Compulsive sexual behavior disorder in an inpatient sample with substance use disorder.

Background: Several studies indicate that compulsive sexual behavior disorder (CSBD) shares core elements with substance use disorder (SUD). These findings support the assumption of common mechanisms in addiction, which may lead to a higher tendency in patients with SUD to have comorbid CSBD. Nevertheless, this relationship between CSBD and SUD is poorly understood to date. Aim: This study aimed to compare the prevalence of CSBD and its subtype pornography use disorder (PUD) between a SUD group and a matched control group. Herein, we aimed to test whether patients with SUD are more likely to have a comorbid CSBD/PUD. We further hypothesized that a higher CSBD/PUD prevalence in patients with SUD is accompanied by more pronounced CSBD- and PUD-related personal characteristics. Methods: We assessed CSBD, PUD, and related personal characteristics in an inpatient SUD sample (N = 92) and a healthy control sample matched by age, gender, and educational level. Outcomes: Primary outcomes were the diagnoses of CSBD/PUD as assessed by questionnaires. CSBD/PUD-related personal characteristics were the early onset of problematic pornography consumption, relationship status as a single person, a high sexual motivation, a high level of time spent watching pornography, and a high degree of problematic pornography consumption (Problematic Pornography Consumption Scale, short version). Results: There was no significant difference between groups regarding CSBD prevalence (SUD sample, 3.3%; control sample, 7.6%) and PUD prevalence (SUD sample, 2.2%; control sample, 6.5%). We found relationship status as a single person and the sexual motivation dimension of importance of sex to be the only CSBD-related personal characteristics that were more pronounced in the SUD sample than the matched control group. Clinical Implications: Results indicate no higher tendency for patients with SUD to develop comorbid CSBD/PUD, yet important vulnerabilities (eg, emotional dysregulation) should be considered when treating addictive disorder to prevent possible symptom displacement. Strengths and Limitations: A strength of the study is that we compared a sample of patients with SUD with a matched control sample and used an instrument based on ICD-11 criteria for CSBD. Possible limitations are significant differences between the groups because of the restrictions in an inpatient clinic that may have influenced responses (eg, roommates) and that the control group was not screened for SUD. Therefore, the results should be interpreted with some caution. Conclusion: We found no evidence of an overcomorbidity of SUD and CSBD/PUD. However, a higher rate of vulnerability factors for CSBD/PUD in the SUD sample might suggest some similarities between SUD and CSBD/PUD.

Two subtypes of compulsive sexual behavior disorder.

Models explaining addictive behaviors such as the Interaction of Person-Affect-Cognition-Execution (I-PACE) model emphasize the importance of reinforcement mechanisms for developing and maintaining these behaviors, including compulsive sexual behavior disorder (CSBD) as well as personal characteristics as vulnerability factors. This study aimed to determine whether there are CSBD subtypes distinguished by reinforcement sensitivity. We hypothesize that one subtype is sensitive to positive reinforcement (C+subtype) and one is sensitive to negative reinforcement (È»-subtype). We calculated a cluster analysis with data from 62 patients with CSBD and tested differences between the identified clusters by t-test. The sample consisted only of men. Cluster variables were: the sensitivity to the Behavioral Inhibition and Approach System (BIS/BAS), the severity of depressive symptoms (BDI-II), the severity of Trait Anxiety (STAI-T), Sexual Sensation Seeking (SSSS), Thrill- and Adventure-Seeking (SSS-V subscale), Disinhibition (SSS-V subscale), Experience Seeking (SSS-V subscale), and Boredom Susceptibility (SSS-V subscale). Between-cluster differences were analyzed for Trait Sexual Motivation (TSMQ) and Sexual Compulsivity (SCS). The results showed a two-cluster solution with cluster 1 representing patients sensitive to negative reinforcement (È»-subtype) and cluster 2 representing patients sensitive to positive reinforcement (C+subtype). No significant difference in symptom severity of Sexual Compulsivity between clusters was found. Cluster 2 showed higher Importance of Sex and a higher motivation to seek sexual encounters than cluster 2. We found a two-cluster solution regarding reinforcement sensitivity in patients with CSBD. This may have clinical implications regarding individual therapy by focusing on the underlying maintenance mechanisms.

On the current psychotherapeutic situation for persons with pornography use disorder in Germany.

