Diagnosing Porn Addiction & Compulsive Sexual Behavior Disorder

Hey there everybody. And welcome back to this series on pornography addiction and compulsive sexual behavior disorder. I'm your host, Dr. Donnelly Snipes. And in this video we're going to talk about the diagnosis itself. We'll start out by talking about common paths to porn use, not necessarily abuse or addiction, and then explore the continuum from use to abuse to addiction. How do people start watching porn? It's not something you just wake up one day and go, hey, I'm going to go online and search for porn. Something triggers it in your mind. It could be early use or curiosity. When youth start developing their secondary sex characteristics, they may start getting curious. When they learn about some of it from friends, from peers, from whatever, they may get curious. Unfortunately, I found out when my son was a teenager, they may also, when they play certain video games, be bombarded with or exposed to ads of a relatively sexually explicit nature, which may lead them to exploring. And it may not be exploring with the intention of masturbation. It may be exploring with the intention of learning. Peer pressure is another reason people use. Whether it is, you know, high school or college or in relationships, there may be some people who are watching and other people who are there along for the ride, encouraged to watch and may succumb to that peer pressure. Social learning is another path to porn use. I know stories of a lot of people who are my age whose parents subscribe to Playboy or Playgirl and those magazines were hidden away under their parents bed and they remember going and stealing their parents magazines or stealing, borrowing them in order to look at them out of curiosity. But they learned, my parents do it, you know, it must be okay. We also have a lot of social learning from the media. And when my daughter was younger, I remember watching some shows that were on network TV that were on mainstream TV that made me blush and I'm like, okay, change in the channel. Now it's becoming increasingly difficult to find what used to be referred to as family friendly programming. So there is a lot more sexuality and overt sexuality on in the media. Tension release is another path to porn use. Some people, especially if they've are older, they've experienced orgasm, they recognize the benefits of sex and orgasm, they may start using it as a method for tension release when they're really stressed out. Some people start using porn when they're out of a relationship, but they've got that sexual tension and they either don't have time to find a relationship, they are afraid to try to find a new one because they have low self esteem. They're just assuming they're going to be rejected or they feel like their social skills are really low or they've tried and they keep getting rejected so they've just given up. There's a lot of reasons people aren't in relationships these days. And that doesn't change the fact that they have a libido, they have a sexual aspect to themselves. And some people end up finding porn or beginning to watch porn because of mismatched sexual appetites or desires in relationships. And we talked about this a little bit in part one, but in a lot of relationships, partners may not have the exact same sexual appetites. And one compromise is being okay with the partner with the higher sexual appetite watching porn and relieving their sexual tension through that as opposed to feeling sexually deprived or as opposed to engaging in some sort of nefarious affair. Not everybody's good with that, and that's between partners. But it is important to recognize that that is one of the reasons that many people cite in couples counseling. Many people cite that they actually started to use porn was because they weren't getting it enough and having an open discussion about what enough means and if there are alternatives to satisfying the partner with the higher sexual appetite. So let's talk about pornography addiction, which the official label for it is compulsive sexual behavior disorder. And CSBD is actually a diagnosis in the ICD 11 now, which is the World Health Organization's version of the DSM. So it is a official documented diagnosis. However, it is really important to not overuse or over pathologize it. As a clinician, if you don't like pornography, if you don't agree with pornography use, okay, that is, those are your beliefs. But it just because somebody is watching porn, even if they're watching porn and their partner doesn't know about it, that doesn't necessarily mean it is a diagnosable problem. So let's look at the diagnostic criteria. Pretty straightforward. A persistent pattern or failure to control intense repetitive sexual impulses or urges resulting in a repetitive sexual behavior over at least a six month period manifested in one or more of the following. So this isn't just a fleeting idea. This is an intense desire. This is what we might call a compulsion or a craving. If we're talking about, if we were talking about addiction and drugs. So it needs to be manifested by one or more of the following problems. The person neglects their health, personal care or other interests, activities and responsibilities in order to engage in the sexual behavior or in order to recover from the sexual behavior. Or they have unsuccessful efforts to control or significantly reduce the behavior when they try to do it. And that is one that gets a little hinky sometimes because the person who is watching porn, for example, or engaging in the compulsive sexual behavior may not have any desire to cut down or quit. So they're not really trying that hard. But what the other people see who are telling them they have to cut down is that they're unable. So we need to look at unable or willing when we're making this particular part of the diagnosis. If the person's unable to control or significantly reduce the behavior, that's one thing. Okay, meets the criteria. If they're unwilling, that doesn't meet the criteria marked distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. Now, this is one of those catchalls that if they come in and they say, this is causing me major problems in my relationship, okay meets the criteria. One thing it does Note in the ICD11 is that personal distress, guilt and shame about watching porn or masturbating or engaging in particular sexual behaviors that is entirely related to a personal moral judgment about the sexual impulses, urges, or behaviors is not sufficient. So if the only distress you're experiencing as a result of pornography use or compulsive sexual behaviors is shame and guilt, then according to the ICD 11, it would not meet the criteria for diagnosis if that was your only symptom. I will add the caveat that just because someone may not meet the full criteria for diagnosis doesn't mean there's not a problem. If somebody is presenting with in your office, they're