Tuesday, September 29, 2015

Porn Addiction Study and the DSM – 5 Debate over Whether to Include Hypersexuality.

This blog has repeatedly commented on the problems of diagnosing ‘sex addiction’ and hypersexuality.  See “Arrival of the Death Star,” “Out of the Shadows,” “Umbra,” and “Ken Zucker, PhD and Michael First, MD’s DSM – 5 Plenary at AASECT” on this blog for additional discussion of this issue. To summarize those problems briefly:
  
       1)      Disagreement exists on how ‘too much sex’ might be recognized behaviorally, a      requirement needed for reliability,
       2)      The model postulating that ‘sex addiction’ might be similar to chemical addictions      might not be valid,
       3)      If the criteria for too much sex cannot be objectively operationalized, psychiatry might be discredit for making illnesses of ordinary behaviors, thereby loosing legitimacy and
       4)      If the diagnosis is intrinsically stigmatizing, the costs of labeling need to be proven to be offset by medical benefits of treatment that require that disadvantage, otherwise alternate means need to be used where the cost benefit is superior.
       5)      Additional obstacles to ‘sex addiction’ treatments include the legitimating of past addicts as paraprofessional therapists.  This biases such treatment by making acceptance of the label ‘addict’ a quantification to do treatment, and makes that acceptance an integral part of treatment for clients. 
       6)      While there can be little objection to self-labeling in chemical addictions where the behavior of taking drugs for recreational purposes is illegal, it is objectionable to advocate complete abstinence for otherwise healthy sexual behaviors,
       7)      This labeling problem becomes particularly problematic when social prejudices and religious attitudes contest with the scientific criteria for defining sexual behaviors that are in social dispute such as homosexuality, variant gender expression, BDSM and polyamory.

All of which might seem to be a damning case, but sex addiction practitioners have five crucial advantages which perpetuate use of their terms and ideology:

      1)      The public has already come to accept the term ‘sex addiction’.  Its wide use and recognition make it an effective marketing tool.
      2)      Because psychiatry has weak construct validity, sex addiction therapies that make clients feel better cannot easily be removed from the professional cant,
      3)      The biological mechanisms that underlie all perceptions of pleasure have neurological similarities, and it is quite difficult to conduct research that identifies whether these mechanisms are causes or effects.  The scientific jury is still largely out as to whether effective neurological agents might not be developed to treat excessive or unwanted sexual behavior, and their is big money at stake, and
      4)      The therapeutic techniques of ‘sex addiction’ therapies and less stigmatizing treatments overlap considerably.
      5)      Psychiatry, psychotherapy, and religious ideologists all have some vested interest in showing that they have explanatory power in understanding problems of sexual behavior above and beyond the client’ self-definition.  After all, if we do not know something special, why should anyone expect us to offer special relief for their discomforts.

J. Grubb et al from Case Western Reserve University recently showed that belief one had a porn addiction was more strongly associated with a variety of problem symptoms than the extent of actual porn use.  In a series of careful studies, Grubbs replicated his findings and used a design that allowed for imputing causality.  The end results; moralistic religious attitudes and belief that one is a porn addict cause more depression, anger and anxiety than the degree of porn actual use.  The adoption of the label does seem to cause the negative feelings.

This Grubb study was not bullet proof.  One might argue that the porn addiction attitudinal measure, Grubb used, the CUIC, is not the best measure of that condition, and that it not the best operationalization of the concept. It does have a high degree of face validity in assessing whether a respondent is troubled by their porn use. The subjects were self-selected to participate, with a high degree of porn use, and these conclusions might only be valid among relatively frequent porn users, and that people troubled by their porn use might be over represented in such a sample.  That would tend to justify conclusions about people coming into therapy with complaints, but not for the general population.  However, these arguments might all be true and the study’s conclusions still be valid.  Criticisms and all, the study has certainly shown that for some populations, the label is worse than the underlying behavior it attempts to describe in causing subjective distress.

Aside from the evaluation of what intellectual substance might underlie 'porn addiction' ideology, the study presented in this thread also elucidates a critical problem that led to the decision not to include hypersexuality in the DSM – 5.

If the frequency of sexual activity is unrelated to negative psychological symptoms, but the holding of an idea or a social label is, different raters will have a hard time agreeing on the threshold for a diagnoses more reliably than by simply asking the client's opinion.  M.Foucault had no trouble recognizing the philosophical obstacles to professionalizing any conversation about sexuality in which the client is a more authoritative source of information than the professionals.  To be a persuasive demonstration of the superiority of professional opinion, the precision of a diagnosis needs to stem from special professional expertise.
 
Note also how similar this argument about the possible harm in the idea of ‘porn addiction’ is in structure to Moser's and Kleinplatz's arguments about paraphilia in the DSMs.  Since DSM - IV, we have operated under a two part diagnostic system.  Part 1 determines whether a behavior is weird: sadistic, masochistic, or centered on a child, or transvestic for example.  These are all pretty easy to code as different from hetero-normative sexuality and different from each other, thus meeting the reliability criteria well. But Moser and Klienplatz have argued that these behaviors don’t have a great deal in common beyond social stigma, and the concept that all paraphilias are somehow alike is culturally biased, not scientific.  Part 2 assesses either work and life disruption, or subjective dissatisfaction by the client.  It is this second part that is problematical in the view of Foucault cited above.  While some raters can be trained to objectify work or life disruption using criteria like divorce, legal trouble, job loss, etc., the degree of life dissatisfaction remains primarily within the domain of the client’s internal and subjective experience.
  