Background and aims: For the first time, the ICD-11 provides the diagnosis compulsive sexual behavior disorder (CSBD) that can be assigned for pornography use disorder (PUD). This study aimed to estimate the prevalence of PUD and associated consequences in Germany, to identify the psychotherapy demand among likely PUD (lPUD) cases and the treatment supply in different psychotherapeutic settings, to survey psychotherapists' level of expertise regarding PUD, and to identify predictors for psychotherapy demand. Methods: Four studies were conducted: 1. Online study in the general population (n = 2070; m = 48.9%, f = 50.8%, d = 0.2%), 2. Survey among practicing psychotherapists (n = 983), 3. Survey of psychotherapists in psychotherapeutic outpatient clinics (n = 185), 4. Interviews with psychotherapeutic inpatient clinics (n = 28). Results: The estimated prevalence of lPUD in the online study was 4.7% and men were 6.3 times more often affected than women. Compared to individuals without PUD, individuals with lPUD more often indicated negative consequences in performance-related areas. Among lPUD cases, 51.2% of men and 64.3% of women were interested in a specialized PUD treatment. Psychotherapists reported 1.2%-2.9% of lPUD cases among their patients. 43.2%-61.5% of psychotherapists stated to be poorly informed about PUD. Only 7% of psychotherapeutic inpatient clinics provided specific treatments to patients with PUD. While, among other factors, negative consequences attributed to lPUD were predictive for psychotherapy demand, weekly pornography consumption, subjective well-being, and religious attachment were not. Discussion and conclusions: Although PUD occurs quite often in Germany, availability of mental health care services for PUD is poor. Specific PUD treatments are urgently needed.

Individual cortisol response to acute stress influences neural processing of sexual cues.

Background and aims: Problematic pornography use can be conceptualized as an impulse control disorder or alternatively as a behavioral addiction. Stress is an important trigger in addiction, but less is known about the neural effect of stress in problematic pornography use. Therefore, we aimed at investigating the effect of stress during the anticipation and viewing of sexually explicit material while considering person characteristics related to potentially being at risk for developing problematic pornography use. Methods: In an fMRI study (n = 157 men, age: mean = 25.46, SD = 4.11) we used a sexual incentive delay task. A social stress test was used to induce stress in half of the participants. Salivary cortisol was repeatedly measured and person characteristics were considered moderating the effects of cortisol response. Results: We found no group differences in the neural responses during the anticipation phase, but a higher reactivity to sexual stimuli in the dACC in the stress group. Acute stress activated a pronounced cortisol response, which positively correlated with neural activations in the reward system (NAcc, dACC) to sexual cues. Further, the individual time spent on pornography use moderated the effect of cortisol in some regions of the reward system (dACC, mOFC). Discussion and conclusions: Our results suggest that acute stress related increases in cortisol can enhance the incentive value of cues announcing sexual stimuli. This might explain why acute stress is considered a trigger of pornography use and relapse and why individual stress response might be a risk factor for developing a problematic pornography use.

Effects of Depression on Processing and Evaluation of Sexual Stimuli in Women.

BACKGROUND: Sexual dysfunctions are commonly associated with depression by which women are particularly affected. AIM: In the following study, we looked at which stage-early attention-related processes or later evaluation-related processes-of the processing of sexual stimuli deviations occur in depressed individuals. METHODS: We examined 96 women who either suffered from a major depressive disorder, or had recovered from it, and a healthy control group. The early level of attention processes was represented by reaction time tasks (dot probe, line orientation, picture categorization). In addition, implicit approach and avoidance behavior was tested by the Approach-Avoidance Task. Later evaluation of the visual material was determined with the help of a questionnaire for recording automatic negative thoughts regarding sexuality. OUTCOMES: Reaction times and explicit ratings as well as the Becks Depression Inventory (BDI II), the Trait Sexual Motivation Questionnaire (TSMQ), the Sexual Modes Questionnaire (SMQ) and a screening for sexual dysfunction were used. RESULTS: Depressed women did not differ significantly from healthy women in their attention processes and approach-avoidance behavior. However, there were clear differences in explicit assessment and automatic thoughts about sexual stimuli. Women who had recovered from depression lay between the 2 groups. CLINICAL IMPLICATIONS: The results indicated that the therapy of sexual dysfunction in depressed patients should focus more on automatic thoughts than on attention processes. STRENGTHS & LIMITATIONS: This study is the first to experimentally research the attention processes of depression towards sexual stimuli. However, participants were only tested on one occasion so that change of attention processes and evaluation of sexual stimuli over the course of a depression could not be assessed. CONCLUSION: Our novel findings demonstrate the role of attention processes in sexual dysfunctions of depressed women and suggest potential mechanisms that may underlie the observed correlation between depression and sexual dysfunction. Baranowski AM, Noll A-K, Golder S, et al. Effects of Depression on Processing and Evaluation of Sexual Stimuli in Women. J Sex Med 2022;19:441-451.

