Neurocognitive Mechanisms in Compulsive Sexual Behavior Disorder

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DOI: 10.1007/s11930-018-0176-z
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Purpose of Review The current review summarizes the latest findings concerning neurobiological mechanisms of compulsive sexual behavior disorder (CSBD) and provides recommendations for future research specific to the diagnostic classification of the condition. Recent Findings 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 compulsive sexual behavior features include the frontal and temporal cortices, amygdala, and striatum, including the nucleus accumbens. Summary Despite much neuroscience research finding many similarities between CSBD and substance and behavioral addictions, the World Health Organization included CSBD in the ICD-11 as an impulse-control disorder. Although previous research has helped to highlight some underlying mechanisms of the condition, additional investigations are needed to fully understand this phenomenon and resolve classification issues surrounding CSBD.
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Current Sexual Health Reports
ISSN 1548-3584
Curr Sex Health Rep
DOI 10.1007/s11930-018-0176-z
Neurocognitive Mechanisms in Compulsive
Sexual Behavior Disorder
Ewelina Kowalewska, Joshua B.Grubbs,
Marc N.Potenza, Mateusz Gola,
Małgorzata Draps & Shane W.Kraus
1 23
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Neurocognitive Mechanisms in Compulsive Sexual Behavior Disorder
Ewelina Kowalewska
&Joshua B. Grubbs
&Marc N. Potenza
&Mateusz Gola
&Małgorzata Draps
Shane W. Kraus
#This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply 2018
Purpose of Review The current review summarizes the latest findings concerning neurobiological mechanisms of compulsive
sexual behavior disorder (CSBD) and provides recommendations for future research specific to the diagnostic classification of
the condition.
Recent Findings 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 compulsive sexual behavior
features include the frontal and temporal cortices, amygdala, and striatum, including the nucleus accumbens.
Summary Despite much neuroscience research finding many similarities between CSBD and substance and behavioral addic-
tions, the World Health Organization included CSBD in the ICD-11 as an impulse-control disorder. Although previous research
has helped to highlight some underlying mechanisms of the condition, additional investigations are needed to fully understand
this phenomenon and resolve classification issues surrounding CSBD.
Keywords Compulsive sexual behavior .Neuroscience .Gender
Compulsive sexual behavior (CSB) is a debated topic that is
also known as sexual addiction, hypersexuality, sexual
dependence, sexual impulsivity, nymphomania, or out-of-
control sexual behavior [127]. Although precise rates are
unclear given limited epidemiological research, CSB is esti-
mated to affect 36% of the adult population and is more
This article is part of the Topical Collection on Sexual Orientation and
*Shane W. Kraus
Ewelina Kowalewska
Joshua B. Grubbs
Marc N. Potenza
Mateusz Gola
Małgorzata Draps
SWPS University of Social Sciences and Humanities,
Warsaw, Poland
Clinical Neuroscience Laboratory, Institute of Psychology, Polish
Academy of Sciences, Warsaw, Poland
Department of Psychology, Bowling Green State University,
Bowling Green, OH, USA
Departments of Psychiatry, Neuroscience and Child Study Center,
Yale University, New Haven, CT, USA
Connecticut Council on Problem Gambling, Wethersfield, CT, USA
Connecticut Mental Health Center, New Haven, CT, USA
Swartz Center for Computational Neuroscience, Institute for Neural
Computations, University of California, San Diego, USA
VISN 1 New England MIRECC, Edith Nourse Rogers Memorial
Veterans Hospital, 200 Spring Road, Building 5, Room 135B,
Bedford, MA 01730, USA
Division of Addiction Psychiatry, University of Massachusetts
Medical School, Worcester, MA, USA
Current Sexual Health Reports
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common in men than women [28••,29••,3032]. Due to the
associated distress and impairment reported by men and wom-
en with CSB [46,30,3338], the World Health Organization
(WHO) has recommended including compulsive sexual be-
havior disorder (CSBD) in the forthcoming 11th edition of
the International Classification of Diseases (6C72) [39••].
This inclusion should help increase access to treatment for
unserved populations, reduce stigma and shame associated
with help-seeking, promote concerted research efforts, and
increase international attention on this condition [40,41••].
Over the last 20 years, there have been varying definitions
used to describe dysregulated sexual behaviors often charac-
terized by excessive engagement in nonparaphilic sexual ac-
tivities (e.g., frequent casual/anonymous sex and problematic
use of pornography). For the current review, we will use the
term CSB as an overarching term for describing problematic,
excessive sexual behavior.
CSB has been conceptualized as an obsessivecompulsive-
spectrum disorder, an impulse-control disorder, and addictive
behavior [42,43]. The symptoms of CSBD are like those
proposed in 2010 for the DSM-5 diagnosis of hypersexual
disorder [44]. Hypersexual disorder was ultimately excluded
by the American Psychiatric Association from DSM-5 for
multiple reasons; the lack of neurobiological and genetic stud-
ies was among the most noted reasons [45,46]. More recently,
CSB has received considerable attention in both popular cul-
ture and social sciences, particularly given health disparities
affecting at-risk and underserved groups. Despite the consid-
erable increase in studies of CSB (including those studying
sexual addiction,”“hypersexuality,and sexual compulsiv-
ity), relatively little research has examined neural underpin-
nings of CSB [4,36]. This article reviews neurobiological
mechanisms of CSB and provides recommendations for future
research, as related to diagnostic classification of CSBD.
CSB as an Addictive Disorder
Brain regions involved in processing rewards are likely im-
portant for understanding the origins, formation, and mainte-
nance of addictive behaviors [47]. Structures within a so-
called reward systemare activated by potentially reinforc-
ing stimuli, such as addictive drugs in addictions. A major
neurotransmitter involved in processing rewards is dopamine,
especially within the mesolimbic pathway involving the ven-
tral tegmental area (VTA) and its connections with the nucleus
accumbens (NAc), as well as the amygdala, hippocampus, and
prefrontal cortex [48]. Additional neurotransmitters and path-
ways are involved in processing rewards and pleasure, and
these warrant considerations given that dopamine has been
implicated to varying degrees in individual drug and behav-
ioral addictions in humans [4951].
