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A considerable amount of interest has been generated by recent media coverage of an article by Steele, Staley, Fong and Prause (2013) from the most recent issue of Socioaffective Neuroscience & Psychology. After a thorough reading of the article, I can say that it is a well referenced and a good-faith attempt to understand what is colloquially known as sex addiction. But sex addiction isn’t a diagnosable disorder, is it? Hypersexuality (where sex addiction might have found itself residing) was considered and subsequent dismissed from the DSM-V (although open for reconsideration for the next revision - whenever that may be...), and many who thought of the disorder as sex addiction saw this as a crushing blow. Unfortunately, the experiences of many in the mental health profession continue to attest to the persistence of high sexual drive and its link to sexual impropriety and psychological distress. This being the case, the self-identification of sexual addiction/porn addiction/hypersexuality/HSD still has an enormous impact on our culture and in the lives of many which is why the Steele, Staley, Fong and Prause article grabs our attention when in the headlines.
High Sexual Desire (HSD) served as the object of the researchers in this study. Their primary emphasis was on cortical regulation of sexual desire, and relied on studies examining Electroencephalography (EEG) activity in those self-identifying as experiencing problems with viewing porn online. While high sexual desire is not the exclusive reason for viewing pornography (the Pornography Consumption Inventory, suggests that many who view porn online do so for additional reasons other than sexual desire), the researhcers compared responses of sexaul images to non-sexual images (neutral, unpleasant, and pleasant-but-not sexual in nature). In an an innovative approach the problem, they used Event-Related Potentials (ERPs) from a variety of pictures (sexual and non-sexual) and monitored cortical activity using EEG to see if those self-identifying with HSD had a heightened cortical ‘radar’ for sexual cues. One component of the image induced ERP wave, called the P300, was used as the marker for this radar. Sexual cue P300s were compared to neutral, pleasant (non-sexual) and unpleasant visual stimuli and if this was related to any of the standard ‘paper-and-pencil’ measures of HSD, sexual compulsivity, sexual risk taking, pornography consumption effects. They were interested in seeing if the P300 wave looked like those from other literature who suffer from drug abuse/addiction (higher amplitudes) or those who are impulsive (lower amplitudes).
A straightforward methodology was employed: subjects were recruited, signed informed consent, answered the questionnaires, then ERPs were recorded through use of EEG. Responses to 245 images (38 sexual, 37 pleasant non-sexual, 75 neutral, 75 unpleasant), each presented for one second were then analyzed. It should be noted that all of the pictures contained people, and I highly recommend reading the original study’s methods if you want additional detail about how this was done. Here are a handful of observations about the study:
1) The recruitment problems the researchers faced illustrate the difficulty all researchers have when doing studies in this area - a lack of diagnostic criteria. Without an accepted way of classifying/diagnosing problems related to sexual compulsivity/impulsivity/addiction/HSD, researchers are left to fend for themselves. The end result is a myriad of nomenclature and a lack of clear standards for study inclusion. In addition, even though not classified as a DSM-V diagnosis, the authors reported a reluctance of one institution’s Institutional Review Board for ethical review of human research to approve the study.
2) There is no non-clinical control group for either the EEG data or the questionnaire measures. This is unfortunate, but could easily be addressed in a later study and the authors acknowledge this limitation. Not a major issue, in my opinion, but one nonetheless.
3) The amplitudes for the sexual stimuli were higher (suggesting addiction), but this was not correlated with the other measures of sexual desire, compulsivity, risk taking or pornography consumption. It is very possible that the lack of P300 amplitude for the sexual stimuli in this study was due to habituation to viewing sexually explicit material; this is, after all, why they were in the study. Individuals self-reporting problematic viewing pornography can consume hundreds of images in one sitting. The impact of regular viewing of pornography (and the cumulative effect this may have on P300 sensitivity), along with reports that P300 more quickly habituate in risk-seekers, might suggest that their result is what they should have seen. Also, the laboratory context needs to be remembered; most problematic porn viewers don’t view single second shots of porn interspersed with landscapes, portraits, and mutilated bodies with electrodes attached to their heads. It is only a snapshop of a sliver of a larger sexual experience/dysfunction.
4) The P300 measures suggest that the issue for those with this problem may be more akin to impulsivity (which more quickly habituates when compared to addicts), and later components of the ERP (i.e. the Late Positive Potentials measures in the 500-750msec window) indicate that the stimuli is more sensitive to motivational processes.
5) What is not to missed is that this study did not look at subcortical activation. Sexual desire is typically considered to be a subcortical process, and regulation is cortical. While there is a significant interplay between the two, a fully integrated understanding of how sexual dysregulation occurs is the direction in which we should be headed. The presence of the P500-750 actually does indicated a deeper motivational issue, however the P300 suggests that it may rapidly habituate (i.e. the pictures begin to blur together).
What was of greater interest to me, however, is that in the very same volume that this study was reported, an article by Dr. Donald Hilton Jr. from the University of Texas Health Science Center at San Antonio provides an excellent argument for the movement away from the language of addiction towards a more nuanced understanding of mental illness that is informed by research in neural plasticity. This is part of the ongoing conversation that is part of the larger question of how we understand and view mental illness. It is nice to see that progress is being made towards understanding the many dimensions of sexuality and how it can become a source of psychological, relational and social distress for so many. While well intentioned, media reports often miss the subtleties of theory, data and interpretation related to research of this kind. And while it is especially true when it comes to neuroscience research, when it comes to titular matters of sexuality reporting can often stray towards appeals to our own biases and sensationalism.The study by Steele, Staley, Fong and Prause is an important first step in filling in the picture of what many refer to as sex addiction, and the authors are incredibly generous, cautious and thoughtful in their writing and interpretation of the results. Underneath it all, the process of science continues and informs the language that we use to engage the mental health issues that need to be addressed.