The Impact of Negative Mood on Event-Related Potentials When Viewing Pornographic Pictures.

Background: Negative affective states may increase the risk for problematic pornography use. Underlying neurophysiological mechanisms are, however, not completely understood. Previous research suggests that the participants' emotional state may affect neural processing of sexual stimuli. The aim of this study was to investigate neural correlates of negative affect-induced alterations in sexual cue reactivity in healthy men. The moderating effects of habitual porn consumption, trait sexual motivation, and symptoms of cybersex addiction were also considered. Method: Sixty-four healthy men engaged in a sexual cue reactivity task (passive viewing of explicit sexual pictures and neutral pictures depicting scenes of social interaction) during negative (n = 32) vs. neutral affect (n = 32), induced via tailored feedback on a performance task. Self-reported sexual arousal and event-related brain potentials indicated cue reactivity and motivated attention. Symptoms of cybersex addiction and trait sexual motivation were assessed with the help of the short Internet Addiction Test, adapted to online sexual activities, and the Trait Sexual Motivation Questionnaire. Results: Negative feedback increased negative affect after the performance task. While sexual pictures compared to neutral pictures elicited significantly larger P300 and late positive potential (LPP) amplitudes, there was no general effect of negative feedback on sexual stimuli-related P300 and LPP amplitudes. In the negative feedback group, men with higher solitary sexual motivation levels showed higher P300/LPP difference amplitudes for sexual stimuli compared to men with lower levels of solitary sexual motivation. The opposite effect was found in the group with neutral feedback. There was no link to other aspects of trait sexual motivation and symptoms of cybersex addiction. Conclusions: Results suggest that higher levels of solitary sexual motivation may enhance motivated attention toward sexual stimuli among men receiving negative performance feedback. Other characteristics of sexual behaviors and traits provided no exploratory value. Future studies extending onto men suffering from compulsive sexual behavior disorder will have to closer look at the neurophysiological bases of why and when some men develop an addictive pornography consumption.

Sexual incentive delay in the scanner: Sexual cue and reward processing, and links to problematic porn consumption and sexual motivation.

BACKGROUND AND AIMS: The use of pornography, while unproblematic for the majority, can grow into addiction-like behavior which in its extreme form is labeled as compulsive sexual behavioral disorder in the ICD-11 (WHO, 2018). The aim of this study was to investigate the addiction-specific reactivity to cues in order to better understand underlying mechanisms in the development of this disorder. METHODS: We have used an optimized Sexual Incentive Delay Task to study brain activity in reward associated brain areas during an anticipation phase (with cues predicting pornographic videos, control videos or no videos) and a corresponding delivery phase in healthy men. Correlations to indicators of problematic pornography use, the time spent on pornography use, and trait sexual motivation were analyzed. RESULTS: The results of 74 men showed that reward-related brain areas (amygdala, dorsal cingulate cortex, orbitofrontal cortex, nucleus accumbens, thalamus, putamen, caudate nucleus, and insula) were significantly more activated by both the pornographic videos and the pornographic cues than by control videos and control cues, respectively. However, we found no relationship between these activations and indicators of problematic pornography use, time spent on pornography use, or with trait sexual motivation. DISCUSSION AND CONCLUSIONS: The activity in reward-related brain areas to both visual sexual stimuli as well as cues indicates that optimization of the Sexual Incentive Delay Task was successful. Presumably, associations between reward-related brain activity and indicators for problematic or pathological pornography use might only occur in samples with increased levels and not in a rather healthy sample used in the present study.

Subjective reward value of visual sexual stimuli is coded in human striatum and orbitofrontal cortex.