According to the incentive salience theory, different brain
mechanisms influence motivation to obtain reward (want-
ing) and the actual hedonic experience of reward (liking)
[52]. Whereas wantingmay be closely related to dopami-
nergic neurotransmission in the ventral striatum (VStr) and
orbitofrontal cortex, networks dedicated to creating wanting
motivations and pleasurable feelings are more complex [49,
VStr reward-related reactivity has been studied in addictive
disorders such as alcohol, cocaine, opioid use disorders, and
gambling disorder [5558]. Volkow and colleagues describe
four important components of addiction: (1) sensitization in-
volving cue reactivity and craving, (2) desensitization involv-
ing habituation, (3) hypofrontality, and (4) malfunctioning
stress systems [59]. Thus far, research of CSB has largely
focused on cue reactivity, craving, and habituation. The first
neuroimaging studies of CSB were focused on examining
potential similarities between CSB and addictions, with a spe-
cific focus on the incentive salience theory that is based on
preconscious neural sensitization related to changes in
dopamine-related motivation systems [60]. In this model, re-
peated exposure to potentially addictive drugs may change
brain cells and circuits that regulate the attribution of incentive
salience to stimuli, which is a psychological process involved
in motivated behavior. Because of this exposure, brain circuits
may become hypersensitive (or sensitized), thereby contribut-
ing to the development of pathological levels of incentive
salience for target substances and their associated cues.
Pathological incentive motivation (wanting) for drugs may
last for years, even if drug use is discontinued. It may involve
implicit (unconscious wanting) or explicit (conscious craving)
processes. The incentive salience model has been proposed to
potentially contribute to the development and maintenance of
CSB [1,2].
Data support the incentive salience model for CSB. For
example, Voon and colleagues examined cue-induced activity
in the dorsal anterior cingulate cortex (dACC)Vstramyg-
dala functional network [1]. Men with CSB as compared to
those without showed increased VStr, dACC, and amygdala
responses to pornographic video clips. These findings in the
context of the larger literature suggest that sex and drug-cue
reactivity involve largely overlapping regions and networks
[61,62]. Men with CSB as compared to those without also
reported higher wanting (subjective sexual desire) of pornog-
raphy stimuli and lower liking which is consistent with an
incentive salience theory [1]. Similarly, Mechelmans and col-
leagues found that men withCSB as compared to men without
showed enhanced early attentional bias toward sexually ex-
plicit stimuli but not to neutral cues [2]. These findings sug-
gest similarities in enhanced attentional bias observed in stud-
ies examining drug cues in addictions.
In 2015, Seok and Sohn found that among men with CSB
as compared to those without, greater activity was observed in
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the dorsolateral prefrontal cortex (dlPFC), caudate, inferior
supramarginal gyrus of the parietal lobe, dACC, and thalamus
in response to sexual cues [63]. They also found that the se-
verity of CSB symptoms was correlated with cue-induced
activation of the dlPFC and thalamus. In 2016, Brand and
colleagues observed greater activation of the VStr for pre-
ferred pornographic material as compared to non-preferred
pornographic material among men with CSB. Specifically,
they found that VStr activity was positively associated with
self-reported symptoms of addictive use of Internet pornogra-
phy (assessed by the short Internet Addiction Test modified
for cybersex (s-148 IATsex)) [64,65].
Recently, Klucken and colleagues observed that participants
with CSB compared to participants without displayed greater
activation of the amygdala during presentation of conditioned
cues (colored squares) predicting erotic pictures (rewards) [66].
The results are similar to other studies examining amygdala
activation among individuals with substance use disorders
and men with CSB watching sexually explicit video clips [1,
67]. Using EEG, Steele and colleagues observed a higher P300
amplitude to sexual images (when compared to neutral pic-
tures) among individuals self-identified as having problems
with CSB, resonating with prior research of processing visual
drug cues in drug addiction [68,69].
In 2017, Gola and colleagues published results of a study
using functional magnetic resonance imaging (fMRI) to ex-
amine Vstr responses to erotic and monetary stimuli among
men seeking treatment for CSB and men without CSB [6].
Participants were engaged in an incentive delay task [54,70,
71] while undergoing fMRI scanning. During this task, they
received erotic or monetary rewards preceded by predictive
cues. Men with CSB differed from those without in VStr re-
sponses to cues predicting erotic pictures, but not in their
responses to erotic pictures. Additionally, men with CSB ver-
sus men without CSB showed greater VStr activation specif-
ically for cues predicting erotic pictures and not for those
predicting monetary rewards. Relative sensitivity to cues
(predicting erotic pictures vs. monetary gains) was found to
be related to an increased behavioral motivation for viewing
erotic images (wanting), intensity of CSB, amount of por-
nography used per week, and frequency of weekly masturba-
tion. These findings suggest similarities between CSB and
addictions, an important role for learned cues in CSB, and
possible treatment approaches, particularly interventions fo-
cused on teaching skills to individuals to successfully cope
with cravings/urges [72]. Furthermore, habituation may be
revealed through decreased reward sensitivity to normally sa-
lient stimuli and may impact reward responses to sexual stim-
uli including pornography viewing and partnered sex [1,68].
Habituation has also been implicated in substance and behav-
ioral addictions [7379].
In 2014, Kuhn and Gallinat observed decreased VStr reac-
tivity in response to erotic pictures in a group of participants
watching pornography frequently, when compared to partici-
pants watching pornography rarely [80]. Decreased functional
connectivity between the left dlPFC and right VStr was also
observed. Impairment in fronto-striatal circuity has been relat-
ed to inappropriate or disadvantageous behavioral choices ir-
respective of potential negative outcome and impaired regu-
lation of craving in drug addiction [81,82]. Individuals with
CSB may have reduced executive control when exposed to
pornographic material [83,84]. Kuhn and Gallinat also found
that the gray-matter volume of the right striatum (caudate nu-
cleus), which has been implicated in approach-attachment be-
haviors and related to motivational states associated with ro-
mantic love, was negatively associated with the duration of
internet pornography viewing [80,85,86]. These findings
raise the possibility that frequent use of pornography may
decrease brain activation in response to sexual stimuli and
increase habituation to sexual pictures although longitudinal
studies are needed to exclude other possibilities.
