Neurocognitive Mechanisms in Compulsive Sexual Behavior Disorder

Abstract

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.

Full text

1 23
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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SEXUAL ORIENTATION AND IDENTITY (E COLEMAN AND J VENCILL, SECTION EDITORS)
Neurocognitive Mechanisms in Compulsive Sexual Behavior Disorder
Ewelina Kowalewska
1,2
&Joshua B. Grubbs
3
&Marc N. Potenza
4,5,6
&Mateusz Gola
2,7
&Małgorzata Draps
2
&
Shane W. Kraus
8,9
#This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply 2018
Abstract
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
Introduction
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 [1–27]. Although precise rates are
unclear given limited epidemiological research, CSB is esti-
mated to affect 3–6% of the adult population and is more
This article is part of the Topical Collection on Sexual Orientation and
Identity
*Shane W. Kraus
shane.kraus@va.gov
Ewelina Kowalewska
ekowalewska@st.swps.edu.pl
Joshua B. Grubbs
grubbsj@bgsu.edu
Marc N. Potenza
marc.potenza@yale.edu
Mateusz Gola
mgola@ucsd.edu
Małgorzata Draps
mwordecha@psych.pan.pl
1
SWPS University of Social Sciences and Humanities,
Warsaw, Poland
2
Clinical Neuroscience Laboratory, Institute of Psychology, Polish
Academy of Sciences, Warsaw, Poland
3
Department of Psychology, Bowling Green State University,
Bowling Green, OH, USA
4
Departments of Psychiatry, Neuroscience and Child Study Center,
Yale University, New Haven, CT, USA
5
Connecticut Council on Problem Gambling, Wethersfield, CT, USA
6
Connecticut Mental Health Center, New Haven, CT, USA
7
Swartz Center for Computational Neuroscience, Institute for Neural
Computations, University of California, San Diego, USA
8
VISN 1 New England MIRECC, Edith Nourse Rogers Memorial
Veterans Hospital, 200 Spring Road, Building 5, Room 135B,
Bedford, MA 01730, USA
9
Division of Addiction Psychiatry, University of Massachusetts
Medical School, Worcester, MA, USA
Current Sexual Health Reports
https://doi.org/10.1007/s11930-018-0176-z
Author's personal copy

common in men than women [28••,29••,30–32]. Due to the
associated distress and impairment reported by men and wom-
en with CSB [4–6,30,33–38], 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 obsessive–compulsive-
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 system”are 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 [49–51].
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 “wanting”may 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,
53,54].
VStr reward-related reactivity has been studied in addictive
disorders such as alcohol, cocaine, opioid use disorders, and
gambling disorder [55–58]. 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)—Vstr—amyg-
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 [73–79].
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 participants—individuals “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
Classified”in 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 [93–97]. 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
[94,95,99].
Data suggest differences between individuals with and
without CSB on self-report and task-based measures of im-
pulsivity [100–103]. 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
[104].
Among treatment-seeking samples, 48 to 55% of people
may exhibit high levels of generalized impulsivity on Barratt
Impulsiveness Scale [105–107]. 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
maylinkmoststronglytohypersexualitybutnottospecific
forms of CSB like problematic pornography use. It raises
questions about CSBD’s 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 Obsessive–Compulsive-Spectrum
Disorder?
Trichotillomania, previously classified as an impulse–control
disorder in DSM-IV, has been re-classified with obsessive–
compulsive disorder (OCD) as an obsessive–compulsive 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 obsessive–compulsive features
using the Obsessive–Compulsive 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
OCD.
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Structural Neural Changes among CSB
Individuals
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 Parkinson’sdisease[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 obsessive–compulsive. 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
Casino.
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
Behavioral
Self-report
Neurobiological
▪Conduct intercultural studies on larger samples; include more women, ethnic and sexual minorities, economically disadvantaged
persons, and persons with cognitive and physical disabilities
Clinical
Behavioral
Self-report
Neurobiological
▪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
Clinical
Pharmacological
Neurobiological
▪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
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