Human neuroimaging research suggests the existence of one core network for the subjective valuation of rewards, including the striatum and orbitofrontal cortex. However, there is little research on the neural representation of subjective reward values of visual sexual stimuli (VSS) and on the role of these subjective valuations in the development of related addictive behaviors. Here, we investigate how neural reactivity to VSS is connected to individual preference using functional magnetic resonance imaging (fMRI). During the fMRI scan, 72 men viewed different VSS film clips. Ratings regarding valence and sexual arousal were collected and used as parametric modulators in the fMRI analysis. Subjects also filled out questionnaires on self-reported symptoms of problematic pornography use (PPU). Firstly, we found that neural reactivity towards VSS clips in the nucleus accumbens, caudate nucleus and orbitofrontal cortex was positively correlated with individual ratings of the respective VSS in all subjects. Second, the strength of the association between neural activity and sexual arousal ratings was positively correlated with self-reported symptoms of PPU. The first result suggests a precise appraisal of VSS according to individual preferences in established reward valuation regions. Secondly, stronger neural differentiation based on preference in participants with more PPU symptoms indicates an increased importance of VSS/preference fit in these individuals. This heightened correspondence between individual liking and neural activity may facilitate PPU development by increased signaling of incentive salience, thus boosting motivation to seek out and respond to these preferred stimuli.

Effects of acute psychosocial stress on the hypothalamic-pituitary-thyroid (HPT) axis in healthy women.

OBJECTIVE: The individual set point of the hypothalamic-pituitary-thyroid (HPT) axis is largely genetically determined. Apart from this genetic predisposition, the HPT axis may also be malleable to environmental demands such as psychosocial stress. Indeed, previous research has indicated that critical life events often precede the onset of autoimmune thyroid diseases, and subtle abnormalities in HPT functioning are present in some patients with stress-related disorders such as depression. However, no studies have investigated whether exposure to psychosocial stress leads to an immediate activation of the HPT axis. METHODS: A total of N = 30 healthy women attended two laboratory appointments in a randomized order. An intravenous catheter was inserted at the beginning of each appointment. In the stress session, this was followed by the Trier Social Stress Test (TSST). Plasma samples to determine thyroid-stimulating hormone (TSH), triiodothyronine (T3), and thyroxine (T4) were taken at baseline and 20, 50, and 110 min after the TSST started. In the control session, participants rested and were instructed to read magazines, while the sampling schedule was maintained. RESULTS: There was a significant rise in TSH concentrations in response to the TSST, with a peak observed 20 min after stressor onset, and a steady decline thereafter. No such response was observed in the control session. The TSST did not increase T3 or T4. CONCLUSION: The finding that acute psychosocial stress is able to elicit a significant increase in TSH is relevant to our understanding of a number of stress-related illnesses presenting with abnormalities of the HPT axis.

Effects of cognitive-behavioral stress management training in individuals with functional somatic symptoms - an exploratory randomized controlled trial.

Stress is discussed as a risk factor in the manifestation and maintenance of functional somatic (FS) symptoms. However, there is a lack of evidence regarding the effects of cognitive-behavioral stress management training (CBSM) on FS symptoms and the (potentially mediating) role of the neuroendocrine system. This study aims to examine stress-related psychological and neuroendocrine changes after receiving a brief CBSM in individuals with FS symptoms. Forty-three participants of both sexes, who reported at least one current FS symptom, were analyzed (treatment group (TG) n = 21, waitlist control group (WCG) n = 22) using mixed models. Number of symptoms, psychological stress, and salivary cortisol levels were assessed at pretreatment, posttreatment, and 6 months later. Mixed model analyses did not reveal significant differences between the TG and the WCG regarding number of FS symptoms (p > 0.05), psychological stress measures (p > 0.05) or the cortisol awakening response (CAR) (p > 0.05). The TG presented lower diurnal cortisol levels at pretreatment, posttreatment and 6 months later (p < 0.05). We did not find significant beneficial effects that were specific to CBSM. Further research should be undertaken to investigate the effects of CBSM on real life stress or laboratory stressors in subjects with FS symptoms. Moreover, learning cognitive restructuring and establishing new coping strategies into everyday life might require more time. This study is a first step in filling the gap in understanding the influences of CBSM as a brief intervention on psychological and biological aspects of stress in participants with FS symptoms and will hopefully inform larger trials of CBSM for FS symptoms.