A study using EEG, conducted by Prause and colleagues,
suggested that individuals who feel distressed about their por-
nography use, as compared to a control group who do not feel
distress about their use of pornography, may require
more/greater visual stimulationtoevokebrainresponses
[87]. Hypersexual participantsindividuals experiencing
problems regulating their viewing of sexual images(M=
3.8 h per week)exhibited less neural activation (measured
by late positive potential in the EEG signal) when exposed to
sexual images than did the comparison group when exposed
to the same images. Depending on the interpretation of sexual
stimuli in this study (as a cue or reward; for more see Gola
et al. [4]), the findings may support other observations indi-
cating habituation effects in addictions [4]. In 2015, Banca
and colleagues observed that men with CSB preferred novel
sexual stimuli and demonstrated findings suggestive of habit-
uation in the dACC when exposed repeatedly to the same
images [88]. Results of the aforementioned studies suggest
that frequent pornography use may decrease reward sensitiv-
ity, possibly leading to increased habituation and tolerance,
thereby enhancing the need for greater stimulation to be sex-
ually aroused. However, longitudinal studies are indicated to
examine this possibility further. Taken together, neuroimaging
research to date has provided initial support for the notion that
CSB shares similarities with drug, gambling, and gaming ad-
dictions with respect to altered brain networks and processes,
including sensitization and habituation.
CSB as an Impulse-Control Disorder?
The category of Impulse-Control Disorders Not Elsewhere
Classifiedin DSM-IV was heterogeneous in nature and in-
cluded multiple disorders that have since been re-classified as
being addictive (gambling disorder) or obsessive
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compulsive-related (trichotillomania) in DSM-5 [89,90]. The
current category in the DSM-5 focuses on disruptive, impulse-
control, and conduct disorders, becoming more homogeneous
in its focus by including kleptomania, pyromania, intermittent
explosive disorder, oppositional defiant disorder, conduct dis-
order, and antisocial personality disorder [90]. The category of
impulse-control disorders in the ICD-11 includes these first
three disorders and CSBD, raising questions regarding the
most appropriate classification. Given this context, how
CSBD relates to the transdiagnostic construct of impulsivity
warrants additional consideration for classification as well as
clinical purposes.
Impulsivity may be defined as a, predisposition towards
rapid, unplanned reactions to internal or external stimuli with
diminished regard to the negative consequences to the impul-
sive individual or others[91]. Impulsivity has been associat-
ed with hypersexuality [92]. Impulsivity is a multidimensional
construct with different types (e.g., choice, response) that may
have trait and state characteristics [9397]. Different forms of
impulsivity may be assessed via self-report or via tasks. They
may correlate weakly or not all, even within the same form of
impulsivity; importantly, they may relate differentially to clin-
ical characteristics and outcomes [98]. Response impulsivity
may be measured by performance on inhibitory control tasks,
such as the stop signal or Go/No-Go tasks, whereas choice
impulsivity may be assessed through delay discounting tasks
Data suggest differences between individuals with and
without CSB on self-report and task-based measures of im-
pulsivity [100103]. Furthermore, impulsivity and craving
seem to be associated with the severity of symptoms of dys-
regulated pornography use, such as loss of control [64,104].
For instance, one study found interacting effects of levels of
impulsivity measured by self-report and behavioral tasks with
respect to cumulative influences on symptom severity of CSB
Among treatment-seeking samples, 48 to 55% of people
may exhibit high levels of generalized impulsivity on Barratt
Impulsiveness Scale [105107]. In contrast, other data suggest
that some patients seeking treatment for CSB do not have
other impulsive behaviors or comorbid addictions beyond
their struggles with sexual behaviors. This is consistent with
findings from a large online survey of men and women sug-
gesting relatively weak relations between impulsivity and
some aspects of CSB (problematic pornography use) and
stronger relations with others (hypersexuality) [108,109].
Similarly, in a study using different measures of individuals
with problematic pornography use (mean time of weekly por-
nography use = 287.87 min) and those without (mean time of
weekly pornography use = 50.77 min) did not differ on self-
reported (UPPS-P Scale) or task-based (Stop Signal Task)
measures of impulsivity [110]. Further, Reid and colleagues
did not observe differences between individuals with CSB and
healthy controls on neuropsychological tests of executive
functioning (i.e., response inhibition, motor speed, selective
attention, vigilance, cognitive flexibility, concept formation,
and set shifting), even after adjusting for cognitive ability in
analyses [103]. Together, findings suggest that impulsivity
forms of CSB like problematic pornography use. It raises
questions about CSBDs classification as an impulse-control
disorder in the ICD-11 and highlights the need for precise
assessments of different forms of CSB. This is particularly
important since some research indicates that impulsivity and
subdomains of impulse-control disorder differ on conceptual
and pathophysiological level [93,98,111].
CSB as an ObsessiveCompulsive-Spectrum
Trichotillomania, previously classified as an impulsecontrol
disorder in DSM-IV, has been re-classified with obsessive
compulsive disorder (OCD) as an obsessivecompulsive and
related disorde r in DSM-5 [90]. Other DSM-IV impulse-con-
trol disorders like gambling disorder exhibit significant differ-
ences from OCD, supporting their classification in separate
categories [112]. Compulsivity is a transdiagnostic construct
that involves, the performance of repetitive and functionally
impairing overt or covert behavior without adaptive function,
performed in a stereotyped or habitual fashion, either accord-
ing to rigid rules or as a means to avoid negative conse-
quences[93]. OCD exhibits high levels of compulsivity;
however, so do substance addictions and behavioral addic-
tions like gambling disorder [98]. Traditionally, compulsive
and impulsive disorders were construed as lying along oppo-
site ends of a spectrum; however, data suggest the constructs
as being orthogonal with many disorders scoring high on mea-
sures of both impulsivity and compulsivity [93,113].
Regarding CSB, sexual obsessions have also been described
as time-consuming and interfering and may relate theoretical-
ly to OCD or to OCD-related features [114].
Recent studies assessing obsessivecompulsive features
using the ObsessiveCompulsive Inventory-Revised (OCI-
R) did not show elevations among individuals with CSB [6,
37,115]. Similarly, a large online survey found aspects of
compulsivity only weakly related to problematic pornog-
raphy use [109]. Together, these findings do not show
strong support for considering CSB as an obsessive
compulsive-related disorder. Neural features underlying
compulsive behaviors have been described and overlap
across multiple disorders [93]. Further studies using
psychometrically validated and neuroimaging methods
in larger clinical treatment-seeking samples are needed
to examine further how CSBD may relate to compulsivity and
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Structural Neural Changes among CSB
Thus far, most neuroimaging studies have focused on func-
tional alterations in individuals with CSB, and results suggest
that CSB symptoms are linked to specific neural processes [1,
63,80]. Although task-based studies have deepened our
knowledge about regional activation and functional connec-
tivity, additional approaches should be used.