there for a reason. There's some problem somewhere. And even if they don't neatly fit into the criteria, we don't send them away. We address the problem that is keeping them from achieving their definition of a rich and meaningful life. The individual continues to engage in the repetitive sexual behavior despite adverse consequences. They start having relationship problems. The relationship is important to them. Now, if the relationship's not important to them, that's a whole different ball game. If the relationship's important to them and they are having problems in that relationship because of the porn use and they keep using porn, then okay, then we're squarely in the diagnostic area. The person continues to engage in repetitive sexual behavior even when they derive little or no satisfaction from it. Now, I thought that one was interesting. And it's not better accounted for by another mental disorder or other medical condition and is not due to the effects of a substance or medication. One of the things that we see in people that engage in compulsive sexual behaviors, whether it's porn or something else, is over time, the intensity of the release, the intensity of the orgasm, the feelings afterwards, and even sometimes the anticipation leading up to it. It starts to become blunted as the HPA axis and the rest of the nervous system and changes as a result of excessive use. Then the pleasure from it is going to become increasingly less. Just like people who abuse drugs, they develop tolerance and they need more in order to get the same high. Now, there's only so much you can do with sex in order to get that same high. One of the things that we do see is people increasing the shock value, if you will, of the pornography that they're watching. Or they increase the risk in what they're doing in order to increase the endor. Endorphins and the adrenaline and the rush associated with it. So they have their own way of responding to tolerance. But when we see that, when we see them having to engage in increasingly risky or shocking behaviors, then that kind of falls under this criteria of not receiving the same level of satisfaction from the same level of activity. Let's talk about differential diagnosis. Hypersexuality, as they call it, is prevalent in a lot of different things. And the first thing that I will say is different people have different sexual appetites. And some people have a very strong sex drive and have a lot of sexual drive. We don't want to pathologize that if it's not causing them problems in their life. If they don't meet the criteria where it's causing them to neglect certain areas of their life or whatever, then it's not a problem. They just have a high sex drive. Okay? We want to make sure that we're clear on that. However, for some people who have a history of trauma or personality disorders, they may use sex as a means of emotional regulation, as a means of stabilizing their sense of self, or as a method for avoidance or numbing. And it's important to rule out both trauma complex post traumatic stress disorder, as well as what the DSM 5TR labels as personality disorders. Before we necessarily assign a diagnosis. A diagnosis of compulsive sexual behavior disorder. If the reason the person is engaging in the sexual behavior is simply to manage their emotions or stabilize their sense of self as a result of trying to cope with their personality disorder, then. Or their trauma history, then compulsive sexual behavior disorder would not be additionally diagnosed. We don't want to give them a laundry list of diagnoses. Bipolar disorder is another one that we really need to be aware of because it's a very prevalent disorder in throughout the world and in North America. And one of the signs of a hypomanic or a manic episode is a dramatic increase in sexual drive where some people will again, we'll call it hypersexuality, but it's different than the person's normal or typical level of sexual drive. So when a person starts to evidence this increase in sexual behavior, oftentimes that's an early warning sign of an impending hypomanic or manic episode. And there again you would not give the diagnosis of compulsive sexual behavior disorder if the hypersexuality is caused as or is a symptom of the manic episode. In terms of paraphilic disorders, the core feature of paraphilias is an intense pattern of atypical sexual arousal manifested by sexual thoughts, fantasies, urges or behaviors and have resulted in actions toward non consenting individuals or are associated with marked distress or significant risk of injury. And this is another one that I think we really need to have an open and honest discussion about. Because for example, voyeurism and exhibitionism, when done between consenting adults, is not a paraphilic disorder when that's just what some people like to do. And so it needs to be in order to be a paraphilia. It needs to be done toward non consenting individuals. So if the people are consenting and they're adults, then it's probably not a paraphilic disorder. BDSM is different, as I mentioned earlier, than diagnosis 6D33, which is coercive sexual sex sadism disorder, Coercive sexual Satan Sadism disorder is done to someone who is non consenting. You're coercing them, you're forcing them, you're manipulating them. BDSM the hallmark, again I'll say it, safe, sane and consensual. Yes, in some of the scenes the sub may seem like they are powerless, but in reality in bdsm, the sub actually has a lot of power in designing this, the scene. And it is the dom's responsibility to try to play out the scene in a way that helps meet the subs needs. But again, that's a lot of stuff that we'll cover in the BDSM video. Pornography is everywhere and it's becoming even more mainstream. Like other addictions, use exists along a continuum. Problematic use or diagnosis of porn addiction, or what they call compulsive sexual behavior disorder requires neglecting health or other important activities or problems in one or more important areas of life or unsuccessful efforts to control the behavior so the person's unable to not unwilling but unable Shame and stigma about porn use and problematic porn use or PPU are keeping people from talking about it and seeking help. So we really need to start talking about it and helping people see that there are tools that can help them if this is a problem for them and start helping them understand. All right. Yeah. Porn doesn't exist in a vacuum and these things that you're experiencing experiencing in your life may have some connection to the porn use. So we need to start taking a look at addressing you as a whole person, not just figuring out how to help you stop watching porn, but we need to look at all the other issues that are contributing to that porn use and contributing to that those withdrawal symptoms and the mood symptoms when you are not using. Thanks for watching and I look forward to seeing you next time.