and the striatum the study said. Dysfunction of this circuitry has been related to inappropriate behavioral choices, such as drug seeking, regardless of the potential negative outcome. We assume that subjects with a high porn consumption need increasing stimulation to receive the same amount of reward. That could mean that regular consumption of pornography more or less wears out your reward system. That would fit perfectly the hypothesis that their reward systems need growing stimulation.

Lead researcher Valerie Voon said:.

Part 1: Introduction - Your Brain on Porn - Animated Series

There are clear differences in brain activity between patients who have compulsive sexual behaviour and healthy volunteers. These differences mirror those of drug addicts. Voon et al. Compared to healthy volunteers, CSB subjects had greater subjective sexual desire or wanting to explicit cues and had greater liking scores to erotic cues, thus demonstrating a dissociation between wanting and liking.

This indicates sensitization or habituation. CSB subjects reported that as a result of excessive use of sexually explicit materials. CSB subjects compared to healthy volunteers had significantly more difficulty with sexual arousal and experienced more erectile difficulties in intimate sexual relationships but not to sexually explicit material. An excerpt:. Our findings of enhanced attentional bias suggest possible overlaps with enhanced attentional bias observed in studies of drug cues in disorders of addictions.

These findings converge with recent findings of neural reactivity to sexually explicit cues in [porn addicts] in a network similar to that implicated in drug-cue-reactivity studies and provide support for incentive motivation theories of addiction underlying the aberrant response to sexual cues in [porn addicts].

This finding dovetails with our recent observation that sexually explicit videos were associated with greater activity in a neural network similar to that observed in drug-cue-reactivity studies. Greater desire or wanting rather than liking was further associated with activity in this neural network.

These studies together provide support for an incentive motivation theory of addiction underlying the aberrant response towards sexual cues in CSB. Using questionnaires, we assessed the severity of cybersex addiction in general, as well as propensity for sexual excitation, general problematic sexual behavior, and severity of psychological symptoms. Additionally, an experimental paradigm, including a subjective arousal rating of pornographic pictures, as well as indicators of craving, was conducted.

Results indicated that IPU rated pornographic pictures as more arousing and reported greater craving due to pornographic picture presentation compared with NIPU. Moreover, craving, sexual arousal rating of pictures, sensitivity to sexual excitation, problematic sexual behavior, and severity of psychological symptoms predicted tendencies toward cybersex addiction in IPU.

Being in a relationship, number of sexual contacts, satisfaction with sexual contacts, and use of interactive cybersex were not associated with cybersex addiction. These results are in line with those reported for heterosexual males in previous studies. Findings regarding the reinforcing nature of sexual arousal, the mechanisms of learning, and the role of cue reactivity and craving in the development of cybersex addiction in IPU need to be discussed.

The nature of a phenomenon often called cybersex addiction CA and its mechanisms of development are discussed. Previous work suggests that some individuals might be vulnerable to CA, while positive reinforcement and cue-reactivity are considered to be core mechanisms of CA development.

In this study, heterosexual males rated pornographic pictures and indicated their increase of sexual arousal. Moreover, tendencies towards CA, sensitivity to sexual excitation, and dysfunctional use of sex in general were assessed.

The results of the study show that there are factors of vulnerability to CA and provide evidence for the role of sexual gratification and dysfunctional coping in the development of CA. Compared to controls porn addicts preferred sexual novelty and conditioned cues associated porn.

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