White- or gray-matter measures have been studied in CSB
[102,116]. In 2009, Miner and colleagues found that individ-
uals with CSB, as compared to those without, displayed better
superior frontal region mean diffusivity and exhibited poorer
inhibitive control. In a study of men with and without CSB
from 2016, greater left amygdala volume was observed in the
CSB group and relatively reduced resting-state functional
connectivity was observed between the amygdala and dlPFC
[116]. Reduction of brain volumes in the temporal lobe, fron-
tal lobe, hippocampus, and amygdala were found to be related
to the symptoms of hypersexuality in patients with dementia
or Parkinsonsdisease[117,118]. These seemingly opposing
patterns of amygdala volume relating to CSB highlight the
importance of considering co-occurring neuropsychiatric dis-
orders in understanding the neurobiology of CSB.
In 2018, Seok and Sohn used voxel-based morphometry
(VBM) and resting-state connectivity analysis to examine
gray-matter and resting-state measures in CSB [119]. Men
with CSB showed significant gray-matter reduction in the
temporal gyrus. Left superior temporal gyrus (STG) volume
was negatively correlated with the severity of CSB (i.e.,
Sexual Addiction Screening Test-Revised [SAST] and
Hypersexual Behavior Inventory [HBI] scores) [120,121].
Additionally, altered left STG-left precuneus and left STG-
right caudate connectivities were observed. Lastly, results re-
vealed a significant negative correlation between severity of
CSB and functional connectivity of the left STG to the right
caudate nucleus.
While the neuroimaging studies of CSB have been illumi-
nating, little is known about alternation in brain structures and
functional connectivity among CSB individuals, particularly
from treatment studies or other longitudinal designs.
Integration of findings from other domains (e.g., genetic and
epigenetic) will also be important to consider in future studies.
Additionally, findings directly comparing specific disorders
and incorporating transdiagnostic measures will allow for col-
lection of important information that could inform classification
and intervention development efforts currently underway.
Conclusions and Recommendations
This article reviews scientific knowledge regarding neural
mechanisms of CSB from three perspectives: addictive,
impulse-control, and obsessivecompulsive. Several studies
suggest relationships between CSB and increased sensitivity
for erotic rewards or cues predicting these rewards, and others
suggest that CSB is related to increased cue-conditioning for
erotic stimuli [1,6,36,64,66]. Studies also suggest that CSB
symptoms are associated with elevated anxiety [34,37,122].
Although gaps exist in our understanding of CSB, multiple
brain regions (including frontal, parietal, and temporal corti-
ces, amygdala, and striatum) have been linked to CSB and
related features.
CSBD has been included in the current version of the ICD-
11 as an impulse-control disorder [39••]. As described by the
WHO, Impulse-control disorders are characterized by the
repeated failure to resist an impulse, drive, or urge to perform
an act that is rewarding to the person, at least in the short-term,
despite consequences such as longer-term harm either to the
individual or to others, marked distress about the behaviour
pattern, or significant impairment in personal, family, social,
educational, occupational, or other important areas of func-
tioning[39••]. Current findings raise important questions re-
garding the classification of CSBD. Many disorders charac-
terized by impaired impulse-control are classified elsewhere
in the ICD-11 (for example, gambling, gaming, and substance
use disorders are classified as being addictive disorders) [123].
Currently, CSBD constitutes a heterogeneous disorder, and
further refinement of CSBD criteria should distinguish be-
tween different subtypes, some of which may relate to the
heterogeneity of sexual behaviors problematic for individuals
[33,108,124]. Heterogeneity in CSBD may in part explain
seeming discrepancies which are noticeable across studies.
Although neuroimaging studies find multiple similarities be-
tween CSB and substance and behavioraladdictions, addition-
al research is needed to fully understand how neurocognition
relates to the clinical characteristics of CSB, especially with
respect to sexual behaviors subtypes. Multiple studies have
focused exclusively on problematic use of pornography which
may limit generalizability to other sexual behaviors. Further,
inclusion/exclusion criteria for CSB research participants have
varied across studies, also raising questions regarding gener-
alizability and comparability across studies.
Future Directions
Several limitations should be noted with respect to current
neuroimaging studies and be considered when planning future
investigations (see Table 1). A primary limitation involves
small sample sizes that are largely white, male, and heterosex-
ual. More research is needed to recruit larger, ethnically di-
verse samples of men and women with CSB and individuals
of different sexual identities and orientations. For example, no
systematic scientific studies have investigated neurocognitive
processes of CSB in women. Such studies are needed given
data linking sexual impulsivity to greater psychopathology in
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women as compared to men and other data which suggest
gender-related differences in clinical populations with CSB
[25,30]. As women and men with addictions may demon-
strate different motivations (e.g., relating to negative versus
positive reinforcement) for engaging in addictive behaviors
and show differences in stress and drug-cue responsivity, fu-
ture neurobiological studies should consider stress systems
and related processes in gender-related investigations of
CSBD given its current inclusion in the ICD-11 as a mental
health disorder [125,126].
Similarly, there is a need to conduct systematic research
focusing on ethnic and sexual minorities to clarify our under-
standing of CSB among these groups. Screening instruments
for CSB have been mostly tested and validated on white
European men. Moreover, current studies have focused pre-
dominantly on heterosexual men. More research examining
clinical characteristics of CSB among gay and bisexual men
and women is needed. Neurobiological research of specific
groups (transgender, polyamorous, kink, other) and activities
(pornography viewing, compulsive masturbation, casual
anonymous sex, other) is also needed. Given such limitations,
existing results should be interpreted cautiously.
Direct comparison of CSBD with other disorders (e.g.,
substance use, gambling, gaming, and other disorders) is
needed, as is incorporation of other non-imaging modalities
(e.g., genetic, epigenetic) and use of other imaging ap-
proaches. Techniques like positron emission tomography
could also provide important insight into neurochemical un-
derpinnings of CSBD.