Thus the reliability for paraphilia as research criteria depends heavily on the culturally biased and stigmatized dimensions that can be coded consistently to overcome the ambiguity and subjectivity of client complaints.

As an advocate for better mental health treatment on this list, I have a duty to expose any psychotherapeutic practice that labels variant (non-heteronormative) behavior as pathological on its face.  That is pretty obvious in those that label homosexual, consensually non-monogamous, or consensual BDSM behaviors as pathological or addicted by definition.  But that is exactly what the DSM - IV and 5 systems do if they go beyond subjective client distress.

Given these findings by Grubb et al, suggesting that even where the client reports high subjective distress, the poison may well lie in the label and stigma, not the behavior.  I would suggest this evaluation should be a top priority of evaluation on any variant behavior that enters the consulting room. 

Furthermore, labeling and stigma are the prime suspects in guilty and ashamed clients whose behavior is highly consensual. In most cases, a therapeutic goal of overcoming the stigma will be justified.  It is a disadvantage for many such clients to start with an authoriatative-sounding diagnosis.

Personality disorder is the likely characteristic of persons whose variant behavior harms others while the client reports low subjective distress.  Behavioral control, empathy for others, and accepting painful labels are likely therapeutic goals.
 
Many problems of life functioning are partner relational problems or failure to find community that are best solved by counseling about how to find and use community resources, or how to handle conflict in the relationship.

None of these require a paraphilia diagnosis from the DSM -5, and none require a hypersexuality or ‘sex addiction’ diagnosis that isn’t even in the manual.


Resources:

Grubb, J, Stauner N, Exeline J, et al. Perceived Addiction to Internet Pornography and Psychological Distress:  Examining Relationships Concurrently Over Time Psychology of Addictive Behaviors. 2015

Moser, C and Kleinplatz, P DSM-IV-TR and the Paraphilias Journal of Psychology and Human Sexuality 02/2006; 17(3-4)

Kleinplatz, P and Moser, C Politics versus Science Journal of Psychology and Human Sexuality 02/2006; 17 (3-4)

C Moser When is an Unusual Behavior a Mental Disorder? Archives of Sexual Behavior 11/208; 38(3): 323-5

Shindel, A and Moser, C Why are the Paraphilias Mental Disorders? Journal of Sexual Medicine 11/2010; 8(3):927-9

Moser, C Hypersexual Disorder:  Searching for Clarity Sexual Addiction and Compulsivity 01/2013; 20

Moser C A Rejoinder to Carpenter and Krueger:  It is about Clarity and Consistency Sexual Addiction and Compulsivity 01/2013

Moser C Hypersexual Disorder: Just More Muddled Thinking Archives of Sexual Behavior 10/2010; 40(2)

Foucault, M (1979) History of Sexuality, Volume 1: An Introduction London: Allen Lane

Copyright Russell J Stambaugh Ann Arbor, MI September, 2015

5 comments:

  1. From what I've heard, the definition of "addiction" varies widely from one mental health community to another - my friends outside the US generally seem to feel that we USians like to label any problematic thoughts or behaviors as "addiction," and I think they have a point. I wish we could save the word for those behaviors in which withdrawal causes clinically significant physical symptoms (e.g., heroin), and have a different word for problematic uses of food, sex, gambling et al. IIRC, when I was in high school we were taught that heroin, cocaine, alcohol, etc., were "addictive," and that other drugs that they didn't want us to use were "habit-forming" - has this distinction disappeared entirely?

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  2. Great article Russell. Couple comments:
    -Janet, drug/alcohol treatment has/is moved away from use of the word addiction, as reflecting an ill defined, subjective concept. Do sex addiction therapists are using antiquated theory.

    - Russell, one clarification is important. The subjects in Grubbs study were not self selected treatment seekers, but were selected from wide pools of subjects, on basis of porn use. Thus these data are quite generalizable.

    One important thing in that is that these were not apparently, by and large, people diagnosed by sex addiction therapists. Instead, many were likely people who adopted these self diagnoses based on the general public, media, pop psych acceptance and promotion of the term and concept.

    Now, sex addiction therapists are the ones giving the concept credibility, defending it and promoting it in the media. Further, they benefit financially from the popularity and general acceptance. So, I hold them responsible for the harm done by the general public acceptance of a harmful concept.

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  3. I find it interesting how those in the SA industry are so quick to summarily dismiss these findings...

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  4. Re: David's reply about my characterization of the sample as self-selected. It is recruited from pools of high porn users. So my criticism that it may not be generalizable to the entire population remains correct. But David is correct in his assertions that these results are generalizable to the kinds of people sex therapists and other professionals are likely to see regarding complaints about porn use.

    An his point, that we are all responsible, is not only the larger one, but the crucial place to intervene. I guess we need to do two things: Not over emphasize the role of assigning any diagnostic labels we do not absolutely have to. In this I am a fierce supporter of Doug Braun-Harvey's preferred term "Problem Sexual Behavior. And avoid the suspect addiction analogy.

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  5. Excellent review of these thoughts/threads.

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