Thyroid Functioning and Fatigue in Women With Functional Somatic Syndromes - Role of Early Life Adversity.

Objective: Fatigue is a core feature of functional somatic syndromes (FSS). Fatigue is also prominent in patients with thyroid diseases, which is unsurprising given the role of the hypothalamic-pituitary-thyroid (HPT) axis in regulating physiological energy demands. Research in healthy women has shown that early life adversity is linked with alterations in the HPT axis. In view of the substantial prevalence of early life adversity in patients with FSS, our aim was to investigate whether HPT functioning is related to (a) fatigue, and (b) early life adversity in these patients. Methods:N = 33 female patients with FSS and n = 30 age-matched controls were recruited. Fasting morning blood samples were taken to determine thyroid-stimulating hormone (TSH), free triiodothyronine (fT3), and thyroxine (fT4). General, physical, and mental fatigue were measured via the multidimensional fatigue inventory (MFI). Early life adversity was measured using the childhood trauma questionnaire (CTQ). Results: Patients with FSS did not differ from controls in any thyroid parameters (all p > 0.672). However, the lower the patients' TSH and the higher their fT4, the greater was their general (ß = -0.32, p = 0.064; ß = 0.35, p = 0.038) and physical (ß = -0.47, p = 0.007; ß = 0.32, p = 0.077) fatigue. In addition, emotional neglect (ß = -0.32, p = 0.057), physical neglect (ß = -0.60, p = 0.001), physical abuse (ß = -0.47, p = 0.015), and sexual abuse (ß = -0.40, p = 0.026) were linked with lower TSH. Conclusion: The lower TSH and the higher fT4, the more fatigue was reported by patients with FSS. In addition, lower TSH was linked with more early life adversity. Larger, prospective studies are warranted to determine whether HPT functioning may be a mediating pathway between early life adversity and fatigue in FSS.

Endocrine dysregulation in women with irritable bowel syndrome according to Rome II criteria.

The etiology of the irritable bowel syndrome (IBS) is unexplained: biological, psychological and social factors must be considered. This study examined if differences in HPA-axis activity already exist in those who do not yet fulfill IBS criteria (i.e. "subthreshold IBS"). We also investigated whether there were differences between those who reported clinically relevant (i.e. distressing) IBS symptoms and those who did not. Thirty-six women were subdivided into three groups (IBS group, subthreshold IBS group, control group). Results showed differences in morning cortisol levels (U = 11.58; p < 0.05), with IBS patients showing a lower cortisol response compared to controls. Subthreshold IBS patients were comparable to controls regarding endocrine function. Diurnal cortisol levels did not differ between groups. Group comparisons between distressed subjects and non-distressed subjects regarding cortisol levels did not reach significance. The finding of endocrine abnormalities (at least in a sub-set of patients) is important since these might be associated with deficient pain processing in IBS.

Distress criterion influences prevalence rates of functional gastrointestinal disorders.

BACKGROUND: Functional gastrointestinal disorders (FGID) are defined by a combination of chronic or recurrent gastrointestinal symptoms. Prevalence rates of FGID are high. Symptoms are associated with distress, and sufferers show high stress levels. However, the current diagnostic criteria do not consider subjective distress elicited by the symptoms, thus potentially leading to overestimated prevalence rates. The aim of this study was to explore the reduction in prevalence rates when distress is considered in the diagnostic criteria. METHODS: In this web-based study, FGID were diagnosed using the Rome II criteria. Prevalence rates with and without subjective distress elicited by the symptoms were computed. Additionally, stress levels and stress reactivity were assessed. RESULTS: Prevalence rates of FGID in our sample were similar to those in other studies. However, when considering the distress criterion, on average, a decrease of 38.51% was found in the prevalence rates of FGID. Sufferers who were subjectively distressed by their symptoms reported significantly higher stress levels than non-distressed subjects (all p < 0.001). CONCLUSIONS: The consideration of a criterion of subjective distress in the diagnosis of FGID has consequences for actual prevalence rates of FGID. Distressed subjects differ markedly from non-distressed subjects in terms of their stress levels. The inclusion of a distress criterion in the ongoing development of diagnostic criteria for FGID is therefore warranted.