The heterogeneity of CSB may also be clarified through
careful assessment of clinical features that may be obtained in
part from qualitative research like focus group or diary assess-
ment methods [37]. Such research could also provide insight
into longitudinal questions like whether problematic pornogra-
phy use may lead to sexual dysfunction, and integrating
neurocognitive assessments into such studies could provide in-
sight into neurobiological mechanisms. Further, as behavioral
and pharmacological interventions are formally tested for their
efficacies in treating CSBD, integration of neurocognitive as-
sessments could help identify mechanisms of effective treat-
ments for CSBD and potential biomarkers. This last point may
be particularly important because the inclusion of CSBD in the
ICD-11 will likely increase the number of individuals seeking
treatment for CSBD. Specifically, the inclusion of CSBD in the
ICD-11 should raise awareness in patients, providers, and others
and potentially remove other barriers (e.g., reimbursement from
insurance providers) that may currently exist for CSBD.
Funding Information This work supported by: The Department of
Veterans Affairs, Veterans Health Administration, VISN 1 New
England Mental Illness Research, Education, and Clinical Center (SK);
Jubilee Grant for doctoral students of the Interdisciplinary Doctoral
Studies financed by SWPS University of Social Sciences and
Humanities in Poland (EK); The Polish National Science Centre grant
OPUS(2014/15/B/HS6/03792) (MG, EK, and MW); The Connecticut
Council on Problem Gambling (MNP); The Connecticut Department of
Mental Health and Addiction Services (MNP). The views expressed are
those of the authors and do not necessarilyreflect the position or policy of
the Department of Veterans Affairs, United States government, or other
funding agencies.
Compliance with Ethical Standards
Conflict of Interest Ewelina Kowalewska, Joshua B. Grubbs, Mateusz
Gola, Małgorzata Draps, and Shane W. Kraus each declare no potential
conflicts of interest.
Marc N. Potenza reports consulting fees from Jazz Pharmaceuticals,
Opiant (Lightlake) Pharmaceuticals, Las Vegas Sands, Legal firms, Shire
Pharmaceuticals, and research support to Yale from Mohegan Sun
Human and Animal Rights and Informed Consent This article does not
contain any studies with human or animal subjects performed by any of
the authors.
Table 1 Recommendations for neuroscientific studies of compulsive sexual behavior disorder
Data Goal
Conduct intercultural studies on larger samples; include more women, ethnic and sexual minorities, economically disadvantaged
persons, and persons with cognitive and physical disabilities
Large, well-powered field trials to assess and validate proposed CSBD diagnostic criteria
Examine the heterogeneous nature of CSBD
Examine the role of impulsivity and other transdiagnostic constructs in the development and maintenance of CSBD
Assess the relationship between brain structure and function and treatment outcomes for treatment-seeking individuals with CSBD
Identification of efficacious and well-tolerated pharmacological and behavioral treatments in randomized clinical trials of individuals
with CSBD
Neurobiological Further examination of structural, functional, neurochemical, and other data and their integration
Examine neurobiological mechanisms underlying specific aspects of CSBD including sexual function and dysfunction
Genetic Conduct genome-wide association studies (GWAS) on CSBD
Examine genetic factors that may serve as vulnerability factors for the development of CSBD
Study environmental and epigenetic influences on processes in CSBD
Curr Sex Health Rep
Author's personal copy
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  • ... Despite the official recognition of CSBD, there remain several controversies about the diagnosis, particularly as it relates to excessive pornography use. For example, despite intense debates about whether CSBD represents an addictive disorder (Kowalewska et al., 2018;, in lay audiences, excessive pornography use is often viewed as an addiction (Perry, 2019;Taylor, 2020). There is also evidence that the application of the CSBD diagnosis can be skewed by demographic differences in clients (Klein, Briken, Schroder, & Fuss, 2019) or greater religiousness on the part of therapists (Droubay & Butters, 2019;Hecker, Trepper, Wetchler, & Fontaine, 1995). ...
    ... We did not assess for impulsivity on the part of participants, which may be a salient concern given research suggesting that impulsivity compared with compulsivity continues to be an important distinction in understanding behavioral addictions (Grant et al., 2014). Moreover, the distinctions between impulsivity, compulsivity, and addiction are not always clear in CSBD research and represent an area in need of more in-depth empirical inquiry (Kowalewska et al., 2018;Kraus, Voon, & Potenza, 2016) We also note that this was not a study of clinical or treatment-seeking populations. As such, our results do not clarify whether moral incongruence is a driving factor in the self-perception of pornography addiction among treatment seekers. ...
    pornography use may qualify for the new diagnosis of Compulsive Sexual Behavior Disorder (CSBD) in the forthcoming ICD-11. There is also evidence, however, that moral incongruence (i.e., a misalignment of moral beliefs about sexual behavior and actual sexual behavior) may inflate self-reports of problems associated with pornography use. Prior work suggests religiousness may drive such moral incongruence. Using a large sample matched to U.S. representative norms (Total: N=2,519; past-year pornography users: N=1,424, 66.4% men), the present work examined the interaction between pornography use and religiousness in predicting self-reported addiction to pornography. Results indicated that religiousness moderated the association between pornography use and self-reported addiction so that, despite a negative association between religiousness and use, at higher levels of religiousness, pornography use was more strongly related to self-reports of addiction.
  • ... Despite the official recognition of CSBD, there remain several controversies about the diagnosis, particularly as it relates to excessive pornography use. For example, despite intense debates about whether CSBD represents an addictive disorder (Kowalewska et al., 2018;, in lay audiences, excessive pornography use is often viewed as an addiction (Perry, 2019;Taylor, 2020). There is also evidence that the application of the CSBD diagnosis can be skewed by demographic differences in clients (Klein, Briken, Schroder, & Fuss, 2019) or greater religiousness on the part of therapists (Droubay & Butters, 2019;Hecker, Trepper, Wetchler, & Fontaine, 1995). ...
    ... We did not assess for impulsivity on the part of participants, which may be a salient concern given research suggesting that impulsivity compared with compulsivity continues to be an important distinction in understanding behavioral addictions (Grant et al., 2014). Moreover, the distinctions between impulsivity, compulsivity, and addiction are not always clear in CSBD research and represent an area in need of more in-depth empirical inquiry (Kowalewska et al., 2018;Kraus, Voon, & Potenza, 2016) We also note that this was not a study of clinical or treatment-seeking populations. As such, our results do not clarify whether moral incongruence is a driving factor in the self-perception of pornography addiction among treatment seekers. ...
    In the United States, pornography use is common, and it is increasingly a clinical concern under some circumstances. Excessive pornography use may qualify for the new diagnosis of compulsive sexual behavior disorder (CSBD) in the forthcoming 11th version of the International Classification of Diseases. There is also evidence, however, that moral incongruence (i.e., a misalignment of moral beliefs about sexual behavior and actual sexual behavior) may inflate self-reports of problems associated with pornography use. Prior work suggests religiousness may drive such moral incongruence. Using a large sample matched to U.S. representative norms (total: N = 2,519; past-year pornography users: n = 1,424, 66.4% men), we examined the interaction between pornography use and religiousness in predicting self-reported addiction to pornography. Results indicated that religiousness moderated the association between pornography use and self-reported addiction so that, despite a negative association between religiousness and use, at higher levels of religiousness, pornography use was more strongly related to self-reports of addiction.
  • ... Received 14 October 2019; Received in revised form 12 January 2020; Accepted 13 January 2020 and, roughly 10% of this clinical population highlighted two or more BAs (Di Nicola et al., 2015). This approach laid the foundations for neuroscience studies that highlighted similar brain functional alterations linked to sensitization, habituation, impulse control, and reward processing among gambling disorder, compulsive sex and SUDs (e.g., Fauth-Bühler, Mann, & Potenza, 2017;Kowalewska et al., 2018). ...
    ... Accordingly, the study hypothesized no significant associations between mindful acceptance attitudes and the severity of comorbid addictive behaviors with AUD. These considerations were based on available neuroimaging data that highlighted similar alterations within brain attentional networks (e.g., anterior cingulate cortex, dorsolateral prefrontal cortex) among BAs and other inflexible behaviors (Donnelly et al., 2018;Fauth-Bühler et al., 2017;Kowalewska et al., 2018;Mestre-Bach, Steward, Jiménez-Murcia, & Fernández-Aranda, 2017). Moreover, the emerging evidence did not detect significant associations between mindful acceptance dimension and BAs (e.g., de Lisle, Dowling, & Allen, 2012), as well as with other inflexible behaviors (e.g., Adams et al., 2012). ...
    Individuals with alcohol use disorder (AUD) and other substance use disorders (SUDs) frequently show co-occurrent behavioral addictions (BAs) (i.e., gambling and compulsive sex) and other inflexible behaviors (IBs) (i.e., compulsive buying and dysfunctional eating behaviors). The covariation of these conditions might be explained by a role of emotion dysregulation (ED) and executive dysfunctions. This study aims at investigating whether ED and self-regulation of attention (SRA) could be common processes that underpin BAs and other IBs among individuals with AUD. The study hypothesized that SRA should represent a key protective factor for the relationships between ED and BAs/IBs. The research included 319 treatment-seeking individuals with a primary diagnosis of AUD. Five independent multiple parallel mediational models were tested. Self-report instruments were administered in order to assess ED, BAs and other IBs, which represented independent and dependent variables respectively. SRA was self-report assessed and, it was considered the key mediator variable. The analyses highlighted significant total effects of ED on the severity of BAs and IBs. SRA fully mediated the relationships between ED and BAs/IBs, with exception of gambling. ED and SRA should be considered common dimensions that explain the covariation of BAs and IBs among individuals with AUD. SRA represents an adaptive form of emotion regulation that sustains the engagement in goal-oriented behaviors. Future neuroimaging and longitudinal studies are recommended in order to demonstrate the role of ED and SRA on development, maintenance and treatment of BAs and IBs among individuals with SUDs.
  • ... Data from self-report, behavioral, electrophysiological, and neuroimaging studies demonstrate an involvement of psychological processes and underlying neural correlates that have been investigated and established to varying degrees for substance-use disorders and gambling/gaming disorders (criterion 3). Commonalities noted in prior studies include cue-reactivity and craving accompanied by increased activity in reward-related brain areas, attentional biases, disadvantageous decision-making, and (stimuli-specific) inhibitory control (e.g., Antons & Brand, 2018;Antons, Mueller, et al., 2019;Bothe et al., 2019;Brand, Snagowski, Laier, & Maderwald, 2016;Gola et al., 2017;Klucken, Wehrum-Osinsky, Schweckendiek, Kruse, & Stark, 2016;Kowalewska et al., 2018;Mechelmans et al., 2014;Stark, Klucken, Potenza, Brand, & Strahler, 2018;Voon et al., 2014). ...
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    Background: Gambling and gaming disorders have been included as "disorders due to addictive behaviors" in the International Classification of Diseases (ICD-11). Other problematic behaviors may be considered as "other specified disorders due to addictive behaviors (6C5Y)." Methods: Narrative review, experts' opinions. Results: We suggest the following meta-level criteria for considering potential addictive behaviors as fulfilling the category of "other specified disorders due to addictive behaviors":1. Clinical relevance: Empirical evidence from multiple scientific studies demonstrates that the specific potential addictive behavior is clinically relevant and individuals experience negative consequences and functional impairments in daily life due to the problematic and potentially addictive behavior.2. Theoretical embedding: Current theories and theoretical models belonging to the field of research on addictive behaviors describe and explain most appropriately the candidate phenomenon of a potential addictive behavior.3. Empirical evidence: Data based on self-reports, clinical interviews, surveys, behavioral experiments, and, if available, biological investigations (neural, physiological, genetic) suggest that psychological (and neurobiological) mechanisms involved in other addictive behaviors are also valid for the candidate phenomenon. Varying degrees of support for problematic forms of pornography use, buying and shopping, and use of social networks are available. These conditions may fit the category of "other specified disorders due to addictive behaviors". Conclusion: It is important not to over-pathologize everyday-life behavior while concurrently not trivializing conditions that are of clinical importance and that deserve public health considerations. The proposed meta-level-criteria may help guide both research efforts and clinical practice.
  • ... Several studies have indicated that also in individuals with higher symptom severity of problematic IP use or compulsive sexual behaviors, the ventral striatum, as part of the impulsive system, and the dorsolateral prefrontal cortex, as part of the reflective system, are hyperactive during cue-reactivity (Brand, Snagowski, Laier, & Maderwald, 2016;Gola et al., 2017;Seok & Sohn, 2015). These studies show that symptom severity is associated with increased processing of sexual stimuli within the impulsive and the reflective system (also see reviews on problematic pornography use and CSBD by Kowalewska et al., 2018;Stark et al., 2018). The hyperactivity of the reflective system may be interpreted as an increase in effort needed by individuals to maintain control over temptations, which are mainly driven by the impulsive system. ...
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    Background and aims Diminished control over a specific behavior is a core characteristic in addictive behaviors such as problematic Internet-pornography (IP) use. First studies suggest that a hyperactivity of the impulsive system is one reason for impulsive behaviors in the context of problematic IP use. The tripartite-process theory of addiction explains neurocognitive mechanisms beyond common dual-process theories in addictive behaviors. However, the role of the reflective and interoceptive system is still unresolved. Methods The study comprised a stop-signal task (SST) including neutral and pornographic images during fMRI and questionnaires to investigate associations between symptoms of problematic IP use, craving, and neural activity of the impulsive, reflective, and interoceptive system. We examined 28 heterosexual males with varying symptom severity of problematic IP use. Results Data indicates that individuals with more symptoms of problematic IP use showed better performance in the SST which was linked to decreased insula and inferior frontal gyrus activity during pornographic image processing. An increase in craving was associated with lower activity of the ventral striatum during pornographic image processing. The interoceptive system showed varying effects. Increased insula activity during inhibitory control and decreased activity during pornographic image processing were associated with higher inhibitory control performance. Discussion and Conclusion Effects of tolerance and motivational aspects may explain the better inhibitory control performance in individuals with higher symptom severity which was associated with differential activity of the interoceptive and reflective system. Diminished control over IP use presumably results from the interaction between the impulsive, reflective, and interoceptive systems.
  • ... Two a priori hypothesis were tested. Because current evidence suggest that CSBD may be classified as an addictive disorder beyond other competing models (Gola et al., 2017;Kowalewska et al., 2018;Kraus et al., 2016;Potenza, Gola, Voon, Kor, & Kraus, 2017) and SUDs are common in this population (Reid & Meyer, 2016), it was hypothesized that prevalence of SUDs would be significantly higher in CSBD participants. To the extent that CSBD patients tend to use sex as a coping mechanism (Kafka, 2010;Lew-Starowicz, Lewczuk, Nowakowska, Kraus, & Gola, 2019;Schultz, Hook, Davis, Penberthy, & Reid, 2014), we also hypothesized that prevalence of disorders where emotional dysregulation plays an important role would be increased in CSBD participants. ...
    Compulsive Sexual Behavior Disorder (CSBD) is characterized by a persistent failure to control intense and recurrent sexual impulses, urges, and/or thoughts, resulting in repetitive sexual behavior that causes a marked impairment in important areas of functioning. Data collected from clinical populations suggest that CSBD frequently co-occurs with other Axis I and II psychiatric disorders; however, studies conducted so far suffer from methodological shortcomings that prevent the determination of accurate psychiatric comorbidity rates. The purpose of this study was to explore psychiatric comorbidity in a sample of individuals with and without CSBD. The study sample comprised 383 participants distributed into two groups through a cluster analyses: 315 participants without CSBD (non-CSBD) and 68 qualifying as sexually compulsives (CSBD). Participants were assessed for co-occurring Axis I and II clinical conditions using structured clinical interviews for the DSM-IV (SCID-I and II). The majority of CSBD participants (91.2%) met the criteria for at least one Axis I disorder, compared to 66% in non-CSBD participants. CSBD participants were more likely to report an increased prevalence of alcohol dependence (16.2%), alcohol abuse (44%), major depressive disorder (39.7%), bulimia nervosa (5.9%), adjustment disorders (20.6%), and other substances –mainly cannabis and cocaine– abuse or dependence (22.1%). Concerning Axis II, prevalence of borderline personality disorder was significantly higher in CSBD participants (5.9%). As expected, prevalence of different psychiatric conditions was significantly increased among sexually compulsive participants, revealing comorbidity patterns with important implications in the conceptualization, assessment, and treatment of patients with CSBD.
  • ... This recognition is an important first step for furthering discussion of compulsive/problematic sexual behaviors/disorders. Nevertheless, questions remain regarding appropriate categorization of the disorder, as it shares many underlying features with addiction [51,53,88]. Estimates of CSB have been reported to range from approximately 3-6% of US adults [33], including 3% of men and 1% of women [68]. ...
    Purpose of Review Information on potential risk factors and clinical correlates of compulsive sexual behavior (CSB) may help inform more effective prevention and treatment measures. Sexual victimization, specifically, child sexual abuse (CSA), has been associated with CSB. Recent Findings This systematic review describes 21 studies on the relationship between CSA and CSB. Most studies identified a significant association between CSA and CSB. However, variability in measurements, potential differences in links among community versus clinical samples, relevance of research among college samples, lack of support for gender-related differences, and the need for more longitudinal designs were identified. Summary Research would benefit from more formalized assessments of CSB across different populations. Prevention efforts should be aimed toward individuals who experienced CSA and/or other abuse, particularly if they report engaging in risky sexual behavior. Individuals with CSB who have experienced sexual abuse may benefit from trauma-focused treatment.
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    In questo testo viene affrontato il tema delle dipendenze patologiche in senso lato, sia le dipendenze da sostanze che inducono assuefazione (quelle legali, come l'alcol, il tabacco, i farmaci di prescrizione, e quelle illegali, come la marijuana, la cocaina, l'eroina), sia le dipendenze comportamentali (gioco, videogiochi, sesso, lavoro, esercizio fisico, shopping o cibo). Non tutti i comportamenti compulsivi sono considerati dipendenze, ma sono ormai così diffusi da non poter essere ignorati. Il testo però non sarebbe completo, se non fosse anche capace di trasmettere la speranza e offrire delle soluzioni. Con questo obiettivo, analizza quindi una serie di elementi chiave con cui si confrontano le persone dipendenti che cercano aiuto. Forte della sua esperienza, l’autore, che lavora da alcuni anni in un Centro per il Recupero delle Dipendenze, ci introduce a cos’è il recupero e come va inquadrato terapeuticamente, a cosa servono i gruppi di mutuo aiuto, che differenza c'è tra forza di volontà e buona volontà, cosa sono i pensieri intrusivi e come affrontarli, e molto altro. Il testo è di facile lettura ed è rivolto a tutti coloro che sono interessati a questo tema complesso, ma intende anche essere di supporto a chi cerca informazioni più specifiche, per questo l’autore arricchisce la sua opera con numerose citazioni che fanno riferimento a pubblicazioni scientifiche di fama internazionale.
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    Background and aims Compulsive sexual behaviors (CSBs) are an important clinical and social issue. Despite the increasing number of studies, some of CSB’s aspects remain under-investigated. Here, we explore the nature of CSB, such as binge pornography use and masturbation (PuM), and verify the correspondence between self-perceived factors leading to such behavior with its measures obtained in a diary assessment. Methods Semi-structuralized interviews with nine treatment-seeking males aged 22–37 years (M = 31.7, SD = 4.85) were followed by a questionnaire and a 10-week-long diary assessment, allowing us to acquire real-life daily patterns of CSB. Results Six out of nine subjects experienced binge (multiple hours or times a day) PuM. All subjects presented a high level of anxiety and perceived PuM as a way to regulate mood and stress. Data collected in the diary assessment uncovered a high diversity in the patterns of sexual behaviors (such as frequency of regular and binge PuM) and its correlates. Binge PuM was related to decreased mood and/or increased stress or anxiety. The causal relation between these correlates remains undetermined. Discussion and conclusions Binge PuM seems to be one of the most characteristic behavior among males who are seeking treatment for CSB and is related to the feeling of losing control over one’s sexual activity. CSB individuals indicate a variety of binge triggers. Also, diary assessment data indicate that specific correlates of binge PuM (decreased mood, increased stress, and anxiety) differ between subjects. It suggests the existence of significant individual differences in binge PuM behaviors, and a need to study these differences, as it may help guide personalized treatment.
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    Impulsivity and compulsivity are transdiagnostic features associated with clinically relevant aspects of psychiatric disorders, including addictions. However, little research has investigated how impulsivity and compulsivity relate to hypersexuality and problematic pornography use. Thus, the aims of the present study were to investigate (a) self-reported impulsivity and compulsivity with respect to hypersexuality and problematic pornography use and (b) the similarities and possible differences between hypersexuality and problematic pornography use in these domains. Utilizing structural equation modeling (SEM) in a large community sample (N = 13,778 participants; female = 4,151, 30.1%), results indicated that impulsivity (β = .28, β = .26) and compulsivity (β = .23, β = .14) were weakly related to problematic pornography use among males and females, respectively. Impulsivity had a stronger relationship (β = .41, β = .42) with hypersexuality than did compulsivity (β = .21, β = .16) among males and females, respectively. Consequently, impulsivity and compulsivity may not contribute as substantially to problematic pornography use as some scholars have proposed. On the other hand, impulsivity might have a more prominent role in hypersexuality than in problematic pornography use. Future research should examine further social and situational factors associated with problematic pornography use.
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    Neuroimaging studies on the characteristics of hypersexual disorder have been accumulating, yet alternations in brain structures and functional connectivity in individuals with problematic hypersexual behavior (PHB) has only recently been studied. This study aimed to investigate gray matter deficits and resting-state abnormalities in individuals with PHB using voxel-based morphometry and resting-state connectivity analysis. Seventeen individuals with PHB and 19 age-matched healthy controls participated in this study. Gray matter volume of the brain and resting-state connectivity were measured using 3T magnetic resonance imaging. Compared to healthy subjects, individuals with PHB had significant reductions in gray matter volume in the left superior temporal gyrus (STG) and right middle temporal gyrus. Individuals with PHB also exhibited a decrease in resting-state functional connectivity between the left STG and left precuneus and between the left STG and right caudate. The gray matter volume of the left STG and its resting-state functional connectivity with the right caudate both showed significant negative correlations with the severity of PHB. The findings suggest that structural deficits and resting-state functional impairments in the left STG might be linked to PHB and provide new insights into the underlying neural mechanisms of PHB.
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    During the last decade, there has been heated debate regarding whether compulsive sexual behaviour should be classified as a mental/behavioural disorder. Compulsive sexual behaviour disorder has been proposed for inclusion as an impulse control disorder in the ICD-11. It is characterized by a persistent pattern of failure to control intense, repetitive sexual impulses or urges, resulting in repetitive sexual behaviour over an extended period (e.g., six months or more) that causes marked distress or impairment in personal, family, social, educational, occupational or other important areas of functioning.
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    Introduction: Impulsivity has been identified to be involved in the development and maintenance of specific Internet-use disorders (IUD). It can be differentiated between relatively stable trait impulsivity and state impulsivity which is dependent on environmental and affective factors such as craving. Following the I-PACE (Interaction of Person-Affect-Cognition-Execution) model, both trait and state impulsivity may play an interactive role in IUD. The present study aimed to investigate the relationship between trait and state impulsivity and symptom severity of Internet-pornography-use disorder (IPD) as one form of IUD. Methods: Fifty heterosexual males participated in this study. State impulsivity was measured with reaction times in a modified stop-signal task. Each participant conducted two blocks of this task which included neutral and pornographic pictures. Moreover, current subjective craving, trait impulsivity, and symptom severity of IPD were assessed using several questionnaires. Results: Results indicate that trait impulsivity was associated with higher symptom severity of IPD. Especially those males with higher trait impulsivity and state impulsivity in the pornographic condition of the stop-signal task as well as those with high craving reactions showed severe symptoms of IPD. Conclusion: The results indicate that both trait and state impulsivity play a crucial role in the development of IPD. In accordance with dual-process models of addiction, the results may be indicative of an imbalance between the impulsive and reflective systems which might be triggered by pornographic material. This may result in loss of control over the Internet-pornography use albeit experiencing negative consequences.
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    Background and Aims: Previous studies examined psychological factors related to treatment-seeking for problematic pornography use (PU) among males. In this study, we focused on females who seek treatment for problematic PU and compared them with non-problematic pornography users with regards to variables related to problematic PU. Secondly, we investigated the relationships between critical constructs related to problematic PU with the path analysis method, emphasizing the predictors for treatment-seeking among women. We also compared our results to previous studies on males. Methods: A survey study was conducted on 719 Polish speaking Caucasian females, 14-63 years old, including 39 treatment-seekers for problematic PU. Results: The positive relationship between the mere amount of PU and Treatment-Seeking loses its significance after introducing two other predictors of treatment-seeking: religiosity and negative symptoms associated with PU. This pattern is different than the results obtained in previous studies on males. Discussion: Differently from previous studies on male samples, our analysis showed that in the case of women mere amount of PU may be related with treatment-seeking behavior even after accounting for negative symptoms associated with PU. Moreover, religiousness is a significant predictor of treatment-seeking among women, which may indicate that in the case of women, treatment-seeking for problematic PU is motivated not only by experienced negative symptoms of PU, but also by personal beliefs about PU and social norms. Conclusion: For females, negative symptoms associated with PU, the amount of PU and religiosity are associated with treatment-seeking. Those factors should be taken into account in treatment.